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Cut the Risk: Workplace Violence Prevention Download Glenn French's presentation: Download Eric Roher's presentation: Download Patti Boucher's presentation: Wednesday November 30 2005 Operator: Good morning ladies and gentlemen. Welcome to the Health Care Health & Safety Association Workplace Violence Prevention Teleconference. At this time all participants are in a listen-only mode. Following the presentation we will conduct a question-and-answer session and participants are asked to press star, one, to register for a question. Should you require any assistance during the call, please press the star, then zero. I will now turn the presentation over to the moderator. Please, go ahead. Jeff Harris: Thank you. Good morning everyone and welcome to "Cut the Risk", Health Care Health & Safety Association's Teleconference on Workplace Violence Prevention. My name is Jeff Harris and I'm the Health Care Health & Safety Association Consultant for South East Toronto Region and it is my pleasure to be the moderator for today's call. For those of you who'd like to follow along with today's presentation and you have access to a computer, please log on to our website and click on the teleconference link. All three of our guests have kindly provided copies of their presentations for you to download. There is no question that workplace violence is prevalent in the health care system, but as you will hear over the next hour or so it's very, very preventable. Our guests - each an expert in their field - will help us develop a better understanding of not only prevention programs, but also legal and ethical responsibilities. Joining us today are Glenn French, the President and CEO of the Canadian Initiative on Workplace Violence. Glenn will be speaking about the Canadian perspective on workplace violence. Also joining us is Eric Roher, a partner with the law firm Borden, Ladner and Gervais. Eric specializes in labour relations and employment law. His presentation today includes employers' legal obligations to demonstrate reasonable precaution for the protection of employees. Our final presenter is Ontario Safety Association for Community and Healthcare Consultant Patti Boucher, who will talk about developing and implementing a workplace violence program. I'd just like to take a moment and welcome all of our presenters today. We do have a packed program this morning and I'd like to start by turning the presentation over to Glenn French from the Canadian Initiative on Workplace Violence. The Canadian Institute of Workplace Violence is a social research firm that studies trends in workplace conduct and catalogues methods that organizations and unions use to reduce risk of workplace aggression. Welcome Glenn. Glenn French: Thank you and thank you very much for inviting me here and it's always a pleasure to be amongst such distinguished panelists. The role that I have today is to talk a little bit about, from a Canadian perspective, the whole issue of workplace violence. If you were to walk on the street and ask people what violence was, most people would articulate that it's a form of physical aggression of some sort. We really need to start at the very beginning, what are we talking about? And the second thing we need to talk about is, is it prevalent and is it escalating in Canada? Now, the issue regarding defining workplace violence is hotly debated. Many of you probably know that in 2000, the labour code changed. There are two or three little lines on Part II of the Occupational Health and Safety Act, which states from a federal perspective that employers need to take prescribed steps to prevent or to protect employees from workplace violence. You also probably know that we are still waiting for the regulations to come down. One of the reasons for that, and for a slowness in legislating this issue, is that people are having a difficult time defining what violence is. They're having difficulty on two basic parameters and I'd like to point them out. One is, the question is hotly debated, what it is. Is it a physical act? Or is it an indirect, more psychological act? And from anything from harassment to bullying, which is a new term, which we're all talking about, intimidation and that type of thing, or is it a physical act or a threat of a physical act. So that's one debate that goes on. And people will follow or line up on either side of that continuum. The second continuum that people are arguing about is, what is the source of workplace violence? Does it come from inside the workplace or does it come from outside the workplace? And again, this is hotly debated, whereby some people will say we only want to deal with violence of a physical nature from outside the workplace, from customers, patients, students, and the like. So these two continuums are being hotly debated and it's one of the reasons why there's a little slowness in terms of legislating. In our organization, we have landed on a particular sort of definition in which has been largely borrowed from many other sources. We're quite favorably impressed with the definition that was put out by the TUC in Britain. There it says, "Any incident in which a person is abused, threatened or assaulted in circumstances relating to their work." Now, that covers a lot of ground. And these behaviours could originate from customers, co-workers at any level of the organization, so it talks about where the violence would come from, and this definition would include all forms of harassment, bullying, intimidation, physical threats and assaults, robbery and other intrusive behaviours. It's a very comprehensive definition. Our particular view is that if you only look at violence of a physical nature from a particular source, you're leaving out a great deal. As my comments will focus on the face of violence within Canada, it does encompass to a large measure those kinds of indirect acts that many of us have known for many, many years. The big question is, is violence escalating here in Canada or is it something that many of us are just talking more about? There is some evidence to suggest that in Canada, we have nothing to be proud of. Many years gone by, people have tended to look south of the border and say that it is an American phenomenon, or acts of violence are the result of a psychiatric impairment of some sort of someone who's deranged in some way. And I would propose that many of us, if you pushed us to the limit, would become aggressive in some way. So, it is certain we should not think of this as something that is only happening to a small minority. There is some suggestion that people are becoming a little bit more aggressive as time goes on, and I'll talk about that in a second. For those of you who want to get a glimpse, here is a bit of the background on some of the data on the issue, in Canada. In 1999, the International Labour Organization did a wonderful job at trying to look at a number of companies in over 30 countries with respect to aggressiveness on the job. Canada ranked fourth on that list, behind Romania, Argentina. France and Great Britain were at the top. Most people would say, "Well, that can't be accurate because the United States is not on the list." We all know that everyday you can turn on the TV and see things south of the border where someone has been shot or maimed in some way. However, looking at it from the Canadian perspective, if you live south of the border you have a better chance of being a fatality. So, for example, if you're a woman working in Florida, the second leading cause of occupational death in Florida for women is gunshot. In Canada however, we do it the Canadian way. We harass, bully and intimidate. So that seems to be the perspective here. If you look at the various incidents that happen here that are tragedies, whether there's been a murder or something, these are not instances generally that have happened spontaneously, out of the blue. There's generally a long ramp up of issues relating to intimidation, harassment, that type of thing. So, take for example, the OC Transpo incident. That's an incident that has been analyzed over and over and over again. We note that years have gone by when an individual felt that he was being in a sense ignored or harassed because of a speech impediment. We look at issues that happened on the West Coast in Kamloops. Again, issues relating to job loss were a big factor there. So when you take a look at the issue of violence, it is something that we really need to attend, not just to the fatalities that happen, although we need to sort of do a post mortem on those, but we also need to very seriously take a look at all of the indirect acts of aggressiveness that happen on the job. It's from this particular group that I would suggest that we start to see the possibility of some significant violence, physical violence to come. And that's why it's our strong belief that it should be defined as something that is not just a physical act and outside the workplace. It's something that happens in the workplace and it's something that could be indirect. You'll note, and I'm sure Eric will talk about this a little bit, that provinces each do various things with their Occupational Health and Safety Act, with respect to the whole issue of violence. Quebec has, in the last two years enshrined the whole notion of psychological harassments. So you can see, depending on where you live, it is defined in very different ways. There are a host of smaller pieces of research in Canada that gives us a little bit of a glimpse. There is no one pivotal piece of research that we can all look at to say, "Ah hah, there it is. We have a serious problem here." We also note that the International Labour Organization [found] that we're 19 per cent higher than they are, when it comes to the whole issue of psychological assaults on the job. When you look at Canada versus the United States, we are just as aggressive in many ways, we just simply do it differently. The CUPE 1993 Occupational Health and Safety survey was striking in the sense that 70 per cent of people who responded were verbally assaulted or had verbal incidences on the job. Forty per cent felt that they have been struck or grabbed during that time. We know that sexual harassment is becoming the fastest growing