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A provincial study of nurses' psychological health and safety in British Columbia, Canada : Final Report Havaei, Farinaz; MacPhee, Maura; McLeod, Chris B.; Ma, Andy; Gear, Adriane; Sorensen, Christine 2020

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         A PROVINCIAL STUDY OF NURSES’ PSYCHOLOGICAL HEALTH AND SAFETY IN BRITISH COLUMBIA, CANADA FINAL REPORT                      2  ACKNOWLEDGEMENTS:  This research project was funded by the BC Nurses’ Union and the Social Science for Humanities Research Council of Canada. The research provides valuable insights into the workplace risk factors and psychological health and safety of BC nurses; as well as support the scholarship of BC nurse researchers, graduate and doctoral students. We would like to thank the nurses who participated in this survey study.           3  THE RESEARCH TEAM  PRINCIPAL INVESTIGATOR  Farinaz Havaei, RN, PhD Assistant Professor UBC School of Nursing 2211 Wesbrook Mall, RM T25 Vancouver, BC, Canada V6T 2B5 farinaz.havaei@ubc.ca  CO-INVESTIGATORS:   Maura MacPhee, RN, PhD Professor  UBC School of Nursing   Chris McLeod, PhD Associate Professor  UBC School of Population and Public Health   Andy Ma, MERM graduate student  UBC School of Educational Psychology   BCNU CONSULTANTS:   Adriane Gear, RN Christine Sorensen, RN           4 Table of Contents LIST OF TABLES .............................................................................................................................................. 6 LIST OF FIGURES ............................................................................................................................................ 7 EXECUTIVE SUMMARY .................................................................................................................................. 8 BACKGROUND ............................................................................................................................................... 9 METHOD ........................................................................................................................................................ 9 MEASUREMENT ........................................................................................................................................ 9 FINDINGS: THE ACUTE CARE SECTOR .......................................................................................................... 11 DEMOGRAPHIC PROFILE OF ACUTE CARE NURSE RESPONDENTS .......................................................... 11 OVERALL WORKPLACE FACTORS ............................................................................................................. 13 GUARDING MINDS AT WORK PSYCHOSOCIAL FACTORS .................................................................... 13 WORKPLACE VIOLENCE ....................................................................................................................... 16 NURSE FACTORS ...................................................................................................................................... 21 NURSE OUTCOMES ................................................................................................................................. 22 HEALTH AND WELLBEING ................................................................................................................... 22 QUALITY AND SAFETY ......................................................................................................................... 26 FINDINGS: THE COMMUNITY CARE SECTOR ............................................................................................... 27 DEMOGRAPHIC PROFILE OF COMMUNITY CARE NURSES ...................................................................... 27 OVERALL WORKPLACE FACTORS ............................................................................................................. 29 GUARDING MINDS AT WORK PSYCHOSOCIAL FACTORS .................................................................... 29 WORKPLACE VIOLENCE ....................................................................................................................... 32 NURSE FACTORS ...................................................................................................................................... 37 NURSE OUTCOMES ................................................................................................................................. 38 HEALTH AND WELLBEING ................................................................................................................... 38 QUALITY AND SAFETY ......................................................................................................................... 41 FINDINGS: THE LONG-TERM CARE SECTOR ................................................................................................ 43 DEMOGRAPHIC PROFILE OF LONG-TERM CARE NURSES........................................................................ 43 OVERALL WORKPLACE FACTORS ............................................................................................................. 45 GUARDING MINDS AT WORK PSYCHOSOCIAL FACTORS .................................................................... 45 WORKPLACE VIOLENCE ....................................................................................................................... 48 NURSE FACTORS ...................................................................................................................................... 54 NURSE OUTCOMES ................................................................................................................................. 55 HEALTH AND WELLBEING ................................................................................................................... 55 5 QUALITY AND SAFETY ......................................................................................................................... 58 REFERENCE: ................................................................................................................................................. 60  6 LIST OF TABLES Table 1. Study Variables .............................................................................................................................................. 10 ACUTE CARE SECTOR Table 2. Demographic characteristics of direct care providers in the acute care sector ............................................ 11 Table 3. Demographic characteristics relevant to respondents’ primary workplace .................................................. 12 Table 4. Descriptive statistics of GM@W subscale sum scores ................................................................................... 13 Table 5. Frequencies of GM@W subscale scores by categories of concern ................................................................ 15 Table 6. Frequencies for workplace violence frequency by type (Valid N = 3058) ...................................................... 16 Table 7. Descriptive statistics for workplace violence frequency by type ................................................................... 16 Table 8. Frequency table for experiences following workplace violence exposure in the last year ........................... 21 Table 9. Descriptive statistics for nurse outcome measures ....................................................................................... 22 Table 10. Proportions and frequencies for nurse outcome categories as defined by sum score cutoffs. .................. 23 Table 11. Item-level descriptive statistics for responses to questions drawn from VR-12. ........................................ 23 Table 12. Proportions for VR12 item responses. ......................................................................................................... 24 Table 13. Frequencies and proportions for nurses’ perceptions on overall quality and safety .................................. 26 COMMUNITY CARE  Table 14. Demographic characteristics of nurses in the community care sector ........................................................ 27 Table 15. Demographic characteristics relevant to respondents’ primary workplace ................................................ 28 Table 16. Descriptive statistics of GM@W subscale sum scores ................................................................................. 29 Table 17. Frequencies of GM@W subscale scores by categories of concern.............................................................. 31 Table 18. Frequencies for workplace violence frequency by type (Valid N = 813) ...................................................... 32 Table 19. Descriptive statistics for workplace violence frequency by type ................................................................. 32 Table 20. Frequency table for experiences following workplace violence exposure in the last year ......................... 37 Table 21. Descriptive statistics for nurse outcome measures ..................................................................................... 38 Table 22. Proportions and frequencies for nurse outcome categories as defined by sum score cutoffs ................... 38 Table 23. Item-level descriptive statistics for responses to questions drawn from VR-12 ......................................... 39 Table 24. Proportions for VR12 item responses .......................................................................................................... 40 Table 25. Frequencies and proportions for nurses’ perceptions on overall quality and safety .................................. 41 LONG TERM CARE  Table 26. Demographic characteristics of nurses in the long-term care sector .......................................................... 43 Table 27. Demographic characteristics relevant to respondents’ primary workplace ................................................ 44 Table 28. Descriptive statistics of GM@W subscale sum scores ................................................................................. 45 Table 29. Frequencies of GM@W subscale scores by categories of concern.............................................................. 47 Table 30. Frequencies for workplace violence frequency by type (Valid N = 412) ...................................................... 48 Table 31. Descriptive statistics for workplace violence frequency by type ................................................................. 49 Table 32. Frequency table for experiences following workplace violence exposure in the last year ......................... 54 Table 33. Descriptive statistics for nurse outcome measures ..................................................................................... 55 Table 34. Proportions and frequencies for nurse outcome categories as defined by sum score cutoffs ................... 55 Table 35. Item-level descriptive statistics for responses to questions drawn from VR-12 ......................................... 56 Table 36. Proportions for VR12 item responses .......................................................................................................... 57 Table 37. Frequencies and proportions for nurses’ perceptions on overall quality and safety .................................. 