Prevalence and Characteristics of Workplace Violence Towards Healthcare Workers in Primary Healthcare Settings in Muscat, Oman

TL;DR

This study examines the high prevalence of workplace violence against healthcare workers in primary care settings in Muscat, Oman, highlighting the need for better training and institutional responses.

Contribution

The study provides the first assessment of workplace violence in primary healthcare settings in Muscat, Oman.

Findings

64.2% of healthcare workers in Muscat experienced workplace violence, with verbal abuse and bullying being most common.

Nurses were most frequently targeted, and patients were the main perpetrators.

Many incidents went unreported or uninvestigated, despite existing policies.

Abstract

Workplace violence (WPV) is a growing occupational health concern, with healthcare workers (HCWs) particularly at risk. While high rates of WPV towards HCWs have been reported in emergency and psychiatry settings in Oman, little is known about its prevalence in primary care. This study aimed to assess the prevalence and characteristics of WPV towards HCWs in primary care settings in Muscat, Oman.

This cross-sectional study was conducted between November and December 2024 in Muscat's primary health centres using the validated Workplace Violence in the Health Sector Country Questionnaire. Descriptive statistics and inferential analyses (Chi-square and logistic regression) were used to assess prevalence and associated factors of WPV.

A total of 218 participants were included (response rate = 74.7%). The overall prevalence of WPV was 64.2% (95% confidence interval: 57.8–70.6%) with verbal abuse and bullying/mobbing being the most common forms. Victims were most often nurses, followed by physicians, while patients were the primary perpetrators. Significant associations were found between violence type and perpetrator identity, victim response, perceived preventability and reasons for not reporting. Despite existing policies, many participants lacked training or awareness of reporting procedures. Most incidents were not investigated and had no consequences for the perpetrators.

WPV is a major issue for primary HCWs in Muscat, Oman. Gaps in awareness, training and institutional response highlight the need for stronger prevention, accountability and support measures to protect HCWs and ensure quality patient care.

Tables

Table 1.. Sociodemographic and occupational characteristics of healthcare workers in primary care settings in Muscat, Oman (N = 218).

Characteristic	n (%)
Gender
Male	16 (7.3)
Female	202 (92.7)
Age in years
21–30	8 (3.7)
31–40	112 (51.4)
41–50	87 (39.9)
51–60	11 (5)
Nationality
Omani	182 (83.5)
Non-Omani	36 (16.5)
Marital status
Single	14 (6.4)
Married	187 (85.5)
Divorced	14 (6.4)
Widowed	3(1.4)
Category of HCW
Nurse	97 (44.5)
Physician	32 (14.7)
Pharmacist	11 (5)
Medical orderly	27 (12.4)
Other*	51 (23.4)
Number of years of work experience
≤5	1 (0.5)
6–10	13 (6)
11–15	17 (7.8)
16–20	80 (36.7)
21–25	61 (28)
>25	46 (21)
Shift-based work
Yes	218 (100)
No	0 (0)

Table 2.. Perceptions of workplace violence concerns and reporting procedures among healthcare workers in primary care settings in Muscat, Oman (N = 218).

Item	n (%)
Level of concern regarding WPV
Not at all	75 (34.4)
Mildly	75 (34.4)
Moderately	47 (21.6)
Highly	21 (9.6)
Availability of WPV reporting procedures/policies
Yes	128 (58.7)
No	41 (18.8)
Unsure	49 (22.5)
Knowledge of how to report WPV
Yes	121 (55.5)
No	41 (18.8)
Unsure	56 (25.7)
Institutional encouragement to report WPV
Yes	116 (53.2)
No	45 (20.6)
Unsure	57 (26.1)
Training provided on how to report WPV
Yes	36 (16.5)
No	39 (17.9)
Unsure	143 (65.6)

Table 3.. Prevalence of workplace violence towards healthcare workers in primary care settings in Muscat, Oman (N = 218).

