(This is the second of two companion essays on assaultive psychiatric patients. The first focused on the characteristics of patient assailants. This second essay focuses on staff victims. The interested reader will want to read both essays to have a comprehensive understanding of this worldwide problem.)
Psychiatric patient assaults on healthcare staff are a worldwide occupational hazard.1 These assaults may result in death, permanent or temporary disability, medical injury, intense psychological fear, increased costs in medical/legal expenses, increased utilization of sick leave, lost productivity, and staff turnover. These assaults include physical assaults (any unwanted physical contact with intent to harm), sexual assaults (any unwanted sexual behaviors), nonverbal intimidation (using objects rather than words to communicate anger), and verbal abuse/racial epithets (verbal statements meant to frighten staff). All healthcare staff are at risk of patient assaults, especially nursing personnel who have the most contact with patients.
In the international research published on staff victims in the 1990s, 18 studies documented 4,302 staff victims. Of these, 1,399 were male staff and 2,903 were female staff. These assaults occurred in all types of healthcare settings: emergency rooms, inpatient wards, outpatient clinics, day programs, and community residences. All disciplines and job groupings were at risk, with nursing staff at greatest risk.
The first decade of the present century has seen the fielding of a wide variety of policies and procedure to provide cost-effective, high quality care in safe environments. New initiatives have included advances in psychopharmacology, improved rehabilitation services, restraint-reduction initiatives, increased forensic assessments and services, and more flexible community-based residential programs. These initiatives have been in response to specific patient deficits and needs.
In this short essay, we ask several basic questions: What are the current worldwide characteristics of staff victims of patient assaults? In the first decade of the present century, do these characteristics differ from the characteristics reported in the previous decade? Thirdly, did the new policy initiatives to increase safety and reduce violence in fact achieve the results? We shall focus first on the worldwide studies as a whole and then the studies for North America and Europe. Our review will close with some suggestions to enhance staff safety and to address the psychological sequelae in staff victims of patient assaults.
The International Findings
From 2000 to 2012, there were 28 published studies worldwide that documented 17,220 assaults on 17,043 staff victims. There were 7,284 male and 9,485 female staff victims.2. Their average age was 37 years and they had an average 7 years of experience. Both male and female staff were at equal risk. The most frequently requested resources to assist with patient assaults were being taught the warning signs of loss of control, being taught various coping strategies (e.g., de-escalating patients verbally, restraint-free interventions), and post-incident crisis counseling.
Even though many patient-staff assault are never reported and, thus, remain undercounted, the research time frame of these published 28 published studies varied from 1 month to 240 months for a total time of observation and data gathering of 66.75 years. In these 28 studies 2 no study made any reference to staff-victim assaults and any of the new policy initiatives meant to reduce such violence.
The North American Findings
There were 11 published studies in North America that reported 8,048 assaults on 10,622 staff victims. In those studies that reported gender there were 5,093 male and 5,529 female staff victims. Both male and female staff were at equal risk for assault. The research time frame in these studies was 56.91 years.
The European Findings
There were 13 European studies that documented 8,112 assaults on 4,857 staff victims. In those studies reporting gender there were 1,753 male and 2,830 female staff victims. Both genders were at equal risk for assault. The research time frame was 8.58 years.
Other Continents’ Findings
Four other continent studies reported 1,060 assaults on 1,564 staff victims. Those studies reporting gender documented 439 male and 1,125 female staff victims. Male staff was most at risk (especially as victims of repeated assaults). The research time frame was 1.25 years.
A Worldwide Perspective
This worldwide research clearly documents the extent of this patient violence as an occupational hazard and is similar to the research findings of the 1990s. Whereas many assaults result in soft tissue injuries, many are more violent and result in significant medical injury and intense psychological fear. Yet, the research on staff victims is one-fifth that of patient assailants.1 In addition, staff victims’ research varies greatly in extent in various countries. The North America and European findings are many and are likely representative of staff victims. The research from the other four continents is so sparse that no firm conclusions may be drawn.
