Health Committee on May 16th, 2019

[Marilyn Gladu, Conservative, Sarnia—Lambton, ON]

Thank you, Chair, and thank you, witnesses.

I come from a petrochemical background where we were very concerned about safety and security in the workplace. We would have incident reporting whenever there was an incident, and from that we would figure out the predominant causes and put mitigations in place.

From all the testimony we're hearing, it looks like data on who is perpetrating the violence is not available in many cases. We know anecdotally that it's people with dementia or mental health issues, people with addiction issues, and people who are frustrated with wait times and an inadequate staff-to-patient ratio. Are there other causes that you see a lot that I should add to that list?

Mr. Hayes, I figured you would have some data.

[Thomas Hayes]

Sure. I think that's a really important point. This is something that we've tried to focus a lot of attention on. You heard me say that we had 58 injuries in the last year. To add to that, we had another 530 incident reports that were reported just as a “good catch”, meaning there was no injury, no first aid needed whatsoever, but just that this happened so that we could have some more data. As you said, we looked at what the contributing causes were.

From that we see in our experience that, yes, there are areas of the hospital that are higher risk and perhaps there are some patients who are more likely to be involved in violence. But really, at the first point, it can be anybody who has had a bad day and gotten some bad news, because this is what happens in health care.

Perhaps you're a parent whose child is being taken out of your custody and into child services. This is a really difficult life transition. We haven't talked about this much, but 70% of the staff in my environment are women. You've heard that from several of the other witnesses. We know that women are more likely to be the target of domestic abuse. What that means for us is that we know that at any given time, with 14,000 staff, there are probably hundreds of people who work for us who are living a very complicated life. Sometimes that domestic abuse can work its way into the workplace, or one of those people can have the right circumstances and the courage to ask for support. How can we provide a better, safer environment for them at the workplace?

Those are two kinds of spots. There are many others, but those are two that stick out to me that people don't think about a lot of times.

[Marilyn Gladu, Conservative, Sarnia—Lambton, ON]

Those are great.

Dr. Gill.

[Dr. Kulvinder Gill]

The demographic of physicians here in Canada is changing dramatically. We now have more female than male medical students. In the coming decade we will have more female than male practising physicians, but there's also a changing demographic in terms of race.

In urban centres such as Vancouver and Toronto, by 2031 it is projected that the majority of the practising doctors will actually be people of colour. Research has shown that women are subjected to greater sexual harassment compared with men, and women of colour, in particular, are at an even greater risk.

To address the previous question about whether we are seeing an increase in violence or just more reporting of it, there's actually a combination of both. There's more dialogue, allowing for discussions to happen that previously were not happening. We are also seeing increased violence due to the demographic change, but also due to the increased strains on the overall health care system.

[Marilyn Gladu, Conservative, Sarnia—Lambton, ON]

Excellent.

Let's talk a little bit about the issue of the very many women who are working in health care. Going back to my own history, I used to travel around the world by myself, which can be a dangerous thing in different parts of the world. Different strategies can be put in place to try to protect people. It's definitely not good to have people working alone, but we see this happening with the current resourcing.

We've had some helpful suggestions. One suggestion is for a buddy system. It can be especially effective for new people to be paired up with someone so they're never alone. That gives them a sense of security—and I recognize that there's a bit of a resource thing here. Other ideas are video surveillance, controlled entry, and warning signs on the wall like they have at airports, where you can't be violent or abusive with the workers or you won't be allowed on the plane. That was recommended for everywhere except those in emergency, where people do not want to refuse care to individuals even if they're violent. We also heard about incident reporting and follow-up training on de-escalation, and about resources to reduce wait times.

Are there other solutions we should add to that list?

[Isabelle St-Pierre, Registered Nurse, Canadian Nurses Association]

If I may add, the suggestions you're making are good when it's physical violence, and maybe physical violence from patients or their families, but there are also all the issues of professional-to-professional violence sometimes. When we talk about this type of violence, unfortunately, having a camera or a buzzer will not address that.

Again, it talks to the complexity of what's needed. Different types of violence will require different types of strategies.

[Dr. Kulvinder Gill]

The majority of [Technical difficulty—Editor] physicians actually practise outside of hospital settings. They're in the community and in private practices, often solo practices, so it makes it much more challenging to ensure their safety, particularly if it's a solo practice run by a female physician.

[Thomas Hayes]

Can I add to that as well?

[Marilyn Gladu, Conservative, Sarnia—Lambton, ON]

Sure.

[Thomas Hayes]

Perhaps this was said and I didn't hear it, but I would mention two things. The first is a means of summoning assistance, particularly if you're alone, by which I mean something digital or a radio or a panic button, something that will go to a security office or a supervisor or someone else.

The second one that I think is really important and that we don't talk about much is a way to communicate the risk of violence, or perhaps a previous history of violence, by this individual. Most importantly, how do we communicate that between different health care providers? I introduced the Ottawa Hospital and its 19 sites, but there are other hospitals in the city. There are lots of long-term care providers. People come in from the police and paramedics. Let's say a patient is going from one care provider to another, to the physician or nurse or whoever. How do we ensure that as part of that handover, they will see that, “Oh, this is Mr. Hayes, and he might try to bite you when you try to feed him”?

[The Chair, Liberal, Bill Casey]

With that thought, we'll go on to Mr. Davies.

[Don Davies, NDP, Vancouver Kingsway, BC]

Thank you.

Thank you to all the witnesses for being here.

Isabelle, I think you mentioned that we need to have more standardized language. That was one of your suggestions. Can you give me an example of standardized language that would be helpful in addressing this issue?

