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The neglected toll of violence against health care workers

An excerpt from ‘Code White: Sounding the Alarm on Violence against Health Care Workers’

LabourHuman Rights

Health care workers experience the highest level of workplace violence of all occupational groups. Sixty-one percent of registered nurses experienced serious workplace violence, according to a 2017 survey by the Canadian Federation of Nurses Unions. Photo courtesy the Canadian Union of Public Employees.

The following is an excerpt from Code White: Sounding the Alarm on Violence against Health Care Workers by Margaret M. Keith and James T. Brophy, released this year by Between the Lines.


In 2018, an ER nurse in the Winnipeg Health Sciences Centre (HSC) was brutally assaulted by a patient. The attack left her with long-lasting psychological injuries, such as frightening flashbacks, panic attacks, and depression. She told CBC News:

It’s absolutely awful. I tried to go to counselling. I’m on antidepressants now. I feel totally defeated. Just defeated. Because nobody’s really doing anything about it. Every single day there’s a violent incident in HSC emerg. Every day. And no one seems to acknowledge it… People are lashing out, hitting us, attacking us. Guns have been pulled out, weapons have been pulled out, we’ve been threatened, punched, kicked, spat on, everything. Everything. I feel like I’m going into a knife fight without a knife.


So the question emerges: Can anything really be done to protect health care staff from violence? The answer, according to the health care workers we talked to in our research, is emphatically yes. The voluminous research that has been published concurs. For over two decades studies have provided myriad potential remedies. Some would require significant financial investment, such as hospital redesign and increased staffing. Others require only small changes, such as removing last names from staff name tags or facility names from staff parking passes. Interestingly, many of the health care workers’ ideas for violence prevention coincide with ideas for improving the quality of care for patients and residents.

One recommendation made by academic researchers is that all violent or abusive incidents be treated seriously, including derogatory verbal comments and threats. The importance of recognizing verbal assault as a form of violence cannot be overlooked, since it has been shown in domestic relationships to be a risk factor or precursor for battery. When verbal and low-level abuse are tolerated, more serious forms of violence may follow.

Prevention is sometimes categorized as primary, secondary, and tertiary. Primary prevention aims to stop violence from occurring in the first place. Secondary prevention is meant to help potential victims from being hurt should violence occur. Tertiary prevention includes strategies for protecting victims of violence from further harm or ongoing harm. Let’s look at what is required at each of those levels.

Primary prevention is key

In 2013, a newly minted nurse who was working alone in a mental health facility in Kamloops, British Columbia, was seriously injured when a patient punched her in the face and knocked her to the ground. Seven co-workers and the police finally rescued her from her attacker, but not before she had been so deeply psychologically traumatized that she would never be able to return to her job in the facility. Tracy Quewezance, a union official with the BC Nurses’ Union, said, “Nurses are working short, caring for patients that even the jail can’t handle.” The brutal attack and its ongoing effects likely could have been prevented if proper conditions and safeguards had been in place. This is true of most violent incidents. The majority of the solutions proposed by the health care workers we interviewed fall within the realm of primary prevention. Here are their ideas.

Staffing levels

It should be no surprise that, in interview after interview, adequate staffing levels topped the list of violence prevention strategies. We know that when in-patients have been waiting for long periods of time to be attended to by health care staff, they can feel neglected. They might be in pain and awaiting medication, thirsty or hungry, or need to use the bathroom. They might be lonely or fearful and need some comfort. They are often trapped in their beds or chairs, and the wait can seem endless. Some will take out their mounting frustration on the first person who approaches. Their anger can present as aggressive behaviour ranging anywhere from rudeness to verbal abuse to physical assault—in extreme cases, even homicide.

As a nurse in a large urban centre explained, increasing the staffing levels during the evening and night shifts might prevent frustration-related violence. A long-term care worker explained, “That’s when the incidents are happening. We have lots of code whites on the night shift or right at change of shift when all the staff is busy doing charting.”

