After working as a nurse's aide in Springfield Memorial Hospital's emergency department for four years, and after dodging a chair swung at her by one visitor and being pinned to the ground by another, Susan decided to leave for a different health care setting.
Part of the reason for resigning once she completed her training to become a registered nurse was the upswing in threats and violence against the staff by patients and visitors she witnessed and experienced firsthand. It was especially noticeable during the COVID-19 pandemic.
"People were more on a sensitive, hairpin trigger," said Susan, who asked that her real name not be published because she feared repercussions from future employers in the health care community. "It took less to set people off. I feel like these patients got aggressive a lot more frequently."
As the pandemic enters its fourth year, hospitals in central Illinois and the rest of the state are treating fewer COVID-19 patients. But like their counterparts nationwide, Illinois hospitals are contending with the pandemic's other aftereffects: There's an even worse shortage of registered nurses, an overall worker shortage, the financial effects of those trends and an upsurge in workplace violence.
Memorial Health officials say they are working to address all of the issues, with violence at the top of the list.
"We're really worried about the state of our workforce," said Charles "Chuck" Callahan, president and chief executive officer of Springfield Memorial Hospital and president of the Memorial Health Hospital Group.
The rate of nonfatal occupational injuries and illnesses related to violence in hospitals such as Springfield Memorial is more than four times higher than among private-sector workers overall, he said.
"If that continues, how are we going to get the next generation of the health care workforce?" Callahan asked.
When staff members suffer, care is disrupted for the patient acting out as well as for other patients, and employees' fear of violence "undercuts their desire to remain a health care worker," he said. "For all those reasons, we really want to take a strong stance."
After meeting with police and the Sangamon County state's attorney in September, Memorial Health officials say they are putting in place policies to regularly press charges and put prosecutors in a better position to hold patients or visitors accountable when they physically abuse or attack staff, unless the perpetrators have mental illness.
Sangamon County State's Attorney Dan Wright said: "My office is deeply committed to the safety of all citizens of Sangamon County. It is critical to work closely with local law enforcement and our partners in the medical community to ensure violence against hospital staff is reported, investigated and prosecuted where a criminal offense can be proven beyond a reasonable doubt."
Aggressive behavior increases
The health system's stance marks a major change in practice, but Memorial Health employees reported 599 incidents of verbal or physical aggression in the fiscal year that ended Sept. 30. The incidents almost always involved aggression by patients and visitors against staff members.
Incident totals in fiscal 2022 exceeded the prior year's by 48%, and incidents in the fiscal year ending in September 2021 exceeded the previous year's incidents by 25%, Memorial officials said.
Some of the increase is happening because Memorial Health is encouraging employees to report, Callahan said, but he believes the numbers represent a real upsurge in violence.
Reports of Springfield police being dispatched to the emergency room of Springfield Memorial, a 500-bed hospital, track with the spike Memorial is seeing, according to Assistant Springfield Police Chief Joshua Stuenkel.
Callahan said Memorial's zero-tolerance policy is designed to "keep our staff safe, so if you come to this environment and are aggressive and commit violence upon our staff, we're going to call the cops, and you're going to be arrested, and we're going to help to hopefully get you prosecuted.
"Partly, it's to send a strong message to our staff that 'We've got your back.'"
Other actions Memorial is taking include communicating more with police who bring potentially violent patients to the ER, expanding staff training on de-escalation techniques, instituting debriefing sessions after violent episodes, and making unarmed security officers – as well as gun-carrying off-duty police officers hired by Memorial – more visible in public and patient-care areas.
Memorial officials also have made sure equipment, as well as cabinets and drawers containing materials that could be used as weapons, have been removed or locked.
Memorial Health began the initiatives after having security assessments conducted systemwide by the U.S. Department of Homeland Security, Callahan said. The actions make sense from a patient care standpoint, he said, adding that the initiatives will help Memorial Health, the parent organization of Springfield Memorial, attract and retain staff.
