Podcast

Code White: Protecting ED staff from workplace violence

January 27, 2022 CMA

Code White is a measure used in many health care settings to alert workers to a real or perceived threat of violence. These days, the codes are being declared more frequently, especially in emergency departments. Join Dr. Howard Ovens as he shares what his colleagues endure every day, including verbal and physical abuse and sexual harassment, and find out why the Canadian Association of Emergency Physicians is calling for a national plan to improve safety and security in emergency departments.

"The pandemic has escalated all of this because everybody's testy and patients and families have shorter fuses. They’re acting out, especially around things like visitor restrictions and wait times. And with masks on, it's harder to establish rapport and a human connection... The entire atmosphere is much tenser, and it's contributed to an exodus from the profession.” - Dr. Howard Ovens, Emergency physician

In this episode, host Dr. Caroline Gérin‑Lajoie also speaks to medical psychotherapist Dr. Marcia Kostenuik about steps health care workers can take to prevent patient abuse and how they can recover from emotionally-charged interactions.

This episode is available in English only.

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Code White: Protecting ED staff from workplace violence

Dr. Caroline Gérin-Lajoie: Welcome to season two of Sound Mind, a podcast about physician wellness and medical culture. I'm your host, Dr. Caroline Gérin-Lajoie.

Dr. Caroline Gérin-Lajoie: Code white is a term used in many healthcare settings to alert workers to a real or perceived threat of violence, and sadly, more are being called on a regular basis, especially in emergency departments, or EDs. Just listen to these sobering statistics. Healthcare workers face four times as great a rate of workplace violence than other professions. More than 50% of emergency department nurses will be sexually harassed or assaulted this year, and more than half are physically or verbally abused in any given week. And nearly 70% of emergency physicians say ED violence increased in the past five years, contributing to an already high ED physician burnout rate.

Dr. Caroline Gérin-Lajoie: Recently, the Canadian Association of Emergency Physicians, or CAEP, called for the development of a national safety standard, which outlines best practices, benchmarks, and comprehensive plans for improved safety and security in emergency departments. They want hospital administrators to make full and complete efforts to help address the rising incidents and increasing toll of emergency department violence.

Dr. Caroline Gérin-Lajoie: Later in the podcast, I will speak with Dr. Marcia Kostenuik about how physicians and nurses can better predict interactions that are likely to become violent and what steps they can take to prevent abuse. But first, let's step inside the ER through the eyes of Dr. Howard Ovens. Dr. Ovens is an emergency physician and former director of the Department of Emergency Medicine for the Sinai Health System in Toronto, Canada. He is a current member of the CAEP Public Affairs Committee. We asked him to describe a workplace incident that stands out in his mind.

Dr. Howard Ovens: The first one was this incident where I was on duty, and the police brought me this man from another emergency department. He was drunk in a park, sleeping on the ground, had not asked for any help. Probably does this most days of the week. A good-intentioned citizen called 9-1-1, and he was taken to an emergency department. A nurse was taking his vital signs at triage. He roused. In his stupor, I don't know his personality, I don't know his character, he reached out and groped her. She was tremendously angry, insulted, traumatized, and called the police. She wanted him charged with sexual assault.

Dr. Howard Ovens: The police came. He went back to sleep in his alcoholic state. When the police arrived and roused him, he got startled and tried to run away. The police chased him. In that ensuing encounter, he fell, hit his head, and suffered a laceration, which required repair. The emergency department that he was in said, "We will not repair him. He's no longer allowed here, because he assaulted one of our nurses," so they brought him from one emergency department to another emergency department. He had started to sober more. Didn't recall groping the nurse. Was polite, apologetic, remorseful, and absolutely horrified to be facing a charge of sexual assault. The police were actually, as I was repairing his wound, talking amongst themselves about the dilemma of having to charge this guy with a serious crime versus understanding the nurse's position of being fed up.

