Canadian Occupational Safety

AUGUST/SEPTEMBER 2017 19 Ontario, Saskatchewan and Manitoba — have launched specifi c initiatives to address the growing problem of workplace violence in health care. One such initiative is around reporting. While the number of incidents and injuries caused by vio- lence is already staggering, the real numbers are likely higher because incidents are largely under-reported. "Violence or acts of aggression are being normalized," says Sandra Cripps, CEO of the Saskatchewan Association of Safe Workplaces in Health in Regina. "People are not choosing to say 'Oh this isn't report- able' (but) if you're just exposed to something so much, it just naturally becomes normalized as a part of every day." Nova Scotia is requiring health- care facilities to have different options available for staff to report violence, such as on their computer, mobile phone, tablet or on paper. Staff must understand the obligation to report workplace violence and be able to do so without fear of reprisal. They are required to notify their supervi- sor or manager about all incidents or threats, even if there is no injury. Ontario's recently released Work- place Violence Prevention in Health Care Report includes 23 recommenda- tions to reduce incidents of workplace violence in hospitals and across the health sector. One recommendation notes the reporting system must cap- ture workplace violence incidents that result in psychological as well as physical injuries. Northwood has a strong culture of reporting; one that actively engages managers as well. "If people come to see me for an issue I will say, 'Did you report that?' and if they say no, we will sit down and do it together or get the manager to do it with the employee," says James. One issue to keep in mind is that some employees may not be report- ing workplace violence because it just doesn't really bother them, she says. "There's a whole variety of responses to violence, so some people are very sensitive and will report everything and other people just laugh it off," James says. "So we don't get as many reports from people who maybe don't perceive it as being a big deal." A risk assessment is the criti- cal fi rst step in determining what solutions can be put in place at any given health-care facility to address violence. PSHSA recommends work- place violence risk assessments be completed at least annually. Revisions are needed when there is a change in the nature of the workplace, type of work or conditions of work, such as decreased staffi ng levels or increased resident population. It recommends assessments be completed for the organization as a whole as well as the specifi c department or unit. "Not every health-care facility and even every unit have the same level of risk. So what you may do in an outpa- tient physio clinic to control the risk of violence would be very different than in perhaps a medical surgical unit," says Van hulle. "In emergency departments, it's a higher risk area… Same in intensive care units, pal- liative care units and then there are units where it's typically lower, like maternity, as an example." ASSESS CLIENTS Individual client risk assessments are also very important. This should include behaviours observed, his- tory of violence and risk rating scale, according to PSHSA. Employers are required by law to take every reason- able precaution to protect the worker, including disclosing information about a violent or potentially violent patient. Patient fl agging can help with such disclosure as it identifi es violence-related risks and signifi es to the worker to take extra precautions. Flagging can take many forms. One common approach is using electronic health records, but it's important the fl ag stands out. The system should use either active f lags (where a pop-up is displayed each time the fi le is opened) or passive fl ags (which are prominently displayed on the screen), according to PSHSA. Colour-coded labels and pull-tabs can be used on paper-based charts. Other visual cues may be colour- coded wristbands, door or bedside signage, coloured markers outside a patient's door or a sticker on a mobil- ity aid. These visual cues can relay safety concerns to members of the care team who do not have access to patient medical records, such as housekeeping, maintenance, volun- teers or the dietary staff. Security personnel play an important role in health-care facilities. Nova Scotia is requiring full integration of security personnel into the care team for emer- gency departments as of August. They must be trained with other members of the care team, given guidelines for workplace safety and included in safety huddles and joint occupational health and safety committees. In the case of a "code white" — an actual or potential violent or behav- ioural situation — nurses should not be involved at all in physically handling the patient, rather, security should step in, says Duteil. "It's in contravention to our profes- sional obligations because it is not establishing a therapeutic relation- ship. It's putting ourselves in harm and we are just not going to do it," she says. "We will assist with a clinical process of a code white; we will pro- vide medication as needed; we will act accordingly to ensure the safety of all those involved, but we will not be taking down patients." Northwood found that "code white" often escalated the situation when it was health-related violence — violence due to a mental health issue, for example — so it's using "code blue" (a medical emergency) for these instances. "They come with uniforms on and they get them down on the fl oor and tackle them and it really triggered a lot of people when they were in crisis anyway," says James. "Whereas when we have professionals respond initially to a code blue, they under- stand their residents, they know the situation so they are able to respond but also have (security) in the back- ground as resources, so if they needed someone to come in, they are right there. They could be down the hall; maybe a bit inconspicuous." Personal communication devices are important tools in keeping health-care workers safe, but they are not as prevalent as they should be, says Duteil. "Why don't nurses all have two-way communication systems? I toured Vancouver General Hospital the other day and their emergency nurses — in a very large department — have no method of contacting each other in the event of an emergency," she says. A personal communication system may be particularly useful for com- munity nurses who often don't know what they are getting themselves into when they go into a client's home. "Community nurses walk into a home to do a baby visit and they have no idea there's weapons in the home. You don't see a police offi cer walking into a home without shoul- der dispatch immediately to help if needed. Nurses have none of that," says Duteil. "They have no method of instantly hitting a button and saying 'I'm in trouble.'" The government of Nova Scotia requires all health-care employees who may be alone with patients, visitors or family to have a tool to con- tact other staff or request assistance. Northwood's smaller nursing home is currently piloting personal panic but- tons with nurses on the night shift. "If you are in a room with a resi- dent and something happens, the door shuts, you could yell and people wouldn't hear you, so they are able to press that. We don't have the evalu- ation of that yet, but it's something we're tr ying for lone health-care workers on night shift," James says. Other forms of communication can help ensure the safety of staff, such as an emergency button under the desk or a dedicated emergency phone number. TRAIN FOR RISK LEVEL Heath-care staff need to be prop- erly trained on handling violent and aggressive situations. All staff should receive basic orientation around workplace violence. From there, each organization should use a risk assess- ment to decide which level of training each employee needs. The fi rst step is always trying to de-escalate the situation with verbal communication, says Cripps. A nurse might say: "I don't like what you're doing and I want you to stop. Mrs. Smith you are grabbing my arm very tightly, I don't think you realize that. Could you let go?" All of Nor thwood 's front-line staff undergo training for dealing with dementia, since its clients are senior citizens. "(It's) intended to help identify triggers and help de-escalate when people are becoming aggressive," says James. "If they don't want to have a bath or shower, how do we redirect them gently and conversationally and respectfully into a different direction? It's helping to be proactive and keep it from being escalated to violence if somebody is agitated." The government of Nova Scotia also requires hands-on training in non-violent crisis intervention for employees in higher risk areas. This includes different holds and physi- cal techniques that can be used if a patient does become violent. It's important to note that prop- erly responding to a crisis situation is something that needs to be learned and practised, says Van hulle. "An immediate response is not uni- form to all people. We all have history that dictates how we respond to a cer- tain behaviour," she says. "Some might think, 'If we train you once, we've told you, you should get it and you should be able to respond appropriately' but that type of training in stressful situa- tions, that requires specifi c cues to be identifi ed and a specifi c style of com- munication is not something you can take a course on once and expect to be able to react appropriately all the time without the ability to practice." It's also important for health-care workers to learn to constantly be aware of their surroundings. They should never allow themselves to be cornered in a room, they should always be able to locate a safe exit and they should be monitoring what could be used as a weapon, says Cripps. "The fan is always the fan, but could that stick stand become a weapon? It's

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