Having sufficient staff to meet patients’ or residents’ particular needs would go a long way towards reducing their agitation. When dealing with potentially aggressive individuals, it is also imperative that enough staff be available to work in teams of two or three—or more if necessary. As one of the health care workers we spoke with said, “You need to be regularly working in pairs. There is safety in numbers.” Another said:

If you could call three staff to come into the room [of an aggressive resident], you’d be protected. If you had one that could hold their hands, you could talk to them and distract them while the other two are doing care.


Depending on the department or the facilities, a certain number of sick calls from staff seems to be expected and accepted. It can be difficult to find replacements at short notice. Some of the staff we spoke with said they and their co-workers are reticent to accept calls to come in to work because they so desperately need time to recover, mentally and physically.

Ontario is operating at abysmally low staffing levels—far below other provinces or countries in the OECD. The fix for short-staffing seems simple enough. Facilities need to have enough personnel on hand on a regular basis. They also need to have more stand-by staff on the roster to fill in for those who have called in sick. Looking even more critically at what needs to be done, conditions for staff need to be such that they don’t require so much sick time to recover from stress and exhaustion.

The health care workers we interviewed also felt that it would be helpful to be able to let patients, residents, or family members know when they are working short. It might make them feel a little more sympathetic towards the harried staff and less likely to lash out. Dr. James Phillips, from the Beth Israel Deaconess Medical Center in Boston, has taken a long, hard look at the problem of violence. He pored over many studies looking for modifiable risk factors for Type II violence, or assault of a health care worker by a patient or family member. After completing his review of potential solutions, he concluded, “Perhaps most important are recommendations that health care organizations revise their policies in order to improve staffing levels during busy periods to reduce crowding and wait times.”

In long-term care facilities, higher staffing levels are crucial in order to reduce resident aggression against staff and each other. As a long-term care nurse said, “The biggest thing, I think, is that we need to start to help develop therapeutic professional relationships with the residents… but we don’t have the time to do that.”

Dr. James Struthers told us:

You cannot have good quality care delivered to long-term care homes without adequate staffing, without a staff-to-resident ratio at least double what we currently have… Because again and again we hear, and we can see it from what workers tell us, and what family members tell us, what staff and what residents tell us, that the most important part of getting good quality care is getting to know the residents, having continuity of care, having time to care, having time to sit down to talk, to touch, to hear, to listen and to communicate and to understand the person that you’re delivering care to, and to understand the symptoms that that person might be acting out… Because they can’t deliver a caring environment, they can’t deliver good quality relational care, they can’t take the time to reduce agitation and anxiety and aggression on the part of the people that they have to deal with on a daily basis… If you create staffing levels that are twice as high per resident in Canada, which is the case in Sweden and Norway, then you’re going to get less violence occurring in the home and better working conditions and living conditions for residents.

Design of the work environment

With some careful planning, health care facilities can be engineered to eliminate many risk factors. Some of the fixes are as simple as securing loose furniture and eliminating other potential weapons, such as hard, heavy, or sharp objects.

Units, especially those requiring constant monitoring of patients or residents, should be designed to improve the sight lines. Some of the long-term care staff we spoke with said a circular design with the nursing station in the centre would be ideal. Barriers can also be installed at nursing stations for added protection.

Seclusion rooms need to be made available for out-of-control patients or residents. In some facilities, there are none at all. In others, the rooms may be all occupied or be in use for other purposes due to overcrowding or lack of beds. That creates a real problem when an aggressive patient needs to be isolated.

Staff should also have secure areas—safe rooms with safe exit options—that they can easily access. One health care worker told us, “We created a safe room where nurses could run to, lock the door, and we have a phone.”

Protective technology

Security cameras and easily accessible emergency alarms should be installed where needed. Personal alarms should also be made available to all staff coming into contact with patients, residents, family members, or the public.

The injured ER nurse from the Winnipeg Health Sciences Centre believes further measures are needed, given the increase of meth-fuelled violence and the ready availability of weapons. She told the reporter:

I want to come into work feeling safe. I want to come into work like not worried that I’m going to get a black eye. Or worse. Or get stabbed. What I want to see done is I want metal detectors. That would help me feel a lot safer. And probably the patients too.

