Healthcare workers help all of us in our darkest hours—relieving our pain, restoring our health, and comforting us and our loved ones. They deserve respectful, dignified, and safe workplaces. But more and more, they fear coming to work. Workplace violence has been increasing, making hospitals among the most dangerous places to work. Driven by the corporatization of care, which puts profits over patients (and which you can read about here), and exacerbated during the COVID-19 pandemic, the staffing crisis is feeding into this crisis of violence.
To better understand the extraordinary challenges facing healthcare workers, we spoke with four union leaders about their experiences with workplace violence and the changes—both institutional and legislative—needed to keep healthcare workers safe: Donna Phillips, an intensive care unit nurse with Providence Alaska Medical Center, the labor council chair of the Alaska Nurses Association, and an AFT vice president; Stacey Sever, a former emergency room and flight nurse with Providence Health & Services and the health and safety committee chair of the Alaska Nurses Association; Jill Hasen, a physician assistant in the University of Michigan’s Rogel Cancer Center and the president of the United Physician Assistants of Michigan Medicine; and Carolyn Cole, a community mental health nurse with the Broome Developmental Disabilities Services Office and an executive board member and council leader of New York state’s Public Employees Federation.
As these four leaders make clear, we can’t count on hospitals and healthcare systems to protect workers. We have to fight for the changes that will keep healthcare workers safe through collective bargaining and legislative action. That’s why the AFT, led by its Healthcare Staffing Shortage Task Force, is calling for passage of the federal Workplace Violence Prevention for Health Care and Social Service Workers Act. Passed by the House of Representatives in 2021 but stalled in the Senate, this bill would require the Occupational Safety and Health Administration (OSHA) to issue a standard on workplace violence prevention planning and implementation. Join the fight for passage by checking out our toolkit.
EDITORS: What experiences have you and your members had with workplace violence?
STACEY SEVER: I’ve been a nurse with the same hospital here in Anchorage for 25 years. Most of my clinical experience is in the emergency department (ED), but I have also been an ED flight nurse and a nurse educator. Now I’m working a desk job, and one of the things that pushed me to this job was the increasing violence that I’ve seen over the years. Of course, earlier in my career we’d see violence in the emergency room from a patient who was under the influence of drugs or alcohol or who had mental health issues, but that happened maybe once every six months. Now, it happens once a shift in different departments, and it has become a serious issue. Staff are getting hurt and losing days on the job because of their injuries.
DONNA PHILLIPS: I am a nurse in the ICU of the same facility, and I’ve been here about 28 years, so I’ve seen the same increase in violence with little done to give workers increased protection. There are no metal detectors in our hospital, and we’ve had patients come into the ED with firearms in their backpacks. Hospitals can be highly emotionally charged environments. When patients or their loved ones are in a health crisis and they feel they’re not getting the one-on-one attention they need, they get upset—understandably—and can easily be pushed to the brink. I’ve had people grab my arm so hard that I thought it was going to be broken.
JILL HASEN: My department is orthopedic oncology, but I know we’ve also had some violent incidents in the ED here in Ann Arbor. There have been two incidents recently in which psychiatric patients have assaulted healthcare workers: in one case, a physician was punched, and in the other, a nurse was tackled by a naked patient. Both of these incidents occurred because the more contained area of the ED where psych patients are seen was full. So these patients were in an area that was not monitored as closely, and they were able to leave their rooms and assault the clinicians.
STACEY: We’re also seeing increased violence in our outpatient clinics and in other units in our hospital. Up on the floors, some patients who are at risk for falling must have a patient care tech (PCT) sit in the room with them. Sometimes those patients are violent, and then I’ll read in my hospital’s safety reports about PCTs getting punched or kicked.
And the obstetrics area has seen increased violence from the partners who come in with our patients. Verbal altercations are a daily occurrence. Staff are quite frequently subjected to verbal abuse, including racial slurs. And staff are increasingly unsafe even off the job, when they’re in the community. One patient recognized a caregiver at the mall and threatened them. These incidents are happening so often now that they almost blur together.
CAROLYN COLE: Over the 40 years of my nursing career, I’ve experienced my share of workplace violence: I’ve been kicked, punched, shoved, peed on—you name it. But in my time as a community mental health nurse for New York state, I’ve experienced workplace violence at levels I’ve never seen before. My caseload is primarily patients with a dual diagnosis of mental illness and developmental disabilities. I travel out in the community alone to visit them, and it can be dangerous.
