Violence in healthcare among caregivers: a scourge with devastating consequences for patients and teams

The healthcare sector, by its very nature, is a high-pressure environment where numerous professional categories work together to care for patients. However, under this pressure, an alarming reality emerges: the deterioration of working relationships due to violence and oppressive behavior among caregivers. This phenomenon, far from being anecdotal, has devastating consequences not only for individuals and teams, but also, and critically, for the quality of care and patient safety. Professional organizations recognize the urgency of this issue and are actively committed to combating it, emphasizing the imperative of improved communication, strengthened cooperation, and unwavering team cohesion.

Prevalence and alarming findings of violence in healthcare settings

Violence and oppressive behavior in healthcare settings are persistent and widespread problems, documented by numerous studies and surveys. Their figures reveal a worrying situation affecting all levels of the medical and dental professions.

According to the 2021 NHS (National Health Service) Staff Survey for England, nearly 19% of all NHS staff reported experiencing at least one incident of harassment, intimidation, or abuse from colleagues in the previous twelve months. This means that approximately one-fifth of all NHS staff report each year experiencing harassment, bullying, and denigration from colleagues. Studies in the United States have highlighted a direct link between disruptive behavior and adverse events, particularly in the perioperative period. These studies attributed 67% of adverse events, 71% of medical errors, and 27% of perioperative deaths to disruptive behavior. The problem of bullying within the medical and dental professions is not new. As early as 2002, a British Medical Association (BMA) survey of junior doctors revealed that nearly 50% of the sample reported having been bullied in the previous year. Although the sample size (594 doctors) was small, these figures already suggested that bullying was a significant problem. In 2014, the General Medical Council's (GMC) national training survey in the UK explored the issue of bullying among trainees. 8% of junior doctors reported experiencing some form of bullying or denigration, and surgery was ranked as the second most affected specialty in this regard, just behind obstetrics and gynecology. In 2015, the President of the Royal Australasian College of Surgeons (RACS) publicly apologized for the extent of bullying behavior found in surgical settings in Australia and New Zealand, where up to 50% of surgeons had been subjected to bullying. This situation led to the launch of their "Let's Operate with Respect" campaign. The Royal College of Obstetricians and Gynaecologists (RCOG) published the results of its survey on consultant bullying in 2016. Up to 44% of respondents described persistent bullying, and a third of these described it as severe. In response to these findings and the GMC survey, the RCOG implemented initiatives for its members, including an online toolkit and regional "anti-bullying mentors" outside the training hierarchy. The Royal College of Surgeons of Edinburgh (RCSEd) also conducted its own survey of its members in 2014. This survey revealed that 60% of surgical trainees reported being bullied in their workplace, and almost all described witnessing it. Furthermore, this survey highlighted that the problem was not limited to trainees, as 34% of all responding Members and Fellows reported having been intimidated. On the French side, the Health Commission of the Anesthesiologist-Resuscitator at Work (SMART) of the French College of Anesthesiologists-Resuscitators (CFAR) conducted a survey in 2018 on working relationships in technical settings. The results are equally alarming: more than 90% of healthcare professionals have already experienced conflict with another professional. More specifically, 63% have been victims of violence from another healthcare professional, while 30% have been perpetrators of violence against another healthcare professional. The survey also revealed that 97% of reported violence was verbal, 14% physical against people, and 12% physical against property. This finding is accompanied by a general feeling of powerlessness, since 75% of healthcare workers feel helpless in the face of conflict, and only 16% of facilities have a formalized conflict reporting procedure. Healthcare workers are an at-risk group who often feel helpless in the face of their own physical and psychological suffering at work.

This data confirms that violence among healthcare workers is a global problem, affecting various specialties and career levels, with profound implications for staff well-being and the quality of care.

