Surge in workplace violence the last straw for Canada’s pandemic-weary healthcare workers

By Henrietta Van hulle

The risk of violence is nothing new to Canada’s healthcare workers. In my 17 years as a frontline nurse, I was hit, pinched, scratched and verbally abused. Thankfully these incidents never resulted in serious injury. But I know I was one of the lucky ones.

Throughout Canada’s health care sector, violent incidents and acts of aggression continue to escalate in both frequency and severity. Healthcare workers describe violent events as daily occurrences, some so serious that they result in a range of physical or psychological issues, from chronic mental stress to anxiety, depression or post-traumatic stress disorder.

According to Ontario’s Workplace Safety and Insurance Board, assaults, violent acts and harassment in the province’s healthcare sector have steadily increased over the past several years, nearly doubling from 2012 to 2019. Workplace violence was the cause of 14 per cent of all lost-time injuries in 2019 in the healthcare sector – more than the injury claims allowed for exposures to harmful substances or environments. In 2020, while COVID-19 exposures accounted for the majority of lost-time injuries in Ontario’s healthcare sector, workplace violence remained among the top five injury types, with 993 cases.

As alarming as these figures are, it’s only the tip of the iceberg. The reality is likely more shocking as incidents of violence and aggression have been found to be severely underreported. Research indicates that this is most often associated with the normalization of violence among healthcare workers, and is attributed to the belief that violence is simply “part of the job”. Red tape, blame, lack of response from management and fear of reprisal are among other reasons.

The rise in incidents can be attributed to an aging population, increasing rates of dementia, a lack of access to mental health resources, overcrowding and wait times, and staffing shortages, just to name a few. Now, we add pandemic-related tensions to the list.

Perhaps unsurprisingly, COVID-19 has exacerbated the situation. The pandemic has created an emotionally-charged environment ripe for aggression and violence, both in the hospital setting and out in the community. Some patients are prompted to commit aggressive acts out of fear for their health. Family members are responding to the loss of relatives, the inability to say goodbye or carry out funerals or other rituals as they’d like. Hospital workers are dealing with confrontations related to the enforcement of public health measures. Out in the community, healthcare workers have been stigmatized, harassed, threatened or assaulted for fear of spreading the virus.

Recent polling shows verbal, physical, sexual and racially directed violence against healthcare staff surging during the pandemic. A large provincial survey of hospital-based RPNs conducted by the Canadian Union of Public Employees (CUPE) and SEIU Healthcare found that 66 per cent of the more than 2,600 respondents said violence toward them or their coworkers from patients or patients’ family members has increased in the last 18 months. Hostility stemming from the pandemic is making an already stressful job that much more difficult. In the same poll, 87 per cent of RPNs said they have considered leaving their jobs.

If these behaviours are allowed to continue or worsen, the work environment and quality of care is certain to suffer. As feelings of anxiety and vulnerability deepen, workers may disengage, become less productive and feel less committed to their work, regardless of whether they are the target of the abuse. Failure to address inappropriate and unacceptable behaviours has financial consequences, too. Workplaces can experience increases in lost-time from work, workers compensation costs or health and medical expenses. Employers may also face charges, lawsuits or other legal action as a result of inaction and failure to protect workers.

Every worker should expect a safe and healthy work environment; violence should never be tolerated as part of the job. Hospital employers and management have a duty to protect employee health and safety and address unsafe working conditions, including includes taking action to prevent violent acts and threats of violence. Ontario’s Occupational Health and Safety Act (OHSA) requires employers to assess the risks of workplace violence and implement a policy and prevention program. Here are just a few examples of recommended program elements.

Conduct Regular Workplace Violence Risk Assessments

In Ontario, the OHSA states that employers must assess and control risks of workplace violence arising from the nature of the workplace, type of work and conditions of work. Workplace violence risk assessments enable the healthcare organization to identify risks and prioritize action. This needs to be done as often as necessary to ensure that organizational policies and programs continue to protect workers. For these reasons, a workplace violence risk assessment should be completed at least annually, though each organization should have its own processes for determining how often to complete an assessment, and when to evaluate the effectiveness of the process. In light of the recent intimidation healthcare workers are facing just by going to work, this new risk should be assessed to ensure the workplace measures and procedures address this new threat.

