Violence against health care workers and its impact on career choices among medical interns: a cross sectional study

INTRODUCTION

According to the WHO framework guidelines (2002), “Workplace violence is defined as the situations where staffs are ill-treated, intimidated or attacked in conditions linked to their workplace, including commuting to and from the workplace, involving an explicit or implicit challenge to their safety, well-being or health”.¹ It can be physical violence or psychological violence or a combination of both. It can be in any form like assault, abuse, bullying, mobbing, harassment either sexual or racial or psychological threat.¹ Among various professions, Health Care professionals are faced with an alarmingly high rate of violence these days.² In comparison with other professions, health care workers face four times greater risk for workplace violence.³ Violence against healthcare workers is not new, but in recent times, it has grown up in epidemic proportions. Violence among health care workers has been a topic of alarming concern not only in the Indian subcontinent but all over the world.⁴ In the United Kingdom, one-third of healthcare workers had faced violence at the workplace.⁵ In Asia, violence against medical professionals has been reported majorly from countries such as India, China, Israel, Pakistan, and Bangladesh.^6-10 The Indian scenario is even disheartening. In India, almost 75% of the doctors had dealt with one or the other form of violence during their practice.¹¹ According to the reports of Indian Medical Association, over 80% of doctors are stressed out in their profession and nearly 56% don't sleep comfortably for even 7 hours a day.¹² The nature of violence against healthcare workers in India is different from the scenario in Western countries due to many reasons. In India, violence perpetrators are mainly patient relatives and sympathizing strangers.¹³ In India only 40.8% of the health expenditure is borne by the government whereas the remaining expenditure is borne by the people themselves.¹⁴ Lack of a generalized Health Insurance system for health care provision is a major reason for the inadequate delivery of healthcare services which leads to various complications in patients which in turn serves as a catalyst for violence against healthcare workers.¹⁵ Unexpected healthcare expenses often push families into a load of debt and financial instability. Being burdened by the enormous debts and the ailment of the loved one, delivery of a bad news by the healthcare workers turns into verbal abuses against the healthcare workers which easily escalate to physical violence. However, in the western world, financial trouble is not the major causal factor as a great part of the healthcare expenditure is borne by the government.¹⁶ The majority of the incidents occur at night time, in intensive care units and psychiatric wards. The perpetrators are usually the patients who are under the influence of drugs, alcohol or psychiatric patients.^17,18 This study aims at evaluating the awareness about violence against healthcare workers among Medical Interns and to assess the impact of the current rising trends in violence against healthcare workers on the minds of Medical Interns.

METHODS

This study has been carried out as a descriptive-cross sectional study for a duration of 2 months (July to August 2021) at a tertiary healthcare centre in Kanniyakumari district of Tamil Nadu. From the study. There have been no similar studies from Tamil Nadu, so we assumed p=50% and take 10% as absolute precision at 95% confidence interval which yielded a sample size of 100. Selection criteria included medical interns pursuing their CRRI (Compulsory Rotatory Residential Internship) from 2 medical colleges in Kanniyakumari district, Tamilnadu. Therefore we selected 100 Medical interns by simple random sampling. A 16-item predetermined; pre-tested, semi-structured questionnaire was adapted onto an online questionnaire format using Google Forms. After getting informed consent, the participants were given access to fill the questionnaire. There were no incomplete entries. The data thus obtained was extrapolated onto Microsoft Excel sheet and descriptive statistical analysis was done using SPSS version 22.

RESULTS

The age distribution of the study group ranges from 21 to 27 years. 69% (69) of the study population were female whereas 31% (31) were male.

Awareness about violence against healthcare workers most prone for violence

68% (68) of the study population said that interns are the most prone victims for violence against healthcare professionals whereas 26% (26) chose Junior residents, 4% (4) chose Senior consultants and 2% (2) of them chose nurses to be the most prone victims for violence against healthcare professionals. 37% (37) of them said that male healthcare professionals are more prone for violence whereas 13% (13) of them said that female healthcare professionals are more prone fore violence. The remaining 50% (50) said that both genders are affected equally. Among the various departments in the hospital, 91% (91) thought that Casualty/ER is the most common department to be associated with work place violence. The remaining responses have been elaborated in (Figure 1).

Reason for violence

Total 73% (73) of the study population thought that unexpected death of the patient is the most common reason for violence against healthcare workers. 73% (73) considered unexpected complications, 50% (50) thought procedures not being explained properly to the patients/bystanders, 33% (33) thought extended stay, 38% (38) thought very high hospital charges and 24% (24) thought bad service at the hospital are the main reason for violence against healthcare workers.