Dr. Howard Ovens: The other thought I had is I could understand that nurse would not want to provide care to that patient, but why transfer him to another emergency department? Were my nurses more deserving of potential abuse from this guy than the nurses at the other department? What was the logic behind saying, "Take him to another emergency department"? And of course, there is this movement to have zero tolerance. In the absence of hospitals really doing their job to provide a safe workplace for our staff, staff are taking it into their own hands, and they're declaring zero tolerance. The dilemma they're creating for some of my physician colleagues is they're asking them to support an eviction of a patient who they feel has crossed a line before that patient has really been assessed for their medical state, their mental competency, and responsibility for their actions.

Dr. Caroline Gérin-Lajoie: Dr. Ovens shared this experience in an email thread with colleagues at CAEP, and the response caught him off guard.

Dr. Howard Ovens: I had just been offline for a few hours on duty or something. The thread just exploded with people from all over the country sharing similar stories. I was like, "Oh my God, what's going on?" This was pre-pandemic. A lot of it was behavior that was fueled by the methamphetamine crisis, because meth users tend to be particularly agitated and act out a lot verbally as well as, at times, physically. They're found in every community, and they also are very, very at risk for a lot of serious medical complications.

Dr. Caroline Gérin-Lajoie: That nationwide reaction prompted Dr. Ovens to write a blog post that helped inform the CAEP position statement on violence in the emergency department. As he says, this was all before the pandemic. He finds behaviors have only become worse as hospitals battle wave after wave of COVID-19.

Dr. Howard Ovens: The pandemic has escalated all of this, because everybody's testy, and patients have shorter fuses, families have shorter fuses. The people who are responsible for their actions, some competent patients, many family members are acting out, especially around things like visitor restrictions as well as wait times. And of course, with masks on, it's harder to establish rapport and a human connection, and I think that the resilience and tolerance of the staff to put up with this stuff is also lessened. The entire atmosphere is much tenser, and it's contributed to exodus from the profession, especially by nurses, and a staffing crisis. And of course, it's a death spiral, because if two of your colleagues call in sick and you're working with two colleagues who are new grads who aren't really experienced, and you're an experienced nurse and you're supposed to cover more of the department and support the junior colleagues, you're just even more overwhelmed and fragile, and it just takes off from there. It's a real crisis. The solution to it, primarily, is on hospitals and governments to financially support hospitals to provide a safe place for patients and staff to do their work.

Dr. Caroline Gérin-Lajoie: The stress of the emergency room environment is not only provoking troubling behaviors in patients. Physicians are noticing it themselves and in their colleagues.

Dr. Howard Ovens: Just before Christmas, I was on duty with a young colleague. Very hard-working, conscientious guy. He was handing over at the end of his shift to me and giving me a couple of stories. After he told me the second story, I said, "That's fine." I was waiting for him to say something, and there was a long silence. I looked at him and I said, "Something else?" He said, "I just lost it with a patient." I said, "Well, what happened?"

Dr. Howard Ovens: The patient was not particularly acutely ill. They had a bit of an agenda. There was an intervention they were looking for to be granted by the emergency department. My colleague had done a careful and conscientious assessment, felt that intervention wasn't indicated, and tried to explain this in a very patient and constructive manner, and the patient greeted his explanation with dismissive sarcasm. He said he just felt like that's the last straw, turned away, walked away from her, kicked a garbage can as hard as he could. This is the story he told me. Did one lap around the department, went back in and said, "You don't trust my advice, and I can't put up with any more sarcasm from you, so please just leave." As losing it goes, that was fairly mild, but it was very troubling to him. He really felt horrible. He said, "I'm tapped out." He said, "I have zero empathy left." That's a fairly typical story. I'm afraid we're going to lose him from the discipline, is my big fear, because he's a guy who's about five years out. He's just getting to the peak of his skills, and we should get another 20 years out of this guy. I'm afraid we're losing a lot of people, so I worry about the future of emergency services in Canada, actually.

