labor Violence Against Healthcare Workers Is on the Rise – What’s Behind This Social Ill?
Dr Teresa Valle has experienced several attacks, but she remembers the first one much more clearly than the others. It was in 2007, in the emergency department waiting room. Eight months pregnant at the time, she approached a patient with severe toothache. To help him endure the wait, she took him a painkiller and a glass of water. “He threw it in my face,” says the doctor, reliving the incident 17 years later. “It didn’t do me any physical harm, but it harmed me inside.”
After that first act of aggression, there came a second and a third and a fourth. There were death threats, insults, attempts to slap her face. There were several lawsuits, several restraining orders. The toll of 20 years of medical practice, the flip side of her vocation that she could never have imagined. “It wasn’t just me, we all suffered it. We would walk each other to the car when we finished the afternoon shift, just in case.”
Health workers have become regular victims of violence, easy targets for a society that vents its anger against those who are there to care for others.
It is a global phenomenon. Around 25 per cent of the victims of workplace violence around the world are health workers, with over 60 per cent having experienced a violent incident.
It is the symptom of a social ill (workplace violence is experienced by one in five people overall) that affects the health sector with greater virulence than, for example, education – which accounts for 7 per cent of attacks, transport – also 7 per cent, or the police – with 5 per cent.
Institutions such as the World Health Organization (WHO) or the International Labour Organization (ILO) refer to violence against healthcare workers as “an international emergency”, with implications for the professionals themselves but also for health systems as a whole. “Once, a patient threatened us with a pair of scissors,” says Valle. “I locked myself in the bathroom, I was scared to death. Why should I have to go through that when I’m only doing my job?”
Data missing
For a long time, attacks on health workers were a problem that was only murmured about between colleagues. “It was like with gender violence, everything was kept hidden. The workers suffer, because their role as carers is called into question. The victims themselves feel guilty. They feel at fault, and they feel ashamed,” José Manuel Bendaña, a member of the National Violence Observatory (ONA) of the Spanish Medical Colleges Organisation, tells Equal Times.
The phenomenon did not become public knowledge until the turn of the century. In 2002, the WHO and the ILO published the first Framework Guidelines for Addressing Workplace Violence in the Health Sector. Since then, the priority has been to quantify the violence, to see how far it reaches. In 2010, Spain became one of the first countries to set up an observatory, on the initiative of the Spanish Medical Colleges Organisation, after a female doctor was murdered by a patient.
“It was very difficult to start collecting data. We’re still a long way from having real figures,” admits Bendaña. Because not all attacks are reported, let alone reach the courts – barely 10 per cent, according to the organisation.
Only the most serious attacks, those that involve physical violence, are covered, while the other forms of violence – the most common, according to all the studies – such as verbal abuse, threats and coercion, continue to be kept quiet in many cases, either because they are normalised or for fear of reprisals.
The data now available shows a steady rise in the violence, year on year, with the sole exception of 2020 when the Covid-19 pandemic reduced face-to-face healthcare. Record levels were reached in 2023. In Spain, for example, more than 14,000 attacks were reported, 24.05 per 1,000 health workers. That is four points higher than in 2022. In France, reports of physical or verbal violence rose by 27 per cent last year. In Australia, the number of compensation claims for work-related violence has increased by 56 per cent since 2017. In India, 75 per cent of doctors said they had experienced some form of violence while similar incidents were experienced in 96 per cent of hospitals in China.
Yet many countries do not have the tools to collect data. In Europe, the only countries that do are Spain, France, Italy, Portugal and Belgium. That is why medical associations in Spain and France have come together to try to establish a single form for recording attacks across the whole of Europe. Information is vital, they insist, especially to establish where it happens and why, to prevent it from happening again. For the moment, we know that most of the violence occurs in emergency departments and primary care settings. Nurses and doctors are most affected. Those who work alone, at night or in patient’s homes are the most at risk. Patients – followed by their relatives – are the main perpetrators. And not necessarily people with mental health problems or addictions, but patients of all kinds.
“We are unprotected”
In 2019, Valle decided to leave the emergency department of the hospital where she was working because of the attacks. She moved to a health centre. “But when I got there I found that the number of attacks in primary care was much higher and we also have the handicap that the security measures are much more wanting.” The doctor, who is now also part of the SMA medical trade union of Andalusia, describes the health centres as “mousetraps”. Many have no security guards or no communicating consultation rooms to provide an escape route in case of emergency. “I have found myself working with an aggressor at the door and being unable to leave the consultation room. We are unprotected, helpless in the face of an attack.”
In Spain, new security measures were already introduced in healthcare environments back in the year 2000, such as the Alertcops application to facilitate communication with police forces, courses to learn how to detect signs of threats or deal with hostile behaviour, the establishment of health police interlocutors. Even the Penal Code was amended to class violence against health workers as an attack on authority (although only serious threats and injuries).
Other countries have video surveillance systems, metal detectors, a register of assailants. In Italy, some trade unions have even called for army protection. Strengthening security seems to be the most urgent matter, but is it enough to tackle the problem from the security angle alone?
