Major reasons were Unrealistic expectations of patients, communication failure, human error, unexpected outcome, sub-standard care and management failure-Lubna Baig

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ICRC study findings on violence against HCPs and at HCFs

Major reasons were Unrealistic expectations of
patients, communication failure, human error,
unexpected outcome,sub-standard care and
management failure - Lubna Baig

Most violent incidents took place at Accidents &
Emergency, Emergency obstetrics departments

Abusive language was most common violence and
there is a general acceptance for verbal abuse

By our special correspondent

KARACHI: International Committee of Red Cross initiated a study to find out the reasons and cause of violence against healthcare professionals and at healthcare facilities in Karachi sometime ago. The initial findings of this study were presented at a meeting held at PMA House Karachi on Saturday June 6, 2015 which was very well attended by all the stake holders i.e., healthcare professionals, heads of medical institutions, representative from the law enforcing agencies, NGOs and the city administration. The researchers included Prof. Lubna Baig, Dean APPNA Institute of Public Health at Jinnah Sindh Medical University,  Dr. Seemin Jamali  Joint Executive Director JPMC in charge of Accidents and  Emergency Center, Prof. Kamran Hameed Dean  Ziauddin Medical University and Dr. Kausar S.Khan from Aga Khan University.


Prof. Lubna Baig

Presenting the initial finings of the study, Prof. Lubna Baig said that 41.8% of the violent incidents occurred in Accidents and Emergency department followed by 39.4% at emergency obstetrics and 13.6% at wards. Abusive language was the most common violence which accounted for 82.8%. Speaking about the reasons for violence she mentioned unrealistic expectations, communication failure, human error, unexpected outcome, substandard care, financial pressure and management failure. About 2% of the victims of violence died, 50.3% expressed hopelessness, 84.7% required treatment, 51% took no action, 22.9% did not report, only 4.4% sought counselling and 1.55 pretended that it never happened. When asked for reasons for not reporting 45.7% did not think it was important, 13.4% were afraid of negative consequences and 31% thought it was useless?

The objective of the study Prof. Lubna Baig stated was to identify ways and means to improve safety of healthcare professionals, patients and who care for all of them. We also wanted to find out the type of violence, major sites, areas of violence, gauge its intensity and tolerance for violence by the healthcare professionals besides sensitizing the stake holders about this issue. The institutions which participated in this study included JPMC, Civil Hospital Karachi, Hospitals in Landhi, Korangi, Abbasi Shaheed Hospital, both the teaching hospitals affiliated with Ziauddin Medical University. The NGOs who cooperated included HELP HANDS, AMAN, and MSF while ambulance services that cooperated included Edhi, Chippa, and KKF. Ranges, Police from law enforcing agencies, numerous electronic and print media groups were also involved.  Before undertaking the study, five day intensive training programme was organized for those who were to collect the data. Over eight hundred questionnaires were distributed and those who responded included 59.7% male and 40.3% female.  Reports received included 581 (70.7%) from hospitals, 149 (18%) from ambulance service and 92 (4%) from NGOs. Maximum number of response was received from Ziauddin Hospital 172 followed by JPMC 132 and 79 from Civil Hospital Karachi.

Apart from abusive language, other forms of violence included rush and push fists and damage to furniture. Majority of the perpetrators 58.1% were patient attendants, 81 .7% violent incidents took place within the hospital, 14.8% outside the hospital and 3.5% during field visits.

Giving further details of the study Prof. Lubna Baig said that  out of over eight hundred incidents of violence,  only 221 were reported to the management,  7.9% were reported to police, 62.3% said nothing happened  after reporting and  in 29% just warning was issued. Further enquires revealed that 53.5% did not know if any changes were made at the hospitals after these violent incidents. When asked as to what measures they think should be taken to protect the healthcare professionals against such violent incidents,  35.8% said we need to make investment in human resources, appointing security guards, putting up security gates, 34.8% favored screening of patients, 38% opined that we should install panic buttons while  39% favored reduced period of working alone. Pushing and hitting with no injury is accepted because if they report to police, in case of no injuries, nothing happens. At times patients demand facilities which do not exist at hospitals which results in violent behaviour of the patients and their attendants.


The investigators also found lot of frustration due to injustice, no triage system for patients and awareness among the patients that sickest patient will be seen first. Every body wishes to be seen first. Then there is lack of counseling skills, communication skills and lack of training to de-escalate violence. Positive experience of this study, Prof.Lubna Baig opined was responsive management and seniors.

Recommendations

The investigators have recommended  increased security,  panic buttons,  increase in staff, improvement in hospital management, no politics in hospitals, avoiding unknown persons, exit planning, formation of community health committees and involvement of community leaders, training in management of violence, team work for healthcare professionals, improvement in communication skills, professional response from media, law enforcing agencies, educating the people to respect the law and above all the media must tell the truth.

