1. Background about violence in the health care sector, primary contact with a violent patient


There are studies confirming that more than one quarter of violent cases in society take place in the health service. The health service was identified as being significantly more at risk from the point of view of an attack probability in many foreign studies. There is an increase in domestic and street violence and this penetrates into the workplace of healthcare professionals. There are more weapons in the streets and people increasingly use more violence to try to solve their problems. These factors affect the health service. The violence in any form is increasing in society and it is possible to say, that acts of violence are increasingly more brutal. Interventions practised by healthcare professionals take place in very tense situations, which can easily lead to violent outbursts. This is why the media are increasingly informing the public about attacks on healthcare professionals (Di Martino, 2003; Huckshorn, 2009). In addition, in Czech society criminality is generally on the increase (Marešová, 2001; Marešová 2009).[1]

When confronted with violence, a feeling of a threat is induced and also the likelihood of person’s inadequate reaction (Dynáková, 2005). The behaviour of some healthcare staff members that  sometimes can be poor or non-professional, which in turn, may provoke potential attackers to attack. Insufficient knowledge of anamnesis may result in using words or behaviours of the healthcare professional that unconsciously evokes unpleasant memories or experiences for the patient causing disagreeable feelings and leading to aggression (Flutter, 2007). Violence in the health service is not only committed by patients, but there are also situations in which healthcare staff members can escalate violence against patients (Hahn, 2010). Eventually, general consequences contribute not only to the fluctuation of healthcare staff members, but influence the whole society (Johnes, 2013).  

Nowadays, violence is considered as a regular phenomenon in the health service and there are authors who speak already about this as an endemic occurrence (Koukolík, 2008; Duxbury, 2005). All over the world, considerable attention is dedicated to this phenomenon by means of a wide expert platform. There is the European Violence in Psychiatry Research Group (EViPRG) in Europe, members of which are mainly general nurses.  

In its entirety, it is possible to refer to basic points that are common for studies from the period 2004-2010 and that should become the foundation for next observations: 

  • That violence is widely spread in the health service in the Czech Republic
  • Verbal aggression preponderates over physical aggression
  • There is a lack of central or local data collection dealing with violence in the health service
  • Completed studies have a low number of respondents 
  • Some violent acts are caused by healthcare staff members themselves
  • A continuous programme of violence prevention in schools is lacking

Despite these studies, there is not enough focus on the phenomenon of violence in the health service in the Czech Republic. This issue in not transparent and there is neither standard procedures nor preventive measures. Lastly, but not least, there is no concept of education in the field of violence and aggression prevention for healthcare staff members.

The priority should be a quality-based service on the protection against violent behaviour on both sides. It is a very demanding task requiring ethical and expert standards supported by the therapeutic climate of the health service environment. There is a need to ensure compliance with occupational safety and health principles, thus, a proposition of a close cooperation with occupational health services. 

Consequences can be serious. For example, there were 14 % of all accidents at work of healthcare staff members due to violence and aggression, 50 % of them being mortal in the USA in 2004 (Zampieron, 2010). Average estimated expenses due to physical violence at work amounted approximately to £60.5 million in the United Kingdom in 2008. The current amount is higher than £100 million every year at the present time (NHS Counter Fraud Service, 2007). 

On the basis of basis of studies described above, it is possible to characterise the violence prevention in the field of medical services in the Czech Republic as follows:

  • Statistics show increasing violence in the society (health services)
  • Studies aim at a larger number of respondents
  • Violent acts maintain the same frequency
  • Healthcare staff members do not always communicate professionally
  • Educational events are directed more at professional communication
  • The focus is on greater quality and lecturers' experiences 
  • A system of data reporting is lacking and healthcare staff members are not always motivated  to report all incidences
  • There is no corresponding education at schools
  • Regular repetition of gained knowledge and skills is lacking
  • Absent supervision 

In the case of these projects mentioned above, the data was gained only from questionnaires, not through personal contacts; therefore, it is necessary to document the facts by means of structured interviews respectively with focus group technique. It is only then that it is possible to find the real conflict cause in the health service. The health service is a field of a very specialized care and there are differences when compared with social care service or other branches. Furthermore, the above-mentioned social service was involved in the previous projects and very interesting findings about violence by healthcare staff members against patients were recorded only secondarily. These so-called attribute faults can appear in a study, when variables that have principally a situational influence on the respective issue are omitted or not respected. 

On one hand, there are high demands on health care staff and on the other hand, there is minimal education in this area for future medical personnel. It is important to be aware of and to consider high professional standards in healthcare and, at the same time, to respect ethical behaviour, tiredness and the need of loosening negative emotions, not only of medical personnel but also of patients. Conflicts in health services are caused by escalated negative emotions, but also, situations have to be taken into account when healthcare staff may be a trigger factor in some violent episodes – often unwittingly. A new study should be performed that will focus on a detailed analysis of violent situations (a large questionnaire survey in a community supported by structured interviews), because if we want to develop mechanisms preventing conflicts in health services, where efforts to save lives and their quality shall prevail over violent situations, causal mechanisms have to be identified first (Zimbardo, 2008).

The result of a situation, where a drunken or psychiatric patient attacked a physician or a paramedic when  scolding a patient, is a one-way result.  Such a result does not evaluate the situation; it describes it only with regard to contents. The fact that since 2006 violent crimes have been continuing to grow has also to be taken in account. This circumstance is caused by political and economic changes in the Czech Republic that can sometimes lead to a significant growth of criminal activities. The increased number of murders can be explained just by a decreased risk of being detected and punished, as well as, by increased economic inequality. Czech data does not differ even after this increase from the average in developed countries, where 2-4 murders or attempted murders per 100 000 inhabitants occur (Vevera, 2009). Also, the fact that has to be accepted is that a patient who is in the hands of a healthcare staff member feels the power on his side and he wants to use it (Špatenková, 2003). A number of situational factors that often seem to be simple can affect the behaviour of healthcare staff members and patients more strongly than we can possibly imagine. The influence of individual roles in the profession has to be emphasized as well as the authority effect, when patients are afraid of asking a physician of anything (Lánský, 2012). Also the uniform effect is possible, it can increase a feeling of power, importance and according to Fraser (1974) can be also a source of supremacy (anonymity power). Also  time pressure has to be considered (Darley,1973), because the willingness to provide assistance in emergencies accounts for only 10% and leads to stereotyping and labelling (Franz, 2006). 

News media reports mainly about situations when a patient attacks a healthcare staff member. General nurses and paramedics are indeed in the course of medical care the target of violence in most cases, because they spend – in contrast to other medical professions – much more time with a patient. On the other side, on the basis of experiences and past studies there are more incidents, when healthcare staff members are not able to control their negative emotions and their behaviour provokes potential attackers to violence. Patients expect healthcare staff members to be understanding, treat them humanly and to be interested.  

[1] From 1973 till 1999 a rapid rise. 2000 – 2012 decrease linearly approximately 10 000 – 20 000 delicts / year = overall slight increase approximately 80 000 delicts as compared with 2000 – 2012, ATTENTION! = 2012: 304 528; 2013: 325 366 delicts (www.policie.cz)