Is it Possible to Decrease Violence against Healthcare Workers in a Simple, Cost-effective Way?: A New Concept

BACKGROUND Healthcare professionals (HCP), physicians, and nurses are 'shielders' who shield the population from different health problems. However, ironically, the situation becomes perverse if these 'shielders' have to constantly run for protection from the people they are protecting. Yes, violence against HCP (VaHCP) has become a real menace and no particular measure has proven to be effective so far.[1-3] VaHCP is a global phenomenon that is underreported, ubiquitous, persistently tolerated, and largely ignored.[2,3] A large meta-analysis of 253 studies (331,554 participants) found the global prevalence of nonphysical violence against HCP to be 42.5% and physical violence to be 24.4%.[2] In the last 10 years, violence against HCP has risen exponentially in India.[4,5] There are multiple factors responsible for this. Conventionally, for centuries, the medical profession has been labelled a 'noble profession' in India, where doctors were expected to serve selflessly in return for 'utmost respect equating them to the status of God'. As the public healthcare facilities were grossly inadequate for a growing population of over a billion people, the last three decades saw a rapid increase in private hospitals. Private healthcare is not always cheap. However, higher fees charged by doctors in private healthcare are perceived as 'greed' and 'betrayal' from the selfless service norm, and a fall from the 'divine pedestal'. 'Selfless gods' are now seen as 'greedy bandits' by many. The media, riding on sensationalism, only added fuel and acted as a catalyst.[6] This has a negative impact on the psyche of HCP.[2,3,7] Ultimately, healthcare delivery suffers immensely in the long term.[6,7] Doctors become fearful and more defensive and avoid admitting seriously ill patients.[2,7] This affects healthcare delivery, especially in critical cases.[7] Overall, the trend of violence and its effect on medical professionals is very dismal and with no help from any government sector (politicians, administrators, police, or judiciary), HCP are rapidly losing enthusiasm and becoming despondent. METHODS Aim The aim was to reduce the incidence of VaHCP. A team comprising of hospital executives, CEO of a hospital system, CEO of a research institute, senior faculty in medical colleges, practicing doctors in a corporate hospital, residents, IT (information technology) experts, ethical experts and legal experts of the country conceived the idea, deliberated on legal and ethical aspects, developed, and launched the application-cum-website, SHEELD. The execution of project Against this background of rampant VaHCP and with no hope from any quarter, we hypothesize that a simple innovation, SHEELD, can prove to be a cost-effective measure to tackle this serious global public health problem. One of the root causes of the persistence of violence against HCP is nonaccountability of perpetrators. SHEELD is primarily targeted against this notion and acts by creating fear in the mind of the perpetrators that their inappropriate actions would not go unaccounted. Any VaHCP by the perpetrator, physical or nonphysical, would be disseminated by the affected HCP to all HCP in the country. This could make future treatment of the perpetrator more arduous. The main aim is not to hinder the treatment of the perpetrator in any way but to create fear in his/her mind that this potential possibility (his future treatment becomes difficult) exists if he/she resorts to VaHCP. After extensive research and consultations with ethical, legal, and IT experts in the country, a cellphone application (app) – SHEELD, linked with a website (www.sheeld.in) was developed and launched in India in October 2021. Approval was obtained from the Hospital Ethical Committee. The purpose of SHEELD is twofold: first, to share the details of persons resorting to VaHCP with every HCP across the country, and second, to create awareness among the public that such an app (SHEELD) exists. Once it is known that SHEELD exists, the perpetrators would be more cautious. The dissemination of this information alone would act as a deterrent to most offenders. The application has been kept very simple and user-friendly. An HCP needs to register on SHEELD by filling in basic information (name, contact, email address, etc.). Only HCP with an Indian cellphone number can register as a one-time password is sent to the cellphone for verification during the registration process. The HCP needs to agree to certain terms and conditions listed on the website/app. These terms and conditions were framed to protect the patient's privacy and rights and to ensure that no legal, ethical, or IT laws of the country are breached while using SHEELD by HCP. Once registered, the HCP can use SHEELD on a cellphone app or website (www.sheeld.in) free of cost. There are two sections in SHEELD – REPORTING and SEARCH [Figure 1, left upper panel, Table 1].Figure 1: Left upper panel: Home page on SHEELD – Showing search and reporting icons. Left middle panel: Reporting page on SHEELD – In this, the registered HCP can enter the details of the offender and select one or more of the misconduct categories. Left lower panel: Search page on SHEELD – This is used before any patient's treatment is initiated. Right panel: The SHEELD poster sample to be