The unsettling reality of violence against healthcare workers: Past,present and future

Sir,

In recent years, a surge of workplace violence against healthcare workers (HCW) has been observed in India, affecting both their physical and psychological well-being. ¹ A startling 75% of all Indian doctors have faced workplace violence, as reported by the Indian Medical Association.^1,2 According to the World Health Organization, any form of abuse, threat or assault imposing an explicit or implicit threat on the safety, well-being or health of workers, also during commuting from and to work, falls under the term ‘workplace violence’. ³

Despite the assumed efforts of HCW and the advantages of technological and scientific advancements in the medical field, multiple factors still hinder the quality of care provided. ² Such hindrances include poor infrastructure, ineffective governmental policies, high costs, commercialization of healthcare and political pressure, potentially sparking tensions and conflicts. ² Globally, workplace violence has unfortunately become an inevitable component embedded within healthcare ² where it has become four times more common amongst HCWs when compared to other professions. ²

Moreover, recent studies suggest this problem is much more widespread than is officially reported, ² accounting for three incidents of violence per 10,000 HCW, five times greater than the global rate, ³ and hugely higher compared to China and the United Kingdom, which have both taken strict legal actions against violence. ³ A cross-sectional study in Chennai showed greater prevalence amongst males than females. ¹ Most incidents reported were psychological. However, some incidents resulted in fatalities, emphasizing the urgency of finding an appropriate solution. ¹ In most cases, the perpetrators were the patients involved in particular scenarios, their relatives or third parties affiliated. ⁴ Not surprisingly, most doctors in India are concerned about their safety at work, and some are considering carrying weapons or self-defence tools to protect themselves.^1,2

Factors contributing to the increasing violence against HCW doubling from 2021 to 2021^4,5 include the advent of COVID-19, ³ the role of the media, poor or ineffective communication and negligence of doctors, ² actual or perceived deterioration owing to inappropriate treatment,^1,2 unrealistic expectations or unsympathetic or unclear explanations. ⁵ High costs especially if extended or unexpected, particularly if thought unwarranted, contribute to conflict, as do psychological stress, delays, dissatisfaction, miscommunication, denial of admission, violations of visiting hours and sudden demise of patients. Working in isolated areas, the stress of intensive care units and emergency settings was also found to increase the risks of violence against HCWs, particularly during late night shifts and morning outpatient hours. ⁶

The law in India varies in different states, differing in stringency, and extent. ³ Moreover, there are no laws pertaining to violence against HCWs in four and five states and union territories, respectively, also demonstrating the weak implementation of laws in real-life situations. ³ In 2020, an act was enforced deeming any form of violence against HCWs a non-bailable, cognizable offence, worthy of imprisonment for 3 months to 5 years with fines of US$ 250–1000. ³ Despite such action, the implementation of laws varies and is therefore considered weak and does not provide protection for HCWs from violence. Consequently, activist groups have demanded action. ³

A comprehensive approach to managing incidents of violence against HCWs is required. ¹ Improved security measures and alarm systems are necessary. Although de-escalation programs do not reduce violent incidents alone, they help identify and handle aggressive patients. ⁷ Increasing surveillance is also crucial in formulating targeted programmes to tackle the root causes of conflict, as well as helping to provide insights into the true burden of the phenomenon. ⁵ Educational approaches shunning violence and providing a balanced view of HCW, as opposed to that often presented in the media, could have a pivotal role in avoiding violence generally. Meticulous reporting of incidents and re-emphasizing the legal penalties of workplace violence against HCWs, may shape a better public opinion of the image and role of HCWs.^1,5,6