All right. We'll talk about this in committee business. You certainly brought up an issue that I think is prevalent.
Back to violence faced by health care workers. This is going to be another interesting study for us. We welcome our guests today.
On behalf of the Canadian Association of Emergency Physicians, we have Dr. Alan Drummond, co-chair, public affairs committee.
On behalf of the Canadian Federation of Nurses, we have Linda Silas, president.
On behalf of the Canadian Support Workers Association, we have Miranda Ferrier by video conference from Guelph.
On behalf of the Paramedic Chiefs of Canada, we have Randy Mellow, president. Now we're going to find out if you're really mellow.
Everyone has a 10-minute opening statement. We'll start with the Canadian Association of Emergency Physicians, Dr. Drummond.
That's more than I anticipated, so thank you very much.
The Canadian Association of Emergency Physicians is the national specialty society for emergency medicine in Canada, with over 2,500 members.
With the birth of our specialty approximately 40 years ago, our primary focus was on education and training to identify and treat life- and limb-threatening emergencies. Over the ensuing decades, our role has changed. Emergency physicians now bear daily witness to failed social policies that result in increasing visits to our departments by patients with substance abuse—including alcoholism—poverty, marginalization and violence. The latter, in particular, is of grave and increasing concern to both our members and our nursing colleagues.
Health care providers have a fourfold higher rate of workplace violence, and 50% of all attacks on health care workers occur in the emergency-department setting. Our nursing colleagues in particular bear the brunt of much of this violence. Most of the assaults on emergency department personnel were by patients or visitors, and the degree of physical violence has been increasing.
It is both under-reported and underappreciated. Studies have shown that only about 30% of violent incidents in the emergency department are reported to higher authorities.
The root causes and contributing factors to violence have been well described. There's a very extensive literature base. As with many problems that beset the emergency department, many contributors lie outside the department itself, and are societal and cultural in nature.
Chronic oppression, with racism, poverty, inequity and social exclusion, lead to substance abuse, mental illness and violent behaviour.
All are important, but substance abuse, and in particular the increasing incidence of crystal meth use in the western provinces, has many of our western colleagues particularly concerned.
As the population ages, complex presentations of the elderly in the emergency department, coupled with prolonged waits for care, as a result of crowded hospitals, lead to an increased risk of delirium and violent acts by the elderly.
While violence in the community is certainly a driver for violence in the ER, it is not the sole driver. There are factors intrinsic to our departments and to our hospitals, including overcrowding and increased wait times, that lead to immeasurable stress for our patients and their families, as they wait eight, 12 or 24 hours to be seen. We have insufficient—in our view—nursing staffing ratios, leading to poor communication and poor basic care of the patient who's been deemed to require admission. They wait in the hallways, and it's totally unacceptable.
We also have poor environmental design, all of which lead to an increased risk of violence in the emergency department.
With respect to the effects, multiple studies and reports have shown that exposure to violence in the ER has a deleterious and demoralizing effect on staff, most notably nursing staff. Occupational strain, impaired job performance, fear of patients and future assaults, decreased feelings of safety and reduced job satisfaction have all been commonly identified.
It also leads to absenteeism, lost-time injuries and prematurely shortened careers. Workplace violence in the health care sector also has a large and well-quantitated economic effect.
This is a national problem that requires a national solution. I know that many of you believe that health care is a provincial responsibility, and it largely is, although you're paying part of the health care tax dollar. However, you could be very helpful, I think, in helping develop a template of best practices to be shared with your provincial colleagues.
Violence in the emergency department, as I stated, is a symptom of a much bigger problem—broadly societal—with racism, poverty, substance abuse, gang and personal violence and inadequate upstream mental health resources for the mentally ill and, of course, those with substance abuse. This is a societal issue, and is beyond the immediate control of emergency physicians.
Within the hospital and the emergency department per se, however, we can consider the following. While individual staff members can contribute to safety through their practice and behaviours, ultimately, the legal and moral responsibility to provide a safe workplace falls to the employer, and thus to a hospital's administration, from board to departmental leadership.
