Violence on Health Professionals : Experience of the Obstetrics & Gynecology and Pediatrics Departments at the University Teaching Hospital of Bouaké , Côte d ’ Ivoire

Introduction: Violence in hospital is a major Public Health issue. In Côte d’Ivoire, acts of violence against health professionals exist and may sometimes take a dramatic turn. Objective: To research the causes of this violence for the purpose to prevent them. Materials and Methods: This is a cross-sectional, descriptive study conducted in the Obstetrics & Gynecology and Pediatrics departments at the University Teaching Hospital of Bouaké from 26 January 2016 to 24 February 2016. It included 129 health workers who gave their consent. The data collection was done through individual interviews followed by a focus group according to the socio-professional category. Results: Out of 129 health professionals included, 100 were a victim of violence i.e. a frequency of 77.5%. Most of the violence occurred during “on-call hours” (55.8%) in the emergency units (34.8%). The violence was verbal (52.5%), physical (28.6%), moral and psychological (11.6%), theft (7.3%). The aggression was mainly related to patient’s care (32.1%), visiting hours (26%) and the low level of understanding of the person (16.5%). The victim’s immediate feelings were dominated by frustration (26.7%), discouragement (21.3%) and insecurity (18.3%). The victims received a medical assistance in 9% of cases. To prevent this violence, the staff mainly offered to raise awareness about violence (27.6%) and the respect for How to cite this paper: Asse, K.V., Azagoh-Kouadio, R., Yao, K.C., Aka-Tanoh, K.A., Avi, C., Yeboua, K.R., Yenan, J.P., Ehouman, M.A., Doumbia, Y. and Plo, K.J. (2018) Violence on Health Professionals: Experience of the Obstetrics & Gynecology and Pediatrics Departments at the University Teaching Hospital of Bouaké, Côte d’Ivoire. Open Journal of Pediatrics, 8, 8-18. https://doi.org/10.4236/ojped.2018.81002 Received: December 2, 2017 Accepted: February 25, 2018 Published: February 28, 2018 Copyright © 2018 by authors and Scientific Research Publishing Inc. This work is licensed under the Creative Commons Attribution International License (CC BY 4.0). http://creativecommons.org/licenses/by/4.0/ Open Access


Introduction
The World Health Organization (WHO) defines violence at workplace as the intentional use of real or apprehended power against a person or group of people, in work-related circumstances leading to a high degree of probability of trauma, psychological harm, mischief or deprivation and death [1].When it occurs in the hospital, the victim may be a patient, a caregiver or a health worker.In the latter case, the global prevalence is estimated to be between 37% and 86% [2] [3].The abused staff is vulnerable and depressed.He is demotivated and is less involved in the working activities [4].This negatively impacts on the quality and cost of the care provided.Indeed, in the United Kingdom (UK), it has been estimated that the violence and stress resulting from this kind of violence could be jointly responsible for about 30% of all illness and accident-related expenses.On the basis of these figures, the violence would increase from 0.5% to 3.5% the annual Gross Domestic Product (GDP) of the UK [4].Furthermore, according to their National Institute for Safety at Work of United States (US), Stress and psychiatric disorders among workers following workplace violence results in job loss valued at $19 billion and $3 billion in productivity decline [3]-[10].The caregiver does not "consciously" or voluntarily hurt the patient.Most often it happens when it is annoyed or irritated by a third person [11].He then unintentionally transmits this negative attitude to the patient during care by a lack of attention and or commitment towards him [11].This lack of attention to the patient occurs especially when the work periods are long and the workload is heavy [12] as it could be the case in the pediatric and Obstetrics & gynecology departments.Despite the importance of this problem, there are very few studies in sub-Saharan Africa dealing with violence at workplace in hospital settings [13] [14].In Côte d'Ivoire, acts of violence against medical health personnel exist and may sometimes take the form of drama [15], which led the Medical Board of Doctors to propose a white paper in 2013.What are the motivational causes of the aggression on hospital staff?A good knowledge of these causes will make it possible to put in place measures to increase the safety of the staff and the patients but also to guarantee the quality of the care for a reduction of the infant morbidity and mortality.The aim of the study was to investigate the causes of this violence for the prevention and improvement of the professional practice.

Materials
This is a prospective cross-sectional study with descriptive intent.It took place at the University Teaching Hospital (CHU) of Bouaké in the Pediatric and Obstetrics & Gynecology departments from 26 January 2016 to 24 February 2016.The Pediatrics and Obstetrics & Gynecology departments, are the only tertiary-level referral services in the health pyramid in the Gbêkê region.They are located at about 347 km from Abidjan, the economic capital in the south of the country.The annual admissions in the department of Pediatrics, all units combined (Neonatology and General Pediatrics) is nearly 19,000 patients and has 99 workers all socio-professional category.Similarly, The Obstetrics & Gynecology Department has 138 active staff.These two services represent in terms of activities, nearly two-thirds of the total volume of activities of the University Teaching Hospital of Bouaké and therefore constitute the main gateway to this reference health facility in the Gbêkê administrative region.The study population is represented by the staff of both departments.Included in the study were all personnel working in these services, recognized by the Human Resources Department of the University Teaching Hospital (CHU) of Bouaké, present at the time of the survey and gave a written informed consent.All personnel absent at the time of the investigation due to illness, leave or annual leave were not included in the study.

