Health-care workers in B.C. are facing an epidemic of workplace violence
Health & Safety british columbia Health-Care Workers Nurses workplace violence
By Moira Wyton and Zak Vescera/The Tyee
Ten years after she was assaulted at work, Pam Owen still remembers her attacker’s empty eyes as he pinned her backwards over a washing machine and beat her head.
“There was just nothing there, he was not registering anything,” said the former recreational therapist, who worked with mental health and addictions patients for Vancouver Coastal Health.
The pain of being wrenched backwards was so blinding Owen did not realize the attacker had strangled her and punched her repeatedly in the face until he was pulled off by three nurses, five long minutes later.
In shock, Owen drove herself home from the UBC Hospital to Vancouver’s North Shore, insisting to colleagues she was fine.
But the horrified looks of her husband and son at the bruises and scrapes on her neck and face when she arrived home on March 17, 2012, instantly convinced her otherwise.
Her mental and emotional injuries would run deeper and last far longer than the serious physical injuries.
Within days, she was diagnosed with the worst case of whiplash most of her doctors had seen. It took years for the full extent of the damage to become clear: neck and shoulder injuries, symptoms of a traumatic brain injury and post-traumatic stress disorder, all of which have permanently altered Owen’s life.
“For the first year, I was seeing my doctor, my massage therapist, my psychologist, my chiropractor, my physiotherapist two to four times per week,” recalls Owen. “It took over my entire life.”
Damning 2014 WorkSafeBC investigation
The highly publicized attack on Owen and a damning 2014 investigation by WorkSafeBC brought renewed attention to an ongoing epidemic of violence against health-care workers in British Columbia.
From 2010 to 2021, B.C. nurses reported nearly 4,500 injuries related to the use of violence or force that caused them to miss work to WorkSafeBC.
From 2017 to 2021, WorkSafeBC found workers in health and social services — a broad cross-section of professions that includes nurses, care aides and various medical staff — were roughly three times more likely to report a violence-related injury than the provincial average. Several high-profile violent cases have been reported in recent years, including a patient’s attack on a psychiatrist at Penticton Regional Hospital in 2014 which has left the doctor unable to work since.
But those only reflect cases where workers submitted those reports. In reality, some employees say they are punched, scratched, bitten, groped and shoved so often that many no longer bother filling out the paperwork.
“I don’t know if I could count. It really depends on the week,” Rhonda Bruce said. Bruce is a representative of the Hospital Employees’ Union and a rehabilitation assistant who has worked in long-term care for more than 30 years. She’s lost track of how many times she’s faced violence on the job.
“Sometimes it could be weekly. Sometimes it could be monthly. Sometimes it could be hourly,” Bruce said.
95 per cent affected by violence at some point in their career: Research
Research from Canada and the United States estimates violence affects more than 95 per cent of health-care workers through the course of their careers.
Emergency health workers bear a disproportionate amount of that. In a 2014 study of paramedics in Canada, about 75 per cent reported experiencing violence in the last year, three times the estimated average for other health-care workers.
BC Nurses’ Union president Aman Grewal said the true number of attacks is “significantly” higher because many incidents are never reported.
Violence has become so common, multiple sources told The Tyee, workers see it as part of the job and not a problem to report. And if they do report it and nothing changes, they’re unlikely to report future incidents.
“This isn’t acceptable behaviour in banks or grocery stores in any public forum,” Grewal said. “Yet it’s been so normalized in nursing and in health care.”
Pledge for more security guards
In late October, B.C. Health Minister Adrian Dix pledged to place 320 security staff at 26 acute care sites across the province where attacks are most common.
“This is not a situation we can afford or justify, and it is certainly one that we cannot endure,” Dix said at the time, hoping that health-care workers would “take comfort” in the announcement.
The Health Ministry did not make Dix available for an interview.
Workers and union leaders, though, believe the root of the problem is much more complex. They say the attacks on health-care workers are the result of short-staffing; a mental health and substance use crisis; a lack of trauma-informed care; a growing reliance on medications in long-term care and what one health-care leader could only describe as “pandemic rage.”
They warn that these problems aren’t just affecting the workers’ own health and patient care, but are pushing health-care workers out of the profession, deepening a human resources shortage felt across the country.
“It’s kind of a breaking point that happens with members,” Bruce said. “I see that a lot with members that all of a sudden they hit this breaking point? and often, they go off work and don’t return.”
Code white crisis
When Grewal began work as a nurse 35 years ago, she would occasionally hear a “code white” — a hospital alarm about a violent or aggressive person.
