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With Queensland health care workers facing alarming levels of workplace violence and aggression, it is essential for health organisations to adopt a safety culture to stop this bad behaviour in its tracks, writes Dr Elise Witter.
A recent night shift I completed in the emergency department (ED) ended quite literally with a bang — the sound of a hole being punched in the ED wall, as an agitated patient threatened to kill me and my nursing colleagues, before tearing a computer off the wall and hurling it at terrified staff. Sadly, this experience is all too common in the health care setting.
The Australian Medical Association Queensland (AMAQ) Resident Hospital Health Check for 2023 revealed that a third of doctors-in-training do not feel safe at work (here). This alarming figure aligns with a reported increase in violence and aggression towards health care workers, with a 13% increase in the past year compared with 2019–2020. In addition to occupational violence, doctors also reported ongoing concerns, with widespread bullying and harassment and fear that fatigue might lead to patient errors. With widespread staff shortages ongoing, urgent action is required to provide a safe working environment for health care workers and thus support retention and the sustainability of the medical workforce in Queensland.
Occupational violence
Occupational violence is estimated to affect up to 95% of Australian health care workers annually, and presents a particular challenge in rural and remote facilities and emergency and mental health settings. This includes verbal, physical and sexual violence, with nurses and paramedics experiencing the highest exposure. Exposure to occupational violence results in potential physical and psychological injury, reduced staff morale, and staff attrition (here). It significantly affects staff retention. Staff exposed to occupational violence face a complicated ethical dilemma between balancing their own personal safety with the delivery of patient care, creating moral injury and compounding distress. It also confers substantial economic cost with absenteeism, lost productivity and work compensation claims, with some hospital and health services averaging costs up to $17 106 per work cover claim in some areas.
The aetiology of violence occurring in the health care setting is complex and multifactorial, reflecting environmental, patient and staff factors. Illness, cognitive impairment, pain, trauma, frustration with wait terms or regulations such as no smoking, lack of satisfaction with care, staff attitudes and behaviour and the impacts of substance use can all precipitate violence and aggression. With the number of beds per 1000 population declining, wait times in the ED escalating and staff reporting staff shortages and increased levels of fatigue, the current face of health care represents the perfect storm of risk factors for occupational violence.
Occupational violence has long been acknowledged as a problem for the health care sector, with a Queensland Health taskforce established in 2016 that issued a series of recommendations around prevention and response to occupational violence. Despite this, the frequency and severity of occupational violence against health care workers continue to soar, indicating ongoing deficits in the system response to occupational violence. Concerningly, occupational violence is widely under-reported due to lack of recognition, minimising due to patient illness or other factors, and overly complex reporting structures (here). Gross under-reporting is likely widespread, with one study identifying that, despite 300 duress alarms being activated in one Australian ED, only ten incidents were formally reported (here). This suggests the true extent of the problem is even greater than reported.
Potential interventions
What then can be done to tackle the complex issue of occupational violence? It is clear that prevention should be paramount. From the design of hospital and health services to the systems and individuals within them, there are various interventions that should be implemented in occupational violence prevention. A focus on built environment, ensuring adequate lighting, safe spaces for staff to retreat through, dual exits, purpose-built safe assessment rooms and high visibility should be incorporated into building design and planning to reduce occupational violence risk. Other fixtures such as closed-circuit television (CCTV) also have evidence that they reduce risk and high levels of support from health care staff.
In addition to environmental factors, it is essential for organisations to adopt a safety culture and prioritise occupational violence prevention and responses. With significant legislative and economic consequences for occupational violence, hospitals and health services simply cannot afford to neglect this issue. Lack of organisational support is associated with reduced professional competence, presenting a clear patient safety risk. Although many organisations endorse a “zero tolerance” policy towards occupational violence, in practice, occupational violence is widely tolerated. It is excused due to patient factors such as mental illness or intoxication, it is under-reported, and support for victims can be ad hoc or even absent (here). Furthermore, there is very limited evidence that a “zero tolerance” policy leads to demonstrable reductions in occupational violence. Therefore, a more nuanced approach incorporating multiple strategies is needed, starting with the fostering of a safety culture from leaders within the health system.
Other interventions include the implementation of structured prevention programs such as Safewards and the development of acute response teams. There is preliminary evidence for these programs, but they are yet to be widely adopted and rigorously evaluated. Use of other systems such as duress alarms have poor evidence for effectiveness, despite their widespread uptake. Conversely, visible security and police beats have some promising evidence, highlighting the importance of coordinating with other stakeholders such as the police and ambulance service in response to occupational violence.