Type of WPV	n (%)	95% CI
Physical abuse	6 (2.8)	1.3–5.9
Verbal abuse	74 (33.9)	28.0–40.5
Bullying/mobbing	49 (22.5)	17.4–28.5
Sexual harassment	3 (1.4)	0.5–4.0
Racial harassment	8 (3.7)	1.9–7.1
Total	140 (64.2)	57.8–70.6

Table 4.. Characteristics of workplace violence incidents reported by healthcare workers in primary care settings in Muscat, Oman (n = 140).

	Type of WPV, n (%)
Characteristic	Physical abuse (n = 6)	Verbal abuse (n = 74)	Bullying/mobbing (n = 49)	Sexual harassment (n = 3)	Racial harassment (n = 8)	Total
Victim of incident
Nurse	-	31 (41.9)	22 (44.9)	-	-	53 (37.9)
Physician	2 (33.3)	17 (23.0)	9 (18.5)	-	3 (37.5)	31 (22.1)
Pharmacist	2 (33.3)	9 (12.2)	6 (12.2)	-	1 (12.5)	18 (13.0)
Medical orderly	2 (33.3)	6 (8.1)	8 (16.4)	3 (100)	4 (50.0)	23 (16.4)
Radiographer	-	-	1 (2.0)	-	-	1 (0.7)
Medical records	-	4 (5.4)	1 (2.0)	-	-	5 (3.6)
Community nurse	-	3 (4.0)	-	-	-	3 (2.1)
Dietitian/health educators	-	2 (2.7)	1 (2.0)	-	-	3 (2.1)
Other*	-	2 (2.7)	1 (2.0)	-	-	3 (2.1)
Perpetrator of incident
Patient/client	4 (66.7)	48 (64.9)	21 (42.9)	-	1 (12.5)	74 (52.9)
Patient/client's relative		6 (8.1)	1 (2)	-	-	7 (5.0)
Staff member	-	11 (14.9)	18 (36.7)	-	6 (75.0)	35 (25)
Management/supervisor	2 (33.3)	6 (8.1)	7 (14.3)	-	1 (12.5)	16 (11.4)
Member of the public	-	3 (4.1)	2 (4.1)	-	-	5 (3.6)
Unspecified	-	-	-	3 (100)	-	3 (2.1)
Location of incident
Inside health facility	6 (100)	66 (89.2)	45 (91.8)	-	8 (100)	125 (89.3)
At patient/client's home	-	6 (8.1)	-	-	-	6 (4.3)
Other	-	2 (2.7)	4 (8.2)	3 (100)	-	9 (6.4)
Perceived preventability of incident
Yes	4 (66.7)	66 (89.2)	39 (79.6)	3 (100)	8 (100)	120 (85.7)
No	2 (33.3)	8 (10.8)	-	-	-	10 (7.1)
Unsure	-	-	10 (20.4)	-	-	10 (7.1)
Victim's response to incident*
No action taken	-	26 (35.1)	24 (49)	2 (66.7)	5 (62.5)	57 (40.7)
Told perpetrator to stop	2 (33.3)	23 (31.1)	10 (20.4)	-	3 (37.5)	38 (27.1)
Told friends/family	2 (33.3)	7 (9.5)	5 (10.2)	-	2 (25.0)	16 (11.4)
Told a colleague	2 (33.3)	14 (18.9)	6 (12.2)	-	-	22 (15.7)
Reported to supervisor/person in charge	4 (66.7)	25 (33.8)	7 (14.3)	-	1 (12.5)	37 (26.4)
Completed incident/accident form	2 (33.3)	9 (12.2)	2 (4.1)	-	1 (12.5)	14 (10.0)
Sought counselling	4 (66.7)	3 (4.1)	2 (4.1)	-	-	9 (6.4)
Other	-	2 (2.7)	3 (6.1)	1 (33.3)	-	6 (4.3)

Table 5.. Aftermath of workplace violence incidents reported by healthcare workers in primary care settings in Muscat, Oman (n = 140).

