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

The healthcare sector, by its very nature, is a high-pressure environment where numerous professional groups work together to care for patients. However, under this pressure, an alarming reality emerges: the deterioration of working relationships due to violence and abusive behavior among healthcare providers. This phenomenon, far from being isolated, 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 abusive behavior in healthcare settings are persistent and widespread problems, as documented by numerous studies and surveys. The data reveal a concerning 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. In France, the Health Commission of Anesthesiologists and Resuscitators at Work (SMART) of the French College of Anesthesiologists and Resuscitators (CFAR) conducted a survey in 2018 on working relationships in clinical 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 a high-risk group who often feel helpless in the face of their own physical and psychological suffering at work.

This data confirms that violence against 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 Various Forms of Oppressive Behavior

Oppressive behavior in healthcare settings is not limited to blatant and easily identifiable acts; it encompasses 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 an incident in which 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 lawsuit 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 in 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 abusive behavior in healthcare settings extend far beyond immediate conflicts, profoundly affecting the health and well-being of healthcare 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 costs, the most critical and alarming effect is the serious impact on patient care. Bullying and denigration have a proven detrimental impact on patient outcomes, diverting resources and attention that are needed for care. The Royal College of Surgeons of Edinburgh (RCSEd) emphasizes 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 wealth 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, including 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 settings—operating rooms, intensive care units, emergency departments, and other intervention areas—are high-pressure environments. These environments are often complex and confined, 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 do not 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 hotbed of conflict due to its complexity, operational pressures, and the involvement of numerous professions, each with distinct professional objectives and differing views on patient 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 have a voice. However, this transition can also create tensions.

Differences in profession, age, experience, and goals among healthcare professionals complicate relationships and are sources of conflict that can significantly impact staff well-being. Unresolved differences can lead to tension, communication breakdowns, and ultimately open conflict. Understanding these multifaceted 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 stems from work initiated in 2014, following an investigation that identified a significant problem across all levels and specialties of surgery. The RCSEd strives to: Develop a series of Professional Standards for the prevention of bullying and denigration in the healthcare sector. These standards outline 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) launched the "1 Patient 1 Team" campaign. This campaign, launched in response to an alarming trend of deteriorating working relationships, aims to raise awareness among all healthcare professionals working in clinical 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, at 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 toward a common goal: the patient. Cordial understanding, respect, and self-control contribute to quality care and well-being at work.

These initiatives demonstrate a shared understanding and a strong commitment on the part of professional organizations to transform workplace cultures and make compassion a cornerstone of healthcare.

Tools and strategies for preventing and managing 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 arise. 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 Care System: Guidelines on expected behaviors to foster 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 Behavior Affects the Team and Patient Care: Real-life case studies illustrating the impact of oppressive behavior on team morale, mental health, and patient safety.
• Negotiation: Negotiation strategies for surgeons to reduce workplace conflict and support patient care, including tips for building trust through 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 be distributed to promote cooperation and teamwork.
• A Code of Conduct for the entire team to sign, promoting respect and professional conduct.
• The Hippocratic Oath and the Physician's Oath (Declaration of Geneva) to be distributed, reminding professionals of their ethical commitments.
• Documentation including a summary of the legal framework, a bibliography, and the report from the National Observatory on 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.
• Quick-reference guides on how to respond to hostile behavior or intervene in the event of a sudden conflict between professionals.
• An analysis sheet called REACT (Team Meeting for Conflict Analysis at Work) designed to help manage conflicts calmly and identify 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 restore their well-being at work.
• Guidelines for the management of disruptive behavior, including a memorandum of understanding between the Departments of Justice, Labor, and the Interior regarding the security of healthcare facilities.

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

Improving team cohesion and workplace culture

The fight against violence among caregivers is not limited to conflict management; it also—and above all—involves fostering a positive work culture and strengthening team cohesion. It is with this in mind that several initiatives are being developed.

The "1 Patient 1 Team" campaign emphasizes that cordial understanding, a smile, respect, and self-control in daily life contribute to the quality of care, recognition of professional value, and «well-being» at work. The fundamental idea is that we belong to the same team around a common goal: the patient. It is essential to play collectively on the healthcare field.

