Violence towards Nurses in the Health Care Sector
We have all heard before of the abuse and violence that happen in nursing homes; but what we tend to hear more about is how nurses are abusing patients, those being patients that are older, disabled and coming closer to the end of their life span. Patients sometimes receive such negative abuse from nurses, this consists of physical abuse which is defined as any action with the intention to cause any physical or bodily harm to someone; for example this would include a nurse hitting or slapping a patient or even pushing them around. You often hear about nurses neglecting their patients, this is a deliberate action where nurses deprive the patients of what they need, this includes a nurse that purposely withholds a patient from eating, drinking or giving them their medication ("Abuse in Canada's Nursing Homes", 2012). It’s quite sad to see how this action takes place in nursing homes; a nursing home is a place for the elderly to go to because they can no longer take care of themselves and they need the assistance in their day to day activities. The nurses in long-term care facilities are there to provide residents with the care that they need and require, as they cannot do it themselves. Patients will often receive mental abuse from staff, that is, an act with the intention to cause any emotional harm to someone ("Abuse in Canada's Nursing Homes", 2012). You often hear about nurses yelling or threatening patients; this seems hard to understand why they would do such a horrible act of violence towards patients, the elderly are usually very soft-spoken and kind hearted people. We have all wondered why this is happening, nonetheless, it needs to be stopped. A common reason is that nursing homes tend to be understaffed which creates more of a workload and puts more pressure and stress upon the nurses that they become so frustrated they will take it out on the patient. Working in a nursing home is difficult as it is; there is a lot of work involved which sometimes can be very unpleasant and this leads to lower staff morale ("Abuse in Canada's Nursing Homes", 2012).
What I am here to talk to you about is the fact that this situation happens on both sides. Nurses have been physically and mentally abused by patients or residents in the past and it is still happening today. According to Statistics Canada, “a substantial proportion of Canada’s nurses experience physical and emotional abuse at the hands of patients.” (Shields & Wilkins, 2009). Workplace climate factors are creating greater risks of on the job abuse towards nursing staff from patients or residents; there is a lack of staffing and resources and a poor social connection between the patients and nursing staff (Shields & Wilkins, 2009). Workplace violence is a very common situation within health care facilities, which it should not be. You may hear on the news of someone being injured at work due to a co-worker, or hear from a friend or family member that they are being harassed or violated at work, whether it is physical or mental – that is considered an act of workplace violence. There are commercials on the television and you hear about it on the news that elder abuse is happening in nursing homes, but what they need to show you is the reverse side of the problem; patients threatening, harassing or abusing nurses in a manner that harms them both physically and mentally. This happens more often than what people may believe and this act of violence is not one that you hear about often. Nurses will tell the board or their employer that it could be a possibility that symptoms of psychosis could have led to the assault towards them, but patients will typically say it was how the nurse was interacting with them that would have triggered the incident (Newbill, Marth, Coleman, Menditto, Carson, & Beck, 2010). In our minds we believe that firefighting and law enforcement are high-risk jobs, but it is a fact that along with those professions, health care professionals are more at risk to workplace violence.
According to the Bill 168, Occupational Health and Safety Amendment Act (Violence and Harassment in the Workplace) subsection 1 (1) (a) ‘workplace violence’ is defined as “the exercise of physical force by a person against a worker, in a workplace, that causes or could cause physical injury to the worker”. These workplace violence acts include threatening behaviour, physical attacks, harassment or any verbal abuse. Working in a community based setting is a work-related factor that can increase your risk of violence and the most common occupational groups that are more at risk over others are health care employees, then followed by correctional officers and social service employees (CCOHS, 2012). Workplace violence has a negative effect on staff, this can cause them depression, anxiety, sleep deficiency and stress which can cause poor job performance and higher intentions on resigning from their jobs, thus creating staff shortage.
