When Tom Kelsch heads to his job as a registered nurse in Mercy Health Muskegon's emergency department, he knows, almost without a doubt, that he'll be threatened by a patient or their family that day.
He knows he may see someone's fist in his face, as has happened in the past, or have to endure a barrage of angry words screamed at him.
“I get threatened every day at work," said Kelsch. “They say, 'I know where you live; I'll be visiting you.' They say they're going to come and kill me; they say, 'I know where you park and what you drive.' It's pretty awful what we deal with. I've been spit on."
These incidents are not new to Kelsch, or likely anyone who works in emergency medicine. Patients, facing extreme and life-threatening pain, can lash out, as can stressed and grieving families. Violence against health care workers has been on the rise nationally for years.
But during the COVID-19 pandemic, the frequency of these attacks have soared, Kelsch said.
“I started working in the [emergency room] 11 years ago, and every year it was slightly getting worse with patients verbally assaulting us, physically assaulting us — but since the pandemic started, it has gone up tenfold," he said.
Across Michigan, doctors, nurses and other medical professionals spoke to the Advance about workplaces increasingly filled with aggressive and violent patients and their family members: people who are angry over pandemic policies, such as mask requirements and visitor restrictions, and take it out on those trying to save their lives.
Workers described people throwing punches and hurling cascades of threats at them after long waits in understaffed emergency rooms. Others will yell at doctors because they don't believe their COVID diagnoses, and patients have threatened legal action if they don't receive ivermectin — a drug used to deworm horses that some prominent conservatives are pushing as a COVID-19 treatment despite a specific warning from the Federal Drug Administration not to do so.
It's a landscape filled with doctors and nurses exhausted by a pandemic that has now dragged on for more than a year and a half, staff who are leaving the field because they're burned out, and workers having to wear what essentially amounts to panic buttons so security can come running if they are attacked.
“There's a lot of anger towards health care workers in general," said Dr. Matthew Trunsky, a pulmonologist and the director of palliative care at Beaumont Hospital in Troy. “A year and a half ago, people were sending us party trays and food. All of a sudden, we're kind of the enemies. We're taking the brunt of families' anger."
“People are angry, and I think the anger is based on public misinformation on what works and what doesn't work to treat the disease," Trunsky added.
'When we are surging with COVID patients, we are experiencing a surge in aggression'
In the years leading up to the pandemic, health care workers across the country were increasingly reporting an uptick in physical and verbal attacks against them.
The U.S. Bureau of Labor Statistics reported in 2018 that medical workers accounted for 73% of all nonfatal workplace injuries from violence. Data from the U.S. Occupational Safety and Health Administration (OSHA) shows health care employees were, on average, nearly four times more likely to experience violence at work than individuals in private industry overall between 2002 and 2013.
A 2018 survey of about 3,500 emergency physicians in the United States reported 71% of the doctors had witnessed an assault, and 47% of the physicians were physically attacked themselves. Meanwhile, 97% of those surveyed stated the main source of the assaults was patients, and 83% said a patient had threatened to return to the health care facility to harm them. Nurses take on even more of the brunt of this violence, according to the Emergency Nurses Association, with 70% of emergency nurses reporting being the victim of physical assaults while on the job.
In Michigan, attacks against health care workers were becoming so pronounced in the year before the pandemic that the Michigan Health and Hospital Association (MHA) formed a “workplace safety collaborative" in March 2019 that aimed to address this surge in violence through de-escalation training and other efforts.
“We launched it after hearing for many months that frontline caregivers were suffering from abuse from patients, from family members of patients," said Brian Peters, the CEO at the MHA.
“The reality was if we didn't get our arms around this issue, you'd see a rise in burnout and folks who would leave the field, and it would get in the way of frontline caregivers' ability to provide quality care," Peters said.
The mounting violence in health care settings, particularly hospitals, has been significantly intensified by the pandemic, according to medical personnel. There's been a confluence of misinformation about the pandemic, such as the false idea that masks don't work to prevent COVID's spread — something a trove of major medical studies have repeatedly proved otherwise; an increase in mental health issues, including substance abuse; and longer wait times in emergency rooms due to staffing shortages.
All that has led to an explosive environment in which health care workers are routinely dealing with abusive patients, according to health care professionals interviewed by the Advance.
Like hospitals across the state and country, Spectrum Health in West Michigan has seen a spike in both verbal and physical assaults. Before the pandemic, there were about 100 verbal or physical acts of aggression reported monthly at Spectrum; now, that number is close to 350 incidents each month, according to Dr. Joshua Kooistra, the senior vice president and chief medical officer at Spectrum Health.
