Stigma. Violence. Are these Competing Priorities or an Opportunity?
calendar icon April 4th, 2018
author icon Kim Slade
Stigma. Violence. Are these Competing Priorities or an Opportunity?

As hospitals move to implement protections for healthcare workers related to violence in the workplace, there are concerns that patients may be stigmatized as a result of risk assessment and flagging processes.  I want to explore if addressing violence and stigma constitute competing priorities, or an opportunity to have in depth and important patient centered care conversations.


Violence is an issue. Just look at some of these numbers highlighted on – 34% of nurses reported a physical assault from a patient in the previous year; 808 healthcare workers in Ontario missed work last year because of violence.


As hospitals and other healthcare facilities move to implement policies to address workplace violence, it is important to take a holistic approach that considers the care provider, the patient and potentially even the patient’s family members. One tool that can be utilized to identify risk is the Individual Client Risk Assessment (ICRA) from PSHSA’s Violence Assessment Toolkit.


An extensive list of stakeholders, including senior representatives from healthcare organizations, frontline staff and labour unions, were involved in the development of the ICRA Tool. This group utilized evidence-based literature as the foundation for the development of the ICRA Tool and the supporting resources in the toolkit. This literature review included examining validated tools currently used in healthcare, mental health and addiction settings. The tools included the Broset Violence Checklist (BVC©) ( which can be used by healthcare professionals to identify imminent violent behaviours; and the Dynamic Appraisal of Situational Aggression (DASA) ( which is a tool that assesses the likelihood that a patient or client will become aggressive within a psychiatric inpatient environment.


The ICRA Tool is designed to help care providers identify risk factors and levels associated with workplace violence, and it promotes the idea that by conducting regular client-risk assessments, providers can apply control interventions that promote both employee and client safety, as well as ensure client-centred care. So how does it do that? The assessment tool has the worker rate, in an easy to understand yes/no fashion, the patient’s history of violence and 11 behaviours resulting in a risk rating. The use of the tool does not end with the risk rating, which is not made clear in the article. Following the risk rating, the worker continues to identify control measures which are put in place and include everything from applying the appropriate flagging system according to hospital policy to scanning the area for potential risks and removing them, to even discussing the result with the patient if it is safe to do so.


During this discussion with the patient, the healthcare worker can identify what may be contributing to the patient’s behaviours, such as hunger, pain, lighting, noise, etc., so that action can be taken to address factors that might be causing distress, agitation or feelings of anger. This active discussion continues to identify preventative measures that can be put in place to support the patient. Finally, the healthcare worker can use the information they have gathered to identify what they and the patient think are potential de-escalation techniques.


Hospital policies can then utilize various mechanisms to communicate risk, including indications within electronic files as well as through other visual signals that can be seen by hospital staff who do not have access to electronic files. This is similar to protocols put in place to identify allergies or, in some cases, end of life trajectories in long term care facilities so that people working in or near the area are aware and informed.


From a lay-person’s perspective, the tool itself seems to support a positive interaction between the healthcare worker and the patient. However, that does not mean that it will address existing and accepted stigmatizing behaviours that may, or may not, exist in the workplace environment.


So what role can healthcare workers play in the implementation of the tool to support both protecting the safety of front line workers and reducing stigmatizing behaviours within their work environment?


An important aspect of implementing this type of tool and supporting policy is education. This education should include the purpose of the risk assessment, how to identify and implement control measures, and hospital procedures. But what about stigma? Is this considered during education? The resources and tools designed to support the implementation of the ICRA Tool highlight the importance of terminology and a focus on contributing factors that may be impacting a patient’s health and wellbeing. Perhaps, there needs to be a specific conversation, and an effort to provide education to workers, supervisors and managers about the link between these protective measures and the potential for stigmatizaing behaviours.


The ICRA Tool, which contains the Violence Assessment Tool, is very comprehensive and went through exhaustive review before its release for use by healthcare workplaces. It has also been reviewed by two other provinces and is subsequently in use in Alberta and Saskatchewan. We are continuing to seek funding to evaluate the tool to better understand its application within the workplace and its role in reducing injuries and illnesses. The tool is designed to provide a snapshot of behaviours, and then it helps the healthcare worker determine appropriate control measures for the protection of both the patient and the worker.


The tool’s intent is not to stigmatize patients, but it intends to identify, assess and put in place controls that foster positive patient-centered care, deescalate risks and support both workers and patients to safely return to their homes and communities at the end of their shift or hospital stay. Additionally, patient assessments for behavious that may indicate a risk of imminent violence are a long standing practice in mental health facilities around the world and the tool in no way indicates that mental health patients are violent. However, healthcare environments should have an open discussion about the potential for stigmatization of patients, particularly those who are receiving mental health care.


I do not think that violence against workers and the stigmatization of patients are competing priorities within a healthcare environment. I believe the factors that impact both have overlapping contributing factors such as resource allocation, time pressures and increasing needs from the community. It is possible that mental health professionals within healthcare environments could play an important part in this aspect of implementation. As they learn about the tool and supporting policies and procedures, they may be able to provide input and guidance to ensure that behaviours fostering the stigmatization of patients, particularly those with mental health and addiction issues, are considered and addressed.


The implementation of these policies and tools in healthcare environments could present an opportunity for a uniquely collaborative and equally patient and worker-centered holistic approach to address workplace violence.

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