Facing threat of violence, health care workers in Toronto’s ERs learn to protect themselves

The patient’s name is Rowan, and he is not happy to be held in a hospital against his will.

Rowan was admitted to an inpatient psychiatry unit for bizarre behaviour and paranoia after coming in off the streets to receive IV antibiotics for a leg wound.

“Get me out of here! Get me out of here!” he screams, punctuating his demands with expletives and smacking a rolled-up magazine against the purple chairs in a patient lounge.

At the doorway to the lounge, a group of nurses and other health care workers array themselves in a V, like a wedge of geese flying in formation.

The nurse at the head of the flock talks to Rowan as he paces frantically in a black hoodie, shorts and grey Crocs. She offers him ointment for his leg, something to eat, a nicotine inhaler – anything that might calm him down. When Rowan strides toward the lead nurse, two colleagues put their hands on her shoulders and guide her backward, out of harm’s way.

Eventually, another nurse steps forward. She offers Rowan extra-strength Tylenol and apple juice. He agrees. “Pause,” the nurse says to her co-workers, making a T with her hands like she’s calling for a time out. “In this situation, is it safe to approach and give the medicine?”

The nurse is free to stop and ask for advice because “Rowan” is actually Jon De Leon, an actor who has supplemented his theatre and TV work for the past decade with gigs playing patients in training simulations.

One day this summer, Mr. De Leon acted the part of Rowan for nine staff at Toronto’s University Health Network as part of the hospital’s efforts to mitigate violence against nurses and other front-line medical providers.

The three-day program, abbreviated as TIDES for “Trauma-Informed De-escalation Education for Safety and Self-Protection,” was developed by the Centre for Addiction and Mental Health, the largest psychiatric hospital in the country.

CAMH trained UHN staff to deliver TIDES directly. More than 3,100 staff have completed at least one day of the program since December, 2023.

UHN, which includes the Toronto General and Toronto Western hospitals, saw the rate of physical and verbal violence against workers in emergency departments triple between 2020 and 2024. The rate reached 3.14 violent incidents for every 1,000 visits to the ER last year, up from 1.05 in 2020, when COVID-19 struck.

As the pandemic dragged on, a wave of physical and verbal attacks against Canadian health workers washed over hospitals.

The effects linger to this day, according to the results of a survey published in March of more than 4,700 nurses conducted for the Canadian Federation of Nurses Unions. It found that 59 per cent of the respondents experienced violence or abuse on the job in the past year. The most common type was verbal or physical abuse from patients or their families.

The situation at Manitoba’s largest hospital is a case in point. The provincial government is planning to permanently station police officers in the emergency department at Health Sciences Centre Winnipeg after a nursing union voted last month to “grey list” the hospital, a designation that discourages members from working there because the union considers it unsafe.

The problem is severe enough that Linda Silas, the president of the CFNU, said her organization plans to make violence in the health care workplace the subject of a policy breakfast with federal, provincial and territorial health ministers this fall. “We know violence is going up. We know workers’ compensation [claims] are going up on violence and mental-health issues, and we’re still not training our work force in prevention,” Ms. Silas said.

The nursing organization’s recent survey found that only 37 per cent of respondents had received violence prevention training similar to what UHN is offering through TIDES.

Ms. Silas and others working in the public health system say the pandemic exacerbated societal challenges that were already contributing to increased violence against nurses and their colleagues before COVID-19 hit. The substance abuse and housing crises put more people on the street, some of whom landed in emergency departments. The aging of the population led to more patients with dementia lashing out in confusion. Patients and caregivers of all kinds lost their tempers with health workers during long waits in Canada’s often overcrowded, short-staffed hospitals.

At the same time, health care staff have become less willing to put up with maltreatment on the job. They and their employers at some Canadian hospitals, including UHN, have been more diligently documenting the phenomenon. “I remember being a young nurse and being punched,” said Aideen Carroll, a veteran mental-health nurse at UHN. “You wouldn’t think of filling out an incident report, because somebody would be looking at you like, ‘What’d you do an incident report for? That’s just part of being a nurse.’”

Ms. Carroll is one of the instructors for TIDES at UHN. In July, she led a group of 16 health workers, including nurses, personal support workers and occupational therapists, through a separate TIDES training day that focused on physical skills, such as avoiding punches and kicks and breaking the grip of patients who clamp their hands around workers’ necks. “I’ve experienced all these,” Ms. Carroll said, speaking in the thick brogue of her native Ireland to a circle of trainees inside a windowless conference room at Toronto General.

One time, Ms. Carroll said, a patient choked her and wouldn’t let go. “What happened in this situation, that I learned a little bit later, was this patient thought that the vital signs machine was a machine gun and that I was going to shoot him,” Ms. Carroll told the group.

The attack happened not on the mental-health unit, where she has spent most of her career, but on an orthopedic floor. She shared the story to underscore that staff must be prepared for violence anywhere in the hospital. To demonstrate this, Andrew Uren, a charge guard on UHN’s in-house security team and another TIDES instructor, wrapped his arm around Ms. Carroll’s neck from behind. “We’re very concerned about this because this is actually life-threatening,” Ms. Carroll explained. “This has the ability to cut off your airway.”