complaint in the Human Rights tribunals now since 1991. There other thing to take a look at and people can debate the data in a host of ways. That's why I say you really can't look at one particular piece of research and say, "This is the pivotal piece." You have to take a look at the entire pattern from a number of sources. For example, and for those of you who have downloaded any of the material from the website, you'll see that there are a couple of slides here on Criminal Violations and a comparison between 1998 and 2000. This was put together by Stats Canada. We segmented by just simply looking at incidences of violence in the home and instances of violence in the workplace. You can see, per centage-wise from 1998 to the year 2000, it hasn't changed a great deal, which might suggest to people that really the problem hasn't evolved. We're talking about it more. But when you start looking at the raw numbers, you can see that there have been actual increases per case, and that they've increased since 1998 to 2000. So you look at things such as homicide, which is up significantly in terms of raw numbers. You take a look at criminal harassment and that type of thing. So there has been, from a raw data perspective an increase. It's just proportionate, has remained the same over that period of time. Again I would suggest that, not only are there more incidences that seem to be happening and being reported, but we are also talking about it more. People are less tolerant of certain behaviours in the workplace and are now willing to speak up. Legislators and lawmakers are now starting to stand up and say, "We need to deal with this." And every time there's a tragic incident in Canada, the debate heats up for a while. Then, regrettably, sometimes it fades away after a time. Our main issue is to keep the debate and the dialogue going as much as we can, so I congratulate each one of you for being here. In 1999, we did a survey of all labour unions in Canada. We certainly appreciate those who responded. People are more than willing to get copies of the executive summary. Sixty-six per cent of people who responded said that they had noticed an increase in the amount of violence that was happening in their particular workplace. Violence was described or defined as a physical act, as well as a psychological act. They felt that most of the psychological sort of harassment or intimidation came from within the workplace, worker-to-worker, supervisor to worker, and they felt that a lot of the physical aggression came from outside the workplace. People who are in service industry positions such as nursing, retail, education, were more prone to be struck, grabbed, hit in some way. Seventy-eight per cent of these labour unions had taken some concrete steps, and given more education in the workplace. The primary focus on was women, because women are defined as being a vulnerable group within the workplace. We know from the International Labour Organization, that women are more apt to be the victims in a workplace than anybody else. [Regarding] the issue of whether or not Canada and the United States are starting to merge to be one - there is still a strong belief, and I certainly believe this - the remedies for workplace violence in Canada really should be dealt with from our perspective, as opposed to simply trying to take south of the border remedies and put them in a Canadian context. The face of violence in Canada is quite different than it would be south of the border in terms of the physicality of it all. Other types of research that we've done on this whole issue confirms the notion that many of the trade unionists are stating - at least in the survey that we did in '99 - that a lot of the instances of violence tend to be of an indirect nature, as opposed to a direct nature. And I think we have one thing to be thankful for, that, at least in Canada, we're not seeing these kinds of tragic events on a regular routine basis. However, my argument would be that we need to do something early on in order to make sure that that doesn't happen here. I'd like you to walk away from my portion of the presentation knowing that violence is a multi-faceted issue. It comes from inside and outside the workplace. It can be physical and it could be non-physical and psychological in nature. The anatomy of violence is really predicated on three basic issues from our perspective. If you do the research on this whole issue, you'd probably see it yourself, and that is the person who is the aggressor, offender, would quite often see this as being the only way out. In many cases, they have exhausted all the avenues of complaint and they find this is the only, only route out, to be aggressive in some way. The second thing is that they see it as a viable solution. That may be a function of where they came from, how they've been educated, how they grew up, but they see it as a viable solution. Being aggressive is something they could do, given the fact that they've exhausted all other avenues. And thirdly - and this is the most important thing, I think, for all of us - and the organization or an organization may, in some cases, actually facilitate it or simply may be passive and allow it to happen. And I think this is the one thing that we could do something about. We may not be able to know or change the belief system of someone, but we at least can protect the workplace by doing something if we know that something may be going on. Now, what's needed? I just want to summarize my particular piece here, what's needed here, and we will be required, I'm sure, in this province as it is in some other provinces, to do some risk and hazard assessment in our own workplaces. That's critically important, because violence takes on a different shape in whatever the workplace may be and we will be required to do that, as perhaps they are in BC and Saskatchewan. We will need to be taking some preventative strategies based upon the unique experience of your particular workplace. W will need, at some point, to have a full violence prevention program in whatever our workplace may be. What that will entail, and what I would suggest it should entail, is a very clear idea of what violence is, how it's reported and [how it's] investigated. An emergency response plan needs to be in place, not just for violence but for other types of instances that we need to sort of respond quickly. Access to assistance is a critically important issue, not only just to the direct victims but victims who may have witnessed any kind of incident. We need to follow up every single incident that may happen in our particular workplaces to ensure that we can remedy it in the future and that we may be able to better protect people. Incident follow-up is a critical part of your prevention plan. Training and education will be ever so important - orienting people to your own violence prevention policy and procedures. There are some core qualities that people need to have, I think, to make workplaces safe. One of them may be, in my belief, is that anyone within a leadership position, as a core competency, needs to be able to mitigate and understand how to manage conflicts in the workplace. It's a very important skill for everyone to have. Unfortunately, sometimes we do see people promoted into positions, maybe because they're technically sound, but they may not have the skill to be able to manage people effectively, especially people who are angry. The last but the most very important issue is the whole notion of reviewing your program on a routine basis, to ensure that it's compliant with whatever the existing laws may be. Eric will be speaking about that here in a second, but also to ensure that you are taking every opportunity to modify and change, based upon the experience in your workplace over the course of the year, or six months, or whatever you decide is a reasonable time to evaluate your program. So, in summary, before I turn the floor over, what I would like you to leave with is the notion that violence or aggression, if you want to call it that, is both a physical and a non-physical act happening both inside and outside the workplace. There may be some evidence that we are talking about this issue more, but there is also evidence that it seems to be escalating to some degree in Canada. The types of violence in Canada - and there's a propensity of evidence - suggests that it's relating to indirect, hostile relations in the workplace. These will be escalating sort of in more physical acts as time goes on, but we are a long way away from being the United States. In order to remedy this, we really do need to have a series of measures in place starting with a risk assessment in each workplace that we have. Jeff Harris: Okay. Thank you. For those on the phone that have questions for Glenn, he will be taking your calls following all our presentations, and if you would like to register for our call, please press star, one, on your touchtone phone to register with the Operator. I'd now like to take this opportunity to turn over our call to our legal expert on the panel, Eric Roher. As I mentioned earlier, Eric is a partner with the firm Borden, Ladner and Gervais. He also has written several books including Violence in the Workplace, published in 1999 by Carswell Canada. Welcome Eric. Eric Roher: Thank you very much, Jeff, and I am delighted and thrilled to be here. It is obviously a very, very important and timely issue and it is my onerous task to try to make legal issues acceptable and understandable and straightforward. When Jeff started the discussion this morning, he described the name of this forum as "Cut the Risk" and from our perspective, from a legal perspective, that is what this is all about. It is about managing, planning, organizing, controlling activities that contain an element of risk, so the risk is reduced and lowered. The point is that risk management is critical in anything you do. From a legal perspective, we have an obligation to show due diligence and reasonable care to minimize and reduce your legal liability. In addition to demonstrating good risk management techniques, you are, in fact, creating a positive and productive work environment for your employees. What I am essentially talking about today is creating a culture of improvement in your workplace, where you