Dr. Caroline Gérin-Lajoie: Dr. Howard Ovens is an emergency physician at Mount Sinai Hospital in Toronto. The CAEP statement pointed to the structural changes hospitals need to increase safety in emergency rooms, including better staffing ratios and improved security measures. But it also advocated for staff training to recognize aggressive and escalating behaviors and deescalation training for all emergency staff. Dr. Marcia Kostenuik is an expert in exactly this kind of work and has years of experience working in the ER. She is also a medical psychotherapist and a frequent presenter on physician wellness. Dr. Kostenuik, thank you for joining us.

Dr. Marcia Kostenuik: Thank you so much, Caroline. It's a joy to be here.

Dr. Caroline Gérin-Lajoie: Can I start by asking you a little bit about your career trajectory from working in family medicine, in emergency medicine, and also in medical psychotherapy?

Dr. Marcia Kostenuik: Sure. We're all reluctant. A lot of us in medicine are reluctant to share our personal stories, but it's one of the things I teach in physician wellness and burnout prevention. We need to share our stories to be authentic, to be vulnerable, and I always hope that I can share in a way that's also professional. I think that's good role modeling for the rest of us to show that we can share without creating so much vulnerability that we're too uncomfortable, so I'll do my best.

Dr. Marcia Kostenuik: Yeah, I loved working in the ER department. I was there about 10 years in a very busy Ontario emerge department. I loved the work, but one thing I found is that the physicians and staff didn't really have a great handle on dealing with mental health problems, and it was one of the things that made them want to quit or not show up. And often, I would show up for my shift, and they would all just usher me to the psych room, they called it at the time. Somehow, I became the go-to.

Dr. Marcia Kostenuik: I got learning, especially about borderline personality, self-harm, suicidality, overdoses, especially when I found out that suicide was the number one killer of young people, and really going all the way into maybe around age 40, 44. This was killing more people than all the other stuff that I had been trained to deal with, like diabetic ketoacidosis and MIs and cancer, at least in that age group. It seemed to me important to try to get good at it or skilled at it or have some way of coping. I ended up speaking and writing on suicide prevention and adolescent suicide prevention. And then at one point, I actually lost a dear friend and physician colleague to suicide, which was quite overwhelming, so I ended up focusing on physician health and working with the physician health program, saying, "Please, I'm happy to take the referrals," focused my training into medical psychotherapy and a whole bunch of different modalities, and physician wellness and burnout more specifically.

Dr. Caroline Gérin-Lajoie: You're still doing a lot of work with ER physicians at the moment, and you spend quite a bit of time in the hospitals. Are you seeing the kind of patient behaviors Dr. Ovens is describing?

Dr. Marcia Kostenuik: Absolutely. Some people know I've been dealing with my dad's sudden failing health. He was diagnosed with a brain tumor. I've been to multiple hospitals, emergency departments in Toronto, and outside of Toronto. And I, while I'm there, ask everybody how they're feeling, how they're doing, and how work is going. I saw a woman was in her bare feet, walking from outside to inside, yelling. Her husband was screaming. They kept threatening to call security and police, and everything was escalating, and I was just trying to help my dad stay calm and breathe. We're definitely seeing it.

Dr. Caroline Gérin-Lajoie: Of course, the pandemic has added another layer of stress to an already stretched system and culture. How is this changing your approach to working with physicians, and have their challenges or struggles changed through the pandemic?

Dr. Marcia Kostenuik: I think when I speak to large groups, physicians, even individual physicians, I always try to put myself in their shoes. I worked during SARS in the ER department, and it was... We had full hazmat suits at the time. I really like to show them, "I know where you're coming from. I've been in the front lines, and I'm seeing what's going on right now." I can't give them a long, complex explanation and understanding of what's going on neurobiologically and all of the theories, although that's very interesting. What they need is a rapid solution.