These are a few of the major considerations and the literature is quite extensive, so I will keep this relatively short.
There should be an increased focus on appropriate facility design, with a limited number of controlled entry points to the emergency department with the capability to rapidly lock down the department.
Monitoring is often an afterthought, but there must be a visible security presence 24-7 with adequate backup available in response to an actual or potential incident. It's always the last thing to happen, usually after the incident has already happened.
Regarding skills and attitudes, all emergency department personnel should receive training in non-violent de-escalation to defuse the situation.
There should be clear policies and procedures in place with regular staff training to cover how staff should respond to a high-risk situation, including and regrettably, the active shooter protocol, which is now a part of many urban hospitals.
There should be care plans. Security as well as the clinical staff should have a system for tracking the high-risk individuals and identifying them on return, as well as ideally suggesting a safe approach individualized to a person's behaviours and known clinical issues.
There should be an incident reporting system, as well as a process for incident review. There needs to be a clear line of accountability for all aspects of emergency department safety for our nursing colleagues, patients and ourselves.
We hear the phrase zero tolerance. We believe that—and this is really quite important to stress—violence in the emergency department is first and foremost a medical symptom which requires an assessment to diagnose the etiology. Intoxication, psychosis and mania, dementia and delirium, brain trauma and tumours are all potential causes of violent behaviour.
Violence can also be reflective of a much bigger socio-economic problem, as previously discussed. We support zero tolerance of violence in the emergency department and every incident requires an institutional response, but the phrase “zero tolerance” cannot be used as an excuse to evict or ban patients who have not been properly assessed. This only makes us complicit in a culture of stigmatization and inequity. We believe violent patients deserve the very best possible assessment and care from their ED providers. Their individual social circumstances must be considered in their ultimate care plan. The zero tolerance lies with zero tolerance of an administration that turns a blind eye to the issue of safety in a department.
Thank you very much.
Good afternoon, everyone.
Thank you for inviting me on behalf of CFNU. We represent over 200,000 nurses across the country. My name is Linda Silas. I am a proud nurse and a proud New Brunswicker. Thank you to the committee for doing this study. I remember testifying here on other issues. When violence in the workplace was mentioned, it was a surprise to everyone, so we are very pleased to see this.
Workplace violence is a growing epidemic among health care workers as staffing levels heavily decline, patient acuity increases and weak security protocols fail to offer adequate protection. From a Canada-wide survey, 61% of nurses reported abuse, harassment and assault on the job during the last year. A recent survey here in Ontario said that 68% of nurses and personal support workers experienced violence on the job. We know that these numbers are unacceptable.
CFNU members across the country recently shared with me different examples. I literally sent an email to my board telling them I was appearing at the committee on May 14 and asking for any examples that came to mind. Last June a nurse in Newfoundland and Labrador was stabbed multiple times with a pen. Last fall a nurse supervisor in P.E.I., working in a long-term care facility, was punched over and over in the throat and tripped and pinched by a resident. This March, in my own hospital in New Brunswick, a nurse was attacked and strangled for 11 minutes by a patient's spouse before security showed up. Of course, she is still off. In Nova Scotia, violence in some facilities has reached a point where the nurses have begun pursuing charges against patients and family members who strike them. Earlier this month in Manitoba, on three consecutive days a nurse was punched in the stomach by a patient.
Studies in Manitoba also talk about ER, as Dr. Drummond mentioned, where 30% of ER nurses have been physically assaulted once a week in the last year. Last year, a nurse in Saskatchewan was brutally assaulted by a patient to the point where one more blow to his nose would have been fatal. That was March 2018 and he is still not working. He will probably never work again. In March of this year, a patient's visitor brought a gun into a hospital in Alberta. The last time Dr. Drummond and I testified together in front of you, it was about gun control.
