Health care workers, unfortunately, have to face dealing with violent and abusive patients and visitors. One such incident occurred at the London Health Science Centre (LHSC), Victoria Hospital, adult mental health unit in April of 2017.

A male patient with a known history of violence assaulted a registered nurse after being admitted. The Ontario Ministry of Labour became involved, arising from the hospitals responsibilities under the Occupational Health & Safety Act (OHSA). A mediated settlement was reached which included the requirement that LHSC use a “violence assessment tool” going forward in which to assess and screen patients for violent and/or aggressive behavior.

The tool is known as the Acute Violence Assessment Tool (AVST) from the Public Services Health and Safety Association.

Scoring System

The AVST scores patients through a point system. Points are assessed based on any history of violence and ongoing observations of behaviour such as irritability, confusion, agitation, screaming, or threatening. A patient having one to three points is labelled a moderate risk, one with four or five points is considered to be a high risk, and any patients with greater than five points is assessed as being at a high risk for aggression or violence.

Once assessed as violent and/or aggressive, cautionary warnings are placed in the patient’s electronic chart. In addition, visible warnings will be implemented through the use of purple wrist bands and signs by the patient’s room showing a large exclamation point! The goal is to protect hospital staff by warning them of the patient’s potential for violence.

LHSC had implemented a violence screening tool since 2009 but its use was not universal. As of May of this year, it is to be used throughout the hospital for both inpatients and outpatients. The policy is also in the process of being reviewed and modified as a result of the settlement with the Ministry of Labour.

Other hospitals are, or will be, considering their own policies and legal responsibilities in the hopes of protecting their staff, nurses and doctors from being victims of patient or visitor violence.

Opposition

The policy, especially its outward implementation, has not gone unopposed. The psychiatrists at LHSC have commenced wearing their own purple wristbands which read “End the Stigma”. The protest is based on their concern that the use of warning signs is detrimental to their patients. The colour appears also purposively chosen for the more common the colour is on peopleès wrists the less stigma or impact they will have.

Other mental health advocates who have expressed concern are the Canadian Mental Health Association, the Arch Disability Law Centre and the Ontario Medical Association feeling that the armbands and signs are an invasion of privacy, are stigmatizing, and are counter-productive.

Commentary

How does this conflict between the best possible patient care and the safety of health care workers get resolved?

You would think that what is in the best interests of the patients would emerge as the priority. Nurses are, after all, patient advocates. In addition, various mental health experts and advocates feel the policy is both wrong and patient harmful, further placing more of the emphasis on patient care.

The counterbalance is the protection of staff from physical harm, a stance that is backed up by the OHSA and the Ministry of Labour as well the Ontario Nurses Association, as advocates for nurses.

Who advocates then on the patients behalf or in opposition to the policy? Does the Psychiatric Patient Advocate Office do so? Is it the Ministry of Health? The likely answer is that no group will do so unless there is a patient complaint.

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