Gender Disparities in Workplace Violence Among Italian Healthcare Workers: A Cross-Sectional Study
Main Article Content
Keywords
Workplace violence, gender disparities, transgender & gender expansive, healthcare workers, workplace safety
Abstract
Background: Workplace violence (WPV) is a prevalent issue globally among Healthcare Workers (HCWs). Moreover, WPV may disproportionately impact marginalized groups within the healthcare workforce, such as women and gender minorities. This study aims to examine the prevalence of WPV experienced by HCWs through a gender-focused lens and to investigate factors influencing the risk of WPV. Methods: A cross-sectional observational study was conducted over a month in Apulia, Italy, involving employees from major healthcare institutions, including hospitals, Local Health Authorities, selected correctional facilities, and Residences for Execution of Security Measures. The study used the Italian-validated WHO Workplace Violence in the Health Sector questionnaire, modified to include 'Other' in the gender definition. Results: 3,259 HCWs participated, representing 88.8% of the 3,670 invited participants. The prevalence of violence incidents within the last 12 months was 29.6% in the HAW group and 57.1% in the CRW group. Within the HAW group, transgender and gender expansive (TGE) workers exhibited a higher prevalence of verbal, physical, and sexual harassment. Logistic regression analysis identified gender, job type, night shifts, interactions with specific patients, and the type of medical settings as significant predictors of experiencing various kinds of violence. Conclusions: The study underscores the vulnerability of TGE and female HCWs to workplace violence. These findings underscore the imperative for comprehensive yet gender-sensitive interventions promoting safety, equity, and inclusion in the healthcare workplace.
References
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13. Eliason MJ, Dibble SL, Robertson PA. Lesbian, gay, bisexual, and transgender (LGBT) physicians' experiences in the workplace. J Homosex. 2011; 58(10):1355-71. Doi: https://doi.org/10.1080/00918369.2011.614902
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15. Stufano A, Buonvino N, Cagnazzo F, et al. Efficacy of the Measures Adopted to Prevent COVID-19 Outbreaks in an Italian Correctional Facility for Inmates Affected by Chronic Diseases. Front Public Health. 2021;9:694795. Doi: https://doi.org/10.3389/fpubh.2021.694795
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18. Liu J, Gan Y, Jiang H, et al. Prevalence of workplace violence against healthcare workers: a systematic review and meta-analysis. Occup Environ Med. 2019;76(12):927-937. Doi: https://doi.org/10.1136/oemed-2019-105849
19. Civilotti C, Berlanda S, Iozzino L. Hospital-based healthcare workers victims of workplace violence in Italy: a scoping review. Int J Environ Res Public Health. 2021;18(11):5860. Doi: HTTPS://DOI.ORG/10.3390/ijerph18115860
20. Acquadro Maran D, Cortese CG, Pavanelli P, Fornero G, Gianino MM. Gender differences in reporting workplace violence: a qualitative analysis of administrative records of violent episodes experienced by healthcare workers in a large public Italian hospital. BMJ Open. 2019;9(11):e031546. Doi: https://doi.org/10.1136/bmjopen-2019-031546
21. Magnavita N, Heponiemi T. Violence towards health care workers in a Public Health Care Facility in Italy: a re-peated cross-sectional study. BMC health services research. 2012;12:1-9. Doi: https://doi.org/10.1186/1472-6963-12-108
22. Ferrinho P, Patrício SR, Craveiro I, Sidat M. Is workplace violence against health care workers in Mozambique gender related? Int J Health Plann Manage. 2023;38(1):265-269. Doi: https://doi.org/10.1002/hpm.3603
23. Dassisti L, Stufano A, Lovreglio P, Vimercati L, Loconsole P, Grattagliano I. Women and men, authors and victims of workplace bullying in Italy: a literature review. Med Lav. 2020;111(6):463-477. Doi: https://doi.org/10.23749/mdl.v111i6.9408
24. Vieira-Meyer APGF, Ferreira RGLA, Albuquerque GA, et al. Gender and Violence in the Daily Routine of Commu-nity Health Workers in Fortaleza, Brazil. J Community Health. 2023; 48(5):810-818. Doi: https://doi.org/10.1007/s10900-023-01221-9
25. Lorber J. 1994. Paradoxes of Gender. New Haven, CT: Yale University Press. https://xyonline.net/sites/xyonline.net/files/2019-08/Lorber%2C%20Paradoxes%20of%20Gender%20%281994%29.pdf (Last Accessed January 14, 2025).
