Kerbside Consult

When the Patient Becomes the Threat

Workplace violence in Malaysian healthcare — and where compassion, professional duty and staff safety meet.

Cyberdoc — writing on medicine since 1995

Violence doesn't always mean a punch

When we hear workplace violence, we tend to imagine physical assault.

In healthcare, much of it is less visible: shouting, insults, threats, intimidation and other forms of psychological aggression.

A Malaysian study involving 231 healthcare workers in emergency departments found that 38% had experienced workplace violence during the preceding six months. Among those affected, 88.9% experienced psychological violence. Sahiran, Minhat & Saliluddin, Journal of Health Research.

Another study of 136 doctors and nurses in a Kuala Lumpur public hospital reported workplace violence among 71.3% of respondents during the previous year. Verbal abuse was the most common form. Zainal, Rasdi & Saliluddin, 2018.

The studies involved different populations, settings and methods. Their percentages should not be interpreted as national prevalence estimates.

Sometimes the threat isn't the patient

The title of this article is deliberately imperfect. Sometimes the patient isn't the threat at all.

The Kuala Lumpur study found relatives and visitors were the most common perpetrators of verbal and physical violence. In the emergency-department study, more than half of the violence involved combinations of perpetrator types; relatives alone accounted for almost a quarter.

It is not difficult to understand how confrontation develops. Someone has waited hours with a sick child. A family does not understand why an elderly parent has not been admitted. A relative wants an answer the doctor cannot yet give. At the Kuala Lumpur conference, Ministry of Health Medical Development Division director Dr Nor Hayati Ibrahim identified waiting times as one factor that can trigger anger in government hospitals.

There is another important distinction. Aggressive behaviour may sometimes be caused by delirium, dementia, intoxication, hypoxia, neurological disease or psychiatric illness. Ministry of Health guidance recognises medical causes of aggression and emphasises assessment and de-escalation. MOH Guidelines on Management of Aggressive Patients.

A delirious patient striking a nurse and a relative deliberately threatening that nurse may create the same immediate safety problem. They are not necessarily the same clinical or behavioural problem.

The violence nobody reports

Perhaps the most revealing Malaysian finding is what happens afterwards.

A Melaka study involving 557 public-hospital healthcare workers who had experienced workplace violence during the preceding 12 months found that only 177 — 31.8% — reported it. Psychological violence was the most common form experienced. Minhat & Sahiran, Malaysian Family Physician, 2023.

Why so little reporting? The figures alone cannot tell us. But the degree of under-reporting raises another question: has some aggression become normalised as simply “part of the job”?

Where do we draw the line?

Healthcare workers inevitably deal with distress. A frightened patient needs patience. A grieving family needs compassion. An angry relative may need an explanation. A confused patient needs appropriate clinical care.

But none of this requires accepting threats or violence.

The recent APHM statement therefore raises a legitimate question: when does difficult behaviour become sufficiently abusive that non-emergency care cannot reasonably continue in the same way?

The precise professional and legal boundaries are more complicated than the headline suggests. APHM's statement should not itself be interpreted as establishing a general Malaysian legal rule.

What is clearer is what should happen before matters reach that point. Malaysia's Ministry of Health already has guidance covering recognition of aggression, assessment of underlying causes, de-escalation, security or police involvement when necessary, documentation, debriefing and incident reporting.

The issue is therefore not simply whether hospitals have policies. It is whether those policies work when somebody is actually being threatened.

Before anger becomes violence

Safety is part of care

The aim cannot be to turn hospitals into hostile environments or treat every raised voice as a security incident.

Patients should expect compassion, respect and safe medical care. Healthcare workers should be able to expect the same.

Hospitals will never be completely calm places. People will arrive frightened, hurting, grieving and sometimes angry. Managing that distress has always been part of medicine.

Abuse should not be.

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