Policy and Political Action

Policy & Political Action

RNAO Submission on Violence Faced by Healthcare Workers To the Federal Standing Committee on Health

The Registered Nurses’ Association of Ontario (RNAO) is the professional association representing registered nurses (RN), nurse practitioners (NP) and nursing students in all settings and roles across Ontario. It is the strong, credible voice leading the nursing profession to influence and promote healthy public policy. 
RNAO is pleased that the Standing Committee on Health is studying violence faced by healthcare workers, and we hope the Committee can trigger change that will make a substantive difference. Violence in health care is all too common a problem, and we are all the worse for it. Violence in its various manifestations adversely affects the health of healthcare workers, and it in turn harms their ability to provide the best care possible for Canadians in the healthcare system. 

We know that healthcare workers ironically face disproportionately worse health outcomes than other workers: for example, 11 percent of the Ontario workforce covered by the Workplace Safety and Insurance Board (WSIB) are in health care, but they are responsible for 16 percent of WSIB lost-time claims. Similarly, nurses in the Canadian public sector suffer a higher rate of absenteeism than that for all occupations: 9 percent vs. 5.7 percent. The cost of that absenteeism has been put at $989 million for 2016. 

The alarmingly high level of violence in health care only makes that worse, and it falls particularly on nurses, who are vulnerable because of their frontline roles. As our colleagues from the Ontario Medical Association told the Committee, “there are more reported incidents of violence against nurses in Canada than firefighters and police officers combined.”  According to Vector, 61 percent of Canadian Federation of Nurses Unions members reported “serious problems at work with at least one type of workplace violence in the previous 12 months.” An Ontario survey found that in the previous 12 months, 68 percent of front-line health workers had been physically assaulted, 86 percent had faced verbal violence, and 42 percent had been sexually assaulted or harassed. 

Violence can take different forms. All are damaging and none of them is acceptable. Physical violence is the use of physical that causes or could cause injury. Other expressions of violence include sexual aggression, verbal statements, behaviours and acts that imply the threat of violence.  To this, we add psychological violence, which includes “harassment, bullying, intimidation and demeaning treatments.” 

It is not surprising that violence is so prevalent in the sector: the risk factors are high:

  • Many patients and their families are stressed by the illness and challenges in accessing health care in a timely fashion. They must often wait in great discomfort and uncertainty while short-staffed departments struggle to see to all patients’ needs.
  • Some clients will have histories of violence or substance abuse, yet the staffing has not been adjusted to meet those more intensive needs.
  • Many clients suffer from pain, behavioural challenges and cognitive impairments that may predispose them to violence.
  • Due to resource constraints, the acuity level in all setting has gotten high, and that stresses both clients and health providers.
  • Nurses and other health care workers are often not accorded their due respect and are too often expected to take violence and abuse as a hazard of the job. Nobody should have to face that in any setting.

This situation is exacerbated by lack of attention to and resources for violence prevention that leave health workers more vulnerable. Short-staffing and inadequate security preparation and training can leave workers without the support necessary to defuse violent situations. Workers may not be aware of which patients are potentially violent and security staff may not be adequately trained to deal with violence when it happens. Facilities are often poorly designed to deter and respond to violence, with inadequate lighting, unsecured access and areas that are isolated from observation and help. Nothing less than a comprehensive national strategy is required.

RNAO Recommendations

The problem of violence against health workers is widespread in the Canadian health system, and a systematic response is required to the many risk factors we have cited here.  Many of the recommendations are drawn from RNAO’s forthcoming revised best practice guideline on workplace violence in health care.

  1. Develop a national strategy to reduce violence in health care. This should include all of the following measures that may be moved through targeted transfers:
  2. Urge provincial and territorial governments to enact and enforce legislation that promotes a violence-free workplace. This would include a review of existing legislation and regulations in consultation with professional associations, regulatory bodies, unions and health service organizations. Such legislation must include mandatory reporting and whistle-blower protection for those who report violence in the workplace. It must also include structural changes that equalize power bases, as this is a key contributor to aggression.  Specifically, it must transform legislated Medical Advisory Committees into legislated Interprofessional Advisory Committees that will allow all health-care providers to participate fully in creating a healthy work environment and excellence in patient care. This does not preclude the utilization of discipline-specific professional practice committees to address discipline-specific practice issues.  
  3. Equalize power bases by urging provincial and territorial governments to ensure that Chief Nursing Officers/Chief Nursing Executives are members of the governing boards of their respective facilities, as it is mandated in Ontario for hospital CNEs  and for board of health CNOs. 
  4.  Increase healthcare staffing levels, particularly for RNs and NPs. This will reduce stress on patients and staff alike, as well as provide more of the support for staff when facing potentially violent situations. As part of that strategy, harmonize upwards the very unequal distribution of staff-to-population ratios across the country. For example, Ontario would require over 21,000 more RNs and NPs to catch up with the rest of the country.
  5. Expand health care services according to need. This will address access issues and ensure clients are served in the appropriate level of care.
  6. Support comprehensive training for all staff in identifying risk of violence, de-escalation of violence and personal protection including break-away techniques in the event of an attack. 
  7. Support the development of risk assessment tools by health service organizations. Ensure that health workers conduct risk assessments using validated tool. 
  8. Support health service organizations to implement protective and security measures, such as the followin
    • documentation and communication of a person’s previous incident(s) of violence;
    • equipment to protect against violent behaviours, and a standardized approach for deciding what, when and how to use these;
    • environmental security measures, including locked doors, closed-circuit cameras and alarm systems; and
    • formal reporting systems that are simple to use. 
  9.  Urge provincial and territorial governments to direct health service organizations to implement a process for formal incident reviews immediately following a violent event to discuss the details of what occurred, the approach that was used and the strategies for violence prevention in the future.
  10. Urge provincial and territorial governments to direct health service organizations and academic institutions to implement appropriate policies and codes of conduct to address harassment and bullying in the workplace and learning environment. 
  11. Urge provincial and territorial governments to direct health service organizations to provide education to health workers on how to identify harassment and bullying, understand the impact of harassment and bullying, and use effective communication strategies. Support formal leaders in health service organizations and academic institutions be actively involved in preventing and addressing harassment and bullying to support health workers and students by doing the following:
    • understanding and reinforcing policies that address harassment and bullying; and
    • providing mentorship and role modelling of professional behaviour. 
  12. Support, as part of an interactive learning approach, students to learn to use guided communication responses to address harassment and bullying from multiple sources within an academic institution or a clinical learning environment. 


There is a serious and widespread problem of violence facing nurses and other health care workers across Canada, and strong federal leadership can make a difference. Studying the problem is a first step, and we respectfully ask the Standing Committee to use all powers at its disposal to respond as decisively as possible to this very urgent situation, particularly heeding the advice of organizations representing the health workforce.

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