Correspondence Address:
Geetu Singh
Department of Community Medicine, S N Medical College, Agra - 282 002, Uttar Pradesh
India

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Workplace violence (WPV) has become an alarming phenomenon worldwide. Health sector personnel are particularly at risk of WPV. This new epidemic invading medical corridors called “violence against health-care workers and professionals” is disturbing. India is not the only country facing violence against its medical practitioners; this is a global phenomenon.[1],[2],[3] WPV is defined as any act or threat of physical violence, harassment, intimidation, or other threatening disruptive behaviors that occur at the work site. The WHO states, “Between 8% and 38% of health workers suffer physical violence at some point in their careers.” Previous studies have shown that health-care workers are more likely than other workers to be victims of violence.[4] Several independent studies all over the world have reported the prevalence of WPV among physicians to be 56%–75%.[5],[6] Limited research done in India showed violence from 40% to 78% in different forms.[7],[8]

WPV in the health sector has a major impact on the effectiveness of health systems, especially in developing countries. Instances of patients' relatives assaulting the treating doctor are a common scenario all over India. The problem has many facets. In India, the rise of corporate hospitals and commercialization of health have influenced people's perception of physicians. With very poor expenditure on public health, violence against the health workers is only a symptom of deeper problems in India's broken health-care system. Lack of trust in the doctor–patient relationship is a major blow to profession nowadays. With shortage of nearly 5-lakh doctors, overburdened hospitals, inadequate facilities, long waiting hours, delay in treatment, and miscommunication give an edge to this crisis. Whatever the provocation, justifying any violence against a doctor has to be strongly condemned. Violence against doctors, which has definitely increased over the past decades, has limited research in India. Hence, this multicentric study was conducted with objectives to determine the prevalence, perceived risk factors, and measures to prevent WPV among doctors.

This was a multicentric cross-sectional study in government medical colleges of Uttar Pradesh from November 2017 to January 2018. The sample consisted of all 2nd- and 3rd-year resident doctors from three colleges (Agra, Aligarh, and Jhansi). All resident doctors working for at least 1 year in the hospital were eligible for the study. Residents from clinical departments (surgery, orthopedics, medicine, obstetrics and gynecology, orthopedics, ophthalmology, anesthesia, pediatrics, ENT, and radiology) were included. Those who did not give consent were excluded. Thus, 305 doctors were part of the study.

An anonymous, pretested, prevalidated in a similar setting, self-administered questionnaire was used. The questionnaire has five sections: profile of participants, prevalence and type of WPV, consequences and influence of WPV, perceived reasons, and measures to prevent WPV and worry level about violence among doctors. The definition of WPV from the WHO, which is used by researchers worldwide, is included.[2] Physical violence refers to physical attacks resulting in physical and psychological harm, including hitting, kicking, shooting, barring, pushing, biting, and other violent acts, such as sexual harassment and rape; psychological violence is the intentional act against the person or collective force that results in physical, mental, spiritual, moral, and social damages, including insults, threats, attacks, verbal abuse, and harassment.[2] Data were compiled in Excel and analyzed using statistical software, in the form of descriptive statistics and proportions, appropriate statistical tests applied and results are presented accordingly. The ethics committee of SN Medical College, Agra, gave ethical approval for the study, and all the participants gave informed consent.

Out of total 305 resident doctors participated in the study, 98 (32.1%) were female and 207 (67.9%) were male. Majority of the participants (81.9%) were of the age group of 20–30 years and from the departments of surgery, orthopedics, medicine, obstetrics, and gynecology. Nearly 87% have witnessed WPV in the past 12 months. Thirty percent said that they have witnessed violence several times in a month. 69.5% of resident doctors reported to have experienced violence in one or other form. It was observed that out of 212 participants who were victims of violence, 70% were exposed to verbal abuse, followed by physical (47.2%) and threat (20%). No case of sexual abuse was reported. In some incidents of physical violence, sticks, knives, and furniture were used to thrash doctors. The most common place of violence was emergency department (ED) (68.4%) and wards (30.1%). On further analysis, no department-wise difference was found. Incidents occurred during day (43.4%), evening (42.3%), or night (48.1%). In most incidents, relatives and attendants (69.3%) were involved in violence. Political leaders and even police become perpetrators in some incidents [Table 1].{Table 1}

