Fatima M, Azher S, Mohan A, Wara U, Shaikh M. Physical violence against health care workers in government hospitals of Pakistan and its impact on their mental health. HPHR. 2021; 33.
In health-care settings, workplace violence is a severe and troubling problem. According to research, health-care staff are the most vulnerable to such abuse. The aim of this section is to discuss physical abuse against healthcare workers (HCWs), which is a serious issue that is seldom discussed. It is a very alarming situation, especially in lower income countries like Pakistan. There have been instances where doctors have been killed in the hospital while performing their duties and still not many preventive measures are taken to prevent these instances from happening. HCWs in a government set up are susceptible to such abuse which can take a huge toll on their mental health.
Workplace violence is violence or the threat of violence against workers. It can occur at or outside the workplace and can range from threats and verbal abuse to physical assaults and homicide (What Is Workplace Violence? Who Is Vulnerable?, 2002) The healthcare workers are at a 16-fold higher risk of being exposed to violence in comparison to other workplaces (Zubairi et al., 2019) According to the World Health Organization (WHO), up to 38% of healthcare workers (HCWs) are subjected to physical abuse at some point during their careers, resulting in social trauma and burnout, which influences healthcare quality (Violence against Health Workers, n.d.). Violence against healthcare workers is common all around the world but lately these cases have increased dramatically in Pakistan because of the fragile law enforcement infrastructure and negligible security provided by the government (Shaikh et al., 2020). Pakistan Medical Association (PMA) has condemned such incidents several times and demanded law enforcement agencies to take preventive measures against such incidents in future (Jubalpori Yaseen, 2020).
The effects of violence have developed as the incidence of physical violence has risen in Pakistan, especially in emergency departments and wards within health care centers. According to a nationwide survey conducted in Pakistan’s major tertiary care hospitals, more than 70% of emergency room staff had witnessed some form of violence, with just 12% of doctors reporting physical abuse and 65% reporting verbal abuse (Mirza et al., 2012). In another survey on healthcare violence, almost two-thirds of the participants had either encountered or seen a kind of violence in the healthcare setting with substandard treatment being the leading cause of abuse (Baig et al., 2018).
Continuous fear and distress among healthcare workers have caused severe detrimental effects on their emotional health and attitude towards employment, as well as on patients who are unable to get high-quality treatment in times of stress. According to a cross-sectional study conducted among four of Karachi’s major hospitals, health care staff who have been subjected to physical assault and violence exhibited signs of post-traumatic stress, with 42.4% displaying emotional exhaustion and 72.9% experiencing depersonalization (Zafar et al., 2016).
The emergence of Covid-19 in 2020 also imposed a great deal of pressure on healthcare staff (HCWs), as they were the ones who had to deal with the problem firsthand. While working on the front lines, health care professionals have faced dozens of new obstacles. That includes long work hours, a lack of personal protective equipment (PPE), and a persistent risk of contracting COVID-19 or passing it on to family members. Amidst such stressful and unpredictable situations, a significant increase in abuse against healthcare workers has been recorded around the country (Bhatti et al., 2021). Furthermore, many renowned doctors have been assassinated for money or because of their ethnic, racial, or sectarian affiliations, leading to the exodus of most healthcare staff from the country due to shortage of safe working environments, leaving a question mark for the higher authorities as to whether they would be able to work and live safely in an Islamic Republic nation.
Many incidents have occurred in Pakistan’s health care facilities, mostly government hospitals, where patients or their attendants have verbally or physically abused the doctors, nurses, and other hospital personnel. There have been several incidents where powerful people have taken law into their own hands and shot the doctors. One such incident happened on June 18, 2020, where an on-call doctor was shot in the leg by a patient who then appeared to be a detained officer suffering from mental illness (Basit Amin, 2020). He was later charged, and Pakistan Medical Association (PMA) ordered that doctors and healthcare workers be provided with adequate security in order to avoid similar accidents.
Whenever a country experiences a state of emergency, there is a sudden uptick in abuse incidents due to influx of patients and a shortage of services. Many cases have been reported recently during Covid-19 in which perpetrators have instigated violence in response to a hospital’s refusal to hand over the dead bodies of patients before the results of a COVID-19 diagnostic test are obtained, as mandated by hospital policies based on government directives (Imtiaz Ali, 2020). A mob vandalized the COVID-19 isolation ward of Jinnah Postgraduate Medical Centre in Karachi on May 15, 2020, and attempted to assault all medical staff on duty taking the body of a deceased COVID-19 patient forcibly without following government guidelines (“Mob Vandalises JPMC Ward after Hospital’s Refusal to Hand over Covid-19 Patients Body ,” 2020). Just a few days later, a similar incident happened in Peshawar’s Lady Reading Hospital, where a 50-year-old critically ill woman was brought in and suspected of having COVID-19. When the doctor ordered a COVID-19 medical test, the attendant became furious, accusing the doctor of not making the right diagnosis, resulting in arson and violence in the hospital (“Targeting Hospitals,” 2020).
According to a cross sectional analysis conducted in Peshawar, at least 51% of the healthcare workers reported to have suffered from violence, verbal violence being the commonest among them affecting nearly half of the health care workers (45%). Physical violence was recorded by a quarter of the respondents either alone or in conjunction with other types of violence. Nearly two-thirds of the cases involved attendants, families, or patients as offenders (Khan et al., 2021). Similarly, in a study conducted in Karachi reports of verbal violence (30.5%) were more abundant than physical violence (14.6%). The main offenders were found to be those who assisted patients (Baig et al., 2018). Following these tragic events, most of the hospitals sought help from the police and other law enforcement agencies to keep the staff and the hospitals secured.
