University, Karachi, Pakistan and â Department of Emergency, Jinnah Postgraduate Medical Center, ... an important challenge faced by health care personnel in.
The Journal of Emergency Medicine, Vol. 45, No. 5, pp. 761–772, 2013 Copyright Ó 2013 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/$ - see front matter
http://dx.doi.org/10.1016/j.jemermed.2013.04.049
Violence: Recognition, Management, and Prevention
HEALTH CARE PERSONNEL AND WORKPLACE VIOLENCE IN THE EMERGENCY DEPARTMENTS OF A VOLATILE METROPOLIS: RESULTS FROM KARACHI, PAKISTAN Waleed Zafar, MBBS, MSC, MPH, SCD,* Emaduddin Siddiqui, MBBS,* Kiran Ejaz, MBBS, MSC,* Muhammad Umer Shehzad, MBBS,* Uzma Rahim Khan, MBBS, MSC,* Seemin Jamali, MBBS,† and Junaid A. Razzak, MD, PHD* *Department of Emergency Medicine, World Health Organization Collaborating Center for Emergency Medicine and Trauma Care, Aga Khan University, Karachi, Pakistan and †Department of Emergency, Jinnah Postgraduate Medical Center, Karachi, Pakistan Reprint Address: Waleed Zafar, MBBS, MSC, MPH, SCD, Department of Emergency Medicine, Aga Khan University, Karachi 74800, Pakistan
, Abstract—Background: Workplace violence (WPV) is an important challenge faced by health care personnel in the emergency department (ED). Study Objectives: To determine the prevalence and nature of WPV reported by physicians and nurses working in the EDs of four of the largest tertiary care hospitals in Karachi, Pakistan and to understand the mental health impact of experiencing WPV. Methods: This cross-sectional survey was conducted between September and November 2008 using a widely used questionnaire developed by the World Health Organization. Overall, 266 (86% response rate) questionnaires were included in this study. Results: A total of 44 (16.5%) physicians and nurses said they had been physically attacked, and 193 (72.5%) said that they had experienced verbal abuse in the last 12 months. Among those who reported physical attack, 29.6% reported that the last incident involved a weapon, and in 64% of cases the attacker was a patient’s relative. Eightysix percent thought that the last attack could have been prevented, and 64% said that no action was taken against the attacker. After adjusting for covariates, physicians were less likely than nurses to report physical attack (odds ratio [OR] 0.46; 95% confidence interval [CI] 0.2–1.0), and personnel with greater work experience (OR 4.8; 95% CI 2.0– 11.7) and those who said that there were procedures to report WPV in their workplace (OR 3.2; 95% CI 1.6–6.5) were more likely to report verbal abuse. WPV was associated with mental health effects in the form of bothersome memories, super-alertness, and feelings of avoidance and
futility. Conclusion: WPV is an important challenge in the EDs of large hospitals in Karachi. A majority of respondents feel that WPV is preventable, but only a minority of attackers face consequences. Ó 2013 Elsevier Inc. , Keywords—workplace violence; emergency department; mental health; Karachi; Pakistan
INTRODUCTION Workplace violence (WPV), verbal abuse, and threatened or actual physical violence, is an important challenge faced by physicians and nurses in emergency departments (EDs) the world over (1–9). Emergency health care personnel, due to the frontline nature of their jobs, are at an increased risk of experiencing WPV compared to other health care specialties (2,4,7–10). Experiencing WPV has, in turn, been associated with perceptions of poor mental health, burnout, and delivery of suboptimal care to patients among health care personnel (4,6,10–12). WPV is expected to be a particular problem in a large volatile metropolis like Karachi, Pakistan, with its recent history of political-, ethnic-, and sectarian-motivated violence and a general deterioration in law enforcement (13–16). A new low in violence against health care personnel working in an ED was reached when a bomb
RECEIVED: 11 December 2012; FINAL SUBMISSION RECEIVED: 12 April 2013; ACCEPTED: 30 April 2013 761
No Teaching hospital* 600–650 patients Public Jinnah Post-graduate Medical Center (JPMC)
Free
Public Civil Hospital Karachi (CHK)
Free
Private Liaquat National Hospital (LNH)
ED = emergency department; EM = Emergency Medicine. * Teaching hospital for both undergraduate and graduate medical education.
25–30 physicians; 20–27 nurses
No Teaching hospital* 800–850 patients 13–18 physicians; 13–20 nurses
Teaching hospital* 90–100 patients 27–30 physicians; 50–60 nurses
Teaching hospital* 120–140 patients 25–31 physicians; 45–50 nurses Private Aga Khan University Hospital (AKUH)
Mostly out of pocket
ED Shifts Sector Hospital
We obtained a complete list of physicians and nurses working in the four EDs at the beginning of September 2008. Trained research assistants (RA) then approached these personnel in person to explain the objectives of the study and to invite them to participate. Participants were enrolled after oral consent and requested to fill out the paper questionnaire without providing identifying information and to return the questionnaires to the RAs. No compensation was offered for participation in the study. The data collection took place between September and November 2008.