Hospital setup and workplace violence

Total 57% (57) of the study population thought that government run primary health care centres and community health care centres are the most common hospital setups where violence against healthcare workers occurs. 14% (14) chose private clinics, 13% (13) chose Government run tertiary healthcare centres, 12% (12) chose nursing homes and 4% (4) thought corporate multispecialty hospitals were more prone for violence against healthcare workers.

Impact of violence against healthcare workers on the attitude of medical interns

Attitude towards rising violence: 41% (41) of the study population felt anxious about the current rising trends in violence against healthcare workers. 53% (53) felt sad. 73% (73) felt disappointed and 67% (67) felt angry over the current rising trends in violence against healthcare workers. 78% (78) of the study population were aware of laws related to violence against healthcare workers whereas 22% (22) of the study population had no knowledge about the laws related to violence against healthcare workers.

Alternate approach to bypass violent behavior: On a question about alternate approaches that can be adopted by the bystanders instead of opting for violence, 49% (49) of the study population suggested the patients/bystanders to file a police complaint and deal with it legally. 47% (47) of them suggested they complain to the hospital management/HRD. 62% (62) suggested the bystanders to have a calm and clear conversation with the panel of doctors. 49% (49) of them suggested that a team of grief counsellors should convey bad news to the bystanders in a gentle manner. Experience among medical interns: 10% (10) of the study population have been victims of violence against healthcare workers whereas 27% (27) of the study population have been witnesses to violence against another healthcare worker. Response to a scenario of violence: In a question about the most probable reaction of the medical interns if faced with a situation of workplace violence, 37% (37) of the study population said they would try to defend themselves, 23% (23) of them said they would call the police, 20% (20) of them said they would seek help from the nearby people and 20% (20) of them said that they would run away and escape from the place. Impact on future plans: On a question, whether the current rising trends in violence against healthcare workers has impacted their decision about their future career plans, 80% (80) said that the current rise in violence has made an impact over their decision regarding future career plans, whereas 20% (20) have said that the current rise in violence against healthcare workers has no impact over their future career plans. Out of the 80% who have decided to change their future plans, 30% (24) of them prefer to pursue their medical career abroad, 23.75% (19) wants to work in government hospitals, 15% (12) of them prefer to work in corporate hospitals, 11.25% (9) of them have decided to pursue non-clinical PG courses , 8.75% (7) of them prefer to join administrative services such as IAS, 6.25% (5) of them want to quit medical career altogether and pursue a different career and 5% (4) of them prefer to run their own clinic (Figure 2). Preference of workplace among interns: In a question regarding the scenario where the interns were asked to choose a place to work in the current circumstances, 46% (46) of the study population preferred to work in corporate hospitals, 33% (33) of them prefer to work in Government owned tertiary healthcare centres, 11 (11) percent of them prefer to work in government run PHC/CHC and 10% (10) of them prefer to start their own private clinic.

Steps to prevent violence against healthcare workers

On a question regarding the steps that can be taken to prevent workplace violence, 90% suggested that allowing only one bystander per patient will help to prevent violence against healthcare workers. 86% suggested restrictions of visitor entry into Casualty. The other suggestions to prevent workplace violence are listed in (Figure 3).

DISCUSSION

Kesavan et al in their study, ‘workplace violence against healthcare professionals’ in Chennai concluded that workplace violence against doctors is frequent although in most of the situations it is psychological and healthcare staff should be trained to identify, manage and prevent violent situations and also pointed that that a nationwide law for the prevention of violence against healthcare professionals and institutions should be developed.¹⁹ Similarly in our study 84% (84) of our study population suggested that healthcare professionals should receive adequate self defense training in order to tackle situations of workplace violence. Prathiba et al in their study

