Good afternoon. Welcome to meeting 145 of the Standing Committee on Health. We're continuing our study of violence faced by health care workers.
We have a number of excellent people to testify with us today. From the Canadian Nurses Association, we have Josette Roussel, the Program Lead for Nursing Practice and Policy, and Isabelle St-Pierre, a registered nurse. As well, we have, from Concerned Ontario Doctors, Dr. Kulvinder Gill, the President.
From the Fédération interprofessionnelle de la santé du Québec, we welcome Linda Lapointe, who is its Vice-President, and Laurier Ouellet, who is President of the Syndicat des professionnelles en soins de Chaudière-Appalaches.
From the Ottawa Hospital, we have Thomas Hayes, the Director of Safety, Security, Parking and Staff Health in the HR department.
Each of you will have 10 minutes for your remarks. We'll begin with the Canadian Nurses Association.
Josette, you have 10 minutes.
Thank you, Madam Chair and members of the committee, for the invitation.
My name is Josette Roussel. I'm a registered nurse and the Program Lead for Nursing Practice and Policy at the Canadian Nurses Association. I'm joined today by my colleague, Ms. Isabelle St-Pierre, who is a registered nurse and an associate professor at the Université du Québec en Outaouais. Ms. St-Pierre also has her doctorate in nursing, with a focus on horizontal workplace violence.
The Canadian Nurses Association is the national and international professional voice of nursing care in Canada. It represents more than 135,000 nurses in 13 provinces and territories of Canada.
The CNA advances the practice and profession of nursing in order to improve health outcomes and to reinforce the public and non-profit health system in Canada.
Canada's health care system couldn't function without nurses. Nurses work in a variety of settings, including hospitals, nursing homes, rehabilitation centres, clinics, community agencies, correctional services, long-term care and home care settings.
Violence in health care is not a new problem. Violence can be overt, such as physical, verbal, financial and sexual behaviours, or it can be covert, such as neglect, rudeness or humiliation in front of others. Violence can occur between employees of an organization, such as between nurses or between employees and non-employees, for example, between patients and nurses.
In fact, violence is a widely recognized global issue, with one-third of nurses worldwide being victims of physical assault, two-thirds being exposed to non-physical violence at work, and 80% being victims of some form of workplace violence. Although these numbers show an alarming situation, it is much worse. Only 19% of nurses formally report workplace violence.
Statistics show that 60% of new nurses who experienced workplace violence will resign from their first place of work within six months of employment, and of these nurses, 50% will choose to leave the profession altogether. Nurses are the most at risk of being attacked in their workplace, second to police officers.
While all nurses are at risk of workplace violence, we know that nurses working in long-term care, emergency departments and psychiatric settings may be more at risk, as well as night-shift workers and novice nurses.
Perpetrators of workplace violence include patients, and patients' families or visitors. They can be doctors, managers, other nurses or other employees. The work environment is also known to contribute to workplace violence. Examples of organizational factors that contribute to the problem include excessive workloads; inadequate staffing; excessive use of overtime, both mandatory and voluntary; lack of managerial support when reporting instances of workplace violence, and a lack of perceived consequence when committing violent acts.
Some of the most reported workplace violence consequences include physical injuries, post-traumatic disorders, burnout, anger management issues and persistent fear and anxiety, to name a few. Statistics from the Workplace Safety and Insurance Board in Ontario show that in 2016 lost-time injuries due to workplace violence in the health care sector greatly outnumbered those in other sectors, with over 800 injuries compared to manufacturing at 138, construction at three and mining at zero.
The effects of workplace violence in the health care sector are significant, and their consequences are real. Violence negatively affects outcomes for patients, nurses and organizations.
CNA has four recommendations to make to the committee.
The first is that the federal government lead a pan-Canadian strategy to study why workplace violence continues to be an issue and why initiatives continue to have limited success. This study may include conducting consultations, round tables, and a public inquiry seeking feedback from politicians, senior leaders, health care professionals, patients and families. This federal government study would also lead to clear, more targeted definitions of violence to move toward a common language to allow comparison of data.