One of my patients, a 79-year-old woman with a history of aggression, headbutted me and broke my eye socket, nose, and cheekbone. She was having cardiac issues, and I’d gone with her to the emergency department because I knew the experience would be confusing and scary for her. The ED nurse who was helping me take care of her left the room to get her a sedative, and as he returned, she caught me good. A month later, I was called to the home she was living in, and she was chasing a staff member around the room, trying to beat them with a walker. Thankfully, in these instances, no one was gravely injured, but other healthcare workers in my agency have been injured so badly by patients that they’ve been put permanently on disability.
EDITORS: Give us the bigger picture as you see it. What underlying problems are driving workplace violence?
JILL: One key problem is that hospitals and EDs have been severely understaffed and overworked with the numbers of patients with COVID-19—and now RSV—and the numbers of people who use emergency care as their primary care. Of course, staffing shortages aren’t just a pandemic problem, but the last few years have seen these shortages worsening.
DONNA: And they’re worsening at the same time that issues with mental health and substance abuse are growing. As Stacey mentioned, we used to see occasional violent incidents in the ED from patients under the influence or with mental illness, but we’re seeing so many more patients with these issues than we used to. We have seen many patients become aggressive and verbally abusive because they’re having withdrawal symptoms from alcohol or opioids.
We’re also seeing increased violence among patients without these issues. In healthcare, we’ve given patients the expectation of zero pain. So when they have a surgery or treatment and we can’t completely take their pain away, they become frustrated or agitated. And then if we can’t meet their needs right away because of inadequate staffing, their agitation is compounded. Patients don’t know that while they’re waiting for you to help them out of bed or to the bathroom, you’re down the hall prioritizing someone who can’t breathe. And inadequate staffing also means that there’s no help when you have a crisis with a patient. When you have somebody who’s getting violent and you need to get them anti-anxiety medicine and you’re holding onto them so they don’t pull out their lifesaving breathing tube, you look out in the hallway for help and there’s nobody there. So staffing is a huge part of the reason that violent incidents are increasing.
CAROLYN: Substance misuse is a huge driver of workplace violence issues in smaller rural areas like mine as well. The opioid crisis here persists because people are unable to get help when they need it. Additionally, many people have lost their jobs, and even if they could find more work, they don’t have a vehicle and there’s no public transportation.
Many cases of violence that I have seen also involved mental health issues, and that’s not a coincidence. Substance abuse is interrelated with mental health. Today, it’s very difficult to get a doctor to prescribe an opioid, so people are trying to self-medicate because they feel like they can’t get anybody to understand what they’re going through. And it’s exacerbated by the staffing shortage and lack of access to mental health services. Our local hospitals no longer have psych units, so now the closest unit is about 80 minutes away, and the nearest outpatient clinic is over 45 minutes away. And once the pandemic hit, we had a plethora of mentally ill people in the community who couldn’t get services anywhere for weeks or longer. When you’re in crisis and you can’t be seen by a mental health professional or you’re asked to drive 80 minutes to get help, what are you going to turn to? Alcohol or drugs. And that’s a “perfect storm” scenario for violence.
STACEY: An additional problem I see is that when patients come in, they are sicker than they have ever been before. But hospitals keep cutting staff while putting constraints on our time with patients. We’ve seen an increase in pressure ulcers and other hospital-acquired conditions because we’re being pulled away from being able to give the extra care that we are used to providing. For example, we’ve got elderly patients who aren’t very mobile, and we need to be able to take our time with them. Something as simple as a trip to the bathroom can take 30 minutes or more just to get them upright in bed and make sure that they’re not lightheaded and won’t pass out because they’ve been lying down a lot. But management has unrealistic expectations of what can be done with the number of staff on a unit and is even adding patients to already overworked nurses.
In nursing school, you learn how important it is to develop trust with your patient and their family, but you can’t do that if you can’t spend time with them. Patients are putting their lives in your hands. How do they trust you if you’re always rushing in and out, essentially saying, “Oh, here are your pills. I’ve got to go,” or “Here, let’s change your bed. I’ve got to go”? Most nurses want to be able to give the type of care that we would want our children or mothers to receive. When we’re not allowed the time to do that, it can feel like we’re cutting corners. And going home after a shift thinking “I wish I’d done something more” really weighs on nurses.