Cost of Care to ED Patients
Selection of Participants
Table 1. Selected Characteristics of the Hospitals Participating in the Study
This study was a cross-sectional survey conducted in the EDs of four of the largest tertiary care hospitals in Karachi, Pakistan. Two of these hospitals, Aga Khan University Hospital (AKUH) and Liaquat National Hospital (LNH), are private non-profit, and the other two, Civil Hospital Karachi (CHK) and JPMC are in the public sector. Selected characteristics of these hospitals are presented in Table 1. Currently, only AKUH has a dedicated Emergency Medicine (EM) residency program staffed by EM residents and emergency physicians with 4 years of postgraduate training in EM after a 5-year undergraduate program of medical education and 1 year of internship. The EDs of all other hospitals are staffed by full-time physicians who usually do not have any postgraduate training, as well as rotating interns and residents from Departments of Medicine, Surgery, Orthopedics, and Pediatrics. Nursing staff in all the participating EDs had or were studying towards a Registered Nurse (RN) degree that is awarded after 4 years of nursing training after high school. The study was approved by the Ethics Research Committee of the AKUH as well as the ethics committees of all the participating hospitals.
Number of Physicians and Nurses in ED Per Day (All Shifts Included)
Study Design and Setting
24-hour ED; Physicians work in two and nurses in three shifts 24-hour ED; Physicians and nurses work in three shifts 24-hour ED; Physicians and nurses work in three shifts 24-hour ED; Physicians and nurses work in three shifts
MATERIALS AND METHODS
Mostly out of pocket
Number of Patients Seen Per Day in the ED
Status
Offers Graduate Training in EM
targeting the ED of Jinnah Postgraduate Medical Center (JPMC), a large tertiary care hospital in Karachi, went off just outside the main entrance of the ED on February 5, 2010, killing 13 people (17–19). At the time, health care personnel were busy tending to casualties being brought from the site of another bombing the same day. Authorities managed to defuse in time yet another bomb in the parking lot of the hospital (17,18). WPV in Karachi EDs has remained understudied (15,20). The aim of this study was to determine the prevalence and nature of WPV reported by physicians and nurses working in the EDs of four large tertiary care hospitals in Karachi and to understand the mental health impact of experiencing WPV.
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WPV in the Emergency Departments of Karachi
Methods of Measurement We adapted a survey instrument developed by the Joint Programme on Workplace Violence in the Health Sector of the International Labor Office, the International Council of Nurses, the World Health Organization, and the Public Services International (ILO/ICN/WHO/PSI Joint Programme) (21). This questionnaire has been used in several other countries (22–28). For its use in Karachi, Pakistan, we used the English version developed by the ILO/ICN/WHO/PSI Joint Programme, as well as its translation in Urdu, the common language in Karachi (available as online supplemental material). The translation was first done by a professional translator at AKUH and was then back-translated by a different translator to verify. The authors, fully bilingual in Urdu and English, also examined the translation and approved it. The English and the Urdu versions of the questionnaire were then pilot tested with a sample of 10 physicians and nurses in the ED of AKUH. A trained researcher first administered the survey and then asked the respondents about their understanding of the questions and whether they had any concerns or queries. Both versions of the questionnaire were found to be fully understandable in the local context and only slight modifications to the translation were needed. The revised versions were then used in this study after the approval of the Ethics Research Committee of the AKUH. The questionnaire was divided into the following sections: the first section had 19 questions regarding personal and workplace characteristics. The second section had questions about physical violence in the workplace, defined as use of ‘‘physical force against another person that results in physical, sexual, or psychological harm and includes beating, kicking, slapping, stabbing, shooting, pushing, biting, and pinching, among others.’’ The primary question of interest in this section was whether in the last 12 months the respondent had been physically attacked in the workplace. Follow-up questions on whether a weapon was involved, the identity of the attacker, the place and time of the attack, and the consequences for the attacker referred to the last time that the respondent was physically attacked in the workplace. Another set of questions asked the respondents to rate on a 5-point scale (‘‘Not at All,’’ ‘‘A Little Bit,’’ ‘‘Moderately,’’ ‘‘Quite a Bit,’’ and ‘‘Extremely’’) how bothered they have been since the last attack by 1) repeated, disturbing memories, thoughts, or images of the attack; 2) avoiding thinking about or talking about the attack or avoiding having feelings related to it; 3) being ‘‘superalert’’ or watchful and on guard; and 4) feeling like everything they did was an effort? The third section was related to psychological violence or verbal abuse, defined as ‘‘bullying, mobbing, harassment, and verbal abuse that
