Violence in hospitals, a serious global public health problem and leading cause of fatality, misery and designations, is one of the most complex, multifaceted and diverse, emerging occupational threats. It is ill-defined, underreported, understudied and on the increase concern, for healthcare workers worldwide including Pakistan. Workplace ferocity in health care setting is recognized but not regulated. Doctors are on the front lines and back bones in healthcare-settings. This so called, cream of nation is now being humiliated everywhere on the earth. In spite of raised scientific attention to the problem, there are negligible prevention intervention studies on how to tackle savagery towards healthcare-workers.
Annually about 1.5 million medical employees are being hurtled worldwide. Section 153-A of PPC deals the malpractice. U.S. Bureau of Labor statistics indicates that hospital workers are five times more likely to be assaulted on job than workers in other industries. The first ever nationwide study on violence conducted by Ali Khawaja and Hira conducted in 2011 showed that 76.9% of 675 young physicians in emergency departments were victimized; 65% verbally; 11.9% physically. Another cross –sectional study on violence in healthcare-settings in Pakistan, was carried out by Nashiz Imran in2013, according to which 74% doctors are assaulted by patients and their families.43% violence on physicians in Agha Khan University and 58% violence on G.Ps in Australia—the fully equipped and rich with highly trained human resources shows that there is really some fault on this or that side.
The problem is not only in secondary and tertiary health facilities, rather with great magnitude in primary health facilities. The common places of hindrance for health actors are emergency departments, ICUs and psychiatry wards (due to patients of dementia, psychosis and schizophrenia. The victims here are almost always nurses).
The situation has become so worst that few clinicians are thinking about the learning of Karate, Tokendo and other Martial arts for self defense and believe that this will also boost up the their confidence. Many young Pakistani prefer to serve abroad to get rid of the fight.
Some doctors and health workers now do not even consider verbal violence as violence at all as they are so used to violence The main reason for acceptance of fierceness may be any including the consideration of it the patient’s right or part of the profession and fear of adverse consequences of reporting, lengthy humiliating complicated investigation procedures, lack of witnesses ,repeated court visits, political influence in institutions, poor law and order, injustice and slow judicial system/no fear of punishment, poverty/inability to pay high cost of care, kidnapping, including threat to life or job.
The studies highlight that there is substantial variation of violence, both within and between countries in form and incidence. The bhattaism (extortion), kidnapping for ransom or targeted killing absolutely rare where as verbal threats are more than physical assault in Punjab as compared to Karachi. The public hospitals have more incidence of sadism than private hospitals. Most of the time people give way to ambulances owned by government,1122, or NGOs happily in the Punjab. The healthcare circle being victim are clinicians ,nurses, paramedics, vaccinators, lady health workers, ambulance drivers, security guards ,administrative, clerical staff, medico-legal officers, social workers, laboratory technicians, blood bank workers, NGO workers and vehicles . The perpetrators at top are patients’ relatives, followed by unknown persons, addicts, thieves etc.
The World Health Organization (WHO) defines violence as “the intentional use of physical force or power, threatened or actual, against oneself, another person, or against a group or community that either results in or has a high likelihood of resulting in injury, death, psychological harm, mal-development, or deprivation.” The 39th World Health Assembly specifically discussed the issue and agreed that healthcare providers are vulnerable to occupational violence ranging from blocking or interfering with timely access to care, discrimination in access to care, killing, injuring, kidnapping, harassment, threats, intimidation, robbery to bombing ,looting and intimidating patients care; and interruption of medical care, forceful interference with the running of health-care services etc. Maternity cases, newborn babies and the infirm are also sufferers sometimes. Violence against healthcare-settings is a widespread issue and has been come down on internationally. The developing countries have reported high incidences of physical and verbal violence in the emergency departments but that number is not even close to the breadth seen in Pakistan, particularly in Karachi, in recent past. The Punjab, though less, also has trend in turbulence against health-care professionals.