A tense society, an unresponsive system
“The society we find ourselves in is a mirror of society as it really is. The level of tension and aggressiveness is also passed on to the health sector,” explains Paloma Repila of the SATSE nursing union. This tension is further heightened by a mismatch of expectations. The main trigger for the violence is linked to this: patients ‘feel’ they are not receiving adequate care.
“Patients are more empowered, but not in a positive way. It’s not that they are better informed or more autonomous,” says Repila. “What happens is that people go to the doctor or nurse demanding what they have to do for them. This creates unrealistic expectations, affecting trust and respect.”
The level of care also falls short of expectations because the system is failing. The deterioration in public health care – which accounts for 80 per cent of the attacks, relative to private health care – is closely linked to the increase in violence, which is fuelled, as the World Medical Association for example acknowledges, by factors such as staff shortages, long waiting times, overcrowding in waiting areas and a lack of trust in health workers.
Studies show that where there are fewer nurses there are more attacks; or that the precariousness, temporary nature and stress of healthcare workers are predictors of violent behaviour. “There is a direct link: precarious working conditions, such as temporary or part-time work, often leave health workers more exposed and unsupported, heightening their vulnerability to violence. These are also the workers who are least likely to report abuses, for fear of reprisals. Unionisation rates are notably lower among precarious workers, which limits their union protection and support,” the European Public Services Union (EPSU) tells Equal Times.
So, is reinforced security enough to solve the problem? “Of course not,” say Javier Rodríguez and Alejandra Martínez, members of the Medical Anthropology Observatory (OAM) and authors of the most recent study on violence against health workers in Spain. They describe the phenomenon with the metaphor of a tree on which the leaves are the violence from patients – be it physical or verbal – the trunk is the institutional violence exercised by management – which includes the administrative burden or the lack of support for workers – and the roots are the structural violence – the lack of resources, the precarious conditions, the lack of job security.
“Violence, for example, is only giving you five minutes to see to a patient,” says Rodríguez.
The three types of violence interact and are self-reinforcing, according to the study. “That’s why we have to start from the roots and the trunk,” says Martínez, “That way, the leaves will be different.” This includes legislative measures (in Spain, for example, there have long been calls for a shared law on violence for the whole country), judicial measures, including improved complaints mechanisms, organisational measures, such as better staffing, working hours and working conditions, or even environmental measures, and avoiding waiting rooms that are too small or poorly equipped. All of these were already part of the guidelines issued by the WHO and ILO in 2002. “Changing and improving work practices is a most effective, inexpensive way of diffusing workplace violence,” said the document.
“We need general and sector specific policies to better prevent violence, and these policies must be designed together with trade unions and workers,” insists the EPSU. “This is what we have started to do in the EU, by negotiating a new set of guidelines on workplace violence. Although they are not binding, they can have a significant impact on national policies.”
There is a consensus that no form of violence can be justified, but there is also a consensus that work can be done to prevent a breeding ground for violence. ‘‘General education on health care needs to be improved,’’ points out the Spanish Patients’ Organisations Platform (POP). In a survey of its own, conducted with chronically ill people, satisfaction with healthcare was rated as low, especially since the pandemic. In 43 per cent of cases, for example, the patients responded that they did not sufficiently understand the information communicated to them about their diagnosis. “Communication between health workers and patients clearly needs to be improved and enhanced,” underlines the platform.
The gender factor
Data not only helps with prevention, it also helps to highlight other types of underlying causes, such as the gender factor. In 78 per cent of cases, the health workers attacked are women. They receive twice as many insults and threats.
It could be argued that this is because women account for 67 per cent of overall employment in the health sector and are therefore statistically more at risk. But, as some studies point out, this would be an oversimplification.
Violence against women workers is a structural problem in a sector where women are in the majority. They occupy only 25 per cent of leadership positions and are over-represented in the jobs most likely to be attacked.
Added to this is the sexist component to many of the attacks, including cases of sexual harassment, which account for 12 per cent of violence against health workers. “There are patients who lose respect for you because you are a woman, they become emboldened, and they look on you differently,” says Valle.
The study by Martínez and Rodríguez also recommends analysing other variables like gender, such as age, nationality or religion, alluding to the growing incorporation of health workers from different backgrounds. In any case, further research is needed, as the cost of this type of violence is becoming increasingly high.
It translates, for example, into higher levels of stress, anxiety and burnout among professionals.
“Nothing repairs the damage inside you. You go back to work afraid, afraid that it will happen to you again, you are careful with your words, you don’t do your job as you should, in a relaxed and safe way. It’s not just about the doctor, the violence has repercussions for all patients,” explains Valle.
“I have colleagues who have reduced their working hours or refused to work in a certain facility after being attacked,” says Repila of the nurses’ union. “Violence curtails professional freedom and even affects pay.”
According to WHO forecasts, it is estimated that, by 2030, 18 million new health workers will be required to meet the world’s health needs. It will be difficult to attract them if people in the sector still have to go to work with a sense of fear.
María José Carmona is a journalist specialising in social and human rights. She currently contributes to various digital media outlets, including Planeta Futuro (El País), eldiario.es, El Confidencial and Público.
This article has been translated from Spanish by Louise Durkin.
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