TRENDS OF VIOLENCE AGAINST HEALTHCARE WOKERS

AND FACILITIES

OUTLINE

1) INTRODUCTION
i) Violence according to World Health Organization
ii) Some facts and figures
iii) Effects of violence

2) VIOLENCE AGAINST HEALTH-CAREWORKERS

i) Physical violence
ii) Bullying and Verbal assault
iii) Sexual harassment

3) VIOLENCE AGAINST HEALTH-CARE FACILITIES

i) Trends of violence
ii) High risk zones
a) Intensive Care unit
b) Parking lots
c) Trouble for ambulances
iii) War torn regions

4) REASONS OF VIOLENCE
i) Altered mental condition
ii) Stress, worry and anxiety
iii) Other factors
5) CASE STUDY OF DIFFERENT REGIONS
i) Condition in Pakistan
ii) Situation in USA
iii) Violence and other regions of the world

6) STRATEGIES TO END VIOLENCE

i) Devising of protection law
ii) Violence management training
iii) Use of security equipments

7) CONCLUSION
World health organization describes violence as "the intentional use of physical force or power,
threatened or actual, against oneself, another person, or against a group or community, which
either results in or has a high likelihood of resulting in injury, death, psychological harm,
maldevelopment, or deprivation." So, violence is not just the physical deprivation of someone
from his own rights but also the psychological dispossession of thoughts and intellectual
hindrances which in result affects the person mentally and physically. Health-care workers are
under constant threat of violence, especially by patients and their families. A study conducted
by the World Health Organization reveals that about 8% to 38% of the health-care workers have
faced physical or psychological violence at some point in their career. However, nearly 70% to
80% of the violence is never reported, therefore, estimates are likely to be very much higher
than this. In a country like USA, health-care workers are more likely to be victimized than any
other workplace. Approximately 8 assaults per 10,000 workers compared with 2 assaults per
10,000 workers for a general workplace. This violence often results in low moral of health-care
workers, severe depression, anxiety and resigning from the job. It also contributes towards the
declining quality of health services to the patients. The violence against health-care workers
and facilities is significantly affecting the health-care conditions and necessary steps and
lawmaking required in this direction.
The violence against health-care workers has turned into an epidemic. The major types of
violence are physical abuse, mental torture, verbal maltreat and psychological terror.
Physical violence is one of the major contributors in violence against health-care workers.
Punching, kicking, scratching, biting, spitting are the most common form of physical violence
against nurses and medical staff that arises quite rapidly in the last decade. In a 2014 survey by
the Bureau of Labor Statistics showed that almost 80 percent of nurses reported being attacked
on the job within the past year and the attacks are on a rise. The same survey also revealed that
50% of violence comes from patients and their family members when they are drunk or sedated
on drugs. Most of the perpetrators attack nurses just because of their frustration. They
considered nurses as the main source of their repression and out of their misery they attack
medical staff to release their anger. The injury data of Bureau of Labor Statistics of 2016
unveiled that the people who experienced workplace trauma 70% of the times were healthcare
workers, out of which 21% required 31 or more days off from work to recover completely.
Moreover, the fatality data of 2016 disclosed that out of 500 workplace homicide victims, 23%
or 115 were from healthcare facilities or performing protective service activities. In 2018 a clinic
in Ohio region seized a staggering 30,000 weapons from patients and their relatives. These
weapons were largely consist of sharp and pointed tools such as knives, box cutters, razors
blades, screwdrivers, pepper sprays and stun guns, whereas matchsticks, lighters and brass
knuckles are very common things carried by patient’s relatives and friends to terrorize medical
staff. Health-care facilities are not any different from churches, malls or movie theaters, so it is
mandatory to provide safety for the employees and medical staff.
Moreover, another kind of violence medical workers face every now and then is verbal abuse or
bullying. Patients and their family members accuse, threaten abuse and ridicule health-care
workers and blame them for their own suffering and disdain. A study conducted in Saudi-Arabia
which included 738 health-care workers revealed that verbal abuse or bullying is the most
common form of violence that health-care workers came across in their daily job routine and
