Preventing Violence, Harassment and Bullying Against Health Workers Second Edition Disclaimer

Best Practice Guideline

JULY 2019 Preventing Violence, Harassment and Bullying Against Health Workers Second Edition Disclaimer

These guidelines are not binding on nurses, other health workers, or the organizations that employ them. The use of these guidelines should be flexible and based on individual needs and local circumstances. They constitute neither a liability nor discharge from liability. While every effort has been made to ensure the accuracy of the contents at the time of publication, neither the authors nor the Registered Nurses’ Association of Ontario (RNAO) gives any guarantee as to the accuracy of the information contained in them or accepts any liability with respect to loss, damage, injury or expense arising from any such errors or omission in the contents of this work.

With the exception of those portions of this document for which a specific prohibition or limitation against copying appears, the balance of this document may be produced, reproduced and published in its entirety, without modification, in any form, including in electronic form, for educational or non-commercial purposes. Should any adaptation of the material be required for any reason, written permission must be obtained from RNAO. Appropriate credit or citation must appear on all copied materials as follows:

Registered Nurses’ Association of Ontario (RNAO). Preventing violence, harassment and bullying against health workers. 2nd ed. Toronto (ON): RNAO; 2019.

Funding

This work is funded by the Ontario Ministry of Health and Long-Term Care. All work produced by RNAO is editorially independent from its funding source.

Conflict of Interest

In the context of RNAO best practice guideline development, the term ‘conflict of interest’ (COI) refers to situations in which an expert panel member’s financial, professional, intellectual, personal, organizational and/or any other relationship may compromise their ability to independently conduct panel work. Declarations of COI that might be construed as constituting a perceived and/or actual conflict were made by all members of the RNAO expert panel prior to their participation in guideline development work using a standard form (https://rnao.ca/bpg/guidelines/ workplaceviolence). Expert panel members also updated their COI at the beginning of each guideline meeting. Any COI declared by an expert panel member was reviewed by the RNAO Best Practice Guideline Development and Research Team and expert panel co-chairs. No limiting conflicts were identified. See “Declarations of Conflicts of Interest Summary” at https://rnao.ca/bpg/guidelines/workplaceviolence.

Contact Information Registered Nurses’ Association of Ontario 158 Pearl Street, Toronto, Ontario M5H 1L3 Website: www.RNAO.ca/bpg Preventing Violence, Harassment and Bullying Against Health Workers Second Edition Preventing Violence, Harassment and Bullying Against Health Workers - Second Edition

Greetings from Doris Grinspun, Chief Executive Officer, Registered Nurses’ Association of Ontario

The Registered Nurses’ Association of Ontario (RNAO) is delighted to present the second edition of the healthy work environment best practice guideline (BPG) Preventing Violence, Harassment and Bullying Against Health Workers. Evidence- based practice supports the excellence in service that health professionals are committed to delivering every day.

We offer our heartfelt thanks to the many stakeholders who make our vision for BPGs a reality. First, and most important, we thank the Government of Ontario that recognized early on RNAO’s capacity to lead a program that has gained worldwide recognition and is committed to fund it. We also thank the co-chairs of the RNAO expert panel, Henrietta Van Hulle (Vice President, Client Outreach at the Public Services Health & Safety Association) and Dr. Gordon Gillespie (Professor and Deputy Director of the Graduate Occupational Health Nursing Program at the University of Cincinnati), for their invaluable expertise and stewardship of this BPG. Thank you to RNAO staff Giulia Zucal (Guideline Development Methodologist Co- Lead), Laura Ferreira-Legere (Former Guideline Development Methodologist Co-Lead), Erica D’Souza (Project Coordinator), Megan Bamford (Associate Director, Guideline Development and Evaluation), and the rest of the RNAO Best Practice Guideline Development and Research Team for their intense and expert work in the production of this BPG. Special thanks to the expert panel for generously providing their time, knowledge and perspectives to deliver a rigorous and robust evidence-based resource that will guide the education and practice of millions of health workers. We couldn’t have done it without you!

Successful uptake of BPGs requires a concerted effort from educators, clinicians, employers, policy-makers, researchers, and funders. The nursing and health communities, with their unwavering commitment and passion for excellence in patient care, provide the expertise and countless hours of volunteer work essential to the development of new and next edition BPGs. Employers have responded enthusiastically by becoming Best Practice Spotlight Organizations (BPSO®), sponsoring best practice champions, implementing BPGs and evaluating their impact on patient and organizational outcomes. Governments at home and abroad have joined in this awesome journey. Together, we are building a culture of evidence-based practice that benefits all.

We invite you to share this BPG with your colleagues from nursing and other professions, with the patient advisors who are partnering within organizations, and with the government agencies with which you work. We have much to learn from one another. Together, we must ensure safe and healthy workplaces for nurses and all other health workers so that the public receives the best possible care every time they come in contact with us – making them the real winners of this great effort!

Doris Grinspun, RN, MSN, PhD, LLD (hon), Dr (hc), FAAN, O. ONT. Chief Executive Officer Registered Nurses’ Association of Ontario Preventing Violence, Harassment and Bullying Against Health Workers - Second Edition

Table of Contents

How to Use this Document ...... 5

Purpose and Scope ...... 6

Interpretation of Evidence and Recommendation Statements ...... 11

Summary of Recommendations ...... 14 BACKGROUND

Best Practice Guideline Evaluation...... 18

RNAO Best Practice Guideline Development and Research Team ...... 23

RNAO Best Practice Guideline Expert Panel ...... 24

Stakeholder Acknowledgment ...... 26

Organizing Framework for the System and Healthy Work Environments Best Practice Guidelines Project ...... 29

Background Context ...... 33

Recommendations ...... 36 RECOMMENDATIONS

Research Gaps and Future Implications ...... 85

Implementation Strategies ...... 87 REFERENCES References ...... 89

BEST PRACTICE GUIDELINES • www.RNAO.ca 3 Preventing Violence, Harassment and Bullying Against Health Workers - Second Edition

Table of Contents

Appendix A: Glossary of Terms ...... 98

Appendix B: RNAO Best Practice Guidelines and Resources that Align with this Best Practice Guideline ...... 105

Appendix C: Best Practice Guideline Development Methods...... 107

Appendix D: Process for Best Practice Guideline and Systematic Review ...... 119

Appendix E: Indicator Development Process ...... 123

Appendix F: Risk Factors ...... 125

Appendix G: STAMPEDAR Framework ...... 127

Appendix H: Validated Risk Assessment Tools ...... 129 APPENDICES Appendix I: Approaches to Education Delivery ...... 136

Appendix J: Safewards Model ...... 140

Appendix K: Communication Responses Lanyard Card ...... 143

Appendix L: Workplace Health and Safety Survey Vulnerability Scale ...... 144

Appendix M: Resources ...... 147

Appendix N: Description of the Toolkit ...... 151

Endorsements ...... 152 ENDORSEMENTS ENDORSEMENTS

Notes ...... 155 NOTES

4 REGISTERED NURSES’ ASSOCIATION OF ONTARIO BACKGROUND 5

G . To . To bullying , as well as as well , as G and Glossary Terms of G www.RNAO.ca Toolkit: Implementation Implementation Toolkit: www.RNAO.ca/bpg health workers harassment , G ) can be found in the be) can found . For more information, please see information, more . For G and other other and G violence programs in relation to the recommendations the recommendations to in relation programs G nurses BEST PRACTICE GUIDELINES • BEST PRACTICE receiving care. This BPG should be reviewed and be should BPG This care. receiving G * is a comprehensive document designed to support support designed to document a comprehensive * is G www.RNAO.ca education family . It is not intended to be a manual or “how-to” guide; rather, rather, guide; “how-to” or beto a manual intended not is . It G (BPG) (1), are available at at available (1), are . best practice guideline and academic institutions in creating and sustaining positive work environments. It It environments. work positive sustaining and creating in academic institutions and G on p. 87. p. on Preventing Violence, Harassment and Bullying Against Health Workers - Second - Edition Workers Health Against Bullying and Harassment Violence, Preventing evidence-based practice nursing , colleagues, visitors, persons or their or persons visitors, , colleagues, G and the evidence that supports them. We particularly recommend that practice and academic practice and that particularly recommend them. We supports the evidence that and G ). . G www.RNAO.ca/contact

formal leaders formal

Identify existing needs or gaps in your policies, procedures, protocols and educational programs. programs. educational and protocols policies, procedures, your in gaps needs or existing Identify organization’s your be can used address to that and setting your to applicable are that the recommendations Note gaps. needs or existing evaluating best practices and sustaining recommendations, integrating or implementing for a plan Develop outcomes Read the Organizing Framework for the System and Healthy Work Environments Best Practice Guidelines Best Practice Guidelines Environments Work Healthy and the System for Framework Read the Organizing environments. work healthy model for the conceptual with yourself familiarize section and Project and protocols policies, procedures, existing your Assess in this BPG. Appendix A Appendix ( Throughout this document, terms that are marked with a superscript G ( superscript a with marked are terms that document, this Throughout * We are interested in hearing your feedback on this BPG and how you have implemented it. Please share your story your Please share it. implemented have you how and this BPG on feedback your in hearing interested are We at us with All of the RNAO BPGs are available for download, free of charge, on the RNAO website at at website the RNAO on charge, free of download, for available are BPGs the RNAO All of topic. by browse or keyword by a particular search locate BPG, of Best Practice Guidelines, Second Edition Edition Second Guidelines, Practice Best of Strategies Implementation Implementation resources, including the Registered Nurses’ Association of Ontario (RNAO) (RNAO) Ontario of Association Nurses’ the Registered including resources, Implementation 4. 5. 3. 2. If your organization is adopting this BPG, we recommend that you follow these steps: follow you that recommend we this BPG, adopting is organization your If 1. recommendations use. daily for feasible are that in formats this BPG adapt settings Nurses and other health workers, administrators and educators who lead and facilitate practice changes will find practice changes facilitate who lead and educators and administrators health workers, other and Nurses support to tools and programs educational protocols, policies, procedures, developing for invaluable this document reviewingthe from will Those in direct benefit care academic environments. and workplaces healthy and safe persons and families accessing your organization and your health system. In addition, this BPG offers an overviewan of offers this BPG addition, In health system. your and organization your accessing families and persons evidence-based the best possible care. providing for supports and structures appropriate applied in accordance with the needs of individual organizations, academic institutions or other practice settings. settings. practice other or academic institutions organizations, individual the needs with of in accordance applied the and health workers of preferences the needs with and implementation its contextualizing recommend We it is a tool to guide best practices and enhance decision-making for for decision-making enhance best guide and practices to a tool is it workplace of knowledge have or experience, encounter who may students from health service organizations for resources provides How to Use this Document to Use How environment work healthy This BACKGROUND 6 colleagues, visitors, persons and families. their knowledge of workplace violence, harassment and bullying from formal leaders(such as management and faculty), institutions, and it by utilized workers can health be all and students may who encounter experience, or have These steps informedscope the this of BPG. This BPG is organizationsapplicable service health all to academic and    team took following the steps: To and determine scope the organization of BPG, RNAO this the Guideline Practice Best Development and Research Scope BPG (see Research Team and RNAO the panel to and determine expert scope the priority recommendation questions for this A systematic and comprehensive analysis was completed by RNAO the Guideline Practice Best Development and address areas all where workers health and students at can be risk of encountering violence. harassment and bullying are prevalent sectors; consequently, inall diversity the panel of is essential to expert the long-term care, home care, health mental care primary health, and family teams. health Workplace violence, organizations,of service health institutions, academic practiceareas and sectors ranging from acute care, pediatrics, It was comprised of individuals holding clinical, administrative, and student security academic, roles across arange and inworkplace lived experience violence, harassment and bullying. The RNAOpanel was interprofessional. expert For development the of BPG, this RNAO convened panel an consisting expert of agroup of individuals with expertise environments optimize also teaching and learning settings. inacademic are an enabler for nurses and other workers health to optimize outcomes clinical for receiving those care. Such and institutions academic through adoption the practices.Safe of and evidence-based healthy work environments Safety and Well-being of the Nurse This BPG thereplaces RNAO BPGs system as awhole. andpolicies education, with aim the of achieving optimal outcomes health for people, communities and health the families with lived BPGs promote experience. consistency and excellence care, inclinical administrative practices, care positions, students, educators, administrators and executives, researchers policy-makers, and persons and clinical, healthy work environment and system health topics, intended for nurses and other workers health indirect RNAO BPGs are systematically documents that developed, evidence-based include recommendations on specific Purpose Purpose andScope Preventing Violence, Harassment and Bullying Against Health Workers Edition -Second

in organizations; and and consulted panel co-chairs with expert the and entire the panel inMay expert 2017. conducted two RNAO the reviewed BPGs Well-being of the Nurse REGISTERED NURSES’ ASSOCIATION OF ONTARIO Appendix C scoping reviews scoping ).

Preventing and Managing Violence in the Workplace (2); (2008) (2,3).It organizations to enhance is used to safety the be of service health G of literature the to determine existing research on bullying among workers health Preventing and Managing Violence in the Workplace ( (3)and 2009) and Workplace Health, Safety Workplace

Health,

BACKGROUND 7 www.RNAO.ca BEST PRACTICE GUIDELINES • BEST PRACTICE Any health setting or workplace where a health worker provides care to persons and/or and/or persons to care provides a health worker where workplace or health setting Any Preventing Violence, Harassment and Bullying Against Health Workers - Second - Edition Workers Health Against Bullying and Harassment Violence, Preventing Defined as “all people engaged in actions whose primary intent is to enhance health” (7). This (7). This health” to enhance is primary whose in actions “all intent engaged people Definedas Refers to a person in a formal leadership position, including managers, supervisors, clinical managers, including position, leadership in a formal a person to Refers Comments or behaviours that are unwelcome and persistent, including sexual harassment (6). Remarks, (6). Remarks, sexual harassment including persistent, and unwelcome are that behaviours or Comments Obtaining theoretical knowledge and cultivating the ability to use critical thinking and decision-making use critical decision-making to thinking and the ability cultivating and knowledge theoretical Obtaining Repeated and persistent behaviours that can include social isolation, creating or spreading rumours, rumours, spreading or creating social include isolation, can that behaviours persistent and Repeated implementation strategies and tools for organizations; for tools and strategies implementation and criteria; evaluation in knowledge. gaps and opportunities research future risk assessment tools and strategies; and tools assessment risk responsibilities; and requirements policies, procedures, organizational strategies; and approaches educational

the recommendations is not limited to acute care unless otherwise care stated. acute to limited not is the recommendations families and practices within their scope (e.g., acute care, home health care, primary care, community care or long- or care community primary care, health care, home care, their scope within practices acute (e.g., and families of the applicability and health service occur can in any bullying organization, and harassment Violence, term care). in this definition when they enter a clinicalplacement. a when they enter in this definition serviceHealth organization: workers) and additional support staff (e.g., patient transportation workers, dietary staff and volunteers) who come come who volunteers) dietaryand staff workers, transportation (e.g., patient staff support additional and workers) included are program in a health worker enrolled Students their families. and care receiving persons with contact into Health worker: Health social workers physicians, practical nurses, registered nurses, registered (e.g., health professionals regulated includes outreach and assistants physician workers, personal support (e.g., health workers unregulated physiotherapists), and health workers from persons; (b) between colleagues; (c) between students and health workers; and (d) between and health workers; and (b) between (c) between colleagues; persons; students from health workers health workers. and leaders formal jokes or innuendos that demean, ridicule, intimidate or offend a health worker or student are considered examples of examples considered are student or worker health a offend or ridicule, demean, intimidate that innuendos or jokes occur: can (a) towards harassment academic institution, or a health service In organization harassment. workplace educators, faculty and administrators. faculty and educators, Harassment: their role within the organization. the organization. within their role leader:Formal skills. Education includes three continuous and fluid levels: awareness, training for specific needs and competency- specificand needs for training awareness, levels: fluid and continuous three includes skills. Education and the health worker practice of the scope to of be tailored should (5). Education based specialization skills, and between formal leaders and health workers. health workers. and leaders between formal Education: withholding job responsibilities (4). In a health service organization or academic institution, bullying can occur: can bullying academic institution, or a health service (4). In organization job responsibilities withholding (d) and health workers; and (b) between (c) between colleagues; persons; students from health workers (a) towards Key Concepts Used in this Best Practice Guideline Used in this Best Practice Key Concepts Bullying: and abuse, or threatening abusing physically a person, intimidating criticism, unjustified or in excessive engaging      Specifically, the BPG will address how to recognize, prevent, and manage violence, harassment and bullying in bullying the and harassment violence, manage and prevent, recognize, to how BPG will the address Specifically, areas: will the following focus on It workplace.  BACKGROUND 8     The following conditions and topics are not coveredscope withinthe this of BPG: Topics OutsidetheScopeofthisBestPractice Guideline mitigate its occurrence. of care and stigmatization; for that reason, it to is understand critical cause the of violence inorder to prevent and or aperson with unmet Labeling abehavioural needs. or psychological as illness “violent” can result inaltered levels behavioural and psychological symptoms of an (e.g., illness dementia or delirium) that are exhibited to express met It is important to note that violence from aperson receiving care, family their or avisitor result the can be of discussions literature inthe (e.g., studies or reports) alternative use terms (such as “aggression”). a worker or throwing an at object aworker (24).Exceptions of to use the termthroughout this when BPG this occur workplace violence include: threats, verbal threatening notes, shaking afistthe in worker’s face, hitting/trying to hit mostthe prevalent of type workplace violence is from person receiving the care or family their (25).Examples of physical force that can to lead physical harm are considered also organizations, violence (24).In service health aggression,Sexual statements, verbal non-verbal behaviours, or that acts are reasonably interpreted as athreat of Violence: an organization (9). Vertical violence: during placement aclinical definition (see for “health worker”). training inan institution academic and/or lab setting. skills The studentsis term not to describe used practicing Student: discussionswhen literature inthe (e.g., studies or reports) alternative use terms (e.g., patient, client or resident). (e.g., parents, caregivers, and friends substitute decision-makers) (11,12).Exceptions of to use the termoccur this organizations (10).The term “person” notwill only include an individualthe system, in health theirbut family also forpartnering terms Replaces health. the “patient,” “client” and “resident,” are which across used service health Person: humiliation and exclusion (9). most common example of horizontal violence is harassment, including abuse, verbal threats, intimidation, criticism, organization. on Depending literature, the horizontal referred violence be can also to as “lateral violence” (8).The Horizontal violence: Preventing Violence, Harassment and Bullying Against Health Workers Edition -Second

organization or institution academic (although some recommendations may indirectly applicable be to issue). this institutionacademic has who relationship apersonal to worker health the employed at service health the thatacts to donot workers health pertain or students. Terrorist events or mass incidents of violence that within setting. ahealth occur Domestic and/or by violence perpetrated aperson not sexual employed organization by service health the or Violence, bullying and/or harassment organization outside of service ahealth or institution, academic or any such Workplace violence, bullying and/or harassment initiated by worker ahealth against aperson receiving care. An individual with whom worker ahealth has established atherapeutic relationship for of purpose the An individual currently enrolled inany worker health education program is who receiving education or REGISTERED NURSES’ ASSOCIATION OF ONTARIO The use, or attempted use, of physical force againstpersonthat a causes, or couldcause, physical injury. Violence, harassment or bullying are colleagues who that between occurs at unequal levels within Violence, harassment or bullying directed at are colleagues who of level equal within an BACKGROUND 9 Appendix C. Appendix ) PICO research research PICO , recognition of of , recognition G www.RNAO.ca incivility : time and utility : time and G BEST PRACTICE GUIDELINES • BEST PRACTICE surrogate outcomes surrogate ( , perceived safety of health workers, attitudes and values of health of values and attitudes health workers, of safety , perceived G and accessibility in practice accessibility and

Should education and training programs on preventing and managing workplace workplace managing and preventing on programs training and education Should Should health workers be recommended to use risk assessment tools to detect to tools useassessment risk to be recommended health workers Should restraints G Should organizational policies and procedures to prevent and manage workplace workplace manage and prevent to procedures policies and organizational Should Preventing Violence, Harassment and Bullying Against Health Workers - Second - Edition Workers Health Against Bullying and Harassment Violence, Preventing validity , G and development of this BPG. For the PICO research questions and the detailed process of how how of the detailed process and questions research the PICO For this BPG. of development and G Reliability Patient injury, use of use of injury, Patient Physical environment (surrogate outcomes: health worker injury, incident reporting, assault and threat threat and assault reporting, incident injury, health worker outcomes: (surrogate environment Physical

(population, intervention, comparison, outcomes) developed by the RNAO expert guide the to panel the RNAO by developed outcomes) comparison, intervention, (population, G These priority recommendation questions are condensed versions of the more comprehensive more of the versions condensed are questions recommendation priority These procedures, and education on approaches to prevent and manage workplace violence, harassment and bullying in bullying and harassment violence, workplace manage and prevent to approaches on education and procedures, education. and practice Recommendations are presented based on the recommendation question they answer. question based the recommendation on presented are Recommendations and policies organizational assessment, to risk related guidance provide BPG in this recommendations The Recommendations questions systematic reviews please see outcomes, and questions recommendation expert determined these priority panel the RNAO Note: Note: Outcomes: Outcomes: turnover worker health staff and injury, health worker workers, Recommendation Question #3: Question Recommendation and persons for outcomes improve to health workers for be recommended bullying and/or harassment violence, health workers? towards health workers) and health worker well-being (surrogate outcomes: perceived perceived outcomes: (surrogate well-being health worker and health workers) towards policybullying, implementation) worker outcomes? outcomes? worker Outcomes: Recommendation Question #2: Question Recommendation health and organizational improve to be recommended health workers among bullying and/or harassment violence, behaviours indicative of workplace violence, harassment and/or bullying? and/or harassment violence, workplace of indicative behaviours Outcomes: by the RNAO expert panel. They informed the development of this BPG. of this development the expert They informed panel. the RNAO by #1: Question Recommendation Recommendation Questions Recommendation developed were outcomes and questions recommendation priority following the Based theabove, scope defined on BACKGROUND 10      RNAO BPGs and other resources on following the related topics: RNAOOther resources BPGs and evidence-based may support implementation of BPG. this See that AlignwiththisBestPracticeGuideline Registered Nurses'AssociationofOntarioBestPracticeGuidelinesandResources Preventing Violence, Harassment and Bullying Against Health Workers Edition -Second interprofessional cultural safe, effective staffing and practices. workload managing and mitigating conflict; and implementation science, implementation frameworks and resources; REGISTERED NURSES’ ASSOCIATION OF ONTARIO sensitivity health teamhealth G ; G ; Appendix B for for BACKGROUND 11 methods. For methods. For high, moderate, low low moderate, high, G www.RNAO.ca . Reprinted with permission. permission. with . Reprinted BEST PRACTICE GUIDELINES • BEST PRACTICE for the definition of these categories. of these categories. the definition for (i.e., the extent to which the review finding is a reasonable reasonable is a which the review to finding the extent (i.e., G Table 1 . See Grading of Recommendations Assessment, Development and Evaluation Evaluation and Development Assessment, Recommendations of Grading very low https://gdt.gradepro.org/app/handbook/handbook.html#h.svwngs6pm0f2 or qualitative research qualitative . Preventing Violence, Harassment and Bullying Against Health Workers - Second - Edition Workers Health Against Bullying and Harassment Violence, Preventing We have very little confidence in the effect estimate: The true effect is likely to effect estimate: The true little confidence in the effect have very We from the estimate of effect. be substantially different We are very confident that the true effect lies close to that of the estimate of are very confident that the true effect We the effect. is likely estimate: The true effect are moderately confident in the effect We but there is a possibility that it is effect, to be close to the estimate of the substantially different. may be estimate is limited: The true effect Our confidence in the effect from the estimate of the effect. substantially different DEFINITION for the definitions of these categories. the definitions for Appendix C Appendix ConfidenceEvidenceReviews in the Research (CERQual) from of Qualitative Table 2 Table high, moderate, low low moderate, high, and . See G

Reprinted from The GRADE Working Group. Quality of evidence. In Schunemann H, Brozek J, Guyatt G, et al., editors. Handbook for grading the grading for Handbook G, et editors. al., Guyatt J, Brozek H, In Schunemann of evidence. Quality Group. Working GRADE The from Reprinted

Very Low Very Moderate Low CERTAINTY OF CERTAINTY EVIDENCE High OVERALL very low or as CERQual) (14). For qualitative evidence, an overall judgment of the confidence is made per finding in relation to relation in made is per finding the confidence of judgment overall evidence, an qualitative CERQual)as For (14). in as evidence the confidence CERQual categorizes relevant. as statement, each recommendation Confidence in Evidence for in evidence confidence The to referred methods GRADE-CERQual (hereafter determined using is interest) of the phenomenon of representation Quality of evidence grades. Available from: from: evidence grades.Quality Available of Source: 5.1, 2013. Table unknown]; publisher unknown: [place [Internet]. approach the GRADE using recommendations of the strength evidence and of quality Table 1: Certainty of Evidence 1: Certainty of Table evidence across all prioritized outcomes per recommendation question. GRADE categorizes the overall certainty of of certainty the overall categorizes GRADE question. per recommendation outcomes all prioritized evidence across evidence as The certainty of evidence (i.e., the level of confidence we have that an estimate of effect is true) for quantitative quantitative effect for is of true) estimate an that have we of confidence level of the (i.e., evidence certainty The outcome, prioritized each for the evidence synthesizing methods(13). After GRADE determined using is research of certainty the by considering of is determined evidence overall certainty evidence assessed. The is of the certainty Certainty of Evidence Certainty of (GRADE) GRADE-CERQual and GRADE the use of including process, development the guideline about information more to methods, refer Statements the using developed are BPGs RNAO Interpretation of Evidence and Recommendation of Evidence Interpretation BACKGROUND 12    and following the key criteria (see Recommendations are formulated as Strength ofRecommendations in also such, strength the of many of recommendations the is strong explanation the (see of strength of recommendations, outweighed potential the harms noted research inthe or evidence indicated from As practiceexperience. personal thatdetermined benefits the and health worker values and preferences for many the interventionsof clearly still that evidence in the is either low low. or very Despite generally the low panel certainty of expert the evidence, eliminate contextual factors). For reason, this of all recommendations the have acertainty of or evidence confidence experimental variables or blind participants to outcomes. the Therefore,the majority of researchthis in areafrom is sensitive nature of issue, the it is difficult to conduct research thatstudies use control groups, adjust for confounding institutions, multi-faceted initiatives are often implemented.Due the complexity to initiativesthese of theand Note: documented decisions made by RNAO guideline development see methodologists –please For more information on process the of determining certainty the and/or confidence evidence – thethe andof The certaintyassigned and/or confidenceevidence be can of foundbelow directly eachrecommendation statement. permission. Implementseries. 2018;13(Suppl Sci. 1):1-10.Table 3,Description of level of confidence finding ina the CERQual in review approach; Reprinted p.6. with Source: Table in Evidence 2:Confidence Preventing Violence, Harassment and Bullying Against Health Workers Edition -Second

potential impact on equity. health values and preferences balance of benefits and harms Very Low Low Moderate High EVIDENCE CONFIDENCE IN To address workplace violence, harassment organizations and bullying service inhealth and academic Reprinted from Lewin S, Booth A,GlentonReprinted S,Booth from C,etal. Applying Lewin GRADE-CERQual to qualitative synthesis evidence findings: introduction the to Appendix C REGISTERED NURSES’ ASSOCIATION OF ONTARIO G or studies, observational as opposed to ). the phenomenonofinterest. It isnotclearwhetherthereviewfindingareasonablerepresentationof phenomenon ofinterest. It ispossiblethatthereviewfindingareasonablerepresentationof of interest. It islikelythatthefindingareasonablerepresentationofphenomenon phenomenon ofinterest. It ishighlylikelythatthefindingareasonablerepresentationof DEFINITION Discussion of Discussion Evidence strong or or conditional randomized controlled trials randomized by considering certainty the and/or confidenceevidence in , below,

for definitions): G (which by (which nature their Appendix C quasi- . BACKGROUND 13

against an intervention) intervention) an for www.RNAO.ca BEST PRACTICE GUIDELINES • BEST PRACTICE . provides a rationale for why the expert panel made the decision the expert the decision made why panel for a rationale provides Appendix C Appendix table. For more information on the process used by the expert panel to determine the expert determine used to by panel the process on information more For table. denote the relative importance or worth placed on health outcomes from following a following from health outcomes placed on worth or importance the relative denote includes a list of relevant resources (e.g., websites, books and organizations) that support support that organizations) books and websites, (e.g., resources relevant of a list includes Preventing Violence, Harassment and Bullying Against Health Workers - Second - Edition Workers Health Against Bullying and Harassment Violence, Preventing identifies the potential desirable and undesirable outcomes reported in the literature when reported in literature the outcomes undesirable and desirable the potential identifies highlight pragmatic information for nurses and members of the interprofessional team. This This team. the interprofessional of members and nurses for information highlight pragmatic identifies the potential impact that the recommended practice could have on health across healthon across practicehave could recommended the that impact the potential identifies Supporting Resources: Resources: Supporting quality not was review and the systematic part in this section of listed not was Content the recommendations. imply these does lists not of in one a resource of the inclusion and exhaustive, not is the list such, As appraised. the RNAO. from endorsement an to rate a recommendation as strong or conditional. conditional. or strong as a recommendation rate to Practice Notes: or BPGs other (e.g., sources other review and/or the systematic evidence from supporting include section may expert panel). the RNAO the systematic reviews and, when applicable, the RNAO expert panel. the RNAO when applicable, reviews and, the systematic Equity:Health the applicable, when and, reviews the systematic from research include may This section populations. different expert panel. RNAO Recommendation: of Justification Expert Panel Benefits and Harms: Harms: and Benefits review. the systematic from research in this section includes used. is practice Content the recommended Preferences: and Values from research include this section may for perspective. Content particular a person-centered clinical action from 6. 5. 4. 3. 2. 1. Discussion of Evidence sections: main following the includes recommendation each follows Evidence that of Discussion The Summary of Recommendations Summary Recommendations of please see recommendation, each of the strength The strength of the recommendation statement is detailed directly below each recommendation statement and in and the statement recommendation each is detailed directly below statement recommendation of the strength The an intervention) (13). A conditional recommendation implies that not all will persons be not best served that the implies by recommendation (13). A conditional intervention) an and preferences personal circumstances, of consideration careful more a need is for “there action: recommended (13). values” A conditional recommendation reflects the expert panel’s confidence that while some uncertainty exists, the exists, uncertainty whilesome that confidence reflects expertthe panel’s recommendation A conditional recommendation conditional a (i.e., effects undesirable the outweigh probably effects desirable recommendation conditional a (i.e., effects desirable the outweigh probably effects the undesirable that or Conditional Recommendation its undesirable effects (strong recommendation for an intervention) or that the undesirable effects of an intervention intervention an of effects undesirable the or that an intervention) for recommendation effects (strong undesirable its recommendation strong (13). A an intervention)” against recommendation effects (strong desirable its outweigh will persons be of best action (13). served the recommended the majority by that implies Strong Recommendation Strong outweigh intervention an of effects desirable "the that confidence reflects expertthe panel’s recommendation A strong BACKGROUND 14 prevention and management of workplace violence, harassment and bullying. The following recommendations shouldbe implemented part as of a multi-intervention, organizational strategy for Health, Safety and Well-being of the Nurse This BPG thereplaces RNAO BPGs Summary ofRecommendations Preventing Violence, Harassment and Bullying Against Health Workers Edition -Second workers, orstudents leaders, otherhealth and bullyingfromformal addressing harassment Recommendation behaviour frompersons addressing violent Recommendations Outcomes: harassment and/orbullying? Should healthworkers berecommendedtouseriskassessmenttoolsdetectbehavioursindicativeofworkplaceviolence, Recommendation Question#1: RECOMMENDATIONS REGISTERED NURSES’ ASSOCIATION OF ONTARIO Reliability, validity andaccessibilityinpractice(surrogateoutcomes: timeandutility) vertical violence a qualityimprovementplantoaddresshorizontaland/or of validated riskassessmenttoolstomeasureanddevelop organizations andacademicinstitutionssupporttheuse The expertpanelsuggeststhathealthservice Recommendation 1.3: tool . a violenceriskassessmentonallpersonsusingvalidated The expertpanelrecommendsthathealthworkers conduct Recommendation 1.2:   plan shouldincludethefollowing: integrating aviolenceriskassessmenttoolforpersons organizations establishanimplementationplanfor The expertpanelrecommendsthathealthservice Recommendation 1.1:

education andtrainingonthechosentoolforallhealth selection ofariskassessmenttoolthatisapplicableto workers whoprovidedirectcare the clinicalpopulationandsetting; and

Preventing and Managing Violence in the Workplace (2008) (2). . . . This (2009) (3)and RECOMMENDATION STRENGTH OFTHE Conditional Strong Strong Workplace BACKGROUND 15 Strong Strong Strong Strong www.RNAO.ca STRENGTH OF THE STRENGTH RECOMMENDATION . . BEST PRACTICE GUIDELINES • BEST PRACTICE for specific education 3.3 to . Recommendations 3.1 workplace violence; and workplace violence; incidents standardized approach for deciding what, when, and how when, standardized approach for deciding what, to use these; and closed-circuit cameras and alarm systems; previous incident(s) of violence; understanding and implementing policies against reviewing and acting on reported workplace violence equipment to protect against violent behaviours, and a equipment to protect against violent behaviours, doors, including locked environmental security measures, to use formal reporting systems that are simple documentation and communication of a person’s documentation and communication of a person’s

and the strategies for violence prevention in the future 4: Recommendation 2 .4: expert panel recommends that health service The organizations implement a process for formal incident reviews immediately following a violent event to discuss used, the approach that was the details of what occurred, following:      Recommendation 2 .3: expert panel recommends that formal leaders within The in health service organizations support health workers preventing and addressing workplace violence by doing the organizations provide education and training to health organizations provide persons on addressing violent behaviours from workers (see content) . Recommendation 2 .2: expert panel recommends that health service The measures, organizations implement protective and security such as the following:  1: Recommendation 2 .1: that health service expert panel recommends The Preventing Violence, Harassment and Bullying Against Health Workers - Second - Edition Workers Health Against Bullying and Harassment Violence, Preventing Physical environment (surrogate outcomes: health worker injury, incident reporting, assault and threat towards health and threat towards assault reporting, incident injury, health worker (surrogate outcomes: Physical environment addressing violent behaviour from persons Recommendations workers) and health worker well-being (surrogate outcomes: perceived incivility, recognition of bullying, policy implementation) recognition of bullying, perceived incivility, outcomes: well-being (surrogate and health worker workers) health workers be recommended to improve organizational and health worker outcomes? improve organizational and health worker be recommended to health workers Outcomes: Recommendation Question #2: Question Recommendation harassment and/or bullying among manage workplace violence, policies and procedures to prevent and Should organizational RECOMMENDATIONS BACKGROUND 16 Preventing Violence, Harassment and Bullying Against Health Workers Edition -Second or students leaders, healthworkers and bullyingfromformal addressing harassment Recommendations RECOMMENDATIONS REGISTERED NURSES’ ASSOCIATION OF ONTARIO   the following: bullying tosupporthealthworkers andstudentsbydoing involved inpreventingandaddressingharassment service organizationsandacademicinstitutionsbeactively The expertpanelrecommendsthatformalleadersinhealth Recommendation 2.7: environment . harassment andbullyingintheworkplacelearning appropriate policiesandcodesofconducttoaddress organizations andacademicinstitutionsimplement The expertpanelrecommendsthathealthservice Recommendation 2.6: 3 .5forspecificeducationcontent) harassment andbullying(seeRecommendations3.4 to healthworkers andstudentsonaddressingworkplace and academicinstitutionsprovideeducationtraining The expertpanelsuggeststhathealthserviceorganizations Recommendation 2.5:

providing mentorshipandrolemodellingofprofessional understanding andreinforcingpoliciesthataddress behaviour harassment andbullying; and .