are continually examining your policies and procedures and revising them. This is what Glenn has indicated it is quite important, and in addition, creating an environment of continuous learning in your organization, where you are learning from your experiences and sharing best practices among your colleagues. From the outset, Glenn did point out a definition of workplace violence. The Ontario Public Service Employees' Association has a definition that they have used. It is any act of aggression that causes physical or emotional harm, including assault. It deals with threat, verbal abuse, sexual harassment and racial or religious harassment. The Ontario Nurses' Association says that violence includes assault, which includes the threat or injury that's obviously physical violence, but could also be psychological; battery, which includes unlawful force; threats, which whether intended or not intended, if there's an intent to harm or if someone perceives that their safety and security is in danger, that is considered a threat under the criminal code; sexual harassment and unwelcome sexual advances; and verbal abuse. That is their definition of violence. The British Columbia Nurses' Association in its definition of violence says that violence includes name-calling, swearing, hitting, biting, scratching, pinching, and using a weapon. So, as you can see, violence is a broad-ranging entity. The recent statistics from the Registered Nurses' Association in Manitoba and Ontario indicate that more than half of registered nurses have, or indicated that they have, been physically assaulted in the workplace, which is really a shocking and startling statistic - over 50 per cent of RNs have been physically assaulted in their workplace. Recent study indicates that of 400 nurses surveyed, 63 per cent indicated that they experienced verbal abuse in the past year and 35 per cent said that they experienced attempts at physical harm. Twenty-one per cent of nurses in a recent Nova Scotia study indicated that they had been victims of physical attack. So, it is prevalent. It is common. It is a real concern in our workplaces in general, but in particular in our health care and hospital workplaces. In the Ontario Nurses' Association 1995 study, out of 800 Ontario nurses surveyed, 59 per cent indicated that they had been assaulted on the job and 35 per cent said that they had been assaulted in 12 months prior to the survey being taken; again, very serious concerns. Younger clinicians and nurses are more often the target of client aggression due to, the experts indicate, their limited experience and often lack of training. A report from 1995 indicated that health care workers faced a similar level of risk to that of our local police, so again, a serious problem. From a legal perspective, what are we looking at? We are looking at, first of all, from a common law view, the principle of negligence, that we as health care practitioners, as hospitals, as health care providers have a duty of care to our patients and to our staff to show due diligence and reasonable care to protect them in terms of workplace safety and security. We are in charge of the overall health and safety of our workplace. There is a principle called vicarious liability that we are responsible, as the employer for incidents that take place in our workplace, to ensure that, where possible, our workplaces are safe and secure. The critical legal principle is foreseeability. We have an obligation to protect individuals from reasonably foreseeable risks of harm. If something happens out of the blue, something unexpected, something that you can never predict, then in general we cannot be held liable for that. But if we have patients, let's say with violent propensities - we have individuals that come in and threaten and harass - or other employees who might have a history of violence or of harassment, then we have an obligation to show, take due diligence and reasonable care, to try to protect the individuals. Our obligation is to protect people from reasonably foreseeable risks of harm. And as I say, it is the employer who has liability. There are two major cases, one was called Shaw and Lavac, an Ontario Human Rights case, where a female employee, Ms. Shaw, had been harassed for a number of years in the workplace. One of her co-workers had called her "fridge sister" and had made all kinds of derogatory comments about her for years, and the employer knew it was happening and did nothing. The Ontario Human Rights Board of Inquiry concluded that not only was the co-worker liable and was involved in clear harassment, but the tribunal said, in fact, the employer is liable. The employer is liable for what goes on in the workplace. There's an obligation for the employer to wake up and to ensure that his or her workplaces are safe and secure and take preventative action. These legal principles will form a notion of violence prevention and emergency response planning strategies that Glenn has spoken about and Patti will speak about shortly. From a legal perspective, the burden of proof is on the plaintiff or the individual complainant to show, on a balance of probability, that the hospital or health care provider did not meet the standard of care of a reasonable person in the given circumstances. There is an obligation to take due diligence and reasonable care to protect individuals. What does the individual have to do to establish negligence? A patient or a worker would have to show that the hospital or health care provider owed a duty of care to that individual. Then the individual will have to show that the hospital or health care provider breached that duty of care. Then the individual will have to show that the hospital or health care provider's breach was a cause of the plaintiff's injury. And lastly, the plaintiff would have to show that they suffered actual damage or loss, as a result of the injury. It's not enough for the individual to say, "Well, I'm not happy with how this doctor or nurse performed, I'm not happy about my treatment." In fact, the plaintiff or patient or employee has to demonstrate that they suffered an actual loss or damage as a result of the action or injury for them to be able to assert a negligent claim. You should recognize that when these actions take place, plaintiffs take what's called, "the shotgun approach." They go after everybody. They go after the health care provider. They may go after the President of the hospital. They may go after the head of your unit and they may go after the nurse who was involved. They tend to take a shotgun approach. You should also know that you have insurance, which is a good news story for you. Most of the health care providers, if you're a hospital, you have what's called HIROC, which is the reciprocal insurer. HIROC will generally defend the hospital, and if you're a senior manager with the hospital or you're a supervisor with the hospital and you're acting in the course of your duties, then your insurer will defend you against any kind of claim of negligence or carelessness or recklessness, in terms of an allegation. The good news is that you have insurance and if you're acting in the course of your duties, then your health care provider's insurance should cover you. Where it may not cover you is an area of what's called "frolic." If you're walking through Fairview Mall or Yorkdale Mall and you run into a patient, and you end up in a fight with that patient that just erupts outside the course of your duties, the hospital and the insurer will simply say, "Sorry, but that's outside the scope of your duties." With respect to the principle of foreseeability, a key determination is whether the employer or health care provider had a responsibility to take action; then, the question is not only what the employer knew but what he or she ought to have known. Ought the employer to have recognized that this incident of harassment had been ongoing? And did the people talk about it? One of the issues that took place recently was a very tragic situation in Toronto at Father McGuigan High School, in which one student was involved in being harassed by members of the basketball team at the school. Sixteen students were arrested by police. One of the issues that's been asked is "Where were the teachers?" The allegations of harassment took place over an entire year and they were ongoing and continuous. Where was the school staff and why weren't they aware that anything was going on involving this student over a year period? What is the applicable legislation? There are whole series of acts or statutes that apply. The Occupational Health and Safety Act applies in this case, Workplace Safety and Insurance Act, Human Rights Code. We have a compensation for Victims of Crime Act, and we have the Criminal Code, and other acts that apply. Very briefly, let me talk about the Occupational Health and Safety Act. This is a legislation that came into force in 1979 and it's designed to set administrative, legal and procedural standards for health and safety in Ontario. That, effectively, creates what is called "An internal responsibility system in each of your workplaces" and all workplaces with over 20 employees are required to have an Occupational Health and Safety Committee. This places responsibility for health and safety on the stakeholders in your workplace, which includes, obviously the employer, but also the employees, the supervisors and individual workers. You all have collective responsibility, through your Occupational Health and Safety Committee. The Act asserts obligations on the employer. For example, the employer has an obligation to provide information, instruction and supervision to a worker to protect him or herself. The critical one is that the employer, the health care provider, or the hospital has a legal obligation to take every reasonable precaution under the circumstances for a worker's protection. It's not enough to say, "I didn't know" or, "No one told me," and the like, but you've got to be somewhat proactive in recognizing that there's a possibility of harm or risk and take reasonable precautions to protect a worker's safety. There's an obligation on the employer to prepare and review, at least annually, a written Occupational Health and Safety Policy, and to develop and maintain a program to implement that