The second is that the federal government create a hub for promising practices and create information-sharing opportunities for organizations to discuss best practices and learn from incidents and near misses.
Third, we recommend that the federal government support funding to evaluate existing programs and successful strategies and conduct a longitudinal research program on workplace violence. These evaluations should focus on learning from incidents and near misses, on what health care professionals say is effective in their organizations and on ensuring that policies have the intended on-the-ground outcomes.
Finally, we recommend that the federal government collaborate with provincial and territorial health ministries and health care organizations to develop prevention strategies to take into account individuals' characteristics, interpersonal factors and organizational factors. Such strategies could include, for example, minimum system enhancement initiatives related to health human resources, communications and work environments.
Along with these recommendations, I would also like to point out that part of the problem is that definitions of what constitutes workplace violence vary. Many words are used interchangeably and there is no one standard typology that classifies episodes of workplace violence. CNA's full submission to the committee will further outline the complexity of varying definitions. However, there is a need for more standardized language to describe the problem. There's also an ongoing debate as to whether intent should be considered as part of the definition as well.
In closing, with an upward trend in the number of incidents of workplace violence in health care, CNA believes that workplace violence requires immediate federal government action, including support for the victims. By adopting the recommendations made here today, the standing committee can address the growing need for prevention, evaluation and intervention pertaining to workplace violence in the health care sector.
It will take a sustained, concerted effort and collaboration if we are to achieve what we all want: violence-free workplaces and the resulting improvement in outcomes for patients, nurses and organizations. As well, because different factors contribute to violence perpetrated by patients' families or health care professionals, it will require different and multi-faceted strategies to alleviate it. It is not a simple one-size-fits all approach or solution.
I would again like to thank the committee for providing CNA with the opportunity to share our perspective and recommendations. Let's all work together to create a better future for our health care sector workers and nurses.
We look forward to your questions. Thank you.
I'm a front-line physician practising in Brampton and Milton, Ontario; a medical educator; and the co-founder and president of Concerned Ontario Doctors.
I thank you for the opportunity to address the Commons standing committee on health about your study into the violence faced by Canada's front-line physicians on behalf of Concerned Ontario Doctors, a grassroots, not-for-profit organization representing nearly 11,000 community and academic family physicians and specialists across Ontario. We advocate for a patient-centred, sustainable, accessible and high-quality health care system.
Canada's health care system was once a source of great pride for our country. It is unfathomable that we now rank third last for accessibility to patient care amongst all the wealthiest nations in the world. Ontario is in the midst of an historic health care crisis, with Ontario's doctors now into our eighth unprecedented year of billions of dollars in deep cuts to our essential front-line patient care, leaving more than one million patients in Ontario without a family doctor, creating province-wide emergency room gridlock, and causing wait times to explode, with some specialists' wait times rising to up to three years. Patients are increasingly projecting their frustrations and anger with the broken health care system onto front-line doctors.
The World Health Organization defines workplace violence as “the intentional use of physical force or power, threatened or actual, against another person or against...a group of people, that results in or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment, or deprivation.”
Health care is known to have the highest incidence of workplace violence. Ontario's nearly 29,000 physicians provide essential medical care to Ontario's 14 million citizens, with more than 300,000 patients cared for by Ontario's doctors every single day. It is crucial that governments address violence against front-line physicians in all aspects of front-line patient care delivery, from hospitals and long-term care homes to community clinics and home visits.
Canadian physicians working in hospitals and psychiatric ER departments and in after-hours clinics have an increased risk of encountering an abusive and violent patient, as do physicians making house calls and those who treat large numbers of patients with mental illness and addiction.
The majority of Ontario's front-line physicians face increased risks of violence in providing care in medical and walk-in clinics within the community. When de-escalation attempts fail, the only option that exists—often after the violence and abuse has already occurred—is for the front-line secretarial staff and doctors to call police. Front-line physicians have reported violence ranging from verbal abuse, racism and sexual harassment to physical violence, including patients spitting, biting, kicking, groping, punching, stabbing and assaulting physicians.
