Hospital Staff: Under Workplace Stress

"Staggering [the number of hospital health workers as well as non-nursing staff reporting escalating violence]."
"The rate of assault against clerical staff, against cleaners, against dietary aides would be in the neighbourhood of about 34 percent."
"They [the assailants] may be people with mental illness, people high on opiates, people distressed about the quality of their care, or distressed about the length of time they've waited -- and they take that aggression out on the health-care staff that they meet."
"You've got in Canadian society, unfortunately, a very high degree of tolerance for violence against women. So you've got this general societal attitude and it doesn't stop at the door of the hospital. It comes right in and it's compounded by the fact that if you assault someone in a hospital, you may not face charges."
Michael Hurley, president, Ontario Council of Hospital Unions

An organization that represents health care worker unions in Ontario argues there needs to be more accountability for violence perpetrated against health care providers. (Shutterstock/John Panella)

"I've been kicked, spat on, bitten, pushed and had verbal abuse. Violence is really a daily occurrence at the hospital."
"In my opinion as a nurse, I am there to nurse, to nurture, to help people get well. It's become an expectation that I become part of the goon squad [those hospital personnel tasked with the need to deal with unruly patients due to the lack of trained crisis teams], so to speak."
"For me and my colleagues, we don't want to do that. We've been hurt, we've been thrown to the floor. I had my head banged against the wall."
Linda Clayborne, retired, forensic psychiatric nurse

Emergency room and psychiatric nurses and workers involved in elder and in-home care are at an especially high risk.  Credit: COD Newsroom via flickr

"I've certainly not read anything like this. Has this changed socially accepted norms about what you can and cannot say to a health care professional?"
"Is this ... unmasking attitudes that have been there all along and now, in our polarized societies, people feel less constrained in expressing them? Probably."
"Why would patients allow their own irrational biases to get in the way of their health care? Clearly we need to learn more."
"Because of our sense of professionalism and our code of ethics, we're committed to letting that stuff roll off our backs, but meanwhile all your emotions are boiling inside, and you're thinking, 'Oh my God, what do I do now? What do I say? How do I behave?"                                                                                               Dr. Beth A. Lown, associate professor of medicine, Harvard Medical School

"Often we meet people at their lowest. Sometimes we can have primitive responses to stressful situations, and one of them can be targeting of the other when we're feeling cornered or vulnerable."
"It was like, 'Go back to where you came from; this is going to be our country again, you [expletive] raghead'. And things can be less insidious than that. Like 'Wow, your English is so good'. Yeah, not to be arrogant, but I went to grad school twice. But that's not the point. The conceptualization of me, as a bearded brown man, is of the other."
Dr. Nikhil Patel, psychiatry resident, Cambridge Health Alliance Massachusetts

The Ontario Council of Hospital Unions (OCHU)  has released a survey of about 2,000 health-care workers which concludes that nurses, personal support workers and other hospital staff have become targets of patients; emotional lack of civility in hospitals not only across the province of Ontario but throughout Canada. The survey reported that close to 70 percent of respondents report having experienced a minimum of one incident of physical violence in the year just pas.

On the other hand, 20 percent of those taking part in the survey described nine or more assaults against them in the past year perpetrated by patients. As for non-physical abuse, threatening gestures, intimidation, insults, 83 percent claimed to have been targeted with one incident and 35 percent reported at least nine. In the study group 42 percent of workers reported at least one incident of assault or sexual harassment, while six percent stated such assaults occurred to them nine times or more through the course of a year.

And it is not just nurses and other health-care employees, but also clerks. As an example, a mentally ill patient at a hospital in Smiths Falls took possession of a pair of blunt scissors from the desk of the admitting clerk and plunged the scissors into her neck. "Had she had a Plexiglas barrier completely around her, that couldn't have happened" stated OCHU president Michael Hurley. Budget constraints leave hospitals unable to commit to even minimal protective investments for their staff.

As well, the health-care sector is dominated by women, with 85 percent of the staff female, reflecting the fact that they are as vulnerable in a hospital setting as women can be in general society. Nurse Clayborne points out that in her experience incidents of violence began to manifest about the same time that staff cuts began taking place in an effort to reign in costs associated with maintaining hospitals, about 15 years ago, when the trained crisis teams who usually responded to such situations disappeared due to cost-cutting measures.

In the United States badly behaved patients have been cited as making life difficult for doctors as well, where racist, sexist and bigoted verbal patient attacks have become commonplace. Not only have African-American doctors been the subject of racial slurs, they're also asked to surrender care for white patients to white doctors. Cultural and racist stereotypes have complicated working arrangements for Asian-American physicians and for female doctors, sexually harassed by patients during physical exams.

