clinician safety

EMERGENCY PSYCHIATRY 0193-953>(/99 $8.00 + .OO

CLINICIAN SAFETY

James Robert Brasic, MD, MPH, and Douglas Fogelman, MD

Violence is a serious occupational hazard in health care workplace~.*~, 55, 87, 132 Front-line health care workers, including nurses, physicians, psychologist^,^^, 44 social 44 pharmacist^,"^ home health aides, and health professional students, face constant risk for assault by patients on a daily basis. Understanding the basic principles of clinician security enables workers to safely provide compassionate and effective care.

This article discusses the assessment of violent patients, emphasiz- ing not only patient risk factors for violence but also clinician traits that increase and decrease the risk for assault. The use of verbal and pharmacologic interventions with acutely violent individuals is dis- cussed. Finally, issues related to the prevention of assaults on staff, such as the implementation of training programs and the creation of a safe physical setting for patient care, are addressed. This article does not deal with the legal aspects of clinician assault and its prevention; the use of physical restraints; the acute and long-term assessment and treatment of clinicians who experience verbal, psychological, sexual, and physical violence; and the issues of clinician safety with special populations, such as pregnant women and prisoners.

The cooperation of the Health and Hospitals Corporation of the City of New York is gratefully acknowledged.

From the Comprehensive Psychiatric Emergency Program ORB), and the Psychopharma- cology Clinic (DF), Bellevue Hospital Center; and the Department of Psychiatry, New York University School of Medicine (JRB, DF), New York, New York

THE PSYCHIATRIC CLINICS OF NORTH AMERICA

VOLUME 22 NUMBER 4 * DECEMBER 1999 923

924 BRASIC & FOGELMAN

VIOLENCE IN CONTEMPORARY SOCIETY

Violence among children, adolescent~,~~ and adults is a growing public health pr~blem.~, l2 Unconventional beliefs, such as the notion that violent acts are normal and appropriate, as well as poor relationships with parents and teachers, are hypothesized to result in an amoral subculture of vi~lence,~ typically in poor, adolescent males26 in small cities and in large urban Among juvenile delinquents, persons with criminal histories are more likely to commit crimes.41 Although youths may seek gang membership for protection, they typically encoun- ter more violence after joining ga11gs.5~ Several theories, including neuro- biologic hypo these^,'^^ have been proposed to explain14, 27, 47, 56 adult interpersonal assault and physical aggression toward other persons, resulting in morbidity and m0rta1ity.l~~ The insights to the origins and results of violence provided by social, anthropologic, psychoanalytic, artistic, and other humanistic disciplines are beyond the scope of this article.

Untreated mental disorders, especially substance-induced disorders, are frequently associated with violent acts. The use of alcohol7, 14, 67 and drugs has been observed in victims26 and perpetrators of violence.z, 33, 35,

91, lo2, 133 The combination of mental disorders,2o* 45, 69, 90, lol, lo2, noncompli- ance with prescribed medication and clinical appointment^,^', 129 and the use of and other substances102 are associated with severe violent acts in community ~ettings.'~, 112, lZ2

VIOLENCE IN HEALTH CARE SETTINGS

Assaults on health care workersz7* 31, 'I3, 133 constitute a significant threaP, l 3 I to the day-to-day functioning of health care businesses. Vio- lence in health care environments is typically precipitated by drug and alcohol use by the patient,'" 33, 91, 129 other mental disorder^,^', lz9 home- lessness, gang warfare, frustration caused by overcrowding and long waits, and worries about medical expenses.60 Clinicians can occasionally predict which psychiatric inpatients will exhibit violence.94 This article characterizes the locations, victims, and perpetrators of assaults.

Location of Assault

Most assaults on health care workers occur in emergency departments (EDs).* Despite the low patient volume, violent incidents are likely to occur in EDs at night.lo6 In addition, violent incidents in EDs are likely to involve patients in police custody and patients requiring medical and psychiatric c1earance.lo6 Violent confrontations are also in-

*References 6, 33, 44, 58, 59, 76, 86, 91, 105, and 133.

CLINICIAN SAFETY 925

creasing in I C U S ~ ~ and psychiatric inpatient geriatric psychiatric units.lls

64, lZ9, 139 especially

Profession of Victims

Physicians

E D s , ~ ~ are likely to be assaulted.8, 113

Physicians in large regional general hospitals, particularly those in

Mental Health Care Providers

Mental health care providers in general are likely to be assaulted on the job." 85, 132 In a survey of assaults on approximately 7000 government employees, 50% of mental health care providers were assaulted at

Psychiatrists

Patient assaults on psychiatrists are common. Surveys have deter- mined that as many as half of psychiatrists studied have been as- ~au l t ed ,~~ , 46, 48, 89, 117 particularly at the beginning of the residency.2s, 34,

59,100 Assault by patients59 and families39 is likely to be directed toward young physicians who are early in their medical careers.

