Workplace violence: What we’ve learned

 By Henrietta Van hulle

An emergency room nurse is attacked by a patient. She is punched, kicked and threatened. On top of her physical ailments, she suffers long-term effects from depression, panic attacks and stress. She questions her future in nursing.

By now, regrettably, it’s a familiar story.

Workplace violence continues to be one of the most pressing concern facing health care workers, patients, residents and clients across our health care sector. In 2017, health care received 18 per cent of total lost-time injury claims in Canada, more than any other industry (AWCBC, 2017). 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 (Ontario Ministry of Labour, 2015). Workplace violence is a serious concern leading to physical, psychological, interpersonal and financial harms for health care workers (Brophy et al., 2018).

There’s no question that attitudes toward workplace violence are shifting. As associations and unions roll out public awareness campaigns, health care workers are becoming less willing to tolerate violence as just “part of the job” and are raising more concerns about safety. The issue has prompted governments and health care organizations across the country to make prevention a priority.

Between 2015 and 2017, Public Services Health & Safety Association (PSHSA) developed a series of free tools and resources in partnership with stakeholders across health care and labour to support health care workplaces in reducing and preventing the risk of workplace violence. The Violence, Aggression and Responsive Behaviours (VARB) toolkits focused on: Workplace Violence Risk Assessment, Individual Client Risk Assessment, Risk Communication (Flagging), Security and Personal Safety Response System. These first five toolkits were designed for use in hospitals, long-term care, community care and emergency medical services to protect those workers who are most at risk of workplace violence, including nurses, nurses’ aids and orderlies, other allied health care staff, community and social service workers, and visiting home care workers.

An evidence-based evaluation was recently completed to better understand the VARB toolkits’ awareness, impact and effectiveness on workplace violence prevention and controls, and to identify lessons learned about toolkit design and use. The evaluation findings were based on an inventory of toolkit use at all Ontario hospitals, in-depth case studies at six hospitals, and interviews with a small number of hospitals that were not using, or not sure if they would use, the toolkits. The results are compelling, and provide further insight into how we can begin to affect positive change when it comes to addressing such a pervasive, systemic issue.

The evaluation revealed promising uptake and awareness rates. The study found that 75 per cent of Ontario public hospitals are aware of at least one of the VARB toolkits, and that 67 per cent of Ontario public hospitals are using at least one of the VARB toolkits within their organization. The toolkits have also been accessed and used beyond Ontario, by health care organizations in other provinces and in the United States.

The reasons driving health care organizations to implement the toolkits largely revolved around two major themes: concerns over mounting incidents and enforcement events. “Our organization decided to apply these tools as we saw our incidents of violence on the rise and we wanted to have a better grasp on what our gaps were so that we could reduce these incidents in frequency and severity,” as one regional hospital explains. “The Ministry of Labour had also made this a priority focus. They performed several inspections using PSHSA’s tools. Using these tools helped us to be well-prepared for these visits and allowed us to have a better organized plan, response and documented strategy to reduce violence in the workplace.”

Further to uptake and awareness, the study also found that the toolkits had a positive impact on how hospitals prevent and manage workplace violence. 89per cent of hospitals reported that use of the toolkits ended up improving their processes, programs and systems to prevent and manage workplace violence. Hospitals used the VARB toolkits to identify and address safety risks, consider safety proactively in planning (i.e. new builds, units or programs), and validate or improve existing practices. The in-depth case studies provided more insight into how organizations were implementing the toolkits along with some initial impacts.


A regional hospital uses the Workplace Violence Risk Assessment in every department at least once a year. “It helps us to identify risk and develop an action plan. The categories were helpful in educating our staff on risk of violence and things to look for, as well as potential solutions. These have been helpful in putting recommendations forward for change and we have seen several positive changes as a result of using these risk assessments.”

A large community hospital recognized that its existing patient alert code system was not helpful for communicating the risk of violence on a day-to-day basis. They used the Risk Communication toolkit to refine the system and add alert codes which were much more effective in communicating real-time risk.

A teaching hospital was preparing to establish a new program within a different hospital site. Before the site opened, they used the Workplace Violence Risk Assessment so that appropriate controls could be implemented ahead of time.

A specialized mental health hospital used the toolkits as a best practice reference for assessing the comprehensive mechanisms they already had in place to ensure a safe environment, including policies, risk assessment processes, security and risk communication programs, and personal safety response systems. This helped to identify some improvement opportunities to their existing practices.

A small hospital carried out a Workplace Violence Risk Assessment of all departments which delivered an action plan. As a result, the hospital has implemented a new communication system, introduced a new system for tracking staff training and launched an awareness campaign.

Several organizations within the health system across Canada are putting out toolkits and guidelines each year, but few have achieved the kind of uptake and impact as the VARB toolkits. The evaluation credited this strong uptake to the high quality of the toolkits and the endorsement from the Ontario Ministry of Labour. Key factors contributing to the effectiveness of the toolkits were their credibility, comprehensiveness, flexibility, ease of use and the collaborative stakeholder engagement approach that was employed when designing the toolkits.

In terms of whether toolkit implementation has resulted in an overall reduction in incidents, we know this will take more time to validate. However, some participating health care organizations are already seeing positive shifts in this direction. “While some violent incidents continue, such as patients with cognitive disruptions acting out on staff – it is the nature of the condition of the patient and there are some risk factors we are unable to eliminate – we have been able to reduce our risk levels by better preparing our staff to watch out for and address these aggressive behaviours, such as with training, patient flagging and alerts,” explains a Director from one of the case study sites. “So, although the frequency of violent attempts or incidents has not decreased as of yet, we have seen the severity of violent incidents reduced.”

The evaluation results will be used to optimize and improve the current five VARB toolkits and related processes, as well as inform future resource development as it relates to workplace violence prevention in health care and beyond. Throughout the evaluation process, emerging findings were shared with PSHSA, who has already began work improving the current toolkits. These insights will also inform the development of the next four VARB toolkits, set to be released in early 2020.

Overall, the VARB project serves as an example of a successful approach with leaders coming together from across to address a systemic issue. While the positive results are certainly encouraging, there is still work to be done. This is especially true given that reported incidents are expected to spike in the immediate future as awareness around the issue increases and health care workers are further encouraged to report.

There is no doubt that resolving this issue requires a multi-faceted approach. As these early results demonstrate, continued partnership and collaboration among system stakeholders, including government, labour unions, professional associations, patient advocates, and representatives from community, home and hospital settings is integral. We will also need to continue advancing public awareness of the issue of workplace violence in health care, and encourage adoption and continued use of available and validated prevention resources and supports, such as the VARB toolkits. Another priority will be extending this work and support outside hospitals to the long term care and community and home care sectors who also struggle to assess and control the risk of violence within their organizations.

Our health care system’s greatest asset are the committed, skilled and compassionate individuals that dedicate their careers to the care of others. Let’s attain a future where violent incidents aren’t status quo, and shift the culture so that our health care workers come to expect protection, safety and security in the workplace.

Together, we can change the story for the emergency room nurse.

You can access the full evaluation report and case study summary, along with the VARB toolkits and additional resources at



Henrietta Van hulle is the Vice President of Client Outreach at Public Services Health & Safety Association, and holds a Masters of Health Services Management.