To deal with this surge, Kooistra said they've implemented a “staff duress system" in which employees wear a button they can push that sends their location to security. Spectrum, which operates hospitals and other health care facilities throughout West Michigan, is also “training staff and security in de-escalation techniques" to calm irate patients or family members, Kooistra said.
At Sparrow Hospital in Lansing, staff would have to deal with about one or two aggressive patients daily prior to COVID. That has grown to six or seven patients being physically or verbally abusive every day during the pandemic, Sparrow Hospital Chief Nursing Officer Amy Brown said. Like Spectrum, Sparrow has worked to increase both staff and patient safety through de-escalation training, and Brown said the hospital brought on a “trained dog" to accompany security officers attempting to quell patient aggression beginning in June 2020.
“We haven't had to use the dog in an aggressive manner, but we've used the dog to de-escalate situations," Brown said. “If there's a dog with a security officer and a person is acting out, the presence of the dog calms the situation down."
Kooistra said the abuse that happens against health care workers at his workplace now rises with the number of COVID patients.
“When we are surging with COVID patients, we are experiencing a surge in aggression," Kooistra said.
He added that there has been a “definite increase in aggression around masking."
“I think people have firmly held beliefs about the utility of masks," he said. “In health care, we require them. That can lead to aggression towards health care workers as the messenger [that patients must wear masks]."
It's not just that people are battling illnesses, tired of the pandemic and becoming more violent in hospitals, some of those interviewed said. It's that hospital staff are increasingly having to work with unvaccinated patients because they are now overwhelmingly the ones who are coming down with serious COVID cases and dying.
At this point in the pandemic, attitudes towards vaccination are heavily rooted in partisanship — your party affiliation is far more likely than any other factor, including age, race or ethnicity, to determine whether you get the COVID vaccine, according to a Sept. 28 report from the Kaiser Family Foundation.
“The largest remaining gap in vaccination rates is by partisanship, with 90% of Democrats saying they have gotten at least one dose compared to 68% of independents and 58% of Republicans," wrote the San Francisco-based Kaiser Family Foundation, a nonprofit focused on national health issues.
Those in conservative areas are also far more likely to die from COVID. Charles Gaba, a health care analyst based in Bloomfield Township, reported in September that, since June, the virus has killed about 47 out of every 100,000 people in counties where former President Donald Trump received at least 70% of the vote in 2020 against now-President Joe Biden. Meanwhile, COVID has killed about 10 out of every 100,000 people in counties where Trump garnered less than 32% of the vote.
With partisanship dominating views towards vaccination, that in turn lends itself to an unvaccinated population often aligned with a variety of attitudes around health care and the pandemic in general that are rooted in what the Washington D.C.-based think tank the Brookings Institute calls a “seemingly intractable cultural divide in American society between the parties." If you're an unvaccinated patient battling COVID-19 in the hospital right now, you're more likely than those who are vaccinated to be Republican and opposed to a variety of COVID-19 health measures, such as masking and vaccine mandates for workplaces.
“There's this divisiveness that's occurred in society," Kooistra said. “People have firmly held beliefs that they're unwavering on, and they're not having grace with one another. …The safety measures, such as masking, social distancing and some visitor restrictions — I'd ask the general public to be a little more understanding of why those are in place. Have grace with us. It's not the health care worker who's trying to take care of you who's responsible for those requirements."
But right now, some patients are not heeding calls for patience. At Beaumont, for example, patients have become angered over COVID diagnoses and refuse to believe they have the disease, Trunsky said. Some will say “you'll hear from my lawyer" if the hospital doesn't give them ivermectin — the horse dewormer that is now being pushed by some high profile Republicans as a treatment for COVID — while others will tell their caregivers that they would rather die than get the vaccine, Trunsky said.
“There was a woman whose husband died of COVID who said she would never feel comfortable recommending the vaccine for family and friends," said Trunsky, who has lost about 100 patients to COVID.
“Ninety percent of our [COVID] patients are unvaccinated; 90% of deaths are unvaccinated," he continued, referring to national statistics. “The vast majority of them are unnecessary. To argue in any way that the vaccine doesn't work is dishonest, and it's resulting in the deaths of fellow Americans."
'They are completely out-of-their-minds mad at the whole situation'
In addition to misinformation about the pandemic, health care workers cited an increase in mental health challenges during the pandemic and growing wait times in emergency rooms due to staff shortages playing roles in the surge of aggression from patients.