Methods
We conducted a guided interview with all staff meeting the inclusion criteria.The information collected was recorded on two structured survey sheets, anonymized and validated by one independent expert.In this study, the level of education of staff was defined as follows: primary (≤6 years of education), secondary (7 and 13 years of education), higher (≥14 years of education).The data was captured and analyzed on the statistical software SPSS version 20.The analysis was descriptive and consisted of calculating the numbers and determining averages and proportions.Quantitative variables were analyzed as mean with standard deviation.The qualitative variables were expressed as a proportion.The comparison of the quantitative variables was done with the chi-2 test.The threshold of significance was set for a value of p ≤ 0.05.

Ethical Considerations
They were materialized by the informed consent of the participants, the anonymity of the data collection forms and by the research authorization from the Scientific Medical Directorate of the University Teaching Hospital with copying to the heads of the services concerned.

Socio-Demographic Characteristics
From the total of 237 health professionals in both services, 129 participants were and 3 days).The sex of the victim was the only factor significantly associated with the violence (Table 3).

Consequences of Violence, Management and Suggestions to Staff
The four main feelings of the victims of violence were frustration (26.7%), discouragement (21.3%), feelings of insecurity (18.3%) and humiliation (17%).The victims reported that violence affected their working activity in 44% of cases.It was the lack of self-investment (59.6%), the desire to change jobs (24.2%) and the lack of compassion (14.1%).Nine of the 100 victims (9%) reported having received medical assistance after the attack.All the victims claimed that they had no legal recourse after the attack.To prevent violence on the staff, the victims proposed to raise awareness against violence (27.6%), to campaign for respect for the staff working in the hospital (25%) and the implementation of a policy of zero tolerance to violence (12.5%).

Study Limitation
This cross-sectional and descriptive study aims to investigate the causes of violence against staff working in the pediatric and Obstetrics & Gynecology departments of the University Teaching Hospital (CHU) of Bouaké with a view to prevent it and improve the professional practice.It relies on staff declarations based on honor from memory without confirmation of their accuracy by incident reporting forms.As a result, memory bias is possible.In addition, the study is mono-centric and does not take into account cases of violence against staff perpetrated in other health centers.As a result, the results of the study cannot be generalized to the whole country.Nevertheless, despite the methodological  related to management (32.1%),visiting time (26%) and low level of understanding of the subject (16.5%).For Abodunrin et al. [14] in 2014, the reasons were the waiting time (80.6%), the insults of the staff against the patient (61.8%) and the unavailability of staff (43.1%).In Egypt, Samir et al. [23] in 2009 reported negligence (40.5%) and misconduct (35.8%) as the main causes.In Palestine Motasem et al. [20] in 2015 reported that the main reasons for the violence were the waiting time, lack of measures to prevent violence and the dissatisfaction of parents or patients.The perpetrator is often a parent or a visitor of the hospitalized patient (71.1%), of male gender (55%) with an estimated age between 30 and 40 years (47.2%).Often, it maybe the patients themselves (21%) or a staff member (8%).However, there is no significant difference between the sex, the assumed age and the nature of the violence.These results are comparable to data from the literature [14] [22] [23].When the perpetrator is a staff member, it is a doctor in 43%, a care giver in 43% and an administrative staff in 14%.The work shows that the victim is mostly male (P = 0.045) but with no relationship to the socio-professional category, the service, the seniority in the profession and the seniority in the service.In the study by Aden et al. [13] carried out in 2012 in Morocco, the proportion of nurses and doctors victims of violence in the line of duty was respectively 86% and 78%.In our work, although there is no significant difference in the socio-professional category of victims, we nevertheless notice that security guards (100%) and assistants nursing (81.5%) are more assaulted than the nurses & midwives (76.7%) and the doctors (72.9%).This may reflect a lack of consideration by the perpetrators vis-à-vis of staff of lower educational backgrounds.

Consequences of Violence, Staff Management and Suggestions
In the study, the abused staffs are mostly frustrated, feel humiliated and insecure, with discouragement, abandon or lack of concentration as drawback.The feelings experienced by the staff have already been reported by other authors in the literature [14] [21] [24].In the study, only 9% of victims reported having received a medical assistance.None of these victims received legal and psychological support.The absence of complaint with regards to the aggression by the victims to the hospital management or either by ignorance or by negligence explains the lack of the medical, psychological and legal support observed in the study.Indeed, at the University Teaching Hospital of Bouaké, the process of taking care of the abused person begins only when the victim declares the incident to the hospital management by filling out the declaration form.Unfortunately, in the majority of cases, this declaration form that grants the right to medical, legal and psychological assistance is not completed by the victims.
Proposals have been made by the staff to address the violence occurring in the hospital.All suggestions are aimed at preventing violence at different levels viz.
awareness against violence (27.6%), campaign for respect for the staff working in the hospital (25%) and the implementation of a policy of zero tolerance to vi-

. Characteristics of the Violence One
hundred of the 129 staffs interviewed said they had been victims of violence at least once i.e. a frequency of 77.5%.Forty-five were from the Pediatrics Department and 55 from Obstetrics & Gynecology.There were 49 men and 51 women i.e. a sex ratio of 0.96.

Table 2 .
Characteristics of the violence.

Table 3 .
Factors associated with violence against staff.