Violence Prevention Planning Resource Pages

Violence Prevention Planning Resource Pages

Establishing a Violence Prevention Working Group Forming an Effective Working Group A violence prevention program is part of an organization s overall OHS program. The working group can be composed of the joint worker/employer health and safety committee or sub committee of the joint committee. Workplaces with 10 to 19 regularly employed workers, which are required to have a worker health and safety representative instead of a joint committee, may decide to involve individuals with expertise in specialized areas. Any such person must be jointly agreed to by the JOHS committee. Consider who should be invited to participate in the working group based on the nature and complexity of the organization and the expertise needed for specific tasks: A broad representation from each site, department, and shift Safety personnel, employee assistance representatives, and security who are responsible for the overall safety performance of the organization Individuals with expertise in specialized areas, for example, psychiatry, dementia, head injury, or substance abuse. (If sufficient expertise is not available within the organization consider consulting outside experts.) The structure and commitment of the working group will play a key role in determining the quality of the violence prevention program. Input from all levels of the organization will ensure that policies and procedures are relevant to the unique nature of the workplace, work environment, type of patient/client population, and risk/hazards workers may encounter. Res. - 1

Overall Violence Prevention Program Planning Guide Activities Establish steering committee (joint reps from workers/union and employers) Develop steering committee terms of reference Ensure violence prevention policy in place Timelines (6-12 Months) Person(s) Responsible Resource Requirements Status Develop communication plan for informing staff/workers/families Create risk assessment work plan which includes risk identification / assessment & the prioritizing of risks Meet with steering committee to plan interventions/risk controls Implement interventions/risk controls Monitor interventions/risk controls Evaluate interventions/risk controls Document and report results to senior management Formal review of VP program Res. - 2

Res. - 3 SAMPLE WORKSHEET - INFORMATION SUMMARY Date/ Time Data Source Incident Description Occupation Involved Incident Locations Contributing Factors Corrective Actions Action Following Incident

Environmental Physical and social Worksheet 1 Risk Factor (Hazards) for Violence Individual Client and worker Organizational Policies, procedures, work process, training Res. - 4

Worksheet 2 Risk Reduction Planning Worksheet Job or Job Task: Hazards: 1. Level of Risk 2. List recommended control measures using the table and hierarchy below. If a control is not possible, move to the next category. Category Hazard Control Measure Practicable Elimination 1. 2. 1. Substitution 2. 1. Engineering Control 2. 1. Administrative Control 2. 1. PPE 2. Res. - 5

Risk Factor(Hazard): Worksheet 3 Intervention Action Plan Level of Risk High Medium Low Current Policies and Procedures Possible Interventions/ Controls Chosen Control & Objective Activity Timeline Person Responsible Resources Required Status Monitoring and Evaluation Activities Certified Complete: (Employer Representative) Date Certified Complete: (Worker Representative) Date Res. - 6

BCGEU SAMPLE RISK FACTORS CHECKLIST Use this checklist to assist in identifying risk factors that affect the workplace. This process takes into consideration job characteristics, environmental conditions, client characteristics and situational risk elements. Characteristics of a workers occupation that might increase risk: The risk of violence is generally higher when the worker occupation involves physical contact with clients, particularly if the contact is one where the job involves regulation enforcement. List any job characteristic that can potentially place a worker at an increased risk of violence such as: Dealing with the public Child apprehension Delivering social services Working alone Working at night Performing security functions Changing nature or level of services Organization of work Violence considered part of the job Public perception that organization does not do enough to protect workers Denial of service Client characteristics that might be risk factors: What are the risk factors related to the client that may create risk of violence. The idea is to list any characteristic that could have caused the incident to occur. Examples could include the following: Chronically disgruntled History of violence Pushes limit of normal conduct Unresolved psychological problems Domestic abuser Financial distress Verbal abuse or threats Abuse of alcohol or drugs Destroys property Mental or physical injury or illness Medication or substance abuse Gang activity Client access to weapons Workplace Violence Protection BCGEU September 2004 Adapted for use in the Joint Workplace Violence Risk Assessment course Res. - 7

Environmental conditions that might increase the risk of violence: Consider the time of day, location of the worksite, time of the year, and any other contributing environmental factors such as the following: Workers working alone or who work in high crime neighborhoods Workers who work in remote or isolated areas Workers who travel by car Nightshift Correctional settings with increased inmate population Clients who can touch employees Poor lighting Physical design and worksite layout Low service counters Obscured windows Public accessibility Reception areas Interview rooms Parking lot Situational risk: What is the nature of the interaction whether from a client or a family member. Some of the items to consider would be the prior history of the client, and violence prevention initiatives that are in place. What are the policies and procedures that might increase the risk to the worker assigned, including the location where the work is being performed? Community profile Working at night Working late or early No check in or out procedure High crime areas No method of communications Arriving and leaving court proceedings Wearing a uniform when leaving work Unwanted public having access to building No evacuation plan Having to wait for appointments Investigation taking place Workplace Violence Protection BCGEU September 2004 Adapted for use in the Joint Workplace Violence Risk Assessment course Res. - 8