Today, she said they’re a regular part of life for her union’s members.
Vancouver Coastal Health and Fraser Health Authority did not provide data on the number and frequency of reported code whites to The Tyee by publication time, but did confirm the health authorities still use the code.
The people who commit violence are as varied and complex as their motivations.
“It can be anything from a parent of a child that’s upset that their child isn’t getting the care they feel their child needs in a certain time frame,” Grewal said. “You can have people with dementia who don’t have any control over their cognition who may attack a nurse. You may have people from the general public who will perpetrate these as well as patients, their family members, visitors. You just don’t know where it’s coming from.”
Attacks ‘significantly’ more common
In recent years, Grewal says such attacks have become “significantly” more common.
She said part of the challenge is an ongoing crisis of mental illness and substance use care that, without adequate preventative support, often results in patients seeking help in emergency rooms and in hospitals.
Often, Grewal said, those places have relatively few security staff, putting nurses in challenging situations where they are treating patients who may be violent or experience psychosis.
“Usually, it’s the nurse who is the lead in the code white. They’re the ones that are the hands-on people. They’re the ones that have to restrain the violent patient,” Grewal said. “We’ve had situations where people come in with RCMP and they’re handcuffed and they’ve got a few corrections people with them, and then they’re left alone with the nurse. They come in with this big entourage, then they’re left just with the nurse.”
16 per cent of comp claims related to violence, aggression
According to WorksafeBC data, 16 per cent of time-loss claims submitted by nurses working in acute 2010 to 2021 were related to violence or aggression. The proportion for long-term care was even higher at 18 per cent.
Bruce says that reflects the experience of long-term care workers, as a wave of aging people hit a system unprepared to care for their needs.
“The sites were very much designed for people that walked independently with walkers,” Bruce said. Today, many sites “have everything from people who are totally bedridden to people who have dementia and are wandering around.” About 60 per cent of residents in long-term care have cognitive impairments, according to the head the BC Care Providers Association Terry Lake.
In 2018, the BC Seniors’ Advocate reported 57 per cent of residents were categorized as having high or very high needs, up by three per cent in comparison to 2013. About 35 per cent of residents have Alzheimer’s or other dementias, said the report.
Bruce said the buildings themselves are often not designed to care for those patients. “One time I had come out of my office door and a resident grabbed me,” Bruce said. She moved to dodge away. “But if I was stuck in my office, I would have had no option,” she said.
Staffing shortages mean workers sometimes struggle to meet a resident’s care plan, creating more opportunities for something to go wrong.
Bruce doesn’t blame the patients. Some, she said, are living with dementia, or are on medications that make them unaware of their surroundings and actions.
“Where there isn’t enough staff, your workload increases. And then the tension on the floor increases,” Bruce said.
Violent or erratic behaviour in long-term care is not a new concern, but it is not well-tracked. A 2016 report from the BC Seniors’ Advocate outlined 422 aggressive incidents between residents in one year but remarked there was no standard system for reporting these incidents between residents or against staff.
A later report has also warned about the over-prescription of antipsychotic medications in such homes as a response to violent behaviour — something many say is a poor substitute for human interaction and other care that has dwindled particularly during the pandemic. The number of residents prescribed anti-psychotic medications rose by 10 per cent in the first year of the pandemic, seniors’ advocate Isobel Mackenzie reported, to 26.5 per cent of patients in 2021.
Bruce said she and other staff sometimes have to intervene when residents become violent with each other, and may face attacks themselves. Sometimes, Bruce said, they’re so short-staffed they don’t have the 20 or 30 minutes it takes to report an incident.
Staff often continue providing care to their attackers
Saleema Dhalla, CEO of SafeCare BC, said staff shortages mean many assaulted workers are forced to continue providing care to the patient who attacked them.
“We need more staff there to help when something goes wrong,” she said. SafeCare BC is an industry-funded nonprofit that educates workers, managers and families on preventing violence in long-term care.
“Many of our care aides are working overtime. And not a little overtime. A lot of overtime. This is the highest level of overtime I’ve ever seen. There never used to be overtime for care aides or housekeepers or dietary staff. Now it’s a normal thing for members to work overtime,” Bruce said.
Aly Devji, CEO of the Langley Care Society, said anger from families about their loved one’s care or being unable to visit or not wear a mask due to pandemic precautions can also boil over into verbal or physical violence.
It’s led to many care aides and nurses off on medical leave or leaving the profession altogether, he said, which interrupts the relationships that are so important for people with dementia, mental health challenges or who have previous medical trauma.
