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Health Services: Where danger lurks
Medical and health services, normally respected and spared from outside violence, are today becoming an arena for threats and even violent attacks. Nurses and paramedical personnel are not at all happy to find themselves in the line-of-fire. In many countries, these professionals are questioning this situation and expressing growing concerns.
A patient becomes violent and coldly stabs an emergency room doctor while discussing the patient's injuries. A visiting nurse is mugged by a group of drug addicts undergoing withdrawal. Ambulance personnel are violently ganged up on by members of the same family.
What did they do wrong? In all three cases, they had arrived several minutes late.
Such incidents, which regularly make newspaper headlines, illustrate a persistent worry within the health professions and are prompting a growing sense of insecurity among healthcare professionals.
Violence in hospitals, and in the health care services in general, is not a new phenomenon. Certain health care environments had already been singled out as high-risk areas. This is the case especially of emergency services, and psychiatric and geriatric units, where the patients show significant behavioural problems because of particular pathologies or addictive behaviour, which very often cause sporadic attacks of nerves or characteristic symptoms of aggressiveness.
What is new and becoming worrying is the frequency of recorded attacks. General medicine, maternity, pediatrics, and reception areas are no longer spared. This trend toward increased acts of violence, signals a disintegration of social ties, and concerns nearly all health establishments, whether in city centres, or urban or rural areas.
The targets: medical or nursing students, nurses, nurses' aides, and ambulance personnel who are "easy prey". The most common forms of aggression are verbal, and include offensive or racist remarks and rudeness. Intimidation and assault (grabbing, hitting, jostling, throwing things, etc.) also occur frequently. Unfortunately, these events can sometimes take a tragic turn; cases of homicide are not unusual.
A sector prone to violence
This type of violence can also take on other aspects depending on local conditions. In Northern Ireland, for example, hospitals are sometimes targeted by paramilitary groups. In India, Africa and Asia, provincial hospitals have been regularly attacked by political, religious, or ethnic groups. In the suburbs of Paris, the number of incidents recorded over the last two years has increased sharply. For the most part, they come from delinquency, especially in its new forms of depredation.
"It's the street outside which comes directly into the hospital," says one hospital director.
A hospital complex south of Paris provides an example. A study found that "the waiting room floors are regularly tagged to mark the territory of each gang from the nearby neighbourhoods... Dealers come to sell their drugs directly in the rooms of patients being treated for drug addiction. Gangs come to settle their disputes in the hallways...Visitors stroll around the floors with pit bulls or in the cafeteria, which has become the headquarters of the gangs..."
Another almost daily preoccupation is the theft of medicines, or blackmail, especially involving narcotics. Even more serious, youth gangs no longer hesitate to pursue their victims into the wards or even into recovery rooms.
These gangs, who reign within the hospital compound, plague the daily lives of the staff and leave even security personnel - who also receive threats - powerless, in a place which should, on the contrary, bring calm and comfort.
Besides this external violence, health professionals must also face the hostility of certain patients and their families. Faced with an institution often perceived as strict and sometimes authoritarian in its operation, the virus of violence finds it a natural ground for spontaneous growth. The staff, whatever their competence and good will, find themselves caught between "a rock and a hard place".
Not making things any simpler, female personnel are also confronted by sexual harassment. According to the International Council of Nurses in Geneva, the phenomenon has reached an alarming level. Sixty-nine per cent of nurses queried in the United Kingdom suffered sexual harassment, 48 per cent in Ireland, and 76 per cent in the United States. Also pervasive is so-called "horizontal violence", that is, abusive acts perpetrated by colleagues or by doctors.
Seen from inside, several factors make the health care milieu especially vulnerable. In particular, the free movement of the public within hospitals and clinics, which is conducive to the presence of groups of organized gangs, attracted by the availability of drugs, money and valuable objects; the violence in neighbouring communities with the resulting increase in the carrying of arms; the obligation to accept more and more people, very often in a context of budget restrictions and staff reductions; schedules and working conditions leading to the isolation of staff; the deterioration of access to health care, as well as the sometimes difficult relations between the medical team and the patients or their families; personnel little prepared to deal with crisis situations or violence.
In short, dysfunctions (unsuitable premises, weak internal organization, long waiting lines, ineffective alarm and transmission systems, abusive or oppressive medical power...) which causes discomfort, insecurity, stress, and even aggression.
Under such conditions, employees feel increasingly severely the stress introduced in their functions, with the distinct impression of no longer being respected by their clients. They also deplore the absence of support from the institutions which they serve.
Moreover, numerous studies have revealed that many cases of aggression suffered by health care workers are concealed out of fear of reprisals, tarnishing their professional image or harming the reputation of the establishment. In addition, there still exists in this sector a tendency to play down these incidents because the idea that "violence is part of the risks of the profession." Thus, for example, the statistics on reports of work accidents involving acts of violence in certain hospitals do not always reflect the reality of the dangers incurred.
Anticipate and control violence: A double challenge
The ongoing awareness-raising campaigns initiated by professional organizations and unions have now led authorities and employers concerned to respond. This takes different forms in different countries.
Equality of access to health care and well-being could be seriously compromised if working conditions or workplaces continue to elicit disillusionment among the professionals. Therefore, it is clear that the public authorities and the employers have a key role to play to guarantee a decent and safe working environment.
In spite of everything, health services constitute a sector of the future, called upon to develop continually over the following years. In fact, several ILO studies (see World of Work, No. 5, 1993) pointed out the sector's good employment prospects, because of demographic growth and the ageing of the population, in the industrialized countries as well as in low-income countries.
To this end, a safe work environment free from danger is a basic element for providing quality health care. To reach that point, an innovative and effective strategy of prevention remains a priority. In this regard, a 1998 ILO report on violence at work gives precise instructions which can serve as a framework for establishing a prevention policy based on a participative procedure and the commitment of all the professionals and authorities concerned.
Still, it is not always possible to prevent all violent incidents. Nevertheless several types of action at least allow the risks and their consequences to be minimized. Most recommended prevention strategies underline the importance for each organization to adopt a prevention plan, which must include the following elements:
The role of unions, professional organizations and the ILO
To maintain their values, unions and professional organizations must promote better awareness of the phenomenon as well as responses which are best suited to the working environment and the concerns of workers.
Concretely, they can help to collect testimony from victims, employees or users of the facilities, and take a more active role in the implementation of various prevention, control, and training measures. The various initiatives and positions taken here and there show that the profession intends from now on to strive to restore a culture of non-violence in the health care environment:
All of these initiatives cannot truly be sustained unless the public authorities supply legislative mechanisms and adequate resources. During the last five years several countries have adopted legislative mechanisms and innovative regulations to combat aggressiveness and violence in the workplace. They also cover certain categories of workers, including those of the social and health services. In the United Kingdom, for example, the Minister of Health has devised a plan of action for reducing the risk of violence against the staff of the National Health Service. The objective is a reduction in violence of 20 per cent in 2001, and 30 per cent by the year 2002. Moreover, additional budgetary funds are allocated for the support of training activities.
- Bernard E. Gbézo, Consultant, Mobilization of human resources in the hospital environment.