Health & Safety Services Violence Prevention Employee Risk Assessment Survey In the development/revision of Violence Prevention materials, and in accordance with the Workers' Compensation Board of BC (WCB), a comprehensive risk assessment must be performed in any place of employment in which a risk of injury to workers arising out of their employment may be present. The WCB Regulation defines violence as "the attempted or actual exercise by a person, other than a worker, of any physical force so as to cause injury to a worker, and includes any threatening statement or behaviour which gives a worker reasonable cause to believe that he or she is at risk of injury." The staff survey will be of great assistance in the completion of the risk assessment for your workplace and facility. Your responses are anonymous and the results will be shared with the Occupational Health and Safety Committee. GENERAL EMPLOYEE INFORMATION Facility or Location of Work Job Title Department Date (dd/mm/yy) Number of Years in Current Work Area Number of Years in Current Job/Position WORKING ALONE 1. In the last 12 months, have you been required to work alone (i.e. no other staff member, security or RCMP present in the area)? Every day 3 or more times per week 5 or more times per month 1 time per month Less than 5 occasions Never 2. Did you (or would you if you have never worked alone) feel at an increased risk of violence because you work alone? Yes No Don't Know EXPERIENCES WITHIN PAST 12 MONTHS 3. In the past 12 months, have you witnessed an aggressive act by someone other than a co-worker? Yes No If "Yes", was this act reported? Yes No Don't Know 4. In the past 12 months, have you been subject to an incident of violence (verbal or physical)? Yes No If "Yes", please indicate the number of incidents: If "No please move to question #25 5. Where did the incident(s) take place? At Bedside or In Patient's/Resident's/Client's Bedroom Within Immediate Work Area (i.e. nursing station, Corridor Conference Room, Bathroom, Staff Room, Office, etc.) Other Area Within The Facility: Parking Area Vehicle Resident's House Other: (please specify) 6. Did you seek medical aid as a result of the incident(s)? Yes No 7. Did you have time off from work as a result of the incident(s)? Yes No 8. If injured as a result of the violent act, the injury resulted in: Minor laceration Major laceration Minor bruising Major bruising Fracture Sprain or Strain Internal Injuries Head Injury Stress Other: (please specify) 9. Who was the aggressor (i.e. the person who precipitated the violent act)? Patient Resident Family Member of Patient/Resident/Client Client Visitor of Patient/Resident Neighbor/Visitor of Client Public Physician Unknown Other: (please specify) 10. Was the aggressor? Male Female Unknown 11. What was the nature of the incident? (please check all that apply) You were: Struck by an object Grabbed/held by the aggressor Kicked/punched/slapped by the aggressor Pushed by the aggressor Spit on Verbally threatened Other: (please specify) Jan 2000 Page 1 OF 3 Res. - 9

Health & Safety Services Violence Prevention Employee Risk Assessment Survey 12. If verbally threatened, were the threats to: Injure you Sexually assault you Kill you Injure members of your family Damage or destroy your property Other: (please specify) 13. Under what circumstances did the act of violence occur - that is, what events preceded the act or what do you believe precipitated the violent act? Interaction with patient/resident/client/public under the effects Providing physical care to patients/residents/clients who are of alcohol or drugs known to be violent Interaction with known violent person Handling or delivery of drugs Stressful situation resulting from bad news or negative Handling cash or other items that might precipitate violent acts information Enforcing rules of conduct, e.g. noise level, visiting hours, Other: (please specify) smoking policy, etc. 14. Prior to the incident, did you suspect that a violent incident might arise? No Yes, documented on care plan Yes, identified on alert/risk identification system Yes, warned by other professional or staff in the area Yes, warned by supervisor or manager Yes, warned by co-worker Yes, personal previous knowledge of behaviour Other: (please specify) 15. At what time did the incident(s) happen? 0800 to 1600 1600 to 2400 2400 to 0800 16. Were other people, other than the aggressor, close enough to provide assistance at the time the incident(s) occurred? No Yes, other employees Yes, security or RCMP Yes, other: (please specify) 17. Were the incident(s) reported? No Yes, verbally to manager or supervisor Yes, using Unusual Occurrence Report Yes, using Accident and Injury Report Yes, verbally to union representative Yes, other: (please specify) 18. What was done as a result of the violent incident? Don't know Nothing to my knowledge Modification to work area or work procedures Adjustment to care plan More training Additional security or RCMP presence Other: (please specify) 19. Do you think corrective action was adequate? Yes No Don't Know 20. Were you offered Critical Incident Stress defusing or debriefing as a result of the incident(s)? Yes No 21. Were you offered counseling through an Employee and Family Assistance Program (EFAP)? Yes No 22. If you received Critical Incident Stress defusing or debriefing, or accessed counseling through an EFAP, did you find it useful? Very helpful Helpful Not helpful Didn't receive 23. Was the Occupational Health and Safety Committee involved in the investigation of the violent incident(s)? Yes No Don't Know 24. Was the Workers' Compensation Board involved in the investigation of the violent incident(s)? Yes No Don't Know KNOWLEDGE LEVEL 25. Do you know the current policy(s) and procedure(s) for identification of aggressive patients/residents/clients/public? Yes No Don't know 26. Do you know the current policy(s) and procedure(s) for reporting incidents of violence? Yes No Don't know 27. Have you received specific training on Violence Prevention in the workplace? No Yes, at new hire orientation Yes, in the last 2 years at current workplace Yes, through outside organization/institution Yes, other: (please specify) 28. If Yes, do you feel the training was adequate to enable you to: (check those applicable) Recognize the potential for violence in your workplace Respond to violence or threats of violence Obtain assistance Report and document incidents of violence Jan 2000 Page 2 OF 3 Res. - 10