policy. There are obligations on the supervisors and on your department heads to take action and every reasonable precaution in the circumstances to protect a worker's safety. There are also obligations on the workers themselves. Employees are required to report their employer or supervisor any existence of a hazard. You've got to look at your staff and say, "Well you've got a duty under the legislation to report." They've got to be informed of that duty and trained in it. If something happens, one of the big concerns that we have, particularly from patients or from teachers in a school context, is the concern about reprisal or retaliation. There's got to be a culture in your organization that people feel free to report things and people will be protected from any reprisal and retaliation, and that this will be taken seriously and we will respond to them. Workers have to be informed that they have a duty to also co-operate and report any existence of a hazard or any allegation of harassment. The Ministry of Labour appoints inspectors who have the authority to issue work orders or stop work orders where a hazard exists in the workplace. In certain circumstances, there are laws and rules pertaining to an employee's ability to refuse work, but only if there are significant hazards. That operates in certain circumstances where a nurse is trained, and is informed, that the expectation is that she or he is to deal with patients who are high risk; then, the obligation is to undertake those duties and obligations. You just can't say "Well, this patient hit me, so I have a duty to refuse work," but in fact, that's an expectation and is integrated as part of the duties and job description. You just can't do that; it's got to be higher standards than just saying, "Well, I'm not happy, I'm going to refuse to do the job," that you could be subject to discipline if you did that. There are health and safety adjudicators that make rulings with respect to the obligation of an employer to provide adequate staffing levels, to protect that health care environment, and to ensure that aggressive or violent clients are minimized and under control. We briefly talked about the Ontario Human Rights Code. Harassment is a prohibited activity under the Code. Under the Code, harassment is defined as "Engaging in a course of vexatious comment or conduct that is known or ought to reasonably be known to be unwelcome." Although the term says, "engaging in a course of comment or conduct," which implies it's ongoing or persistent, the Ontario Human Rights Commission has held that one serious act of misconduct, one serious assault, could in fact be a form of harassment. The critical point here is for you to have your ears to the ground, to be listening to what people are saying. If you have reason to believe that there's harassment of your staff or in the workplace or a harassment of patients, then you have a proactive obligation to take action to try to prevent it. As you know, harassment includes inappropriate comments, jokes or suggestions or any kind of sexual harassment; it includes unwanted touching, unwanted comments, jokes of a sexual nature. Harassment can also be things that are said. For example, if I make a comment to a third person about an inappropriate thing, for example, an inappropriate sexual joke, an inappropriate racial comment, if a third party hears that and is offended, then I could be accused of creating a poisonous environment. The individual who is the receiver may not be offended but making comments of a general nature in the staff room offend people, that could be involved in creating a poisonous environment that may not have people feel comfortable. You should know that almost anyone can file a human rights complaint. It's free. You can go to the Ontario Human Rights Commission and file it. It is often seen as what we call "the forum of last resort" for employees or for patients in a health care environment. The Criminal Code has aspects that are important. For example, assault is defined as "An intentional application of force to another person without that person's consent" and it includes attempts or threats to use force. The point is, any unwanted physical touching could be seen as an assault; any threat to one's well-being. If you're threatened by a patient, or if you're threatened by a staff member, that could be a form of assault. When you call the police, the police will do an investigation. In general, it's the police that will lay the charge, so just be aware of that, that the police lay the charge. You, as the victim, would be called as a witness. In general you're not prosecuting the case, it's the police that are prosecuting. The police lay the charge and you're just a witness. The standard of care is based on beyond a reasonable doubt. It is a different standard of care than in a general negligence lawsuit, where the standard of care is based on what's called 'a balance of probabilities'. I am talking about managing the risk at your workplace, planning, organizing and controlling activities that contain an element of risk in order to minimize or reduce legal liability. For health care workers, what I'm specifically talking about, and I know Patti will elaborate on these points, in order to minimize legal liability and legal risk, that when you're working alone at night, there should be, perhaps, additional staff to ensure protection, surveillance cameras, and a safe environment. When you're interacting with violent patients, that's another area of high risk. [Another area is] dealing with public complaints, providing care and advice that perhaps impact on a client's life, where there could be a volatile situation or propensity towards violence. Handling money or medication is another area that could add to risk in the workplace. Patti will elaborate on these points, but to minimize legal liability, what we strongly advise is developing a workplace violence prevention program. Glenn indicated obtaining management commitment and employee involvement - it's got to come from the top in terms of the key players. It's got to come from senior management and getting the union involved in developing a positive workplace violence prevention program. To minimize legal liability, what we strongly advise is developing a policy of zero tolerance in your organization for workplace violence, describing the standard of behaviour, expecting all persons in your workplace to talk about respect and civility and responsibility as to how people are to behave in your workplace, developing a plan in your workplace for maintaining security, providing a mechanism that encourages employees to report all incidences promptly. In conclusion, let me quote Harvard Business School business professor John Cotter. He wrote a book called Leading Change, and in it he talks about how to assist companies to accomplish organizational change. Professor Cotter says that the first stage in the change process is to establish a sense of urgency. He observes that "creating a strong sense of urgency usually demands bold and even risky actions that take place." He talks about creating a vision and strategy that's got to come from the top, that's got to be from the leaders of your organization. My point is, we need an organizational commitment from the management team, as well as an overall will and an allocation of resources, to create a positive workplace violence prevention program that will change the culture of your organization to create a culture of learning and a culture of improvement. Those are my comments. Thanks. Jeff Harris: Thank you, Eric. If any of our listeners have any questions about Eric's presentation, please press star, one, to register with the operator. Our final presenter is a fellow Health Care Health & Safety Association Consultant, Patti Boucher. Patti has extensive working knowledge of the development and implementation of Occupational Health and Safety Systems, Safe Handling of Client Programs and Workplace Violence Prevention Programs. She is instrumental in the development of Health Care Health & Safety Association's new four-part series, a guide to developing Workplace Violence Prevention. Hi Patti. Patti Boucher: Good morning everybody. I'm going to begin my discussion by really identifying the complexity of workplace violence in the health care setting. In order to get a handle on the complexity, it is important to clearly distinguish the four types of violence, as identified by Cal/OSHA in 1995. Type I identifies that there is criminal intent; the perpetrator of violence has no relationship to the workplace. For example in a health care setting, if somebody were to come in to the work setting and steal, rob or commit a violent act against a worker. The perpetrator has no relationship with the organization. In Type II, the perpetrator of violence is the client, customer and/or patient. When we examine the lost time injury trends over the last four years, client-related violence or client aggression is the major issue. I'm going to address this type of violence towards the end of my presentation and introduce an approach that we're going to be trialing in long-term care. This approach examines our patient, resident and client care strategies, examining the cause of responsive behaviours and client aggression. Type III is the worker-to-worker type violence. The perpetrators are employees. Employees can be anybody with a contracted relationship, such as physicians, surgeons, or it can be front-line workers. It can be supervisors, managers or contracted service workers. The perpetrator is a worker who has a relationship with the organization. Type IV is when the perpetrator has a personal relationship with an employee, such as a loved one that comes into the workplace and commits a violent act. In the development of the new series of Workplace Violence Prevention products, I carefully examined the Cal/OSHA classification of workplace violence and developed a plan which segregates the approach for dealing with the various types of workplace violence. The first booklet in the series is entitled Implementing the Program in Your Organization. I will detail the steps in program development. You may recall the previous Workplace Violence prevention document, initially published in 1999 and rewritten in 2001. This is an