Mental health care clinics, emergency rooms, pediatric units, medical-surgical units, and long- term care facilities are among the sectors where HCWs are at significant risk of being assaulted (Lipscomb JA, 1992). Limited knowledge provided to the attendant, as well as waiting their turn due to overcrowding in government facilities, all add to the attendant’s sudden indignation. An increasingly overburdened HCW deals with enraged attendants who lack understanding and knowledge of protocols, making it much more difficult for health care staff to cope. Despite such atrocities, most violent incidents remain unreported, and no charges are brought hindering effective interventions. Given the increased interaction with patients at high risk of causing crime, such as opioid addicts, alcoholics, mentally disturbed persons, and gang members, the observed rise in the number and intensity of violent events over time is unsurprising (Lin & Liu, 2005).
Educational and regulatory measures should be taken to reduce the number of such incidents. An employee should receive safety and health training, with proper risk management strategies and action plans. Awareness campaigns on the importance of one attendant policy, waiting for their turn and the instructions of HCWs related to treatment should take place.
HCWs’ well-being is harmed when they are subjected to physical or verbal abuse. It is the most serious issue impacting their well-being and competitiveness. In almost all forms of abuse, including minor acts, the victims experience trauma, which has long-term, negative health consequences. The doctors who have experienced physical assault are likely to get serious or fatal injuries. One or more after-effects of such incidents include flashbacks, insomnia, fearfulness or taking time off work. Violent attacks may not only cause bodily injuries but can also have post traumatic consequences with high rates of mental stress. The consequences are emotions such as anger or anxiety extending to psychological disorders such as burnout (Franz et al., 2010). Physical violence especially the use of weapons against HCWs, contributes to the prevalence of PTSD.
Recently during COVID pandemic with increased workload and increased cases of physical violence HCWs face aggravated psychological pressure and physical risk which endangers them and eventually the healthcare system is compromised (Vizheh et al., 2020). With increase in such incidents and very little social support, stress, and fear increase. HCWs who experience physical violence should adopt effective coping mechanisms and receive social support by family and friends for recovering from the trauma (C M Fernandes, 1999). Violence in healthcare services often reflects the community in which service is provided.
HCWs concern regarding their security must be given due priority by provincial and federal governments. The rise in cases of physical violence against HCWs is raising several questions about capacity of the government to tackle such situations. In this regard the government must act responsibly to ensure better security for protection of healthcare professionals. Several times doctors have gathered to protest multiple instances of assaults on healthcare professionals, criticizing the authorities for neither taking any action against the offenders nor devising a law to protect health workers against such violence (Mandhro S, 2020). The media networks can play a major role in highlighting the problem of attacks on HCWs.
The complaint system for health care workers launched by the government of Pakistan in June 2020 is a step much needed, and other countries can benefit by developing similar mechanisms for health care workers to express their concerns (Maqbool S, 2020)(Martins et al., 2020). Identification of suspected cases, introduction of personal protective equipment and proper administrative measures must be taken to ensure that better security is provided to HCWs (Khalid & Ali, 2020). Pakistan and other countries with similar situations could also seek the aid of countries where more modern law enforcement agencies are working to implement such changes (Martins et al., 2020). For instance, The Health Care in Danger team of the International Committee of the Red Cross recently published a checklist for preventing violence against health-care workers in the COVID-19 response (Pakistan: New Law to Prevent Violence against Health-Care Workers, Facilities and Patients in Khyber Pakhtunkhwa, 2021). It provides a practical, actionable summary of important measures for preventing, reducing, and relieving the effects of violence against health-care workers and patients during the COVID-19 response. Our main aim should be to protect HCWs well-being and ensure that they apply the ethical principles of health care.
Violence against healthcare workers is a major public health problem with a high prevalence. This may influence their well-being and may result in low job morale, putting healthcare provision at risk in a developing country like Pakistan’s already strained healthcare system. As a result, for the provision of vital services, the protection of the injured and ill, healthcare workers, healthcare facilities, and emergency vehicles is critical. Measures must be implemented by the administration of healthcare facilities, the provincial health department, and local law enforcement agencies to increase hospital and personnel security and enhance the required coordination. Patient and attendant convenience should be enhanced by providing consistent signage and information desks, waiting rooms, a one-attendant policy, as well as improving the quality of healthcare services. Healthcare staff should be trained in de-escalation of aggression, effective negotiation and dispute resolution skills, and ethics by the administrations of both public and private healthcare facilities. These can be evaluated through research in local settings, with participation not just from the healthcare sector, but also from the government, the administration, politicians, law enforcement, civil society, and international organizations.
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Zubairi, A. J., Ali, M., Sheikh, S., & Ahmad, T. (2019). Workplace violence against doctors involved in clinical care at a tertiary care hospital in Pakistan (Vol. 69, Issue 09).
Madiha Fatima is a medical student and looks forward to being a practicing doctor.
Syeda Rimsha Azher is a 4th year medical student who is pursuing her passion for the medical field through unlimited hard work. She also has a great interest in writing research articles and to excel in it.
Anmol Mohan is a fourth-year medical student at Karachi Medical and Dental College in Karachi, Pakistan, where she was born and raised. Her interests lie in research and medicine specialties, specifically cardiology and pulmonology.
As a medical researcher, she noticed a lack of passion and/or advice for research among medical students. As a result, she believes she can participate in medical research and contribute her time and effort to a variety of research projects that provide audiences with medicine/health-related insights while also improving her own level of knowledge.
Um Ul Wara is an aspiring medical student of Karachi Medical and Dental College, and a research enthusiast.
Muhammad Taha Arshad Shaikh is a dedicated researcher and a philanthropic student who wants to play their part in making the society a better place.