BELIEFS ABOUT YOUR JOB Health & Safety Services Violence Prevention Employee Risk Assessment Survey Regardless of whether you have experienced an incident of either actual or threatened violence, please answer the following questions. 29. Is the risk of violence in your workplace a serious concern for you? Yes No Don't Know 30. If Yes, how often would you say this concern impacts you? Daily Weekly Monthly Occasionally Infrequently Other (please specify) 31. Do you feel you would be supported by your manager or supervisor in reporting incidents of violence? Yes No Don't know 32. If you believe you are at risk, is it as an individual or as a consequence of the nature of your occupation? Individual Occupation Both Don't know 33. Do you believe your occupational risk is related to the nature of your work environment? Yes No Don't know 34. If Yes, could that be related to: (check all those applicable) The city or geographical area of service The facility location or layout The number of entrances into your work area Signage i.e. lack of or characteristics of Noise and lighting Visibility of your work area Other: (please specify) 35. Do you believe your occupational risk is related to the nature of your interactions with patients/residents/clients/public? Yes No Don't know 36. If Yes, could that be related to: (check all those applicable) Delivery of hands-on patient care Giving and receiving of information Delivery of medications Explaining of policies/procedures Enforcing of policies/procedures Entry into private homes and residences Other: (please specify) 37. Do you believe risk to aggression is related to personal attributes? Yes No Don't Know 38. If Yes, could that be related to: (check all those applicable) Gender Experience Confidence in communication skills Training relating to personal safety Other (please specify) 39. Do you believe incidents of violence may go unreported? Yes No Don't Know COMMENTS AND RECOMMENDATIONS Additional comments and recommendations on anything about violence in your workplace, the causes and how to reduce the risks and number of incidents Jan 2000 Page 3 OF 3 Res. - 11

SUGGESTED GUIDELINES KEY ELEMENTS OF A WORKPLACE VIOLENCE AND AGGRESSIVE BEHAVIOUR PREVENTION PROGRAM (WVABPP) I. Organizational commitment and support Commitment o Allocation of resources and appropriate authority to responsible parties o Clear lines of authority and accountability what happens to a report, who follows up, outcomes. Communications o Provide staff with regular updates o Build links with community resources o Work together with community to promote a safe, nonviolent culture Employer s Workplace Violence Policy Preamble: Statement of Belief employer commitment to a violence-free workplace safety priority: staff, patient/client/visitor, environment zero tolerance for violence expectations of clients/community balance of good patient care (clinical practice) with workplace safety (OH&S) create an organizational safety culture Definitions of violence (WCB SECTION 4.27) Regulatory requirements WCB, part 3 (regulations 3.5, 3.6, 3.9, 3.12, 3.18) and part 4 (regulations 4.27 4.31) Goals of WVABPP Responsibilities: Board of Directors Senior Executive Team Directors/Medical Directors Managers and Supervisors Employees and Medical Staff Corporate Employee and Workplace Health and Safety (EWHS) Joint Health and Safety Committees Contractors Res. - 12

II. Risk Assessment Site/sector-specific o acute care o complex/long term care o community/home care o mental health and social services/addictions services o other risks may pertain to location, geography, size of institution, demography Identify the hazards (incident reports, investigations, OHS program evaluations, records of training, policies and procedures in place, WHITE database, employee questionnaires, focus groups) gives baseline data to be able to evaluate pre and post intervention; review hazards re: worker, clients, environmental (physical, social) and organizational (employer) o Evaluate existing precautions, policies and procedures o Assess the risk and set priorities for action III. Interventions before incident (general and site-specific) prevention of violence Engineering controls o layout o alarms o locks o signage o security o cell phones o staffing levels Administrative controls Policies and procedures (corporate and site-specific): o Employee identification o Violence alert identification o Visiting guidelines/rules o Application of restraints o Patients who are victims of criminal acts o Patients under custody o Search of a patient s belongings for weapons o Patient consumption of intoxicating/illegal substance o Alcohol and drug withdrawal management o Working alone o Control of crime scene/incident scene/patient/visitor o Guidelines for safe work practice in various healthcare settings Res. - 13

