Psychiatric Patients’ Assaults on Staff: A Worldwide Review, 2017-22


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It happened again last night and several more times today. You wouldn’t know that of course. The media did not report it, politicians ignored it, and there are no specific protest groups addressing it. Again, you wouldn’t know about it. Yet it did happen. It actually happened many times. All over the world. Some psychiatric patient has assaulted his or her healthcare provider. These patient assaults are a serious part of the volume of violence that occurs in society every day and are very real and very painful for employee victims.

In two previous blogs (1,2), I reviewed the published literature on this often-overlooked form of violence against others: from 2000 to 2017. The findings were fairly uniform throughout these years. The victims were largely nursing personnel who were in their late-third decade and had an average 8 years of experience. Since nurses spend more time on the wards, they have more patient interactions, and provide several hands-on medical services for the patients. Hence, the possible increased risk. For clinicians and facility managers seeking to reduce this risk to nursing, a basic question occurs as to whether these research findings are in fact accurate. Are nurses really at an actual increased risk?

The two previous reviews (1,2) raised questions about the accuracy of these findings. In many of the studies that were reviewed, there were differing definitions of patient assaults. Whereas most included physical assaults, studies usually excluded nonverbal threats (e.g., damage to property) and oral/racially derogatory threats. In addition, there were a variety of ways in which the assault data were collected from surveys, quality-of-work questionnaires, and incident reports. Apart from incident reports completed at the time of the assault, the other approaches are subject to selective memory of events and to memory decay over time. The studies were often retrospective in nature rather than prospective studies over time. Few studies assessed severity, so that a patient who was screaming would be recorded in the same way as a physical assault that resulted in medical injury. Clearly, these problems impair accuracy and make possible interventions by clinicians and managers more difficult and problematic.

The present blog (3) continues where the previous left off and reports the medical/scientific data on patient assaults from the next five-year period, 2017-22. The studies cited in this review are from international institutions, appeared in English, and included psychiatric-inpatient, outpatient, emergency room, and community settings. The subjects were adult patients from countries all over the world, including developing countries such as Botswana, Ghana, and Nigeria. Forensic patients were included. Child, adolescent, and special-population studies (e.g., autism) were excluded.

In the 2017-22 review period, 24 research studies meet the above criteria. There were 39,034 assaults perpetrated on 34,679 staff victims. These victims, as noted, were primarily nursing personnel, with 12% of the victims being male and 88% female. Overall, these employees were on average 37-years old with 10 years of experience. They were not primarily new-hires. The number of female victims for this 5-year period is again significant and may be understood in at least one of three ways. First, this finding may be an artifact of the studies’ research designs noted above, the concerns clinicians and managers fear. This could happen in any number of ways. For example, it might be that some studies were voluntary in nature and that many male employees declined participation. Second, this finding of increased female victims may be factually accurate in that there were in fact more female victims. Third, this finding may also reflect a form of violence against women. If the second or third explanation is accurate, there is enough accuracy for clinicians and managers to implement some basic interventions. They could add more male staff on the units; have campus security present on high-risk units, such as the emergency room and high-acuity forensic units; and provide refresher safety trainings for employee staff. Nursing unions could also raise the issues of female victims of violence with their media contacts.

Several of these studies (60%) requested further training in aggression management. These facilities could include additional trainings in nonviolent self-defense, trauma-informed care, de-escalation, and some system of nonviolent self-defense. Since some of these requests are being voiced by the developing countries. It may be helpful to create an online website to serve as a repository for these types of trainings that are in the public domain. This website would serve as a resource for those facilities where onsite resources may be more limited. The various training manuals could be adapted for local agency needs.

Finally, 40% of these studies also request support services for employee victims. There is one program in the published literature on this matter. It is known as the Assaulted Staff Action Program (ASAP) (4). It is a voluntary, system-wide, peer-help crisis-intervention program to assist staff victims with the psychological aftermath of patient assaults. In its 34 years of continuous service it has provided services to over 10,500 employee victims on 45 teams in 9 U.S. states. ASAP has been chosen as an innovative practice by the governments of the Province of Ontario, Canada, and the federal government of the United States.

Patients’ assaults on staff will continue and research designs will continue to improve, yet as noted there is sufficient accurate data now to provide both helpful strategies to reduce the risk of onset and to field needed post-incident support services for these employee victims. It would be helpful if this form of human suffering were also noted in the media so as to raise public awareness of this issue.

References

1. Flannery, R. B. Jr. “Staff Victims of Psychiatric Patient Assaults: A Worldwide Perspective.” January 16, 2015.

2. Flannery, R. B. Jr. “Precipitants to Patient Assaults: A Worldwide Review, 2013-17.” February 9, 2018.

3. Flannery, R. B. Jr., Flannery, G. J. “Characteristics of International Staff Victims of Psychiatric Patient Assaults: Review of Published Findings, 2017-2022.” Psychiatric Quarterly, 2023.

4. Flannery, R. B. Jr. The Assaulted Staff Action Program (ASAP): Coping with the Psychological Aftermath of Violence. Riverdale, NY: American Mental Health Fdn, 2012.

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Dr. Raymond B. Flannery Jr., Ph.D. FACLP, 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: elomke[at]americanmentalhealthfoundation.org.

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