Tripartite workshop highlights workplace violence

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In February 2005, trade unions and employers in Bulgarian healthcare, along with the government, held a national workshop on workplace violence in the sector, as part of the follow-up to an international programme on the issue. Participants discussed the implementation of activities under a 2003-5 action plan and the findings of a survey, and a further action plan was adopted for 2005-7. A significant recent development has been inclusion of the issue of workplace violence in the health sector collective agreement for 2004.

In 2001 International Labour Organisation (ILO), theInternational Council of Nurses (ICN), the World Health Organisation (WHO) and Public Services International (PSI) launched a joint programme on workplace violence in the health sector. Bulgaria was selected as one of the countries to conduct a national project within the programme.

A survey on workplace violence in the health sector, Bulgaria's first such research, was carried out in 2001 by the Institute for Social and Trade Union Research (ISTUR). In October 2003, a tripartite workshop was held on the issue, organised by both Bulgarian trade union federations in the health sector - the Federation of Health Trade Unions affiliated to the Confederation of Independent Trade Unions in Bulgaria (CITUB) and the Medical Federation of the Confederation of Labour Podkrepa (Support)- supported by ILO, WHO and PSI (BG0311202N). The main findings of the country study were presented, as were ILO/ICN/WHO/PSI framework guidelines on workplace violence. The participants adopted a 2003-5 action plan for addressing and preventing workplace violence. Following a decision under the joint programme, a seminar was held on 3-4 February 2005 to follow up and evaluate activities in Bulgaria.

Follow-up survey

A follow-up survey on workplace violence in the health sector was conducted by ISTUR in December 2004-January 2005, using a questionnaire developed by the joint programme, with the aim of assessing the present situation in the sector and evaluating the impact of the framework guidelines.

The survey found that:

• there is already an enhanced level of awareness of the problem of workplace violence among trade unions and health establishments, according to more than 50% of respondents. However, the rise in awareness is lowest among the authorities and institutions that have the greatest responsibility for the establishment of adequate conditions to counteract workplace violence - ie employers' organisations and the government;

• the level of both physical and psychological violence has increased over the past two years. The share of respondents reporting a higher level of physical violence is surprisingly high, taking into account the relatively low levels of physical violence reported in the 2001 survey . Thus 34.1% of respondents believe that physical violence has increased between patients and health workers, 23.3% believe that it has increased between colleagues, and 18.2% that it has increased between managers and subordinates. Over half of the respondents reported higher psychological violence in all areas of interpersonal relationships - 59.6% between patients and staff, 65.0% between colleagues, and 63.3% between workers and management. The growth of the psychological violence among colleagues - something that was not so visible in the 2001 survey - is regarded as alarming;

• violence is said to be largely associated with the failures and inadequacies of current healthcare reforms, which creates stress and makes both the patients and the health workers very nervous. Many conflicts arise because of the inadequate funding of health establishments. This leads to a chronic shortage of medical drugs and supplies and, together with a requirement for additional payment for treatment and requests for donations, creates conditions for the appearance of different forms of psychological violence among patients. The higher level of psychological violence between colleagues and between management and healthcare workers is again largely attributed to the reforms. Among the reasons cited are low pay, managers’ constant use of threats of redundancies and discipline, use of authoritarian management methods and unfair fund distribution;

• no serious changes have been registered over the past two years with respect to the development of policy on workplace violence, according to 40% of respondents. The remaining respondents, however, report that many health establishments now make a timely response to complaints and incidents related to violence, that these issues are now more freely discussed, that training is provided and that explanatory work is conducted by the trade unions. Most importantly, the unions have succeeded in addressing the issue in collective agreements. Employers' policy is focused mainly on taking measures related to health and safety at work and, in some cases, verbal harassment and mobbing/bullying;

• the level of awareness of the framework guidelines seems to be good, though not as high as was expected. The wording and the structure of the guidelines are generally seen as accessible and no recommendations were made for complementing the contents. The guidelines are viewed as a useful tool in the development of policies and initiatives in health establishments. Among respondents: 64.1% state that the framework guidelines help them undertake activities at the work place; 48.7% that they help them identify acts of violence at the workplace; 33.3% that they are a tool in defining and identifying the scope of workplace violence; and 25.6% that they help delineate the responsibilities of the major actors; and

• the main activities that respondents think should be undertaken in the future include public awareness campaigns (64.3%), training (57.1%), after-the-event interventions (41.8%) and risk assessment (37.8%). About a fifth of respondents also see a need for research and monitoring.