26. Dray KK, Smith VRE, Kostecki TP, Sabat IE, Thomson CR. Moving beyond the gender binary: Examining work-place perceptions of nonbinary and transgender employees. Gender Work Organ. 2020;27(6):1181–1191. Doi: https://doi.org/10.1111/gwao.12455
27. Chang TC, Rafael A, Candelario C, et al. LGBTQ+ Identity and Ophthalmologist Burnout. Am J Ophthalmol. 2023;246:66-85. Doi: HTTPS://DOI.ORG/10.1016/j.ajo.2022.10.002
28. Davidson S, Halsall J. Gender inequality: Nonbinary transgender people in the workplace. Cogent Social Sciences. 2016;2:1236511. Doi: https://doi.org/10.1080/23311886.2016.1236511
29. Nadal KL, Skolnik A, Wong Y. Interpersonal and systemic microaggressions toward transgender people: Implica-tions for counseling. Journal of LGBT Issues in Counseling. 2012;6(1):55-82. Doi: https://doi.org/10.1080/15538605.2012.648583
30. Huffman AH, Mills MJ, Howes SS, Albritton MD. Workplace support and affirming behaviors: Moving toward a transgender, gender diverse, and non-binary friendly workplace. International Journal of Transgender Health. 2021;22(3):225–242. Doi: https://doi.org/10.1080/26895269.2020.1861575
31. Parodi JB, Burgos LM, Garcia-Zamora S, et al. Gender differences in workplace violence against physicians and nurses in Latin America: a survey from the Interamerican Society of Cardiology. Public Health. 2023; 225:127-132. Doi: https://doi.org/10.1016/j.puhe.2023.09.030
32. George AS, McConville FE, de Vries S, Nigenda G, Sarfraz S, McIsaac M. Violence against female health workers is tip of iceberg of gender power imbalances. BMJ. 2020; 371:m3546. Doi: https://doi.org/10.1136/bmj.m3546
33. Sun L, Zhang W, Qi F, Wang Y. Gender Differences for the Prevalence and Risk Factors of Workplace Violence Among Healthcare Professionals in Shandong, China. Front Public Health. 2022;10:873936. Doi: https://doi.org/10.3389/fpubh.2022.873936
34. Derscheid DJ, Arnetz JE. Patient and Family Member Violent Situations in a Pediatric Hospital: A Descriptive Study. J Pediatr Nurs. 2020;55: 241-249. Doi: https://doi.org/10.1016/j.pedn.2020.07.014
35. Yu R, Topiwala A, Jacoby R, Fazel S. Aggressive Behaviors in Alzheimer Disease and Mild Cognitive Impairment: Systematic Review and Meta-Analysis. Am J Geriatr Psychiatry. 2019;27(3):290-300. Doi: https://doi.org/10.1016/j.jagp.2018.10.008
36. Recio-Saucedo A, Dall'Ora C, Maruotti A, et al. What impact does nursing care left undone have on patient out-comes? Review of the literature. J Clin Nurs. 2018;27(11-12):2248-2259. Doi: https://doi.org/10.1111/jocn.14058
37. Girasek H, Nagy VA, Fekete S, Ungvari GS, Gazdag G. Prevalence and correlates of aggressive behavior in psychi-atric inpatient populations. World J Psychiatry. 2022; 12(1): 1-23. HTTPS://DOI.ORG/10.5498/wjp.v12.i1.1
38. Magnavita N, Larese Filon F, Giorgi G, Meraglia I, Chirico F. Assessing Workplace Violence: Methodological Consi-derations. Med Lav. 2024;115(1):e2024003. Doi: https://doi.org/10.23749/mdl.v115i1.15186
39. Cashmore AW, Indig D, Hampton SE, Hegney DG, Jalaludin B. Workplace abuse among correctional health pro-fessionals in New South Wales, Australia. Aust Health Rev. 2012;36(2):184-90. Doi: https://doi.org/10.1071/AH11043
40. Malonda-Vidal E, Samper-García P, Llorca-Mestre A, Muñoz-Navarro R, Mestre-Escrivá V. Traditional Masculinity and Aggression in Adolescence: Its Relationship with Emotional Processes. Int J Environ Res Public Health. 2021; 18(18): 9802. Doi: https://doi.org/10.3390/ijerph18189802
41. Scott-Storey K, O'Donnell S, Ford-Gilboe M, et al. What About the Men? A Critical Review of Men's Experiences of Intimate Partner Violence. Trauma Violence Abuse. 2023;24(2):858-872. Doi: https://doi.org/10.1177/15248380211043827