Characteristic	Type of WPV, n (%)					Total
	Physical abuse (n = 6)	Verbal abuse (n = 74)	Bullying/mobbing (n = 49)	Sexual harassment (n = 3)	Racial harassment (n = 8)
Action taken to investigate incident
Yes	2 (33.3)	14 (18.9)	4 (8.2)	2 (66.7)	3 (37.5)	25 (17.9)
No	2 (33.3)	55 (74.3)	31 (63.3)	1 (33.3)	3 (37.5)	92 (65.7)
Unsure	2 (33.3)	5 (6.8)	14 (28.6)	-	2 (25.0)	23 (16.4)
Party responsible for investigation
Health facility administration	2 (33.3)	16	6	-	3 (37.5)	27 (19.3)
Police	-	1	-	-	-	1 (0.7)
Community group	2 (33.3)	-	-	-	-	2 (1.4)
None	2 (33.3)	46	26	-	-	74 (52.9)
Other	-	11	17	3 (100)	5 (62.5)	36 (25.7)
Consequences for perpetrator
None	6 (100)	45 (60.8)	37 (75.5)	2 (66.7)	5 (62.5)	95 (67.9)
Verbal warning	-	9 (12.1)	2 (4.1)	-	3 (27.5)	13 (9.3)
Care discontinued	-	1 (1.4)	-	-	-	1 (0.7)
Prosecution	-	1 (1.4)	-	-	-	1 (0.7)
Unsure	-	14 (18.9)	6 (12.2)	-	-	20 (14.3)
Other	-	4 (5.4)	4 (8.2)	1 (33.3)	-	10 (7.1)
Support offered by employer/supervisor *
Opportunity to speak	6 (100)	36 (48.6)	14 (28.6)	2 (66.7)	3 (37.5)	61 (43.6)
Other	4 (66.7)	15 (20.3)	11 (22.4)	-	2 (25)	32 (22.9)
Victim's reasons for not reporting incident *
Perceived incident as unimportant	-	15 (20.3)	12 (24.5)	-	4 (50)	31 (22.1)
Shame	-	3 (4.1)	6 (12.2)	-	1 (12.5)	10 (7.1)
Guilt/self-blame	-	3 (4.1)	-	-	1 (12.5)	4 (2.9)
Fear of repercussions	2 (33.3)	4 (5.4)	11 (22.4)	-	4 (50.0)	21 (15.0)
Belief that no action would be taken	2 (33.3)	35 (47.3)	23 (46.9)	2 (66.7)	2 (25.0)	64 (45.7)
Lack of knowledge of reporting procedures/     appropriate contact person	2 (33.3)	11 (14.9)	7 (14.3)	2 (66.7)	-	22 (15.7)
Other	-	17 (23.0)	7 (14.3)	1 (33.3)	-	25 (17.9)
Satisfaction with handling of incident
Satisfied	0	5(6.8)	2 (4.0)	2 (66.7)	2 (25.0)	11 (7.9)
Dissatisfied	6 (100)	49 (66.2)	33 (67.4)	1 (33.3)	5 (62.5)	94 (67.1)
Neutral	0	20(27)	14 (28.6)	0	1 (12.5)	35 (25.0)

Table 6.. Associations between selected variables and type of workplace violence experienced.

Variable	χ 2	P value	Key association summary
Perpetrator of incident	28.03	<0.001*	Patients mainly in verbal/physical violence; staff more in bullying and racial harassment
Victim's response to incident	10.13	0.038*	Verbal abuse is more likely to lead to confrontation; bullying is more likely to lead to no action
Perceived preventability of incident (yes)	16.18	0.003*	Victims of verbal and bullying incidents more often felt the violence was preventable
Victim's reasons for not reporting incident (belief that no action would be taken)	11.01	0.026*	Belief that no action would be taken was more reported among bullying victims
Consequences for perpetrator	3.41	0.491	No significant association
Reported psychological impact	3.65	0.160	No significant association

