Case Summary
It’s a nightmarish situation. A distraught mom brings her 7-year-old child kicking and screaming into an emergency department. The doctor prescribes medications to calm him down. Four security guards hold down the child’s arms and legs while the nurse pinches his nose, shoves the pills into his mouth and holds her hand over his mouth for 5 to 10 seconds. The hospital later fires the nurse for patient abuse. The union claims wrongful dismissal and the Ontario arbitrator agrees. The hospital would have been well within its rights to expressly prohibit staff from physically forcing a non-consenting minor to take medications. But it didn’t do so. And the hospital’s failure to establish written policies or guidelines addressing this situation meant that the nurse had to exercise her own best judgment in deciding how to handle this chaotic and distressing situation based on her years of experience in nursing. Accordingly, the hospital was out of line in ending her employment [Ontario Nurses’ Association v Royal Victoria Hospital, 2025 CanLII 43167 (ON LA), May 12, 2025].

Why This Case Matters

For OHS managers across Canada, this case illustrates a recurring and dangerous problem: what happens when workplaces do not provide clear procedures for responding to volatile or violent situations. The nurse at the centre of this case was accused of patient abuse. The hospital believed her conduct crossed a line. But in the absence of a written policy, training, or guidelines, the arbitrator ruled she was forced to rely on her own judgment in the heat of a chaotic moment.

This ruling is not just about one nurse or one hospital. It is about the responsibilities of employers to define what is acceptable, to establish clear violence and force protocols, and to ensure staff are trained on them. Without these measures, workers are left exposed—sometimes to accusations of misconduct, sometimes to personal injury, and always to moral stress when they must improvise in crisis.

For OHS managers, the question is straightforward: are your workplace violence protocols written, clear, and actively reinforced? And if not, what risks are you exposing both your workers and your organization to?

The Complexity of Violence in Healthcare

Healthcare workplaces face some of the most volatile scenarios imaginable. Patients may be confused, medicated, or in distress. Families may be panicked or angry. Staff may have to respond to combative behaviours in emergency rooms, psychiatric wards, or long-term care facilities. In all of these cases, safety protocols must balance two imperatives: protecting the worker and protecting the patient.

This balance is never easy. Force may sometimes be necessary to prevent harm—for example, restraining a patient trying to harm themselves or others. But how much force is acceptable? When is restraint therapeutic, and when does it cross into abuse? These are not questions that can be left to “best judgment” in the moment. They require clear rules, training, and oversight.

In the Ontario case, the arbitrator emphasized that the hospital could have legally prohibited the exact conduct that occurred. If a written policy had barred staff from physically forcing medication into a minor’s mouth, the nurse could have been dismissed for cause. But because the hospital left that gap, the nurse’s improvised decision could not be treated as misconduct.

The OHS Perspective on Policy Gaps

Occupational health and safety law in Canada requires employers to protect workers from workplace violence and harassment. In Ontario, that duty is set out in section 32.0.1 of the Occupational Health and Safety Act. Similar provisions exist in Alberta, BC, and other jurisdictions. While these laws primarily focus on protecting workers, they implicitly recognize that workplaces without protocols put everyone at risk—including patients, clients, and the public.

From an OHS management standpoint, the absence of a policy is itself a hazard. It creates uncertainty, inconsistency, and moral injury. Workers are left to guess what is acceptable. Supervisors are left to enforce unwritten expectations. And when something goes wrong, blame is assigned after the fact. That is the opposite of due diligence.

Training and Competency in Violence Response

This case also raises questions about training. Was the nurse ever instructed on how to handle combative pediatric patients? Did she receive refresher training on de-escalation, restraint, or medication administration under duress? If not, then the hospital not only lacked policies but also failed in its training obligations.

Across Canada, competency training standards require workers in safety-sensitive roles to have knowledge, instruction, and supervision appropriate to their duties. For healthcare staff, that includes training on workplace violence prevention. But competency is not just about knowing what to do; it is about having clear procedures to follow. A worker cannot be competent in a policy that does not exist.

