This study provides insight into the impact of WPV on workplace injuries and absenteeism among Bangladeshi HWs. Our results show that workplace injuries and absenteeism due to WPV are prevalent among HWs. In particular, males and young HWs working in emergency, surgery, gynecology & obstetrics departments in public hospitals are at high risk.

The present study found that the magnitude of injuries due to WPV varied significantly by HW’s working departments. For example, the injury incidence due to WPV was substantially higher among HWs who worked in the emergency, surgery, and gynecology & obstetrics departments compared to HWs who worked in the other departments. It’s well documented that the working department in health facilities plays a pivotal role in workplace injuries due to WPV [4,5,6]. A number of studies highlighted that the following departments are the most vulnerable for serious violence incidents (such as physical violence, and injuries) than the other departments: emergency [5, 6, 11,12,13], surgery [14], intensive care unit [15] and gynecology & obstetrics departments [32].

The study revealed that the emergency department was the most vulnerable places where the incidence of injury occurred more frequently. This result is consistent with the findings in the USA [13], Finland [23], and Australia [15], where the emergency department HWs experienced more workplace injuries compared to the HWs from other departments. The findings are also in line with a more recent Bangladeshi study that showed the percentage of physical violence at work against doctors was higher for those who worked in the emergency department [7]. The possible reason behind this study's findings could be that the emergency department is the doorway to the inpatient departments, which is why it is the first department to deal with critical patients, followed by the inpatient departments [33]. These patients often die either in an emergency room or inpatient ward despite the best efforts of the HWs. In most cases, patients’ relatives or visitors typically blame HWs for all defects, which in turn exposes them to aggression, and these lead to violent severe incidents such as injury in the workplace. There may also be a lack of health literacy among patients and their relatives. This is because they are unfamiliar with the process of sorting patients’ clinical judgements based on the severity of their health conditions. This process includes difficult decisions by HWs regarding who to provide care for immediately, who can wait, and who cannot be saved [34]. However, patients expect to be seen immediately when they arrive at an emergency department. This leads to a lack of communication is one of the key factors for violent incidents. It is always a challenge in the emergency department to manage heterogeneous patients of various ages, mentalities, and disease severity [12, 35]. Therefore, policymakers need to develop adequate patient protocols for the emergency department, where many people shout out for healthcare and do more to ensure that HWs can work without violent incidents to curb violence. The cause of violent incidents in hospital departments can be investigated in future research, especially workplace injuries in the emergency department.

This study also found that workplace injury was prevalent in the surgery department. This result is consistent with the findings in Australia [14] and India [32], where workplace injury in the surgical department was more prevalent than other forms of violence. The possible reason could be patients with dementia, the emergence of delirium after surgery, or delirium related to drug or alcohol abuse. There is an ongoing threat in the surgical department because HWs must interact with potentially harmful patients or visitors daily. It may result in violent incidents in the surgery department. While available research focuses on the other departments such as the emergency unit [5, 12, 14, 15]. Therefore, it needs to be more research on workplace injuries among HWs due to violent incidents addressing the problem in in-hospital surgical settings. It's unfortunate that workplace injuries due to WPV a tragic realities that extend beyond emergency and surgery departments to sensitive intensive care units. A study conducted in Australia reported that violent incidents were rising in intensive care units [15]. This finding is in line with our results. It could be that increased pressure to admit to the intensive care unit from the emergency department earlier could be a factor contributing to the perceived increase in violent incidents.

According to our study data, we observed a higher rate of absenteeism occurring in the emergency department due to WPV than in other departments. This result is consistent with the findings in the USA [13], China [19], Sweden [36], and Finland [23], where HWs who worked in the emergency department were injured due to WPV taking sick leave or quitting their job. This level of absenteeism is alarming in the emergency department, where severe and emergency cases are treated. Researchers urge that a lack of comprehensive policies for dealing with patients and tackling violent incidents in the emergency department is causing fear, and dissatisfaction among HWs [12, 35], making them absent more often and taking more prolonged periods off-duty due to sickness [5, 19], which has a long-lasting severe negative impact on the health system [18].

A health system’s overall performance is primarily determined by the quality, numbers, composition, and distribution of HWs, which comprise doctors, nurses, midwives and many other categories. It’s pertinent to mention here that Bangladesh still needs more HWs to achieve the recommended global median of 48.6 HWs per 10,000 population by 2030 [37]. A recent WHO report has mentioned that Bangladesh currently presents an estimated 33.17 density of recognised and 15.83 unrecognised HWs and the numbers are unequally distributed across the country’s health system [38]. With this gap, managing a considerable number of patients in the emergency department is strenuous in this growing populated country [39]. Therefore, the lack of human resources for health challenges and gaps needs to be addressed as soon as possible to reduce workplace injuries in hospitals, especially in the emergency department.