‘Violence against health care providers’ in Thoothukudi district , Tamil Nadu concluded that increasing number of violence against Health Care Providers is attributed to the communication gap between the patients and doctors which can be bridged by improving the communication skill of Healthcare professionals.²⁰ However in our study, most of the participants (73%, 73) suggest that the most common cause for workplace violence against healthcare professionals is unexpected death and untoward complications occurring to patients admitted to the hospital and majority of them (92%, 92) suggested that enhancing the security coverage in hospitals will help alleviate the outbreak of workplace violence against healthcare professionals. Furthermore Garg et al conducted a study, 'Low reporting of violence against health-care workers in India in spite of high prevalence’ in India and concluded that sensitising workshops should be conducted to increase the level of awareness, which will result in reduction in the prevalence of violence and building a safe and secured workplace for health-care providers.²¹ Similarly in our study 92% (92) of the participants suggest media sensitisation and 86% (86) of them suggest putting up awareness messages such as posters will help to bring down workplace violence against healthcare professionals. Vento et al in their study, ‘violence against healthcare workers: a worldwide phenomenon with serious consequences’ stated that all workers have a right to be safe on their job, and healthcare workers are no exception; the idea that violence is inherent to doctors and nurses’ work, especially in certain departments, needs to be fought; urgent measures must be implemented to ensure the safety of all HCWs in their environment, and the needed resources must be allocated.²² They also specified that the failure to do so will worsen the care that they are employed to deliver and will ultimately negatively affect the whole healthcare system worldwide. Our study adds to the results of Vento et al by bringing out the negative effect of the increasing WPV against healthcare workers which are the career change plans among interns and their lack of interest towards working in government hospital setups. Malarout et al conducted a study 'Factors contributing to workplace violence against doctors in a tertiary care teaching’ in South India and concluded that doctors need to ensure effective communication with their patients and periodic updates to the patient party regarding the condition of the patient should be ensured.²³ But in our study, majority (88%, 88) of the participants suggest that hospitals should recruit a team of grievance counsellors who should be responsible for explaining the condition of the patient to the bystanders in an acceptable way rather than the concerned doctor alone explaining the news to the bystanders. This will help to decrease the stress upon the attending doctors. Kaplan et al did a study ‘Violence against health care workers’ in Turkey, and emphasized that the reasons for the violence need to be identified, and the measures should be discussed with health care workers and professional organizations and should be put into practice.²⁴ In our study we have found out that unexpected death of patient, unexpected complications in patients, conditions/procedures not explained properly, extended hospital stay, increased cost of hospital stay and bad service in hospital are the common causes for the outbreak of workplace violence against healthcare professionals and we have also arrived at various ideas for alleviating the rise of WPV against HCW. Chauhan et al conducted a study, 'Preventing violence against health-care workers and vandalism ’in India, among doctors and they found out that by improving the emergency care in hospitals can minimize the chances of violence against health care workers.²⁵ However from our study we can conclude that in addition to improving the facilities in the ER, restricting the entry of bystanders into the ER wing will also help to decrease the workplace violence against healthcare workers. Thus, to prevent the incidence of workplace violence against healthcare workers we, not only have to improve patient care in the hospital but also have to strengthen security in hospitals and make sure the communication between the team of doctors and the bystander occurs in a smooth manner. Kumar et al in their study, ‘A survey on workplace violence experienced by critical care physicians’ concluded that a large number of their study population had to change their place and pattern of work due to WPV.²⁶ In our study we have brought out the impact of violence against healthcare workers in the minds of the future doctors of this society, the Medical Interns and we have found out that majority of them are planning to immigrate to foreign countries to pursue their career and a significant number of interns are planning to quit this profession and only a handful of the participants are willing to work in government hospitals. This reiterates the negative impact of violence against healthcare workers in the minds of medical interns

Limitations

The cross-sectional design only captures a snapshot of intern perspectives, preventing the establishment of causal relationships or long-term trends. The study's scope was confined to medical interns in two medical colleges in Kanniyakumari, limiting the broader applicability of findings. Also, the reliance on self-reported experiences of workplace violence may introduce bias, as perceptions and interpretations can vary among respondents.

CONCLUSION

Our study has shown that a considerable number of interns are not willing to work in government hospitals and majority of them are planning to immigrate abroad for their further studies. This will adversely affect the healthcare standards in the country especially in rural areas. Therefore, appropriate steps should be taken to safeguard the healthcare workers employed in all forms of healthcare set-up. Thus, our study has brought out the various causes of violence against healthcare professionals, which category of healthcare professionals are affected the most, its impact in the minds of medical interns and various ideas that can be implemented to prevent violence against healthcare professionals.

