FROM THE ICN
By David Benton, PhD, RGN, RMN, FFNF, FRCN, and Lindsey Williamson, BA
Safeguarding Health Care Workers Across the globe, violence is presenting a challenge to care. Editor’s note: The International Council of Nurses (ICN) is a federation of more than 130 international nursing organizations. We invited the ICN to contribute a periodic column highlighting some of its initiatives to address global nursing issues. For more information, see the ICN Web site at www.icn.ch.
I
n August 2014 came horrifying news: Two nurses attending a workshop in the African kingdom of Lesotho were brutally murdered, their bloodied bodies found abandoned in a field. Subsequent reports urged governments to “prioritize the safety of nurses,”1 warning that the scarcity of nurses coupled with danger to their well-being threatens the ability to provide care for people in need. News from conflict zones across the globe only highlights the crisis in care. In Iraq, health care has broken down after medical professionals fled the country following a series of murders and abductions. In Afghanistan, nearly 60 districts are unreachable by health care workers. Murders, abductions, and assaults have resulted in the country being identified as “one of the most dangerous places for aid workers.”2 (For information on violence against American nurses, see Homegrown Dangers.3-6) Across the globe, nurses, patients, and the ability to deliver care are increasingly under attack. What can we do? The ICN Code of Ethics for Nurses states, “The nurse takes appropriate action to safeguard individuals, families and communities when their health is endangered by a co-worker or any other person.”7 When danger threatens an individual nurse or an entire health care facility, it jeopardizes our ability to meet the needs of our patients and compromises our ability to care. Nurses and other health care professionals working in conflict areas face ongoing threats to their personal safety as well as overwhelming pressure to uphold their ethical principles. This was the case in Bahrain in 2011, for example, when, during protests against the government, nurses and physicians provided care to all those in need, regardless of their political affiliation. As a result, many were arrested and charged with participating in efforts to overthrow the Bahraini monarchy and taking part in illegal rallies. Other [email protected]
Paramedics from the Palestine Red Crescent Society are caught in the conflict as they give medical attention to the wounded in Kalandia, one of the largest Israeli military checkpoints in the occupied West Bank. Photo by ICRC / Amnon Gutman.
examples of the increasing violence against health care workers in areas of conflict include the bombing of hospitals and the deaths of hundreds of health workers and patients in Syria and the targeted killing of more than 70 polio vaccine workers in Pakistan. In fact, from January 2012 to July 2014, the International Committee of the Red Cross (ICRC) documented more than 2,300 incidents involving serious acts or threats of violence against health services in 23 countries.8 Violence against patients and health care workers is one of the most serious yet overlooked humanitarian issues today, disrupting health care services when and where they are needed most. The issue has been increasingly brought to light in the international community. In October 2013, a report of the United Nations (UN) Special Rapporteur proposed concrete AJN ▼ December 2014
▼
Vol. 114, No. 12
61
FROM THE ICN
Homegrown Dangers
Recent studies expose violence against American nurses. As the International Council of Nurses points out in its work on establishing positive practice environments for nurses, what affects the nurse also affects the patient.3 Although nurses must be ensured respectful treatment and a safe work environment in order to provide quality care, recent research shows this will be an uphill battle. •• Violence in the U.S. workplace is highest in health care settings, according to a recent report in the Lancet, where there are four times the number of assaults on health care workers compared with other occupations.4 •• Twenty-five percent of emergency nurses surveyed for a 2011 study said they had experienced frequent physical violence.5 •• Of the 5,000 participating nurses in a 2014 study, 76% experienced verbal or physical violence, such as shouting or yelling, swearing, and scratching or kicking.6 The situation was even worse for emergency nurses: in this cohort, 87% had been verbally assaulted and 50% had been physically attacked.
steps toward realizing the right to health of all people in conflict situations.9 The issue was also raised at a meeting of the World Health Assembly, the governing body of the World Health Organization (WHO), where governments decide on global health policy. This year, a resolution was passed calling for increased reporting by the WHO of attacks on health care in conflict settings. Following this resolution, the ICRC, Médecins Sans Frontières (Doctors Without Borders), and the Safeguarding Health in Conflict Coalition launched campaigns highlighting attacks on health workers. And the mandate of the UN secretarygeneral’s special representative on children in armed conflict was expanded in 2011 to call for all parties that attacked schools and hospitals to be held accountable for these acts and placed on the secretary-general’s annual list of those committing grave violations against children.2, 10
WHAT IS THE ICN DOING?
