Understanding, Measuring, and Ameliorating Workplace Violence in Healthcare: A Canadian Systematic Framework to Address a Global Healthcare Phenomenon (preprint)

Background: Globally, healthcare institutions have seen a marked rise in workplace violence (WPV), especially since the Covid-19 pandemic began, affecting primarily acute care and emergency departments (EDs). At the University Health Network (UHN) in Toronto, Canada, WPV incidents in EDs jumped 169% from 0.43 to 1.15 events per 1000 visits (p<.0001). In response, UHN initiated a comprehensive quality improvement (QI) project to address WPV. This study presents the project's design, implementation, results, and key takeaways, aiming to showcase effective and trauma-informed strategies for mitigating WPV in healthcare settings. Methods: Our multi-intervention QI initiative was guided by the Systems Engineering Initiative for Patient Safety (SEIPS) 3.0 framework. We also leveraged the SEIPS 101 tools to aid in crafting each QI intervention. This approach amalgamated various methodologies to approach WPV, incorporating literature reviews, a modified Delphi method, qualitative interviews, surveys, quantitative data gathering and pragmatic interventions. Results: Our complex intervention contained a total of 12 subprojects. We reviewed existing literature (n=84) pertaining to WPV in healthcare. N = 229 quality indicators utilized to measure WPV in healthcare were extracted from the literature and underwent a Delphi process which yielded 17 quality indicators for a new organizational WPV dashboard. WPV theories were critically reviewed in the context of intervention development. Educational initiatives (n=2) were implemented including ad-hoc point of care training, as well as rollout of a comprehensive trauma-informed training program for WPV prevention, verbal de-escalation and management of escalated responsive behaviour. Further changes involved establishing a Code White Governance Committee, enhancing WPV reporting and addressing underreporting. Debriefing was structured into hot and cold debriefing models. Additionally, environmental indicators promoting mutual respect were introduced, alongside security enhancements including wearable video devices for all security guards and a 100% increase in ED security guards. Outreach initiatives were implemented including qualitative interviews with ED staff (n=75) and the development of a patient partner and community outreach group. Conclusions: WPV in healthcare is a complex phenomenon that urgently requires effective solutions. We developed a 13-step framework that offers guidance for healthcare institutions seeking to develop a systemic approach in addressing WPV tailored to their organization’s needs.

Omicron and future public health emergencies: Sustainability and insights into support programs for healthcare providers (preprint)

Background: The mental health of healthcare workers (HCWs) has been at the forefront throughout the COVID-19 pandemic. While workplace-based support programs have been developed in hospitals globally, few systematically collected data. While critical to their success, information on these programs and the experience of mental healthcare providers (MHP) who support colleagues is limited. The objective of this study was to explore the experiences of MHP caring for HCW colleagues within a novel workplace-based mental health support program during the COVID-19 pandemic, to provide insights on facilitators, areas for improvement and barriers to program sustainability. Methods: This qualitative study used semi-structured interviews conducted by videoconference between September 2020 to October 2021.  UHN CARES (University Health Network Coping and Resilience for Employees and Staff) Program was developed during the first wave of the COVID-19 pandemic in March 2020. It supports over 21,000 staff members within the UHN, Canada’s largest academic health research institution, in Toronto, Canada. Purposive sampling was used to select 10 of the 22 MHP in the UHN CARES Program. Using a critical realism framework, key components required to sustain a successful workplace-based mental health support program for HCWs and balance the needs of MHP were determined. Results: Six psychiatrists and four psychologists with varying roles at UHN participated in 17 interviews, with repeat interviews exploring changes over time within the pandemic and program. Components which facilitated the success of the program included flexibility in scheduling, confidential health record storage, comprehensive administrative support, availability of resources and adaptive quality improvement approach. Recommendations for improvement included opportunities for peer supervision, triaging of cases, and managing HCW expectations. MHP found caring for HCWs to be meaningful and they utilized existing clinical skills during sessions. Challenges included working in a virtual setting, navigating boundaries when caring for colleagues, and managing the range of service users and their needs.Conclusions: These findings suggest how support programs can be structured for HCWs, how to provide support, and how to sustain this support, allowing health systems to balance the needs of HCWs and MHPs in preparation for future public health emergencies.