Full text

1. Introduction

Workplace violence (WPV) is a global concern affecting diverse professional settings, with healthcare among the most impacted sectors.^12^ According to a joint programme between the International Labour Office (ILO), International Council of Nurses (ICN) and World Health Organization (WHO), WPV is defined as “incidents where staff are abused, threatened, or assaulted in circumstances related to their work,” encompassing physical, verbal, sexual and psychological abuse as well as harassment.^3^ Alarmingly, up to 62% of healthcare workers (HCWs) worldwide are estimated to have experienced some form of violence at work.^4^

Primary HCWs, particularly physicians, nurses and support staff, are frequently on the frontline of patient interactions, making them especially vulnerable to aggression.^5^ Numerous international studies have documented the scope of WPV in healthcare. In the United States, HCWs at 6 hospitals reported a 12-month prevalence of 39% for patient- or visitor-perpetrated violence, including 1,180 physical assaults, 2,260 threats and 5,576 incidents of verbal abuse, with direct care providers at especially high risk.^6^ In Europe, a Slovenian study identified patients and physicians as the primary perpetrators of verbal violence against nurses, while nurse leaders were reported as frequent sources of leadership-related aggression.^7^ Similarly, a cross-sectional survey in China revealed that 7.8% of hospital nurses experienced physical violence, 68.9% verbal abuse, 35.5% threats and 12.8% sexual harassment.^8^

In the Arabian Gulf, a large, multinational study found that 20.9% of HCWs in emergency departments across Saudi Arabia and the United Arab Emirates had experienced physical attacks, of which 32.3% involved weapons, while 75.6% reported verbal abuse or bullying.^9^ Patients and their relatives were the primary aggressors in 89% of incidents.^9^ Key factors contributing to WPV in primary care, as identified in a study from Saudi Arabia, include the lack of penalties for offenders, overcrowding, communication barriers, long waiting times, inadequate staff training and unmet service expectations.^10^

In Oman, the Ministry of Health issued a national policy in 2020 to address WPV in healthcare settings and promote a safe and respectful work environment. However, existing evidence on WPV in Oman is primarily hospital-based.^1112^ For example, one study in four governmental hospitals in Al-Sharqiyah and Al-Dakhiliyah Governorates (two major regional divisions in Oman) revealed that 87.4% of emergency department nurses had experienced at least one form of WPV in the preceding 12 months, predominantly non-physical in nature and most commonly occurring during weekends and night shifts.^11^ Another study found that 90.6% of nurses in two psychiatric hospitals had been exposed to WPV, with incidents especially prevalent among inpatient staff.^12^ However, there remains a lack of comprehensive data on the types, frequency, risk factors and reporting behaviours associated with WPV in primary care settings in Oman. No national study to date has comprehensively assessed WPV among primary health care, the first point of patient contact for the majority of the population.

Violence in the workplace has been strongly linked to diminished job satisfaction, emotional exhaustion, psychological distress, burnout and increased staff turnover among HCWs.^131415^ Recognising the scope and characteristics of WPV is therefore essential for developing preventive policies, improving working conditions and protecting the mental and physical well-being of healthcare providers. Accordingly, this study aimed to determine the prevalence, characteristics and associated factors of WPV among primary care HCWs in Muscat, Oman. The findings will hopefully inform evidence-based recommendations for institutional and policy-level interventions.

2. Methods

This cross-sectional study was conducted between November and December 2024 at primary care institutions in Muscat Governorate, Oman. The target population comprised various categories of HCWs who had been working in their current patient care roles for at least 6 continuous months across all primary healthcare centres in Muscat Governorate. This encompassed physicians, nurses, community nurses, pharmacists, laboratory technicians, radiographers, dieticians, health educators, medical records technicians and medical orderlies. Non-clinical administrative personnel, as well as HCWs who are not actively working during the study period, were excluded.

