Abuse of Clients

Allegations of abuse of clients reported to HIROC cover a broad spectrum of abuse. Examples include reported, suspected, and witnessed incidents of sexual or physical assault, racism, discrimination, harassment, threats, and financial abuse of clients by other clients, staff, volunteers, visitors, or healthcare practitioners. In order to adequately respond to such claims, it is essential to be able to demonstrate the healthcare organization and its volunteers, employees, independent contractors, and learners met the relevant standards of care, implemented and adhered to appropriate policies, and responded promptly to reports of abuse or circumstances where the potential for abuse might be reasonably anticipated. The failure to take timely action in response to reported allegations, suspected, or witnessed incidents is a common finding in HIROC claims.

Expected Outcomes

Nurturing a “zero-tolerance” culture toward client abuse by:
o      Implementing a reliable screening, hiring, and privileging process;
o      Providing multifaceted and targeted education programs to all volunteers, employees, independent contractors , learners, clients, and caregivers;
o      Conducting periodic environmental design and physical layout risk assessments.

Adopt formal strategies to support timely reporting, response and investigation of suspected, witnessed or reported abuse of clients.

Implement formal strategies to provide targeted education and training to support and enhance the prevention, reporting, and investigation of client abuse.

Definitions and Acronyms

• Client – includes all persons who receive healthcare and related services including patients, residents and persons in-care
• ED – emergency department
• Healthcare organizations - organizations engaged in providing, financing, improving, supervising, evaluating, or other activity related to health care

Common Claims Themes and Contributing Factors

Organizational

• Facility design and layout deficiencies.
• Insufficient or inadequate staffing level and mix based on workload and client acuity.
• Workload and stress experienced by care providers resulting in staff burnout contributing to inadequate interactions with clients.
• Inconsistent background and police checks for visitors, employees, independent contractors, volunteers, and learners.
• Perceived and actual tolerance of unprofessional, inappropriate, disruptive, retaliatory, racist, biased, or discriminatory behaviour by care providers.
• Lack of assessment tools to assist in identifying persons under care at risk of harming others or wandering.

Knowledge and Judgement

• Failure to adequately identify, document, or monitor a client at risk of harming others.
• Failure to comply with restraint policies and practices including restraint prevention strategies.
• Inadequately performed client risk assessments.
• Failure to comply with observation policy requirements.
• Failure to escalate, follow-up, and intervene on reports of sexual abuse or unusual behaviour, including:
  • Hesitancy to report unusual behaviour involving co-workers;
  • Assumption that false reports are common in areas such as mental health care settings;
  • Lack of awareness and compliance with local abuse prevention and response protocols.

Mitigation Strategies

Screening, Hiring, and Privileging Processes

• Adopt current legislation compliant best practices for the recruitment, background checks / screening, hiring, and performance management of volunteers, employees, independent contractors, and learners (refer to Wrongful Dismissal and Inappropriate Credentialing, Reappointment and Performance Management Risk Reference Sheets for further details).

Additional Considerations

Examples of elements to address in applicant background checks:

• A form to enable any third party to release information related to the applicant;
• Standardized criteria for references to rate the applicant;
• Ensuring all references are personally contacted (ideally verbally) prior to hire or granting of privileges;
• Ensure healthcare background checks take place before hire or appointment.

• Require that all volunteers, employees, independent contractors, and learners annually sign-off on the organization’s ‘code of conduct’ policies (Canadian Medical Association, 2018) (College of Physicians & Surgeons of Alberta, 2023) (Canadian Nurses Association, 2017) (College of Nurses of Ontario, 2019) (Ontario Personal Support Workers Association, n.d.) (College of Nurses of Ontario, 2020) (College of Physicians and Surgeons of Ontario, 2008).

Safety Culture

• Adopt a principle-based zero tolerance approach toward any form of client abuse while in-care (AbuDagga, Wolfe, Carome, & Oshel, 2019) (College Of Respiratory Therapists Of Ontario, 2018) (College of Occupational Therapists of Ontario, n.d.) (HIROC & BLG, 2021) (The Joint Commission, 2019a).

Additional Considerations

Examples of elements of a principle based zero tolerance for abuse of clients:

• Clients who report an incident of physical, sexual, or financial abuse while in care are entitled to be heard. Their right to dignity and confidentiality to be respected and protected throughout the process of communication, investigation, and organizational response, regardless of whether the event is perceived as being ‘false’, and should be treated with compassion and understanding;
• Respecting the client’s right to choose the support services and care they feel are most appropriate, the extent to which they communicate about their experience / the incident, if at all, the right to be protected from reprisal for reporting an incident and, their right to report (or not) the incident to the police / RCMP;
• Ensuring the organization’s investigation procedures are transparent;
• Volunteers, employees, independent contractors, and learners are expected to immediately report client abuse incidents they have witnessed or have knowledge of, or where they suspect that abuse of a client has occurred or may occur while in-care.

