Over the past two weeks, TVO.org has published the accounts of seven workers in Ontario hospitals who spoke about the issues of harassment in the workplace and burnout during the pandemic. Some asked to remain anonymous; some have left the field.
But these issues are not new. James Brophy and Margaret Keith, adjunct professors at the University of Windsor, have researched occupational health for more than four decades. Since 2016, they’ve studied workplace violence in health care, publishing studies as well as a book, Code White: Sounding the Alarm on Violence Against Health Care Workers, which was released last year.
TVO.org speaks with Brophy and Keith about the roots of the problem, the part played by racism and sexism, and where we go from here.
TVO.org: I read some of your work going back to 2017, and in it you note that some research suggests that violence for nurses is more prevalent than it is for say, police officers. It’s an “everyday” occurrence. That surprised me. Can you give me a big-picture overview of workplace violence in the health-care sector?
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Margaret Keith: We have statistics that we’ve included — there have been some recorded numbers — but as we are going through these, I should say that the prevalence of violence is really under-reported. We don’t know, because those statistics aren’t being collected. A lot of the health-care workers don’t report, so the numbers we’re giving you, as shocking as they are, underestimate the severity and the prevalence of violence.
James Brophy: That point was substantiated by a 2019 federal parliamentary committee report, which made very clear that the widespread under-reporting of violence does exactly as Margaret said: it underestimates the full extent of the epidemic of violence in hospitals and long-term care.
So, between 2006 and 2015, there were over 16,000 violence-related lost-time injuries among Canadian health-care workers, compared to 7,500 for those in all non-health-care occupations combined. In 2017, the Canadian Federation of Nurses Unions reported that 61 per cent of the nurses surveyed experienced serious workplace violence, compared to 15 per cent in other industries. In 2017, as well, the Ontario Council of Hospital Unions/CUPE commissioned a provincewide poll of their members to investigate the prevalence of violence perpetrated against hospital staff by patients. Of the almost 2,000 people that were polled, 68 per cent of the nurses and personal-support workers had experienced at least one incident of physical violence in the past year. And this doesn’t record the amount of verbal abuse, racialized abuse, sexual harassment, and sexual assault that is also a part of the day-to-day experience of health-care workers — both in hospitals and in long-term care, and in home care as well.
Keith: The harm that’s done by violence against health-care workers goes so far beyond lost-time injuries. People are traumatized. They’re feeling exploited. We talked to health-care workers who would leave their shift, go to the parking lot, and sit in their car and cry before they could head off home, because they were just so upset by what was going on. There are some people who are experiencing violence of some sort on a daily basis.
We found that this was particularly true in some of the psychiatric units, in the emergency rooms, and in long-term care, which came as a real surprise to us.
People with dementia, some of them quite young and quite strong, who are lashing out and seriously injuring people. We spoke to a health-care worker who had been violently sexually assaulted while trying to shower a man who was in his 50s. He was strong, he had mild dementia, and she was alone in a shower room with him. He sexually assaulted her, left her really fighting for her life. She managed to get out of the room and away from it. She had been calling for help; nobody had heard her because there wasn’t enough staff. They didn’t have the bells — the call bells really don’t do anything, because they’re constantly ringing.
She went to her supervisor and said, “I’ve got to go home” and described what had happened, and this supervisor said, “You can’t leave — we’re short-staffed, and you have to stay.” She ended up having to leave anyway, she was so traumatized by the events.
TVO.org: You both mentioned sexual assault. How gendered is this problem, and how does that affect how we should think about it?
Keith: Well, I think it’s important to note that at least 85 per cent of health-care workers are women, and many of them are racialized, and in workplaces that are predominantly women and racialized workers, we have found there just isn’t as much attention paid to occupational health.
In the case of health-care workers, I think that what’s happening is that a lot of these incidents are — we don’t know about them, because the health-care industry is hiding behind rules of confidentiality and so on. People are not able to speak out. As a woman, this really struck me as being, in many ways, characteristic of violence against women in society, where women are sort of expected to just put up with it. Not talk about it. Often they’re blamed.
