Associations among the workplace violence, burnout, depressive symptoms, suicidality, and turnover intention in training physicians: a network analysis of nationwide survey

Depression and anxiety are the most common mental disorders among physicians, who have a greater risk of suicide than those in other professional occupations. Relationships among a demanding workload, workplace violence, burnout, and intention to turnover have also been reported. The current study examined the principal components and propagating patterns of mental health and working environment interactions in training physicians. A total of 1981 training physicians completed online self-report questionnaires during September–October (midpoint of the training year) 2020. Regularized partial correlations in a mixed graphical model (MGM) and joint probability distributions (directed acyclic graph; DAG) were estimated for four subtypes of workplace violence (verbal abuse/physical violence perpetrated by clients/hospital staff), three burnout subdomains (Maslach Burnout Inventory), thoughts about quitting, and nine depressive symptoms, including suicidality, comprising the DSM-5 diagnostic criteria for major depressive disorder (assessed using the Patient Health Questionnaire-9). Thoughts of death/self-harm showed directional dependencies on the joint probability distributions of psychomotor agitation/retardation, concentration difficulty, self-reproach, and sadness in the DAG. In the MGM, a partial correlation with psychomotor agitation/retardation (r = 0.196) accounted for 56.5% of the variance in thoughts of death/self-harm. Partial correlations with concentration difficulties (r = 0.294), self-reproach (r = 0.257), changes in appetite (r = 0.184), and worker-on-worker physical violence (r = 0.240) in the MGM accounted for 54.4% of the variance in psychomotor agitation/retardation. Thoughts about quitting were partially correlated with and dependent upon the joint probability distributions of emotional exhaustion (r = 0.222), fatigue (r = 0.142), anhedonia (r = 0.178), and sadness (r = 0.237). In contrast, worker-on-worker (r = 0.417) and client-on-physician (r = 0.167) verbal abuse had regularized partial correlations with directional dependencies on thoughts about quitting. Organization-level interventions aiming to reduce the worker-on-worker violence and individual-level approaches of clinical screening program and psychiatric counseling clinic are required. Follow-up studies to verify the effectiveness of these interventions for training physicians are needed.

the nine depressive symptoms comprising the DSM-5 diagnostic criteria for major depressive disorder were retained as separate nodes in the network analyses in the current study.Also, in consideration of previous studies for physicians that reported heterogeneity in associations of sex with depression 6 , burnout 5 , workplace violence 11,44 , turnover intention 45 , and suicidality 46 , we performed between-group comparisons of MGM and DAG between male and female physicians.As study hypotheses, we expected to find connections of workplace violence, burnout, thoughts about quitting, depression, and thoughts about death or self-harm with depressive symptoms such as psychomotor retardation/agitation, feelings of worthlessness, and emotional exhaustion in the MGM 47,48 .Second, we hypothesized that, in the DAG, psychomotor changes and feelings of worthlessness would be conditionally dependent on thoughts about death/self-harm 49,50 .Third, a joint probability distribution was expected among emotional exhaustion, reports of workplace violence, and thoughts about quitting.

Participants
The current study was conducted between 23 September 2020 and 14 October 2020 and used self-report questionnaires.After obtaining a license to practice as a physician from the Ministry of Health and Welfare (https:// www.mohw.go.kr/ eng/), almost all new medical doctors undertake further training at training hospitals to become medical specialists.A 1-year internship and 4-year residency in a specialty (3-year residency for internal medicine, general surgery, pediatrics, and family medicine), which typically starts in March and ends in February of the next year, are required to apply for the test to qualify as a medical specialist.September and October are in the middle of the medical training year, which starts in March, and midyear is well suited for assessing training physician mental health-working environment interactions.
This study included medical interns or residents affiliated with training hospitals in the Republic of Korea, who were members of the Korean Intern Resident Association (KIRA) as of September 2020 (N = 13,571) and were willing to voluntarily participate in our web-based survey during September-October 2020.Promotional documents were posted on the KIRA website (http:// young md.org/).After reading the promotional documents, the medical intern or resident clicked the link for the online survey.Informed consent was indicated by clicking the "Start" button on the front page of the Google survey.The survey was anonymous, and confidentiality was ensured.Study participation was on a first-come, first-served basis during the 3-week data acquisition period, and 1981 (14.6% of the total population) of medical interns and residents took part.Participants were given coffee vouchers worth 4 USD as remuneration.This study was approved by the Clinical Research Ethics Committee of Seoul National University College of Medicine and Hospital (IRB No. 2202-019-1296).All procedures followed the relevant guidelines and regulations.