58     7 LIST OF FIGURES ACUTE CARE SECTOR Figure 1. Proportion of responses in categories of concern for each GM@W psychosocial factor ............................ 14 Figure 2. Proportion of responses reporting workplace discrimination, bullying/harassment, and/or unfair treatment. ................................................................................................................................................................... 15 Figure 3. Sources of workplace violence by type ......................................................................................................... 17 Figure 4. Proportions for typical reporting responses to workplace violence experience, by violence type .............. 18 Figure 5. Factors contributing to decisions not to formally report workplace violence through the Workplace Health Call Centre (N = 2745) .................................................................................................................................................. 19 Figure 6. Witnessed workplace violence over the last year (N = 3028) ....................................................................... 20 Figure 7. Perceptions of whether employers have taken appropriate measures to prevent workplace violence (N = 3030) ............................................................................................................................................................................ 20 Figure 8. Experiences as a result of exposure to workplace violence ......................................................................... 21 Figure 9. Proportions for responses to item “How do you feel about your life as a whole right now?” (N=2861) ..... 25 COMMUNITY CARE Figure 10. Proportion of responses in categories of concern for each GM@W psychosocial factor .......................... 30 Figure 11. Proportion of responses reporting workplace discrimination, bullying/harassment, and/or unfair treatment .................................................................................................................................................................... 31 Figure 12. Sources of workplace violence by type ....................................................................................................... 33 Figure 13. Proportions for typical reporting responses to workplace violence by type .............................................. 34 Figure 14. Factors contributing to decisions not to formally report workplace violence through the Workplace Health Call Centre (N = 604) ........................................................................................................................................ 35 Figure 15. Witnessed workplace violence over the last year (N = 802) ....................................................................... 36 Figure 16. Perceptions of whether employers have taken appropriate measures to prevent workplace violence (N = 802) .............................................................................................................................................................................. 36 Figure 17. Experiences as a result of exposure to workplace violence ....................................................................... 37 Figure 18. Proportions for responses to item “How do you feel about your life as a whole right now?” (N=766) ..... 41 LONG TERM CARE Figure 19. Proportion of responses in categories of concern for each GM@W psychosocial factor .......................... 46 Figure 20. Proportion of responses reporting workplace discrimination, bullying/harassment, and/or unfair treatment .................................................................................................................................................................... 48 Figure 21. Sources of workplace violence by type ....................................................................................................... 50 Figure 22. Proportions for typical reporting responses to workplace violence experience, by violence type ............ 51 Figure 23. Factors contributing to decisions not to formally report workplace violence through the Workplace Health Call Centre (N = 353) ........................................................................................................................................ 52 Figure 24. Witnessed workplace violence over the last year (N = 403) ....................................................................... 53 Figure 25. Perceptions of whether employers have taken appropriate measures to prevent workplace violence (N = 405) .............................................................................................................................................................................. 53 Figure 26. Experiences as a result of exposure to workplace violence ....................................................................... 54 Figure 27. Proportions for responses to item “How do you feel about your life as a whole right now?” (N=377) ..... 58    8 EXECUTIVE SUMMARY  Over 5,500 BC nurses responded to this survey about their psychological health and safety. The survey we used includes a series of valid and reliable measures of nurses’ perceptions of their work environments and exposure to workplace violence (workplace factors), workplace violence experiences (nurse factors), and psychological health and wellbeing and quality and safety of patient care delivery (nurse outcomes). The survey was administered among BC nurses across different roles (direct care, education and leadership) and sectors (acute care, community care, long-term care). However, for this report, we present findings from direct care nurses who reported actively working at the time of the study. The report is divided into three sections for each sector: acute, community and long-term care. We are most confident in our findings from the acute care sector, because of the large sample size and the similarities between our findings and those reported in the nursing research literature.  Because there is so much data, we need to conduct ongoing analyses with more sophisticated statistics. This report of our preliminary findings, however, provides us with many insights into what is happening out there in BC nurses’ work environments and their state of psychological health and safety.  Key findings:  • Nurses in all three sectors were significantly or seriously concerned about workload management and psychological protection in their work environments.  • Nurses is all three sectors reported concerning rates of exposure to emotional abuse (72%-86%), threat of assault (59%-83%), physical assault (29%-85%), verbal sexual harassment (40%-59%) and sexual assault (4%-17%) over the last year. patients/residents and their families/visitors were identified as the most common perpetrators of all types of workplace violence towards nurses.  • A significant majority of nurses in all three sectors (52%-77%) reported witnessing workplace towards their colleagues over the last year. • Nurses in all three sectors often either do not report workplace violence or only use informal channels of reporting. Common reasons for not reporting workplace violence include believing that nothing will change after reporting incident/s and lack of leadership support.  • Most common consequences of workplace violence across all three sectors include insomnia (67%-74%), showing up to work despite feeling ill (60%-63%), calling in sick (41%-45%), physical injury (23%-38%), using medication (35%-40%), and seeking professional care/treatment (35%-42%). • Across all three sectors, over 50% of the respondents reported high emotional exhaustion; 42-50% were above the cut-off point for posttraumatic stress disorder (PTSD); 30%-32% reported moderate to severe depression; and 26%-29% reported moderate to severe anxiety.  • About 8% to 14% of participants reported the quality of nursing care delivered as poor or fair; and 11%-17% gave their primary workplace a failing or a poor patient safety grade.  • Over 30% of the nurses would not recommend their workplace to a nurse colleague as a good place to work.   9 BACKGROUND  Every week, in Canada a minimum of 500,000 employees are unable to work due to poor mental health (Mental Health Commission of Canada [MHCC], 2017). As a result, the lost productivity due to absenteeism and job turnover cost employers more than $6 billion (MHCC, 2017). Workplace risk factors, such as heavy workload and workplace violence play a major role in compromising employees’ mental health and their ability to work effectively (Employment and Social Development of Canada, 2016). Nurses and other frontline healthcare providers are prone to these risk factors in their workplace, and as such suffer from extreme challenges in their health and wellbeing and their ability to provide quality and safe patient care (Berriosa et al., 2015; Brandfor & Reed, 2016). A large proportion of nurses suffer from mental health problems related to workplace exposures such as depression and Post-Traumatic Stress Disorder (PTSD), and these conditions affect their ability to provide effective patient care (Canadian Federation of Nurses Union, 2017; Canadian Institute of Health Information and Statistics Canada, 2006; Murphy et al., 2012). Given that Canada will be experiencing a shortage of about 60,000 fulltime nurses by 2022 (Murphy et al., 2012), it is critical that we foster working environments that retain trained nursing professionals and encourage new professionals to pursue this career. The purpose of this report is to provide preliminary evidence to establish the baseline on workplace risk factors and their associated health and performance indicators among the nursing workforce in British Columbia (BC), Canada.  METHOD  An exploratory province-wide survey study was conducted by the University of BC research team in partnership with the BC Nurses’ Union (BCNU). The survey was advertised through multiple platforms including BCNU e-News mailout, social media and word of mouth. BCNU invited nurse members (47,000) to complete a 25-minute Qualtrics survey. To increase response rate, the survey was open for two months; weekly e-mail reminders were sent through BCNU e-news; and a raffle draw for two Apple Watches was offered. Overall, a total of 5,512 nurses, yielding 12% response rate, participated in the study. This report includes responses from direct care nurses who were actively working at the time of the study. The results are aggregated by healthcare sector: acute care, community care and long-term care. For this report, descriptive statistics were used to analyze the data using the Statistical Package for Social Sciences (SPSS). Work is underway to conduct more sophisticated statistical analyses to gain a better understanding of the association between workplace risk factors and health and wellbeing and performance indicators. This study has been peer-reviewed and funded by the Social Sciences and Humanities Research Council (ORS #F19-04340) and ethics approval has been obtained from the University Behavioural Research Ethics Board (#H18-02724). MEASUREMENT  Table 1 shows study variables. Our survey questions were classified into demographics, work-related risk factors, nurse factors and nurse outcomes.     