|Year : 2019 | Volume
| Issue : 12 | Page : 4015-4020
Medical vandalism: Awareness and opinions; beyond the clinician's window
Julie A Thomas1, Joel J Thomas1, Annie B Paul1, Sourya Acharya2, Samarth Shukla3, Aamil Rasheed2, Sree K Pratapa2
1 MBBS Student, Datta Meghe Institute of Medical Sciences, Jawaharlal Nehru Medical College, Sawangi (Meghe), Wardha, Maharashtra, India
2 Department of Internal Medicine, Datta Meghe Institute of Medical Sciences, Jawaharlal Nehru Medical College, Sawangi (Meghe), Wardha, Maharashtra, India
3 Department of Pathology, Datta Meghe Institute of Medical Sciences, Jawaharlal Nehru Medical College, Sawangi (Meghe), Wardha, Maharashtra, India
|Date of Submission||26-Sep-2019|
|Date of Decision||03-Oct-2019|
|Date of Acceptance||04-Oct-2019|
|Date of Web Publication||10-Dec-2019|
Dr. Julie A Thomas
Sharda Girls Hostel, Room No. G6, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences (DU), Sawangi (M), Wardha, Maharshtra - 442 001
Source of Support: None, Conflict of Interest: None
Background and Aims: Medical vandalism has become a major matter of concern in today's world. The number of violent mob attacks on doctors and other medical personnel is on the rise. This trend is having a negative impact on the proper functioning of healthcare system thus affecting the quality of care and treatment. The aim of this study is to assess the awareness and opinions of the stakeholders in healthcare facilities about vandalism in today's medical practice. Methods: A cross-sectional survey study was conducted in Acharya Vinoba Bhave Rural Hospital among 360 participants, comprising of nurses, patient's relatives, security personnel and non-medical staff in the Emergency Care Units and wards. A detailed questionnaire was prepared and used to assess the opinion of the subjects covering various aspects of medical vandalism such as prevalence of vandalism, experiences of vandalism at work, various factors causing medical vandalism, initiatives taken by the respondents to curb vandalism and awareness about various laws implemented by the government that help prevent vandalism. Results: Majority of the participants were of the opinion that medical vandalism was prevalent in India. Overcrowding of patients, inadequate skilled healthcare providers and occurrence of sudden death in casualty are among the major factors that trigger vandalism. This issue has been on the rise in both government and private setups, and nurses seem to be the major victims of such cruelness. 80% of the subjects admitted that verbal abuse was more common than physical abuse. Conclusion: Although violence against all healthcare professionals has been recorded since historical times, the current scenario of the country is disturbing. Immediate measures need to be taken to curb vandalism. Various laws need to be implemented to strictly punish those who create violence. Likewise, institutions must ensure the availability of adequate staff and facilities to reduce events that make the bystanders aggressive.
Keywords: Emergency care, stakeholders, sudden death, vandalism
|How to cite this article:|
Thomas JA, Thomas JJ, Paul AB, Acharya S, Shukla S, Rasheed A, Pratapa SK. Medical vandalism: Awareness and opinions; beyond the clinician's window. J Family Med Prim Care 2019;8:4015-20
|How to cite this URL:|
Thomas JA, Thomas JJ, Paul AB, Acharya S, Shukla S, Rasheed A, Pratapa SK. Medical vandalism: Awareness and opinions; beyond the clinician's window. J Family Med Prim Care [serial online] 2019 [cited 2020 Jan 22];8:4015-20. Available from: http://www.jfmpc.com/text.asp?2019/8/12/4015/272507
| Introduction|| |
Vandalism has become a major matter of contention among all generations. According to The World Health Organization, violence is defined as “The intentional use of physical force or power, threatened or actual, against oneself, another person, or against a group or community, that either results in or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment or deprivation.”. It has greatly affected the smooth functioning of the healthcare system. Frequent attacks against the doctors, nurses and other healthcare providers have affected the quality of care and treatment of the patient.
Historical scenario and worldwide occurrence
Violence against the doctors, nurses and paramedical staff have been reported since the ancient times. Medical vandalism is not restricted to a particular country. It has been reported all over the globe. Incidents were reported in the USA where over 100 healthcare workers died as a result of vandalism during the period between 1980 and 1990. It was reported from the Shandong province in June 2010 that a nurse and a doctor were stabbed to death by the son of a patient who died of liver cancer after 13 years. Another incident was reported from the Fujian province where a pediatrician was badly injured as he jumped out from the 5th floor window to escape from the violent relative of a newborn who had died under his care.