o Patients with history of violence o Requesting assistance process o Right of refusal o Clinical practice guidelines IV. Education/Training Needs assessment - what types based on evaluation of previous training and follow-up re: did people actually use the training? o Information about use of current and new engineering and administrative controls o Skills training re: prevention and management of aggressive behaviour (PMAB) o General guidelines for managing aggressive behaviour (also develop sitespecific guidelines) o Causes of aggression and violence - triggers o Prevention - assessing stages of aggressive behaviour/de-escalation techniques o Interaction with aggressive people breakaway training, restraint techniques V. Interventions after incident response to violence development of policies and procedures as well as education and training in implementation of controls. Emergency Response Mechanisms o Code white o Security, police, etc. Incident Protocols o Incident reporting, documentation, investigation o Follow-up for client/staff counseling and support o Incident debriefing; staff support (EFAP, CISM) Investigation/Follow-up o Documentation o Legal action criminal charges VI. WVABPP Audit/Evaluation Annually at least with follow-up after introducing certain interventions Determine what is to be measured, e.g., knowledge/awareness level, change in worker injury, violent incidents, perceptions of workers safety, knowing how to respond post training, etc. Must be assessed before interventions are introduced. Criteria for success: o Information reported on incident reports - documentation o Time frame risk assessments must be done regularly and incident reports analyzed monthly o Response to assessments - Who does them?; What happens to the assessments? How quickly are they responded to? o Guidelines need to be site specific for different work settings o Credibility adequately funded and fully implemented Res. - 14

o Sustainability incorporated into all aspects of daily schedule, actions documented, programs reviewed regularly o Management commitment managers must ensure development and endorsement of a written violence prevention policy o Employee involvement in risk assessment and determining interventions; regular consultation re: how it is working? o Dissemination of policy to all employees in an accessible format Kathryn Wellington Occupational Health and Safety Agency for Healthcare (OHSAH) September 2006 Res. - 15

PREVENTING VIOLENT AND AGGRESSIVE BEHAVIOUR IN HEALTHCARE: Excerpts from a Literature Review (OHSAH) Y. Cvitkovich June 2005 Background Four World Health Organization (WHO) reports provide a background of violence prevention programs and what are consensus interventions: Di Martino (2003), Wiskow (2003), Richards (2003), and Sethi et al (2003). Di Martino (2003) reports that violence in the health sector constitutes 25% of all workplace violence. He discusses the risk factors for violence in the workplace and describes the relationship between work stress and workplace violence. Wiskow (2003) compared 12 violence prevention guidelines across four countries: Sweden (1), the United Kingdom (4), The USA (2), Australia (5) and reports that the National Health Service (NHS) Zero Tolerance commitment to reducing risk of violence for the health workforce is the most comprehensive of all the violence prevention programs. Examples of the UK guidelines are presented in Appendix 1). Richards (2003) summarizes the different types of interventions based on the practice in the United Kingdom. Sethi et al (2003) provides a handbook for the documentation of violence prevention programs. Criteria for Evaluating Violence Prevention Programs Wiskow (2003) in a WHO review of international programs reports the following criteria for evaluating violence prevention programs: Information reported Time frame Relevance (setting-specific) Credibility Sustainability Management commitment Employee involvement Dissemination. An effective program is setting-specific with measurable, achievable objectives within realistic timeframes. Information reported The minimum information required in reporting a violent incident in the workplace: Details of victim and perpetrator Location, date, time of incident Circumstances of incident - actions taken prior (risk assessment, training) and during incident (e.g., conflict resolution method attempted, etc. [de-escalation, breakaway techniques, restraint techniques]) Details of outcome (injuries, time off, etc.) Action taken post-incident (medical aid, psychological aid, legal action/ consequences regarding perpetrators, follow-up on victim, reporting, tracking & analysis of incidents, review of risk assessment & training) Res. - 16

(Information reported continued) The following series of questions are recommended as a guide for auditing (evaluating) a violence prevention program. Series Q1 Do the incident reports provide at least the minimum information required above? Time frame: Risk assessments must be done regularly or when there is a change in setting, work procedures or client disposition. Record analysis must be conducted at a minimum on a monthly basis. Series Q2 Who does the assessment? What is done with the assessment? (Filed, Posted, Distributed, Reviewed). How regularly are assessments reviewed? What action was taken? (e.g., prior to next home visit, the worker calls client to ensure that the dog is tied up or confirms that the aggressive relative is not going to be present). Is there any documentation of warnings concerning the withholding treatment if the client refuses to act on requests to decrease risk factors? Is there any documentation regarding complaints by client concerning the threat of withholding services and whether the supervisor supported the worker s situation? Series Q3 Is there some evidence of documentation concerning analysis of records ( i.e., minutes of JOHS discussion, action taken, etc )? Is there documentation of post-incident responses: 1) within 1 hour of incident, 2) 24-hour follow-up; and 36-hour follow-up. Is there documentation regarding the analysis of the post-incident response? Is there evidence of pre-post measures to evaluate the effect of the trauma and the intervention? Relevance: The guidelines may cover a variety of work settings. Series Q4 - Do the guidelines differentiate between settings? Do the guidelines explicitly provide case studies relevant to the work setting? Environmental change is more relevant to stationary institutions but less relevant to outreach workers. Societal background may influence content of guidelines. Wiskow (2003) provides the following examples: Res. - 17