displayed at prominent places in hospitals, nursing homes, and clinicsTable 1: Demonstration of SHEELD app/websiteIn the REPORTING section, the registered HCP can enter the details of the offender [Figure 1, left middle panel]. Only two details of the offender can be put on SHEELD – (a) basic contact details (name, age, cellphone number, city, state) and (b) one or more of the misconduct categories can be selected (1. Noncompliant, 2. Payment problems, 3. Verbal abuse, 4. Threat, and 5. Physical violence). Apart from this information, there is no provision for entering any other details like the patient's medical or other sensitive data. As per Indian government guidelines, a unique identification number (Aadhaar number) cannot be shared publicly. Therefore, the patient's identity is linked to the name and cellphone number. (Even though the cellphone number can be changed by the perpetrator, this is unlikely as the process is cumbersome.) The contact details of the HCP reporting about the offender (reporting HCP) are also stored along with the offender's details in the reporting section. The SEARCH section is used by treating HCP before any patient's treatment is initiated especially before hospital admission [Figure 1, left lower panel]. If the name and cellphone number of the patient are found in the reported offender's list, then the HCP reporting the offender may be contacted and details sought. After communicating with the reporting HCP, if the treating HCP is convinced about the misconduct of the 'perpetrator', then the perpetrator may be dealt with as per permissible laws of the country (taking written assurance, referring the patient to a higher center, etc.) SHEELD is simple, user-friendly, minimally time-consuming (registration on SHEELD takes about 3–5 min), free to use, and seems effective. All ethical and legal issues have been taken into consideration while designing the app. RESULTS SHEELD was launched in October 2021 and, since then, hundreds of HCP have registered on it. The SHEELD posters have already been displayed at prominent places in several hospitals, nursing homes, and clinics to create awareness among public about the existence of SHEELD [Figure 1, right panel]. In a short span of time, the response is encouraging and the initiative looks effective as per the feedback given by the user HCP. However, the long-term impact would be known only after a few years. DISCUSSION Considering the huge population of 1.4 billion in India and hundreds of cases of violence against HCP every month, even if SHEELD is able to prevent a small percentage of these unwanted events, it would translate into large numbers and the aim of making the app would be more than accomplished. There are a few major hurdles in launching and making this concept effective Legal and Ethical Sharing information: It is paramount that no sensitive or medical information of the offender is shared on SHEELD.Overcoming this hurdle: Therefore, to take care of this, there is no provision for sharing any information on SHEELD. Only one of the five misconduct categories can be selected (1. Noncompliant, 2. Payment problems, 3. Verbal abuse, 4. Threat, and 5. Physical violence) [Figure 1, left middle panel].Potential litigation: It is possible that in an unlikely scenario, if a repeated offender is not attended properly by a healthcare facility when his history is available to the facility, the offender might charge the facility or app/website developer for the inconvenience or loss to health caused.Overcoming this hurdle: All the HCP registering on SHEELD are required to agree and give consent to the terms and conditions. These conditions specify to treat all patients as per the law of the land. The aim of SHEELD is not to deny healthcare to any patient (even if the patient is a repeat offender) but to enable the healthcare facility to prepare accordingly and handle the repeated offender appropriately as per the existing laws. The efficacy of the concept lies more in creating deterrence in the minds of potential offenders rather than actually creating a hindrance in the provision of healthcare services. Usage of ConceptAnother hurdle is to make healthcare personnel understand the concept and use it widely. The efficacy of the concept lies in its widespread usage and creating awareness in the public about this concept.Overcoming this hurdle: The app/website has been kept simple, user-friendly, and free so that a maximum of healthcare personnel can utilize it. The idea and concept of SHEELD can be reproduced and used all across the globe. For this, the terms and conditions and information disseminated on SHEELD may be modified as per the ethical and legal rules of the country. SHEELD would help create a database of the offenders and help in identifying repeat offenders. More effective would be the deterrence caused by creating fear in the mind of repeated offenders through the widespread usage of SHEELD across healthcare facilities. In the current scenario when no measure is proving effective against VaHCP, SHEELD seems like an oasis in the desert. SHEELD may not eradicate the problem but has the potential to decrease it significantly. Once the SHEELD network is established, along with preventing VaHCP, the SHEELD concept can also be used for other purposes in which information needs to be shared among HCP. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.