The role of the individual health care worker in preventing occupational violence must also be considered. Training and education in risk assessment, recognition of occupational violence, response, and strategies to verbally de-escalate or defuse risky patients is demonstrated to reduce occupational violence, though there is minimal effect on mitigating physical attacks. However, training is not mandatory and the current offering is sporadic and requires two days away from clinical duties, reducing its accessibility and uptake. Furthermore, there are concerns that an overemphasis on individual training can divert responsibility from organisations to provide safe environments. Individuals can also partake in incident reporting to collate data and inform future planning for prevention, but this is frequently neglected. One reason for this is that incident reporting forms are cumbersome and time-consuming. Reducing the length and administrative burden associated with incident reporting may enhance its occurrence and improve data collection.
Finally, despite these preventive strategies, it is inevitable that occupational violence will continue to occur to some degree. It is essential that processes exist to support victims and provide psychological care where needed, to ameliorate the risk of severe and enduring impact of occupational violence incidents (here). Options such as formal debriefing, employee assistance programs and targeted counselling should be made available (here). There is inconsistency in the practice of postvention, which requires a consistent and systematic response and adequate reporting to inform.
In summary, doctors and other health care professionals are under attack in unprecedented numbers in the workplace. The reasons for occupational violence are multifarious, but the current strain on the health care system increases the risk to health care workers, and this is likely to continue to escalate. Urgent and directed strategies encompassing structural, environmental, organisational and individual factors are required to reduce the risk to doctors and their health care colleagues. We all deserve to feel safe at work.
Dr Elise Witter is Psychiatry Registrar at Cairns Base Hospital and Health Service.
The statements or opinions expressed in this article reflect the views of the authors and do not necessarily represent the official policy of the AMA, the MJA or InSight+ unless so stated.
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There are no protections in place for a health practitioner working on her own in private practice. A patient with a serious criminal record for violence and sexual assault against women does not need to declare his criminal record. So a practitioner can unknowingly be placed at risk with a dangerous patient.
I write as a victim of assault by a disturbed patient. My injury was compounded by the subsequent legal process which compounded my trauma. I was limited to be a “witness” for an incompetent public prosecutor and later a successful appeal Doctors are fair game for lawyers.
I have worked in many smaller hospitals in Kimberley,Tasmania and rural Queensland.
They have NO security staff and no plan of what to do in an incident other than call the police.
If you are lucky there may be a wardie who can help ,otherwise it’s all on the nurses and doctors to descalate it.
I think we need to start naming and shaming places with poor security and incidents in our GP forums to warn staff who may not want to work/locum there.
If staff refuse to work there maybe they will do something!
Thank you Dr Witter for an excellent opinion piece on a serious issue. Verbal and physical assault in medicine should never be accepted as “just part of the job”. Nor should safety be compromised because of “a duty of care”. More steps must be taken to keep all health care workers safe. Here is a piece written by Dr Gifar Hassan and I in 2023 – on the 17th anniversary of the killing of Dr Khulod Maarouf Hassan in her general practice for further information on this important topic.
https://insightplus.mja.com.au/2023/19/every-doctor-has-a-right-to-a-safe-workplace/
Over my career, one of the main changes that has increased aggressive behaviour among ED patients is the nature of the common drugs of abuse. In the days when narcotics dominated, there was a risk of blood-borne infection but patients were generally obtunded rather than violent.
The increased use of recreational sympathomimetics has led to a major increase in violence and aggression.
We have not designed or created adequate facilities or models of care to cope with this change.
This is an excellent article and I commend Dr Witter for writing it and its comprehensive nature.
The all too common phenomenon is made worse when the victim of the violence – in this case the health professional – becomes blamed.
Victim blaming and scapegoating of the professional leads to reluctance to reporting crime (apart from the unconscionable behaviour of not supporting an injured party and seeking justice leading to further harms).
Processes and supports must be put into place in all organisations should be supportive, proactive and be coupled with stringent laws as in Victoria, where violence against healthcare professionals incurs stiff penalties.
Dr. Witter offers the real solution to occupational violence in the healthcare sector when she reports:
“Therefore, a more nuanced approach incorporating multiple strategies is needed, starting with the fostering of a safety culture from leaders within the health system.”
