The scale of the analysis sets it apart from earlier attempts to quantify the problem. Previous reviews had focused largely on nurses alone and had become outdated as the volume of published research accelerated. To close that gap, the research team, drawn from institutions including the Rajaie Cardiovascular Institute in Tehran, Tehran University of Medical Sciences, and the Monash Bioethics Centre in Australia, searched six databases: PubMed, Scopus, Web of Science, Magiran, the Science Information Database, and IranDoc, capturing records published up to March 2025. They registered the study protocol in advance with PROSPERO, the international prospective register of systematic reviews, under registration number CRD420261479604, a step designed to guard against selective reporting and post hoc changes in methodology.

Methodological rigor was central to the design. Each included study was appraised with the Mixed Methods Appraisal Tool, or MMAT, a validated instrument for assessing the quality of primary research across different study designs. The team then extracted prevalence data and synthesized it using a random-effects proportional meta-analysis model, the standard statistical approach when the goal is to estimate a pooled proportion across studies that differ in population, setting, and measurement. Random-effects modeling assumes that the true prevalence may vary from study to study rather than assuming a single fixed value, which makes it appropriate for a phenomenon as context-dependent as workplace violence. The authors also formally assessed statistical heterogeneity and publication bias, the two most common threats to the validity of pooled estimates.

The headline number, 83 percent, is striking enough, but the breakdown by violence typology reveals where the danger actually concentrates. Verbal violence was by far the most common form, with a pooled prevalence of 76 percent (95 percent CI: 69 to 82 percent). Physical violence affected 27 percent of workers (95 percent CI: 21 to 35 percent), racial violence 11 percent (95 percent CI: 7 to 17 percent), and sexual violence 4 percent (95 percent CI: 3 to 7 percent). In other words, while the specter of physical assault dominates public imagination, the everyday reality for most clinicians is a barrage of shouting, insults, threats, and humiliation, a form of abuse that is easier to dismiss but, the evidence suggests, no less corrosive over time.

The heterogeneity statistics deserve careful attention from anyone interpreting these figures. The I² values, which describe the proportion of variability in observed estimates attributable to true differences between studies rather than chance, were extremely high across all outcomes: 94 percent for overall violence, 98 percent for verbal violence, 97 percent for physical violence, and 94 percent for both racial and sexual violence. Such values signal that the underlying studies differ substantially, whether in the populations sampled, the definitions of violence used, the recall periods applied, or the settings surveyed. This does not invalidate the pooled estimates, but it means the confidence intervals should be read as summaries of a diverse evidence landscape rather than as precise point predictions for any single hospital or year.

Publication bias, the tendency for studies reporting higher prevalence to be published more readily than those reporting lower prevalence, was also formally evaluated. In proportional meta-analyses of this kind, such bias can inflate pooled estimates, which is one reason the authors’ transparent reporting of heterogeneity and bias assessment matters. The sheer number of included studies and participants, 95 papers and nearly 41,000 individuals, provides a degree of statistical stability that smaller reviews cannot match, and the breadth of the search strategy, spanning both international and Persian-language databases, reduces the risk that important local evidence was missed simply because it was published outside the mainstream Western literature.

Beyond the numbers, the qualitative synthesis of the included studies identified recurring drivers of violent incidents. Public unawareness of the duties and limits of healthcare staff emerged as a frequent correlate, as did critical staff shortages. Both factors point to a common mechanism: when patients and families wait long hours in overcrowded facilities and do not understand why, frustration can curdle into aggression directed at the nearest person in a white coat. Understaffing compounds the problem in a second way, because stretched-thin staff have less time to de-escalate conflicts, less bandwidth to communicate clearly, and fewer colleagues to call on when a situation turns threatening.

The consequences documented in the literature extend well beyond the moment of the incident. The review links exposure to workplace violence with psychological distress and burnout among staff, outcomes that in turn correlate with reduced occupational performance. This creates a feedback loop with direct clinical implications: violence drives experienced clinicians toward exhaustion, absence, and early exit from the profession, which deepens the staffing shortage, which in turn raises the risk of further violence. Breaking that loop, the authors argue, requires policymakers and hospital administrators to move beyond passive oversight and adopt targeted, systemic interventions rather than relying on individual resilience or after-the-fact disciplinary responses.

The practical measures the authors propose are concrete. They include establishing optimal nurse-to-patient staffing ratios, so that wards are not chronically operating below safe capacity; enhancing physical security infrastructure in high-risk departments, with emergency wards singled out as a priority given their round-the-clock exposure to distressed patients and visitors; and launching nationwide public awareness campaigns to better align patient expectations with clinical realities. The third recommendation is notable because it treats violence prevention as a communication problem as much as a security problem, aiming to address the misunderstanding of staff roles and responsibilities that the qualitative evidence identified as a recurring trigger for abuse.

The findings resonate far beyond Iran. Workplace violence against healthcare workers is recognized by the World Health Organization and the International Labour Organization as a pervasive global crisis, and studies from other countries have reported similarly high rates of verbal abuse against emergency department staff. What this review adds is a rigorously pooled, up-to-date, nationally scoped estimate for a country whose health system has been under sustained pressure, along with a template for how such evidence should be generated: pre-registered protocols, validated quality appraisal, random-effects proportional modeling, and explicit attention to heterogeneity and publication bias. For hospital administrators everywhere, the message is uncomfortable but clear. If more than three-quarters of the workforce is being verbally abused and more than a quarter physically attacked, violence is not an aberration to be managed case by case. It is an occupational hazard that demands the same systematic engineering of controls, staffing, environment, and public education that medicine applies to any other preventable harm.

Subject of Research: Prevalence of workplace violence against healthcare workers in Iran

Article Title: Workplace violence against healthcare staff in Iran: a systematic review and proportional meta-analysis

Article References: Ghaseminejad-Raeini, A., Shirinezhad, A., Babaei, M., Feyzi, A., Soheili, A., Farrokhzadeh, F., Chaibakhsh, S., Mazloomzadeh, S., Parsapour, A., Modabber, M., Shamsi Gooshki, E., & Khaleghparast, S. (2026). Workplace violence against healthcare staff in Iran: a systematic review and proportional meta-analysis. BMC Health Services Research. https://doi.org/10.1186/s12913-026-15830-2

Image Credits: AI Generated

DOI: 10.1186/s12913-026-15830-2

Keywords: workplace violence, healthcare workers, Iran, systematic review, meta-analysis, verbal abuse, nurses, burnout, hospital safety, emergency departments, public health, staff shortages