Health Committee on May 14th, 2019

[Randy Mellow]

I'd just like to say I absolutely support what you've said around holding the employers accountable for safety in the workplace, but I think before we do that, we collectively—and hopefully, those in the room here will agree—have an obligation to support them in doing so.

If I use our work with PTSD as an example, we've come together, and we've invested money in research to better understand the problem and to better understand mitigation strategies. We've developed a national action plan and will soon have a national framework on this, and I think the same focus needs to happen for violence in the workplace.

In the PTSD world, we have worked with CSA to develop a standard for workplace health and psychological health and safety. That type of standard could be applied in the violence piece if we better understood the problem. I think we have an obligation to support employers before we hold them accountable.

[The Chair, Liberal, Bill Casey]

Thanks very much.

Now we go to Mr. McKinnon.

[Ron McKinnon, Liberal, Coquitlam—Port Coquitlam, BC]

Thank you, Chair.

Thank you all for being here.

Dr. Drummond, you started to talk about this with Mr. Davies. I want to talk about violence as a medical symptom. In those cases, as you said, the assault wouldn't necessarily be criminal because there would be no criminal responsibility.

I think that all of the witnesses here speak to environments with different places on the continuum. In a hospital, you may have the opportunity to assess people and their medical symptoms in the ER and perhaps in the admission process, but in a case of circumstances where violence is a medical symptom, you still have the danger.

What can one do to protect the workers, the health care workers, from that danger when it's really a medical consequence?

[Dr. Alan Drummond]

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.

[Ron McKinnon, Liberal, Coquitlam—Port Coquitlam, BC]

Thank you.

Would anyone else like to respond to this?

[Linda Silas]

I totally agree, and it's a question of staffing too. You have to have enough people to take care of the sick. Especially if violence is related as a medical symptom, you need trained people there.

[Ron McKinnon, Liberal, Coquitlam—Port Coquitlam, BC]

You have all mentioned that some of the violence comes not from the patient, but it's due to bystanders or family. What is the nature of that violence? What triggers it? Are there emotional issues, or are there other medical circumstances that they themselves have?

[Dr. Alan Drummond]

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.

[Ron McKinnon, Liberal, Coquitlam—Port Coquitlam, BC]

Thank you.

I have time for one quick question. I would like to ask Ms. Silas. You spoke having a baton as something that security personnel need. I was wondering if there's any wisdom in also suggesting tasers?

[Linda Silas]

Sorry, could you repeat? I didn't hear.

[Ron McKinnon, Liberal, Coquitlam—Port Coquitlam, BC]

You suggested that what's important for security personnel to have would be a baton. I was wondering about things like tasers, whether that would be useful or appropriate or contraindicated in any way.

[Linda Silas]

With all due respect, I'm far from a security expert so it is whatever the security team decides. One thing they've been asking us is flagging. We need to flag patients who have violent history, patients who have family members who have a violent history. It's a very taboo thing in health care, I think you'd agree, because am I going to pull a purple dot. We put flagging for allergies, if I'm a vegan or a vegetarian, but we won't put flagging if I'm violent or I have a violent history. We have to get over those.

Security needs to deal with what they have and as an employer, they have to give them the tools they need.

[The Chair, Liberal, Bill Casey]

Okay, we're done.

Now we're going to start our five-minute round with Mr. Lobb.

[Ben Lobb, Conservative, Huron—Bruce, ON]

Thanks very much, Mr. Chair.

There is a lot to discuss and I think the panel here today has brought up some great points. Dr. Drummond, you did bring up a good point about crowding and we think about the population, I don't know if you want to call it explosion, but the population growth in our urban areas. You mentioned Ottawa and you think about how much Ottawa has grown in the last 10 years and really, have the facilities been able to keep up? I don't think they have, so—

[Dr. Alan Drummond]

What's changed has been the percentage of the elderly and it's currently around 13% or 15%, those of us over 65, c'est moi, and increasing so that by 2030, around 30% of the population will be elderly. We have not prepared for that.

In fact, with the health care restructuring in the mid-1990s we had an across-the-board, across-the-nation reduction of acute care bed capacity in this country of about 30%. Of the remaining beds that still are available, we have about a 15% ALC rate, which is alternate level of care patient, which is the patient who requires to be somewhere other than a hospital but can't go home. From the mid-1990s to the 2019, we've actually had about a 45% reduction in acute care bed capacity.