Data were collected using the Workplace Violence in the Health Sector Country Case Study – Questionnaire, a standardised and validated tool developed by the ILO, ICN, WHO and PSI;^16^ these had previously been used in Oman and other countries with a similar cultural context, such as Saudi Arabia.^111217^ The questionnaire contained 32 items divided into four sections: (1) sociodemographic variables; (2) frequency and type of WPV incidents experienced; (3) participants' responses to violence; and (4) health sector polices and WPV measures. The types of abuse have been classified into the following categories, each accompanied by clear definitions to assist participants in understanding them and ensure clarity for participants: 1 - Physical Violence: use of physical force, such as hitting, kicking, pushing, biting or other actions that may cause physical harm. 2 - Verbal Abuse: behaviours that humiliate, insult or degrade an individual, including shouting, disrespectful language or threats. 3 - Bullying/Mobbing: repeated, persistent and harmful behaviours intended to humiliate, undermine or intimidate a worker over time. 4 - Sexual Harassment: any unwanted and unwelcome sexual behaviours, whether verbal, non-verbal or physical, that cause humiliation, intimidation or offence. 5 - Racial Harassment: unwanted conduct based on race, ethnicity, language, colour, national origin or religion that violates a person's dignity or creates a hostile work environment. The questionnaire was distributed online via the institutional e-mail, with a link sent to the entire target population. An electronic reminder was sent after 1 month.

Collected data were analysed using the Statistical Package for Social Sciences (SPSS), Version 22.0 (IBM Corp., Armonk, New York, USA). The level of statistical significance was set at P ≤0.05. A multivariate logistic regression model using a forward (Wald) model was performed to identify factors associated with the type of WPV experienced, including perpetrator characteristics, participant responses, reporting behaviour and perceptions of preventability.

3. Results

A total of 218 participants completed the questionnaire (response rate = 74.7%). The majority were female (92.7%), married (85.5%) and Omani nationals (83.5%). Most participants were aged 31–40 years (51.4%) and primarily represented nurses, physicians and medical orderlies. Over 60% had more than 15 years of experience. All participants were engaged in shift-based work [Table 1].

Mild to moderate concerns about WPV were reported by most respondents (56%). Just over half of the participants knew how to report WPV (55.5%) and noted institutional encouragement (53.2%). Only 16.5% received reporting training, while 18.8% were unsure about its availability [Table 2].

The overall prevalence of WPV was 64.2% (95% CI: 57.8–70.6%). Verbal abuse was the most common, followed by bullying/mobbing. Physical abuse, racial harassment and sexual harassment were less frequently reported [Table 3].

Nurses constituted the largest proportion of victims. Notably, all sexual harassment cases were reported by medical orderlies and all 6 reported physical abuse incidents were evenly distributed across physicians, pharmacists and medical orderlies. Most incidents occurred inside health facilities during morning shifts on weekdays. Patients/clients were the most frequent perpetrators, especially in cases of verbal and physical abuse, while staff were more often responsible for bullying and racial harassment. In all the sexual harassment cases, the perpetrator was not specified; 85.7% of participants believed the incident could have been prevented. Common responses included inaction, confronting the perpetrator or reporting to a supervisor, while incident form submission and counselling were rare (10% and 6.4%, respectively) [Table 4].

Although institutional encouragement to report was perceived, 65.7% of incidents were not investigated. When action was taken, health administration was most often involved. Non-reporting was commonly attributed to lack of faith in the system, or perceptions of the incident being trivial; 2 out of 3 victims of sexual harassment were unsure about the appropriate channels for reporting their experiences. Most perpetrators faced no consequences and 67.1% of victims were dissatisfied with how the incident was handled [Table 5].

Psychological effects varied by WPV type. Hypervigilance and difficulty performing tasks were most common in verbal abuse victims, while emotional exhaustion and avoidant behaviours were frequent in bullying cases. All sexual harassment victims reported moderate to severe symptoms. Over half of all WPV-exposed staff experienced psychological distress.