A bill has been passed for resident’s rights, care and services, also known as the Residents’ Bill of Rights which is part II of the Long-Term Care Homes Act, 2007. This bill states that they have the right to respect and dignity, the right to be protected from abuse, the right to not be neglected and the right to have proper care. These bills state a zero tolerance policy for abuse towards residents or patients (Act, 2007). If a nurse attacks a patient they would automatically be sentenced to court and/or jail since residents have the bill of rights that they can conform to. On the other hand if a resident physically or mentally attacks a nurse, employers will not do anything towards that resident. Nurses do have associations on this subject that they can refer to or ask for assistance from, but not a bill or law that they can follow to protect their rights as a worker and to protect their safety; the laws are limited for health care workers compared to other occupations.
Many studies show that violence toward nurses is unrecognized and not reported enough; nurses are at risk of harm when working with cognitively impaired residents. (Toronto Police Association v. Toronto Police Services Board, 2008). Long-term care facilities are turning into what they call a “dumping ground” for people who are mentally unfit; it’s turning out that one in five nursing homes are now recognized as highly aggressive. The beds in nursing homes are considerably cheaper than psychiatric hospital beds, which is why the government has had to shut more of them down, this is leading to a growing number of people with dementia and other illnesses ending up in long-term care facilities (McKie, 2007). It is not the fault of the resident, but the family and the facility or residence itself for accepting patients in that condition knowing that they could potentially harm the staff.
All healthcare providers face a potentially high risk of workplace abuse from patients, especially nurses since they are a majority of females and are more vulnerable. A survey has shown that one third of all nurses have been assaulted by patients from a 2005 study that gathered information from 12,200 nurses across Canada. The study has shown the different clinical areas where nurses work; the physical assault was especially high in geriatrics/long-term care (50%), as compared to palliative care (47%), psychiatric/mental health (44%), critical care (44%), or emergency room (42%). This study breaks down that (34%) of nurses working in long-term care facilities reported physical abuse, and (47%) reported emotional abuse (CCOHS, 2012). From any other occupation, health care workers represent nearly 67% of all workplace violence claims sent to WSIB and with the highest number of violence and injuries (WSIB, 2009). The violence in nursing homes across Ontario has been rapidly increasing over the years, the number of violent incidents from residents of long-term care has nearly tripled between 2003 and 2006, reports show that it has increased from 446 to 1, 416 incidents. In between those years in 2004 and 2005 there were more than 150,000 seniors living in nursing homes across Canada, which means that one out of every thirty people aged sixty-five or older have a case of attacking health-care workers. The numbers were one in five for people that are eighty-five years and older, and many of these patients require continuous care. Alzheimer’s, a form of dementia, affect one in twenty Canadians aged sixty-five and over and one in four eighty-five and older (McKie, 2007).
Vivian Miller is proof that these statistics are true as she is a nurse in the long-term care facilities. Miller has been working as a nurse for thirty years, and the last twenty years have been at River Glen Haven Nursing Home. Over the course of her time working there she has not encountered many extreme acts of violence with her patients. She was first attacked in June 2010 when she was in the room assisting a man in a wheelchair. The man said to Miller “you are the one” and came after her in his wheelchair. The man had a bar across his wheelchair, grabbed Miller by the back of her uniform and whipped her across his wheelchair and dumped her upside down. He then grabbed her leg and dragged her down the hall. Another nurse noticed Miller and helped her right away, she was sent to the doctors and the employer filled out all the required Workplace Safety and Insurance Board paperwork. What this patient did was an example of workplace violence; he is a person exercising physical force against a worker, in a workplace that caused physical injury to the worker (Subsection 1 (1) a. of the Occupational Health and Safety Act). Miller did not receive any time off for her injury and was to return to work on her scheduled work days, though she was still aching. The reasoning behind that is Miller’s employer has a policy that if you are not “bed-ridden” than you must return to work. She was given light duties for six months and was continuing physiotherapy to heal her back. Her employer kept asking her to return to her normal duties as there was not enough funds to replace her at work, her employer was having other nurses do double the work to cover Miller’s normal duties. She went back to normal duties and not even 15 days later she was attacked again at work by a different resident. She was giving the resident a bath and as he finished his bath he left back to his room. Miller was cleaning out the tub and the resident returned to the bathroom and all of a sudden came up behind her using both of his fists with full power and was punching her in the back (where she was previously injured) and in the back of the head. “He had full intentions on hurting me” she said; he has been known around the nursing home to lose his temper, other nurses working on the same floor have been attacked by this patient before and are a little frightened of him. Another nurse heard Miller screaming and calling for help and came to see what was wrong, that nurse along with another pulled the resident off her and she was driven to the doctor’s office. The employer once again filled out the necessary paperwork. As Miller was still able to walk she was deemed not bed-ridden, according to her employer. She went back to work her scheduled shifts, but on light duties. As her employer does not have the funds to higher another nurse, they once again harassed Miller to return to normal duties. This patient was reported to management as he has injured other employees before; the employer would not do anything about the fact as it is not the patients fault, the patient has dementia (Miller, 2012).
