Bart Pfankuch

South Dakota News Watch

Increasing anger and even violence toward healthcare workers in South Dakota and across the U.S. is adding great stress on practitioners who are already enduring the pain and hardship of providing care during the deadly COVID-19 pandemic.

Healthcare workers in South Dakota have been called offensive names, faced threats at work or at home, had things thrown at them, and occasionally have endured direct physical violence. The aggression is being displayed by both patients and family members.

In the short term, dealing with inappropriate behavior takes the focus of doctors, nurses and aides away from patients who need help. In the long term, the outbursts are driving some healthcare professionals out of the field, worsening a worker shortage that threatens to reduce overall patient care and efficiency of the American medical system.

Ashley Kingdon-Reese of Huron, S.D., is an independent nurse who provides at-home care and runs a nursing consultancy. Preventing violence and anger against nurses and other healthcare workers has been a topic of concern for several years, but especially since the pandemic began.

Kingdon-Reese recently experienced violence firsthand while providing nursing care to a woman with behavioral problems who had a potential infection and needed to be taken from her home to a clinic.

The patient grew frustrated and angry after being forced to wear a mask at the clinic, Kingdon-Reese said.

“She jumped out of bed, pushed me against the wall and bit me in my thigh and I had to do what I could to get her off me,” recalled Kingdon-Reese, who serves as the government relations committee chair for the South Dakota Nurses Association. “Part of it was obviously behavioral health, but the other part was she didn’t want to wear a mask and she was very big into social media that said, ‘You can’t tell me what to do.’”

Kingdon-Reese and others are asking medical patients and the public to reduce their tension level before entering a healthcare facility and to try to remember that providers are there to help them, not hurt them.

“It starts with putting the facts out and advocating for our industry so people know that we’re human, and we’ve dedicated our lives to this and it isn’t easy,” Kingdon-Reese said. “We’re not asking for your devotion or appreciation, we’re just asking for decency.”

Dr. Kara Dahl, a physician in the emergency room at the Sanford Aberdeen Medical Center, said there is no doubt that incidents of inappropriate, threatening or violent behavior toward healthcare workers has been on the rise since the pandemic began.

“You can almost guarantee that you’re going to be name-called or disrespected in some capacity at least once a week,” said Dahl, president of the South Dakota Medical Association. “The frequency of getting to the magnitude of calling security is rising at such an alarming rate, it’s no longer just an occasional thing.”

The anger displayed toward healthcare workers has multiplied the stresses of dealing with a deadly pandemic in an industry already beset by worker shortages. The moment anger or violence arises, patient care overall is immediately damaged, not only for the patient involved but for all patients, Dahl said.

“If we are pulled from a more critical situation to have to deal with a behavioral issue, that is definitely impacting patient care,” she said. “The more disruptive the behavior or outburst, the more it takes us away from the bedsides of other patients who need help.”

Politics and stress brought to healthcare settings

Many healthcare practitioners see the rise in anger as an outcome of the political polarization surrounding prevention and treatment of COVID-19, and the rise of misinformation campaigns by conservative television and radio commentators and on social media. Disdain for healthcare workers prior to the pandemic was caused mostly by frustration with the increasing role of insurance companies in what treatments are offered and at what cost, according to experts.

Dahl said the recent anger toward healthcare workers can be traced in some cases to a generalized angst many people are feeling from the ongoing employment, health and social stresses caused by the COVID-19 pandemic.

“Sometimes those attacks are not even directed at us, they’re directed [by] an overall anger and upset with their overall everyday lives,” Dahl said.

Whatever the cause of the rising tension, the result is that the healthcare industry is seeing workers getting burned out and enduring stress that hampers their effectiveness — with some prompted to leave the field completely.

The long-range result may be that as medical professionals leave the industry, hospitals and clinics will see a worsening of the ongoing shortage of nurses, aides, technicians and physicians, said Dr. Jeremy Cauwels, chief physician of Sanford Health in Sioux Falls.

“I think it’s reasonable to say that there are people leaving health care because of this, because for many people there are easier ways to make a living than being verbally or sometimes physically assaulted,” Cauwels said.

