There is a dreadful paradox lurking in the health sector: hospitals, clinics, nursing homes and other facilities devoted to healing are also often the sites of violence directed against care providers and other staff. In this instalment of Healthcare Quarterly, we are proud to publish a trio of essays that shed light on the issue of workplace violence and offer policies and approaches to aid in its prevention.
First off is an account by Erna Bujna et al. about workplace violence prevention (WVP) efforts undertaken at Toronto East General Hospital (TEGH). Among the tactics implemented to date are a Workplace Violence Prevention Committee (which includes the hospital's CEO), zero-tolerance posters and a voice-activated communication system for staff. Bujna and her co-authors document the many positive results of TEGH's WVP initiatives, and offer lessons for other organizations, including the value of partnering with labour organizations, the "personal engagement" of senior leaders and applying policies equally to all staff.
As the TEGH case makes clear, patients do, even when preventive measures are in place, sometimes assault their care providers. Sarah Flogen and her co-authors present "considerations" pertaining to the laying of criminal charges against such offenders. Their article synthesizes the information provided by members of a special panel, which comprised a police officer, registered nurse, nurse manager and other experts. The points Flogen et al. review are fascinating and highlight the legal, ethical and professional complexity of such situations; for example, the various kinds of "assault" according to the Criminal Code of Canada, healthcare workers' duty to protect their patients' personal health information when filing a complaint and limits on professionals' "duty of care" to their patients.
The first two articles raise a vital question: how exactly can care providers and others determine the ideal balance between delivering care and managing personal safety? That is the nub of the contribution by Suzette Brémault-Phillips et al., which focuses on "responsive behaviours" (RBs) – including verbal and physical abuse – among people with neurological, mental health or developmental disorders. One promising approach to dealing with this "wicked problem," the authors contend, is to create and support collaborative "grassroots initiatives." Offering the case of Behavioural Supports Alberta (BSA) as their example, Brémault-Phillips address how this "community of research, interest and practice" provides a "neutral ground" for productive knowledge generation, idea exchange and networking, as well as, among other ends, ideas that can help to reshape policy and practice.
Child and Youth Health
Child and youth health is a recurring topic for Healthcare Quarterly. In this issue, Mary-Anny Hiltz and her co-investigators address the collaboration – by the Canadian Institutes of Health Research and the Canadian Association of Pediatric Health Centres – on a policy analysis focused on the "the unique features of a pediatric care setting … that should influence choice and implementation of a formal priority setting and resource allocation (PSRA) process." Based on pediatric healthcare's "distinct features" and "particular complexities," Hiltz et al. report on their creation of a policy-relevant, "made-for-child-health" PSRA lens centred around three themes: population diversity, outcomes measurement and patients/public engagement.
Many hospitals are struggling to implement standardized order sets. Via a literature review and focus groups, Susan Hall studied the "relationships" that lead to the successful adoption of these tools. Looking specifically at context, Hall discerned the importance of considering the stage of implementation and, within each stage, patient, user and order set characteristics. Attending to these elements, she argues, leads to particular "approach choices" (e.g., behavioural) tied to each phase and their associated considerations (e.g., the number and location of computers). Order set adoption is a "living process," Hall concludes, and effecting such change within a hospital – a "complex adaptive system" – requires "central administration and on-going monitoring."
Our next two articles involve a perennial theme in healthcare: the quest to reorganize human resources in order – among other things – to optimize patient care and staff wellbeing. Michael Sharpe and his co-authors examine how to improve access to care as it concerns "timely consultation" with an intensivist for critically ill patients. Reporting on the development and evaluation of a regional on-call system in Ontario's South West Local Health Integration Network (SW LHIN), Sharpe et al. outline the implementation of a call roster comprising intensivists who did not have primary on-call responsibilities in an intensive care unit (ICU). The project led to decreases in response time as well as the time for referring physicians to talk to an intensivist or sub-specialty physician. In addition, a resounding 90.9% of respondents to a satisfaction survey said the process provided "the best possible care." It is little surprise that the process is now a policy in all SW LHIN hospitals.
Residents often work long – sometimes brutal – hours, and developing guidelines to restrict their work hours is a major concern for policymakers and healthcare administrators. Z. Amy Fang and Darren Hudson recount the impact of a trial shift-based system for residents in an ICU that entailed each resident working a total of 14 12-hour shifts. A follow-up survey revealed that, while the change was well-intentioned, residents, attending physicians and some nurses deemed the arrangement a failure. This example, Fang and Hudson underscore, shows the need for careful planning and flexibility when it comes to setting work hour restrictions.
This issue of Healthcare Quarterly wraps up with another of Tina Saryeddine's absorbing book reviews. This time, she takes us inside Birgit Krols' Accidental Inventions: The Chance Discoveries that Changed Our Lives, a popular account of well-known products that arose by "accident" – from penicillin to Silly Putty, superglue to stethoscopes. Beyond relating some of their curious origins, Saryeddine gleans lessons about the role of "intention" in the transformation of inventions into innovations. She also sifts out implications for the healthcare sector in terms of critical "requisites" and enabling "conditions" such as environment, policy and funding – not surprisingly, considerations that also figure largely throughout all the other essays in this issue.
– The Editors
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