The participants stated that in most instances (35.3%), no action was taken immediately in regard to violence. Some of immediate actions were verbal warning issued to perpetrators, incident reported to police, and care given to patients discontinued. In none of the cases, an aggressor was prosecuted. Sixty-five percent of doctors said that the incident could be prevented and 85% felt that dissatisfied the way incident was handled. Half of the respondents stated that it was useless to report the matter. 60.3% of study participants reported that they had repeated disturbing memories, thoughts, or images of the attack while 70% mentioned that they even avoided thinking about or talking about the attack. However, just 2.3% skipped their duties even after being bothered about such incidents of violence.

Nonavailability of medicines (38.6%) and less staff (36.7%) were cited as major reasons behind violence [Table 2]. Doctors said miscommunication (20.9%) and ineffective communication (14.7%) between attendants and doctors as factors for trigger of violence many times. Measures suggested for the prevention of such incidents were having more hospital staff (56.3%), better management of system (50.8%), security and law (48.1%), and more medicine supply (31.1%). About 70% of resident doctors said that they are very much worried about WPV [Table 2].{Table 2}

Overall 69.5% reported some form of WPV in this study. The magnitude of problem is comparable to various international and national studies. It has been reported globally from the UK, China, and Australia[1],[6],[9],[10] Few studies from India showed the prevalence of violence from 40% and 47.02% in Delhi to 78% in Manipur.[7],[8],[11] Verbal insults and abuse were the most common forms of violence similar to other studies (75%–91%).[7],[8] However, Farooq et al. found physical assault form of violence in majority of the cases (52.2%), followed by verbal abuse.[12] The ED is found to be the most common place of violence, even in most of the studies because of its vulnerability.[7] Similar to other studies,[7],[8] this study showed that in most incidents, it is patient or the relatives (69.3%) who are involved in violence. This is categorized as a type II assaults and accounted for most common of WPV even in the US.[13] Doctors were also mobbed by the public along with attendants, this prompts to act on the number of attendants in hospitals, visiting hours should be fixed, especially in intensive care unit settings, and necessary information regarding patient status and prognosis should be communicated.

Analysis of reasons for violence holds important to suggest solutions. Important factors from our study were nonavailability of medicines, less staff and more workload, dissatisfaction with services, and poor communication. Studies from Delhi and Manipur discussed poor communication skills,[7],[8] overcrowding in hospitals, frequent shortage of medicines, and poor working conditions of doctors in hospitals as triggering factors.[7] A similar study from a tertiary care setting indicated more or less related reasons for violence such as long waiting periods, delayed medical provision, violation of visiting hours and patient's dissatisfaction with nursing care, psychological stress, and denial of hospital admission due to the limited availability of beds in the wards.[11]

It was a matter of concern that 50% of doctors in our study stated that it was useless to report the matter. Only 44.2% of doctors reported the event to the authorities.[7] In another study, 20% were asked to “stay silent,” 75% of the doctors were offered defusing, and only 14.6% discussed the incident with authorities. News from Maharashtra reading 53 doctors attacked in two years, not a single conviction (Mumbai Mirror, March 22, 2017) highlights apathy of system and lack of management at institution level. Adverse consequences of violence in our study were similar to those reported by others. Violence among doctors results in low morale, low job satisfaction and many doctors do not want their children to pursue career in medical field.[10] Occupational violence has been associated with reduced productivity, increased turnover, absenteeism, and reduced quality of life. Thus, there is an urgent need to institute policies and measures to deter violence in the health sector.

Violence in any form is not good for society. As high as 69.5% resident doctors had experienced some kind of WPV. In backdrop of no established protocol for tackling such violence strict legislation, workplace management and reporting of violence should be in place. Further qualitative research studies on violence among other health-care providers and on patients and stakeholders' perspectives on violence should also be considered.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References