Psychiatric residents are especially vulnerable to physical and sexual assault by patients. Resident physicians with a high risk for assault by patients include those who are highly irritable, speak up when angry, or fight in physically threatening ~ituations."~ Resident physicians report that patient assaults often were provoked.34, 89 Resident physicians have indicated that causes of assault usually can be anticipateds9 and include inappropriate facilities, inadequately trained staff, and psychopathic and intoxicated patients. Assault against psychiatric residents is common in EDs and acute psychiatric inpatient units. Assault against psychiatric residents typically occurs in interview rooms containing dangerous objects and lacking outward opening doors, accessible alarm buttons, and visual and auditory monitoring. Assault on psychiatric residents charac- teristically occurs when the residents are pressured to dismiss police officers in order to conduct interviews unassisted and when emergency buzzers yield tardy responses by untrained, small, elderly security officers. Assault on psychiatric residents also is likely on psychiatric units staffed solely by women at night.34 Residents reported experiencing fear of patients who admitted that they carried knives. Residents indicated that requesting that the department and the hospital decrease assault on residents led to the accusation that the residents were troublemakers. Residents did not report some assault because of shame, guilt, fear of blame, and denial. Threat of violence or completed assault by patients is often the most upsetting experience of a psychiatric residency.30, 78


Psychiatric trainees often feel unsupported by staff, colleagues, and super- visors during and after assaults or threats of assault by patients.3O. 78, 79

Countertransference reactions by clinicians to violent patients can have an adverse effect on the assessment and treatment of patients. A psychiatrist may experience anxiety, fear, anger, and helplessness in response to assault by a patient. Defense mechanisms used by psychiatrists working with violent patients include denial, projection, and identification. Projection may lead clinicians to overreact. Denial may prevent psychiatrists from obtaining important historical information related to the potential for violent behaviorss and from reacting appropriately to potentially violent patients with possibly disastrous consequencesP

Case report: A 48-year-old man with obsessive-compulsive, psychotic, and schizoid traits presents with anxiety and delusions of perse- cution and reference. His psychiatric resident prescribes cognitive behavior therapy and psychopharmacology until the patient incorporates the resident into his delusional system and threatens him.

Nursing Staff Nursing staff are likely to fall victim to assault by patients,* espe-

cially in EDs~~, 33, 59, 76 and psychiatric hospitals.63* 85, lo7 In psychiatric hospitals, nurses are victims of as many as 90% of assaults.138 Nurses on inpatient psychiatric units in public hospitals are likely victims of as- ~aul t .~ , 99, 114, 115, 137 Assault on nursing staff by psychiatric patients commonly occurs during the administration of medication and the use of physical restraint^.^^ Nurses in psychogeriatric units are especially likely to be assaulted by patient^.^, 11, 137

Several theories have been proposed to explain assault on nurses.56, 84, 92, 97-99 Student nurses and other younger and inexperienced nursesz7 with poor communication skills are especially likely to experience violent assault from patients.137 Femalelo3 and male7 nurses and aides are vulnerable to assault. Violence is more commonly experienced by nurses who smoke cigarettes, drink coffee at work, use alcohol after work to relax, and are dissatisfied with work.7

Home Health Aides Home health aides typically work in private residences.lo3, 128 The

relationship between a home health aide and the client is often a special alliance that isolates health care workers from others, creating opportuni- ties for assault.lo3 The presence of weapons, vicious animals, and violent individuals in the home threatens the welfare of home health aides.72, 128

Home health aides may benefit by requiring that patients contract to notify the aides immediately if patients feel like assaulting the aides.”

Social Workers

workers are more likely to become victims of attack by patients.62, 13*

Social workers are likely to be assaulted at work.44 Younger social

*References 5, 8, 31, 44, 53, 61, 83, 85, 96, 113, 114, 120, 123, 132, 136, and 137.


