Violence against healthcare workers is a worldwide problem that is affecting most countries including Egypt (McPhaul & Lipscomb, 2004). During the last decade, the problem became more obvious as part of the general deterioration of security services (Sulaiman, 2019). There was extensive media coverage of cases of physical violence and assaults against Egyptian doctors. Nurses are also subject to different types of violence: verbal, physical and sexual, but those incidents usually receive fewer media coverage than those of the doctors. It is not unusual to read in the news or in the social media about doctors who were beaten or injured by the patients or their relatives. In May 2018, a physician in Sahel Teaching Hospital was beaten by a patient relative and had a fractured nose (Ghaly, 2018). In January 2016, two physicians got assaulted by two policemen as one physician rejected their request to write a fabricated medical report (Sulaiman, 2018), an incident that led to escalation by the Egyptian Doctors Syndicate and protesting of thousands of physicians. What makes the issue worse is that physicians are subject to violence not only from the patients and their relatives but also from official officers as in the previous example which is not the only incident of its type (BBC News Arabic, 2016).
Many studies assessed the rates of workplace violence in different healthcare settings in Egypt. About 86% of the nurses working in obstetrics and gynecology departments in Cairo reported that they have been exposed to workplace violence during the 6 months preceding the study (Samir, Mohamed, Moustafa, & Abou Saif, 2012). The most common type of violence was the psychological type in the form of verbal abuse and disrespect by ignoring the nurse’s presence, followed by physical violence and sexual harassment. In the Main University Hospital in Alexandria, the prevalence of violence exposure among female employees was 73% with the verbal violence as the most common type followed by physical and sexual violence (Moustafa & Gewaifel, 2013). In Beni Suef Governorate, the exposure to violence perpetrated by the patients or their relatives in the last year was 86% among nurses and 80% among physicians. This study was conducted in different types of governmental hospitals. In Ismailia Governorate, a study conducted in the emergency department in Suez Canal University Hospital including physicians, nurses and coworkers showed that the percentage of exposure to violence in the whole sample was 60% (Abdellah & Salama, 2017).
Exposure of healthcare workers to workplace violence has many adverse consequences on them, the quality of healthcare service and the whole healthcare system. Studies (Lanctôt, Guay, & behavior, 2014) (Al-Shiyab & Ababneh, 2018; Cooper & Swanson, 2002) illustrated different types of consequences of healthcare workplace violence.
- Physical consequences following aggression include direct injury, bruises, bites, abrasions, scratches, lacerations, and pain. Those usually lead to absence from work and long rehabilitation.
- Psychological consequences include posttraumatic stress disorder, hypervigilance, irritability, sleep difficulties, depression and other types of disorders.
- Emotional consequences included anger, sadness, fear, disgust, and frustration. Sometimes, violence can result in negative emotional reactions as hatred, resentment, animosity, and desire for revenge.
- Work functioning consequences come in the forms of permanent disability, quitting the job, going on sick leaves, work absence, transfer to other departments, effects on work behaviour and productivity and decreased job satisfaction.
- Relationship with patients and quality of care consequences occur as some victims may be afraid of their patients, lose the pleasure of care of patients or reduced the quantity or quality of the time spent with patients. Some social consequences are in the form of affection of their social, family and personal lives.
- Financial consequences are mainly due to the absence of workers following workplace violence. One of the main concerns of workplace violence that is affecting the health care system in Egypt is that more and more physicians are quitting their jobs in governmental hospitals. One of the key figures of the Egyptian Doctors Syndicate mentioned that the physicians who resigned during 2016 were 1044 and the number increased to 2049 during 2017 and again went up to 2397 during 2018. Those are alarming numbers in a country that is suffering already from the brain drain of its well-qualified physicians and shortage of its healthcare workers (Egyptian Doctors Syndicate, 2018).
Dealing with the problem of workplace violence in Egyptian healthcare settings cannot be properly analyzed without understanding the political and social context. The Egyptian Government is spending very low percent of the GPD on healthcare leaving the hospital in a poorly functioning condition (Gericke et al., 2019). Hospitals are usually understaffed, there is a shortage of medical supplies and the equipment is old and sometimes out of service. This puts the healthcare workers in direct confrontation with the patients. This happens in the case that the service required is not available in the hospital as an ICU bed for example, or the patient condition is too critical for the hospital to deal with (Sulaiman, 2019). The issue is getting more complicated by the media coverage of medical issues that are usually blaming healthcare workers for any deficiencies or inappropriate outcomes in healthcare. As a result, patients and their relatives are having negative attitudes against healthcare professionals making them more susceptible to aggression and violence. Emergency departments in most government hospitals are overutilized and having a chaotic appearance which gives the impression that there is no order or discipline and any violence will have no consequences.
Healthcare workers are usually working in an unprotected environment, with the complete absence of security guards in some departments. In case they are present, most of the time they are ineffective being unarmed and patients are usually accompanied by several relatives as part of the traditional Egyptian culture. With a high level of illiteracy in Egypt resulting in low awareness about the nature of the healthcare service and its complications, there is a high chance of misunderstanding which can lead to some sorts of violence. This is more likely to occur in healthcare organizations as both the healthcare workers and the patients are present in a highly stressful environment making them more susceptible to aggression (Spelten et al., 2017). Substance abuse by some patients or their relatives puts more burden on the healthcare workers who may be under the threat of physical violence by those individuals who may be armed and dangerous, with the absence of any security precautions to detect for metals or limit the access of the armed individuals.