[Isabelle St-Pierre]

“Workplace violence” could be an umbrella term to describe what happens in the workplace, but when we talk about “harassment” or “bullying” or “mobbing”, people interpret them in different ways. When you try to compare data between institutions, that's where the problem lies.

Let's say that for the term “harassment” the definition should include that it's repeated behaviour. If it's a one-time deal, then it wouldn't be called harassment. Maybe if we had some little terms that would discriminate between these, we would know what is meant by all the terminology. I see violence as being on a continuum, and there's escalation; for some people, incivility is considered violent, and for others it's not. That's where things get murky.

[Don Davies, NDP, Vancouver Kingsway, BC]

Perhaps if there were national guidelines or standards that all health facilities could implement, we would be able to get more standardized data.

That leads me to a question for you, Dr. Gill, and maybe for Isabelle as well. Can you give me a rough idea of what percentage of sexual harassment or assault is by co-workers, both horizontally and laterally, versus by patients and the general public?

[Dr. Kulvinder Gill]

Concerned Ontario Doctors is presently undertaking a survey of all of Ontario's practising physicians and medical trainees. We'll have more information, hopefully, by the end of the month. It addresses sexual harassment and violence, along with many other things.

A survey of Canadian medical residents just came out a few months ago. According to the survey, most of the violence and harassment comes from patients, followed by senior attendings, followed by peers.

[Don Davies, NDP, Vancouver Kingsway, BC]

Isabelle, do you have any evidence on that?

[Isabelle St-Pierre]

There was a 2005 study done that was financed by Health Canada and Statistics Canada. It was pan-Canadian, and it showed, again, it was mostly patients and their families, followed by health care professionals. I can give you the statistics if you want.

[Don Davies, NDP, Vancouver Kingsway, BC]

I asked this question to our last panel earlier this week, and they didn't know the answer. I'm wondering if you have any evidence.

We know that workplace violence is happening in both a culpable and non-culpable way. We have examples of the 85-year-old suffering from dementia or the person who suffers from psychosis or bipolar disorder all the way to someone who really should know better, like patients or people who are simply angry and unable to control themselves.

Can you give the committee a broad idea of what percentage of this violence happens among the culpable versus the non-culpable? I think that radically different perspectives and responses have to be developed for each of those two categories. Can you give us an idea of how that breaks down?

[Thomas Hayes]

Sure. I'm just pulling up the number of flags that we've applied. Within Ontario hospitals, you're required to keep track of this information so that you can communicate the risk back and forth. At the Ottawa Hospital, we track whether violence has been prevalent between family members or patients themselves. That gives us some sense as to whether it's culpable or non-culpable, assuming that a family member or visitor is more likely to be culpable versus the patients themselves, who are more likely experiencing delirium or dementia.

These numbers are startling, but we've been tracking this information since 2010. Currently among our patient population, we have just over 3,500 active violence prevalence flags. Just over 3,000 of those relate to patients, and several hundred relate to family members or visitors.

[Don Davies, NDP, Vancouver Kingsway, BC]

I will stay with you, Mr. Hayes.

In our last meeting, Linda Silas, President of the Canadian Federation of Nurses Unions, cited the Ottawa Hospital as an example of a health care facility that had implemented best practices around violence prevention, and she recommended that it was something this committee should look to as a model.

What are those best practices? What are you doing that has been so positive?

[Thomas Hayes]

Thank you, and I thank Ms. Silas for that compliment as well.

We've been working hard on this issue. The key thing for us has been, first of all, collaboration. There is collaboration with front-line staff across the board, whether it's a physician, a nurse, a clerk or a housekeeper. There is collaboration with the joint health and safety committee. You've heard from other witnesses that this is in place, but sometimes it's not effective. In our organization, we changed that by having executives as members of the joint health and safety committee so that there is much more serious attention paid to that committee.

Then there is collaboration with labour groups. Maybe we thought we had all the answers before. You tend to think of it that way if you're in a management role. I hate to say it, but that can happen. You fall into habits like that, and sometimes you need to stop and think about front-line staff. Engaging with an organization like the ONA—the Ontario Nurses’ Association—and other nursing labour units helped us to get back to the evidence around best practices.

Then lastly, in Ontario there is the Public Services Health and Safety Association, one of the safety associations under the Ministry of Labour, and it has published evidence-based best practices that are available on their website. We have taken a look at those, along with other recommendations from other provinces.

[Don Davies, NDP, Vancouver Kingsway, BC]

How are we doing for time, Mr. Chair?

[The Chair, Liberal, Bill Casey]

You have 19 seconds.

[Don Davies, NDP, Vancouver Kingsway, BC]

Bill C-434, which I introduced in the House a week or two ago, would make violence against a health care professional in a health care setting an aggravating factor in sentencing.

I'm just wondering if you could give our committee some sense of how your members and the people you represent would take that. If that were legislated into law, what would be the response?

[Dr. Kulvinder Gill]

That's actually one of our key recommendations. The Australian government of several years ago passed similar legislation, and it is applicable to front-line physicians, nurses and paramedics. A patient who is engaged in serious assault can be sentenced to up to 14 years.

Presently, there is zero accountability from patients. In terms of your previous question about dementia versus patients who are actually cognizant of their behaviour, I think a lot of that has to do with the type of health care facility.

In emergency room settings, for example, we tend to see more patients who are suffering from other illnesses that would impair their ability. We see more addiction and mental health issues there. In family doctors' clinics and in specialists' clinics, we see patients who are very alert and very aware of their actions. There's a significant difference in terms of patient culpability based upon where the care is provided.