Patient Characteristics Predictive of Clinician Assault

Caution must be exercised when using past events in an attempt to predict future violence among patients.111,121 The demographic class most likely to assault clinicians is unemployed young (< 40 y) men33 of low socioeconomic status.* Historical patient characteristics predicting clinician assault include:

First visiP History of violence4, 5. 10. 14. 43, 45, 60, 93, 102. 137

Job 1 0 ~ ~ 4 3 , 52. 132, 133

Poor therapeutic alliance13 Previous incidents of clinician assaulP2, 77, 82

Treatment non~ompliance~~, 122

Several reasons have been identified to explain the assault of clinicians by patients:

Denial of admission sought by patient Involuntary hospitalization of an unwilling patient Retaliation for unfavorable outcomes133 Robbery for drugs, medical equipment, money, and jewelry133 Setting limitss9, lZ4

Problematic clinician-patient relationship manifested by repeated assault of same patient on same clinician138

Among the principal symptoms predicting assault on clinicians are:

lo2 (including perse~utory~~) Delusionsz3, 42, 51,

Hall~cinations~~, 93, lo2

Plan to assaulP3, 51

Pain76 137

Recent threat to assault% 5,43, 51, 71, 73, 76, 77,94,102. 104

Many signs characterize patients likely to assault clinicians. These include:

Anger4, 42, 43, 51, 76, 86, 102, 135

Catatonia102 Chanting33 Clenched jaw76, lZ6

Confusion42, lo2

Demanding immediate attention5, 76

Excitementy3 Flared Flushed face5 Hands lZ6 or gripping5, 43

Hostility42, 51, 93 Impulsivity4, 42, 43, 51, 67, 82, 104, 120, 130

*References 3, 33, 45, 48, 60, 70, 76, 89, and 102.

928 BRAS16 ((r FOGELMAN

Intoxication with alcoho14,5,10, 33,41, 42, 51, 71. 82, 91, 109,112, 113, 135

Intoxication with stimulants5,24,33,42 Jealousy42, Io2

Overactive5, 137

Pointing33 Possession of a weapon5, 51, 71.77

Pushing furniture5 RestlessnesslZ6 ScarslZ6 Shouting33 Slamming objects5 Staring eyes33, Sudden movements33 Suspiciou~ness~~ Tattoos126 Tension93, lZ6

Uncoopera t i ~ e n e s s ~ ~ Widened eyeslZ6

Loud5 43. 86, 137

Pacing33, 86, 126

Specific mental, neurologic, and medical disorders are also associated with clinician assault and include:

Paranoid schizophrenia116

Bipolar disorder63, 119, 135 (manic phase868 93)

Mental retardation5, 27, 40, l02,137

Paranoid psychosis18,117

Alcohol intoxication33,

Substance into~ication~~, 44, 86

Mental

(de~ompensated~~) SchizophreniaZ9,45,48, 60, 86, 89,102,112, 123, 133, 134

Dementia5 18, 27, 40, 86

Personality disorder5 44. 48, 50. 60. 65, 68, 86, 102, 120, 133, 135

Alcohol withdrawaI5. 14, 24, 60. 67,86, 112, 135

Anabolic CocainelZ5 AmphetamineslZ5 Phency~lidine'~~

Substance withdrawal5, 14,43. 6or86, 112, 135

Post-traumatic stress disorderu Learning

Neurologic Brain infectionlZ5

Brain lesionss0 Diffuse80 Hypothalamusso


Multisiteso Orbitofrontal cortexso

Brain tumor125 Cerebral infarctionIs. 93

Fungal meningitis93 Head injury43,

IntracerebraP Subarachnoids6 Subdurals6

Hepatic encephalopathys6 Huntington diseaselZs Limbic encephalitislZs Multiple sclerosiss6 Parkinson diseases6 Seizure 80,

Interictalso Postictals6 Temporal lobe epilepsys6

Wilson diseaselZs

End~crinopathies'~~ Medicals6

Cushing syndrome86 Hyperparathyr~idism'~~ Hypo thyr~id ism'~~ Thyrotoxi~osis~~~

Infectionss6 AIDSs6 Syphiliss6 Tuberculosiss6

Medications (lamotriginels) Metabolic disorders

Anoxias6 Electrolyte imbalances6 Hypochole~terolemia~~ Hypoglycemias6 Hypoxias6

Hyperthermia& Hypothermias6

Manganese12s Organophosphate~~~5

Folic acid deficiencylZs Niacin deficiencylZ5 Pyridoxine deficiencylZ5 Vitamin B,, deficiency12s

Temperature abnormalities

Toxins125

Vitamin deficiencys6,


PREVENTION OF CLINICIAN ASSAULT

Because violence in health care settings is often under-reported,lo6 reliable and valid2I mechanisms must be established for the accurate and complete reporting of violent incidents against staff. Mandatory reporting of all known or suspected incidents of violence may be necessary to realize the magnitude 9f the problem. Effective plans to prevent violence in health care facilities require a correct estimate of the full extent of threats and assault toward health care professionals. Adminis- trators must address the reasons for failure of staff to report violence including denial, shame, fear of blame, lack of administrative support, and the belief that assault is a normal part of the job.34 Employers have a responsibility to produce and maintain a safe working envir~nment. '~~