The International Council of Nurses (ICN) is actively engaged in two initiatives to protect health care workers and ensure the safe delivery of care. The Health Care in Danger project, a collaboration of the ICN and the ICRC, among others, aims 62
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to make access to health care more secure during situations of armed violence. The project has developed materials including a film, Health Care in Danger: The Human Cost, and a publication, Health Care in Danger: The Responsibilities of Health-Care Personnel Working in Armed Conflicts and Other Emergencies (both are available for purchase on the project’s Web site: https://shop.icrc.org/health-care-in-danger.html). Health Care in Danger has also developed and endorsed a document titled “Ethical Principles of Health Care in Times of Armed Conflict and Other Emergencies” (available soon on the ICN Web site: www. icn.ch) and has agreed to work for the promotion and implementation of these principles wherever possible. The principles state clearly that the ethics of providing health care do not change in times of conflict and, indeed, are the same in times of peace. Health Care in Danger has also launched an elearning module that presents the legal framework for providing health care during armed conflict and other emergencies. The module uses interactive case studies, learning activities, animation, and other media to guide viewers through the main legal principles and familiarize them with common dilemmas faced by health care personnel. Another module has also been developed that uses real-world examples of ethical dilemmas to educate health care personnel on their rights and responsibilities. Available at www.healthcareindanger.org/elearning, the module addresses specific issues that health care workers may face during crises to prepare them to respond effectively so they can continue to provide the necessary care to their patients.
Nurses need to create the circumstances where we can focus on care—not on protecting ourselves. The Safeguarding Health in Conflict Coalition works to promote respect for international humanitarian and human rights laws that support the safety and security of health facilities, health care workers, ambulances, and patients. The ICN is a founding member of the coalition, whose goal is to ensure safety during periods of armed conflict or civil violence. This is achieved by monitoring attacks on and threats to civilian health; demanding accountability ajnonline.com
for perpetrators at national and international levels; enhancing the visibility and understanding of the nature, extent, and effects of attacks on health services; and empowering local groups to play an active role in championing their right to health. In addition, in partnership with Human Rights Watch, the coalition recently released a report, Under Attack: Violence Against Health Workers, Patients, and Facilities, which describes recent attacks on health care workers to raise awareness and highlight the urgent actions needed to end the violence.2
A system of monitoring attacks on patients, hospitals, and health care professionals must be established. WHAT CAN NURSES DO?
Nurses need to create the circumstances where we can focus on care—not on protecting ourselves. On the global stage, the ICN urges nurses and national nurses’ associations to call on their governments to • respect international law and ensure the immediate provision of humanitarian assistance, including health care, to refugees and displaced persons. • facilitate the open and coordinated access of international humanitarian organizations in affected regions. • undertake cooperative action with local branches of government, UN agencies, and nongovernmental organizations to provide suitable health services, without discrimination, for all those in need. • guarantee that nurses’ and other health care workers’ duty to care is not obstructed. If we are serious about meeting the health care needs of those we serve, then this major threat to the ability to deliver services needs to be addressed. Such change can’t be accomplished by nurses alone. It requires political commitment across the spectrum, bringing together different participants—governments, lawmakers, health care providers, and academics—to deliberate solutions, establish recommendations, and make sure that the recommendations are implemented at the national level. We need to have clear ethical principles in place to ensure that health care professionals understand their [email protected]
roles and responsibilities in both conflicts and emergency situations. A system of monitoring attacks on patients, hospitals, and health care professionals must be established, and we must demand accountability for perpetrators—whether they are individuals, armies, or rebel groups. Finally, we need to empower providers and civil society groups to be champions for their right to health. ▼
David Benton is the chief executive officer and Lindsey Williamson is the communications officer of the International Council of Nurses, Geneva, Switzerland. Contact author: Lindsey Williamson, [email protected]. The authors have disclosed no potential conflicts of interest, financial or otherwise.
