Introduction

On 13 June 2018, the House of Commons Standing Committee on Health (the Committee) agreed to the following motion:

That, pursuant to Standing Order 108(2), the Committee undertake a study on the violence faced by healthcare workers in hospitals, long-term care facilities and in home care settings in order to develop recommendations on actions that the federal government can take, in partnership with the provinces and territories, to improve violence prevention in health care; that the Committee report its findings and recommendations to the House; and that, pursuant to Standing Order 109, the Committee request that the Government table a comprehensive response to the report.[1]

From 14 May 2019 to 6 June 2019, the Committee held four meetings and received eight written submissions as part of this study, where it heard from organizations representing the interests of nurses, physicians, paramedics, personal support workers, long-term care facilities; and occupational health and safety experts and researchers. These witnesses provided the Committee with an overview of the scope and impact of workplace violence in health care settings across Canada. The witnesses also outlined ways in which the federal government, in collaboration with the provinces and territories, could help address the violence experienced by health care workers. This report provides a summary of the testimony received and recommendations to the Government of Canada on how to move forward in this area.

Overview of Workplace Violence Facing Health Care Workers in Canada

What is Workplace Violence?

According to witnesses appearing before the Committee, there is not a standard definition of workplace violence in health care settings in Canada, which means it is difficult to understand the full scope of this violence or compare data across jurisdictions.[2] According to the Canadian Nurses Association, workplace violence can include:

• Physical violence, which involves the use of physical force by a person against a worker in a workplace that causes or could cause physical injury.
• Psychological violence, which includes harassment, bullying, intimidation and demeaning treatment of a worker.
• Sexual harassment, which is a form of harassment that includes repeated unwanted sexual behaviour that has harmful consequences for the victim.
• Financial violence, which is defined as actions taken to prevent advancement or promotion of an individual, which may have a financial impact.[3]

The Committee heard that workplace violence in health care settings can be perpetrated by patients, family members, other members of the public, co-workers or managers.[4]

Scope of Workplace Violence in Health Care Settings across Canada

Witnesses explained that workplace violence in health care settings is a widespread problem. According to Ms. Linda Silas, President, Canadian Federation of Nurses Unions (CFNU), 61% of nurses who participated in a cross-country survey reported experiencing abuse, harassment and assault during the year preceding the survey.[5] In addition, a 2010 survey of members of the College of Family Physicians of Canada found that one third of respondents had been exposed to some form of aggressive behaviour from a patient or a patient’s family in the past month.[6] A 2014 study of 1,676 paramedics in Canada found that 75% reported experiencing violence of some sort and 74% reported experiencing multiple forms of violence annually.[7] The Committee also heard that 89% of personal support workers had experienced physical violence on the job based upon a poll commissioned by the Ontario Council of Hospital Unions (OCHU) and the Canadian Union of Public Employees (CUPE) in January 2019, with 62% indicating that they had experienced violence on a weekly basis.[8] Witnesses explained that the high concentration of women in the health care sector means that the violence perpetrated in this sector mostly affects women, as Ms. Linda Lapointe, Vice-President, Fédération interprofessionnelle de la santé du Québec, pointed out:

We represent more than 90% of nurses, nursing assistants, respiratory therapists and clinical perfusionists in Quebec. Ninety per cent of our members are women, and they experience various forms of violence on a daily basis.[9]

While there is a risk of health care workers experiencing violence in all health care settings, the Committee heard that 50% of all attacks on health care workers occur in emergency departments.[10] Health care workers working in psychiatric settings and long-term care facilities also face greater risk of experiencing violence because of the high needs of patients in these facilities.[11] In addition, the Committee heard that health care workers working in home care and community-care settings also face greater risks of violence because they are often working alone in these settings and lack training on how to de-escalate violence.[12]

Witnesses explained that these statistics are just the tip of the iceberg in terms of understanding the rates of workplace violence facing health care workers across Canada because incidences of violence often go unreported due to fears of reprisal from employers.[13] The 2019 OCHU/CUPE poll found that 53% of health care workers did not report incidents of violence.[14] To address the issue of under-reporting, witnesses recommended that the federal government provide funding to the Canadian Institute for Health Information to collect standardized national statistics on workplace violence.[15] They also recommended that provinces and territories implement “whistleblower” legislation to protect individuals who report violence from reprisals such as losing their jobs or experiencing a reduction in work hours.[16]