Flagging

In October 2019, a sixty-two-year-old patient in a Sudbury, Ontario, hospital stabbed a nurse with a screwdriver after she entered his room. She was seriously injured. It came out that the patient had threatened a staff person the previous day with a wrench, but no formal report had been filed and he hadn’t been flagged as being potentially violent. It should be obvious that the patient should not have had access to tools that could be used as weapons—particularly after he had brandished one the day before the more serious attack.

Our interviewees and the published studies agree that patients who have displayed aggressive behaviour or escalating agitation need to be clearly identified in their charts as well as in a manner that is visible to all staff, such as with wrist bands, colour coding, or signs. While this isn’t a guarantee of protection, it does at least provide some warning that the patient may strike out.

Several of the health care staff we spoke with said it would also be useful to have province-wide access to chart information—including flagging—to inform them of previous behaviours in patients who have been transferred. The issue of flagging, however, is fraught with controversy because it can stigmatize patients or residents who are situationally desperate or confused and may be also be subject to discrimination. Long-term care staff, for example, mentioned that the practice, which they felt would be helpful to warn them and other staff of potentially aggressive residents, isn’t done in their facilities. A PSW told us, “We need a flagging system to warn us about residents who have a history of violence. We used to flag the door, but they stopped it for privacy reasons.”

Flagging may not, on its own, provide much actual protection. The question remains regarding what concrete actions are to be taken when a potentially violent patient or resident is identified. Will more staff be assigned to care for the flagged individual or other special measures be instituted? Andria Bianchi, a bioethicist at the University Health Network in Toronto, told the London Free Press, “There’s no use in flagging or identifying something without a plan to manage it.”

Zero tolerance

We were travelling home on a VIA train from Toronto to Windsor after attending an OCHU-CUPE conference on violence against staff. We had heard one health care worker after another describe the lack of concern they felt their employer was displaying about the issue. The subject of zero tolerance signage came up, and it seemed most of those present didn’t have such signs in place in their workplaces. As our train was pulling out of Union Station, the conductor began his announcements. We were struck by the fact that he included a statement saying that VIA would not tolerate any “verbal or physical abuse, threats, harassment, or intimidating behaviours.” We have since seen signs displaying similar messages in our own doctor’s and dentist’s offices, at medical labs, and even in coffee shops or on local public transit. Signage in itself, however, is not enough. Dr. Katherine Lippel, who wrote an article entitled “Conceptualising Violence at Work through a Gender Lens,” explains:

A key factor in reducing exposure to psychological violence, including bullying and harassment, as well as sexual harassment is to find ways to make these behaviours unacceptable in the workplace. This is achieved not just by posting policies declaring them to be unacceptable but by changing the workplace culture so that there is a shared perception that such behaviour, that may have been prevalent and accepted years ago, is no longer tolerated either by management or by workers and their unions. The active participation of unions in educating the workforce with regard to sexual harassment or bullying can be far more successful in reducing these behaviours than top down orders from management or zero tolerance policies that raise the stakes for perpetrators, possibly exacerbating ill-feeling in the workplace.


In 2019, the Ontario Ministry of Health and Long-Term Care and the Ministry of Labour provided administrators with a few tools to help protect their staff from violence. While they fall far short of addressing underlying causes, they do recommend that signs be posted saying, “Violence in the workplace cannot be tolerated.” It’s a baby step in the right direction. The enforcement of zero tolerance policies remains a stumbling block.

Management, doctor, and co-worker respect

Several of the health care workers we talked to said they had experienced a decrease in respect from patients and visitors over the past few years. They feel that when there is little respect dis- played, there is a greater likelihood of verbal and physical abuse. We were told, “You need to be respected and the supervisors and doctors need to demonstrate respect for you in front of patients and family members—otherwise they are going to pick on you.”