42. Sacco A. Physical violence against healthcare workers employed at a local health unit in the Lazio Region, Italy: A cross-sectional study. G Ital Psicol Med Lav. 2022;2:50-56. Doi: https://doi.org/10.69088/2022/LFNM5
43. Di Prinzio RR, Bondanini G, De Falco F, et al. The Management of Workplace Violence against Healthcare Work-ers: A Multidisciplinary Team for Total Worker Health® Approach in a Hospital. Int J Environ Res Public Health. 2022;20(1):196. Doi: https://doi.org/10.3390/ijerph20010196
44. Viottini E, Politano G, Fornero G, et al. Determinants of aggression against all health care workers in a large-sized university hospital. BMC Health Serv Res. 2020;20:215. Doi: https://doi.org/10.1186/s12913-020-05084-x
45. Veronesi G, Ferrario MM, Giusti EM, et al. Systematic Violence Monitoring to Reduce Underreporting and to Better Inform Workplace Violence Prevention Among Health Care Workers: Before-and-After Prospective Study. JMIR Public Health Surveill. 2023;9:e47377. Doi: https://doi.org/10.2196/47377
46. Magnavita N, Meraglia I, Viti G, Gasbarri M. Measuring the Risk of Violence Through Health Surveillance. Int J Environ Res Public Health. 2024;21(12):1708. Doi: https://doi.org/10.3390/ijerph21121708
47. Magnavita N, Meraglia I, Viti G, Gasbarri M. Tracking Workplace Violence over 20 Years. Int J Environ Res Public Health. 2024;21(11):1438. Doi: https://doi.org/10.3390/ijerph21111438
48. Ferri P, Stifani S, Accoto A, Bonetti L, Rubbi I, Di Lorenzo R. Violence Against Nurses in the Triage Area: A Mixed-Methods Study. J Emerg Nurs. 2020;46:384-397. Doi: https://doi.org/10.1016/j.jen.2020.02.013
49. Zaboli A, Sibilio S, Magnarelli G, Mian M, Brigo F, Turcato G. Nurses in the eye of the storm: A study of violence against healthcare personnel working in the emergency department. Emerg Med J. 2024;41:501-502. Doi: https://doi.org/10.1136/emermed-2023-213646
2. WHO. Preventing violence against health workers. Geneva: World Health Organization; 2022 https://www.who.int/activities/preventing-violence-against-health-workers (Last Accessed January 14, 2025).
3. Bhatti OA, Rauf H, Aziz N, Martins RS, Khan JA. Violence against Healthcare Workers during the COVID-19 Pan-demic: A Review of Incidents from a Lower-Middle-Income Country. Ann Glob Health. 2021;87(1):41. Doi: https://doi.org/10.5334/aogh.3203
4. Kumari A, Kaur T, Ranjan P, Chopra S, Sarkar S, Baitha U. Workplace violence against doctors: Characteristics, risk factors, and mitigation strategies. J Postgrad Med. 2020;66(3):149-154. Doi: https://doi.org/10.4103/jpgm.JPGM_96_20
5. Banga A, Mautong H, Alamoudi R, et al. Violence Study of Healthcare Workers and Systems-a global survey. BMJ Glob Health. 2023; 8(9): e013101. Doi: https://doi.org/10.1136/bmjgh-2023-013101
6. Magnavita N, Mele L, Meraglia I, et al. The Impact of Workplace Violence on Headache and Sleep Problems in Nurses. Int J Environ Res Public Health. 2022;19(20):13423. Doi: https://doi.org/10.3390/ijerph192013423
7. Lim MC, Jeffree MS, Saupin SS, Giloi N, Lukman KA. Workplace violence in healthcare settings: The risk factors, implications and collaborative preventive measures. Ann Med Surg (Lond). 2022;78:103727. Doi: https://doi.org/10.1016/j.amsu.2022.103727
8. Jagsi R, Griffith KA, Jones R, Perumalswami CR, Ubel P, Stewart A. Sexual Harassment and Discrimination Expe-riences of Academic Medical Faculty. JAMA. 2016; 315(19):2120-1. Doi: https://doi.org/10.1001/jama.2016.2188
9. Sari H, Yildiz İ, Çağla Baloğlu S, Özel M, Tekalp R. The frequency of workplace violence against healthcare work-ers and affecting factors. PLoS One. 2023;18(7):e0289363. Doi: https://doi.org/10.1371/journal.pone.0289363
10. Varghese A, Joseph J, Vijay VR, et al. Prevalence and determinants of workplace violence among nurses in the South-East Asian and Western Pacific Regions: a systematic review and meta-analysis. J Clin Nurs. 2022;31(7-8): 798-819. Doi: https://doi.org/10.1111/jocn.15987