Callahan and other Memorial leaders believe the overall stress heaped on society by the pandemic, combined with ongoing requirements to wear masks and restrict visitors, has accelerated an upward trend of workplace violence in hospitals and other health care settings.
Edgar Curtis, Memorial Health's president and chief executive officer, said: "I understand that these are unprecedented times in my nearly five decades of working in health care. The resilience in society is lower. People are not as patient. People are not as kind. We see that everywhere. I'm sure it's worse in other parts of the country, but it's noticeable here, too."
"While it may feel harsh to press charges on somebody that exercises violence – not mental illness, but violence in the ER – we have to do those things," Curtis said.
Illinois Times asked to speak with officials at HSHS St. John's and Hospital Sisters Health System about the workplace violence trend. The hospital responded with a statement that said, in part: "Patient and colleague safety is our top priority. HSHS St. John's Hospital has promptly responded to the changing health care landscape, giving our colleagues the tools, education and resources needed to de-escalate violence before it occurs and the resources and support needed to manage aggressive behavior, as well as the support to press charges. ... HSHS St. John's Hospital is a safe, healing environment for patients and colleagues, and aggression is not tolerated."
Across Illinois and the rest of the country, health care professionals and hospital staff "are experiencing an alarming increase in instances of verbal and physical abuse from hospital visitors and patients," said Paris Ervin, spokesperson for the Illinois Health and Hospital Association.
"As part of an effort to address workplace violence and protect workers, IHA member hospitals have updated internal safety policies, provided education on how to report incidents of violence, hired additional security, partnered with local law enforcement and trained staff on de-escalation techniques," Ervin said.
ER doctors feeling the trend
A 2022 poll indicated more than eight in 10 emergency medicine doctors believe the rate of violence in EDs has increased, with 45% saying it has greatly increased over the past five years, according to the American College of Emergency Physicians.
Fifty-five percent of doctors responding to the poll said they have been physically assaulted, compared with 47% in 2018, and 79% said they had witnessed an assault on a health care worker, compared with 71% in 2018.
Dr. Christopher McDowell, chair of emergency medicine at Southern Illinois University School of Medicine, serves patients in Springfield Memorial's ED and said similar increases are happening in Springfield. He has both witnessed and been on the receiving end of aggressive behavior.
The violence hasn't reached the level of stabbings or shootings that require hospitalization, officials said, recalling the 2006 throat-slashing of a cardiologist on a fourth-floor intensive-care unit at HSHS St. John's Hospital by a significant other of a patient. The doctor survived; the woman charged, who used a box-cutter or similar cutting instrument, was convicted in 2007 and sentenced to 15 years in prison for armed violence.
Since then, cases of pushing, shoving and hitting, and threats of the same, are on the rise, Callahan said.
The move toward more arrests and criminal prosecutions for bad behavior is "critically important to the staff," McDowell said. "When they see that that's being enforced, it provides them an added measure of comfort that they have a safe environment to do their job."
Susan, the former nurse's aide, is in her 20s. She said she was ecstatic to hear Memorial officials are taking steps to both reduce workplace violence and boost morale since she resigned.
It was frustrating and demeaning to staff members when people committing violence weren't prosecuted, she said.
"You'd have patients being belligerent and threatening you on a daily basis," Susan said.
Some patients were being evaluated for psychiatric issues and didn't want to be there, she said. But the threats didn't just come from patients and visitors with mental health concerns. Some were upset about wait times in the ER. Some didn't like the visitor restrictions.
Callahan said the risks of aggressive behavior are higher in hospitals anyway because some patients have dementia or other mental illnesses, are intoxicated or high, or withdrawing from substance use. "We also may have to give them bad news when they are here," he said.
Callahan said Memorial officials understand when patients who have an underlying mental health issue become aggressive. But he said the pandemic appears to have brought overall agitation to another level, leading people to "choose to act out violently to get something that they want."
At Memorial Health, most of officials' concerns center on the emergency room, but they have seen tempers flare in lobby areas.
