Dr. Shakti Kumar Gupta
Violence against healthcare providers and damage to Hospitals by relatives of patients has become extremely common. The changing social fabric and increased level of sensitivities can be attributed to this barbaric behavior. Even during the ongoing pandemic instances of such aggression are coming to limelight which is not good for the existing scenario.There is a growing number of aggressive, abusive and violent acts perpetrated by patients and visitors on health care givers. The challenges hospitals face is how to prevent, mitigate, control, and respond to violence within the caring and compassionate nature of the hospital environment. An act of violence has an impact on the patients’ wellbeing, the healthcare providers as well as the hospital. Violence has such impact on Healthcare establishments that it reflects in their care providing process.
Q 1 . Assault on doctors and hospitals are on the rise, what do you think are the reasons for the same?
Ans: Since last few years, reports of violence against doctors, sometimes leading to grievous hurt or murder, are making headlines across the world. Several such incidences have been reported from India too. An ongoing study by Indian Medical Association (IMA) reports that 75 per cent of doctors in India have faced violence at some point of time in their life, and most of the time, it is verbal abuse. Emergency and ICU are the most violent venues, and, visiting hours is the most violent time. Electronic and print media also do not have real understanding of the challenges faced by the doctors.
One of the important dimensions of violence to the doctors in Government and corporate hospitals is the ‘feeling of wrong doing’ by the doctors for financial gain or for avoiding his/her duties. Anxiety, long waiting period before the patient could speak to a doctor and the feeling that doctor is not giving enough attention to his/her patients engender frustration giving rise to violence. Majority of the hospitals in India do not have good grievance redressal system in place. Legal procedure in India also takes inordinately long time.
Nowadays, MBBS students during internship, focus more on theoretical knowledge to excel in competitive exams, rather than practicing the practical aspects in dealing with patients. This is one of the reasons for low confidence when it comes to treating patients. Many practical aspects of handling emergencies can be learnt only by experience. Studies have shown that seniority of the doctor matters, i.e., a senior doctor faces less violence than junior doctors. This may be attributed to better handling of the situation, or getting respect from patient’s relatives because of their long years of experience.
Q 2. There is a law in place in certain states against assault. Why is it not being used to deter such incidents?
Ans: There are many laws for protection of Healthcare professionals.
(a) Doctors’ protection Act in India:
(i) Any damage or act of violence against Medicare professionals is an act punishable by law. Medicare professionals include doctors, nurses, paramedics, medical students and hospital attendants/staff.
(ii) Any damage to the property or the Institution of Medicare service is prohibited. Destruction of hospital beds, burning of ambulances, smashing medical stores is punishable by law.
(iii) Imprisonment to lawbreakers for a minimum period of 3 years and fine amount of INR 50,000 to be imposed, if found guilty.
(iv) Offenders of medical professionals/medical colleges can be cognizable or non-cognizable crime depending upon the offences committed.
(v) Damage to any medical devices and equipment is a punishable offence and the offenders are liable to pay twice the amount of the damaged equipment’s cost.
(b) Protection laws in the interest of Physicians:
(i) A Judge bench formed in 2005, August Justice R.C Lahoti, Justice G.P Mathur and Justice P.K Subramanian said, Medical Negligence Act amounting to culpable homicide shall be punished with IPC 304-A, imprisonment extending upto many years depending on the medical negligence.
(ii) The law mentions that prima-facie evidence before the court is to be submitted and verified by a government doctor of the same rank. This law also protects the physicians from false allegations and fake complaints.
Last but not the least, Government needs to take definitive steps to safeguard healthcare professionals. More stringent punishment and penalties should be imposed on the perpetrators. Central Laws against violence on healthcare workers and institutions (IPC, CrPC) should be introduced. The Government should simultaneous stress on improving quality of healthcare in India and increase the health budget. At no point should the healthcare professionals bear the brunt of falling infrastructure.
Q 3. What initiatives should a hospital take to prevent such assaults?
Ans: The management should form committee jointly with employees to formulate policy on safety and health. Analysis of worksite hazards and regular inspections should be done. Any accident or near miss incident should be thoroughly investigated.
The security of healthcare facility should be ensured by deploying adequate guards and conducting mock drills to check compliance to standard operating procedures. Displaying policy and rules helps discourage the agitated attendants. Insurance of the establishment and workers should be done to ensure financial security.