JILL: It weighs on us, too. In the old days, physician assistants could actually spend time with our patients—we could sit and talk and really connect to build that trust. I mean, I knew where my patients spent their summer vacations every year. I think that’s all lost now in this push to get more patients and more profits in the door. Now I get just 15 minutes with each patient, and I have to see so many patients per shift because management says that’s the national benchmark, but does that make it right? I just saw a patient who’d had a hemipelvectomy, where we’d removed half of their pelvis and the rest of the leg because of cancer. It’s not right that I only get 15 minutes with that patient, or that I have to tell them, “I know we just cut off half of your body—and by the way, there’s a positive margin in there, so we might have to take more—but I’ve got to go.”
And it does feel like cutting corners, especially when patients aren’t getting the education that they need to stay healthy after they leave us. I see that with my post-op patients. When they’re discharged, they get an envelope of written instructions as part of their discharge summary—but those summaries are done by a resident, a learner with less experience than nurses on the floor who have been here a long time. But the nurses don’t have time to sit down and talk to them. Or if they do, there’s no time to also talk to the family member who comes to pick up the patient, and the patient forgets the instructions because they’re on oxycodone for pain or they assume their family members will handle everything. It’s a huge problem. Education is falling to the wayside because our nurses don’t have enough time.
DONNA: And we’re also not considering the consequences of omission of care—when I give my patients their meds on time but can’t help them go for a walk, for instance. That all adds to why people end up staying in hospitals longer. Studies have shown that increased staffing decreases length of stay, helps people get better, and decreases mortality in hospitals.* But it’s hard to get hospitals to do the right thing, and as a union leader it’s very frustrating when you know that violence and moral injury are happening because there’s not enough staffing. It all ties together and revolves around having enough people taking care of those patients.
CAROLYN: Not having enough time and resources to do your job is incredibly stressful for staff, which creates another concern for workplace violence. Over the last years of the pandemic that we’ve been dealing with inadequate staffing, exhaustion, and burnout—and being afraid for our health and the health of our loved ones because we weren’t being provided PPE—we’ve seen more nurses struggling with addiction and mental issues and a spike in bullying and violent incidents between staff members. Some staff were working doubles, triples, even staying for days because there was no one else to cover shifts in our 24-hour care facilities. The strain of overwork can cause tempers to flare, and without management taking this problem seriously and providing needed mental health services and support, things can escalate. We had a group home staff member instigate an altercation with a colleague. Luckily, no one was hurt, but management should’ve addressed the overwork that led to that situation long before it escalated. We have a great employee assistance program (EAP), so when I heard what happened, I contacted EAP and they went to the group home to support the rest of the staff.
JILL: That just underscores the ripple effect of the lack of staffing. We’re in a pressure cooker, and emotions get high on all sides. Patients and family members who were already fearful because of the health issue that brought them in for care get agitated and angry when they have to wait a long time to be seen or have their questions answered. And they’re yelling at a manager in the lobby or shoving a staff member—or worse. On the clinician side, I’m stressed because there’s not enough time to see patients, and I have a heavier workload because all the medical assistants in our clinic have quit due to the bad work environment. When I’m an hour behind and patients are yelling, I feel like I’m failing. And I end up in the bathroom at work crying, being snippy with a nurse, or yelling at the lady in the car beside me as I drive home. None of us set out to react in these ways, but stress can push people to do things they wouldn’t do under normal circumstances.
DONNA: Managers don’t really have it easier. They want to prove their value to the administration, but their solutions don’t address the problems that are creating these circumstances. And I think these large healthcare systems put pressure on the managers of frontline staff, until they end up doing things that they wouldn’t normally do if they weren’t also under tremendous stress. Under the corporate model, administrators push and push and push people until they crack.
STACEY: It’s a vicious cycle because this downward pressure is reflected in the care that is given to the patient. And it’s reflected not only in the way patients or family members lash out but also in the lack of support and coping mechanisms to deal with it when they do. When a patient or family member is yelling at a manager and the manager’s only recourse is to offer them a coupon for a free cafeteria meal, how is that really dealing with the issue? Solving this crisis is going to take something much bigger. It’s going to take legislation and a huge culture change to make sure that the healthcare environment is a safe place to be—for patients and clinicians.