Over the years, several violent incidents occurred in which many innocent healthcare providers lost their lives and this does not include threats, verbal violence and snatchings. .In DHQ hospital Muzafergarh one of the senior doctors lost vision in an attack by assailants supported by a political celebrity. The Pakistan Medical Association (PMA), that raises the issues of health-care providers, claims that there have been almost 128 doctors killed from 1995 until 2015 across Pakistan. The highest number of incidents happened in 2014, when around 18 deaths were reported. The bomb blast in hospital in Quetta in a hospital, few months back on a crowd after the death of a lawyer is constantly pinching my memories
Unfortunately the community, appears to have a different expectation that HCPs—as members of caring professions—should continue to serve, regardless of the risks they may face, -perhaps being made of stainless steel stuff. The assault may be of any type: spit on face, push, pulled shirt ; causing neck constriction, sexual remarks, corrosive pouring, threatening and beating physically with fists and feet, cutting pocket and snatching mobile phones, looting, forced entry, damage to gate ,buildings, furniture ,damage or extrusion of doctor name-plates , shooting into, encircling or other forceful interruption with the smooth running of health-care facilities, been reported.
Harassments and physical attacks on healthcare –givers come mostly from the attendants or the heirs of recently died patient. This is very disheartening and can demoralize the young future doctors.
Living in a time of anxiousness, horrifying politico –economical instability, unemployment, political agitations ,flagrant illiteracy and financial constrains coupled with ,wide spread unethical commercialization and lack of infrastructures have created impatience, anger and frustration, and increased the level and decreased the threshold of crime and violence in common man . The attackers on healthcare –providers are not pre-meditated. Most of the times, the relatives of the patient have emptied their pocket .When they have to purchase the medicine and other item again and again, their anger manifests as barbarity. When relatives are told about the improvement of patient’s condition, they are very thankful to God and doctors. Sometimes if the patient becomes serious and followed by death, their relatives react emotionally.
In the past, the death was accepted as fate or will of Allah due to trust on doctors that what he did in the best interest of patient. Now public is relatively educated and more right conscious. When the people come to know the vested interests for surgery and eventually death, they have the right to be enemy and show wildness.
Moreover, it has become a fashion of professors in public hospitals to be absent, come late, or having attitude suggestive of consultation at private clinics. What impact it will have on the trainees and poor patients?
Misconception about the polio drops for making their children infertile or having some pig contents in it is still cause of refusal resulting in conflict when vaccinator insists for polio immunization.
One important cause of violence healthcare-settings is the illiteracy, especially the health education. Lack of education along with dissatisfaction about the complicated English health system we have presently, has lead not only to violence but also has developed a culture where someone is happy to insult a doctor or teacher and respect an S.H.O. or patwari in most of the laymen ,living in villages .
Communication failure, due to doctor being busy, ensuring 100% success, lack of training in communication skills and experience, not updating the critical patient repeatedly, breaking bad news or reporting death by a junior doctor becomes a cause of violence.
Scarcity of medicine, rush at parchee window (registration slip), overcrowded uncomfortable insufficient waiting rooms, long waiting times, limited contact with physicians, resentment with the treatment and/or friction with the physician, lack of resting places for relatives at night stay and poor environmental designs play their own role to make the people tensed.
The assignment load on young trainee resident doctors, being on duty day and night, even for 48 hours, making rounds, attending calls from other wards, advising investigations, performing emergency operations, fixing the managerial issues of ward etc ,is too much and not compatible with salary.
Complicated registration and referral process, delay in operation turn, insurance issues, paper work of imbursement, issuance of sick certificates and medico-legal reports, conducting autopsies may provoke the patient or relative easily.
Researchers have also identified: lack of staff training and policies for managing intimidations with potentially volatile patients; access to fire arms; unrestricted movement of the public; unmet demands; unreasonable expectations; perception of low standard care and trend to seek high level care even for minor ailment by celebrities and VIP culture are other paramount factors resulting in vehemence into healthcare- settings.
Other triggers making the patient’s attendants quarrelsome may be strained family relations, patients under the effect of drugs and alcohol, mentally ill patients , arrangement of high tea and lunches during duty hours, evening shifts, night time working, predominantly female staffing, understaffing or working alone, easy access, habit of creating chaos and mayhem ,gaining attention of healthcare providers, lack of sense to respect others, inadequate security, presence of ATMs and pharmacies (due to availability of drugs and money), culture of accompanying 4-5 attendants a patient outside the operation theatres and even in the wards.
