Workplace violence against health workers is defined as any incident in which health workers are abused, intimidated, or physically attacked in relation to their work, It poses explicit or implicit threats to their safety, well-being, or health and has become a critical occupational and public-health concern worldwide^1,2. Influenced by the uneven distribution of medical resources, strained doctor–patient relationships, and social prejudice³, healthcare workers experience substantially higher risks of verbal, threatening, and physical assaults. A systematic review involving 331,544 participants showed that the overall exposure rate to workplace violence against health workers was 61.9%⁴. Despite its frequency and harm, workplace violence against health workers remains underreported and in adequately addressed⁵. Studies repeatedly document low formal reporting and widespread reliance on “forbearance and move on” response^6,7, suggesting not only deficiencies in institutional protection but also deeper organizational norms that shape how hospitals respond to violence.

According to Schein’s model of organizational culture (1992, p. 12 )⁸, culture represents “a pattern of shared basic assumptions learned by a group as it solves its problems of external adaptation and internal integration.” In healthcare institutions, workplace violence, as an abnormal but frequently occurring high-risk situation, its handling methods can often more clearly reflect the deep cultural orientation of the organization⁹. Therefore, the "tolerance or intolerance" orientation that emerged in response to the violent incidents can be regarded as the specific manifestation of hospital culture in this particular situation. Building on this framework, we focus on a specific cultural mechanism: forbearance culture, defined as the perceived organizational tolerance, downplaying, or normalization of violence. Evidence across countries indicates that unsupportive or punitive climates, ambiguous reporting procedures, and low expectations of managerial follow-up deter reporting and increase psychological burden¹⁰ Conversely, supportive and justice-oriented cultures can buffer the individual consequences of workplace violence against health workers by validating incidents, lowering reporting costs, and mobilizing organizational resources.^9,11.

Previous research on the psychological effects of workplace violence against health workers has primarily focused on individual factors (e.g., personality traits, coping style, resilience) and institutional measures (e.g., security systems, reporting mechanisms)^12,13.These studies have improved understanding of post-violence psychological responses, however, the organizational-cultural pathways through which workplace violence against health workers affects mental health remain understudied, particularly the role of perceived forbearance culture as a mechanism linking violence exposure to anxiety, depression, and burnout. Hospital culture functions as a deep organizational mechanism that shapes how individuals and institutions interact and, consequently, how psychological outcomes develop after exposure to workplace violence. Following high-impact incidents, healthcare workers reinterpret the event and evaluate the organization’s attitude. Managerial responses and past incident handling inform employees’ perceptions of the organizational climate, which in turn influence their psychological reactions¹⁴. Accordingly, we propose a meso-level account in which hospital culture shapes post-violence coping and recovery. When forbearance norms are salient, employees are more likely to adopt low-cost compliance strategies (e.g., silence, avoidance, non-reporting), thereby reducing access to organizational support and prolonging threat appraisal, which in turn deteriorates mental health. This yields our first two hypotheses:

H1: Exposure to workplace violence against health workers will significantly impair health workers’ mental health.

H2: Perceived forbearance culture mediates the association between workplace violence against health workers and health workers’ mental health.

We further argue that this cultural mechanism has a boundary condition: job demands. Drawing on the Job Demands–Resources (JD-R) model and Conservation of Resources (COR) theory, high-demand contexts (long hours, frequent night shifts, dense patient throughput, rapid task cadence) accelerate the depletion of time, attention, and emotion-regulation resources, while increasing the opportunity costs of taking corrective action^15,16. Under such conditions, a forbearance culture operates as a strong situation: by raising the perceived costs of reporting and lowering expected returns (e.g., little managerial follow-up, potential social sanctions), it nudges staff toward “resource-concerving” choices, such as silence rather than. escalation. This demands × norms interaction reduces the likelihood of restorative behaviors (e.g., formal reporting, seeking support), and intensifies the translation of cultural forbearance into anxiety, emotional exhaustion, and depressive symptoms. Based on the above evidence, this study proposes the following hypotheses:

H3: Job demands moderates the relationship between forbearance culture and mental health, such that the adverse effects of forbearance culture are stronger under high work-intensity conditions.

