Multi-level approach to workplace violence against healthcare workers

Dear Sir,

I read with interest in the Readers’ Forum, an important review of the rise of workplace violence against healthcare workers (HCWs) and a worrying lack of legal protection and enforcement in certain jurisdictions. ¹ This is a problem that must be addressed urgently, as abuse of HCWs is not only morally unacceptable, but also further contributes to psychological distress (depression, anxiety and burnout) faced by HCWs. ² I suggest a multi-level approach (both societal/health system and local hospital/physician level) to mitigate workplace violence against HCWs, and offer a multi-tiered strategy to abusive or violent patients which may be implemented in clinical practice.

At the societal level, there must be stringent deterrence against workplace violence enforceable through legal sanction, ¹ adequate coverage with fair and accurate portrayal of such incidents in the mainstream media ³ and strengthening of healthcare infrastructure and system to address true root causes of conflicts in doctor–patient relationships (viz. inadequate healthcare personnel, resources and facilities, exorbitant healthcare costs, long waiting times for clinical consultation and overcrowding in hospitals). ⁴

At the local hospital/physician level, frontline clinicians need to be adequately equipped and supported with proper institutional protocols, workplace emergency response systems ⁵ and simulation practices. ⁶ Psychological support for victims of workplace violence must be available and provided by on-site occupational health physicians, nurses or psychologists. ⁷

In particular, workplace violence against HCWs by patients or relatives (of sound mind) typically results when there is a mismatch in expectation and/or misperception of a medico-social situation. As such, healthcare workers must therefore be adequately trained in effective communication with patients and their families – in particular, (1) the careful, simple, comprehensible and palatable articulation of clinical information, management plans and expected outcome; (2) management of patient expectations in the initial phase; (3) the adoption of verbal de-escalation techniques when necessary; and (4) being politely assertive in the setting of professional boundaries in all clinical interactions (viz. knowing when and how to end a conversation and when to walk away, with an apology, in the face of persistent verbal abuse or inappropriate/rude remarks).

On the other hand, the general population must be educated through the media, sensitive films, and other relevant platforms on the realities and inner workings of healthcare institutions (including periods of shortages in healthcare personnel and resources). It is important to quench the spread of medical misinformation and promote public trust in healthcare systems by maintaining high professional standards and accountability (which includes disciplining errant or fraudulent HCWs).

In clinical practice, a patient exhibiting violent or abusive behaviour may be suffering from an impaired mental capacity (e.g. cognitive impairment, psychiatric illness, delirium and drug/alcohol intoxication) which may warrant appropriate treatment or even sedation. In patients with sound mind intentionally exhibiting violent or abusive behaviour, verbal and/or written warnings should initially be issued and documented clearly in the medical records. Law enforcement or security personnel should be at hand in cases of potential physical violence. In serious cases of recalcitrant violent/abusive conduct, official banning of patients from seeking treatment at a healthcare institution may even be warranted. Both the General Medical Council of the United Kingdom ⁸ and the American Medical Association ⁹ guidelines suggest that refusal to provide medical treatment to violent, abusive or threatening patients is ethically permissible. Nonetheless, HCWs are obliged to provide emergency treatment for all patients with life-threatening conditions, in line with the professional ethos of beneficence and non-maleficence.