In an article about workplace incivility, occupational health nurses Natasha Collins and Bonnie Rogers wrote that negative and hurtful interpersonal interactions are growing in workplaces—both in the public and private sector—and that they not only cause personal harm, but also carry a heavy financial cost as co-operation and teamwork break down and burnout increases.

The American Nurses Association produced a position statement on “Incivility, Bullying, and Workplace Violence.” It condemns all forms of violence against staff—including violence that is perpetrated by co-workers, management, and other professionals. It also draws a link between general incivility and violence:

[Incivility] may… include name-calling, using a condescending tone, and expressing public criticism. The negative impact of incivility can be significant and far-reaching and can affect not only the targets themselves, but also bystanders, peers, stakeholders, and organizations. If left unaddressed, it may progress in some cases to threatening situations or violence. Oftentimes incivility is not directed at any specific person or persons. However, it may perpetuate or become a precursor to bullying and workplace violence; therefore, it cannot be characterized as innocuous or inconsequential.


The statement makes a number of recommendations for employers to follow. They are intended to prevent violence, acknowledge and support those who have suffered a violent incident, and mitigate ongoing harm, including conducting “a root cause analysis to understand all factors contributing to workplace violence.”

Violence protection training

Staff who are working in high-risk areas or with high-risk patients need to be properly trained in de-escalation techniques. Yet the health care staff we spoke with were very dissatisfied with the training they received. Often it consisted simply of a brief online course. Many felt they would benefit from comprehensive in-person training—regularly updated—to better equip them to recognize signs of potential violence or conditions that might lead to violence. A nurse working in long-term care told us:

We need better training, [such as] Crisis Intervention Training, which is more in-depth. It’s more hands-on. It teaches you valuable skills and it would be an ideal thing for a long-term care facility. The key word is intervention—it actually teaches you how to stop it.

Appropriate staff placement

Staff must be appropriately assigned. Where there is a likelihood of violence, only those staff with specialized training and experience should be put in place. We heard many stories about younger nurses—new graduates—being thrown into situations where aggressive patients seemed to be aware of the staff person’s inexperience and fear and took advantage of it. In his report for the ILO and WHO, Vittorio Di Martino wrote:

The age and experience of workers is another factor that can either increase or diminish the possibility of aggression. Previous experience of handling similar difficult situations, which is obviously associated with age, should enable workers to react more wisely than inexperienced staff. This explains the higher risk of violence towards young nurses’ aides compared with the risk for more experienced older nurses.


A German study of aggression against health care workers found that being under thirty years of age almost doubled one’s risk of being verbally or physically assaulted.

Reduce agitation

Many strategies could be employed to reduce the agitation, frustration, fear, humiliation, disrespect, and anger that patients, residents, and their advocates or family members experience within what sometimes seems to be a heartless, rushed, deficient system. Besides providing an adequate number of appropriately assigned staff in order to reduce wait times and allow for relational care, many practical measures can be put into practice.

Provide translators and cultural sensitivity training

A study of patients in two large Toronto hospitals found that about a quarter were not fluent in English. Although interpreters are provided, they have to be pre-booked and are often unavailable when needed. Several of our study participants expressed their own frustration regarding their inability to explain to their patients or residents what they were doing for them.

They might not speak English and they can’t tell me what they want. My employer says they have translation services but there are no translators available. I’ve worked with all sorts of people where I’ve been expected to speak Portuguese, Italian, Spanish. It’s a contributor to violence because, if I could talk to them, maybe we could figure out why they’re so upset.

Provide recreational programs

Having too much time on their hands between care activities can lead to boredom, stress, fear, and related agitation and anger among patients and residents. Research has found that the bio- medical model of health care, which sees patients primarily as biological entities or sets of symptoms to be medically treated, ignores the importance of addressing patients’ psychosocial needs. The British Medical Association recommends that patients be able to engage in creative and recreational activities. Music programs, arts, crafts, and games have been shown to improve mood and reduce anxiety. Gardens, sunny patient rooms and common areas, and nature scenes can help. Boredom, monotony, and inactivity have also been shown to increase confusion and agitation in long-term care residents with dementia. As one worker observed:

When a music group comes to the unit, there’s less stress; it’s more calm. Or if they have activities, there are only a few people walking around. There’s less commotion. And we can do more important things for the resident. And you have more time to spend with them.