The Indian perspective
Indian doctors and nurses are under immense pressure and fear in their workplaces. The number of cases of violence reported against healthcare professionals have increased dramatically in India. Verbal abuse is the most common form of violence experienced by the healthcare staff. The attack intensifies by a mob of random bystanders supporting the relatives even without knowing the cause. A study conducted by the Indian Medical Association (IMA) shows that more than 75% of the doctors face violence at work. An incident was reported in Mansa district of Punjab in 2014 where a doctor's clinic was burnt down as a result of the death of a boy who died even after being referred to a tertiary hospital. Nurses equally face such cruelty due to their close contact with patients and their relatives. Various studies have concluded that violence against nurses has an incidence rate of 25 per 10,000.
This study was conducted to assess the psychology and opinions of the subjects about vandalism in practice of medicine and the various factors triggering the issue, actions taken by the nurses and other healthcare workers after the incident and suggestions or advices to prevent similar events. This study did not include treating clinicians per se to have an unbiased idea from others but clinicians.
To assess the opinions of the stakeholders in healthcare facilities about vandalism in today's medical practice.
| Methods|| |
A cross-sectional survey study was conducted in Acharya Vinoba Bhave Rural Hospital, a 1200-bedded tertiary care hospital situated in Sawangi (Meghe), Wardha, Maharashtra, India from March 2019 to August 2019. The present study was conducted after obtaining ethical committee clearance on 10/03/2019.
The study subjects included nursing staff, patient's relatives, security personnel and non-medical staff in the Emergency Care Units and wards. The present study did not include any of the treating physicians.
A detailed questionnaire was prepared and translated to the local language (Marathi). It was distributed to all the subjects for duration of 10 minutes after which the questionnaires were collected back. The aim and the method of conducting the study were elaborated to the participants. A written informed consent was obtained from every participant. Any queries regarding the survey were answered by the research team. The current study was validated by the Department of Community Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences (Deemed University); by the School for Health Professions Education and Research (SHPER) and by the Research and Development Cell, JNMC, DMIMS (DU). Institutional ethical clearance was obtained before the commencement of this study.
Separate questionnaires were made for each stakeholder. Information included basic demographic details, prevalence of vandalism, experiences of vandalism at work, various factors causing medical vandalism, initiatives taken by the respondents to curb vandalism and awareness about various laws implemented by the government that help prevent vandalism. The relatives of patients in casualty and those admitted in the critical care units (CCU) and wards were questioned based on 3 dimensions:
- Dimension of informing
- Dimension of empathy
- Dimension of trust
Compilation of the entire data collected was done in a MS Excel Spreadsheet. Analysis was done by using SPSS 24.0 version statistical package using descriptive statistics only.
| Results|| |
The survey comprised of 360 participants that included 100 nurses, 200 patient's relatives, 30 security personnel and 30 non-medical staff. Almost equal number of males and females were interviewed among the relatives while the group of nurses comprised of mainly females and the last group mainly involved men.
Amongst the nurses who took part in the survey, 92% agreed to the existence of medical vandalism. Almost half of them (49%) were of the opinion that vandalism is prevalent in private hospitals, up against 29% of them who found it more in government hospitals and 22% of them who find it relevant in both places. 86% of the nurses agreed to the problem increasing nowadays and only 64% of the participants felt safe in their workplaces. Among the factors triggering vandalism, overcrowding seemed to be the major problem (76%), followed by lack of skilled healthcare providers in Emergency Care Units (53%), poor patient relative's background (47%), medical negligence (32%), non-availability of drugs (28%), sudden death in casualty (27%) and lack of resources in a hospital setup (8%). (Values represented in brackets denote the percentage of nurses who agreed to that particular factor being a trigger for vandalism) 45% of the nurses reported to have experienced vandalism earlier while 35% fear to be at the risk of being a victim of medical vandalism. When asked about their response in case of an incidence of vandalism, 72% preferred to inform higher hospital authorities, while 17% of the subjects preferred police intimation and the rest preferred to be silent. The knowledge about laws (imprisonment and fines) with respect to medical vandalism seemed to be poor among the nursing staff interviewed, as only 49% of them were aware of the existence of such laws. Majority of the subjects (94%) believed that nurses were at more risk to vandalism as compared to doctors in a hospital setting.