RECOMMENDATION STRENGTH OFTHE Conditional Strong Strong BACKGROUND 17 Strong Strong Strong Strong Conditional www.RNAO.ca STRENGTH OF THE STRENGTH RECOMMENDATION . BEST PRACTICE GUIDELINES • BEST PRACTICE . . . harassment and bullying, and use effective communication harassment and bullying, strategies Recommendation 3 .5: as part of an expert panel recommends that, The students learn to use interactive learning approach, guided communication responses to address harassment and bullying from multiple sources within an academic institution or clinical learning environment . 3: Recommendation 3 .3: are expert panel recommends that health workers The techniques and when to provided training in breakaway techniques in violent incidents safely use breakaway Recommendation 3 .4: expert panel suggests that health service organizations The on how to identify provide education to health workers understand the impact of harassment and bullying, The expert panel recommends that health service expert panel recommends The on workers organizations provide education to health from the risk factors and triggers for violent behaviours persons Recommendation 3 .2: expert panel recommends that health service The on organizations provide training to health workers including communication and de-escalation techniques, to prevent and/or reduce violent re-direction strategies, incidents within their organizations 1: Recommendation 3 .1: Preventing Violence, Harassment and Bullying Against Health Workers - Second - Edition Workers Health Against Bullying and Harassment Violence, Preventing Patient injury, use of restraints, perceived safety of health workers, attitudes and values of health workers, health of health workers, attitudes and values of health workers, perceived safety use of restraints, injury, Patient and bullying from formal health workers leaders, or students Recommendations addressing harassment behaviour from persons Recommendations addressing violent Recommendation Question #3: Question #3: Recommendation harassment and/or bullying be workplace violence, training programs on preventing and managing Should education and for persons and health workers? to improve outcomes workers recommended for health Outcomes: turnover and health worker injury, worker RECOMMENDATIONS BACKGROUND 18 related to human resources. Table 3 workplacethe inOntario and Canada.The following measures supportwill quality improvement evaluation.and practice setting. There aredata few repositories/indicator libraries available forviolence, harassment and bullying in to practice changes evaluate evidence-based implementing when measures the most aBPG. Select relevant to the Tables Edition For additional information, refer please to RNAO the    three categories: structure, process, and outcome (15). DonabedianThe informs model the development of indicators forevaluating care,quality health which includes implementation and impact. As you implement recommendations the BPG, inthis we ask you to consider how you monitor will and evaluate its Best PracticeGuidelineEvaluation Preventing Violence, Harassment and Bullying Against Health Workers Edition -Second

health service organizations, service health institutions academic or systems health (15). Outcome analyzes effect the of carequality the on health status personsof populations,and health workforce, provision of quality care. Process examines provided being activities health the to, for, and with persons or populations of as part the to ensure quality care. It includes physical resources, human resources, and information and financial resources. required the Structure describes attributes organization of system, health the service health or institution academic

3 (1). provides potential structure measures associated recommendation with all statements to assess attributes , REGISTERED NURSES’ ASSOCIATION OF ONTARIO 4 , and 5 provide potential structure, process and outcome measures to assess BPG success. It is important Toolkit: Implementation of Best Practice Guidelines, Second BACKGROUND 19 New New www.RNAO.ca MEASURES IN DATA IN DATA MEASURES REPOSITORIES/ INSTRUMENTS BEST PRACTICE GUIDELINES • BEST PRACTICE Preventing Violence, Harassment and Bullying Against Health Workers - Second - Edition Workers Health Against Bullying and Harassment Violence, Preventing Total number of students Total Total number of health workers who provide direct number of health workers who provide Total : Total number of health workers : Total Number of health workers who provide direct care Number of health workers who provide Number of students who received education and Number of students who received : Number of health workers who received education workers who received education : Number of health Numerator: on the selected violence risk who received education and training assessment tool Denominator: care persons Denominator: Numerator: violent behaviours from training on assessing and addressing Numerator from and addressing violent behaviours and training on assessing persons Denominator

provide direct care who received Percentage of health workers who violence risk assessment tool education and training on the selected ACADEMIC INSTITUTIONS: education and training on Percentage of students who received from persons assessing and addressing violent behaviours

HEALTH SERVICE ORGANIZATIONS: SERVICE HEALTH and training workers who received education Percentage of health persons addressing violent behaviours from on assessing and STRUCTURE MEASURES Table 3: Structure Measures for Overall for Success BPG Measures 3: Structure Table BACKGROUND 20 Table 4:Process Measures BPG Success for Overall specific recommendation statements and support process improvement. Table 4 Preventing Violence, Harassment and Bullying Against Health Workers Edition -Second 2.4 1.2 1.1 RECOMMENDATION supports evaluation of practice changes during implementation. The measures are directly associatedwith REGISTERED NURSES’ ASSOCIATION OF ONTARIO completed immediatelyfollowingaviolentevent Percentage ofdocumentedincidentreviews violence riskassessmentusingavalidatedtool Percentage ofpersonswithadocumented PROCESS MEASURES Denominator: violent event reviews completedimmediatelyfollowinga Numerator: Denominator: validated tool documented violenceriskassessmentusinga Numerator:

Number ofdocumentedincident Number ofpersonswitha Total numberofpersons Total numberofviolentevents INSTRUMENTS REPOSITORIES/ IN DATA MEASURES New New BACKGROUND 21 www.RNAO.ca Partial HQO Partial HQO Partial HQO Ontario (HQO) Partial Health Quality Partial Health Quality MEASURES IN DATA MEASURES IN DATA REPOSITORIES/ INSTRUMENTS BEST PRACTICE GUIDELINES • BEST PRACTICE

1 Preventing Violence, Harassment and Bullying Against Health Workers - Second - Edition Workers Health Against Bullying and Harassment Violence, Preventing Total number of workplace violence incidents Total Total number of full-time equivalents Total Total number of workplace violence incidents number of workplace violence incidents Total Total number of workplace violence incidents number of workplace violence incidents Total Number of workplace violence incidents (reported by Number of workplace violence incidents Number of workplace violence incidents (reported by Number of workplace violence incidents (reported by Number of workplace violence incidents Number of workplace violence incidents (reported by violence incidents (reported Number of workplace provides potential outcome measures associated with all recommendation statements to assess overall BPG BPG overall assess to statements all with recommendation associated measures outcome potential provides Numerator: health workers) resulting in physical injury Denominator: (reported by health workers) Numerator: miss health workers) resulting in a near Denominator: (reported by health workers) Denominator: (reported by health workers) Numerator: work off health workers) resulting in time Numerator: health workers) Denominator: workers) resulting in physical injury Percentage of workplace violence incidents (reported by health incidents (reported by health Percentage of workplace violence workers) resulting in a near miss Percentage of workplace violence incidents (reported by health Percentage of workplace violence work workers) resulting in time off per 100 full-time equivalents (FTE) per 100 full-time OUTCOME MEASURES health workers) violence incidents (reported by Rate of workplace Near miss: An incident that occurred but did not result in physical and/or psychological injury or illness to the health worker illness to or injury psychological and/or in physical result did not occurred but that incident An miss: Near 1 Table 5: Outcome Measures for Overall for Success BPG Measures 5: Outcome Table Table 5 Table success. BACKGROUND 22   RNAOOther resources for evaluation the and monitoring of BPGs include following: the Preventing Violence, Harassment and Bullying Against Health Workers Edition -Second

ehealth/bpgordersets in determining impact the of BPG implementation on health specific outcomes.visit Please process measures. The ability to link structure and process indicatorswith client specific outcome indicators aids BPG Order Sets practicechangesbest visit (16).Please relationships practice and between outcomes to advance quality and advocate for resources that and support policy practice cultures,evidence-based optimize patient safety, improve patient outcomes and engage staff inidentifying comparative analyses. The internationaldata NQuIRE system waslaunched in August 2012 to create and sustain strives to leverage reliable and measures, valid minimizereporting burden and evaluation align measures to enable times” principle. By complementing other established and emerging performance measurement systems, NQuIRE administrative data and existing performance measures wherever possible, adhering to a“collect once, many use nursing-sensitivebased, process and outcome indicators. NQuIRE indicator definitions withare aligned available implementation by BPSOs worldwide. Thedata NQuIRE system compares collects, and data reports on guideline- Internationalthe AffairsBest Centre,Practice andGuideline allows BPSOs Nursing Indicators Quality for and Reporting Evaluation REGISTERED NURSES’ ASSOCIATION OF ONTARIO TM

G embedded within electronic embedded records provide amechanism for electronic data capture of for more information. RNAO.ca/bpg/initiatives/nquire ® (NQuIRE ® ), aunique nursing data system housed in for more information. ® to measure impact the of BPG http://RNAO.ca/ BACKGROUND 23

www.RNAO.ca

PhD, MPhil, MSc, Bed, BSc RN, PhD, CNeph(C) RN, MSN, PhD, LLD (hon), Dr RN, BScN BEST PRACTICE GUIDELINES • BEST PRACTICE the guideline appendices during her Masters of Nursing Nursing of Masters her during appendices the guideline University). (Ryerson placement student Toronto, ON Toronto, Doris Grinspun, O. ONT. (hc), FAAN, Officer Chief Executive Ontario of Association Nurses’ Registered ON Toronto, Lucia Costantini, Development, Guideline Director, Associate Former Evaluation and Research Guidelines and PracticeCentre Best Affairs International Ontario of Association Nurses’ Registered ON Toronto, Acknowledgments by: completed search Systematic UHN HealthSearch to contributions her for RN, Fu, Special Meng to thanks Danny Wang, Danny Wang, Analyst Evaluation Guidelines and PracticeCentre Best Affairs International Ontario of Association Nurse’ Registered ON Toronto, Shanoja Naik, Dr. Outcomes Health Scientist/Statistician, Data NQuIRE Research, Guidelines and PracticeCentre Best Affairs International Ontario of Association Nurses’ Registered

RN, MScN RN, BN, MHSc RN, MScN Preventing Violence, Harassment and Bullying Against Health Workers - Second - Edition Workers Health Against Bullying and Harassment Violence, Preventing

BSc, GC, DipHlthProm RN, BScN, MA BSc (Hons)

Research Team Research Registered Nurses’ Association of Ontario Association Nurses’ Registered and Development Guideline Practice Best Registered Nurses’ Association of Ontario of Association Nurses’ Registered ON Toronto, Project Coordinator, Implementation Sciences Implementation Coordinator, Project Guidelines and PracticeCentre Best Affairs International Toronto, ON Toronto, Oliwia Klej, Program Manager, Implementation Sciences Implementation Manager, Program Guidelines and PracticeCentre Best Affairs International Ontario of Association Nurses’ Registered Toronto, ON Toronto, Althea Stewart-Pyne, Guideline Development Project Coordinator Project Development Guideline Guidelines and PracticeCentre Best Affairs International Ontario of Association Nurses’ Registered Toronto, ON Toronto, Erica D’Souza, International Affairs and Best Practice Guidelines Guidelines and PracticeCentre Best Affairs International Ontario of Association Nurses’ Registered Megan R. Bamford, and Development Guideline Director, Associate Evaluation Registered Nurses’ Association of Ontario of Association Nurses’ Registered ON Toronto, 2017 – May 2018) Guidelines and PracticeCentre Best Affairs International Laura Ferreira-Legere, (Lead, MayGuideline Development Methodologist International Affairs and Best Practice Guidelines Guidelines and PracticeCentre Best Affairs International Ontario of Association Nurses’ Registered ON Toronto, 2018 – present) Research and Development Guideline Senior Manager, Giulia Zucal, Methodologist (Lead, MayGuideline Development BACKGROUND 24 Toronto, ON Michael Garron Hospital Manager, and Labour Employee Relations Nader Boutros, Toronto, ON Centre for Addiction and Mental Health Director, &Safety Security Andrew Aris Toronto, ON Michael Garron Hospital and Nursing Chief Executive Vice-President, Patient Health Experience, Professions Irene Andress, Toronto, ON Centre for Addiction and Mental Health Inpatient Manager, WFSU &SOTU Jamie Amaral, Toronto, ON Health and SafetyPublic Services Association Vice-President, Client Outreach Expert PanelCo-Chair COHN(C), CRSP, CDMP Henrietta Van hulle, Cincinnati, Ohio, USA University of Cincinnati of College Nursing Health Nursing Program Professor, Deputy Director, Graduate Occupational Expert PanelCo-Chair CPEN, PHCNS-BC,FAEN, FAAN Gordon Gillespie, Preventing Violence, Harassment and Bullying Against Health Workers Edition -Second Best PracticeGuidelineExpertPanel Registered Nurses’AssociationofOntario REGISTERED NURSES’ ASSOCIATION OF ONTARIO RN, MSN RN, BScN CHRL PhD, DNP, RN,CEN,CNE, RN, BN, MHSM, RN, BN,MHSM, National Representative, Health and Safety Andréane Chenier, Region 4 Ontario Nurses Association Vice President Health and Safety Laurie Brown, Scarborough, ON Scarborough Health Network SpotlightPractice Organization® Lead Director of Quality, Safety and Patient Best Experience, Kimberley Brophy, Whitby, ON Ontario Shores Centre for Mental Health Sciences Leader, Practice Clinical Professional Practice Sarah Kipping, Toronto, ON SickKids Hospital Nurse Practitioner, Burns and Plastic Surgery Charis Kelly, Lethbridge, AB McKesson Canada Health Services Alberta Nicole A.Gibson, Ottawa, ON Children’s Hospital of Ontario Eastern Operations Director Chris Clement, Sudbury, ON Canadian Union of Public Employees RN(EC), MN,NP-Pediatrics RN RN, BScN,MA RN, MSN,CPMHN(C) RN, BN,MNStudent RN, MN MSc, PhD

BACKGROUND 25 www.RNAO.ca RN, BScN RN, BA, BScN, MN RN, BA, BScN, BEST PRACTICE GUIDELINES • BEST PRACTICE Amanda Ottley, Ottley, Amanda Occupational Health Nurse Health Occupational ON Toronto, Juanita Rickard, Vice-President Association Nurses Indigenous Canadian ON Ottawa, Preventing Violence, Harassment and Bullying Against Health Workers - Second - Edition Workers Health Against Bullying and Harassment Violence, Preventing MD, MPH, BScN, BSc (hons),MD, MPH, BScN, BSc RN, BHA, GNC(C) RN, BHA, Ethics Diploma, RN ON Toronto, Markham, ON Burton Mohan, Metzie Lacroxi, Metzie Clinical Services Director, Senior Living Sienna BACKGROUND 26 Hamilton, ON Hamilton Health Sciences Registered Nurse Ashleigh Davis, Port Hope, ON Pineridge Health District Unit Public Health Nurse Marisa Curran, Toronto, ON University Health Network Registered Nurse Stephanie Crump, Toronto, ON St. Michael’s Hospital Workplace Violence Prevention Programming Manager Heather Charlesworth, Ottawa, ON Sandy Hill Community Health Center –OasisClinic Nursing Team (Acting) Leader Taliesin MagbooCahill, Kamloops, BC ThompsonRivers University Lecturer Sheila Blackstock, Sault Ste. Marie, ON Retired Sylvia Alloy-Kommusaar, Newronville, ON of HealthMinistry and Long Term Care Provincial Nursing Chief Officer Michelle Acorn, Appendix C services. health workers,health educators, students, individuals with lived knowledgeable experience, administrators, and funders of of organizations, health institutions, academic practiceareas, and sectors. Participants include nurses and other As acomponent of guideline the development process, feedback was obtained from participants across range awide Stakeholder Acknowledgment Preventing Violence, Harassment and Bullying Against Health Workers Edition -Second REGISTERED NURSES’ ASSOCIATION OF ONTARIO ). RNAO wishes to acknowledge following the individuals for contribution their BPG: this inreviewing Stakeholders RN, BScN RN, BScN DNP, NP, PHCAdult RN, MScN,COHN BSocSc, BScN, RN, MScN(c) BSocSc, BScN,RN,MScN(c) G representing diverse were perspectives solicited also for feedback their (see MSc, M.Ad.Ed BA, BSN,RN RN Nipissing University Professor Assistant Kathryn Ewers, Kitchener, ON Conestoga College Instructor MEd Juanita DeJong, Toronto, ON ScarboroughThe Rouge Hospital Staff Nurse Kathy Greig, Toronto, ON Baycrest Health Sciences Preparedness Manager, Security, Telecommunications &Emergency Martin Green, Toronto, ON Retired Lela Fishkin, ThunderBay, ON ThunderBay RegionalCentre Sciences Health Nursing Leader Practice George Fieber, Toronto, ON Humber River Hospital DirectorSenior Nataly Farshait, North Bay, ON RN RPN CHPA RN RN, MSN,Med MN, CPN(C),CHE Assoc. Sc. RN, GNC (C), BScN, Assoc. Sc.RN,GNC(C),BScN,

BACKGROUND 27

RN, BScN, RN, BScN www.RNAO.ca

RN, MN RN, BScN, MN RN, BScN BScN, MN, RN N, BScN, MN, CNS, CMSN(C) N, BScN, MN, CNS, RN, BA(H), INTN ASA, COHN(C), RN, BA(H), BEST PRACTICE GUIDELINES • BEST PRACTICE Quality Improvement Specialist Quality Improvement Quality Ontario Health ON Toronto, Jessica Po Ying Lok, Jessica Po Ying Practice Professional of Manager Care Health Home VHA ON Toronto, Drew MacNeil, Clinical Practice Manager Healthcare Grace Hotel-Dieu ON Windsor, Jeny Mahendrakumar 3 Student BScN Year Alberta of Red Deer College/University Alberta Red Deer, Maradiaga Rivas, Vanessa Nurse Registered Revera Inc. Sciences and Health Hamilton ON Hannon, Margaret Millward, Jill King, Jill King, DEGREE COHN-S,ERGONOMIC CEO Inc. Safety and Health King Newmarket, ON Kanika Kohli, ON London, Lisa Lallion, R Specialist Clinical Nurse Clinic Stroke The Scarborough ON Toronto, Madeline Logan-Johnbaptiste, MBA, ENC(C), CHE(C) Health Mackenzie ON Hill, Richmond RN, MHSc Preventing Violence, Harassment and Bullying Against Health Workers - Second - Edition Workers Health Against Bullying and Harassment Violence, Preventing RN MN, RN(EC) BScN, RN RN, JD(c) EdD RN RN, MScN, CPMHN(C) Services ON Toronto, Miran Kim, Nurse Health Mental Correctional and Safety Ministry Community of Lakeridge Health ON Oshawa, Shannon Kift, Nurse Research University of Toronto and Hospital for Sick Children Sick for Hospital and Toronto of University ON Toronto, Sahana Kesavarajah Clinical extern and student Nursing Margaret Keatings, ON Toronto, Manager, Patient Care Patient Manager, Health Center Mental Ottawa Royal The Brockville, ON Hamilton, ON Hamilton, Steven Hunt, Clinical Nurse Specialist Clinical Nurse Hamilton Healthcare Joseph’s St. Atikokan, ON Kelly Holt, Laura Hendren, Laura Hendren, Practitioner Nurse Team Health Family Atikokan Finlandia Nursing Home Nursing Finlandia ON Sudbury, Jennifer Hawkins, Jennifer Hawkins, Care of Director (NIOSH) USA Virginia, West Dan Hartley, Dan Hartley, Epidemiologist Health and Safety Occupational for Institute National BACKGROUND 28 Toronto, ON Children’s of Toronto Aid Society Infant Nurse Specialist Nancy Smith, Toronto, ON Network Princess Margaret Cancer Center –University Health RegisteredOncology Nurse Sabeena Santhirakumaran, Toronto, ON Humber River Hospital Registered Nurse Madhumathi Rao, Toronto, ON St. Michael’s Hospital Registered Nurse Katie Poon, Toronto, ON St. Michael’s Hosptial EducatorClinical Tasha Penney, Kamloops, BC ThompsonRivers University Professor Assistant Noeman Mirza, Preventing Violence, Harassment and Bullying Against Health Workers Edition -Second Stakeholder reviewers have given consent to publication the of names their and relevant information BPG. inthis REGISTERED NURSES’ ASSOCIATION OF ONTARIO RN RN, BScN,MN RN, MN,CPMHN(C) RN, PhD RN, BScN,MN RN,BScN,BSc St. Joseph’s Healthcare Hamilton Registered Nurse Natasa Vukojevic, Toronto, ON Centennial College Nursing Professor Joyce Tsui, Hamilton, ON McMaster Children’s Hospital Registered Nurse Grace Terry, Aurora, ON RegionalSouthlake Health Centre Nurse Educator Olivia Soave, Toronto, ON Sunnybrook Health Centre Sciences Advanced Nurse Practice Aaron Watamaniuk, Hamilton, ON RN, BScN,MN RN, BScN RN, BScN RN RN,MN(c) BACKGROUND 29 www.RNAO.ca BEST PRACTICE GUIDELINES • BEST PRACTICE Preventing Violence, Harassment and Bullying Against Health Workers - Second - Edition Workers Health Against Bullying and Harassment Violence, Preventing represents a conceptual model for healthy work environments for nurses, including the components, factors factors the components, including nurses, for environments work healthy model for a conceptual represents

Individual-level, organizational-level and system-level factors determine whether a work environment is healthy. healthy. is environment whether determine a work factors system-level and organizational-level Individual-level, of quality nurses, the of well-being and health affect the in combination) or all (individually levels three at Factors and generic are factors while the remaining profession, each to unique are factors occupational and Professional Healthy work environments are essential for high-quality, safe person care. care. person safe high-quality, for essential are environments work Healthy apply to all to professions/occupations. apply person outcomes, organization and system performance, and societal outcomes. At each level, there are policy are there each level, At societal and outcomes. performance, system and organization outcomes, person components. professional/occupational and components, cognitive/psycho/social/cultural components,

influences individual experience, interventions to promote healthy work environments must target multiple levels levels multiple target must environments work healthy promote to experience, interventions individual influences (18, 19) itself the indeed, system – and, the system of components and Because it is the combination of factors and components that determines the nature of the work environment and and environment the work of the nature determines that components and factors of theBecausecombination is it    The following assumptions underlie the model: the underlie assumptions following The  persons, organizations, systems and society as a whole (17). The lines within the model are dotted, showing the showing dotted, are model society within the lines (17). The and a whole as systems organizations, persons, the model. of all components among interactions synergistic (meso) and external (macro) contexts. The dotted lines within the model indicate the interdependence among the among interdependence the model indicate the within lines dotted The contexts. external (macro) (meso) and nurses, environments: work healthy those who benefit from the model are of the center At components. various Figure 1 1 Figure organizational (micro), individual the or levels: contexts the three represent circles concentric Three outcomes. and They comprise numerous components, including: physical, structural and policy components; professional and and professional structural and policy components; physical, including: components, numerous They comprise (142). These components sociological, cultural and psychological, cognitive, and components; occupational multidimensional. and them complex them, make among the relationships and components, Healthy work environments are practice settings that (a) maximize the health and well-being of nurses and other other and nurses of well-being the health and (a) maximize that settings practice are environments work Healthy societal and outcomes. resident client, patient, and performance organizational (b) improve and health workers Healthy Work Environments Best Practice Best Environments Work Healthy Project Guidelines Organizing Framework for the System and the System for Framework Organizing BACKGROUND 30 knowledge. Indianapolis (IN):Sigma Theta Tau International; 2018. p. 69-92. Source: Figure Model 1:Conceptual for Healthy Work Environments Preventing Violence, Harassment and Bullying Against Health Workers Edition -Second Banjok I,Stewart-Pyne A. Creating healthy workplaces: enabling excellence. clinical In: Grinspun D, Bajnok I,editors. Transforming nursing through REGISTERED NURSES’ ASSOCIATION OF ONTARIO onitiesco

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a n n d i i a id t i u o a n t a u e s e n o actos a e s si o on a e Oc ss cu s io ationa acto na O ccu ati ona actos of autonomy over practice, their and nature the of their nurses, include these of scope their practice, level the naturethe and role of profession/occupation. the For that shape ahealthy work environment are derived from The organizational professional/occupational factors andethics reflective practice. balance. Knowledge and include skills nurse’s the values, self-confidence and ability to maintain a work–life profession, as well as his or her resilience, adaptability, commitment to his or her patient, organization and of work (20).Personal attributes include anurse’s to physical, the cognitive and demands psychosocial knowledge and that skills determine how nurses respond Individual nurse factors include attributes, personal the Figure 4:Professional/Occupational Components disciplines and domains. and role policy and socialization within and social across national and international levels that influence health andpolicies regulations at provincial, the territorial, professional/occupationalExternal factors include interprofessional relationships. BACKGROUND 33 www.RNAO.ca BEST PRACTICE GUIDELINES • BEST PRACTICE Preventing Violence, Harassment and Bullying Against Health Workers - Second - Edition Workers Health Against Bullying and Harassment Violence, Preventing

Incivility can include futile communication, disrespect, indifference, neglect, disregard, or impolite speech, and can result speech, can and or impolite neglect, disregard, indifference, disrespect, futile communication, include can Incivility bullying of the high rates in health care, issues prevalent are harassment and violence (27). Although burnout and in stress (29).issue an emergent has become workers healthof retention and productivity well-being, on the effects its and which is defined as a deterioration in relationships between peers in the workplace (9, 26), between students and health and (9, 26), students between between workplace in peers the relationships in as a deterioration defined which is (28). academic institution faculty in an and between students (27), or environment in the clinical learning workers worker or student are considered to be workplace harassment. Bullying is a repeated and persistent behaviour that can that behaviour persistent and a repeated is Bullying harassment. be to workplace considered are student or worker physically a person, intimidating criticism, unjustified or excessive rumours, spreading or creating socialinclude isolation, incivility, from differ of violence forms (4). These two job responsibilities withholding and abuse, threatening or abusing Harassment refers to comments or behaviours towards a health worker that are unwelcome and persistent, including including persistent, and unwelcome are that a health worker towards behaviours or comments to refers Harassment health a offend or ridicule, demean, intimidate that innuendos or jokes remarks, example, (6). For sexual harassment directed at colleagues who are of equal level within an organization (8). This is in contrast to verticalto which violence, is in contrast (8). This organization an within equal level of who colleagues are at directed organization. an within levels unequal at between who colleagues are bullying or harassment violence, is Other forms of negative behaviours in the workplace include horizontal or lateral violence and vertical and violence. violence lateral or horizontal include in the workplace behaviours negative of Other forms bullying and harassment violence, denote to used interchangeably are that terms are violence lateral or Horizontal Examples of this include verbal threats, threatening notes, shaking a fist in the worker’s face, hitting/trying to hit a to hit hitting/trying face, worker’s in the a fist shaking notes, threatening verbal threats, this include of Examples (24). a worker object at an throwing or worker injury. Sexual aggression, verbal statements, non-verbal behaviours or acts that are reasonably interpreted as a threat a threat as interpreted reasonably are acts that or behaviours non-verbal verbal statements, Sexual aggression, injury. health service (24). In violence organizations, also considered are harm lead physical to can that force physical of (25). their family or care the receiving person from is in health care violence workplace type of prevalent the most Service Organization? physical cause, could or causes, that person a against force physical of use, attempted the or use, is violence Generally, combined (23). combined Harassment and Bullying within a Health Violence, What is Considered to be number of violence-related lost time injuries for frontline health workers was more than double that for police and police and for that double than more was health workers frontline for time injuries lost violence-related of number to 2015 from 2006 increase This (23). years over 10 of 66 per cent increase an - servicecombined correctional officers service correctional police and officers for increase of the rate than times greater three is that a rate occurredhas at of Canada (AWCBC) found that the health and social the health and services that injuries: lost-time found of industry number the highest had Canada (AWCBC) of fact, 2015 the in all (23). In sectors across all injuries lost-time of 18 per cent industry represented in that injuries This BPG recognizes the dramatic increase in the prevalence and severity of workplace violence towards health towards violence workplace of and severity prevalence in the increase recognizes dramatic BPG the This Boards Compensation Workers’ of the Association that surprising not is in all It health sectors. students and workers harassed (21). For nurses, a global review that included 150,000 nurses from 160 international samples reported that that reported samples 160 international from 150,000 nurses a global included review nurses, that (21). For harassed experienced had thirds non-physical two their careers, during assaulted been had third physically one than more experienced(22). had 40 per bullying cent and assaults found that of the almost 2000 front-line health workers surveyed, 68 per cent had been physically assaulted in the assaulted surveyed, been had 68 per physically cent health workers 2000 front-line the almost of that found or been had 42 per sexually experienced had cent and assaulted 86 per verbal violence cent 12 months, previous Workplace violence is a global issue that is prevalent in all health service organizations and academic institutions, academic institutions, and in all health service prevalent is that organizations a global is violence issue Workplace Unions Hospital of by Council Ontario the report commissioned 2017 A students. and workers allhealth affects and Background Context Background Issue? a Significant Violence Is Workplace BACKGROUND 34 quality improvement plans of hospitals, and that overall the number of workplace violent incidents reported (38). be workplace violence towards workers health (including physicians, subcontractors and students) included be inthe yet widelyviolence under-reported, is pervasive of Health Ministry the and Long-Term Care recently mandated that quarter sought help from aunion and only cent 60 per reported actually event the (29).Given that fact the workplace Although cent 61per of nurses some form inCanadaexperienced of 2016 and violence between 2017,only one pleasure inworking with patients, and spending less with time patients, thereby reducing quality the of care (31). of workplace violence may include increased sick leave productivity (36),decreased (37),fear of patients, lack of thought of leaving jobto their work for adifferent employer or change professions entirely consequencesOther (29). consequencesThese negatively impact recruitment and retention (35); for example,per cent 66 of nurses have     workplace violence: In addition to economic the costs, workers health endure many physical and psychological consequences as aresult of for public full-time nurses sector cent, was 9per resulting inan estimated cost of $989million annually (29). national 2016report found that average the rate of absenteeism for occupations all cent, was 5.7per but that rate the hospital lost-time injuries (23).Workplace to leads violence absenteeism, also among particularly nurses: aCanadian The cost of workplaceviolence inOntario hospitalsalone is $23.8million annually, contributingper cent to 10 of Violence? What arethePersonalandEconomicCostsConsequencesofWorkplace     workplace violence into four main types: Violence classified can according be to source.type andits occupationalIn 2001, health researchers classified Service Organization? What aretheClassificationsof Violence, HarassmentandBullyinginaHealth Preventing Violence, Harassment and Bullying Against Health Workers Edition -Second

such as anxiety and depression ideation (32),suicidal (33),and headaches and disturbances sleep (34). irritability, difficulties concentrating, disturbances, sleep depression, anxiety and burnout (31). threatening injuries (31). becomes violent and/or aggressive towards or them others workplace inthe (30). Type relationships): 4(personal contract workers) and violence is directed towards another employee. bullying.perpetrator The current is a pastor employee (including managers, supervisors, physicians or other Type 3(worker to worker): visitor. or person receiving care or avisitor becomes violent who and/or aggressive toward worker ahealth or another person Type 2(client or customer): employees. Thisviolence typically includes such acts as robbery, pilfering and/ortrespassing. Type intent): 1(criminal Consequences of prolonged and persistent bullying include increased risk of mental and somatic concerns, health Emotional consequences can include anger, sadness, fear and mistrust (31). Commonly reported psychological consequences include post-traumatic stress disorder, hyper-vigilance, Physical consequences include physical injury(e.g., bites bruises, and lacerations), headaches, pain and life- REGISTERED NURSES’ ASSOCIATION OF ONTARIO The perpetrator The violenceof has no legitimate relationship the to business or its This type Thistype violence of is referred to as horizontalviolence. or vertical canIt include Thisthe is most commonsource violencesetting.of the perpetrator in health The isa The perpetratorThe has a relationshipwith an employee outside the of workplace but BACKGROUND 35 www.RNAO.ca BEST PRACTICE GUIDELINES • BEST PRACTICE Preventing Violence, Harassment and Bullying Against Health Workers - Second - Edition Workers Health Against Bullying and Harassment Violence, Preventing organizations and health workers recognize, prevent and manage workplace violence, harassment and bullying. bullying. and harassment violence, workplace manage and prevent recognize, health workers and organizations the concerted efforts of multiple key stakeholders, including federal and provincial governments, unions, health unions, governments, provincial federaland including keystakeholders, multiple of efforts the concerted healthon has violence Owing the effect detrimental to that the public. and persons, employees, organizations, help to evidence-based best recommendations practice provides this BPG care, receiving persons and workers Aside from legislation, prevention and management of workplace violence, harassment and bullying will require will require bullying and harassment violence, workplace of management and prevention legislation, from Aside include creating written workplace violence and harassment policies, and developing and maintaining a program to to a program maintaining and developing policies, and harassment and violence workplace written creating include willnot measures injury (39). These physical from employees protect to precautions and policies, training implement (29). enforced consistently and meaningfullybe unless effective and academic institution, the employer must enforce prevention policies and strategies for workplace violence, violence, workplace for strategies policies and prevention enforce must the employer academic institution, and (Bill 168), employers Act Amendment Safety and Health Occupational the Ontario Under bullying. and harassment these actions of (20). A few in the workplace violence manage and prevent to items action key a set of follow must What are Prevention and Management Initiatives from a System-level? from a Initiatives and Management Prevention What are everyone a health in service of organization the responsibility is environment work a safe of the creation Although RECOMMENDATIONS 36 Preventing Violence, Harassment and Bullying Against Health Workers Edition -Second Should health workers be recommended to use risk assessment tools to detect behaviours Should healthworkersberecommendedtouseriskassessmenttoolsdetectbehaviours RECOMMENDATION QUESTION#1: Recommendations organization had acceptable an implementation plan inplace. Instruments that had an implementation plan prior to adoption their inan Regardless of to tool assess the risk used for the violence, literature the importance highlightsthe of having overall conclusion about probability the of (e.g., low, violence occurring medium or (40). high) static and dynamic risk factors, but include they discretion clinical to presence weigh the of risk factors and draw an unemployment) factors to arrive at probability an expected (40).SPJ that instruments occur violence use will also formula or equation to combine known risk for violence with static (e.g., age) and dynamic (e.g., substance abuse and literature:in the Assessing risk for the violent behaviour for is crucial safety the of workers. health Two of types tools were identified Benefits andHarms Discussion ofEvidence: Recommendations Addressing Behaviourfrom Violent PersonsandFamilies Outcomes: indicative ofworkplaceviolence,harassmentand/orbullying? associated with having an implementation plan. and good Certainty oftheevidenceeffects: Strength oftherecommendation:   following: plan forintegratingaviolenceriskassessmenttoolpersons.Thisshouldincludethe The expertpanelrecommendsthathealthserviceorganizationsestablishanimplementation Recommendation 1.1:

and education andtrainingonthechosentoolforallhealthworkerswhoprovidedirectcare. selection ofariskassessmenttoolthatisapplicabletotheclinicalpopulationandsetting; REGISTERED NURSES’ ASSOCIATION OF ONTARIO inter-rater reliability Reliability, validityandaccessibilityinpractice(surrogate outcomes:timeandutility) actuarial instruments predictive validity G between health workers health between (42).None of included the studies reported on harms the G and and Strong Very low structured professionalstructured judgement (SPJ) G with to respect ability their to predict patient aggression (41-43) G . Actuarial tools a use RECOMMENDATIONS 37 www.RNAO.ca BEST PRACTICE GUIDELINES • BEST PRACTICE (reliability and validity) of these tools had a period of staff training as a component of as a component a period these had training tools staff of validity) of and (reliability G Preventing Violence, Harassment and Bullying Against Health Workers - Second - Edition Workers Health Against Bullying and Harassment Violence, Preventing Education and Training on the Chosen Tool for Health Workers Providing Direct Care Direct Providing Workers Health for Tool Chosen the on Training and Education Selection of a Risk Assessment Tool that is Applicable to the Clinical Population and Setting Setting and Population Clinical the to is Applicable that Tool Assessment a Risk of Selection psychometric properties psychometric staff education and training to enhance the utility, reliability and validity of the chosen tools within the clinical tools chosenwithin the of the validity and reliability utility, the to enhance and training education staff to strong. be recommendation of the expertthe strength determined the panel Therefore, environment. The expert panel attributed high value to having an implementation plan in place prior to the clinical or clinicalto the prior place in plan an implementation having to high value attributed expertThe panel adequate tooland selection appropriate expert The valued tool. panel assessment a risk use of organizational impact health equity. health equity. impact Expert Panel Justification of Recommendation violence risk assessments (through the use of a risk assessment tool) could potentially decrease practices that decrease that practices potentially could tool) assessment a risk the use of (through assessments risk violence can plan implementation an how of understanding improve to required is research More persons. harm or stigmatize Health Equity toolused being in assessment to a risk prior plan an implementation establishing expertthat suggests The panel conduct health workers in how the consistency Supporting health equity. improve potentially could care direct implementation process (42, 49). Health workers favour tools that are quick, easy and useful, because they empower useful, because easy they and empower quick, are that tools favour workers (42, 49). Health process implementation (45). events minimize violent proactively to staff Evidence suggests that health workers value receiving training prior to the organizational implementation of a of implementation the organizational to prior training receiving value health workers that suggests Evidence the after and during support ongoing of the availability they appreciate (47, 48), and tool new assessment risk clinical cases (41, 47) and research evidence demonstrating the ability of the tool to predict patient aggression (45). aggression patient predict to the tool of the ability evidence demonstrating research clinical cases (41, 47) and and Preferences Values the implementation plan. The staff education and training included theoretical information about the tools (40, 41, the tools about information theoretical included and training education staff The plan. the implementation pseudo- using the tools scoring with (41), practice the results interpret and the tool score to how on 43, 45), training (ABRAT) (45) and the Short-Term Assessment of Risk and Treatability (START) (41). The Dynamic Appraisal of Appraisal (41). The Dynamic (START) Treatability and Risk of Assessment the Short-Term (45) and (ABRAT) assessed that (42). Studies in the literature examined tool actuarial assessment an was (DASA) Aggression Situational the Tool Assessment Risk Behavior Aggressive the included in literature the examined tools assessment SPJ Specific given to the applicability of the tool to the setting and population before the tools are broadly adopted. adopted. broadly are the tools before population and the setting to the tool of the applicability to given have not been confirmed in all practice settings and among all populations, and generalizability in allhealth servicegeneralizability and all populations, among been and practice in all confirmed not settings have be should practice, use consideration to when tool in selecting a (43, 44). Therefore, be assumed cannot organizations purpose of the instrument (40). Prior to implementing a tool in an organization, a careful analysis of costs, training training costs, of analysis a careful organization, in an a tool implementing to Prior (40). purpose the instrument of actuarial and/or SPJ the use of against or for preference (i.e., preferences organizational user and and requirements, tools assessment risk violence of reliability and the validity that be noted should (40). It be needs to considered tools) Mental health professionals across 44 countries emphasized the importance of “goodness of fit” in risk assessment, assessment, in risk fit” of “goodness of the importance emphasized 44 countries across health professionals Mental and setting between the population, “fit” or the applicability depend on should choice instrument that such Components of an effective implementation plan identified in the literature included selection of a risk assessment assessment of arisk selection included literature inthe identified plan implementation effective an of Components all health workers for the tool on training and education and setting, and the clinical population to applicable tool care. direct who provide RECOMMENDATIONS 38 Preventing Violence, Harassment and Bullying Against Health Workers Edition -Second   Practice Notes Supporting Resources 

 includedskills following: the interventions following aviolence risk assessment, see please interventions that worker health the must once take identified. risk has been For more information potentialon admission (50). and daily (41-42).One study found that average the amount of until time aviolent incident arose was 4.4days after were generally completed once during hospitalization or weekly (48),within first the 24 hours of admission (45) articulate clearly decision this to workers health of as part implementation the plan. However, risk assessments responsibility of organization the frame atime to for set risk assessments when should completed be and to  marb-project/ Available from: [Internet]. Toronto (ON):PSHSA;c2018. & ResponsiveBehaviour(VARB) Project (PSHSA). PSHSAViolence, Aggression Public ServicesHealth&SafetyAssociation RESOURCE There is no consistent agreementthe literature in regardingtimingthe riskof assessments;thus, theit is Educational found methods delivery literature inthe effective to be for supporting health workerknowledge and panel emphasizedThe expert the importance of providingtraining not just the on tool itself, but also the on

