Policy on Violence Against Doctors

1- Introduction

The concept of violence is multidimensional and complex, as acknowledged by leading international bodies. The Council of Europe defines violence as not just an isolated act but a complex phenomenon involving a range of behaviours, including actions or threats  that can result in physical, verbal, or psychological harm [1]. The World Health Organization further extends this definition to encompass the impact on individual healthcare providers and their communities, thereby acknowledging the systemic nature of violence [2]. This complexity arises from various factors, such as societal norms, healthcare settings, and the culture in which it occurs. Multiple actors often perpetuate violence from patients and their families to colleagues and even institutional frameworks. This can create a culture of acceptance or normalization of such acts. Therefore, violence cannot be restricted to singular, isolated incidents but must be understood as part of a broader, more intricate landscape that requires multifaceted solutions.

Over the last decade, the European Medical Organizations led by the Council of European Medical Orders (CEOM) have adopted several statements condemning violence against healthcare professionals, including doctors [3-5]. In 2019, the annual European Awareness Day on Violence Against Doctors and Other Healthcare Professionals was launched. While these steps demonstrate societal and organisational acknowledgement of the issue, violence against Junior Doctors continues to escalate. This violence takes multiple forms,   including   physical,   verbal,   emotional/psychological,   sexual,   and institutional violence. These acts of aggression not only jeopardise the well-being of Junior Doctors but also affect the quality of healthcare delivery and the broader healthcare system. In light of the COVID-19 pandemic, evidence suggests an alarming increase in violence, fuelled by media narratives and system-wide stressors [6]. With this backdrop, it is critical to address this pervasive problem urgently.

2 - Vulnerability of Junior Doctors

Junior Doctors occupy a unique and particularly vulnerable position within the healthcare system. They are not only medical professionals but also undergoing Postgraduate Training (PGT) and are in the early stages of their careers, working in under resourced health & education systems, making them susceptible to gaps in supervision and support. Where training is rotational and/or junior doctors are employed on fixed-term contracts it is difficult for junior doctors to report incidents of violence as they may change employers or not be aware of procedures and processes at multiple places of work. Junior Doctors often work longer hours, have intense workloads and lack adequate resting times, exacerbating stress and reducing their ability to manage violent or aggressive behaviour effectively. Furthermore, research indicates that those working in Primary Care, Psychiatry, and Emergency Medicine are at exceptionally high risk of experiencing violence.[6] Their hierarchical status within the healthcare ecosystem leaves them with less autonomy, making them more vulnerable to abuses of power from senior staff. They are also often responsible for providing care during high-stress situations such as night shifts and emergency room settings—environments where the risk of violent incidents is significantly elevated. This heightened risk is compounded by a lack of comprehensive training in managing violence or aggressive behavior, and inadequate security staff, systems and protocols; this leaves them ill-equipped to navigate these challenging scenarios. Instances of violence against Junior Doctors have even been observed during their free time, an issue attributed to a lack of anonymity and insufficient safeguards from employers.

3 - Consequences of violence

The repercussions of violence against Junior Doctors extend far beyond individual suffering and have systemic implications that are detrimental to healthcare as a whole. Firstly, instances of violence compromise the quality of care, as doctors in stressful or hazardous environments are less able to focus fully on patient needs. Secondly, a culture of violence fosters defensive attitudes among healthcare professionals, which can manifest as reluctance to engage with patients fully or take necessary but risk-associated actions, thereby reducing the efficacy of healthcare delivery. Thirdly, frequent exposure to violence accelerates the onset of burnout, moral injury, and can contribute to long-term mental health conditions. These factors not only diminish the well-being of Junior Doctors but also have a cascading effect on healthcare systems, leading to decreased staff retention, increased costs, and reduced public trust in healthcare services.

4 - Recommendations

The recommendations herein aim to bring a comprehensive change, targeting individual, institutional, and societal levels to effectively reduce violence against Junior Doctors.

Individual Measures

• Enhanced Training in Communication Skills and De-escalation Techniques: Junior Doctors should receive comprehensive training in nonviolent communication and crisis intervention to help prevent escalation of confrontational situations.