extension of that document, but provides greater detail. There are many more tools to assist you in developing a comprehensive program. Booklet two deals strictly with crisis prevention and communication strategies. Every worker that is hired into the organization needs to be equipped with knowledge and education on recognizing escalating behaviours and know how to effectively communicate in an effort to de-escalate. This document also addresses emergency response mechanisms. Booklet three is Developing Human Resource Strategies for Managing Workplace Violence. This really addresses the Type III and the Type IV workplace violence, where we're dealing with the worker-to-worker and personal relationship types of violence events. And then Booklet four, which is currently in draft and which will be released by the end of December is entitled Preventing Client Aggression Through Gentle Persuasive Approaches©. I'll expand on this document following my presentation on the steps to program development. There are five steps in developing a Workplace Violence Prevention Program - and this is evidence based. I took a careful look at the literature and recommended best practices. The first step begins with securing management commitment - this is the foundation of an effective program. Senior management really needs to be committed to this program, in terms of ensuring that there are adequate resources to develop, implement and maintain the program. Maintaining that program means integrating it into your risk management systems. It means managing risk of workplace violence from the perspective of your patients, your clients, from your employees, and also from the general public, visitors, and family members. It's also necessary for senior management to appoint a program leader to coordinate the development of this comprehensive program. The program leader must be capable to coordinate and lead a multidisciplinary committee, comprised of front-line workers, union members, management and other key persons in your organization to together and collaboratively develop this program. The second phase of program development is assessing your program needs. And I really want to spend some time talking about this. This is critical. You can't just hire somebody from an external agency to come in and develop your program. You need to be certain that you have done your homework and examine each and every indicator that is feeding into this whole issue of workplace violence and client aggression. You need to examine your geographical community and identify whether there is a potential risk for violent incidents against your staff in your organization's direct geographical location. This is especially challenging for community workers. There needs to be an emphasis placed on employers in the community setting to ensure that all types of risk are assessed prior to employees providing care and services in the home and community setting. The second phase of this risk assessment is examining your internal documents that you currently use to report incidents, accidents, and events of workplace violence, such as security reports, emergency response mechanism reports, unusual occurrence reports, client abuse reports, employee assistance program usage, and also employee incidents and accidents reports. The third phase of this risk assessment is examining your physical environment for key security breaches, or lack of security devices. The physical environment should also be examined from a patient or resident care perspective. The literature supports that certain environmental factors, such as noise and overcrowding, may actually cause violent incidents by increasing anxiety levels and predisposing the client to escalating and response behaviours leading to client aggression. Following an examination of the physical environment, you need to carefully examine your work setting and the types of clients that you are providing services for. This assessment examines the prevalence of dementias, psychological disorders, and psychiatric conditions. There are conditions that can contribute to escalating and responsive behaviours, leading to client aggression. An examination of point-of-care practices and the way in which caregivers approach resident, client and patient care needs to be conducted and person-centered care strategies incorporated into our approach to resident, client, or patient care, in an effort to decrease client aggression. The last assessment, and a very important assessment, is looking at the employees' perception. Do employees feel safe at work? Do they feel that there are certain areas of risk? Is there certain work activities where they feel more at risk? Is there an open communication system in the organization where employees can openly report incidents of violence and are supported throughout the investigation? Is there appropriate follow up? Is the incident or event investigated? Is management supportive? This is a very important piece to ensuring that the organization is thoroughly assessing the needs of the workplace. In the document entitled 'Implementing The Program In Your Organization', I carefully incorporated the recommendations of the focus group, held back in January 2005. The group was looking for tools to assist them through the risk assessment phase of program development. There are detailed assessment tools that have been developed: workplace violence documentation analysis tool, a unit or workplace incident/accident analysis collection tool; an organizational workplace violence incident/accident summary tool; a detailed environmental assessment tool, coupled with a community workplace assessment tool; and a work setting and client risk factors checklist, so that you could examine those high risk activities, settings and clients that can increase the risk for responsive behaviour and client aggression; a checklist of risk factors for aggressive behaviour; a point-of-care staff work practice assessment tool; and then a very detailed workplace violence employee survey, (much more comprehensive than the one previously published in the document Workplace Violence Prevention Program, by Health Care Health & Safety Association). The risk assessment phase of the program development is truly your road map to developing your comprehensive program. It is looking at the specific needs of your organization and summarizing those needs identified through the detailed risk assessment and then designing a comprehensive program that includes a workplace violence prevention policy and associated procedures. In the document, I have included a sample policy and procedures, such as what your emergency response team should look like and an investigative tool that is part of the Employee Workplace Violence Event Report Form. The investigative tool moves the investigator from identifying the basic cause to the underlying cause, and then the loss of control issue, so that the organization can move to a continuous quality improvement framework, and strengthening those components of your workplace violence prevention program that may need improvement. In addition, other procedures include the development of the appropriate environmental and security controls dependent on the needs identified through that risk assessment phase. Also, administrative control procedures are required - this focuses on the actual work planning, work organization and approach to patient, client or resident care - and, in addition, a focus on work practices that decreases the risk for violence against workers and also increases client or resident safety. Step four is implementing the program and ensuring that all critical steps are completed. This includes the communication of the policy and procedures, organization-wide, in fact, communicated to the point that it is actually part of a marketing strategy. This may be a significant change in the culture of the organization; thus, change management strategies may be an important component of the marketing strategies. Also in this implementing the program phase, is developing and presenting staff training. There are a variety of different training elements that are required, dependent on where the worker is working, what unit, what area, and what the significant risks are. All persons should receive an orientation to the workplace violence prevention program policy and procedures and the employer must ensure that they are familiar with accessing assistance such as debriefing or services through the employee assistance program. Workplace-specific training or site-specific training should detail specific patient, resident or client care strategies. In addition, emergency response team training will require different training. This is described in the document; it details very specifically the type of training that is required to demonstrate due diligence. The last step in implementing the program is actually launching the program; this is the implementation of a marketing plan to ensure that the program is communicated organization-wide in various forums. The last step is what we call Evaluating the Program. This is a key element and an element that's often forgotten in organizations. It is examining all aspects of the program to ensure that the program is effective, functional and that staff feel safe at work. So the goal of program evaluation is to create and maintain a safe working environment without the threat of violence. It's reviewing, revising and enhancing and improving components, based on the programs self-audit. A self-audit tool is included in the document, and then, of course, the results of various indicators such as qualitative and quantitative measures that you've implemented throughout this program. This will then allow you to continuously improve, as I suggested, through your continuous quality improvement framework, your workplace violence prevention program. I'm going to talk a little bit about our second resource document, entitled Developing Crisis Prevention and Communication Strategies. At this point, I would also like to add that OSACH will be offering educational sessions in the topics of the Workplace Violence Prevention series. Book Two addresses staff education and training in crisis intervention and communication skills, recognizing violence through key assessment skills, and