Patient flagging may decrease violence in health care

We continue to hear about concerning incidents of workplace violence across the country, particularly in the health-care sector, against health-care workers. The events that are reported in the media are only the most catastrophic, however statistics from workers' compensation boards indicate that in some provinces, reported violent events against health-care workers exceed those against police officers and correctional workers.

In Ontario, hospitals, nursing homes and home care are the largest segments in health care, representing over 75 per cent of 787,000 health-care workers. These sub-sectors also represent where workplace violence events are most prevalent. In 2013, 30.6 per cent of lost-time injuries due to workplace violence in Ontario occurred in the health-care sector and in Canada, out of 34 occupational categories, more work days were lost among nurses than any other category.

It is likely that many more workers are injured at work due to violence than indicated by statistics. Health-care workers are seeing these incidents as part of the job. In response to this issue, most provinces and territories have enacted legislation to protect workers from violence. The challenge in health-care remains the source of the hazard.

In many instances, the source of the violent event is the patient or client that the health-care worker is trying to assist and, in many cases, there is no intent to cause harm (for example, the patient is not aware of the consequence of his actions and is responding to an event in the only way he knows how at that instant). Intent should not change the requirement for health-care workers to report the incident, but it may change how the incident is dealt with.

We do know that regardless of intent, the patient remains the highest risk to caregivers from a workplace violence standpoint, so mitigation measures that focus on them as the source should be the most robust. In Ontario, there are components of the Occupational Health and Safety Act that require control measures for the patient as the risk: Requirement to complete a risk assessment, notify staff of a history of violence and the duty of the employer and supervisor to do everything reasonable in the circumstances to protect the worker.

There are some universal care practices we can use to decrease risk, but when there is a heightened risk, additional measures must be developed. One such measure is the implementation of a patient flagging and preventative care planning process. This process ensures health-care workers are aware there is a history or increased risk of violence or a responsive behaviour from a particular patient, but also triggers them to develop a care plan to ensure the patient is protected from harm, yet still receives the quality of care required.

In this approach, patients with a history or increased risk of violence would be "flagged." But ethical consideration must also be looked at. According to Robert Butcher, president of Foundations: Consultants on Ethics and Values Canada in London, Ont, first, the workplace needs to consider what is the threshold or trigger for flagging? Does "history" mean a criminal conviction for violence? And violence under what circumstances? Does it only count if it was an incident that occurred within the facility and not if there was a report of violence from another agency? How violent would the violence have to be to qualify? Physical contact or threatening gestures?

Second, how do you flag? If the flag is private (a notation on the chart perhaps) it does not help those who do not have access to the chart. If it is public, a wristband or a sign on the room, it broadcasts the patient’s private information to the world.

Third, what impact does the flag have on staff behaviour? What do staff do (or not do) differently for this patient (with a history or risk of violence) that they would not do (or do) for any other patient? Could those safety practices be incorporated into standard care thus removing the need for the flag? Might the difference in treatment caused by the flag exacerbate the risk of violent behaviour?

Finally, what is the evidence? What is the evidence that flagging patients diminishes the incidence of violent assaults on staff? And how is that balanced against the harm that is caused to patients by flagging them.

This is a difficult topic. There are competing interests and rights at stake. There is a fine line to be walked with dangers on either side. Too little attention to staff safety leads to the harm, pain and tragedy of reasonably avoidable injury. Too much concern for staff safety could lead to diminished treatment, loss of privacy and harm to patients. Patient care is inherently risky.

That being said, this process is being discussed as a leading practice in Ontario, where several large hospital have shown that using this process decreases the number of violent events towards workers.