Overview

Workplace violence against health workers is a recognized occupational hazard in healthcare, yet the organizational mechanisms that translate exposure into psychological harm remain insufficiently understood. This study aimed to test three hypotheses: (H1) WPV is associated with impaired mental health among healthcare workers; (H2) a forbearance or “silencing” culture mediates this association; and (H3) job demands moderates this pathway. The results broadly supported all hypotheses: WPV was linked to poorer mental health both directly and indirectly through forbearance culture. The moderating role of work intensity was evident across multiple indicators, being statistically stronger for depression and observed for anxiety primarily under high-intensity conditions during the COVID-19 period.

Across this multi-province, cross-sectional sample of Chinese healthcare workers, exposure to workplace violence against health workers was associated with poorer mental health, confirming H1. The relationship affected mental health both directly and indirectly through perceived forbearance culture, consistent with H2. This mediating effect was particularly strong among participants reporting high work intensity, which supports H3. The moderation was observed in the link between forbearance culture and mental health rather than between workplace violence against health workers and culture. The moderating effects of work intensity were multi-dimensional: daily work intensity, long working hours, and COVID-period workload all strengthened the adverse impact of forbearance culture on mental health, whereas night-shift frequency showed no significant effect.

The confirmation of H1 aligns with extensive evidence positioning WPV as a psycho-social stressor that threatens worker well-being^3,4,18. Recurrent exposure to verbal or physical aggression erodes psychological safety and triggers anxiety, depressive symptoms, and emotional exhaustion. This finding echoes prior research connecting WPV to burnout and turnover intention among healthcare professionals¹⁹, emphasizing that violence constitutes not merely a physical risk but a sustained psychological burden.

Consistent with H2, forbearance culture emerged as a key organizational mechanism linking WPV to mental-health outcomes. When employees perceive their institutions as tacitly tolerant of violence or discouraging of reporting, they experience reduced organizational justice and support, which intensifies distress beyond the violent incident itself ^20,21.Such perceptions may generate feelings of neglect, unfairness, and helplessness, reinforcing avoidance and self-suppression rather than active coping. In hospital environments where informal norms implicitly emphasize “not making trouble” or “remaining silent,” healthcare workers may internalize these expectations, suppress emotional responses, and experience heightened anxiety, depression, and professional exhaustion. From the Job Demands–Resources (JD-R) and Conservation of Resources (COR) perspectives, such a culture represents a loss of psychological and social resources, compounding exposure stressors²². This study advances prior literature by identifying organizational silence as a meso-level mediator rather than a mere consequence of strain. Conversely, when organizations cultivate a culture of “safe reporting” and mutual support, the resulting sense of fairness and psychological safety may buffer the negative consequences of violence.

Support for H3 indicates that heavy workloads intensify vulnerability to the harmful influence of forbearance culture. The moderation was statistically significant for depression across several indicators of work intensity: daily workload, long working hours, and pandemic-period demands. While for anxiety, a significant interaction emerged only during the COVID-19 period. This pattern suggests that chronic job demands are more strongly linked to depressive symptoms, whereas acute high-pressure situations elicit greater anxiety responses. When job demands related factors are high, clinicians have fewer emotional and cognitive resources available to manage organizational stressors, increasing the risk of strain. By contrast, when workload is moderate, available resources and support can buffer these effects and sustain well-being ^23,24. When healthcare workers operate under extreme workload while simultaneously perceiving that their organization encourages endurance and silence, they may lack the psychological resources needed to manage this compounded stress, thereby amplifying anxiety and depressive reactions. By contrast, when workloads are more manageable, individuals can draw on more emotional regulation and social support, diminishing the cultural risk. This pattern aligns with JD-R predictions that excessive demands combined with scarce resources precipitate exhaustion and distress²⁵. Notably, moderation appeared only on the culture - mental-health segment, implying that workload does not alter perceptions of forbearance culture after violence but amplifies its psychological toll once established. The stronger mediation for depression suggests that prolonged exposure to workplace violence against health workers and a culture of silence cultivates cumulative depletion and hopelessness, consistent with the chronic nature of depressive symptoms frequently observed among physicians experiencing sustained occupational stress²⁶. These findings imply that anxiety may be more reactive to short-term surges in workload, while depression reflects cumulative exposure to sustained job demands combined with cultural pressures to remain silent.