10 Table 1. Study Variables Demographics  Workplace factors  Nurse factors  Nurse outcomes  -Individual characteristics:  --Age  --Gender --Designation --Employment status --Role  --Education  --Education location  --Nursing experience --Minority group   Workplace characteristics:  --Health authority --Sector  --Nursing specialty -- Workplace geography -Facility    -Work environment conditions (13 factors from GM@W) (Centre for Applied Research in Mental Health and Addiction, 2018)  -Workplace violence: --Types and sources (Hesketh et al., 2003) --Reporting  --Reason for not reporting  --Witnessing   -Workplace violence experiences: --absenteeism  --Presenteeism  --Medication intake  --sleeping difficulty  --physical injury  --Professional treatment   -Health and wellbeing:  --PTSD (Twigg et al., 2008) --Anxiety (Spitzer et al., 2006) --Depression (Kroenke et al., 2001) --Burnout (Maslach et al., 1996) --Quality of life    -Quality of care: --Good place to work --Good place for care --Safety grade --Quality and safe patient care (Sermeus et al., 2011)          BCNU Report  Acute Care, Direct Care Provider  11 FINDINGS: THE ACUTE CARE SECTOR DEMOGRAPHIC PROFILE OF ACUTE CARE NURSE RESPONDENTS This section focuses on survey findings related to direct care providers in the acute care sector (N=3301). Within this group, the mean respondent age was 38.6 years (SD = 11.3), and 90.8% of respondents were female. Approximately 82% were RNs, 52% reported having an undergraduate degree, and 63% reported working full-time. Approximately 64% of this sample reported greater than five years of overall nursing experience. Table 2 provides a profile of direct care nurses by age, gender, professional designation, education, nursing experience, and identification with BCNU equity-seeking caucuses. Table 3 provides a number of demographic characteristics relevant to the respondents’ primary workplace. Table 2. Demographic characteristics of direct care providers in the acute care sector Characteristics N % Age   Under 25 185 5.7 25 to 34 1304 39.7 35 to 44 797 24.3 45 to 54 603 18.4 55 and above 392 12.0 Gender   Female 2995 90.8 Male 296 9.0 Prefer to describe 8 0.2 Professional Designation   LPN 436 13.2 RN 2700 81.8 RPN 137 4.1 Dually registered (RN/RPN) 9 0.3 Student nurse 13 0.4 Other 5 0.2 Education   Diploma/Certificate 885 26.9 Undergraduate degree 1701 51.6 Graduate degree 667 20.2 Other 46 1.4 Any nursing education outside Canada   No 2832 86.2 Yes 452 13.8 Overall nursing experience   5 years or less 1180 35.8 6 to 10 years 724 22.0 11 to 15 years 541 16.4 16 to 20 years 230 7.0 BCNU Report  Acute Care, Direct Care Provider  12 21 years or more 618 18.8 Identification with BCNU equity-seeking caucuses (respondents may identify with multiple caucuses simultaneously)   Indigenous Leadership Circle 135 4.3 LGBTQ 145 4.7 Mosaic of Colour 364 11.6 Workers with Disabilities 126 4.1  Table 3. Demographic characteristics relevant to respondents’ primary workplace Primary workplace N % Health authority   Fraser Health 830 25.1 Vancouver Island Health 607 18.4 Interior Health 565 17.1 Vancouver Coastal Health 447 13.6 Provincial Health Services 362 11.0 Northern Health 340 10.3 Providence Health 140 4.2 First Nations Health 4 0.1 Workplace geography   Urban 2154 65.6 Suburban 559 17.0 Rural 573 17.4 Nursing practice area   Ambulatory care 87 2.6 Community mental health 4 0.1 Emergency 466 14.1 Home and community care 7 0.2 Indigenous health 1 0.0 Intensive care 367 11.1 Medical/surgical 1173 35.5 Mental health or psychiatry 282 8.5 Obstetrics 307 9.3 Oncology 34 1.0 OR/PACU 205 6.2 Palliative 42 1.3 Pediatrics 83 2.5 Public health 1 0.0 Rehabilitation 56 1.7 Other, please specify 109 3.3 Mixed (A combination of other areas) 74 2.2 Employment status   Full-time 2084 63.2 Part-time 827 25.1 Casual 389 11.8 BCNU Report  Acute Care, Direct Care Provider  13 OVERALL WORKPLACE FACTORS GUARDING MINDS AT WORK PSYCHOSOCIAL FACTORS As part of this survey, the Guarding Minds at Work (GM@W) assessment tool was used to explore nurses’ psychological health and safety in the workplace. The GM@W consists of 13 subscales, each of which assesses a specific psychosocial factor. Each subscale contains five statements, to which respondents indicate their level of agreement along a four-point Likert scale (strongly disagree, somewhat disagree, somewhat agree, strongly agree). The sum of responses to a subscale creates a score for the corresponding factor, with lower scores indicating higher risk to nurses’ psychological health and safety. Table 4 provides a list of all 13 psychosocial factors and summarizes the subscale score for each. More than 90% of respondents agreed with the following individual GM@W items: - I am proud of the work I do. (95.7%) - My work is an important part of who I am. (94%) - I have the social and emotional skills needed to do my job well. (93.8%) - In my job, I know what I am expected to do. (93.1%) - I am willing to give extra effort at work if needed. (92.5%) Less than one-third (33.3%) of respondents agreed with the following items: - My work is free from unnecessary interruptions and disruptions. (22.2%) - I have energy left at the end of most workdays for my personal life. (23%) - My employer is committed to minimizing unnecessary stress at work. (23.6%) - Employees and management trust one another. (30.6%) - My company appreciates extra effort made by employees. (31.1%)  Table 4. Descriptive statistics of GM@W subscale sum scores Subscale/Psychosocial factor N Mean SD Min Max Psychological support 3058 12.42 3.38 5 20 Organizational culture 3074 12.61 3.19 5 20 Clear leadership and expectations 3072 12.92 3.19 5 20 Civility and respect 3066 13.00 3.14 5 20 Psychological competencies and requirements 3051 14.18 2.72 5 20 Growth and development 3061 13.07 3.32 5 20 Recognition and reward 3060 11.94 3.39 5 20 Involvement and influence 3062 13.54 3.10 5 20 Workload management 3054 11.68 3.34 5 20 Engagement 3061 16.86 2.52 5 20 Balance 3062 11.77 3.34 5 20 Psychological protection 3054 11.29 3.62 5 20 Protection of physical safety 3043 12.69 3.70 5 20  BCNU Report  Acute Care, Direct Care Provider  14 To facilitate comparison, the range of possible scores for a GM@W psychosocial factor can be categorized into four levels of concern: Serious Concern (5-9), Significant Concern (10-13), Minimum Concern (14-16), and Relative Strength (17-20). Figure 1 and Table 5 display the proportion of responses that fall into each category of concern.  The psychosocial factors with the highest proportion of responses falling into the Significant or Serious Concern categories were psychological protection (71.1%), workload management (69.5%), and balance (69.3%). On the other hand, the factors with the highest proportion of responses falling into the Minimum Concern or Relative Strength were engagement (91.2%), psychological competencies and requirements (62.8%), and involvement and influence (55.6%).  Figure 1. Proportion of responses in categories of concern for each GM@W psychosocial factor     BCNU Report  Acute Care, Direct Care Provider  15 Table 5. Frequencies of GM@W subscale scores by categories of concern Subscale Serious Concern Significant Concern Minimum Concern Relative Strength % N % N % N % N Psychological support 21.1 646 38.2 1169 29.8 912 10.8 331 Organizational culture 16.7 512 43.3 1330 29.2 899 10.8 333 Clear leadership and expectations 16.1 494 38.4 1181 33.2 1019 12.3 378 Civility and respect 13.5 413 41.2 1264 32.9 1008 12.4 381 Psychological competencies and  Requirements 5.2 158 32.0 975 43.7 1334 19.1 584 Growth and development 14.4 442 38.0 1162 33.5 1024 14.1 433 Recognition and reward 24.5 751 42.3 1295 24.3 745 8.8 269 Involvement and influence 10.5 323 33.9 1038 40.8 1249 14.8 452 Workload management 27.1 827 42.4 1296 22.9 698 7.6 233 Engagement 1.1 34 7.7 235 33.2 1016 58.0 1776 Balance 26.3 804 43.0 1317 22.5 690 8.2 251 Psychological protection 32.2 984 38.9 1187 21.5 657 7.4 226 Protection of physical safety 20.3 618 33.6 1022 32.9 1002 13.2 401  In addition to the 65 statements representing the 13 psychosocial factors, the GM@W also includes three items on workplace discrimination, bullying/harassment, and unfair treatment. Figure 2 presents the affirmative response rate to each. Figure 2. Proportion of responses reporting workplace discrimination, bullying/harassment, and/or unfair treatment.   BCNU Report  Acute Care, Direct Care Provider  16 WORKPLACE VIOLENCE FREQUENCY OF WORKPLACE VIOLENCE BY TYPE The first set of questions examining workplace violence asked about the frequencies of different types of workplace violence, querying respondents “Over the last year, how frequently have you experienced each of the following types of violence in your primary workplace?” The five types presented were physical assault, threat of assault, emotional abuse, verbal sexual harassment, and sexual assault. For each type, respondents selected from seven options of increasing frequency, ranging from “Never” to “Every day.” The type of workplace violence with the highest proportion of experience was emotional abuse, with approximately 86% of respondents reporting some frequency of experience within the last year. The type with the lowest proportion of experience was sexual assault, with approximately 13% of respondents reporting experiencing sexual assault in their primary workplace within the last year. Table 6 presents proportions for experiential frequencies by type of workplace violence. Table 7 summarizes the mean response by type.  Table 6. Frequencies for workplace violence frequency by type (Valid N = 3058) Type of workplace violence Frequency Never A few times a year or less Once a month A few times a month Once a week A few times a week Every day Physical assault N 793 1287 329 383 99 133 34 % 25.9 42.1 10.8 12.5 3.2 4.3 1.1 Threat of assault N 523 1093 364 496 160 289 133 % 17.1 35.7 11.9 16.2 5.2 9.5 4.4 Emotional abuse N 435 1123 404 466 191 279 160 % 14.2 36.7 13.2 15.2 6.2 9.1 5.2 Verbal sexual harassment N 1247 1150 225 244 77 81 34 % 40.8 37.6 7.4 8.0 2.5 2.6 1.1 Sexual assault N 2662 332 35 17 4 6 2 % 87.1 10.9 1.1 0.6 0.1 0.2 0.1  Table 7. Descriptive statistics for workplace violence frequency by type Type of workplace violence N Mean^ SD^ Min^ Max^ Physical assault 3058 1.43 1.40 0 6 Threat of assault 3058 2.02 1.72 0 6 Emotional abuse 3058 2.11 1.73 0 6 Verbal sexual harassment 3058 1.06 1.31 0 6 Sexual assault 3058 0.17 0.52 0 6 ^ Note: Workplace violence frequency is coded numerically as follows: 0: Never, 1: A few times a year or less […] 5: A few times a week, 6: Every day  BCNU Report  Acute Care, Direct Care Provider  17 SOURCES OF WORKPLACE VIOLENCE Respondents who reported experiencing workplace violence were then asked a second set of questions about the sources of the workplace violence. For each reported type of violence (a response other than “Never”), the respondent was queried “Please indicate the source of workplace violence (check all that apply)” and presented seven options: patients, family/visitors, physicians, nursing co-workers, allied health, management, and other. Figure 3 displays the proportion of affirmative responses for each source, for each workplace violence type. Figure 3. Sources of workplace violence by type   BCNU Report  Acute Care, Direct Care Provider  18 RESPONDING TO EACH TYPE OF WORKPLACE VIOLENCE Respondents who reported experiencing workplace violence were also asked about their typical response to each type of violence. This set of questions asked