Finally, the Committee heard from witnesses that health care workers experience devasting impacts from workplace violence. As Ms. Jennifer Lyle, Liaison, National Alliance for Safety and Health in Healthcare, Canadian Association for Long Term Care (CALTC) articulated:

Beyond the numbers, there is the human toll. There is the care aid who is sexually assaulted by a home care client with dementia. There is the nurse who is punched in the jaw by a senior suffering from delirium. There is the personal support worker who doesn’t know how she could possibly face going back to work. Finally, there is the senior whose care is impacted because the person they rely on, the person the have developed a relationship with, is no longer available to help because of workplace injury.[17]

Witnesses explained that workplace violence has an impact on the delivery of care, as it results in staff shortages due to workplace injuries and high rates of burnout and workplace stress that affect quality of care and increase costs to the health care system.[18] As Ms. Henrietta Van hulle, Vice-President, Client Outreach, Public Services Health and Safety Association stated to the Committee:

Health care employers consider violence an occupational health and safety issue, but it needs to be considered a care issue. There is absolutely no hope for quality of care without considering worker safety. Having safe health care workers means better care.[19]

Factors Contributing to Workplace Violence in Health Care Settings

Witnesses explained that various factors are contributing to workplace violence in health care settings. In terms of patient characteristics, the Committee heard that the aging of the population is one of the factors contributing to workplace violence in health care settings, as health care workers are providing care for a greater number of seniors with increasingly complex needs.[20] Ms. Jennifer Lyle, CALTC explained that currently 62% of patients in long-term care and 28% of home care clients have some form of dementia, proportions that are expected to increase by 2031 when over 937,000 Canadians are expected to have dementia, a 66% increase from the number of Canadians who have dementia today (564,000).[21] The Committee learned that individuals with dementia may become aggressive due to the progression of their disease or if they are in situations where their needs are not are being met.[22] Other patient characteristics that contribute to an increased risk of violence include psychiatric and substance use disorders.[23]

In addition, witnesses explained that structural challenges within the health care system contribute to workplace violence. The Committee heard that staff shortages and heavy workloads contribute to violence because health care workers have less time to provide care to patients, which leads to frustration among patients and family members.[24] Furthermore, overcrowding and long-wait-times can also trigger violence and agitation among patient and family members in emergency departments.[25] Witnesses also explained that current hospital and long-term care building designs with long monochrome corridors and bright lighting can confuse and frustrate patients with cognitive impairments.[26] Finally, many health care settings do not have adequate security and surveillance systems in place to help deter or respond to violence.[27]

More broadly, the Committee heard that there is a culture of acceptance or normalization of violence within the health care system that prevents change from occurring, as Ms. Margaret Keith Adjunct Faculty, Sociology Department, University of Windsor, articulated:

The culture of silence around the issue of violence is a major barrier to acknowledging its existence and consequently, addressing it. However, although the public has been kept in the dark about this issue, it is not a problem that is unknown within the health care community.[28]

How to Address Workplace Violence Facing Health Care Workers

Witnesses explained that the violence experienced by health care workers can be prevented or reduced. While recognizing that the health and safety of workers in health care settings is regulated by provincial and territorial occupational health and safety legislation,[29] witnesses identified ways in the federal government could play a role in addressing violence facing health care workers.

