Workplace violence has become an endemic problem, about one-fourth of the world’s workplace violence occurs in Health care. Social media portrays incident of violence against doctors and nurses every couple of days which goes viral instantly. The Indian Medical Association reported that 75% of doctors experiencing violence at work while 80 % of all assaults on nurses go unreported.
Despite the alarming incidents of assaults against health workers, hospital violence is still known little to the general public and few states offer specific legal deterrents for assaulting health workers. Violence against health-care providers is underreported, understudied, and undertreated making it difficult to find effective strategies for preventing and managing outbreaks of violence.
In western countries, patients are the perpetrators of violence in contrast to the Asian sub-continent including India, where patients are not violence makers, but their relatives or apparently sympathetic individuals, political leaders and political parties.
The factors influencing Workplace Violence in health care is multi-factorial.
Policy factors
Meagre health budget and poor quality healthcare
India spends close to 2% of the total budget, which is dismal compared to other countries. According to the WHO, just 33% of Indian healthcare expenditure is from government sources and the remaining is from out-of-pocket expenditure pushing many households into poverty. The public healthcare system in India is on the verge of collapse with poor infrastructure and disproportionate Doctor, Nurse patient ratio. Rise in violence against the health workers is the reflection of the ailing Indian health care system.
Institutional Factors
Overall deterioration of public health services
Government hospitals follow welfare model. Majority of people are poor without health insurance. Hospitals offering subsidized medical care are swamped with patients and their attendants. The average medical officer in the outpatient department sees close to 350 patients a day often compromising the quality of care while attending to huge number of patients in a small window of time. This may impart a perception of neglect to the patient. Waiting in long lines for hours, opaque billing systems, ineffective communication can easily drive some patient’s attendant at the brink of an emotional cliff. Shortages of blood, drugs, linen and other items are a major concern. Further, diagnostic equipment such as ultrasound and X-ray machines are routinely out of order, forcing patients to get these investigations done at private centers for a fee. Staff shortages also force relatives to take on substantial responsibility for nursing the patient. Above all violence is easily orchestrated in government hospitals due lack adequate security.
Professional factors
Poor communication
Indian medical and nursing schools are excellent in imparting medical training to their students; however teaching empathy toward the patient is lacking. Whereas in clinical practice, effective patient–doctor communication like explanation for the occurrence of the symptom/sign, likely duration of treatment, and empathy are key predictors of patient satisfaction. Caregivers must be trained in breaking bad news, empathizing and communicating with their patients.
Class, culture and medical education
Class difference between doctors and the patient community, little practical experience and knowledge about the background of patients, their problems and their expectations can be a contributing factors. “Today’s doctors do not connect with patients who are the indigent poor and live in slums. The rift between the educated class and the labor class of India has never been wider. The burgeoning intellectual class of doctors has become alienated from the grass root society.
Local factors
Mob mentality
Mob mentality frequently snowballs into a violent crisis in hospitals. In India, emotional turmoil due to death of a loved one is sometimes used by local politicians as an opportunity to demonstrate their political relevance by orchestrating violence at the clinical establishment. Unique to India, the unfortunate death of a patient is sometimes given religious and caste color by some miscreants.
Lack of faith in the judicial process
Lack of faith in the law and order machinery and the judiciary contributes to exacting immediate revenge, seeking ‘pound of flesh’ using physical means rather than filing a case in court in cases of suspected negligence. The public is cognizant of nonexistence of laws for the protection and safety of the medical community and feels no apprehension in manhandling. Since such acts of violence go unpunished, it emboldens the mob and encourages the re-occurrence.
Negative Role of Media
Poor image of doctors and Nurse portrayed by media
Trust in the doctor–patient relationship has taken a beating over the last few decades. With the media publishing sensational stories of organ theft, medical negligence and malpractice, reports of unnecessary tests and needless invasive procedures has sowed seeds of distrust and skepticism deep in the minds of the people causing the public to embark on a frenzied witch hunt.
Preventive Measures
Responsibility of Government and political parties
Policymakers should understand that the overall health of the people contributes to the efficiency of the workforce, in turn, contributing to the growth of the economy. More health budget spending would translate to better facilities and increased doctor, nurse–patient ratio, leading to a better health delivery. The government needs to concentrate its activities on preventive medicine and put effort on Nutrition, immunization, health education, pollution control, personal hygiene, and access to clean water, unadulterated milk, unadulterated food, substandard drugs and provide facilities for exercise, playground, etc.
Legal steps needed to be taken by the government
The Prevention of Violence against Medicare Persons and Institutions Acts, which have been notified in some states including Delhi, Haryana, Rajasthan, Tamil Nadu, Odisha, in the past 10 years, have failed to address the issue. Mobocracy cannot be allowed to raise its ugly head. Law should be enacted to safeguard the safety of doctors and nurses. Assaulting medical personnel on duty should be made a cognizable offense, with serious consequences.
Responsibility of organizational institutions
To ensure a safe and respectful workplace, mandatory protections against violence in the workplace such as zero-tolerance policies and comprehensive prevention programs, reporting mechanisms and disciplinary policies should be established. The most important step in preventing mob violence in a hospital is restricting entry of public. Entry should be strictly by passes preferably by deploying ex-army personnel.
Standard operating procedure (SOP) and Insurance
All hospitals should develop an SOP for violence. Mock drills need to be conducted and each member of the staff should be clear about his role if the situation of such violence does arise. Insure the establishment against mob violence, damage to property and injury to workers to at least mitigate the financial losses that are incurred in the aftermath of violence.
Responsibility of the patient family and society at large
There is an immense responsibility of patients, relatives and society at large to prevent violence. Avenues of dispute redressal should be used to sort out disputes rather than through violence. Vandalism and violence in a hospital is a criminal offense and any civilized society must condemn such mishaps unequivocally.
Responsibility of the media
The media is the window of the society. It is the responsibility of both print and electronic media not to sensationalize such news. Medicine is not a black and white subject and so also its management. Diagnosis of a patient is essentially hypothetico-deductive process, with new evidence through investigations and knowledge, the diagnosis of some of the cases continues to be refined. However, whatever the diagnosis be, the management of patient generally includes such uncertainties and treatment continues. Media should create open platform for discussion between public and healthcare workers to identify lapse and understand each other. Demonising physicians should be avoided and conviction of health care workers should be left to the courts.
Conclusion
Violence in the healthcare threatens the delivery of effective, quality care and violates individual rights to personal dignity and integrity. Hospitals are sanctums of healing and recuperation. In addition to jeopardizing the safety of medical personnel, violence threatens patient safety and hampers their recovery to health. In order to tackle the issue, health care workers need to accept the problem, discuss the various causative factors, understand the public sentiment and collaborate with the government to find a solution. Formulation of legal provisions and standards to ensure the safety of health workers is the need of the hour.
Thungchanbeni S Ezung, Nursing Educator at RIMS. Email: beniaiims@gmail.com