eventually it became a part of their job life. Almost 33% of medical workers complained about
the verbal abuse in past or rude behavior by family or relatives of patients. This study also
unveiled that the ratio between male and female health-care workers is almost the same with
57.9% male and 57.2% female, are being affected by verbal violence. This type of violence often
occurred at home health sector because workers provide care at client’s home. In USA overall
61% workers reported workplace violence at client’s home annually, whereas, the original
violence rate is considered to be much higher than this because of the culture that medical
workers are naturally violence resistant and it is the part of their job. Another study, done by
International Committee of Red Cross (ICTC) and Khyber medical college, Peshawar, shows that
almost 50% of the health-care providers had experienced verbal violence and bullying and 61%
of them were worried about the workplace violence. Remember the study consisted of around
842 health-care providers. Talking about physicians or surgeons, they are also get affected by
verbal violence. A study conducted by Kowalenko at the University of Michigan, reported that
specifically 75% of surgeons and physicians are verbally assaulted. The research also included
pediatrics as well as they are also a victim of workplace violence by patient’s family and
relatives. Verbal violence and bullying have deep and negative effects on health-care services
especially declining in quality of services and low moral to provide health-care facilities.
In addition, the cases of sexual harassment are very common in medical health facilities.
Perpetrators usually harass their subordinates and assistants in the name of financial favors and
promotions. The victims do not raise their voice against perpetrators due to lack of training,
lack of incident reporting policy and management support, previous experience of lack of action
against the perpetrators, and fear of adverse consequences and fear of stereotypes of society.
As a result, perpetrators became fearless and stronger day by day. The highest rate of sexual
harassment is in the “Anglo” region, which included Australia, England, Ireland, USA, Canada,
New Zealand, and Scotland and is the lowest in Europe. A descriptive cross-sectional study and
In-depth interview was conducted among 123 health workers of Baglung district of Nepal to
collect qualitative data. Almost 12% of the workers reported that they were sexually assaulted
while performing their duties in the past 12 months. The main hurdle in reporting these cases is
the clichéd thinking of our society and the fear of societal pressure. Victims afraid that it will
malign their honor and dignity. Sexual harassment is not just a dilemma of medical facilities but
it’s a common threat to both male and female at workplace.
Also, health-care workers are not the only victims of violence but health-care facilities are also
under ruthless savagery. The damage can cost government and NGOs up-to billions in property
and machinery losses.
Similarly, trends are showing that violence against health-care facilities is increasing with every
passing day. Only in USA from 2002 to 2013 the rate of significant workplace violence incidents
was more than four times greater in healthcare than in private industry on average, as reported
by the United States Department of Labor. In fact, healthcare accounts for almost as many
serious vicious injuries as all other industries combined. The major area of concern is that the
violence against health-care facilities is financially very costly. Hospitals on average spent an
estimated $1.1 billion in training and security costs to avoid violence within their facilities, plus
$429 million in medical care, staffing, indemnity, and other costs resulting from violence against
hospital facilities, according to a 2017 report commissioned by the American Hospital
Association. Kevin Tuohey, president of the International Association for Healthcare Security
and Safety, stated in a 2017 publication, "While hospitals have always been looked at as places
of refuge, as places that were really safe, I think in the last 10 years that's changed, and I think
that they are no longer exempt." As the matter of the fact, with increasing security and caution
measures taken by hospital management, there is no corresponding decrease in violence cases
but infact, the numbers of these cases are on the rise as compare to the past decade or so.
As discussed earlier, health-care facilities are not a safe haven anymore, there are certain areas
in these facilities that are more vulnerable to violent attacks as compared to others.

