Abstract
Health care workers have never had an easy job – or a safe job. Home care workers, nurses and hospital workers, who frequently must lift heavy patients and work with hazardous drugs and chemicals, have higher injury rates than construction workers or coal miners. Added to that are injuries and sometimes deaths resulting from assaults and workplace violence, especially in emergency rooms, mental health facilities and long-term care facilities. It is their story that health and safety advocates Margaret M. Keith and James T. Brophy tackle in Code White: Sounding the Alarm on Violence Against Healthcare Workers. But this isn’t just a book about horror stories. Keith and Brophy dig deep into the root causes of violence against healthcare workers and then make recommendations about what can be done to protect healthcare workers.
Healthcare workers were not trained in mixed martial arts. There are no classes in self-defense on nursing school curricula. Nevertheless, their workplaces often resemble combat zones: On a daily basis I am hit, punched, spat at, sworn at, slapped, bitten. I’ve had hot coffee thrown at me. I’ve gone home with burns on my hands (p. 27).
I was just fixing his shoelace and he punched me in the back of the neck. I didn’t see it coming (p. 28).
He grabbed my arm and turned me around his chair and pulled me up and over. I had bruises on my ribs and he sprained my wrist I was in physiotherapy for weeks and I still have pain (p. 28).
These are not reports from law enforcement officers or corrections employes trained in hand-to-hand combat. Or workers out of some post-apocalyptic late-night movie. These accounts are from a typical day for healthcare workers who have dedicated their lives to caring for their patients, not fighting off assaults.
Keith and Brophy describe the typical work day in today’s mental health, long-term care and acute care hospitals throughout Canada. According to a union survey, more than two-thirds of registered practical nurses and personal support workers in Ontario, Canada had experienced at least one incident of physical violence over the last year and 20 percent had experienced at least nine incidents (p. 14). Many of these assaults result in serious physical injuries as well as to workers’ mental health, such as post-traumatic stress disorder (PTSD). Between the physical and mental injuries, many of these workers are never able to return to work.
Although the authors of Code White are Canadian and focus mainly on working conditions in Canada, this short book provides essential reading for US labor advocates who are interested in understanding and addressing the root causes of assaults as well as the immediate and systemic changes that must occur to ensure safe workplaces for the employes and a decent therapeutic environment for patients and residents.
Despite the different health care systems in Canada and the United States, identical workplace violence problems have plagued US institutions for decades. Both systems are victims of official neglect, underinvestment, and understaffing, all of which affect in-patient care and worker safety. The causes of workplace violence, the solutions to the problem and the strategies to get there are just as relevant in the United States as they are north of the border.
I have been working in the field of workplace safety and health in American unions and the US government for more than 40 years. From my first days in the early 1980s when I directed a union health and safety program, I listened to horrific stories of assaults endured by healthcare workers. It was happening at a time of deinstitutionalization and disinvestment in mental healthcare in the United States. People who needed close supervision because of mental health disorders or drug problems were being thrown out onto the street without adequate care or placed in community homes that didn’t always have the capacity or expertise to address their problems. Some with histories of violence or drug problems ended up in acute care hospitals or on the streets, where social workers attempted to address their problems. Patients and family members in emergency rooms were facing longer lines and more wait times to receive dwindling services from fewer staff. Cutting costs and increasing profits in long-term care facilities meant that elderly patients lacked the care they needed. Employers routinely dismissed these violent attacks as random, unpredictable events that were “just part of the job.”
Although the American Federation of State, County and Municipal Employes and other healthcare unions pressed the issue -- mostly futilely -- with the federal Occupational Safety and Health Administration (OSHA) and state health departments, progress in the United States has been hard and slow. In the 1980s and early 1990s, most health care administrators as well as federal OSHA leadership refused to consider workplace violence an appropriate issue that an agency that dealt primarily with falls, machine guarding and chemical issues could – or should -- address. The only solution they saw at that point was to increase staffing levels, a management prerogative that OSHA was loath to interfere with.
Meanwhile, state health departments pleaded poverty and rejected the notion that a worker’s right to a safe workplace should compete with a patient’s right to not be restrained, physically or pharmaceutically.