To sustainably improve team cohesion, the sources suggest several approaches:

• Involvement of administration: Conflict management and improved cohesion can only be achieved as a team, and it is important to involve the hospital's administration in this process.
• Continuous improvement programs: The Haute Autorité de Santé (HAS) offers specific programs, such as the "Continuous Improvement of Teamwork Program (PACTE)" and the "Medical Team Accreditation Program". Team accreditation is seen as the sum of individual skills that creates a collective competence, with common objectives and a sharing of responsibilities to improve the quality and safety of care. Another program is the "Solution for Patient Safety: Cooperation between Anesthesiologists and Surgeons". The Fédération de Chirurgie Viscérale et Digestive (FCVD) emphasizes that teamwork among operating room staff, combined with a perfect definition of tasks, is essential to improving the safety and quality of care.
• Participatory Approach: The Observatory for Quality of Life at Work (QVT) for Healthcare and Medico-Social Professionals supports this campaign, the results of which will be promoted and shared as part of a participatory approach.
• Understanding the differences to better cooperate: Conflicts often reflect a lack of understanding of the issues of different specialties called upon to work together. The campaign emphasizes the importance of interdisciplinarity, which draws on everyone's skills, and highlights the determining role played by each professional. The effectiveness of the operating room depends on the efficiency of this interdisciplinarity.
• The culture of professionalism and respect: Prevention involves a better understanding of the problems, better control of our own reactions and emotions, and participation in conflict management workshops. These efforts must be reinforced at the institutional level by a culture of professionalism, teamwork, and interdisciplinary respect.
• The power of collective commitment: A concrete example is given where the collective commitment of the 45 people present in an operating room (orderlies, scrub nurses, nurse anesthetists, surgeons, anesthesiologists intensivists) made it possible to put an end to verbal violence. The proposal that "anyone who uses verbal violence will be considered unfit to carry out their activity on the same day" was adopted unanimously and had an immediate and lasting effect. This collective "contract" seems to have been very effective.
• Develop interpersonal skills: For physicians, it is essential to acquire skills in human resource management, such as supporting change, defusing conflicts, and facilitating the coordination of "teammates."

Ultimately, teamwork is essential to the quality of care. Teams must be healthy, with constructive and effective internal processes, to fully contribute to the health of the population. This implies that all team members adopt optimal teamwork practices.

The role of the various stakeholders and collective commitment

The fight against violence and the promotion of a positive culture in the healthcare sector require a collective commitment and the active participation of all stakeholders, from students to managers, including all professional categories.

Awareness campaigns, such as the RCSEd's "Let's Remove It" and the CFAR/SFAR's "1 Patient 1 Team", are aimed at a very broad audience. The RCSEd targets all surgical and dental professions, as well as its Members and Fellows. The "1 Patient 1 Team" campaign is aimed at multi-professional teams on technical platforms, including:

• Anesthesiologists-intensivists
• Surgeons
• Radiologists
• Gastroenterologists
• Gynecologists-Obstetricians
• Cardiologists
• Resuscitators
• Emergency physicians
• Perfusionists
• Midwives
• Nurse Anesthetists
• Operating Room Nurses
• Nurses
• Radiology Technologists
• Healthcare assistants
• Orderlies
• Cleaning staff

It also extends to the care services with which these platforms are related and is aimed at managers, inviting them to reflect on the organizations and levers for corrective measures.

Responsibility is shared by all. The RCSEd survey showed that the problem of bullying is not just a matter for trainees, but also affects Members and Fellows. The "1 Patient 1 Team" campaign insists that it is the business of all members of care teams.

Collective engagement is a cornerstone of the proposed solutions. The "1 Patient 1 Team" initiative brings together nearly 40 institutional partners, including the National Academy of Surgery, which emphasizes that the patient is cared for by an entire team and that all links must work in harmony. The Association for Hospital Practitioners & Assimilated (APPA) emphasizes the importance of promoting team cohesion, conflict prevention, and management as essential in the hospital. The ANMTEPH, as occupational medicine, emphasizes the importance of working relationships for staff health. The National Council of the Order of Midwives is committed to this campaign, which carries the fundamental values of cooperation and respect, essential to the quality of care.

Unions such as the Fédération des Médecins de France (FMF) or the Syndicat National des Infirmiers-Anesthésistes (SNIA) also support the campaign, recognizing that quality of work life and safety in the operating room depend on a united and cooperative team. The Syndicat National des Praticiens Hospitaliers Anesthésistes-Réanimateurs Élargi (SNPHARe) points out that the concept of teamwork is being undermined by current challenges, but that it is essential to "resynchronize medical time" and value the concept of teamwork to restore meaning to the profession and ensure the best care.

The National Council of Nurses, strongly involved in addressing workplace suffering and psychosocial risks, emphasizes the importance of unity to recall the meaning of teamwork and mutual respect, both for patients and for caregivers themselves.

In conclusion, the eradication of interprofessional violence and the improvement of quality of life at work and patient safety require a concerted, constant, and inclusive effort from the entire healthcare community. Every professional, every organization, every hierarchical level has a crucial role to play in building an environment where respect, communication, and cooperation are the foundations of quality patient care. The initiatives of the RCSEd and CFAR/SFAR are eloquent examples of this collective commitment, emphasizing that "To care, let's play collectively!". This is a long-term commitment, because prevention is essential and the crisis is always dramatic.

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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