Communicate about wait times in the ER

Research has established that violence occurs frequently in crowded ERs. International investigators Cheshin Arik and colleagues have found, “The atmosphere in ED [the emergency department] is usually stressful, especially among patients and escorts who always consider their medical problem as urgent, requiring immediate attention.” Their fear and anger can escalate as their wait increases; this escalation can result in verbal or physical violence against staff.

When we were presenting the preliminary results of our first study to health care staff at their annual occupational health conference, several attendees raised the idea of posting ER wait times. Studies have shown that when patients and their family members are forewarned about long waits, they are less likely to became agitated and angry.

When we, ourselves, needed to visit an ER after an accident during a family vacation in New Hampshire, we noticed that wait times were posted on lighted signs outside the various local hospitals and urgent care centres. It helped us to decide which facility to choose.

Of course, in many communities, there is only one hospital, so shopping for shorter wait times isn’t an option. Many Canadian hospitals do post expected wait times online, but not everyone is in a position to access the internet when they are suffering from an illness or injury that requires an ER visit. And patients have to take into account sudden unexpected demand and the triaging process, which might put those needing more urgent care ahead of them.

But even the simple courtesy of checking in with waiting patients would help. Have you ever wondered if you have been forgotten or overlooked as the clock ticks endlessly? It’s unnerving. Effectively and frequently communicating with ER patients about their status and likely remaining wait time could go a long way towards reassuring them and reducing their anger.

Virtual visits with doctors or urgent care centres might also cut down on the number of patients using the ER. During the COVID-19 pandemic, there was a significant increase in telephone and virtual consults. Provincial and territorial governments established temporary billing codes specifically for telemedicine and virtual care. Perhaps we should cautiously consider maintaining some aspects of this model, where applicable, when the pandemic is under control. We say cautiously because many critics, including the Canadian Medical Association, have expressed concern that virtual visits might exclude those who do not have access to or an adequate comfort level with technology. The CMA also warns:

Its disadvantages include the inability to perform most physical examinations or procedures, difficulty establishing new therapeutic relationships, dealing with some complex mental health issues, miss- ing body language and nonverbal cues and lacking the full degree of comfort and support that can be provided in person.

Create a positive environment

Improvements can be made to the overall atmosphere in a hospital or other care facility, making it more calming and conducive to relaxation, rest, and healing.

It’s loud at the hospital. You’ve got call bells. You’ve got overhead announcements. And it’s not a quiet environment for the patients… It agitates them.

Simple trips out into the sunshine have been shown to elevate residents’ mood and improve their behaviour towards each other and the staff. A growing body of research demonstrates the value of providing access to the outdoors for those living with dementia. For example, a report produced in Australia found:

Gardens designed specifically to support people with dementia provide therapeutic activities designed to maximise retained cognitive and physical abilities and lessen the confusion and agitation often associated with the condition.

OCHU is the hospital division of the Canadian Union of Public Employees (CUPE) which represents over 70,000 health care workers Ontario-wide. Photo courtesy the Canadian Union of Public Employees.

Develop alternative long-term care models

Long-term care staff offered several ideas for improving conditions for residents, and by extension, reducing the risk of violence against staff.

We can’t be putting the old and frail with the young and mentally disturbed.
We need more family involvement. And when residents are admit- ted, families should sign a code of conduct acknowledging how and how not to treat staff.
They have to hire more BSO [Behavioural Supports Ontario] nurses. Can you imagine four hundred beds and only one BSO?
We don’t have enough male PSWs. I think that male PSWs should be looking after male residents as opposed to women doing it.
And they might not be whacking at them as often as they whack at women.


Interestingly, many of the prevention ideas put forward by the participants mirror those suggested by the Ontario Long Term Care Association, namely, increased funding, increased staffing, more one-to-one care, redesigned buildings, and in-house BSO teams.