respondents “Which option best describes how you typically respond to workplace violence?” for each reported type. The three options available were “I do not report the incident(s)”, “I informally report the incident(s) (e.g., management, PSLS system)”, and “I formally report the incident(s) (i.e., Workplace Health Call Centre).” Frequencies for the three options were calculated, as shown in Figure 4 for each type of workplace violence. Emotional abuse was the type of workplace violence most often not reported, with about 64% of respondents stating that they typically did not report experiences of emotional abuse. Of the five types of workplace violence, emotional abuse also had the lowest proportions for informal reporting (31%) and formal reporting (5%). Conversely, physical assault had the lowest proportion of “do not report” responses (19%), and the highest proportion for “informally report” (58%) as well as for “formally report” responses (23%). Figure 4. Proportions for typical reporting responses to workplace violence experience, by violence type   BCNU Report  Acute Care, Direct Care Provider  19 FACTORS CONTRIBUTING TO DECISION TO NOT FORMALLY REPORT WORKPLACE VIOLENCE The next set of questions delved further into the nurses’ reporting responses after experiencing workplace violence, specifically the proportion of respondents answering that they did not typically formally report one or more type of workplace violence. Nurses that noted experiencing some type of workplace violence and noted that their typical response (for any type) was to not report or informally report were further queried, “What factors contributed to your decision to NOT formally report workplace violence through the Workplace Health Call Centre (check all that apply)?” The nine available factors to select from were ‘violence is part of my job’, ‘fear of retaliation’, ‘fear of being seen as weak or incompetent’, ‘lack of leadership support’, ‘nothing will change after reporting incident(s)’, ‘feelings of sympathy with the perpetrator’, ‘I didn’t know this was the formal process’, ‘this was not the formal process at my workplace,’ and ‘other’. Respondents selecting the ‘other’ factor were presented a follow-up question to specify in text. The proportion of selection for each factor are shown in descending order in Figure 5. The most commonly selected factor was “Nothing will change after reporting incident(s)”, as selected by 70% of the 2745 applicable respondents. The least commonly selected factor was “This is not the formal process at my workplace” (4.8%). Figure 5. Factors contributing to decisions not to formally report workplace violence through the Workplace Health Call Centre (N = 2745)   BCNU Report  Acute Care, Direct Care Provider  20 The previous questions on workplace violence have focused on nurses’ direct experiences with workplace violence, examining the types, sources, and typical responses to experiences of workplace violence. To examine nurses’ indirect experiences with workplace violence, respondents were asked “Over the last year, have you ever witnessed any type of workplace violence without being directly involved?” As shown in Figure 6, more than three-quarters of respondents reported witnessing workplace violence over the last year.  Finally, respondents were asked for their opinion on their employers’ response to workplace violence in their primary workplace. The final question in the workplace violence section of the survey queried, “To what extent do you think your employer has taken appropriate measures to prevent violence in your primary workplace?” The five available choices ranged from “Not at all” to “A great deal.” The proportions of responses are displayed in Figure 7. With the five responses coded from “Not at all” to “A great deal” as 0 to 4, the mean response score was 1.66 (SD = .99).     Figure 6. Witnessed workplace violence over the last year (N = 3028)  Figure 7. Perceptions of whether employers have taken appropriate measures to prevent workplace violence (N = 3030)  BCNU Report  Acute Care, Direct Care Provider  21 NURSE FACTORS EXPERIENCES AS A RESULT OF WORKPLACE VIOLENCE EXPOSURE This survey included a number of question sets to assess respondents’ perceptions of their physical and psychological health. The first series of questions followed up on nurses’ exposure to workplace violence, asking respondents to select all applicable experiences in response to, “Have you had any of the following experiences as a result of exposure to workplace violence in your primary workplace over the last year?” The six experiences listed were absenteeism (“Called in sick”), presenteeism (“Showed up to work despite feeling unwell”), medication (“used prescribed and/or over the counter medication, e.g., pain relievers, anti-anxiety medication”), insomnia (“difficulty falling asleep”), and professional care/treatment (“sought professional care/treatment, e.g. medical care, psychological care”). The results are presented in Table 8 and arranged in descending order in Figure 8.  For all six adverse experiences, at least one-third of respondents reported occurrences. The most common experience was insomnia/sleep difficulty (73.7%), followed by presenteeism/showing up to work despite feeling unwell (63.1%). Figure 8. Experiences as a result of exposure to workplace violence   Table 8. Frequency table for experiences following workplace violence exposure in the last year Experience Total N Yes No % N % N Absenteeism 2787 44.4 1237 55.6 1550 Presenteeism 2780 63.1 1753 36.9 1027 Medication 2741 35.9 984 64.1 1757 Insomnia 2802 73.7 2066 26.3 736 Physical Injury 2758 37.1 1024 62.9 1734 Professional Care/Treatment 2760 35.3 974 64.7 1786 BCNU Report  Acute Care, Direct Care Provider  22 NURSE OUTCOMES HEALTH AND WELLBEING  Several established tools were included in the survey to assess respondents’ psychological ill-being, with screening tools for post-traumatic stress disorder (PTSD), generalized anxiety disorder, major depressive disorder, and emotional exhaustion/burnout. Summary information for the data is displayed in Table 9. Category proportions, as defined by cutoff values, are shown in Table 20. Table 9. Descriptive statistics for nurse outcome measures Measure N Mean SD Min Max Posttraumatic Stress Symptoms-14 (PTSS-14) 3016 45.16 17.98 14 98 Generalized Anxiety Disorder-7 (GAD-7) 2997 7.02 5.40 0 21 Patient Health Questionnaire-9 (Depression; PHQ-9) 2996 7.50 5.90 0 27 Maslach Burnout Inventory - Human Services Survey for Medical Personnel:       Emotional Exhaustion (MBI-HSS (MP)) 2903 28.81 12.70 0 54 Depersonalization (MBI-HSS (MP)) 2904 9.85 6.90 0 30 Personal Accomplishment (MBI-HSS (MP)) 2876 33.93 7.83 0 48  PTSD: Post-traumatic stress disorder was assessed using the Posttraumatic Stress Symptoms-14 (PTSS-14) instrument, a measure consisting of 14 items reflecting feelings, such as “The need to withdraw from others”, “Frequent mood swings” and “muscular tension”. Respondents rated how frequently they experienced each feeling along a 7-point Likert scale, ranging from 1 = Never, to 7 = Always. Total scores of 45 or higher were categorized as positive for PTSD. Approximately half of respondents scored within this ‘positive’ range. Anxiety: Generalized anxiety disorder was assessed using the Generalized Anxiety Disorder-7 (GAD7) instrument, which consists of seven items such as “Feeling nervous, anxious or on edge” and “Trouble relaxing”. Responses on frequency within the last two weeks were given along a 4-point Likert scale, ranging from 0 = Not at all, to 3 = Nearly every day. Sum scores were categorized as: 0-4 = no anxiety, 5-9 = mild, 10-14 = moderate, 15-21 = severe. Approximately 63% of respondents scored within some level of anxiety, with 11% within the severe anxiety range. Depression: The Patient Health Questionnaire-9 (PHQ-9) consists of nine items reflecting perceptions such as poor appetite, anhedonia, and depressive mood. Respondents rated how often they were bothered by each perception within the last two weeks, along a 4-point Likert scale, ranging from 0 = Not at all, to 3 Nearly every day. Sum scores were categorized as 0-4 = no depression, 5-9 = mild, 10-14 = moderate, 15-19 = moderately severe, and 20-27 = severe depression. Approximately 63% of respondents were categorized at some level of depression. Burnout: To assess nurse burnout, this survey used the Maslow Burnout Inventory - Human Services Survey, which includes three subscales of Emotional Exhaustion, Depersonalization, and Personal Accomplishment. Items in the scale include statements such as: for Emotional Exhaustion (9 items), “I feel emotionally drained from my work” and “I feel like I'm at the end of my rope”; for BCNU Report  Acute Care, Direct Care Provider  23 Depersonalization (5 items), “I worry that this job is hardening me emotionally”; for Personal Accomplishment (8 statements), “I feel very energetic”. Respondents rated the frequency of each feeling along a 7-point Likert scale of increasing frequency, ranging from 0 = Never, 1 = A few times a year or less; to 5 = A few times a week, 6 = Every day. Subscale sum scores were categorized by cutoff scores: for emotional exhaustion, 0-18 = low, 19-26 = moderate, ≥ 27 = high; for depersonalization 0-6 = low, 7-12 = moderate, ≥ 13 = high; for personal accomplishment, 0-31 = low, 32-38 = moderate, ≥ 39 = high. Approximately 57% of respondents indicated high emotional exhaustion, 34% indicated high depersonalization, and 34% indicated low personal accomplishment. Table 10. Proportions and frequencies for nurse outcome categories as defined by sum score cutoffs. Measure Category (by cutoffs) N PTSS-14 Below cutoff Above cutoff     50.5% (1524) 49.5% (1492)    3016 GAD-7 No anxiety Mild anxiety Moderate anxiety Severe anxiety   36.8% (1103) 35.2% (1054) 16.7% (500) 11.3% (340)  2997 PHQ-9 No depression Mild depression Moderate depression Moderately severe depression Severe depression  37.2% (1116) 31.6% (946) 17.1% (513) 9.5% (286) 4.5% (135) 2996 Emotional Exhaustion (MBI-HSS) Low EE Moderate EE High EE   2903 23.6% (684) 19.4% (562) 57.1% (1657)   Depersonalization (MBI-HSS) Low DP Moderate DP High DP   2904 37.5% (1089) 28.4% (824) 34.1% (991)   Personal Accomplishment (MBI-HSS) Low PA Moderate PA High PA   2876 33.9% (976) 34.9% (1003) 31.2% (897)    To assess respondents’ overall perspective of their health, questions from the Veterans RAND 12 Item Health Survey (VR-12) were used. Thirteen items that correspond to various domains of health, including perceptions of overall general health, interference or limitations due to pain, physical health or emotional problems were used. Table 21 presents an item-level summary of respondents’ data. Item-level proportions for responses to items 1 through 13 are displayed in Table 22. Figure 9 displays proportions for responses to a life satisfaction item, “Using a scale of 0 to 10, where 0 means "very dissatisfied" and 10 means "very satisfied", how do you feel about your life as a whole right now?” Table 11. Item-level descriptive statistics for responses to questions drawn from VR-12. Item question N Mean SD Min Max BCNU Report  Acute Care, Direct Care Provider  24 In general, would you say your health is... 2879 3.12 0.91 1 5 The following questions are about your activities you might do during a typical day. Does your health now limit you in these activities? If so, how much? Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling or playing golf. 2890 1.24 0.49 1 3 Climbing several flights of stairs. 2883 1.29 0.53 1 3 During the past 4 weeks, have you had any of the following problems with your work or other regular daily activities as a result of your physical health? Accomplished less than you would like. 2893 2.23 1.12 1 5 Were limited in the kind of work or other activities 2886 1.93 1.04 1 5 Accomplished less than you would like. 2885 2.37 1.09 1 5 Didn't do work or other activities as carefully as usual. 2875 2.03 0.98 1 5 Thinking about the past 4 weeks, answer the following questions: How much did pain interfere with your normal work (including both work outside the home and housework)? 2890 2.22 1.08 1 5 How much of the time have you felt calm and peaceful? 2888 2.88 0.91 1 5 How much of the time did you have a lot of energy? 2887 2.64 0.90 1 5 How much of the time have you felt downhearted and blue? 2881 2.39 0.96 1 5 How much of the time has your physical health or emotional problems interfered with your social activities (like visiting with friends, relatives, etc.)? 2886 2.53 1.05 1 5 Compared to one year ago… How would you rate your physical health in general now? 2890 2.77 0.88 1 5 How would you rate your emotional problems (such as feeling anxious, depressed or irritable) now? 2886 2.66 0.98 1 5  Table 12. Proportions for VR12 item responses. Item Response N Poor Fair Good Very good Excellent Rating of general health 2.8% 21.0% 43.4% 26.5% 6.3% 2879 Did health limit your ability to do typical daily activities… Not limited at all Limited a little Limited a lot  Moderate activities. 79.1% 18.0% 3.0% 2890 Climbing several flights of stairs. 75.2% 20.9% 3.9% 2883 Problems due to physical health (Last 4 weeks) None of the time A little of the time Some of the time Most of the time All of the time N Accomplished less than you would like. 33.3% 28.2% 24.4% 11.0% 3.1% 2893 Were limited in the kind of work or other activities. 45.6% 26.1% 20.0% 6.6% 1.7% 2886 BCNU Report  Acute Care, Direct Care Provider  25 Accomplished less than you would like. 25.1% 32.2% 26.8% 12.2% 3.6% 2885 Didn't do work or other activities as carefully as usual. 35.9% 34.3% 22.1% 6.3% 1.5% 2875 In the last 4 weeks… None of the time A little of the time Some of the time Most of the time All of the time N Pain interfered with normal work 31.7% 30.4% 24.8% 10.6% 2.5% 2890 Felt calm and peaceful 5.2% 30.7% 37.1% 25.3% 1.8% 2888 Had a lot of energy 10.0% 34.0% 39.0% 16.0% 1.0% 2887 Felt downhearted and blue? 17.7% 40.0% 29.8% 10.7% 1.9% 2881 Physical health or emotional problems interfered with social life 17.9% 32.2% 31.7% 15.0% 3.2% 2886 Compared to one year ago, rating of… Much worse Slightly worse About the same Slightly better Much better N General physical health 5.1% 33.3% 45.3% 12.0% 4.3% 2890 Emotional problems 10.6% 34.2% 38.0% 12.6% 4.6% 2886  Figure 9. Proportions for responses to item “How do you feel about your life as a whole right now?” (N=2861)   BCNU Report  Acute Care, Direct Care Provider  26 QUALITY AND SAFETY Nurses were polled for their perceptions on quality of care and safety in their primary workplace, with questions asking about the quality of the nursing care they delivered, the overall patient safety, and the likelihood of recommending their primary workplace for care and as a workplace. The responses are tabulated by category in Table 23.  Respondents were confident in the quality of nursing care they delivered, with 88.1% describing the general quality of nursing care they delivered as good or excellent, and 86% describing the quality of care they delivered on their last shift as good or excellent. Approximately 22% of nurses gave a negative overall grade for patient safety in their primary workplace, while 8% assigned a grade of Excellent.  For recommendations, 76.5% of respondents were likely to recommend their primary workplace to friends and family if they needed care. 63.5% were likely to recommend their primary workplace to a nurse colleague as a good place to work. Table 13. Frequencies and proportions for nurses’ perceptions on overall quality and safety Quality of care questions Poor Fair Good Excellent N In general, how would you describe the quality of nursing care you delivered to patients in your primary workplace? 1.4% (39)  10.5% (302)  54.2% (1566)  33.9% (980) 2887 How would you describe the quality of nursing care you delivered to patients in your primary workplace on your last shift? 2.2% (63)  12.0% (346)  48.7% (1404)  37.2% (1072)  2885  Patient safety grade question Failing Poor Acceptable Very good Excellent N Please give your primary workplace an overall grade on patient safety. 6.1% (176)  16.1% (464)  38.5% (1111)  31.8% (916)  7.6% (218)  2885  Recommendation questions Definitely no Probably no Probably yes Definitely yes N Would you recommend your primary workplace to your friends and family if they needed care? 6.5% (186)  16.9% (486)  46.5% (1339)  30.2% (870)  2881 Would you recommend your primary workplace to a nurse colleague as a good place to work? 9.6% (276)  26.9% (776)  44.5% (1286)  19.0% (549)  2887  BCNU Report Community Care 27 FINDINGS: THE COMMUNITY CARE SECTOR DEMOGRAPHIC PROFILE OF COMMUNITY CARE NURSES This section focuses on survey findings related to nurses working in community care settings (N=870). The mean respondent age was 44.8 years (SD = 11.2), with the predominant age categories being 35 to 44 (28%) and 45 to 54 (28%). Nurses under 25 years old accounted for less than 2% of respondents. Generally, respondents were mostly female (92%), RNs (74%), and direct care providers (82%). Roughly half (49%) had an undergraduate degree as their highest level of education. Approximately 64% had greater than ten years of overall nursing experience. Table 24 provides a profile of the community care nurses by age, gender, professional designation, education, nursing experience, and identification with BCNU equity-seeking caucuses. Table 25 displays demographic data relevant to the respondents’ primary workplace. Table 14. Demographic characteristics of nurses in the community care sector Characteristics N % Age   Under 25 15 1.7 25 to 34 167 19.0 35 to 44 246 28.0 45 to 54 245 27.9 55 and above 206 23.4 Gender   Female 815 92.3 Male 64 7.2 Prefer to describe 4 0.5 Professional Designation   LPN 92 10.4 RN 655 74.1 RPN 122 13.8 Dually registered (RN/RPN) 7 0.8 Other 8 0.9 Education   Diploma/Certificate 256 29.4 Undergraduate degree 427 49 Graduate degree 181 20.8 Other 7 0.8 Any nursing education outside Canada   No 779 90.1 Yes 86 9.9 Overall nursing experience   5 years or less 156 18.0 6 to 10 years 159 18.3 11 to 15 years 152 17.5 16 to 20 years 96 11.0 BCNU Report Community Care 28 21 years or more 306 35.2 Identification with BCNU equity-seeking caucuses (respondents may identify with multiple caucuses simultaneously)   Indigenous Leadership Circle 40 5.0 LGBTQ 49 6.1 Mosaic of Colour 85 10.6 Workers with Disabilities 64 7.2  Table 15. Demographic characteristics relevant to respondents’ primary workplace Primary workplace N % Primary nursing role   Direct care provider 711 81.7 Nurse leader 88 10.1 Educator 43 4.9 Provides direct patient/client care   Yes 763 87.6 No 108 12.4 Health authority   Vancouver Island Health 175 19.8 Fraser Health 173 19.6 Interior Health 170 19.3 Vancouver Coastal Health 144 16.3 Northern Health 103 11.7 Provincial Health Services 83 9.4 First Nations Health 6 0.7 Providence Health 6 0.7 Workplace geography   Urban 490 55.6 Suburban 188 21.3 Rural 203 23.0 Nursing practice area   Ambulatory care 19 2.2 Community mental health 190 21.6 Home and community care 337 38.4 Indigenous health 4 0.5 Long-term care 2 0.2 Medical/surgical 1 0.1 Mental health or psychiatry 61 6.9 Obstetrics 2 0.2 Oncology 8 0.9 OR/PACU 2 0.2 Palliative 31 3.5 Pediatrics 3 0.3 Public health 146 16.6 Rehabilitation 4 0.5 BCNU Report Community Care 29 Other, please specify 60 6.8 Mixed (A combination of other areas) 8 0.9 Employment status   Full-time 503 57.7 Part-time 284 32.6 Casual 84 9.6  OVERALL WORKPLACE FACTORS GUARDING MINDS AT WORK PSYCHOSOCIAL FACTORS Based on average subscale scores (see Table 26), community nurses reported ‘psychological protection’, ‘clear leadership and expectations’, and ‘workload management’ as the lowest-scoring GM@W subscales. The three highest scoring subscales were ‘engagement’, ‘psychological competencies and requirements’, and ‘involvement and influence’.  At the individual item level, the following statements had the highest rates of endorsement, with more than 90% of respondents agreeing: - I am proud of the work I do. (96.4%) - I have the social and emotional skills needed to do my job well. (95.2%) - I am willing to give extra effort at work if needed. (92.8%) - My work is an important part of who I am. (92.5%) The statements with the lowest proportion of agreement (approximately one-third or less) were: - My work is free from unnecessary interruptions and disruptions. (30.2%) - My employer is committed to minimizing unnecessary stress at work. (33.4%) Table 16. Descriptive statistics of GM@W subscale sum scores Subscale/Psychosocial factor N Mean SD Min Max Psychological support 817 13.13 3.63 5 20 Organizational culture 816 12.62 3.55 5 20 Clear leadership and expectations 824 12.57 3.64 5 20 Civility and respect 822 13.34 3.59 5 20 Psychological competencies and requirements 816 14.16 2.86 5 20 Growth and development 817 13.06 3.68 5 20 Recognition and reward 818 12.72 3.65 5 20 Involvement and influence 820 14.03 3.55 5 20 Workload management 821 12.60 3.44 5 20 Engagement 820 17.00 2.68 5 20 Balance 820 12.75 3.72 5 20 Psychological protection 812 12.41 3.95 5 20 Protection of physical safety 815 13.82 3.73 5 20  BCNU Report Community Care 30 Subscale scores were also categorized into four levels of concern based on cutoff scores (proportions are shown in Figure 10 and Table 27). Based on category proportions, community nurses reported the highest levels of concern for workload management, with 59% of responses falling into the Significant or Serious Concern categories. Other factors with high levels of concern included organizational culture (58% Significant or Serious Concern), clear leadership and expectations (58%), psychological protection (58%), and recognition and reward (57%). The psychosocial factor with the lowest level of concern was engagement, with 91% of responses in minimum concern or relative strength categories.  