TITLE: ADDRESSING VIOLENCE AGAINST MEDICAL WORKERS.

Abstract:

Over the last few years, there have been several reports on the rising violence against health care professionals. The purpose of this research is to divert readers’ attention to the horrifying treatment faced by doctors, nurses, and other medical staff. The damage that this kind of violence causes major repercussions, and failure to address it may cause this to worsen. Physical violence can instill PTSD (Post traumatic stress disorder) to health care providers. This study investigates the impact that such violent cases have had on the medical professionals and on the medical sector. Most cases of violence are allegedly due to the medical negligence by the doctors, which triggers the patient or their relative. Media reports and blogs indicate that most crimes occur in rural areas with medical sectors with less amenities or government hospitals.

Keywords:

Workplace violence (WPV), Doctor- patient conflict, Harassment, Assault prevention in health care.

Introduction:

“Incidents where staff are abused, threatened or assaulted in circumstances related to their work, including commuting to and from work, involving an explicit or implicit challenge to their safety, well-being or health.” [1] In a country case study by Vittorio di Martino where he surveyed Brazil, Bulgaria, Lebanon, South Africa, and Australia on workplace violence.

Violence in work environment has been prominent since decades. A person whose life is threatened due to the use of physical violence, sexual violence or verbal abuse. Workplace violence occurs in any organization, but health care providers (doctors, nurses and ambulance staff) are the most vulnerable to such work place violence due to their exposure to treating people in distress. Currently, workplace violence has become an unavoidable aspect of health care sector globally. [2]The annual incidence of WPV is four times more in health care industry (8 serious cases per 10,000 full time employees) as compared to other professions (2 per 10,000 full-time employees).

Though there are workplace guidelines and rights to protect its workers, there’s been fewer inquiries and accountability compared to the data of these crimes. Medical professionals lead a stressful life dealing with terminally ill patients and patients who are undergoing life-altering operations. [3]Violence is common against the medical professionals as they are in direct contact with people in anguish. Indian medical association (IMA) conducted a study in India and key findings of the study are as

More than 75% doctors have faced some type of violence and 12% of such attacks have been physical.
82.7% medical staff feel stressed and anxious.
70% of the attacks are committed by patients relative.

Medical workers are the backbone of any nation. They are crucial for having a sturdy nation, and without them, any powerful nation would be in shambles. [4]The Medical profession is the most respected profession in the world. According to the study conducted, most violent attacks were on male Doctors at private hospitals. Most of such attacks took place during the night shift, and 45% of violent attacks took place in an emergency ward. [5]The WHO recognized violence against women in healthcare as health priority and declared strengthening the role of the health system to address the violence against women and bring in positive media attention to the voiceless.

This is not only the condition in India but statistically, they are the most targeted professionals in the world. This leads to doctors and nurses feeling unsafe in their day-to-day life at their workplace, resulting in them being demotivated. Violence against healthcare staff is intolerable. It not only has a huge impact on their psychological and physical security but also damages the health sector a whole due to the dent created by the violence. Medical professionals are also known as frontline workers due to their need and promptness in any threatening situations.

[6]The Indian medical association (IMA) states that according to the study done by them, over 75% of the doctors have faced violence of some kind in their work place. Most of such cases involved the assaulter being the patient’s relative. The medical staff working at government hospitals, last- year medical students and junior doctors bear the brunt of these violent crimes. India’s poorly funded medical sector makes such matter worse; additionally, the over growing population and improper management due to limited medical staff has potentially threatened the overall medical sector industry of the country.

Research Methodology:

This research aims to understand the nature of assaults on doctors and nurses. It gathered data from sources including blogs, articles journals and websites which surveyed the healthcare professionals and their encounter with violence at workplace. This research is combined with data from interviews of affected doctors and nurses and news articles reported in the news.

Review of Literature:

The Ministry of Health and Family Welfare (MoHFW) proposed a central bill, ‘The healthcare service personnel and clinical establishments (Prohibition of violence and damage to property) Bill (2019)’. This bill promises imprisonment for 6 months to 7 years with a fine of 50,000-5,00,000 INR and in cases of major grievous injury, fine of 2,00,000-10,00,000 INR along with 3-10 years of imprisonment.