EDITORS: How are you and your members fighting to make your workplaces safer?
JILL: We organized to get the changes we need. I actually started our union from the ground up. I stood up in a meeting and held up the word “union” on a piece of paper like Norma Rae because our working conditions had become untenable. Employees hated their jobs; everyone was burnt out and wanted to quit. Honestly, if I weren’t president of this union, I would’ve retired this year. The strain of being pushed from patient to patient without having enough time or resources to do my job is just too much.
We got our first contract in June 2021, so this work is new and hard, but we’re making progress. We’re having the necessary conversations in labor-management committees and workgroups and bringing attention to the workload issues that our frontline workers are experiencing so that we can get a resolution.
I’m pleased to say that Michigan Medicine is stepping up and trying to address workplace violence and the issues that lead to it. They put proactive measures in place even before the Joint Commission revised its workplace violence prevention guidelines in January 2022.† One of the most beneficial measures is the workplace violence prevention team, a multidisciplinary group that meets regularly to debrief about any incidents and make sure people are getting the communication, help, and resources they need in the aftermath. The team also provides training and education and develops prevention strategies that influence policies and procedures related to workplace violence and safety. We’ve seen positive changes as a result, such as hospital-wide town halls following the ED assaults to provide employees with de-escalation training and added security in the ED areas that previously weren’t being closely monitored.
Management is also stepping up in some ways. They’re providing resources for employees who’ve been involved in a workplace violence incident and getting training to better address incidents of aggression between staff. In the old days, the default management response for employees involved in an altercation was discipline. Now they’re really trying to give employees the resources they need to improve communication with their colleagues.
STACEY: As a union, we’ve also pushed to increase safety measures in our facility. The hospital brought us all together to talk about workplace violence incidents in what they called Caregiver Cafes. One of the topics we talked about is scene safety, which I was already familiar with because of my background as a paramedic. Scene safety is one of the first things you learn while becoming an EMT, but it’s not routinely taught in nursing. A nurse’s job is to care for their patient, so if a patient falls out of bed, the nurse’s first instinct is to rush into the room to stop them from getting hurt. But if the patient has a history of aggression and the nurse is alone, that’s an incident waiting to happen.
So I felt it was imperative that we work to change the nursing culture to include scene safety. Fortunately, the hospital has slowly embraced this concept and put in some measures to help identify patients who are at risk for violence. Now, there’s a red banner that is placed in a patient’s electronic medical record to indicate they have violent tendencies, and there’s talk of using discreet signs outside these patients’ rooms directing ancillary staff to check with nurses before entering the room, so no one goes in alone.
But we need to do far more. Tragically, Doug Brant, a Providence Home Health Care nurse, was murdered in December by a patient’s grandson during Brant’s first visit to the patient’s home. That horrific incident seems to have motivated our administrators to revitalize workplace violence prevention programs systemwide. Here at Providence Alaska Medical Center, they’ve hired a quality program manager for workplace violence prevention who is reestablishing our workplace violence committee. When that committee was initially formed before the pandemic, I had to fight to join it; this time, I’ve been invited—so I’m hopeful that now we’ll see meaningful action. We cannot continue to put nurses, or any staff, in harm’s way.
DONNA: When I was in my early 20s, I worked in a psychiatric ICU with a patient who had jumped from a parking garage and broken his back. He was in a plaster cast from his neck to his groin. I was in the room interviewing him for his psych intake, and he started telling me how much he hated women and getting very verbally aggressive. He may have been in a body cast, but he was a big guy, and I was sitting in a corner with him between me and the door. I was scared that I was going to die.
Recently, I saw a communication from one of our managers reminding staff to protect themselves and never place themselves in a situation where an escalating patient or family member is between them and the door. It’s common sense, but it’s something I had to learn the hard way, so I’m glad that management is now emphasizing scene safety in this way. Nurses tend to just want to do good, but not everyone who walks into a hospital has the greatest intentions. And sometimes people with the greatest intentions get pushed to the brink.