Measures
The online self-report questionnaire used in this study was about four A4 pages long and took 5-10 min to complete.Demographic data (sex, training stage, and weekly work hours) and information about workplace violence (number of incidents and perpetrators of verbal abuse, physical violence, or sexual harassment), burnout [emotional exhaustion, depersonalization, and personal achievement, measured using the Maslach Burnout Inventory (MBI) 51,52 ], turnover intention, and depressive symptoms, including suicidality [sadness, anhedonia, insomnia, appetite change, fatigue, self-reproach, psychomotor changes, concentration difficulty, thoughts of self-harm or suicide, measured using the Patient Health Questionnaire-9 (PHQ-9) [53][54][55] ] were acquired.The internal consistency of the MBI data was good (Cronbach's alpha = 0.856), and that of the PHQ-9 data was excellent (Cronbach's alpha = 0.916).The Cronbach's alpha values were calculated using the cronbach.alphafunction in the R package ltm (https:// rdrr.io/ cran/ ltm/).Appropriate monitoring of participant responses was ensured during this web-based survey.
Reports of verbal abuse, physical violence, and sexual harassment in the workplace within the past 4 months were recorded in terms of the number of incidents (0, 1, 2, 3, 4, or ≥ 5 events) and the perpetrators [patient(s)/ caregiver(s), physician(s), and other hospital staff; multiple responses permitted].Burnout was measured using a version of the MBI validated for use in Korea 51,52 .We purchased the MBI license before administering the instrument via the MindGarden (http:// www.mindg arden.com) webpage.The 22 items of the MBI are scored using a 7-point Likert-type scale (0, not at all; 1, a few times per year; 2, once a month; 3, a few times per month; 4, once a week; 5, a few times per week; 6, every day).The cut-off scores for the burnout subdomains followed previous Korean studies, as follows: emotional exhaustion, ≥ 27; depersonalization, ≥ 10; and personal accomplishment, ≤ 33 56,57 .Higher scores reflect higher levels of emotional exhaustion (9 items) and depersonalization (5 items), and lower scores reflect lower levels of personal achievement (8 items, including reverse-coded ones) 58 .Thoughts about quitting medical training were measured using a single item ("During the past 4 months, have you ever thought about quitting?") that required a "yes" or "no" response.Depressive symptoms were measured using the version of the PHQ-9 validated for use in Korea [53][54][55] .Responses to the PHQ-9 items were scored on a 4-point Likert scale (0, not at all; 1, 2-6 days; 2, 7-12 days; 3, nearly every day).Total PHQ-9 scores range between 0 and 27.The cut-off for moderate depressive mood was a total PHQ-9 score ≥ 10, as reported previously for the Korean population 55,59,60 .The response to item 9 of the PHQ-9 was used to determine the presence (answer = 1-3) or absence (answer = 0) of suicidality.