In a 2010 survey of Canada's family doctors, approximately one-third reported having endured aggressive behaviour from a patient or a patient's family member in the previous month. During their career, 98% reported at least one abusive incident. Of those, 75% were major incidents, such as sexual harassment, whereas nearly 40% were severe, such as sexual assault or stalking. The results varied for female physicians working on-call. Female physicians' sense of safety decreased dramatically to 7.2% during on-call duties, compared with male physicians at 75%. Of the physicians who experienced an abusive event in the previous month, 55% were not aware of any policies to protect them; 76% did not seek help, and 64% did not report the abusive event.
Physicians are increasingly experiencing cyberstalking and cyber-bullying by patients. In a recent Medscape survey of physicians in North America, nearly 40% of doctors reported online abuse. More patient hostility has been associated with online anonymity.
The National Academies of Sciences, Engineering and Medicine's 2018 report on women found, shockingly, that sexual harassment of women is most prevalent in medicine of all STEM fields, because in medicine, the harassers are colleagues, supervisors, staff and also patients. Four key factors were identified in the reports as creating higher levels of risk for sexual harassment in medicine. These included men having positions of power and authority, organizational tolerance of sexual harassment, hierarchal relationships, and isolating environments.
As many as 50% of female medical students report experiencing sexual harassment. Many research studies and reviews describe a culture of harassment in medicine, which has long-term implications for the profession, including significant reductions in professional, psychological and physical health. In Canada, most medical students are now women, and medicine now has a greater representation of people of colour within the profession than in the general population. However, women and people of colour occupy only a tiny fraction of leadership positions. It is the toxic culture within medicine that pushes women and people of colour out of leadership positions and that creates glass ceilings.
Violence against front-line physicians is associated with increased stress, burnout, addiction and risk of developing mental health illness, including depression, anxiety and suicidal ideation. It may also result in absences or refusal to work in high-risk areas and poorer patient outcomes. This is deeply concerning, as the burnout rate reported by Canada's nearly 87,000 physicians is now at 50%, and Ontario’s physicians have a historic burnout rate of 63%.
Medicine has the highest suicide rate of any profession. This is an alarming public health crisis. The physician suicide rate is already more than twice that of the general population, with male doctors killing themselves at a rate that is 40% higher than of men in the general population, and female doctors killing themselves at a rate that is 130% higher than of women in general.
Ironically, physicians’ provincial and territorial regulatory and licensing bodies do not recognize mental health and physical health as being equal. One of the greatest barriers to physicians receiving the mental health care they so desperately need remains mandatory reporting to provincial and territorial regulatory and licensing bodies. The majority of front-line physicians suffer in silence, fearing the implications for their medical licence and their livelihood of reporting.
Canada is entering uncharted territory, with our senior population projected to grow by 68% over the next 20 years. With our health care system already stretched well beyond its limits due to deep cuts and heavy rationing of front-line patient care, violence on the front lines of Canada's health care system will only escalate.
The Government of Canada has the opportunity to provide a strong leadership role in bringing collective change across provinces and territories. Concerned Ontario Doctors has 11 key recommendations.
One is a zero-tolerance policy toward workplace violence and harassment on the front lines of Canada's health care system.
Two is a universal definition of workplace violence.
Three is visible security and surveillance for workplace violence in hospitals, mental health facilities and long-term care homes, with formal reporting processes protecting against reprisals.
Four is development of comprehensive strategies to address the safety of physicians practising within community and walk-in clinics, providing home care visits and overnight on-call care, with formal reporting processes protecting against reprisals.
Five is that medical school and residency curriculums include mandatory training on approaches to de-escalation when encountering sexism, racism, harassment, verbal abuse and physical abuse from patients.
Six is that provincial and territorial medical regulatory and licensing colleges develop policies to address situations of sexism, racism, harassment, verbal abuse and physical abuse from patients against medical trainees and physicians and ensure that these policies are in line with the respective provincial-territorial human rights codes.