[7]WHO, ILO, ICN and PSI came together and developed A Framework guideline for addressing workplace violence in the health care sector. This framework was to make policies to prevent violence. In addition to this, they made study protocol to research the vast consequences of such violence in medical sectors.

The Indian Penal Code, 1860 (IPC) provisions, especially Section 323, 325, 352, 506, function as a resort, and as far as property damage is concerned, Section 425 is also imposed.

Sec 323 Punishment for voluntarily causing hurt.

[8]Whoever, except in the case provided for by section 334, voluntarily causes hurt, shall be punished with imprisonment of either description for a term which may extend to one year, or with fine which may extend to one thousand rupees, or with both.

Sec 325 Punishment for voluntarily causing grievous hurt.

[9]Whoever, except in the case provided for by section 335, voluntarily causes grievous hurt, shall be punished with imprisonment of either description for a term which may extend to seven years, and shall also be liable to fine.

Sec 352 [10]Whoever assaults or uses criminal force to any person otherwise than on grave and sudden provocation given by that person, shall be punished with imprisonment of either description for a term which may extend to three months, or with fine which may extend to five hundred rupees, or with both.

Sec 425 [11]Mischief may be committed by an act affecting property belonging to the person who commits the act, or to that person and others jointly.

Sec 506 of the IPC states [12]Whoever commits, the offence of criminal intimidation shall be punished with imprisonment of either description for a term which may extend to two years, or with fine, or with both.

Due the spike in violence against health care workers in the southern India, [13]the Medical Association’s (IMA) Sulphi Noohu, the Kerala president, released a statement: “At least five cases of attacks on doctors are reported every month in Kerala and more than 200 such attacks, including intimidation and threats, have been reported in the past three years,”

The National Institute for Occupational Safety and Health defines Workplace violence (WPV) as [14]“an act or threat of violence on a spectrum that ranges from verbal abuse to physical and even lethal assault towards persons at work or on duty.” In India there were 225 incidents in 2020 and 110 incidents in 2021 these cases have severely increased after the COVID – 19.

The apex court, in Jerryl Banait v. UOI on 8^th April, 2020.

In this case, the doctor was attacked and faced stone pelting while he was screening patients. Here the court stated and directed that

[15]“It is the duty of the government of India and the state/Union Territories police authority to provide police security when necessary to the doctors and the medical staff in hospitals where patients have been diagnosed by covid 29. The state shall take necessary actions against persons who commit violence when doctors or medical staff is on duty.”

There are several cases that gained attention due to the rise in violence against medical workers. One such case, for instance, is the Abdul Naser v. state of Kerala on 12^th February, 2020.

The gravity of injury that doctor/hospital employee sustained.
The damage caused to the property.
The circumstances in which these acts were committed.[16]

These circumstances can help one understand the grievances of the offence and the remedies that should be taken after the violent act has occurred.

[17]In Thiruvananthapuram, Kerala Dr. Vandana Das was killed by an intoxicated patient that was brought in by the Kerala police for medical examination at the Kottarakkara Taluk Hospital. The young house surgeon was stabbed over six times, leading to the wounds on her back and abdomen which resulted in her death.

The following are the news reports reporting violence against healthcare professionals:

[18]In 2019, a junior doctor was attacked in West Bengal, leading to a mass resignation of doctors as a sign of protest. This attack was due to the death of a patient, the family alleged medical negligence by the medical staff.

[19]In 2019, Father and 17-year-old son beat up medical officer when they were asked to wait for nurse to return before giving the tetanus injection at Sub District Government Hospital, Kamptee, Maharashtra.

[20]On September 1^st, 2019, ‘73-year-old Assam Doctor Dies After Being Beaten Up by Tea Garden Workers Over Colleague’s Death’ News18, (New Delhi, 1 September 2019).

