When violence occurs in hospitals

Local studies reveal that healthcare staff working in the Emergency Department face a significantly higher risk of violent behaviour, compared to their colleagues in other departments. — Photos: Filepic

The objective of any patient who goes to a hospital, is to seek care for their medical condition(s).

The recent report of such a patient requiring emergency surgery after he was stabbed by another patient in the Emergency Department of a public hospital has brought into focus the fact that the issue of violence in healthcare facilities has to yet to be addressed.

The World Health Organization (WHO) defines violence as “the deliberate use of physical force or power, threatened or actual, against oneself, another person, or against a group or community, that has consequences or has a high probability of resulting in injury, death, mental distress, maldevelopment, or deprivation”.

The US Occupational Safety and Health Administration (OSHA) defines workplace violence (WPV) as “any act or threat of physical violence, harassment, intimidation, or other threatening disruptive behaviour that occurs at work”.

There is global data that healthcare staff are disproportionately affected by WPV.

For example, an April 2020 statistics fact sheet from the US Bureau of Labour reported that healthcare staff accounted for 73% of all non-fatal workplace injuries and illnesses due to violence in 2018.

This number has been steadily increasing since the tracking of these specific events began in 2011.

According to the US OSHA, the rate of serious WPV incidents in the healthcare sector was generally four times higher in the private sector from 2002 to 2013.

Malaysia has a similar Department of Occupational Safety and Health (DOSH) in the Human Resources Ministry that enforces the Occupational Safety and Health Act.

However, there is no national data on WPV in the healthcare sector.

Abused by relatives

Verbal abuse is the most common form of WPV in healthcare facilities. — Posed by models

There have been limited publications on WPV in Malaysia.

However, all of their findings are cause for concern.

A study of the prevalence of WPV among 410 nurses in a public hospital in Penang, published in November (2022) in the Medical Journal of Malaysia, reported that the prevalence of reported WPV was 43.9%.

The common forms of WPV were verbal abuse (82.2%), followed by psychological violence (8.9%), physical violence (8.3%) and sexual violence (0.6%).

The perpetrators were primarily relatives of patients (51.7%), followed by patients (30%).

Nurses working in the Emergency Department were six times more likely to experience WPV than in other departments.

In addition, nurses in the age group of 30 years or more were twice more likely to experience WPV.

A study of 71 pre-hospital care staff in a teaching hospital in the Klang Valley, published last March (2022) in the Medical Journal of Malaysia, reported that the frequency of at least one WPV incident over past 12 months was 56.3%.

The common forms of WPV were verbal abuse (53.5%), physical abuse (9.9%) and racial abuse (14.1%).

None experienced sexual abuse.

Of the 38 staff who experienced verbal abuse, 16 (42%) took no action, eight (21.1%) pretended it never happened, and only five (13.2%) filed an actual complaint.

A study of 136 randomly-selected doctors and nurses in a public hospital in Kuala Lumpur, published in November 2018 in the Malaysian Journal of Medicine and Health Sciences, reported that the frequency of WPV was 71.3%.

Nurses experienced a slightly higher frequency of WPV (73.2%), compared to doctors (69.2%).

The common forms of WPV were verbal abuse (70.6%), followed by bullying/mobbing (29.4%), physical violence (11.0%) and sexual harassment (6.6%).

The perpetrators were mostly relatives of patients and visitors, followed by patients.

Those working in the Emergency Department were 17 times more likely to report WPV than those working in Paediatric Department.

Younger staff were also more likely to experience WPV.

Proactive action required

Violent behaviour towards doctors and nurses is most likely to come from the relatives of patients, based on local research findings.

Healthcare employers have a legal and ethical obligation to maintain a safe setting for patients, doctors, nurses and other healthcare professionals.

It is obvious that there should be zero tolerance of WPV in healthcare facilities.

No healthcare staff comes to work to be a subject of violence.

Neither does a patient who seeks healthcare.

Employers who do not demonstrate a clear commitment to protecting their staff from WPV will be more susceptible to staff attrition and industrial action – something that healthcare employers can do without.

While DOSH has had the Guidance for the Prevention of Stress and Violence at the Workplace since 2001, the question is whether it has been enforced, and if so, the scale of its enforcement.

Have DOSH’s inspectors been trained to request from healthcare employers, including the Health Ministry, evidence that they understand the various safety risks that are inherent in the healthcare sector, and that their staff have been provided adequate education, training and security?

There should be criminal penalties for those who knowingly assault or intimidate healthcare staff and patients.

The perpetrators of WPV in healthcare facilities should be treated no differently from those of other violent acts, irrespective of whether they are patients or healthcare staff.

It is time that consideration be given to an amendment to the Occupational Safety and Health Act to include as a criminal offence, the failure to take reasonable preventive and corrective actions to WPV.

The inclusion of individuals in senior management in the criminal liability will spur action that is sorely needed to address the scourge of WPV.

In the meantime, there is an urgent need to assess the policies and procedures in WPV to ensure that there is a safe setting in healthcare facilities for both patients and staff.

An example is a review of the process for identifying patients who have a tendency to violent behaviours towards others, and the steps to minimise the risks of such violent behaviours.

A firm, visible and genuine commitment to a safety culture for patients and healthcare staff will not only reduce legal risks significantly, but will also improve patient care, improve patient satisfaction, boost employee morale and reduce staff attrition.

Dr Milton Lum is a past president of the Federation of Private Medical Practitioners Associations and the Malaysian Medical Association. For more information, email [e-mail]. The views expressed do not represent that of organisations that the writer is associated with. The information provided is for educational and communication purposes only, and it should not be construed as personal medical advice. Information published in this article is not intended to replace, supplant or augment a consultation with a health professional regarding the reader’s own medical care. The Star disclaims all responsibility for any losses, damage to property or personal injury suffered directly or indirectly from reliance on such information.