200 individuals who were relatives of patients admitted in AVBRH were interviewed and 188 (94%) of them agreed to medical vandalism being existent in our country. The term 'Medical Vandalism' had encompassed a variety of deeds in the minds of the subjects as described graphically in [Figure 1]. Lack of patience among the relatives of patients was reportedly the greatest factor agreed to by the subjects among the other factors that trigger medical vandalism. [Figure 2] depicts the graphical representation of the same.
When questioned about the attitude of the doctors and other hospital staff towards the patients and their relatives, 98% of the patient relatives admitted that generally they were being treated well, while the rest pointed out that they were treated rightly only after requesting the staff to do so. The subjects were asked various questions with respect to the following dimensions.
- Dimension of informing as shown in [Figure 3]
- Dimension of empathy as shown in [Figure 4]
- Dimension of trust as shown in [Figure 5]
Security personnel and non-medical staff
All 60 subjects who were interviewed agreed to the existence of medical vandalism. Half (50%) of the individuals were of the opinion that vandalism was prominent in government institutions, while 13% thought they were more in private hospitals and the rest (28.3%) felt it was present in both setups. 93.33% individuals believed that the problem is increasing these days while the rest were of the opinion that the incidence rates have remained more or less constant. The workers were of a mixed opinion when asked about the factors that triggered vandalism. [Figure 6] depicts their opinion.
|Figure 6: Factors triggering vandalism from the perspective of security personnel and non-medical staff|
Click here to view
Two-thirds (66.6%) of the subjects interviewed confessed to have experienced vandalism earlier in their workplaces and surprisingly none of them reported the event to higher officials. Lack of knowledge may be attributed as a reason for this as 20% of the subjects were not aware of the necessity to report or document such an event. The security personnel and non-medical staff had equally agreed that proper security system and CCTV facilities were the main actions taken by the institution to prevent any incidents of vandalism. The graphical representations for the above results are depicted below in [Figure 7]. Overall, 80% of the study subjects interviewed were of the opinion that verbal abuse was more common than physical abuse. [Figure 8] shows the above results:
| Discussion|| |
The rising occurrence of medical vandalism is becoming a huge burden for our country. This is the reason that intrigued us to conduct a study on this topic and similar studies enable us in spreading awareness that in turn helps in preventing such incidents in future. Our study provided an opportunity to assess the prevalence of medical vandalism, various factors leading to vandalism and the initiatives taken by the institution to combat vandalism. While the nurses were of the opinion that medical vandalism was predominantly more in the private sector, the non-medical staff felt it to be more common in the governmental institutions. Nevertheless, other studies have reported that violence against healthcare professionals occurs at an immense rate in the private healthcare establishments mainly. Majority of our respondents believe that the problem is increasing in the current century which is also evident from other studies conducted elsewhere. Our current study reported that almost half of the nurses along with two-thirds of the security personnel and the staff involved in the emergency care units, paramedics faced vandalism. Our study concluded that verbal abuse was more commonly experienced as compared to physical assaults. This is similar to the results obtained from the Medscape Medical News poll which involved nurses, physicians and pharmacists. Another cross-sectional study conducted among the Jordanian nurses in 2010 reported that verbal abuse was prevalent from which shouting and swearing by the patient relatives were the frequent types. The results of our study were consistent with other studies, which also reported that nurses were highly exposed to violence at workplace in comparison to physicians.,,,,,,, According to a survey done in Baghdad that covered 700 healthcare workers from 6 major hospitals and 20 primary healthcare centers, it was concluded that more than 85% of the workers were exposed to severe violence in their career. The major cause of violence was the unsatisfactory quality of medical services and lack of various hospital supplies. The global threat of violence negatively affects their physical and mental well-being therefore leading to poor work performances.
