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In August, Israeli health-care workers went on strike against violence in hospitals . Four months later, there is still no improvement in sight.Equipped with headset and holster, Asi Zanzuri walks quickly toward the emergency room. A patient started screaming in the examination room, says the doctor’s crackling voice over the beeper. It is 10 a.m. and it is already the fifth call during Zanzuri’s shift. As head of security at Ichilov Hospital’s intensive care unit, he has a lot to do.“I always intervene immediately – if possible, before anything happens,” he says while walking. There is a great difference between the work of a hospital security guard and a doorman in a nightclub, Zanzuri says laughingly. “You have to be sensitive, you have to mediate. Many people’s nerves here are on edge. You’re basically a psychologist as well,” he says.As the keyring on his hip rattles with every step, Zanzuri makes his way to the examination room to help the doctor in distress. Three security men are on duty at the emergency section at any time of the day and the in-house police station is located right across the entrance. Very necessary, adds Zanzuri. With around 500 patients per day, the emergency room at Ichilov Hospital is the biggest in the country and a place of tragedies and turmoil. Many patients have to wait hours for their treatment.“Sometimes it takes more than a day for a regular bed to be vacant. Patients and relatives tend to get impatient and blame the staff for the situation,” says Dr. Karin Heller, head surgeon of the emergency room. Verbal attacks and insults are no longer a surprise to her, she says. She currently is in a legal dispute with the granddaughter of a former patient.“A few months ago I was seriously assaulted and suffered scratches and bruises,” she reports. An elderly woman had to wait more than 24 hours in the emergency room. Finally, her granddaughter lost patience, stormed behind the reception, threw Heller’s computer in the air and began to hit and scratch the doctor.This kind of attack on a health-care worker is not a rare sight. Three months ago, nurses and doctors took to the streets all over the country to protest against violence following a Health Ministry report. The survey assumed an average of more than 3,000 cases of attacks on health staff per year. However, only 11% of the incidents are reported to the police and only a fraction of those are brought to court. In March last year, the topic started to attract public attention when nurse Tova Karero was set on fire and killed in a clinic in Holon. According to the indictment, the patient lost his temper because the flu shot the nurse had given him did not agree with him.A month later, a nurse in Be’er Ya’acov was injured with a knife; 31-year-old Osher Bakhit stabbed Rachel Kovo when the hospital refused to provide re-treatment.“Until immediate action is taken to ease the unbearable burden and protect health-care workers, nurses will not abandon this fight,” union chairwoman Ilana Cohen said preceding the protests. “It’s inconceivable that the government is standing by and watching health-care facilities turn into war zones.”BUT DID Ilana Cohen keep her word? Has the situation improved after the protests or was the fight just abandoned?“I have my doubts that it got better,” Zanzuri says. “On the contrary. I actually feel that violence has increased. As if a number of copycats now act in the belief that such behavior is fine in hospitals.”Following the health-care report, the ministry set up a special committee in order to compile a catalogue of recommendations for further security measures. Proposals range from implementing on-site police, installing emergency buttons to mandatory self-defense classes for the staff. But is that really the solution?“None of these suggestions address the origin of the issue,” says Avi Shushan, head of public relations at Ichilov Hospital. “I refuse to believe that people come to a clinic to start a fistfight. The problem is that we are understaffed, that the facilities are insufficient and that patients often have to wait far too long,” he concludes.Of course, such shortcomings are far from being an exclusively Israeli problem. According to the World Health Organization, violence against health staff is on the rise worldwide. The agency assumes that between 8% and 38% of workers suffer physical violence at some point in their careers, depending on location and work unit. Other studies from industrial nations with health-care systems comparable to Israel mention similarly alarming numbers. A recent survey from Germany finds that 51% of doctors and nurses have experienced damage to their property. In Australia about a third of nurses in city hospitals reported serious emotional abuse.A study from the US concludes that 59% of nurses are being assaulted once a week and 16% of the personnel report that they are assaulted on a daily basis. Moreover, the report states that staff in the emergency room is at a five times higher risk of being exposed to violence than those in the regular departments and that nurses are experiencing almost twice as many violent incidents as physicians. It comes as no surprise that working in such an environment will affect professional functioning and increase the risk of mistakes, including errors in decision-making and misdiagnosis.What distinguishes the Israeli situation from the others is, however, that violent occurrences have often been unrecognized, underreported and more frequent in their nature. A study by the International Journal of Nursing Practice shows that 72% of health workers experienced violence over the past year, but that only 26% reported the incidents. This goes in accordance with a publication by the Israeli Medical Association stating that incidents in Israel are reported less frequently than in other countries. The reasons are still unknown.Could a central, anonymous reporting system be of any help?“Again, such ideas only combat the symptoms of a faulty system,” says Avi Shushan. “We need to resolve the lack of funding and raise public awareness. This is a problem that has not been talked about enough. Maybe the attention will gradually bring about change.”According to Shushan the workers must recognize that violence is a problem and refuse to accept it as “part of the job.” Most important, staff shortages must be resolved. Otherwise, doctors and nurses are becoming scapegoats for a deficit in the system from which they are the first to suffer.