• Implement multifaceted strategies to support and encourage early reporting of suspected, witnessed, or reported abuse incidents of persons under care (Manitoba Health, n.d.) (HIROC & BLG, 2021) (Association of Registered Nurses of Newfoundland and Labrador, 2008) (College of Licensed Practical Nurses of Newfoundland and Labrador, 2019) (ECRI, 2020).
• Implement formal strategies to prompt the timely completion of violence risk assessments and the development of formal care plans for clients with a history of and / or currently exhibiting abusive or violent behaviours towards other clients and / or staff (e.g., physical or sexual abusive or inappropriate behaviours, aggressive or combative behaviours) (Registered Nurses’ Association of Ontario, 2022) (National Initiative for the Care of the Elderly).
• Adopt standardized terminology for assessing, communicating, and documenting observation or supervision levels of clients at risk of or currently exhibiting abusive and / or violent behaviours.
• Implement processes to assess and support a client’s request to be attended by a staff member of the same or different gender (where possible).
• Implement formal strategies to develop and maintain a work environment which supports and expects:
  • Early response to suspected, reported, or witnessed abuse of clients including seeking assistance from peers, leadership, and other resources;
  • Assertive and respectful questioning and challenging of care decisions (in order to obtain clarity and / or to advance client safety concerns);
  • Zero tolerance of intra- and inter-disciplinary bullying and intimidation.
• Adopt a standardized and formalized chain of command (‘escalation’) protocol for the rapid escalation of unresolved care disagreements related to concerns about questionable client conditions, orders, or care delivery (Canadian Medical Protective Association, 2021) (Canadian Patient Safety Institute, 2020) (Provincial Council for Maternal and Child Health, 2022); for smaller organizations, consider the need to include successively higher level of authority (e.g., the Chief of Staff, administration on call or other executive leaders) to ensure a satisfactory resolution is achieved.

Incident / Emergency Response

• Adopt a standardized response protocol or checklist to support decision making following allegations of suspected, reported, or witnessed sexual or physical abuse of persons under care that includes the immediate response (e.g., protecting individuals, notifying leadership, securing locations and evidence), the prompt activation of the incident response protocol, incident investigation, debrief, documentation, and closure (HIROC & BLG, 2021) (The Joint Commission, 2019a).

In collaboration with legal counsel and Subscribers, HIROC released the Allegations of Sexual Assault Incident Response Toolkit for Healthcare Organizations & Providers (link). Subscribers are encouraged to review and incorporate the best practice response checklist and recommendations focusing on the immediate actions, investigation, and organizational learning. 

Facility Design, Space and Security

• Conduct periodic environmental design and physical layout risk assessments to prevent and minimize abuse of clients while in care, in particular (but not limited to) clinical areas such as mental health units, ED, and memory and aging programs; ensure there is unobstructed view of common areas, bathroom doorways etc. (Hunt & Sine, 2015) (Occupational Safety and Health Administration, 2016). 

Team Training and Education

• Implement formal multifaceted and targeted education strategies (e.g., interdisciplinary workshops, in-situ simulations, and emergency skills drills; sharing of learnings and trends from periodic chart audits, extracts, analysis of reported incidents, and medical-legal matters) to support and enhance the ongoing identification and reporting of abuse of persons under care (Registered Nurses’ Association of Ontario, 2022) (DuBois, et al., 2019).

Additional Considerations

Examples of elements to address in education strategies to support and enhance the ongoing prevention, identification, and reporting of client abuse while in-care:

• The organization’s definition of ‘client abuse’ (e.g., physical abuse, sexual abuse, threats, non-therapeutic relationships, intimidations, racism, biases and discrimination, financial abuse, harassment, and cyber abuse);
• Formal diversity, equity, inclusion, and belonging training;
• Signs of abuse (e.g., unexplained injuries, bruises, signs of over and under medication, fear, anxiety, withdrawal, or cowering);
• Boundary issues and suspicious signs of potential abusive situations (e.g., staff spending extra time with one client beyond the therapeutic need, changing client assignments to provide preferential care to one client, kissing and hugging clients, changes in a client’s comfort levels with a particular staff member);
• How to activate and manage the Code White response for violent persons;
• Mandatory external reporting requirements (e.g., incidents involving minors must be reported to the province or territorial children’s agency; alleged assailants who are regulated health professionals must be reported to the respective provincial / territorial professional regulatory body / college);
• Consent and privacy considerations for disclosure to third parties (e.g., families, police).

• Implement staff education in non-violent crisis interventions, de-escalation techniques for volunteers, employees, independent contractors, and learners working with at risk populations or higher risk programs (e.g., mental health units, EDs, memory and aging programs) (ECRI, 2020) (The Joint Commission, 2019b).

