Preventing patient-on-staff violence

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A new tool is being created in Ontario to assess workplace environments within mental health facilities to help prevent .

The Public Services Health & Safety Association (PSHSA) has partnered with the Ontario Shores Centre for Mental Health Sciences, a health-care facility, and the Institute for Work & Health (IWH), a research organization, to create and pilot the Clinical Practice Assessment Tool (CPAT). This self-report survey asks caregivers to asses work environment factors associated with the prevention of patient-on-staff violence in mental health-care units or facilities.

Why the tool is necessary

Workplace violence―when employees are abused threatened or assaulted in circumstances related to their job―is a fact of life in Ontario’s health care facilities. Research shows health-care professionals are at higher risk of workplace violence than other service providers such as police officers, prison guards and bank personnel. Patient-on-staff violence in health-care is particularly a problem in mental health units and facilities.


Ontario’s Workplace Safety and Insurance Board reported in 2012 that violence accounted for 37 per cent of lost-time injuries in psychiatric hospitals. Other research shows that psychiatric nurses report the highest rates of violent events among all nurses. Indeed, a study of psychiatric departments in Minnesota found a two-fold greater risk of violent events compared to nurses in other departments.

Patient-on-staff violence is not limited to nurses within mental health-care facilities. In one study of physiotherapists working in mental health-care, 51 per cent reported being assaulted at work during their career, and 24 per cent reported being assaulted in the previous year.

Victims of workplace violence may suffer from minor, sustained or life-endangering injuries.  Beyond physical pain, many victims live with debilitating residual emotional and psychological effects, such as post-traumatic stress disorder. In addition, staff victimization has negative repercussions for an organization’s delivery of quality care, including decreased staff productivity, impaired job performance and increased errors.

Contrary to what some believe, patient-on-staff violence is not “part of the job” in health-care and, in particular, mental health-care. Many organizations, such as the Canadian Nurses Association and Canadian Federation of Nurses Union, promote “zero tolerance” of any type of violence. Actions at all levels – organizational to individual – must be taken to effectively address patient-on-staff violence at work. To that end, health-care organizations need scientifically credible tools to assess the conditions of their clinical environments to make appropriate and effective changes that will protect staff from violence at the hands of patients.

How the tool was developed

This is where the development of the Clinical Practice Assessment Tool comes in.Through a self-report survey, CPAT asks caregivers in mental health-care units or facilities to assess work environment factors that may prevent patient-on-staff violence. The survey as it was initially conceived asked questions in seven areas:

  1. Leadership commitment
  2. Support for violence prevention programs
  3. Environmental supports for staff safety
  4. Staff development
  5. Client (i.e., patient) admission/transfer and assessment for violence and aggression risk
  6. Client engagement
  7. Client care and communication


The partners developing the tool conducted five focus groups between September 2013 and April 2014 (see figure) with experts in workplace violence and frontline staff from Ontario Shores. The aim was to get their feedback on the tool.

Staff violence


Figure: Timeline of focus groups with sample size

Through the feedback, the partners learned the following: (1) Several questions implied that staff members were to blame for violent patients. (2) Several questions were ambiguous or not relevant to patient-on-staff violence. (3) Questions were missing about the effectiveness of education and training programs, interdisciplinary teamwork, the debriefing process and whether or not staff felt safe. (4) The client care and communication section was not relevant. These findings resulted in revisions to the CPAT for caregivers.


Overall, the experts and staff taking part in the focus groups felt that the CPAT for caregivers is an important tool that can help keep staff safe in mental health-care units and facilities, with the potential for the tool to be used in other health-care sectors as well. The caregiver CPAT is now ready for further testing in the workplace to ensure its validity and reliability.

Hospitals and health care professionals strive to provide patients with the highest quality care. Quality care is not just limited to clinical indicators; it also includes the quality of the work environment. If health care professionals are not safe at work, they cannot do their jobs successfully, ultimately affecting the care patients receive. CPAT has the potential to be an effective tool that health care leaders can use to provide staff with healthy and safe work environments.

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