Seven is to ensure that front-line doctors have democratic representation that is accountable and transparent. According to OECD experts, harassment and corruption flourish and create a toxic environment when there is monopoly power. Ontario is unique in having a provincial medical association granted mandatory government-legislated dues from all physicians. That has created an untenable situation. Governments have a responsibility to protect patients and physicians, and to address toxicity and lack of democratic representation by repealing such legislation and undertaking an independent forensic review.
Eight is whistleblower legislation to protect physicians and all health care workers when they reporting wrongdoings impacting front-line and patient safety.
Nine is the creation of a front-line health care ombudsman, similar to that of other countries such as Australia, to allow for confidential reporting and to have a mandate to protect front-line workers.
Ten is that all levels of governments should address the alarming physician burnout and suicide epidemic.
Eleven is amendments to the Criminal Code to allow its provisions to apply to physicians, nurses and health care workers who are subjected to workplace violence, similar to those that already exist for transit workers and police officers.
Lastly, violence against front-line physicians, nurses and health care workers is a complex and multi-faceted societal problem that demands a comprehensive and multi-pronged approach, which is only possible with all of us working together.
Thank you, Mr. Chair and committee members, for providing me the opportunity to speak to you today about workplace violence in health care.
My name is Thomas Hayes. I'm the Director of Safety, Security, Parking and Staff Health at The Ottawa Hospital. I've been at the hospital for over 16 years. We're one of Ontario's largest hospitals, with close to 16,000 staff, including 4,400 nurses, 1,400 physicians and midwives and 1,100 volunteers. We're a teaching hospital with thousands of students each year. We have 19 sites across the city of Ottawa. We see over 174,000 emergency visits a year and nearly 1.2 million ambulatory care visits, and last year, we delivered 6,211 babies. We have over 2,000 researchers and are ranked third in Canada for peer-reviewed funding from the Canadian Institutes of Health Research.
At the same time, last year we had 58 staff members who suffered injuries at work as a result of violence that was serious enough that they lost time from work or needed to see a physician. The security team at the hospital responded to an average of seven code white urgent physical interventions a day and three pre-emptive calls a day.
I want to acknowledge that violence in health care is a difficult topic to talk about. I want to tell you about two stories, and I've changed some of the aspects of these stories to protect the confidentiality of those involved
First, imagine you're a nurse. You're working in an emergency service. It's night. You have several patients being assessed and treated while they're being considered for admission, one of whom is with a visitor. It's been a long shift, and the security guard in your area asks if he can go get a coffee. You say, of course. Everything's quiet and everyone needs a break once in awhile.
Now you're alone. A few minutes pass and one of the patients under your care starts pacing the hall and trying to get into the rooms of the other patients. You go into the hall to speak to him, and he starts returning to his room.
The next thing you know, he's lunged at you, grabbing you, pulling your shirt over your head and punching you as you fall to the floor to protect yourself. The visitor, hearing the commotion, peers into the hallway, sees what's happening, goes back into the room and hits a panic button on the wall. Luckily, the security office is right across the hall from your area, and seconds later, four guards arrive and start to restrain the patient who's punching you, who by now seems to have lost interest in continuing to assault you. A nurse and a physician arrive to help as well, and you crawl to the locked nursing station to start to recover. What if that visitor hadn't been there? What if the visitor had left a few minutes earlier? You had no way of summoning assistance. There was no system or schedule in place to replace that guard who needed a break.
Fast forward a couple of years. You're a dialysis nurse working in the evening as several patients finish their day-long treatment. You know from your safety huddle earlier in the shift that one of the patients has exhibited violent and disruptive behaviour in past visits. Your manager had invited a safety officer and a member of the joint health and safety committee to provide a refresher on violence prevention training at your last team meeting and had encouraged people to report and to summon assistance when they needed it. They told you that this could happen anywhere in the hospital, not just in the emergency department or in mental health areas, and that, in fact, at one of the other campuses recently, a dialysis patient had come to his treatment with a large knife in his bag.
You notice that the patient is starting to get very upset with another nurse, who's trying to calm him down and lower his voice. You ask the clerk to call a code white, and you hear it paged overhead, calmly, almost right away. Less than a minute later, several security guards arrive, along with the overnight nursing supervisor. They check in with you, and together they approach the patient to discuss his concerns and are able to de-escalate the situation.
