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Violence Against Health-Care Workers Is a Silent Epidemic

An excerpt from ‘Code White,’ out now with BTL Books.

Margaret M Keith and James T Brophy 2 Sep

Margaret M. Keith is an occupational and environmental health advocate and researcher and the former executive director of the Windsor Occupational Health Information Service. James T. Brophy is a career researcher and advocate focusing on occupational and environmental health, and the former executive director of the Occupational Health Clinics for Ontario Workers.

[Editor’s note: ‘Code White: Sounding the Alarm on Violence Against Health-Care Workers’ documents violence carried out by patients and their families against health-care workers. The main targets of this violence, write researchers Margaret M. Keith and James T. Brophy, are women and racialized workers in less prestigious jobs, like nurses, personal support workers, aides and cleaners.

Keith and Brophy share first-hand accounts from over 100 health-care workers, connecting the dots between violence, systemic issues and underfunding in health care. ]

On the morning of Aug. 24, 2011, Dianne Paulin, an experienced psychiatric nurse in North Bay, Ontario, began her shift on the forensic unit — the unit that deals with patients found not criminally responsible — at the local psychiatric hospital. She learned that a new patient, a man in his early 20s with a complex mental health diagnosis, had been admitted the night before.

Her supervisor told her the new admission was to be her prime patient. Paulin reviewed his chart and noted that he was young and strong, about six foot two, weighing 260 pounds. And he had a history of violence. Her new patient had been placed in a seclusion room upon admission because he was extremely agitated.

He had assaulted two police officers who had been called when he had attacked someone in the group home where he was living. As Paulin later learned, her patient had been removed from his family home and placed in the group home in the first place because he had physically assaulted his father and had been sexually aggressive with his mother.

When Paulin opened the door to the seclusion room, she observed right away that the patient was heavily soiled, mumbling and visibly upset. She relieved the nurse who been attending to him and set out to establish a rapport with her new patient. Paulin had years of experience working with psychiatric patients and was confident in her ability to develop a respectful working relationship with even the most difficult cases. She was sure she would be able to manage him, and as it turned out, she was able to convince him that he should take a shower, get changed, and have something to eat. Her patient was soon stable enough to be moved to a private room.

A psychotic patient who is prone to violence can be just a hair-trigger away from snapping. That is precisely what happened when Paulin went to check on him later that day. She relieved the nurse who was sitting with him and found her patient on his bed crying. When she asked what was wrong, he said he wanted to use the phone. She explained that he could use it as soon as the other staff returned from their dinner breaks.

When he began demanding the phone, she repeated that he would have to wait a little while. He quickly turned from unhappy to irate. He jumped up from the bed, yelling something unintelligible, and grabbed a chair. Paulin turned to leave the room but found that the door had closed behind her. Then he unleashed his fury.

“I was barricaded behind the door with the chair hard against me,” Paulin says. “He pounded me on my head, my face, and on my shoulders. He was yelling and screaming while he punched me. And a patient who was on the other side of the door started yelling and screaming.”

A code white was called, letting other staff know that someone needed help with a violent incident. After what seemed an eternity, staff did arrive, but they were blocked from entering the room. Injured but desperate, Paulin pushed back against the chair with all her strength so that her rescuers could get the door open.

The patient immediately turned and swung at the first person who rushed into the room. As more staff came in, he began to settle down and was ultimately calmed enough to walk to the seclusion room.

In shock, Paulin was not immediately aware of how extensive her injuries were. She remembers finding it difficult to walk and her co-workers having to help her to the nursing station. There she broke down.

“I started crying and shaking, and crying and shaking, and crying,” Paulin says. “‘Are you hurt?’ I don’t know. I don’t know if I’m hurt. I don’t know. I just got hit all over. Am I hurt? Well, yeah, I’m hurt here, here, everything hurts, I don’t know. Then, because I was shaking too much to walk, they took me in a wheelchair to the emergency department.”

This brutal incident would change the course of Paulin’s life.

What do we mean by violence?

Paulin’s story is a clear example of violence in the health-care workplace. We heard many shocking stories of physical violence like this one. But we also heard stories of health-care workers experiencing verbal abuse, hostile behaviour, hate speech and sexual harassment, all of which are acts of violence against health-care workers.

Workplace violence is really an expression of societal violence, except that in the world outside of work, there are agencies and institutions in place that are intended to help to prevent violence, support victims and bring the perpetrators to justice.

“We’ve got to stop saying, when people cross over the threshold of their workplace, they lose the same rights they have outside,” Colin Lambert, former CUPE national director of health and safety, once said. “That right should not be taken away from workers simply because they step over that magical line of workplace versus public place.”

Violence that takes place in hospitals and long-term care facilities is generally reactive, such as spontaneously lashing out at a convenient target, often an immediate caregiver. It is usually referred to as “responsive behaviour” in psychiatric and dementia care facilities, taking into account the conditions or stimuli that might trigger it.

