Hospital Violence: Why we Cannot Protect our own Doctors?

According to a study by the Indian Medical Association, over 75% of doctors have faced violence at work. Doctors faced maximum violence when providing emergency services, with as many as 48.8% of such incidents reported from intensive care units (ICUs) or after a patient had undergone surgery, the study said. Relatives and attendants of patients were often found guilty of such actions. According to the findings, data of the past five years showed that escorts of patients committed 68.33% of the violence.

Government hospitals that lack appropriate security arrangements are also more at risk of such attacks. During night hours, it is often the medical officer who plays the role of the doctor as well as that of the security guard. There is no established protocol for tackling violence. Even a delay in attending to a patient can make his or her attendants go berserk. Since most patients lack health insurance, sometimes the diagnosis comes as a financial disaster and shocks them into an emotional turmoil, resulting in anger towards the hospital staff.  

Every hospital is like a war zone. There’s anxiety, time pressure, threat of loss of life. No matter how capable and committed, a doctor can’t always save lives. There is tremendous pressure on doctors to routinely relay bad news to families on the brink of losing a loved one. This makes every healthcare worker vulnerable. It is a sad reality that three out of every four doctors and healthcare workers admit to have been subjected to some form of verbal or physical abuse.

Public hospitals in India have massive workloads. These doctors work continuously for more than 24 hours, oftentimes without any food or rest. They see patients 4-5 times more in number than elsewhere in the world. Commiserating with relatives over the demise of a patient is something every doctor would like to do. But the circumstances may not allow it, because there is another life that needs to be saved. Nurses and other hospital staff also often face the ire of upset relatives. Other factors associated with violence in hospitals are long wait times, psychiatric patients, patients who have a history of violence and patients under the influence of drugs or alcohol, according to a study published in Journal of Emergency Medicine.

Reasons for assaults

The immediate cause for violence is certainly emotional. However, nothing justifies these assaults. The inability to accept an unexpected death in the family may be the triggering point. The root cause lies in the gap between the expectations and limitations. In the public sector, the background cause for violence is inadequacy of infrastructure and human resources. In the corporate sector, an additional factor of out-of-pocket expenditure might also add to the anger. In addition, reduced doctor patient interaction time and lack of time to brief the relatives regarding the condition of the patient and non-availability of professional counsellors are some other triggers.

Doctor-patient relationship is a relationship that relies on trust and empathy. Equipped with the current medical knowledge and tools in his/her field of expertise, the aim of the doctor is to help the patient, to his/her best capacity. Medical discipline relies on the premise of beneficence (benefit) over maleficence (harm). “The intent is clearly to help the patient and not to cause any deliberate harm,” says Dr. Sameer Malhotra, Director, Department of Mental Health and Behavioural Sciences, Max Super Speciality Hospital.

It takes significant effort, passion and hard work, to become a doctor. It is not only a “job”. In general, with growing consumerism, fast pace of life, significant reliance on technology and limited information available on the net, growing impatience and lack of acceptance of any potential side effect, many a times patients unknowingly create a significant pressure on the doctor, forgetting his/her humane limitations. Underlying personality profile of the patient or his/her relatives can also lead to negative judgements and negative display of feelings towards the therapist that hits at the very fabric of the doctor-patient relationship.

Sharing his views on the subject, Prof AK Gupta, Medical Superintendent cum HOD Hospital Administration, PGI Chandigarh, says, “Peripheral health systems including primary health centres, do not inspire confidence among the patients and as such patients rush to bigger hospitals resulting in increased patient load more than the handling capacity of these hospitals.” There are few societal factors like impatience, demand for immediate attention and lack of acceptance of prioritisation done by hospital staff to cater to critical patients first in overcrowded emergencies.

“A healthcare system that is stretched for resources and lack of adequate manpower are some of the reasons,” says Dr. Anoop Amarnath, Chief of Clinical Services, Manipal Hospitals. Inadequate security within examination room and lack of action against assaulters are prime reasons as we have not really seen that doctors have been assaulted and something has been done to deter the relatives.