The healthcare professionals need to be vigilant about various indicators of violence such as STAMP (Staring, change in Tone and volume of voice, Anxious behavior, Mumbling and incoherent speech of a Patient or attendant). An empathetic attitude and clear communication helps to avoid a lot of misunderstandings. The rise in medico-legal cases yet again hints at need of detailed documentation at every step of treatment and its informed consent.
Q 4. How does the rising cost of security affect the cost of patient care at a hospital?
Ans: Yes, there will be an increased cost to employ security mechanisms and most important is that, the overall cost of healthcare will further hike, which is undesirable.
Q 5. Is the hospital fraternity getting enough support from the Government to stop this?
Ans: Yes, the government is extremely sensitive to the needs and is responding adequately. However, physical one to one manning and providing security for every hospital is difficult, owing to the challenges of manpower in our country. The government should punish unlawful behaviour of anybody who harms the doctor and vandalizes the hospital.
Q 6. In a country with huge dearth of medical professionals, especially doctors, how does this affect the morale of the workforce? Steps to be taken in a Govt Hospital to prevent recurrences?
Ans: The morale of Doctors is low, when they are left all to themselves to fend for these challenges. The recent incident in a Kolkata hospital gave out very clearly the desperation and the frustration levels of the doctors. In government hospitals, the following can be done as a part of general reform for the hospital services in the form of:
(a) Improvement of services in a global fashion.
(b) Employment of adequate number of doctors and other steps to ease the rush of patients and long waiting hours.
(c) Use of computer and internet technology to monitor, optimize and reduce long waiting periods for the patients in the waiting rooms.
(d) Hospital security should be strengthened and it needs to be properly interlocked with nearby police station.
(e) Arms/Ammunition by patient or their relatives should not be allowed inside the hospital.
(f) There should be transparency on rates of different investigations, rents and other expenses in the hospital.
(g) There should be a proper complaint redressal system in the hospital, so that patients and relatives should not sought to violence.
(h) Training of MOs to tackle with various psychological aspects and be empathetic towards patients and their relatives.
(j) Empowerment through training in various aspects of Management, not only the medical knowledge, but also, manpower, material & resource management, which will help in managing critical situations in Casualty, where resources are limited.
Q7: is violence against Health professionals prevalent in other countries? How are they handling this.
Ans: The violence in healthcare workplace is a global phenomena. WHO states that about 8% -38% of health Workers suffer physical violence at some point in career. In USA in a study over 5 years in 170 university hospitals, 57% of Emergency room employees were threatened with a weapon. In 2008 a study by British Medical Association of 600 doctors found that 1/3rd have been victims of violence, 52% did not report the incident. In China >1million cases of violence against HCPs is there every year. A Chinese hospital association survey of 316 hospitals, found that violence increased from 20.6 assaults in 2008 per hospital to 27.3 in 2012. In Israel 70% of physicians, 90% of support staff in emergency room reported violence, mostly verbal, while in Pakistan a study by Imran et. al found 74% respondents of Public sector healthcare facility, Lahore were victims over 12 months.
In Spain 20th April is National day against aggression in Healthcare facilities where it promotes social awareness and encourages professionals to fight against this scourge and their Motto is ” Against health workers aggression: Zero tolerance”.
Q 8. Do’s and Don’ts for Doctor which may be crucial in avoiding violence and provide favourable outcome for both, the doctor and the patients.
(a) Do inform police whenever necessary.
(b) Do extend all possible co-operation to the police.
(c) Do furnish copies of medical records to police, court or relatives whenever demanded. Consent of patient may be taken while providing information to police.
(d) Do follow the legal procedures.
(e) Do have a valid informed consent for the treatment.
(f) Do preserve the documents, records especially in medico-legal, controversial or complicated cases.
(g) Do insist for post-mortem examination, if the cause of death can’t be ascertained.
(h) Do involve medical associations, medico-legal cells, voluntary organizations, whenever legal problem arises.
(j) Do consult a lawyer before giving any reply.
(k) Don’t panic.
(l) Don’t manipulate or tamper with the documents.
(m) Don’t perform any Unlawful or unethical acts.
(n) Don’t issue false or bogus certificates.
(o) Don’t neglect the treatment while completing legal formalities, especially in serious or emergency situation.
(The author is Medical Superintendent, All India Institute of Medical Sciences, Dr. R.P. Centre, New Delhi)
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