Danger on the job
Patient assaults on St. Joe’s staff soar amid changes to mental-health treatment and budget cuts
STAFF MEMBERS AT ST. JOSEPH’S West 5th site have used pillows and mattresses to shield themselves from patients, says a Ministry of Labour report.
The hospital’s mental health facility, located at the corner of Fennell Avenue West and West 5th Street, has had 24 orders issued against it since Dec. 16, 2015.
Twenty of those orders came in June, and in that inspector’s notes it says staff told him about the use of the makeshift protective materials.
On Friday, a registered practical nurse (RPN) was assaulted by a patient who tackled and groped her when she pulled away from his attempt to kiss her.
The incident has led to a call from CUPE Local 786 president Domenic DiPasquale to have St. Joseph’s double up staff when interacting with patients.
This past winter, there were at least six assaults on staff at the West 5th campus, including hot coffee thrown in a nurse’s face, another having his nose broken, and a beating that left a nurse unconscious.
The Mountain site, which was part of a half-billion-dollar overhaul of the previous mental health care site, opened two years ago and is centred on destigmatizing mental health and addiction.
Since the new site opened, the numbers of physical assaults on nurses has jumped 41 per cent — from 80 at the old site in 2013 to 113 at the new site in 2015, according to data from St. Joe’s.
“We are trying to strike that balance between stigma and safety of staff,” said Dr. David Higgins, president of St. Joseph’s Healthcare, adding that recent process changes have put them on the right track.
One of the orders requires an assessment of personalized protective equipment for employees.
Other problems cited include issues with posting workplace violence and harassment policies, and providing non-violent crisis intervention training to employees.
The winter incidents prompted St. Joe’s to commission an external review, conducted by mental health and workplace violence experts from across Ontario, on workplace safety.
The final report has not yet been issued to the hospital’s violence prevention committee.
The Ministry of Labour said Wednesday the hospital has complied with 11 of the 20 June orders, including policy postings, risk assessments, and precautions to ensure patients do not enter certain areas of the hospital. The hospital has met all deadlines for orders due in July.
Nine of the orders still “in process” include one of two orders to provide training for non-violent crisis intervention train-
“We are trying to strike that balance between stigma and safety of staff.” DR. DAVID HIGGINS PRESIDENT OF ST. JOSEPH’S HEALTHCARE
ing. Training was ordered on two separate units.
THE PHILOSOPHY of West 5th — a departure from how St. Joe’s previously administered mental health services — has brought changes to the model of care.
It has meant combining mental health and addiction services — often closely related — while providing care to the general public in an effort to reduce the sense of separation from society for those who are mentally ill.
That meant reducing the number of seclusion rooms and providing patients with as much personal freedom as possible through an electronic key card system.
“I’m worried about our members’ safety first,” DiPasquale said.
“Once we do that we can work on the stigma.”
While its Charlton campus employs unionized security workers making around $25 an hour, the security officers at West 5th are contracted out and earn closer to minimum wage, said DiPasquale.
St. Joe’s did not verify the wage earnings of its security team.
Since February, the hospital has replaced all 1,400 of the personal alarms staff currently use to call for help by clicking a button on a lanyard around their neck.
During some of the winter assaults, between Dec. 16 and Feb. 3, seven staff alarms failed.
The MOL orders include briefing the West 5th Joint Health and Safety Committee on proposed solutions to the problems.
Higgins said St. Joe’s is working with the committee as required by the Occupational Health and Safety Act.
He said management has to evaluate the committee’s recommendation, but it has the “right to respectfully decline” in certain circumstances.
Vicki McKenna, vice-president of the Ontario Nurses Association, said she is frustrated that members of the committee previously made recommendations resembling those of the ministry.
That includes recommendations dating back to 2015 to have all staff trained in non-violent crisis intervention training.
Higgins said the external review, conducted by expert physicians and nurses from across Ontario, will help close gaps found in their internal review, and progress already made around staff and patient safety.
EARLIER THIS YEAR, St. Joe’s announced 136 impending job cuts in an effort to help balance a $26-million budgetary gap, something Higgins admitted was a “challenge.”
Before the announcement, there had been concerns raised by nursing unions about understaffing at West 5th.
“When you have less staff, you have a lower quality of care — period,” DiPasquale said.
“A lower quality of care means patients will be lashing out more frequently.”
Higgins said that “front-line nursing hours are not changing” at the West 5th campus because the facility is “changing the mix of skills.”