The Multiple Forms of Oppressive Behavior

Oppressive behavior in healthcare settings is not limited to blatant and easily identifiable acts; They encompass a wide range of actions, some subtle, others overt, but all detrimental to the work environment and the quality of care. Sources identify several categories of these behaviors. Broadly speaking, the terms used to describe these actions include bullying, undermining, harassment, and abuse. These behaviors are contrary to professional practices as described by regulatory bodies such as the General Medical Council and the Nursing and Midwifery Council. More specifically, the CFAR campaign aims to prevent so-called "acute" conflicts within teams, such as incivility, verbal abuse, and even physical violence. Verbal abuse is particularly prevalent, accounting for 97% of reported incidents of violence among healthcare professionals, according to the 2018 SMART survey. The 2018 ONVS report details this verbal abuse perpetrated by physicians, both men and women, against each other or other staff. It manifests as incessant criticism and reproaches regarding the real or perceived professional incompetence of peers or colleagues. It can also take the form of a hostile attitude, vulgar remarks, or constant denigration of the work performed, whether in private or in public. These behaviors can escalate to psychological harassment. In addition to verbal abuse, physical violence can also occur, although less frequently, with 14% of reported cases involving physical violence against individuals and 12% involving property. A concrete example mentioned in the sources is that of an incident where a surgeon threw the contaminated contents of a syringe in the face of an operating room nurse, leading the Nursing Board to file a civil suit to prosecute the perpetrator. Disruptive behaviors can be more subtle and insidious, making them difficult to recognize. These can be hostile or aggressive behaviors that are not necessarily physically violent, but which create a toxic atmosphere. The article on voices of reason points out that action still needs to be taken against other forms of violence, sometimes very subtle and invisible, but just as detrimental to the physical and mental health of professionals. Recognizing these signs, whether you experience them yourself or witness them, is a crucial step in dealing with them. Finally, denigration, which consists of undermining a colleague's authority or competence, is also a form of oppression. The fact that the RCSEd survey showed that 60% of surgical trainees had experienced bullying and that nearly 100% had witnessed it suggests that these behaviors are deeply rooted in the culture of some work environments. These various manifestations of oppressive behavior, whether blatant or subtle, contribute to an unhealthy work environment that has repercussions far beyond the individuals directly involved. src="https://cdn.prod.website-files.com/61f1c5bbc327ec3679e7457c/688709a1aaff27465dd82de7_be94ebbe-7add-4d0f-98a7-6b8986eee0e1.webp" width="auto" height="auto" loading="lazy">

Devastating Impacts on Individuals, Teams, and Patient Safety

The consequences of violence and oppressive behavior in healthcare settings extend far beyond immediate conflicts, profoundly affecting the health and well-being of professionals, team dynamics, and ultimately, the safety and quality of patient care.

Impact on Individuals and Teams:Bullying behaviors, Bullying and abuse have a devastating impact on individuals and teams. They not only damage the morale and mental health of healthcare professionals, but also the overall work environment. Affected healthcare professionals may experience stress, dissatisfaction, and exhaustion, potentially leading to burnout. A survey of French doctors specifically examined burnout among anesthesiologists. The negative impact also translates into direct and indirect costs for the healthcare system. In the UK, it is estimated that bullying, denigration, and abuse cost the NHS in England at least £2.3 billion annually due to sick leave, staff turnover, decreased productivity, and workplace relationship problems. Verbal abuse can wound more deeply than a scalpel, with lasting effects on working conditions.

Impact on patient safety and quality: Beyond the human and financial impact, the most critical and alarming effect is the serious consequence on patient care. Bullying and denigration have a proven and detrimental impact on patient outcomes, diverting resources and attention needed for care. The Royal College of Surgeons of Edinburgh (RCSEd) insists that deteriorating relationships are not simply a matter of "being nice": bullying directly affects patients.