Unfortunately, for health care workers, they do not have the right to refuse unsafe work as they are considered emergency workers and can only refuse work if a joint health and safety committee member notices it is a dangerous work environment; but there is no need for nurses to get injured on the job as much as they do. When you have a patient that is a threat to a nurse, than that employee should have the right to refuse unsafe work since this patient could directly endanger the safety of another person (ONA, Occupational Health & Safety: A guide for ONA members, 2010). Since nurses are more likely to be injured at work, human resources should have a better policy, if any, in stated in the workplace with guidelines and procedures on workplace violence, this nursing home that Miller works at does not have any type of policy regarding violence in the workplace visibly posted.
Section 32.0.1 of the act requires that employers prepare policies in respect to workplace violence and harassment, section 32.0.4 of the act states that if an employer is aware or ought to be aware that domestic violence is likely to expose a worker to physical injury that may occur in the workplace, the employer must provide due diligence and take every reasonable precaution to protect the worker (Bill 168). Miller’s employer did not provide due diligence as the employer was aware of this resident being a threat to the nurses and they did not take every precaution reasonable as she was injured at work along with others from that resident. After her accident at work, he was still not moved to another floor or even another residence; she had to work on the same floor doing light duties, nervous that this resident may attack her again. It is to my understanding that this employer is in violation of the Occupational Health & Safety Act and could potentially be held liable (ONA, Occupational Health & Safety: A guide for ONA members, 2010). According to the nursing home act, it implies many causes for resident discharge, but for many other reasons, none toward residents physically attacking or injuring nursing staff due to a mental illness that they have. What should be done and what should be instated in the nursing home act is that if any mentally ill resident were to physically injure any staff members or any other residents of the facility, resident discharge should apply. Those residents that Miller was attacked by should be admitted to a hospital or psychiatric institute where more educated nurses and other health care workers are willing to provide the accommodation, care and secure environment that they need (O. Reg. 121/02, s. 4.).
From a human resources perspective, safety measures such as procedures, policies, appropriate staffing levels, workplace factors (such as a healthy work environment), and a zero-tolerance rule must all be in place to reduce the risk of violence in the workplace. Employers are responsible for implementing these procedures and policies to endorse the well-being of nurses. The government also has a responsibility to support and fund these healthy work environments and the safety of nurses. The Occupational Health and Safety act states that employers must enforce this section of the act regarding violence and harassment in the workplace.