As the healthcare worker crisis grew, two events in the early 1990s began to change OSHA’s mindset. In 1992, the US Department of Labor Solicitors Office issued an opinion finding that violence could be considered a hazard enforced under OSHA’s general duty clause, a general requirement that employers provide a safe workplace. 1
Shortly thereafter, following the brutal stabbing death of a social worker by her client, California OSHA official Joyce Simonowitz developed guidance that took the same approach to addressing workplace violence that health and safety officials took to address other hazards: Identify the risk factors, then apply the hierarchy of controls: engineering controls like locked doors and communications devices, and administrative controls like training and adequate staffing. 2
Finally, in 1996, federal OSHA issued its first Guidelines for Workplace Violence in Health Care and Social Services and began enforcement under OSHA’s General Duty Clause. 3
Assaults are often blamed on mentally ill patients, drug abuse or dementia. But solutions to the problem of workplace violence go much deeper than individual patients or lack of government enforcement. Keith and Brophy vividly describe the working conditions of healthcare workers as well as the immediate and root causes of violence in healthcare workplaces. Chronic underinvestment has led to serious understaffing, lack of therapeutic services for patients, and lack of protections and training for workers. Wait times in emergency rooms are significantly longer, leading to acute frustration among patients and family members. In addition, because of cutbacks in facilities where they can receive more appropriate treatment, the police are dumping more people suffering from drug addiction and mental health issues in the E.R.
The stories from acute care hospitals are upsetting, but the stories from long-term care are heartbreaking. As staffing levels drop and more recordkeeping is required, patients and their families are increasingly frustrated by longer wait times and lower quality services. Personal care workers are unable to spend quality time with residents of long-term care, many of whom have serious memory care and physical issues.
Staffing levels are so low that workers have to rush from resident to resident without spending any time listening or talking to them, getting them to the bathroom or getting them dressed for a rushed meal. Not surprisingly, the neglect leads to frustration, and ultimately violence.
In addition, residents are much sicker now. Whereas many used to walk in with suitcases, now most are wheeled in from the hospital.
The tragedy is that it was not always that way: When we first started working there, the patient-worker ratio was totally different. It was, like one staff to five residents. Now it’s one to seventeen. You had time to paint their nails Your carts had cream to massage their feet and back (p. 109).
COVID-19 has only made matters worse, with frustrated family members who aren't allowed to see dying patients and politically motivated hostility toward caregivers.
The authors extensively cover the psychological injuries caused by workplace violence. Post-traumatic stress disorder (PTSD) is a familiar problem, especially for those with military combat experience. But healthcare workers experience similar combat-like situations. The Manitoba Nurses Association reported that 40 percent of their members experience PTSD symptoms related to violence at work. And those psychological injuries are compounded by failure of management to provide appropriate support or interventions despite the fact that “timely and appropriate support and intervention have been shown to decrease the likelihood of ongoing psychological trauma (p. 33).” One nurse who was physically and sexually assaulted was provided no counseling or referral to a sexual assault center. Such neglect is the rule, not the exception.
Added to this is the “blame game,” where workers are personally blamed for the attacks they endured and retaliated against for trying to improve working conditions or for speaking out publicly because management considers assaults “just part of the job.” In my work, I would often hear unbelievable stories from healthcare workers who were “counseled” and disciplined even before their physical injuries were addressed. After all, managers reasoned, the duty of healthcare workers was to keep the patients under control; if the patients were out of control, the workers had clearly failed in their job duties. End of story. The fear of retaliation for reporting incidents or speaking out also discourages workers from reporting.
And as in the United States, workers’ compensation systems are reluctant to approve compensation for work-related psychological injuries.
A key theme of the book is that there is no conflict between patient care and workplace safety; nor is there any conflict between a patient’s right to humane and therapeutic care and a worker’s right to a safe workplace. Addressing staffing issues not only prevents assaults, but also provides better therapeutic interventions for patients and residents.
What can be done about workplace violence in healthcare institutions? The immediate solutions are obvious and proven: additional staffing to provide quality patient care and to protect workers who are under attack. Structuring facilities so that they are safe, with locked rooms, desks that can’t be reached across, adequate lighting and panic alarms. Administrative procedures like training workers in de-escalation techniques, flagging patients with a history of violence and recording and investigating all violent incidents. In addition, focus needs to be placed on better care and follow-up for victims of violence; not just their physical wounds, but their psychological wounds as well. And finally, government officials, management and patient advocates need to recognize that all workers have a right to come home safe at the end of the work day.
But the real solutions cannot be found in each individual workplace. The causes of workplace violence in healthcare institutions are largely systemic and the solutions must be systemic as well. In the United States, OSHA is working on a new standard to protect workers in healthcare and social services. 4 But OSHA standards often take decades to finalize. To speed up the process, the US House of Representatives passed bipartisan legislation in 2019 and in 2021, that would have required OSHA to issue a workplace violence standard within 24 months. 5 The bill has not come to a vote in the Senate.
Canada has a much more decentralized worker protection system, but workers have stronger unions to protect them and effect change. They are working to improve staffing, training and protections while fighting the myths that workplace assaults are “part of the job” and that healthcare workers are to blame. Ultimately, in both Canada and the United States, healthcare workers and their unions will be the key to meaningful change.
