Health Committee on June 6th, 2019

[Adriane Gear]

I think our first recommendation would be to invest in our mental health care system. We need to make sure there are proactive strategies to support those living with mental illness. We certainly want to see a reduction of stigma, and that there's access to care.

Unfortunately, what happens in a lot of cases is that patients have decompensated to the point that they are in a real crisis. It's in those situations that we are seeing an escalation of violence. If we can provide appropriate care in a timely way, I think that would go a long way toward addressing some of the violence we see within that population.

It's access to care.

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

Very good.

Now I have a question for Henrietta. I'm surprised. I come from a chemical engineering background. We have the Green Book in Ontario, which should make any employer who has workplace incidents of violence and harassment going on follow up. Does that not apply to hospitals? Why are employers like hospitals and long-term care facilities not doing their due diligence in some cases?

[Henrietta Van hulle]

I think the focus is on care rather than on prevention of occupational health and safety injuries. I think most of them understand the requirements of the book, but without the tools and resources, they struggle to implement them. I think that's the bigger issue. That's one of the reasons we've developed the tool kits. All of them kind of point to a piece of the legislation in Ontario, which is actually doing that risk assessment first, doing that assessment of the patient where the biggest risk is. Ms. Sidhu had asked about things like intoxication and withdrawal. Those are the types of things that are assessed at that level. Then there is the flagging, which really is risk communication. Whenever there is a risk from any type of hazard, it needs to be communicated. That's part of the flagging process. It's not dissimilar to what you would do if a patient had an infectious disease in a health care setting. You would need to communicate that to everyone who came into contact with that person. It's the same thing when there is a risk of violence.

[The Chair, Liberal, Bill Casey]

Thanks very much.

Now we go to Mr. Rankin.

[Murray Rankin, NDP, Victoria, BC]

Thank you, Chair; and thank you to all the witnesses for a really interesting presentation.

I want to start with my friends from the B.C. Nurses' Union.

Ms. Gear, thank you for your presentation. I have a question for both you and Mr. Singh. I really appreciate what you have told us and the work that you're doing.

For example, I'm very impressed with the brochure, “Have You Experienced a Violent Incident at Work?”, which says in very clear terms, “Here's what to do”. I think it is empowering to the nurses who you represent.

Marilyn Gladu talked about her family member. I have a sister, Joyce Rankin, who's a nurse in Toronto, and she has told me about the increasing problem that you've all put your finger on. I don't think Canadians really understand.

Thanks for your anecdotes about Victoria, Kamloops and Prince George. I was particularly disturbed when you said that 40% of members in your survey might be considering leaving. My goodness, we have a shortage already. To think 40% might leave just because of violence is extremely sobering.

Before asking my question, I want to thank you as well for supporting my colleague Don Davies' private member's bill on the sentencing issue, although you were quick to say that criminalization is not the way to go but only part of the solution.

Here's my question to start.

Regarding your brochure that I referenced, about experiencing violence, I have two things I want to ask. First, you talk about calling the nurses' violence support line and you give a 1-800 number for that. Do you have any data on how many people are calling and what the implications of that have been? Has it been a good idea? Should other nurses' unions across the country or employers do a similar thing?

Then, as the final point on what to do, you say, “After a traumatic incident, you may benefit from a critical incident stress debriefing”. I want to hear what that critical incident stress debriefing entails.

[Adriane Gear]

The violence support hotline was really something that came about because our members told us that it's very difficult to report. Although there are processes in place, it's confusing. There is so much documentation and there are so many requirements to report unsafe patient events, it gets confused with reporting events that impact worker safety.

We were also told by our members that they didn't feel supported when they reported violence, that some of the questions they were asked really were almost blaming: “Well, what did you do to provoke the violence?”

For those reasons, and to gather additional data, we thought it was important to provide a support line. What happens now is that our members do have the option of calling BCNU directly.

What we do is help navigate, because this doesn't replace the requirement to still report to the employer and participate in workplace investigations, but it does allow us, at a time when somebody has been physically and/or emotionally traumatized, to provide that support and help navigate the process, which is quite cumbersome. We can also initiate other elements of recovery supports from our union.

It has been successful. Certainly we don't find that nurses are calling in the moment, but usually it's after the fact and just to get some additional support. A lot of times, nurses want to be heard. Even if they don't want action taken, they want what has happened to them to be validated.

It has been successful. I don't have data with me, but if you were interested, I could certainly follow up and get you some of our findings.

