Doctors under attack at work: 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.