WMA Statement on Violence in the Health Sector by Patients and Those Close to Them
Adopted by the 63rd WMA General Assembly, Bangkok, Thailand, October 2012
All persons have the right to work in a safe environment without the threat of violence. Workplace violence includes both physical and non-physical (psychological) violence. Given that non-physical abuse, such as harassment and threats, can have severe psychological consequences, a broad definition of workplace violence should be used. For the purposes of this statement we will use the widely accepted definition of workplace violence, as used by the WHO: "The intentional use of power, threatened or actual, against another person or against a group, in work-related circumstances, that either results in or has a high degree of likelihood of resulting in injury, death, psychological harm, mal-development, or deprivation".
Violence, apart from the numerous health effects it can have on its victims, also has potentially destructive social effects. Violence against health workers, including physicians, not only affects the individuals directly involved, but also impacts the entire healthcare system and its delivery. Such acts of violence affect the quality of the working environment, which has the potential to detrimentally impact the quality of patient care. Further, violence can affect the availability of care, particularly in impoverished areas.
While workplace violence is indisputably a global issue, various cultural differences among countries must be taken into consideration in order to accurately understand the concept of violence on a universal level. Significant differences exist in terms of what constitutes violence and what specific forms of workplace violence are most likely to occur. Threats and other forms of psychological violence are widely recognized to be more prevalent than physical violence. Reasons and causes of violence in the healthcare setting are extremely complex.
Several studies have identified common triggers for acts of violence in the health sector to be delays in receiving treatment and dissatisfaction with the treatment provided. Moreover, patients may act aggressively as a result of their medical condition, the medication they take or the use of alcohol and other drugs. Another important example is that individuals may threaten or perpetrate physical violence against healthcare workers because they oppose, on the basis of their social, political or religious beliefs, a specific area of medical practice.
A multi-faceted approach encompassing the areas of legislation, security, data collection, training, environmental factors, public awareness and financial incentives is required in order to successfully address the issue of violence in the health sector.
In addition, collaboration among various stakeholders (including governments, National Medical Associations (NMAs), hospitals, general health services, management, insurance companies, trainers, preceptors, researchers, police and legal authorities) is more effective than the individual efforts of any one party. As the representatives of physicians, NMAs should take an active role in combating violence in the health sector and also encourage other key stakeholders to act, thus further protecting the quality of the working environment for healthcare employees and the quality of patient care.
This collaborative approach to addressing violence in the health sector must be promoted throughout the world.
The WMA encourages National Medical Associations (NMAs) to act in the following areas:
Strategy - NMAs should encourage healthcare institutions to develop and implement a protocol to deal with acts of violence. The protocol should include the following:
- A zero-tolerance policy towards workplace violence.
- A universal definition of workplace violence.
- A predetermined plan for maintaining security in the workplace.
- A designated plan of action for healthcare professionals to take when violence takes place.
- A system for reporting and recording acts of violence, which may include reporting to legal and/or police authorities.
- A means to ensure that employees who report violence do not face reprisals.
In order for this protocol to be effective, it is necessary for the management and administration of healthcare institutions to communicate and take the necessary steps to ensure that all staff are aware of the strategy.
Policymaking - In order to help increase patient satisfaction, national priorities and limitations on medical care should be clearly addressed by government institutions.
The state has obligations to ensure the safety and security of patients, physicians, and other healthcare workers. This includes providing an appropriate physical environment. Hence, healthcare systems should be designed to promote the safety of healthcare staff and patients. An institution which has experienced an act of violence by a patient may require the provision of extra security, as all healthcare workers have the right to be protected in their work place.
In some jurisdictions, physicians might have the right to refuse to treat a violent patient. In such cases, they must ensure that adequate alternative arrangements are made by the relevant authorities in order to safeguard the patient's health and treatment.
Patients with acute, chronic or illness-induced mental health disturbances may act violently toward caregivers; those offering care to these patients must be adequately protected.
Training - A well-trained and vigilant staff supported by management can be a key deterrent of violent acts. NMAs should work with undergraduate and postgraduate education providers to ensure that healthcare professionals are trained in the following: communication skills and recognising and handling potentially violent persons and high risk situations in order to prevent incidents of violence. The cultivation of physician-patient relationships based on respect and mutual trust will not only improve the quality of patient care, but will also foster feelings of security resulting in a reduced risk of violence.
Communication - NMAs should work with other key stakeholders to increase awareness of violence in the health sector. When appropriate, they should inform healthcare workers and the public when acts of violence occur and encourage physicians to report acts of violence through the appropriate channels.
Further, once an act of violence has taken place, the victim should be informed about the procedures undertaken thereafter.
Support to victims - Medical, psychological and legal counselling and support should be provided to staff members who have been the victims of threats and/or acts of violence while at work.
Data Collection - NMAs should lobby their governments and/or hospital boards to establish appropriate reporting systems enabling all healthcare workers to report anonymously and without reprisal, any threats or incidents of violence. Such a system should assess in terms of number, type and severity, incidents of violence within an institution and resulting injuries. The system should be used to analyse the effectiveness of preventative strategies. Aggregated data and analyses should be made available to NMAs.
Investigation - In all cases of violence there should be some form of investigation to better understand the causes and to aid in prevention of future violence. In some cases, the investigation may lead to prosecution under civil or criminal codes. The procedure should be, as much as possible, authoritative-led and uncomplicated for the victim.
Security - NMAs should work to ensure that appropriate security measures are in place in all healthcare institutions and that acts of violence in the healthcare sector are given a high priority by law-enforcement institutions. A routine violence risk audit should be implemented in order to identify which jobs and locations are at highest risk for violence. Examples of high risk areas include general practice premises, mental health treatment facilities and high traffic areas of hospitals including the emergency department.
The risk of violence may be ameliorated by a variety of means which could include placing security guards in these high risk areas and at the entrance of buildings, by the installation of security cameras and alarm devices for use by health professionals, and by maintaining sufficient lighting in work areas, contributing to an environment conducive to vigilance and safety.
Financial - NMAs should encourage their governments to allocate appropriate funds in order to effectively tackle violence in the health sector.
 Carmi-Iluz T, Peleg R, Freud T, Shvartzman P. Verbal and physical violence towards hospital- and community- based physicians in the Negev: an observational study BMC Health Service Research 2005, 5:54
Derazon H, Nissimian S, Yosefy C, Peled R, Hay E. Violence in the emergency department (Article in Hebrew) Harefuah. 1999 Aug;137(3-4):95-101, 175.
Landua S F. Violence against medical and non-medical personnel in hospital emergency wards in Israel Research Report, Submitted to the Israel National Institute for Health Policyand Health Services Research, December 2004