Team discussions about risk assessment the tool, including how to understand ratings, the and provision the of The adoption of a “train-the-trainer”educational approach. For example, ina studythat evaluated the feedback on pseudo-clinical cases (41). feedback on cases pseudo-clinical key individuals educated then and trained stafftheir in long-termrespective care facilities (45). individuals long-term inthe care facility were trained by investigators on how to aviolence use risk tool. These effectiveness the ABRATof to predict aggressivebehaviour in recently admitted long-termcare residents, key REGISTERED NURSES’ ASSOCIATION OF ONTARIO . https://www.pshsa.ca/article/   DESCRIPTION

Safety ResponseSystemToolkit. Handbook, SecurityToolkit andthePersonal client populations),includingtheFlagging (designed fordifferent typesofsettingsand violence riskassessmenttoolsandtoolkits aggression, violenceandresponsivebehaviour. approach toreducetheimpactandincidenceof with aconsistentandconsensus-based Includes accesstoavarietyofworkplace Model andtoolkittoprovidetheworkplace Recommendations 3.1 to to 3.3 . RECOMMENDATIONS 39 for more on www.RNAO.ca Recommendation 1.1 Recommendation BEST PRACTICE GUIDELINES • BEST PRACTICE Very low Very Strong Preventing Violence, Harassment and Bullying Against Health Workers - Second - Edition Workers Health Against Bullying and Harassment Violence, Preventing Strength of the recommendation: recommendation: of the Strength evidence of effects: Certainty of the RECOMMENDATION 1.2: 1.2: RECOMMENDATION on all risk assessment a violence workers conduct that health panel recommends The expert tool. using a validated persons complete the tool was inconvenient and were uncertain about interventions they could adopt once the assessment the assessment once they adopt could interventions uncertain about were and inconvenient was the tool complete (49). made was completed the DASA stated it was quick and easy-to-use, they could easily share information about patients, it was was it patients, about information they easily easy-to-use, share could and quick was it stated the DASA completed admission the patient’s into incorporated became it ultimately and to complete, inexperienced staff for appropriate the time needed to felt the tool, over clinical judgment their own preferred however, nurses, (49). Some assessment and reliable methods to triage potentially violent patients, and they enabled early focused interventions, helped staff staff helped focused early interventions, they enabled and patients, violent triage potentially methods to reliable and who (48). Nurses signs” risk “signature identifying useful for were (45) and situations violent identify impending Values and Preferences Values be them to simple found START) and (particularly ABRAT who tools used SPJ health workers that suggests Evidence be time-consuming, which reduces the time nurses spend with patients, and the scoring system can be considered be can considered system the scoring and patients, spend with the time nurses which reduces be time-consuming, (42). characteristics negative individual’s an on focus solely because assessments disrespectful stigmatizing or tool was used and tested in mental health in-patient units, an adult acute care unit and a secure extended care unit. unit. a secure care extended and unit care acute adult an units, health in-patient in mental tested used was tool and accuracy violence, a high of has degree in predicting the DASA these populations, across that indicates Evidence can tool the DASA (42, 47, 49). However, clinical judgments unaided and tools SPJ to particularly in comparison START tool found it difficult to make finer distinctions between high, moderate or no evidence of violence risk (48). violence of no or evidence distinctions between finer high, moderate to make difficult it found tool START (42). This DASA tool: actuarial one the for in literature the found properties was of psychometric assessment The (45), and agreement between subject matter experts using the START tool tends to be higher than ratings conducted conducted be ratings to higher than tends tool experts the START using between matter subject agreement (45), and who used the health workers of 44 per cent also that reported study (48). One health professionals mental general by reliability between health workers, and users of the tool endorsed its utility, low degree of difficulty and ease of andease difficulty of degree low utility, its endorsed the tool of users and between health workers, reliability predict an to be sufficient not may tool the ABRAT suggests research practice (48). However, within completion provider health mental as a qualifications specialized or training if the have user does violence not for risk individual’s (41, 43, 45, 48, 50-52). Two SPJ tools – the ABRAT (45) and the Workplace Assessment of Targeted Violence Risk Risk Violence Targeted of Assessment the Workplace (45) and – the ABRAT tools SPJ (41, 43, 45, 48, 50-52). Two high have to also (41), was found the START tool, SPJ (44, 45). One good to reliability fair (44) – had (WAVR-21) these instruments). these instruments). accurately incidents predict violent to specificallyability intheir acceptable, found was tools SPJ of validity The wide variety of violence risk assessment tools were identified in the literature, and their reliability, validity and utility in and validity reliability, and their in literature, the identified were tools assessment risk violence wide variety of demonstrated tools that assessment risk Violence health serviceorganizations. different assessed across were practice (see actuarial approach or SPJ an either adopted utility and validity high reliability, Health workers who provide direct care to persons should conduct a violence risk assessment to identify persons whoidentify persons to assessment risk a violence conduct should persons to care direct who provide workers Health A injuries. and events violent of the incidence decreasing potentially thereby behaviours, violent higher of risk at are Discussion of Evidence: Discussion of Benefits and Harms RECOMMENDATIONS 40 Preventing Violence, Harassment and Bullying Against Health Workers Edition -Second the alert system to persons. identify is used alert Decisionsthe on must alerting made at be organizational the level, and the persons can increase or equity health decrease system depending of on adopted setting, type alert the the and how stigmatized and can which labelled, impactpanel care emphasized (49).The expert that potentially identifying violent Health equity may impacted negatively be as aresult of using risk assessment tools: persons may inadvertently be Health Equity      Practice Notes panel strength the determined expert of recommendation the strong. to be of workers health and persons compared to harm the that ifrisk assessments could occur are not made. Therefore,the have on equity, health panel attributed expert the value higher to conducting violence risk assessments for safety the Despite low certainty and very evidence inthe uncertainty about impact the that aviolence risk assessment could Expert PanelJustificationofRecommendation approaches were provided to patients were who women (e.g., one-to-one nursing, limit setting and reassurance) (53). restrictive interventions (PRN) (e.g., medications as needed and observations), whereas more interpersonal subsequent interventions that were implemented (53).Results suggested that men were more likely to receive differ for men and women. completedNurses the DASA forpatients threeon forensic acute units and documented negatively canGender also affectequity, health suchthat interventions chosen to prevent and/or mitigate aggression characteristics (such as gender) could result inpotential inconsistencies and inequities incare. that risk factors to specific women maybe missingfrom the (51). tool Usingthat a tool lacks validity patientfor all Although validity, tool the had good there were rates higher of positives false for women than men, indicates which Violence Risk Screening-10 (V-RISK-10) for tool was assessed its ability to predict violence inmen and women. professionals generally under-report violence from persons are who women (51).With to respect gender, the Interestingly, number the of women involved inviolent events is underestimated, and and male both female health benefits balance between and harms for health workers personsand be considered to need carefully.

environment person is the inwhich currently in. term care with substitute decision makers), violence risk assessments should completed be on family the and the organization. See Validation of some of tools is these currently inprogress. protect workers (39).Thus, the risk use of assessment tools is highly recommendedsettingswhere in there risk. is workplace violence asto ensure often necessary thatas deemed policiestheir and programs on workplaceviolence workers. resources are inplace (such as adequate staffing and safety equipment) (53). potentially prevent violent behaviour or from escalating, organizations occurring to need ensure that proper Aside from person receiving the care and depending on setting setting the with (e.g., guardians, pediatric long- Risk assessment tools should appropriate be for of scope the practice of worker health the and role their within the In Ontario, the Adequate resources and time necessary to complete arisk assessment tool are important critically for health Although risk assessments provide away to highlight imminent risk, and interventions implemented can be to REGISTERED NURSES’ ASSOCIATION OF ONTARIO Occupational Health and Safety Amendment Act Recommendation 1.1 for more on of selection the an appropriate risk assessment tool. states that employers to need assess for risk of the RECOMMENDATIONS 41 for a list of factors factors of a list for www.RNAO.ca Appendix F Appendix BEST PRACTICE GUIDELINES • BEST PRACTICE Preventing Violence, Harassment and Bullying Against Health Workers - Second - Edition Workers Health Against Bullying and Harassment Violence, Preventing for the nine STAMPEDAR components that classify risk of violence and their corresponding cues their corresponding and violence classify of risk that components STAMPEDAR the nine for for examples of actuarial and SJP tools used to support a violence risk assessment as identified in identified as assessment risk a violence used support tools to SJP actuarial and of examples for Appendix G Appendix H Appendix Health workers should consider both risk and protective factors for violence. Protective factors are based on an based an on are factors Protective violence. for factors protective both and risk consider should workers Health a increase that factors situational and the dispositional of need be to aware health workers that suggests Evidence A communication strategy to relay findings from the risk assessment needs to be identified. The expertneedsto panel be identified. assessment the risk from findings relay to strategy A communication If the alert for violence risk was due to the acute clinical status of the person (e.g., delirium after surgery), the after delirium the (e.g., person of clinical status the acute to due was risk violence the alertIf for an of thedevelopment violence, for risk at as being is identified aafter person that expertnoted The panel Organizations need to ensure that health workers are educated and trained such that the same quality of care (e.g., (e.g., care of quality thesame that such trained and educated are health workers that ensure need to Organizations that may predict violent or aggressive behaviours. aggressive or violent predict may that behaviours. aggressive or violent of the incidents prevent and predict health workers help to review. the systematic ability (41). Evidence suggests that assessing a patient’s positive or protective traits also reduces negative biases biases negative also reduces traits protective or positive a patient’s assessing that suggests (41). Evidence ability (41). relationships therapeutic improves and health providers among patient that towards multiple (51), of violence history a and gender include can or circumstances These traits violence. for risk person’s See (50). home in a group living and admission involuntary admissions, hospital those who are unable to access the document. This was also emphasized in a qualitative study, such that such that study, qualitative in a was also This emphasized the document. access to unable those who are was housekeepers) or workers dietary (e.g., support personal staff, groups between occupational communication medical the patient’s to access have did not and huddles care in nursing included not because theylacking were (21). charts predictive they increase can and the likelihood they reduce violent, become which can strengths, individual’s address the person’s triggers for violence, provide the appropriate level of care and ultimately make the make ultimately and care of level the appropriate provide violence, triggers for the person’s address persons. and health workers for safer environment easy and in a clear be shared should the assessment risk arises from that pertinent information that emphasized to it ineffectual make would as that or paper-based), (electronic record healthto the be confined not way: should it person’s risk for violence should be re-assessed once their clinical status returns to baseline. In collaboration with with collaboration In baseline. to returns their clinical status be once re-assessed should violence for risk person’s in the remain should risk violence if the alert determine discuss and for can team the the person, healthcare health workers. with have they may interactions future for clinical chart person’s and understand health workers that will ensure care of a plan Developing required. is plan care individualized infection control precautions, violence precautions or fall risk precautions) is provided to all persons, regardless of of all regardless to persons, provided is fallprecautions) risk or precautions violence precautions, control infection precautions. their“alert” See See

        RECOMMENDATIONS 42 Preventing Violence, Harassment and Bullying Against Health Workers Edition -Second Supporting Resources pdf Assessment-Tool-ICRA-Poster-V2.1-2017.04.25. VPRPSAEN0417-Individual-Client-Risk- www.pshsa.ca/wp-content/uploads/2017/05/ [date unknown].Available from: (VAT) [Internet].Toronto (ON):PSHSA; (PSHSA). UsetheViolence AssessmentTool Public ServicesHealth&SafetyAssociation tools/individual-client-risk-assessment/ Available from: [Internet]. Toronto (ON):PSHSA;c2018. (PSHSA). IndividualClientRiskAssessment Public ServicesHealth&SafetyAssociation riskassessment.no date unknown].Available from: Trondheim (Norway):[publisherunknown; Brøset Violence Checklist[Internet]. Linaker, BushIversen,Almvik,etal.bvc: https://www.ais-harm.com/harm Hamilton; c2018].Available from: [Internet]. [publisherStJoseph’s Healthcare Anatomy ofRiskManagementHARM Chaimowitz G,MamakM.TheHamilton RESOURCE REGISTERED NURSES’ ASSOCIATION OF ONTARIO https://workplace-violence.ca/ http://www. https://     DESCRIPTION     

an actuarialinstrumentthatassistsinthe Provides theBrøsetViolence Checklist, housing. users whoarestreet-involvedorintransitional psychiatric settings,andvulnerableservice settings, adultin-patientsinacuteandchronic youth offenders indetention ortreatment in-patients intheforensicpsychiatricunit, Available forvariouspopulations,including Includes past,currentandfutureassessments. historical (static)anddynamicfactors. the assessmentofriskviolencebycombining Structured clinicaljudgmenttooltoassistin the fullversionoftool. Provides linktothePSHSAwebsitedownload factors forviolence. VAT toolthatassessesstaticanddynamicrisk Provides aone-pagesummarizedversionofthe care, communitycareandemergencyservices. Toolkit canbeusedinacutecare,long-term example policy. suggestions forcontrolinterventionsandan Includes theViolence AssessmentTool, preventative measurestobeimplemented. triggers thatcanleadtoviolenceinorderfor Toolkit toidentifyclientbehavioursand prediction ofimminentviolentbehaviour. RECOMMENDATIONS 43

www.RNAO.ca BEST PRACTICE GUIDELINES • BEST PRACTICE Very low Very Conditional

Preventing Violence, Harassment and Bullying Against Health Workers - Second - Edition Workers Health Against Bullying and Harassment Violence, Preventing Certainty of the evidence of effects: evidence of effects: Certainty of the The expert panel suggests that health service organizations and academic institutions support and academic institutions suggests that health service organizations The expert panel plan and develop a quality improvement risk assessment tools to measure the use of validated and/or vertical violence. to address horizontal recommendation: of the Strength RECOMMENDATION 1.3: RECOMMENDATION In organizations that implemented valid tools to measure harassment and bullying, health workers generally generally health workers bullying, and harassment measure to valid tools implemented that organizations In easy to were those that (56, 58) and administer easy to and brief were that tools on value placed greater and preferred (58). interpret There were no studies found that assessed the psychometric properties of tools that measured bullying between students. bullying students. between measured tools that of properties assessed psychometric the that found studies no were There and Preferences Values Environment Survey), and both had good inter-rater reliability (58, 59). reliability Survey), both good had inter-rater and Environment allowed for the examination of multiple sources of bullying within the environment (57). Two tools were found found were tools (57). Two the environment within bullying of sources multiple of the examination for allowed in Clinical Uncivil Behavior (the students nursing towards staff clinical nursing from violence examined that in the Clinical Learning Behaviors Uncivil Civil and of Perception Student the Nursing and tool Education Nursing care setting and generalizability to other health settings is difficult (55, 56). One tool that assessed horizontal and horizontal assessed that One tool (55, 56). difficult is health settings other to generalizability and setting care and properties psychometric adequate Scale) Behavior demonstrated Aggressive vertical (the Hospital violence predictive ability is questionable because they were used by charge nurses or nurse managers, and not staff nurses (26, staff not and managers, nurse or nurses charge used because by they were questionable is ability predictive Intimidation assessed vertical (the that Survey Workplace violence tools of for also was validity found 54). Adequate acute in an was Survey), implementation Behavior although Clinician Disruptive Hopkins the John and Instrument Tools that specifically examined horizontal violence (the Lateral Violence in Nursing Survey and the Horizontal Horizontal Survey and the Nursing in Violence (the violence Lateral specificallyhorizontal examined that Tools in their the confidence and the tools of the generalizability validity; adequate however, Scale) demonstrated Violence (55, 56), and both (57). Tools also were identified that detected incivility from staff nurses towards students in clinical in students towards nurses staff detectedfrom incivility that identified also were both(57). Tools (55, 56), and (58, 59). placements implementing quality improvement initiatives if horizontal and vertical violence exists – is important for the physical the physical for important – is vertical exists and violence if horizontal initiatives improvement quality implementing bullying and harassment predicted that tools assessment Risk persons. and health workers of well-being mental and power those of peers vertical (26, 54), in a position from from violence violence assessed horizontal in the workplace Benefits and Harms –and academic institutions and vertical health service within and violence horizontal organizations for Assessing Discussion of Evidence: Recommendation Addressing Harassment and Bullying from Formal Leaders, Health Workers Health Workers Formal Leaders, from and Bullying Harassment Addressing Recommendation or Students RECOMMENDATIONS 44 Preventing Violence, Harassment and Bullying Against Health Workers Edition -Second and impact the on individual the worker, makes which it difficultascertain to health how equity is affected. More panel emphasized also expert that tools the currently lack ability the to measure extent the of bullying and harassment environment on depends organization’s the to willingness address issue the adequately once it identified. has been The The impact equity on health of using a tool to identify harassment and thebullying in workplace or learning Health Equity Supporting Resources   Practice Notes recommendation conditional. to be harm to employees and/or students complete who panel tool; the thus, strength the determined expert the of the to change culture the and remedy issue. the An organization that is unwilling to positive enact change could cause behaviours exist setting, inahealth negativity steps not could setting ifthe escalate, does necessary the take especially of harm to workers and students. For example, ifresults indicate that degree of ahigh harassing and bullying byused organizations to interpret and results the use from validated the tools could potentially influenceriskthe from formal leaders or colleagues due to variability outcomes. inthe panel emphasized The expert that the methods panel couldThe expert not attribute value high the to use of thattools measure harassing and behavioursbullying Expert PanelJustificationofRecommendation organization service in ahealth or learning environment. research is required to understand how tools that measure harassing and bullying behaviours can affectequity health

formulate aplan of actionto address issue the of harassment and bullying. organization service health or institution. academic The resultsto be stimulatecanused then discussion and gathered.be Questionnaire-COPSOQ-II/Engelsk-udgave Sporgeskemaer/Copenhagen-Psychosocial- Available from: the Working Environment;[dateunknown]. Copenhagen: NationalResearchCentrefor Questionnaire –COPSOQII[Internet]. Environment. CopenhagenPsychosocial National ResearchCentrefortheWorking RESOURCE The riskThe assessment canbe tool an avenue for health workers to comment anonymously culturethe on their of Use organization atool that is validated for service health or particular the institution academic where data the will REGISTERED NURSES’ ASSOCIATION OF ONTARIO http://nfa.dk/da/Vaerktoejer/

  DESCRIPTION

for different targetgroups. Provides threequestionnairesthataretailored environment. assessing andimprovingthepsychosocialwork Developed inDenmarkwiththeaimof RECOMMENDATIONS 45 to www.RNAO.ca Recommendations 3.1 BEST PRACTICE GUIDELINES • BEST PRACTICE Low Strong Preventing Violence, Harassment and Bullying Against Health Workers - Second - Edition Workers Health Against Bullying and Harassment Violence, Preventing Physical environment (surrogate outcomes: health worker injury, incident reporting, assault incident reporting, health worker injury, outcomes: (surrogate Physical environment for specific education content). Certainty of the evidence of effects: Certainty of the evidence of effects: The expert panel recommends that health service organizations provide education and training health service organizations provide education and training The expert panel recommends that violent behaviours from persons (see to health workers on addressing 3.3 of the recommendation: Strength RECOMMENDATION 2.1: RECOMMENDATION be taken, that violence is part of the job, that reporting takes too much time, or not wanting to involve managers (61). managers involve to wanting not or time, takes too much reporting that the job, part is of violence be taken, that It is also important to note that there is potential for decreased formal violence incident reporting following an an following reporting incident violence decreased formal for potential is there that note to also is important It health among to due perceptions be may (61). This component educational an includes that initiative organizational would action no that be reported, should harm physical causing serious and as perceived incidents only that workers unclear which components of education are most effective. effective. most are education of which components unclear aggression and violence experienced in health service organizations (57-59). Evidence suggests that multi-component multi-component that suggests (57-59). Evidence experienced violence in health service and aggression organizations and (60-62) injuries decreased staff health workers for training and education include that initiatives organizational is it utilized, approaches of the (60, 62). Due diversity to health workers against threat and assault of rates reduced Benefits and Harms – manage and prevent – or prevent to organizations by implemented commonly are programs training and Education Discussion of Evidence: Recommendations Addressing Violent Behaviour from Persons Violent from Behaviour Recommendations Addressing the prevention and management of workplace violence, harassment and bullying, in alignment with findings from the from findings with in alignment bullying, and harassment violence, workplace of management and the prevention review. systematic workplace violence, harassment and bullying from all sources (e.g., persons, health workers and students) (60-63). students) and health workers persons, (e.g., all sources from bullying and harassment violence, workplace in literature. the identified interventions the multi-component of based components on are Recommendations for initiative organizational multi-intervention of a as part be implemented should recommendations following The The recommendations that emerged from this recommendation question are based on literature that examined examined that on literature basedare question recommendation this from emerged that recommendations The of management and the prevention for strategies multi-component organizational of the implementation Outcomes: outcomes: perceived well-being (surrogate workers) and health worker health towards and threat implementation). of bullying, policy recognition incivility, violence, harassment and/or bullying among health workers be recommended to improve to workers be recommended among health bullying harassment and/or violence, and health worker outcomes? organizational RECOMMENDATION QUESTION #2: QUESTION RECOMMENDATION workplace and manage to prevent policies and procedures organizational Should RECOMMENDATIONS 46 Preventing Violence, Harassment and Bullying Against Health Workers Edition -Second Internetthe was time-consuming and to led problems technical (64). it in was beneficial reducing workplaceviolence. However,some health workers that reported education offered on Generally, workers health participated who inan organizational initiative that had an educational component found Values and Preferences      behaviours to increase knowledge and skills: The following are considerations for the design andeducational delivery of trainingand content on addressingviolent Practice Notes workplace violence and strength the determined of recommendation the strong. to be panel The expert attributed more value to organizational initiativesthat includeeducation trainingand to reduce equity, panel emphasized expert the importance the of educational approaches that increase knowledge and skill. Despite low the certainty and evidence impact inthe uncertain the that education and have training will on health Expert PanelJustificationofRecommendation understanding of impact the of education and training on workplace violence and equity. health simulation with scenarios standardized patients and/or workers health (65).More research is required to improve of staff, human and material resources fundsand required foreducation programs,when incorporating particularly with education and training affectequity. can also health For example, one study emphasizedthe extensive amount provided across different organizations, theand consistency timingand educationalof refreshers. The cost associated Health equity on access the may based to educators vary inviolence, educational the with expertise approaches Health Equity See See See and families. violence. Appendix I organization. responding to workplace violence (65). manage workplace violence. Results suggested an increase worker inhealth in self-reported self-efficacy simulationthe allowed workers health to reflect their on observations and strategize appropriate responses to separate realistic simulations using standardized patients to elicit authentic feelings and responses. Debriefing after how to and identify approach workplace violence. Subsequent to lectures, the workers health participated inthree registered nurses, physicians, workers social guards and security attend lectures that provided information about example, to educate workers health on how to respond to violence inan emergency department, one study had simulation training) to provide workers health with different strategies for learning acquisition.and skill For Education should tailored also be of to scope the practice of worker health the and role their within the Education should include an active learning component (such as ademonstration, return demonstration or Education and training should include refreshers, and drills on-the-job training. Appendix J Recommendations 3.1 REGISTERED NURSES’ ASSOCIATION OF ONTARIO for additional information on approaches and strategies for delivering education on workplace for Safewards the Model and 10principles to make environments safer for workers, health persons to 3.3 for informationeducational on specific contentthat See shouldbe addressed. RECOMMENDATIONS 47 www.RNAO.ca BEST PRACTICE GUIDELINES • BEST PRACTICE Provides Basic, Advanced and Supervisor-level Provides Basic, Advanced and Supervisor-level security at the Basic level include fundamental Topics at the Advanced level include communicating Topics training program, health In the Supervisor-level Provides an overview of approaches to be included Applicable to multiple diverse settings and health Offers information about the evidence-based Gentle information about Offers education about the GPA Provides information such as a blog and videos that Provides resources, manage and Provides training and consulting to and the Courses are available in both Canada training for health security and safety officers. training for health security and safety organizations and skills, the role of security in health security. health care emergency management throughout the organization and effectively role within the organization. defining security’s security professionals with some supervisory as selecting and responsibilities will cover topics such risks, managing managing employees, mitigating security events and making informed decisions. in workplace violence prevention programs and education. and social service workers. Persuasive Approach (GPA) that educates care (GPA) Persuasive Approach respond to responsive behaviours providers how to effectively. you can register for it. curriculum and how demonstrate GPA. a safe manner. prevent challenging behaviour in intervention and United States in non-violent crisis dementia care specialities.

      DESCRIPTION      http:// https://www. Preventing Violence, Harassment and Bullying Against Health Workers - Second - Edition Workers Health Against Bullying and Harassment Violence, Preventing https://ageinc.ca/ [place unknown]: U.S. Department of Safety and Health Occupational Labor, from: Administration; 2016. Available https://www.osha.gov/Publications/ osha3148.pdf Occupational Safety and Health Administration. Guidelines for preventing workplace violence for healthcare and social service workers [Internet]. Security & Safety (IAHSS). Certifications Security & Safety (IAHSS). Certifications [Internet]. [place unknown: publisher from: unknown]; c2018. Available www.iahss.org/?page=certifications CPI; c2018. Available from: CPI; c2018. Available crisisprevention.com/en-CA/Training-and- Events International Association for Healthcare Crisis Prevention Institute (CPI). Training Crisis Prevention Institute (CPI). Training and events [Internet]. [place unknown]: Advanced Gerontological Education Advanced Gerontological Approaches (AGE). Gentle Persuasive (ON): AGE; [Internet]. Hamilton (GPA) from: c2017. Available about-gpa-2/ RESOURCE Supporting Resources Supporting RECOMMENDATIONS 48 Preventing Violence, Harassment and Bullying Against Health Workers Edition -Second en/ prevention/violence/activities/workplace/ http://www.who.int/violence_injury_ Services International.Available from: World HealthOrganization;andPublic by theInternationalCouncilofNurses; Organization; 2002.Jointlypublished [Internet]. Geneva:InternationalLabour workplace violenceinthehealthsector Framework guidelinesforaddressing World HealthOrganization;etal. International CouncilofNurses; International LabourOffice; from: unknown]: Safewards;c2018.Available implementation [Internet].[place Safewards. ResourcesforSafewards workplace-violence-and-harassment www.ontario.ca/page/understand-law- for Ontario;2016.Available from: [Internet]. Toronto (ON):Queen’s Printer and harassment:understandingthelaw safety guidelines.Workplace violence Ontario MinistryofLabour. Healthand RESOURCE REGISTERED NURSES’ ASSOCIATION OF ONTARIO http://www.safewards.net

https://     DESCRIPTION  

of healthworkersinthisapproach. plan, implementandevaluatethepotentialtraining on howtousetheinterventions,andmethods patients andworkers. at makinghealthorganizationssaferforboth harassment policiesandprograms. workplace violenceprogramsand Act. requirements intheOccupationalHealthandSafety about theworkplaceviolenceandharassment employers, andconstructorsoftheworkplace violence preventionprogramsandeducation. in theworkplace. Provides anoverviewofthemodelitself,resources The Safewardsmodelisasetof10principlesaimed Provides samplesofworkplaceviolencepolicies, Provides anexplanationforworkers,supervisors, Provides considerationswhendevelopingworkplace Intended tosupportallthoseresponsibleforsafety RECOMMENDATIONS 49 communication communication www.RNAO.ca BEST PRACTICE GUIDELINES • BEST PRACTICE Low Strong Moderate Preventing Violence, Harassment and Bullying Against Health Workers - Second - Edition Workers Health Against Bullying and Harassment Violence, Preventing

about a person’s previous incidents of violence. For example, unit staff completed an initial assessment assessment an initial completed staff unit example, For violence. of incidents previous a person’s about G Documentation and Communication of a Person’s Previous Incident(s) of Violence of Incident(s) Previous a Person’s of Communication and Documentation systems; and systems that are simple to use. formal reporting documentation and communication of a person’s previous incident(s) of violence; and communication of a person’s documentation for deciding and a standardized approach against violent behaviours, equipment to protect how to use these; what, when and and alarm doors, closed-circuit cameras measures, including locked environmental security

Certainty of the evidence of effects: Certainty of the evidence of effects: Confidence in the evidence:  of the recommendation: Strength    RECOMMENDATION 2.2: 2.2: RECOMMENDATION and protective implement service organizations that health panel recommends The expert such as the following: security measures, bedside safety handoffs where oncoming and outgoing staff discuss patient-related information (e.g., patient’s patient’s (e.g., information patient-related discuss staff outgoing and oncoming where bedside handoffs safety the patient; of in the presence protocol) behavioural the individualized and behavior recent and the patient; about information hold that binders information patient easily accessible are andwhether they onthe unit patients ofthe all displays updated every shift,that board, identification a patient (63). violence high for risk at huddles between shifts to discuss aggressive patient behaviours and how to manage them; manage to how and behaviours patient aggressive to discuss between shifts huddles

    with pertinent information about the person’s violence history prior to engaging and interacting with them (63). with interacting and engaging to history prior violence the person’s about pertinent information with the following: included strategies Other communication protect health workers from patient aggression. The initiative included various documentation and and documentation various included initiative The aggression. patient from health workers protect strategies workers health provided This six months. in the previous their behaviour about caregivers interview a person’s with A quality improvement initiative in one psychiatric unit for patients with high-risk behaviours was implemented to to implemented was high-risk with behaviours patients for unit psychiatric in one initiative improvement A quality list the following components. the following list The research evidence explores the use of various protective and security measures to support health workers within within workers health support to and securitymeasures protective of various use the explores evidence research The are security and measures which protective unclear is it utilized, approaches of the Due diversity to organization. an literature inthe those identified However, (60, 66-68). assaults and injuries worker health reducing in effective most Discussion of Evidence: Benefits and Harms RECOMMENDATIONS 50 Preventing Violence, Harassment and Bullying Against Health Workers Edition -Second recorded; number the of days recordable between staff injuries improved,also increasingfrom 26.5 to 124(63). One year afterthe implementation these strategiesof (and per centothers), a65 in decrease staff injuries was security equipment,security protective measures and safety procedures on equity. health to prevent and/or manage violent situations. More research is required to increase understanding of impact the of Health equity on workers health whether may based vary have equipment access to security and safety procedures Health Equity tolerated by organization the and its prevention is not apriority (70). procedures –are not consistently incorporated and adhered to, workers health feel that violence and aggression is Evidence suggests that initiatives when personnel –such and as security safety personal incident devices, reporting Values andPreferences consuming (67). and patient systems, alert as opposed to formal reporting systems that felt they were difficultuse to time- and Nurses participated who inaqualitative study were more likely to report workplace violence through records medical alarms systems and surveillance that perception increased their of safety (66,69). workers;health instead, it was responsiveness the of personnel responded who and security to and monitored the participantsdevices, intwo qualitative studies reported that alarms alone didnot of increase sense the safety among steps to prevent necessary the violence and/or (67).However, from injury occurring with to respect alarm personal instance, of use the apatient system that alert identifiedpatients who were riskat beingviolent of enabled takestaff to precautionssecurity to prevent violence and injuryand increase feelings of safety inan effective way (66,67,69). For (60). Acommon theme identified amongthree qualitative studies suggested the forneed appropriateequipment and other sites that didnot implement changes, the there was no significantthe rate in decrease of assaults threatsand cent(23.5 per and decrease) threats cent (24.5per were decrease) recorded; however, site the when was compared to After changes the environmentto were implemented in one hospital, significant the decreases in both rate of assaults changes, such as installation the of safety systems (e.g., panic buttons, locked doors and closed-circuit cameras) (64). Multi-component organizational initiatives to prevent and manage workplace include violence also environmental sleeves Kevlar of equipment should worn be or accessible easily engaging when with person (63).Equipment the available included aboutinterview aperson’s challenging behaviours, worker health the followed decision the key to arrive at what type decision key indicated what of type equipment on to and information use Based when. from assessment initial the safety equipment available for workers health to protect against aggressive patient behaviour. An accompanying In conjunction with documentation and communication strategies, previously the mentioned organization had also Equipment to Protect Against Violent Behaviours and aStandardized Approach for Deciding What, When Formal Reporting Systems that are Simple to Use Environmental Security Measures, including Locked Doors, Closed-circuit Cameras and Alarm Systems and How to Use Them REGISTERED NURSES’ ASSOCIATION OF ONTARIO G and gloves, forearm faceshields pads, and hair covers.