You provide a report in the safety learning system, where you're encouraged to report issues that relate to both staff and patient safety. The next day, your manager checks in with you after reading the report to make sure that you're okay. She thanks you for your action and lets you know she will be reviewing the incident with the violence prevention working group to see if there is anything else that can be learned from this event and shared with other departments.
At the Ottawa Hospital, we realized several years ago that we didn't really know how widespread violence against our staff members was and that it was much more serious than we thought. We decided that in order to achieve our vision to provide each patient with the world-class care, exceptional service and compassion we would want for our loved ones, we needed to provide that care and compassion to our staff as well. We expanded our corporate strategy to include a quadruple aim. Beyond better quality at lower cost, healthier populations and a better patient experience, it now includes a better staff experience. We have learned that through collaboration with labour groups like the Ontario Nurses' Association and our front-line staff, including physicians, we create a safer environment.
We know we still have a long way to go, like every other healthcare workplace, to address violence, but at least we feel more comfortable that our staff are not afraid to report issues so that they can be addressed in a way that respects the needs of patients, visitors and staff.
Good afternoon, committee members.
First, we want to thank you for this invitation and to tell you we feel it is extremely important for us to be involved in this study as you are addressing an essential issue for the 76,000 members of the Fédération interprofessionnelle de la santé du Québec.
My name is Linda Lapointe, and I am Vice-President of the FIQ and responsible for the occupational health a safety sector. 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.
With me today is Laurier Ouellet, President of the Syndicat des professionnelles en soins de Chaudière-Appalaches. That union is affiliated with the FIQ and represents 3,500 nurses, nursing assistants and respiratory therapists in the region.
Health care professionals experience various forms of violence: physical, psychological, sexual and organizational. That violence may be active or passive, direct or indirect. We know that psychological violence is seven times more likely to occur than physical violence.
Specific information on health professionals is hard to come by because the available data cover all personnel in the social affairs sector. Consequently, it is difficult to form a clear picture of violence cases in the health care sector, particularly in long-term care facilities and in home care. In addition, as a result of underreporting—we'll come back to that later—the figures we're giving you today are merely the tip of the iceberg.
According to the statistics provided by the Commission des normes, de l'équité, de la santé et de la sécurité au travail, the CNESST, on violence, stress and harassment in the workplace, there was a 27% increase in accepted injury cases during the period from 2014 to 2017. Of those cases, 32% were attributable to physical violence and 12% to psychological violence. There was also an overall 11% increase in sexual and psychological harassment cases. Lastly, it was observed that women were involved in a large percentage of of those violence cases. For 2017 alone, the victims of 73% of injuries attributable to physical violence and 68% of those attributable to psychological violence were women.
The health sector alone accounts for 61% of accepted injury cases attributable to physical violence, although health personnel represent only 10% of the staff of all institutions covered by the commission. The number of accepted claims for injuries caused by violence in the workplace rose by nearly 25% between 2015 and 2017.
The consequences of violence are extremely serious and cause considerable pain and distress in the lives of health care professionals. Mr. Ouellet will explain this to you in greater detail.
I wanted to testify on the everyday conditions of violence experienced in the health sector at all facilities: long-term care centres, hospitals and even patients' homes. That violence is an omnipresent and everyday phenomenon. I am talking here about violence committed against patients in the form of threats, verbal attacks, blows, spitting, scratching and the like. This is the nature of our everyday work. In addition to the violence that certain patients exhibit as a result of the medical hierarchy and the lack of control that health care institutions such as mine have over doctors, unacceptable language, psychological harassment and contempt are factors that female workers deal with every day.
The media occasionally report the tragedy of pregnant women who lose unborn children as a result of violence suffered in the workplace. That's what happened to Ariel Garneau, who lost her unborn child as a result of a blow to the abdomen last winter. Even that kind of incident occurs every day, and when it happens to pregnant women, that violence is so intolerable it is referred to in those terms. It is not so clearly characterized in other instances. Very few measures are taken to prevent it. What's worse, our employers want pregnant women to stay on the job, in increasingly dangerous settings, even longer than was previously the case.