"People don't like being constrained," Callahan said. "They tell us, 'You can't make me wear a mask,' or 'That's a sham' or 'You can't limit the number of visitors.'"
Hospitals increasingly are seeing people brought to ERs who have criminal or mental health issues when jails and treatment centers are full, he said.
"I think the pandemic just put a weight on a lot of different parts of society, and I think we're seeing that manifest in a lot of different ways, and the increased violence is one of those ways," Callahan said.
Memorial's "critical incident stress debriefing" is an important element of the local response, Callahan said. After a violent episode, staff members involved take a "time out" to discuss whether they feel safe, need mental health support services and feel well enough to return to their shifts. They and their managers also look at what can be learned from what happened to prevent future occurrences.
The reaction from employees to all of the steps has been positive, Callahan said.
"I would hope that their level of comfort that leadership and the organization is working on their behalf to make them safe, would increase," he said.
Staffing concerns and financial woes
But workplace violence is only one of the issues affecting staffing levels. Ervin, the IHA spokesperson, said hospital employment across the country is down by more than 100,000 compared with pre-pandemic levels, and hospitals are reporting labor costs have gone up by 20%.
"These rising costs, in addition to the inflationary cost increases for medical supplies, are putting unique fiscal pressures on hospital operations," Ervin said.
After several years of workers providing care to patients during the worst times of the pandemic, Memorial Health and other institutions saw many nurses and other employees retiring early or leaving for other health care settings. Beginning in 2022, Memorial felt the biggest impact of "less interest in working in 24-hour-a-day, seven-day-a-week operations," Curtis said.
Memorial had to rely even more on temporary staffing agencies for nurses and other professionals, but the costs for temporary staff is several times higher than for permanent staff, and that devastated Memorial's bottom line.
Memorial Health posted a record $107 million operating loss in the fiscal year that ended Sept. 30, 2022, said Curtis, a former chair of the board of the Illinois Health and Hospital Association. The Springfield-based nonprofit health system operates Springfield Memorial and hospitals in Jacksonville, Taylorville, Lincoln and Decatur.
Revenues went up 5.2% in the most recent fiscal year, but expenses rose 17.3%. "That's not a typo," Curtis said.
Before the pandemic, Memorial Health would spend about $1 million per month for temporary workers. That expense peaked in summer 2022 at about $13 million per month.
"You can kind of take that number times 12 and figure out where our losses came from," Curtis said.
Things are getting better, though, with a reduced need for temporary staff. In the first three months of the new fiscal year – October, November and December – revenues rose 8.5% and expenses were up only 7.3%, Curtis said.
"While I'm very happy with the first-quarter results, I in no way want you to think we're out of the woods, because we're not," he said.
Memorial has put in place a "strengthen-our-future improvement plan" with 130 initiatives to either grow revenues or cut expenses in an environment with 70% of revenues based on reimbursement rates largely fixed by government payers for Medicare and Medicaid patients, he said.
Layoffs aren't being considered in the organization, which employs 9,000 people, Curtis said.
"We don't want to send any signals to the workforce that we have any thoughts of furloughs or reductions in force," he said. "However, getting in here as a new hire, unless you're in a clinical area, is very difficult."
The health system's finances are "very stable," Curtis said. But Memorial Health, a $1.5 billion-a-year organization, is facing challenges being felt throughout the U.S. health care industry.
"Two-thirds of Illinois hospitals are in the red right now," Curtis said. However, "I'm bullish about the future," he said. "We're going to navigate through this as a country, but it's going to take a few years. It's not going to take a few months."
Hospital Sisters Health System, based near Riverton and operating HSHS St. John's in Springfield and 14 other hospitals in Illinois and Wisconsin, posted a $67 million operating loss in the fiscal year that ended June 30. The nonprofit system reported an additional operating loss of $66 million in July through September alone.
"This is not sustainable, and HSHS is taking action to strengthen our financial position," HSHS spokeswoman Catie Sheehan said.