Significant associations were observed between the type of WPV and several variables. A highly significant relationship was found with the perpetrator of the incident (P <0.001), with patients more commonly involved in verbal and physical violence, while staff members were more frequently reported in bullying and racial harassment cases. The perceived preventability of the incident also varied significantly by violence type (P = 0.003), with verbal abuse and bullying more often viewed as preventable. Additionally, victim responses differed significantly (P = 0.038); verbal abuse more often led to confrontation, while bullying was more likely to result in no action taken. A significant association was also found between reasons for not reporting and type of violence (P = 0.026), where the belief that no action would be taken was more common among bullying victims. In contrast, there were no significant associations between the type of violence and perpetrator consequences and reported psychological impact [Table 6]. Although gender-based differences in WPV could be of interest, the relatively low proportion of male participants in this study (7.3 %) did not permit a meaningful stratified analysis.

Respondents identified a range of measures implemented in their facilities to prevent or address WPV. Security-related features, such as guards and alarm systems, were the most commonly reported (38.5%). Workplace environment improvements, including adequate lighting and cleanliness, were noted by 27.1% of participants. An equal proportion (27.1%) indicated that no preventive measures were in place. Less frequently mentioned strategies included patient screening (10.1%), increased staffing (9.6%) and training programmes (8.3%).

Participants also assessed the perceived effectiveness of different strategies. Closed-circuit television (CCTV) cameras were rated as effective by 88.1%, followed by training (87.2%) and security presence (83%). Additionally, reducing instances of working alone (72.9%) and implementing check-in procedures (71.6%) were seen as beneficial. However, despite these high ratings, such measures were reported to be available in only a limited number of primary care facilities.

4. Discussion

This study aimed to determine the prevalence, characteristics and associated factors of WPV against HCWs in primary healthcare settings, which are often underrepresented in the literature that typically focuses on hospital-based care. The findings revealed that 64.2% of HCWs in primary care centres in Muscat had experienced at least one form of WPV, highlighting the widespread nature of the issue even outside hospital environments. This result aligns with international studies that report WPV rates ranging from 45.6–90%, depending on the setting and methodology used.^5^ A recent systematic review and meta-analysis found an overall prevalence of 61.9%, with verbal abuse being the most common form of WPV, followed by threats, physical violence and sexual harassment.^17^ The present study similarly identified verbal abuse and bullying/mobbing as the most prevalent types of WPV. While physical abuse is more frequently reported in emergency and hospital settings—often linked to the stress experienced by patients and their families during acute illnesses.^518^ Sexual harassment is less common, with reported rates ranging from 2–17%, which is consistent with the present study's findings.^519^

Although all HCWs are vulnerable to WPV, nurses are consistently identified as the most frequent targets, followed by physicians.^2021^ This is largely due to their direct and prolonged contact with patients and families. Indeed, in the present study, patients accounted for the majority of perpetrators (52.9%), which is in line with earlier research showing that patients and their relatives were the main aggressors.^510^ By comparison, WPV perpetrated by patients' relatives was much less frequent in the present study (5%). Generally, patients and relatives are the main perpetrators of physical and verbal abuse, whereas bullying or mobbing is more commonly attributed to management and colleagues;^22^ these findings are consistent with the present study.

Regarding responses to WPV, a substantial proportion of victims in the present study, took no action, while fewer reported incidents to supervisors. A study from Saudi Arabia reported similar inaction, with nearly half of HCWs (48.0%) choosing not to respond, although reporting was somewhat higher at 38.2% than the present study.^20^ Under-reporting of WPV is a persistent challenge, primarily linked to perceptions that workplace policies for managing violence are ineffective.^523^ Findings from the present study reinforce this, as the most common reason for not reporting was the belief that it would be “useless, as no action will be taken.”