We deeply appreciate the support provided by MP Doug Eyolfson for supporting the e-petition that the CFNU recently submitted on violence against health care workers. I cannot emphasize enough how important it is for Canada to tackle this crisis, not only for the health care workers from coast to coast to coast who signed the e-petititon but for all Canadians. As we frequently say in nursing, when nurses and health care workers aren't safe, patients aren't safe either. Nurses are even more susceptible to violence in the workplace than any other type of workers who work directly with the public. There were more than 4,000 incidents of serious workplace violence against nurses—serious enough to prevent them from going to work—reported in the last five years. That number—4,000—is higher than for police and firefighters combined. In order to tackle this mounting crisis, we need to go to the heart of the problem. For this we need to have an occupational health and safety lens in both staffing and training.
On January 17 of this year, a nurse and a security guard were assaulted at the Southlake community health centre in Newmarket, Ontario. The nurse, a 33-year-old mother with young children, was struck in the face and suffered skull fractures and a brain bleed. Between April 2018 and December 2018, an eight-month period, we saw 170 violent incidents reported by staff in the same hospital. Nurses describe the hospital as bursting at the seams.
We're calling on the federal government to undertake a comprehensive study in health care human resource planning to determine the current and future shortage and to equip governments across the country with tools to address this shortage. The federal government can, once again, lead by example. lt can implement the highest recognized, comprehensive violence-prevention programs and infrastructure, including hands-on de-escalation training, appropriately trained in-house security, communications devices for staff, wellness programs focused on the physical and mental health of health care workers, and the flagging of patients with a history of violence.
We are calling on this committee to recommend that the federal government legislate national minimum standards of security training for health care environments. To ensure that positive training programs are put in place in a harmonized fashion, minimum standards must exist for health care environments across the country through appropriate legislative changes.
Further, security must be part of the circle of care and viewed as an integral part of the care team. The CFNU is advocating for a revision to the Criminal Code through Bill as a tool to deter violence against health care workers. The bill amends the Criminal Code to require courts to consider assaults on health care workers as aggravating circumstances for the purposes of sentencing. A similar provision already exists for police officers and transit workers. We commend MP Don Davies for introducing this bill and urge this committee to recommend that Parliament adopt Bill C-434. The CFNU is calling on the federal government to enforce the Westray law, which holds employers criminally responsible for negligence causing physical injury to workers.
Currently, standardized national statistics on workplace violence do not exist. The Canadian lnstitute for Health Information, CIHI, which collects and reports facility-level data, needs to publicly report data on facility-level violence in the workplace.
ln closing, Canada's nurses are appealing to members of this committee to amplify your voice in the committee's report to the federal government. We are calling for a comprehensive federal study on health human resources planning; targeted federal funding to enhance protections for health care workers through violence-prevention infrastructure and programs, with community police included as an essential partner within joint health and safety committees; the adoption by the federal government of best practices around violence prevention in federally regulated health care settings; the legislating of minimum national standards for security training in health care environments; support from this committee for Bill and the promotion and use of the Westray law by Crown prosecutors in cases involving health care workers; and federal funding toward CIHl's collecting and reporting of data on facility-level violence in the workplace.
My name is Miranda Ferrier. I am a personal support worker. I have worked in long-term care and home care settings in Ontario for many years as a front-line personal support worker. I'm also the founder and president of the Canadian Support Workers Association and the Ontario Personal Support Workers Association.
Unfortunately, violence faced by health care workers is nothing new. Over the last 20 years, the incidence of violence against support workers has increased to the point where this profession, and consequently health care in Canada, is now firmly past crisis. In Canada, support workers occupy a very unique role in health care in that they are responsible daily for providing Canadians with the most personal and intimate care. They become a constant for these Canadians and, many times, a part of their family.
Support workers face violence on the job daily. This has become so prevalent that it is now viewed as the norm. Is this right? Absolutely not. However, we believe that it will take a small change in our health care system to help rectify this issue for the support workers.