Network analyses
Multiple associations among the nine depressive symptoms of major depressive disorder (including thoughts of death/self-harm) in the DSM-5 (PHQ-9), three burnout subdomains (MBI), thoughts about quitting, and four subtypes of workplace violence (physical violence/verbal abuse [client-on-physician/worker-on-worker]) during medical training were examined using MGM 28 and DAG 61 network analyses.The nodes were selected based on previous research.First, depressive symptoms 38 , including thoughts of death/self-harm 7 , are associated with an increased risk of burnout.Second, burnout is associated with increased thoughts about quitting [2][3][4] .Third, perceived workplace violence may be associated with reduced work performance, anger, burnout, depression, and thoughts about quitting 7,16,19,20,22 .In these networks, variables are nodes (M = 15 for the current study), and "edges" reflect undirected (MGM) 61 and directional (DAG) 25 joint probability distributions of conditional dependencies among nodes.
First, the MGM estimates regularized partial correlation coefficients, which represent edge weights in nodewise regression 31 , using the R-package mgm 28 .The thickness of each edge in the MGM represents the strength of the association, with thicker edges representing stronger associations 62 .Of note, aiming to remove potentially spurious associations and to ensure a more robust network structure, a penalty based on the least absolute shrinkage and selection operator (LASSO) 63 was applied to shrink the edge weights and to reduce smaller edge weights to zero.For finding the optimal MGM structure, we also utilized a pairwise model (interaction order k = 2) and the extended Bayesian information criterion (tuning parameter γ = 0) 25 .Variables that were not connected when conditioned on other variables were considered independent 64 .To identify the principal nodes reflecting trends in mental health-working environment interactions within a given MGM network 33 , a local graph metric of betweenness centrality (proportion of all short paths in the network that contain a given node) 65 was calculated.Two nodes ranked in the top 12% for betweenness centrality were defined as hubs 26,27,43 .R 2 regression values were estimated for each node to quantify how well it was predicted by other nodes with which it shared an edge 25,66,67 .These "node predictability values" are represented as pie charts 66 .The MGM network structure was visualized as a circular layout using the R-package qgraph 62 .
Second, the DAG provides a probabilistic graphical model (Bayesian network) that represents the joint probability distribution of conditional dependencies (shown by directed and noncircular edges) among the variables (or nodes).By applying the hill-climbing greedy search algorithm using the R package bnlearn 68 , the DAG added edges (connecting different variables or nodes), and then removed them/reversed their direction until the BIC goodness-of-fit cut-off was reached 42 .Whether an edge exists between two variables was determined by an iterative procedure with 10,000 bootstraps 42,69 .The average network structure was determined by retaining the dominant edges among the 10,000 bootstrapped networks, according to a statistically determined cut-off point; edges with high sensitivity and specificity were retained 42,70 .Finally, BIC values were computed for each edge, with higher values signifying greater importance within the network structure 42 .
In addition, MGM subgroup estimates were determined for males (n = 1,102; Fig. 1C) and females (n = 879; Fig. 1D) separately.Invariance between the MGM of males (n = 1,102) and MGM of females (n = 879) was tested using the permutation test (number of permutations = 10,000) and the NetworkComparisonTest (NCT) toolbox in R software 71,72 .We tested for differences in global strength, network structure invariance, and the invariance of betweenness centrality values between the networks.Additional DAGs were generated for subgroups of males (n = 1,102; Fig. 2B) and females (n = 879; Fig. 2C) separately.

Role of the funder
The funders of the study had no role in study design, data collection, data analysis, data interpretation, or writing of the report.The corresponding author had full access to all the data in the report and had final responsibility for the decision to submit for publication.

Network analyses: network structures, hub nodes, and key edges of the MGM and DAG
The MGM or regularized undirected partial correlations among the nine depressive symptoms of major depressive disorder (including thoughts of death/self-harm) in the DSM-5, three burnout subdomains, thoughts about quitting, and four subtypes of workplace violence during medical training are presented in Fig. 1A.The pie charts surrounding each node 66 in Fig. 1A depict the node predictability (R 2 ) 67 , which is the predictability of each node by nodes connected via edges in the MGM.In contrast, the DAG shown in Fig. 2A estimates the propagating patterns among the nodes based on cross-sectional data 24 .The presence of downstream component B next to the directional arrow implies the upstream (before the arrowhead in the DAG) occurrence of component A.
Sadness had the highest node predictability value, of 62.3%, in the MGM and was the most upstream component in the DAG.Self-reproach was dependent on sadness and was associated with all other depressive symptoms, except sleep disturbance and appetite changes, in the DAG.The burnout subdomain of low personal accomplishment was dependent on self-reproach.Among the three burnout subdomains, node predictability was higher for emotional exhaustion (74.7%) and depersonalization (65.1%) than personal accomplishment of depressive symptoms with burnout and workplace violence, respectively.Worker-on-worker verbal abuse and emotional exhaustion were not independent, but they were conditionally independent on thoughts about quitting in the MGM and DAG.

