Canada Faces a Surge in Healthcare Violence
NIOSH emerging as key ally on U.S. OSHA reg
While OSHA continues to promulgate a violence prevention regulation, our neighbors to the north are dealing with a similar problem of threatened healthcare workers.
In the province of Ontario, with a population of some 15 million people, patient demand for treatment has outstripped available beds, creating delays and crowding that stress both healthcare workers and patients, says Michael Hurley, president of the Ontario Council of Hospital Unions.
“The hospitals are operating at over 100% occupancy levels,” he tells Hospital Employee Health. “We have had a closure of psychiatric facilities and there are a number of other factors. We have people waiting longer for services, so in the ERs [and other areas of healthcare] we are seeing an increasing number of assaults. I think a part of that is tied to frustration.”
Citing other aggravating factors that will be familiar to employee health professionals, Hurley also notes that the problems are not limited to Ontario.
“[Funds] for treating psychiatric facilities in the community have been cut back systematically; I’m sure they have in the U.S. as well,” he says. “There is a shortage of acute care beds. Only the most acutely ill people get into them and these units are understaffed. The staff are vulnerable. Compounding this problem you’ve got opioid use — people coming into emergency rooms really stoned and aggressive.”
Factoring gender and cultural bias into the equation, Hurley thinks violence against women is too easily accepted in Canada and nurses do not feel empowered to speak out.
“[Healthcare] is a predominantly female work environment and those social attributes permeate,” he says. “It’s not just a visitor or patient assaulting a nurse or healthcare worker — it’s also that management doesn’t necessarily want that reported.”
Hurley and colleagues recently wrote a letter to labor officials in the province, demanding the protection of healthcare workers be made an immediate priority. Existing violence protection regulations should be enforced in healthcare inspections and audits, the union argues.
“[We have] documented incident after incident of abuse, threats, assaults, and sexual harassment, both physical and verbal, within the healthcare sector,” the union letter states.
The union is participating in an ongoing research project that has not been published yet, but documents violent incidents described by 54 healthcare workers participating in group interviews.
“The study documented widespread and systemically accepted violence in each of the locations and occupational groups,” the letter states. “The researchers met many healthcare staff who had sustained serious, life-altering injuries and many who suffered from post-traumatic stress disorder (PTSD), which has deeply affected their quality of life and the well-being of their families. … Lack of respect, underfunding, and understaffing were universally identified as significant contributors to workplace violence. [Violent incidents are] not reported — partly because of the long-standing culture of acceptance and partly because the victims fear retribution.”
NIOSH Advice to OSHA
Similar themes have been expressed in comments to U.S. OSHA, which announced Jan. 10, 2017, that it will promulgate a proposed regulation on healthcare violence. OSHA issued a request for information1 on Dec. 7, 2016, asking for comments and suggestions as to how to best proceed with violence prevention strategies in healthcare.
One recently filed comment of note came from the National Institute of Occupational Health and Safety (NIOSH), which lacks enforcement power but could play a key role in developing the standard. A branch of the CDC, NIOSH submitted comments that were certainly supportive and informative, but carefully avoided outright endorsement of a regulation.
“The comments are suggestions for OSHA to consider if a rule is promulgated,” NIOSH told HEH in response to an email inquiry.
For example, NIOSH advised OSHA “to make the standard effective and enforceable, [it] will need to provide guidelines and examples, such as variables for determining reporting thresholds (e.g. severity of physical injury/mental duress and level of threat/physical force used by perpetrator).”
HEH asked NIOSH if it had such guidelines and examples to provide OSHA.
“NIOSH does not have specific guidelines,” a NIOSH representative said in a statement attributed generally to agency researchers. “Findings from several independent surveys, reported in the workplace violence literature, indicate underreporting of workplace violence by healthcare workers may be an issue. The requirements for reporting an injury or illness on the OSHA 300 log are not applicable to reporting all injuries or illnesses that may result from workplace violence. The level of property damage is an example of a threshold that could be set to indicate the potential for physical violence to persons. For example, workplace violence may result in property damage, but not any physical injury to the worker. Although not required to be reported on any OSHA form, this type of incident should be reported to management and an incident investigation should be conducted to assist with preventing similar incidents in the future.”
On the issue of healthcare staffing, NIOSH said in the comments submitted to OSHA that “staffing issues could be addressed by establishing a range of staff-to-patient ratios based on industry best practices and input from healthcare and social assistance workers.”
HEH sought clarification whether NIOSH had any data showing that insufficient staffing is linked to violence, or on what staff ratios should be recommended in healthcare.
“When workplace violence occurs, it is usually a combination of factors in any given situation that can be cited as contributing factors,” NIOSH responded. “Staffing issues have been mentioned in several peer-reviewed articles as a contributing factor. Many issues, including previous incidents of workplace violence, determine the level of staffing required in any healthcare unit/department/facility.”
In terms of incivility and threats, NIOSH cited an FBI report on workplace violence in advising OSHA on the importance of “an environment that encourages reporting verbal violence.”
An OSHA standard may also need a “section specific to home healthcare and social service workers because of the unique work conditions,” NIOSH advised the agency. Documentation of workplace violence training should be required, NIOSH noted, recommending OSHA “maintain records for at least five years of relevant workplace violence incidents (like verbal abuse) that are not required to be reported on the OSHA 300 log, but are important to consider in the context of a comprehensive violence prevention program.”
REFERENCE
- OSHA. Prevention of Workplace Violence in Healthcare and Social Assistance. Fed Reg. 2016-29197. Dec. 7, 2016: http://bit.ly/2hB5gL5.
While OSHA continues to promulgate a violence prevention regulation, our neighbors to the north are dealing with a similar problem of threatened healthcare workers.
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