This investigation was embedded in a practice-oriented occupational health assessment designed for use in routine hospital settings rather than as a longitudinal clinical trial, which prioritizes ecological validity and real-world feasibility over experimental control. Data collection was coordinated by experienced teams using validated mental-health instruments, and sampling was stratified across eastern, central, and western regions of China to reflect variation in facilities and staffing patterns. In this sense, the study emphasizes real-world relevance and operational feasibility in environments where time and reporting burden are constrained.

The study design emphasized practical implementation and analytic efficiency rather than experimental control. Its cross-sectional format allows breadth of coverage across hospital systems while deferring causal inference to future longitudinal work. Brief, single-item indicators of forbearance culture and workload were intentionally selected to ensure completion in high-pressure clinical contexts, where survey fatigue and reporting barriers often compromise data quality. This concise structure enabled a consistent response rate and facilitated integration into routine occupational assessments. While multilevel modeling and more detailed taxonomies of violence could yield finer distinctions between organizational processes, the chosen approach prioritized scalability, comparability, and operational feasibility across diverse hospital settings²¹. The design thus reflects a deliberate trade-off: reduced measurement granularity in exchange for ecological validity and implementation potential within the realities of healthcare work.

The way variables were measured likely influenced the observed patterns. For example, using a single global measure of workplace-violence exposure broadened coverage but limited insight into specific incident types, and perceptions of organizational culture were examined at the individual rather than the unit or hospital level. These choices fit the study’s goal of producing findings that can be used in everyday practice. The focus was on pinpointing organizational factors that connect exposure and psychological outcomes. Simple, repeatable tools can still provide stable and meaningful data to guide action.

Overall, the study provides an ecologically valid, theory-anchored snapshot of how WPV relates to anxiety and depression through organizational culture under varying work intensities. The brevity and scalability of its measures enhance practical application for hospital leaders seeking to embed WPV monitoring within broader well-being initiatives, while the analytic framework offers a reproducible bridge from exposure recognition to organizational action. Nevertheless, results should be interpreted within the cultural and institutional context of Chinese healthcare systems, and replication in other national settings is warranted.

Implications for Practice and Policy.

Based on these findings, several organizational and policy actions are recommended: (1) Hospitals should establish and enforce zero-forbearance, non-punitive reporting systems for all forms of aggression, supported by transparent leadership accountability. (2) Reporting should be simplified and normalized through confidential, mobile-enabled tools that allow protected time and capture near-miss verbal incidents. (3) Institutions must standardize post-incident protocols, ensuring rapid debriefing, documented follow-through, and access to psychological first aid or employee-assistance services. (4) Administrators should treat workload as a safety variable by maintaining adequate staffing, setting shift-length limits, and integrating workload metrics into WPV monitoring dashboards. (5) Organizations need to assess and remediate silencing climate via periodic surveys on psychological safety, leader performance indicators linked to WPV response, and transparent unit-level action plans. (6) Finally, comprehensive prevention training and environmental controls, including de-escalation exercises, peer-support networks, panic alarms, and visible security in high-risk zones, should be institutionalized. Together, these measures address both the incident level (prevention and response) and the contextual level (culture and workload), the twin levers identified as pivotal for safeguarding healthcare workers’ mental health.

Future Research Directions.

Future studies could build on these findings by adopting designs that follow healthcare workers over time and draw on information from multiple sources. Broader and more refined measures of organizational culture and workload would allow a fuller understanding of how these factors influence mental health. It may also be useful to explore intervention approaches that strengthen reporting systems, promote fair and supportive workplace cultures, and address staffing or workload pressures. Comparative research across regions and healthcare settings could clarify whether these relationships hold in different organizational and cultural contexts.

In summary, WPV undermines clinicians’ mental health not only through direct exposure but through the organizational message that such violence must be endured. A forbearance culture mediates this relationship, and high workload exacerbates its harm. When organizations encourage timely reporting and visible managerial support, they can enhance psychological safety and resilience among staff. Health systems that cultivate non-punitive reporting climates, ensure consistent post-incident support, and proactively manage workload are best positioned to protect healthcare workers’ psychological well-being. By integrating violence prevention, supportive culture, and workload management, organizations can break the cycle of silence and strain, fostering a resilient workforce and safer patient care.