Goals of intervention
The goal of any intervention targeting this issue is to prevent or minimize the occurrence of workplace violence pretreated by patients or their relatives in all its forms: verbal, physical and sexual. This can be accomplished through interventions targeting the victim (healthcare workers), the vector (patients and their relatives), or the environment (healthcare organizations and social environment). Minimization of the workplace violence shall result in protecting and securing healthcare workers, improving the quality of care delivered to the patients, reduction of the financial loss and decreasing healthcare workers job dissatisfaction (Alameddine, Mourad, & Dimassi, 2015).
Policy instruments addressing the problem
The applicable policy instrument targeting this problem is governmental regulation. This can be done through issuing or amending the law that ensures the prevention of violence in healthcare facilities. Enforcement of this law, securing the healthcare environment are compulsory actions taken by the government to address the problem. The regulations should consider workplace violence as a crime with deterrent punishments. The Saudi Ministry of Health announced that those who attack health practitioners in the workplace are subject to up to 10 years in prison and a fine of up to SR1 million (266.665$)(Saudi Gazette report, 2018) in a trial to protect healthcare workers against verbal and physical violence.
Using the media campaigns as an awareness tool can be used efficiently in order to change the negative attitudes towards the healthcare workers and the consequences of violating the law by committing violence in any healthcare setting.
Implementations considerations and barriers
Many considerations are to be thought of while addressing this problem:
The first barrier to consider is the financial barrier when thinking of implementing additional security instruments as surveillance cameras or improving the workplace environment. Any renovations or staff training programs will require financial resources while the healthcare budget is very limited.
One political issue to consider is that the sufferings of the healthcare workers are not considered a priority for most parliamentarians and policymakers (Daabes, 2018). This needs to be carefully considered when thinking of law issuing or amending in order to protect healthcare workers. Advocacy and lobbying for this issue by the Health Minister and the Medical Syndicate is crucial as there have been trials for years to issue such a law modification, but nothing is finalized.
The current process of dealing with workplace violence is inadequate, the healthcare worker may report to the police authorities that he was assaulted, on the other side, the vector may also claim that he was assaulted by the healthcare worker and it ends up being considered a quarrel which will not protect the rights of the healthcare worker or lead to punishment of the protractor (Tarek & Sulaiman, 2018; Sulaiman, 2019). There was a previous trail to constitute a specialized police force to secure hospitals, protect healthcare workers and deal with any cases of violence in hospitals during 2013 (Zayed & Farouk, 2013). This initiative stopped probably due to the change in the political mood after 2013. The common idea that there is no action is taken by the healthcare managers or by the authorities leads to a further problem of underreporting of violence incidents (Al-Turki, Afify, & AlAteeq, 2016). Health workers may consider those kinds of violence as part of the nature of their jobs and may become afraid of being blamed if they reported such incidents.
Stakeholders and interest groups
Many stakeholders and interest groups are involved in the protection of healthcare workers and should be addressed while advocating for this policy:
- The parliamentarians, especially those who have medical background should advocate for issuing a law or amendment of the current law to raise the level of punishment for those committing violence against healthcare workers. They have a role in convincing their colleagues about the importance of such a law.
- The Ministry of Health and Population (MOHP) has many roles in addressing this problem. It can suggest for a law amendment, advocate for it with parliamentarians and raise other politicians awareness about the problem (Hussain, 2019). Many other roles are the protection of the healthcare workers through improving the physical environment, solving the problem of understaffing, improving the security precautions in the public hospitals and providing the proper training for its personnel to deal with situations of workplace violence.
- The Egyptian Medical Syndicate and the Nursing Syndicate have a role in providing support for their individuals. This support can be in the form of an effective electronic reporting system and providing legal support for its individuals whenever needed. One of the most important roles is to participate in suggesting a law to protect the healthcare workers and to advocate for it until the final issuing and implementation (Daabes, 2018).
- The Ministry of Interior (MOI) has a crucial role in protecting the healthcare institutions and the immediate response to deal with the cases of violence in an appropriate way. This form of response will give an image of protected healthcare facilities and will reduce the incidence of such events. MOI may consider securing the healthcare facilities a less priority issue due to being overwhelmed by activities to protect the political regimen. This would require the advocacy and efforts of the syndicates and MOHP to raise it as a priority for the MOI.
- Patients and their families should advocate for safer work environment to protect both patients and healthcare workers. The resulting safer environment and less job dissatisfaction will contribute to improving the level of healthcare quality. The recent phenomenon of migration of skilled healthcare workers may endanger the whole healthcare system in Egypt.
- The negative attitude of media that is blaming the victim (the healthcare workers) should stop and be directed to the organizations instead of the individuals. Media has an important role in raising public awareness towards the respect of the healthcare workers and the consequences of any violence targeting them.
