The annual World Day for Safety and Health at Work, observed on 28th April.....
Healthcare workers are susceptible to reactive violence from patients and their attendants, affecting their mental and physical well-being. The annual World Day for Safety and Health at Work, observed on 28th April, promotes the prevention of occupational accidents and diseases globally. You! takes a look…
We are all aware of the importance of healthcare systems in our lives. The time one is born until they die; one has an abundance of encounters with prescription medication, hospital visits, primary care visits, and even multiple scans and test. A sound healthcare system is mandatory for the smooth running of nations. And, in the wake of the global coronavirus pandemic, we need the healthcare industry more than ever to help combat the current crisis.
While on one hand we applaud the healthcare professionals for their heroics on a daily basis, there exists violence against healthcare workers (HCWs) in various forms among all cadres and at different levels of care. The annual World Day for Safety and Health at Work, observed on 28th April, promotes the prevention of occupational accidents and diseases globally. It is an awareness campaign intended to focus international attention on the magnitude of the problem and on how promoting and creating a safety and health culture can help reduce the number of work-related deaths and injuries.
Workplace violence has been defined as ‘any incident where staff are abused, threatened or assaulted in circumstances relating to their work involving an explicit or implicit challenge to their safety, well-being and health’. Almost a quarter of workplace violence occurs within the healthcare sector. Violence against healthcare workers (HCWs) is a global phenomenon and was declared a major public health problem in the Forty Ninth World Health Assembly in 1996. Many countries have reported high incidence of physical and verbal violence especially in the emergency departments. HCWs are mostly susceptible to reactive violence from patients and their attendants, affecting their mental and physical well-being.
According to a study, ‘The magnitude and determinants of violence against healthcare workers in Pakistan’, published this year, more than one-third (38.4 per cent) of HCWs reported having experienced any form of violence in the span of 6 months in 2019. Verbal violence was the most commonly experienced form (33.9 per cent), followed by physical violence (6.6 per cent). The main reasons for physical violence was death of patients (17.6 per cent), serious conditions of patients (16.6 per cent) and delay in care (13.4 per cent). Among the different types of HCWs, emergency vehicle operators were significantly more likely to experience verbal violence compared with lady health workers (LHWs). Among hospital HCWs, those working in private hospitals were significantly less likely to experience physical violence and verbal violence.
In 2012, Dr Umair-ul-Islam, Professor of Surgery was brutally injured by an angry mob while he was trying to save a patient. The patient was a gunshot victim and expired soon after he was brought to the ER, as he sustained injuries on his head, nose and ear. Not only the doctor but a technician’s bones were fractured during this. The incident was followed by strikes and the shutdown of OPDs (Out-Patient Department) and OTs (Operation Theatres) across the entire province. Security was demanded for HCWs with a warning of a severe brain drain, if protection was not guaranteed to them.
Dr Faraz*, a professor and senior doctor, recounts a similar incident he experienced, “While I was a junior doctor at a government hospital in Lyari, gunmen raided the emergency ward with a dead body. They demanded the doctors to revive him, failure to do so otherwise would end up in dire consequences. We were stressed and anxious during the whole time and feared for our lives. However, a peon – who was God-sent for us – helped us escape through a back way. I still get a little shaken up when I have to narrate this story.”
Research, studies and reports in Pakistan have highlighted the issue of violence against healthcare providers, in which they have been subjected to all forms of violence ranging from verbal and physical misbehaviour to even threats of extortion and kidnapping for ransom.
Case in point, Madiha’s* parents are doctors and two of the many doctors who are often sent extortion receipts. “My parents often threatened for ‘chanda’ or ‘bhatta’. These receipts just have a bullet drawn on them and addressed to the doctor. We thought it might be a one-time thing but it is delivered every now and then for several years now. My parents spent years studying and practicing medicine to be where they are. It’s really painful for us to be ripped off like this while being in fear of our life,” she laments.
If it’s not extortions, it is kidnapping for ransom. Dr Malik* came from affluence and practiced in a slum area. Around three years ago, he was kidnapped during daylight hours and kept in captivity for weeks. A ransom of 80 lacs was demanded and the doctor was only released after Intelligence agencies got involved and the ransom was paid in full.