The result of this study showed that work-related absenteeism is more prevalent in the gynecology and obstetrics departments. A possible reason behind the findings of this study could be women may lack confidence when defending against violent incidents and fear working in the workplace [40]. In Bangladesh, women are more likely than men to specialise in specific fields due to gender norms, such as gynecology & obstetrics [41]. For these gender norms, the female HWs portion is high in this department, and therefore, women's chances of experiencing WPV are high [24]. Female victims have a high chance of being absent from work due to fear, insecurities and self-image in their workplace. This may lead to an increase in gender imbalance in country’s health system. Therefore, the Bangladesh government must encourage more females to engage in medical careers by raising investment in health resources and minimising public distrust between HWs and the general people. Policymakers should also establish health facilities as safe workplaces for future female health workforces to tackle the country’s shortage of HWs by introducing staff training in skills, cultural diversity, interpersonal communication, and conflict management. In line with existing international findings [14, 15], our study found that the surgery and intensive care departments experienced more workplace absenteeism. It is common for these departments to deal with a high number of critical patients, causing them to feel dissatisfied and stressed out. Hence, the HWs take a break from work and may turn to quit their jobs. In the context of Bangladesh, an in-depth study is required to examine the possible reason for occurring workplace injuries and absenteeism due to WPV in hospital departments.

Notably, the ratio of adequate HWs and patients is going under a very incompatible condition in Bangladesh [28, 38]. For instance, the country’s estimated density of 9.9 doctors, nurses and midwives per 10,000 population in 2019 [42] is far below than the minimum threshold of 44.5 HWs per 10,000 population for the attainment of SDGs outlined in the WHO Global Strategy on Human Resources for Health: Workforce 2030 [43]. In this situation, workplace injuries and absenteeism at work due to WPV will not only increase the crisis but may also cripple the quality health care services in Bangladesh [7, 27]. It is undeniable that workplace injuries and absenteeism due to WPV among HWs partly reflect the disadvantages of Bangladesh’s medical and health systems [7, 27, 28].

The policy implications of our findings are the development of effective national policies to prevent workplace injuries and absenteeism due to WPV among HWs. Our study documented significant injury incidents in the working departments, such as emergency, surgery, intensive care and gynecology and obstetrics departments in Bangladeshi hospitals. The high incidence of injuries in various hospital departments exhibits the country’s lack of ability of a health system to resolve the issue, leading to absenteeism among HWs. These highlight the need for an urgent call for policies and measures for zero tolerance of WPV against Bangladeshi HWs. Therefore, policymakers must approve a law that makes it clear that the law protects the legitimate rights of HWs and their safety must not be infringed upon. For example, we might consider a national ordinance similar to the Nepali government's historic law to protect health workforces named the “Safety and Security of Health Workers and Health Institutions Ordinance, 2022” [21]. In the alternative, we may ratify legislation identical to a Chinese law approved in 2019 that protects HWs from WPV perpetrating serious violence that disturbs medical work [44]. In addition to legislation, much still needs to be done before Bangladeshi HWs can live without WPV. The distrust between patients and HWs has social, cultural, and economic roots and is unlikely to disappear soon. Therefore, the authors stress the importance of breaking down growing communication barriers between patients and HWs by building mutual respect, raising public awareness and representation of stakeholders in the health sector [45]. Furthermore, workplace absenteeism due to injuries as result of WPV among HWs must be stopped immediately, while the country lags behind in the ratio between HWs and population, thereby hindering proper and timely healthcare services [27,28,29, 42]. If this trend persists, Bangladesh’s health system cannot afford the HWs' absenteeism as they are essential to meet UHC and SDGs target 3 by 2030 [46]. Therefore, the Bangladesh government should establish healthcare institution as a safe workplace for HWs to ensure safe and accessible health care to all and pay attention to strategic investments in the country’s health workforces. Simultaneously, in line with global strategies, policymakers should introduce a specific policy at the national level following international policy recommendations for workplace safety [47]. Finally, the authors emphasise exploring an effective and sustainable solutions for a long-term workplace violence mitigation.

This study has some strengths. First, it used a large, nationally representative dataset from eight administrative division suggesting the findings have external validity [27]. Second, it is the first study to identify the magnitude of injuries and work absenteeism due to WPV by working departments among Bangladeshi HWs. This study also has some limitations. The study did not consider the verbal bulling and harassment as a WPV and their consequences were not justified. As this is cross-sectional study, the findings are correctional only. Finally, there was a possible recall bias in self-reported workplace injuries and absenteeism.