Violence against health workers is a global problem, writes Margret Jaeger, a medical anthropologist researching violent incidents in an Austrian hospital.
This paper was presented at the Northern Network for Medical Humanities Research Congress 2021.
Violence against health workers is a global problem (WHO 2002). Studies show four major reasons for this: alcohol intake, drug intake, lack of staff and long waiting times (d´Ettore et al. 2018; Ampos et al. 2020). The literature suggests two groups of patients from whom violent acts are “more expected” – psychiatric patients and people with a diagnosis of Dementia or Alzheimer (d’Ettorre et. al. 2018; Shafran-Tikva et. al. 2017) – and observes that extra measures are often taken to protect staff working with these groups. Aggression harms health workers physically and psychologically, contributing to increased rates of sick leave and poor staff retention rates; the highest rates of incidence against staff are found in nurses, who consequently leave their job after a few years of practice (Lanctôt & Guay 2014; Eurofound 2015).
Dramatic events, such as the attempt to kill an Austrian cardiologist in an emergency room waiting area in July 2019 have attracted media attention (Der Standard, 10.07.2019), although it is unclear whether attacks on hospital workers are increasing or whether the press is simply giving more attention to the issue (Stefan & Dorfmeister, 2007); there are some suggestions that Covid-19 regulations in hospitals may have led to a higher incidence of cases (Aerzteblatt, 2020). In general, however, violent incidents in daily hospital routines remain invisible to the outside world. Some internal visibility is gained when incidents are officially reported, mainly through entries in critical incident reporting systems (CIRS) that exist for quality and risk management in many hospitals. Reporting systems are intended to allow hospital managers to gather data on violent incidents and plan mitigating measures to protect their employees. However, our research shows that such systems are often flawed and fail to capture sufficient information, with implications for health worker safety.
Between January and March 2020, working in collaboration with a hospital in Austria,[i] our team (Margret Jaeger as a medical anthropologist, Julia Wahl and Julia Wiesinger as psychologists) used data triangulation to collect and analyse information for a pilot study of violent incidents against healthcare workers. Before beginning data collection, entries from the hospital´s 2009 to 2019 reporting system were reviewed, and recommendations for improvement in the system were developed in autumn 2019. Prior’s document analysis method (2011) was used to analyse the reporting system entries and link them to information from the hospital. Our systematic literature review (due for publication 2021) shows that the topic is not as broadly discussed as we had initially anticipated. However, we have been told by healthcare workers that many hospitals do conduct internal surveys into the occurrence of violent incidents, for the purpose of planning additional measures to protect their workers: the results of these investigations are often unpublished, in part because they might cause a bad reputation for the hospital (according to an insider comment from a quality manager in 2019).
Our interview collection was interrupted on the 10th of March 2020 by the pandemic and was not resumed until summer 2021. We conducted non-participant observation in the waiting area of the emergency unit, 29 problem-based interviews (out of 110 employees; including the chief nurses of the units) and carried out qualitative content analysis (Mayring 2015).
Overall, the data from nurses, physicians, nursing assistants and administrative assistants shows that staff often do not officially report violent incidents but instead rely on their colleague´s immediate support during the incident and later debriefing. Incidents are reported verbally to the chief nurses who coordinate the wards but are not written formally into the electronic reporting systems. Health workers reported that violent incidents take place as frequently as “at least once a week” up to “every day”; this mostly consists of verbal aggression against nurses and the reception staff who receive the (new) patients. Entries in the reporting system are mostly from security staff who are obliged to keep official notes. Interviewed staff were often unaware of their employer´s legal responsibility to implement protective measures; many were not aware who in their organization was officially responsible for dealing with violent offences. otably, staff working with dementia patients manifested a more tolerant attitude to violent behavior and acknowledged the helpful presence of patients’ relatives or nursing home staff.
A prevailing attitude was “You have to cope with it”. Linking nurses’ answers to their demographic data showed that elderly nurses are more likely to see violent incidents “as part of the job”; for example, one interviewee noted, “If you do not stand this, this job is not for you”. Younger nurses, who were more likely to have received some training about dealing with violent incidents, showed less willingness to “cope with it”, and were more likely to speak up and ask for help. Making incidents visible through the internal reporting system was not understood by staff as an effective measure. After we shared our findings, hospital management redesigned the system, intending to make it easier for staff to report incidents. This is important: whilst the time available for documenting incidents is understandably limited in a busy hospital environment, hospital managers require quantitative and qualitative proof of a problem before putting mitigating measures in place.
The report of our study to the hospital, submitted in December 2020, ends with recommendations for structural changes in the waiting area and within the hospital, for improvements to the reporting system, and suggestions for a campaign to raise staff awareness about the importance of reporting violent incidences. We are looking forward to the continuity of the cooperation when the hospital allows our entrance again.
Margret Jaeger is an Austrian medical anthropologist who teaches health students/professionals around the world. She was the principal investigator of the project. Her current research focuses on younger women´s experiences with osteoporosis. https://www.sfu.ac.at/de/person/jaeger-margret/ https://psychologie.sfu-linz.ac.at/de/forschung-publikationen/medical-anthropology/
Julia Wiesinger has a master in clinical psychology and is currently in a training program for the exercise of the profession in a hospital in Austria. She was responsible for the data collection in the emergency unit.
Julia Wahl has a master in clinical psychology and is currently in a training program for the exercise of the profession in a hospital in Germany. She was responsible for the data collection in the internal medicine unit.
Ampos, L. F., da Silva Fernandes, M. N., Tavares, J. P., de Lima Trindade, L., & Dal Pai, D. (2020). Estratégias de enfrentamento, medidas preventivas e de controle da violência laboral em atenção primária à saúde. Research, Society and Development, 9(11), e2279119780-e2279119780.
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[i] The hospital has been anonymised for purposes of data protection.