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Handbook of WMA Policies
S-2012-06-2012 ⏐ World Medical Association
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
PREAMBLE
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 psy-
chological 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 physi-
cians, not only affects the individuals directly involved, but also impacts the entire health-
care 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 provided1
.
Moreover, patients may act aggressively as a result of their medical condition, the medi-
cation 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.
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Handbook of WMA Policies
S-2012-06-2012 ⏐ World Medical Association
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 environ-
ment 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.
RECOMMENDATIONS
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:
1. A zero-tolerance policy towards workplace violence.
2. A universal definition of workplace violence.
3. A predetermined plan for maintaining security in the workplace.
4. A designated plan of action for healthcare professionals to take when violence
takes place.
5. A system for reporting and recording acts of violence, which may include
reporting to legal and/or police authorities.
6. 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 admin-
istration 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 limita-
tions 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 pro-
tected.
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 edu-
cation providers to ensure that healthcare professionals are trained in the following: com-
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Bangkok ⏐ S-2012-06-2012
Violence in the Health Sector
munication 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 anony-
mously 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 pre-
ventative 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 imple-
mented 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.
1
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 SF. 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
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