Mortality investigations at facilities such as the NHS Trusts of Mid Staffordshire and Morecombe Bay have identified a breakdown in teamwork as one of the causes. There is a mountain of evidence showing the detrimental effect of intimidation and denigration on team performance. Providing care requires teamwork, and conflict degrades the quality of care. The CFAR SMART survey revealed that 97% of respondents stated that conflict compromises the quality of care. Conflict-related problems increase the risk of errors and jeopardize patient safety. Analyses of adverse events associated with care (AEACs) have shown that approximately 27% of these inpatient AEACs were due to insufficient communication between professionals. Clear communication and cooperation are essential to minimize preparation or equipment deficiencies and avoid last-minute cancellations, which cause stress and jeopardize patient care. An oppressive work environment can compromise patient care. In summary, cordial understanding, a smile, respect, and self-control on a daily basis are essential for quality care. The concept of a cohesive team, centered on the patient and their needs, can only improve patient engagement and understanding. The strong link between interprofessional tensions and the occurrence of adverse events associated with care, even morbidity and mortality, should encourage collective efforts to improve workplace relationships. Root Causes of Conflict and Violence in Hospitals: Conflict and violence among healthcare professionals are not isolated or random phenomena; they are often symptoms of deeper problems, rooted in the work environment, organizational structures, and interpersonal dynamics. Analyzing these causes is essential for developing effective solutions. The work environment of healthcare professionals is inherently conducive to tension. Technical platforms – operating rooms, intensive care units, emergency departments, and other interventional platforms – are high-pressure environments. These environments are often complex and enclosed, involving numerous professional categories with interdependent tasks related to patient care. The stress inherent in surgical activity, combined with this confinement, can be a source of conflict. According to the CFAR SMART commission, conflicts should most often be seen as symptoms of a system in distress. The underlying causes of conflict situations are often organizational or communication-related. Healthcare professionals don't always have the opportunity to reflect as a team on the factors contributing to these situations. The 2018 SMART survey identified the main causes of conflict: Poor communication and a lack of understanding of each other's priorities are cited by more than 90% of healthcare professionals as major factors. Workload, fatigue, and staff shortages also contribute significantly. Poor organization of care, as well as inadequate management and supervision, are frequently identified organizational causes. Finally, interpersonal factors such as personality, abuse, or power struggles also play a role. These rivalries, combined with personality clashes, can exacerbate violence.

The operating room, in particular, is a breeding ground for conflict due to its complexity, production pressures, and the involvement of numerous professions, each with distinct professional objectives and a different perception of care and risk management. The traditional hierarchy, dominated by the surgeon, is gradually giving way to a patient-centered, interprofessional, and interdisciplinary system that allows everyone to express themselves. However, this transition can also generate tensions.

Differences in professions, age, experience, and objectives among healthcare professionals complicate relationships and are sources of conflict that can significantly impact staff health. Unresolved differences can cause tension, communication breakdowns, and ultimately open conflict. Understanding these multifactorial causes makes it clear that conflict resolution requires a comprehensive approach that goes beyond immediate reactions to address structural and cultural issues. Organizational Initiatives and Commitments to Combat Violence: Faced with the scale and devastating consequences of violence among healthcare professionals, many professional organizations have mobilized to implement campaigns and initiatives aimed at eradicating such behavior and promoting a healthy and respectful work environment. The Royal College of Surgeons of Edinburgh (RCSEd) is strongly committed to this fight. The College has a zero-tolerance approach to bullying, denigration, and harassment, and categorically condemns them in all circumstances. This commitment is the result of work begun in 2014, following its investigation which identified a significant problem at all stages and grades of surgery. The RCSEd strives to: Produce a series of Professional Standards for the prevention of bullying and denigration in the healthcare service. These standards define the expectations for Members and Fellows to foster respectful and inclusive workplaces and ensure patient safety.

On the other hand, in France, the Occupational Health of Anesthesiologists and Critical Care Physicians (SMART) commission of the French College of Anesthesiologists and Critical Care Physicians (CFAR) initiated the "1 Patient 1 Team" campaign. This campaign, launched following an alarming observation of deteriorating working relationships, aims to raise awareness among all healthcare professionals working in technical settings. It is aimed at multidisciplinary teams, including trainees, and is not limited to technical platforms but extends to related care services, as well as managers. The objectives of the "1 Patient 1 Team" campaign are clear: To prevent so-called "acute" conflicts (incivility, verbal and physical violence) and to offer tools for their management and analysis; to reduce the occurrence of conflict situations by seeking to resolve disagreements immediately, from the first sign, in order to prevent them from escalating into open conflict; and to promote communication, cooperation, and team cohesion. The central message is that all professionals belong to the same team, working towards a common goal: the patient. Cordial understanding, respect, and self-control contribute to quality care and well-being at work.

