Margaret M. Keith and James T. Brophy, Code White: Sounding the Alarm on Violence Against Health Care Workers (Toronto: Between the Lines, 2021)

Have you ever been in a hospital and heard the words “code white” come over the audio system? I am not sure if I have or not. I am certain, however, that I would not have known what they meant. After reading Margaret Keith and Jim Brophy’s powerful book with those words as its title, I would know. “Code White” is the term used in hospitals to alert staff that a violent incident is taking place and immediate assistance is required.

The many – extremely difficult to listen to – stories recorded by Keith and Brophy speak to this violence as it was experienced by frontline health care workers in both hospitals and long-term care facilities. A real strength of the book is that the workers’ stories describe being viciously attacked by patients and their family members – attacks that have left them with permanent injuries or impairments that have changed their lives in fundamental ways, including not being able to physically and/or mentally perform their jobs. They listened as female health care workers, a growing percentage of whom are racialized, spoke about the many times they had been subjected to physical attacks but also to verbal abuse that was related to, or centred on, their gender, i.e., the comments focused on their breasts, genital area, and perceived racialized backgrounds. In this last regard, Keith and Brophy write of a “racialized healthcare worker” who told them of a “patient who was targeting Black staff … using her cane to whack people and calling them the N-word and calling them other degrading slurs – whatever she could say.” Adding insult to injury, these and other instances were “never addressed in the [managerial] report.” How would you feel “if it wasn’t addressed … would you feel human?” (41)

To the surprise of Keith and Brophy, both highly knowledgeable, well-seasoned, and respected occupational health and safety researchers, these varied forms of violence were neither new nor unacknowledged in terms of published research. Indeed, in 2017 when at the behest of the leadership of the Ontario Council of Hospital Unions (ochu-cupe), they embarked on this research they found that in “1983 the World Health Organization (who) had proclaimed that physical assaults on staff by patients was a significant problem.” A further literature search in 2019 revealed “that over a thousand articles on ‘workplace violence hospital’ or ‘workplace violence against nurses’ had appeared in international peer-reviewed academic journals in the previous twenty years.”(11)

The issue of workplace violence relating to healthcare workers was not new. Keith and Brophy discovered, however, that neither was going away. Indeed, given the alarmingly high percentages of healthcare workers they interviewed and surveyed who stated that they had experienced one or more forms of violence in their workplaces, they concluded that it was getting worse.

What are the determinates of this rampant, and, critically, seemingly unchecked violence in these two workplace settings? Keith and Brophy spend a good amount of time and space addressing this question and provide a layered and insightful response. At the level of hospital wards and the resident rooms in long-term care homes, the answer is clear: understaffing. According to Keith and Brophy (and a host of healthcare researchers whom their research builds upon), whatever the particularities of these different workplaces, violence involving staff in both settings stems from forms of “societal violence” coming through the front doors via sick and anguished patients and worried family members, some of whom become dangerously belligerent when healthcare staff do not attend to them in good time. The fact is, they cannot respond in the desired time frame because of a pervasive and worsening shortage of workers – workers in sufficient numbers to truly care for patients, not only in emergency situations, but on an ongoing basis. This sentiment had particular resonance among healthcare workers in long-term care homes.

At the political level, the decisions of a string of progressively neoliberal provincial governments, dating back to the 1990s and the Conservative government of Mike Harris, to restructure, i.e., close hospitals and encourage for-profit long-term care homes, and slowly but surely decrease health care funding, have led inexorably to this shortage of healthcare staff. The pressures felt by the remaining workforces to provide care – the care they wanted to provide when they chose to become health care workers – under such trying, and, really, impossible circumstances, has led to an overall deterioration in the “conditions of care” such that, with the additional concerns associated with covid-19, increasing numbers are leaving their jobs. The various crises in our healthcare systems are deepening.

In Code White, Keith and Brophy point to their lengthy and enduring research history. They also make it clear that they are committed activists – that they have long desired not only to interpret the world, but to also change it. What, then, are their prescriptions for change?

The authors provide a thoughtful array of suggestions for change that, if they were implemented, would go a very long way towards addressing the problem of workplace violence. Not surprisingly, hiring more staff tops their list – as it does the lists of other researchers and health care activists. Knowing the political/economic obstacles that strew the hiring pathways, Keith and Brophy also suggest more possible and practical changes, such as altering the design of hospital wards so that healthcare staff could more easily monitor their patients, establishing a monitoring system that identifies problematic or potentially problematic patients, and the thorough training of selected health care personnel in health and safety programs and measures designed to both perceive potential problems and to actively and knowledgeably intervene in violent situations.

As Keith and Brophy are fully aware, for these and their other proposals to get on the drawing boards, they must be put there by the workers themselves. The question is thus raised: why the relative silence of healthcare workers on workplace violence? Why have we not seen an uprising of healthcare workers themselves and/or their unions?

Their answer, revealed to them via their studies, revolves around one aspect or another of the powers of employers. Keith and Brophy argue that, especially as neoliberal forms of governance and control have taken firm hold in this sector, workers have learned that their employers will go to great lengths to keep their dirty laundry hidden. For, what would it mean for any given hospital’s reputation if the violence that repeatedly bursts forth in the wards and emergency departments were to become public knowledge? Surely, that would damage the public’s trust in that hospital. Surely, it would attract the attention of government officials charged with overseeing their operations and funding. It is the same, perhaps worse, for long-term care facilities.

So, workers have learned that speaking up will earn them the wrath of their employers. They could be fired – as it happened to one of the workers in Keith and Brophy’s study. They have also been subjected to the attempts by their supervisors and, at times, even co-workers, to make them feel that the violent episode that injured them was their fault or, that it comes with the job. As in the case cited above, the incident would simply go unreported, leaving them to feel less than human.

Healthcare workers have, thus, learned that overt resistance can be perilous to their continued employment and/or largely futile. They have learned that they can expect little or no assistance from their co-workers, their supervisors, senior hospital management, and in the great majority of examples, their joint health and safety committees, which Keith and Brophy found in too many cases to be either non-existent or ineffectual.

For Keith and Brophy, the way forward is collective action. In this regard, the pervasive and, in thousands of cases, the tragic impact of covid-19 in hospitals and especially in long-term care homes, has served not only as a prism into the effects of the massive undermining of the “conditions of care,” but hopefully, as a ‘code white’ alarm to healthcare workers and their unions to take up the issue of workplace violence.

In the end, this reviewer shares in the authors’ hopes that exposing the disintegrating “conditions of care” in our health care institutions will serve as the missing plank to the foundation from which collective activism will spring. For this to happen, however, further connections must be made, with a critical one being a fundamental recognition that “capitalism” cares little for the health and well-being of workers – be they miners, steelworkers, grocery clerks, office workers, or health care workers. As Marx wrote in Chapter 10 of Capital: “It is self-evident that the labourer is nothing else, his whole life through, than labour-power… In its blind, unrestrainable passion, its ware-wolf hunger for surplus labour, capital oversteps not only the moral, but even the merely physical maximum bounds of the working day. It usurps the time for growth, development, and health maintenance of the body… Capital cares nothing for the length of life of labour-power.” (Capital, Vol 1: New York 1906:291)

Code White. Violence is part of the bone and sinew of capitalist labour processes.

Robert Storey

McMaster University

DOI: https://doi.org/10.52975/llt.2022v89.0029.