Intensive Care Units that were once considered as the most secure and reliable zone for
patients are not safe anymore. There has been periodically ravaging situation seen at the
Intensive Care Units of hospitals, where relatives and medical staff brawl against each other.
Because the ICU consists of the severely ill patients, visitors to this area may be extremely
tensed, stressed, and demanding of staff attention, which may or may appear to be in short
supply. This combination can lead to verbal aggression toward staff and can escalate into a
physical assault, especially if staff is not properly trained to handle such situations. In 2015,
medical and surgical hospitals had an incident rate of 6.0 per 100 full-time workers, according
to the U.S. Bureau of Labor Statistics. Similarly, parking lot are also prone to violent activities
because parking areas are mostly dark, may offer many hiding places, and may be deserted at
certain hours. In addition, ambulances also face difficulties on daily basis. The very first victim
of any anarchy is an ambulance which is delivering injured people to the hospital. Mob usually
targets the innocuous ambulance to release their frustration by setting it on fire. Similarly,
roadblocks, traffic jams also hinder the routine work of ambulances. In Thailand “More than
20% of patients needing immediate medical attention have died on their way to the hospital
because of delays due to traffic jams and uncooperative motorists”, National Institute of
Emergency Medicine (NIEM) secretary-general said. These brutalities against health-care
facilities, in turn, increases the medical cost and making it very difficult for government and
private Non-Governmental Organizations to provide and maintain medical facilities to
impoverish and needy people.
Furthermore, providing health-care facilities in war-torn areas is also a myriad of a task.
Doctors, paramedical staff and health facilities always remain in the line of fire. “Violation
Documentation Center” in Syria is a Damascus-based human rights organization. The center
reports that 12 of the physicians were tortured to death in prison, 3 were arrested, tortured
and then executed in prison and another 12 were executed in the field. About 50 nurses have
also been killed. Syrian authorities say 57% of public hospitals have been damaged and 36% are
no longer functional and in total at least 130 doctors have been killed and 477 imprisoned
during the Syrian Arab Republic’s two-year civil war. Similarly, in Yemen, a WHO spokesperson,
Mr. Jasarevic who was in Yemen in February, said that at least 274 health facilities had been
damaged or destroyed as a result of the conflict, and some 44 health workers either killed or
injured. The Yemen war has destroyed half of its health-facilities up-till now according to United
Nation health agency. Moreover, the US war on terror costs Pakistan around $252 billion in
total which includes destruction of health facilities and other infrastructure as mentioned by
Mr. Hafiz Pasha in his book titled “Growth and Inequality”. The barbarism against health-care
facilities in war-torn areas has been a major hurdle for organizations like United Nations and
World Health Organization. It not only cost human life but also add-up the financial cost of
medical aid to war-torn areas.

