But despite its prevalence, workplace violence in healthcare is ‘an underreported, ubiquitous, and persistent problem that has been tolerated and largely ignored’. This is partly because the studies simply haven’t been done. According to the Brophys’ research, prior to 2000, violence against healthcare workers was barely on the agenda: when in February 2017 they searched Medline for ‘workplace violence against nurses’ they found ‘155 international articles, 149 of which were published from 2000 to the time of the search’.
But the global data gap when it comes to the sexual harassment and violence women face in the workplace is not just down to a failure to research the issue. It’s also down to the vast majority of women not reporting.44 And this in turn is partly down to organisations not putting in place adequate procedures for dealing with the issue. Women don’t report because they fear reprisals and because they fear nothing will be done – both of which are reasonable expectations in many industries.45 ‘We scream,’ one nurse told the Brophys. ‘The best we can do is scream.’
The inadequacy of procedures to deal with the kind of harassment that female workers face is itself likely also a result of a data gap. Leadership in all sectors is male-dominated and the reality is that men do not face this kind of aggression in the way women do.46 And so, rather like the Google leadership not thinking to put in pregnancy parking, many organisations don’t think to put in procedures to deal adequately with sexual harassment and violence. It’s another example of how much a diversity of experience at the top matters for everyone – and how much it matters if we are serious about closing the data gap.47
The Brophys warn that gender is also ‘typically [. . .] absent in analyses of health sector violence’. This is unfortunate. According to the International Council of Nurses, ‘nurses are the healthcare workers most at risk’ – and the vast majority of nurses are women. The absence of gender analysis also means that most of the research doesn’t factor in the chronic underreporting of sexual violence: the Brophys found that only 12% of the workers in their study reported it. ‘We don’t report sexual violence because it happens so frequently,’ explained one woman who had been ‘grabbed many times’. But an awareness that the official data is ‘believed to grossly underestimate the incidence due to widespread underreporting’ just isn’t in the literature, Brophy tells me. This meta data gap goes unremarked.
The violence nurses face at work is not helped by traditional hospital design. The long hallways isolate workers, explains Brophy, scattering them far away from each other. ‘Those hallways are terrible,’ one worker told Brophy. ‘You work way over there – and you can’t communicate. I would prefer a full roundabout circle.’ This would be an improvement, Brophy points out, because it would enable staff to support each other better. ‘If the area was rounded, workers wouldn’t be off on one end. If there was two people one would hear something going on.’ Most nursing stations don’t have protective shatterproof barriers or exits behind the desk, leaving nurses vulnerable to attack. Another worker told Brophy about the time her co-worker was sexually assaulted by a patient. ‘[Th]e inspector recommended that they put glass up. The hospital fought them on it. They said it stigmatises the patients.’
Both the workers Brophy interviewed and the US’s Occupational Health and Safety Administration have highlighted several design features of traditional hospitals (‘unsecured access/egress; insufficient heating or cooling; irritating noise levels; unsecured items’) that compound the safety issue – all of which could be addressed without stigmatising anyone. Governments could also reverse policies that result in routine understaffing – an issue that Brophy ‘heard in every group in every location’, with workers identifying wait times as ‘a trigger’ for violent behaviour directed towards staff. ‘If you don’t have the staff to immediately address their issue – if they’re kept waiting – they are more likely to escalate in their behaviour,’ explained one worker.
Redesigning hospital layouts and increasing staffing levels of course don’t come cheap – but there’s likely a cost argument that could be made given the amount of time off from injuries and stress workers are taking. Unfortunately, this data is not being ‘adequately collected’, Brophy tells me. But, he continues, ‘I can tell you there’s not a doubt in my mind that that is a very high stress work environment and that the demand on people and the limited amount of control they have is the perfect scenario for job burnout.’
And then there’s the cost implications of training people who then leave the profession, which came up repeatedly in the focus groups the Brophys conducted. ‘We had nurses with twenty-five to thirty years’ seniority saying “I’m gonna become a cleaner,” or “I’m gonna work in the kitchen because I can’t deal with it any more. I can’t handle the lack of support and the danger and the risk and coming in every day and facing these things and then being negated and unsupported.”’
But even without taking this more long-term view there are plenty of lower-cost options, some of them dazzlingly simple. Consistently charting and flagging patient violence; making reporting procedures less onerous – and having supervisors actually read the reports; ensuring alarms make different noises depending on their purpose: ‘[I]n one instance, the patient call bell, bathroom assist bell, Code Blue for respiratory or cardiac arrest, and staff emergency alarms all made the same sound in the nurse’s station’ (fans of British 1970s TV will recognise this problem with alarms as the plot of an actual Fawlty Towers episode).
Signs making it clear what behaviour is and isn’t acceptable would also be inexpensive. ‘I notice at the hospital coffee shop they have a sign that says they won’t tolerate any type of verbal abuse,’ one woman told the Brophys. ‘But there’s no signs on our units that say that. [. . .] There is a poster about if you’re widowed and lonely, here’s a singles website. But you won’t put up a violence sign for us?’
Perhaps most staggeringly simple, participants in the Brophys’ research ‘suggested that they be permitted to have their last names removed from their name tags – at their employer’s expense – as a safety measure’. This would avoid incidents such as when a visitor to the hospital told a female worker, ‘Very nice to meet you, [her name]. And you know, you shouldn’t have your last name on your badge because I can just look you up and find out who you are and where you live.’
Women have always worked. They have worked unpaid, underpaid, underappreciated, and invisibly, but they have always worked. But the modern workplace does not work for women. From its location, to its hours, to its regulatory standards, it has been designed around the lives of men and it is no longer fit for purpose. The world of work needs a wholesale redesign – of its regulations, of its equipment, of its culture – and this redesign must be led by data on female bodies and female lives. We have to start recognising that the work women do is not an added extra, a bonus that we could do without: women’s work, paid and unpaid, is the backbone of our society and our economy. It’s about time we started valuing it.
PART III
Design
CHAPTER 7
The Plough Hypothesis