RECOMMENDATIONS 51 www.RNAO.ca need to be considered and implemented implemented and be need to considered 3.3 to BEST PRACTICE GUIDELINES • BEST PRACTICE Recommendations 3.1 Recommendations Preventing Violence, Harassment and Bullying Against Health Workers - Second - Edition Workers Health Against Bullying and Harassment Violence, Preventing Clear guidance on what the health worker needs to do regarding the security and safety strategy or approach is is approach or strategy the security safety and do regarding needs to the health worker what on Clear guidance what including incidents, of violent on documentation the and training education crucial includes (63, 67). This report. pertinent to is information relationship between health workers and security important. is and personnel between health workers relationship a consume not and easy-to-use be efficient, should systems, reporting incident including strategies, Implemented reporting time consuming, and too burdensome is a system feel health workers (63, 67). If resources time or of lot injury (71). physical lead to do not that incidents particularly for occur, will not Primary prevention strategies as outlined in outlined as strategies Primary prevention procedures. safety and security to equipment in addition in which the the region within laws safety align health and with should Security strategies safety and being implemented. is recommendation (64, 66). A good working the initiative of in the implementation beSecurity included should personnel maintaining and following up on these measures (as required). Stakeholders should include individuals from from individuals include should Stakeholders required). (as these measures on up following and maintaining for who will clinical units) advocate or safety health and occupational resources, human (e.g., departments various the health worker. both the and person of well-being and the safety or paper-based section,electronic Harms and in the Benefits outlined strategies the communication to addition In been has admitted. patient violent a potentially that be can used alert notify to health workers or health records measures and procedures outlined in the recommendation. outlined procedures and measures The a policy. within security and measures protective of the implementation document should Organizations the on up following and maintaining implementing, for responsible policy identifythe stakeholders should implemented. are that security and measures protective implementing, for willwho responsible stakeholders be relevant of team a convene should organization The Organizations should conduct a gap analysis based on their resources, and implement the necessary tools, implement and based their resources, on analysis a gap conduct should Organizations

         Practice Notes the following: consider to important is it procedures, safety and security equipment incorporating When protective measures in relation to the harm that can result when these measures are not in place. Therefore, expertthe Therefore, place. in not are when these measures result can that the harm to in relation measures protective be to strong. the recommendation of determined the strength panel Expert Panel Justification of Recommendation Justification Expert Panel procedures safety and security that equipment impact the variable in the evidence and certainty the low Despite security and implement that initiatives organizational to high value the expert attributed panel health equity, on have RECOMMENDATIONS 52 Preventing Violence, Harassment and Bullying Against Health Workers Edition -Second Supporting Resources Security-Toolkit-v1.1-2017.04.21.pdf content/uploads/2017/04/VPRMNKEN0317- Available from: [Internet]. Toronto (ON):PSHSA;2017. (PSHSA). Securitytoolkit:resourcemanual Public ServicesHealth&SafetyAssociation December-2014.pdf Violence-Health-Care-Section-21-Committee- ca/wp-content/uploads/2014/12/Workplace- 2014. Available from: Health CareandSafetyCommittee; violence [Internet].[placeunknown]:Ontario note forworkplaceparties#8: Occupational HealthandSafetyAct.Guidance Committee UnderSection21ofthe Ontario HealthCareandSafety iahss.org/?page=certifications unknown]; c2018.Available from: [Internet]. [placeunknown:publisher Security &Safety(IAHSS).Certifications International AssociationforHealthcare CSA-Z1003-13_BNQ_9700-803_2013_EN.pdf codes-and-standards/publications/CAN_ from: Jointly publishedbytheCSA.Available unknown]: Bureaudenormalisation;2013. staged implementation[Internet].[place prevention, promotion,andguidanceto health andsafetyintheworkplace– de normalisationduQuébec.Psychological Canadian StandardsAssociation(CSA);Bureau RESOURCE REGISTERED NURSES’ ASSOCIATION OF ONTARIO https://www.csagroup.org/documents/ https://www.pshsa.ca/wp- https://www.pshsa. http://www.    DESCRIPTION     

organizations toimprovethehealthandsafety personnel, managersanddirectorsinhealth workplace. preventive andprotectivemeasuresinthe psychologically healthyandsafeworkplace. systematic approachtodevelopandsustaina requirements foradocumentedand organizations, thisdocumentspecifies customized actionplan. program gapsanddevelop acomprehensiveand program. organizations establishaneffective security violence policyandprogram. when developingandmaintainingaworkplace understand theirlegislativeresponsibilities the risksofworkplaceviolenceinhealthcare. would beconsideredgoodpracticestoreduce professional associationrequirements. with regulatory, accreditationandhealth-care environments. TheGuidelinesareincongruence health-care facility)toprovidesafeandsecure of thetype,sizeorgeographiclocationtheir to assisthealth-careadministrators(regardless of theworkplace. IAHSS hasalistofcertificationsforsecurity Provides specificguidanceonsomekey Although notspecifictohealthservice Provides sampletoolstoidentifysecurity Designed tohelpcommunityandhealthservice Assists organizationsandhealthworkersto Offers guidanceonsafetyproceduresthat Provides bothindustryanddesignguidelines RECOMMENDATIONS 53 www.RNAO.ca BEST PRACTICE GUIDELINES • BEST PRACTICE A component of the personal safety response A component of the personal safety with Some devices include a cellular phone the essential The Sentinel Event Alert describes Tools and information that organizations that organizations and information Tools health organizations, a For community and system toolkit listed above, this appendix system toolkit listed above, this appendix tools and provides an overview of the various (e.g., devices, their features and the setting or long-term care) where they acute community, are most applicable. radios, working alone app, pagers, two-way physical alarms and more. safety culture role of leadership in developing a within an organization, and it recommends events from steps to reduce and prevent adverse occurring. can use when implementing a flagging-alert can use when implementing health workers of violence- program to advise related risks. resources when implementing toolkit containing when a system to summon immediate assistance or in a workplace violence episode is imminent progress.

   DESCRIPTION   https://workplace- Preventing Violence, Harassment and Bullying Against Health Workers - Second - Edition Workers Health Against Bullying and Harassment Violence, Preventing https://www.jointcommission. https://workplace-violence.ca/ Sentinel Alert Event [Internet]. [place Sentinel Alert Event [Internet]. [place c2018. unknown]: The Joint Commission; from: Available org/sentinel_event.aspx options and features tools. Toronto (ON): options and features tools. Toronto from: PSHSA; [date unknown]. Available https://workplace-violence.ca/wp-content/ uploads/2017/06/VWVTLHEN1117-Appendix- D-Overview-of-PSRS-Device-Options-and- Features-Tool.pdf violence.ca/tools/personal-safety-response- system/ Public Services Health & Safety Association PSRS device (PSHSA). Appendix D: overview of Public Services Health & Safety Association Public Services Health Safety Response System (PSHSA). Personal (ON): PSHSA; [date [Internet]. Toronto from: unknown]. Available (PSHSA). Communicating the Risk of (PSHSA). Communicating Handbook A Flagging Program Violence: Care [Internet]. for Maximizing Preventative unknown]. (ON): PSHSA; [date Toronto from: Available tools/flagging/ RESOURCE Association Health & Safety Public Services RECOMMENDATIONS 54 Preventing Violence, Harassment and Bullying Against Health Workers Edition -Second supported reported an they when incident same ifthe manager clinical past, inthe especially was working (71). In one study, participants stated didnot they report incidents of violence and/or aggression didnot they because feel Values andPreferences workers,health and it to reporting inthe led adecrease of future incidents (69). follow-up and managerial support afterviolent a patient event created feelings of disappointment solitudeand in of safety and support among workers health during and afterviolent incidents (68,69). For instance,lack of routine Two qualitative studies identifiedthe important rolethat managers haveand supervisors incontributing to feelings aggression and threats of patient aggression (61). decreased committed by patients towards workers health increased. In contrast, reporting of overall incidents of workplace aggressive and violent events that arose inan emergency department, only reporting of physical actual aggression was reported (62).However, one study found that after management encouraged health workers to report any including in-depth assessments of successes the and challenges of events the cent –a48per instaff decrease injuries example, incidents when of patient aggression towards workers health were consistently by reviewed leadership – instaff A decrease notedalso injury whenis formal leaders encourage and workplacereview violence incidents. For and manage workplace violence (62,63). included leadership rounds to ensure thorough understanding and adoption of and policies interventions to prevent in documented staff injuries was found after implementation ofamulti-component workplace violence initative that andpolicies are supportive of implementation, their rates of staff injurydecrease. For instance,per cent a65 decrease The literature demonstratesthat when formal leaders have an understanding of workplaceviolence prevention Benefits andHarms Discussion ofEvidence: Confidence intheevidence: Certainty oftheevidenceeffects: Strength oftherecommendation:   health workersinpreventingandaddressingworkplaceviolencebydoingthefollowing: The expertpanelrecommendsthatformalleaderswithinhealthserviceorganizationssupport RECOMMENDATION 2.3:

reviewing andactingonreportedworkplaceviolenceincidents. understanding andimplementingpoliciesagainstworkplaceviolence; REGISTERED NURSES’ ASSOCIATION OF ONTARIO Low Strong Low RECOMMENDATIONS 55 www.RNAO.ca BEST PRACTICE GUIDELINES • BEST PRACTICE Preventing Violence, Harassment and Bullying Against Health Workers - Second - Edition Workers Health Against Bullying and Harassment Violence, Preventing understanding and implementing policies against workplace violence, and in the review of violent incidents. violent in the review of and violence, workplace policies against implementing and understanding all with parties leaders need follow-up to formal incidents, violence workplace reviewing the reported from Aside the incident prevent and damage its been mitigate taken to have steps what indicate and in the incident involved occurring from again. afraid of the potential for negative repercussions from management and their employer or professional body (21). professional or their employer and management from repercussions negative for the potential of afraid in post-incident and participate incidents violence workplace report to encouraged and supported be should Staff judgment. reviews, free from in the actively to participate managers nurse enable purposeful as such and patients dialogue staff with Strategies of process in the workers health involve should leaders formal (68). Thus, patients and health workers of safety To ensure that formal leaders have the capacity and capability to support health workers effectively, organizations organizations effectively, health workers support to capability and the capacity have leaders formal that ensure To violence. workplace of in the area training and education in support, invest to required are reviewing violent health workers, in supporting involved be need leaders to actively formal other and Managers (61, 62). violence against advocates that a culture promoting and change embracing and understanding incidents, because they reports were incident complete to reluctant were health workers that found study qualitative One

    Practice Notes  competence in health workers, which can potentially increase health equity. For that reason, despite the low certainty certainty the low despite reason, that For healthequity. increase potentially which can in health workers, competence be to strong. the recommendation of in the evidence, the expert determined the strength panel The expert panel attributed more value to having formal leaders use strategies and skills to assist health workers to workers health skillsassist to and use strategies leaders formal having to value more attributed expertThe panel and of a satisfaction instils sense and of safety a culture promotes This incidents. violent manage and/or prevent involvement has on health equity. health equity. on has involvement of Recommendation Expert Panel Justification working conditions. Health workers who feel protected and supported at work are able to deliver quality care to to care quality deliver to able are work at supported and protected who feel workers Health conditions. working leadership of that impact the understanding to increase required is research More effectively. clients and patients Health Equity uncertain an has violence workplace managing and in preventing involvement leadership and managerial Although safe create leaders when formal increases health equity that assume to reasonable is it health equity, on impact RECOMMENDATIONS 56 Preventing Violence, Harassment and Bullying Against Health Workers Edition -Second Supporting Resources Available from: U.S. DepartmentofVeterans Affairs; c2018. National CenterforPTSD.Washington (DC): U.S DepartmentofVeterans Affairs. PTSD: ptsdassociation.com/ c2006-2018. Available at: London (ON):PTSDAssociationofCanada; the PTSDAssociationofCanada[Internet]. PTSD AssociationofCanada.Welcome to Investigate.pdf ca/wp-content/uploads/2013/02/How_To_ 2013. Available from: incident [Internet].Toronto (ON):PSHSA; (PSHSA). Fastfacts:howtoinvestigatean Public ServicesHealth&SafetyAssociation guidance-workplace-violence-en.pdf hqontario.ca/Portals/0/documents/qi/qip/ HQO; 2017.Available from: violence prevention[Internet].Toronto (ON): improvement planguidance:workplace Health QualityOntario(HQO). RESOURCE REGISTERED NURSES’ ASSOCIATION OF ONTARIO https://www.ptsd.va.gov https://www.pshsa. http://www. http://www.      DESCRIPTION     

property, butitisanundesiredevent. in anyharmtotheworkerorcausedamage incident. conducting aninvestigationintoareported on workplaceviolence. plans. Ontario forthe2018/2019qualityimprovement of themandatoryworkplaceviolenceindicatorin providers. it alsocanbeusedbyprimaryandhealthcare immediate aftermathofdisasterandterrorism, individuals withPTSD. individuals suffering fromPTSDorfamilies of experiencing PTSD. caregivers andfamilieswhocareforpersons PTSD, personsatriskofexperiencingand articles, researchandcopingstrategies. is currentlybeingcreatedbyPSHSA. workers. discussion betweenformalleadersandhealth The intentionoftheinvestigationistostimulate The reportedincidentisonethatdidnotresult A guidethatoutlinesthestepsinvolvedwhen Includes guidanceforimprovingreportingculture Supports hospitalsinmeetingtheexpectations Although theresourcesweredevelopedfor Provides manuals,modulesandresourcesfor The informationisforpersonsexperiencing Provides informationaboutPTSD,including A toolkitonhowtoinvestigateviolentincidents RECOMMENDATIONS 57 www.RNAO.ca BEST PRACTICE GUIDELINES • BEST PRACTICE Health workers have the right to do their jobs in right to do their have the Health workers safer workplaces benefit Hospitals that are on assessing supervisory Provides direction completed by It is recommended that the tool be a safe environment, free from violence. a safe environment, a safe environment enables everyone, because meet the evolving needs of all health workers to patients more effectively. risk training competency and associated violence for a specific setting. including a multi-stakeholder assessment team, senior management and others.

DESCRIPTION     Preventing Violence, Harassment and Bullying Against Health Workers - Second - Edition Workers Health Against Bullying and Harassment Violence, Preventing https://www.pshsa.ca/wp- https://www.pshsa.ca/wp-content/ Available from: Available content/uploads/2017/03/P9_VPRTLAEN0317- Training-Matrix.pdf Accountability-Framework-2.pdf Prevention in Violence Workplace matrix Training Healthcare Leadership Table. date unknown]. [Internet]. [place, publisher, Healthcare Leadership Table. A framework A framework Table. Healthcare Leadership a safer workplace for making hospitals violence [Internet]. free from workplace date unknown]. Available [place, publisher, from: uploads/2017/03/P1_VPRTLYEN0217- RESOURCE in Prevention Violence Workplace RECOMMENDATIONS 58 Preventing Violence, Harassment and Bullying Against Health Workers Edition -Second reviews afterreviews violent events have equity. on health anddialogue is from free blame. More research is required to improve understanding of impact the that post-incident with physical and emotional support, and post-incident ifthe is conducted review inamanner that encourages open panel Thesuggeststhat expert equity health may increase if health workers involvedviolent ina incident are provided Health Equity abandoned support when from management was lacking after adifficult or dangerous event (70). should addressed and be given priority. This is elucidated ina qualitative meta-synthesis,where staff feltisolated and incident should feel supported by co-workers and formal leaders,and that physical their and mental well-being panel emphasizedThe expert that before engagingpost-incident ina review,the health worker involvedthe in Values andPreferences are contacted and staff are providedwith helpful information on managingthe incident (69). resolved, such that event ifthe is seriously taken by managers it is more likely appropriately to be handled (e.g., police In one qualitative study, attitude the of manager the was found factor acritical to inhow be violent the event is prevent and manage violent incidents (63). understanding of workplace violence and contribute to continued the development of organizational initiatives to months afterthe initiative commenced (63). Participationpost-incident in also wasfound reviews to increase incidents,the factors that specifically event the led to per cent (63).A65 in decrease staff injuries was found nine In aquality improvement initiative, a17-item questionnaire completed by staff was introducedviolent to review (62). Five years after implementation,per cent a48 in decrease staff injuries was (62). reported challenges and successes of techniques the and used, to create recommendations for improvement and prevention event (62).Huddles provided an opportunity to and review reflect the incident,on including adiscussion the on larger organizational initiative, debriefing with huddles staff were held immediately followingaggressive an patient miss. Incident verbally during can ahuddle reviews occur (62)or inan online or paper format (63).As of part a A Benefits andHarms Discussion ofEvidence: formal incident review Confidence intheevidence: Certainty oftheevidenceeffects: Strength oftherecommendation: the approachthatwasusedandstrategiesforviolencepreventioninfuture. incident reviewsimmediatelyfollowingaviolenteventtodiscussthedetailsofwhatoccurred, The expertpanelrecommendsthathealthserviceorganizationsimplementaprocessforformal RECOMMENDATION 2.4: REGISTERED NURSES’ ASSOCIATION OF ONTARIO G is a method to and is discuss amethod analyze events the leading up to an accident, injuryor near Moderate Strong Low RECOMMENDATIONS 59 www.RNAO.ca BEST PRACTICE GUIDELINES • BEST PRACTICE Preventing Violence, Harassment and Bullying Against Health Workers - Second - Edition Workers Health Against Bullying and Harassment Violence, Preventing are high levels of psychological safety among colleagues (72). colleagues among safety psychological of high levels are have to employers 2009) requires Act, Amendment Safety and Health Bill 168 (the Occupational Ontario, In harassment; and/or violence workplace of incidents report use to can employees that procedures and measures and/or violence workplace of complaints or incidents manage and investigate to a procedure have they also must (24). harassment Discussion of the incident needs to be conducted in a sensitive manner that does not place blame on the health on blame place does not that manner in a sensitive be needs to conducted the incident of Discussion worker. such positive, is environment safety health and occupational when the overall likely more is support Post-incident violence, of management and the prevention for in place training policies and has whenas the organization and there their staff, for environment a safe supervisors support a priority, made is safety health and occupational reviews. implementing, for willwho responsible stakeholders be relevant of team a convene should organization The various from individuals include should Stakeholders review. incident the formal on up following and maintaining the for who will clinical units) advocate or safety health and occupational resources, human (e.g., departments the health worker. and both the patient of well-being and safety Although the formal incident review should be conducted immediately following the event, the time frame may the may time frame the event, following immediately be review conducted should incident the formal Although for required is the event review of informal immediate an minimum, At vary the situation. on depending injury. further or harm prevent to be to established measures protective The policyshould reviews a policy. within incident formal of the implementation document should Organizations incident the formal on up following and maintaining implementing, for responsible identify the stakeholders Promoting the recovery of health workers from the aftermath of the violent incident should occur. should incident of violent the the aftermath from health workers of the recovery Promoting

       Practice Notes reviews: post-incident when conducting the following consider to important is It participate in purposeful and supportive discussions. Therefore, the expert panel determined the strength of the expertthe strength determined the panel Therefore, discussions. in purposeful supportive participate and be to strong. recommendation Expert Panel Justification of Recommendation Justification Expert Panel health on review will have incident a formal that the uncertain in theimpact evidence and certainty the low Despite actively leaders and both health reviews workers where post-incident to high value the expert attributed panel equity, RECOMMENDATIONS 60 Preventing Violence, Harassment and Bullying Against Health Workers Edition -Second Supporting Resources goo.gl/RT2M2W work process[Internet].Available from: Employer’s responsibilitiesinthereturnto Workplace SafetyandInsuranceBoard. Investigate.pdf ca/wp-content/uploads/2013/02/How_To_ 2013. Available from: incident [Internet].Toronto (ON):PSHSA; (PSHSA). Fastfacts:howtoinvestigatean Public ServicesHealth&SafetyAssociation Incident%20Analysis%20Framework.PDF IncidentAnalysis/Documents/Canadian%20 patientsafetyinstitute.ca/en/toolsResources/ Institute; 2012.Available from: Edmonton (AB):CanadianPatientSafety incident analysisframework[Internet]. Saskatchewan Health;etal.Canadian for SafeMedicationPracticesCanada; Canadian PatientSafetyInstitute;Institute Legislative AssemblyofOntario;2009. in theWorkplace). Toronto (ON): Amendment Act(Violence andHarassment Bill 168.OccupationalHealthandSafety RESOURCE REGISTERED NURSES’ ASSOCIATION OF ONTARIO https://www.pshsa. http://www.    DESCRIPTION     

future risk. improvements canbemadeinordertoreduce recommendations canbecreated,and patient careinhealthsettings. conducting acriticalincidentanalysisrelatedto from workplaceviolenceandharassment. organizations mustfollowtoprotectemployees work. and whatisinvolvedintheprocessofreturningto on whatisrequiredafteraworkplaceincident currently beingcreatedbyPSHSA. workers. discussion betweenformalleadersandhealth property, butanundesiredeventdidoccur. in anyharmtotheworker, orcausedamageto incident. conducting aninvestigationintoareported Describes howanincidentcanbeanalyzed, Provides aframeworkandinformationfor Bill 168outlinesrequirementsthatworkplace Provides employersofinjuredworkerswithinsight A toolkitonhowtoinvestigateviolentincidentsis The intentionoftheinvestigationistostimulate The reportedincidentisonethatdidnotresult A guidethatoutlinesthestepsinvolvedwhen RECOMMENDATIONS 61

www.RNAO.ca BEST PRACTICE GUIDELINES • BEST PRACTICE Civility, Respect, and Engagement in the Workforce Respect, in the Workforce Engagement and Civility, for specific education content). for specific education 3.5 and

Low Conditional Preventing Violence, Harassment and Bullying Against Health Workers - Second - Edition Workers Health Against Bullying and Harassment Violence, Preventing measured the effectiveness of the the effectiveness measured G Recommendations 3.4 Recommendations meta-analysis intervention on harassment and bullying. CREW is a tailored organizational intervention that includes includes that intervention organizational a tailored is CREW bullying. and harassment on intervention G Certainty of the evidence of effects: evidence of effects: Certainty of the The expert panel suggests that health service organizations and academic institutions provide and academic institutions suggests that health service organizations The expert panel harassment students on addressing workplace to health workers and education and training and bullying (see recommendation: of the Strength RECOMMENDATION 2.5: 2.5: RECOMMENDATION students, improve the quality of work life and ultimately increase quality care. quality increase ultimately and life work of the quality improve students, populations who are oppressed, can also reduce leadership and professional opportunities. Implementing educational educational Implementing opportunities. professional and leadership also can reduce oppressed, who are populations and health workers empower the forefront, to the issue bring can bullying and harassment address that programs Health Equity harassing by be affected disproportionately may identity of intersections multiple with students and workers Health particularly at directed bullying, and (35). Harassment health inequity increase that behaviours bullying and respect to education and training on workplace harassment and bullying. bullying. and harassment workplace on training and education respect to Values and Preferences Values with students or workers of health preferences and onthe reported values that identified no literature was There of the program led other health departments within the school – as well as for-profit and non-profit agencies within agencies non-profit and for-profit as well the – as school within health departments led other the program of (35). staff multicultural their own for the workshops of the inclusion request – to the community and learn how to manage the political landscape in which they are situated (35). A 10 to 33 per cent increase in the increase 33 per (35). A 10 to cent situated in which they the political are landscape manage to learn how and also became Students implemented. were workshops the after found was bullying recognize to students of ability success The (35). zones work bully-free creating they served for and bullying, ending advocates to as dedicated more Education as a Hispanic-serving and minority-serving institution, an educational workshop was incorporated into into incorporated was workshop educational an minority-serving a Hispanic-serving as institution, and Education for was workshops of these aim two-hour (35). The program nursing methodology thethe undergraduate teaching of strategies, behavioural and communication learning by empowered become bullying, recognize to students nursing To enhance professional opportunities for nursing students attending a college designated by the U.S. Department of of Department the U.S. by designated a college attending students nursing for opportunities professional enhance To training facilitators and hospital leaders on methods to discuss and improve working relationships in the workplace in the workplace relationships working improve discuss methods and to on leaders hospital and facilitators training a demonstrated study one and scores, civility in an increase perceived indicated meta-analysis of the results (73). The supervisor (8). decrease in perceived incivility organizations and academic institutions is important for identifying and addressing issues of harassment and and harassment of issues addressing and identifying for important is academic institutions and organizations A bullying. (CREW) Benefits and Harms in health service bullying and harassment address to education with students and health workers Providing Discussion of Evidence: Recommendations Addressing Harassment and Bullying from Formal Leaders, Health Workers Workers Health Formal Leaders, from and Bullying Harassment Addressing Recommendations or Students RECOMMENDATIONS 62 Preventing Violence, Harassment and Bullying Against Health Workers Edition -Second and not does include resources to support workers health and students.panelcautions also The expert that education inappropriately. According panel, to education expert the potentially can be ifit harmful is not delivered effectively workers and students due to low certaintyand evidence inthe possibility the that education may delivered be panel couldThe expert not attribute value high to providingeducation about harassment and bullying for health Expert PanelJustificationofRecommendation     bullying: It is important to consider following the before implementing education and training on workplace harassment and Practice Notes bullying to needs occur. Therefore,panel the determined strengththe expert the of recommendationbe conditional. to cannot astand-alone be approach; instead, alarger cultural shift towards an environmentfromfree harassment and

and bullying, refer to For additional information on approaches and potential strategies to deliver education on workplace harassment and more.meetings, huddles, in-services, help Thiswill to increase awareness and resolve conflicts. Harassment and bullying should addressed continuously, be with discussion of topic the during team occurring regiontheir and deliver education as mandated. organizationsHealth service and institutions academic have aresponsibility legislation necessary tothe in review with of ahistory violent behaviour an who employee may encounter workplace inthe (24). 168). Moreover, employers to employees need lettheir know ifthere is arisk of workplace violence from aperson aboutinstruction contents the of workplace the violence and workplace harassment and policies programs (Bill Legislation inOntario, Canadastates that employers to need provide employees their with information and REGISTERED NURSES’ ASSOCIATION OF ONTARIO Appendix I . RECOMMENDATIONS 63 www.RNAO.ca BEST PRACTICE GUIDELINES • BEST PRACTICE Legislation that sets out requirements for health Legislation that sets out requirements such Requirements for hospitals are listed, on Provides organizations with guidance Outlines the legislation in Ontario, Canada, Outlines the legislation workplace Bill 168 outlines requirements that care providers employed in Ontario hospitals. care providers employed in Ontario as the establishment of an interprofessional hospital’s quality committee that includes the chief nursing executive. complying with the Ontario Occupational on employer Health and Safety Amendment Act responsibilities for addressing violence, in the harassment and domestic violence workplace. to advance the action plan of the provincial to advance the action sexual violence and government to stop schools, workplaces and harassment across rental units. employees organizations must follow to protect from workplace violence and harassment.

   DESCRIPTION   https://www. Preventing Violence, Harassment and Bullying Against Health Workers - Second - Edition Workers Health Against Bullying and Harassment Violence, Preventing https://www.ola.org/ http://www.health.gov.on.ca/ http://www.health.gov.on.ca/ (PSHSA). Fast facts. Workplace violence: (PSHSA). Fast facts. Workplace Health complying with the Occupational (ON): and Safety Act [Internet]. Toronto from: PSHSA; 2010. Available pshsa.ca/wp-content/uploads/2013/01/ FFWorkplaceViolence.pdf en/pro/ programs/ecfa/legislation/act.aspx Public Services Health & Safety Association Assembly of Ontario; 2009. (ON): Excellent Care for All Act. Toronto Care; 2010. Ministry of Health and Long-Term from: Available en/legislative-business/bills/parliament-41/ session-1/bill-132 Safety Bill 168. Occupational Health and and Harassment Amendment Act (Violence Legislative (ON): Toronto in the Workplace). Bill 132. Sexual Violence and Harassment Bill 132. Sexual Violence Survivors and Action Plan Act (Supporting Harassment). and Violence Challenging Sexual of Ontario; (ON): Legislative Assembly Toronto from: 2016. Available RESOURCE Supporting Resources Supporting RECOMMENDATIONS 64 Preventing Violence, Harassment and Bullying Against Health Workers Edition -Second and bullying workplace inthe and institutions: academic It is important to consider following the implementing when and policies of codes conduct that address harassment Practice Notes panel strength the determined expert the of recommendation the strong. to be consistently understood, implemented and endorsed, workers health and students feel safe and supported. Therefore, and of codes conduct are notpanel inplace. emphasized The expert that policieswhen and codes of conduct are harassment and bullying due to harm the that could potentially to workers health occur and students ifsuch policies equity, panel attributed expert the more value to implementation the of and policies of codes conduct that address Despite low the certainty and evidence inthe variable the impact that and/or policies of codes conduct have on health Expert PanelJustificationofRecommendation is required to increase understanding of impact the of anti-harassment and anti-bullying on policies equity. health areor ifthey setting, particularly academic well-understood and consistently endorsed and supported. More research Health equity on how may based and/or policies the vary of codes conduct are implemented across an organization Health Equity and learning academic environment. torespect implementation the of and policies of codes conduct to address harassment and bullying workplace inthe There was no literature identified thatvalues reported the on and preferenceshealth of workers and students with Values andPreferences respectively) four months after the code of conduct was implemented (8). and students reported inperceived adecrease uncivil behaviour classroom inthe cent (58per and cent, 25per from classes and settings; clinical it outlined also were consequences the rules not ifthose followed faculty (74).Both implemented. The code of conduct includedground rules forbehaviour, misconduct and issues such as removal change across organization the (8).In anursing undergraduate program, of acode conduct to address bullying was are by guided practicesand best implemented by adesignated council that legislates and standardizes practice implemented (8).Results suggested that adoption successful ofis policies contingent these on having that policies A literature was conducted review to assess how that policies address lateral violence inhospitals are effectively Benefits andHarms Discussion ofEvidence: Certainty oftheevidenceeffects: Strength oftherecommendation: the workplaceandlearningenvironment. implement appropriatepoliciesandcodesofconducttoaddressharassmentbullyingin The expertpanelrecommendsthathealthserviceorganizationsandacademicinstitutions RECOMMENDATION 2.6: REGISTERED NURSES’ ASSOCIATION OF ONTARIO Strong Low RECOMMENDATIONS 65 www.RNAO.ca for more details. details. more for Provides a policy developed by Alberta Provides a policy developed by Alberta Bill 168 outlines requirements that Provides policy resources for developing Although not specific to health service Health Services to describe strategies Health Services to describe strategies to) for the prevention of (and response workplace violence. workplace organizations must follow to protect employees from workplace violence and harassment. anti-harassment and anti-bullying policies. Includes links to sample policies and training resources. organizations, these resources could still be applicable when an organization is creating or modifying existing policies.

BEST PRACTICE GUIDELINES • BEST PRACTICE     DESCRIPTION Recommendation 2.7 Recommendation Preventing Violence, Harassment and Bullying Against Health Workers - Second - Edition Workers Health Against Bullying and Harassment Violence, Preventing https://www.shrm.org/ https://extranet.ahsnet.ca/teams/ pages/experts-recommend-workplace-bullying- policies.aspx Binney E. Experts Recommend Workplace Bullying Binney E. Experts Recommend Workplace Policies [Internet]. 2012 Oct 2. [place unknown]: Society for Human Resource Management; from: c2018. Available resourcesandtools/hr-topics/employee-relations/ Bill 168. Occupational Health and Safety Bill 168. Occupational Health and and Harassment in the Amendment Act (Violence (ON): Legislative Assembly of Toronto Workplace). Ontario; 2009. prevention and response [Internet]. [place prevention and response [Internet]. 2014. unknown]: Alberta Health Services; from: Available policydocuments/1/clp-ahs-pol-workplace-violence- prevention-response.pdf RESOURCE violence: Alberta Health Services. Workplace effective (8). In order to participate actively in daily activities, administrators need to understand workflows, workflows, need to understand activities, administrators in daily actively to participate order In (8). effective conflict. of actual sources and/or potential and pressures codesof policies and implementing and when developing involved and be consulted should workers Health academic institution. and in a health serviceconduct organization in a positive manner. in a positive for (8). Instead, practices anti-bullying promote do not strategies dissemination passive policies and Zero tolerance and support understand, leaders need consistently to formal occur, policies to of successful implementation to policies. Refer anti-bullying and anti-harassment endorse be policies to violence lateral for activities in a workplace in daily participate actively need to Administrators Under Bill 168, employers in Ontario, Canada are required to write policies on workplace violence and harassment. harassment. and violence workplace policies on write to required Canada are in Ontario, Bill 168, employers Under (24). effectiveness their to ensure annually at least reviewed must be These policies resources the have must academic institutions and health service that organizations expertThe emphasized panel students or workers health affect to bullying and harassment address policies that for in order in place culture and

Supporting Resources      RECOMMENDATIONS 66 Preventing Violence, Harassment and Bullying Against Health Workers Edition -Second harassment_en.pdf Available from: [Toronto (ON)]:Queen’s PrinterforOntario;2016. Occupational HealthandSafetyAct[Internet]. address: workplaceharassmentunderOntario’s Ontario MinistryofLabour. Codeofpracticeto https://rnao.ca/bpg/guidelines/workplaceviolence Michael GarronHospital;2018.Available from: discrimination preventionpolicy. [placeunknown]: Michael GarronHospital.Harassmentand RESOURCE REGISTERED NURSES’ ASSOCIATION OF ONTARIO https://files.ontario.ca/workplace_    DESCRIPTION

Amendment Act the harassment legalresponsibilitiesunder to helpmeettheirworkplace workplace harassmentinOntario. order toaddressissuesthatarise. process thatisimpartialandefficientin to provideacomplaintandresolution about thestandardsofconduct,and hospital committee,toprovideeducation discrimination amongmembersofthe awareness ofharassmentand Employers canfollowthesepractices Describes acodeofpracticetoaddress Policy documentcreatedtoincrease Occupational HealthandSafety . RECOMMENDATIONS 67 www.RNAO.ca

BEST PRACTICE GUIDELINES • BEST PRACTICE Low Strong Moderate Preventing Violence, Harassment and Bullying Against Health Workers - Second - Edition Workers Health Against Bullying and Harassment Violence, Preventing Providing Mentorship and Role Modelling of Professional Behaviour Understanding and Reinforcing Policies that Address Harassment and Bullying and Harassment Address that Policies Reinforcing and Understanding understanding and reinforcing policies that address harassment and bullying; and harassment and bullying; reinforcing policies that address understanding and behaviour. and role modelling of professional providing mentorship

Strength of the recommendation: recommendation: of the Strength evidence of effects: Certainty of the Confidence in the evidence: support health workers and students by doing the following: and students by doing support health workers   RECOMMENDATION 2.7: 2.7: RECOMMENDATION academic and service organizations leaders in health that formal panel recommends The expert bullying to addressing harassment and involved in preventing and institutions be actively anti-bullying workshop and mentoring of nursing students by faculty led to increased awareness of the bullying the bullying of faculty awareness increased led to by students nursing of mentoring and workshop anti-bullying increased and behaviours in bullying self-involvement of their recognition as well as students, among phenomenon (35). bullying ending to commitment safe and respectful work environment where everyone was expected to behave with courtesy (8). The initiative initiative (8). The courtesy with everyone expected was where behave to environment respectful and work safe policies (8). An violence all lateral of endorsement and the uptake evidenced as by implemented, successfully was An organizational initiative to prevent lateral violence used the concept of “managers as champions” to create a create to champions” as “managers of used violence the concept lateral prevent to initiative organizational An bullying behaviours, and were not shared with the entire organization (75). organization the entire with shared not were and behaviours, bullying managers from various units across 15 hospitals identified several challenges when trying to understand and and when tryingchallenges several identified to understand 15 hospitals across units various from managers effectively and consistently implement to difficult were policies. Policies anti-bullying and anti-harassment reinforce or harassing reprimanding or acknowledging in role the manager’s outline explicitly not did unclear, when they were implementation of policies to occur, managers and supervisors were required to show support, understanding understanding support, show to required supervisors were and managers occur, policies to of implementation interviewed nurse that study one instance, (37, 66, 75). For actions policies and anti-bullying of endorsement and A common theme identified among three qualitative studies was that for the successful and consistent consistent and successful the for was that studies qualitative three among identified theme A common institutions. institutions. Benefits and Harms leadership and managerial having of highlights the importance research qualitative and Both quantitative academic and in health service organizations harassment and bullying address and/or prevent to involvement Discussion of Evidence: RECOMMENDATIONS 68 Preventing Violence, Harassment and Bullying Against Health Workers Edition -Second and donot enforce “no tolerance” are policies perceived by workers health as aggravating lateral violence (76). contrast, donot leaders who have apresence on unit, the are not supportive of staff, overlook unprofessionalbehaviour message that are they committed to achieving and maintaining anti-harassment and anti-bullying standards (8).In Health workers value actively leaders who participate daily inthe operations of organization, the it because the sends Values and Preferences     preventing and addressing harassment and bullying: The following are strategiesthat can effectively increase the ability ofleaders be to formal involvedactively in Practice Notes panel strength the determined expert the of recommendation the strong. to be leaders inaddressing harassment and bullying inorder to foster asafe and supportive workplace culture. Therefore, and variable the impact on equity, health panel attributed expert the value high to active the involvement of formal Despite low of certainty body quantitative inthe moderate evidence, confidence body the of in qualitativeevidence, Expert PanelJustificationofRecommendation harassment and arise reported. to need be ofincrease sense the safety and support perceived by workers health and students issues when of bullying and/or bullying –and policies professional model who behaviour –promote positive working environments. Thiscan and bullying. Formal have leaders who ability the and to understand skills and reinforce anti-harassment and anti- Health equity may vary, depending on effectiveness the of formal leaders in preventing and addressing harassment Health Equity

health workershealth inmanaging difficult these situations. learned. Formal hold leaders can also frequent coaching sessions to increase competence the and confidence of storiespersonal and/or about experiences how handled similar situations, they including successes the and lessons panel thatviolence determined (76).The expert one way to encourage is reporting for formal leaders to share that support peer after an incident of horizontalviolence is a protective factorthat can mitigatethe effects the of worsenwill ifincidents of bullying are reported with formal or leaders (37).In discussed contrast, nurses report involve superiors inconflict management. identified This thealso in was literature:health workers fearbullying panel emphasizedThe expert that health workers often are being alienatedconcerned with peers they if their by environment (27). preceptorstheir for errors inapatient’sperpetuated signs. vital This acts of incivilitywithinthe learning clinical such as alack of guidance from preceptors, their receiving excessive demands for chores, and blamed being by preceptors, and physicians during placements. clinical their The nursing students arange experienced of situations Ineffective leadership was experienced by nursing studentswho felt disrespected and by neglected nurses, or bullying behaviours not does indicate that behaviours these donot exist. appropriately. Moreover, it is important that formal aware leaders be that not hearing or witnessing harassing and/ organization (see complete avalidated risk assessment to assess extent the of harassment and/or bullying on unit the or within the safer at work (66).For example, formal leaderscan regularly workers health interview and/or ask workers health to Managers approachable, to need be supportive inactions to andprevent purposeful violence; helps this staff feel inturn elicit will which positive responses from workers health (8). Managers and leaders must demonstrate commitment to improving quality the of workplace the environment, REGISTERED NURSES’ ASSOCIATION OF ONTARIO Recommendation 1.3 ). With information, this able formalbe to intervene leaderswill RECOMMENDATIONS 69 www.RNAO.ca BEST PRACTICE GUIDELINES • BEST PRACTICE Designed for an emergency department manager Designed for an emergency department templates. Provides practical solutions and reporting to download on Provides a list of available resources on possible Additional resources also are available Highlights the role of nurses in formal leadership Highlights the role further suggested Provides additional resources and or team leader as a resource for developing and or team leader as a resource for developing to address and implementing a comprehensive plan staff. manage workplace violence and protect of psychological assessment, action and evaluation health safety in the workplace. on distinguishing threats to psychological safety and mental distress and mental between mental injury, illness. positions in the prevention and management of positions in the prevention colleagues in conflict between nurses, clients and the workplace. reading.