The facility is replacing many registered nurses with registered practical nurses, who make less and require less education.
The positions that are eliminated will come from bed conversions and other program changes, Higgins said.
In June, St. Joe’s spokesperson Agnes Bongers wrote that operational changes have meant the number of nurses at West 5th has remained “about the same” compared to 2015. Those operational changes include the recent opening of the seniors’ mental health unit.
The ONA’s McKenna said registered nursing jobs have not been cut yet — but that they were not being replaced, either.
“There has not been an overt reduction, but if someone transfers or retires they haven’t been replacing them,” she said.
“They are replaced by younger, more inexperienced workers,” which can compound violent incidences, said DiPasquale.
He also said that not all positions left open by departing RPNs were being replaced.
Higgins said he does not believe patients will experience a decline in care, but he recognizes the need for a provincewide discussion on providing a safe workspace in the face of budgetary constraints imposed by federal and provincial governments.
This issue is not exclusive to St. Joe’s, he said.
“There has been no significant funding increase in the hospital sector for several years now and inflation keeps going up.”
ACROSS THE PROVINCE, 11 per cent of lost-time claims from nurses are due to workplace violence, says the Ontario Nurses Association.
Erna Bujna, health and safety representative for the association, said the trend in rising assaults at St. Joe’s can also be seen provincewide.
She said some health care facilities report up to 4,000 security calls and 500 violent incidents in a year.
Provincial data show more than 600 lost-time injuries in 2013, and 88 of those were reported by a single hospital — something Bujna says demonstrates “there is huge under-reporting.”
Henrietta Van hulle, executive director of Health and Community Services for the Public Services Health and Safety Association, a publicly funded group that works to reduce workplace risks and prevent occupational injuries and illnesses, said lost-time injuries increased to 680 in 2014 from 624 in 2012 for Ontario nurses.
Of the 10 occupations recording the highest number of lost-time injuries in Ontario, four of them are in health care, said Van hulle.
That includes registered nurses and registered practical nurses, with registered nurses experiencing a higher number of lost-time injuries than correctional service officers.
“We have seen a steady increase over the last 10 years,” said Van hulle. “It has been a trend.”
The difficulty is figuring out why they are on the rise, said Van hulle. One theory is that reporting has improved. Another, that injuries to nurses are getting more severe under rising health-care pressures.
Some hospitals have been known to discourage reporting, or even violate provincial legislation in order to deflate their numbers, said Bujna.
She recognizes increased reporting as contributing to the increase, but believes “rising acuity of patients and staffing shortages” to also be central issues in this debate.
“It’s not just mental health, it’s people frustrated with the system, it’s people frustrated with wait times,” said Bujna.
AT MICHAEL GARRON THE Hospital, formerly known as the Toronto East General Hospital, more nurses are calling for help, but fewer staff are getting seriously injured year over year.
In 2007, the hospital’s CEO recognized violent incidents were not being properly addressed and instituted a zero-tolerance policy for violence.
All hospital staff is equipped with a personal alarm that allows twoway communication with security, and a double click system that brings security to their location.
The hospital has made “significant investments” in training, with the inhouse security team getting “over and above” what is necessary and nurses receiving emotional intelligence training.
Both groups run simulations throughout the year to practice what they’ve learned.
“There is no silver bullet,” said the hospital’s chief nursing executive Irene Andress. “You need to do this very intentionally and methodically over time.”
Andress, whose organization has been recognized by the Ontario Nursing Association as a leader in staff and patient safety, said the intention has to start with direction from senior management.
Garron has introduced signage to promote a culture against violence, partnered with outside agencies to help implement change and continually seeks out new data.
It also uses a tracking system that allows nurses to flag patients who have displayed aggression in the past to give future staff tips on what that patient’s triggers are and how to de-escalate.
Since February, St. Joe’s has begun piloting a similar dangerous patienttracking system, though Higgins notes this system needs to be used cautiously. It has also ensured crisis intervention training is documented, and an evaluation system to review incidents.
Higgins said Garron is one of the “bigger Ontario hospitals” St. Joe’s will be looking to for guidance.
He said increased training, encouraging reporting, and data analysis will be critical to minimizing aggressive situations when they arise.
“I feel we’ve got to keep the pressure on to ensure that we have the appropriate systems and that our staff feel safe,” said Higgins.
“There is no silver bullet. You need to do this very intentionally and methodically over time.” IRENE ANDRESS MICHAEL GARRON HOSPITAL CHIEF NURSING EXECUTIVE