1) The USA guidelines are more relevant to violence related to guns whereas in other countries this issue is less relevant. 2) Developing countries have a greater weakness in overall infrastructure of their health system and do not have many options for post-incident response. 3) Panic buttons and mobile phones may be less realistic for rural clinics and remote areas (due to lack of available service). Credibility: To be effective, a violence prevention program must be adequately funded and fully implemented. Series Q5 - Is implementation of violence prevention programs enforced? Are there significant examples of citations for non-compliance? Is there documentation showing that action was taken following non-compliance? Does zero tolerance receive buy-in from all sectors? What process do they have to measure this? Is the measurement process effective? What resources are made available to enable implementation of violence prevention programs? Is there a budget? How often is the budget reviewed? Are resources made available for control measures? How much is provided? Is there allowance for increase or re-distribution of budget according to changing risks? Sustainability: To be effective, a violence prevention program must be incorporated into all aspects of the daily schedule, systems maintained, actions documented and programs reviewed on a regular basis. Series Q6 - How well are strategies integrated into daily work on a regular basis? Is there documentation of violence prevention drills and objective assessments by police/health authorities? Is there documentation of refresher training for each worker? Is there an assessment of the worker s knowledge and skill at managing violence and aggression (de-escalation, breakaway techniques, restraint techniques)? Is there documentation showing the tracking and analysis of the frequency and type of aggression incidents? Is there documentation showing action taken to rectify the factors that caused the aggression incident? Res. - 18

Management Commitment: To be effective, a violence prevention program must have tangible commitment from management. Managers must ensure the development and endorsement of a written violence prevention policy including the following: Recognition of workplace violence risk and pledge to protect staff at work Employer s legal obligations Employer s goals and objectives with the program Details of managers and employees responsibilities Details of the local prevention and reduction plan. Provide staff with regular updates and progress reports (in-house newsletter, annual reports on action taken and improvement measures introduced).allocation of resources and appropriate authority to responsible parties. Series Q7 - Is there documentation illustrating that the policy is implemented as a living actionable program and not just a paper copy? Employee involvement: Successful programs profit substantially with the experience and feedback from staff. Series Q8- Are workers involved in the process of risk assessments and determining the best ways of using prevention measures? Is there documentation showing that staff are consulted on a regular basis through the joint OH&S committee and through surveys? (Minutes of JOHS meetings, reports of incidents and action taking) Dissemination: To be effective the written program must be communicated and be accessible to all employees. Series Q9 Are relevant sections of policy provided in a readily accessible format (card, booklet, posters)? Is the policy published on internet? Is time made available for group discussions regarding: incidents, what could be done differently, what triggers were missed, was post-incident action effective? Res. - 19

Guidelines Thirty-five current violence prevention guidelines were reviewed as current practice (see Appendix 1). All the government and union guidelines agree that a risk assessment is the key to prevention of violence in the workplace. There is consensus that a risk assessment must lead to violence prevention programs tailored to the particular needs of each specific healthcare setting. There is general consensus declaring that violence prevention must be based on effective implementation of three main steps: 1) Identification of the problem(s) or hazard(s) 2) Evaluation of existing precautions 3) Assessment of the risk. A violence prevention program should have the following components: 1) A risk assessment evaluating the risks arising from administrative/work procedures and environmental factors 2) Education and training of personnel to help them identify potential risks and to manage aggression 3) Incident reporting and investigations 4) Post-incident responses and follow-up to moderate the effect of the trauma 5) Program reviews to determine what changes are required to make the program more effective. Risk Factors There is consensus regarding the risk factors for violence in the workplace. The Chappell-Di Martino model focuses on the relationship between personal and environmental factors at work. The model emphasizes the necessity of combating violence by integrated preventive action tackling all the elements involved. Most guidelines focus on environmental factors and administrative procedures as key elements contributing to the potential for violence in the workplace. Chappel- Di Martino Model Factors Perpetrator (client, Victim (worker, patient, resident) bystander, client) Workplace (hospital, nursing home, community) Work task situation Risk Factors Violence history Male Youth Difficult childhood Alcohol/drugs Mental health Stress Age Appearance Experience Health Skills Gender Personality/temperament Attitudes & expectations Physical layout Organizational setting Managerial style Workplace culture Permeability from external environment Alone/in isolation With public With valuables With people in distress In school with special vulnerability Res. - 20