    DESCRIPTION   https:// https://www. Preventing Violence, Harassment and Bullying Against Health Workers - Second - Edition Workers Health Against Bullying and Harassment Violence, Preventing https://www.ena.org/docs/default- (CARMHA); c2018. Available from: (CARMHA); c2018. Available www.guardingmindsatwork.ca/resources Guarding Minds @ Work: A Workplace A Workplace Guarding Minds @ Work: Safety. Guide to Psychological Health and Documents and Resources [Internet]. [place unknown]: Centre for Applied Research in Mental Health and Addiction from: source/resource-library/practice-resources/ toolkits/workplaceviolencetoolkit. pdf?sfvrsn=6785bc04_28 cno.org/globalassets/docs/prac/47004_ conflict_prev.pdf ENA Emergency Nurses Association (ENA). toolkit: workplace violence [Internet]. Des Plaines (IL): ENA; 2010. Available College of Nurses of Ontario (CNO). College of Nurses conflict prevention and Practice guideline: (ON): management [Internet]. Toronto from: CNO; 2017. Available RESOURCE harassment and bullying within health service organizations and academic institutions. academic institutions. and health service within bullying and organizations harassment The expert panel stressed the importance of providing formal leaders with the necessary education to address to address necessary leaders the with formal education providing of expertstressed importance The the panel is what about information include should Education successfully. bullying and harassment about concerns IV).Type I through (i.e., of violence the classifications with along bullying, and harassment violence, considered of issues resolve to resources skillsand support, adequate require leaders formal that expertThe emphasized panel

Supporting Resources   RECOMMENDATIONS 70 Preventing Violence, Harassment and Bullying Against Health Workers Edition -Second and healthworkers? harassment and/orbullyingberecommended forhealthworkerstoimprove outcomesforpersons Should educationandtrainingprograms onpreventing andmanagingworkplaceviolence, RECOMMENDATION QUESTION#3: uncertain impactuncertain on equity, health panel strength the determined expert the of recommendation the strong. to be inpersons thatobserve indicate aviolent incident is imminent. Therefore, despite lowevidence certainty the and in an display violent behaviours.panel emphasized The expert that education should includethatcues health workers can itbecause could support improvements attitudes in the and perceptions that workers health have towards persons who panel The expert attributed value high to providing health workerswitheducation riskon factors triggersand for violence, Expert PanelJustificationofRecommendation identification equity. on health organization. More research to improve is needed understanding of impact the of education regarding risk factor “at risk” patient may stigmatizing be protocol unlessthis is commonplace on unit the and implemented across an workers inamanner that avoids For stigma. example, hanging on asign door the or placing ban awrist on the increase ifinformation about an individualrisk” identified being as “high forviolence is communicated to health it on depends how education the to communicate is used panel risk. Thesuggeststhat expert equity health may Providing education to workers health on identifying risk factors has an impact uncertain on equity, health because Health Equity thattriggers may indicate become violent aperson will were positively received by staff health (79). Evidence suggests that educational programs that provided workers health with information about and cues the Values andPreferences aggression that sustained can be for months several aftereducation is completed (8,77-80). suggests evidence improvements(8, 77-80).Overall, attitude inthe of workers health towards patient violence and workershealth knowledge and with necessary the tools to mitigate and/or prevent patient and family aggression Education for workers health on how to risk factors identify and for triggers because violence is beneficial, it provides Benefits andHarms Discussion ofEvidence: Recommendations Addressing Behaviourfrom Violent Persons health workers,workerinjury, andhealthworkerturnover Outcomes: Certainty oftheevidenceeffects: Strength oftherecommendation: workers ontheriskfactorsandtriggersforviolentbehavioursfrompersons. The expertpanelrecommendsthathealthserviceorganizationsprovideeducationto RECOMMENDATION 3.1: REGISTERED NURSES’ ASSOCIATION OF ONTARIO

Patient injury, useofrestraints, perceived safetyofhealthworkers,attitudesandvalues Strong Low RECOMMENDATIONS 71 www.RNAO.ca BEST PRACTICE GUIDELINES • BEST PRACTICE Provides an overview of triggers and Although specific to care planning, the list Provides guidance on exploring the Provides guidance on exploring the Describes assessment and care workers A free online course to help health include definitions and types of Topics Contains links to training and resource Includes resources about risk factors, predisposing factors (risk factors) for violence. of risk factors and triggers can be applicable to a variety of health workers in various settings. underlying causes of behavioural and underlying causes of behavioural that psychological symptoms of dementia could illicit aggressive behaviours. older recommendations specifically for adults with dementia, delirium and depression. of understand the scope and nature workplace violence. violence, the consequences of violence, risk factors for violence and prevention strategies for both organizations and nurses. materials about workplace violence and workplace violence prevention for nurses. prevention programs, training and enforcement.

        DESCRIPTION http:// https:// https://www. Preventing Violence, Harassment and Bullying Against Health Workers - Second - Edition Workers Health Against Bullying and Harassment Violence, Preventing for a list of risk factors or triggers that may predict violent or aggressive behaviours in persons. in persons. behaviours aggressive or violent predict may triggers that or factors risk of a list for https://www.cdc.gov/niosh/topics/

Appendix F Appendix

It is important to recognize that in some situations there is no warning that a violent event is imminent or that a risk that or imminent is event violent a that warning no is there situations in some that recognize to important is It to be adopted. blame) not (and support of a is crucialit culture for In these situations, been identified. not has factor See coping with patients who enage in aggressive behavior (81). behavior in aggressive who enage patients with coping process. planning care the person-centered into be integrated should Triggers they also care, the receiving person to be tailored triggers may and while the factors risk that note to important is It visitors. and families to becan applied them. stigmatizing than rather risk at persons supporting focus on should Education Risk factors and triggers should be identified to help prevent violent events from occurring. Training provided to provided Training occurring. from events violent prevent help to be identified triggers should and factors Risk or skills prevent to communication patients, from behaviour violent of signs the warning about health workers in confidence increase self-reported may safety personal maintain to strategies and situation, diffuse violent the www.pshsa.ca/wp-content/uploads/2017/03/P7_ VPRTLCEN0317-Triggers-and-Care-Planning.pdf Leadership Table. Triggers and care planning in Triggers Leadership Table. workplace violence prevention [Internet]. [place, from: Available date unknown]. publisher, Workplace Violence Prevention in Health Care Violence Workplace Violence [Internet]. Available from: [Internet]. Available Violence osha.gov/dte/library/ United States Department of Labour Occupational Safety and Health Administration. Workplace Available from: Available violence/training_nurses.html Health (NIOSH). Occupational Violence: Workplace Workplace Health (NIOSH). Occupational Violence: [place Prevention for Nurses. [Internet]. Violence 2018. unknown]: Centers for Disease Control; The National Institute for Occupational Safety and The National Institute for Occupational RNAO.ca/bpg/guidelines/assessment-and-care-older- adults-delirium-dementia-and-depression Delirium, dementia, and depression in older adults: Delirium, dementia, and depression [Internet]. assessment and care, second edition from: (ON): RNAO; 2016. Available Toronto RESOURCE Ontario (RNAO). Registered Nurses’ Association of

Supporting Resources      Practice Notes Practice  RECOMMENDATIONS 72 Preventing Violence, Harassment and Bullying Against Health Workers Edition -Second per centper (89). restrained was found to increase by cent 52per (83),and of odds the incidents new of restraint increased by use 43 De-escalation harmful. training Aftertraining be can also the on technique,the duration thattime of patients were (62, 88). implementation of education on communication strategies within alarger workplace violence prevention program Finally, two studies reported a49and cent 63per instaff decrease injuries over a five-year period following the maintained two months assessed when afterthe intervention (87). weeks aftertraining,the and asignificantdecrease after 16 weeks (86). Staff attitudes also improved, this and was and de-escalation found skills anon-significantthe in decrease number of aggressive incidentsdayper eight (79). Furthermore, an Internet intervention that included and videos narration to train staff on re-direction strategies patient aggressive behaviours increased also (85).They awareness aboutthe quality of staff–patient communication simulations, to led significant improvementsthe in attitudesthat participants had aboutthe factors that can cause Education and training inde-escalation techniques and effective communication including skills, lectures and participants had about why patients aggressively act (77). education on aggression –and training on communication strategies –found improvements perceptions inthe that aggressively atwo-day (82).Likewise, aggression management course for psychiatric nurses that and included theory strategies); generally to led these improvements attitudes inthe that participants had about patients behaved who studies was training content on de-escalation techniques (including and verbal non-verbal communication effectivenessthe of aggression managementtraining for nurses and nursing students.Common amongthe included A component of de-escalation training is education on communication strategies. Asystematic investigated review centa 6–75per rate inthe decrease of restraint (62,83,84). use component organizational initiative, worker health education about de-escalation strategies associated haswith been de-escalation training on restraint demonstrated use areduction inphysical restraint (82).As use of part amulti- for need the mechanical and chemical restraints. Asystematic of review four studies that investigated effect the of De-escalation Benefits andHarms Discussion ofEvidence: Certainty oftheevidenceeffects: Strength oftherecommendation: prevent and/orreduceviolentincidentswithintheirorganizations. workers onde-escalationtechniques,includingcommunicationandre-directionstrategies,to The expertpanelrecommendsthathealthserviceorganizationsprovidetrainingto RECOMMENDATION 3.2: REGISTERED NURSES’ ASSOCIATION OF ONTARIO G is astrategy to prevent and/or reduce escalation of aggressive and violent incidents, and to decrease Strong Very low RECOMMENDATIONS 73 www.RNAO.ca BEST PRACTICE GUIDELINES • BEST PRACTICE Preventing Violence, Harassment and Bullying Against Health Workers - Second - Edition Workers Health Against Bullying and Harassment Violence, Preventing panel determined the strength of the recommendation to be to strong. the recommendation of determined the strength panel to the potential harm that could result from the adoption of such techniques. The expert panel emphasized that that expert The emphasized techniques. panel such of the adoption from result could that harm the potential to the use reduces training de-escalation that personal experiences indicate and reports improvement quality numerous the expert Therefore, safety. staff and patient increases it that and in health service force organizations, physical of Expert Panel Justification of Recommendation – the expert health equity panel on uncertainimpact an in the evidence the very certainty – and low Despite methods compared de-escalation using by aggression and violence of the incidents reducing to value more attributed understanding of the impact of de-escalation techniques on health equity. on techniques de-escalation of the impact of understanding depending on the resources required (92). The study used a simulation-based approach to train health workers workers health to train approach used a simulation-based study (92). The required the resources on depending needed to staff of number time and the extensive reported it and techniques, re-direction and communication on improve to required is research (92). More the education received everyone their department within that ensure techniques can increase health worker competence when addressing violent patient behaviour in a non-restrictive, in a non-restrictive, behaviour patient violent when addressing competence health worker increase can techniques health affect equity also can negatively education study, in one highlighted as However, respectful and manner. safe Many of the included studies were conducted in psychiatric in-patient settings (62, 83, 84, 89). Individuals with with (62, 83, 84, 89). Individuals settings in-patient in psychiatric conducted were studies the included of Many can that histories unique and identities intersecting have may in these illness environments who reside mental de-escalation optimal surrounding Education experienceshealththeir affect equity. with disproportionately adequate training and understanding of how the strategies should be used in practice to improve safety for workers. workers. for safety be used improve should in practice to the strategies how of understanding and training adequate Health Equity One education program was actually initially rejected by health workers as being more unsafe, even though its aim aim its even though unsafe, being more as healthworkers actually rejected initially was by program education One of importance the indicate may This (88). re-direction and communication through practice unsafe change to was Moreover, it was important for health workers that de-escalation training be conducted in short sessions (as opposed opposed (as sessions in short be conducted training de-escalation that health workers for important was it Moreover, be periodically held refreshers (91). that and workshops) lengthy to also believed that their attitude towards persons who behaved aggresively improved (91). This was in contrast to in contrast was (91). This improved aggresively who behaved persons towards also their attitude believed that (91). patients aggressive dealing when with confidence of a lack who reported group, in the control health providers simulation session (90). Participants in a mixed-method quasi-experimental study that was conducted across various various across conducted was that study in a mixed-method quasi-experimental Participants (90). session simulation skills, empathy and listening them active taught training de-escalation that reported hospitals teaching two in units providers These health patients. aggressive with communicating when competence and their confidence increasing a high degree of user acceptance (86) and was rated high for usefulness and satisfaction (87). Nurses, patient care care patient Nurses, (87). satisfaction usefulness and high for rated was (86) and user acceptance a high of degree were verbal de-escalation about training simulation in interprofessional security and who participated staff assistants the after occurred that discussion the appreciated and simulation, through gained learning highlywith the satisfied Values and Preferences and Values (79), had health workers by received well was strategies re-direction and communication on education Generally, A limitation with all of the aforementioned studies is that the follow-up periods ranged from six months to two years, years, two to six months periods from ranged the follow-up that is studies the aforementioned all with of A limitation techniques. de-escalation on education of the sustainability determine to challenging it which makes RECOMMENDATIONS 74 Preventing Violence, Harassment and Bullying Against Health Workers Edition -Second   It is important to consider following the providing when education on de-escalation techniques: Practice Notes          

Moreover, mandatory and ongoing refreshers, re-training and simulation are to ensure critical competency. Education should tailored be of to scope the practiceof worker health the and role their within organization. the education about de-escalation techniques. In order to positively impact person and worker health safety, workers health require adequate and effective emphasized, continued the as does for need compassionate and person-centered care. When educating workers health about de-escalation techniques, importance the of staffsafety be to needs program. and afterviolence a preventioneducation program, and to measurethe effectiveness ofa communication training See to de-escalate used tense situationsbe by engaging staff both patients.and See       Patients were aggressive strategies these because were more efficient time when staffingand was problematic (95). providers reported using more restrictive behaviours (e.g., PRN medication or physical restraints) patients when Health workers require adequate resources to engage effectively inde-escalation strategies. For example, health needed. place. For that reason, targeted communication training organizations for workers health all service health inall is panel Thestated expert that violent behaviour from persons,canoccur families andvisitors, regardless time of or include ongoing support and reinforcement of strategies. learned the panel Thestated expert that education to safeneeds the on focus execution the of techniques, thatand it should improve workers’ health psychological well-being, distress level, and communication competence (94). difficult situationsvaluable bea also may interventiondecreaseaggression to towardshealth workers, also and Workshops that on focus communication techniques, group dynamics and managing discomfort, and with dealing interprofessional communication and teamwork (65,90). When possible, simulation should include avarietyof direct care team members inorder to promote effective confidence and preparedness been (90). hasreported de-escalate or actual potential agreesive behaviour (93).Moreover, an increase ability, inself-reported skills, workershealth increase knowledge their on how to recognize factors the that may to lead violence and how to appropriate and verbal nonverbal communication strategies to de-escalate situation) the and simulated scenarios, When education includes lectures both (e.g., about potential risk factors and how to recognize and them,

Act authentically (95). and truthfully Foster of provider asense the equality between and patient. Facilitate patient coping strategies. situation,the and suggesting (not enforcing) alternative strategies ifnecessary. Involve patients de-escalation inthe process by listening to patient, the asking what them want they to doto fix Ask patients why are they behaving aggressively as opposedto imposing own their assumptions. Tolerate patient’s the escalating behaviour, and give and time them space. Appendix L Appendix J REGISTERED NURSES’ ASSOCIATION OF ONTARIO

emphasize that de-escalation is aprocess where providers health following: dothe for Safewards the Model. This internationally includes model recognized 10interventionsthat can for Institute the for Work &Health to measure (IWH)scale worker vulnerability to injury before RECOMMENDATIONS 75 www.RNAO.ca Provides a full list of eight e-learning Provides a full list of eight e-learning links modules on violence prevention and to access the modules. Describes how respectful communication Describes how respectful escalation or can be used to prevent crisis before it defuse an emotional emergency. becomes a behavioural and verbal Non-verbal, vocal presented. communication is strategies that Describes additional workers can use to respond to an emotional crisis to prevent it from becoming a behavioural emergency. de- Explains when and how to use various escalation strategies. BEST PRACTICE GUIDELINES • BEST PRACTICE  DESCRIPTION     Preventing Violence, Harassment and Bullying Against Health Workers - Second - Edition Workers Health Against Bullying and Harassment Violence, Preventing http://www.heabc.bc.ca/VPM/ http://www.heabc.bc.ca/VPM/ http://www.heabc.bc.ca/Page4272.aspx#. from: Ws4LhIjwZPZ Available from: Available RespondRisk2_Strategies/story_html5.html Columbia Health Employers Association of British Available (HEABC). E-learning Modules [Internet]. RespondRisk1_Communication/story_html5.html Association of British Columbia Health Employers prevention. Respond to the risk: (HEABC). Violence part 2 – perform de-escalation – communication date unknown]. [Internet]. [place, publisher, Health Employers Association of British Columbia Health Employers Respond to the risk: prevention. (HEABC). Violence de-escalation – communication part 1 – perform date unknown]. publisher, [Internet]. [place, from: Available ONLINE MODULES ON DE-ESCALATION ONLINE Supporting Resources Supporting RECOMMENDATIONS 76 Preventing Violence, Harassment and Bullying Against Health Workers Edition -Second www.umabcanada.com/ unknown]; c2011.Available from: [Internet]. [placeunknown:publisher and managingaggressivebehaviour Behaviour (UMAB)Canada.Understanding Understanding andManagingAggressive org/training-programs Available from: Management GroupInc.;[dateunknown]. programs [Internet].[Oakville(ON)]:Safe Safe ManagementGroup.Training Events crisisprevention.com/en-CA/Training-and- CPI; c2018.Available from: and events[Internet].[placeunknown]: Crisis PreventionInstitute(CPI).Training Updated-191212.aspx ca/Public/Files/BSO/BETSI-Full-Version- 2012. Available from: [place unknown:publisherunknown]; introduction andoverview[Internet]. supports inventory:sectionA– Behavioural educationandtraining and Training ConsortiumCommittee. Behavioural SupportsOntarioEducation gpa-2/ Available from: [Internet]. Hamilton(ON):AGE;c2017. Gentle PersuasiveApproaches(GPA) Advanced GerontologicalEducation(AGE). PROGRAMS ANDCOURSES LINKS TOSPECIFICTRAINING REGISTERED NURSES’ ASSOCIATION OF ONTARIO http://safemanagement. https://ageinc.ca/about- http://brainxchange. https://www. http://      DESCRIPTION       appropriate educationprogramsandsupporting Provides guidanceonchoosingthemost responsive behaviours. quality patient-centredcareforolderadultswith tool forprovidersinterestedinprovidingsafe, Provides aneducationanddecision-making demonstrate GPA. Provides resources,suchasablogandvideosthat curriculum andhowyoucanregisterforit. Provides informationabouttheGPA education behaviours effectively. care providershowtorespondresponsive Gentle PersuasiveApproach(GPA) thateducates Offers informationabout theevidence-based unsafe manner. who experiencedifficulty andmayexpressitinan and caregiverswhoworkdirectlywithpeople Provides resourcesandtoolsforhealthworkers service providerandpeoplereceivingcare. developed toaddressthesafetyneedsofboth Describes theUMABprogram,whichwas and SocialServices. recognized bytheOntarioMinistryofCommunity The crisisinterventiontrainingprogramis workplaces andcontexts. programs relatedtosafetyinavarietyof based inOakville,Ontario,thatprovidestraining Safe managementgroupisatrainingprovider dementia carespecialities. United Statesinnon-violentcrisisinterventionand Courses areavailableinbothCanadaandthe prevent challengingbehaviourinasafemanner. Provides trainingandconsultingtomanage older adults. the applicationofnewknowledgeintopracticefor RECOMMENDATIONS 77 www.RNAO.ca BEST PRACTICE GUIDELINES • BEST PRACTICE establishing therapeutic relationships. enhance Provides resources and support to and the the quality of the partnerships nurses individuals interprofessional team have with accessing care. Describes the expectations for all nurses in for all nurses in the expectations Describes and terminating a establishing, maintaining therapeutic relationship. on using therapeutic Provides guidance communication. recommendations for Provides evidence-based using a trauma-informed crisis intervention lens. to enhance crisis care. Lists additional resources integrating Provides resources and support for the area of evidence-based nursing practice in  DESCRIPTION      http:// https://RNAO. Preventing Violence, Harassment and Bullying Against Health Workers - Second - Edition Workers Health Against Bullying and Harassment Violence, Preventing http://www.cno.org/ http://RNAO.ca/bpg/guidelines/person-and- family-centred-care ca/bpg/guidelines/establishing-therapeutic- relationships Ontario Registered Nurses’ Association of care. (RNAO). Person- and family-centered from: (ON): RNAO; 2015. Available Toronto Registered Nurses’ Association of Ontario (RNAO). Establishing therapeutic (ON): relationships [Internet]. Toronto from: RNAO; 2006. Available (RNAO). Crisis intervention for adults using a (RNAO). Crisis intervention approach: initial four weeks trauma-informed 3rd ed. [Internet]. Toronto of management. from: (ON): RNAO; 2017. Available RNAO.ca/bpg/guidelines/crisis-intervention Therapeutic nurse-client relationship, Therapeutic nurse-client CNO; (ON): Toronto revised 2006 [Internet]. from: 2018. Available globalassets/docs/prac/41033_therapeutic.pdf Association of Ontario Registered Nurses’ RESOURCE (CNO). Nurses of Ontario College of RECOMMENDATIONS 78 Preventing Violence, Harassment and Bullying Against Health Workers Edition -Second  It is important to consider following the employing when breakaway techniques: Practice Notes injury. Therefore,panel the determined strengththe expert the of recommendationbe strong.to themselveswith astrategy to extract from aviolent incident, and it potentially exposure decreases to harm and severe value to worker health safety. When adequately trained, of use the breakaway techniques provides workers health Despite low the certainty and evidence inthe an impact uncertain on equity, health panel attributed expert the more Expert PanelJustificationofRecommendation equity.health improving quality the of care. More research is required to better understand impact the of breakaway techniques on of workers health inprevention to methods address violent situations, avoid injuries and increase safety, potentially patients (96).Organization-wide training on breakaway techniques may increase confidence the and competence Health workers feel who unsafe may more be likely to implement coercive or restrictive practices that can harm Health Equity effective forsome learning, had concerns about the use of breakaway techniques in circumstancesreal-life (97). to manage different patienttypes of aggression.Although nurses feltthat activelyparticipating the in workshop was Participants found training the on breakaway as techniques it useful, confidence increased particularly their to be and de-escalation learn and breakaway techniques that to respond used can be to aggressive or violent persons. community participate inaworkshop services) to develop aviolence risk assessment and management plan, One quasi-experimental study had nursingfrom staff four wards (emergency, neuroscience, agedcare and Values andPreferences important to ensure competency (96). centa 46per increase inperceived safety. of Loss acquired skills was evident, suggesting that routine refreshers are and violence (96).Research examining effectiveness the of breakaway techniquetraining foundthat nurses reported workplace violence; instead, training the can complement education that on prevention focuses the of aggression samethe not time physically compromising aggressor the (96).Breakaway techniques donot address issue the of Breakaway Benefits andHarms Discussion ofEvidence: aggression and violence (96). Education on breakaway techniques is provided as acomplement to education that on prevention focuses the of Certainty oftheevidenceeffects: Strength oftherecommendation: techniques andwhentosafelyusebreakawayinviolentincidents. The expertpanelrecommendsthathealthworkersareprovidedtraininginbreakaway RECOMMENDATION 3.3: REGISTERED NURSES’ ASSOCIATION OF ONTARIO

techniques G are strategies to remove used oneself safely from various holds, grabs and at pulls, while Strong Low RECOMMENDATIONS 79 www.RNAO.ca ), should always be used always ), should ) Recommendation 3.2 Recommendation BEST PRACTICE GUIDELINES • BEST PRACTICE and prevent challenging behaviour in a and prevent challenging behaviour safe manner. and Courses are available in both Canada the United States in non-violent crisis intervention and dementia care specialities. Provides important information on a first- primary prevention of violence as line defence before using breakaway techniques. Provides a supplement to other prevention approaches, because it describes how and hospitals can partner with patients families to help prevent violence in the workplace. Provides training and consulting to manage Provides training and consulting to    DESCRIPTION  Recommendation 3.2 Recommendation Preventing Violence, Harassment and Bullying Against Health Workers - Second - Edition Workers Health Against Bullying and Harassment Violence, Preventing (also see supporting resources in resources (also see supporting https://www.crisisprevention.com/ Families-in-Workplace-Violence-Prevention-and- sample-brochure.pdf in workplace violence prevention: a handbook for in workplace violence prevention: [Internet]. organizational leaders in healthcare from: Available date unknown]. [place, publisher, https://www.pshsa.ca/wp-content/uploads/2017/03/ P8_VPRTLBEN0317-Engaging-Patients-and- en-CA/Training-and-Events Prevention in Health Care Violence Workplace Engaging patients and families Leadership Table. RESOURCE and Crisis Prevention Institute (CPI). Training CPI; c2018. events [Internet]. [place unknown]: from: Available If a worker uses the technique incorrectly during a violent incident, a culture of support (and not blame) for the for blame) not (and support of a culture incident, a violent during incorrectly uses the technique a worker If setting. practice or the unit of regardless be adopted, should worker environment and the persons receiving care. care. receiving the persons and environment the using practice to crucial opportunities (i.e., are simulation and re-training refreshers, ongoing Mandatory the using injury from sustaining for the potential reduce and competency ensure to this will help technique); and refreshers skill maintenance, that felt who study one in by participants reported was also This technique. (92). required was training competency ongoing Other techniques, such as communication and de-escalation (see de-escalation and communication as such Other techniques, to extract mayrequired be techniques breakaway then to ineffective, be prove approaches those Should first. situation. dangerous a harmful or from oneself unit organization, healthon based the berequired modified should as techniques breakaway on Training Supporting Resources Supporting Resources     RECOMMENDATIONS 80 Preventing Violence, Harassment and Bullying Against Health Workers Edition -Second or Students Recommendations Addressing HarassmentandBullyingfrom FormalLeaders,HealthWorkers potential forpanel harm. emphasized The expert that behavioursbullying could worsen becomeor amplified including identification the of issue and communication strategies to manage it effectivelybecause there – isa panel couldThe expert not attribute more value educatingto health workers about harassment and bullying – Expert PanelJustification ofRecommendation harassment can significantly impactthe quality and continuity careof that patients receive (101). patient care and outcomes (101).Alternatively, organizational staff turnover related to problemswith bullying and “non-toxic,” there is for atendency workers health more to be engaged and productive, translates which to better culture of organization the and overall the presence of bullying and harassment. In environments as described panel Thesuggeststhat expert the impact this of recommendation equity on health be dependentwould the on Health Equity education for workers health on harassment organizations. and bullying service inhealth There was no literature identified thatvalues reported the on and preferenceshealth of workers to with respect Values andPreferences centper over three years), and turnover rates (from cent 8.9per cent to 6.0per over three years) (103). weredecreases found inreported awareness of incivility among nurses (101).Moreover, nurses when are trained inassertivecommunication skills, by nurses (99,100).Education and discussion about impact the of incivility resulted cent ina6per increase in Education and similation about activities issue the of incivility to inperceived led decreases of acts incivility reported Results suggested anon-significant increasethe in nurse’s awareness lateralof violence (98). cards withcue conflict,to deal with effective verbal responses and an outline ofexpected professional behaviours. intervention to combat nurse-to-nurse lateral violence and included about history theory issue, the resources on how organization service health and perceived the safety of workers health on (specifically measures of incivility). An studies exploredSeveral effectiveness the educationalof programs to increase awareness about thebullying in Benefits andHarms Discussion ofEvidence: Confidence intheevidence: Certainty oftheevidenceeffects: Strength oftherecommendation: bullying, anduseeffective communicationstrategies. workers onhowtoidentifyharassmentandbullying,understandtheimpactof The expertpanelsuggeststhathealthserviceorganizationsprovideeducationto RECOMMENDATION 3.4: REGISTERED NURSES’ ASSOCIATION OF ONTARIO mobbing Low Conditional G (102), verbal abuse (102),verbal at work rates (103),vacancy (from cent 8.9per to 3.0 Low

RECOMMENDATIONS 81 www.RNAO.ca developers and leaders with information and data. A handbook for employers, supervisors, co-workers and victims of bullying to of learn about the prevalence and effects bullying, and to obtain information about how to prevent and/or manage it. A tool for clinicians, leaders and educators A tool for clinicians, leaders and educators that structures communication between members of the interprofessional team. ways for educators Identifies effective to teach and model constructive ways to address and manage workplace bullying. Provides students with tools to address bullying, and provides curriculum BEST PRACTICE GUIDELINES • BEST PRACTICE  DESCRIPTION    .

http://www.ihi.