This is a really troubling finding of ours that, when the health-care workers would go to their supervisor to report an incident, the first thing they ask is, “Well, how did you approach the patient?” They felt that they were instantly being blamed for something that they did wrong. They were told that they were dressing provocatively, if you can imagine, or, you know, smiling in a way that might have brought on assault. It really troubles me that all this violence and sexual assault is going on in a workplace that’s mostly female.
Brophy: When Margaret and I were conducting our interviews and focus groups, we were so struck by the parallels of violence against women in our society — the way that they’re blamed, unsupported. The institution is silent, and the regulatory system is so broken that there’s little or no protection or mechanism for addressing this.
I don’t know if you remember, in 2017, the #MeToo movement was recognized by Time magazine as the quote-unquote Person of the Year. This is like an international award — it’s very well-known, very famous. On that cover were images of six or seven women from different areas who had played some role in exposing sexual harassment and violence and so forth. One of the pictures, though, didn’t have the woman’s face. It simply had her shoulder. That person was a hospital worker, and she was fearful that if she spoke publicly about this, she would be disciplined or possibly fired. So, if you can imagine that you don’t even feel a level of protection on the cover of Time, then it gives you a certain feel for the kind of atmosphere that exists in terms of this problem.
TVO.org: We’ve been speaking mostly about the pre-pandemic period. What has changed in the past two years?
Keith: We finished our research just before the pandemic began, and we were nervous about what the effect was going to be on health-care workers — never did we imagine that it would turn out to be as bad as it was, but we knew that they were already very short-staffed, facing violence; they were demoralized. They were already telling us that they are unable to provide adequate care and were feeling so badly. People who love their profession, who have gone in it to help people, and were not able to help them the way they knew they should be able to.
We did a study early on in the pandemic; we spoke to health-care workers about what work was like during the pandemic. And, of course, we heard all the stories about how they felt they were not being adequately protected. They weren’t being given N95 respirators; they were being told all they had to do was wear a surgical mask and stay six feet away, wash their hands, and so on. We all know now that we really missed the boat on protections early on, but they also talked to us about violence and how it had increased.
And then there was the fact that family members were not allowed in to help with patients and with residents, which left everything on the shoulders of the health-care workers. Their workload increased dramatically, and the patients’ and residents’ agitation increased dramatically. Many of them were locked in their rooms. The whole mood just ended up being so much more tense, and health-care workers were being targeted by the agitated patients and residents.
Brophy: As Margaret said, we had just completed our study on long-term care and violence. We were very nervous because the classic systemic problems that are actually breeding violence in the health-care system — understaffing, underfunding, the collapse of our regulatory system, unwillingness to recognize the kind of supports that are needed — all of this was even more pronounced in long-term care than in the hospital system. We thought, “Oh my god, this is going to be a disaster.” What turned out is, long-term care has been characterized as a national disgrace.
The other thing is that, when we were doing the study on the pandemic and its impact, one of the things we were really mindful of was the SARS commission report in 2006, which laid out a roadmap that addressed these issues based on the experience that we had with the SARS epidemic. It was a very insightful report. I normally don’t recommend royal-commission reports, unless you suffer from insomnia, but in this case, Judge Archie Campbell really did understand what was going on. He promoted the precautionary principle. He talks about the need for N95 masks. He said that the Ministry of Labour and the Ministry of Health must go into health-care facilities and create a culture of safety. All the things that were ignored and have been ignored through the whole pandemic. This really illustrates the systemic nature of this problem, that it’s caused, not just by sexism or the patriarchy — although they’re certainly players.
The health of health-care workers is a barometer for the health of the health-care system, and vice versa — the fact that our health-care system is in such a deep crisis is reflected in these incidents of abuse and violence.