Risk Assessment WorkSafe BC (2000) defines risk assessment as a step-by-step look at the workplace and work process to: 1) Determine what violence prevention measures are already in place 2) Identify potentially hazardous conditions, operations, activities, and situations that could contribute to workplace violence 3) Determine the risk of future violent incidents. What Should be Included in the Risk Assessment? 1) Baseline Information: A baseline of previous violent incidents including: the number, location, nature, severity, timing and frequency of different types of incidents, previous staff/worker surveys (BCGEU, 1998; OSHA, 2004) Investigations of incidents and follow-up action taken, records of injuries (WCB of BC, 2000; OSHA, 2004) OHS program evaluations (WCB of BC, 2000) Records of training (WCB of BC, 2000) Policies and procedures (BCGEU, 1998) Any violence prevention measures in place Security reports; security arrangements and measures; workplace security evaluations Workplace environment arrangements and layout (floor plan). 2) Inspecting the Workplace A) Institutional Workplace (hospital, nursing home, health centre) Worksite Environment (see WCB of BC 2000, Checklist B3; AFSCME, Appendix A; Vancouver Coastal 2004 Appendix B; OSHA, 2004; OHSAH, 2005) Lighting (Casteel & Peek-Asa, 2000; ) Staff level and deployment (working in isolation, a buddy system or with others), peak workload times (may cause strain in public/client/resident temperament) (BCGEU, 1998; AFSCME, 1998) The health team skill mix meets the patients needs. (ICN, 2000) Other patients Provision for exchange of information between staff (regarding daily conditions, client moods, flagging history of aggression, etc.) (Vancouver Coastal, 2004; AFSCME, 1998; ICN, 2000). Res. - 21

Extracts April 11, 2006 BC S OCCUPATIONAL HEALTH AND SAFETY REGULATION Accessed at: http://www2.worksafebc.com/publications/ohsregulation/home.asp Res. - 22

BC OCCUPATIONAL HEALTH AND SAFETY REGULATION Part 3 Rights and Responsibilities Extracts April 11, 2006 Correction of Unsafe Conditions 3.9 Remedy without delay Unsafe or harmful conditions found in the course of an inspection must be remedied without delay. 3.10 Reporting unsafe conditions Whenever a person observes what appears to be an unsafe or harmful condition or act the person must report it as soon as possible to a supervisor or to the employer, and the person receiving the report must investigate the reported unsafe condition or act and must ensure that any necessary corrective action is taken without delay. 3.11 Emergency circumstances If emergency action is required to correct a condition which constitutes an immediate threat to workers only those qualified and properly instructed workers necessary to correct the unsafe condition may be exposed to the hazard, and every possible effort much be made to control the hazard while this is being done. 3.12 Procedure for refusal (1) A person must not carry out or cause to be carried out any work process or operate or cause to be operated any tool, appliance or equipment if that person has reasonable cause to believe that to do so would create an undue hazard to the health and safety of any person. (2) A worker who refuses to carry out a work process or operate a tool, appliance or equipment pursuant to subsection (1) must immediately report the circumstances of the unsafe condition to his or her supervisor or employer. (3) A supervisor or employer receiving a report made under subsection (2) must immediately investigate the matter and (a) ensure that any unsafe condition is remedied without delay, or (b) if in his or her opinion the report is not valid, must so inform the person who made the report. (4) If the procedure under subsection (3) does not resolve the matter and the worker continues to refuse to carry out the work process or operate the tool, appliance or Accessed at: http://www2.worksafebc.com/publications/ohsregulation/home.asp Res. - 23

Extracts April 11, 2006 equipment, the supervisor or employer must investigate the matter in the presence of the worker who made the report and in the presence of (a) a worker member of the joint committee, (b) a worker who is selected by a trade union representing the worker, or (c) if there is no joint committee or the worker is not represented by a trade union, any other reasonably available worker selected by the worker. (5) If the investigation under subsection (4) does not resolve the matter and the worker continues to refuse to carry out the work process or operate the tool, appliance or equipment, both the supervisor, or the employer, and the worker must immediately notify an officer, who must investigate the matter without undue delay and issue whatever orders are deemed necessary. 3.13 No discriminatory action (1) A worker must not be subject to discriminatory action as defined in section 150 of Part 3 of the Workers Compensation Act because the worker has acted in compliance with section 3.12 or with an order made by an officer. (2) Temporary assignment to alternative work at no loss in pay to the worker until the matter in section 3.12 is resolved is deemed not to constitute discriminatory action. Note: The prohibition against discriminatory action is established in the Workers Compensation Act Part 3, Division 6, sections 150 through 153. http://www2.worksafebc.com/publications/ohsregulation/part3.asp - top Accessed at: http://www2.worksafebc.com/publications/ohsregulation/home.asp Res. - 24