People keep on coming, but there's nowhere for them to go. The promise has always been we're going to provide better preventative health services and home care. I can tell you that it's a joke. People can't got home so they end up in the hospital waiting months to find a nursing home bed, which doesn't exist. That is a problem which causes crowding. It's not population growth, it's the relative age of the population and inadequate social resources for the elderly.

[Ben Lobb, Conservative, Huron—Bruce, ON]

I was thinking about Mr. Davies' comments about if you get punched or kicked should you be charged with assault, etc. I understand where Mr. Davies is coming from, but I'm thinking in one of my communities I represent in Goderich they have a mental health floor and probably on a daily basis there would be two, three or four charges filed just on staff getting kicked, punched, spit at, shoved, etc. It is a tough balance, and I think our health care workers do take a lot and our doctors take a lot; there's no doubt about it. If you read the news you'll see that liquor store clerks are being assaulted by people trying to break through with booze they're stealing. Convenience store people and people who work at Shoppers Drug Mart just let people walk by with stolen goods because they're afraid of being stabbed or punched in the face.

I know we've always had these problems, but it does seem more prevalent today. Is this because there's just a general lack of respect for human beings, or is this drugs? We just finished a study on crystal meth addiction. Is this because people are so addicted now that they're desperate and doing desperate actions? What is it? I know we did talk about crowding, but it's not the guy my dad's age doing this. Is it the addict who's the problem now, or where are we at?

[Dr. Alan Drummond]

I think it's broader than that. I think there's a lot of inequity in health care; there's a lot of poverty; there's racism that leads to violence in our community at large. A lot of the conversation here is focused on what you can do in the hospital setting. I'm not a Liberal, but the liberal part of my soul would ask these questions. What are we doing upstream to deal with access for the untreated schizophrenic who can't access mental health services in a rural community? What are we doing for the people who have substance abuse issues, who can't access appropriate programs to manage their substance abuse? What are we doing to deal with the disenfranchised somebody in the inner city core? Those things need to be addressed or violence will not go away.

[Ben Lobb, Conservative, Huron—Bruce, ON]

There's no doubt about that. We don't have to go too far from the steps of Parliament to see the issues with homelessness and addiction here in Ottawa.

I have one last question because my time is running short. This is to Miranda. How many support workers, or PSWs, are we short in Ontario, or in Canada? It must be tens of thousands, I would think. Do you guys have a number?

[Miranda Ferrier]

Do you know what? We're the only association in all of Canada for support workers. We have guesstimates; that's the best we can do. In Ontario alone, we've guesstimated there are approximately 135,000 personal support workers with only 52,000 working now. If you look at the mass amount we have in Ontario versus New Brunswick, let's say, that number is a lot lower for support workers and PSWs because the province is smaller. What we're seeing is a huge decrease in PSWs, period. We're seeing schools closing across Canada that actually trained them to become support workers. We are past crisis. We are in the red when it comes to the front line of health care in Canada.

[Ben Lobb, Conservative, Huron—Bruce, ON]

Thank you.

[The Chair, Liberal, Bill Casey]

Ms. Sidhu, you have five minutes.

[Sonia Sidhu, Liberal, Brampton South, ON]

Thank you, Mr. Chair, I'm sharing my time with Doug.

Thank you to all the panellists.

Dr. Drummond, you spoke about the crowd. I'm from Brampton South and we have 900,000 residents and it's the ninth largest city, and we have just one hospital. There are more provincial health care cuts. It's not acceptable; everyone deserves good care. My question is where do you see more incidents. Is it in the hospitals, the long-term care facilities or the home care facility?

[Dr. Alan Drummond]

Speaking for the emergency department, it's clear. It's a daily issue of concern both rural and urban. The degrees of violence differ. There may be a quantum leap from shooting somebody in Cobourg to swearing at a nurse, but we're all entitled to a respectful, safe work environment. This is not to minimize verbal abuse. I get more than my share. For a lot of people, it wears them down. They put on their nurse's uniform, they go to work, they're community oriented, they want to do a good job for their community, they're here to serve, they're here to help but they're not here to be somebody's whipping boy or target for unacceptable behaviour. It happens in every community.

[Sonia Sidhu, Liberal, Brampton South, ON]

I think, as my colleague said, we need to do research to put in national data. Do you agree with that?

[Dr. Alan Drummond]

Canada is a country of research and papers and studies that all end up gathering dust in some filing cabinet somewhere. The take-home message here must be that, regardless of what the studies show, at every part of the continuum in health care there needs to be institutional accountability for the safety of our workers and the safety of our patients. That doesn't need research.