There’s an epidemic that no one wants to talk about. This epidemic affects you deeply, yet it remains a dirty little secret. That epidemic is workplace violence in healthcare. According to a recently published article by The American Journal of Managed Care, 75% of the workplace violence reported in the United States occurs in healthcare settings. Doctors, Nurses, and Nursing Aids are more likely to be assaulted in their daily work than police officers or prison guards. Violence against healthcare workers is so endemic that many healthcare workers simply consider it to be a part of the job. This results in a gross under-reporting of violence by most healthcare workers. The AJMC reports that workplace violence in healthcare costs healthcare workers and hospital systems 2.7 billion dollars per year as a result of the treatment of injuries, lost time, and damage to equipment. These dollars and cents numbers fail to take into account the toll this violence takes on healthcare workers. We are your sons, your daughters, your mothers, your fathers, your neighbors, or maybe even yourselves. We experience trauma on a daily basis in the form of intimidation, hitting, kicking, spitting, biting, scratching and verbal abuse.
You might be wondering how this affects you. Your caregivers experience Moral Injury as a result of violence, managed healthcare, and staffing shortages. A Stat News article published July 26, 2019 defines Moral Injury as mental, emotional, and spiritual distress people feel after perpetrating, failing to prevent, or bearing witness to acts that transgress deeply held moral beliefs. This phenomenon was first noted in military personnel in the form of PTSD type symptoms in individuals not directly engaged in combat. Further investigation revealed that those who simply played a supporting role often felt guilt, remorse, and distress in knowing that their actions ultimately led to death and destruction. Healthcare workers are exposed to violence daily. They also find themselves at odds with the reality of managed healthcare which often prescribes less care than caregivers feel is needed for their patients. An example might be a homeless patient who has a case of early pneumonia. This patient might not meet the hospital’s criteria for admission, so they would be prescribed antibiotics and discharged, The caregiver knows that this patient will have to return to the cold, wet confines of their tent with the distinct possibility that their medication will be stolen. The caregiver feels that this patient would benefit from hospitalization in a warm, dry, clean environment where his medication is administered by nursing staff; however, this patient doesn’t meet hospital admission criteria, so the caregiver has no choice but to discharge the patient. This creates a moral injury to the caregiver because they are powerless to provide the care that they feel the patient really needs. Moral injury also occurs when caregivers witness or fall victim to violence in the workplace. The caregiver oath is”:do no harm.” When a caregiver experiences or bears witness to violence their strongly held moral beliefs are insulted in a way that often results in caregivers becoming anxious, jaded, apathetic, or in some cases leaving the profession altogether, Many caregivers, myself included, need therapy and counseling to cope with the day to day reality of violence and managed care, This affects patients directly. As a nurse, I find myself at odds with my desire to provide the care that I know my patients need, and the care that I am able to deliver due to time constraints related to staffing shortages, budgetary constraints related to managed care, and the stress of dealing with a sicker, more violent patient population. Staffing shortages and managed care are directly responsible for a great deal of violence in healthcare.
When a patient comes to an Emergency Department they are frequently afraid, in pain, and experiencing distress. The reality of modern healthcare in the United States is caregivers are asked to do more work and cut costs wherever possible. Lean projects where tasks and responsibilities are shifted to existing employees rather than hiring additional staff to do these tasks are making their way into healthcare. One example is that some hospital systems are now requiring their nursing staff to add the task of stocking supplies to an already unbearable workload. Where there once was a stocking tech responsible for this task, now nurses are responsible for this task. This takes the nurse away from the bedside. Sometimes 5 minutes at the bedside comforting and reassuring a patient is the difference between a calm patient who feels like they are being cared for and an angry patient who feels like their needs aren’t being met. We have all seen an ugly confrontation between a customer and employee of some business. These confrontations frequently include verbal and psychological abuse, and sometimes even physical violence all over the customer getting pickles on his burger when he said no pickles. Imagine how this anger and distress is multiplied when someone is in an ER for severe abdominal pain, but either the doctor hasn’t had time to order pain medication, the nurse is too busy to give it in a timely manner, or the emergency department is overcrowded resulting in patients waiting for hours before even seeing a provider.
One of the biggest contributing factors to violence in healthcare, and especially in emergency departments, is drug and alcohol intoxication and mental illness. Oregon has the second-highest instance of methamphetamine use in the nation. It is also estimated that one in five Oregonians suffer from some form of mental illness. Community resources designed to keep patients out of emergency departments are not sufficient to meet the needs of mental health patients. As a result, ERs are overwhelmed by patients with acute mental health needs. The average time a patient spends in an emergency department awaiting an inpatient bed is 3 to 5 days. It;s not uncommon for a 45 bed emergency department to have a dozen or more mental health patients boarding waiting on an inpatient bed. This strains department resources and results in longer wait times for patients with emergent medical conditions. Longer wait times are directly related to increased violence in the emergency department. Mental health patients and drug and alcohol-intoxicated patients can often become violent. In order to keep patients and staff alike safe, additional resources must be directed to these patients taking those resources away from other patients. This frequently results in delays in care. Patients already in pain and distress can become impatient and angry over the perception that they simply are being ignored when the truth is that caregivers are doing the absolute best they can to meet everyone’s needs. I can not stress enough that this is not a department, hospital, or healthcare system problem. This is an economic, social, and political problem. I have full confidence that given the resources my management and administration would give me whatever I asked for to meet the needs of my patients. Lack of funding for mental health and addiction services, dwindling Medicare and Medicaid reimbursement rates, and reimbursements managed by for-profit health insurance corporations all contribute to a scarcity of resources needed to provide the care my patients need. Oddly enough, the United States spends $10,224 per person on healthcare. This equates to 18% of U.S. yearly GDP. Average life expectancy in the U.S is 79.10 years and infant mortality rates are 5.8 deaths per 1000 live births. Conversely, Japan spends $4,717 dollars per person on healthcare and has an average life expectancy of 85.03 and an infant mortality rate of 2 deaths per 1000 live births. The problem with healthcare in the U.S. is not that we don’t spend enough money on healthcare, but that we spend the money on the wrong things. The U.S. spends 3.5 trillion dollars per year on healthcare with an estimated 1.1 trillion going to administration. The majority of the rest of our spending goes to profits for insurance companies, healthcare systems, pharmaceutical companies, and suppliers of durable medical equipment. Proper healthcare is simply out of reach for many Americans due to burdensome administrative costs and the profit demands of healthcare-related industries. This leads to many Americans putting off health concerns until they reach a crisis point and end up in the ER. This leads to crowding in the ER and sicker patient than we have seen in the past. Now we have come full circle to the issues that lead to violence in healthcare.
So the big question is what can we do to curb violence and the resulting trauma and moral injury to caregivers, patients, and families? In 2019, the Oregon Nurse’s Association sponsored the Healthcare Worker Protection act. This bill requires greater transparency, stronger security, and protection for workers reporting violence in the workplace. This is a great first step, but there is much to be done. Funding mental health services must become a priority. Funding drug and alcohol rehabilitation services must become a priority. Solving the homelessness epidemic must be a priority. It takes community involvement, economic support, and the political will to enact bold change, Another essential step is to ensure that every Oregonian has not just access to care, but affordable care. It’s long past time for Oregon, and indeed the United States, to provide healthcare for all of its citizens as so many other nations have done with overwhelming success. The political will to act comes not from the folks down in Salem. It comes from each representative’s constituency. It starts with you. Call, email, or write your representative today, and demand bold action. Then show up at the polls and elect those with the courage to abandon the status quo and move Oregon boldly into the future.