Unfortunately, in Australia violence and aggression in the health care setting has become commonplace. Even some almost 25 years ago the Perrone report from the Australian Institute of Criminology, published in 1999, identified the high level of violence in the health industry in Australia at the time [Perrone 1999]. In the following year, Harulow [2000 ] advised: “The increasing incidence of violence within all areas of the Australian health care system is a serious concern to nurses and requires immediate action.” Mayhew and Chappell’s study into the occupational violence experience of Australian health workers, published in 2003, found that of the 200 nurses surveyed, 147 had experienced a total of 311 separate violent events in the 12 months preceding the survey [Mayhew and Chappell 2003]. Reporting in 2010, the Queensland Nurses’ Union advised that in some Emergency Departments in Queensland, violence was common with nursing staff reporting several episodes each week [QNU 2010]. Later still, in 2013, Pich et al. [2013] reported on the experiences of Australian Emergency Department nurses proffering that violence in healthcare is a significant issue and one that is increasing in prevalence globally. Nurses have been identified as the professional group at most risk, with patients the main source of this violence [Pich et al. 2013]. Thus, in the past, it seems nurses were the target of unwanted aggression. That aggression has now spread to doctors and paramedics.
Front-line workers are at risk. Ashamedly, management sees aggression as part of the job. They are not on the front line and they are not at risk. However, they have the responsibility to ensure that their organizations are safe for their workers
As we know, workplace violence and aggression rears its ugly head in adult Emergency Departments. Nonetheless, we must be cognizant of aggression in other parts of hospitals. In a study by Hopper et al. [2012] of patient and visitor aggression over 14 months at the Royal Children’s Hospital, Melbourne, it was found that workplace aggression was also evident on the wards. Whereas patients involved were most commonly affected by a mental disorder, frustration, and/or a developmental disability, visitor aggression, manifested as both verbal and physical violence, was due mainly to frustration and occasionally drugs.
The effects of workplace violence in those institutions that poorly manage the phenomenon lead to dissatisfaction and alienation amongst staff. Protection and emotional support must come from healthcare executives. However, based on the continuing plague of violence and aggression in Australia’s healthcare facilities it would appear they
have been very slow to adopt such measures and others are not giving the matter the attention warranted.
Fortunately, workplace violence in recent times, particularly in the hospital setting and in the field of paramedic ambulance officers, is catching the attention of the Queensland Government. More needs to be done for no doubt, the effects of workplace violence on healthcare staff can be devastating. These effects include physical harm, stress, reduced work performance, and low morale. For these reasons, the issue of workplace violence is a challenging one, especially at a time when Australia is struggling to maintain and strengthen its healthcare workforce. Healthcare executives have a moral, if not legal, responsibility to ensure safe staffing levels are maintained with an appropriate skill mix of staff. They should ensure that their staff receive regular training in violence/aggression minimization. Worksites should also provide counseling services for those staff who have been victims of violence.
There is a need to manage workplace aggression and violence with evidence-based interventions [see: Martinez 2016, Mitchell et al. 2020; Kumari et al. 2022].
Dr. Witter is to be praised for her article.
On display during a recent visit to a hospital security office was a large cache of potentially lethal weapons taken from visitors. Dangerous times requiring that security officers or police empowered to do searches need to be stationed wherever there is a reasonable possibility of serious violence.
Thank you Elise for this important article. This sentence made me reflect on what we are doing here “Staff exposed to occupational violence face a complicated ethical dilemma between balancing their own personal safety with the delivery of patient care, creating moral injury and compounding distress.”.
Why is our personal safety a complicated ethical dilemma? How did we get here? We have all done our BLS training, and know that the old ABC has been replaced with DRABC- and the rule is that the rescuer’s safety comes first. Always. Even if that means the death of the person who needs rescuing.
Of course there is nuance – a low level of risk for a massive benefit – that’s a different equation. But risking assault to suture a scalp laceration on a drunk patient? I’ve been there, and most of us have.
The Medical Training survey just published shows increasing levels of adverse behaviour from patients/carers/families being directed towards doctors in training. For the last 3 years, it has been going up every year.
We need clarity from employers and regulators about when it is OK to refuse treatment – certainly consequences of death or permanent loss of function, a parent getting agitated about their child, or capacity impaired by mental health crisis, warrant attempting to continue treatment, but otherwise, it can be argued that withdrawal of treatment from violent or abusive patients is justified, appropriate and morally should not be a dilemma at all.
The lack of an occupational health and safety approach to most of the workplace hazards that doctors and other healthcare workers face still has me perplexed, and the prevention and post-vention measures described are the absolute minimum that would be accorded other workers who faced occupational violence.