OHS Canada Magazine

A recent spate of violence against healthcare workers in Ontario and British Columbia has revived the debate on whether healthcare institutions are doing enough to protect employees on the job.

On December 29, a registered nurse was beaten and critically injured while providing care to a patient at the Centre for Addiction and Mental Health (CAMH) in Toronto. The employer did not notify the Ontario Ministry of Labour until nearly a day later, in contravention of the Occupational Health and Safety Act (OHSA).

The centre is also facing charges over another incident that occurred in January 2014. A nurse was beaten by a patient, and another nurse who came to her assistance was also hurt. In a statement issued on December 23, CAMH says it is “very disappointed” that the labour ministry has laid charges against the Centre and that it will defend them in court.

Earlier in December, a nurse was attacked by a patient in the emergency room of Southlake Regional Health Centre in Newmarket, Ontario, following a similar incident in 2013. Out west, a doctor at Penticton Regional Hospital in British Columbia was found unconscious after being savagely beaten by a patient on December 5. Nurses at the hospital reported that the patient had walked out of a closed-door session calmly and announced that the staff member might be dead.

Gayle Duteil, president of the British Columbia Nurses’ Union (BCNU) in Burnaby, says the attack in the Penticton hospital highlights the dangerous lack of security in the province’s psychiatric and forensic facilities. “Every day, nurses and other healthcare professionals put themselves on the line and risk being attacked on the job, because of inadequate protection against violent patients,” Duteil says in a statement.


Since the attack, BCNU has called on the Interior Health Authority in Kelowna to launch an investigation, provide personal alarms and cameras and assign security personnel to psychiatric units. It has also demanded that the patient not be returned to the unit and that if the patient is sent to another site, a risk assessment and safety plan must be put in place, along with additional trained staff and security prior to transfer.

On the Receiving End

The healthcare sector is particularly prone to violence, and healthcare workers are 16 times more likely to be victims of, or witnesses to, acts of violence compared to other public-service personnel, concludes a review by Stéphane Guay, associate research professor with the department of psychiatry at the University of Montreal. Guay co-authored the systematic review of literature on violence against healthcare workers, the findings of which were published last October.

“Most of these acts are committed by patients or their relatives and can cause many adverse effects. However, to date, no literature review has identified all the consequences that victims or witnesses of workplace violence may face,” he says.

The review, which looked at 68 studies, reveals seven types of consequences that may result from acts of workplace violence: physical; psychological; emotional; financial; social repercussions like a sense of insecurity; those related to functioning at work, such as sick leave; and those related to patient relationships and quality of patient care, including a sense of fear toward patients in general and loss of pleasure in working with patients.

The review also shows that violence has the most negative effects on an individual’s psychological and emotional states. According to four of the studies reviewed, between five and 32 per cent of victims suffer from post-traumatic stress. Increased vigilance, irritability and sleep disorders were also reported. Consequences at the professional level were also significant. In 12 of the 68 studies reviewed, 13 to 60 per cent of victims considered leaving their jobs after an act of violence.

According to a chart from the Ontario Nurses’ Association (ONA) comparing the province’s lost-time injuries between healthcare workers and those in manufacturing, construction and mining, there were 639 lost-time injuries from workplace violence among healthcare workers in 2013, compared to 77, 10 and one in the other industries respectively.

Nancy Johnson, labour relations specialist in oh&s and workers’ compensation with the ONA in Toronto, says the biggest challenge in addressing violence in the healthcare sector is employers not fully understanding workplace health and safety law and the potential personal liabilities in failing to protect workers. “Enforcement agencies have not been holding them to account when they fail to take every reasonable precaution to protect workers,” she suggests.

Security measures in healthcare institutions vary widely, depending on patient volume, the nature of the client population, location and whether the facility is a mental-health centre, a remote hospital with few workers overnight or one located in a high-crime neighbourhood.

The contracts employers have with providers or workers also determine the security measures adopted. Johnson says some security guards are not allowed to touch a person, while others can physically restrain an individual. “Given the preventable injuries our members have suffered in attacks, security measures in many institutions are woefully inadequate to protect workers and their patients.”

According to Henrietta Van hulle, executive director of health and community services with the Public Services Health and Safety Association (PSHSA) in Toronto, providing care in high-stress situations contributes to the heightened risk of violence for healthcare workers. “The other risk factor is that the person you are providing care to has psychological issues or dementia that might preclude them from being aware of the consequence of their action.”

Susan Fuciarelli, director of health and community services with the PSHSA, says healthcare workers never really know who is coming in the door. “And if that patient or client is transferred from one institution or organization to another, that history does not necessarily follow them.”

Johnson is likely to agree. “There is a requirement in our OHSA for the employer to advise workers of a history of violence of a person they may encounter at work. In our experience, healthcare employers struggle with the notion of furnishing that information,” she says.

Van hulle advises healthcare organizations to follow the hierarchy of controls when looking at risk factors. “The biggest piece is risk assessment,” she says, stressing the need for a process to identify patients with a risk for violent behaviour and to ensure that the information is communicated to staff in a way that complies with other regulatory requirements.

Sharing best practices in workplace-violence prevention among healthcare institutions is also recommended. Van hulle reveals that the PSHSA is undertaking a project, jointly funded by Ontario’s labour ministry and the PSHSA, that looks at workplace-violence issues in the province. “The outcome of this project is to have a toolkit with a different number of tools, processes, checklists or best-practice listings of what organizations can do, because there are pockets of excellence and we would like that to be available to everyone.”


Step by Step

According to the guideline Developing Workplace Violence and Harassment Policies and Programs by the Occupational Health and Safety Council of Ontario, certain types of work conditions can put employees at risk of workplace violence. They include handling cash, having direct contact with clients, working alone or in small numbers, working with unstable or volatile people, operating in a community-based setting and having a mobile workplace.

As the Occupational Health and Safety Act requires a place of employment to have a policy and program on workplace violence, the first step in developing such a program is to identify the violence hazards in a workplace, the community and similar workplaces. This is followed by assessing the risk of violence in the workplace. The possible controls identified in this step can help when drawing up a workplace-violence program, which should involve workers, supervisors, joint health and safety committee representatives and/or the union. Lastly, employers should monitor and evaluate the effectiveness of the program — an ongoing process that may require occasional improvements.


Jean Lian is editor of OHS Canada.

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