It was 90 minutes into her shift at an Edmonton emergency room when Sarah Basuric heard a commotion. When the 30-year-old nurse parted a curtain to investigate, she walked into what she calls a “cloud.” Immediately, her eyes started burning and she struggled to breathe. “I grabbed onto a bedside table because the edges of my vision were going black,” says Ms. Basuric, who was quickly admitted to the intensive care unit after it was discovered that a patient had released bear spray from a concealed can.
Seven months later, Ms. Basuric is still on leave from Edmonton’s Royal Alexandra Hospital after being diagnosed with post-traumatic stress disorder. This wasn’t her first time being assaulted at work; two years earlier, a patient picked up a bedside table and threw it at her head.
Violence, verbal abuse, harassment and assault have plagued health care workplaces for decades, says Linda Silas, president of the Canadian Federation of Nurses Unions (CFNU): “The first stop-the-violence campaign I worked on was in 1991.” But the pandemic has ushered in new urgency. Understaffing and long wait times for care have been chronic triggers for aggression, and they’ve been made worse by COVID-19. In a recent poll of 2,600 front-line workers conducted by the Canadian Union of Public Employees (CUPE), 66 per cent said workplace violence had increased during the pandemic and 26 per cent said it had “increased a lot,” with racialized workers reporting even higher rates of abuse. But in Canada, where health care is a provincial file, coping with a countrywide problem is tricky. Absent national standards for prevention and mitigation, many hospitals are scrambling to create safeguards on their own.
“We didn’t really know how to start,” says David Kodama, an emergency physician at St. Michael’s Hospital in Toronto. He noticed an uptick in abusive patient behaviours about a year and a half ago, which prompted the hospital’s safety committee to create an online dashboard that flags patients who have the potential to be violent or abusive. The dashboard uses a scoring system called the Acute Care Violence Assessment Tool put out by the Public Services Health & Safety Association (PSHSA), a non-profit that is partially funded by the Ontario government. In use now for about a month, it is the first step to what Dr. Kodama hopes will be “a more comprehensive” approach that will eventually help staffers identify which patients need to be seen earlier or when to bring in community supports to help de-escalate situations.
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The tool, which is free, has been around since 2017, but uptake has been slow and sporadic. Henrietta Van hulle, vice-president of client outreach at PSHSA, says at least eight other Ontario hospitals are now using some version of the organization’s violence assessment tool (there are more than 380 hospitals in the province). She would like to see the Ministry of Health and Long-Term Care continue to encourage – if not mandate – that organizations implement leading practices and make sure that at minimum their staff get the education, training and protective strategies they need.
Nova Scotia is attempting such a province-wide approach.
The health crisis wrought by COVID-19 presents more safety challenges, says Angela Keenan, provincial director of occupational health safety and wellness at the Nova Scotia Health Authority. “We’re in a situation with the pandemic where it’s escalating people’s behaviours.”
The authority began to address the problem in 2015 and over time has ushered in province-wide protocols, including flagging aggressive patients and training staff in de-escalation and self-defence, Ms. Keenan says. The risks remain significant, however. Earlier this month, a hospital in the province’s central zone had a “code black,” or bomb threat, she says. Her transparency about the challenges of keeping health care workers safe is rare. Few of the hospitals and health units across Canada that The Globe and Mail reached out to chose to comment publicly.
Jamie Stewart, an ER nurse at Cobequid Community Health Centre in Lower Sackville, N.S., doesn’t feel safe at work. A nurse for 27 years, he says the provincial authority does take safety seriously, but he doesn’t know how effective some of the approaches are when you are “seeing 120 people a day and you only have one security guard on staff.” His workplace flags potentially violent patients with a purple sticker on their chart. “That’s great but that purple sticker isn’t going to help when this person tries to beat me up.”
Safety concerns are felt strongly in rural ERs, which often lack security. “You’re just subject to abuse. It’s not easy to manage,” says Kevin Wasko, an emergency physician who is also a physician executive for Integrated Rural Health with the Saskatchewan Health Authority.
“Some provinces are probably doing better than others but none is doing enough,” says Alan Drummond, an ER doctor and family physician in Perth, Ont. He wants national standards for prevention and mitigation.
He continues: “Canada is such a Balkanized country in terms of health care delivery. Everyone is reinventing the wheel and there’s never any consistency and this goes on in perpetuity.” Workplace violence prevention programs are pivotal to care but they can’t compensate for gaps in primary care or distract from long wait times and understaffing issues, all of which can lead to abuse. Solving those problems requires funding, Dr. Drummond says.
Ms. Keenan wants to see more funding put into violence-prevention programs. Hospitals and health care settings that have the highest risks of violence – ERs, for example – should receive greater resources to protect workers and patients.
Ms. Silas would like to see the government amend the Criminal Code to make the assault of a health care worker an aggravating factor when it comes to sentencing, similar to assaults on police or public transit workers. Prompted by public outcry over anti-vaccination protests in front of hospitals, Prime Minister Justin Trudeau campaigned on a promise this summer to make obstructing entry to health care institutions and the intimidation and harassment of health care workers a criminal offence.
Dr. Drummond doesn’t think we’re going to be able to “police” our way out of the problem. Many perpetrating violence, he says, are intoxicated or under the influence of drugs, suffering from dementia or psychiatric disorders. They’re coping with poverty, inequity and some of the same austerity measures that plague hospitals, he adds.
While health care workers and advocates hope to pressure government authorities and hospital administrators to look for solutions, Ms. Basuric is taking the time to heal without pressure to return to work. The hospital has implemented changes she believes will make the ER safer. (A spokesperson for the Royal Alexandra Hospital confirmed a safety ambassador role was created and a behavioural safety alert program was put in place, among other changes.) The alleged bear-spray assailant has been charged with one count of possession of a weapon for dangerous purpose, and Ms. Basuric is eager for him to face the consequences in court: “It’s not okay to assault health care workers. It should never be okay.”
In the meantime, abuse is a daily occurrence, one seemingly without relief, Dr. Drummond says. “Every night someone in my family medicine practice goes home in tears because some little old lady who would normally bring them cookies is now giving them the middle finger.”
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