Discussions and recommendations at workshop

The workshop in February 2005 attracted significant attention among the social partners, public officials, government representatives and the media. More than 50 people attended the opening of the event. The president of the parliamentary Health Commission confirmed to the workshop participants his support for further addressing workplace violence in the health sector. The growing importance of the issue and a will to support initiatives to address violence at work was also confirmed by representatives of the Ministry of Health, the Ministry of Labour, the Chief Labour Inspectorate, the National Association of Employers in Healthcare, the National Health Insurance Fund, and the unions and professional associations of doctors, nurses and pharmacists.

Trade union and employer representatives reported and discussed activities and achievements in Bulgaria since October 2003 in addressing workplace violence at national, sectoral and institution level. One of most important achievements at national level was the inclusion of the issue of workplace violence in the health sector collective agreement for 2004. Other activities and good practices aimed at awareness-raising, capacity-building and prevention that were reported included:

• training seminars on the prevention of workplace violence have been organised for trade union leaders in Sofia and other cities;

• the proportion of health institutions with health and safety at work committees has been increased from 36% to 80%;

• security measures, reporting procedures, victim support and training of staff have been introduced at the Pirogov hospital in Sofia; and

• security measures, teamworking and written procedures have been introduced at the Sofia Emergency Centre.

The main recommendations of participants at the workshop included a need for all stakeholders to make a commitment to address and prevent workplace violence. Further, support and training materials need to be developed, and the dissemination of the framework guidelines increased. A strong need was expressed to develop more specific training modules with the assistance of ILO and PSI.

2005-7 action plan

Working in two groups, the workshop participants developed a further action plan for 2005-7, taking into account the discussions and recommendations and an assessment of needs. The plan identifies priorities, sets objectives and outlines the next steps to be taken.

The main goals of the plan are to:

• expand knowledge in institutions and among the public; and

• reduce the incidence of workplace violence.

The objectives are to:

• develop an information and monitoring system;

• design and implement public awareness campaigns;

• develop a national training system in this area;

• review legislation and work on the legislative framework; and

• continue regional cooperation

The activities to be carried out under the action plan are:

• development of an information and monitoring system;

• public awareness campaigns;

• establishment of a national training system;

• development of specific training modules;

• development of educational materials; and

• 'training the trainers' programmes.

In terms of the legislative framework, the action plan provides for:

• reviewing current Bulgarian legislation to identify potential and gaps in addressing workplace violence;

• comparing Bulgarian with EU legislation and regulations

• discussing and identifying needs for amendments of the legislation;

• clarifying the responsibilities of the social partners in addressing workplace violence in sectoral collective agreements and, on this basis, promoting the development of policies in every health institution outlining preventive measures and responses to incidents; and

• promoting ratification of ILO Conventions 149 (nursing personnel), 151 (labour relations in the public service), 171 (night work) and 175 (part-time work).

Finally, the plan promotes regional cooperation by:

• providing support to trade unions in neighbouring countries; and

• organising regional meetings to discuss the problem and share good practice.

Commentary

The major reasons for the increased violence found in the health sector reflect the societal environment: the failure of health reforms, creating stress in staff and patients; poor working conditions; and inadequate equipment in health services. The incidents of violence are also attributed to the tense situation in the healthcare labour market, with high unemployment rates and ongoing health sector reforms causing job insecurity and an atmosphere among workers of fear of losing their job.

The survey findings and workshop discussions show that, despite some important achievements since the beginning of the joint programme activities in Bulgaria in 2001, the most important steps on the long 'high road' to tackling workplace violence still lie before the social partners. The needs for adequate legislation, capacity-building, knowledge dissemination and the development of reporting procedures, data collection and monitoring systems are urgent. The core work is still ahead, requiring the commitment and involvement of all stakeholders. Social dialogue at all levels is an important feature in implementing policies at the workplace. Great potential for further success lies in the highly motivated trade unions and supportive employers’ representatives in many of the health establishments. (Nadezhda Daskalova, Institute for Social and Trade Union Research)