These initiatives demonstrate a collective awareness and a strong commitment from professional organizations to transform work cultures and make compassion a cornerstone of healthcare.

Tools and strategies to prevent and manage acute conflicts

To move from awareness to action, organizations have developed a range of practical tools and strategies to help healthcare professionals prevent conflicts and manage them effectively when they occur. These resources aim to equip healthcare professionals with the skills needed to navigate complex and emotionally charged environments. The Royal College of Surgeons of Edinburgh (RCSEd) offers a comprehensive anti-bullying resource hub for surgical and dental professionals. Among these resources are:

• Standards for the Prevention of Bullying and Undermining in the Health Service: Guidelines on expected behaviors to create respectful work environments and ensure patient safety.
• The Facts and the Law: Information on the legal protections available to healthcare professionals against bullying, harassment, and discrimination, as well as the steps to take.
• The Literature and the Specialties: A synthesis of studies and surveys on the prevalence of bullying and its impact, including the RCSEd's response.
• How Oppressive Behaviour Affects the Team and Patient Care: Real-life case studies illustrating the impact of oppressive behaviors on team morale, mental health, and patient safety.
• Negotiation: Negotiation strategies for surgeons to reduce workplace conflict and support patient care, with tips for building trust in communication and resolving tensions.
• Resources to Help Change the Culture: Posters, presentations, accredited training, and events to transform surgical culture and promote a healthier work environment.

The CFAR/SFAR's "1 Patient 1 Team" campaign also offers a comprehensive "toolkit" for conflict prevention and management. These tools are available for free download.

To prevent conflicts, the campaign offers:

• Campaign visuals to distribute to promote cooperation and teamwork.
• A Code of Conduct for the entire team to sign, encouraging respect and professional behavior.
• The Hippocratic Oath and the Physician's Oath (Declaration of Geneva) to distribute, reminding professionals of their ethical commitments.
• Documentation including a summary of the legal framework, a bibliography, and the report from the National Observatory of Violence in Healthcare Settings (ONVS).

To manage conflicts In acute situations, the tools focus on immediate action and analysis:

• Interactive training videos on conflict management in the operating room. For example, the video "Dealing with a conflict situation in the operating room: How to respond to hostile or aggressive behavior?" offers different responses: aggressive, passive, passive-aggressive, and assertive. The assertive response involves using active listening and communication centered on the feelings and needs of both parties in order to find a compromise solution. Another series of videos addresses "How to express disagreement?" with passive, direct, and factual and open responses.
• Immediate reaction sheets to know how to react to hostile behavior or intervene in the event of an acute conflict between professionals.
• An analysis sheet called REACT (Team Meeting for Conflict Analysis at Work) for calmly managing conflicts and finding corrective measures for work organization.
• Simulation training for conflict management. The French-Speaking Society for Simulation in Healthcare (SoFraSimS) supports this approach to help professionals understand their role within the group, the needs and skills of others, and to regain well-being at work.
• Guidelines for the management of disruptive behavior, including a memorandum of understanding between the Ministries of Justice, Labor, and the Interior concerning the security of healthcare facilities.

These tools and strategies, whether offered by the RCSEd or the CFAR/SFAR, demonstrate a concerted effort to equip healthcare professionals with the relational and conflict management skills essential for effective teamwork and patient safety.

Improving team cohesion and work culture

The fight against violence among caregivers is not limited to conflict management; elle passe aussi, et surtout, par la construction d'une culture de travail positive et le renforcement de la cohésion d'équipe. C'est dans cet esprit que plusieurs initiatives sont développées.