11. Westafer LM, Freiermuth CE, Lall MD, Muder SJ, Ragone EL, Jarman AF. Experiences of Transgender and Gender Expansive Physicians. JAMA Netw Open. 2022;5(6):e2219791. Doi: https://doi.org/10.1001/jamanetworkopen.2022.19791
12. Dimant OE, Cook TE, Greene RE, Radix AE. Experiences of Transgender and Gender Nonbinary Medical Students and Physicians. Transgend Health. 2019;4(1):209-216. Doi: https://doi.org/10.1089/trgh.2019.0021
13. Eliason MJ, Dibble SL, Robertson PA. Lesbian, gay, bisexual, and transgender (LGBT) physicians' experiences in the workplace. J Homosex. 2011; 58(10):1355-71. Doi: https://doi.org/10.1080/00918369.2011.614902
14. Lyver B, Gorla J, Schulz-Quach C. et al. Identifying quality indicators to measure workplace violence in healthcare settings: a rapid review. BMC Emerg Med. 2024;24(1):29. Doi: https://doi.org/10.1186/s12873-024-00943-w
15. Stufano A, Buonvino N, Cagnazzo F, et al. Efficacy of the Measures Adopted to Prevent COVID-19 Outbreaks in an Italian Correctional Facility for Inmates Affected by Chronic Diseases. Front Public Health. 2021;9:694795. Doi: https://doi.org/10.3389/fpubh.2021.694795
16. La Torre G, Sestili C, Iavazzo E, Mannocci A. Workplace Violence in the health sector: validation of the Italian ver-sion of the WHO questionnaire. Clin Ter. 2017;168(3):e199-e202. Doi: https://doi.org/10.7417/T.2017.2006
17. International Labour Office, International Council of Nurses, World Health Organisation, Public Services Inter-national. Workplace Violence in the Health Sector Country Case Study – Questionnaire. World Health Organisa-tion; 2003. https://www.who.int/publications/m/item/workplace-violence-in-the-health-sector-country-case-study-research-instruments---survey-questionnaire (accessed January 22, 2024)
18. Liu J, Gan Y, Jiang H, et al. Prevalence of workplace violence against healthcare workers: a systematic review and meta-analysis. Occup Environ Med. 2019;76(12):927-937. Doi: https://doi.org/10.1136/oemed-2019-105849
19. Civilotti C, Berlanda S, Iozzino L. Hospital-based healthcare workers victims of workplace violence in Italy: a scoping review. Int J Environ Res Public Health. 2021;18(11):5860. Doi: HTTPS://DOI.ORG/10.3390/ijerph18115860
20. Acquadro Maran D, Cortese CG, Pavanelli P, Fornero G, Gianino MM. Gender differences in reporting workplace violence: a qualitative analysis of administrative records of violent episodes experienced by healthcare workers in a large public Italian hospital. BMJ Open. 2019;9(11):e031546. Doi: https://doi.org/10.1136/bmjopen-2019-031546
21. Magnavita N, Heponiemi T. Violence towards health care workers in a Public Health Care Facility in Italy: a re-peated cross-sectional study. BMC health services research. 2012;12:1-9. Doi: https://doi.org/10.1186/1472-6963-12-108
22. Ferrinho P, Patrício SR, Craveiro I, Sidat M. Is workplace violence against health care workers in Mozambique gender related? Int J Health Plann Manage. 2023;38(1):265-269. Doi: https://doi.org/10.1002/hpm.3603
23. Dassisti L, Stufano A, Lovreglio P, Vimercati L, Loconsole P, Grattagliano I. Women and men, authors and victims of workplace bullying in Italy: a literature review. Med Lav. 2020;111(6):463-477. Doi: https://doi.org/10.23749/mdl.v111i6.9408
24. Vieira-Meyer APGF, Ferreira RGLA, Albuquerque GA, et al. Gender and Violence in the Daily Routine of Commu-nity Health Workers in Fortaleza, Brazil. J Community Health. 2023; 48(5):810-818. Doi: https://doi.org/10.1007/s10900-023-01221-9
25. Lorber J. 1994. Paradoxes of Gender. New Haven, CT: Yale University Press. https://xyonline.net/sites/xyonline.net/files/2019-08/Lorber%2C%20Paradoxes%20of%20Gender%20%281994%29.pdf (Last Accessed January 14, 2025).