Figure 10. Proportion of responses in categories of concern for each GM@W psychosocial factor     BCNU Report Community Care 31 Table 17. Frequencies of GM@W subscale scores by categories of concern Subscale Serious Concern Significant Concern Minimum Concern Relative Strength % N % N % N % N Psychological support 17.3 141 33.0 270 30.6 250 19.1 156 Organizational culture 19.6 160 38.4 313 29.2 238 12.9 105 Clear leadership and expectations 22.8 188 34.8 287 28.2 232 14.2 117 Civility and respect 15.9 131 32.1 264 32.1 264 19.8 163 Psychological competencies and  requirements 5.5 45 34.8 284 39.2 320 20.5 167 Growth and development 17.5 143 35.1 287 30.4 248 17.0 139 Recognition and reward 20.3 166 37.2 304 25.9 212 16.6 136 Involvement and influence 11.8 97 28.7 235 34.1 280 25.4 208 Workload management 19.1 157 40.0 328 27.0 222 13.9 114 Engagement 1.6 13 7.2 59 30.4 249 60.9 499 Balance 21.0 172 35.6 292 26.7 219 16.7 137 Psychological protection 24.5 199 33.1 269 27.5 223 14.9 121 Protection of physical safety 13.4 109 28.8 235 34.8 284 22.9 187  Figure 11 presents the affirmative response proportion for the three GM@W items on workplace discrimination, bullying/harassment, and unfair treatment. Figure 11. Proportion of responses reporting workplace discrimination, bullying/harassment, and/or unfair treatment   BCNU Report Community Care 32 WORKPLACE VIOLENCE FREQUENCY OF WORKPLACE VIOLENCE BY TYPE For community care nurses, the type of workplace violence with the highest proportion of experience was emotional abuse, with approximately 72% of respondents reporting some level of experience within the last year. In descending order by proportion, the violence types following emotional abuse were threat of assault (59%), verbal sexual harassment (40%), and then physical assault (29%). Sexual assault had the lowest proportion of experiences, with 97% reporting no experiences within the last year. A complete summary of workplace violence frequencies by type is presented in Table 28 and Table 29. Table 18. Frequencies for workplace violence frequency by type (Valid N = 813) Type of workplace violence Frequency Never A few times a year or less Once a month A few times a month Once a week A few times a week Every day Physical assault N 575 193 20 15 2 4 4 % 70.7 23.7 2.5 1.9 0.3 0.5 0.5 Threat of assault N 332 301 57 61 12 35 15 % 40.8 37.0 7.0 7.5 1.5 4.3 1.9 Emotional abuse N 230 318 75 91 29 52 18 % 28.3 39.1 9.2 11.2 3.6 6.4 2.2 Verbal sexual harassment N 486 232 30 42 9 9 5 % 59.8 28.5 3.7 5.2 1.1 1.1 0.6 Sexual assault N 784 25 2 0 1 1 0 % 96.4 3.1 0.3 0.0 0.1 0.1 0.0  Table 19. Descriptive statistics for workplace violence frequency by type Type of workplace violence N Mean^ SD^ Min^ Max^ Physical assault 813 0.41 0.82 0 6 Threat of assault 813 1.12 1.43 0 6 Emotional abuse 813 1.51 1.57 0 6 Verbal sexual harassment 813 0.65 1.07 0 6 Sexual assault 813 0.05 0.30 0 5 ^ Note: Workplace violence frequency is coded numerically as follows: 0: Never, 1: A few times a year or less […] 5: A few times a week, 6: Every day      BCNU Report Community Care 33 SOURCES OF WORKPLACE VIOLENCE As shown in Figure 12, community care nurses who experienced workplace violence reported on which sources they had experienced each type of workplace violence from. Patients were the most common source for all types of workplace violence, with the selecting proportion of applicable respondents ranging from 83% to 98%. The second most frequent source across all types was family/visitors. Figure 12. Sources of workplace violence by type   BCNU Report Community Care 34 RESPONDING TO EACH TYPE OF WORKPLACE VIOLENCE For community care respondents, the two types of workplace violence most commonly not reported were emotional abuse (52% did not typically report) and verbal sexual harassment (47%). Emotional abuse and verbal sexual harassment were also least likely to have a typical response of formal reporting. Physical assault and sexual assault were typically reported, with over 80% of respondents reporting incidents whether formally or informally. Response proportions by type are shown in Figure 13. Figure 13. Proportions for typical reporting responses to workplace violence by type     BCNU Report Community Care 35 FACTORS CONTRIBUTING TO DECISION TO NOT FORMALLY REPORT WORKPLACE VIOLENCE As shown in Figure 14, the most common contributing factors for respondents’ decisions to not formally report workplace violence were “Nothing will change after reporting incident(s)” (61%) and “Lack of leadership support” (40%). The least common factors were “This is not the formal process at my workplace” (7%) and “Violence is part of my job” (17%). Figure 14. Factors contributing to decisions not to formally report workplace violence through the Workplace Health Call Centre (N = 604)       BCNU Report Community Care 36 As shown in Figure 15, roughly half of the community care respondents reported witnessing workplace violence without being directly involved over the last year. Respondents were also polled on the extent to which their employers were taking appropriate preventative measures against workplace violence. Approximately two-thirds of respondents (67%) rated their employers’ efforts to prevent violence as ‘moderately’ or more favorably. Proportions are shown in Figure 16.         Figure 15. Witnessed workplace violence over the last year (N = 802)  Figure 16. Perceptions of whether employers have taken appropriate measures to prevent workplace violence (N = 802)  BCNU Report Community Care 37 NURSE FACTORS EXPERIENCES AS A RESULT OF WORKPLACE VIOLENCE EXPOSURE Within community care nurses that reported exposure to workplace violence, the most common experience following the exposure was insomnia/sleep difficulty (71%), followed by presenteeism/showing up to work despite feeling unwell (60%). The least common experience for community care respondents was physical injury (23%). Proportions for each experience are shown in Table 30, and experiences are shown in descending “yes” proportions in Figure 17. Figure 17. Experiences as a result of exposure to workplace violence   Table 20. Frequency table for experiences following workplace violence exposure in the last year Experience Total N Yes No % N % N Absenteeism 632 41.3 261 58.7 371 Presenteeism 639 60.3 385 39.7 254 Medication 626 34.5 216 65.5 410 Insomnia 647 70.9 459 29.1 188 Physical Injury 619 23.3 144 76.7 475 Professional Care/Treatment 632 42.1 266 57.9 366     BCNU Report Community Care 38 NURSE OUTCOMES HEALTH AND WELLBEING  Screening tools for post-traumatic stress disorder (PTSD), generalized anxiety disorder, major depressive disorder, and emotional exhaustion/burnout were included in the survey to assess psychological health. Descriptive statistics for each measure are shown in Table 31. Scores for each tool were also categorized by cutoffs; category proportions are shown in Table 32. Table 21. Descriptive statistics for nurse outcome measures Measure N Mean SD Min Max Posttraumatic Stress Symptoms-14 (PTSS-14) 799 43.37 18.21 14 98 Generalized Anxiety Disorder-7 (GAD-7) 795 6.87 5.66 0 21 Patient Health Questionnaire-9 (Depression; PHQ-9) 795 7.24 6.01 0 27 Maslach Burnout Inventory - Human Services Survey for Medical Personnel:       Emotional Exhaustion (MBI-HSS (MP)) 769 26.84 13.33 0 54 Depersonalization (MBI-HSS (MP)) 767 7.17 6.60 0 29 Personal Accomplishment (MBI-HSS (MP)) 757 35.66 7.54 0 48  PTSD: On the PTSS-14, 44% of community care respondents scored above 45, within the range categorized as positive for PTSD. Anxiety: Approximately 59% of respondents had scores of 5 or higher, or within categories denoting some level of anxiety; 14% scored 15-21 or within the severe anxiety range. Depression: Approximately 58% of respondents scored 5 or higher and were categorized at some level of depression, with 5% scoring 20-27 or within the severe depression range.  Burnout: More than half of respondents (51%) scored higher than 27 on EE, indicating a high level of emotional exhaustion. Approximately 21% scored at a high level of depersonalization, and 25% had low levels of personal accomplishment. Table 22. Proportions and frequencies for nurse outcome categories as defined by sum score cutoffs Measure Category (by cutoffs) N PTSS-14 Below cutoff Above cutoff     56.1% (448) 43.9% (351)    799 GAD-7 No anxiety Mild anxiety Moderate anxiety Severe anxiety   40.9% (325) 30.4% (242) 14.8% (118) 13.8% (110)  795 PHQ-9 No depression Mild depression Moderate depression Moderately severe depression Severe depression  42.0% 27.9% 15.5% 9.8% 4.8% 795 BCNU Report Community Care 39 (334) (222) (123) (78) (38) Emotional exhaustion (MBI-HSS) Low EE Moderate EE High EE    29.6% (228) 19.4% (149) 51.0% (392)   769 Depersonalization (MBI-HSS) Low DP Moderate DP High DP   767 57.6% (442) 21.6% (166) 20.7% (159)   Personal Accomplishment (MBI-HSS) Low PA Moderate PA High PA   757 25.4% (192) 34.6% (262) 40.0% (303)   To assess community care nurses’ overall perspectives of their health, questions drawn from the Veterans RAND 12 Item Health Survey (VR-12) were used. Item-level descriptive statistics are shown in Table 33, and response proportions are shown in Table 34 and Figure 18. Table 23. Item-level descriptive statistics for responses to questions drawn from VR-12 Item question N Mean SD Min Max In general, would you say your health is... 770 3.07 0.91 1 5 The following questions are about your activities you might do during a typical day. Does your health now limit you in these activities? If so, how much? Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling or playing golf. 772 1.33 0.58 1 3 Climbing several flights of stairs. 771 1.35 0.59 1 3 During the past 4 weeks, have you had any of the following problems with your work or other regular daily activities as a result of your physical health? Accomplished less than you would like. 773 2.19 1.16 1 5 Were limited in the kind of work or other activities. 769 1.92 1.07 1 5 Accomplished less than you would like. 773 2.44 1.14 1 5 Didn't do work or other activities as carefully as usual. 771 2.00 1.00 1 5 Thinking about the past 4 weeks, answer the following questions: How much did pain interfere with your normal work (including both work outside the home and housework)? 772 2.28 1.17 1 5 How much of the time have you felt calm and peaceful? 771 2.90 0.91 1 5 How much of the time did you have a lot of energy? 771 2.62 0.97 1 5 How much of the time have you felt downhearted and blue? 770 2.37 1.00 1 5 How much of the time has your physical health or emotional problems interfered with your social activities (like visiting with friends, relatives, etc.)? 771 2.57 1.08 1 5 Compared to one year ago… How would you rate your physical health in general now? 772 2.87 0.99 1 5 BCNU Report Community Care 40 How would you rate your emotional problems (such as feeling anxious, depressed or irritable) now? 771 2.80 1.09 1 5  Table 24. Proportions for VR12 item responses Item Response N Poor Fair Good Very good Excellent Rating of general health 2.2% 26.0% 40.5% 25.5% 5.8% 770 Did health limit your ability to do typical daily activities… Not limited at all Limited a little Limited a lot N Moderate activities. 72.0% 22.5% 5.4% 772 Climbing several flights of stairs. 71.1% 22.8% 6.1% 771 Problems due to physical health (Last 4 weeks) None of the time A little of the time Some of the time Most of the time All of the time N Accomplished less than you would like. 35.7% 28.5% 21.3% 9.8% 4.7% 773 Were limited in the kind of work or other activities. 46.9% 26.0% 17.7% 6.8% 2.6% 769 Accomplished less than you would like. 23.4% 33.0% 25.2% 12.8% 5.6% 773 Didn't do work or other activities as carefully as usual. 38.1% 33.9% 20.8% 4.8% 2.5% 771 In the last 4 weeks… None of the time A little of the time Some of the time Most of the time All of the time N Pain interfered with normal work 32.6% 28.0% 23.6% 10.8% 5.1% 772 Felt calm and peaceful 5.8% 28.0% 37.7% 27.4% 1.0% 771 Had a lot of energy 13.9% 30.5% 35.9% 19.1% 0.6% 771 Felt downhearted and blue? 20.5% 38.1% 27.1% 12.3% 1.9% 770 Physical health or emotional problems interfered with social life 18.8% 29.7% 30.9% 17.4% 3.2% 771 Compared to one year ago, rating of… Much worse Slightly worse About the same Slightly better Much better N General physical health 7.3% 27.2% 43.7% 14.8% 7.1% 772 Emotional problems 12.2% 26.6% 38.8% 13.9% 8.6% 771   BCNU Report Community Care 41 Figure 18. Proportions for responses to item “How do you feel about your life as a whole right now?” (N=766)  QUALITY AND SAFETY As shown in Table 35, respondents were asked how they would describe the quality of care, safety, and likelihood of recommendation for their primary workplace. For quality of care, approximately 92% of community care nurses rated the general quality of care they provided as good to excellent. 