Dr. Marcia Kostenuik: Some doctors are saying things to me like they're so ready to snap. What did Howard say? Testy, short fuse, acting out, right? The last straw. All of these expressions. One of them said they were thinking they might "go out in a blaze of glory." And I said, "Please do not do that, for your sake, for others' sake, because this isn't going to do any good to anybody." I was thinking about the concept of just having physicians return to professionalism, just our professional standard, that first day of medical school, our oath to do no harm. I think the return to professionalism, what I'm meaning is I don't expect you to feel empathy. That student was just being brutally honest. He was saying, "What's come up for me? Oh, empty, no empathy." Right? Well, I can't change that. I would validate and say, "Wow, that's how you're feeling. That's a sign of how exhausted and really a sign of burnout."

Dr. Marcia Kostenuik: In that case, we can actually shift into cognitive empathy. That's just intellectually knowing this person is suffering. Doesn't mean you like them, doesn't mean you have a lot of strong feelings of empathy for them. Once you understand that and you understand what's happening in you, you can actually shift to just compassionate action, or at least neutral action, or stepping away or taking a break or asking a colleague for perspective, doing the breathing practices. I've taught it with the CMA Wellness Connection. Quick, simple practice. It takes a minute or two. It can get you back in your prefrontal cortex, out of that amygdala hijack, and you're able to at least respond professionally. It doesn't have to be perfect and you don't have to feel all warm and fuzzy, but it would be great for you and others to try to do no harm, and at least use cognitive empathy if possible, and respond with a small gesture that will reduce the other person's suffering. That would be ideal. That's compassionate action. Yeah.

Dr. Caroline Gérin-Lajoie: So much of the physical and verbal abuse seems out of the physician's control, whether it's due to poor staffing levels or a lack of security measures. What can physicians do to prevent a situation from escalating?

Dr. Marcia Kostenuik: Yeah. This is a great question, and I worry a little bit in answering it, about creating that exact situation where I'm putting too much on the physician and nurse, and I'm not being empathetic and understanding enough to their situation. I would probably rewind back to the system level at that point and think exactly what you're saying. What could be done to prevent it, but even earlier, even before, in Howard's story, before that nurse is exposed to the groping patient? What could be done to anticipate that at a system level?

Dr. Marcia Kostenuik: First of all, number one, we need to know what workplace violence is. Most of us, like me, we didn't even consider it workplace violence. I certainly never reported it. I was part of the problem by not recognizing that. And then we don't empathize with our colleagues and say, "Oh my goodness, what an awful thing you went through." And the administration, the staff, the colleagues, everybody has to be on board, because... I think, Caroline, you would know. With PTSD, post-traumatic stress disorder and trauma, what creates that is the lack of support at the time of the trauma. If people feel supported by their colleagues and staff and administration, they don't develop such long-term trauma.

Dr. Marcia Kostenuik: The doctors I talk to say, "You're the first person I've told this incident, and it happened 37 years ago." Some of them are retirement age. They tell me about a trauma they experienced in residency. I get that one a lot. Yeah. The solution I've read about is the rapid reporting system. After you teach all of your staff, what is workplace violence? This is what it is, so don't miss it. You need to be able to report it. What they found is reporting was too difficult and cumbersome and took 20 minutes in a new EMR system no one could find. It should take one to two minutes to complete, and you put the patient name, the number, brief description of the incident, and that's pretty much it. And it needs 100% backup from administration or whoever's listening to it so it doesn't fall through the cracks.

Dr. Marcia Kostenuik: Then you need security, you need the zero tolerance, you need the police called, you need charges pressed. All of that stuff, which I didn't know when I looked into this and it's not how I worked. And then you need to have it reported in the media, which is surprising. Some people thought that wouldn't help, but it does help, because it sends a message to the public. This is not okay anymore. Never was, but it's certainly not okay now. Charges were pressed. That's going to support our physicians. That can be part of the policy. Very practical. And the data that I read was impressive on what a huge change this made in the emerge department. There was at least a 50% change in people recognizing what is workplace violence, and they were more than happy to report it when they knew it would be quick and it would actually be responded to.