Sparrow Hospital in Lansing, for example, has seen an increase in patients with “mental health needs that are going untreated and increased abuse of alcohol and drugs; more people are coming in under the influence," said Brown, the hospital's chief nursing officer.
In Michigan, about two-thirds of adults reported feeling depressed, down or hopeless to varying degrees in September, according to the U.S. Census Bureau's “Household Pulse" survey. The bureau's ongoing survey aims to collect data on a wide variety of issues, from mental health to housing insecurity, during the COVID-19 pandemic.
About 20.8% of Michigan adults reported feeling that way every day over the course of two weeks in September, the survey said. Approximately 17.8% of Michigan adults reported feeling depressed, down or hopeless more than half the time in the past two weeks, while 29% said they felt that way several days a week over the same time period, according to the survey. About 32% of Michigan adults said they experienced no depression.
These numbers are far greater than pre-COVID statistics. According to the Kaiser Family Foundation, one in 10 adults reported symptoms of anxiety or depressive disorder in 2019. About 12% of adults nationwide reported drinking more during the pandemic, the Kaiser Family Foundation reported.
Kooistra said that Spectrum Health too can attribute some of the patient aggression to “an increase in mental illness" and a rise in substance use. Kelsch, the nurse at Mercy Health in Muskegon, attributes much of the rise in patient violence to individuals having difficulties accessing care from primary physicians during the pandemic and ending up seeking care in an understaffed emergency room.
Health care facilities state- and nationwide have struggled for years to find nurses; now, that shortage is even greater because pandemic burnout is pushing workers from the field, according to those interviewed by the Advance. Currently, there are some 12,000 listings on the job site Indeed.com for registered nurse positions in a variety of health care settings in Michigan, including hospitals.
“It's very difficult for patients to get in and see their primary care doctors," Kelsch said. “By the time they get to the ER, they're frustrated. The family is even more frustrated. They come to the ER, and they are completely out-of-their-minds mad at the whole situation."
“There have been multiple times when the patient is waiting four, five hours in the [emergency department] to be seen," he continued. “I have patients physically bring their fist up to me and punch me because they're mad that someone got [to be seen by a doctor] before them."
If Trinity Health, the parent company for Mercy Health in Muskegon, negotiated the nurses' contract that has been expired for more than two years, Kelsch said he believes the facility would be able to fill open positions with “competitive wages."
“We've been trying to sit down at the table with Trinity, but they won't," he said. “They refuse to give us a competitive wage. We stay because this is our community, and we want to be able to take care of the community we love. But pay us what we're worth, and you won't have a nursing shortage. The staff shortage is staff burnout."
In a statement provided to the Advance, Mercy Health said its “leadership has not declined to meet for contract negotiations."
“In fact, we initially commenced negotiations with SEIU in September 2019," the statement said. “Due to a representation election between our two nursing units, these negotiations were paused until after the election. Mercy Health has since been meeting with SEIU regularly since February 2021 to negotiate a contract for our registered nurses and are looking forward to signing an agreement with SEIU that is fair and sustainable for both parties."
A representative for SEIU, Kevin Lignell, backed Kelsch's statement and said Mercy Health is “stalling" on negotiations.
With regards to increasing nurses' pay, Mercy Health said, “unfortunately, until we reach an agreement, we are unable to make adjustments to wages." The hospital said it has “offered several bonus pay plans such as retention, critical staffing and COVID incentives for our nurses and other staff members, which the union has opposed."
Legislation aims to protect health care workers
Federal and state lawmakers have also begun taking aim at the increase in violence against health care workers.
In April, the U.S. House passed the Workplace Violence Prevention for Health Care and Social Services Workers Act — a bill introduced by Rep. Joe Courtney (D-Conn.) and co-sponsored by 145 other members, including five Michigan Democrats: U.S. Reps. Andy Levin (D-Bloomfield Twp.), Debbie Dingell (D-Dearborn), Dan Kildee (D-Flint), Haley Stevens (D-Rochester), and Rashida Tlaib (D-Detroit).
The legislation, which garnered bipartisan support in the House and which the Senate has not voted on, would require OSHA to mandate that health care and social service employers develop and implement workplace violence prevention plans. It would also require that employers provide further training and education on workplace violence and adopt policies that protect employees from retaliation for reporting violent incidents.
“Front line workers should be able to trust that they will be protected in the workplace and get home safely at the end of the workday," Kildee said in a statement to the Advance.