[Murray Rankin, NDP, Victoria, BC]

I'd appreciate that. I think that would be useful.

I'm asking this next question of all the witnesses who wish to answer, and perhaps Ms. Schultz in particular.

We heard a lot about psychological versus physical violence. Linda Silas, who is the president of the Canadian Federation of Nurses Unions, says that the law should be simple: “If you hit a nurse, you go to jail!” That sounds as though it's a pretty simple message, but when you think about people with psychological harm, it really doesn't work, because of course, criminalization, having to have the mental element, might not apply if you are suffering from dementia or Alzheimer's, or the like.

I'd like to know, then, if criminalization isn't the answer, what you think should be the answer for people with psychological damage. What should we do? I've heard a lot of things about how we should make the workplace safer, about the structural problems with understaffing, and not leaving people alone on the shift.

In particular, Dr. Margaret Keith and Dr. Brophy's study talked about 56 participants, just seven of whom were men. Women are obviously disproportionately impacted. Are racialized Canadians also disproportionately impacted?

I'd like you to talk about that, and if you have an opportunity to talk about the psychological aspects, people with psychological harm and how we can address those issues, I'd be grateful as well.

[James Brophy]

You have asked a lot of questions, and I'm sure all the people at the table want to talk to you about those issues, because they are fundamental to what's going on in health care.

I think we need to ask why the prevalence of violence is so widespread in the health care setting, where it far exceeds the level of violence that even police and corrections officers face. Why, in almost every statistic across the country, do we find that health care staff are suffering rates of violence far in excess of any other occupation?

You mentioned the issue of women, and I think it's fundamental here. This is an occupation in which women predominate, and violence against women in our society is a major issue. The way violence is treated in the health care setting is so reminiscent of how domestic violence is treated.

As our friends from British Columbia have said, health care workers are blamed. Most post-incident briefings, or debriefings, start off with, “How did you approach this person?” The onus is already on the health care person, as if their behaviour is the source of the problem.

This issue of why the public doesn't know about this has been brought up a number of times. I agree; the public does not know. One of the factors is the fear of reprisal that health care staff across the country fear and face.

In Ontario, a nurse spoke out at a conference on violence, didn't name her workplace and simply said that violence was a major issue. When she returned, she was fired. The union engaged for almost two years in an arbitration case, spending hundreds of thousands of dollars that finally brought this person back to work.

When we conducted our study, in every single community we went to, the session started with people saying, “Protect us. We don't want to be identified. We know about this incident of someone being fired. We are afraid of speaking out.” Again, this is very much paralleling the attributes, if you will, of violence against women in our society, and how it is treated.

[The Chair, Liberal, Bill Casey]

I'm sorry. We have to move along now. We're over time on that question.

We're going to move now to Dr. Eyolfson.

[Doug Eyolfson, Liberal, Charleswood—St. James—Assiniboia—Headingley, MB]

Thank you, Mr. Chair. Thank you all.

I hope I can get through all of the questions I have, in the time I have.

I'm a physician. I worked in emergency for 20 years and, of course, I saw pretty much every department in the hospital during my training.

One of the problems I saw all through my training is that you would have a patient who is confused—whether this is dementia, or some other process—and at risk of wandering. They would sometimes fall. I've seen broken hips in patients who fell out of their beds because they were confused. I've stitched up a few heads.

There was always a Catch-22. Physical restraints are considered unsuitable and inhumane. You would have sedatives, but there is more of a push that you have consent from families. Some families don't consent to this, and we don't have staff available for 24-7 care.

I'm going to throw this out to the B.C. Nurses' Union first. How do we balance these competing priorities, when we're left with no option that is acceptable?

[Adriane Gear]

That's a great question. I wish I had the answer. That is the issue. We want to provide safe, ethical care to our patients. We want to make sure there are enough staff to safely provide dignified care.

The reality is that care is being provided in environments that lack resources. They lack human resources. I think that's why we're looking to you. We need to have some kind of support. Provide us the staff, training and appropriate environment, so nurses and health care workers can do what we do best, and provide care to those people.

We recognize that in those situations where you have a demented elderly person who's confused, they are scared. Their behaviours are not directed at us personally, but the reality is that nurses and other health care workers are becoming injured. We don't have enough of us already. We're looking to you, as the decision-makers, to create change, so we can have safe health care places for our patients.

[Doug Eyolfson, Liberal, Charleswood—St. James—Assiniboia—Headingley, MB]

Okay, thank you.

