Journal of Hospital & Medical Management

Keywords

Violence; Emergency service; Impact; Medical staff

Materials and Methods

This is a qualitative descriptive study, carried out on a sample of 107 medical staff working in the emergency services in all the hospitals of the governorate of Kef (regional hospital of Kef, district hospitals of Dahmani, Sers, Tajerouine, Ksour, Nebeur, Sakiet sidi Youssef), with the morning, afternoon and night shifts. The 107 participants are distributed as follows: 24 healthcare workers from the Kef regional hospital, 23 from the Dahmani district, 18 caregivers from Sers, 13 participants from Tajerouine, 9 interviewed at Ksour, 11 caregivers from Nebeur and 9 staff from Sakiet sidi Youssef. Our study is carried out over a period of 8 months (from October 2018 until May 2019) using a questionnaire consisting of 31 questions studying different concepts such as the factors favouring violence, prevalence of cases of violence, the impact of an assault on the physical and psychological health of caregivers, as well as their personal and professional lives and preventive measures in the face of an act of violence.

Results

Our population is predominantly female (57%), and made up of a variety of professional statuses including more than half were nurses (58%), 14%are doctors, 17.7% are nursing assistants, and10.3% are technicians and reception staff. The vast majority of participants said they were victims of acts of violence (85.98%), with (100%) threat type verbal abuse (77%) and insults (63%), and only 27.17% suffered a physical violence such as beating (44%) and scratches (24%). The perpetrator was in the majority of cases, the accompanying person (82.60%) and male in75% of cases. The immediate actions to be taken were: the declaration to the police (65.21%), a colleague's request for help (28.26%) and 25% of the population did nothing. Late, 17.39% of cases consult doctors, 20.65% write a report to the manager, while44.56% of cases do nothing in the face of this aggression. For the vast majority of participants, the mode of work organization is a factor favouring violence, (85.98%) of cases, where resources human and material were implicated (premises inadequate, for 68.74% of cases and the lack of material, for 63.04% of cases), as well as the conditions at work (overload of work, for 65.21% of cases and patient dissatisfaction, in 53.26% of cases). Acts of violence affect physical health of the caregiver, resulting in wounds, observed in 44% of participants and bleeding, in28% of caregivers. They also affect their psychological health, resulting in stress, in 97.82% of participants and by a feeling of guilt, observed among 43.4% of health professionals. In addition, these attacks have an impact on personal life care providers (family conflicts, for 9.13% of aggressive cases and behaviours, for 35.86% of cases) and their professional life (the demotivation observed in 47.82% of caregivers and the lack of concentration, for 39.13% of professionals. Finally, 72.89% of caregivers declared that this problem is always overlooked on the part of the administration of their establishment, and 84.11% among them feel the need for medico-psychological care after the occurrence of an aggression.

Discussions

The most observed professional status in the emergency departments of the governorate of Kef, are the nurses (58%) which makes this member of the healthcare team, the more exposed to acts of aggression as demonstrated “Lyneham” in his study carried out in 2014 among caregivers with various professional statuses, the main result was: that nurses are affected in almost half of the cases. [4] We made sure to specify the type of violence most common in our target population, and we have found that verbal abuse is the most common type observed in caregivers, this can be explained by the fact that physical violence is accompanied in the majority of cases, that of verbal violence which sometimes seem to be the only modes of expression known to patients and their caregivers. These antisocial behaviours are unpredictable, difficult to manage and a source of anxiety for all staff. [5,6] Verbal violence most often causes psychological problems, ranging from simple stress to “burnout”. In the same context that our study, we quote the report of the ONVS drafted in 2014, which reinforces our data, in which, he reports that among 10638 reports of breaches to identified persons,36.7% are insults. [4] Immediately upon the occurrence of an act of violence, whatever its nature (verbal or physical), some caregivers are in shock of this conflictual situation, which means that different reactions from one caregiver to another, from where we found that half of the participants in our study resort to the police (65.21%) as first solution whereas in 25% of cases, the caregivers avoid making the situation worse, and have nothing in the face of this violence. The late actions to be taken by caregivers in the face of acts of violence differ, it was found that 20.65%of participants write a report to hierarchical managers, 17.39% consult in order to have an initial medical certificate, while the majority of participants, 44.56%, do not face this aggression which explains the statistics published by the Ministry of Health in Tunisia, who postulate that only 327 acts of aggression were committed during the year 2012 in all Tunisian hospitals audiences. Among these assaults, 62 acts were targeted the emergency services. Avoidance of caregivers to seek their rights testifies that culture of silence is ruining our health facilities.So, the victim should report the accident within 24 hours to his manager, indicating the place where it occurred, the circumstances and contact details of any witnesses. [5] The confrontation of the aggressor and the victim takes place in the workplace in a well-defined circumstances, certain particularities favour the emergence of violence which is confirmed by85.98% of the participants who consider that the organization of their work is a factor favouring the occurrence of violence, accusing

mainly: unsuitable locals and work areas (68.47%), lack of material (63.04%) as well as staff (61.95%). Work overload and individualized work were mentioned by 65.21% of staff because they may prevent optimal management of patients and can cause engorgement of the emergencies, and increased morbidity / mortality, as well as increased consumption of resources. They generate also an increase in waiting times, source of patient dissatisfaction which is amplified by the less empathetic attitude of overloaded caregivers. [7,8] In the emergency room, each patient thinks that their situation is highest priority and the most serious, thus ignoring the sorting system that we adopted to organize our job. [9] This justifies these causes of aggression: Patient / caregiver dissatisfaction (53.26%), the long waiting time (29.34%), lack of communication (caregiver / patient / family), for 33.69%cases and working with people in distress (psychiatric illness, drug addicts, alcoholic, handcuffed…etc., declared by 28.26% of the participants. This research studies the different consequences of violence on the health of the caregiver so, the most frequent immediate consequences are: stress 97.82% and feelings of guilt43.47%. Stress is particularly present in caregivers’ teams, for reasons of overwork, daily confrontation with suffering and lack of recognition. It can have different effects on the people, Indeed, each individual reacts differently to situations because stress develops properly in character of the individual, as well as the consequences may appear are

- Affective consequences: anxiety, hostility, anger, violence, dysphoria, sadness, loss of hope, demoralization, distress, aggression towards the entourage.