Recommendation 3.5 Recommendation Preventing Violence, Harassment and Bullying Against Health Workers - Second - Edition Workers Health Against Bullying and Harassment Violence, Preventing https://www.pshsa.ca/wp- Interactive role-play and simulations should be implemented to practice strategies to manage incivility, and to to and incivility, manage to strategies practice to be implemented should simulations and role-play Interactive (92, 105). personal experiences incivility with of discussions open the clinical learning and in academic institutions students for bullying and harassment address to Strategies in be can found environment Training strategies to increase assertiveness can include confidently expressing thoughts and feelings, taking feelings, and thoughts expressing confidently include can assertiveness increase to strategies Training (102). conflict without rights protecting and stress with coping well, criticism or presentations Point Power include can health workers among incivility of awareness increase to Education didactic (101, 105). teaching Employee involvement in the development of an educational program may facilitate adoption of strategies to to strategies of adoption facilitate may program educational an of in the development involvement Employee 100 of a team project improvement quality in one example, vertical For and violence. lateral address the communicate behaviours, negative to target strategies to develop convened were staff interprofessional Survey strategies. the follow to accountable remained staff that ensure and the organization, across strategies by vertical and aggression a decrease in lateral suggested implementation after collected years two results (104). employees The expert panel emphasized that tools and strategies need to be provided to health workers to encourage effective effective encourage to workers healthto needprovided to be strategies and tools that expertThe emphasized panel health service within be adopted should organizations a process that and bullying, and harassment dialogue about situations. bullying and harassing handle to academic institutions and content/uploads/2013/02/BullyWkplace.pdf Bullying in the workplace: a handbook for the (ON): PSHSA; workplace [Internet]. 1st ed. Toronto from: 2010. Available Public Services Health & Safety Association (PSHSA). Advancement in Nursing Education. 2016;2(1):1-17. Fehr FC, Seibel LM. Cognitive rehearsal training for upskilling undergraduate nursing students Quality against bullying: a qualitative pilot study. org/resources/pages/tools/sbartoolkit.aspx Situation-Background-Assessment-Recommendation Situation-Background-Assessment-Recommendation [Internet]. [place unknown]: Institute for Healthcare from: Improvement; c2018. Available RESOURCE SBAR Tool: Institute for Healthcare Improvement. Supporting Resources       Practice Notes bullying: and harassment address and understand workers heath assist to approaches educational are following The when harassment and bullying are identified as significant problems on a unit or within an organization. A power power A organization. an within or on a unit problems as significant identified are bullying and when harassment managed. is problem the how and on the perpetrator depending or be exacerbated ensue also could differential to be conditional. recommendation of the expertthe strength determined the panel Therefore, RECOMMENDATIONS 82 Preventing Violence, Harassment and Bullying Against Health Workers Edition -Second and communication guided techniques on equity. health environments. More research is required to improve understanding of impact the of interactive learning approaches capable to intervene confronted when with harassment and bullying institutions inacademic and/or learning clinical participate inrole-play simulations and effective learn communication responses maybe more confident and panel Thesuggeststhat expert the impact this of recommendation would increaseequity. health Studentswho Health Equity readings and class discussion helped to them recognize bullying behaviours and engage incoping strategies (107). respond to bullying were valuable. deemed also Students reported that ability the to supplement online the with videos settings,to inclinical scenarios links literature, reflective activities and in-class role-play simulations of how to Interactive learning modules for undergraduate nursing students and midwifery that included of videos bullying taught how them to effectively communicate in stressful situations and advocate forsafetythe patientstheir of (106). (99). learning experiences reported beneficial toParticipants be in another study feltthe cognitive rehearsal activity lanyard cards that outlined communication responses were valued, and training the and role-play simulations were Feedback from participants the included inthe studies was positive: interactive the programs were well received, the Values andPreferences the see please importance of safeguarding students from potentially recreating upsetting To scenarios. mitigate potential this harm, Neither study reported any harms as aresult of educational the interventions; however, the discussed both increase perception intheir of confidence to handlefuture situations (99). and address harassment and bullying (99,100).With cognitive the rehearsal training, students reported an also harassment and bullying, and allowed to them practice effective actions and strategies couldthey adopt to prevent training (99)and role-play enabled simulations students curricula to (99,100).Both explore perceptions their of environment to address issue the of harassment and bullying.educational The programs included cognitive rehearsal Two qualitative research studies explored of use the interactive educational programs for students inan academic Benefits andHarms Discussion ofEvidence: Confidence intheevidence: Strength oftherecommendation: sources withinanacademicinstitutionoraclinicallearningenvironment. to useguidedcommunicationresponsesaddressharassmentandbullyingfrommultiple The expertpanelrecommendsthat,aspartofaninteractivelearningapproach,studentslearn RECOMMENDATION 3.5: REGISTERED NURSES’ ASSOCIATION OF ONTARIO Practice NotesPractice below. Low Strong RECOMMENDATIONS 83 www.RNAO.ca BEST PRACTICE GUIDELINES • BEST PRACTICE . Appendix K Appendix Preventing Violence, Harassment and Bullying Against Health Workers - Second - Edition Workers Health Against Bullying and Harassment Violence, Preventing need improvement, and explore strategies that can be implemented when confronted with incidents in the future in the future incidents with when confronted be can implemented that strategies explore and need improvement, (106). & Seibel (2016), Fehr by conducted in the study outlined responses the communication on information more For in card please see the lanyard Allowing students to withdraw from an exercise at any point if they find the role-play upsetting – and providing providing and – upsetting role-play if they find the point any at exercise an from withdraw to students Allowing when consider to strategies important – are activity the simulation of the content about in advance information (99, 100). this issue on education implementing participants sothat environment safe held in a should be sessions debriefing simulations, rehearsal cognitive After or well went identifyaspects that activity, respectto simulated the with feelings and on their thoughts reflect can engagement and learning (107). learning and engagement cognitive (28) and intervene to how and incivility video scenarios) about or slides as (such modules E-learning to increase avenues effective provide (109) can respond to how and behaviours disruptive about training rehearsal inthe both toincivility appropriately respond and to identify students nursing self-efficacy of and the ability (99). in the health service behaviours organization disruptive (100) and academic environment An integrative literature review found that the most effective teaching methods are active ones that educate educate ones that active are methods teaching effective the most that review found literature integrative An (e.g., practicenewly to strategies learned ability them the offer and bullying address to techniques on students (108). rehearsal) cognitive student enhances and facilitates discussion) in-class and modalities videos, (e.g., readings a variety of Using       It is important to consider the following when implementing an interactive learning approach to address harassment harassment address to approach learning interactive an when implementing the following consider to important is It bullying: and Therefore, the expert panel determined the strength of the recommendation to strong. be recommendation of the expertthe strength determined the panel Therefore, Practice Notes harms that could result. The expert panel agreed that students need guided communication responses that will assist willassist that responses need guided communication students expertagreed The that panel result. could that harms academic settings. faculty in clinical or or colleagues from situations challenging with when confronted them if and Expert Panel Justification of Recommendation Justification Expert Panel to interactive value more attributed expertthe evidence, panel qualitative in of the body confidence low Despite potential any to than bullying and harassment skill addressing in and knowledge improving for approaches learning RECOMMENDATIONS 84 Preventing Violence, Harassment and Bullying Against Health Workers Edition -Second Supporting Resources education-nursing http://RNAO.ca/bpg/guidelines/practice- Toronto (ON):RNAO;2016.Available from: (RNAO). Practiceeducationinnursing[Internet]. Registered Nurses’AssociationofOntario UsingAppreciativeInquiryJun122011JFMAB.pdf com/mmhm/exercises/2_ https://www.strategiesdesantementale. Centre; [dateunknown].Available from: [Internet]. [placeunknown]:Great-West Life Exercise: usingappreciativeinquiry the Workplace. Communicatingeffectively. Great-West LifeCentreforMentalHealth in RESOURCE REGISTERED NURSES’ ASSOCIATION OF ONTARIO    DESCRIPTION for nursingstudentsinavarietyofpractice effective teachingandlearningstrategies nurses understandhowtofosterandsupport help nurseeducators,preceptorsandstaff This BPGprovidesrecommendationsthat effectiveness. bullying educationtodetermineprogram students before,duringandafterinteractive questions couldbeusedbyfacultytoask Although specifictotheworkplace, how tomanageadistressedworker. strengths-oriented questionstodetermine appreciative inquiryandopen-ended, Provides guidancetoemployersonusing settings. RECOMMENDATIONS 85 www.RNAO.ca . Studies conducted in these areas in these areas conducted . Studies Table 6 BEST PRACTICE GUIDELINES • BEST PRACTICE organizations to address violence from persons and/or families. Identification of individual characteristics that are strong Identification of individual characteristics predictors of violence. bullying of risk assessment tools that measure Validation and harassment. that measure Impact of using risk assessment tools bullying and harassing behaviours. of two or more components Comparing the effectiveness program. of an organizational initiative or instruments or Development of valid and reliable related to workplace measures that capture indicators in order to decrease violence, harassment and/or bullying studies. heterogeneity of outcomes across Longitudinal studies on the sustainability of organizational interventions to prevent and manage workplace violence, harassment and/or bullying. Longitudinal studies on the dose and frequency of education programs. of two or more Comparison studies on the effectiveness policies implemented to reduce workplace violence, safety. harassment and/or bullying and to increase staff Identifying interventions or approaches implemented by Studies on the reliability and validity of instruments in Studies on the reliability and validity populations in order settings and with different different to increase their generalizability. with implementing Studies that assess the costs associated and education of risk assessment tools, and the training health workers.          PRIORITY RESEARCH AREA PRIORITY RESEARCH   Preventing Violence, Harassment and Bullying Against Health Workers - Second - Edition Workers Health Against Bullying and Harassment Violence, Preventing Physical environment Reliability, validity and Reliability,

and threat towards health workers) and health worker well-being (surrogate outcomes: perceived recognition of bullying, incivility, policy implementation) improve organizational and health improve worker outcomes? Outcomes: (surrogate outcomes: health worker incident reporting, assault injury, RECOMMENDATION QUESTION #2: RECOMMENDATION Should organizational policies and and manage to prevent procedures workplace violence, harassment and/or bullying among health to workers be recommended Outcomes: accessibility in practice (surrogate outcomes: time and utility) recommended to use risk recommended assessment tools to detect behaviours indicative of workplace violence, harassment and/or bullying? RECOMMENDATION QUESTION RECOMMENDATION QUESTION #1: RECOMMENDATION Should health workers be Table 6: Priority Research Areas for Each Recommendation Question Question Each Recommendation for Areas Research 6: Priority Table and bullying in health service organizations and academic institutions. The list is not exhaustive; other areas of of areas other exhaustive; not is list The academic institutions. and in health service bullying and organizations be required. may research and the expert panel identified the priority areas for research set out in out set research for areas priority the expertthe identified and panel harassment violence, workplace of management and prevention further evidence support to provide would Research Gaps and Future Implications Future and Gaps Research Team Research and Development Best Practice Guideline the this RNAO BPG, reviewing theevidence for In RECOMMENDATIONS 86 Preventing Violence, Harassment and Bullying Against Health Workers Edition -Second turnover worker injury, andhealthworker values ofhealthworkers, health workers,attitudesand restraints, perceivedsafetyof Outcomes: and healthworkers? to improve outcomesfor persons recommended forhealth workers harassment and/orbullyingbe managing workplaceviolence, programs onpreventing and Should educationandtraining RECOMMENDATION QUESTION#3: RECOMMENDATION QUESTION REGISTERED NURSES’ ASSOCIATION OF ONTARIO Patient injury, useof       PRIORITY RESEARCHAREA   Effectiveness ofbullyingeducationinanundergraduate Comparison studiesontheeffectiveness ofthefollowing: statistical analysestodecreaseriskofbias. experimental studiesthatadoptmoresophisticated If randomizedcontroltrialsarenotfeasible,thenquasi- harassment and/orbullying. worker educationand/ortrainingonworkplaceviolence, Longitudinal studiesonthesustainabilityofhealth outcomes. Effectiveness ofde-escalation trainingonhealthworker reducing and/orpreventinginjurytotheperson. Effectiveness ofhealthworker educationandtrainingon in clinicalplacements. Identification ofthenumberstudentswhoareinjured communication strategies. Effectiveness ofeducatingundergraduatestudentsin curriculum.   methods ofdeliveryorfacilitatorattributes. and/or methodsoftraining;and individual componentsofaneducationalintervention RECOMMENDATIONS 87 . www.RNAO.ca Toolkit: Implementation Implementation Toolkit: BEST PRACTICE GUIDELINES • BEST PRACTICE , which develops the capacity of individual nurses to foster foster to nurses individual of the capacity , which develops ® provides an evidence-informed process for doing this (1). It can be can this (1). It doing for process evidence-informed an provides ). It also guides the adaptation of the new knowledge to the local context and and the local to the new knowledge context of also guides the adaptation ). It Figure 5 Figure Preventing Violence, Harassment and Bullying Against Health Workers - Second - Edition Workers Health Against Bullying and Harassment Violence, Preventing provides clear, concise and actionable intervention statements derived from practice from derived statements intervention actionable and concise clear, provides TM www.RNAO.ca/bpg/resources/toolkit-implementation-best-practice-guidelines-second-edition uses the “Knowledge-to-Action” framework to demonstrate the process steps required for knowledge knowledge for required steps the process demonstrate to framework uses the “Knowledge-to-Action” is based on emerging evidence that successful uptake of best practices in health care is more likely when likely more is bestin health practices care of successful uptake evidence that based emerging is on designation, which supports implementation at the organization and system levels. BPSOs focus on focus on BPSOs levels. system and the organization at implementation which supports designation, ®

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BPSO RNAO multiple sustain and evaluate to implement, the specific with evidence-basedmandate cultures developing BPGs. The Nursing Best Practice Champion Network PracticeNursing Best Champion The BPGs. of adoption and engagement awareness, BPG Order Set The also be they used may but Sets records, be embedded Order electronic can within readily BPG recommendations. environments. hybrid or in paper-based evaluation of the BPG’s impact is embedded in the process; and embedded is in the impact process; the BPG’s of evaluation all aspects the implementation. of complete to resources adequate are there the BPG is tailored to the local to context; tailored is the BPG addressed; assessed and are the BPG using to facilitators barriers and selected; are theBPG use of promote to interventions sustained; and monitored systematically is theBPG use of leaders at all levels are committed to supporting BPG implementation; BPG supporting to committed all are levels at leaders process; participatory a systematic, through implementation selected for are BPGs in implementation; the engaged and identified are relevant are the BPGs whom for stakeholders assessed; is BPGs implementing for readiness environmental 3. 2. dissemination, incorporating a variety of strategies, including the following: the following: including strategies, of variety a incorporating dissemination, 1. to begin the process of tailoring the new knowledge to local to the new settings. knowledge tailoring of beginto the process to approach use a coordinated We BPGs. our of implementation and deployment widespread to committed is RNAO inquiry and synthesis (110) (see inquiry synthesis and and to identify gaps BPGs) as (such tools knowledge using and identifying suggests This framework implementation.  The         The occur:the following  of Best Practice Guidelines, Second Edition Second Guidelines, Practice Best of downloaded at distribution of BPGs for practice to change: BPGs must be adapted for each practice setting in a systematic and and a systematic in setting each practice for be adapted must BPGs change: to practice for BPGs of distribution RNAO The 2012 localthe fit context. recommendations that ensure to way participatory Implementation Strategies Implementation and awareness than takes more It challenging. and multi-faceted is care of thepoint at BPGs Implementing RECOMMENDATIONS 88 Preventing Violence, Harassment and Bullying Against Health Workers Edition -Second    Information about our implementation strategies found can be at following the locations: In addition, we offer annualcapacity-building learning institutes BPGson specific their and implementation. 2009. p. 151-159.Adapted with permission. Source: Figure 5:Knowledge-to-Action Framework  r St Interventions/Implementation events RNAO capacity-building learning institutes and other professional development opportunities: RNAO BPSOs RNAO BPG Order Sets RNAO Champions Practice Best Network . Chapter 4: Select, . . Chapter 2, Resour . . . Chapter 2, . . Chapter 2, Local Context Adapt Knowledgeto . . Knowledge Use Barrier Assess F Stak vested interest stak implementation ofBPG facilitators Implementation str RNA Business Case Stak Stak Define stak Initial identificationof Setting upinfrastructurefor overcome Identification ofbarriersand How tomaximizeand ategies Adapted by RNAO the panel from expert Straus S,Tetroe J, Graham ID, editors. Knowledge translation care. inhealth Oxford (UK):Wiley-Blackwell; eholder eholders eholder tools eholder analysisprocess O Resources

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Workplace Ridenour ML, Hendricks Printer for (ON): Queens About Us. [Internet]. Toronto (HQO). Health Quality Ontario: Health Quality Ontario 143. 142. 141. 139. 140. 138. APPENDICES 98 Preventing Violence, Harassment and Bullying Against Health Workers Edition -Second Appendix A:GlossaryofTerms 4. 3. 2. 1. forevidence eachindividual finding: CERQual criteria: workers; and formal (d)between leaders and workers. health (a)towardscan occur: workers health from students persons; colleagues; (c)between (b)between and health and withholding jobresponsibilities organization (4).In service ahealth or institution, academic harassment engaging inexcessive or unjustified criticism, intimidatingperson, a physically abusing threateningor abuse, Bullying: other efforts all when have failed. not physically compromising aggressor the or perpetrator” confused (96).These techniques should be used only Breakaway techniques: inpaper-basedused or hybrid environments. recommendation. BPG readily within can electronic Order be embedded records, Sets™ but may also they be BPG Order Set outcomeshealth for people, communities and system health the (112). consistency and excellence care, inclinical and policies health education, health ultimately leading to optimal persons and families their on systemclinical, specific and healthy work environment topics. BPGs promote recommendations for nurses, members of interprofessional the team, educators, and leaders,policy-makers (BPG): guideline practice Best worker providing direct care. (40).They are violenceto create occurring used a riskformal assessmentthat typicallyis conducted by a health risk and other factors static (both and dynamic) for violence inorder to arrive at probability an expected of Actuarial instruments: supports finding review the and phenomenon of interest (113). Adequacy of data, whereby an overall assessment is made about richness the and quantity of data that convincing explanation for findings. review the Coherence, whereby an assessment is studies made of primary the provide whether sufficient data and a research question. made regarding applicability the of findings the population, the to phenomenon settingand theoutlined in Relevance, whereby study each primary that supports afinding are together assessed and adecision is it was conducted. Methodological limitations, at look which issues study of design inthe primary the or problems way inthe REGISTERED NURSES’ ASSOCIATION OF ONTARIO Repeated and persistent behaviours that can isolation, include social creating or spreading rumours, TM : Provides clear, concise and actionable intervention statements derived from apractice When using CERQual, four components contribute to assessment the of confidencethe in Actuarial risk assessment instruments aformula use or equation to combine known Methods for “safe the removal of yourself from various holds, grabs and pulls, whilst BPGs are systematically developed, evidence-based documents that include APPENDICES 99 www.RNAO.ca The Confidence in the The Confidence BEST PRACTICE GUIDELINES • BEST PRACTICE CREW is a flexible and tailored organizational organizational and tailored a flexible is CREW A variety of verbal and non-verbal techniques that can be adopted to reduce and/ reduce to be can adopted that techniques non-verbal verbal and of A variety Preventing Violence, Harassment and Bullying Against Health Workers - Second - Edition Workers Health Against Bullying and Harassment Violence, Preventing Awareness, understanding and attitude towards a culture, which requires self-awareness self-awareness which requires a culture, towards attitude and understanding Awareness, An approach using a set of interventions and techniques that have been adopted to reduce or or reduce to been adopted have that techniques and interventions a set of using approach An When limitations in the individual studies potentially bias the results in GRADE and GRADE- and in GRADE the results bias potentially studies in the individual limitations When A process used to reach agreement among a group or expert panel during a Delphi or modified or a Delphi expert during or panel a group among agreement used reach to A process Obtaining theoretical knowledge and cultivating the ability to use critical decision- to thinking and the ability cultivating and knowledge theoretical Obtaining Using verbal and non-verbal skills (e.g., using a calm and gentle tone of voice, body language, posture, eye posture, body language, voice, of tone gentle a calm skills and using (e.g., non-verbal verbal and Using (118). the aggressor de-escalate to listening) active and contact Engaging individuals who are displaying aggression by establishing a bond with them and maintaining a maintaining them and with a bond establishing by aggression displaying who are individuals Engaging connection. and rapport the meaning the aggressor, of based knowledge intervene time to on the optimal about Decision-making in the setting. available the resources and behaviour, the aggressive of danger and the situation. and the area of safety Assessing competency-based skills, and specialization (5). Education should be tailored to the scope of practice of the practice of the scope to of be tailored should (5). Education specialization skills,competency-based and the organization. within their role and health worker priority outcome may begin with high certainty, but due to serious limitations in one or more of the five the five of more or in one limitations serious to due but begin high with certainty, may outcome priority (13). levels two or one by will down it be criteria, GRADE rated Education: specificand needs for training awareness, levels: fluid and continuous three includes skills.making Education 4. Downgrade: one evidence for quantitative a body of example, evidence will of decrease theCERQual, (119). For quality 1. 2. 3. Cultural sensitivity: (117). insight and De-escalation: the following: include can a period Interventions escalation. during of aggression and violence eliminate Consensus: to all required was expert from members panel agreement 70 per cent of (116). A consensus technique Delphi this BPG. within therecommendations of strength and the direction determine ConfidenceEvidenceReviews in the Research (CERQual): from of Qualitative the assessing for (CERQual) a methodological is Research approach Reviews Qualitative from of Evidence of outcome an about evidence qualitative of a from body placed can be in findings that confidence of amount the represents reviewreasonably to decide if the finding means a transparent provides assessment The interest. (113). health recommendations expert make panels help which can study, under phenomenon Communication strategies: Communication include strategies communication of (115). Examples aggression and/or the violence experience of prevent or empathy, closed questions, and open dynamics, group mirroring, cues, body non-verbal language, verbal and (102). opinions of the reception and feelings, negative and positive of the expression Civility, Respect, and Engagement in the Workforce (CREW): Respect, Workforce in the Engagement and Civility, discuss methods to leaders for hospital and facilitators for component a training includes that intervention (114). relationships working improving APPENDICES 100 Preventing Violence, Harassment and Bullying Against Health Workers Edition -Second 5. 4. 3. 2. 1. forevidence eachoutcome: GRADE criteria: publication bias (13). evaluated on risk of based bias, consistency of results, relevance of studies, the precision of estimates the and recommendations inasystematic manner. body evidence The of for an important and/or critical outcome is for assessing quality the of of inaconsistent abody evidence and transparent way, and for developing Recommendations Assessment, Development, and Evaluation approach (GRADE) is amethodological Grading of Recommendations Assessment, Development and Evaluation (GRADE): educators, and faculty administrators. Formal leader: verbally during can ahuddle occur miss. (62)or Reviews inan online or paper format (63). Formal incident review: involvement of any of individuals these care intheir on his based or her capacity” (12). identifies as significant in his or herlife. person…The receiving care thedetermines importance and level of attachments) with person receiving the care. health Aperson’s family may include whom person the those all bondsclose (friendships, commitments, shared households and child-rearing responsibilities, and romantic Family: process development inthe of recommendations (13). benefits and harms eachof intervention considered, and increasetransparency aboutthe decision-making outline important factors that can determine recommendation, the panel inform members expert about the from to recommendations. evidence frameworkthe Theof purpose is to summarizethe researchevidence, (EtD)Evidence-to-Decision framework: inclusion of patient preferences (120). and patient expertise clinical values. Unifies and encouragesresearchwithevidence expertise theclinical nursing practice: Evidence-based potentially includes only positive or statistically significant results (13). Publication bias, where adecision is made about of body published the whether literature for an outcome research question. regarding applicability the of findings the population, the to intervention and outcome theoutlined in Indirectness, whereby study each primary that supports an outcome and is assessed adecision is made included, as well as width the of confidence the across intervals body evidence. a of Imprecision, refers which of results to on accuracy the number the based of participants and/or events point same inthe direction or are different. Inconsistency, at looks which of and results the abody evidence whether assesses from eachresearch study Risk of on bias, flaws focuses the which the design in of a study or problems in its execution. REGISTERED NURSES’ ASSOCIATION OF ONTARIO “A to refer term used to individuals are who related (biologically, emotionally or to legally) and/or have Refers to aperson inaformal leadership position, including managers, clinical supervisors, When using GRADE, five components contribute the to assessment of confidence the in A method to and discuss A method analyze events the leading up to an accident, injuryor near The integration strongestthe of methodologically researchwithevidence A table that facilitates panels to expert make decisions moving when The Grading of APPENDICES 101 www.RNAO.ca BEST PRACTICE GUIDELINES • BEST PRACTICE “A team comprised of multiple health-care providers (regulated and and (regulated providers health-care multiple of comprised team “A Within this BPG, this term can represent any health setting or workplace in which workplace or health setting any represent this this term can BPG, Within Preventing Violence, Harassment and Bullying Against Health Workers - Second - Edition Workers Health Against Bullying and Harassment Violence, Preventing A measure to assess the level of agreement in scores or collected data between two or between collected or two data or in scores agreement of the level assess to A measure Violence, harassment or bullying directed at colleagues who are at equal level within an an within equal level at who colleagues are at directed bullying or harassment Violence, Defined as “all people engaged in actions whose primary intent is to enhance health” (7). This (7). This health” to enhance is primary whose in actions “all intent engaged people Definedas Made of a strong, synthetic fibre, these sleeves are a type of personal protective equipment that that equipment protective of a typepersonal are thesesleeves fibre, synthetic a strong, of Made Comments or behaviours that that are unwelcome and persistent, including sexual harassment sexual harassment including persistent, and unwelcome are that that behaviours or Comments A deterioration in relationships between peers in the workplace (9, 26), between students and health and between (9, 26), students between peers in the workplace in relationships A deterioration more observers (raters) (121). observers (raters) more Kevlar sleeves: (122). heat and abrasions cuts, from protect can Interprofessional health team: health team: Interprofessional services and health care people to quality and comprehensive deliver to collaboratively who work unregulated) (12). settings” health-care across betweenwithin, and reliability: Inter-rater workers in the clinical learning environment (27), or between students and faculty in an academic institution academic institution faculty in an and between students (27), or environment in the clinical learning workers speech, or impolite neglect, disregard, indifference, disrespect, futile communication, include can (28). Incivility hostility violence, horizontal harassment, bullying, also includes (27). It burnout and in stress result can and (105). conflict and organization. Depending on the literature, horizontal violence can also be referred to as “lateral violence” (8). violence” “lateral as to also can be violence referred horizontal the literature, Depending on organization. intimidation, threats, verbalabuse, including harassment, is violence horizontal of example common most The (9). exclusion and humiliation criticism, Incivility: a health worker provides care to persons and/or families and practices within their scope. Violence, harassment harassment their scope. Violence, practices within and families and/or persons to care provides a health worker not are the recommendations of the applicability and health service occur can in any bullying organization, and unless otherwise care stated. acute to limited violence: Horizontal workers and physiotherapists), unregulated health workers (e.g., personal support workers, physician assistants assistants physician workers, personal support (e.g., health workers unregulated physiotherapists), and workers and their care receiving with persons contact into come who staff support additional and workers) outreach and a when they enter in this definition included also are program in a health worker enrolled Students families. clinical placement. serviceHealth organization: harassment can occur: (a) towards health workers from persons; (b) between colleagues; (c) between students (b) between (c) between colleagues; persons; students from health workers occur: can (a) towards harassment health workers. leaders and (d) between formal and health workers; and worker: Health social physicians, practical nurses, registered nurses, registered (e.g., health professionals regulated includes Harassment: student or worker health a offend or ridicule, demean, intimidate that innuendos or jokes (6). Remarks, academic institution, or a health serviceIn organization harassment. workplace of examples considered are APPENDICES 102 Preventing Violence, Harassment and Bullying Against Health Workers Edition -Second and describe phenomenaand describe (126). explainedbe within contexts the structures, using of an social interactive and subjective approach to investigate Qualitative research: See include reliability and validity (125). thatso individuals one. to atool best the seeking can use choose The most common measurement properties practice andclinical assessment. health These properties indicatethe quality the of questionnaire or instrument Psychometric properties: Predictive validity: 4. 3. 2. 1. PICO research question: (e.g., parents, caregivers, substitute friends, decision-makers, groups, communities and populations) (11,12). organizations. The term “person” notwill only include an individualthe system, in health their familybut also forpartnering terms Replaces health. the “patient,” “client,” and “resident,” are which across used service health Person: search and systematic are reviews more (13). focused decision-making, important but not for critical decision-making, or not important. In doing, so literature the to assess ifan intervention is successful. In GRADE, outcomes are on prioritized are ifthey based for critical Outcomes: nurseclinical specialists” (12). Ontario), registered psychiatric nurses and nurses inadvanced practiceroles such as nurse practitioners and Nurse: towards asingle individual (99). Mobbing: See summarize results the of included the studies (123). Meta-analysis: reliability and validity systematic review The outcomethat is of interest (13). alternativeThe or comparison intervention. The interventionbe investigated. to patientThe populationor that being is studied. REGISTERED NURSES’ ASSOCIATION OF ONTARIO “Refers to registered nurses, nurses practical licensed (referred to as registered nurses practical in An individual with whom worker ahealth has established atherapeutic relationship for of purpose the Persistent and escalating antagonistic and harassing behaviours directed by one or more people A dependent variable, or and/or clinical the status functional of apatient or population, that is used Asystematic of review randomized controlled that statistical to trials uses methods analyze and The ability to assess accuratelythat the likelihood eventan (124). (suchoccur violence)as will An approach to research that to convey seeks how human behaviour and can experiences Aframework to outline question. afocused It specifies four components: The measurement properties of questionnaires or instruments in used research, APPENDICES 103 www.RNAO.ca BEST PRACTICE GUIDELINES • BEST PRACTICE Structured professional judgment (SPJ) instruments use specified instruments (SPJ) judgment professional Structured An experiment in which the investigator assigns one or more more or one assigns in which the investigator experiment An A study that estimates causal effects by observing the exposure of interest, but in but observingby of interest, effects causal exposure the estimates that A study Preventing Violence, Harassment and Bullying Against Health Workers - Second - Edition Workers Health Against Bullying and Harassment Violence, Preventing The degree to which results from a measurement procedure can be reproduced with minimal with reproduced can be procedure measurement a from results to which degree The A surrogate outcome is a substitute measure to the one originally selected. Surrogate selected. originally Surrogate the one to measure a substitute is outcome A surrogate A course of suggested action(s) that directly answers a recommendation question. A question. a recommendation answers directly action(s) that suggested of A course A scoping review is a means to map existing literature or evidence in order to identify research identify research to evidence in order or literature existing map to review a means is A scoping An individual, group or organization that has a vested interest in the decisions and actions actions and in the decisions interest a vested has that organization or group individual, An “Physical, chemical or environmental measures used to control the physical or behavioural activity of of activity behavioural or the physical used control to measures environmental or chemical “Physical, psychometric properties properties psychometric Surrogate outcome: outcome: Surrogate (13). unexplored or lacking is outcomes the desired when evidence about considered are outcomes Structured professional judgement (SPJ): (SPJ): judgement professional Structured overall an draw and factors risk of the weigh presence to clinical discretion and dynamic) and (static factors risk formal risk a high)are (40). They or medium occurring violence low, of (e.g., the probability about conclusion care. direct providing a health worker by conducted typically is that assessment gaps, summarize research findings and/or inform systematic reviews (129). systematic inform and/or findings research summarize gaps, Stakeholder: of the all include Stakeholders (130). actions and decisions influence to attempt may and organizations of problem. to the or solution change by the who will affected indirectly be or directly groups and individuals Restraint: Restraint: body” his/her (128). of a portion or a person Scoping review: Reliability (reliable): (reliable): Reliability result. reach the same but times different use at a tool could users two example, (123). For error measurement See Recommendation: Recommendation: potential its of in consideration made is and the literature review of based a systematic is on recommendation healthon equity. impact and perspective, a person-centered from preferences and values harms, and benefits is It expert consensus. through panel conditional or strong either strength, given are All recommendations take cannot recommendations as be viewed prescriptive, not as should recommendations that note to important (13). clinical circumstances and organizational individual, of features the unique all of account into Randomized trial controlled (RCT): (receives the experimental group either allocated to randomly who are participants to interventions (123). intervention) no (placebo or group control or treatment) (conventional the comparison and intervention) Quasi-experimental study:Quasi-experimental before-and- (e.g., randomization lack and the researcher by controlled directly not are which the experiments (127). designs) after APPENDICES 104 Preventing Violence, Harassment and Bullying Against Health Workers Edition -Second See See reason, it to is understand critical cause the of violence inorder to prevent and mitigate its occurrence. aperson asunmet Labeling “violent” needs. can result inaltered levels of care and stigmatization; for that and psychological symptoms of an (e.g., illness dementia or delirium) that are exhibited to express met or It is important to note that aggressive behaviours from aperson receiving care result the can be of behavioural face, to hitting/trying hit aworker or throwing an at object aworker (24). (25). Examples of workplace violence include: threats, verbal threatening notes, shaking afistthe in worker’s organizations, most the prevalent of type workplace violence is from person receiving the care or family their as athreat of physical force that can to lead physical harm are considered also violence (24).In service health injury. aggression, Sexual statements, verbal non-verbal behaviours, or that acts are reasonably interpreted Violence: within an organization (9). Vertical violence: See tool would considered be if it valid accurately measures construct the that it aims to measure. Validity (valid): See analyzes data from included the studies and presents sometimes them, using statistical (123). methods and explicit to methods identify, and appraise critically select relevant research. Asystematic and collects review Systematic review: horizontal violence violence horizontal psychometric properties meta-analysis REGISTERED NURSES’ ASSOCIATION OF ONTARIO The use, or attempted use, of physical force againstpersonthat a causes, or couldcause, physical The degreewhich a to measurement is likelyfreeandtrue be of to bias (123). For example, a Violence, harassment or bullying are colleagues who that between occurs at unequal levels Acomprehensive of review literature the that clearly uses formulated questions and systematic and vertical violence vertical APPENDICES 105

www.RNAO.ca BEST PRACTICE GUIDELINES • BEST PRACTICE https://RNAO.ca/sites/rnao-ca/files/Embracing_ https://RNAO.ca/bpg/resources/toolkit-implementation-best- http://dissemination-implementation.org/content/resources.aspx https://RNAO.ca/sites/rnao-ca/files/DevelopingAndSustainingBPG.pdf http://www.patientsafetyinstitute.ca/en/toolsResources/ from: Registered Nurses’ Association of Ontario (RNAO). Developing and sustaining interprofessional health care: optimizing patients/clients, (ON): RNAO; 2013. Available organizational, and system outcomes. Toronto from: and mitigating Ontario (RNAO). Managing Registered Nurses’ Association of Available from: 2012. Toronto (ON): RNAO; conflict in health-care teams. https://RNAO.ca/sites/rnao-ca/files/Managing-conflict-healthcare-teams_ hwe_bpg.pdf Scaling-up of Evidence-based Practices Center (SISEP); c2013-2018. Co- Scaling-up of Evidence-based Practices from: Research Network. Available published by National Implementation https://implementation.fpg.unc.edu/ frameworks: getting started kit Safer Healthcare Now! Improvement Healthcare Now!; 2015. Available [Internet]. [place unknown]: Safer from: ImprovementFramework/Documents/Improvement%20Frameworks%20 GSK%20EN.PDF Dissemination & Implementation Models in Health Research & Practice. date unknown]. Available Seminal Publications [Internet]. [place, publisher, diversity in health care: developing cultural competence. Toronto (ON): cultural competence. Toronto diversity in health care: developing from: RNAO; 2007. Available Cultural_Diversity_in_Health_Care_-_Developing_Cultural_Competence.pdf implementation Ontario (RNAO). Toolkit: Registered Nurses’ Association of RNAO; 2012. (ON): edition. Toronto of best practice guidelines, second from: Available practice-guidelines-second-edition Active Implementation Network’s The National Implementation Research Hill (NC): State Implementation and Hub. Get Started [Internet]. Chapel RESOURCE(S) Embracing cultural Association of Ontario (RNAO). Registered Nurses’ Preventing Violence, Harassment and Bullying Against Health Workers - Second - Edition Workers Health Against Bullying and Harassment Violence, Preventing

mitigating conflicts health team Managing and Interprofessional Interprofessional resources Implementation science, implementation frameworks, and TOPIC Cultural sensitivity The following are topics and some suggested RNAO BPGs and resources from other organizations that align with that organizations other from resources and BPGs RNAO suggested and some topics are following The this BPG. Ontario Best Practice Guidelines and Resources and Guidelines Practice Best Ontario Practice Guideline with this Best that Align Appendix B: Registered Nurses' Association of Association Nurses' Registered B: Appendix APPENDICES 106 Preventing Violence, Harassment and Bullying Against Health Workers Edition -Second workload practices staffing and Safe andeffective Restraints TOPIC REGISTERED NURSES’ ASSOCIATION OF ONTARIO RESOURCE(S) files/bpg/Staffing_and_Workload_Practices_2017.pdf Toronto (ON):RNAO;2017.Available from: sustaining safe,effective staffingandworkloadpractices,secondedition. Registered Nurses’AssociationofOntario(RNAO).Developingand alternative-approaches-use-restraints 2012. Available from: alternative approachestotheuseofrestraints.Toronto (ON):RNAO; Registered Nurses’AssociationofOntario(RNAO).Promotingsafety: https://RNAO.ca/bpg/guidelines/promoting-safety- https://RNAO.ca/sites/rnao-ca/ APPENDICES 107 ). https:// (2009) (3) and (2009) (3) and Appendix D Appendix www.RNAO.ca in ; other nursing and health and nursing ; other © , p. 6). To determine the scope determine To 6). , p. Figure 6 Figure and BPSOs and © Purpose Scope and BEST PRACTICE GUIDELINES • BEST PRACTICE . (2008) (2) were reviewed to inform the purpose scope inform and reviewed to (2008) (2) were Preventing and Managing Violence in the Workplace Workplace the in Violence Managing and Preventing https://RNAO.ca Preventing Violence, Harassment and Bullying Against Health Workers - Second - Edition Workers Health Against Bullying and Harassment Violence, Preventing .) RNAO also aims for persons impacted by BPG recommendations, especially with persons recommendations, BPG by impacted persons for also aims .) RNAO

the inclusion criteria used, is available at at used, available criteria is the inclusion the literature reviews of scoping 2015, two 2013 and In conducted. were the literature reviews of scoping Two between health providers bullying on literature the existing of understanding a better undertaken develop to were in health service organizations. guidelines. The resources and guides were reviewed for content, scope of practice related to nurses and and nurses to related practiceof scope content, reviewedfor were guides and resources The guidelines. based a on were the screened guidelines of None quality. and accessibility members, team interprofessional the Appraisal using be could be appraised to true that guidelines considered not they were and review, systematic II) (143) (see II (AGREE Instrument Evaluation and Research for Guidelines of and searched websites of the list including guidelines, existing for strategy the search about Detailed information A guideline search and gap analysis. The RNAO Best Practice Guideline Development and Research Team Team Research and Development Guideline Practice Best RNAO The analysis. gap and search A guideline 2011 between January published content relevant other and guidelines for websites of list established an searched existing of an understanding to gain was analysis gap and purpose of 2017. The search guideline the January and identify to and in health service bullying and organizations, harassment violence, regarding guidelines guides was and resources 20 reputable of A list this the BPG. purpose scope of develop and to opportunities additional suggest to alsoasked were expertmembers panel RNAO The sources. international from compiled A review of previous BPGs. The RNAO BPGs RNAO The BPGs. previous A review of Nurse the of Well-being and Safety Health, Workplace this BPG. of

provider associations; topic-relevant technical associations or organizations; and advocacy bodies. When relevant, a advocacy bodies. and relevant, When organizations; or technical associations topic-relevant associations; provider the BPG of served editions prior on previously who have expert members from panel interest of expression an call for completed. is for researchers in the topic area; recommendations from key informant interviews; drawing from established established from interviews; drawing informant key from recommendations area; in the topic researchers for Network Champions groups, interest RNAO as such networks, professional lived experiences and caregivers, to be included as expert panel members. expert as members. be to panel included caregivers, experienceslived and literature the searching including an expert of panel, and selects members finds RNAO that ways numerous are There In alignment with the Statement on Diversity and Inclusivity that appears in its Mission and Values, RNAO aims for for aims RNAO Values, and Mission in its appears that Inclusivity and Diversity on the Statement with alignment In at Values and Mission of RNAO the a copy find can the expert (you of panel in the membership diversity RNAO.ca/about/mission Assembly of the Expert Panel 3. 2. 1. Scoping the Guideline (see cover BPG willwilland not an RNAO what out The scope sets steps: the following conducted Team Research and Development Best Practice Guideline the this RNAO BPG, of in its commitment that every BPG be based on the best available evidence. The GRADE and CERQual methods have CERQualmethodsand have every GRADE evidence. The that be BPG based the bestavailable on commitment in its development. guideline for standards meet international and framework a rigorous provide to been implemented Methods unwavering is methods. and RNAO process development guideline overviewan of RNAO the presents Appendix This Appendix C: Best Practice Guideline Development Guideline Best Practice C: Appendix APPENDICES 108 Preventing Violence, Harassment and Bullying Against Health Workers Edition -Second The expert panel engagedThe expert the in following activities: Panel team representing arange of sectors and practice areas, and the persons with (see lived experience nursing practice, administration, research, education and policy, as well as other members of interprofessional the For BPG, RNAO this the Guideline Practice Best Development and Research Team assembled apanel from of experts     panel co-chairsThe expert the led following activities:       point Likert scale thatpoint scale ranged Likert from “strongly agree” to “strongly disagree” to determine top the 11outcomes across member recommendation the reviewed questions and participated inaconfidential online vote usingseven- a This comprehensive list potentialof outcomes was presentedpanel the expert to for a panel vote. Each expert literaturethe and panel discussion co-chairs. with expert the that BPG this could potentially address was developed, informed by guideline the gap analysis, scoping the of review recommendation questions to include were modified further priority outcomes. Acomprehensive list of outcomes and scope in-person to recommendation determine purpose, the questions for BPG. this In July 2017,the In May RNAO 2017,the Guideline Practice Best Development and Research Team panel and convened expert Identifying PriorityRecommendationQuestions andOutcomes Interest Summary Research Team panel and co-chairs. expert No limiting conflicts wereSee “ identified. COI declared by panel an member was by expert reviewed RNAO the Guideline Practice Best Development and workplaceviolence prior to participation their inguideline development work using astandard form ( construed as constituting aperceived and/or conflict actual were made membersall by the RNAOof panel expert relationship may compromise ability their to independently conduct panel work. Declarations of COI that might be panel anin which member’s expert financial, professional, intellectual,personal, organizational and/or any other In context the of RNAO practice guideline best development, term ‘conflict the of interest’ (COI) refers to situations Conflict ofInterest

coordinator; moderated and as tiebreakers acted invoting processes. provided in-depth guidance on and/or clinical research issues; and facilitated panel meetings; expert monthly co-chair meetings with guideline the development methodologists and guideline development project identified appropriate stakeholdersthe draft to priorreview to publication. participated development inthe of evaluation indicators; and provided feedback on draft the the of BPG; participated ina recommendation the determined questions and outcomes addressed toBPG; inthe be approved of scope the BPG; the , p. 24). REGISTERED NURSES’ ASSOCIATION OF ONTARIO ). Expert panel members updated also ). Expert COI their at of beginning the eachguideline Any meeting. ” at consensus https://rnao.ca/bpg/guidelines/workplaceviolence G development process to finalize recommendation statements; . https://rnao.ca/bpg/guidelines/ Declarations of Conflicts of Declarations of Conflicts RNAO Expert APPENDICES 109 ). www.RNAO.ca ), and health worker well-being (critical) well-being health worker ), and BEST PRACTICE GUIDELINES • BEST PRACTICE ). surrogate outcomes: health worker injury, incident incident injury, worker health outcomes: surrogate Should organizational policies and procedures to prevent and manage manage and prevent to procedures policies and organizational Should Should education and training programs on preventing and managing managing and preventing on programs training and education Should Should health workers be recommended to use risk assessment tools to detect to tools use assessment risk to be recommended health workers Should Preventing Violence, Harassment and Bullying Against Health Workers - Second - Edition Workers Health Against Bullying and Harassment Violence, Preventing surrogate outcomes: perceived incivility, recognition of bullying, policy implementation policy bullying, of recognition incivility, perceived outcomes: surrogate surrogate outcomes: utility and time and utility outcomes: surrogate Health workers. Health Education and training programs on preventing and managing workplace violence, violence, workplace managing and preventing on programs training and Education Health workers. Health Health workers. Health Organizational policies and procedures for workplace violence, harassment and/or bullying. and/or harassment violence, workplace for procedures policies and Organizational Person or co-worker risk assessment tools. assessment risk co-worker or Person Patient injury (important), use of restraints (critical), perceived safety of health workers, health workers, of safety (critical), perceived restraints use of injury (important), Patient Physical environment (important) ( (important) environment Physical Reliability (less important), validity (important), accessibility in practice (less important) important) (less in practice accessibility (important), validity important), (less Reliability No education and training programs on preventing and managing workplace violence, violence, workplace managing and preventing on programs training and education No No organizational policies and procedures for workplace violence, harassment and/or and/or harassment violence, workplace for procedures policies and organizational No No risk assessment tools. assessment risk No harassment and/or bullying. and/or harassment bullying. and/or harassment and injury (important), (critical), health worker health workers of values and attitudes important). (less turnover health worker bullying. bullying. workers health towards threat and assault reporting, ( (