26. Dray KK, Smith VRE, Kostecki TP, Sabat IE, Thomson CR. Moving beyond the gender binary: Examining work-place perceptions of nonbinary and transgender employees. Gender Work Organ. 2020;27(6):1181–1191. Doi: https://doi.org/10.1111/gwao.12455
27. Chang TC, Rafael A, Candelario C, et al. LGBTQ+ Identity and Ophthalmologist Burnout. Am J Ophthalmol. 2023;246:66-85. Doi: HTTPS://DOI.ORG/10.1016/j.ajo.2022.10.002
28. Davidson S, Halsall J. Gender inequality: Nonbinary transgender people in the workplace. Cogent Social Sciences. 2016;2:1236511. Doi: https://doi.org/10.1080/23311886.2016.1236511
29. Nadal KL, Skolnik A, Wong Y. Interpersonal and systemic microaggressions toward transgender people: Implica-tions for counseling. Journal of LGBT Issues in Counseling. 2012;6(1):55-82. Doi: https://doi.org/10.1080/15538605.2012.648583
30. Huffman AH, Mills MJ, Howes SS, Albritton MD. Workplace support and affirming behaviors: Moving toward a transgender, gender diverse, and non-binary friendly workplace. International Journal of Transgender Health. 2021;22(3):225–242. Doi: https://doi.org/10.1080/26895269.2020.1861575
31. Parodi JB, Burgos LM, Garcia-Zamora S, et al. Gender differences in workplace violence against physicians and nurses in Latin America: a survey from the Interamerican Society of Cardiology. Public Health. 2023; 225:127-132. Doi: https://doi.org/10.1016/j.puhe.2023.09.030
32. George AS, McConville FE, de Vries S, Nigenda G, Sarfraz S, McIsaac M. Violence against female health workers is tip of iceberg of gender power imbalances. BMJ. 2020; 371:m3546. Doi: https://doi.org/10.1136/bmj.m3546
33. Sun L, Zhang W, Qi F, Wang Y. Gender Differences for the Prevalence and Risk Factors of Workplace Violence Among Healthcare Professionals in Shandong, China. Front Public Health. 2022;10:873936. Doi: https://doi.org/10.3389/fpubh.2022.873936
34. Derscheid DJ, Arnetz JE. Patient and Family Member Violent Situations in a Pediatric Hospital: A Descriptive Study. J Pediatr Nurs. 2020;55: 241-249. Doi: https://doi.org/10.1016/j.pedn.2020.07.014
35. Yu R, Topiwala A, Jacoby R, Fazel S. Aggressive Behaviors in Alzheimer Disease and Mild Cognitive Impairment: Systematic Review and Meta-Analysis. Am J Geriatr Psychiatry. 2019;27(3):290-300. Doi: https://doi.org/10.1016/j.jagp.2018.10.008
36. Recio-Saucedo A, Dall'Ora C, Maruotti A, et al. What impact does nursing care left undone have on patient out-comes? Review of the literature. J Clin Nurs. 2018;27(11-12):2248-2259. Doi: https://doi.org/10.1111/jocn.14058
37. Girasek H, Nagy VA, Fekete S, Ungvari GS, Gazdag G. Prevalence and correlates of aggressive behavior in psychi-atric inpatient populations. World J Psychiatry. 2022; 12(1): 1-23. HTTPS://DOI.ORG/10.5498/wjp.v12.i1.1
38. Magnavita N, Larese Filon F, Giorgi G, Meraglia I, Chirico F. Assessing Workplace Violence: Methodological Consi-derations. Med Lav. 2024;115(1):e2024003. Doi: https://doi.org/10.23749/mdl.v115i1.15186
39. Cashmore AW, Indig D, Hampton SE, Hegney DG, Jalaludin B. Workplace abuse among correctional health pro-fessionals in New South Wales, Australia. Aust Health Rev. 2012;36(2):184-90. Doi: https://doi.org/10.1071/AH11043