Right now support workers are responsible for caring for up to 15 residents per shift in long-term care homes, or more, in some cases. They also care for up to 16 clients a day in home care across our province.
One of the situations that comes to my mind occurred in August of last year, near Toronto, Ontario. One of our member personal support workers was stabbed on the job, while working in home care, by a grandson of a client. She survived, but that just shows how we are at such a critical and crisis level.
No matter where they work, the system is constantly plagued by short-staffing due to two reasons. There is no professional acknowledgement, as personal support workers and support workers across our wonderful nation are not regulated, and there is no accountability. As a result, the support workers in Canada are professionally isolated, lack the tools to advocate for their own safety and must contend with a profession that is 600% more dangerous than being a police officer or firefighter. On the flip side, they can be fired for abuse, walk down the street and get hired as a support worker again without any recourse. Add in the levels of burnout across our nation and we have our current situation.
In order to properly address the issue of violence faced by support workers, the provinces and federal government must allow the support worker to have the same professional respect offered to all other members practising health care in Canada. This professional recognition is not only long overdue, but it would end the pervasive culture of fear so prevalent in health care. Our Ontario association has long been lobbying and advocating for self-regulation of the support workers, even receiving an endorsement from the Canadian Nurses Association.
The presence of this culture of acceptance has resulted in a situation where the support workers are simply unable to report incidents of abuse for fear their employment will be terminated and their professional reputations ruined.
In order to effectively address the issue of violence faced by support workers, the Canadian Support Workers Association and the Ontario Personal Support Workers Association are formally calling on this committee to endorse and formally recommend to provincial health ministries that the Canadian Support Workers Association and its provincial chapters form the self-regulatory body for the support workers across Canada. This action would promote a recognition of the value that these workers provide to health care in Canada through effective and confidential whistle-blower protection. It would end the professional regulatory gap that allows for the continued tolerance of abusive behaviours towards the support workers and those in their care. It would provide assurance that there will be a sustainable and stable workforce to care for Canada's most vulnerable for decades to come. We are currently losing support workers at a rate of 33% quarterly.
Self-regulation will create a respected profession, which will provide the safety net and accountability so desperately needed for our most vulnerable in all of our communities across Canada.
This model of self-regulation has proven successful partially in Ontario, with our association there representing over 32,000 personal support workers. We have had no abuse claims to date.
Thank you very much for giving me the time.
Good afternoon, Mr. Chair, and members of the committee.
I would like to start off by thanking you for the invitation to appear here today and for the opportunity to contribute to a crucially important discussion on violence faced by health care workers, and specific to my community, violence faced by paramedics.
It's my distinct honour to be here today as the president of the Paramedic Chiefs of Canada. That's an association that represents paramedic chiefs and service chiefs across all of our provinces and territories.
I was to present today with the Paramedic Association of Canada as well, which represents our practitioners. Unfortunately, they were not able to be here. But we share this message that we're bringing to you today.
We're pleased to participate in this national dialogue on this important issue that's crucial to the safety of paramedics in Canada on the front line, in our communications centres and in our hospitals, and by extension, the safety of Canadians.
We can't address this issue without also including the paramedic service organizations, their leadership that works with paramedics each and every day, as well as the families that need to be included in this dialogue, as they are such important social supports to paramedics.
In Canada, there are over 40,000 paramedics who stand ready to respond to people in need and to save lives. Unfortunately, each day, as they perform these tasks with compassion and dedication, these same individuals are at very high risk of being victims of violence and abuse. Regrettably, paramedics are often the target of physical and verbal violence, bullying, threats, sexual assault and sexual harassment. Physical violence includes, but is not limited to, pushing, punching, scratching, kicking, biting, slapping and the use of weapons. Acts of violence and abuse may come from patients, the families of the patients and even bystanders at emergency scenes. Sadly, all too often paramedics are victims of violence by the very patients they're trying to care for.
