Taking action against workplace violence

I was a frontline nurse for 17 years. The work was challenging and rewarding, and it was a career I absolutely loved. During that time, however, I was hit, pinched, scratched and verbally abused on several occasions. The events were not what I would call frequent, nor did they ever result in serious injury. I consider myself among the lucky.

Like many healthcare professionals, I’ve come to learn that this is not the case for everyone. Throughout Canada’s healthcare sector, violent incidents and acts of aggression are escalating in both frequency and severity.

An employee is threatened and struck with a phone.

A nurse removing a BiPAP mask is kicked.

An employee is bitten while administering medication.

Oftentimes, healthcare workers describe violent events like these as daily occurrences, some so serious in nature that they result in a range of physical or psychological issues, from chronic mental stress to anxiety, depression or post-traumatic stress disorder. The rise in incidents can be attributed to an aging population, increasing rates of dementia, a lack of access to mental health resources, and overcrowding and wait times in healthcare organizations, just to name a few.

Workplace violence is one of the most pressing issues affecting healthcare workers today. The affected population is significant. Healthcare and social services represent a large portion – approximately 13 per cent – of Canada’s total labour market. In 2015, healthcare received 19 per cent of total national injury claims, more than any other industry in Canada. In Ontario alone, violent-related incidents made up 10 per cent of all lost-time injury claims in hospitals in 2015, costing these institutions over $23 million that same year. In one health region in Saskatchewan, violent incidents almost doubled from 224 in the first two quarters of 2015-16 up to 416 over the same period just one year later. In New Brunswick, 66 per cent of nurses reported experiencing physical or verbal abuse during a one-year period.

As alarming as these figures are, the reality is likely even more shocking as incidents of violence and acts of aggression have been found to be severely underreported. Research indicates that this is associated with the normalization of violence for healthcare workers, and is attributed to the belief that violence and aggression is “simply part of the job”. Efforts toward reversing this notion is another important task that many jurisdictions are actively working on.

For healthcare organizations across the country, acknowledging that there is a problem is the first step. The next is taking action to affect real change. By taking a proactive approach to tackling violence in the healthcare sector, we can create safer environments for healthcare workers while simultaneously improving patient care. Provinces and healthcare organizations across the country are stepping up to start the conversation, develop and implement solutions, and work toward eliminating this critical hazard.

In response, the Public Services Health & Safety Association (PSHSA) launched www.workplace-violence.ca, an interactive framework providing workplaces with a consistent, scalable and consensus-based approach to building a comprehensive workplace violence prevention program for healthcare. Included are five Violence, Aggression and Responsive Behaviours (VARB) toolkits which were developed in collaboration with the Ontario Ministry of Labour, Ontario Ministry of Health & Long Term Care, labour unions, healthcare leaders, patient advocate representatives, safety experts, employer and professional associations and other key stakeholders.

The use of the PSHSA VARB toolkits are one of 23 recommendations put forward by Ontario’s Workplace Violence Prevention in Healthcare Leadership Table Report. More resources and changes are expected as other recommendations are rolled out in the near future. “The Violence Leadership Table was a good first start”, says Linda Haslam-Stroud, President of the Ontario Nurses Association. “It is critical that we continue to build on this work, using the practical tools available to assess risk and prevent workplace violence. I applaud the hospital CEOs who have committed to using these tools and urge others to join them.”

Hospitals across the province are being advised to integrate the interactive tools into their workplace violence prevention programs. The tools found in each of the five toolkits provide a simple step-by-step implementation process that allows for customization to meet the unique needs of every workplace. “[Workplace violence in healthcare] is a complex issue that requires individualized approaches tailored to each unique workplace”, explains Anthony Dale, CEO of the Ontario Hospital Association. “As hospitals continue to work through the recommendations put forth by the Leadership Table, it is important to create solutions that reflect their individual missions, the services they provide and that best suit the needs of their staff and community.” An organization with an existing workplace violence prevention program is able to use the VARB tools to evaluate or enhance current program components.

  • The Workplace Violence Risk Assessment Toolkit: This toolkit is designed to support healthcare organizations in identifying workplace-specific hazards, establishing their risk rating, identifying controls and implementing an action plan.