Officials and healthcare providers at Monument Health in Rapid City have been the target of a recent protest campaign by the wife of a man who has been receiving treatment in the COVID-19 ward at the hospital.

The woman has criticized the care her husband has received in numerous online videos and postings. She has held signs outside the hospital, posted the name and phone number of the Monument Health patient liaison, and urged people to call and complain on her behalf. The woman’s social media posts call the coronavirus a “bio-weapon” launched against Americans, refers to the pandemic as a “scamdemic” and insists that Monument employees receive financial bonuses for each patient assigned to the COVID ward and for each person who dies of COVID-19 at the hospital.

In response, someone started a Gofundme account to raise money to buy takeout meals for Monument emergency room staff. So far, the effort has raised $2,150 from 106 donors and meals have been provided to hospital staff, according to the Gofundme page.

Kingdon-Reese has begun to worry that unless the anger, disrespect and violence against healthcare workers abates, nursing positions and other healthcare jobs may go unfilled. In that case, she said, health care may become dominated by less experienced or less well-trained workers.

“Because of this, we’re losing an industry that everybody needs,” she said. “Everyone in their life is going to need health care at some point.”

Leaders of the healthcare industry regularly post articles and information on the growing risks to employees in the industry, and share ideas and procedures to improve safety.

Research confirms rising anger

In the U.S. Congress, an act to protect healthcare and social service workers from violence by requiring employers to create safety protocols remains stalled in the Senate after passage by the House of Representatives in 2019.

South Dakota is one of many states that have taken legislative action in recent years to address violence against healthcare workers.

In 2018, former Gov. Dennis Daugaard signed into law a bill that increased the penalty from a misdemeanor to a felony for anyone who assaults a healthcare worker who is providing patient care.

Research into the escalating anger and violence toward healthcare workers has picked up in pace and intensity in recent years.

Survey results published in August 2020 in the Journal of the American Medical Association showed that nearly a quarter of all physicians who responded had endured personal attacks on social media. Female physicians were more likely to report online sexual harassment.

The World Health Organization found in February 2022 that as many as 38% of healthcare workers around the world suffered physical violence at some point during their careers. The U.S. Bureau of Labor Statistics found that workplace violence against American healthcare workers nearly doubled in frequency from 2011 to 2018. Violence was found at five times the rate in healthcare compared with all other industries, and healthcare workers made up 73% of all nonfatal workplace injuries due to violence in the country in 2018.

Nurses, who have much of the direct medical interaction with patients and their family members, are enduring much of the anger and violence arising during the pandemic.

National Nurses United, a professional association with 175,000 members across the U.S., surveyed 15,000 registered nurses in late 2020 and found that 20% had faced increased workplace violence since the COVID-19 pandemic began. Nearly 80% of nurses reported higher stress levels, about two-thirds reported feeling sad or depressed, and more than half had difficulty sleeping since the pandemic hit.

News reports from around the country and world have highlighted the increase in violence and the rising concerns. A hospital group in Missouri provided panic buttons to 400 nurses; a nurse in Colorado had an unknown liquid thrown at her while working at a COVID-19 vaccine clinic; and many hospitals are advising workers not to leave work while wearing scrubs that identify them as healthcare workers.

Violence and anger toward medical workers is not unique to the COVID-19 pandemic, though surveys and anecdotal reports indicate the pandemic has made the risks to healthcare workers higher and more frequent.

Hospitals get proactive to protect workers

Monument Health officials would not discuss the situation with the protesting woman due to privacy concerns and because the situation is ongoing, spokesman Dan Daly said.

But the West River hospital group is far from unique in facing backlash from patients or family members who are upset or

angry, said Nicole Kerkenbush, director of nursing at Monument Health.

Monument has taken a proactive approach to reducing unhelpful or tense interactions between people in its hospitals, Kerkenbush said.

Monument has a Workplace Violence Committee that meets monthly or more frequently if needed to discuss recent incidents but mostly to develop strategies to reduce tension or potential violence.

“We look for ways we can prevent these situations from happening at all,” she said. “But also, how do we make sure people know how to react when they do happen?”