In addition to the reasons cited above, one other cause of violence against arises from the fact that MBBS studies also focuses more on theoretical knowledge to excel in competitive exams, rather than practicing the practical aspects in dealing with patients. “This is one of the reasons for low confidence when it comes to treating patients, as many practical aspects of handling emergencies can be learnt only by experience,” says Dr. Shakti Gupta, Medical Superintendent, AIIMS, Delhi.

Studies have shown that seniority of the doctor matters, i.e., a senior doctor faces less violence than junior doctors. This may be attributed to better handling of the situation, or getting respect from patient’s relatives because of their long years of experience.

What does the law say?

There are laws in certain states, however strict implementation of these laws is required. The main reason for violence at healthcare facilities as mentioned by Dr. RV Asokan, Honorary Secretary General, Indian Medical Association, is the lack of political will in implementing the state laws. However, lack of a Central Law and appropriate amendments to IPC and CrPc also are the reasons why the state laws are toothless. “It is also the need of the hour to educate and warn people who assault healthcare personnel that they would need to face consequences as per these laws,” Dr. Amarnath says.

In addition to having a law in place, doctor-patient communication also needs to be strengthened; if some patient is deteriorating rapidly it has to be communicated to relatives. Effective communication with patients and their families regarding the nature of illness and professional counselling play a part, as trust, not just law and order, has a huge role. Generally, patient or the consumer gains sympathy because a patient has died. “As our society is pro-consumer, even the consumer protection act is for the people and because of this sympathy wave we don’t see much of real action,” says Dr. Suganthi Iyer, Medico-legal expert & Deputy Director at P.D. Hinduja National Hospital, Mumbai.

At PGIMER, notices clearly depicting the message of zero tolerance towards violence against doctors and other healthcare workers have been displayed at various places.

Expectations from the government

It is pertinent that hospitals and government need to work in tandem to ensure the safety of healthcare personnel. PGIMER reports of receiving reasonable amount of support from the administration for prevention of violence at their facility. However, the hospital fraternity is of the view that they are not receiving adequate support and understanding from the government. “We expect a comprehensive central law addressing deterrence, security and determinants of violence,” says Dr. Asokan. He further adds the need for the availability of professional counsellors in every ward to fight the menace. To prevent violence against doctors, government spending on healthcare must be increased and the Indian Penal Code should be changed to provide for a tougher penalty that could act as a deterrent to violence against doctors.

Empowerment through training in various aspects of management, not only the medical knowledge, but also, manpower, material & resource management, which will help in managing critical situations in casualty, where resources are limited

Hospitals have to register the complaint and the police stations have to be sensitised to register the complaints. As some police stations may just make a non-cognizable (NC) complaint and not FIR, unless FIR is filed no action is taken. Most people file NC and not FIR so no action is taken against the assault.

Doctor-patient relationship is not and should not be viewed with a ‘consumeristic’ eye. No other discipline ensures sure success, yet people don’t sue their lawyers, judges, policy makers for taking wrong decisions or for not meeting their desired outcomes. In the western world most of the CME programs prepare doctors for court appearances. The very fabric of trust has been hit with the consumer clause. “There is a need to seriously reconsider removing such a clause, to ensure that the doctor-patient relationship gets its due place,” Dr Malhotra says.

Government needs to take definitive steps to safeguard healthcare professionals. More stringent punishment and penalties should be imposed on the perpetrators as is the case in many countries. “Central Laws against violence on healthcare workers and institutions (IPC, CrPC) should be introduced,” Dr. Gupta says. And in the event of assault, demonstrative action including imprisonment should be imposed. Apart from enacting such laws, it is also important to have on-the ground support to prevent atrocities. The government should simultaneous stress on improving quality of healthcare in India and increase the health budget. At no point should the healthcare professionals bear the brunt of falling infrastructure.

In government hospitals, the following can be done as a part of general reform for the hospital services:

• Improvement of services in a global fashion
• Adequate number of doctors and other steps to ease the rush of patients and long waiting hours
• Use of computer and internet technology to monitor, optimize and reduce long waiting periods
• Strengthening Hospital security and properly interlock with nearby police station
• Arms/Ammunition by patient or their relatives should not be allowed inside the hospital
• Transparency on rates of different investigations, rents and other expenses in the hospital
• Proper complaint redressal system in the hospital
• Training of MOs to tackle with various psychological aspects and be empathetic towards patients and their relatives

More than just security

Safety and security in hospitals have been a matter of great concern and need to be addressed at all levels. IMA has been demanding a central law encompassing all states and union territories to protect healthcare workers against hospital violence and has declared a zero-tolerance policy against violence on doctors and healthcare establishments.