Violence against the healthcare providers signifies lack of trust and an unhealthy doctor-patient relationship. Through our study we were able to gather distinct opinions about various triggers of vandalism from the perspective of nurses, patient's relatives and other hospital staff. According to the responses from the nurses, it was concluded that the major factor causing vandalism is overcrowding in the hospitals. Nurses find it difficult to manage a large group of patients and their relatives at a particular time in a small confined area. Almost half of the respondents also believe that the lack of skilled healthcare providers and poor cultural background of the relatives also trigger vandalism in a hospital setting. Majority of patient's relatives agreed to have lost patience while listening to the doctor's and nurse's briefing about the patient and about various medical procedures. Other studies reported that incidents occur as a result of patient dissatisfaction with the quality of health facilities. A study conducted in Palestine in 2012 showed that the most of the violence eruption occurs due to lack of a proper policy or a procedure for reporting an incident and lack of actions taken against the perpetrators of violence. Another study done among the healthcare workers in the Abha City, Saudi Arabia, reported that uneducated patients or relatives and the prolonged waiting time were the major causes of initiating such violence which was followed by personality of relatives, less number of hospital staff, overcrowding and lack of security personnel. Some of the other factors were low health literacy rate, expensive healthcare services and lack of doctor-patient communication. The current study conducted among the security personnel and other workers showed a mixed opinion about the various factors of vandalism, out of which medical negligence seemed to be the most important one. The patients, especially those visiting government hospitals, are often attended by the trainees. The duration of communication with the patient is usually less and this disrupts a healthy relationship between physicians and patients eventually resulting in violence. The results of a cross-sectional study conducted among the health personnel in Iran showed that the majority of violence occurs due to lack of people's knowledge about the task of each staff in the hospital.
In the present study, a large number of participants believed that the number of cases of medical vandalism being reported is increasing at higher rates which is in agreement with other studies too. Our study focused on the satisfaction of patients and relatives with various healthcare facilities provided to them. More than half of the respondents reported that they were treated remarkably well in the hospital. The overall attitude of the respondents was evaluated in terms of three dimensions (informing, empathy and trust). The relatives were happy with the personality and approach of the physicians, nurses and other staff.
Safety of the patient in hospitals is the foundation of an efficient healthcare system. This can only be achieved when doctors and other medical personnel are ensured a safe working environment so that they can work with at most dedication and devotion. Various steps can be taken to curb medical vandalism. Strict laws must be implemented by the government to punish violators in order to protect the rights of healthcare professionals. On the other hand, doctors and nurses should also initiate steps to avoid errors during management of a patient. Improving communication skills and training themselves for anxiety, alleviation techniques would serve as an effective tool in preventing vandalism in the long run. Proper documentation of a patient's course of stay in hospital might not prevent violence but it may seem helpful later during when medico legal cases arise. It is necessary to be vigilant all the time to avoid any mishap and to make sure that every patient is given the highest quality care. We hope this study becomes an eye-opener and would help in initiating steps to curb medical vandalism in the near future. We also hope that no more lives of healthcare personnel are lost to violence. Medical vandalism is on the rise at an alarming rate. If this current scenario continues, then it would be a catastrophic blow to the morale of practicing clinicians and would shake the dignity of the whole medical fraternity. It should be dealt with utmost seriousness by all the stakeholders from citizens to governments of the community or else the health care system will collapse. This ugly truth is of prime concern and importance in today's medical practice.
| Conclusion|| |
Although violence against all healthcare professionals has been recorded since historical times, the current scenario of the country is disturbing. The lives of nurses and other healthcare staff are at jeopardy at work. Only a few cases are reported to the higher authorities and brought to public attention by the media.
As overcrowding was the major problem that initiated vandalism, an improved hospital security system need to be adopted providing 24 hour surveillance cameras and trained security personnel. Alarm system in the hospital should be improved and a strong connection with the nearby police station should be maintained in case of emergency. Adequate number of staff in every department would ease the problem caused due to overcrowding of patients. A centralized medical record maintenance system improves the quality of administration. The legislation has a central power to curb vandalism. Proper laws should be implemented by every state government to control such attacks. This should include imprisonment with compensation for the damage caused.
Above all, communication between the healthcare professionals and patients is the key element that needs to be refined at the earliest. A proper understanding about the health condition of the patient and the treatment outcomes should be maintained by the relative. Disputes between the patients and hospital staff should be solved through a grievance redressal system. Each stakeholder in the medical industry is responsible to prevent vandalism in their work environments. A healthy interaction with the relatives, hospital authorities, media and government helps to understand and improve the violence perpetrated against the healthcare system of the country.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
WHO Global Consultation on Violence and Health. Violence: A Public Health Priority. Geneva: World Health Organization; 1996 (document WHO/EHA/SPI.POA.2).