Many people presume true, “with the doctors, criminals have good experience because they can impose upon and get the ransom.
The hospitals are only places where anyone can go, be protected and cured for; and are safe heaven for herds of confectionary sellers, beggars, medical company representatives, massagers and colorful, lovey-dovey ,glamorous youth. In such places anytime, anywhere, any collision can happen, involving the heath care-providers.
In addition, poor lit rooms ; corridors; parking lots and other areas, high turnover rates and possible items on counter tops that could be thrown on a worker, other known causes of assault perpetrated by irritated family members of sick persons , especially in bigger hospitals.
Daily sentimental media reports of poor medical practice and discrepancies in the health setup have overcome in inflaming public distrust and roughness against the healthcare- settings. Patients and attendants who feel aggrieved about treatment are often forced to take issues into their own hands.
One alarming type of assault from medical profession to public, which I have come across, as an in charge, “anti-malpractice campaign” at Bahawal Victoria Hospital Bahawalpur is to convince the patients against doctors working in government hospitals and pursuing them to go to other doctors. These doctors pay to their hired agents for kidnapping the patients from the hospital; general bus stop; wagon stop etc .The malpractice is popularly known as ,rickshaw practice.” as the perpetrators here are rickshaw drivers.
The same hanky-panky that impregnates the other segments of the Pakistani society also reflects in healthcare, resulting in simply loss of patients’ trust on doctors. The medical, paramedics and supporting staff is also responsible for squeezing downtrodden and subsequently resulting in violence by the patient’s attendants as a reaction.
Exorbitant consultation fee, poor care, medical errors, lack of tolerance to listen the patient attentively, behavior as of an officer and not of health giver, doctors’ and paramedics unions like Y.D.A. and P.M.A., culture of ,”look busy do nothing” by the union members are definite factors causing distrust in medical practitioners. Self oriented and beauty conscious lady doctors (80% as compared to male doctors in new batches) and nurses with: attractive makeup; glistening jewelry; fancy dresses; close-fitting pants; matching wallets and shoes, curled naked hair; busy in gossip with young male colleagues, mushroom growth of doctors from China and Russia having substandard medical teaching and training facilities without having their own affiliated teaching hospital, lower the treatment standard, and raise the frustration level amongst public .
Hatred of patients and their families towards medical professionals is justified after incentives from pharmaceutical companies in the form of: overseas tours; heavy lunches; renovation of clinics; smart phones, air conditioners and even vehicles. Given the power and influence of the super rich-the doctor by resorting malpractice in the name of private practice, prescription of undue, low quality, non branded medicine, unnecessary investigations, might seem as if social status and material possessions are the new symbols of personal worth but in everyday life I do not think this is true. At least doctors, members of a noble profession, should not be money making machines.
The doctors accountability is not up to mark .Still not setting the basic indicators of healthcare has resulted in high mortality .Even in this modern era of medicine majority of the major operations in private setup and periphery are being carried out without standard general anesthesia.
Violent incidents have a significant effect on healthcare providers. The impacts of violence included affecting human rights and public health: lower morale, anger, time off work ,burnout, loss of confidence, psychological disturbance, scaring ,decreased motivation to job, damage of properties, getting over conscious ,losing hope ,disturbed memories, insomnia, disability and change in job, damages gender norm, incurring cost of services by victims and families, loss of workplace productivity and cost to employees. Many victims do not take any action against the ruthlessness. Polio eradication has suffered to a considerable limit. According to WHO, 47000 out of 34 million targeted children could not have polio vaccination on one of the National Immunization Day .Dr. Elias Derry, head of Global Polio Eradication of WHO stated,” Vaccinators are real heroes and fit for Noble Prize..Others thought is fruitless to report, while a small percentage of the affected were worried about the consequences due to lack of any specific policy against the attackers by the institution. In study conducted in different hospitals in Lahore, 73% workers do not report due to belief that no action will be taken.
