Sensitivity towards patient's presence to avoid violent situations in hospitals: An observatory study.

CONTEXT: The process of communication includes intense observation based on which opinions are formed or situations are created. A patient whose is in state of panic due to the health conditions feels neglected and becomes skeptical about the treatment hi/she is going to receive. AIMS: The aim of the study is to understand the need for being sensitive towards patient's presence while communicating. SETTINGS AND
DESIGN: It was conducted in the outpatient wing of clinics at three different cities of Karnataka using a Sequential Observatory Study design.
MATERIALS AND METHODS: Based on the results obtained from the pilot study a final schedule was prepared and sent to people using google drive during the month of Dec 2019. Out of 200 filled forms only 55 patients/relatives were qualified for analysis. SPSS version 17.0 software, Microsoft word and Excel were used in data handling and analysis. Textual analysis was used for presenting interview data.
RESULTS: The qualitative analysis of the questionnaires found four emerging themes that disturbed the patients psychologically and such situations could lead to violence. The results prove that patients/relatives observe both verbal and nonverbal communication in the hospital from the time of their entry to exit.
CONCLUSION: The communication intended or unintended made some impact on the perceptions of the patients about the way they are going to be treated. This indicates that the workforce should be conscious of their behaviour. Copyright:

Introduction

Health service is provided by both the public and private sectors in India. The purpose of visit to a hospital by a person could vary but mind-set largely remains traumatic, particularly among the patients and their relatives. As a visitor waits for his/her turn to consult the medical professional, consciously or unconsciously the incidents that are happing are occurring in the hospital and starts formulating opinions in patient's mind. The influence of such observed incidents may get deleted if the consultation with the professional is easy and peaceful. In unsatisfactory conditions the situations may lead to violent or unpleasant experiences.

Violence in hospitals is on increase in recent years. In COVID situation we have observed many instances of violence on Health Care Workers (HCWs) and Primary Care Physicians. The reasons for violent behaviour are many. Apart from medical condition and influence of the medicine, the patient may also have medical history of violent behavior due to some other underlying causes.[1] Although many studies have been conducted in different parts of the world authenticating the prevalence of verbal and physical violence, only a handful of studies have been conducted to examine the reasons. The other important reason for violence could be lack of interpersonal communication skills among employees of hospitals. And the violence on HCWs and Primary Care Physicians during COVID situation is just an example. It is important to note that in a hospital along with medical professionals people belonging to other streams of education are also employed. For example, Front office, Billing Section, Reception, Caretakers, Pharmaceuticals, and House Keeping, etc., The difference in education background leads to disparity in perception towards the presence of patients and the communication pattern. What may look like a normal and routine communication to the Hospital staff may not be perceived in the same way by patients and this could lead to repercussions.

This paper tries not only to identify the areas which are overlooked and could lead to violence. Understanding and accepting the results of survey conducted by Indian Medical Association (IMI) which identifies that nearly 82.7% of the doctors suffer from lack of sleep which causes stress among the medical practitioners and the report also reveals that the doctors have the fear of attacks and criminal prosecution. Totally, 46.3% suffer the fear of violence, 24.2% being used and 13.7% feared criminal prosecution strengths the need for the study.[2]

Debating about violence in hospitals World Health Organization particularly in situations like COVID has observed that “this unprecedented public health emergency has demonstrated that health facilities, medical transport, patients as well as health care workers and their families can—and do—become targets everywhere. This alarming trend reinforces the need for improved measures to protect health care from acts of violence. During the COVID-19 pandemic more than ever, protecting the health and lives of health care providers on the frontline is critical to enabling a better global response. In all situations it is important to identify the grey areas and find amicable solutions for the same. Hence the study.

Reasons for violence in hospitals

Any act of threat of physical violence, harassment, intimidation can be considered as violence.” But violence against doctors who are considered as “Gods” at one point of time are now victims of fear today.[1] Reviewing the violent situations in the past, we find violence primarily triggers when the doctor commits an error or does not pay proper attention to the patient. If there is a violation of medical ethics in the first instance, there is a violation of human ethics in the second case. The reasons for the medical error could largely be related to the ratio of doctor per patient in India. The doctor-population ratio in India is 1:1456 against the WHO recommendation of 1:1000.[3] Despite the population being tripled, the overall doctor population ratio in India is still 1:1800 which is one of the major challenges, India is facing.[4]

Jennifer Fong Ha in her research identifies health literacy, unrealistic expectations from patients, capitalistic approach observed among some doctors are some of the reasons that are listed by researchers in the field.[51] In addition to the above reasons the other reason that could lead to violence could be poor interpersonal communication skills by the medical professionals. The process gets complicated when the interaction is with the person or group of people who is in a traumatic state.[5]

Internal Communication plays a big role in any organisation and especially in hospitals. Daniel et al. in their study socially Responsible Internal Communication? Analysing the combined effect of CSR and Internal Communication on Employees' Affective Bond to Organization quote Henriet Boneu (1990) who observes that the exchange of information and communication produces organizations and assures the winning of an institution.[6] For the smooth operation of an institution, especially for organizations like hospitals, where the customer is offered service irrespective of his financial status, “internal communication becomes a key activity and overpowers the barriers of interpersonal communication”.[7]

“Patients or their relatives watch clinicians and other staff of the hospital closely.[8] They understand the behavioural pattern of the staff and get mentally ready and this may lead to aggressive situations in hospitals if the patient or his relative feels the hospital administration is not treating them suitably. This thought provides a thrust that health care providers working at different levels must be oriented towards the importance and awareness towards sensitivity towards the presence of patients while communicating.