Dr. Seemin Jamali speaking at the occasion about the lessons learnt said that there is high intolerance, patients do not wish to wait, patients approach and attitude in public hospitals is different as compared to their attitude in private hospitals. Ideal situation, she further stated, does not exit every where and we should know the shortcomings of healthcare professionals and healthcare facilities.

Commissioner Karachi Mr. Shoaib Siddiqui who also graced the occasion with his presence said that today’s meeting was very encouraging. He commended the role of PMA and said that security of healthcare professionals is very important. We need to provide them peaceful environment so that they concentrate on their jobs.  HCPs security is always discussed at the fortnightly meetings chaired by Chief Minister Sindh. We analyze and evaluate how much is the threat to them. Violent incidents have decreased and it is time that all sections of the society should join hands to make these efforts a success. Rule of law has been eroded and if it is not tackled this time, we will be encouraging violence. We wish to bring peace to Karachi and Pakistan. He advised all those present including the doctors community to generate hope in them. Extortion calls and threat to the doctors are all monitored. If you do not get response from one institution, go to the other institution. Society as a whole, he said, has become very impatient and intolerant for which awareness by the media is required.

He warned the vested interests within the hospitals who keep on creating law and order situation from time to time and said that such elements have to be taken care of. During the recent NICH crisis, the administration had ordered to arrest and put all such elements behind bars. We are determined and this approach is needed every where. Let us not encourage those who take law in to their own hands and silence will be dangerous for the future generations, he remarked.

Director JPMC Prof. Anis Bhatti in his speech said that we need to train doctors how to convey bad news. There are healthcare delivery lacunas as well. We all are hot headed and lose our temperament. We all need to change our behaviour. Doctors are overworked. At JPMC out of 79 posts of professors, we have just five and only fifty medical officers to run the services at this 1400-bed hospital. At times there is one consultant for three hundred fifty to four hundred patients. We have to be honest with ourselves and work honestly. We must find out why after accident, other incidents, every body rushes to JPMC and Civil Hospital Karachi.? Why they do not go to other hospitals? Over 60,000 deliveries take place at JPMC and many patients who come, why they cannot be managed at other hospitals, he asked? In spite of all that, we are relaxed and hope for a better change in the days to come, he remarked.

Prof. S.M. Tariq Rafi Vice Chancellor of Jinnah Sindh Medical University speaking at the occasion said that PMA has always been on the forefront. This is for the first time that we have collected sound scientific data. We need to carefully analyze it which is a major task. Identify resources and initiate protective measures. We all have become intolerant and unfortunately it has become a part of our national identity, he remarked.

Prof. Tipu Sultan said for such a big city, why we do not have more tertiary care hospitals to reduce rush and workload on JPMC and CHK. We must provide services at the door step or at the district level. Our healthcare facilities are understaffed and we must know how to de-escalate violence.

Mr. Shaukat Ali Jawaid Chief Editor Pulse International commended the study findings and recommendations. He further stated that the investigators wish every one from patients to attendants, law enforcing agencies and administration to change their behaviour but are the healthcare professionals themselves prepared to change? They must initiate self monitoring and accountability to ensure ethical medical practice. Prof. Lubna Baig remarked that in their recommendations they have suggested improvement in communication skills of HCPs, improvement in hospital managements and improvement in quality of care. Prof. Idris Adhi President PMA Karachi pointed out that Healthcare Commission Bill is lying with the Government since long. It is a very useful comprehensive document which takes care of injustice to patients, ethical medical practice, facilities to be available at workplace, standards, quality etc., and we must struggle to ensure that it is passed as soon as possible.

Earlier Mr. Jerome Alexander Imstept from International Committee of the Red Cross (ICRC) in his welcome address said that healthcare institutions in Karachi should come up with solutions to these problems to provide security to healthcare professionals, institutions and patients. This humanitarian issue can be solved and we can keep on working together.

Mr. Maciek Polkowski Head of the project “Healthcare in Danger” addressing the participants said that violence against HCPs is a global issue which his often overlooked. Violence against sick, wounded, violence against HCPs affects the entire healthcare system. People and ambulances are caught in cross fire. Ambulances are deliberately set on fire but at the same time we also need to ensure that these protected vehicles are not misused. ICRC started working on this issue n 2008 and collected evidence of 1809 such incidents. Those involved in violence were local healthcare providers, people from law enforcing agencies, non-State actors and several other perpetrators. To improve healthcare delivery we need to have standardized data collection, improve dialogue and provide for security personnel. We started working in Pakistan in 2014, had a meeting of the working group at Ziauddin Hospital on August 23, 2014 and then the group again met in December 2014. Today findings of our study are being presented and we hope to find out how they can be implemented in the days to come.