Monitoring and Measurement    

• Adopt a standardized, interdisciplinary, collaborative and evidence-based protocol for conducting quality of care reviews involving client abuse resulting in harm or death (e.g., adherence to local protocols; percentage clients exhibiting or with a history of violence / harm / abuse to third parties with a documented care plan); incorporate system thinking and human factors concepts into the review process (Machen, 2023).
• Adopt standardized quality indicators for the prevention, reporting, and investigation of client abuse.
• Incorporate learning from local, provincial, and national abuse of client safety reviews and data into local protocols as well as staff and client education and training (HIROC & BLG, 2021). 

References

• AbuDagga, A., Wolfe, S., Carome, M., & Oshel, R. (2019, 3). Crossing the line: Sexual misconduct by nurses reported to the National Practitioner Data Bank. Public Health Nursing, 36(2), 109-117.
• Association of Registered Nurses of Newfoundland and Labrador. (2008). Registered Nurses professional duty to address unsafe and unethical situations. 
• Canadian Medical Association. (2018). CMA code of ethics and professionalism. 
• Canadian Medical Protective Association. (2021). Resolving conflict between healthcare providers. Retrieved from https://www.cmpa-acpm.ca/en/advice-publications/browse-articles/2021/resolving-conflict-between-healthcare-providers
• Canadian Nurses Association. (2017). Code of ethics for registered nurses. Ottawa, ON.
• Canadian Patient Safety Institute. (2020). Creating a safe space: Strategies to address the psychological safety of healthcare workers. 
• College of Licensed Practical Nurses of Newfoundland and Labrador. (2019). Therapeutic nurse-client relationship. 
• College of Nurses of Ontario. (2019). Code of conduct. Toronto, ON.
• College of Nurses of Ontario. (2020). Employer policies to prevent sexual abuse. Retrieved from https://www.cno.org/en/protect-public/employer-resources/employers-toolkit-sexual-abuse-prevention/employer-policies-to-prevent-sexual-abuse-of-patients/
• College of Occupational Therapists of Ontario. (n.d.). Sexual Abuse Prevention. Retrieved from https://www.coto.org/clientsandthepublic/protecting-the-public/sexual-abuse-prevention
• College of Physicians & Surgeons of Alberta. (2023). Standards of practice. 
• College of Physicians and Surgeons of Ontario. (2008). Guidebook for managing disruptive physician behaviour. 
• College Of Respiratory Therapists Of Ontario. (2018). Professional practice guideline: Abuse awareness & prevention. 
• DuBois, J., Walsh, H., Chibnall, J., Anderson, E., Eggers, M., Fowose, M., & Ziobrowski, H. (2019, 8). Sexual Violation of Patients by Physicians: A Mixed-Methods, Exploratory Analysis of 101 Cases. 
• ECRI. (2020). Violence prevention in the healthcare workplace. 
• Goverment of Canada. (2023). Personnel security screening overview. Retrieved from https://www.tpsgc-pwgsc.gc.ca/esc-src/personnel/enquete-screening-eng.html
• HIROC & BLG. (2021). Allegations of sexual assaul: Incident response toolkit. 
• Hunt, J., & Sine, D. (2015). Common mistakes in designing psychiatric hospitals. Facility Guidelines Institute.
• Machen, S. (2023, 5). Thematic reviews of patient safety incidents as a tool for systems thinking: a quality improvement report. BMJ Open Quality, 12(2), e002020.
• Manitoba Health. (n.d.). Protection for persons in care. Retrieved from Goverment of Manitoba: https://www.gov.mb.ca/health/protection/#:~:text=The%20Protection%20for%20Persons%20In,any%20other%20designated%20health%20facility.
• National Initiative for the Care of the Elderly. (n.d.). Elder Abuse - Assessment and Intervention Reference Guide. 
• Occupational Safety and Health Administration. (2016). Guidelines for preventing workplace violence for healthcare and social service workers. U.S. Department of Labor.
• Ontario Personal Support Workers Association. (n.d.). Code of conduct: 6 principles of OPSWA's code of conduct. Retrieved from https://ontariopswassociation.com/code-of-conduct/#:~:text=Support%20Workers%20act%20with%20integrity,and%20protect%20patients%20from%20harm.
• Provincial Council for Maternal and Child Health. (2022). Safe administration of oxytocin. 
• Registered Nurses’ Association of Ontario. (2022). Preventing and addressing abuse and neglect in long-term care: A pocket guide. 
• Royal College of Nursing. (2020). Raising and escalating concerns. London, UK.
• Shipman, D., & Hooten, J. (2009, 5). Staff background checks: safeguarding vulnerable adults. Nursing Older People, 21(4), 23-26.
• The Honourable Eileen E. Gillese. (2019). Public Inquiry into the safety and security of residents in the long term care homes system. Queen’s Printer for Ontario.
• The Joint Commission. (2019a). Preventing violence in the health care setting. Sentinel Event Alert.
• The Joint Commission. (2019b). De-escalation in health care. Quick Safety(47).