• Promotion of Allyship and Counteraction of Destructive Behaviors: Educational programs should actively work to de-normalize harmful behaviors, including racism, lgbtphobia and misogyny, promoting allyship within the medical community."

National Measures

• National Standards: Implement national standards for violence prevention and reduction in healthcare settings, including strict enforcement of accountability mechanisms.

• Public Awareness: Run national campaigns educating the public about the incidence and implications of violence against healthcare staff, the consequences for perpetrators and the impact of quality of care.

• Research into Causes and solutions: Conduct national and European level research to understand the multi-faceted roots of violence against doctors, including societal, institutional, and political factors.

Institutional Measures

Policies & Systems

• Enforcement of Zero-Tolerance Policies: A strict policy against all forms of violence should be upheld and supported at all levels, from healthcare institutions to legal frameworks.

• Report systems: systems to report violent incidents should be put into place. In case it relates to violence between colleagues they should ensure anonymity.

• Security Measures: Effective security protocols should be in place, including appropriate security and surveillance, panic buttons, and alarms to protect healthcare providers.

• Policies for Managing Violent or Abusive Behaviour: Robust policies should be established for dealing with violent or abusive patients, visitors, and even staff, with clear consequences for such behaviour.

• Accountability Framework: Strict accountability mechanisms should be in place to ensure that policies for reducing violence are effectively implemented and maintained.

• Gender-Based and Sexual Violence: Establish strong policies and support mechanisms to combat workplace gender-based and sexual violence.

Culture

• Addressing Doctor-on-Doctor Violence: Institutions need to expose and eradicate doctor- on-doctor and healthcare worker-on-doctor violence, which include physical violence, bullying, verbal abuse, and more.

• Victim-Centric Approach: Institutions should adopt a "belief-of-victims" approach in policy and action, ensuring that victims of violence feel supported and are encouraged to come forward.

Victim Support

• Support and Credibility for Victims: A culture should be fostered where victims feel supported and believed, with appropriate measures in place for reporting and addressing incidents of violence.

• Active Bystander Training: All staff members should undergo active bystander training to empower them to intervene in potentially harmful situations.

Infrastructure

• Adequate Staffing Levels: Institutions should maintain appropriate ratios of clinical, non- clinical, and security staff to ensure the safety of both healthcare providers and patients.

• Resource Optimization: The healthcare environment should be well-resourced to minimize unnecessary waiting times and rationing, which can contribute to tensions and violent incidents.

• Infrastructure Improvements: Physical spaces should be designed or retrofitted to minimize risks, including avoiding overcrowding in departments, clinics, and wards.

Use of Data

• Protection of Personal Information of workers: prevent access to private information by health professionals or externals

• Comprehensive Data Collection: Gather data on all forms of violence, including specific data regarding intersectional violence (gender, race, religion, disability, sexuality, etc.), and information about perpetrators. Anonymous systems should be in place for reporting doctor-on-doctor violence.

References

1. Compass: Manual for Human Rights Education. Council of Europe. 2020. ISBN 978-92-871-8693- 5
2. World report on violence and health, WHO 2002, Geneva p 5: http://whqlibdoc.who.int/hq/2002/9241545615.pdf
3. CEOM Statement on Violence against doctors and health professionals. European Council of Medical Orders 2018. https://www.ceom- ecmo.eu/sites/default/files/documents/ceom_declaration_on_violence_against_doctors_-_madrid_2018_0.pdf
4. European Medical Organisations’ joint statement on Violence against doctors and other health professionals 2020. https://www.cpme.eu/api/documents/adopted/2020/3/EMOs.Joint_.Statement… NAL_.12.03.2020.pdf
5. Violence against healthcare professionals: a rising threat to the health workforce and patient care. Statement by the European Medical Organizations 2023. https://www.juniordoctors.eu.loc/sites/default/files/2023- 03/PR.Violence%20against%20healthcare%20professionals%20a%20rising%20threat%20to% 20the%20health%20workforce%20and%20patient%20care.pdf
6. Our duty of care: A global call to action to protect the mental health of health and care workers. World Health Organisation 2022. https://www.who.int/publications/m/item/wish_report