Part 4 General Conditions Extracts April 11, 2006 4.19 Physical or mental impairment (1) A worker with a physical or mental impairment which may affect the worker's ability to safely perform assigned work must inform his or her supervisor or employer of the impairment, and must not knowingly do work where the impairment may create an undue risk to the worker or anyone else. (2) A worker must not be assigned to activities where a reported or observed impairment may create an undue risk to the worker or anyone else. 4.20 Impairment by alcohol, drug or other substance (1) A person must not enter or remain at any workplace while the person's ability to work is affected by alcohol, a drug or other substance so as to endanger the person or anyone else. (2) The employer must not knowingly permit a person to remain at any workplace while the person's ability to work is affected by alcohol, a drug or other substance so as to endanger the person or anyone else. (3) A person must not remain at a workplace if the person's behaviour is affected by alcohol, a drug or other substance so as to create an undue risk to workers, except where such a workplace has as one of its purposes the treatment or confinement of such persons. Note: In the application of sections 4.19 and 4.20, workers and employers need to consider the effects of prescription and non-prescription drugs, and fatigue, as potential sources of impairment. There is a need for disclosure of potential impairment from any source, and for adequate supervision of work to ensure reported or observed impairment is effectively managed. Working Alone or In Isolation 4.21 Procedures (1) The employer must develop and implement a written procedure for checking the wellbeing of a worker assigned to work alone or in isolation under conditions which present a risk of disabling injury, if the worker might not be able to secure assistance in the event of injury or other misfortune. (2) The procedure for checking a worker's well-being must include the time interval between checks and the procedure to follow in case the worker cannot be contacted, including provisions for emergency rescue. (3) A person must be designated to establish contact with the worker at predetermined intervals and the results must be recorded by the person. Accessed at: http://www2.worksafebc.com/publications/ohsregulation/home.asp Res. - 25

Extracts April 11, 2006 (4) In addition to checks at regular intervals, a check at the end of the work shift must be done. (5) The procedure for checking a worker's well-being, including time intervals between the checks, must be developed in consultation with the joint committee or the worker health and safety representative, as applicable. (6) Time intervals for checking a worker's well-being must be developed in consultation with the worker assigned to work alone or in isolation. Note: High risk activities require shorter time intervals between checks. The preferred method for checking is visual or two-way voice contact, but where such a system is not practicable, a one-way system which allows the worker to call or signal for help and which will send a call for help if the worker does not reset the device after a predetermined interval is acceptable. 4.22 Training A worker required to work in the circumstances described in section 4.21(1) and any person assigned to check on the worker must be trained in the written procedure for checking the worker's well-being. 4.23 Annual review The procedure and system for checking a worker's well-being must be reviewed at least annually, or more frequently if there is a change in work arrangements which could adversely affect a worker's well-being or a report that the system is not working effectively. Workplace Conduct 4.24 Definition In sections 4.25 and 4.26 "improper activity or behaviour" includes (a) the attempted or actual exercise by a worker towards another worker of any physical force so as to cause injury, and includes any threatening statement or behaviour which gives the worker reasonable cause to believe he or she is at risk of injury, and (b) horseplay, practical jokes, unnecessary running or jumping or similar conduct. Note: Worker means a worker as defined under the Workers Compensation Act, and includes a supervisor or other representative of the employer (see Part 3, Division 1, section 106). Accessed at: http://www2.worksafebc.com/publications/ohsregulation/home.asp Res. - 26

4.25 Prohibition Extracts April 11, 2006 A person must not engage in any improper activity or behaviour at a workplace that might create or constitute a hazard to themselves or to any other person. 4.26 Investigation Improper activity or behaviour must be reported and investigated as required by Part 3 (Rights and Responsibilities). Violence in the Workplace 4.27 Definition In sections 4.28 to 4.31 "violence" means the attempted or actual exercise by a person, other than a worker, of any physical force so as to cause injury to a worker, and includes any threatening statement or behaviour which gives a worker reasonable cause to believe that he or she is at risk of injury. 4.28 Risk assessment (1) A risk assessment must be performed in any workplace in which a risk of injury to workers from violence arising out of their employment may be present. (2) The risk assessment must include the consideration of (a) previous experience in that workplace, (b) occupational experience in similar workplaces, and (c) the location and circumstances in which work will take place. 4.29 Procedures and policies If a risk of injury to workers from violence is identified by an assessment performed under section 4.28 the employer must (a) establish procedures, policies and work environment arrangements to eliminate the risk to workers from violence, and (b) if elimination of the risk to workers is not possible, establish procedures, policies and work environment arrangements to minimize the risk to workers. (c) Repealed. [B.C. Reg. 312/2003, effective October 29, 2003.] Accessed at: http://www2.worksafebc.com/publications/ohsregulation/home.asp Res. - 27