There are many innovative models of care that consider the overall well-being of long-term care residents, including the importance of outdoor activities and access to nature. Some go well beyond the typical institutional model in their designs, in some cases creating secured villages that include shops, theatres, gardens, and other spaces that bring a sense of normalcy to those requiring dementia care. One example of such a facility can be found in Holland. Hogewey dementia village is designed to provide residents a homelike setting and activities that increase their quality of life and sense of belonging and fulfillment, while providing care and safety. Yvonne van Amerongen, an employee at Hogewey, who also helped develop the concept, explained it to CBC News, which reported: “Each household has at least one health-care worker present who helps with housework and other tasks. Residents are free to stroll all through town.”

“You will see [residents] sitting in a restaurant with a glass of wine or buying a box of chocolates from the supermarket,” says van Amerongen of those who still understand the concept of money. A worker and a resident from each house walk to the market daily to buy groceries.

Hogewey has been criticized for its deception of those in care, but defenders of the model observe that the mock village life has had many positive effects on the unsuspecting residents.

“There’s no trick here,” says van Amerongen.

She says that while some Hogewey residents recognize the caregivers as nurses, others simply think of them as “a nice friend.”

In the 1990s Dr. Bill Thomas decided he was going to make the atmosphere in a New York nursing home more like, well, home. As the medical director, he initiated a broad range of activities for the residents in order to combat boredom and feelings of worthlessness. One of the most daring innovations was the introduction of “plants, cats, dogs and birds.” He called his model the Eden Alternative. The resulting improvement in the residents’ overall satisfaction, health, and well-being was remarkable. A few years later he developed another model that he called the Green House model; it is “based on small, homey communal living spaces, where residents share meals around a single large table and caregivers focus on just a few residents each.”

The long-term care staff we spoke with agree that the atmosphere within most Canadian facilities is too stark and institutional.

I would like to see a more homelike setting. I think we need to make it more resident focused. We’re just taking them and saying this is your home and you’re expecting them to adapt.

Several innovative long-term care models are, in fact, being developed in Canada. One of them, while perhaps somewhat less visionary than those created by Dr. Thomas, is the Butterfly model. The Mississauga News reported:

While dementia care has traditionally been task-oriented, the Butterfly care model emphasizes a transformation in the way patients are cared for, with a focus on their emotions and the creation of home-like environments and daily activities they enjoyed earlier in life.

Staffing is key to the success of the model. CUPE, the union representing one such facility in Peel, Ontario, says that it whole- heartedly supports the concept. It is concerned, however, that the staffing levels remain too low to deliver enough relational care without staff suffering burnout from the additional demands the model makes upon them.

Both the Green House model and the Butterfly model have resulted in “happier residents, fewer falls, diminished violence, lessened antipsychotic medication and lower staff turnover.” A resident who was chronically aggressive—using his cane and fists to try to fight off his caregivers—was ousted from several long-term care facilities before being moved to the Peel Butterfly home. When he first arrived, the staff suffered “six weeks of bruising before suggesting the life-long farmer collect hardboiled eggs in the courtyard before tea. It tapped into his past, and the job clicked.” That did the trick. He remained for another two and a half years, until his death, as a happy, co-operative, content resident. The staff attribute his transformation to the innovative program.

Dr. Pat Armstrong and colleagues compared various models and approaches in a report for the City of Toronto. They found that the Wellspring, Butterfly, Green House, and Eden Alternative models share common perspectives. They determined that there were advantages to each and that the Butterfly model and another approach, called Gentle Persuasion, reduced resident responsive behaviours. They concluded that “the mixed evidence does not lead to a recommendation for a single model but rather to a strategy to learn from all the models, adapting promising practices to specific homes and their populations.” The Toronto Star summarized:

All [of the models] have significant benefits, Armstrong’s report concludes, and all emphasize the “importance of care relationships” that embrace the interests of each individual living in the home. Key to success, the report said, are extra staff and flexibility for them to develop those relationships with residents.