“This legislation will protect the brave health care and social services workers who are working tirelessly during this pandemic to keep Michigan families and communities healthy," he continued.
Also in April, state Sen. Jeff Irwin (D-Ann Arbor) introduced a bill that would require hospitals and public health departments to track and disclose incidents of violence, develop plans to prevent workplace violence with input from nurses and other frontline health care workers, and provide training and reporting procedures for employees. The bill stipulates that health care institutions must publish information about incidents of violence on their respective websites.
Should the legislation pass, it would require that hospitals report incidents of violence to a county prosecutor — something the lawmaker said they are currently reluctant to do because, often, those perpetrating the crimes “are their customers," Irwin said, referring to patients.
“There's a built-in incentive not to report these incidents or sweep them under the rug," Irwin said. “My bill focuses on preventing these instances. … If a prosecutor wants to look at a case and decide not to prosecute, that's one thing, but if a hospital is making that determination, that seems like a problem. The legislature needs to step in."
So far, no committee hearing has been scheduled for Irwin's legislation.
“I think the reason this legislation hasn't seen any action is because hospitals don't want this," Irwin said. “It requires them to post information they don't want to post."
But, ultimately, Irwin said, it only helps the public and hospitals to fully acknowledge and address violence against workers.
“Working in health care is always challenging, and has been especially challenging over the last couple of years," Irwin said. “There are a whole lot of leaders who say we need to respect these health care workers. One way the legislature can show a sign of appreciation is to pass legislation that protects them from violence."
“It's going to be hard to recruit people into these jobs if they're dangerous and the community doesn't have their back," Irwin added.
'Geez, I'm just going to throw in the towel': The toll of aggression
As the pandemic stretches on, unvaccinated individuals crowd hospitals and patients become increasingly violent. Health care workers are facing significant burnout that's pushing them from the field in Michigan and nationwide, those the Advance interviewed said.
“It's definitely exacerbating burnout," Kooistra said of the increased violence against hospital employees. “Our staff are taxed with increased patient care volumes and more limited resources. You put on top of that patients or families who are aggressive against team members, and you start to say to yourself, 'Geez, I'm just going to throw in the towel.'"
According to a study conducted by the American Medical Association, 49% of 21,000 frontline health care workers surveyed from May to October of 2020 reported experiencing burnout.
“That's a rate that's higher than any other sector I can think of," said Peters, the CEO of the Michigan Health and Hospital Association.
“Burnout is on the rise," Peters continued and said that can, in part, be attributed to patients and their family members “getting very frustrated and upset" over elective procedures being shut down at the beginning of the pandemic and restrictive visitor policies, which were put in place in order to mitigate the transmission of COVID-19.
“In too many instances, they took that out on hospital employees and, in some cases, got incredibly threatening and physically violent to the point where security had to intervene," Peters said. “That contributes to burnout."
On top of the violence is the fact that doctors and nurses have had to watch as their patients die from COVID-19, Peters said.
“We walk with nurses all the time who tell us they've held an iPad by the bedside so the family of a patient can watch their loved one die," Peters said. “You do that a dozen or more times, as many of our nurses and doctors have done, and now you're talking about a real potential for burnout. We have had over 20,000 Michiganders who have died from COVID — the story I just said is not just a dozen here, a dozen there. It's 20,000 of those."
Addressing this burnout is complicated. Hospitals are providing mental health support to their staff, Peters said, but he and others emphasized the public has to change for health care workers to begin healing from the trauma that has taken root during this pandemic.
“At the beginning [of COVID-19], our frontline caregivers would see the hero signs, banners and ads on TV and radio; that was uplifting," Peters said. “Some of that has faded, and unfortunately we see these instances of violence and distrust. We would harken back to the earlier days of the pandemic, when they were rightly hailed as heroes. They still are."
But it's more than just public recognition that's needed, Trunsky said. It's a public that is willing to recognize what it will take to ultimately end the pandemic: Getting the vaccine.
“The frustration is the vast majority of these illnesses are preventable," he said, referring to COVID-19. “… There's a social responsibility that I think is being overlooked in favor of individuals' civil rights, and as a country we're paying the price with hundreds of thousands of deaths."
Michigan Advance is part of States Newsroom, a network of news bureaus supported by grants and a coalition of donors as a 501c(3) public charity. Michigan Advance maintains editorial independence. Contact Editor Susan Demas for questions: firstname.lastname@example.org. Follow Michigan Advance on Facebook and Twitter.