When a nurse is attacked, others suffer
PTSD a side-effect of working in health care — the most violent workplace of all
As a nurse toiling the overnight shift in the cramped emergency room of the Montreal General Hospital, Sarah has faced all manner of abuse over the years.
She’s been called a “f---ing bitch” by patients angry for having to wait hours on end. She’s received death threats by others coked out of their minds. She’s been spat upon, bitten and punched, sometimes by elderly patients with advanced dementia.
“The most aggressive patients we have, to be honest, are not in the psychiatric emerg,” she said. “They’re in the rest of the emerg. The trauma cases and those taking drugs and alcohol, they are the most aggressive we have — and they are often in the middle of the other patients.”
Sarah didn’t want her real name published because her managers warned the ER staff not to talk to journalists after the near-strangulation of a fellow nurse last September. But Sarah and others nonetheless spoke to the Montreal Gazette to counter the assertion by the head of public affairs, Richard Fahey, that the assault on the nurse was a “rare act of violence.”
They say that violence against hospital workers is a daily reality, and it’s only gotten worse as the Montreal General has slashed costs under pressure from Health Minister Gaétan Barrette.
A study last year by the provincial workplace safety commission, CNESST, revealed that health-care employees are subjected to more psychological and physical violence than any other profession, including law enforcement. The study also found that violence in the health sector rose by 8.3 per cent from 2012 to 2015.
The health sector reported 664 cases of violence against workers across the province in 2015, the latest year for which complete figures are available. That works out to an average of almost two incidents a day. By comparison, the teaching profession reported 420 cases, the second-most-affected sector.
Stéphane Guay, director of the trauma research centre at the Institut universitaire en santé mentale de Montréal, suggested that nurses and patient attendants are more vulnerable to violence, in part because of all the problems plaguing the public health-care system.
“The health sector is the milieu where the volume (of services) is the greatest because of the sheer number of workers as well as the number of patients,” Guay explained.
“Logically, we can easily understand that the risk of violence increases due to the fact that there are fewer services to patients or greater delays to receive service, and there’s a (corresponding) impatience and frustration.”
Guay noted that there’s also a heightened risk of being injured in psychiatric institutions like the Institut Philippe-Pinel de Montréal, which specializes in treating highly mentally unstable patients, some of whom might be violent or sex offenders.
The study by CNESST observed that post-traumatic stress disorder is common among employees who have been attacked. That observation is borne out by Sarah’s experience.
“I know that I’m suffering from PTSD, that’s for sure, for years,” she said. “I’ve developed hypervigilance. I’ve been diagnosed with general anxiety disorder. We work in a violent environment. Everybody feels entitled to be so aggressive with us.”
In the days after the nurse and the orderly who defended her were assaulted, the ER staff were on edge, double-checking panic buttons and doors. They were also boiling with rage. Guay noted that such reactions are not only to be expected, but this a known phenomenon in trauma research.
“In a hospital milieu when an incident of physical violence occurs, there are a lot more witnesses than direct victims,” he said. “These people can also be affected by the events. Our research has shown that they experience posttraumatic stress symptoms that are similar to the direct victims — like the nurse who was nearly strangled.”
Guay urged hospitals to provide more support to injured health workers in the form of individual and group therapy. “It’s not simply sending someone to the employees to do a debriefing for an hour. That’s inadequate.”
At the Montreal General, the injured nurse and orderly have each received psychiatric care. The Montreal General also offered through its employee assistance program group therapy to those who sought it.
Ultimately, Guay recommended, the solution lies in extensive training that emphasizes prevention of violent incidents as well as crisis de-escalation. Guay authored a study that demonstrated the effectiveness of such training, known as the Omega method.
The four-day training teaches health workers how to identify patients who pose risks and how to speak to them to de-escalate a crisis, among many other techniques.
“This is something that’s needed in the health-care system right now,” Guay said of the psychological support and training. “That’s where the most significant improvements need to be made.”
Union leaders, however, have accused Barrette of underfunding the health-care network. They say that’s certainly true at the McGill University Health Centre, which has been forced to chop more than $120 million from its operating budgets since 2012.
Denyse Joseph, the former president of the Union of Nursing and Cardio-Respiratory Professionals of the MUHC, blamed both Barrette and the Montreal General administration for the security breaches.
“The government, the health minister, is approving the budget,” Joseph said. “But at the same time, it’s the MUHC administration that decides what it does with the money, and it didn’t allocate the funds for more nurses and more security guards.”
Barrette, for his part, acknowledged that training must be improved, but he denied that the root cause is a lack of resources.
“I think it has to be about continuous improvement, continuous awareness, training of personnel to detect those people who might pose a gesture that is inappropriate,” he said in an interview in September.
“I think we have enough resources in terms of security as of today,” Barrette added. “I cannot predict (what’s) down the road. If you look at the U.S. where you have armed security guards in ERs, you see events that cannot be prevented — even in those kind of environments. One hundred per cent security is impossible in the health-care sector as it is.”
More than four months after the nurse was throttled by a patient, Sarah said she’s noticed a change in the culture of the ER.
“The nurses around me are more aware that it’s not acceptable for some people to talk the way they talk to us,” she said. “I see a lot of nurses telling patients, ‘OK, that’s enough. Stop talking to me like that.’
“As for myself, I’m writing down incident reports when I have somebody who’s aggressive toward me,” she added. “I usually didn’t fill out those reports because we don’t have the time during our shifts, but I’m doing it now. We’re told that every time something happens, fill out an incident report so we can have more statistics and ask for more of a budget.”
Finally, the ER staff are more emboldened than ever to hold the hospital administration accountable.
“We’re going to keep putting the pressure on.”
Our research has shown that (witnesses) experience post-traumatic stress symptoms that are similar to the direct victims — like the nurse who was nearly strangled.