Article on Violence in Hospitals - 19/6/2006

link to Malta Independent

Violence is the tip of the iceberg
by Raphael Vassallo

Last week’s attack on a leading cardiac specialist has once again cast a spotlight on the problem of violence directed against doctors and nurses. Raphael Vassallo talks to MAM general secretary Dr Martin Balzan about the security situation at St Luke’s

By definition, hospitals the world over are tough places to work in. In the UK, a Royal College of Nursing survey found that eight out of 10 Admissions and Emergency (A&E) nurses had been physically assaulted in 2005. The year before, a similar British Medical Association survey also found that almost half the country’s doctors considered violence to be a serious problem at their place of work, and that only one third of assault cases in hospitals were ever reported to the police.

In this context, the problems faced by the medical staff at St Luke’s Hospital, where doctors and nurses have often been victims of physical or verbal abuse, are not exactly unique. According to Dr Martin Balzan, general secretary of the Medical Association of Malta, the reasons for incidents such as last week’s attack on Mr Alex Manche are likewise common to hospitals elsewhere: among them, an increasing mismatch in the demand and supply of medical services provided.

“The demand for health services has increased enormously in recent years, largely thanks to improved education and public awareness. Today, people are more aware of the services offered at hospitals and health centres than ever before. However, the supply of medical services provided by hospitals and health centres has not increased accordingly. In fact, the very opposite has occurred.”

As perhaps can be expected from a union which has long been arguing for improved conditions at local hospitals, MAM attributes this decrease in medical services to a steady loss of doctors, many of whom are leaving Malta in search of better work conditions abroad. According to Dr Balzan, the effects of this brain drain are most felt in departments such as A&E and pediatric casualty, where tension and anxiety are invariably high.

“We are losing doctors in the first five to 10 years of their careers. It is precisely this category of doctor that usually mans areas such as emergency and pediatric casualty. The resulting lack of medical personnel, combined with an ever-increasing number of patients seeking treatment, often results in the services offered by these departments being stretched to the limits.”

The problem of mismatched supply and demand is not restricted to St Luke’s Hospital alone. Dr Balzan cites examples of District Health Centres, in which a single doctor is sometimes expected to visit as many as 80 patients in an hour. Conditions such as these, coupled with a significant salary gap between Malta and other European member States, also contribute to the brain drain which is exacerbating an already depleted health service.

But despite last week’s violent incident, Dr Balzan is the first to acknowledge that the local situation has actually improved in recent years.

“Ever since the introduction of a uniformed police officer in August 2004, incidents of violence in casualty have been almost completely eradicated. Even verbal abuse – which is by far the most widespread problem locally – has noticeably decreased.”

The decision to post a police officer at casualty was taken after a spate of violent attacks on doctors and nurses in the previous months. In July 2004, MAM had issued directives for a symbolic 30-minute stoppage after two doctors were assaulted in the emergency department.

But while the problems in casualty seem to have been solved, there is still room for improvement in other departments. According to Dr Balzan, one of the main contributing factors to the climate of tension at St Luke’s is the uncontrolled visiting hours regime.

The number of people visiting their relatives in hospital outside the stipulated hours is very high. Dr Balzan said that security in hospital should be organised to make sure that relatives are only present during visiting hours.

“Violence and verbal abuse are not the only issues here. The patients’ privacy, too, suffers as a result of overcrowding. In addition, having too many people around when they’re not supposed to be there creates other problems, too. They may get in the way of doctors and nurses, hampering their ability to carry out their duties. Besides, doctors cannot be expected to perform the task of security personnel, and physically force these people out.”

Dr Balzan and his colleagues at MAM believe that these and other problems can be effectively tackled through education and information. “People need to be informed about the correct hospital procedures. If they have complaints, these ought to be directed to the proper channels.” Furthermore, education would also address one of the more common problems: that of patients and/or visitors making unreasonable demands of doctors and nurses.

At the same time, Dr Balzan argues that the deterrent also has to be effective. “In the case of physical violence, we are pleased to note that the authorities are adopting a tough, zero-tolerance approach. This is the way it should be, as violence against doctors can never be justified. However, we would like to see the same approach also being adopted in the case of verbal abuse.”

And finally, the system of prosecution also needs to change. “It is not enough for the police to present the case in court. A health department lawyer should also be present for the prosecution.”

For all this, Dr Balzan stresses that violent and abusive behaviour is not as widespread a problem as it may appear from the outside.

“Generally, the vast majority of people who come to hospital for treatment or as visitors are well-behaved. It is only a small minority who cause problems.”

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