Network analyses: factors associated with thoughts about quitting and death/self-harm
The node predictability of thoughts about quitting was 26.7% in the MGM, based on the partial correlations with sadness (r = 0.237), anhedonia (r = 0.178), fatigue (r = 0.142), emotional exhaustion (r = 0.222), worker-on-worker verbal abuse (r = 0.417), and client-on-physician verbal abuse (r = 0.167) was 26.7% in the MGM.According to the information on directionality in the DAG, thoughts about quitting were dependent upon the joint probability distributions of emotional exhaustion, fatigue, anhedonia, and sadness.Conversely, perceived workeron-worker verbal abuse (node predictability in the MGM = 12.2%) had regularized partial correlations with, and was dependent on, the joint probability distributions of worker-on-worker physical violence (r = 2.079), thoughts about quitting (r = 0.417), and emotional exhaustion (self-reproach in MGM; r = 0.076).Client-on-physician www.nature.com/scientificreports/verbal abuse (node predictability in MGM = 17.1%) had regularized partial correlations with and directional dependence on the joint probability distributions of client-on-physician physical violence (r = 2.262), depersonalization (no association in MGM), and thoughts about quitting (r = 0.167).
A node predictability value of 56.5% was calculated for thoughts of death/self-harm in the MGM based on the partial correlation with psychomotor agitation/retardation (r = 0.196).Psychomotor agitation/retardation also had partial correlations with concentration difficulties (r = 0.294), self-reproach (r = 0.257), changes in appetite (r = 0.184), and worker-on-worker physical violence (r = 0.240; node predictability in the MGM = 7.8%).Directional dependencies of thoughts of death/self-harm on the joint probability distributions of psychomotor agitation/retardation, concentration difficulty, self-reproach, and sadness were found in the DAG.In contrast, thoughts of death/self-harm in the DAG had a directional association with fatigue (not found in the MGM).

Network analyses: network comparisons of males and females
Network characteristics were compared between the MGM of males (n = 1102; Fig. 1C) and the MGM of females (n = 879; Fig. 1D) using the NCT toolbox in R software 71,72 .The permutation test with the NCT (number of permutations = 10,000) did not detect a significant difference in global strength (i.e., the sum of all edge weights in a network 73 ; P = 0.588) between the MGM of males (global strength = 7.013) and that of females (global strength = 7.223).Additionally, the test for network structure invariance (i.e., differences or similarities between two networks in terms of the structure of node relationships 74 ; P = 0.256) and possible differences in betweenness centrality values (all Ps > 0.05; FDR-corrected) between the MGMs of males and females were not significant.
The directional conditional dependence of thoughts of death/self-harm on the joint probability distributions of sadness, self-reproach, concentration difficulties, and psychomotor agitation/retardation found in the original DAG (Fig. 2A; n = 1981) were preserved in the DAGs for the subgroups of males (Fig. 2B; n = 1102) and females (Fig. 2C; n = 879).The chains of associations from anhedonia to thoughts about quitting, and from thoughts about quitting to perceived worker-on-worker verbal abuse, seen in the original DAG of the entire population (Fig. 2A; n = 1981) were replicated in the DAGs for the subgroups of males (Fig. 2B; n = 1102) and females (Fig. 2C; n = 879).

Study summary
The current study examined the principal components and propagating patterns of mental health-workplace violence interactions in training physicians using an MGM (Fig. 1A) and DAG (Fig. 2A).For estimating the more robust MGM structure without spurious false-positive edges, a LASSO 63 -based penalty approach shrunk the edge weights (= regularized partial correlations) and reduced smaller edge weights to zero.Thoughts of death/self-harm in the MGM had a partial correlation with psychomotor agitation/retardation (r = 0.196), which accounted for 56.5% of the variance in thoughts of death/self-harm (having a node predictability value of 0.565 in the MGM).In turn, partial correlation of psychomotor agitation/retardation with concentration difficulties (r = 0.294), self-reproach (r = 0.257), changes in appetite (r = 0.184), and worker-on-worker physical violence (r = 0.240) could account for 54.4% of the variance in psychomotor agitation/retardation (with a node predictability value of 0.544 in the MGM).Thoughts of death/self-harm demonstrated directional dependencies on the joint probability distributions of psychomotor agitation/retardation, concentration difficulty, self-reproach, and sadness in the DAG.Thoughts about quitting were partially correlated with and dependent upon the joint probability distributions of emotional exhaustion (r = 0.222), fatigue (r = 0.142), anhedonia (r = 0.178), and sadness (r = 0.237).In contrast, worker-on-worker and client-on-physician verbal abuse had regularized partial correlations with directional dependencies on thoughts about quitting (r = 0.417 and 0.167, respectively).All these six edges of partial correlations could account for 26.7% of the variance in thought about quitting (with a node predictability value of 0.267 in the MGM).