REFERENCES 1. Southern African Network of Nurses and Midwives (SANNAM). Lesotho: SANNAM saddened by killing of two senior public health nurses in Lesotho [press release]. AllAfrica 2014 Aug 20. http://allafrica.com/stories/201408200702. html. 2. Human Rights Watch and Safeguarding Health in Conflict Coalition. Under attack: violence against health workers, patients, and facilities. New York; Washington, DC; 2014 May. https://www.hrw.org/sites/default/files/related_material/ HHR0514_brochure_LOWRES.pdf. 3. Baumann A. Positive practice environments: quality workplaces = quality patient care. Information and action tool kit. Geneva, Switzerland: International Council of Nurses; 2007. http://www.icn.ch/images/stories/documents/publications/ ind/indkit2007.pdf. 4. Nelson R. Tackling violence against health-care workers. Lancet 2014;383(9926):1373-4. 5. Emergency Nurses Association. Emergency department violence surveillance study. Des Plaines, IL; 2011 Nov. http://www.ena.org/practice-research/research/Documents/ ENAEDVSReportNovember2011.pdf. 6. Speroni KG, et al. Incidence and cost of nurse workplace violence perpetrated by hospital patients or patient visitors. J Emerg Nurs 2014;40(3):218-28. 7. International Council of Nurses. The ICN code of ethics for nurses. Geneva; 2012. http://www.icn.ch/images/stories/ documents/about/icncode_english.pdf. 8. International Committee of the Red Cross (ICRC). ICRC and WHO urge concrete steps to better protect health care in conflict [press release]. 2014 Sep 25. https://www.icrc.org/ en/document/new-york-icrc-and-who-urge-concrete-steps- better-protect-health-care-conflict. 9. Grover A. Report of the Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health. New York; 2013 Aug 9. A/68/297. Sixty-eight session, United Nations General Assembly; http://www.wma.net/en/20activities/ 20humanrights/20distress/A_-Grover-Report-UN-GAOctober-2013.pdf. 10. United Nations. Security Council adopts text expanding criteria for Secretary-General’s list ‘naming and shaming’ violators of conflict-affected children’s rights [press release]. 2011 Jul 12. http://www.un.org/press/en/2011/sc10319.doc. htm.
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By David Benton, PhD, RGN, RMN, FFNF, FRCN, and Lindsey Williamson, BA
Safeguarding Health Care Workers Across the globe, violence is presenting a challenge to care. Editor’s note: The International Council of Nurses (ICN) is a federation of more than 130 international nursing organizations. We invited the ICN to contribute a periodic column highlighting some of its initiatives to address global nursing issues. For more information, see the ICN Web site at www.icn.ch.
I
n August 2014 came horrifying news: Two nurses attending a workshop in the African kingdom of Lesotho were brutally murdered, their bloodied bodies found abandoned in a field. Subsequent reports urged governments to “prioritize the safety of nurses,”1 warning that the scarcity of nurses coupled with danger to their well-being threatens the ability to provide care for people in need. News from conflict zones across the globe only highlights the crisis in care. In Iraq, health care has broken down after medical professionals fled the country following a series of murders and abductions. In Afghanistan, nearly 60 districts are unreachable by health care workers. Murders, abductions, and assaults have resulted in the country being identified as “one of the most dangerous places for aid workers.”2 (For information on violence against American nurses, see Homegrown Dangers.3-6) Across the globe, nurses, patients, and the ability to deliver care are increasingly under attack. What can we do? The ICN Code of Ethics for Nurses states, “The nurse takes appropriate action to safeguard individuals, families and communities when their health is endangered by a co-worker or any other person.”7 When danger threatens an individual nurse or an entire health care facility, it jeopardizes our ability to meet the needs of our patients and compromises our ability to care. Nurses and other health care professionals working in conflict areas face ongoing threats to their personal safety as well as overwhelming pressure to uphold their ethical principles. This was the case in Bahrain in 2011, for example, when, during protests against the government, nurses and physicians provided care to all those in need, regardless of their political affiliation. As a result, many were arrested and charged with participating in efforts to overthrow the Bahraini monarchy and taking part in illegal rallies. Other [email protected]
Paramedics from the Palestine Red Crescent Society are caught in the conflict as they give medical attention to the wounded in Kalandia, one of the largest Israeli military checkpoints in the occupied West Bank. Photo by ICRC / Amnon Gutman.