Comparison: Outcomes: PICO Research Question: Question: Research PICO Population: Intervention: Outcomes: PICO Research Question: Question: Research PICO Population: Intervention: Comparison: Outcomes: PICO Research Question: Question: Research PICO Population: Intervention: Comparison: workplace violence, harassment and/or bullying be recommended for health workers to improve person and and person improve to health workers for be recommended bullying and/or harassment violence, workplace outcomes? health worker Recommendation Question 3: Question Recommendation Recommendation Question 2: Question Recommendation improve to be recommended health workers among bullying and/or harassment violence, workplace outcomes? health worker and organizational behaviours indicative of workplace violence, harassment and/or bullying? and/or harassment violence, workplace of indicative behaviours Recommendation Question 1: Question Recommendation

recommendation questions and their respective PICO research questions are presented below: presented are questions research PICO their respective and questions recommendation less than 75 per cent. Expert panel co-chairs did not participate in the vote because they functioned as tiebreakers. because they tiebreakers. functioned as in the vote participate did not Expert 75 per co-chairs than cent. less panel reviews. The three which guided the systematic question research a PICO informed question Each recommendation recommendation questions. An outcome with agreement of 91.6 per cent or above was considered critical; an critical; an considered was above or 91.6 per cent of agreement with outcome An questions. recommendation agreement with outcome an and important; considered was per 91.5 to cent per 83.3 cent of agreement with outcome was agreement of if the level excluded were Outcomes important. less considered was 83.2 per to cent 75 per cent of APPENDICES 110 Preventing Violence, Harassment and Bullying Against Health Workers Edition -Second Team and librarian sciences ahealth for eachof PICO the research questions. Asearch for relevant research studies For BPG, this asearch strategy was developed by RNAO’s Guideline Practice Best Development and Research RNAO BPGs are on acomprehensive based and systematic of review literature. the Systematic RetrievaloftheEvidence definition eachof certaintythese criteria.of exclusion criteria and search terms, is available at strategies. information Detailed on search the strategy for systematic the including reviews, inclusion the and panel members wereExpert asked libraries personal to their review for key studies not found through search the Question #3only), Embase, MEDLINE, MEDLINE In-Process and PsycINFO. study All designs were included. Index to Nursing and Health Allied (CINAHL), Education Resources Information Center (ERIC) (for Research RegisterCentral of Controlled Trials, Database (Cochrane of Library Systematic Cochrane Cumulative Reviews), published January inEnglish between 2012and September 2017was applied to following the databases: Cochrane and publication bias –for potential the study and design requires then an examination of fiverisk criteria – of bias, inconsistency, imprecision, indirectness outcome across studies (i.e., for recommendation of per abody evidence) question (13).This processbeginswiththe correct) is using determined GRADE (13).First, methods certainty the of is rated evidence the for each prioritized The certainty of quantitativeevidence (i.e.,the extent which to onebe confidentcan that an estimate the is of effect ofCertainty Evidence Determining CertaintyandConfidenceofEvidence Medline and PsychINFO) for literature and guidelines published January inEnglish between 2018and March 2019. of Discussion the of Evidence for each recommendation statement. Threedatabases weresearched (CINAHL, updated literature to inform content the within values the and preferences, equity health and practicenotes sections In August 2018and March 2019two literature searches were completed librarian with sciences ahealth to search for studies were included across three systematic all (see reviews Data was simultaneously, performed extraction and completed by reviewers both for included all studies. In total, 56 for qualitative studies, and Assessing the Methodological the of Quality Systematic (AMSTAR-2) Reviews (130)was used version of Appraisal Critical the Programme Skills Tool for Qualitative Research (CASP) for (134)was used randomized Studies of Interventions (ROBINS-1) for tool (133)was used quasi-experimental studies, an adapted CochraneRisk The of Bias 2.0(132)wasTool for used randomized controlledtheRisk trials, of Bias in Non- includedAll articleswere independently for assessed risk of bias by study using design validated and reliable tools. on inclusion the and exclusion criteria. Any disagreements were resolved through consensus. Studies were independently for assessed relevance and eligibility by two guideline development methodologists based

systematic Two reviews. reviewers reached consensus on scores all through discussion. REGISTERED NURSES’ ASSOCIATION OF ONTARIO downgrade https://RNAO.ca G of certainty the of for evidence eachoutcome. See Figures 7 . , 8 and and 9 in Appendix D ). Table 7 Table for a APPENDICES 111 www.RNAO.ca https://gdt.gradepro.org/app/ BEST PRACTICE GUIDELINES • BEST PRACTICE , three factors are assessed that can potentially enable rating up up rating enable potentially can assessed that are factors , three Table 7 If the body of evidence has not been rated down for any of the five criteria and and criteria the five of any for down been the rated evidence not body has of If If the body of evidence has not been rated down for any of the five criteria and a large a large and criteria the five of any for down been the rated evidence not body has of If If the body of evidence has not been rated down for any of the five criteria and a and criteria the five of any for down been the rated evidence not body has of If Differences in population Differences in interventions Differences in outcomes measured Differences in comparators. Differences Preventing Violence, Harassment and Bullying Against Health Workers - Second - Edition Workers Health Against Bullying and Harassment Violence, Preventing The degree of uncertainty around the estimate of effect. This is usually related to the estimate of effect. The degree of uncertainty around Studies are examined for sample size, number sample size and number of events. of events and confidence intervals. on study results. If publication bias is Selective publication of studies based is considered. strongly suspected, downgrading the direction and size of effects reported across studies for a defined outcome. reported across studies for a defined size of effects the direction and question and the context within between the research and review Variability be applied (applicability). There are four which the recommendations would sources of indirectness that are assessed: 1. 2. 3. 4. DEFINITION may bias study results. Valid study design and execution that Limitations in the the risk of bias. First, risk of appraisal tools are used to assess and reliable quality examined across all studies for each individual study and then bias is examined per defined outcome. Inconsistency is (heterogeneity) of results across studies. Unexplained differences in and possible explanations the magnitude of difference assessed by exploring Reprinted from: Schunemann H, Brozek J, Guyatt G, et al., editors. Handbook for grading the quality of evidence and the strength of of the strength evidence and of the quality grading for Handbook editors. G, et al., Guyatt J, H, Brozek Schunemann from: Reprinted all residual confounders would result in an underestimation of treatment effect, there is consideration for rating rating for is consideration effect, there treatment of underestimation in an result would confounders all residual (13). up Large effect: of magnitude up. rating for is consideration there present, is effect intervention of the magnitude of estimate Dose-response gradient: up. rating for consideration is there present, is gradient dose-response confounding: plausible of Effect Publication bias Imprecision Inconsistency Indirectness Risk of bias CERTAINTY CERTAINTY CRITERIA 3. 2. the certainty of evidence for observational studies: observational studies: evidence for of the certainty 1. After considering the five criteria outlined in criteria five the considering After Source: Source: from: 2013. Available unknown]; publisher unknown: [place [Internet]. approach the GRADE using recommendations handbook/handbook.html#h.svwngs6pm0f2 Table 7: GRADE Certainty 7: GRADE Criteria Table APPENDICES 112 Preventing Violence, Harassment and Bullying Against Health Workers Edition -Second GRADE certainty criteria for potentially rating up quantitative were evidence independently by assessed two For BPG, five this the GRADE certainty criteria forpotentially downgrading quantitativeevidence threethe and low. See recommendationper question. GRADE categorizes overall the certainty of moderate, as high, evidence low or very The certaintyoverall theevidence combinedis of rating the certaintyof evidence acrossof all prioritized outcomes See 4. 3. 2. 1. phenomenon of interest: Similar to GRADE,has CERQual four criteria to assess confidence the in qualitative findings related toa Confidence inEvidence handbook/handbook.html#h.svwngs6pm0f2 recommendations using GRADE the approach [Internet]. [place unknown: publisher unknown]; 2013.Available from: Source: Table of 8:Certainty Evidence derived from recommendation the questions were certainty assigned this of accordingly. evidence, recommendationof per evidence question on assessments. was these assigned based Recommendations that were guideline development methodologists. Any discrepancies were resolved through consensus. An overall certainty Very Low Low Moderate High EVIDENCE CERTAINTY OF OVERALL Table 9 Table Adequacy. Coherence Relevance Methodological limitations Reprinted from: Schunemann H,Brozek J, Guyatt G,etal., editors. Handbook for grading quality the of and evidence strength the of Table 8 REGISTERED NURSES’ ASSOCIATION OF ONTARIO for adefinition eachof criteria. these of for definitions the categories. these of be substantiallydifferent fromtheestimate ofeffect. We haveverylittleconfidenceintheeffect estimate:Thetrueeffect islikelyto substantially different fromtheestimate oftheeffect. Our confidenceintheeffect estimateis limited: Thetrueeffect maybe substantially different. to beclosetheestimateofeffect, butthereisapossibilitythatit We aremoderatelyconfidentintheeffect estimate:Thetrueeffect islikely the effect. We areveryconfidentthatthetrueeffect liesclosetothatoftheestimate DEFINITION . Reprinted with permission. https://gdt.gradepro.org/app/ APPENDICES 113 www.RNAO.ca BEST PRACTICE GUIDELINES • BEST PRACTICE for the definitions of these categories. of these categories. the definitions for Table 10 Table phenomenon of interest. It is likely that the finding is a reasonable representation of the phenomenon of interest. of the It is possible that the review finding is a reasonable representation phenomenon of interest. of It is not clear whether the review finding is a reasonable representation the phenomenon of interest. DEFINITION the It is highly likely that the finding is a reasonable representation of An assessment of how clear and cogent the fit is between the data from the how clear and cogent the fit is An assessment of that synthesizes the data. Cogent refers primary studies and a review finding to being well-supported or compelling. of richness and quantity of data An overall determination of the degree supporting a review finding. DEFINITION design or conduct of the there are concerns about the The extent to which review finding. contributed evidence to an individual primary studies that primary studies supporting the body of evidence from the The extent to which or population, is applicable to the context (perspective a review finding review question. interest or setting) specified in the phenomenon of Preventing Violence, Harassment and Bullying Against Health Workers - Second - Edition Workers Health Against Bullying and Harassment Violence, Preventing Reprinted from Lewin S, Booth A, Glenton C, et al. Applying GRADE-CERQual to qualitative evidence synthesis findings: introduction to the series. introduction findings: evidence synthesis qualitative to GRADE-CERQual Lewin Applying C, et al. from S, BoothReprinted A, Glenton Reprinted from Lewin S, Booth A, Glenton C, et al. Applying GRADE-CERQual to qualitative evidence synthesis findings: introduction to the series. introduction findings: evidence synthesis qualitative to GRADE-CERQual Lewin Applying C, et al. from S, BoothReprinted A, Glenton Very Low Very Moderate Low EVIDENCE High OVERALL CONFIDENCE OF Adequacy of data Coherence Methodological limitations Relevance CERTAINTY CERTAINTY CRITERIA Implement Sci. 2018;13(Suppl 1): 1-10. Table 3, Description of level of confidence in a review finding in the CERQual approach; p. 6. Reprinted with permission. p. 6. Reprinted approach; review inthe CERQual in a finding confidence of level of 3, Description 1): 1-10. Table Sci. 2018;13(Suppl Implement Source: Source: Table 10: Confidence 10: Evidence in Table Recommendations that included qualitative evidence were assigned an overall confidence in evidence on basedthe confidence overall an assigned evidence were qualitative included that Recommendations review finding. See corresponding Qualitative findings related to each of the prioritized outcomes were independently assessed by the guideline by guideline assessedthe independently were outcomes prioritized of the to each related findings Qualitative consensus. through resolved were Discrepancies criteria. the four using methodologists development Source: Source: with permission. p. 5. Reprinted approach; of CERQualthe of components the 2, Definitions 1): 1-10. Table Sci. 2018;13(Suppl Implement Table 9: CERQual Confidence 9: CERQual Criteria Table APPENDICES 114 Preventing Violence, Harassment and Bullying Against Health Workers Edition -Second guideline development methodologists. Evidence profiles body evidence summarizethe of foreach systematicper outcome review and are developed the by well as general information about of body research the including evidence, key statistical or narrative results (135). GRADE and profiles evidence CERQual are to used present decisions the certaintyon and confidenceevidence, of as Summarizing theEvidence      statement (see For BPG, EtD this the frameworks included following the areas of consideration for eachdrafted recommendation quantitativewith both and qualitative from evidence systematic the reviews. statements are considered by panel an (13).The guideline expert development frameworks draftmethodologists the statements. EtD frameworks are to help used ensure that important all factors required to develop recommendation and considerations on available based panel and judgement evidence expert for formulating recommendation the (EtD)Evidence-to-Decision frameworks FrameworksEvidence-to-Decision Formulating Recommendations RNAO.ca/contact For GRADE the and profiles evidence CERQual foreach systematicper outcome, review contact please us at judgements about confidence the underlyingevidence the foreachtheme. profiles presentedthe decisions made thetwo by reviewers the on four key of supportingbody evidence each theme as related to each outcome recommendation per question.evidence These Similar to profiles GRADE the evidence for used quantitative evidenceresearch, the CERQual profiles presented the profiles evidence CERQual were created forbody the of qualitativeevidence foreach systematicper outcome. review were synthesized using narrative format. underlying for evidence the each outcome (13).For BPG, this studies were conducted, adescription of intervention, the key results and transparent judgments about certainty the presentalso general information about of body including evidence, the population, the countries the where the GRADE certainty criteria for downgrading and three GRADE certainty criteria for rating up.evidence The profiles Evidence profiles forbody the of quantitative studies presentthe decisions made thetwo by reviewers the on fivekey

Health equity. Values and preferences. and/orCertainty confidence evidence.the of balanceThe benefitsof and harms of an intervention. Background information on magnitude the of problem: the 

includes PICO the research question and general context related to research the question. REGISTERED NURSES’ ASSOCIATION OF ONTARIO Table 11 . ): G outline proposed recommendations factors and summarize necessary all meta-analyses CERQual criteria G was not therefore, performed; results G and transparent https:// APPENDICES 115 www.RNAO.ca BEST PRACTICE GUIDELINES • BEST PRACTICE Preventing Violence, Harassment and Bullying Against Health Workers - Second - Edition Workers Health Against Bullying and Harassment Violence, Preventing , 2018. The online vote results were used to help guide discussion to determine to determine the guide discussion usedhelp to were results vote online , 2018. The nd and 22 and st for more on these considerations. on more for Table 11 Table values and preferences; and preferences; and values health equity. on impact potential the balance of benefits and harms; and benefits the of balance of the evidence; confidence and certainty What would be the impact on health equity? health equity? be on the impact would What Is the problem a priority? a priority? the problem Is outcomes? the main value people much in how variability or about uncertainty important there Is or comparison? the intervention the effects favour undesirable Does and the between balance desirable

Following the in-person meeting, the final decisions made on all recommendations were summarized and sent and sent summarized were recommendations on all made the meeting, the in-person final decisions Following the full to electronically expert panel. In cases where 70 per cent consensus could not be reached after one vote, the expert panel co-chairs actedas expertthe co-chairs vote, panel one after be reached not could consensus 70 per cases cent where In final to determine the thedecision. scientific with evidence feedback the expert weighing panel’s by tiebreakers See     a consensus vote of 70 per cent. The voting process was moderated by the expert panel co-chairs and guideline guideline and by expertthe co-chairs panel moderated was process voting The 70 per cent. of vote a consensus the expert was panel statement, a recommendation of the strength determining In methodologists. development the following: consider to asked methodologists facilitated the meeting to allow for adequate discussion for each proposed recommendation. recommendation. each proposed for discussion adequate for allow to the meeting facilitated methodologists and by discussion determined was statement recommendation of each strength and direction on decision The held on March 21 March on held development guideline and expert The co-chairs panel each recommendation. of strength and direction required opportunity for expert panel members to provide written comments related to each of the judgement criteria. criteria. the judgement of each to related comments written provide to expert members panel for opportunity meeting in-person at two-day the to expert the panel presented and calculated were vote online of the results The  was also the There (136). factor on each vote to used were software by GRADEpro the The Likert scales created   recommendation: recommendation:  Using the EtD frameworks as a guiding document, the expert panel members participated in an online vote from from vote online in an participated theexpert document, members a guiding as panel frameworks the EtD Using draft each posedfor were to all expertmembers questions panel following 13, 2018. The March 26, 2018 to February or conditional) of the BPG's recommendations. Expert panel members were also given access to the complete the complete to also access given Expert were members panel recommendations. the BPG's of conditional) or articles.and full-text evidence profiles Decision-making: Determining the Direction and Strength of Recommendations of Strength the Direction and Decision-making: Determining in-person a scheduled two-day to review prior to frameworks the EtD with provided Expert are members panel strong (i.e., strength and intervention) an against or for a recommendation (i.e., the direction determine to meeting APPENDICES 116 Preventing Violence, Harassment and Bullying Against Health Workers Edition -Second Table 11:Key Considerations for Determining theStrength of Recommendations app/handbook/handbook.html#h.svwngs6pm0f2 strength of recommendations using GRADE the approach [Internet]. [place unknown: publisher unknown]; 2013.Available from: Source: equity Health preferences Values and of evidence confidence and Certainty harms Benefits and FACTOR Adapted by RNAO the panel from expert Schunemann H,Brozek J, Guyatt G,etal., editors. Handbook for grading quality the of and evidence the REGISTERED NURSES’ ASSOCIATION OF ONTARIO recommendation iswarranted. inequity, thehigherlikelihoodthataconditional The greaterthepotentialforincreasinghealth quality acrossdifferent populations(138). practice orinterventiononhealthoutcomes Represents thepotentialimpactofrecommended warranted” (137). the likelihoodthataconditionalrecommendationis the uncertaintyinvaluesandpreferences,higher “The morevaluesandpreferencesvaryorthegreater centered perspective(137). of followingaparticularclinicalactionfromperson- The relativeimportanceorworthofthehealthoutcomes recommendation iswarranted(137). confidence, thehigherlikelihoodthatastrong certainty orconfidence;thehigher Recommendations aremadewithdifferent levelsof representation ofthephenomenoninterest(111). of confidencethatareviewfindingisreasonable are adequatetosupportarecommendation.Theextent The extentofconfidencethattheestimatesaneffect recommendation iswarranted”(137). gradient, thehigherlikelihoodthataconditional strong recommendationiswarranted.Thenarrowerthe undesirable effects, the higher thelikelihoodthata “The largerthedifference betweenthedesirableand intervention isused. in theliteraturewhenrecommendedpracticeor Potential desirableandundesirableoutcomesreported DEFINITION systematic review. exclusively fromthe Includes research systematic review. exclusively fromthe Includes research SOURCES panel). from theexpert sources (e.g.,insights available) andother review (when from thesystematic Includes evidence panel). from theexpert sources (e.g.,insights available) andother review (when from thesystematic Includes evidence https://gdt.gradepro.org/ APPENDICES 117 , 2018 and diverse diverse , 2018 and rd www.RNAO.ca ). Second, individuals and and individuals ). Second, to November 23 November to th , p. 26). , p. BEST PRACTICE GUIDELINES • BEST PRACTICE https://RNAO.ca/bpg/get-involved/stakeholder Stakeholder Acknowledgement Stakeholder Preventing Violence, Harassment and Bullying Against Health Workers - Second - Edition Workers Health Against Bullying and Harassment Violence, Preventing Is the guideline title appropriate? title the guideline Is clear? description process development the guideline Is Is the discussion of evidence thorough and does the evidence support the recommendation? does the evidence and support evidence thorough of the discussion Is Is this recommendation clear? clear? this recommendation Is this recommendation? with agree Do you

For this BPG, the stakeholder review process was completed from November 8 November from completed was review process the this stakeholder BPG, For (see feedback perspectives provided modified prior to publication to reflect the feedback received. reflectreceived. feedback to the publication to prior modified the evaluation indicators. Survey submissions are compiled and feedback is summarized by the RNAO Best Practice the RNAO by summarized is feedback and compiled are Survey submissions indicators. the evaluation 28, 2018 November on the expert with held was panel A teleconference Team. Research and Development Guideline were recommendations and content BPG if necessary, and feedback review stakeholder bothto expert and panel  BPG, including of each the sectionfor feedback and comments to include opportunity an survey The provides also   In addition, the stakeholders are asked the following questions about each recommendation: each about questions the following asked are the stakeholders addition, In questions:   Reviewers are asked to read a full draft of the BPG and participate in the review prior to its publication. Stakeholder Stakeholder publication. its to review prior in the and participate BPG of a fullthe read to draft asked Reviewers are following the asked are stakeholders The a survey questionnaire. completing by online submitted is feedback its implementation. Reviewers may be nurses, members of the interprofessional team, nurse executives, administrators, administrators, executives, nurse team, the interprofessional of members be nurses, Reviewers may implementation. its members. their family experience lived and with persons or students nursing experts,educators, research Stakeholder reviewers are individuals with subject matter expertise in the BPG topic or those who may be affected by be those affected who or may expertise topic in the BPG matter subject with individuals are reviewers Stakeholder public call issued on the RNAO website ( website the RNAO call on issued public Development Guideline Practice Best by RNAO the identified are area expertise with topic in theBPG organizations in the review. participate to invited directly they are the expert and and panel, Team Research and as part of the guideline development process. process. development the guideline partas of a recruited through are stakeholders First, ways. in two identified are BPGs RNAO for reviewers Stakeholder RNAO is committed to obtaining feedback from (a) nurses and other health providers from a wide range of practice practice of a wide range from health providers other and (a) nurses from feedback obtaining to committed is RNAO health services, associations of funders (c) stakeholder and and administrators (b) knowledgeable roles, and settings Stakeholder reviewStakeholder Drafting the Best Practice Guideline the Best Practice Drafting and The draft BPG. reviewed ofexpertpanel this the draft the methodologists wrote development guideline The review. proceededstakeholder to external BPG then The feedback. written provided APPENDICES 118 Preventing Violence, Harassment and Bullying Against Health Workers Edition -Second 2. 1. The RNAO commits to updating BPGs, all as follows: Procedure forUpdatingtheBestPracticeGuideline 5. 4. 3. RNAO International AffairsBest CentrePractice andGuideline staff regularly monitor new systematicfor reviews, by reviewed be ateam BPG will of topicEach inthe specialists five area years every following publication the of New editions disseminated of on be BPGs established will based structures and processes. Three months prior milestone, the to review the staff commencesplanning asthe of review follows: on thatBased monitoring, staff may recommend earlieran BPG. forperiod particular revision a Appropriate the decisionthe toand review BPG the earlier revise than planned. consultation with members panel, help of fieldwill inthe otherand expert original inform the specialists experts randomized controlled and other trials relevant literature field. inthe previous edition. e) d) c) b) a) Compile alist field inthe of andforpotential specialists experts participation panel. the expert on The expert Identifying panel potential the co-chairs BPG expert with RNAO's CEO. Developing work adetailed plan with target dates and deliverables for developing edition anew of BPG. the Compiling alist of practiceguidelines clinical new field inthe and scope. refining and the purpose Compiling feedback received and questions encountered during implementation, the including comments and panel will be comprised be panel will of members panel from and expert original ones. the new ofexperiences BPSOs REGISTERED NURSES’ ASSOCIATION OF ONTARIO ® and other implementation sites regarding experiences. their APPENDICES 119 n n www.RNAO.ca elnes ele elnes ele n b eet anel tonal elnes entfe tonal elnes BEST PRACTICE GUIDELINES • BEST PRACTICE n n n n fo alt elnes assesse elnes nle elnes seene elnes afte lates eoe n ebste sea Preventing Violence, Harassment and Bullying Against Health Workers - Second - Edition Workers Health Against Bullying and Harassment Violence, Preventing

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Source: Source: 10.1136/bmj.b2535 2009;339:b2535. doi: BMJ. statement. PRISMA * No formal guidelines addressing workplace violence, harassment or bullying were identified * identified were bullying or harassment violence, workplace addressing guidelines formal * No and Systematic Review Systematic and Guideline 6: ReviewFigure Flow Diagram Process Appendix D: Process for Best Practice Guideline Practice for Best Process D: Appendix APPENDICES 120 PRISMA statement. BMJ. 2009;339:b2535.doi: 10.1136/bmj.b2535 Source: Process Diagram Flow Figure 7:Recommendation Review Question #1Article Outcomes: violence, harassmentand/orbullyingberecommended? Should personorco-workerriskassessmenttoolstodetectbehavioursindicativeofworkplace RECOMMENDATION QUESTION#1: Preventing Violence, Harassment and Bullying Against Health Workers Edition -Second

Physical environment (surrogate outcomes: health worker injury, incident reporting, assault incident reporting, health worker injury, outcomes: (surrogate Physical environment

C T C TCT Adapted by the RNAO expert panel from Moher D, Liberati A, Tetzlaff J, et al. Preferred reporting items for systematic reviews meta-analyses: the and systematic for items reporting Preferred J, et al. A, Tetzlaff Liberati D, Moher expert from panel the RNAO by Adapted Source: Source: 10.1136/bmj.b2535 2009;339:b2535. doi: BMJ. statement. PRISMA Figure 8: Recommendation Question #2 Article Question Review Recommendation 8: Figure Flow DiagramProcess Outcomes: outcomes: perceived well-being (surrogate workers) and health worker health towards and threat implementation) of bullying, policy recognition incivility, violence, harassment and/or bullying among health workers be recommended to improve to workers be recommended among health bullying harassment and/or violence, and health worker outcomes? organizational RECOMMENDATION QUESTION #2: QUESTION RECOMMENDATION workplace and manage to prevent policies and procedures organizational Should APPENDICES 122 Preventing Violence, Harassment and Bullying Against Health Workers Edition -Second health workeroutcomes? harassment and/orbullyingberecommendedforhealthworkerstoimprovepersonand Should educationandtrainingprogramsonpreventingmanagingworkplaceviolence, RECOMMENDATION QUESTION#3: PRISMA statement. BMJ. 2009;339:b2535.doi: 10.1136/bmj.b2535 Source: Process Diagram Flow Figure 9:Recommendation Review Question #3Article health workers,workerinjury, andhealthworkerturnover Outcomes:

Adapted by RNAO the panel from expert Moher D, Liberati A,Tetzlaff al.J, et Preferred reporting items for systematic andthe meta-analyses: reviews C T C TCT REGISTERED NURSES’ ASSOCIATION OF ONTARIO Patient injury, useofrestraints, perceived safetyofhealthworkers,attitudesandvalues eos entfeto atabase sea n eos aftelateseoe assesse foeleane assesse foalt ttle anabstat eos seene tes nle lltet stes lltet stes n n n n n entfe beetanel tonal eos n eos ele lltet stes lltet stes n ele ele n n APPENDICES 123 (if TM www.RNAO.ca ). Figure 10 Figure BEST PRACTICE GUIDELINES • BEST PRACTICE Data quality assessment and evaluation, as well as ongoing feedback feedback ongoing as well as evaluation, and assessment quality Data Indicators are selected and developed through established methodology, methodology, established selected through developed and are Indicators Practice recommendations, overall BPG outcomes and BPG Order Sets Order BPG and outcomes BPG overall Practice recommendations, Proposed indicators are internally validated through face and content validity, and and validity, content face and through validated internally are indicators Proposed website. website. ® Preventing Violence, Harassment and Bullying Against Health Workers - Second - Edition Workers Health Against Bullying and Harassment Violence, Preventing Indicators are published in the Evaluation and Monitoring chart, and data dictionaries are are dictionaries data and chart, Monitoring and in the Evaluation published are Indicators Indicators are developed for BPGs focused on health system priorities, with an emphasis on filling on emphasis an with priorities, focused BPGs health system on for developed are Indicators , ensure purposeful evolution of NQuIRE indicators. NQuIRE of purposeful, ensure evolution ®

ractice test and validation. validation. ractice and test

Data quality assessment and evaluation. evaluation. and assessment quality Data BPSOs from externally validated by national and international organization representatives. representatives. organization international and national by validated externally Implementation. the NQuIRE on published gaps in measurement while reducing the reporting burden. the reporting while reducing in measurement gaps Extraction recommendations. of development. indicator for measures extract reviewed to potential are applicable) selection development. and Indicator expert and consultation. libraries data health information repositories, external data with alignment including BPG selection.BPG 6. 5. 3. 4. P 2. 1. Appendix E: Indicator Development Process Development Indicator E: Appendix ( summarized below are steps process development indicator RNAO The APPENDICES 124 Preventing Violence, Harassment and Bullying Against Health Workers Edition -Second Figure 10:Indicator Development Diagram Flow

Step 6 REGISTERED NURSES’ ASSOCIATION OF ONTARIO

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APPENDICES 125 www.RNAO.ca Jackson D, Wilkes L, Luck L. Cues that Jackson D, Wilkes L, Luck L. Cues that predict violence in the hospital setting: findings from an observational study. Collegian. 2014; 21(1): 65-79. L, Berry B. Aggressive Kim SC, Young Behaviour Risk Assessment tool for newly admitted residents of long-term care homes. J Adv Nurs. 2017; 73(7): 1747-56. et Lee S, Hollander Y, Podubinski T, al. Patient characteristics associated with aggression in mental health units. Psychiatry Res. 2017; 250: 141-5. Sands N, Elsom S, Gerdtz M, et al. Mental health-related risk factors for violence: using the evidence to guide mental health triage decision making. J Psychiatr Ment Health Nurs. 2012; 19(8): 690-701. SUPPORTING REFERENCES SUPPORTING Munro CL, et al. Burk RS, Grap MJ, in critically ill Predictors of agitation Care. 2014; 23 (5): adults. Am J Crit 414-23. al. Considine J, Berry D, Johnson R, et signs as predictors for aggression Vital J Clin Nurs. in hospital patients (VAPA). 2017; 26(17/18): 2593-2604. BEST PRACTICE GUIDELINES • BEST PRACTICE restlessness or pacing thought disturbance (delusions or threatening to leave drug withdrawal history of poly-substance use history of use of illicit substances history of violence/positive attitudes prolonged or intense glaring regular use of psychoactive drugs resistance to health-care practices or aggressive statements aggressive statements auditory/visual hallucinations cognitive impairment (e.g., diagnosis (psychogeriatric, mental drug/alcohol intoxication abusive language (e.g., name calling abusive language states of minds, such as hostility, states of minds, such as hostility, suspiciousness and irritability) toward violence staff confusion, disorientation or memory confusion, disorientation or memory impairment) illness, psychopathy) or swearing) Preventing Violence, Harassment and Bullying Against Health Workers - Second - Edition Workers Health Against Bullying and Harassment Violence, Preventing yelling mumbling agitation anxiety delirium

                    RISK FACTORS 

psychological Behavioural or

FACTOR GROUP FACTOR 1. VIOLENCE RISK Table 12: List of Factors That May Predict Violent or Aggressive Aggressive Behaviours or Violent Predict May That 12: List Factors of Table literature review. Inclusion in this list does not constitute an endorsement by RNAO. RNAO. by endorsement an constitute does in this list not Inclusion review. literature Appendix F: Risk Factors F: Appendix withinthe systematic of is a thoseit identified selection rather, factors; of risk list an exhaustive not is following The APPENDICES 126 Preventing Violence, Harassment and Bullying Against Health Workers Edition -Second 2. Biological FACTOR GROUP VIOLENCE RISK 4. Socio- 3. Environmental economic or situational REGISTERED NURSES’ ASSOCIATION OF ONTARIO                    RISK FACTORS

homelessness life skills(e.g.,lackofemployment) orderliness) (such aspoorhygieneorlackof stress environment discharge. men inthefirstthreemonthsafter are associatedwithviolenceonlyin their hospitalstay. LowlevelsofHDL violence formenandwomenduring cholesterol (HDL)associatedwith deteriorating neurologicalcondition use ofrestraints use ofcatheters quality oftreatment/carereceived physical environment lack ofspace/privacy high levelsofstressortriggers being inisolationroom admission tonew, unfamiliar low pH low levelsofhigh-densitylipoprotein low levelsofcholesterol(TC) increasing severityofillness,suchas decreased oxygenation age youngerthan35years abnormal respiratoryandheartrate social isolation poor socialfunctioningand limited poor self-careandfunctioning gender differences. PsychiatryRes. – aprospectivestudywithfocuson discharge violenceinacutepsychiatry risk markerofinpatientandpost- ø, etal.Lowcholesterollevelasa Eriksen BMS,BjørklyS,Lockertsen 2017; 26(17/18):2593-2604. in hospitalpatients(VAPA). JClinNurs. Vital signsaspredictors for aggression Considine J,BerryD,JohnsonR,etal. 414-23. adults. AmJCritCare.2014;23(5): Predictors ofagitationincriticallyill Burk RS,GrapMJ,MunroCL,etal. SUPPORTING REFERENCES 19(8): 690-701. J PsychiatrMentHealthNurs. 2012; mental healthtriagedecisionmaking. violence: usingtheevidencetoguide Mental health-relatedriskfactorsfor Sands N,ElsomS,GerdtzM,etal. 2817-31. behaviour. JAdvNurs.2017;73(12): staff inmanagingchallengingpatient engaging thecompetenceofnursing effects oftraininginterventionson quantitative systematicreviewofthe Tölli S,PartanenP, KontioR,etal.A 1747-56. care homes.JAdvNurs.2017;73(7): newly admittedresidentsoflong-term Behaviour RiskAssessmenttoolfor Kim SC,Young L,BerryB.Aggressive 414-23. adults. AmJCritCare.2014;23(5): Predictors ofagitationincriticallyill Burk RS,GrapMJ,MunroCL,etal. 2017; 255:1-7. APPENDICES 127 www.RNAO.ca BEST PRACTICE GUIDELINES • BEST PRACTICE intoxication (drugs or alcohol) organic disorders regular attendee at the agency name calling requiring reassurance refusing to stay in room refusing to stay in bed dissatisfied with care not breaking eye contact/no eye contact not breaking eye tone and volume of voice calling out in a loud voice aggressive tone

demanding swearing anxiety agitated muttering unhappy frightened frustrated confusion staring                  CUES      Preventing Violence, Harassment and Bullying Against Health Workers - Second - Edition Workers Health Against Bullying and Harassment Violence, Preventing

umbling isease process nxiety motions acing taring

one D E M P A S T COMPONENT Table 13: STAMPEDAR Components and Cues and Components 13: STAMPEDAR Table classify risk of violence and their corresponding cues. Being alert and aware of these potential behaviours and triggers and behaviours these potential of cues. Being alert aware and their corresponding and violence classify of risk behaviours. aggressive or violent of the incidents prevent and predict health workers help may Appendix G: STAMPEDAR Framework STAMPEDAR G: Appendix that components nine covers The framework framework. overviewSTAMPEDAR an of is the appendix following The APPENDICES 128 Preventing Violence, Harassment and Bullying Against Health Workers Edition -Second Reprinted with permission. Source: R A COMPONENT esources ssertive/non-assertive Reprinted from Chapman L,Styles Perry I,etal. Predicting R, patient aggression against nurses hospital inall areas. Br JNurs. 2009;18(8):476-83. REGISTERED NURSES’ ASSOCIATION OF ONTARIO         CUES over-assertive confrontational disrespectful inappropriate communicationstyles staff knowledgeandskill level staff inexperience long waittimes not assertive APPENDICES 129

www.RNAO.ca

settings.

