A study on perceptions of Doctors on violence againsthealthcare workers in India

Introduction

Since long time, especially in India, doctors and the services rendered by them have been considered holy. But slowly due to many factors, this image of the profession has not just vanished but started degrading further with time. As a result, attacks on doctors and healthcare workers has been on rise in third world countries like India.¹ According to a study by the Indian Medical Association, over 75% of doctors have faced violence at work.² Though many professions have risk of facing violence, health workers are at a high risk around 8%-38% of health workers, at some point in their careers suffer physical violence.³

Violence against health workers is unacceptable. Doctors facing violence have been effected both psychologically and physically.⁴ While physically some of the injuries are grievous, psychologically they developed depression, insomnia, posttraumatic stress and even fear and anxiety causing absenteeism. It not only has an impact on the psychological and physical well-being of health-care staff, but also affects their job motivation.² Among the various groups of health workers, it is mostly the residents that often face more of such attacks. Lack of communication, no communication, or the way they communicate with the patients and their attendants, particularly when the patient is sick, often becomes the reason for such attacks.⁵

As a consequence, this violence compromises the quality of care and puts health-care provision at risk. Hence the study has been done with an aim of understanding the perceptions of residents regarding causes and the necessary steps to be taken against violence.

Materials and methods

In depth interviews were conducted with residents of a Government medical college in Karnataka. Discussions were audio recorded. A total of 30 participants consented and took part in the discussion. Participants were given an option to either attend the interview personally or telephonically. Once the mode of interviewing, date and time was fixed, they had been explained the purpose of the study. Participants were assured of confidentiality. Certain ground rules were set prior to start of the discussion. Participants were not forced to share any information they were uncomfortable with and any misconceptions prevailing were clarified before the closure of discussion.

For coding and generation of coding tree Atlasti 7.0 trial version was used. Verbatim transcripts of the interviews were prepared. Transcripts were imported to Atlasti 7.0 and thematic analysis was done. Codes were generated and the initial code list was prepared. Similar codes were merged and the list of codes was revised. Charting of codes with the respective responses and mapping of codes (coding tree) was done using software. Data was interpreted under respective themes.

Results

Forms of violence: Participants stated that though physical abuse is the most highlighted, while speaking about the violence faced by healthworkers, it is usually the other forms that are more prevalent. Many felt that verbal abuse is the most common type of violence, which is faced by healthworkers not only from the patients and their attendars but also from their superiors or any other staff. Some of them opined that its not the physical or verbal form, anything that makes a person feel awkward, effecting him psychologically or emotionally, hindering his performance at work must be considered as violence. (Fig1)

“Violence could be physical, it can be psychiatric or emotional. It can be in terms of abstract things. Physical harm like hitting, beating, slapping or even tend to harm like verbal violence. These are the various types of violence that I think can happen with healthworkers.”

“Forcing someone to do something that is difficult for him or beyond his scope is also a form of violence, kind of emotional violence.See I m not a all in one specialist still. If patient cant see the difference and expects me to do everything that every specialist does, how can i? General public do not understand that there are different speacialists for different problems.”

Causes of violence

Most of them stated lack of communication skills as the first reason. They felt communication is a very important tool to achieve success in the field, lack of which can cause a lot of hurdles. Insufficient time, patient load and hectic schedules were considered to be important reasons for doctors getting irritated at work. No matter how many years they spend serving in hospitals, sometimes minor mistakes committed either due to rush or patient load would account to negligence. Inadequately trained health staff would be added pressure leading to outrage among public easily. Lack of awareness among public, illiteracy, financial constraints and emotional outrage due to loss of their loved ones are also important causes for the violence seen in India most commonly. They felt many a times its not only the patient s attendars or doctors mistakes that lead to such circumstances instead lack of infrastructure, facilities, absence of security personnel and other administrative issues especially in government setup also contribute and hence the attacks are more seen in public sectors as compared to private. Some of them have felt declining trust on doctors and the profession itself as a whole is contributing to incresing attacks. (fig. 2)

“Private people have good security, big infrastructure, legal cell, and legal advisor. But you know this is not the case with government sector. Government set up like PHC if you see, they don’t have the basic infrastructure, they don’t have basic drugs and the shortage is so much that they are working only with 30-40% of the manpower. Because the patient doesn’t know all this. He thinks that if he goes to the PHC, he should get everything.”