examples of the increasing violence against health care workers in areas of conflict include the bombing of hospitals and the deaths of hundreds of health workers and patients in Syria and the targeted killing of more than 70 polio vaccine workers in Pakistan. In fact, from January 2012 to July 2014, the International Committee of the Red Cross (ICRC) documented more than 2,300 incidents involving serious acts or threats of violence against health services in 23 countries.8 Violence against patients and health care workers is one of the most serious yet overlooked humanitarian issues today, disrupting health care services when and where they are needed most. The issue has been increasingly brought to light in the international community. In October 2013, a report of the United Nations (UN) Special Rapporteur proposed concrete AJN ▼ December 2014
▼
Vol. 114, No. 12
61
FROM THE ICN
Homegrown Dangers
Recent studies expose violence against American nurses. As the International Council of Nurses points out in its work on establishing positive practice environments for nurses, what affects the nurse also affects the patient.3 Although nurses must be ensured respectful treatment and a safe work environment in order to provide quality care, recent research shows this will be an uphill battle. •• Violence in the U.S. workplace is highest in health care settings, according to a recent report in the Lancet, where there are four times the number of assaults on health care workers compared with other occupations.4 •• Twenty-five percent of emergency nurses surveyed for a 2011 study said they had experienced frequent physical violence.5 •• Of the 5,000 participating nurses in a 2014 study, 76% experienced verbal or physical violence, such as shouting or yelling, swearing, and scratching or kicking.6 The situation was even worse for emergency nurses: in this cohort, 87% had been verbally assaulted and 50% had been physically attacked.
steps toward realizing the right to health of all people in conflict situations.9 The issue was also raised at a meeting of the World Health Assembly, the governing body of the World Health Organization (WHO), where governments decide on global health policy. This year, a resolution was passed calling for increased reporting by the WHO of attacks on health care in conflict settings. Following this resolution, the ICRC, Médecins Sans Frontières (Doctors Without Borders), and the Safeguarding Health in Conflict Coalition launched campaigns highlighting attacks on health workers. And the mandate of the UN secretarygeneral’s special representative on children in armed conflict was expanded in 2011 to call for all parties that attacked schools and hospitals to be held accountable for these acts and placed on the secretary-general’s annual list of those committing grave violations against children.2, 10
WHAT IS THE ICN DOING?
The International Council of Nurses (ICN) is actively engaged in two initiatives to protect health care workers and ensure the safe delivery of care. The Health Care in Danger project, a collaboration of the ICN and the ICRC, among others, aims 62
AJN ▼ December 2014
▼
Vol. 114, No. 12
to make access to health care more secure during situations of armed violence. The project has developed materials including a film, Health Care in Danger: The Human Cost, and a publication, Health Care in Danger: The Responsibilities of Health-Care Personnel Working in Armed Conflicts and Other Emergencies (both are available for purchase on the project’s Web site: https://shop.icrc.org/health-care-in-danger.html). Health Care in Danger has also developed and endorsed a document titled “Ethical Principles of Health Care in Times of Armed Conflict and Other Emergencies” (available soon on the ICN Web site: www. icn.ch) and has agreed to work for the promotion and implementation of these principles wherever possible. The principles state clearly that the ethics of providing health care do not change in times of conflict and, indeed, are the same in times of peace. Health Care in Danger has also launched an elearning module that presents the legal framework for providing health care during armed conflict and other emergencies. The module uses interactive case studies, learning activities, animation, and other media to guide viewers through the main legal principles and familiarize them with common dilemmas faced by health care personnel. Another module has also been developed that uses real-world examples of ethical dilemmas to educate health care personnel on their rights and responsibilities. Available at www.healthcareindanger.org/elearning, the module addresses specific issues that health care workers may face during crises to prepare them to respond effectively so they can continue to provide the necessary care to their patients.