40. Malonda-Vidal E, Samper-García P, Llorca-Mestre A, Muñoz-Navarro R, Mestre-Escrivá V. Traditional Masculinity and Aggression in Adolescence: Its Relationship with Emotional Processes. Int J Environ Res Public Health. 2021; 18(18): 9802. Doi: https://doi.org/10.3390/ijerph18189802
41. Scott-Storey K, O'Donnell S, Ford-Gilboe M, et al. What About the Men? A Critical Review of Men's Experiences of Intimate Partner Violence. Trauma Violence Abuse. 2023;24(2):858-872. Doi: https://doi.org/10.1177/15248380211043827
42. Sacco A. Physical violence against healthcare workers employed at a local health unit in the Lazio Region, Italy: A cross-sectional study. G Ital Psicol Med Lav. 2022;2:50-56. Doi: https://doi.org/10.69088/2022/LFNM5
43. Di Prinzio RR, Bondanini G, De Falco F, et al. The Management of Workplace Violence against Healthcare Work-ers: A Multidisciplinary Team for Total Worker Health® Approach in a Hospital. Int J Environ Res Public Health. 2022;20(1):196. Doi: https://doi.org/10.3390/ijerph20010196
44. Viottini E, Politano G, Fornero G, et al. Determinants of aggression against all health care workers in a large-sized university hospital. BMC Health Serv Res. 2020;20:215. Doi: https://doi.org/10.1186/s12913-020-05084-x
45. Veronesi G, Ferrario MM, Giusti EM, et al. Systematic Violence Monitoring to Reduce Underreporting and to Better Inform Workplace Violence Prevention Among Health Care Workers: Before-and-After Prospective Study. JMIR Public Health Surveill. 2023;9:e47377. Doi: https://doi.org/10.2196/47377
46. Magnavita N, Meraglia I, Viti G, Gasbarri M. Measuring the Risk of Violence Through Health Surveillance. Int J Environ Res Public Health. 2024;21(12):1708. Doi: https://doi.org/10.3390/ijerph21121708
47. Magnavita N, Meraglia I, Viti G, Gasbarri M. Tracking Workplace Violence over 20 Years. Int J Environ Res Public Health. 2024;21(11):1438. Doi: https://doi.org/10.3390/ijerph21111438
48. Ferri P, Stifani S, Accoto A, Bonetti L, Rubbi I, Di Lorenzo R. Violence Against Nurses in the Triage Area: A Mixed-Methods Study. J Emerg Nurs. 2020;46:384-397. Doi: https://doi.org/10.1016/j.jen.2020.02.013
49. Zaboli A, Sibilio S, Magnarelli G, Mian M, Brigo F, Turcato G. Nurses in the eye of the storm: A study of violence against healthcare personnel working in the emergency department. Emerg Med J. 2024;41:501-502. Doi: https://doi.org/10.1136/emermed-2023-213646
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Stufano A, De Maria L, Delvecchio G, Sifanno G, Maffione G, Giannelli G, et al. Gender Disparities in Workplace Violence Among Italian Healthcare Workers: A Cross-Sectional Study. Med Lav [Internet]. 2025 Aug. 4 [cited 2025 Oct. 24];116(4):16795. Available from: https://mail.mattioli1885journals.com/index.php/lamedicinadellavoro/article/view/16795
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This work is licensed under a CC BY-NC 4.0 Creative Commons Attribution-NonCommercial 4.0 International License.
How to Cite
1.
Stufano A, De Maria L, Delvecchio G, Sifanno G, Maffione G, Giannelli G, et al. Gender Disparities in Workplace Violence Among Italian Healthcare Workers: A Cross-Sectional Study. Med Lav [Internet]. 2025 Aug. 4 [cited 2025 Oct. 24];116(4):16795. Available from: https://mail.mattioli1885journals.com/index.php/lamedicinadellavoro/article/view/16795