Keith: I think we should just add, too — one of the recommendations of the SARS commission was that we follow the precautionary principle. When there is a probability or a possibility of someone or a number of people being badly hurt by, in this case, a virus, they should be following whatever precautions they can. So we were strongly advocating early on for N95 respirators to be used, because it was quite possible that this was an airborne virus and that it would need airborne protections.
TVO.org: A separate issue that to me seems somewhat connected is health-care worker burnout. The issues seem to have some similar root causes — understaffing, under-resourcing. Do you see them as connected, and have they grown in tandem?
Brophy: We documented in our studies and wrote in our book about the high levels of burnout and anxiety, emotional exhaustion, and so on, that health-care workers face, both before and during the pandemic.
I think these issues are caused by the social setting, the work environment, in which people are living and working. And they are not just related to a person’s individual exhaustion; they’re related to the overall systemic factors that contribute to high workloads, anxiety, fear on the job, lack of respect and appreciation: all these things contribute to that. As Margaret said earlier, when a person has actually experienced physical or sexual assault, or racial assault, they’re not validated — they’re blamed. And so the sense of powerlessness is fostered in this kind of environment.
Our takeaway from all of this is, this is not an individual problem for individual health-care workers. This is a deeply systemic problem arising from the crisis in our health-care system, which is underfunded, understaffed, and continually being privatized and deregulated.
Keith: We talked to so many health-care workers who said they were feeling so completely demoralized and exploited. They felt like they were unable to do their jobs, which was so discouraging and depressing for them. Many of them felt that the situation was absolutely hopeless. They would go in every day and try to be resilient. But there’s only so much resilience that anybody can muster and so, beyond the physical exhaustion, there is an incredible emotional fatigue. We need to really be taking into account not just how violence affects people physically, but how violence, overwork, and all of these other factors affect people emotionally, which affects their whole life. They don’t leave all of that at work and go home and everything’s just fine. They take all of this extreme exhaustion and these feelings of failure and exploitation into their everyday lives.
TVO.org: In your work you also talk about some solutions. What can we do in the short and long term to help health-care workers?
Brophy: We really feel there needs to be a royal commission or a serious examination of our whole health-care system. This is about both during the pandemic and, more fundamentally, exactly where we’re going. We’ve had three or four decades here of major underfunding and cuts to the health-care system. The violence is an expression of the erosion of our health-care system. This is a problem that has run parallel with underfunding and understaffing. Canada is rated among the bottom of industrialized countries in terms of the ratio of beds to patients, and patients to nurses, and so forth. That’s a fundamental problem that has to be addressed.
We had a whole series of recommendations: alarms, flagging, more security, major supports for the health-care workers, training, special identification — you know, those that are potentially violent. Sometimes, there would be a violent incident, and the person from dietary bringing in the tray wouldn’t even have a clue that this had happened, because they weren’t part of that communications network and so on.
Also, this area of working alone. It’s very common, especially in places like long-term care, where you might have one nurse or one PSW taking care of 25, 30 people a night. Maybe there are two wings, and one person is off on one wing and one’s off on the other.
Keith: I think we also have to get past the normalization of violence in health care, the idea that it’s part of the job. Health-care workers are actually told that in those words. There’s no way it should be part of the job. It doesn’t have to be part of the job. There are ways of dealing with violence. As Jim said, there are a number of practical things that can be done.
There are also broader issues that we need to address — things like sexism, racism, classism. We do have to get past the threat of reprisal for speaking publicly. The public needs to know the culture of silence around the issue of violence is a real barrier to acknowledging its existence. That is a problem that we really need to deal with. We need whistleblower protection — we need to make it possible for health-care workers to talk openly about what’s going on. Some of the unions have been speaking more in the past year or two about all of this, and I think that’s wonderful. Individual health-care workers also need to be able to feel that they can safely speak out. This is an issue that we all need to be talking about. It needs to be addressed urgently.
This interview has been condensed and edited for length and clarity.