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humiliates, degrades, or otherwise indicates a lack of respect for the dignity and worth of an individual.’’ The primary question of interest in this section was whether in the last 12 months the respondent had been verbally abused in the workplace and if so, how often. Followup questions related to disturbing memories, etc., like those for physical attack, referred to the last time that the respondent was verbally abused in the workplace. Data Processing and Analysis Based on earlier studies, we hypothesized that the prevalence of experiencing verbal abuse in the ED in the last 12 months by health care personnel is approximately 65%, and physical attack is 15% (7). Given our overall study goal of estimating the experience of physical attack or verbal abuse within 6 5% of true population prevalence, our estimated sample size was 265. All power analyses were conducted using free software, G*Power (version 3.1.5) (29). Questionnaire responses were entered into a database by a trained research assistant (K.E.) and 20% of entries were randomly checked against the paper questionnaires by W.Z. for accuracy. All analyses were conducted using Stata version 11.2 (StataCorp LP, College Station, TX) (30). Kruskal-Wallis test was used to compare selected differences in the ordinal outcomes of mental health impact of WPV between subgroups (31). The Kruskal Wallis test is a non-parametric version of analysis of variance and a generalized form of the Mann-Whitney test that is used when the outcome is ordinal with independent variables having two or more levels (32). To test the association of independent variables with the report of WPV in last 12 months, multiple logistic regression was used. The final models for estimation of adjusted odds ratios were developed based on forward selection using Akaike Information Criterion after collinearity in predictors was ruled out using variance inflation factor (33,34). RESULTS A total of 310 physicians and nurses, identified from the roster and available during duty hours, were approached in person to participate in the study. Overall, 277 questionnaires were returned, of which 266 were complete and included in this study (86% response rate). The demographic characteristics of the overall sample, as well as those who said they had experienced physical attack or verbal abuse in the last 12 months, are reported in Table 2. In the overall sample there were 55% males, 63% respondents younger than 30 years and 10% older than 39 years of age, 53% who were not married, and an equal
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Table 2. Demographic Characteristics of the Sample Characteristics Gender Female Male Age 15
n (%) for Entire Sample (n = 266)
n (%) for Victims of Physical Attack* (n = 44)
n (%) for Victims of Verbal Abuse† (n = 193)
120 (45.1) 146 (54.9)
20 (45.5) 24 (54.5)
89 (46.1) 104 (53.9)
167 (62.8) 72 (27.1) 21 (7.9) 6 (2.2)
22 (50.0) 12 (27.3) 8 (18.2) 2 (4.5)
108 (56.0) 62 (32.1) 18 (9.3) 5 (2.6)
141 (53.0) 125 (47.0)
18 (40.9) 26 (59.1)
100 (51.8) 93 (48.2)
134 (50.4) 132 (49.6)
26 (59.1) 18 (40.9)
103 (53.4) 90 (46.6)
81 (30.5) 63 (23.7) 44 (16.5) 78 (29.3)
14 (31.8) 8 (18.2) 5 (11.4) 17 (38.6)
68 (35.2) 36 (18.7) 29 (15.0) 60 (31.1)
43 (16.2) 128 (48.1) 55 (20.7) 24 (9.0) 12 (4.5) 4 (1.5)
6 (13.6) 16 (36.4) 9 (20.4) 6 (13.6) 7 (15.9) 0 (0)
18 (9.3) 91 (47.2) 48 (24.9) 24 (12.4) 10 (5.2) 2 (1.0)
144 (54.1) 122 (45.9)
22 (50.0) 22 (50.0)
104 (53.9) 89 (46.1)
67 (25.2) 199 (74.8)
7 (15.9) 37 (84.1)
45 (23.3) 148 (76.7)
231 (86.8) 35 (13.2)
35 (79.5) 9 (20.5)
164 (85.0) 29 (15.0)
3 (1.1) 60 (22.6) 81 (30.4) 58 (21.8) 64 (24.1)
1 (2.3) 9 (20.4) 11 (25.0) 3 (6.8) 20 (45.5)
3 (1.6) 41 (21.2) 54 (28.0) 39 (20.2) 56 (29.0)
AKUH = Aga Khan University Hospital; LNH = Liaquat National Hospital; CHK = Civil Hospital Karachi; JPMC = Jinnah Post Graduate Medical Center. * Those who reported being physically attacked in the workplace in the last 12 months. † Those who reported being verbally abused in the workplace in the last 12 months.
proportion of physicians and nurses (134 and 132, respectively). Of the sample, 30.5% came from AKUH, 29% from JPMC, 24% from LNH, and 16.5% from CHK. Sixteen percent of the sample had