Other factors contributing to under-reporting include fear, stigma and lack of awareness of reporting procedures.^24^ In this study, over half of the participants were aware of how to report WPV incidents, compared to significantly higher levels among staff in a psychiatric hospital in Oman.^12^ This discrepancy may reflect a greater perceived risk of violence in psychiatric settings compared to other specialities. Research from the USA has also shown that many violent incidents in hospitals often go unreported, even when staff feel supported by management.^6^ This suggests that encouragement alone, without visible follow-up and accountability, may not lead to meaningful changes in reporting behaviours.

Training similarly plays an important role. In the present study, only a small fraction of participants reported receiving training related to WPV. This finding aligns with the findings of Liu et al., who noted that HCWs often lack formal training on how to report WPV.^17^ Institutional policies without adequate protection measures, education or guidance typically fail to improve reporting behaviours, whereas administrative support, structured training and clear reporting systems have been shown to increase reporting rates.^2526^ ‘Blame culture’ has also been identified as a barrier to reporting.^27^ While respondents in this study did not outright describe a ‘blame culture’, just over half felt encouraged by their administration to report WPV incidents, highlighting that even with policy support, gaps in implementation and staff empowerment persist.

The effects of WPV extend beyond the immediate incident and can have lasting psychological consequences. In the present study, participants reported several psychological impacts, including distressing memories, avoidance, hypervigilance, emotional exhaustion and difficulty performing simple tasks. Notably, the severity of impact varied by type of violence, with sexual harassment showing the greatest effect.

These findings are especially relevant to primary healthcare, where there is often a lack of institutional security and mental health support compared to hospitals. In a system where under-reporting is common and follow-up actions are limited, as this study revealed, the psychological impacts can intensify, leading to feelings of helplessness. Furthermore, 67.1% of victims expressed dissatisfaction with how their incidents were handled, which worsened their emotional distress. Without adequate institutional support, traumatic events can result in chronic psychological strain, negatively affecting job satisfaction and performance. Previous research has also indicated that over half of victims' report experiencing psychological harm and reduced job performance.^2028^ This underscores the need for structured psychological support services, access to confidential counselling and tailored follow-up procedures specifically for primary care settings.

Consequences for the perpetrators of WPV are typically limited. Most studies focus on victims, while disciplinary or legal outcomes for aggressors are rare. In one observational study, although legal aid was provided in all reported cases, 37.1% were not prosecuted, 55.5% remained under prolonged investigation and only a small fraction of cases led to a judicial fine.^23^ In the present study, the majority of reported WPV incidents were not investigated, likely attributable to under-reporting and perceptions of futility.^523^ Moreover, two-thirds of victims expressed dissatisfaction with how the incidents were handled. Similar findings have been reported elsewhere, with dissatisfaction and under-reporting often linked to negative perceptions of existing policies.^51823^

In addition to institutional policies, Oman's Penal Law (2018) explicitly criminalises violence against public employees, including HCWs in the workplace.^29^ However, awareness and utilisation of such legal protections among HCWs appear limited. Factors such as lack of legal literacy, fear of retaliation and cultural reluctance to escalate incidents legally may act as barriers. These gaps highlight the need for greater awareness and training among staff to help HCWs understand and access their legal rights.

Although WPV in primary healthcare remains a significant and complex issue, it is preventable, as acknowledged by most participants in this research. While not every incident can be avoided, comprehensive prevention strategies can reduce both the frequency and severity of violent events. Prior studies highlight several domains of prevention, including institutional safety protocols, staff training and reporting, and support systems.^5^ In addition, strong, clear policies and visible management support are prerequisites for successful WPV prevention programmes. A combination of these factors tends to be more effective than implementing isolated measures, which corresponds with the views expressed by participants in this study.

