Disclosure: Roberta Villa, MD, has disclosed no relevant conflicts of interest.
When a young woman died in Foggia, Italy, around 50 of her enraged friends and relatives decided to punish the healthcare workers they deemed responsible. A video circulating online, showing doctors and nurses barricaded in a room trying to protect themselves from this fury, brings the debate on violence in healthcare to a new level. The crisis is no longer limited to out-of-control psychiatric patients or individual patients or family members losing their temper during difficult moments. An attack like the one in Foggia requires premeditation, especially because the triggering event, a surgical intervention that ended tragically, occurred at the end of a long hospitalization, treatment, and rehabilitation process, not during an emergency.
Despite the potential for human error in the operating room, which the prosecutor's office is investigating, nothing, not even the worst case of malpractice, can justify such an assault. Nor can we get used to violence as if it were an inescapable professional risk associated with hospital work, especially in emergency departments.
In 2023, 16,000 assaults were recorded in Italian hospitals, according to a union of Italian doctors and healthcare managers. One third of these assaults were physical, and 70% of them were directed against women. In August, acts of violence were reported more than once a day in Italy, according to an investigation conducted region by region. These assaults included attempted strangulations, hair pulling, kicks to the face, and verbal death threats. At least one threat with a gun (which was later revealed to be a toy) was reported. At the emergency department of Castellammare di Stabia, a threat with a baseball bat led to hospitalization of a dozen healthcare workers.
Nurses have asked the Italian Army to guard hospitals if law enforcement is unable to do so because of staff shortages. However, the proposal by the far-right Fratelli d'Italia party to extend the ban on access to sports events (which was enacted to keep violent fans out of stadiums) to outpatient clinics and hospitals has not been received warmly, at least by Nursing Up (a nurses' trade union) of the Emilia-Romagna region. The proposal put forward by Senator Ignazio Zullo, group leader of the Labor and Health Commission, would deny free healthcare for 3 years to those who assault doctors and nurses.
"No one can be deprived of the right to health, as established by Article 32 of the Italian Constitution," wrote Nursing Up. The extension of the ban "risks becoming a dangerous precedent, affecting even those who, despite having inappropriate behavior, may find themselves in a situation of physical or psychological vulnerability."
The problem of violence against healthcare professionals extends beyond national borders. According to the World Health Organization (WHO), 8%-38% of healthcare workers worldwide suffer at least one physical attack during their careers. There are no reliable statistics about verbal attacks, which are often not reported. These attacks are sometimes intimidating and can have significant and lasting psychological effects.
The WHO's attention has shifted in recent years, especially to the unacceptable threats to the lives of healthcare workers in war situations or other serious emergencies. These threats clearly have other causes and require different solutions.
The latest documents related to workplace safety in ordinary situations date back to the early 2000s. In many ways, it was a different world compared with that of today, even though it was already clear that violence could contribute to workers' abandonment of healthcare professions. Violence against healthcare workers has exploded with the pandemic, thus exacerbating the vicious circle in which staff shortages worsen service efficiency, the quality of interpersonal relationships, and the time that can be devoted to good communication, which is an essential antidote to any conflict.
A narrative review, published in June in eClinicalMedicine, identified these risk factors for patient and family violence against healthcare workers: unmet expectations or requests, including regarding treatments; stress; acute illness; intoxication; psychiatric illness; delirium or dementia; poor communication from staff; long waits; discomfort or costs associated with treatment; staff shortages; and restrictions on movement, visits, and access.
Things do not seem to have changed qualitatively since 2002, when the WHO developed its guidelines for addressing violence in the healthcare sector. These guidelines consider bullying and all types of verbal and physical sexual harassment among healthcare workers, but it is worth focusing on interactions with the public. In recent years, violence associated with these interactions seems to have increased. Why?
Many factors can be adduced. First, we must acknowledge the difficulties of a system that increasingly fails to meet people's needs, in terms of not only services but also relationships. Is it acceptable to write in a patient's record that he is a "pain in the neck?" Where is the minimum respect that is due to all patients -- including those who are perhaps anxious, hypochondriac, or just annoying -- who seek a doctor's help?