Many studies, especially those in the United States, present far more information on the characteristics of staff victims and included information of discipline, job grouping, specific type and severity of assaults and time of occurrence. The worldwide research community needs to design one, comprehensive, basic research design that includes the common salient variables to be assessed in each study so that findings from different countries can be more readily compared. In addition, at least two other major research issues remain unaddressed. The first is the need for victim studies that are done in institutions that have the newer policies in place to reduce patient violence. In such institutions some form of pre-policy/post-policy data may help immeasurably in reducing the risk of violence. A second research issue includes staff-victim gender. In all crimes, except rape, males are the more likely victims; yet, these worldwide studies on patient assaults indicate an equal gender-victim distribution. Is it because more females are employed in healthcare than in other occupations? Is it because female staff have more hands-on patient responsibilities? Do patients view female staff as more vulnerable? Research is urgently needed to resolve this matter.
Post-incident Crisis Counseling
There are many currently available risk-management strategies to deal with patient assaults.3, 4 The major strategies have also been noted in the companion blog to this essay noted and linked above. However, one repeated request from victims worldwide is for post-incident crisis counseling to address the psychological sequelae to these patient assaults. This request is often unanswered.
To date in the published literature there has been one, consistent, cost-effective, clinically efficacious post-incident counseling program. It is known as the Assaulted Staff Action Program (ASAP)5 that has been fielded continuously for 25 years. ASAP is a voluntary, system-wide, peer-help, crisis intervention program to assist staff victims in addressing any psychological aftermath in the wake of a patient assault. When an assault occurs, the ASAP team member of the institution goes to the assault site and offers ASAP services. If the staff victim accepts, the ASAP team member provides crisis counseling and follow-up with the staff victim after 3 days and again at 10 days to be sure that the victim does not need additional services.
ASAP provides individual crisis counseling, group crisis counseling, a staff victim’s support group, family victim outreach, and referrals for any needed individual longer-term counseling.
To date, there have been 43 ASAP teams in 9 states with 2,025 ASAP team members who have responded to over 5,000 staff victim assaults by patients. ASAP has provided efficacious staff victim support and has been associated with declines in violence facility-wide in some institutions.6 ASAP has been chosen as a best innovative practice by the federal governments of Canada and the United States, and is manualized to serve the needs of other interested agencies.
Violence may occur at times but it does not come with the turf. A program of risk-management strategies3, 4 and post-incident ASAP interventions5 can enhance the safety and well-being of both patients and staff.
1. Flannery R. B. Jr., Wyshak G., Tecce, J., and Flannery, G. J. “Characteristics of international assaultive psychiatric patients: Review of published findings, 2000-2012.” Psychiatric Quarterly, 2014, 85: 303-17.
2.—. “Characteristics of international staff victims of psychiatric patient assaults: Review of published findings, 2000-2012.” Psychiatric Quarterly, 2014, 85: in press.
3. Flannery R. B. Jr. Violence in the Workplace. Riverdale, NY: American Mental Health Foundation, 2012.
4. —. The Violent Person: Professional Risk Management Strategies for Safety and Care. Riverdale, NY: American Mental Health Foundation, 2012.
5. —. The Assaulted Staff Action Program: Coping with the Psychological Aftermath of Violence. Riverdale, NY: American Mental Health Foundation, 2012.
6. Flannery, R. B. Jr., LeVitre, V. Rego, S., and Walker, A. P. “Characteristics of staff victims of psychiatric patient assaults: twenty-year analysis of the Assaulted Staff Action Program (ASAP).” Psychiatric Quarterly, 2011, 81: 11-21.
Raymond B. Flannery Jr., Ph.D. FAPM, Harvard Medical School and The University of Massachusetts Medical School, is an internationally recognized scholar and lecturer on the topics of violence, victimization, and stress management. Dr. Flannery is available for lectures and workshops for all types of groups and may be reached at The American Mental Health Foundation: 212-737-9027 or Email Evander.