The Committee heard that the federal government could support the dissemination and scaling-up of best practices in workplace violence prevention in health care settings.[30] Witnesses explained that many of the solutions to address workplace violence are well documented in the research literature.[31] The solutions include but are not limited to:

• education and training of health care professionals in the de-escalation of violence;
• undertaking violence risk assessments of health care organizations, departments and individual patients;
• flagging of patients who pose a risk for violent behaviour;
• personal safety response systems that allow health care providers to call for help; and
• security personnel and protocols to respond to violence.[32]

Witnesses recommended that the federal government support the spread and scale-up of these best practices by:

• developing national standards for violence prevention training for health care workers;
• providing targeted funding for violence prevention programs;
• creating avenues to share best practices across jurisdictions; and
• funding research evaluating the implementation of best practices.[33]

However, Mary Schulz, Director, Information, Support Services and Education, Alzheimer Society of Canada explained that some violence prevention strategies with respect to dementia patients that are used in health care settings, need to be applied with caution, noting that:

Treatment of agitation and aggression with medication should only begin with an appropriate medical diagnosis ruling out any physical condition such as infections and medication side effects or even environmental factors. When the agitation is serious and represents a risk to the person with dementia, other residents, or staff, certain medications can be used with appropriate monitoring and informed consent of the person with dementia or their substitute decision-maker.[34]

To address structural factors related to workplace violence in health care settings, witnesses recommended that the federal government work with the provinces and territories to address staffing shortages in health care settings by updating the Pan-Canadian Health Human Resources Strategy[35] to reflect the health care needs of seniors, the well-being of health care providers and the shift towards community-based care.[36] The witnesses also recommended that the federal government provide targeted funding through the Investing in Canada Plan[37] to support upgrades to Canada’s aging long-term care facilities and other health care infrastructure to better meet the needs of patients.[38]

Many witnesses and organizations that provided written submissions[39] also expressed support for Private Member’s Bill C-434, An Act to Amend the Criminal Code (Assault Against a Health Care Sector Worker), which was introduced in the 42^nd Parliament and seeks to amend the Criminal Code “to require a court to consider the fact that the victim of an assault is a health care sector worker to be an aggravating circumstance for the purposes of sentencing.”[40] The organizations believe that this amendment would serve as a deterrent for individuals perpetrating violence against health care workers. Some witnesses further noted that the proposed legislation should not apply to patients who are cognitively impaired or otherwise could not be held criminally responsible for their behaviour.[41]

Finally, some witnesses recommended that the federal government support a national public awareness campaign that would bring awareness to the issue of violence facing health care workers and also promote respect for their work.[42]

Committee Observations and Recommendations

The Committee agrees with the findings of these witnesses and believes that the safety and well-being of health care workers is intrinsic to the provision of high-quality care in health care settings across Canada. It therefore recommends:

A Pan-Canadian Framework for the Prevention of Violence in Health Care Settings

Recommendation 1

That the Government of Canada work with the provinces and territories and health care stakeholders to develop a pan-Canadian framework to prevent violence in health care settings, which would include promoting the adoption of best practices in violence prevention across the country.

Public Awareness

Recommendation 2

That the Government of Canada develop a national public awareness campaign that would raise awareness about the violence faced by health care workers and highlight the valuable role health care professionals play in providing care to Canadians.

Criminal Code

Recommendation 3

That the Government of Canada amend the Criminal Code to require a court to consider the fact that the victim of an assault is a health care sector worker to be an aggravating circumstance for the purposes of sentencing.

Research and Surveillance

Recommendation 4

That the Government of Canada provide funding to the Canadian Institute for Health Information to develop standard definitions and terminology in relation to workplace violence in health care settings and collect national standardized statistics in this area.

Recommendation 5

That the Government of Canada provide research funding through the Canadian Institutes of Health Research to evaluate the implementation of best practices in workplace violence prevention in health care settings.

Recommendation 6

That the Government of Canada provide funding through the Canadian Institutes of Health Research to support research identifying ways to prevent gender-based violence in health care settings.

Recommendation 7

That the Government of Canada establish the Canadian Centre for Occupational Health and Safety as a hub for information sharing on best practices in violence prevention in health care settings.

Meeting the Needs of Health Care Professionals

Recommendation 8

That the Government of Canada work with the provinces and territories to address staffing shortages in health care settings by updating the Pan-Canadian Health Human Resources Strategy to reflect the health care needs of seniors, the well-being of health care providers and the shift towards community-based care.

Health Care Infrastructure

Recommendation 9

That the Government of Canada expand its Invest in Canada Plan to provide targeted funding to upgrade existing long-term care facilities and other health care infrastructure to better meet the needs of patients through public-private partnerships.