90% of nurses rated the quality of the care they provided last shift as good to excellent. For patient safety, approximately 11% of respondents gave their primary workplace a negative overall grade. For likelihood of recommendations, 80% were likely to recommend their workplace to friends and family for care, and 69% were likely to recommend their workplace to nurse colleagues as a good place to work. Table 25. Frequencies and proportions for nurses’ perceptions on overall quality and safety Quality of care questions Poor Fair Good Excellent N In general, how would you describe the quality of nursing care you delivered to patients in your primary workplace? 0.8% 7.4% 51.3% 40.5% 770 How would you describe the quality of nursing care you delivered to patients in your primary workplace on your last shift? 0.8% 9.0% 49.0% 41.2% 769  Patient safety grade question Failing Poor Acceptable Very good Excellent N Please give your primary workplace an overall grade on patient safety. 2.9% 8.4% 36.4% 38.9% 13.4% 771  Recommendation questions Definitely no Probably no Probably yes Definitely yes N BCNU Report Community Care 42 Would you recommend your primary workplace to your friends and family if they needed care? 7.1% 12.7% 44.8% 35.3% 770 Would you recommend your primary workplace to a nurse colleague as a good place to work? 9.1% 22.2% 44.1% 24.6% 771  BCNU Report Long-Term Care 43 FINDINGS: THE LONG-TERM CARE SECTOR DEMOGRAPHIC PROFILE OF LONG-TERM CARE NURSES The long-term care sector sample consisted of 446 nurses, 91% of whom were female. The mean respondent age was 45.0 years (SD = 11.7), with the largest age category being 45 to 54 (30%) and the second-largest category being 55 and above (24%). In contrast with the acute care and community care samples, the long-term care respondents had greater proportions of LPNs (59%), diploma/certificate holders (64%), nurses with education outside Canada (24%), and identification with the Mosaic of Colour equity-seeking caucus (23%). A demographic profile is presented in Table 36. Table 26. Demographic characteristics of nurses in the long-term care sector Characteristics N % Age   Under 25 16 3.6 25 to 34 81 18.4 35 to 44 104 23.6 45 to 54 131 29.8 55 and above 108 24.5 Gender   Female 405 91.0 Male 38 8.5 Prefer to describe 2 0.4 Professional Designation   LPN 262 58.7 RN 159 35.7 RPN 14 3.1 Dually registered (RN/RPN) 1 0.2 Other 9 2.0 Education   Diploma/Certificate 281 63.9 Undergraduate degree 70 15.9 Graduate degree 81 18.4 Other 8 1.8 Any nursing education outside Canada   No 334 75.9 Yes 106 24.1 Overall nursing experience   5 years or less 92 21.0 6 to 10 years 112 25.6 11 to 15 years 80 18.3 16 to 20 years 48 11.0 21 years or more 106 24.2 Identification with BCNU equity-seeking caucuses (respondents may identify with multiple caucuses simultaneously)   BCNU Report Long-Term Care 44 Indigenous Leadership Circle 25 6.1 LGBTQ 22 5.5 Mosaic of Colour 94 22.5 Workers with Disabilities 32 8.0  In their primary workplaces, 71% of respondents reported their primary nursing role as direct care provider, and 26% reported nurse leader. Most of the nurses (94%) provided direct patient or client care. Approximately 61% were employed full-time. Table 37 provides demographic characteristics relevant to nurses’ primary workplace. Table 27. Demographic characteristics relevant to respondents’ primary workplace Primary workplace N % Primary nursing role   Direct care provider 315 71.4 Nurse leader 116 26.3 Educator 6 1.4 Provides direct patient/client care   Yes 413 93.7 No 28 6.3 Health authority   Vancouver Coastal Health 123 27.8 Interior Health 85 19.2 Northern Health 68 15.3 Vancouver Island Health 65 14.7 Fraser Health 64 14.4 Providence Health 8 1.8 Provincial Health Services 4 0.9 Workplace geography   Urban 244 54.8 Suburban 79 17.8 Rural 122 27.4 Nursing practice area   Community mental health 1 0.2 Home and community care 4 0.9 Long-term care 398 89.6 Medical/surgical 1 0.2 Mental health or psychiatry 16 3.6 Oncology 1 0.2 OR/PACU 1 0.2 Palliative 11 2.5 Public health 1 0.2 Rehabilitation 5 1.1 Other, please specify 2 0.5 Mixed (A combination of other areas) 3 0.7 Employment status   BCNU Report Long-Term Care 45 Full-time 270 61.2 Part-time 140 31.7 Casual 31 7.0  OVERALL WORKPLACE FACTORS GUARDING MINDS AT WORK PSYCHOSOCIAL FACTORS The Guarding Minds at Work (GM@W) assessment tool was used to assess the long-term care nurses’ workplace psychological health and safety. Summary data for each of the 13 GM@W subscales is shown in Table 38. The subscales with the lowest mean scores were ‘psychological protection’, ‘organizational culture’, and ‘workload management’, indicating that higher risk for these psychosocial factors. The subscales with the highest mean scores were ‘engagement’, ‘psychological competencies and requirements’, and ‘involvement and influence’. The individual items with the highest rates of respondent agreement were: - I am proud of the work I do. (95.9%) - My work is an important part of who I am. (93.3%) - I have the social and emotional skills needed to do my job well. (92.8%) - I am willing to give extra effort at work if needed. (92.8%) The items with the lowest rates of agreement were: - My work is free from unnecessary interruptions and disruptions. (22.2%) - My employer is committed to minimizing unnecessary stress at work. (34.5%) - Employees and management trust one another. (35.7%) - Difficult situations at work are addressed effectively. (36.8%) - Our workplace effectively handles "people problems" that exist between staff. (37.0%) Table 28. Descriptive statistics of GM@W subscale sum scores Subscale/Psychosocial factor N Mean SD Min Max Psychological support 413 12.49 3.73 5 20 Organizational culture 412 12.11 3.52 5 20 Clear leadership and expectations 417 13.19 3.50 5 20 Civility and respect 418 12.31 3.58 5 20 Psychological competencies and requirements 415 14.51 2.96 5 20 Growth and development 414 12.76 3.71 5 20 Recognition and reward 413 12.71 3.68 5 20 Involvement and influence 414 14.01 3.40 5 20 Workload management 415 12.14 3.40 5 20 Engagement 415 17.15 2.73 5 20 Balance 413 12.45 3.73 5 20 Psychological protection 415 11.62 3.93 5 20  BCNU Report Long-Term Care 46 Respondents’ subscale scores were categorized by cutoff values into four levels of concern. The factors with the highest levels of concern for long-term care nurses were psychological protection (65.5% of responses categorized as Serious or Significant concern), organizational culture (64.8%), and workload management (62.7%). Engagement had the lowest level of concern, with 91.3% of responses categorized as Minimum Concern or Relative Strength. Proportions for levels of concern by subscale are shown in Figure 19 and Table 39. Figure 19. Proportion of responses in categories of concern for each GM@W psychosocial factor     BCNU Report Long-Term Care 47 Table 29. Frequencies of GM@W subscale scores by categories of concern Subscale Serious Concern Significant Concern Minimum Concern Relative Strength % N % N % N % N Psychological support 22.5 93 34.4 142 30.5 126 12.6 52 Organizational culture 25.0 103 39.8 164 24.5 101 10.7 44 Clear leadership and expectations 15.1 63 39.1 163 26.9 112 18.9 79 Civility and respect 23.2 97 38.3 160 28.0 117 10.5 44 Psychological competencies and  requirements 5.5 23 29.6 123 40.5 168 24.3 101 Growth and development 22.0 91 32.6 135 30.0 124 15.5 64 Recognition and reward 21.1 87 36.1 149 27.6 114 15.3 63 Involvement and influence 11.1 46 28.0 116 37.7 156 23.2 96 Workload management 22.7 94 40.0 166 27.7 115 9.6 40 Engagement 1.4 6 7.2 30 28.0 116 63.4 263 Balance 23.7 98 33.7 139 28.1 116 14.5 60 Psychological protection 29.9 124 35.7 148 22.7 94 11.8 49 Protection of physical safety 14.8 61 27.6 114 34.1 141 23.5 97  The GM@W also includes three statements on workplace victimization. The proportion of “yes” responses for each item is shown in Figure 20.  BCNU Report Long-Term Care 48 Figure 20. Proportion of responses reporting workplace discrimination, bullying/harassment, and/or unfair treatment   WORKPLACE VIOLENCE FREQUENCY OF WORKPLACE VIOLENCE BY TYPE For long-term care nurses, the most common types of workplace violence experienced were physical assault, threat of assault, and emotional abuse – each with approximately 85% of respondents having some level of experience in the past year. The latter two types were the most frequently experienced types of workplace violence, with 31% of nurses experiencing threat of assault and 30% experiencing emotional abuse on a weekly frequency or higher. Table 40 presents the frequencies for each type of workplace violence, and Table 41 presents summary statistics. Table 30. Frequencies for workplace violence frequency by type (Valid N = 412) Type of workplace violence Frequency Never A few times a year or less Once a month A few times a month Once a week A few times a week Every day Physical assault N 62 152 29 78 26 54 11 % 15.1 36.9 7.0 18.9 6.3 13.1 2.7 Threat of assault N 63 115 38 69 24 60 43 % 15.3 27.9 9.2 16.8 5.8 14.6 10.4 Emotional abuse N 66 136 31 55 32 54 38 BCNU Report Long-Term Care 49 % 16.0 33.0 7.5 13.4 7.8 13.1 9.2 Verbal sexual harassment N 180 129 24 34 21 21 3 % 43.7 31.3 5.8 8.3 5.1 5.1 0.7 Sexual assault N 342 48 5 10 6 0 1 % 83.0 11.7 1.2 2.4 1.5 0.0 0.2  Table 31. Descriptive statistics for workplace violence frequency by type Type of workplace violence N Mean^ SD^ Min^ Max^ Physical assault 412 2.15 1.73 0 6 Threat of assault 412 2.55 1.99 0 6 Emotional abuse 412 2.40 1.98 0 6 Verbal sexual harassment 412 1.18 1.50 0 6 Sexual assault 412 0.29 0.79 0 6 ^ Note: Workplace violence frequency is coded numerically as follows: 0: Never, 1: A few times a year or less […] 5: A few times a week, 6: Every day    BCNU Report Long-Term Care 50 SOURCES OF WORKPLACE VIOLENCE Long-term care nurses who experienced workplace violence of any type in the past year were asked to indicate the sources of violence. Responses are summarized in Figure 21. The most common source was patients for all five types of workplace violence. Figure 21. Sources of workplace violence by type    BCNU Report Long-Term Care 51 RESPONDING TO EACH TYPE OF WORKPLACE VIOLENCE When asked about their response to each type of workplace violence in terms of incident reporting, 54% of long-term care nurses said they did not typically report emotional abuse, and 45% said they did not report verbal sexual harassment. Physical assault was most likely to be reported, with 85% reporting incidents either formally or informally. Figure 22 summarizes typical reporting responses to each type of workplace violence. Figure 22. Proportions for typical reporting responses to workplace violence experience, by violence type     BCNU Report Long-Term Care 52 FACTORS CONTRIBUTING TO DECISION TO NOT FORMALLY REPORT WORKPLACE VIOLENCE Respondents who said they typically did not report or informally reported any type of workplace violence were asked about the contributing factors to their decision. “Nothing will change after reporting incident(s)” was the most common factor amongst long-term care nurses, being selected by approximately 60% of the 353 applicable nurses. “This is not the formal process at my workplace” and “feelings of sympathy with the perpetrator” were the least commonly selected factors. The selecting proportions for each factor are shown in Figure 23. Figure 23. Factors contributing to decisions not to formally report workplace violence through the Workplace Health Call Centre (N = 353)      BCNU Report Long-Term Care 53 Approximately 78% of respondents said they had witnessed workplace violence that they were not directly involved in, over the last year (see Figure 24).          