4.30 Instruction of workers Extracts April 11, 2006 (1) An employer must inform workers who may be exposed to the risk of violence of the nature and extent of the risk. (2) The duty to inform workers in subsection (1) includes a duty to provide information related to the risk of violence from persons who have a history of violent behaviour and whom workers are likely to encounter in the course of their work. (3) The employer must instruct workers who may be exposed to the risk of violence in (a) the means for recognition of the potential for violence, (b) the procedures, policies and work environment arrangements which have been developed to minimize or effectively control the risk to workers from violence, (c) the appropriate response to incidents of violence, including how to obtain assistance, and (d) procedures for reporting, investigating and documenting incidents of violence. 4.31 Advice to consult physician (1) Repealed. [B.C. Reg. 312/2003, effective October 29, 2003.] (2) Repealed. [B.C. Reg. 312/2003, effective October 29, 2003.] (3) The employer must ensure that a worker reporting an injury or adverse symptom as a result of an incident of violence is advised to consult a physician of the worker's choice for treatment or referral. [Amended by B.C. Reg. 312/2003, effective October 29, 2003.] Note: The requirements for risk assessment, procedures and policies, the duty to respond to incidents and to instruct workers are based on the recognition of violence in the workplace as an occupational hazard. This hazard is to be addressed by the occupational health and safety program following the same procedures required by this Occupational Health & Safety Regulation to address other workplace hazards. Accessed at: http://www2.worksafebc.com/publications/ohsregulation/home.asp Res. - 28

Sample Format Joint Health and Safety Committee Recommendation Form To: [1] Date: From: Joint Health & Safety Committee [2] (Co-Chair Signature Employer Representative) [2] (Co-Chair Signature Worker Representative) Please Respond by: [3] (within 21 calendar days.) OH&S Issue: (Give a short, clear and complete description of the issue. Describe what, why, who, where, and when.) [4] Committee Recommendation: (attach a separate sheet if necessary) (Make sure the recommendation deals with workplace health and safety. Include reasons for your recommendation. For complex issues, list options, steps involved and suggested time frame for implementation/completion.) [5] cc: Appropriate Manager, Safety Coordinator, CEO, etc [6] Employer Response: (attach a separate sheet if necessary) (Note to Employer: In your response, if you accept this recommendation please include a time frame for completion. If you reject the recommendation please include your reasons.) [7] Signature: (Department Head or Designate) Date Return: Committee Comments: (Note any follow-up or addition action required by the Committee.) [8] From: WCB JOHSC Handbook, pg 39. By: OHSAH/HELP Team (Feb 2000 - Revised) Date: 30 Dec 05 Res. - 29

Guidelines for Writing Recommendations Send it TO the person who can take action Date the recommendation and send it to the manager or supervisor who has the authority to follow up on it. Send it FROM the co-chairs Have both Joint Health and Safety Committee co-chairs sign the recommendation. Request the employer response within 21 calendar days Include a reminder for a written response within 21 calendar days. Describe the OH&S issue Give a short clear description of the issue: WHAT, WHY, WHO, WHERE, WHEN. Give enough information that the employer does not need to ask for more details/background to make a decision. Refer to any accident, incident, inspection finding, or other occurrence related to the issue. Describe the committee recommendation Make sure the recommendation is about workplace health and safety. Include the reasons for your recommendation. Suggest a timeframe for it to be done. Complex Issues For more complex issues, your employer will likely need details/background information to make a decision. It can be helpful to answer the following questions: Are there specific OH&S legislation or standards that apply? What other options are there? (Describe each.) How well will recommended option fix the problem/address the issue? How long will it take to complete/implement/see results? How much will it cost? Who will be affected? (e.g. number and type of employees) Why did the Committee decide to recommend this option? Often complex issues will involve more than one step. For example: Conducting a Risk Assessment of affected workers. Purchasing equipment or supplies to address the identified risks. Developing safe work procedures to reduce/eliminate the hazard. Providing education and training to affected workers. Source: Joint Occupational Health & Safety Committee Workbook. Feb. 28, 2000. Res. - 30

It may be helpful for the Committee to complete a separate recommendation form for each step so that all relevant information can be included. Copy to appropriate manager It is helpful to forward a copy of the recommendation to higher levels of management (CEO, upper management, safety coordinator, etc.) or anyone who should know about the health and safety recommendation. Include space on the form for your employer s response Provide space for the employer to reply indicating acceptance of the recommendation or giving the reasons for not accepting the recommendation. If it is not reasonably possible for the employer to respond before the end of 21 calendar days, the employer must provide a written explanation for the delay and let the Committee know when the employer will respond. Include space on the form for committee comments The Committee may want to make comments after reviewing the employer response such as noting any follow-up or action required by the Joint Health and Safety Committee. Source: Joint Occupational Health & Safety Committee Workbook. Feb. 28, 2000. Res. - 31

Res. - 32