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community and and community

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(START) disorders; forensic forensic disorders;

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Treatability Treatability substance-related substance-related start/

term future (weeks to months). to (weeks future term

of Risk and and Risk of personality, and and personality, assessment-of-risk-and-treatability-

violence and treatability in the short- the in treatability and violence

Assessment Assessment with mental, mental, with com/forensic-psychology/short-term- dynamic factors to assess the risk for for risk the assess to factors dynamic

Population: Population: Short-Term Short-Term Identifies recent, historical and and historical recent, Identifies Adults http://criminal-justice.iresearchnet. 

STRUCTURED PROFESSIONAL JUDGMENT TOOLS JUDGMENT PROFESSIONAL STRUCTURED

POPULATION TOOL OF NAME DESCRIPTION OF TOOL/APPROACH OF DESCRIPTION REFERENCES

Preventing Violence, Harassment and Bullying Against Health Workers - Second - Edition Workers Health Against Bullying and Harassment Violence, Preventing SETTING OR OR SETTING

Table 14: Validated Tools to Assess for the Risk of Violence of Risk the for Assess to Tools Validated 14: Table

Inclusion in this list does not constitute an endorsement by RNAO. by endorsement an constitute not does list this in Inclusion

The following is not an exhaustive list of risk assessment tools; rather, it is a selection of those identified within the systematic literature review. review. literature systematic the within identified those of selection a is it rather, tools; assessment risk of list exhaustive an not is following The Appendix H: Validated Risk Assessment Tools Tools Assessment Risk Validated H: Appendix APPENDICES 130 Preventing Violence, Harassment and Bullying Against Health Workers Edition -Second

SETTING OR NAME OF TOOL POPULATION DESCRIPTION OF TOOL/APPROACH REFERENCES REGISTERED NURSES’ ASSOCIATION OF ONTARIO

ACTUARIAL TOOLS

Aggressive Setting: Medical-  Predicts potentially aggressive in- Berry B, Young L, Kim SC. Utility of the Behavior Risk surgical units and patients by assessing the following aggressive behavior risk assessment Assessment Tool long-term care using a yes/no checklist: tool in long-term care homes. Geriatr (ABRAT) homes.  agitation Nurs. 2017;38:417-22.  anxiety

 confusion/cognitive impairment

 history of mania

 history of physical aggression

 mumbling

 physically threatening

 shouting

 staring

 threatening to leave.

Workplace Population: Adults  Twenty-one items that look at https://www.wavr21.com/the-wavr- Assessment of and students 18 psychological, behavioural, historical explained/ Violence Risk years of age or and situational factors associated with violence. (WAVR-21) older.  The primary use is the assessment of Setting: A homicidal targeted workplace and workplace or campus violence. campus setting.  The secondary use is the identification of other forms of problematic aggression (e.g., stalking, anger or bullying). APPENDICES

131

for women than men (34). (34). men than women for

www.RNAO.ca

Can have higher rates of false positives positives false of rates higher have Can 

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Setting: Acute and and Acute violence_risk/v_risk_10_english.pdf

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NAME OF TOOL OF NAME POPULATION DESCRIPTION OF TOOL/APPROACH OF DESCRIPTION REFERENCES SETTING OR OR SETTING APPENDICES 132 Preventing Violence, Harassment and Bullying Against Health Workers Edition -Second

SETTING OR NAME OF TOOL POPULATION DESCRIPTION OF TOOL/APPROACH REFERENCES REGISTERED NURSES’ ASSOCIATION OF ONTARIO

ACTUARIAL TOOLS

Dynamic Population: Persons  Identifies likelihood that a person will https://www.centreforperfectcare.com/ Appraisal of on an in-patient become violent or aggressive in the media/1097/dasa.pdf Situational mental health unit. short-term (24 hours). Aggression  Scored on a daily basis, it consists of Setting: Psychiatric (DASA) seven items that measure irritability, in-patient impulsivity, unwillingness to follow environment or instructions, sensitivity to perceived forensic facility. provocation, ease of anger when requests are denied, negative attitudes and verbal threats.

Brøset Violence Population:  Assists in prediction of imminent http://www.riskassessment.no/ Checklist (BVC) Developed based on violent behaviour (i.e., risk for violence data from forensic in the next 24 hours). in-patients.  To be completed per shift or per day (depending on organizational policy). Setting: Tested  Checklist that includes six variables/ in acute wards, behaviours: confused, irritable, nursing homes and boisterous, physically threatening, geriatric wards. verbally threatening and attacking objects.

Violence Risk Population:  Used to predict statistically whether http://www.psyconsult.it/public/ Appraisal Guide Mentally disordered a convicted criminal will reoffend, Protocollo_VRAG_SORAG.pdf (VRAG) offenders and eliminating bias that can occur with unstructured judgements. http://dustinkmacdonald.com/using- individuals with violence-risk-appraisal-guide-vrag/ lower IQs.  The tool is comprised of 12 items that assess the likelihood of re-offending. However, assessors first complete an eight-item worksheet that assesses for psychopathy before the age of 16, including symptoms of conduct disorder. APPENDICES 133

www.RNAO.ca offenders. offenders.

BEST PRACTICE GUIDELINES • BEST PRACTICE

and adolescent adolescent and

offenders or female female or offenders

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centers. However, However, centers.

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and detention detention and psychopathy to that of a “typical” “typical” a of that to psychopathy

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NAME OF TOOL OF NAME POPULATION DESCRIPTION OF TOOL/APPROACH OF DESCRIPTION REFERENCES SETTING OR OR SETTING APPENDICES 134 Preventing Violence, Harassment and Bullying Against Health Workers Edition -Second

SETTING OR NAME OF TOOL POPULATION DESCRIPTION OF TOOL/APPROACH REFERENCES REGISTERED NURSES’ ASSOCIATION OF ONTARIO

ACTUARIAL TOOLS

Hare Population: Adults  Abbreviated version of the PCL-R, used https://www.researchgate.net/ Psychopathy 18 years of age to screen for Psychopathic Personality publication/312447998_Psychopathy_ Checklist: or older in the Disorder. Checklist_Screening_Version_PCLSV Screening general population,  Includes both a semi-structured Version (PCL: SV) or persons in interview and a 12-item scale to assess core personality traits of psychopathy the forensic and socially deviant or antisocial and psychiatric behaviours of psychopathy. population.

Setting: Workplace organizations to screen candidates before offering them employment, or in psychiatric and forensic environments. APPENDICES

135

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examiner asks are determined by by determined are asks examiner

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interview with the person, person, the with interview

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NAME OF TOOL OF NAME POPULATION DESCRIPTION OF TOOL/APPROACH OF DESCRIPTION REFERENCES SETTING OR OR SETTING APPENDICES 136 Preventing Violence, Harassment and Bullying Against Health Workers Edition -Second identifiedwithinthe systematic literature. review Inclusionthis list innot does constitute an endorsement by RNAO. The following is not an exhaustive list potentialof approaches rather, educationto delivery; selection it those is a of Appendix I:ApproachestoEducationDelivery Table 15:Approaches Content of Educational to on Delivery Workplace Violence 1. APPROACH DELIVERY EDUCATION Online education REGISTERED NURSES’ ASSOCIATION OF ONTARIO infrastructure (84). travel, labourcostsandinstitutional it reducesinstructortrainingtime, eLearning iscost-effective because and enhancelearning.Inaddition, to deepencontentunderstanding and detailedexplanationsasameans using onlineinteractiveassessments fundamental skillsandtechniquesby 86). Learnerscanstillacquiremany to eachlearner’s objectives(84, discussions) anditcanbetailored visual approaches,andwritten learning methods(e.g.,audioor the contentcanincludevarious of usinganonlineapproachisthat written assignments.Theadvantage through aseriesofcourseswith videos anddiscussionboards,or Internet, eitherthroughmodules, adult-learning strategiesonthe Online educationcaninvolvevarious USED WITHINTHELITERATURE DESCRIPTION OFTHEAPPROACHES programs canelicitmeaningful months (86).Thissuggeststhatonline effects weresustainedfortwo after onlineeducation,andthe attitudes, self-efficacyandempathy positive resultsinknowledge, A randomizedcontrolledtrialfound RESULTS OFUSINGTHEAPPROACH (84). hours –followingonlineeducation significantly –from36hoursto4 reduced thelengthofrestraintuse the intervention(online)group the authorsfoundthatstaff in randomized controlledstudy, learning outcomes(86).Inanother impacts onlearnersandenhance APPENDICES 137 www.RNAO.ca initiatives and the review of protocols initiatives and the review of protocols and policies to support the prevention of violence and aggression (92). RESULTS OF USING THE APPROACH OF RESULTS Gates (2014) Gillespie, Farra, and increase in found a significant emergency knowledge among six months department employees activity (139). following a simulation staff study, In an observational management attitudes about the did not of violence and aggression change significantly after simulation- the enhanced education. However, simulation-enhanced education prompted the implementation of multiple quality improvement BEST PRACTICE GUIDELINES • BEST PRACTICE safe learning environment, which safe learning environment, which allows them to practice different to ways of reacting and learning how best prevent violence and aggression (100). An interprofessional, team- based approach to the design of simulation-based education can stress attitudes the importance of staff toward violent and aggressive behaviours and improve safety in practice 92). authentic affective responses from responses from authentic affective participants. The responses and perceived impact of role simulations are similar to those exhibited in real- life situations (100). In addition, simulation-based learning can influence the attitudes of learners, and it encourages interprofessional teamwork and shared dialogue (92). Learners can experience stressful situations in a DESCRIPTION OF THE APPROACHES OF THE APPROACHES DESCRIPTION THE LITERATURE USED WITHIN a realistic but safe Role simulation is to address clinical forum for learners as violence and practice issues such Simulation- aggression (92, 100). and role-play based strategies real clinical activity involve imitating learning situations in a controlled they can evoke environment, and Preventing Violence, Harassment and Bullying Against Health Workers - Second - Edition Workers Health Against Bullying and Harassment Violence, Preventing based, interactive strategies 2. Simulation- EDUCATION EDUCATION DELIVERY APPROACH APPENDICES 138 Preventing Violence, Harassment and Bullying Against Health Workers Edition -Second 3. Cognitive APPROACH DELIVERY EDUCATION 4. Train-the-trainer education rehearsal approaches REGISTERED NURSES’ ASSOCIATION OF ONTARIO An exampleofatrain-the-trainer behaviours/attitudes (79,103,105). facilitating unlearningofundesired enhancing self-efficacyand sustainable learningenvironment, their workplace,thuscreatinga they caninturntrainotherswithin content tohealthworkerssothat Trainers providetheeducation promoting empowermenttolearners. on theconceptofmodellingand A train-the-trainerapproachisbased as aresultofworkplaceviolence(98). behaviours thatcanoccur, specifically increased awarenessofinappropriate education enablesnursestohavean confidence (99).Cognitiverehearsal environment, andincreasingskill responses inasafeandcollaborative personal reactions,rehearsing perceptions andbehaviour, managing best practices,recognizingpersonal consideration ofknowledgeand behavioural therapy. Itincludesthe on theprinciplesofcognitive or stressfulsituationsthatisbased approach tonegotiatingemotional Cognitive rehearsaleducationisan USED WITHINTHELITERATURE DESCRIPTION OFTHEAPPROACHES expertise (79). registered nurseswithspecialized clinical educatorsorexperienced practice improvements.Trainers were that wereusedandsuggestionsfor of thevariouslocalapproaches followed byafacilitateddiscussion in acutecaresettings.Thecoursewas team onthepreventionofaggression developed byamulti-disciplinary approach isthetrainingcourse and thatitcontributedtothe effective toolforaddressingbullying, cognitive rehearsaleducationwasan Fehr andSeibel(2016)alsofoundthat the workplace(98). to speakupagainstlateralviolencein judgement andfeltmoreempowered reported relyinglessonexternal personal empowerment.They reported increasedfeelingsof program fornurses,manyparticipants cognitive rehearsaleducation After theimplementationofone RESULTS OFUSINGTHEAPPROACH (103). in aconstructiveandtangibleway communication andleadershipskills had theopportunitytopractice nurses wereenhancedbecausethey assertive communicationskillsof trainer approachtoeducation,the the implementationofatrain-the- et al.(2012)foundthatfollowing Ceravolo, Schwartz,Foltz-Ramos, participants (99). habits andcompetenciesinstudent development ofpositiveattitudes, APPENDICES 139 www.RNAO.ca learned through initial educational learned through initial educational sessions can be integrated into practice only through ongoing re- 79, education and reinforcement (62, 84, 88, 96, 101, 140). RESULTS OF USING THE APPROACH OF RESULTS across the literature A common theme education and is that continuous to workplace training are essential (62, 79, 84, 88, violence prevention 96, 101, 140). content or focus of Regardless of the workers need the education, health regularly to ensure to receive training they are aware of potential hazards and how to protect themselves and their coworkers through established policies and procedures. Refreshers on knowledge, attitudes and skills BEST PRACTICE GUIDELINES • BEST PRACTICE required within some organizations. required within some Leadership and organizational support are keys to successful organizational culture changes, specifically in regards to implementing ongoing re-education (88). DESCRIPTION OF THE APPROACHES OF THE APPROACHES DESCRIPTION THE LITERATURE USED WITHIN and support Consistent reinforcement are needed in order for re-education techniques to integrate learned clinical practice and strategies into are no agreed (62). There often when refreshers to upon criteria for place; however, learning should take re-education is yearly mandatory Preventing Violence, Harassment and Bullying Against Health Workers - Second - Edition Workers Health Against Bullying and Harassment Violence, Preventing approaches to approaches re-education and refresher training 5. Ongoing EDUCATION EDUCATION DELIVERY APPROACH APPENDICES 140 Preventing Violence, Harassment and Bullying Against Health Workers Edition -Second aimed at making environments safer for persons both and families. This appendix provides the Safewardsof an overview Model tableand a describingthe 10 principle interventions Appendix J:SafewardsModel http://www.safewards.net/images/pdf/Safewards%20model.pdf Source: Figure 11:Safewards Model making workplaces health safer environments for workers health both and persons. containment workplace. health inthe table The that followsthe ( model The Safewards ( model Reprinted with permission from Bowers L.Safewards: of model anew conflict and containment on psychiatric wards. Safewards; 2008. Availablefrom REGISTERED NURSES’ ASSOCIATION OF ONTARIO

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E S R APPENDICES 141 www.RNAO.ca BEST PRACTICE GUIDELINES • BEST PRACTICE can support and facilitate discussion, express empathy, acknowledge can support and facilitate discussion, express empathy, frustration and be receptive to concerns to avoid conflict. to build therapeutic relationships, both health In a collaborative effort workers and patients should create one-page profiles of information they are willing to share. The profiles can include things such as likes for and dislikes, and they can be laminated and shared at the bedside patients and in a public area of the health setting for workers. Change of shift reports given to oncoming staff often focus on a often staff Change of shift reports given to oncoming pose to others. This can difficult behaviours or the risks they patient’s health individual. Alternatively, create a negative perception of that positive about each patient while workers should focus on something psychological understanding of giving report and provide a possible any difficult or disruptive behaviour. Health workers should be cognizant of the bad news that is given (or about to be given) to patients and the angry or upset reactions that could result. When health workers can anticipate bad news, they escalating frustrations and miscommunication. Health settings should and miscommunication. Health escalating frustrations displaying tips for using “soft create and regularly update posters workers with reminders on how to words” and distribute postcards to way. frame communication in a positive basic-to-advanced de-escalation Health workers should understand Down be presented by a “Talk techniques, and the information should Posters and handouts should Champion” within the organization. promote utilization of talk down be available to all workers in order techniques. DESCRIPTION of expectations patients should determine a list Health workers and should be setting. At first, these expectations for the unit or health that, they should by the two groups; after decided on independently for all to see on upon. This list should be visible be mutually agreed be referred to the health setting, and it should the unit or within consistently. to avoid patients should work collaboratively Health workers and Preventing Violence, Harassment and Bullying Against Health Workers - Second - Edition Workers Health Against Bullying and Harassment Violence, Preventing Know each other Bad news mitigation Positive words Talk down Talk Soft words Clear mutual expectations INTERVENTION Table 16: Ten Safewards Intervention Principles Intervention Safewards 16: Ten Table APPENDICES 142 Preventing Violence, Harassment and Bullying Against Health Workers Edition -Second Source: Discharge messages Reassurance Calm downmethods Mutual helpmeeting INTERVENTION Adapted by RNAO the panel from expert Safewards: Resources for Safewards Implementation; 2018.Available from: REGISTERED NURSES’ ASSOCIATION OF ONTARIO reassurance duringtheiradmittance. during theirstay. Newpatientsshouldbeshown thesemessagesfor unit, positiveadvicefornewpatientsandwhatwentonintheunit The messageshouldincludetheirname,whattheylikedaboutthe to writeamessagebedisplayedintheunitorhealthsetting. Upon discharge,healthworkersshouldaskifthepatientwouldlike understand theeffect thattheincidenthas hadoneachindividual. be supportedtofeelsafeandsecure,healthworkersshould assess theirunderstandingandprovideanexplanation.Patientsshould patients inahealthsetting,everyoneshouldbespokentoorder Following anincidentthatcouldbepotentiallyanxiety-invokingfor coloring pages. agitated. Theboxmaycontainitemssuchasstressballs,blanketsor should beused(undersupervision)byapatientwhoisincreasingly can promotecomfortandacalmingeffect whenneeded.Thetools Health settingsshouldhaveaboxcontainingitemsforpatientsthat other duringtheday. meeting canbestructuredanddiscusshoweveryonehelpeach (the moreregularlythemeetingsoccur, theshortertheycanbe).The be heldregularlytocreateacultureofhelpingandunderstanding A voluntarymeetingofallpatientsandhealthworkersondutyshould DESCRIPTION http://www.safewards.net/ . APPENDICES 143 . www.RNAO.ca https://doi.org/10.17483/2368-6669.1058 BEST PRACTICE GUIDELINES • BEST PRACTICE Preventing Violence, Harassment and Bullying Against Health Workers - Second - Edition Workers Health Against Bullying and Harassment Violence, Preventing

Reprinted with permission from Fehr FC, Seibel LM. Cognitive rehearsal training for upskilling undergraduate nursing students against bullying: a bullying: against students nursing undergraduate upskilling for training FC, Seibel rehearsal LM. Cognitive Fehr from permission with Reprinted

Source: Source: 2016; 2(1), Article 5 DOI: Education. in Nursing Quality Advancement study. pilot qualitative Figure 12: Communication responses to address harassment and bullying and harassment address to responses Communication 12: Figure in practice settings. In a study by Fehr and Seibel (2016), students used this as a lanyard card to assist them in assist to card used a lanyard this as Seibel and (2016), students Fehr by a study In settings. in practice occurs. it as behaviour bullying to responding Lanyard Card Lanyard bullying and harassment to address responses on communication students to guide tool a provides appendix This Appendix K: Communication Responses Communication K: Appendix APPENDICES 144 Preventing Violence, Harassment and Bullying Against Health Workers Edition -Second The following appendixOccupationalthe is Health and Safety (OHS) vulnerability measure. It was developed at Survey Vulnerability Scale Appendix L:Workplace HealthandSafety within an organization. beforeTheboth measure canbe used and after violence a prevention program initiative evaluate to effectiveness 4. 3. 2. 1. in four areas: Institutethe for Work &Health (IWH)to assess risk for injuryand at illness work. vulnerability assesses scale The Workplace and policies procedures Hazard exposure Worker empowerment to participate ininjuryand prevention. illness Worker awareness of hazards and OHS rights and responsibilities REGISTERED NURSES’ ASSOCIATION OF ONTARIO APPENDICES 145 DK/NA DK/NA Every day Strongly disagree www.RNAO.ca Every week Disagree Every month Agree Every 3 months Strongly agree

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3 voice repetitive times floor Communication understand safety Incidents Work Work or Work There least familiar flammable Perform Interact Experience your Stand Workplace 10 Everyone Do sorting, changing There Systems Manually 16. 15. 6. 5. 7. 14. 3. 4. 8. 9. 13. 10. 2. .... At my workplace 11. 12. In your job, how often do you ...? you often do how job, In your 1. Part 2: Workplace policies and procedures policies Workplace Part 2: please put an X under make the workplace safe. For each item below, in place to This section asks about the kinds of policies and systems or disagree with the statement. the heading that best describes how much you agree This section asks about the kinds of health and safety hazards you might be exposed to in your job. For each item below, please put an X below, might be exposed to in your job. For each item kinds of health and safety hazards you This section asks about the exposed to the stated condition. describes how often you do the stated task or are under the heading that best Part 1: Workplace hazards Workplace Part 1: Workplace health and safety survey and safety health Workplace your health and safety by taking this survey. your opinions about your work and how it affects are invited to share You (OHS) policies and and the occupational health and safety below on the hazards you face on the job Please answer the questions answers will help your name). Your (i.e. we are not asking for you. Please note that the survey is anonymous procedures in place to protect and safety of workers. improvement to better protect the health pinpoint areas that may need feel best question, please indicate the response option you There are no right or wrong answers. For each Answer each question carefully. Know /Not Applicable) stands for Don’t answers the question. (DK/NA Figure 13: Measure to assess risk for injury illness and work assess for risk at to 13: Measure Figure APPENDICES 146 Preventing Violence, Harassment and Bullying Against Health Workers Edition -Second https://www.iwh.on.ca/sites/iwh/files/iwh/tools/ohs_vulnerability_measure_questionnaire_2016.pdf Source: Reprinted from Institute for Work &Health (IWH).Workplace [Internet]. and health safety survey Toronto (ON): IWH;2016.Available from: please putanXundertheheadingthatbestdescribeshowmuchyouagreeordisagreewithstatement. a saferworkplaceforyourselfdependsonbothyouractionsandabilities andyouremployer’s actionsandpractices.Foreachitembelow, This sectionexploresyourabilitytoaskquestionsabout,andparticipate in,healthandsafetyatwork.Your abilitytoparticipateinmaking Part 4: Participationinoccupationalhealthandsafety statement. and employers).Foreachitembelow, pleaseputanXundertheheadingthatbestdescribeshowmuchyouagreeordisagreewith This sectionexploresyourawarenessofoccupationalhealthandsafety (e.g.hazards,therightsandresponsibilitiesofbothemployees Part 3: Occupationalhealthandsafetyawareness 27. 26. 25. 22. 21. 24. 20. 19. 18. 23. At myworkplace .... 17. At myworkplace .... for Institute This . [email protected] to modify thetoolfor and/oruse not modified, andsharedaslongcan beused asIWHiscredited asthesource, http://creativecommons.org/licenses/by-nc-nd/4.0/. Toronto, REGISTERED NURSES’ ASSOCIATION OF ONTARIO eventually I If me I I at I (at If at If I and I I I of theOHS ispart survey

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APPENDICES 147

www.RNAO.ca http://www.arete.ca/ programs/service-to- safety-workplace-violence- prevention-training/ https://www.ccohs.ca https://nursesunions.ca/ https://nursesunions. ca/?s=workplace+violence LINK BEST PRACTICE GUIDELINES • BEST PRACTICE to protect the quality of health care for patients. The website provides multiple tools and resources related to various topics, including psychological violence, workplace violence, and bullying. The CCOHS serves Canadians and the The CCOHS serves Canadians and tools world with credible and relevant and resources to improve workplace health and safety programs. The CFNU advocates for unionized nurses and nursing students across Canada, promotes the nursing profession on a national level, and aims DESCRIPTION Provides workshops on workplace Workshops are violence and conflict. the customizable to meet the needs of workplace. Preventing Violence, Harassment and Bullying Against Health Workers - Second - Edition Workers Health Against Bullying and Harassment Violence, Preventing , which was compiled by the RNAO Best Practice Guideline Development and Research Team and members members and Team Research and Development Best Practice Guideline the RNAO by compiled , which was

Nurses Unions (CFNU) Occupational Health and Safety (CCOHS) Canadian Federation of and Protection, Inc. and Protection, for Canadian Centre ORGANIZATION, ORGANIZATION, PROGRAM OR RESOURCE Safety Training Arete and Bullyingand the source. the source. Harassment, Violence, Workplace on Resources or Information Provide That Organizations 17: Table reliability or currency of the information provided through these sources. Furthermore, RNAO has not determined not has RNAO Furthermore, these sources. through provided the currency information of or reliability be to directed should these resources regarding Questions been evaluated. have which these to resources the extent at the local level. Clinicians also are encouraged to research local supports to which they can refer people. which they refer to local can supports research to encouraged also the local Clinicians are level. at accuracy, the quality, for responsible not is purposes only; RNAO information for provided are Links websites to of the expert panel – with input from external stakeholder reviewers – lists some of the main organizations that that organizations the main of some – lists reviewers external stakeholder from the expert input – with of panel be available may Other resources bullying. and harassment violence, workplace on resources or information provide Appendix M: Resources M: Appendix 17 Table APPENDICES 148 Preventing Violence, Harassment and Bullying Against Health Workers Edition -Second Healthcare (NASHH) Safety andHealthin National Alliancefor Harassment (IAWBH) Workplace Bullyingand Association on International (HQO) Health QualityOntario Institute Canadian PatientSafety Association Canadian Nurses RESOURCE PROGRAM OR ORGANIZATION, REGISTERED NURSES’ ASSOCIATION OF ONTARIO DESCRIPTION associations. of sevenprovincialsenior caresafety care inCanada.Theyare comprised the frontlineofhealthandseniors and eliminateworkplaceinjurieson The NASHHwasestablishedtoreduce bullying andharassment.” based practiceinthefieldofworkplace disseminate researchandevidence- “stimulate, generate,integrateand The aimoftheassociationisto of workplacebullyingandharassment. practitioners whospecializeinthefield IAWBH isagroupofscholarsand for thepeopleofOntario”(141). government inimprovinghealthcare data, andbysupportingthem do byprovidingobjectiveadviceand lines bemoreeffective inwhatthey professionals workingonthefront nurses, doctorsandotherhealth-care quality ofhealthcare.Theyhelp “HQO istheprovincialleadon and quality. particular emphasisonpatientsafety leaders toensuresafehealthcare,with patients, healthcareprovidersand Provides toolsandresourcesfor ethics forregisterednurses. environment. Alsoprovidesacodeof of registerednursesinthehealth policy, andadvocatingfortherole the goalofinfluencinghealthypublic nationally andinternationallywith Represents Canadianregisterednurses patientsafetyinstitute.ca www. edition-secure-interactive pdf-en/code-of-ethics-2017- media/cna/page-content/ https://www.cna-aiic.ca/~/ https://www.cna-aiic.ca LINK http://nashh.ca https://www.iawbh.org/ www.hqontario.ca APPENDICES 149 www.RNAO.ca safety/violence-harassment/ https://www.pshsa.ca/ workplace-violence/ https://www. safetyfirsttraining.ca/ course/onsite-training/ workplace-violence- harassment-training/ LINK https://www.labour.gov. on.ca/english/hs/topics/ workplaceviolence.php https://www.ona.org/ about-ona/our-vision- mission-and-history/ https://www.ona.org/ member-services/health- BEST PRACTICE GUIDELINES • BEST PRACTICE This training provides individuals with (a) the knowledge required to identify potentially violent situations and (b) the skills and strategies to prevent or manage them. resources. Specifically, their website resources. Specifically, focuses on workplace violence and provides resources, supporting on documents and recommendations workplace violence in health care. is a provider of Safety First Training workplace health and safety services. These services include online and onsite training courses on workplace harassment and violence prevention. ONA is the union that represents registered nurses, health professionals, and student affiliates in Ontario. The website provides guidance and and resources about workplace violence harassment. PSHSA works with public sector employees to provide occupational health and safety training and Provides information about the Provides information and Safety Occupational Health tools and Act, including education, development and resources on the of policies and implementation violence and programs on workplace harassment. DESCRIPTION Preventing Violence, Harassment and Bullying Against Health Workers - Second - Edition Workers Health Against Bullying and Harassment Violence, Preventing Safety First Training Public Services Health and Safety Association (PSHSA) Ontario Nurses’ Association (ONA) Ontario Ministry of Ontario Ministry Labour – Workplace Violence and Workplace Harassment ORGANIZATION, ORGANIZATION, OR PROGRAM RESOURCE APPENDICES 150 Preventing Violence, Harassment and Bullying Against Health Workers Edition -Second International (STTI) International Sigma ThetaTau RESOURCE PROGRAM OR ORGANIZATION, (WSPS) Prevention Services Workplace Safety& REGISTERED NURSES’ ASSOCIATION OF ONTARIO DESCRIPTION online course. including a“BullyingintheWorkplace” that arepeer-reviewed and interactive, nursing educationlearningactivities STTI offers numerousonline continuing scholarship, leadershipandservice. to celebrateexcellenceinnursing aim istoadvanceglobalhealthand STTI isanon-profitorganizationwhose organization. a preventionprogramforyour identifying violenceandestablishing provide onlinecoursesabout policies andprograms.Theyalso developing violenceandharassment the workplace,includingatoolkiton about violenceandharassmentin WSPS providestoolsandresources practice-online-course.html solutions-for-nursing- bullying-in-the-workplace- sigmamarketplace.org/ https://www. homepageupdate org/sigma_branded_ https://www.sigmanursing. LINK Topics/Violence- Information-Resources/ http://www.wsps.ca/ Harassment.aspx

APPENDICES 151 (1). The (1). The for guiding guiding for Toolkit www.RNAO.ca www.RNAO.ca/bpg/resources/toolkit- BEST PRACTICE GUIDELINES • BEST PRACTICE Toolkit: Implementation of Best Practice Guidelines Practice Best of Implementation Toolkit: Preventing Violence, Harassment and Bullying Against Health Workers - Second - Edition Workers Health Against Bullying and Harassment Violence, Preventing addresses the following key steps, as illustrated in the Knowledge-to-Action framework (110): (110): framework in the Knowledge-to-Action illustrated as steps, key the following addresses Toolkit provides step-by-step directions for the individuals and groups involved in planning, coordinating coordinating in planning, involved groups and the individuals for directions step-by-step provides

is one key resource for managing this process. It can be downloaded at be can downloaded at It this process. managing for resource key one is assess barriers and facilitators to knowledge use; and knowledge to facilitators barriers and assess identify resources. Toolkit

  Monitor knowledge use. knowledge Monitor outcomes. Evaluate use. knowledge Sustain Adapt knowledge to the local to knowledge context: Adapt interventions. implement Select, and tailor Identify the problem: identify, review and select BPG). (e.g., review and knowledge identify, the problem: Identify Toolkit implementation-best-practice-guidelines-second-edition 6. undertaking.The is a complex clinical impact and positive practicechanges successful effect to BPGs Implementing 4. 5. 3. 2. linear. Therefore, at each phase, preparation for the next phases and reflection on the previous phases is essential. essential. phases is previous onthe reflection and phases next the for preparation phase, at each Therefore, linear. the Specifically, 1. The ratherthan iterative and dynamic is processthat reflect a steps These implementation. the BPG facilitating and Toolkit is based on available evidence, theoretical perspectives and consensus. We recommend the recommend We consensus. perspectives evidence, theoretical and based available is on Toolkit in a health organization. BPG environment work healthy clinical or any of the implementation adequate, and if there is appropriate facilitation. To encourage successful implementation, an RNAO expert panel of expert of panel RNAO an successful implementation, encourage To facilitation. appropriate is if there and adequate, the developed has administrators and researchers nurses, Appendix N: Description of the Toolkit of Description N: Appendix are supports administrative and organizational and resources if planning, be implemented successfully only can BPGs ENDORSEMENTS 152 Preventing Violence, Harassment and Bullying Against Health Workers Edition -Second Endorsements REGISTERED NURSES’ ASSOCIATION OF ONTARIO ENDORSEMENTS 153 www.RNAO.ca BEST PRACTICE GUIDELINES • BEST PRACTICE Preventing Violence, Harassment and Bullying Against Health Workers - Second - Edition Workers Health Against Bullying and Harassment Violence, Preventing ENDORSEMENTS 154 Preventing Violence, Harassment and Bullying Against Health Workers Edition -Second REGISTERED NURSES’ ASSOCIATION OF ONTARIO NOTES 155

www.RNAO.ca

BEST PRACTICE GUIDELINES • BEST PRACTICE Preventing Violence, Harassment and Bullying Against Health Workers - Second - Edition Workers Health Against Bullying and Harassment Violence, Preventing Notes NOTES 156 Notes Preventing Violence, Harassment and Bullying Against Health Workers Edition -Second REGISTERED NURSES’ ASSOCIATION OF ONTARIO

Best Practice Guideline

This project is funded by the Ontario Ministry of Health and Long-Term Care.