Dr. Caroline Gérin-Lajoie: We hear about ER staff, both nurses and physicians, saying that they have to drag themselves into work every day. They are demoralized, exhausted, burned out. How can they manage these feelings?

Dr. Marcia Kostenuik: Oh, that's such a good question. I have such a strong visual image of staff sitting in a parking lot and just almost going through that, "Do I go in, or do I not go in? Am I going to drive home? Am I going to snap? What's going to happen?" What an awful image. When I work with individual physicians, they'll describe that moment, where they were sitting in the car, or wherever they were, deciding. "Can I even go in?"

Dr. Marcia Kostenuik: It's like a trauma response, and it's almost trying to keep you away from the stimulus, from the associated place that is causing you pain, suffering, fear, increased heart rate, increased blood pressure, increased cortisol levels, and then we bypass all of that. They can disconnect their mind from body and just push through it anyway. They push through that instead of mindfully sitting there and saying, "What's coming up for me? It's exhaustion. I haven't slept. I've had nothing to eat. My kids haven't seen me. I'm having difficulty in my relationship at home. I haven't spoken up to someone at work that I need to, or I'm still afraid because last time I was here, I got punched or I was assaulted or it was unsafe for my colleague and I'm afraid it might be unsafe for me." To spend some time mindfully checking in with oneself and saying, "What's going on with me? What is the nature of this? I can't even bring myself there. Could be physical exhaustion, mental, emotional. It could be an element of burnout."

Dr. Marcia Kostenuik: That dread of going in, I think we need to pay attention to it and not only push through. That's your sign that something is not in balance, and it could be that you don't feel safe. But again, it's not to negate the importance of the system-level issues. But my experience is there's going to be no perfect system-level solution. Those things all have to happen, but in the end, there will still be some times that you are unsafe. I think what we can do is be aware. Be aware of your surroundings. What's going on? Who's in the department? What did you just hear over the PA system? Who did they just bring into trauma room? What's going on? Be aware. Be aware of your surroundings. Talk to someone, step away, take a break if you need to. Please don't snap. Be safe. Do whatever it takes to make yourself safe.

Dr. Marcia Kostenuik: I think you can also change your voice, lower yourself. I'd often sit in a chair or try to be lower. Don't fold your arms, don't look and sound scary. Doctors are automatically scary. Even if you're a tiny woman, you're scary to patients, because there's a power differential. That's trauma-informed care that we all should be trained in, in medical school. We have to actively work at seeming safe, and then the amygdala settles down. If they can't see your smile because of a mask, smile with your eyes, smile with your voice, turn your head, lower yourself, show that you're not intimidating. "I'm not going to hurt you." And communicate with your colleagues, look for support, share. And if you're the colleague someone comes to, don't say, "Oh, that's nothing. I was punched in the face." Please listen and support your colleagues. That's going to help all of you.

Dr. Caroline Gérin-Lajoie: Dr. Ovens talked about the ER physician who felt badly about their reaction to a verbally abusive patient. Is there a different approach in this circumstance?

Dr. Marcia Kostenuik: Yeah. This is hugely important. It's the heart of the work I do in psychotherapy and coaching one-on-one with physicians. How do we work with our own emotions? I think of this as repair, and you would know from psychotherapy. We call it a fracture in the therapeutic alliance, or a microfracture. Even just the tiniest little slight that breaks down that trust and safety in the doctor–patient relationship can and should be repaired in psychotherapy. That's not something I learned in emergency medicine, but really valuable and something I learned intuitively and through my experience. If you messed up, you can just be aware. "I messed up. It feels bad." I would say that's normal. We all mess up. You can use self-compassion and say, "Wow, that was a really hard situation. It was difficult. Nobody wants to be in that kind of situation."

