Singapore hospitals may discharge abusive patients who do not need urgent medical care

SINGAPORE: A tripartite workgroup on Friday (Mar 17) called for clear consequences for people who harass healthcare workers, such as discharging abusive patients who do not require urgent medical care.

The other consequences include issuing a warning to the perpetrator, refusing unreasonable requests or preventing abusive caregivers or visitors by preventing them from entering the premises.

The workgroup, set up in April last year, also recommended putting in place effective reporting and escalation protocols, as well as a support structure to provide healthcare workers with the confidence and assurance to report abuse and harassment.

“More needs to be done to stop abuse and harassment so that consequences can act as a deterrent and healthcare workers feel protected by a strong anti-abuse and harassment policy,” said the Tripartite Workgroup for the Prevention of Abuse and Harassment of Healthcare Workers.

HIGH PREVALENCE OF ABUSE AND HARASSMENT

The recommendations come after engagement with more than 3,000 healthcare workers and 1,500 members of the public via surveys and focus group discussions conducted in the second half of last year.

The workgroup found that more than two in three healthcare workers had witnessed or experienced abuse or harassment in the past year. About a third of all healthcare workers witnessed or experienced abuse at least once a week.

Frontline healthcare workers, such as pharmacists, patient service associates and nurses, are more likely to experience abuse and harassment.

For example, 55 per cent of pharmacists witnessed or experienced abuse or harassment at least once a week. This may be due to how pharmacists are often the “last touchpoint” with patients or next-of-kin before discharge from hospital wards or specialist outpatient clinics, the workgroup said.

The most common forms of abuse and harassment are shouting, demeaning comments, and threats by patients and caregivers to file complaints or take legal action against healthcare workers.

Patients and clients (41 per cent) accounted for nearly half of the cases of abuse witnessed or experienced by the healthcare workers surveyed, followed by caregivers and visitors (28 per cent).

Workplace bullying and harassment by colleagues and supervisors made up 31 per cent of such cases. This was more commonly experienced by younger or junior staff. While usually in the form of verbal abuse, there were also instances of physical abuse and sexual harassment, the workgroup said.

“There is high prevalence of abuse and harassment across all healthcare settings, including verbal, physical, sexual, and online abuse,” said the workgroup in summarising its findings and implications.

It added that healthcare workers sometimes normalise abuse and harassment as part of their job, which resulted in them not recognising certain behaviours as abusive or failing to take follow-up action.

"As healthcare workers shared their experiences of abuse and harassment from patients and caregivers, many were also empathetic to their patients and caregivers, acknowledging the stress and uncertainty that they faced," said the workgroup.

The negative perception of the reporting process – such as having to fill up reports outside of working hours, limited action taken against offenders and how they would be perceived by supervisors and colleagues – was another factor behind the “significant” under reporting of abuse and harassment.

Describing these findings as worrying, Health Minister Ong Ye Kung said healthcare is largely a well-respected and dignified profession, but there is always "a small proportion of the public" who behave badly towards healthcare workers. 

“They will demand that healthcare workers do unreasonable things, and then threaten or hurl discriminatory remarks at them when they don’t get their way,” Mr Ong said at a staff engagement session on supporting healthcare workers.

“While it’s a small minority, it is enough to significantly affect morale,” he added.

ZERO-TOLERANCE POLICY

The workgroup recommended developing a "standardised zero-tolerance policy" against abuse and harassment of healthcare workers.

Key to this would be establishing a clear and common definition of abuse and harassment. This includes any inappropriate behaviour or communication that causes a healthcare worker to experience distress, harassment, threat or discrimination, regardless of intention.

“All behaviour or any form of communication that falls within the definition above should be considered abuse or harassment and should not be left unreported,” it said.

Healthcare workers should be provided with a direct and straightforward reporting process, and an escalation protocol and response plan that is equivalent to the severity of the incident, it added. 

Enforcement of consequences will also help deter abusive situations, said the workgroup, noting that the threshold for actions to be reported to the police or handled by the institution should be clearly spelt out.

In cases where legal recourse is available, the threshold and process should be made clear to workers and supervisors.

Institutions should support their employees in making police reports if necessary. They should also develop a suite of internal actions that can be taken independently, regardless of whether legal recourse is available.

This may include issuing a warning to the perpetrator, refusing unreasonable requests or discharging abusive patients who are assessed to not require urgent medical care. They may also prevent abusive caregivers or visitors from entering the premises. 

“Ultimately, to protect healthcare workers, we need to stand up against blatant abusers when abuse happens. In a healthcare setting, this has to be carried out sensitively,” said Mr Ong.

“Where urgent care is needed, care will be delivered regardless ... But where care is not urgent, or if the abuser is a visitor and not a patient, which is often the case, then there must be a disengagement process,” he added.

The workgroup also recommended healthcare institutions train their employees with the skills and knowledge to manage and de-escalate challenging situations. 

In a joint statement, public healthcare clusters – SingHealth, the National Healthcare Group and the National University Health System – expressed their strong support for the recommendations.

The Ministry of Health (MOH) said it will work with these public healthcare clusters to develop details of the standardised zero-tolerance policy against abuse and harassment in the second half of the year.

Private healthcare institutions and community care organisations will be encouraged to refer to this policy when it is ready, and adapt it to their processes and operating models where feasible, said MOH.

A national public education campaign will also be launched in the second half of the year to “align expectations of healthcare workers’ roles, and promote respect” for them. 

NEED FOR PERIODIC REVIEW: UNION

The Healthcare Services Employees’ Union (HSEU) described the recommendations as a good start at tackling abuse and harassment, and expressed hopes that they would be put in place consistently across the healthcare sector.

In addition, the union suggested that MOH carry out periodic reviews of implemented measures and consider how to facilitate sharing within and among institutions on managing recalcitrant perpetrators.

There must also be measures to address workplace bullying and harassment.

“HSEU also strongly encourages our healthcare staff to report such incidents without hesitation,” said president K Thanaletchimi.