Before moving towards a solution to end violence against healthcare providers, it is pertinent to
analyze the basic contributing factors and rationale of why healthcare workers and facilities are
the primary target of violence.
The most frequent and usual characteristic exhibited by perpetrators of violence is altered
mental status associated with delirium, sedation due to medications, or prolonged mental
illness. Due to unconsciousness or unknowingly patients often attack nurses and try to destroy
medical equipment unintentionally. In doing so they often end-up hurting themselves. National
Crime Victimization Survey estimated that between 1993 and 2009, health-care workers had a
20-percent higher rate of workplace violence than the average seen by all workers. In this way,
those working in mental health-care settings, their experience of workplace violence challenge
that of law-enforcement officers, bartenders and security guards. Moreover, the Occupational
Safety and Health Administration guidelines explain it as: “Pain, devastating prognoses,
unfamiliar surroundings, mind- and mood-altering medications and drugs, and disease
progression can also cause agitation and violent behaviors.” Furthermore, it is very important
to note that these incidents do not necessarily depend upon suburb or city areas. The
Midwestern hospital United Kingdom had facilities in both city and suburb areas. It concludes
that patients in certain conditions behave similarly irrespective of their geographical location.
There is no conclusive evidence linking healthcare violence with demographic groups or with
urban-rural emergency departments.
Similarly, Healthcare professionals come into direct contact with a wide range of people who
are under stress due to pain or illness. Stressed environment especially in waiting areas and
around emergency rooms create a troublesome environment. Areas such as Triage and
Emergency units are characterized as high stressed and long waiting hour areas that affects
negatively to all individuals. Ralph Nerette, the director of security at Dana-Farber Cancer
Institute in Boston, explain that “When we have to deliver bad news to a family, there is a lot of
emotion involved, and there are many examples of medical providers who have been the target
of that emotion,” he added. This is such a well-recognized aspect of being a health-care
provider, “that we teach people about where to stand and how to ensure access to the door
should you need to get out of a room.” Furthermore, these incidents are also likely to happen
when nurses and workers were performing tasks involving needles (like blood draws) or moving
patients from one area of the hospital to another or in general any treatment that caused
discomfort is more likely to make a patient turn violent. Laura M. De Castro, a sickle cell disease
specialist from the University of Pittsburgh Medical Center, explains it further as “The
psychosocial components of patients’ lives greatly impact their clinical care. Each patient is
dealing with hardships, poverty, poor coping mechanism, lack of social support, perpetual
stigmatization, and undiagnosed or mismanaged neurocognitive deficits,” All these factors in
the end directed towards the piling-up of frustration and anger of patients which in turn
patients release on health-care service providers, making health-care duties quite difficult to
perform.
Moreover, other factors that catalyze the process of violence are shortage of staff, increased
patient morbidities, exposure to violent individuals, and the absence of strong workplace
violence management programs and protective rules and regulations are all hurdles to
eliminate violence against healthcare workers. The risk factors for violence may vary from
hospital to hospital and in home care settings, depending on size, location and type of care and
facility. Violence may occur anywhere in a hospital. A great number of nurses work outside the
hospital in high-risk public sector healthcare settings such as prison and jail medical units, drug
and alcohol residential treatment facilities, or as visiting nurses. Similarly, Domestic disputes of
patients or visitors, insufficient security measures and mental health of personnel on site, long
wait times or overcrowding in the waiting areas. These factors eventually play a vital role in
increasing the rage of healthcare settings and the chances of fatal attacks on health-care
workers.
A thorough case study of different regions provides a guiding light and trends of violence in
different regions.
Firstly, war on terrorism has brought myriads of trouble for Pakistan. After engaging in it for
more than twenty years, Pakistan has lost nearly 70,000 citizens which include doctors,
paramedic staff, nurses, lady health workers and other health-care staff. Moreover, a $120
billion cost in the name of infrastructure damage is another huge loss for Pakistan. In addition,
a recent study conducted by the International Committee of the Red Cross (ICRC) in
collaboration with the Khyber Medical University and Khyber Pakhtunkhwa health department
in health care centres in Peshawar deduced that 51% of the doctors, nurses, paramedics and
support staff have either experienced or witnessed violence while performing their duties.
Another questionnaire was filled in on-site by trained data collectors for a quantitative study.
Sites were tertiary care hospitals, nongovernmental organizations (NGOs), and ambulance
services. Qualitative data were collected through in-depth interviews and focus group
discussions at the same sites, as well as with other stakeholders including media and law
enforcement agencies. Results were quite discouraging. One-third of the participants had
experienced some form of violence in the last 12 months. Verbal violence was experienced
predominantly (30.5%) than physical violence (14.6%). Persons who accompanied patients
(58.1%) were found to be the major perpetrators. Security staff and ambulance staff were
significantly more likely to report physical violence. Furthermore, private hospitals and local
NGOs providing health services were significantly less likely to report physical violence. Health-
care providers complained about poor facilities, huge workload, and lack of training to deal
with violence. The deficiencies highlighted were mostly inadequate security and lack of training
to respond effectively to violence. Most stakeholders thought that poor quality of services and
low capacity of Health-care providers contributed significantly to violent incidents.
Furthermore, lack of education among general public and failure to communicate important
information efficaciously to patients and their relatives has also been seen as a reason that
provoke violence on health care facilities in Pakistan.
Secondly, conditions are not satisfactory in a place like USA either. Medical staff, doctors,
nurses face serious physical, sexual, and verbal threats on daily basis. Like other regions of the
world, most of the time incidents are not reported and largely ignored. Only 30% of nurses
