Pandemic underlines desperate state of long-term care in Ontario, book says
Authors portray environment rife with violence, underfunding, understaffing
When the pandemic began, healthcare researchers Margaret Keith and James Brophy feared what was coming in long-term care homes and hospitals across Ontario.
They had spent three years interviewing workers about violence in health care and were shocked at what they had been hearing: Regular physical and verbal assaults had become almost routine in a system that was badly understaffed, underfunded and unsupported.
When the pandemic hit, things got worse.
“We were certainly aware that long-term care, in particular, was at the breaking point,” said Brophy. “The lack of support, understaffing and underfunding had all created a climate in which you could just see that disaster could occur. And that is what happened.”
Brophy and Keith, who both have PhDs in occupational and environmental health and are affiliated with the University of Windsor and University of Stirling in Scotland, were just wrapping up years of work on a book about violence in Ontario's health-care system when the pandemic hit. It provided more disturbing material.
That book, Code White: Sounding the Alarm on Violence Against Healthcare Workers, has just been published. A code white in health care is an emergency response to a violent incident.
In an interview, Brophy and Keith said there is a direct line from the rampant violence reported by health-care workers before the pandemic to the devastation that hit long-term care homes, in particular, during the pandemic.
Ontario was among the worst jurisdictions in the world for deaths and infections among long-term care residents during the pandemic. More than 3,700 long-term care residents have died and more than 15,000 have become infected, so far, during the pandemic. In addition, 13 long-term care staff died and more than 7,200 became infected. In Ottawa, 289 long-term care residents died from the disease.
Not only did the lack of staffing and support worsen conditions in long-term care — something that was highlighted when the military went in to hard-hit homes and found residents uncared for and unfed, in some cases — but violence against health workers increased.
Before the pandemic, the authors heard countless stories from health-care workers about being badly hurt, ending up with concussions, missing teeth or broken bones, by patients and their families who often lashed out in frustration about long waits and systemic issues. Because of low staffing, it was more difficult for workers to have support to help prevent injury.
Workers said they were often blamed and silenced when they were injured. Brophy and Keith said they were shocked when they began hearing about the routine violence against health workers, which they hadn't previously been aware of. That is largely because nurses and others are afraid of speaking out for fear of losing their jobs. Three women who worked on the studies that informed the book lost their jobs — one of them, a nurse, was fired after being quoted in a media release saying there is a problem with violence against nurses in Ontario. It took two years for her to be reinstated through arbitration.
When the pandemic began, all those stresses got worse. “Once again, they were expected to work in untenable conditions and now we had a virus putting them at further risk,” Brophy said. In addition, Brophy and Keith said the lack of appropriate protection offered to health-care workers was another layer of harm done to them.
Nurses and other health workers fought for the right to wear more protective N95 masks from the beginning of the pandemic, but were told they didn't need them. Only recently has the Ontario government acknowledged COVID-19 can be airborne, as numerous studies have found.
One nurse, who was told to go into a patient's room and was denied an N95 mask, later developed severe COVID-19 and was asked to continue working until she became too ill to do so. Her colleague told the authors the nurse has recovered physically, but might never be over the emotional toll of the experience.
The authors quote a hospital nurse hoping lessons are learned from the pandemic that will make the system safer.
“At the end of the day, the silver lining of this pandemic is that it has brought to light the dismal condition that health care is actually in. Hopefully, after this pandemic is over, we will build on it and fix what is broken and move forward and build on that so the next time — and there will be a next time — we are ready for it and we won't be in an unsafe situation like this ever again.”
Among their recommendations to reduce violence against healthcare workers are: increased staffing levels; increased funding; and engineered solutions, such as securing loose furniture, erecting barriers and improving sightlines so workers in trouble can get help quickly. They also recommend strategies to reduce agitation among patients and residents; better communications in hospitals and LTC homes; and violence-reduction strategies for workplaces, among other things.
The authors said work should begin now to ensure that in any future pandemic, protective equipment is available and the precautionary principle is followed — meaning workers must be protected against airborne transmission as a precaution even if it is not yet proven. That, critics say, could save lives.
“We are hoping that people will read this book and start to demand changes,” Keith said. “We need to defend this precious public health system.” Code White is published by Between the Lines.