Recommendations

A multicentric study involving interns from different medical colleges all over the country can help us to understand further regarding the impact of violence against healthcare workers on the career choices of medical interns.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

REFERENCES

1. 1. Framework guidelines for addressing workplace violence in the health sector. Available at: https://www.who.int. Accessed on 20 February 2023.
2. 2. Warren B. Workplace violence in hospitals: safe havens no more. Journal of healthcare protection management. Int Assoc Hospital Secur. 2011;27(2):9-17.
3. 3. Kader SB, Rahman M, Hasan M, Hossain M, Saba J, Kaufman S, et al. Workplace violence against doctors in Bangladesh: a content analysis. Front Psychol. 2021:5535.
4. 4. Goodman RA, Jenkins EL, Mercy JA. Workplace-related homicide among health care workers in the United States, 1980 through 1990. JAMA. 1994;272: 1686-8.
5. 5. Pitcher G. BMA survey finds one-third of doctors attacked physically or verbally in 2007. Occup Health Stress Wellbeing. 2008;10:45-9.
6. 6. Mercy T. Chinese doctors are under threat. Lancet. 2010;376(9742):657.
7. 7. Imran N, Pervez MH, Farooq R, Asghar AR. Aggression and violence towards medical doctors and nurses in a public health care facility in Lahore, Pakistan: A preliminary investigation. Khyber Med Univ J. 2013;5(4):179-84.
8. 8. Mirza NM, Amjad AI, Bhatti AB, Shaikh KS, Kiani J, Yusuf MM, et al. Violence and abuse faced by junior physicians in the emergency department from patients and their caretakers: a nationwide study from Pakistan. J Emerg Med. 2012;42(6):727-33.
9. 9. Derazon H, Nissimian S, Yosefy C, Peled R, Hay E. Violence in the emergency department. Harefuah. 1999;137(3-4):95-101.
10. 10. Hobbs FD. Fear of aggression at work among general practitioners who have suffered a previous episode of aggression. Br J Gen Pract. 1994;44(386):390-4.
11. 11. Dey S. Over 75% of doctors have faced violence at work, study finds. Available at: https://timesofindia.indiatimes.com/. Accessed on 20 February 2023.
12. 12. Dora SS, Batool H, Nishu RI, Hamid P. Workplace violence against doctors in India: a traditional review. Cureus. 2020;12(6).
13. 13. Ghosh K. Violence against doctors: a wake-up call. Indian J Med Res. 2018;148(2):130.
14. 14. Govt health expenditure share in GDP increases from 1.15% to 1.35. Available at: https://www.business-standard.com/article/economy-policy/govt-health-expenditure-share-in-gdp-increases-from-1-15-to-1-35-121112900520_1.html. Accessed on 20 February 2023.
15. 15. Fixing India's healthcare system: Strong political commitment is needed to build a system of universal health coverage and better regulations. Available at: https://www.businesstoday.in/current/policy/govt-cuts-health-budget-spending-near-20-percent-for-fy15/story/213819.html 2014. Accessed on 20 February 2023.
16. 16. Hobbs FR, Keane UM. Aggression against doctors: a review. J Royal Soc Med. 1996;89(2):69-72.
17. 17. Ferri P, Silvestri M, Artoni C, Di Lorenzo R. Workplace violence in different settings and among various health professionals in an Italian general hospital: a cross-sectional study. Psychol Res Behav Manage. 2016;9:263.
18. 18. Hobbs FD. Violence in general practice: a survey of general practitioners' views. Br Med J. 1991; 302(6772):329-32.
19. 19. Kesavan R, Jia H, Fang H, Chen R, Jiao M, Wei L, et al. Workplace violence against healthcare professionals in a multiethnic area: a cross-sectional study in southwest China. BMJ. 2020;10(9):e037464.
20. 20. Surya PV, Kannan K, Anandan H. Study on Violence against Health Care Providers. Br Med J. 2019;23:31-8.
21. 21. Garg R. Low reporting of violence against health-care workers in India in spite of high prevalence. Med J Arm Forces India. 2019;75(2):211-5.
22. 22. Vento S, Cainelli F, Vallone A. Violence against healthcare workers: a worldwide phenomenon with serious consequences. Front Public Health. 2020;8: 541.
23. 23. Malarout N, Kamath R. Factors contributing to workplace violence against doctors in a tertiary care teaching hospital in South India. Med J Arm Forces India. 2019;13(3):108.
24. 24. Bekir K, Kannan RER, Anandan H. Study on Violence against Health Care Providers. Br Med J. 2015;12:32-8.
25. 25. Chauhan V, Galwankar S, Kumar R, Raina SK, Aggarwal P, Agrawal N, et al. The 2017 academic college of emergency experts and academy of family physicians of india position statement on preventing violence against health-care workers and vandalization of health-care facilities in India. Int J Critic Ill Injury Sci. 2010;7(2):79.
26. 26. Kumar NS, Munta K, Kumar JR, Rao SM, Dnyaneshwar M, Harde Y. A survey on workplace violence experienced by critical care physicians. Indian J Crit Care Med. 2019;23(7):295.