Nurses need to create the circumstances where we can focus on care—not on protecting ourselves. The Safeguarding Health in Conflict Coalition works to promote respect for international humanitarian and human rights laws that support the safety and security of health facilities, health care workers, ambulances, and patients. The ICN is a founding member of the coalition, whose goal is to ensure safety during periods of armed conflict or civil violence. This is achieved by monitoring attacks on and threats to civilian health; demanding accountability ajnonline.com
for perpetrators at national and international levels; enhancing the visibility and understanding of the nature, extent, and effects of attacks on health services; and empowering local groups to play an active role in championing their right to health. In addition, in partnership with Human Rights Watch, the coalition recently released a report, Under Attack: Violence Against Health Workers, Patients, and Facilities, which describes recent attacks on health care workers to raise awareness and highlight the urgent actions needed to end the violence.2
A system of monitoring attacks on patients, hospitals, and health care professionals must be established. WHAT CAN NURSES DO?
Nurses need to create the circumstances where we can focus on care—not on protecting ourselves. On the global stage, the ICN urges nurses and national nurses’ associations to call on their governments to • respect international law and ensure the immediate provision of humanitarian assistance, including health care, to refugees and displaced persons. • facilitate the open and coordinated access of international humanitarian organizations in affected regions. • undertake cooperative action with local branches of government, UN agencies, and nongovernmental organizations to provide suitable health services, without discrimination, for all those in need. • guarantee that nurses’ and other health care workers’ duty to care is not obstructed. If we are serious about meeting the health care needs of those we serve, then this major threat to the ability to deliver services needs to be addressed. Such change can’t be accomplished by nurses alone. It requires political commitment across the spectrum, bringing together different participants—governments, lawmakers, health care providers, and academics—to deliberate solutions, establish recommendations, and make sure that the recommendations are implemented at the national level. We need to have clear ethical principles in place to ensure that health care professionals understand their [email protected]
roles and responsibilities in both conflicts and emergency situations. A system of monitoring attacks on patients, hospitals, and health care professionals must be established, and we must demand accountability for perpetrators—whether they are individuals, armies, or rebel groups. Finally, we need to empower providers and civil society groups to be champions for their right to health. ▼
David Benton is the chief executive officer and Lindsey Williamson is the communications officer of the International Council of Nurses, Geneva, Switzerland. Contact author: Lindsey Williamson, [email protected]. The authors have disclosed no potential conflicts of interest, financial or otherwise.
REFERENCES 1. Southern African Network of Nurses and Midwives (SANNAM). Lesotho: SANNAM saddened by killing of two senior public health nurses in Lesotho [press release]. AllAfrica 2014 Aug 20. http://allafrica.com/stories/201408200702. html. 2. Human Rights Watch and Safeguarding Health in Conflict Coalition. Under attack: violence against health workers, patients, and facilities. New York; Washington, DC; 2014 May. https://www.hrw.org/sites/default/files/related_material/ HHR0514_brochure_LOWRES.pdf. 3. Baumann A. Positive practice environments: quality workplaces = quality patient care. Information and action tool kit. Geneva, Switzerland: International Council of Nurses; 2007. http://www.icn.ch/images/stories/documents/publications/ ind/indkit2007.pdf. 4. Nelson R. Tackling violence against health-care workers. Lancet 2014;383(9926):1373-4. 5. Emergency Nurses Association. Emergency department violence surveillance study. Des Plaines, IL; 2011 Nov. http://www.ena.org/practice-research/research/Documents/ ENAEDVSReportNovember2011.pdf. 6. Speroni KG, et al. Incidence and cost of nurse workplace violence perpetrated by hospital patients or patient visitors. J Emerg Nurs 2014;40(3):218-28. 7. International Council of Nurses. The ICN code of ethics for nurses. Geneva; 2012. http://www.icn.ch/images/stories/ documents/about/icncode_english.pdf. 8. International Committee of the Red Cross (ICRC). ICRC and WHO urge concrete steps to better protect health care in conflict [press release]. 2014 Sep 25. https://www.icrc.org/ en/document/new-york-icrc-and-who-urge-concrete-steps- better-protect-health-care-conflict. 9. Grover A. Report of the Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health. New York; 2013 Aug 9. A/68/297. Sixty-eight session, United Nations General Assembly; http://www.wma.net/en/20activities/ 20humanrights/20distress/A_-Grover-Report-UN-GAOctober-2013.pdf. 10. United Nations. Security Council adopts text expanding criteria for Secretary-General’s list ‘naming and shaming’ violators of conflict-affected children’s rights [press release]. 2011 Jul 12. http://www.un.org/press/en/2011/sc10319.doc. htm.
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