[21]On august 12^th 2019, ‘Doctors, Nurses Assaulted After Death of Patient at Govt Hospital in Kolkata’ wrote a media outlet. Doctors and nurses of State Run SSKM Hospital, Kolkata assaulted by family member of patient.

A study of workplace violence experienced by doctors and associated risk factors was conducted in a tertiary care hospital of South Delhi, India.

[22]151 doctors participated in this study and they all reported having experienced violence in the past 12 months during their working hours. 39.4% reported violence from the Department of Obstetrics and Gynaecology, while surgery and medicine reported 29.6% cases, and other departments reported around 26.8% and 4.2%. Most cases involved patients or their relatives who assaulted the doctors. It’s also noted in this survey that junior doctors were more prone to such violence due to their lack of experience. This study also takes into consideration the time of violence: 35.1% of such cases occurred during the afternoon while 30.1% took place at night.

Method:

Types of violence faced by health care workers

Workplace violence in health care system is understudied because there’s no specific type of violence that can take place in health care places; there could be various. The National Institute for Occupational Safety and health defines Workplace violence (WPV). Various types of WPV are divided on the basis of the nature of the aggression by the assaulter. Violence can have major consequences such as:

Physical

Physical force used against a person or group to cause harm or show dominance, which results in physical or psychological injury. Patients undergoing treatments with mental health issues can be easily triggered in an unknown environment. This leads to patients acting up and physically abusing the health care worker. For example, slapping, beating, shooting or stabbing with any sharp objects.

Verbal

Verbal violence is the most encountered violence in the health care sector. Verbal threats, bullying or humiliating an individual in front of others. Using racial slurs or threatening them to instill fear of physical or sexual violence.

Psychological

All kinds of violence, like sexual, racial, mobbing, assault, harassment and threat can induce psychological threats against the health care workers. Individuals in this instance can suffer from anxiety, depression and other mental disorder. Psychological impact can affect the overall performances of the individuals. It also demotivates them to treat all patients equally.

[23]WPV can be further classified

Type 1 refers to acts of violence that are associated with crime such as terrorism and thievery
Type 2 includes violence by patients in the health care facility, former patients, or their visitors.
Type 3 includes violence by their work colleagues or helping staff.
Type 4 includes violence against an employee due to personal grudges.

Effective preventive measures include enhanced visibility through improved lighting, transparent doors, and CCTVs. Security of the environment may be improved with door locks, secured furniture, and weapons screening such as metal detectors. Studies have shown environmental preventive measures decrease the incidence of Type I WPV and produce a 50% reduction in the number of weapons brought to the ED.

Reasons and causes behind resorting to violence:

Violence is usually triggered due to psychological distress. Unstable mental health can lead to impulsive acts that can be heinous or injurious to themselves or others. Patients or their relatives can be shock or distress due to the accident or illness. This can set off a behavior they have never experienced, acting up in such situations can set off conducts that puts one’s life in danger unconsciously.
Certain societal factors like poverty, unemployment and crime rate can lead to violence in the area of a health care facility.
Usage of drugs/alcohol can lead patients that are addicts have severe withdrawal symptoms which makes them impulsive in nature.
Overcrowding or hospitals, shortage of medicines, poor infrastructure and poor working conditions. In India, there were 225 incidents in 2020 and 110 incidents in 2021. These cases have severely increased after the COVID – 19

Suggestions:

‘Framework guidelines for addressing workplace violence in the health sector’ by the World Health Organization (WHO) provides guides to tackle such grievances. These guidelines include protocols, emergency alarm systems and emergency codes that can help in emergency cases. Their recommendations like healthy work environment and management policies to ensure medical staff to ask for help when needed.[24] “Over-privatization with major elements of secondary and tertiary care being provided by for-profit health care providers has led to escalating costs and significant out-of-pocket expenditures on health care,” said a medical superintendent and critical care specialist at Holy Family hospital.