She showed the class how to escape: She shrugged her shoulders and “turtled” her neck, then turned her head into the crook of Mr. Uren’s elbow, giving herself space to breathe. Next, she put her hands on his forearms, pulled down with her full weight and wriggled out of his grip.

The TIDES instructors also demonstrated how to safely fend off attacks from elderly patients. Yanking down on the forearm of an agitated grandmother with Alzheimer’s disease could break a bone or leave a bruise.

That’s why CAMH launched a version of TIDES last year specifically for long-term care homes, said Sanjeev Sockalingam, CAMH’s chief medical officer and senior vice-president of education.

CAMH has run bespoke versions of TIDES for non-health care settings as well, including in malls and libraries struggling to respond to unhoused patrons.

“I think the financial hardships, increases in homelessness and the continued concerns about lack of access to addiction supports and mental-health supports in our system have, unfortunately, increased the use of other places for support,” Dr. Sockalingam said. “It’s no surprise that we are seeing other settings wanting to upskill.”

CAMH offered earlier versions of violence-prevention and protection training for staff at the mental-health hospital for about 30 years, but TIDES, the latest version, is more focused on understanding the trauma that might drive a patient to snap.

So although the group led by Ms. Carroll spent an afternoon learning how to safely use chemical and physical restraints on patients who are a danger to themselves and others, the goal of the full TIDES training is to soothe patients to the point where restraints aren’t necessary.

That’s where Mr. De Leon and his portrayal of Rowan came in.

His acting allowed the group of nine health workers to practise responding to a “Code White,” the announcement that rings out from a hospital loudspeaker when a patient or visitor turns aggressive.

There were 349 Code Whites at UHN facilities in the fiscal year ending March 31.

Alize Chandler, another TIDES instructor, prepared the group for Mr. De Leon’s simulation.

The first health worker on the scene, she explained, would be designated the “first responder” and take the lead in communicating with the patient.

“But we want an all-hands-on-deck approach to safety, so I don’t want to be doing this alone,” Ms. Chandler said. “I’m going to have some backup staff come and triangulate with me.”

“Triangulating” means the staff arrange themselves in V shape, so the agitated patient doesn’t feel surrounded.

Earlier, Ms. Chandler and Torie Vaughan, another of the TIDES trainers, talked with the participants about how they could mollify an agitated patient by thinking of the acronym HALTII.

Might the patient be hungry? Offer him a sandwich. Might he be angry? Emphasize that you hear him and understand. Might he be lonely or tired? Hand him a blanket. Might he feel a sense of injustice or pain from an injury? See what you can do to alleviate suffering in the moment.

“This takes curiosity and investigation,” Ms. Vaughan said, “because patients aren’t going to tell you this.”

When the simulation began, it was jarring. Mr. De Leon as Rowan jittered and screamed in a taped-off corner of the beige-walled conference room that was meant to be a small patient lounge.

The staff triangulated and began engaging Rowan. Physiotherapist Anne-Marie Bourgeois stepped to the front and asked him if he smoked.

Rowan perked up and begged to have a guard take him outside for a cigarette. “Security’s gonna be with me! I can have a smoke outside, man!” he shouted.

“That’s not the policy. I’m so sorry,” Ms. Bourgeois said gently. “Do you want nicotine gum?”

Rowan shook his head and replied no.

“What about the inhaler?” Ms. Bourgeois said, and tossed a nicotine inhaler in Rowan’s direction. He took it, and although he kept ranting, he sat down, sucking on the device.

Afterward, the group debriefed. Rowan broke character. As Jon, he told Ms. Bourgeois and her colleagues that by the time he decided to sit, “I really felt safe. And also, when you were rotating in, I felt that there were multiple people on my side.”

After discussing what worked and didn’t through the first simulation, the group repeated the exercise. This time, giving Rowan the Tylenol and juice, along with patience and care, pacified him. The TIDES instructors liked how another participant suggested safely delivering the medication to Rowan by telling him she would be coming forward and setting it on a chair.

Christian Schulz-Quach, a psychiatrist and the medical director of workplace violence prevention at UHN, said he believes TIDES training has contributed to an encouraging recent reduction in workplace violence at the hospital network, though it’s not the lone reason.

UHN recorded 0.73 violent incidents per 1,000 emergency department visits in the first quarter of 2025, a significant drop from 3.14 incidents per 1,000 visits last year.

The network has taken other steps, such as outfitting security staff with body cameras. When security guards tell angry patients they’re being recorded, many just walk away, Dr. Schulz-Quach said.

Now, UHN is piloting panic buttons with real-time location service on the backs of badges for 200 employees in the Toronto General and Toronto Western ERs.

“If someone comes to work and has to be worried that they’ll get psychologically, emotionally or physically harmed, we’re living in a health care world that we cannot tolerate,” Dr. Schulz-Quach said. “We need to change it.”

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