Working Alone - Working With Patients

When working alone, health care and social service workers face a risk of violence for many reasons:

• Isolated work with patients or clients during examinations and treatment.
• Nature of certain medical procedures can make a patient nervous, agitated, etc.
• Working alone in remote locations (including within the hospital or clinic), patients' homes, incident scene, etc.
• Availability of drugs and other medicines at hospitals, clinics and pharmacies, or in emergency response vehicles.
• Public access to most areas of a hospital or clinic.
• Hospitals and clinics that are open to the public 24 hours a day (including the higher risk times of late night or early morning).

It is very important to acknowledge that there is a potential for violence to workers before an incident occurs. Employers should conduct a full assessment of the working conditions, locations, and staff safety. Information is also available in other OSH Answers documents:

• Working Alone - General
• Working Alone - Off-Site
• Violence and Harassment in the Workplace

• Assessment of the patient should include items that relate to staff safety, such as social circumstances, history of substance abuse, psychiatric illnesses, or tendency for aggressive or violent behaviour. Keep in mind that patient confidentiality and worker safety issues must be balanced.
• Ensure there is enough staff to safely manage areas or patients that pose a higher risk of violence. 
• Consider assigning more experienced staff, or staff with a demonstrated ability to handle potentially violent situations, to areas or patients that pose a higher risk of violence.
• Implement procedures so patients are not repeatedly asked for the same information. For example, chart all information that needs to be passed to the attending staff. 
• Ensure all counselling and patient care rooms have two exits, where possible. Staff should be seated between the door and the patient with unimpeded access to exit.
• Identify the circumstances in which the use of physical restraint is appropriate and provide training.
• Establish procedures for assessing, recognizing, and monitoring high-risk patients.
• Establish lock-up procedures for prescription drugs.
• Provide appropriate training and education for all workers. Establish an emergency call system to announce specific situations (e.g., fire, staff needing immediate assistance) and prepare written policies and procedures for responding to these situations.
• Make available additional help or back-up support for workers who request it.
• Encourage workers to report all incidents or near-misses of workplace violence, including threats.
• Discourage workers from carrying keys, pens or other items that could be used as weapons where possible.

• Review the patient's profile before meeting. Take note of any potential concerns and use precautionary measures if necessary (e.g., have another person in the room).
• Approach patients in a non-threatening, respectful manner.
• Provide the right information at the right time. DO NOT overload patients or family members with too much medical information or technical jargon.
• Clearly and fully explain to the patient before and during the procedure; for example,
  • What is involved.
  • How long it will take.
  • Whether it will hurt.
• If you feel threatened, DO NOT conduct intimate examinations of patients alone. Arrange to have a colleague in the room or close by.
• If you can, leave the door open during any potentially violent consultation to allow for visual or verbal contact with other staff.
• Record instances of abuse immediately following the event so that details are not forgotten when reporting.
• Consider transferring aggressive patients to more secure or restrictive settings if possible.
• Investigate all reports. Take corrective actions and review prevention measures.
• Comply with applicable legislation for your jurisdiction.

If a patient becomes hostile during a procedure:

• Stop what you are doing, if possible.
• Ask the patient to tell you what is wrong.
• If you can, correct the situations. Otherwise, explain why you cannot.
• End the procedure in a safe way if you are still concerned about your safety. 
• Politely communicate that the procedure cannot continue if the patient continues their behaviour. 

If you are concerned about the actions of a family member:

• Let them know in clear and simple terms what is expected of them.
• If their behaviour continues or escalates, ask them to take a seat in the waiting room.
• Call security if you feel threatened.

Before you go on a home visit, make sure that you are:

• Trained in the prevention of violence and how to work alone safely.
• Trained in the use of the check-in procedure.
• Briefed about the areas where you will be working.
• Given all the relevant information about the client.

Do:

• Follow procedures for working alone off-site by having a check-in procedure and conducting an assessment of working conditions.
• Preview your cases ahead of time. Assessment of the patient should also include the location of the home (apartment building, private residence, retirement residence, etc.), condition and location of parking lot, other persons in the home, number and nature of pets, etc.
• Know the potential risks of the geographical area you are working in.
• Dress appropriately. Decide if a uniform will help to show who you are or if it will create additional risk.
• Decide if having identification signs on your vehicle will be a benefit or create additional risk for your geographical area.
• Use your judgement. Call your contact person before and after leaving a potentially risky situation.
• Use positive body language.
• Maintain a 'reactionary gap' - a distance that allows you time to react to any movements the other person makes.
• Be aware of your surroundings. Know the location of doors and other exits.
• Visit during the day, especially for the first visit.
• Have training appropriate to your tasks, location and prevention of violence.
• Carry an incident reporting form and fill it in as soon as possible if anything happens. Filling in the form immediately will help you remember more details.

Do Not:

• Do not wear expensive jewellery or carry large amounts of cash.
• Do not touch the other person without permission.
• Do not enter a situation where you feel you are at risk. Contact your office for assistance or more information.

(Adapted from CCOHS Violence in the Workplace Prevention Guide)