STACEY: We dedicated the spring 2019 issue of our Alaska Nurse magazine‡ to workplace violence. We surveyed our members to find out how they’re impacted by violence and spoke with nurses throughout the state to bring awareness to how dangerous workplace violence makes our jobs. I also wrote about the need for scene safety and a culture change around this issue. We are starting to see that culture change, although we had to force it through legislation. In 2018, Alaska enacted workplace violence protection legislation with HB 312, which allows healthcare facilities to press charges for assault on healthcare workers.
Trying to win federal legislation, Donna and I went to Washington, DC, with a few other members in 2019 and met with our state legislators—Sen. Lisa Murkowski, Rep. Don Young, and the staff of Sen. Dan Sullivan. We asked them to support the Workplace Violence Prevention for Health Care and Social Service Workers Act, which demands an OSHA standard on workplace violence. During Nurses Week, we asked all our nurses to write postcards to their legislators. That bill passed in the House (in 2019 as HR 1309 and again in 2021 as HR 1195), so now we need to focus on the Senate.
DONNA: This legislation is critical because hospitals are not going to move on this issue unless they are forced to. I say that having lived through the fight for bloodborne pathogen needlestick legislation§—back then, the hospital claimed they wanted frontline caregivers’ voices to help find a solution, but when the solution cost money, they backpedaled. And in a town like Anchorage without another large health system, there’s less competition for hospital workers, so there’s less incentive to do right by your employees. Now we’re slowly starting to see a culture change in our hospital, like increased arrests for violent incidents and the safety alerts in the electronic medical records, but it took more than us saying, “We need scene safety.” It took the state legislation, the American Hospital Association reversing its position that hospitals could be accountable to themselves on workplace violence, and the Joint Commission issuing its standard.
STACEY: The hospital was definitely not moved to make changes out of the goodness of their hearts. They were losing staff over this issue, and it was costing them money. It’s unfortunate that this is what makes businesses do the right thing. The worker has to be the one to push for change, but it has to be legislated and regulated in order to actually put changes in place.
CAROLYN: Where it’s possible, a labor-management partnership can also help push those changes. It’s taken a lot of hard work, but my union came together to make our workplaces safer. I’ve been part of the Public Employees Federation (PEF) for 30 years and was active as a steward before coming to this agency, so I already had background and great training from PEF on labor-management meetings, workplace violence, health and safety, grievances, and being a good steward. When I became a council leader, representing the members in my region at the executive level in the union, I developed good relationships and open communication with management, and they came to know me as someone who respects their position but also wants to work as a team toward a resolution.
Several years ago at my agency, we had a long discussion about the increasing number of violent assaults in the workplace. We worked with our human resources department to get risk assessments and other tools in place to address workplace violence. That served us well during the pandemic. We’ve had struggles getting everyone fit tested for respirators (and they even had the nerve to fit test administrators before caregivers), but overall, the six counties in my region did very well through the worst part of the pandemic because we had weekly management and union meetings, not just on workplace violence but on everything related to health, safety, and labor management. We found that the number of workplace violence complaints decreased because we had such great rapport with our management that they got involved in developing solutions. They hired additional staff for our group homes, increasing our ability to provide one-on-one care for clients who need closer monitoring. And as these clients are able to get out more, the staff are also calmer and less distressed.
The agency has become diligent about tracking our workplace violence incidents. The one piece we are still working on is workplace bullying. We’ve been pushing for legislation to start identifying bullying, because we’ve found that bullying and harassment are often precursors to more egregious violence. We have encouraged our members to report harassment and bullying as workplace violence, which not only helps address the issue with staff, but also helps reassure our clients, who can become confused and retreat to defending themselves if they see employees arguing. So with our partnership, we’ve been making progress.
EDITORS: What other changes are needed to help prevent violence and keep healthcare workers safe?
DONNA: We need to deal with our recruitment and retention problem. We hire lots of new graduate nurses and put them through training, but the nurses responsible for training are also doing their best to care for a full patient load. How do they have time to teach and really support these new graduates so they can provide the best care? I have never trained as many people as I have where I currently work, but it’s not enough to hire people and put them through a great training program; you have to create an environment where they want to stay. One way to increase retention is to legislate a reasonable nurse-patient ratio, with fines for noncompliance. Legislation would be huge for improving workplace violence, moral injury, and retention. Because what we’re doing now—trying to fill holes with a revolving door of new hires and recruiting nurses internationally (creating shortages in other countries)—just isn’t working.