The hospital group has provided training for nurses, physicians and others in de-escalation techniques and on how to react respectfully and safely when tension arises. The group holds regular meetings among security officials and employees to develop strategies to identify potential hotspots for tension and to develop ways to protect both employees and patients.

One recent review showed that in-patient settings, where people have been admitted for treatment, are prone to negative interactions with patients or visiting family members, Kerkenbush said.

The hospital also collects and analyzes data on where negative interactions occur and has adapted its security strategies as a result.

Additionally, to bring its messaging to all who enter, the hospital has erected a series of posters that urge people to “Please take responsibility for the energy you bring into this space.” The posters also note that, “Your words matter. Your behaviors matter. Our patients and teams matter. Take a slow, deep breath and make sure your energy is in check before entering.”

Kerkenbush doesn’t rule out that misinformation or binary political views on the pandemic are driving some of the inappropriate behavior toward medical professionals. However, she said her belief is that the rise in tense or angry incidents among patients and family members is being driven mostly by the overall tension caused by the COVID-19 pandemic. Many people have had disruptions in their workplaces, at schools, in access to shopping or leisure activities, or have lost a loved one, she noted.

At a recent conference, Kerkenbush said she heard and took heed of the phrase, “Hurting people hurt people,” which helps her understand the pain and agony many have suffered during the pandemic and how it may cause some to act in ways they otherwise would not. Additionally, she pointed to a rise in drug and alcohol use during the pandemic as fueling some negative patient or visitor behaviors.

“It’s mostly people who are worn out or stressed or angry, as they’re not here in the hospital because they’re having their best day ever,” she said.

Cauwels said that the politicization and misinformation surrounding COVID-19 have created distrust in the medical community that is unprecedented and unwarranted.

Wherever people are receiving inaccurate messaging about COVID-19 prevention and treatment, the result is that some patients arrive at the hospital with a predisposition to distrust, resent or even feel violent toward nurses, aides and physicians, Cauwels said.

“With cancer or pneumonia, you don’t try to pick your own treatments; instead you defer to the expertise of the expert in the room,” he said. “My recommendation would be that since you would trust us to make profound medical decisions and do things like transplant your liver, or do surgery on your heart, you can trust us again to make these decisions in the case of COVID or any other illness when you come into the hospital, because it’s what we’re trained to do and these are the decisions we’re trained to make.”

Cauwels said individual patient care can suffer when anger or the threat of violence permeates a medical setting by distracting medical workers from their critical duties or by making them emotionally uneasy and less focused.

Patients are encouraged to learn about their conditions and should feel free to raise questions or make suggestions about potential treatment, Cauwels said. But maintaining a collaborative, respectful demeanor should be expected on both sides of the equation, he said.

“I would never expect your doctor to scream at you to get a certain treatment in place, nor would I expect a patient to scream at me to give a certain medication,” he said. “We have to ask: How do you protect those folks while they’re working on the front lines, working in extremely stressful situations on their best day, and then you have the added difficulty of people who are challenging the therapeutic options they are given but doing so in way that is not respectful or constructive?”

Healthcare workers seek help and support

Some patients or family members make frequent angry calls to the hospitals that also take practitioners away from patients who need help.

Lori Popkes, head of nursing at Avera Health, said Avera has seen an increase in healthcare workers asking for mental health assistance or entering into employee assistance programs due to stress.

Popkes said she has seen a shift over the past couple of years in how medical professionals are viewed by the public, almost “from heroes to zeros,” she said. While nurses and doctors were once viewed with appreciation at the start of the pandemic, they are now held in contempt.

“I do think maybe the public underestimated how much their support and acts of kindness meant to healthcare team members,” Popkes said.

“We saw a number of different things, such as businesses sending letters saying thanks, or organizations stepping forward to provide a special lunch. That’s just something that went by the wayside and got overshadowed with some of this negativity,” she added.

Healthcare workers say they are devoted to helping people and just want to do their jobs well. Dahl said she hopes patients and family members will keep that in mind when visiting a hospital or clinic for any reason.

“Our big ask would be just for people to have some patience and understanding that there are critically ill people here, whether it’s COVID-related or not, and we’re trying our best to prioritize and take care of as many people as possible,” she said. “We’re really doing this because we just want to help people.”