Interventions for Workplace Violence Prevention in Emergency Departments

[25]Enhancing safety measures involves several effective strategies that focus on improving visibility and security in the environment. One crucial aspect is to enhance visibility by installing better lighting throughout the premises. Adequate lighting not only creates a safer atmosphere but also improves overall surveillance and monitoring capabilities. Another essential measure is the installation of transparent doors enhance transparency and visibility within the facility. Transparent doors facilitate easier monitoring of activities and discourage illicit behaviors by promoting a sense of openness and accountability. The implementation of Closed-Circuit Television (CCTV) systems further strengthens security measures by providing continuous surveillance and recording of activities. CCTVs act as a curb against potential violence and enable prompt responses to incidents, thereby contributing significantly to maintaining a secure environment Moreover, ensuring the physical security of the environment involves using robust door locks and securing furniture to prevent unauthorized access and minimize the risk of theft or violence. Secured furniture not only enhances safety but also promotes a sense of stability and orderliness within the premises. Additionally, employing weapons screening technologies such as metal detectors play a crucial role in enhancing security protocols. Metal detectors effectively detect concealed weapons and discourage individuals from carrying weapons into the emergency room, thereby significantly reducing the incidence of violent incidents. Research has demonstrated that comprehensive environmental preventive measures can lead to a substantial decrease in Type I Workplace Violence (WPV) incidents. Specifically, such measures have been associated with a remarkable 50% reduction in the number of weapons brought into emergency department settings. By adopting these proactive strategies, healthcare facilities can create safer environments for both patients and staff, promoting a culture of security and well-being.

Theres a financial burden on Families who are forced to sell their land or other assets to cover their medical expenses at private hospitals. They are in financial burden which makes them expect better outcomes. Their mindset shifts due to their economic conditions. Health care has become a luxury for the majority of the people and not a right. Health care is easily accessible to people who can afford it and that isolates the ones who are financially unfit. Verbal abuse, which leads to psychological, abuse escalates when the patients are anxious about the financial aspect of the treatment. Vikas Bajpai, Public Health Physician, stated, [26]“What you need is a health system that is responsive to people’s health needs in conformity with their dignity. Junior doctors end up bearing the brunt because they are the first in line of duty and manage the medical emergencies where such incidents are most reported.”

Conclusion:

In India, the limited data available on violence against medical professionals reveals disturbing trends. Surveys and studies highlight the severe mistreatment faced by frontline workers. Media reports frequently document crimes against doctors and hospital staff, yet this crucial issue often lacks sufficient attention. Addressing this problem requires a quick action from authorities. Meaningful change hinges on rebuilding public trust and improving healthcare accessibility in rural areas is a place to start making the change.

To effectively battle this ongoing issue, media campaigns are essential. Sharing testimonials from doctors and nurses who have endured violence can foster empathy among patients and their families. This approach has the potential to restore faith in the healthcare system and reduce such heinous crimes. In conclusion, while stricter laws are necessary, their effectiveness lies in stricter enforcement. Additionally, initiatives such as enhancing healthcare infrastructure and raising awareness through media campaigns are vital steps towards safeguarding healthcare workers and promoting a safer environment for all.

Ms. Susan Varghese

Dr. D.Y Patil College of Law, Navi Mumbai.

[1] Workplace violence in the health sector, synthesis report by Vittorio di Martino

[2] Pattern of workplace violence against doctors practicing modern medicine and the subsequent impact on patient care PMC (nih.gov)

[3] Pattern of workplace violence against doctors practicing modern medicine and the subsequent impact on patient care PMC (nih.gov)

[4] Choose A Career In Medicine And Become A Doctor -LAU (laumed.org)

[5] Preventing violence against health workers (who.int)

[6] Pattern of workplace violence against doctors practising modern medicine and the subsequent impact on patient care, in India – PMC (nih.gov)

[7] Preventing violence against health workers (who.int)

[8] Section 323 in The Indian Penal Code, 1860 (indiankanoon.org)

[9] Section 325 in The Indian Penal Code, 1860 (indiankanoon.org)

[10] . Section 352 in The Indian Penal Code, 1860 (indiankanoon.org)