STACEY: When I was an educator many years ago, a nursing preceptor who was training a new employee would have a lessened patient load so they had time to teach the orientee the job. That doesn’t happen anymore. Frequently of late, I’ll hear a report in a safety huddle of an orientee being pulled off the floor to work an assignment because “they were close to coming off orientation anyway” and management needed the staff. That’s pretty scary. And it leads to burnout for both the new and experienced employees. And now, we’ve got even more experienced nurses who are moving to part-time, moving out of bedside care altogether (as I did), or retiring because we’re exhausted, and we want to come home to our families at night. Who will replace us?
It comes down to being valued as an employee. When our facility has a 25 percent turnover rate in the first year of employment, it’s clear that the hospital doesn’t see the value of experienced nurses. They’d rather offer huge sign-on bonuses for new hires than do the work of creating a supportive environment for those of us who stay. We also have a lot of leadership turnover, and the inconsistency that comes with that leads to staff confusion and upheaval. And unfortunately, it does take legislation and a whole culture change to show that nurses are valuable and the patients they take care of are valuable.
JILL: I agree; retention and recruitment are huge issues we need to address. We’ve also lost good, experienced people: nurses who’ve been providing care for 30 years, clerical staff who have 20 years of institutional knowledge, and all of our medical assistants. They left because they can no longer work in this stressful environment. And the new people coming in are so young and inexperienced; there’s not enough staff to mentor or even fully train them. They’re thrown out into patient care sooner than they used to be, sometimes before they’re ready, and that pressure has a snowball effect.
Valuing workers starts with recruitment and means paying all staff—including medical assistants, nurse assistants, patient care associates, custodial staff, lab techs—a living wage with work flexibility and time off, which means resolving workload issues to improve work-life balance. Nurses cannot do their jobs if they don’t have enough medical assistants, and they cannot spend time with their patients if they’re consistently responsible for tasks outside their scope of practice. My members have also been pushing for a workload review for over a year. Full-time physician assistants (PAs) are supposed to work 40 hours a week, but some of us are working up to 60 hours without receiving extra pay or an extra day off, because that would just add extra work to the other PAs in the department. Uncompromising managers are working people ragged, and their “business way” of handling these issues does not include what we clinicians think.
If we’re going to continue to see change on workplace violence, communication is key, as is working with labor and management in committees and work groups to make sure they understand what’s actually happening with the frontline workers providing patient care. If they want to keep us here and keep our operations functioning, they have to think about our work-life balance. We can’t continue working like this.
CAROLYN: I’ve had similar conversations with management; I told them plainly that if they continue to beat down nurses and cause them to leave, management will eventually be out of jobs as well. You can’t run a healthcare agency without nurses. So direct staff need to be paid what they’re worth. And we need to ensure that staff have the resources and support—including policies on PPE and expanded access to mental health services—to do their jobs well, without the fear of violence. In the unfortunate event that they experience violence, they need to be taken seriously—not treated as if being assaulted is in their job description.
What’s also needed is greater awareness about managed healthcare. It’s real, and it’s affecting our patients in big ways as corporations and insurance companies are increasingly dictating things like length of stay and other important care decisions. We need legislative change that gives the healthcare team a voice in these decisions. Medical professionals, not insurance companies, have one-on-one histories with patients. They provide appropriate care based on each patient’s individual needs, not a profit algorithm.
My mother died of cancer when I was 20, and I still remember how wonderful her healthcare team was, how great they were in caring for her and helping us cope. Forty years later, it’s scary to wonder who would care for me if I became sick. This is a national problem, and I think a lot of it is due to healthcare becoming more about profit than people. Corporations can make a great profit and still invest in healthcare worker safety. We need to restore respect to the healthcare field and to those of us who have devoted our lives to caring for patients. A lot has been taken from us. But we are fighting back.
§ To learn more about union efforts to win worker protections against bloodborne pathogens, see “How OSHA Can Better Protect Healthcare Workers” in the Fall 2022 issue of AFT Health Care. (return to article)
[Illustrations by Kasia Bogdanska]