“There are various reasons, there are various factors. Patient factors, administrative factors, lack of political commitment the most important is government expenditure on health is too less.”

Participants felt long working hours exhausts the healthcare workers. So scheduled working hours with adequate rest would be less strainful and allow them to communicate better. Adding and training medical graduates in communication skills during their curriculum is necessary. Apart from these providing adequate logistics, manpower, superior’s support, security personnel, restricting patients attendants are some of the administrative issues that would help to curtail the problem. Increased awareness and health literacy among people and media is also required.

“See if an intern or postgraduate works continuously for 2 or 3 days, what would be his mindset after such hectic work? how do you not expect him to loose his cool at work?”

“If everyone in the hospital does their own duty like what a nurse has to do must be done by her, what a group d has to do must be done by him and ultimately what a doctor has to do he ll do that if he is provided with all the necessary supporting staff. If doctor has to play the role of nurse, group d everyone where the time for him to do what his work is in actual?”

Discussion

Workplace violence has been defined by the World Health Organization as 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.⁴ Workplace violence has become very common among health professionals throughout the world, though the causes and the action taken against it remain varied from region to region. Healthcare workers by nature of their job are more exposed to this risk of violence. Lot of factors are involved in this increased risk and they remain unique to healthcare field. Working with people in distress, working in conditions of special vulnerability, working with inadequate infrastructure and staff are some of the main factors responsible for the situation.⁶ It has been estimated that healthcare workers are four times more likely to be injured and in India, up to 75% of the doctors have been victims of assault at some time during their work.⁴ Another study revealed as high as 69.5% resident doctors had experienced some kind of workplace violence.⁷

Abuse can be many forms though most cases discussed are almost always about physical violence. It may be in the form of telephonic threats, intimidation, oral/verbal abuse, physical but not injurious assault, and physical assault causing injury, murder, vandalism and arson. In the current study many participants had mentioned verbal form as the commonest which is similar to many other studies done in India.^4,7 According to a study done in Delhi, 87.3% of the violence that the doctors faced was verbal while only 9% reported of facing physical violence.⁸ As per WHO verbal form of violence is more common as compared to physical.³

On one side are illiteracy, lack of trust on treating doctors and emotional aspects from patient’s and on the other side are lack of communication skills, negligence, inadequately trained staff and administrative issues from the health sector were reflected as a trigger points for the outbreaks of such violence in the current study. In public hospital, often due to deficiency of staff, patient s attendants are required not only for arranging medicines in emergency but also for various patient-related work ranging from biological sample delivery to laboratory, collection of reports, shifting of patients for various tests, pulling the trolley having patient, providing bed pan, watching the IV fluid administration, Ryle's tube feeding, providing exercise to patient, and so on.⁵ Government hospitals also suffer from some of the administrative issues like overcrowding, long waiting period, shortage of staff dysfunctional equipment and suboptimal infrastructure and thus the need for multiple visits, absence of a congenial environment, lack of beds for admission, poor hygiene and sanitation that further aggravate the situation.⁴ Doctors facing violence have been known to go into depression, develop insomnia, post-traumatic stress and even fear and anxiety causing absenteeism.² Hence it is necessary to take strict action to prevent such incidences.

Only 106,415 doctors are employed by the Government in India, of the 938,861 doctors registered to provide healthcare to a population of over 1.2 billion. Of these, only 27,355 are posted at primary health centers, which typically serve the rural population.⁴ Most importantly availability of adequate number of human resources who are well trained is essential for providing effective healthcare services for the population.⁵ Preventive measures to improve the work environment, work organization and interpersonal relationships at the workplace like conduct of regular meetings, an emergency bell which alerts the staff, continuous surveillance, fixed meeting hours, security personnel etc can help to reduce such tragic events and also protect the sanity of hospital environment.^6,9

Conclusion

Verbal abuse is the most common form of violence. Strengthening the communication skills of young professionals, adequate well trained staff and a violence prevention policy are some of the important measures that helps in curtailing such events.