Workplace violence prevention programs

Under Ontario’s previous government, a task force recommended that health care facilities develop policies and programs to prevent violence and that they be developed with the full engagement of members of the public, the health care staff, and their unions. Dr. Craig Slatin agrees.

Violence prevention experts are not accustomed to workplace dynamics, and they fall back onto their training about individual perpetrators. This orientation will usually result in failed prevention approaches in the workplace. We need workplace violence prevention professionals who understand that workplace conditions and systems must be designed to mitigate and prevent health care workers’ exposures to workplace violence. This requires a commitment to engagement of workers and their unions in developing workplace violence prevention and response strategies, ensuring adequate staffing to prevent workplace violence and harm from potential uncontrollable acts of violence, participatory violence mitigation and prevention training developed with and delivered by worker-trainers, appropriate security systems, commitments to fully report incidents of violence and near miss incidents and to report occupational injuries and illnesses that result from exposures to acts of violence as such—without contestation, and implementation of necessary engineering and administrative controls. These programs and protocols have to be based on comprehensive audits grounded in root-cause analysis conducted with engagement of workers and their unions.

Interestingly, the management team for Toronto East General Hospital put forward a similar view regarding the importance of involving workers in the development of programs.

Despite these legislated requirements, violence against healthcare workers continues as recently reported in the media.

Ultimately, healthcare workers have the right to work in an environment that is free from all forms of abuse and to not fear coming to work at risk of being injured physically or verbally by patients, visitors or their peers. As leaders we must have zero tolerance to all forms of violence in our workplaces. We must take personal responsibility for building the partnerships between staff, labour unions and other stakeholders to make violence reduction interventions a real success. After all, our healthcare professionals and patients are counting on it.


Needless to say, the development of policies is not enough. The agreed-upon measures need to be fully enforced, and the needed resources must be made available in order to enable the enactment of the policies.

Identifying and reporting hazards

Comprehensive hazard identification and hazard reporting must be encouraged, and procedures streamlined to facilitate such reporting. Inspections and documentation should include all existing risk factors for violence, such as flaws in engineering design and gaps in security measures, along with such systemic factors as understaffing. All hazard and inspection reports need to be shared with joint worker-management health and safety committees in order that improvements can be collaboratively planned.

Mental health and addiction facilities

Patients with psychiatric disorders, addiction, and criminal backgrounds related to mental health conditions need to be placed in appropriate facilities, not on general wards in unequipped hospitals.

In our hospital a lot of our violence is because of our patients who are waiting to be put in nursing homes. And the other part of it is not having enough psychiatric facilities so they are on the nursing units until they get a psychiatric bed.

We are in no way suggesting that patients with mental health needs necessarily pose a threat of violence, but appropriately staffed and dedicated mental health facilities are better equipped to deal with any possible aggression. Appropriate placement would improve the safety of the staff, as well as the health and well-being of patients requiring such specialized care.

Consistent regulations

As it stands now, each province and territory has its own government ministry of health and long-term care. Regulations, funding decisions, staffing levels, and so on, are established at a provincial or territorial level. Policies regarding violence against staff are determined at an even more local level—within the hospitals or care facilities themselves. There should be consistent province- or nationwide protections against violence in all health care facilities, as well as additional tailored protections where required.

We, along with other witnesses, had the privilege of presenting to the federal parliamentary Standing Committee on Health in June 2019. The resulting government report included several important recommendations. It was recommended that the federal government support the establishment of best practices for staff protection from violence 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 best practices.

Because so much of violence against staff is structural in nature, it was also 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 to reflect the health care needs of seniors, the well-being of health care providers and the shift towards community-based care.


The committee also recommended targeted funding to “support upgrades to Canada’s aging long-term care facilities and other health care infrastructure to better meet the needs of patients.”

Margaret M. Keith is an occupational and environmental health advocate and researcher, focussing particularly on women and work.

James T. Brophy is a career activist, researcher, and advocate focussing on occupational and environmental health.

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