“The pandemic has been an exacerbating factor, but violence has always existed,” said Devji, who works with the industry-funded nonprofit Safecare BC to provide violence prevention training to long-term care workers, managers and families.
It’s a problem in acute care settings, too.
“Since the COVID-19 pandemic, the risk of incidences of workplace violence has intensified, necessitating a closer look at violence prevention efforts,” a spokesperson for Vancouver Coastal Health wrote in an emailed statement.
Victoria Schmid calls it “pandemic rage.”
Schmid is the CEO of SWITCH BC, an occupational health and safety organization for health-care workers created by the provincial government in 2020.
Before that, she was the leader of the Vancouver Island Health Authority’s COVID-19 response, where she saw firsthand how many members of the public took out their frustration on exhausted health-care workers.
“We are definitely hearing that it is becoming more frequent. I think pandemic rage is a real thing. I think people are really agitated and really pent up,” Schmid said.
At the start of the COVID-19 pandemic, people banged pots and pans on the streets in support of health-care staff. Within a year, the mood had shifted and Grewal says many of her members faced abuse from people frustrated with regulations or visitor restrictions or long waits. Schmid has no doubt it’s contributed to violence in the workplace.
“It is one thing to go to work every day when you feel people have your back,” Schmid said. “It’s a whole other thing to go to work when people are spitting in your face and yelling at you and telling you that you’re a witch because you think COVID-19 is real.”
`Eating your young’
It took over two years for Owen to return to work, where VCH had promised her a role in its violence prevention team when she was well enough.
She missed working directly with patients, supporting them with daily tasks like hygiene and re-learning to take the bus or order a coffee, but she knew she wasn’t ready to go back into that environment. “Seeing someone get back to themselves, feel clean and confident, that was a rewarding day for me once,” Owen said.
But after only six months back at work on VCH’s violence prevention team, Owen says it was the trauma and bullying she endured rather than her injuries that drove her from the health-care field entirely.
She says she felt belittled by the health authority, treated like a victim at work but pressured not to speak about the attack to colleagues or people she trained.
Owen shared emails with the human resources department and managers spanning four months in her new role with The Tyee. She repeatedly expressed frustration with being paired with co-educators long after her training was complete. She felt isolated and treated like a victim at work.
Before her attack, Owen was advocating for government to improve care for her teenage daughter, who struggled with undiagnosed mental health challenges and substance use. She says the health authority all but told her to stop doing so.
“I was beyond angry, just so frustrated that they just wanted to take away my voice,” recalls Owen. “My job was all about advocating for people to have a voice, to stop the stigma of mental health and addictions, and to support marginalized populations? I went into fight mode.”
She had spent the two years after the attack embroiled in union talks about her case, WorkSafeBC claims and investigations and criminal proceedings against her attacker, in between medical appointments and trying to support her daughter.
Decision to press charges
When she learned the patient, who she doesn’t blame for attacking her, had harmed other health-care workers in the past during the course of the WorkSafeBC investigation, she was livid. Determined to make sure no one else was put in danger, she pressed charges.
“Charging an individual who I do not hold accountable for his actions has been one of the most difficult decisions that I have ever had to make,” wrote Owen in her victim impact statement at the time. “There is absolutely no doubt in my mind that if I did not do something extreme then he would end up killing someone.” (The patient was convicted and is now in a forensic hospital.)
The WorkSafeBC report found many failures to keep Owen safe, including failing to note the risk of violence in the patient’s chart, the lack of a proper transition from Riverview Hospital to community services and failure to check panic alarms. They had all cost Owen her health and career, it found.
At the time, VCH accepted the report entirely, implementing its recommendations and paying a $75,000 fine ordered by WorkSafeBC. “There were gaps in the system and the systems now put in place are focusing on physical layout and staffing and education,” the then-head of workplace health told the CBC.
Reading the findings made Owen even angrier.
“In the report and in my work with VCH, I was reading all these policies they said were in place to prevent what happened to me, but it was everything that didn’t happen the day I got beat up,” said Owen. “And seeing all that was so triggering.”
Vancouver Coastal Health declined to comment on Owen’s specific allegations, citing privacy legislation.
In an emailed statement, a spokesperson for the health authority said staff safety is a top priority. It noted all sites are assessed for risk of violence and staff are trained in prevention and de-escalation.
“VCH regularly reviews practices to tailor the best approach to keep staff safe, which includes creating customized enhanced disability management plans that support and accommodate injured workers in returning to work,” read the statement.
A staffing crisis
Schmid’s organization SWITCH BC was created in 2020 as the result of collective agreements between health-care unions and the provincial government.