Ali A, Johna SD. Crime and punishment in ancient surgery: An examination of Assyrian and Egyptian physicians. J Anc Dis Prev Rem 2015;3:119.
Goodman RA, Jenkins EL, Mercy JA. Workplace related homicide among healthcare workers in the US, 1980 theory 1990. JAMA 1994;272;1686-8.
Anonymous. Chinese doctors are under threat. Lancet 2010;376;657.
Dey S. Over 75% of doctors have faced violence at work, study finds. Times of India 4 May2015.
Boy dies during treatment, irate relative ransack clinic, residence. TOI 15 May2014.
Sharma RK, Sharma V. Workplace violence in nursing. J Nurs Care 2016;5:335-7.
Patient Satisfaction Surveys. NEJM Catalyst; January 1, 2018.
Nagpal N. Incidents of violence against doctors in India: Can these be prevented? Natl Med J India 2017;30:97-100.
] [Full text]
Ault A. Majority of Clinicians Experience Verbal Abuse, Intimidation. Medscape Sep 29, 2017.
Ahmed AS. Verbal and physical abuse against Jordanian nurses in the work environment. EMHJ 2012;18:318-24.
Balamurugan G, Tessy TJ, Nandakumar P. Patient's violence towards nurses: A questionnaire survey. Int J Nurs 2012;1:1-7.
Kitaneh M, Hamdan M. Workplace violence against physicians and nurses in Palestinian public hospitals: A cross-sectional study. BMC Health Serv Res 2012;12:469.
Imran N, Pervez MH, Farooq R, Asghar AR. Aggression and violence towards medical doctors and nurses in a public health care facility in Lahore, Pakistan: A preliminary investigation. KMUJ 2013;5:4.
Franz S, Zeh A, Schablon A, Kuhnert S, Nienhaus A. Aggression and violence against health care workers in Germany- A cross sectional retrospective survey. BMC Health Serv Res 2010;10:51.
Khan A, Said AB, Shah BA, Aurangzeb, Islam F. Violence against nurses at public sector hospital of Peshawar, Pakistan. Int J Innov Res Dev 2015;4:5.
Al Bashtawy M. Workplace violence against nurses in emergency departments in Jordan. Int Nurs Rev 2013;60:550-5.
Kumar M, Verma M, Das T, Pardeshi G, Kishore J, Padmanandan A. A study of workplace violence experienced by doctors and associated risk factors in a tertiary care hospital of South Delhi, India. J Clin Diagn Res 2016;10:6-10.
Pund SB, Kuril BM, Doibale MK, Ankushe RT, Kumar P, Siddiqui N. Study of workplace violence, its risk factors and perception about workplace security in doctors of Paithan. Int J Community Med Public Health 2016;4:1987-92.
Lafta RK, Falah N. Violence against health-care workers in a conflict affected city. Med Confl Surviv 2019;35:65-79.
Gupta VK, Kaur N, Gupta M. Is changing curriculum sufficient to curb violence against doctors? Indian Heart J 2016;68:231-41.
Shafran-Tikva S, Chinitz D, Feder-Bubis P. Violence against physicians and nurses in a hospital: How does it happen? A mixed- methods study. Isr J Health Policy Res 2017;6:59.
Alsaleem SA, Alsabaani A, Alamri RS, Hadi RA, Alkhayri MH, Badawi KK, et al
. Violence towards healthcare workers: A study conducted in Abha City, Saudi Arabia. J Family Community Med 2018;25:188-93.
Kar SP. Addressing underlying causes of violence against doctors in India. Lancet 2017;389:1979-80.
Fallahi-Khoshknab M, Oskouie F, Najafi F, Ghazanfari N, Tamizi Z, Afshani S. Physical violence against health care workers: A nationwide study from Iran. Iran J Nurs Midwifery Res 2016;21:232-8.
Berlanda S, Pedrazza M, Fraizzoli M, de Cordova F. Addressing risks of violence against healthcare staff in emergency departments: The effects of job satisfaction and attachment style. Biomed Res Int 2019;2019:5430870.
Sen M, Honavar SG. It's a doc's life- Workplace violence against doctors. Indian J Ophthalmol 2019;67:981-4.
] [Full text]
Ghosh K. Violence against doctors: A wake-up call. Indian J Med Res 2018;148:130-3.
] [Full text]
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]