Internationally, studies have found that between 55% and 83% of paramedics have experienced threats or violence during the performance of their duties annually. In a 2014 study of Canadian paramedics, 75% reported experiencing violence of some sort, 74% reporting multiple forms of violence annually. Of the 1,676 paramedics who participated in this study, 67% reported verbal abuse, 41% reported intimidation, 26% reported physical assault, 4% reported sexual harassment and 3% reported sexual assault. Sadly, these paramedics reported that they felt violence was part of the job.
Violence experienced by paramedic personnel has many consequences. It has been linked to psychological injury in the form of stress, anxiety, post-traumatic stress and burnout. Violence has been linked to physical injuries, resulting in time lost from work in between 17% and 32% of the cases. It has also been linked to the intent to leave the profession early. Violence against paramedics jeopardizes the quality of patient care that paramedics strive to deliver. It also leads to immense financial loss in the health sector, not to mention the indirect and direct costs to the paramedics themselves and their families.
Violence and abuse against paramedics in unacceptable. The Paramedic Chiefs of Canada supports a zero tolerance position on all forms of violence and abuse in all areas of the Canadian paramedic community. There's an immediate need to intervene on this crucial issue.
Our association recommends that interventions to prevent violence need to occur at multiple levels.
First, we feel we need to sponsor and support research. Research is necessary to obtain a better understanding of the scope of the problem, to evaluate the impact of violence on personnel and to assess means of mitigation, as we heard earlier today. Currently, there is only one peer-reviewed article that examines the issue in Canadian paramedics. This is insufficient.
Second, evidence-informed strategies must be developed and training provided for the management of violent patients and situations for front-line personnel.
Third, we must increase public awareness of the human and financial impacts of this issue among health care workers and paramedics.
Fourth, consideration must be given to changes in policy and legislation—as we also heard earlier—to protect paramedics and health care workers through increased punitive measures where appropriate.
We certainly welcome the opportunity to work with the federal government and partners to assist in coordination, research and communication to ensure the safety of all paramedics and health care workers is addressed.
You know, I work in a small town; the good doctor worked in an urban environment in Winnipeg. In my view of the world, I tend to look at what happens in my little department in Perth, Ontario as a manifestation of what happens in the bigger picture. I can tell you that in our small town, which sees about 30,000 patient visits per year, we often have about three nurses on staff at any one point in time. We're chronically understaffed; it's chronically difficult.... There's no acceptance of illness, because it puts the onus on somebody to fill in that shift. Many of them feel incredibly stressed by their sense of community and commitment to work through illness, through family stress, through psychological difficulties.
In our department, where we have a fantastic, supportive team—intercollegial—many of our nurses are getting fed up with the degree of—I'll be polite, because I'm in mixed company—nonsense that happens on a day-to-day basis. It's true that we don't tend to see a lot of the significant violence, such as you might have seen in Winnipeg, but every day there is verbal abuse, grabbing, kicking, scratching—not always by patients, sometimes by their families—and the nurses are traumatized.
Some of our best nurses, who've been with me for nigh on 10 or 20 years, are thinking that they've had enough now and they're going to leave, because there just isn't enough accountability from the hospital to address the problem. They do feel, as my colleague from the personal support workers mentioned, that if they raise the issue, there will be retribution or their problems will not be taken seriously; therefore, they remain silent. It has become that staff feel it's a normal part of the job, but it is not.
In answer to your question, the obvious answer is no, it's not acceptable.
I think it depends on the facility to a certain extent, and the realization that the health care budget is not endless and hospitals are struggling to provide basic care sometimes. Such things as security of health care workers sometimes assumes a low priority when you can't balance your budget for operative procedures. So it's always an afterthought.
There are about 850 emergency departments in this country, divvied up into about five levels of classification from tertiary trauma centres to small rural hospitals such as my own.
Clearly the urban hospitals, with the issues of gangs and substance abuse, often have a very clear and present security presence. Rural communities often don't, and rely on local police detachments for some kind of immediate response, should it be required.