Enable a Risk Communication or Flagging-Alert Program

Employers in Ontario are required to provide all workers at risk with information (including personal information) about a person with a history or risk of violence. Workplaces, in turn, must adopt effective prevention strategies. One such strategy is a flagging-alert program to communicate violence-related risks to healthcare teams. By taking this kind of proactive approach to managing violent, aggressive and responsive behaviours, hospitals can reduce the risk of harm to workers while providing patients with the best possible care.

Establish Emergency Response Procedures

Ontario’s OHSA requires employers to develop and implement measures and procedures for workers to summon immediate assistance when workplace violence occurs or is likely to occur. One important measure is a formal emergency response procedure to workplace violence, also known as Code White. Code White is used in many healthcare settings to alert workers to a real or perceived threat of violence, which includes aggressive or responsive behaviours. Formal Code White procedures also ensure there is standardization and consistency in the response to workplace violence. Everyone in the workplace needs to be trained in the emergency response procedures and understand how to respond to workplace violence. Healthcare organizations are also encouraged to establish effective Personal Safety Response Systems that can effectively summon immediate assistance for impending workplace violence situations or incidents in progress. Recent protests at healthcare settings would indicate a review of current security practices.

Communicate the Work Refusal Process

Workers in Ontario have the legal right to refuse work or refuse to do particular work that they believe endangers them, including situations of workplace violence. This legal right ensures that workers have a voice in situations of real or perceived danger. Employers, supervisors and Joint Health and Safety Committees (JHSC) need to define and support their organizational response to work refusals for reasons of workplace violence. Workers must also understand their right to refuse unsafe work as well as any related processes.

Of course, these are only a few of the actions hospital management and human resources departments can develop, implement and manage to control the risk of violence and prevent violent incidents. When developing a fulsome workplace violence prevention program, hospitals are encouraged to build off established leading practices for workplace violence prevention in healthcare.

An example comes from Public Services Health & Safety Association (PSHSA), an Ontario-based non-profit organization funded by the Ministry of Labour, Training and Skills Development to reduce workplace risks and prevent occupational injury and illness across the province’s public and broader public sector. PSHSA has released eight workplace violence prevention toolkits specifically designed for healthcare organizations to address the largest gaps in workplace violence prevention programs. Applicable to healthcare organizations of any size, the toolkits contain practical tools and resources for each of the aforementioned areas – risk assessment, flagging, emergency response, work refusals – and more to help healthcare organizations control the risk of workplace violence and protect workers. The validated, consensus-based toolkits were built in partnership with stakeholders across Ontario’s healthcare sector and are available free of charge at www.workplace-violence.ca.

An evaluation of the initial five tools was completed to better understand their awareness, use and effectiveness among Ontario hospitals. Overall, 67% of public hospitals in Ontario reported using at least one of the toolkits and, of these, 89% reported improving their processes, programs and systems to prevent and manage workplace violence. Hospitals used the toolkits most often to identify safety risks, consider safety proactively in planning and validate or improve existing efforts.

While the risk of workplace violence is nothing new to Ontario’s healthcare workers, it’s been tolerated for too long. And now, as violent incidents continue to rise amid a growing fourth wave, where healthcare workers are already overwhelmed, burnt out and exhausted, they’ve hit a breaking point.

By building meaningful, cohesive and multi-faceted workplace violence prevention programs, Canadian hospitals can deliver results and sustainability in the prevention of violent incidents and protection of their employees. In turn, this will create a climate where workers feel comfortable coming forward with concerns and improves the ability to recruit and retain employees.

We know that healthcare workers play an integral role in our communities and are our healthcare system’s greatest asset. Ensuring a healthy healthcare workforce free from violence will help sustain quality care for all Canadians.

Henrietta Van hulle is Vice President, Client Outreach at Public Services Health & Safety Association. Henrietta began her career as a Registered Nurse where she cared for patients for 17 years before transitioning to occupational health and safety. Her knowledge and experience encompasses all aspects of occupational health and safety, but specialties include infection prevention and control, workplace violence prevention and disability management. Henrietta has her Master of Health Services Management and Executive Leadership certificates from the Niagara Institute and the Schulich School of Business.