  • Individual Client Risk Assessment: This toolkit is designed to help healthcare organizations identify behaviours and triggers associated with increased risk of violence so that prevention measures for staff and the client may be taken.


  • Communicating the Risk of Violence: This toolkit is designed to support healthcare organizations in developing a proactive flagging-alert program to communicate violence-related risks to healthcare teams. This toolkit provides practical tools and information that will help organizations to establish a sustainable flagging-alert program focused on providing quality preventative care


  • Security: This toolkit is designed to assist healthcare organizations, with or without designated security personnel, to establish an effective security program. This toolkit provides sample tools and resources to increase awareness and understanding of security program functions, program elements, training requirements, allowing organizations to identify security program gaps and develop a comprehensive and customized action plan


  • Personal Safety Response System (PSRS): This toolkit is designed to help healthcare organizations establish an effective PSRS that can effectively summon immediate assistance for impending workplace violence situations or incidents in progress. The tool kit provides practical information regarding legislative requirements, key definitions, devices, procedures, training and implementation considerations.

Through the utilization of these tools, incidents of violence and aggression can be reduced and sustainable outcomes achieved. Thus far, 59 hospitals and healthcare organizations are actively using the tools. Carrie Fletcher, Senior Director of Health Information Management and Enterprise Project Management Office at the Centre for Addiction and Mental Health (CAMH) in Toronto, Ontario stated the PSHSA toolkits are practical and usable. “The toolkits provide a step-by-step process that an organization can use to implement a practice they don’t already have in place, or improve upon a process they do have. At CAMH, we plan to use them for Quality Improvement to enhance our current workplace violence prevention program”.

In my experience, building and enhancing strong, positive relationships and partnerships across the healthcare system enables excellence in prevention; this is why many players are taking a collaborative approach to addressing the widespread issue of workplace violence. While PSHSA’s VARB toolkits were built for Ontario, two additional provinces are currently trialing to evaluate effectiveness in their jurisdictions, teaming up to make better use of respective resources and capitalize on promising practices.

Saskatchewan is also working to address workplace violence in healthcare through their Provincial Violence Prevention Strategy, a collaborative plan which brings together partners from across the province to reduce healthcare’s injury rates through a variety of targeted actions. The group identified PSHSA’s VARB toolkits as a best and promising practice out of Ontario. The Saskatchewan Association for Safety Workplaces in Health (SASWH) is in the process of validating the PSHSA tool kit for use in Saskatchewan in three locations. “To date feedback and evaluations have been very positive” says Sandra Cripps, Chief Executive Officer at SASWH. “SASWH as well as all provincial partners are impressed with the work accomplished by PSHSA in this area, and are most appreciative to access and use these invaluable resources”.

Likewise, Alberta Health Services is evaluating the Individual Client Risk Assessment toolkit for use in Alberta. “Alberta Health Services recently conducted a provincial pilot related to Violence/Aggression Alerts, designed to identify patients who may have a higher propensity of violence or aggression based on their history and observed behaviors”, explains Lindsey Simpson, Acting Director of the Centre of Expertise, Workplace Health & Safety at Alberta Health Services. “The goal of this pilot was to establish a formal mechanism of communication of risk between staff, and from one point of care to the next, to enable the provision of safer, quality care, through more informed conversations and effective care planning. One of the most challenging aspects of this initiative was determining which tool to use to support our staff in the decision-making; ideally one that was intuitive and validated. The screening tool developed by PSHSA was critical to our success, and we look forward to partnering with them in the future.”

As a whole, the Canadian healthcare system is making major strides in addressing the issue of workplace violence. We must continue to remember that our healthcare system’s greatest asset are those committed, skilled and compassionate individuals that dedicate their careers to the duty of care. Ongoing initiative and collaboration will be required to keep them safe at work and doing what they do best. Together, we can attain a future where it isn’t “lucky” for healthcare workers not to experience violent incidents, and shift the culture so that workers come to expect protection from workplace violence as the norm in healthcare.

Henrietta Van hulle is the Executive Director of Health & Community Services at Public Services Health & Safety Association, and holds a Masters of Health Services Management.