The relatively low reporting rates and underutilisation of preventive strategies found in this study may be attributed, in part, to cultural and systemic factors specific to Oman. For instance, the conservative culture and societal norms that discourage confrontation and prioritise social harmony play a significant role. This is particularly relevant for female HCWs, who may experience shame or fear of stigma when reporting abuse. Furthermore, hierarchical structures within the healthcare system may discourage junior staff from reporting incidents involving their superiors. These cultural and systemic factors may account for some of the differences observed compared to other countries and underscore the importance of developing culturally sensitive reporting systems. Further research is essential to thoroughly investigate these factors.

This study was subject to some limitations. It relied on self-administered questionnaires, which may have introduced recall and social desirability biases, particularly in relation to sensitive issues such as sexual harassment or violence perpetrated by colleagues or supervisors. The cross-sectional design also limits the ability to draw temporal or causal inferences. Additionally, the study was conducted solely within primary care centres in Muscat Governorate, limiting the generalisability of the findings to other regions or healthcare settings in Oman. Response bias or under-representation of certain staff categories (e.g., administrative or support staff) may have influenced the findings. Moreover, self-report surveys may not fully capture the depth and complexity of WPV experiences. Future qualitative research is recommended to explore the emotional, cultural and systemic dimensions of WPV in more detail.

5. Conclusion

This study highlights the considerable burden of WPV experienced by HCWs in primary care settings in Muscat. Verbal abuse and bullying/mobbing emerged as the most common forms, with patients identified as the main perpetrators. Despite the presence of institutional policies, many HCWs were unaware of reporting mechanisms and had not received formal training, which contributed to low reporting rates. Most incidents went uninvestigated and few resulted in consequences for perpetrators. To effectively address WPV in primary healthcare settings, a coordinated strategy is needed across multiple levels. At the national level, policymakers and the Ministry of Health should develop and enforce standardised guidelines for preventing WPV, establish culturally sensitive reporting systems and ensure accountability. Within healthcare institutions, strengthening physical safety measures such as CCTV cameras and alarm systems, along with visible administrative support, is essential. Administrators should prioritise regular staff training, provide accessible psychological support and foster a culture that encourages reporting without fear of retaliation. At the individual level, empowering HCW through education and clear reporting pathways can enhance awareness and responsiveness to WPV incidents, ultimately contributing to a safer and more supportive workplace environment.

Authors' Contribution

Manar Al Sanaa Ali Al Zeedi: Supervision, Conceptualization, Methodology, Writing- Original draft preparation, Writing - Review & Editing. Bishara Hamed Al Maamari: Methodology, Resources, Writing - Original draft preparation. Khadija Saleh Al Ghammari: Conceptualization, Methodology, Writing - Original draft preparation. Aisha Rashid AlMufarrji: Conceptualization, Writing - Original draft preparation. Nahid Saif Al Hasni: Conceptualization, Writing - Original draft preparation. Rahma Yaqoob Al Shuhaimi: Conceptualization, Methodology, Writing - Original draft preparation.

Acknowledgement

We would like to thank Zeena Ali Al Mahrooqi and Mrs. Kamla Al Balushi for their contributions to the research idea and data collection. Additionally, we would like to acknowledge Mr. Sathiya Murthi P for his involvement in the data analysis.

Ethics Statement

Ethical clearance for this study was obtained from the regional research and ethical committee of the Directorate General of Health Services, Ministry of Health, Muscat, Oman (Ref: MH/DGHS/DPT/180/2024 issued on 14th Sept 2024). Participant consent was obtained via a consent statement at the beginning of the online self-administered questionnaire. To ensure anonymity and confidentiality, no identifying information was collected from participants and all responses were kept strictly confidential and analysed in aggregate form only.

Generative AI Declaration

This manuscript was revised using Grammarly's AI tool and OpenAI's ChatGPT (GPT-4) for improved grammar and clarity. These tools assisted solely with language editing, while all scientific content, data analysis, interpretations and conclusions were developed by the authors.

Conflict of Interest

The authors declare no conflicts of interest.

Funding

No funding was received for this study.

Data Availability

Data are available upon reasonable request from the corresponding author.