La campagne "1 Patient 1 Équipe" insiste sur le fait que l'entente cordiale, le sourire, le respect et la maîtrise de soi au quotidien participent à la qualité des soins, à la reconnaissance de la valeur professionnelle et au « bien-être» au travail. L'idée fondamentale est que nous appartenons à une même équipe autour d'un objectif commun : le patient. Il est primordial de jouer collectif sur le terrain de la santé.

Pour améliorer durablement la cohésion d'équipe, les sources proposent plusieurs approches :

• Implication de l'administration : La gestion des conflits et l'amélioration de la cohésion ne peuvent se faire qu'en équipe, et il est important d'impliquer l'administration de l'établissement dans cette démarche.
• Programmes d'amélioration continue : La Haute Autorité de Santé (HAS) propose des programmes spécifiques, tels que le "Programme d’Amélioration Continue du Travail en Equipe (PACTE)" et le "Programme d’Accréditation en équipe médicale". L'accréditation en équipe est vue comme la somme des compétences individuelles qui crée une compétence collective, avec des objectifs communs et un partage des responsabilités pour améliorer la qualité et la sécurité des soins. Un autre programme est la "Solution pour la sécurité des patients : Coopération entre anesthésistes-réanimateurs et chirurgiens". La Fédération de Chirurgie Viscérale et Digestive (FCVD) souligne que le travail en équipe des acteurs du bloc opératoire, associé à une parfaite définition des tâches, est indispensable à l'amélioration de la sécurité et de la qualité des soins.
• Démarche participative : L'Observatoire de la Qualité de Vie au Travail (QVT) des Professionnels de la Santé et du Médico-Social soutient cette campagne, dont les résultats auront vocation à être valorisés et partagés, dans le cadre d'une démarche participative.
• Comprendre les différences pour mieux coopérer : Les conflits sont souvent le reflet d'une incompréhension des problématiques de spécialités différentes appelées à travailler ensemble. La campagne souligne l'importance de l'interdisciplinarité, qui fait appel aux compétences de chacun, et met l'accent sur le rôle déterminant joué par chaque professionnel. L'efficacité du bloc opératoire dépend de l'efficience de cette interdisciplinarité.
• La culture du professionnalisme et du respect : La prévention passe par une meilleure compréhension des problèmes, un meilleur contrôle de nos propres réactions et émotions, et la participation à des ateliers sur la gestion des conflits. Ces efforts doivent être renforcés au niveau institutionnel par une culture du professionnalisme, du travail d'équipe et du respect interdisciplinaire.
• Le pouvoir de l'engagement collectif : Un exemple concret est donné où l'engagement collectif des 45 personnes présentes dans un bloc opératoire (brancardiers, IBODE, IADE, Chirurgiens, Anesthésistes Réanimateurs) a permis de mettre fin à la violence verbale. La proposition que "quiconque usera de violences verbales sera considéré comme inapte à exercer son activité le jour même" a été adoptée à l'unanimité et a eu un effet immédiat et durable. Ce "contrat" collectif semble avoir été très efficace.
• Développer des compétences relationnelles : Pour les médecins, il est essentiel d'acquérir des compétences en gestion des ressources humaines, telles qu'accompagner le changement, désamorcer les conflits et faciliter la coordination des "coéquipiers".

En définitive, le travail en équipe est indispensable à la qualité des soins. Les équipes doivent être en bonne santé, avec des processus internes constructifs et efficaces, pour pouvoir contribuer pleinement à la santé de la population. Cela implique que tous les membres des équipes s'approprient des pratiques de travail en équipe optimales.

Le rôle des différents acteurs et l'engagement collectif

La lutte contre la violence et la promotion d'une culture positive dans le secteur de la santé exigent un engagement collectif et la participation active de tous les acteurs, des étudiants aux managers, en passant par toutes les catégories professionnelles.