World Medical Association has also passed a resolution against violence on healthcare establishments and urged to bring stronger legislation against this menace. Threat of violence increases the stress levels of health care workers and sound judgment regarding patient care will be compromised in such situations. Cleveland Clinic in the US has introduced safety measures — such as wireless panic buttons incorporated into ID badges and more safety cameras and plainclothes officers in ERs to deal with violence. Healthcare facilities back home prevent hospital violence with strengthening security, installation of CCTVs, restriction of visitors, modulating the work load of doctors so that every patient gets adequate time and attention from the doctors.

Providing adequate security, declaring a hospital/clinic environment as a ‘no violence zone’, advisory and warnings to prevent any negative body language, intimidation, use of force, aggression of any nature towards the doctor – should be put into place. Patient always has the right to seek second professional opinion, in case of dissatisfaction, instead of retorting to violence. Such values of trust, empathy need to be imbibed right from very young age, through school education, parental efforts and government policies aimed at enhancing life skills and civic responsibilities. Dr. Malhotra is of the view that it’s high time that doctors across the globe are given their rightful place.

Hospitals should be allowed to take patients as per their handling capacity. Government should also improve functioning of peripheral hospitals at each level in the district. Hospitals should have standard operating procedures, more grief counsellors, CCTV’s and above all enough security staff and a system wherein in any eventuality of violence, hospital security system reaches the site quickly. Prompt response from law enforcing agencies is of utmost importance. “Hospitals need to have a strong security infrastructure, rapid response teams, information boards deterring violent behaviour and good communication skills amongst providers,” says Dr. Amarnath.

Other initiatives discussed by Dr. Gupta to prevent hospital violence include formation of a joint committee with employees to formulate policies on safety and health. Analysis of worksite hazards and regular inspections should be done. Any accident or near miss incident should be thoroughly investigated. Insurance of the establishment and workers should be done to ensure financial security.

The healthcare professionals need to be vigilant about various indicators of violence such as STAMP (Staring, change in Tone and volume of voice, Anxious behaviour, Mumbling and incoherent speech of a Patient or attendant). An empathetic attitude and clear communication help avoid a lot of misunderstandings. The rise in medico-legal cases yet again hints at need of detailed documentation at every step of treatment and its informed consent. In addition to good security measures, good connection with police and some kind of code in a hospital to alert security staff and initiate immediate action like grey code or yellow code would go a long way in prevention of assaults.

While prevention of assaults is most important in any healthcare setting, it is equally important to ensure that cost of healthcare is kept at levels affordable for a common man.  Although rising security costs may tend to have an impact on the overall costs, it needs to be optimised. In government hospitals, the rising cost of security may be absorbed by the government, but private and corporate hospitals are likely to pass the same on to the patients. The government is extremely sensitive to the needs and is responding adequately at AIIMS as has been said by Dr. Gupta. However, physical one to one manning and providing security for every hospital is difficult, owing to the challenges of manpower in our country. However, security is a part of financial aspect and budget and every hospital has to take into consideration and work it out individually or take support of the government as it is related to law and order.

“In a country with huge dearth of medical professionals, especially doctors, violence against doctors and healthcare workers is a huge demotivating factor,” says Prof. Gupta. Not only does it lower the morale but it discourages the coming generations to opt for this noble profession. It tends to put unnecessary pressure on the doctors, which can compromise on the flow of treatment process. Any such assaults, no doubt, will have a negative impact on the morale of medical professionals. As we move towards universal health coverage, which involves getting more trained manpower, we need to ensure that the newer generation of doctors are not deterred from entering the profession. Thus, despite of fear of violence, healthcare workers continue thinking that things will improve as they have faith in the law and order of the country.  “We hope that government will listen to all these issues and give a better response,” says Ms. Iyer.