In public hospitals or hospitals attached to medical colleges, the doctors are forced to examine patients more than their capacity and in some time viewing patients in pain could become a matter of routine.[8] But for health care providers it is important to understand without crossing the ethical limitations of the profession if 'pathos' is expressed sufficiently towards the patient by touch, body language-particularly expression of a smile and encouraging words, the battle of winning the confidence of the patient is won and this can reduce the tensions in a traumatic state of mind.[9]

Reviewing the literature that has led to violent situations we can identify that people turned violent either due to the wrong diagnosis or lack of communication. The paper intends to focus its attention on the communication part as the patients and their relatives are not only waiting for the attention of the medical professional but also contemplating, evaluating and judging about the treatment he/she is going to receive.

Materials and Methods

This study employed a situational observatory design. Based on review of literature available and the discussions held with 3 patients who visited different hospitals in the month of Oct 2019, a semi-structured interviews a pilot study was conducted 9 patients who visited different hospitals at different parts of the state, where they had no track of patient history. Ethical committee approval was attained by institutional ethics committee on 19/11/2019 (IEC:934/2019) Based on the results obtained a final questionnaire was sent to people between 15th and 25th of Dec 2019 using various social media platforms which support interaction with the respondents. Out of 200 filled forms received only 55 patients/relatives fulfilled the study specifications. To understand the perception of patients towards communication pattern in hospitals during their visit a pre-requisite condition of visiting a hospital for the first time during last three days was set while analysing the responses received. The questionnaire was sent using various social media platforms and participation was voluntary. After receiving confirming documents related to the date of visit, detailed interviews with the select respondents was conducted using chat-box facility. Patients were asked to recollect the communication process that occurred in their presence. The main objectives of the present investigation are:

To analyse the importance of interpersonal communication in hospitals.

To examine the methods of improving interpersonal skills to reduce misunderstandings in hospital situations.

The quantitative data were analysed using SPSS ver. 21.0. The collected data were subjected to statistical analysis includes frequency, percentages, and Chi-square test for association between demographic profile of respondents who were either patients or relative who accompanied the patient to the hospital. The statistical significance was set at 5% level of significance (p < 0.05).

Analysis and Discussion

A hospital situation which is largely peaceful can turn violent, only during specific occasions. It is important to note that patients or care takers while waiting for the doctor, observe the events and interact with fellow patients/relatives. “According to the feedback received they get ready to react which is a normal behavioural pattern of a human beings.[10] In the personal interview based on a schedule prepared perception of 55 patients towards health care providers was captured and is presented here. The respondents were selected based on convenience stratified sampling method. The respondents visited the hospital as out patients and were first time visitors. The recollected experiences of the respondents' experiences are presented here.

Table 1 details that nearly 27 Male and 28 Female respondents participated in the interview process. The respondents belonged to the age group of 18–60 and to the income group of 30,000–40,000 per month. Respondents with minimum degree as their educational qualification were chosen to record their opinion. Respondents belonged to different parts of Karnataka state, India, who visited the hospital for the first time with no element of familiarity with the hospital and doctor were carefully chosen to gather the response. Amongst the responses received since a larger portion of them could be grouped to have visited a hospital to consult a Dentist, General Medicine, and Gynecology departments, were found in good number during the study period are considered here for analysis. The results indicate that there is no significant change in the perception of patients towards the medical professional's behavior irrespective of their field of specialization. The response obtained out of interview schedule is presented in following paragraphs.

Table 1

Distribution of demographic profile of respondents who were either patients or relative who accompanied the patient to the hospital in the study

Profile	General medicine	%	Gynecology	%	Dentists	%	Total	%	χ2	P
Gender
Male	12	52.17	6	33.33	9	64.29	27	49.09	3.169	0.205
Female	11	47.83	12	66.67	5	35.71	28	50.91
Age groups
18-28 yrs	9	39.13	12	66.67	6	42.86	27	49.09	3.356	0.187
28-38 yrs	14	60.87	3	16.67	0	0.00	17	30.91
38+ yrs	0	0.00	3	16.67	8	57.14	11	20.00
Participants
Patients	18	78.26	10	55.56	11	78.57	39	70.91	3.058	0.217
Relative	5	21.74	8	44.44	3	21.43	16	29.09
Total	23	100.0	18	100.0	14	100.0	55	100.0

Disturbance as perceived by patients

The process of communication includes both verbal and non-verbal. As part of communication we listen, interact, read and observe. Noise, an important element in the process of communication can disturb the process of communication at any point of time. In hospital situation, the noise in patient's mind which is in the form of pain and fear will observe, listen, and try to decode the body language of the service providers according his/her own perception. In the following paragraphs, analysis of patients/observation during the respondents visit to hospital is recorded.