We feel our managers are not adequately held accountable. Staying on budget is the only thing that seems to count, regardless of the consequences for female workers.
This is a particularly insidious form of violence that is experienced in the health sector. It is organizational violence and appears to have two main causes: a sharp increase in workload as a result of budget cuts, and the medical hierarchy and its contempt for female health workers. Reporting is stifled by a conspiracy of silence and threats of punishment.
Organizational violence is a form of violence that causes stress, depression an illness. Many female workers are leaving the health sector. In a small region such as mine, work absences cost more than $40 million. That's enormous.
Female workers are forced to work mandatory overtime, even if they are physically and mentally exhausted, and even if it destroys their family lives. Every week, the union witnesses the tears, crises and distress experienced by female professionals who are required to work overtime under pressure and threats.
Female managers are aware of this violence. In many cases, they are former health professionals and experienced it themselves. The situation gradually tends to be downplayed, the violence is eventually viewed as trivial, no one really deals with the situation, and female health workers ultimately come to view violence as normal. In many cases, they don't even report the situation. The lack of time and excessive workloads also conspire to lower the reporting rate. In my region, we estimate that only 10% of cases are reported. Many factors still need to be understood and much remains to be done.
Mr. Ouellet just referred to many of the factors that contribute to violence, such as excessive workloads and budget cuts. In addition, new public management tools have been introduced together with increasing numbers of performance indicators.
This obsession with efficiency dehumanizes the care provided and the impact on our health professionals. The series of reforms that have been made to the health system in Quebec has absorbed all vital energy and created even larger institutions. The result is a depleted, even exhausted, health sector in which violence levels are rising. These megastructures aren't conducive to proximity management.
Among these reforms, the deinstitutionalization of mental health patients makes it even more difficult to provide safe care. Teams travel to unsecure and unmonitored places to provide services such as in-home support. In addition, the closure of mental health emergency services doesn't reduce the number of patients.
The obstacles and risk factors are significant, and safeguards are inadequate to address their scope. However, we're convinced this is an issue for which every measure counts in building a culture of prevention.
First, FIC demands that the health sector be recognized as a priority group within the meaning of the Act respecting occupational health and safety. That measure would require employers to meet four obligations arising from the act: to establish a prevention program, to create a health program specific to an establishment, to strike an occupational health and safety committee and to designate a prevention representative.
In Quebec, with regard to psychological health, we can rely, in particular, on the provisions of the Act respecting labour standards. However, there is a gap between having a right and being able to exercise it.
We also have the National Standard for Psychological Health and Safety in the Workplace, which is an excellent tool, although its application is voluntary and not widespread.
We spoke about the increasing size of institutions, which creates a distance with managers. There is also a significant gap between the percentage of female care professionals and the number of women managers. In fact, 6% of health managers are men, although they form approximately 10% of the profession, and only 6% of managers are women, whereas they represent nearly 90% of the profession. The question should be why there are so few women in management. Could their presence there improve the situation regarding the violence our members experience?
For many years now, the federation has prioritized, and still prioritizes, action to establish new health professional-patient ratios. The state of knowledge, international experience and ratio projects introduced by FIQ confirm that sufficient numbers of health professionals can provide safe and more humane care. They can do it under an adequate workload in an environment conducive to their occupational health and safety.
The system must consider the needs of professionals to a greater degree, those of pregnant workers who must be reassigned to safe settings and those of female professionals experiencing various forms of violence. Prevention must take precedence, and the violence must stop.
FIQ is greatly concerned about the rate of violence in all forms in the health system. We very much hope that union-management cooperation can finally be established in our institutions so we can address this constantly rising scourge.
I would like to bring to your attention the fact that we just received the report of Quebec's auditor general today, many of findings of which are consistent with those of our federation. They include the fact that Quebec lags significantly behind other administrations and that there are persistent inequities among prevention workers.
Thank you for listening.