report incidents of workplace violence. The reporting rate among physicians is just 26%. Under-
reporting is due to a culture that is resistant to the belief that medical workers are at risk of
patient-initiated violence and a reverie in thinking that violence is a “part of the job”.
Furthermore, the highest number of such assaults in U.S. workplaces each year is directed
against health care workers. Between 2011 and 2013, the number of workplace assaults
averaged approximately 24,000 annually, with approximately 75% occurring in health-care
facilities or against medical staff according to the Occupational Safety and Health
Administration (OSHA). In addition, National Crime Victimization survey from 1993 to 1999
showed that 80% of all workplace homicides were carried on with firearms. Between 2000 and
2011, there were 154 shootings with injury either inside or in the vicinity of USA hospitals, 29%
in the emergency department and 19% on inpatient floors. Most of the time the motives
behind the barbarism were revenge, suicide, and mercy killing. Similarly, medical workers
working in a homecare setting are under the most exposed or violent prone position. In
general, 61% of home care workers report workplace violence annually. Presence of weapons
and drugs, family violence, robbery, and car theft are few common threats these workers faced.
Homicide is the second leading cause of workplace death in this group. Despite of the fact that
various safety measures have been taken in the past but the violence against health-care
workers in USA is increasing abruptly like any other region of the world.
Similarly, situations are eventually deteriorating all over the world. In Canada, a survey showed
that in 2005, one-third of Canadian health-care workers providing direct care in hospitals or
long-term care facilities reported physical violence by a patient in the previous year whereas,
half of them reported emotional abuse. Canadian nurses reported high rates of emotional
violence as well as physical abuse in a report that collected data from 43,000 nurses in 5
countries. Furthermore, in Australia, the violence numbers are accelerating at a rapid pace. The
reasons and effects are quite the same when comparing with other regions of the world. In
1999, the Australian Institute of Criminology ranked the health industry as the most violent
workplace in the country. In addition, 4,765 cases of violence and threats had been reported in
2015-16, but in February 2016-17 they were rose to 6,245 in South Australian public hospitals.
According to sources it has been estimated that nearly 95% of health-care workers and staff
have experienced physical or verbal abuse while simply performing their jobs and caring for
others. Violence against healthcare workers, its causes and effects are almost similar in every
part of the world.
In the end, it is imperative to discuss solutions and strategies to cope-up this heinous problem.
First thing first, necessary lawmaking required in this regard to make it illegal to assault a
health-care worker. The law shouldn’t only criminalize the assault but it should also punish the
perpetrators as strictly as possible. As of June 2012, 30 USA states have formalized a criminal
penalty for the perpetrators. The actual statutes and the severity of punishment for assaulting a
health-care worker vary from state-to-state but one thing is common that these laws make a
strong statement that this savagery will not be tolerated. The formulation of healthcare
workers safety law will not only give them protection but it will also provide a code of conduct
to provide better facilities to patients and eventually enhance the quality of service.
Secondly, hospital management should establish periodic workshops to train their staff against
such violence. They should teach them how to avoid a panic situation and in the end, if a
certain unavoidable situation arises they should know how to handle it peacefully and without
raising the aggression. Also, new graduates should enter the stream with some mandatory
standard training to effectively manage both violent situations and workplace havoc. There
should be a panic button in case of a life-threatening situation that will immediately call the
security officer in charge. Similarly, a proper mechanism and guideline are required in reporting
of violence necessary and mandatory by calling spade a spade. A lot of efforts required in
making health-care workers realize that violence is not a part of the job. Also, awareness
campaigns should be started via print and social media to make common people realize that
violence is not an answer to every tragedy. Moreover, criminal negligence on the part of
hospital management should be discouraged. Authorities should make sure that each and every
incident should be reported and get due attention and violence against health-care workers
shouldn’t be taken lightly.
Lastly, as we are living in the 21st century, we should utilize our technological advancements to
handle violence. Closed Circuit Television cameras should be used with 24/7 monitoring of
violence-prone areas like triage waiting and emergency rooms. Metal detectors, walk through
gates and hand-held scanners with additional security personals can be used at entrance points.
The Henry Ford Hospital in Detroit, USA implemented metal detectors in an effort to avoid
assault weapons from entering the facility. In their first 6 months of installations, security
officials confiscated 33 handguns, 1324 knives, and 97 chemical sprays. This shows the
efficiency and capability of these metal detectors and other security equipment.
In the end, it is pertinent to say that workplace violence is a very complex and attention needed
issue. It is essential that violence in any form against anyone is intolerable. Either it is verbal
assault or physical violence or sexual harassment; the violence of any type is condemnable. It is
mandatory on the part of hospitals to devise a violence management strategy. Furthermore,
necessary legislation is required to provide medical workers with viable security. Health-care
workers should understand that violence is not a part of the job. Under-reporting and
negligence have already claimed the lives of thousands of health-care workers around the
world. Moreover, the violence pattern, reason and repercussions are almost the same in every
part of the world, so it is the duty of international organizations like World Health Organization,
International Committee of the Red Cross, Amnesty International and other non-governmental
organizations to formulate a general standardize strategy and coursework to train health-care
workers to tackle aggressive behavior. Similarly, hospitals can take benefit from a security
device like walk-through gates and scanners to keep an eye on possible violence perpetrators.
At last, whatever the preventive measure used and the concrete measures institute, prevention
is certainly the most lucrative way to tackle assault and violence because “An ounce of
prevention is worth a pound of cure”

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