About 80%, unsatisfied doctors in secondary and tertiary facilities claim themselves as overworked and underpaid, and morale is low. This not only results in rushed, indifferent, and disrespectful treatment of patients, a major cause of doctor-patient tension, but also increases doctors’ perceptivity to hush money. Many doctors would not want their own children to go into medical profession, and significant percentage of clinicians would not prefer to be doctors, given a second chance. Such sentiments are leading to fears of a human resource crisis in the medical profession. “Media and police pictured us bad; we are not as bad as they show us on TV that a patient died due to Dr.’s negligence but they do not show that patient arrived in critical condition.” Is the doctor, view point?
Security and protection of healthcare –actors is the responsibility of organization and state, no doubt. There is not one simple solution of this issue. Recognition and pacification skills by creating and enforcing facility policies for both worker and visitor could have mitigated the situation. Essential elements for a violence prevention program include right and tight security by the presence of police in bigger hospitals, access control, CCT cameras installation, alarm button, more comprehensive health insurance system, zero profit policy for drugs, zero tolerance policy warning, increasing the number of physicians in OPDs especially to improve the patient- physician ratio, preventing huge flow from rural areas by providing more medical facilities in for flog areas, political and management commitment, making the health facilities ( especially emergency & accident department, ICUs) free of politics ; weapon ; cellular phones, establishment of complaint cells and police pickets , provision of jammer services in case, increasing the salary but banning the private practice of doctors working in public hospitals.
Establishing more, far from populous areas, health facilities, now in the form of separate complexes like gynecology, pediatrics, neurosurgery, nephrology and kidney centre; establishing more roomy emergency departments (and partitioning them into surgical, medical, gynecological, trauma and burn compartments), having separate administrative officer, availing freely free medicine and investigations, will be helpful to lower the congestion.
Employee involvement, worksite analysis, promotion of fee transparency, inventing the new laws, taking guideline from international agencies , promoting the ethical values are other solutions to lower the doctor-patient tautness.
The previous hospital or referring doctor should not be criticized. Even homeo-doctors, hakims and peers should be respected especially in the presence of patient and his attendants as it will take time to change the culture. One has the right of second opinion if desires. Never say,” you have reached late”. Behave with patient like relatives or friends, and not take them as customers, rather keep yourself in their place for a moment. It will pay you in the form of respect and money and realize his pain. Giving toffees to the children of the patients like western countries can be practiced here .One frank friend of mine has written, “To be served is your right and to serve you is my duty,” very clearly in his office in Urdu. Media printed and electronic both should spread positive perception of doctors.
The provincial government of Punjab established, Punjab Health Care Commission (PHC) in 2010 with the objectives to enhance the patient satisfaction through redresses of complaint and ensure accountability at all levels like medical negligence, malpractice and administrative failure. The doctors are immune to other public according to this commission. The doctors however, instead of supporting the Provincial Health Care Commission have adopted the confrontation policy against PHC. In medicine nobody has the control on consequences. There are many hurdles and outcomes may not be good. Anger against the clinicians is justifiable if attendants believe the negligence, whereas violence and blocking the roads by keeping the dead body in the middle of road is not the way. The hue and cry of mobs can delay or postpone the management of critically serious patients.
Revision of ,”open merit” policy of admission in medical colleges which has resulted in predominance of female doctors anywhere and implementing 30 :70 female:male ratio, is the need of the day, to lessen the violence in male dominant society.
Being forthright, honest, compassionate, attentive listener, periodic updating the condition of the patient, learning fundamental therapeutic communication skills and empathy, explaining the complications and serious consequences –even death, involving the patient and relatives in decision making and documenting everything ,the physician has discussed with patient and families ,recognizing the violence in workplace and reporting to the authorities may settle the situation and lower the unrealistic expectations, is the solution as stated by expertise at a Symposium on Violence in Healthcare-Settings at Agha Khan University Karachi.
Admittedly, this may be cumbersome to administer. Unfortunately, this problem might even get worse in the future.
A cultural change is required. The doctor and paramedical staff should have real time support and existing resources to ensure that the worker perceives valued, applauded and sheltered consequently after violence. Solely prompt and more regulated systemic change can reverse the growing trend of violence in medical profession.
Author, Dr. Muhammad Younas Varaichue is ENT Consultant at B.V.H. Bahawalpur.