There is often not a direct line to the local police detachment; you have to call 911 to get a policeman to come. The delays can be quite extensive.
My colleague mentioned administrative response to violence in our hospital. Two years ago the nurse in our sister hospital in Smiths Falls was stabbed by a violent patient. Our hospital, then and only then, installed lockdown access to the emergency department. You had to be buzzed in after hours to be allowed in. Only then did they hire a security company to sit after hours, because that's usually when a lot of this stuff happens. The security personnel are octogenarians wearing a jacket, and are probably not of much use, but it looks good in the hospital. Our nurses still feel unsafe.
Why is it an afterthought? I believe administrations embrace the concept that it's part of the job. We have to get beyond that once and for all. As you've heard, a broad consensus of health care workers.... The extent of violence in the emergency department or in the emergency sector or in the hospital sector or in the community sector is such that our most talented and experienced people are saying they'll forget about it. They're leaving their job.
That's a great question, and I think it all goes back to education and training, but somebody has to pay for that education and training. When we talk about verbal de-escalation techniques to lessen the degree of hostility, anger or aggression, somebody has to pay for that, and every nurse, every physician and every clerk in an emergency department setting should be offered that access.
If verbal de-escalation fails, there are other methods to reduce the degree of aggression in a patient, depending on what the circumstances are, be it a toxic syndrome, dementia or delirium. There are medications that can be used and chemical restraints. I think it would be good if we were able to promote—we're talking about best practices here—a best practices solution to the types of toxidromes that we see in the emergency department and what kinds of medications can be used in both rural and urban settings.
This is not something that we like to talk about, but it's a reality, and that's physical restraint. When do you escalate up the degree of intervention you use to lessen the risk of harm to a patient?
We have verbal de-escalation, chemical restraints and physical restraints. Somebody has to pay for all those levels of education, and it can't be a one-off. It has to be an ongoing process of re-education to keep staff, so there has to be an administrative commitment to prioritize safety in the emergency department as one of the core values of that institution, not just for the patient and not just for the staff.
What is lost in the argument is the effect on patients in that emergency department. Someone's sitting there with a child with a sore ear, and in the next room there's some guy dropping f-bombs and throwing his urine all around. That's pretty traumatizing to young families and to family members of the elderly, who are often now forced to stay 24 hours in our emergency department waiting for a bed. There are lots of studies of the impact on nurses and physicians. There are virtually none on the impact of this kind of violence in the emergency department on the patients we serve.
The emergency department is and has become even more so, an extremely stressful environment. I've spent my time in emergency departments not only as somebody who works there but with family members.
The number one issue for emergency personnel, emergency physicians in this country and probably emergency nurses, as well, and to a certain extent paramedics, is crowding. Every hospital in this country is crowded which means that every emergency department has people lying on stretchers for eight, 12, 16, 28 hours waiting for a bed to become available for their loved one to be properly treated. That leads to inadequate care in the emergency department itself because our emergency nurses are trained to deal with emergency situations. It's not really their job to provide toileting care to an 85-year-old lying on a stretcher in a hallway.
The elderly get poor care, not by malfeasance, just because of the nature of the beast. Patients are always coming and always have to be assessed. If I was sitting with my elderly father in an emergency department in Montreal and I was watching him for 24 hours in a brightly lit hallway with no privacy whatsoever, his toileting and basic human needs not being met, I think I would be angry. I think if I was bringing a child with a facial laceration from a dog bite and was forced to sit in the Children's Hospital of Eastern Ontario for 12 hours waiting for somebody to assess my child's laceration, I think I would be angry.
That impact is felt every day. The basic problem is hospital crowding leading to emergency department congestion leading to ridiculous lengths of care which are totally unacceptable in our health care system, coupled with the fact that we have inadequate nursing staff and we have paramedics unable to offload their patients, who then have to sort of sit in hallways waiting for a stretcher in emerg.
If there was one institutional issue that is at the core of all of this, I believe that it's crowding.