Les campagnes de sensibilisation, telles que "Let's Remove It" du RCSEd et "1 Patient 1 Équipe" du CFAR/SFAR, s'adressent à un public très large. Le RCSEd cible l'ensemble des professions chirurgicales et dentaires, ainsi que ses Membres et Fellows. La campagne "1 Patient 1 Équipe" s'adresse aux équipes pluri-professionnelles des plateaux techniques, incluant :

• Anesthésistes-réanimateurs
• Chirurgiens
• Radiologues
• Gastro-entérologues
• Gynéco-obstétriciens
• Cardiologues
• Réanimateurs
• Urgentistes
• Perfusionnistes
• Sages-femmes
• Infirmiers anesthésistes (IADE)
• Infirmiers de bloc opératoire (IBODE)
• Infirmiers
• Manipulateurs radio
• Aides-soignants
• Brancardiers
• Agents d'entretien

Elle s'étend également aux services de soins avec lesquels ces plateaux sont en relation et s'adresse aux managers, les invitant à réfléchir sur les organisations et les leviers pour des mesures correctrices.

La responsabilité est partagée par tous. L'enquête du RCSEd a montré que le problème de l'intimidation n'est pas seulement une question de stagiaires, mais touche aussi les Membres et Fellows. La campagne "1 Patient 1 Équipe" insiste sur le fait que c'est l'affaire de tous les membres des équipes soignantes.

L'engagement collectif est une pierre angulaire des solutions proposées. L'initiative "1 Patient 1 Équipe" réunit près de 40 partenaires institutionnels, dont l'Académie Nationale de Chirurgie, qui rappelle que le patient est pris en charge par toute une équipe et que tous les maillons doivent travailler en harmonie. L'Association pour les Praticiens Hospitaliers & Assimilés (APPA) souligne l'importance de promouvoir la cohésion d'équipe, la prévention et la gestion des conflits comme étant incontournables à l'hôpital. L'ANMTEPH, en tant que médecine du travail, insiste sur l'importance des relations de travail pour la santé du personnel. Le Conseil National de l'Ordre des Sages-Femmes s'engage dans cette campagne qui porte les valeurs fondamentales de coopération et de respect, essentielles à la qualité des soins.

Des syndicats comme la Fédération des Médecins de France (FMF) ou le Syndicat National des Infirmiers-Anesthésistes (SNIA) soutiennent également la campagne, reconnaissant que la qualité de vie au travail et la sécurité au bloc opératoire dépendent d'une équipe unie et coopérative. Le Syndicat National des Praticiens Hospitaliers Anesthésistes-Réanimateurs Élargi (SNPHARe) rappelle que la notion d'équipe est mise à mal par les défis actuels, mais qu'il est essentiel de "resynchroniser les temps médicaux" et de valoriser la notion d'équipe pour redonner du sens au métier et garantir les meilleurs soins.

L'Ordre National des Infirmiers, fortement impliqué face à la souffrance au travail et aux risques psycho-sociaux, souligne l'importance de l'unité pour rappeler le sens du travail en équipe et du respect mutuel, tant pour les patients que pour les soignants eux-mêmes.

En conclusion, l'éradication de la violence interprofessionnelle et l'amélioration de la qualité de vie au travail et de la sécurité des patients requièrent un effort concerté, constant et inclusif de la part de l'ensemble de la communauté des soins de santé. Chaque professionnel, chaque organisation, chaque niveau hiérarchique a un rôle crucial à jouer pour bâtir un environnement où le respect, la communication et la coopération sont les fondements d'une prise en charge patient de qualité. Les initiatives du RCSEd et du CFAR/SFAR sont des exemples éloquents de cet engagement collectif, soulignant que "Pour soigner, jouons collectif !". C'est un engagement de long terme, car la prévention est indispensable et la crise est toujours dramatique.

Sources

https://www.rcsed.ac.uk/policy-guidelines/lets-remove-it/anti-bullying-and-undermining-campaign

https://cfar.org/wp-content/uploads/2019/03/dossier-presse-BD.pdf

https://sfar.org/gestion-des-conflits/

https://www.rcsed.ac.uk/policy-guidelines/lets-remove-it/anti-bullying-and-undermining-campaign/the-literature-and-the-specialities

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