Nonverbal communication

A majority of respondents 78.08% of the patients who visited a doctor of General Medicine found that doctors advised them to narrate the complaint while examining them with their ears plugged with a stethoscope. The patients opined that they did not trust the doctor who did not listen to their explanations and they went for the second opinion. “Maybe we had health complaints that were common for the season, but we felt neglected”. It was found nearly 33.45 percent of the patients went for second opinion and found that “the results did not vary but we were at least assured of the medicine and the prescriptions were right”.

Verbal communication

The results revealed that patients are sensitive to the conversation that occurs between staff members in a hospital. A small portion that is, 10% of the patients who visited dentists mentioned that staff were found ridiculing about the “foul mouth smell of a patient”. “We visit doctors when we have problem. Doctors or hospitals could request the patient to rinse the mouth before starting the check-up” was a suggestion by a senior citizen who was a relative to a patient.

Women respondents (12%) found their doctor disclosing personal details of another patient with her staff, and criticising the patient. “It could be ethical to disclose the details of patient with staff” “what if they were talking about me in front of others”, “what happens to the status of confidentiality” was common observation.

Mobile calls received by the doctor seem to be disturbing a large number of patients. More than 40% of the participants complained about the phone calls received by the doctor. “We understand that doctor's time is precious and someone could be needing his/her advises on emergency, but while listening to the complaint over the phone “how can I trust the prescription suggested for me”, was common concern of respondents expressed. “Waiting time for clarifications” and “Not all were emergency calls” were some of the expressions gathered. This behaviour was largely found among patients who visited General Medicine department of hospitals.

Respondents found the communication between the staff members disturbing. Nearly five percent of the respondents observe staff at the reception counter gossiping about their boss while the patients were waiting for the arrival of the doctor. “The doctor checks the number of patients before his/her arrival” was commonly heard statement by the patients/relatives. Arguments between staff members regarding their duty time, doctor scolding staff nurse, for pushing lot of patients to him/her was also recollected by patients. Nearly 20% of the patients found the reception staff continuously engaged in personal conversations over telephone until the doctor called them for assistance “the conversation was definitely not official as there was lot of giggling” the respondents observed. Nearly 51.55 percent of the respondents who visited hospitals found doctors expressing the overload of patients. They also found that these doctors were not very welcoming. Many respondents complained that doctors not being punctual. A small number of patients felt that the doctors treated them as illiterates.

As observed by other researchers “When people communicate, they make predictions about the effects or outcomes of their communication behaviour; that is, the sender will predict about the person from whom he/she is receiving the message and respond suitably”.[11] The outcome of communication between patient and healthcare provider can be attributed to the concept of responding to stimuli that were observed by Bandura in his Social Cognitive Theory. “People learn through observing others' behaviour, attitudes, and outcomes of those behaviours”.[1213]

Usage of medical terminologies and other common words

Despite of easy access to technology, 75% of the respondents found difficulty in understanding medical terminology used by the medical professionals “It created panic state of mind”. “We understand that medical professionals' ethics do not permit them to use the common man's language. But they could make us understand what exactly those words mean”. Some of the patients expressed they felt “funny” when the doctors used exclusive regional language during the process of examination. For example, “Mootra tanni” (bring urine). “Going by my age, the doctor assumed I cannot understand English so had used 'kannada word, which is not used in colloquial language”. “It took me time to understand what the doctor was asking for” explained a patient.

Knowledge imbalance

A majority of the patients found a knowledge imbalance between the physicians. This was evident during the second opinion observed nearly 45% of the respondents. Though the problem was the same, medicine prescribed and treatment time and method suggested was different” they observed.

Conclusion and Suggestion

Communication, the process of sharing of useful information between two parties in a compassionate way, is one of the important precedents to patients' participation, contentment, entanglement, and understanding in the health care procedure.[12]

The violent reaction of a patient or relative towards health care workers or primary care physicians, professionals could be due to the paucity of information provided to the patients. Using characters of Interpersonal communication effectively if the medical professional explains the nature of the problem and proposed plan of treatment which includes the cost of treatment, the duration for rehabilitation- frequently checking if the patient understood the treatment plan, the patient will understand the concerns. The interpersonal communication skills of the medical professional enhance the knowledge of the patient towards treatment and the facilities that are available in the hospital. The effective nonverbal communication sent through empathetic body language develops positive energy among the patients.[13]

From the study it is evident that the patients and their relatives are volatile by nature. They consciously or unconsciously are aware of their surroundings. Since listening and observing are also included in the process of communication it is then important that in every hospital employee irrespective of its ownership and size should be educated about the communication and behaviour in the presence of a patient/relative.

To usher in this procedure effectively a method should be adopted to evaluate communication pattern. Hospitals can prepare a schedule to receive a feedback about the patients' experiences from the time of entry to exit. The schedule could include a feedback on the quality of a clinician's explanations, display of empathy by clinicians, and whether patients were encouraged to ask questions and participate in decision-making, communication at the front desk, the staff communication within the organization. Adaptation of such a procedure will not only improve quality of service but also could reduce situations that turn violent.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.