"This fiscal year, which started July 1, 2022, is shaping up to be worse with a number of headwinds," she said, listing high inflation, a decrease in patient volume, supply delays and shortages, high labor costs and a reduction in federal and state funding.
Sheehan said HSHS is grateful that the General Assembly recently passed a bill that will provide $460 million in relief funding to hospitals throughout the state and is hopeful Gov. JB Pritzker signs the bill into law.
"We hope to continue working with legislators to improve matters so our operations can be more sustainable," she said.
Efforts to combat nursing shortage
The nursing shortage, exacerbated by the pandemic, "is worse than it's ever been," said Marsha Prater, Memorial Health senior vice president and chief nursing officer. The system employs 2,500 to 2,800 registered nurses, 1,500 of them at Springfield Memorial, the flagship hospital.
"We have twice as many openings as we've had previously," Prater said.
And yet, the aging of the baby-boom generation – people born between 1946 and 1964 – and medical technology keeping people alive longer are swelling the demand for health care, she said.
The nursing shortage, and the related increased costs for temporary nurses, is being felt in the long-term care industry as well. The rise in labor costs was a major factor in the decision by Heritage Operations Group to close the Heritage Health-Springfield nursing home in early 2022, Heritage CEO Benjamin Hart said.
The staffing challenge is "slowly getting better," said Hart, who heads a company that employs 3,000 people at more than 50 skilled-care, assisted-living, supportive-living and independent-living sites in Illinois.
Staffing shortages during the pandemic also were cited by General Assembly lawmakers who passed a bill this month that was signed into law and delayed for two-and-a-half years the imposition of fines against nursing homes failing to comply with minimum staffing requirements.
The delay was needed, Hart said. "Right now, we're in the midst of the worst staffing challenge in the history of our industry," he said. "The industry wants to do the right thing, but you can't punish your way out of this. It's counterproductive."
Memorial Health is working to address the 90,000-person waiting list of people wanting to be admitted to nursing schools nationwide. The work includes investments in nursing programs operated by Lincoln Land Community College, Illinois College, the University of Illinois at Chicago College of Nursing's site at the University of Illinois Springfield, and the Mennonite College of Nursing at Illinois State University.
A satellite site for the Mennonite nursing school is scheduled to open in August at the former home of Shop 'n Save grocery store at 200 North Grand Ave. W. in Springfield. Memorial Health is paying for the $1.6 million in renovations at the North Grand property as party of $6 million in total donations to the Mennonite program over the next 10 years.
The health system also is talking with elementary and secondary students in Springfield and Decatur about the benefits of a career in nursing and other specialties in health care, including respiratory care, radiology and information technology, Prater said.
"There are over 500 different occupations related to health care careers that many of them don't even realize are available, and many of them are very technologically oriented careers, which also is a very big interest of the newer generation," she said.
Elisabeth Klar, Memorial Health senior vice president and chief human resources officer, said the system is considering increasing benefits and compensation "in an effort to not only attract a skilled workforce to Memorial Health but also retain the workforce we do have."
St. John's Chief Nursing Officer Allison Paul said St. John's is expanding its paid "externships" for people working in the hospital while completing nursing school so they can go beyond traditional nurse's aide duties and have more experience working directly with RNs.
The expansion is intended to improve recruitment efforts and help newly hired RNs transition to jobs in the hospital quicker. "We want functioning nurses as soon as possible," she said.
Both health systems offer tuition reimbursement for higher education, and both Springfield Memorial and St. John's are adding licensed practical nurses to help deal with the nursing shortage.
MacKenzie Moyer, 21, currently works part time as a nurse's aide at St. John's while she completes nursing school at Millikin University. She said she is looking forward to taking part in an expanded externship because it would give her more experience caring for the premature infants in the hospital's neonatal intensive-care unit.
She already has a full-time job lined up as an RN in the NICU after graduation in May.
"I always knew that as a nurse I wanted to work with kids," she said. "I babysat all through high school."
Dean Olsen is a senior staff writer at Illinois Times. He can be reached at firstname.lastname@example.org, 217-679-7810 or