As far as the law and order situation is concerned, HCWs don’t have a great luck here as well. In March 2020, a primigravida – woman giving birth for the first time – was brought in at Civil Hospital Karachi as she had decreased foetal movement. She was quickly induced for labour and kept overnight for monitoring. As her condition started to worsen, she was taken in for an emergency C-section in the morning. While the baby survived, the mother couldn’t. The father of the baby was a lawyer and filed a FIR against the six people of the ward – two of whom were from the administration and not even doctors.
The constitution of Pakistan says that no one is authorised to file a FIR against doctors without the approval of Health Care Commission (HCC) to take up such cases for enquiry; as to avoid any bias regarding the medical knowledge. “The issue is that that for post graduates trainees with a mediocre salary, the monthly budget is always tight so to add a lawyer’s fees is burdensome. There is a lot of social rivalry and people with power take advantage of it. We should make sure that we talk about how there are certain conditions where a patient is vulnerable during pregnancy and there is nothing much a doctor can do in such a case. Death is sometimes inevitable. If doctors are subjected to violence for something that was not in their control, and with no support or security, they wouldn’t be able to practice as the fear of false accusations will discourage them to continue,” shares an HOD at Gynae and Obs. department in Civil Hospital Karachi for an on-going court case.
If the workers are stressed about security, it can lead to post-traumatic stress disorder and can decrease job performance and increase burn-out. This also negatively impacts patients who are deprived of good-quality care responsive to their genuine needs in time of trouble. To add to that, many doctors have been killed either for ransom or have been targeted on religious, ethnic and sectarian grounds. As a result of lack of secure environments, outmigration of healthcare providers from the country has also become common and the performance of health sector has been deeply affected.
Despite all these struggles, healthcare workers are dedicated and resilient individuals who continue to care for people. Dr Khan* was a well-known doctor with patients lining up until midnight to get treatment at his clinic. And he made sure that he saw to each one of his patients. In 2014, his clinic was once raided by several armed men, who not only robbed the compounder and the patients waiting but also attempted to kill the doctor. The pharmacist at the clinic opened fire in defence which led to utter chaos and panic. One of the bullets hit a pregnant woman across her abdomen. Concerned and determined to save the woman, Dr Khan immediately took the lady to a hospital and followed up with her for days until she got better. Fortunately, the woman and the baby were fine. After the event, Dr Khan couldn’t return to work for about a week. However, to this day, no one knows if the attack was a mere robbery or a malicious attack. While Dr Khan was persuaded to pursue his profession, he was determined to stay here and help the locals. However, this time, he returned with the authorities providing him security and teaching him how to defend himself.
It is essential for hospitals to have policies and protocols established to deal with violent episodes at their facilities. Policies and protocols should promote peaceful resolutions to violent situations. To be effective, training and policies should not just be focused on the hospital security team but also on clinicians and other frontline employees because they can be part of the de-escalation process.
There need to be procedures in place where – on a standardised basis – the employer can investigate and ask questions because these are case-by-case decisions. Moreover, hospital employees should be required to report workplace violence incidents. Anything an employer can do to encourage reporting of these assaults is important - having clear procedures, explaining how employees can make these reports and who they can go to, having steps for managers and supervisors to take once they receive a report of an assault, and knowing how to contact law enforcement authorities. These things should be planned out in advance and streamlined. Hospital leaders must assure healthcare workers that they will not face retaliation for reporting workplace violence.
Each of us are responsible for stopping deaths and injuries on the job. Governments should dedicate a sizable budget for healthcare as it is responsible for providing the infrastructure, laws and services - necessary to ensure that workers remain employable. The government must see that enterprises flourish; this includes the development of a national policy and programme and a system of inspection to enforce compliance with occupational safety and health legislation and policy. As employers, we are responsible for ensuring that the working environment is safe and healthy. As workers, we are responsible to work safely and to protect ourselves and not to endanger others, to know our rights and to participate in the implementation of preventive measures.
*Names have been changed to conceal identities.