Psychomotor changes underlie thoughts about death or self-harm in training physicians
Which components of depressive symptoms, workplace violence, and burnout are most strongly associated with thoughts about death/self-harm, even after regressing out the effects of other items?The answer was revealed by our MGM (Fig. 1A).The regularized partial correlation between thoughts about death/self-harm and psychomotor changes explained 56.5% of the variance in thoughts about death/self-harm.This result follows those of a previous study in which thoughts about death or self-harm and psychomotor agitation/retardation improved in response to antidepressants (sertraline and/or mirtazapine) 75 .How did the activation of item-level depressive symptoms influence thoughts about death/self-harm?Although we cannot infer causality from the crosssectional data, the presence of a sibling node after the directional arrow suggests the presence of a parent node before the directional arrow in the DAG (Fig. 2).Therefore, we presumed that sadness, feelings of worthlessness, concentration difficulties, and psychomotor changes were present in training physicians who experienced thoughts about death or self-harm.These results follow those of other studies demonstrating close associations among thoughts about death/self-harm, psychomotor agitation/retardation 76 , and feelings of worthlessness in phenotypic networks 77 .Feelings of worthlessness, psychomotor retardation, thoughts about death or self-harm, and psychotic ideation over 6 months can result in role impairment, even in cases of subthreshold depression 78 .Similarly, depressive individuals with thoughts about death/self-harm and impaired executive control and decision-making may change their behavior, for example showing increased risk-taking, poor impulse control, and psychomotor agitation 79 .Access to and knowledge of effective lethal methods of suicide 80,81 , in addition to insufficient time to access mental healthcare 82 , may be associated with the increased risk of suicide seen in physicians relative to non-physicians.Multifaceted interventions combining individual-and organizationallevel approaches are required to reduce the risk of physician suicide 1 and the multiple, interrelated problems found in cases thereof 81 .First, pharmacotherapy to reduce psychomotor agitation 83,84 and cognitive behavioral approaches to anti-suicidal therapy [85][86][87] , including modifying hopelessness and feelings of worthlessness 88,89 are required.Second, organizational interventions to improve work-related risk factors for poor physician mental health, such as work-life imbalance, excessive or conflicting job demands, longer working hours, and interpersonal conflict are important [90][91][92] .

Emotional exhaustion, anhedonia, fatigue, and worker-on-worker verbal abuse underlie thoughts about quitting
Previous studies on hospital staff, including physicians, have reported that a large number of weekly work hours 93 , monthly night shifts 93,94 , lower average monthly income 16,94 , workplace violence 16,[93][94][95][96] , burnout 93,97 , and depressive symptoms 16,94 are associated with thoughts about quitting.Notably, the current study was performed during the COVID-19 pandemic, which imposed severe stress on healthcare systems and economies worldwide, including those of the Republic of Korea.The psychological impacts of the pandemic promoted nervousness and stress in daily life, trouble relaxing, and feelings of failure, followed by trouble concentrating, loss of situational control, and fear of infecting colleagues 34 .Second, worsening mental and social health in people with lower monthly household incomes or education levels became more likely during the COVID-19 pandemic compared to the pre-pandemic era 98 .Healthcare providers in South Korea had to work in critical situations and were overwhelmed by heavy workloads, fear of infection, lifestyle changes, and psychological and physical struggles during the COVID-19 pandemic 99 .Environmental (insufficient personal protective equipment, working in a screening center, prolonged work hours) and psychosocial (fear of infection and death, social stigma, and rejection) aspects of work were associated with poor mental health in South Korean public health physicians on the frontline.In contrast, satisfactory monetary compensation and proactive coping (acceptance and willingness to volunteer on the frontline) were predictive of better mental health 100 .In the MGM of the current study (Fig. 1), the regularized partial correlations of thoughts about quitting with worker-on-worker verbal abuse, emotional exhaustion, sadness, anhedonia, and fatigue explained 26.7% of the variance in thoughts about quitting.This result follows other phenotypic network analyses demonstrating that depressive symptoms 101 , including high self-efficacy (a feeling of invulnerability) 102,103 , anxiety about violence 101,104 , burnout 105 , and perceived social 101 and organizational 93,102 support mediate the relationship between workplace violence and thoughts about quitting.
The current results demonstrate the importance of interventions [106][107][108] targeting both individual 109 and organizational 110 risk factors for thoughts about quitting.The DAG (Fig. 2) implied the presence of anhedonia, fatigue, and emotional exhaustion in training physicians who reported thoughts about quitting.To prevent and remediate emotional exhaustion and intention to quit in training physicians, an organizational approach involving clinical assessment programs targeting emotional exhaustion, sadness, anhedonia, and fatigue is required.It is also necessary to operate a psychiatric counseling clinic for training physicians and establish an administrative system that enables them to schedule visits to the outpatient clinic during the day.Our DAG (Fig. 2) also indicated that worker-on-worker verbal abuse suggests the presence of thoughts about quitting in training physicians (Fig. 2).To prevent and remediate verbal abuse (worker-on-worker and client-on-physician), organizational interventions are paramount.First, organizational policies of cultural reforms particularly in the context of reducing worker-to-worker aggression and violence are required 111 .Second, organizational allocation of sufficient physician manpower to understaffed workplace is required to prevent understaffing-related excessive job demands and workplace aggression/violence 112,113