Section 32.0.1 (2) the policies shall be in written form and shall be posted at a conspicuous place in the workplace (ONA, Workplace Violence, 2010)
In Miller’s case, she has not noticed any type of written policy posted around the workplace as to how to deal with violence and harassment from the abuse of residents. Her employer needs to develop, implement and maintain an effective workplace violence and harassment prevention program. This program needs to start off by having a violence prevention group; this includes staff with the expertise needed, a member from each department, senior management, and health and safety members. The next step would be to conduct a risk assessment to determine what measures are in place, identify hazards and determine future risks. You then need to develop and implement control measure; this would be eliminating the measures that create a risk of injury from violence. Proper training and education is necessary for an effective safety program. Lastly, the employer must conduct an annual review with the violence prevention group (BC, n.d.). Unhealthy work environments make it hard for Ontario to recruit and retain health care workers. Having a healthy work environment in nursing homes is a key component, along with an appropriate level of staffing to provide efficient care for residents. A healthy work environment will help the physical and mental well-being of nursing home employees. A zero-tolerance policy would consist on educating staff of becoming familiar with the warning signs of violent behaviour around them, have them prevent or resolve conflicts and have workers understand the organizational procedures and policies as well as their legal rights as a worker. Post-contact strategies will also have a role when creating the policies for the workplace; employers need to keep track of all incidents so you can avert future incidents. Previous incidents will help in the company’s establishment of a new prevention program (OHSCO, "Developing Workplace Violence and Harassment Policies", n.d.).
The human resources department of the nursing home Miller works at should have enough funding to hire part-time employees to cover injured workers, the injured worker should be able to take the sufficient time off to recover, and for the sake of the other nurses since they were required to do double their workload. Her company has insufficient staffing of full – and part-time nurses; there is always a vacancy on the schedule that goes unfilled and she is called into work often. Replacing nurses is difficult, and heavy workloads are distributed among the staff that require them to do non-nursing duties which takes away from resident care. These are occurring from the very high turnover rate that is happening in the health care sector (ONA, Occupational Health & Safety: A guide for ONA members, 2010). To this day she still has recurring back aches from the previous injuries she had at work; this is due to returning to work so soon after the injury has occurred.
Government action needs to be taken with respect to the amount of health care workers that are becoming injured on the job. Nurses are showing support for a bill to come into play that would consist of when assaulting a health care worker while on duty it would be considered a crime that would have its own set of penalties. Supporting this law will help support nurses when they assist their patients, nurses are often punched, kicked or even spit at. A newspaper article mentions that “If the bill passes, a person who attacks a health-care worker could face jail time up to 2 ½ years and a fine of up to $5,000, or both” (Galang, 2009). This would be a hard bill to overlook as the number of workplace violence fatalities towards nurses are increasing. What they are looking at is that an assault on a nurse is usually seen as part of the job which is why most facilities will discourage workers from filing any charges towards the patients. Patients are not getting as much care as they need since nurses are continually having staffing issues due to workplace violence (Galang, 2009). Alternatively, what should be done is have the Ministry of Health and long-term care to fund specialized facilities rather than just long-term care facilities to care for persons who have dementia or other aggressive behaviour. There should be some way that if a resident who is placed in a nursing home turns out to have aggressive behaviour that cannot be managed, than they should be able to transfer that resident to a care facility that have the capabilities to manage them. Today there are a number of patients with dementia that are lacking institutional care and are estimated to increase in the following years. It is highly recommended of the Ministry of Labour to meet with health care professionals and representatives of long-term care to create short-term and long-term plans to help deal with the number of residents with dementia. Ontario’s government has yet to execute any of these ideas, they do not want to “build jails for the elderly”, it is up to provincial jurisdictions to set the spending limits as the Canada Health Act does not govern care facilities (McKie, 2007).
Many factors contribute to workplace violence in long-term care facilities, and more commonly it seems to be residents with dementia prone to aggressive behaviour. Factors that could trigger a violent outbreak either alone or in combination of would consist of emotional distress, sleep deprivation, or a possibility of the medications used to calm seniors down. These violent outbreaks range from physical actions of shoving, kicking or punching to verbal harassment, thus resulting in severe injuries. We often wonder whether these issues of violent behaviour continually happen from patients not being monitored adequately or whether residents are not being properly assessed before being accepted to long-term care facilities (CBC, Nursing Home Violence Show, 2011). If that is the case then another alternative would be to have security work in long-term care facilities so they can stop an incident from happening easier than another nurse can.

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