In addition, information has become broadly accessible in our society, and ideas about hierarchy have crumbled. The principle that "everyone is equal" is now being applied to medicine. If a patient is convinced of a diagnosis or the need for a test or therapy, then he or she will not accept a health professional's denial as valid. Instead, the denial is considered to result from negligence or budget constraints. The patient is not always wrong, but many demands can frustrate the staff, who sometimes develop a preconceived attitude toward patients. Staff have gone so far as to hang a sign on a patient's door stating that they are not graduates of the "University of Google."
Violence existed before the internet and social networks invaded our lives, so the WHO guidelines from 2002 could still provide practical suggestions about how to address violence in healthcare settings. No magic recipes have emerged in the past 22 years. Studies have not collected solid evidence of the effectiveness of various proposed measures. Yet, the WHO document still provides guidance today.
First, it emphasizes that every facility, from private practices to large hospitals, should conduct a risk assessment that considers its environment and population. Even a trusted family doctor in a mountain village is not 100% safe, but his or her risk is not comparable with that of an emergency department in an area with high criminal or mafia presence, nor with that of a medical guard service where young female doctors also work. The competence of female doctors is often underestimated, given persistent male chauvinism, and their vulnerability can make them easy targets for violence or harassment, potentially of a sexual nature.
Among the situations that entail higher risk, the document lists working alone in a position that requires contact with the public. The risk is especially acute when the professional faces patients in distress (eg, frustration related to pain or illness, psychiatric disorders, or substance abuse), has coveted items (eg, certain medications, expensive instruments, or even syringes), or handles cash (eg, at pharmacy checkouts). In all these cases, workers should undergo continuous or periodic training to acquire awareness of potential dangers and practical and psychological tools to manage unexpected situations.
Organizational factors also can be modified. The first point is the shortage of personnel, which threatens the healthcare system's sustainability. Personnel shortages make it harder to ensure that no worker is left alone, establish adequate shifts, allocate time and space for dialogue, and provide training in welcoming and respectful communication.
Some communication strategies can be applied under current conditions. Rules of behavior for patients and family members can be established explicitly and reiterated through signs or other means. The message should be that no violence of any kind will be tolerated, and the sanctions for those who ignore the warning should be made clear. Episodes of violence, even less severe ones, should be reported to all other staff members and openly discussed. This step alerts the staff and enables support for victims of attack.
In high-risk situations, it is important to have protocols under which workers inform their colleagues when they leave their station and state where they are going and when they plan to return. Emergency codes, such as preestablished passwords that signal a dangerous situation without alerting the potential aggressor, should be established, as should privileged channels for requesting help from law enforcement.
The environment itself can be made safer. Adequate lighting is necessary, and cubicles instead of closed rooms allow workers to listen to what is happening in neighboring areas. It has been shown that clean and well-kept spaces, relaxing colors, low noise levels, a pleasant temperature, and adequate ventilation reduce irritation and tension in patients and health professionals.
There should be easily recognizable reception areas for the public. These areas should be visible from various points and spacious to avoid overcrowding and mutual disturbance among waiting patients. Seating should be comfortable, and entertainment (eg, magazines, TV, games for children) should be provided. Relaxation areas should be established for staff, as well as barriers that protect staff in high-risk situations. Furniture should be attached to the floor to prevent it from being used as a weapon.
It also is necessary to ensure a secure point of entry and exit for health professionals, who must have reserved parking spaces close to the facility. Security personnel should be positioned at the main entrance for the public, in the emergency department, and in high-traffic areas. More surveillance cameras and alarm systems with hidden buttons like those in banks are needed.
Resources are needed to implement all these proposals. We cannot hope for an efficient healthcare system with meager investments that are below the average of the Organisation for Economic Cooperation and Development -- and almost half of those in neighboring countries such as France and Germany. Much money is already needed to renovate dilapidated structures; replace obsolete equipment; and significantly increase the salaries of doctors, nurses, and other healthcare workers. But if we do not offer them a relative sense of security to return home healthy and safe after a shift in the emergency department, all of this may not be enough.