responding appropriately at the various stages of violence. It also details effective communication skills and optimum environmental conditions that may decrease the likelihood for escalating behaviours. In addition, this document touches on cultural sensitivity within the organization, setting up your emergency response team, and dealing with employees' needs during and after crises. This is another significant weakness in health and community care organizations. We don't do enough to thoroughly develop and implement a critical incident stress management program to prevent post-traumatic stress by offering and providing all employees the necessary support and debriefing post-violent events. This is a huge liability for employers as well, as post-traumatic stress is a compensable injury under the WSIB stress policy. So, we need to look after our health and community care employees. Without our health care workers we cannot engage in quality patient, resident or client care. The third book is Developing Human Resources Strategies for Managing Workplace Violence. This deals with the prevention of violence among employees and deals with harassment, domestic violence, threats, carrying weapons, and details specific human resource procedures such as hiring and termination practices. The fourth document, as I said, is currently out for peer review and will be published by mid-December. It's called Preventing Client Aggression Through Gentle Persuasive Approaches©. This is an exciting new partnership between Health Care Health & Safety Association and the Continuing Gerontological Education Co-operative that developed this very thought-provoking, person-centred care curriculum for caring for persons with dementia. It focuses on person-centred care strategies and point of care practices. It is getting the health care worker to really look at the way that we're approaching our residents with dementia or major physiological or psychological conditions and ensure that we're approaching them in a respectful way that protects their privacy, promotes their self-esteem, thus decreasing the opportunity for escalating anxiety, responsive behaviours and client aggression. Currently, across the province, master trainers are undergoing training. These are the regional psychogeriatric resource consultants, the public education coordinators of the Alzheimer's Association and the case managers of Psychiatry and Mental Health Agencies. This is a two-part education initiative that we're going to be trialing in long-term care beginning in February or March of 2006. The first phase of training is the program infrastructure training, which is focused on developing the necessary documented program policies and procedures that supports person-centred care strategies. It highly emphasizes the Ministry of Health and Long-Term Care Standards, specifically Standards 9 and 10 that detail person-centred care strategies. What has happened with the way that we have been traditionally dealing with client aggression? Well, if we look at the lost time injury statistics, they suggest that whatever we've been doing, it is has not been successful and was the impetus behind the search for a program that effectively deals with client aggression. Our traditional approaches to client aggression actually focus on methods to manage, contain or reduce the impact of the aggressive act. It relies on physical methods to deal with the situation and focuses on body containment techniques, based on a philosophy of care that focuses on pathologies, which really, according to the evidence, reinforces negative perceptions of persons with dementia as being assaultive, violent, dangerous and passive recipients of care. Jones, in 1999, basically said, "Traditional methods do not seek to understand the underlying or root cause for the responsive behaviour," and, "It focuses too much on the dictated care regimes, use of physical or chemical restraints." This curriculum was developed as an adjunct to the PIECES, U-First, and Enabler Programs, educational initiatives that were part of the Ontario Ministry of Health and Long-Term Care's Alzheimer Strategy or Initiative Number 1. The philosophy of this program is that an individual's life experience, unique personality, and network of relationships, should be valued and taken into account by staff as having a direct application to the interpretation and response to behavioural episodes. It centres on dealing with our patients, our clients, and our residents with respect and incorporating point-of-care and person-centred care strategies into our client care regimes. It assists our employees and managers to respond effectively and with respect to the catastrophic verbal and physical expressions of needs, demonstrated by persons with dementia in long-term care settings. So, as I have said, the program infrastructure is part one of this program. The educational objectives are detailed in your handouts. The second part of this training will be conducted by the certified GPA© trainers. For more information, you can get onto our website or ask your regional psychogeriatric resource consultant and/or the Hamilton Continuing Education Gerontological Group. I'd like to conclude to emphasize how passionate I am about the safety of our health and community care employees. Employers must strive to demonstrate reasonable precaution by developing a comprehensive program that is reflective of the needs of their organization - including the types of clients, residents and services that you provide. It is also important to ensure that front-line employees are involved in the program development, implementation and evaluation through a multidisciplinary committee. By completing today's teleconference evaluation, you will be entitled to download a free copy of the first three of the booklets just released this week by Health Care Health & Safety Association, the Workplace Violence Prevention series. So I urge you to complete your evaluation post-conference and download your free copy. Thank you. Jeff Harris: Thanks, Patti. I want to turn the call over to our participants. Operator, we're ready to hear from our participants, so if you could line up the first caller for us please? Operator: Sure. Ladies and gentlemen, we will now conduct a question-and-answer session. If you have a question, please press the star, followed by the 1 on your touch-tone phone, and you'll hear a tone acknowledging your request. Your questions will be taken in the order in which they were received. To remove yourself from the queue, please press the pound sign. If you require further assistance, please press the star, then zero. One moment please, for the first question. The first question comes from Jim MacDougall from IWK Health Centre. Please go ahead. Jim MacDougall: Yes, thank you for the opportunity to participate here today. I have more of a question from a legal point of view; how does one balance the duty of a care to our patients against the duty of care to our staff? In particular, I'm referring to a circumstance in which we had a patient who was competent in a palliative care setting who posed a very physical danger, if you will, to the staff in our care. And unfortunately the normal methodologies, if you will, of consulting, trying to console the person, trying to make them understand and was non-effective and the physicians would not actually look at the chemical restraint policies. So, I'm trying to figure out, where does the duty of care to our staff balance against the duty of care to the patients that we serve? Eric Roher: You've asked obviously an extraordinarily difficult and complex question. There's no easy answers and there's a huge gray area and it's all about, as you've said, I think you've answered your question in your question, which is just the answer is striking the balance and you have a duty of care to your patients to ensure that they are safe and secure and protected. And you also have a competing parallel duty of care to your staff. Now, I will say this, though, that in the health care sector, it's quite clear that there's an expectation of health care providers that they will deal with a certain level of reasonable, you know, anxious patient. That they will deal with a certain level of perhaps patients that can't control themselves, patients that don't understand their conduct, patients that Patti indicated may have dementia patients may be autistic, young people that strike out. So, as part of their legal duties and obligations, it's inherent in their job that they're to take on some of these roles. On the other hand, their exposure should not put them, their safety, their security, in jeopardy, and that may mean bringing in additional staff. That may mean putting on special gear such as, there's Kevlar protection devices that are used now in schools in dealing with highly autistic kids, and I'm sure health care providers use the same kind of protective devices. And that may mean saying to some patients, "We're not able to cope with you here. You need to go to a more specialized facility, because at this public hospital we cannot cope with this type of violent, aggressive patient and we may have to assign you to a different type of facility for more specialized care." So, the answer is, there's no easy answer. It's a gray area. And it's a matter of striking that balance and ensuring both protection of your patient, but also, obviously being concerned, very concerned about the safety and security of your staff. Patti Boucher: And if I could comment as well. And this is where it's detailed in this fourth document, Preventing Client Aggression Through Gentle, Persuasive Approaches, that you really need to examine the point-of-care practices, and examine thoroughly the types of clients. In the situation that you described, I would be inclined to ensure that a detailed psychological or behavioural assessment is completed on that individual. And then, a behavioural plan developed and/or other measures to house that patient or client in a more secure setting. There are assessment tools out there. For example, in the case of a dementia resident, the psychogeriatric resource nurse in the region is equipped for dealing with some of these more difficult cases. In addition, residents can be assessed at a Geriatric Assessment Unit or