Dr. Marcia Kostenuik: I also say, "Be compassionate with yourself, but do allow yourself to feel bad a little bit. At least a little bit, just to go there. It shows you do have some empathy and compassion, you care." And then I like to look at... I teach physicians about guilt being adaptive guilt or maladaptive guilt. If you feel guilty, be mindful. "I feel that a lot of guilt is coming up." I sometimes tell doctors, "Turn your guilt down to about a three out of 10," because they usually feel it at an 11 out of 10. I say, "Let's just dial it down for a moment, just as an experiment, down to three out of 10 guilt so that we can work with it." And now let's see. Is it adaptive or maladaptive? If you hit the patient over the head with the bed pan, your guilt is adaptive. It's normal and healthy for you to feel guilty. If you feel guilty that you didn't respond perfectly, that would be maladaptive guilt. You can't expect to that. You have to look at it realistically.

Dr. Marcia Kostenuik: I think to be honest with yourself helps. I love the method of observe and describe that's borrowed from DBT, dialectical behavior therapy. I'll tell physicians things like, "Tell me the whole story, but just as an observer. Describe it factually. If there's emotion, just describe the emotion factually. 'I noticed I was feeling anger.' But take out all the judgment, all the blaming, all the name calling. Just give me the facts." This can really help them. I think, at that point, you can also understand the chain of events. What triggered you? This is an important insight to keep you safe the next time.

Dr. Marcia Kostenuik: And rewind further. What were the vulnerability factors? You hadn't slept, you hadn't eaten, someone else was just yelling at another doctor, a nurse cried to you and said, "I can't take this stuff anymore." Who knows? Maybe you had an argument at home. Try to pay attention to your vulnerability factors and the trigger, and then I would say to repair what is necessary or what you can. Try to learn from the experience, because you've done those earlier steps, and then you might need some new skills if this is something you do all the time. Decide if an apology or some reparative action is needed. Sometimes, you can call the patient back. Sometimes, they can get another visit. Maybe you missed something. Maybe you didn't prescribe what you were supposed to. We're just human. We're not perfect. Feel your feelings, allow some guilt, but don't expect yourself to be perfect. It's a tough job. Yeah.

Dr. Caroline Gérin-Lajoie: Marcia, thank you so much for spending time with us today, and thank you for sharing your wisdom and your experience in the important area of physician wellness.

Dr. Marcia Kostenuik: Thank you so much. I'm really grateful to get to share with all of my colleagues across the country. I appreciate your wonderful questions, and it's always such a delight to get to work with you. Thanks.

Dr. Caroline Gérin-Lajoie: Dr. Marcia Kostenuik is a physician and medical psychotherapist. You've been listening to Sound Mind, a podcast about physician wellness and medical culture. Sound Mind is produced by PodCraft Productions. If you're looking for resources, tools, and research on the topics covered today, please visit the CMA Physician Wellness Hub at cma.ca. And however you're listening to us, please think about giving a rating or review. This makes it easier for others to find the podcast. I'm Dr. Caroline Gérin-Lajoie, thanks for listening.

Code White: Protecting ED staff from workplace violence

Topics

You’re Not Powerless in the Face of Online Harassment

Crucial Conversations

Mental health first aid

Hospitals turning to team-based conflict resolution

Healing the Healers: System-Level Solutions to Physician Burnout

Transforming healthcare organizations

Are you in distress? Get help now.

Code White: Protecting ED staff from workplace violence

Topics

Related resources

You’re Not Powerless in the Face of Online Harassment

Crucial Conversations

Mental health first aid

Hospitals turning to team-based conflict resolution

Healing the Healers: System-Level Solutions to Physician Burnout

Transforming healthcare organizations

Are you in distress? Get help now.

Code White: Protecting ED staff from workplace violence