The authors of this excerpt are Margaret M. Keith, an occupational and environmental health advocate and researcher, and James T. Brophy, former executive director of the Occupational Health Clinics for Ontario Workers.

Patients and their family members may not be at their best when they are seeking emergency care. Patients may be in pain, feeling weak, ill and vulnerable, or experiencing anxiety. Family members may be fearful for and protective of the patients. They are entering a system that is often overtaxed and less responsive to their immediate needs than they would expect it to be. Add into the mix society’s deeply entrenched sexist and racist attitudes, and the health-care staff — most of whom are women, and many of whom are racialized or recent immigrants — become prime targets.

That is not to say that men working in health care do not experience violence on the job. Predominantly female workforces tend not to receive the occupational health attention or protections enjoyed in industries employing mostly men. As a result, all frontline health-care workers — in other words, workers of any gender dealing directly with patients and family members — are more prone to abuse.

Studies have found that nurses, aides, and personal support workers, or PSWs, are most at risk because they are more hands-on and, being lower in the medical hierarchy, may be viewed as easier targets. Physicians, however, are also vulnerable, especially those dealing with emergency room or mental health patients. Cleaners, dietary and clerical staff, and allied workers such as lab assistants and therapists, are not immune to violence either.

After she was attacked, Paulin was taken to ER. There, she was examined, given painkillers, X-rayed and observed. After three hours she was told she should go home and rest. She did manage to sleep. The next morning, Paulin got up and the pain hit with a vengeance. Her face was swollen and bruised. Her head throbbed and her neck and shoulders ached. And so did her legs. She was shocked to see how black and blue they were. “How could that be,” she wondered. His powerful blows had struck her head and upper body. Then she remembered the chair. He had pushed it so hard against her, it had left deep, painful bruising. She didn’t yet know that this would be the beginning of the long unravelling of her personal and professional life.

We first met Paulin six years after the assault had happened, at a conference on violence in the health-care system. While many of the health-care workers we spoke with were reluctant to be identified, Paulin had decided she had nothing to lose by telling others about what had happened to her.

Shaking, her voice quivering, she stood bravely in front of a large group of nurses, PSWs, aides, maintenance staff and other allied workers and talked about the attack and about her injuries. She talked about the callous disregard and abuse that came afterwards from her employer and the compensation board. She described how the indifference and even contempt she experienced from her employer and the compensation system in the aftermath of the attack compounded the harm from the original injuries and left her traumatized and, ultimately, impoverished. The delegates, and the two of us, were moved to tears.

A whispered epidemic

In 2016, increasingly concerned about reports of violence against its members, Ontario Council of Hospital Unions CUPE, which represents registered practical nurses, PSWs and dietary, housekeeping and other health-care staff, organized a conference in Kingston, Ontario, where RPNs from across Ontario could come together to discuss violence in their workplaces.

An impromptu survey revealed that every one of the 150 nurses in attendance had personally experienced violence on the job. One of the participating nurses, Sue McIntyre, spoke briefly to the other conference attendees about the problem of violence against nurses and was later quoted in a media release.

After the conference, she returned to work at the North Bay Regional Health Centre and was called into a meeting with her employer, who then fired her for speaking publicly about her concerns. It took two years and cost her union half a million dollars in arbitration and legal fees to get her successfully reinstated. Her firing, although overturned, seems to have accomplished its likely purpose. It sent a message to health-care workers across the province that they had better keep quiet.

We have spoken with over a hundred health-care workers as part of our formal research and at least that many again informally. Almost universally, we heard how frustrating it is not to be able to talk openly about the problem.

Some conversations took place as part of routine interactions with staff we encountered during our own medical appointments. When asked what we do for a living, we would disclose that we were researching the issue of violence against health-care staff. That almost always resulted in reactions such as, “Oh, thank goodness!” or “Is that ever needed!” before they proceeded, usually unbidden, to tell us their own stories.

A technician at a sleep clinic told us about the sexual harassment she regularly experienced, often by being “invited” into bed by her overnight clients. It disgusted her, but she felt helpless to do anything about it. She had already left a job at another clinic because she felt there were not enough safeguards in place to protect her if a client were to become physically aggressive.

A hospital pre-admission intake staff person, whose office was in a rather isolated location in the building, told us she often felt uneasy meeting with patients alone, but said she has felt somewhat safer since she and her co-workers were issued personal alarms. An ER triage nurse talked about the irate or threatening patients she frequently encountered. She said, “You can’t believe what goes on in here! Thank goodness you’re doing this. People need to know.”

Excerpted from ‘Code White: Sounding the Alarm on Violence Against Health-Care Workers’ by Margaret M. Keith and James T. Brophy. Copyright 2021 Margaret M. Keith and James T. Brophy. Published by Between the Lines Books. Reproduced by arrangement with the publisher. All rights reserved.

'Code White' will launch online today, Sept. 2, at 4 p.m. PDT. Register for the launch through Eventbrite.  [Tyee]

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