through a mental health clinic. Jeff Harris: And I can tell you, you're not the only sector. In the school sector, we have young, autistic kids or identified kids with very, very high needs striking out, lashing out at the educational assistants, lashing out and assaulting teachers and it's a very similar issue. At what point does it effectively become an issue where we say, "Look, you're putting our EAs at risk and we're going to have to reassign you to special programs," and maybe even, "This isn't an education issue, but in fact this is a Ministry of Health issue," or "You've got to go to a special facility at home," and parents don't like that because parents want their children mainstreamed and integrated in the classroom. But we're constantly dealing with this issue of this balance of providing a duty of care both to students, in that case, and to our school staff. But it's a very similar issue, so in other words, I don't want you to think you're the only sector that has these types of very difficult issues to deal with. Jim MacDougall: Thank you. Patti Boucher: Thank you. Jeff Harris: Operator, can we get the next question, please? Operator: Absolutely. The next question comes from Liliana Catapano from Belmont House. Please go ahead. Liliana Catapano: Hi, I'm representing both Belmont House and OANHSS. I wanted to commend OSACH on the work on these four booklets that they've produced. I come from a human resource perspective and what I'm finding is that a great deal of the training resources, the awareness, deals with the physical aggression between the staff, the employee and their client. I'm finding more and more that there's a great deal of aggression, especially that psychological violence that occurs between employees and their peers. And I'm looking for some direction, I guess, on how we can give those employees the tools to deal with peer to peer violence, which I think there's a great deal of that psychological intimidation, harassment piece that is silent. And really we've tried to increase the awareness by talking about core values, and what guidance can we expect from OSACH on that? Patti Boucher: Sorry, just that last question, if you could repeat your last question there, what values? I didn't quite catch you. Liliana Catapano: We've done some work around heightening awareness around core values as an opportunity to raise the awareness of the psychological impact of violence, and that intimidation can be considered violence. The booklets that you have seem to deal more, especially in the training piece, on patient to or resident to staff person. Patti Boucher: Okay. Actually, we do have in our third document dealing with violence among employees. Employees include senior management, workers, physicians, treating practitioners, contracted employees, and anybody that has a relationship with the organization. This can be a major cultural shift in your organization, examining the organizational culture, through a detailed needs assessment and developing and implementing the workplace violence prevention program reflective of the needs. I am speaking about a holistic program, so not just addressing the issue of client aggression, but also focusing in on all four types of the workplace violence and ensuring that all types of violence is defined and clearly outlined in your workplace violence prevention policy. And then it's looking at communication and marketing, this is where organizations fall short. They may put together a workplace violence prevention policy, but that policy isn't alive, it's not implemented in organizations. The culture has not shifted. This is where we have a lot of work to do in our organizations. So, in summary, Health Care Health & Safety Association has a training program that addresses violence among employees that includes workplace discrimination, harassment, bullying and domestic violence. And in addition, we have the crisis prevention education to equip employees with the appropriate assessment, communication and reporting skills. Jeff Harris: Oh yes, go ahead Glenn. Glenn French: Let me just weigh in on this and maybe in a little bit more contentious way. It's Glenn here. It's a great question, and let me just preface what I want to say by saying that some of the best work done on the issue of workplace violence that's coming out of the trade union movement for many, many years now. However, there is a particular difficulty when it comes down to worker-to-worker aggressiveness and that is that this truly, attacking the whole issue of workplace violence, is a team endeavour, meaning it has to be shared by both union and by management. And inevitably, what one finds is that sometimes the organized labour representative may say, "This is a management issue" and will take a step back from addressing the issue with their member. And so if you have a situation where there are two people who are brothers or sisters in the same union, their union needs to be involved in this in a very, very definitive way and can no longer step back on this issue because they have a duty as well. I know they have a duty to represent both parties fairly. I believe that they can do that, but if you're dealing with a situation where two people are part of the same collective agreement or union, then I believe that you need to solicit the help of whoever that is. Eric Roher: And let me just add one other point. This is Eric. From the legal perspective, Glenn in his introductory comments referred to a new amendment to the Labour Standards Act in Quebec. And in June 2004, Quebec did amend their Labour Standards Act and added a whole component regarding sexual harassment and defined - or, sorry, psychological harassment - and defined psychological harassment and basically said that in Quebec psychological harassment will not be tolerated or condoned in Quebec workplaces and then obviously to promote a harassment-free environment. We have not done that in Ontario, but I do know that there is pressure in Ontario to amend our Employment Standards Act to adopt a psychological harassment definition, so that is out there, I do know that. And I know that teachers' unions, in particular, the recent report on bullying among teachers that was released last week and was done by the unions and I know that they have been putting pressure on the Ministry of Education to amend the Employment Standards Act. But that doesn't necessarily mean that you cannot develop your own internal policies. And yes, there's workplace violence prevention policies which are critical. Some organizations I know actually have a workplace harassment policy that doesn't just deal with sexual harassment or racial harassment, but also does deal with psychological harassment, employee to employee. And going back to the point here, obviously, education is important in training staff and really promoting this policy, but so you can have your own internal policy that does specifically deal with psychological harassment and what steps to take and a complaining mechanism. And those things are important to make sure this has got high profile to ensure that there's zero tolerance for this type of conduct in your workplace. Jeff Harris: Thank you. Liliana Catapano: May I make one more comment? Jeff Harris: Sure. Liliana Catapano: Is there any movement at the present for the Ministry of Health and Long-Term Care, the Ministry of Labour and Health Care Health and Safety Association to work in collaboration to develop a program and training tools? Each sector seems to be dealing with it individually and sometimes on a bit of a different perspective. My comment is more, is there an opportunity there for all three parties, or four parties, including the unions, to work together? Patti Boucher: I could tell you that all of our documents were peer-reviewed. ONA and OPSEU spent a great deal of time on these documents. I can also tell you that we are approaching our associations, our partner organizations, such as the Ontario Long-Term Care Association and the Ontario Association for Non-Profit Homes for Seniors. We will be presenting at OANHSS with other professionals from various organizations to collaborate on workplace violence resources and training. And as well, I did send my documents on to the nursing secretariat group at the Ministry of Health and Long-Term Care for peer review of the documents. Liliana Catapano: Thank you. Patti Boucher: Okay. Jeff Harris: Operator, could we have the next question please? Operator: The next question comes from Debbie Skorik from Brant Community Health Care System. Please go ahead. Debbie Skorik: Hello. Can you hear me? Jeff Harris: Hi Debbie. Debbie Skorik: Okay. Hello. We have a question. Basically it was mentioned during the legal issues part of the teleconference is that it was up to the police to charge someone that has assaulted a worker. Why is it up to police to charge a patient that has assaulted a worker and how do the police make the determination to lay the charges, and what about when the police refuse to come to investigate? Eric Roher: Well, you've asked a great question. Okay? And of course, our perspective, and I can tell you I'll be fully honest with you, we act for hospitals and health care providers, so the normal procedure is that where there is an assault in the workplace or where there is a criminal code offence, we will call the police, obviously, and we'll call the police quickly. The police will do an investigation and we provide the police with everyone's statement. The police will get statements from all of the different witnesses. And generally, the police will decide whether there's enough evidence to lay the charge and they will assess the credibility and the consistency of the witnesses and the like and then make a decision to lay a charge of assault, or sexual assault, or sexual interference, or whatever it is. In addition, and you're absolutely right, in addition, if the police decides not to lay the charge, okay, they may say "We've heard all the evidence. We understand what's being alleged but in fact, there is no evidence, in our view, of a criminal offence being committed," or the evidence is shaky or it's not compelling enough. Then, it is possible for the actual employee to go to a Justice of the Peace and lay what's called a Private Information. Okay? You can do