Refresher training is also critical. Violence response practices evolve, and best practices in restraint and de-escalation shift as research advances. Without refresher training, even experienced workers may rely on outdated methods.

The Intersection with Workplace Violence Protocols

So what should a workplace violence protocol cover? This case shows that policies must address not only general threats but also specific scenarios. In healthcare, that includes handling minors, patients under duress, and emergency interventions.

The key is not to create vague statements like “staff must not abuse patients.” Instead, protocols should detail what methods of force are permitted, under what conditions, and who has the authority to approve them. They should also clarify alternatives, such as when chemical restraints may be used, when to call security, and when to defer to physicians.

Without such detail, each incident becomes a subjective judgment call. That is what happened here, and it placed both the nurse and the hospital in a legally indefensible position.

Questions This Case Raises for OHS Managers

1. Can you discipline staff for violating an unwritten rule?

The arbitrator’s ruling suggests not. Without a written policy, the nurse’s actions could not be judged against an objective standard. For OHS managers, this reinforces the need to document expectations clearly.

2. What happens when workers must improvise?

Improvisation is inevitable in emergencies. But when workers improvise in a vacuum of policy, outcomes are unpredictable. The risk of harm rises, and so does the risk of legal disputes.

3. How should violence protocols balance worker safety and client safety?

This is the heart of the challenge. Workers must be protected from assault. Patients must be protected from excessive force. A well-designed protocol recognizes both sides and provides clear, defensible guidance.

4. How do different provinces approach workplace violence protocols?

While all jurisdictions require violence policies, the specifics vary. Ontario requires written policies and programs. Alberta emphasizes hazard assessments. BC requires violence prevention policies and worker training. National employers must reconcile these differences while meeting the highest standard.

Audits and Oversight

As with other elements of OHS, violence protocols must be audited. It is not enough to create a document and leave it on a shelf. Regular audits should ask: Are staff trained and refreshed? Do incident reports show consistency in how protocols are applied? Do workers understand the limits of acceptable force?

JHSCs have a role here too. Committees should review violence policies, monitor incident reports, and make recommendations. In fact, involving worker representatives in protocol development is key to credibility. If workers feel excluded, they may disregard policies as impractical.

The Human Factor

The nurse in this case was caught between professional duty, personal judgment, and a chaotic environment. She chose a method that the hospital later judged harshly, but in the absence of rules, she believed she was acting in the patient’s interest. That is a heavy burden for any worker.

This is where OHS managers must look beyond compliance. The goal is not only to protect the employer from liability but also to protect workers from being placed in impossible situations. Clear protocols are a form of support, giving workers confidence that they are acting within boundaries. Without them, every decision carries personal risk.

Building Resilient Workplace Violence Programs

The lesson from this arbitration is not that discipline is impossible, but that discipline must be anchored in policy. For OHS managers, building resilience means:

• Writing detailed, scenario-based violence protocols.
• Training workers on those protocols, with refreshers as needed.
• Auditing implementation regularly.
• Involving JHSCs in reviewing and updating policies.
• Communicating policies clearly so workers know the boundaries.

These are not just administrative tasks. They are part of creating a safety culture where workers feel supported, patients are protected, and organizations avoid preventable disputes.

Conclusion

The Ontario arbitration on patient abuse termination is a stark reminder that workplace violence protocols are not optional. Without clear written rules, workers are left to improvise under stress, and employers cannot justify discipline when outcomes go wrong.

For Canadian OHS managers, the takeaway is urgent. Violence in the workplace—especially in healthcare—is inevitable. The only question is whether your organization will meet it with clear, defensible procedures or leave workers to guess. Policies, training, audits, and committee involvement are the tools that transform chaos into control.

This case shows the cost of failing to provide them: legal defeat, damaged trust, and workers left exposed. The better path is to build robust violence protocols that protect everyone—workers, patients, and the integrity of the workplace itself.