Previously, a different organization with a similar function supported health and safety training for health-care staff in the province. But it was defunded in 2010, right when many health-care workers anecdotally recall the rates of attacks rising.
One of Schmid’s first priorities is crafting a renewed violence strategy and new training for workers, a job she says will be done in 2024.
Training already exists, she said, but isn’t always available in-person. Many of the resources are in English, she said, even though a large number of health-care workers are women from countries where that isn’t the main language. And while health authorities have a good idea of who has received the training, Schmid said, it’s harder to get that information on the provincial scale. “This curriculum hasn’t been updated in six years. There’s been a lot that has changed in health care,” Schmid said.
One of the most common reasons health-care workers cite for the rising rate of workplace violence is inadequate staffing.
Schmid said that is part of a series of connected problems that are eroding the resilience of workers in the sector.
“You come to work with your own resilience, and the system beats it out of you every day, and you go home and that’s not how it should be,” Schmid said.
One of Schmid’s worries is that the level of violence in health care is pushing people to leave the sector earlier, or not enter it at all.
“We have a younger generation that also isn’t willing to put up with some of that ‘eating your young’ culture that we may have had in health care before,” Schmid said.
Women bear brunt of distress, finds SFU research
Recent research from a Simon Fraser University professor suggests women health-care workers in particular bear the brunt of distress and moral injury, damage caused by being forced to act in ways you feel are against your moral and ethical obligations, on the job. But they also often have the least power to make structural change that would alleviate it.
Violence is a huge part of that. Researcher Julia Smith spoke to one B.C. nurse who said she placed a red dot on the calendar for every day her unit had a violent or aggressive incident.
After one month, the calendar was a sea of red and she stopped tracking it.
“Most of the solutions proposed focus on the individual, like counselling and therapy, and not at the systemic level which would require proper staffing levels and decision-making powers for staff to run units in the best interests of their patients,” said Smith, an assistant professor in the SFU faculty of health sciences.
Placing the burden on the individual to prevent violence and heal when it does happen, rather than the system to change, is what allows this violence and distress to continue, said Owen.
Government and health authorities “know what’s happening, but they don’t want to put in the resources or fund solutions,” she said. “And yet it’s these health-care workers who are showing up and doing their job every day.”
Grewal said Dix’s announcement of new security staff at select B.C. hospitals is a good first step. But she’d prefer it be offered everywhere.
“It should not be on the nurse to be the one also providing security services for themselves, for their patients and the families that are visiting. That is not what nurses went into nursing for, to be security as well as providing care to their patients,” Grewal said.
Dhalla and Devji want to see the same attention paid to long-term care as is paid to acute care.
“This is reminded to us many times: these residents are here for a reason,” Bruce said. “But how do we keep ourselves safe, too? I don’t think we have the perfect answer to that.”
Owen has mixed feelings about the announcement of more security staff.
“It’s what should have happened 10 years ago,” she said. “They knew what was needed when I got attacked, and it took them this long to act.”
Owen says preventing the violence in the first place would take a systemic shift.
The health care environment she tried to help navigate for her daughter, her patients and then herself is deeply traumatizing, Owen stressed. And that trauma breeds distress, and in some cases, as she knows all too well, violence.
“We have to ask ourselves why are people violent in the first place?” Owen said. “If there was more compassionate care, maybe they wouldn’t lash out.”
In 2015, she quit her job and moved to Victoria, a fresh start. She had been in fight mode so long, she only realized how truly, deeply burnt out she was when she was away from it all. Taking in new information and listening to music was difficult and still is. She often felt her mind go completely blank, overwhelmed by a conversation or a new task. At times, she struggled with suicidal thoughts.
“It took me a year to begin to feel even a little OK,” said Owen. Once a high-level soccer and ultimate frisbee player, Owen had to stop sports due to her injuries. She still has chronic neck and shoulder pain. And when she began training her dog Indi out of her behavioural issues, Owen realized she had to regulate herself if she was going to help the pup.
That realization spawned what has been a healing second career, training hundreds of dogs with behavioural issues and supporting their owners. “Most people work with the dogs, but I work with the people,” said Owen.
Owen credits the attack with leading her to a better path. Her fears for other health-care workers, however, still haunt her. Leaving was her only option, but she knows many others don’t have that opportunity.
“All people ever hear about is the incident, not the full impact of how it absolutely changes your life,” said Owen. “But if this happens to you, nobody else really cares. All they care about is that I’m gone. And don’t ever think it’s not going to happen to you.”