that. That's something that's permitted, and you can lay your own charge. I can just tell you that, in general, in acting for hospitals and health care providers, we don't generally encourage our staff to lay criminal charges against patients. Debbie Skorik: That's right. Eric Roher: That's generally not something that we will encourage or support, but it does happen and you can do it, but we don't encourage it. Our view is the better approach would be, allow the police to do a full and thorough investigation and allow them to lay the charge and then it's their prosecution and it's up to the Crown to carry the can, and all you're doing is you're providing your nurses or doctors will come as a witness and it's their case to prosecute. And we feel generally, it's health care providers or hospitals that is really the polices' responsibility. Now secondly, your question was what happens if the police don't come? And I think that's a very serious matter, that if there's an allegation of a criminal offence and the police don't come - that's a serious allegation. The police aren't doing their job. In my experience, that's not the case, that if a health care provider or a hospital called the police, that's a pretty serious matter and the police will show up in a prompt way. They may show up in a uniform, in a marked uniform car, in a cruiser and you may not want to have a policeman barreling down the halls with their revolvers and the like, but they will respond because it's very serious for the police to get called. And all of the hospitals and health care providers have a rapport and relationship with the police. There's generally a protocol and the police will respond quickly where a hospital or a health care provider is calling. And that's a very serious thing if the police don't come and I would certainly meet with your local police, law enforcement provider detachment if the police are not being responsive to calls from hospitals. It's very serious. So I think I've tried to be up-front about that. Male Speaker: Can we have a follow up? Eric Roher: Yeah, sure. Male Speaker: The issue at hand is if there's clear evidence that the police are refusing to charge based on the fact that they are making a decision about the mental capacity of the client. The issue we have is that's not a call for the police to make, that, is in fact, the physician's call, and if the evidence indicates that an assault took place, the charges should be laid. Mental capacity of the client who understands the nature and consequences of his actions is a judgment call for a clinical person and a judgment call for the Judge hearing the case. We have had occasions where the police refused on the basis that they think the person's crazy. Eric Roher: Yes, and that is a very complex issue and you really hit a very important issue. And you're absolutely right; it's up to a physician to make the determination as to whether an individual understands the nature and consequences of his actions and there's no age, as you know. And generally, there is an assessment done by a physician. But it's a complex issue because the police may say, "Look, we're not comfortable laying the charge because the person doesn't understand the nature and consequences of their actions," and the police have got to assess whether, to use a vernacular phrase, whether a charge has legs, because they don't want to be laying a charge and it having going nowhere. On the other hand - and in some cases, the policy may say, "This is not truly a criminal matter, but really a mental health matter. And this person needs help in the mental health world." It's a very complex issue, but I do agree with you. It's not really up to the police to make that determination and it's up to a physician to make the determination. And to what your point is, it may be better for the police to lay the charge and then down the road, an assessment will be properly made by a proper physician as to whether the person does have proper capacity. And I think you're probably right, that's probably the better approach. But it's a very complex issue. Male Speaker: There's a clinical advantage to having the charge laid in, that it can assist many of these types of clients that are aggressive to get the care they need as a requirement of a Court order. It is beyond our ability to enforce under the Mental Health Act. Eric Roher: And you're absolutely right. And it's also a wake up call for the families to know that there's special assistance that's required and that it's a wake up call to families and individuals that they need particular special help. Some of these folks are in denial. Some of these folks are refusing to take their medication. They don't want to deal with these issues. And you're absolutely right, it can be a valuable thing. My experience is, generally, the police will be co-operative and if you particularly ask them to lay a charge and explain the context, they often will be co-operative, but I mean, it's up to them and they have full discretion in deciding whether to lay a charge or not. I totally agree with what you said. Debbie Skorik: Thank you very much. Jeff Harris: Thank you for the questions. Operator, could we have the next question please? Operator: The next question comes from Mary Anne Frappier from Children's Hospital of Eastern Ontario. Please go ahead. Mary Anne Frappier: Hello. Is the CPI program being discouraged, then, for hospitals, the Crisis Prevention Institute program? Patti Boucher: The Crisis Prevention Institute has its place for certain situations and so it's not being discouraged for hospitals. Crisis prevention, or the non-violent crisis intervention techniques, let me talk more generically, are valuable for an emergency response team where patients, visitors or family members that are mentally competent and are able to competently act, the non-violent crisis intervention techniques are appropriate. As well as, there is a component in the non-violent crisis intervention training that deals with assessing and dealing with escalating behaviours. However, with those patients or residents with dementias or major psychological illness or impairment, it is important that you now are aware that there is the Gentle Persuasive Approaches to dementia care that is shown to be far more effective in reducing escalating behaviours that lead to client aggression. So the quick answer is, non-violent crisis intervention techniques and crisis prevention training does have its place in acute care. Mary Anne Frappier: Okay. Will there be a special program for Gentle Persuasive Approaches© for children? Patti Boucher: At this point, it's being rolled out in long-term care and we're going to examine the effectiveness of this in long-term care. Mary Anne Frappier: Thank you. Jeff Harris: Thank you for asking that question. Operator, could we have our last question. Is there one more question there? Operator: Okay. The next question comes from Thomas Heinz from Hotel Dieu Grace Hospital. Please go ahead. Harold Shore: Actually, it's Harold Shore. There's been a lot of discussion about Quebec, but I think everybody should realize Bill C45 that affects all organizations, which encompasses not only the employer in health care but also union and all employees and members. There's due diligence under our Occupational Health and Safety Act in Ontario, but this is due diligence federally that falls under the Criminal Code with possible prosecution to a felony record, a fine and possible jail time. I haven't seen a lot of prosecutions on it but it is on the books, and I think under due diligence that there needs to be more awareness in health care, have some training on it. Eric Roher: Yeah, and you're absolutely right. You're absolutely right. There is recent amendment to the Criminal Code. You should just recognize that in general this has been described laying a criminal charge with respect to a patient or a co-worker in a hospital environment, it's been described as "Cutting butter with a chainsaw" or it's been described as "Frying an egg with a forest fire." In other words, you're taking a fairly radical approach in dealing with a civil workplace or health care problem. And as you can appreciate, and I think the caller indicated earlier, the police in some cases are reluctant to lay charges in a health care environment. So, in general there's got to be fairly strong evidence of a criminal offence being committed for the police to lay a charge. I know there's a general reluctance if there's a civil matter, particularly if it involves a patient in a public health setting, to lay a criminal charge. But you're absolutely right, the criminal code has been amended and that there is an ability where there is a criminal offence for the police to lay a charge. And I agree with you. You should also know that with respect to individuals between the ages of 12 and 17, there's a new what's called Youth Criminal Justice Act. It replaced the Young Offenders Act, and if the individuals are youths under the age of 18 and they're involved in beating up a health care provider, then the charge would be laid under the new Youth Criminal Justice Act. And the provisions of the Criminal Code would apply just to the youth. So that's also new. That came into force on April the 1st, 2003. But you are absolutely right, those provisions do exist in the criminal code. Jeff Harris: Okay, thank you. Operator, any more callers? Operator: There are no further questions. Please continue. Jeff Harris: Okay. Well I'd take this opportunity to thank all our presenters today, Patti Boucher, Glenn French and Eric Roher, for joining us and for their insightful presentations. And I'd also like to thank all our participants for listening in across the province. I'd also remind everybody to visit the Health Care Health & Safety Association webpage and download the presentations and early next week the transcript of this call will be available. And also, we please ask that you fill out your evaluation and download the free copies of the manual. Thanks everybody and have a good day. Glenn French: Thank you very much. Patti Boucher: Thanks. Operator: Ladies and gentlemen, this concludes the conference call for today. Thank you for your participation. Please disconnect your lines.
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