Evidence informed solutions
Violence against healthcare workers is a worldwide problem that is not a new phenomenon. The problem has been studied and analyzed in different countries and in different healthcare settings. The following table presents some of the evidence-informed recommendations to prevent and deal with workplace violence in healthcare. Those recommendations are grouped under three categories: interventions targeting the victim (healthcare workers), the vector (patients and their relatives), or the environment (healthcare organizations and social environment).
Vector (patient or their relatives)
Public awareness regarding the nature of healthcare services, the respect of healthcare workers and the consequences of any committed violence
To increase public awareness about the problem
To improve the public attitudes towards healthcare workers
To aware the public about the consequences of workplace violence
(Di Martino & Trabajo, 2002)
(Spelten et al., 2017)
Victim (healthcare worker)
Training and education of health workers
To ensure their familiarity with policies and procedures to deal with cases of violence and its reporting mechanism
To anticipate cases of impending violence
To protect themselves in cases of violence
(Morrison, Lantos, & Levinson, 1998)
(Baig, Ali, Shaikh, & Polkowski, 2018)
Development of anti-violence teams
A multi disciplinary team that can deal with security problems and violence incidents immediately to prevent or reduce harm
(Cooper & Swanson, 2002)
Nationwide reporting system for all incidents that is easy and simple
To provide the needed assistance and support to the victims
To understand the prevalence and incidence of the problem
To monitor the effectiveness of different interventions
(Cooper & Swanson, 2002)
Counseling sessions for victims of violence
To provide programs for therapy, rehabilitation and support for the victims
To decrease the psychological and work-related consequences
Environment (healthcare organizations and social environment)
Healthcare administration commitment to prevent violence with zero-tolerance policy
Allocating resources for training, screening and risk management.
Improving security systems as surveillance cameras and other needed measures
Rehabilitation and care for victims of violence
(Morrison et al., 1998)
(Cooper & Swanson, 2002)
(Saines & Nursing, 1999)
Legislative changes to raise the level of punishment
to amend the current law or issue a new one making the punishment deterrent for the public
(Di Martino & Trabajo, 2002)
Small police units in large hospitals and high-risk organizations
To reduce the incidents through the official power
Immediate intervention in case of violence
Protection of individuals and institutions
Facilitation of legal reporting of cases of violence
(Di Martino & Trabajo, 2002)
Safe workplace through examination of building designs and the availability security equipment
To ensure a safe work environment that reduces the susceptibility of the workers to violence.
Identification of potential hazards for violence in the workplace
Fixing broken furniture or equipment and their proper maintenance giving impression of discipline and formality
(Mayhew & Chappell, 2003)
(Morrison et al., 1998)
Interventions to deal with the healthcare workplace violence
in Egypt based on evidence and considering the local environment, barriers and
challenges can be in the form of three-sided approach targeting the different
parties involved and reshaping their relationships.
1- Legislative changes increasing the level of punishment
Issuing a new law or making amendments to the current law could be the first intervention to have role in the prevention of the violence against healthcare workers (Di Martino & Trabajo, 2002). Increasing the level of punishment with criminalization of this action is expected to minimize the rate of violence especially from people who think that there will be no consequences of their actions. This national regulation targets improving the environment of the healthcare practice and reorganizes the way the patients may deal with both healthcare workers and institutions.
Regionally, the Saudi ministry of health keeps on exporting a strong message that attacking health practitioners in their workplace can result up to 10 years in prison and a fine of up to SR1 million (266.665$) (Saudi Gazette report, 2018). This warning message is accompanied by a hotline for complaining in case there is any defect in the service provided.
2- Public awareness regarding the nature of healthcare services, the respect of healthcare workers and consequences of any violence.
Raising public awareness and giving them the needed information through mass media campaigns, social media and local media instruments at healthcare facilities is a crucial element in reducing violence incidents (Spelten et al., 2017) . Blaming healthcare workers and accusing them of corruption should be stopped in the media. Awareness messages should cover the expectations of the healthcare provided, responsibilities of the patients in healthcare settings, the expected consequences in case of committing any sort of violence and the right way to make a complaint in case there is any deficiencies (Di Martino & Trabajo, 2002).
Those public awareness campaigns are the responsibility of the government in the form of MOHP and the medical syndicate that has to advocate for the protection of healthcare workers. Awareness campaigns are targeting patients and their relatives (vectors) and aiming at reshaping their attitudes towards healthcare workers.
3- A nationwide electronic reporting system for all incidents that is easy and simple.
This system can be developed through the collaboration of the medical and nursing syndicates. Reporting is an essential step for any effective response (Di Martino & Trabajo, 2002). The system should enble immediate reporting of violence incidents by any healthcare worker and has to be simple and user friendly (Spelten et al., 2017). Employees are encouraged to report any incidents through this system to facilitate monitoring of the problem and providing any needed physical, psychological and legal support (Cooper & Swanson, 2002). Inputs to the system is to be shared with the MOHP for its action and intervention. This reporting system is targeting healthcare professionals and involving the nationwide organizations to have their responsibility in protecting those individuals against violence.
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