66, 95 a complete evaluation, including current neuropsychiatric symptoms and signs, and a detailed past psychiatric history, including violent behavior, are crucial. Careful physical examination and laboratory studies are essential to rule out the mental, neurological, and medical disorders (mentioned earlier) associated with violence, as well as other organic causes of agitation, including:

To attempt to identify individuals prone to violence,1,

Blood indices Cerebrospinal fluid evaluation Tests for syphilis Chemical assessments of blood

Ca++ Ceruloplasmin Creatinine Electrolytes Ethanol Folic acid Glucose Hepatic function tests Thyroid function tests Urea nitrogen Vitamin B,,

HIV testing Radiologic studies

Chest radiograph MR imaging of the head with contrast

Serologic tests for syphilis Tuberculin skin tests Urine

Urinalysis Toxicology

Amphetamines Benzodiazepines Cocaine Methadone Opioids


Emergency assessment of potentially violent individuals may include electroencephalography, lumbar puncture, and MR imaging of the head with contrast to rule out treatable disorders.lZ6

When interacting with individuals who may be violent, clinicians should use strategies to minimize the risk for patient assault, including:

Keep rival gang members in different geographical 10cations.~~ Never release the names, addresses, telephone numbers, or other

Practice an evacuation plan.25 Prohibit the use of alcohol and drugs in the health care facility,

such as randomly sampling the urine of patients and staff for substances.16, 133

Require potentially violent patients to wear hospital gowns to check their clothing for weapons.70, lo5

Report in detail and investigate all threatening or suspicious inci-

Require that all staff wear photo identification badges.3l. 43, 50, 60, 76, lo5, 133

Search all Train staff about ~e1f-defense.l~~

Always be polite and respectful to patients.22, 24, 59,

Be calm.4, 33,124

Avoid constant direct eye contact with potentially assaultive pa- t i e n t ~ . ' ~ ~

Be empathic.49, ST

Do not turn your back on patients.22, 59

Give clear Keep a distance from patients.76, lo5

Leave exits clear.22, 59, 76, lZ8

Listen to patients.lZ4 Remove from your person items that could be used as weapons,

including stethoscope, jewelry, neckties, pens, and flashlight^.^, 59, 76,

Show ~0ncern . l~~ Use beepers and two-way radios to alert staff and police of potential

Use nonthreatening body language.64 Use reflective ~tatements .~~

Assign armed police to patrol parking lots and building Brightly light adjacent parking spaces and exteriors.l13, 133

Hire well-trained, experienced security 58, 76 to use metal detectors for all persons entering the health care facil-

Administrative

identification data about staff.43

dents.50, 105, 133

Behavioral lZ4, lZ6

assault.63,

Environmental

ity.43, 58, 59, 105, 113, 133

Install protective plexiglass in all patient areas.5840, lo5,

Install high-fidelity television monitors and other security equip- 133

ment.25, 31, 33, 58, 60, 63, 70, 76, 77, 113, 133


Install metal poles around the entrance to prevent vehicular entry.lo5 Install safety alarms ("panic buttons") and educate all staff about

Limit access to all clinical areas.5o, 58

Lock all hospital entrances at night.43, Io5

Maintain at least two exits for all consulting and examining

Maintain spacious, attractive, well-lit waiting areas for clients and

Post armed security guards inside and outside of entrances.'05

All staff in departments with a high risk for assault should be

their use.33, 43, 58, 60, 76, 113, 133

rooms.50, 63, 113

visitors.33, 43

trained in the short-term management of violence.87, lo7

STRATEGIES FOR HANDLING ASSAULTIVE PATIENTS

Verbal and Physical Strategies for Assaultive Patients

Several verbal and physical strategies are recommended to handle clinician assault. These strategies must be practiced regularly during in- service training programs for clinicians at risk, and they include:

Verbal assault Answer all questions simply and honestly.60 Be empathic.49, Keep hands still and ~ is ib le .~ Keep the door open.5

Respond to the individual verbally with firmness, calmness, and

Speak softly.5, 22, 96, 124

Stay at least an arm's length from the ~ e r s o n . ~ Stay to the side of the p e r ~ o n . ~ Use nonthreatening body language.64 Use reflective ~taternents.~~

Call for help.48 Deflect a kick with your legs.124 Deflect punches with the palms of the hands.124 Escape.48, lo7