I'll ask this of you because this is, again, an issue with the nurses' union, and I will ask Ms. Van hulle as well for her take on this.

I am from Manitoba. There has been a recent change to the Mental Health Act in Manitoba. When a patient was brought in with a suspected psychiatric complaint, the police would be called. If the patient was to be moved to another facility, the police would be the ones to transfer them if there was a safety issue. If they were picked up in the community, the police would take them in, and they would have to stay with the patient for safety until the patient had been seen and it had been determined that they were admitted to a suitable facility.

This change to the act says that the police no longer have to wait, because the province says that there are more people in the hospital with the training to deal with them; however, there is not more staff.

Can you see any safety considerations or implications with this change?

[Adriane Gear]

I think that is disastrous. The reality is that mental health patients come into our emergency rooms, and they sit for hours, sometimes days. They sit on stretchers in bright lights, and they're in very exposed areas so people can observe them. We have floor cleaners going by, lots of noise and lots of things to trigger them.

Leaving them unattended is not the answer, although I absolutely appreciate the challenge, of course, that law enforcement needs to move on and do what they do best.

Again, I go back to our needing appropriate, timely access for people who are suffering with mental health issues, so that's the problem.

[Doug Eyolfson, Liberal, Charleswood—St. James—Assiniboia—Headingley, MB]

I would tend to agree, and Manitoba's nurses' unions agree as well.

Ms. Schulz from the Alzheimer Society, this is something that's been a problem. It's been going on for years, certainly in my own emergency medicine practice in Manitoba. This may be happening in other provinces.

Patients with dementia would present to the emergency department from the community. Very often they live alone, and a concerned neighbour has found them wandering in their pyjamas in January. They obviously can't go home because there is just no stable environment for them.

What has been the practice, at least in Winnipeg's hospitals, is that the people who are in charge of admitting patients—deciding that a patient goes to a ward—have policies there now that they will not admit patients to hospital if there is no acute medical problem. If the only problem is dementia, they are kept in the emergency department until an appropriate centre is found for them.

This has, on more than one occasion that I can recall, taken over a month. You didn't mishear that. We're talking about a patient with dementia spending a month in an emergency department.

Is this ethically defensible?

[Mary Schulz]

I'm afraid part of that question is out of my scope, but what I certainly can respond to, sir, is that it is not uncommon to have this kind of scenario played out right across this country, unfortunately.

When you say that the person has come with basically no medical problem other than dementia, I would respectfully remind you that dementia is a medical condition, and that a person arriving—

[Doug Eyolfson, Liberal, Charleswood—St. James—Assiniboia—Headingley, MB]

Yes, and I would agree with you on that, but it appears that our people in charge of internal medicine disagree with us on that, but I agree with you, completely.

[Mary Schulz]

Absolutely, I am sure, and there is quite a lot of awareness that needs to be raised among health care providers that the reason that person with dementia arrived in emergency today instead of yesterday or three weeks ago may well be that something has triggered it. There is some reason why the person has arrived in emergency today. Why did they wander; what triggered this; do they have a urinary tract infection; what's going on? They do deserve a thorough medical workup to ensure that there is no medical condition other than the dementia going on.

If, in fact, it is a chronic acerbation of the dementia itself, that's where we get to what I think our colleagues in B.C. have been saying, that we're looking for structural change where that person has a step-down unit that's appropriate to move to in order to free up that emergency bed.

I would put to this group—and I am putting words into folks' mouths, perhaps—that I think we are talking about a culture change. We're talking about not just looking out for the person who has a mental health condition or dementia; we're looking to design environments, assuming that no one is at their best in emergency, no one is at their best when they're in pain, no one is at their best when they are in acute care, and no one is at their best when they move into a long-term care home.

We need to have that basic bar where everyone will benefit from a dementia and mental health-friendly environment where the floor cleaners are not going by at two in the morning, where the lights are dimmed to the extent possible and where there is perhaps classical music playing. These things have been shown to decrease agitation, and if we could start to make that the norm rather than triggering who is on our wait-list who is really at risk for hitting out, I think we might all benefit.

[The Chair, Liberal, Bill Casey]

Thank you very much.

Now I have to wind up the questions with that round. We have some committee business we need to do because of the winding up of Parliament. We have to get it done today. I want to thank our witnesses very much for your information and for helping us to understand how serious this issue is. We appreciate you taking your time to do this. On behalf of the entire committee, thank you all for your help.

We will suspend for a few minutes, and then we'll come back in camera.

[Proceedings continue in camera]