Respondents were also asked to rate how much their employers had taken measures to prevent workplace violence. Approximately 39% of long-term care nurses said that either their employer had taken slight measures or none at all. The mean response, with ‘Not at all’ coded as 0 and ‘A great deal’ coded as 4, was 1.89 (SD = 1.16).     Figure 24. Witnessed workplace violence over the last year (N = 403)  Figure 25. Perceptions of whether employers have taken appropriate measures to prevent workplace violence (N = 405)  BCNU Report Long-Term Care 54 NURSE FACTORS EXPERIENCES AS A RESULT OF WORKPLACE VIOLENCE EXPOSURE As shown in Figure 26 and Table 42, the most common adverse experiences due to exposure to workplace violence were insomnia/sleep difficulties (66%) and presenteeism/showing up to work despite feeling unwell (62%). Physical injury (38%) and seeking professional care or treatment (39%) were the least common experiences.  Figure 26. Experiences as a result of exposure to workplace violence   Table 32. Frequency table for experiences following workplace violence exposure in the last year Experience Total N Yes No % N % N Absenteeism 374 44.9 168 55.1 206 Presenteeism 370 62.2 230 37.8 140 Medication 366 40.4 148 59.6 218 Insomnia 376 66.5 250 33.5 126 Physical Injury 366 37.7 138 62.3 228 Professional Care/Treatment 371 39.1 145 60.9 226     BCNU Report Long-Term Care 55 NURSE OUTCOMES HEALTH AND WELLBEING  Screening tools for post-traumatic stress disorder (PTSD), generalized anxiety disorder, major depressive disorder, and emotional exhaustion/burnout were included in the survey to assess the psychological health of nurses in the long-term care sector. Summary statistics are shown in Table 43, while the proportions for categories defined by cutoff values are shown in Table 44. PTSD: On the PTSS-14 measure, approximately 42% of long-term care respondents scored above the classification cutoff of 45. Anxiety: On the GAD-7 measure, 59% of respondents scored at some level of anxiety, with approximately 15% classified as ‘moderate anxiety’ and 12% as ‘severe anxiety’. Depression: Based on cutoffs for the PHQ-9, 61% of respondents scored at some level of depression. Approximately 32% were classified at moderate to severe depression. Burnout: Approximately 54% of long-term care nurses scored with high levels of emotional exhaustion, 26% scored with high levels of depersonalization, and 34% scored with low levels of personal accomplishment. Table 33. Descriptive statistics for nurse outcome measures Measure N Mean SD Min Max Posttraumatic Stress Symptoms-14 (PTSS-14) 397 42.71 19.20 14 98 Generalized Anxiety Disorder-7 (GAD-7) 392 6.77 5.73 0 21 Patient Health Questionnaire-9 (Depression; PHQ-9) 392 7.67 6.36 0 27 Maslach Burnout Inventory - Human Services Survey for Medical Personnel      Emotional Exhaustion (MBI-HSS (MP)) 373 27.07 13.74 0 54 Depersonalization (MBI-HSS (MP)) 377 8.10 6.93 0 30 Personal Accomplishment (MBI-HSS (MP)) 373 33.59 9.48 0 48  Table 34. Proportions and frequencies for nurse outcome categories as defined by sum score cutoffs Measure Category (by cutoffs) N PTSS-14 Below cutoff Above cutoff     58.2% (231) 41.8% (166)    397 GAD-7 No anxiety Mild anxiety Moderate anxiety Severe anxiety   40.6% (159) 33.4% (131) 14.5% (57) 11.5% (45)  392 PHQ-9 No depression Mild depression Moderate depression Moderately severe depression Severe depression  39.0% 29.3% 16.3% 8.9% 6.4% 392 BCNU Report Long-Term Care 56 (153) (115) (64) (35) (25) Emotional exhaustion (MBI-HSS) Low EE Moderate EE High EE    29.5% (110) 17% (63) 53.6% (200)   373 Depersonalization (MBI-HSS) Low DP Moderate DP High DP   377 52.3% (197) 22.3% (84) 25.5% (96)    Personal Accomplishment (MBI-HSS) Low PA Moderate PA High PA   373 34.0% (127) 33.0% (123) 33.0% (123)    In addition to the measures of psychological health, questions drawn from the Veterans RAND 12 Item Health Survey (VR-12) were used to assess how long-term care nurses felt about their overall health. Table 45 contains item-level summary statistics, while response proportions are shown in Table 34 and Figure 18. Table 35. Item-level descriptive statistics for responses to questions drawn from VR-12 Item question N Mean SD Min Max In general, would you say your health is... 381 3.00 0.93 1 5 The following questions are about your activities you might do during a typical day. Does your health now limit you in these activities? If so, how much? Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling or playing golf. 382 1.33 0.54 1 3 Climbing several flights of stairs. 381 1.38 0.61 1 3 During the past 4 weeks, have you had any of the following problems with your work or other regular daily activities as a result of your physical health? Accomplished less than you would like. 380 2.26 1.16 1 5 Were limited in the kind of work or other activities. 379 2.04 1.09 1 5 Accomplished less than you would like. 378 2.37 1.18 1 5 Didn't do work or other activities as carefully as usual. 380 2.03 1.06 1 5 Thinking about the past 4 weeks, answer the following questions: How much did pain interfere with your normal work (including both work outside the home and housework)? 381 2.48 1.13 1 5 How much of the time have you felt calm and peaceful? 381 3.02 0.93 1 5 How much of the time did you have a lot of energy? 379 2.79 1.01 1 5 How much of the time have you felt downhearted and blue? 381 2.49 0.99 1 5 How much of the time has your physical health or emotional problems interfered with your social activities (like visiting with friends, relatives, etc.)? 381 2.60 1.13 1 5 Compared to one year ago… How would you rate your physical health in general now? 383 2.85 1.03 1 5 BCNU Report Long-Term Care 57 How would you rate your emotional problems (such as feeling anxious, depressed or irritable) now? 383 2.85 1.11 1 5  Table 36. Proportions for VR12 item responses Item Response N Poor Fair Good Very good Excellent Rating of general health 4.5% 24.9% 41.7% 24.1% 4.7% 381 Did health limit your ability to do typical daily activities… Not limited at all Limited a little Limited a lot N Moderate activities. 70.4% 26.2% 3.4% 382 Climbing several flights of stairs. 68.5% 24.9% 6.6% 381 Problems due to physical health (Last 4 weeks) None of the time A little of the time Some of the time Most of the time All of the time N Accomplished less than you would like. 34.2% 24.5% 27.6% 8.7% 5.0% 380 Were limited in the kind of work or other activities. 42.5% 23.2% 25.3% 6.1% 2.9% 379 Accomplished less than you would like. 27.5% 31.5% 23.3% 11.6% 6.1% 378 Didn't do work or other activities as carefully as usual. 38.7% 31.8% 20.5% 5.5% 3.4% 380 In the last 4 weeks… None of the time A little of the time Some of the time Most of the time All of the time N Pain interfered with normal work 23.6% 27.8% 31.2% 12.1% 5.2% 381 Felt calm and peaceful 4.2% 26.5% 35.2% 31.0% 3.1% 381 Had a lot of energy 11.1% 27.2% 35.9% 23.0% 2.9% 379 Felt downhearted and blue? 15.2% 38.1% 31.8% 12.1% 2.9% 381 Physical health or emotional problems interfered with social life 18.6% 29.7% 30.4% 15.2% 6.0% 381 Compared to one year ago, rating of… Much worse Slightly worse About the same Slightly better Much better N General physical health 9.7% 24.8% 44.9% 12.5% 8.1% 383 Emotional problems 10.4% 27.2% 40.7% 10.2% 11.5% 383  BCNU Report Long-Term Care 58 Figure 27. Proportions for responses to item “How do you feel about your life as a whole right now?” (N=377)   QUALITY AND SAFETY In the long-term care sector, 88% of respondents rated the overall quality of care they provided as good or excellent. 86% rated the quality of care they provided last shift as good or excellent. 17% gave their primary workplace a negative overall grade on patient safety. When asked whether or not they would recommend their primary workplace to friends and family for care, or to nursing colleagues for work, approximately 71% of long-term care nurses said they would recommend their workplace to friends and family for care; 67% said they would recommend their workplace to colleagues as a good place to work. Table 37. Frequencies and proportions for nurses’ perceptions on overall quality and safety Quality of care questions Poor Fair Good Excellent N In general, how would you describe the quality of nursing care you delivered to patients in your primary workplace? 0.3% 11.7% 52.3% 35.8% 377 How would you describe the quality of nursing care you delivered to patients in your primary workplace on your last shift? 1.9% 12.5% 47.5% 38.2% 377  Patient safety grade question Failing Poor Acceptable Very good Excellent N Please give your primary workplace an overall grade on patient safety. 4.0% 13.0% 41.0% 31.5% 10.6% 378 BCNU Report Long-Term Care 59  Recommendation questions Definitely no Probably no Probably yes Definitely yes N Would you recommend your primary workplace to your friends and family if they needed care? 9.5% 19.6% 47.9% 23.0% 378 Would you recommend your primary workplace to a nurse colleague as a good place to work? 7.9% 25.1% 47.1% 19.8% 378           BCNU Report Long-Term Care 60 REFERENCE:   Berriosa C, Joffresa Y, Wanga L. Workplace psychological health among Canadian nurses. University of British Columbia Medical Journal. 2015;30. Available from: https://ubcmj.med.ubc.ca/past-issues/ubcmj-volume-6-issue-2/ubcmj_6_2_2015_30/  Brandford AA, Reed DB. Depression in registered nurses: A state of the science. Workplace Health & Safety. 2016;64(10):488-511: 10.1177/2165079916653415 Canadian Federation of Nurses’ Union. Enough is enough: Putting stop to violence in the health care sector. 2017; Available from: https://nursesunions.ca/wp-content/uploads/2017/05/CFNU_Enough-is-Enough_June1_FINALlow.pdf. [Accessed 1st Aug 2019].  Canadian Institute of Health Information and Statistics Canada. Findings from the 2005 National Survey of the Work and Health of Nurses. Ottawa; 2006; Available from https://secure.cihi.ca/free_products/NHSRep06_ENG.pdf  Centre for Applied Research in Mental Health and Addiction. Guarding Minds at Work. 2018; Available from: https://www.guardingmindsatwork.ca/ [Accessed 4th Aug 2019]. 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Archives of Internal Medicine, 166(10), 1092-1097: 10.1001/archinte.166.10.1092  Twigg E, Humphris G, Jones C, Bramwell R, Griffiths RD. Use of a screening questionnaire for post‐traumatic stress disorder (PTSD) on a sample of UK ICU patients. Acta Anaesthesiologica Scandinavica. 2008 Feb;52(2):202-8: 10.1111/j.1399-6576.2007.01531.x  

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