WebMD and Medscape in collaboration with STAT conducted a wide-ranging survey of over 800 American doctors to discover that 59 percent report having had offensive remarks aimed at them in the past five years; a doctor's youthfulness, gender, race or ethnicity all represent fodder for discrimination. Of those affected, 47 percent reported having had a patient request another doctor look after them. Women physicians were more often bias victims than their male counterparts. Even the overweight had offensive remarks directed to them about their weight.

In the U.S., medical researchers have taken to studying unconscious biases from clinicians toward patients "But much less is known about patients' biases toward clinicians, and that is why the current study is important", pointed out Keith O'Brien, a social psychologist at Portland State University. Most physicians claimed their professional organizations provided no training, had no formal polices on how best to handle patient bias. Even colleagues failing to respond when witnessing harassment results in hurt feelings on the part of those who are discriminated against.

"I remember being surprised and embarrassed and humiliated as a medical student when people would say these things ... When it happens to you as a trainee, you tend to think it's your fault on some level. I know that's weird. You think, 'Maybe it's because I'm not competent or maybe I am less smart than a different doctor. Or maybe I shouldn't be here?' There's a lot of shame in being the target of racism, and I think that's part of it."
Dr. Esther Choo, associate professor, Center for Policy and Research in Emergency Medicine, Oregon Health & Science University

• almost 75% of all workplace assaults between 2011 and 2013 happened in healthcare settings;
• 80% of emergency medical workers will experience violence during their careers;
• 78% of emergency department physicians nationwide report being the target of workplace violence in the past year;
• 100% of emergency department nurses report verbal assault and 82.1% report physical assault during the last year;
• 40% of psychiatrists report physical assault;
• the rate of workplace violence among psychiatric aides is 69 times higher than the national rate of workplace violence;
• 61% of home healthcare workers report violence annually; and
• family physicians are also at high risk, although limited data exist in the outpatient setting.                                   Workplace violence, review article review article New England Journal of Medicine

Hospitals as Threats to Health

"It is estimated that on any given day more than 1,600 hospital beds across the country are occupied by a patient who suffered harm that extended his or her hospital stay."
"In addition to what these patients and their families go through, their continued need for treatment also has a cost to the system. In that it keeps other people from getting the help they need."
Report: Canadian Institute of Health Information and the Canadian Patient Safety Institute

"How safe are our hospitals? [They could be a lot safer.]"
"What we see is that most patients get safe care, but the results show one in 18 suffer some harm."
"That is a good reminder there is more work to do to make hospitals as safe as possible."
Kathleen Morris, vice-president, research and analysis, Canadian Institute of Health Information

Tens of thousands of people are unintentionally harmed in Canadian hospitals every year, according to new figures. - Ottawa Citizen

The newly released cross-Canada health report used as an example Belleville resident Herbert Strasser, healthy at 72 but after developing spinal abscesses and C. difficile in after-surgery complications, died, with a coroner concluding that his case represented a "perfect storm" of false assumptions and missed clues. His was an unfortunate death that spurred changes at Kingston General Hospital and at Belleville hospitals.

Source: Canadian Institute for Health Information, Canadian Patient Safety Institute

Of every 18 patients, one patient suffered unintentional harm in 2014-2015 resulting from hospital care that patient received, representing 138,000 patients across the country falling victim to hospital-acquired medical problems through the default of some inadequacy in care. The report, titled Measuring Patient Harm in Canadian Hospitals, highlighted 150 individuals who had the misfortune to have experienced a sponge or other surgical object left inside them, at the conclusion of a surgery.

Of those people so affected, one in eight died, despite authorities feeling themselves unable to claim with any degree if certainty whether it was hospital harm directly implicated in causing those deaths. Additionally, one in five -- about 30,000 people -- suffered more than one form of deleterious health outcome. The rate of such hospital harms is set at 5.6 percent, a steady state in recent years in the country.

A new system to track hospital harm places emphasis on 31 different types of inadvertent health outcomes injurious to people's health prospects. Those range from birth trauma and medication errors to C.difficile infection, patient accidents and medical instruments that have been left in patients during surgical procedures. The purpose of the measuring and tracking on a national scale is to aid hospitals in lowering harm rates and improving patient safety.

Among the most frequently occurring harms listed are urinary tract infections, pneumonia, and electroyte and fluid imbalances. Many hospitals have focused on improving their rates of C. difficile infections, and the going has been extremely difficult. Hospitals devise various protocols to reduce C. difficile, inclusive of organizing SWAT teams to swiftly respond from infection control, housekeeping and logistics department.

Preventable harm can occur in all areas of the hospital. (David Goldman/Associated Press)