- Psychological and psychiatric consequences: chronic fatigue, exhaustion syndrome, depression, suicide thoughts, insomnia, alcoholism, bulimia. [7]

The emergency care team must deal with many difficulties such as the constraints of time, pain, disease, death, suffering, anxiety of patients and their families. When the stress is present, gestures then become less safe and poorer quality of care. [10] Unhealthy stress plus burnout that can have serious repercussions on all aspects of the performance of the healthcare team including 97.82% of cases, suffer from demotivation (47.82%), lack of concentration (39.13%) and a decrease in efficiency in (19.56%). [11] These repercussions affect the quality of care, when caregivers are under excessive stress, it not surprisingly they have difficulty at concentrating on their tasks, which they are doing, for example they make more errors or that they can interrupt the work process, these victims become disorganized and have difficulty managing their time, falling into the trap of professional exhaustion where the professional no longer sees the patient as a person and no longer able to establish a real helping relationship. [12,13] Indeed, all members of the victim's family will be affected by this harmful stress to varying degrees up to psychological malfunctions. We are talking about a “family burnout” which occurs in an insidious way and manifests as family conflicts and aggressive behaviour that lead to divorce or can even traumatize the child. [14] After collecting data from our target population, the result is that 36 health workers of the 92 participants who were victims of violence suffer from family conflicts (39.13%), moreover 33 caregivers said they have behaviours aggressive towards their family and social environment (35.86%), in fact, 26 caregivers declared that they had several relationship problems due to constraints of their work and 38 caregivers affirmed that they have become suspicious of others and impatient with their children. In this same context, several studies have clearly established that the psychological factors, such as stress, anxiety, depression and lack of adequate social relationships exert a negative influence on health, decrease significantly life expectancy and increase the risk of premature death. In addition, the majority of caregivers, 72.89%, have declared that the issue of violence against emergency services staff is not taken into consideration by their administration, which gives them a feeling of insecurity at work.

Recommendations

Our study brings ideas for reflection interesting in the field of research, training and practice. The results from our descriptive survey can provide very important for improving the condition of caregivers exercising in the emergency services, in constant confrontation with restless and demanding patients. For this purpose, we suggest the following recommendations are

• The layout of the premises by limiting the area witch the accompanying person cannot pass.

• Acts of violence must be reported, legal proceedings must be given and the burden of victims must be ensured.

• Ensure a quality welcome within the services emergencies by professionals well trained in communication and sorting.

• Awareness of patients regarding false emergency room.

• Inform patients of the legal circumstance acts of violence.

• Provide medico-psychological care within the establishment sanitary.

• Provide medical and paramedical staff insufficient number.

• Dispatching the emergency department to facilitate transmission of interpersonal orders concerning the care, the alert of dangers and the need for intervention by other members of the team.

• Specific training for staff caregivers regarding the management of violence, reception arrangements and techniques communication.

Violence against healthcare workers has several negative repercussions on his physical health and psychological, as well as on his personal life and professional, which sounds directly or indirectly on the economics of establishments sanitary facilities. Hence migration sometimes appears, in nursing staff, the only solution. Hence January 72019, the Minister of Health, “Abderaouf Cherif” said about 200 physicians have made a request to leave public hospitals. [2] These requests come as a result of attacks on medical executives, in hospitals, especially during night shifts. Let’s remember that attacks on personnel continue to take worrying proportions but not published in the website of the Ministry of Health.

References

1. IRSST (2017) Violence in the workplace: Prevent, intervene and protect from the effects. Br J Nurs 12: 102-107.
2. Tunisia: Because of the attacks, 200 doctors want to leave public hospitals (2019).
3. Violence in emergencies: a sad reality (2005).
4. 5,703 nurse’s victims of violence in 2014 according to an ONVS report (2016).
5. Information note n ° DGCS / SPA / DGS / EA4 / 2019/38 of February 15, 2019 relating to the prevention of the risk of burns by domestic hot water and the risk of legionella in residential establishments for the elderly or for people disabled (2019).
6. Convention for the Safeguarding of the Intangible Cultural Heritage (2003).
7. ACUTE STRESS VS CHRONIC STRESS (2019).
8. Family burnout: stress at home (2016).
9. Toutin T, Benezech M (2007) The victim doctor in his daily practice: what to do for his safety Clinicians who are victims in their daily practice: Ensuring their safety. Ann Med Psychol Psychiatr J 165: 768-773.
10. Eastern Psychiatric Society (2016).
11. EAP Improves Health Status and Productivity, and Demonstrates a Positive ROI (2011).
12. Kim Youngmee, Charles S Carver, Kelly M Shaffer, Ted Gansler (2015) Professional stress a danger for caregivers. Cancer 2: 302-310.
13. Poletti R (2016) National Center for Biotechnology Information Search database. Raetzo MA. Le burnout. Rev Med Suisse 12:1536-1537.
14. Nour Mheidly, Mohamad Y Fares, Jawad Fares (2020) Coping With Stress and Burnout Associated With Telecommunication and Online Learning Health Promot Pract 8: 574969.