Strengths and limitations
The current study has strengths such as relatively large sample size (N = 1981), use of comprehensive instrument battery, and complementary use of both MGM and DAG in network analyses.Also, this study has some limitations.First, it used a cross-sectional design, so causality cannot be inferred.Second, as study participation was on a first-come, first-served basis during the 3-week data acquisition period, representativeness of the study sample for total population cannot be assured.Third, the workplace violence data for the 4-month study period were based on participant recall.Prospective cohort studies may be more suitable, as they minimize recall bias.Fourth, possible protective factors against work-related stress, such as life satisfaction 26 , were not investigated.We limited the length of the survey to reduce participant burden, but could not prioritize measurement of protective factors over mental health and work environment-related factors.Additional phenotypic network analyses of work-related stress, mental health, and other protective and risk factors for thoughts about quitting are required using longitudinal follow-up data and larger sample sizes.

Conclusions
This Figure 1.(A) Mixed graphical model (MGM) of the undirected partial correlations among the frequency of item-level depressive symptoms including thoughts about death/self-harm, severity of burnout subtypes (depersonalization, emotional exhaustion, and lower personal accomplishment), thought about quitting, and workplace violence (physical violence and verbal abuse; patient/client-to-physician and worker-on-worker) in medical interns and residents (n = 1981).The "node predictability value" (variance in a given node's value explained by the nodes with which it is connected) is indicated by the shadowed parts of rings surrounding each node.(B) Betweenness centrality (the proportion of the shortest paths in the network containing a given node) was used as the centrality measure.The x-axis represents z-scores).(C) The MGM model of males (n = 1102).(D) The MGM model of female (n = 879).PHQ901: sadness; PHQ902: anhedonia; PHQ903: sleep disturbance; PHQ904: appetite disturbance; PHQ905: psychomotor agitation/retardation; PHQ906: fatigue; PHQ907: feelings of worthlessness; PHQ908: concentration difficulties; PHQ909: thoughts about death or selfharm; MBIEE: emotional exhaustion; MBIDP: depersonalization; MBIPA: low personal accomplishment; quit: thought about quitting the medical internship or residency; PV_D: worker-to-worker physical violence; PV_P: physical violence perpetrated by a patient/client; VV_D: worker-to-worker verbal abuse; VV_P: patient/clientto-physician verbal abuse.
study used an MGM and DAG to examine the principal components and propagating patterns of mental health-workplace violence interactions in training physicians.Of note, partial correlation with psychomotor agitation/retardation could account for 56.5% of the variance in thoughts of death/self-harm.Moreover, partial correlations with concentration difficulties, self-reproach, changes in appetite, and worker-on-worker physical violence could account for 54.4% of the variance in psychomotor agitation/retardation.Follow-up studies to examine the longitudinal stability of current study findings and the effectiveness of organizationaland individual-level interventions in reducing the workplace violence, thought about quitting, and suicidality of training physicians are required.Most of all, organization-level interventions of cultural reforms aiming to reduce the worker-to-worker aggression/violence, allocation of sufficient physician manpower to prevent the understaffing-related workplace aggression/violence, proactive interruption of workplace violence occurrence by running the simulation-based behavioral training and behavioral emergency response teams are required.Also, individual-level approaches of clinical screening program combined with a psychiatric counseling clinic, that allows for training physician visits during the daytime and provides pharmacotherapy and cognitive behavioral therapy, are needed.

Table 1 .
116hird, organizational-level prompt intervention of workplace violence occurrence by running of simulation-based behavioral training114and operating of Demographic, work-related, and clinical characteristics.behavioralemergencyresponseteams115areneeded. Furrmore, proactive cognitive-behavioral interventions to deal with verbal abuse, as well as preventive screening toolkits combined with one-step psychiatric consultations, are required116.