Canadian doctors and nurses are urgently calling for national measures to prevent the widespread violence plaguing emergency departments.
Emergency departments across Canada are closing areas, restricting hours or shutting down due to staffing shortages; doctors and nurses say violence directed toward them is one of the biggest contributors to people leaving the field.
Health-care workers have a fourfold higher rate of workplace violence than other professions, and health-care providers in the emergency department are at particularly high risk. More than half of emergency department nurses are physically or verbally abused in any given week.
And yet, most of the violence experienced by health-care workers goes unreported due to hospital administrators’ longstanding, prevailing culture of normalization and intimidation, says Alan Drummond, an emergency physician in Perth, Ont.
“On a recent shift,” says Drummond, “I was threatened to be punched in the face after being called every name in the book. I have been a doctor for 43 years, and I left asking myself, ‘Do I really need this in my life?’”
He says hospital administrators only react when pushed by outside investigations, such as coroner inquests or media reports.
“I have never believed hospital administrations give a shit about us (emergency personnel). Hospitals in this country, despite ample evidence, have not hired properly trained security teams, put in safety alarm systems, designed departments with safety in mind and don’t collect data on violence directed toward staff.”
To respond to a growing call to action by its members, the Canadian Association of Emergency Physicians (CAEP) released a statement in August calling for a safe work environment.
Howard Ovens, an emergency physician in Toronto and co-author of the CAEP position statement, says, “Broadly speaking, we are failing our staff, especially our nurses. Hospitals are the employers here. They are the institution that has ultimate responsibility to provide a safe workplace and safe place for patients to seek care.”
The statement outlines effective policies for safe physical spaces, properly trained security personnel and counselling and support for victims of violence.
Eram, an emergency department registered nurse who works at two hospitals in Toronto who did not want her last name used, agrees with reports that the pandemic has exacerbated the problem; low staffing, space constraints, crowding and fears of catching COVID have all played a role.
“Patients are becoming more irate now than they were before and require a lot more verbal de-escalation,” she says.
More than half of emergency department nurses are physically or verbally abused in any given week.
Eram says her departments have instituted measures to curb violent behaviour similar to those outlined in CAEP’s statement. Measures that work, she says, include care plans for patients known to be aggressive during prior visits, security staff circulating at triage and in the waiting room, de-escalation training for all frontline staff and personal panic alarms.
But more can be done, says Eram. “Huddles and debriefs are needed after code whites (response to violent person) take place on shift, but emergency departments are so busy right now, we have to get right back to work.”
Eram also advocates for more simulation and feedback sessions to hone choice of words, body language, tone and cadence. “Let’s act it out together and get feedback. All of this is so important when speaking with patients.”
Ovens says hospital staff are not the only ones suffering the effects of violence. “It is also taking a toll on our patients and families, and as always, it is the highest-risk and most marginalized patients who are paying the price the most,” he says.
He describes how zero-tolerance policies, ones that evict patients for aggressive behaviour, can be deadly for patients with acute medical conditions, intoxication or mental health problems.
Using methamphetamine intoxication as an example, an exponentially increasing condition seen in emergency departments, he says that “intoxication can be associated with agitated behaviour in a way that is outside that person’s voluntary control.”
“These patients can easily go out and come to harm themselves or others and are at risk of seizures and sudden death,” he says. “If we are going to protect the emergency department by kicking these people out, we might as well just lock the door and go out of business.”
Rather than zero tolerance, Ovens calls for national standards to address and prevent violence in hospitals.
“We need a national accreditation process to support physical design aspects, structures, policies and training that promote safe operation of emergency departments,” says Ovens, “We also need security staff trained as part of the health-care team. They are very different than mall security or police officers.”
Drummond agrees but is not confident he will see any meaningful change. In 2019, on behalf of CAEP members, he and other representatives of health-care organizations called for the creation of national hospital safety standards at the House of Commons Standing Committee on Health. After the hearing, the committee requested that the federal government table a comprehensive response to the recommendations in the report Violence Facing Health-care Workers in Canada.
To date, there has been no response.
Drummond says the time to act is now. “Because of the effects of crowding, moral injury, COVID-19 and the enforced acceptance of violence as a social norm, a lot of emergency physicians and nurses are saying, ‘Enough.’”
While Eram has seen her colleagues injured at work, exhausted by abusive behaviours and leaving the profession, she remains focused on making her workplace safer for patients and providers.
“It is hard to ask people to be patient while being a patient right now. We cannot change a person’s behaviour, but we can try to accommodate and change the environment to try to address some of these concerns. We only intend for the best, and we try to do things as best as possible.”