Face the person sideways, not face to If bitten, do not pull away the bitten part. Instead, force the bitten

part to the mouth and nose of the biter to block respirati~n. '~~ If choked, tuck your chin closely to your chest to maintain your

airway and circulation.124

Remain calm.4, 5. 33, 96, 124

asserti~eness.~~, 133* 140

Physical assault

124


If the patient grabs your hair, use your hands to control the hands

Separate waiting areas from patient care areas by a security of the patient.l"

g~ard.33, 50. 133

Pharmacotherapy of Assaultive Patients

The diagnoses of patients determine the appropriate medications for the management of violence. Caution must be exercised when the history is unknown. Intoxication and withdrawal from alcohol, cocaine, stimulants, sedatives, heroin and other street drugs must be suspected in all violent patients until excluded by negative toxicologic screens of blood and urine. Medications must be used with extreme caution or avoided entirely in patients with known or suspected allergies to the administered agents. In addition, adverse effects must be considered, including long-term consequences, such as tardive dyskinesia. Agitated individuals who are intoxicated with alcohol or hypnotic sedatives can usually be safely treated with 2 to 5 mg haloperidol hourly as necessary for aggression. If the individual does not accept medications administered by mouth, then intramuscular injection may be used.

If intoxication with alcohol and other substance is ruled out, then doses of 5 to 10 mg diazepam or 1 to 2 mg lorazepam may be given by mouth hourly until the person is calm. For extremely agitated individuals, intramuscular injections of 5 mg haloperidol and 2 mg lorazepam usually produce tranquility. Patients given haloperidol and other neuro- leptics should be watched carefully for symptoms and signs of the potentially fatal neuroleptic malignant syndrome, which necessitates medical consultation and discontinuation of neur~leptics. '~~

CLINICIAN EDUCATION TO HANDLE PATIENT ASSAULT

Comprehensive training to handle violent patients74 should take place at the start of the employment of physician^,^^ psychologists, social workers, nurses, mental health staff, and hospital police. In one study, training nurses about patient assault reduced incidents of assault on a geriatric psychiatric unit.lls Staff education to decrease the likelihood of patient assault138 should include the following:

Early recognition of potential for aggressive behavior. Involun- tary commitment, repeated admission, and referral from public mental health facilities are predictive of patient assault.l16 Al- though clinical variables, including diagnosis, history of admis- sions, and referral source, are more strongly associated with violence than are demographic variables,l16 both classes of information should be considered while assessing the potentiaI for


violence among individuals. The potential for violence is greatest during a patient's first day in the ho~pital.'~ Because alcohol is associated with violent crimes in juvenile delinquents41 and 0th- ers,lo9 intoxicated patients, particularly those who have used alcohol, present a particular risk for violence. Typically, verbal provo- cation of a person who has consumed alcohol results in violence.1o9 Alcohol may act by suppressing normal inhibition of aggression and by psychomotor activation.lo9 Appropriate management and monitoring of violent patients and patients with a history of violence110 Effectiveness of education to increase safetyIoo

PHYSICAL SETTING

The safety and security of facilities for interviewing and treating

In EDs, interview rooms should be close to the nursing station. All interview rooms should have an accessible, functional alarm system that produces an immediate and appropriate response.133 No dangerous objects should exist in interview rooms. Furniture with rounded and padded edges133 should be fastened to the floor and the walls. Doors should open outward or revolve and should be unable to be locked from inside. Doors should not permit barricade and should have w i n d 0 ~ s . I ~ ~ Staff must provide constant visual and auditory monitoring of interview rooms. Sleeping quarters and offices for clinicians must be secure from unauthorized intrusions. A restraint policy should be explicitly formulated. Restraints should be available in areas where violence could occur. An easily identifiable alarm code should be used to indicate potential or actual assault.loO

patients should be ensured by the following.

STRATEGIES TO DEAL WITH ASSAULT

Administration

As far as hospital administration is concerned, an authority must be responsible for following up incidents of violence. Prompt, formal documentation and reporting of assaults should be mandatory. Clear guidelines must be used to follow-up and support assault victims. Resi- dents and other trainees must not be assigned to facilities with inappropriate safety standards. Residents and other trainees must not be coerced to see potentially violent patients without maximal safety standards.100


As far as hospital staff are concerned, appropriate security personnel must be available for patients with a history of or the potential for violence. Police who bring violent patients into the hospital should be requested to be present until the assessment is completed or until ade- quate hospital staff take over. Trained and capable staff must be available to respond to assault at all times.

ACKNOWLEDGMENTS

The authors are grateful to David Nardacci, MD, Leah Kramnick, CSW, Waguih W. IsHak, MD, Martha Scotzin, PhD, and Margaret OBrien, MA, for their comments, correc- tions, and suggestions on earlier drafts of this article.

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