Violent incidents in mental health centers and psychiatric hospitals are grossly underreported (
+3,
+4,
+5). Numerous studies have attempted to provide information about the frequency of assaults by patients against mental health staff. One review of the literature found that in a survey of 101 therapists, 74 percent had been assaulted at some point during their career; another study reported that 42 percent of the 115 psychiatrists at an academic center had been assaulted at least once (
+4).
Owen and colleagues (
+5) investigated the frequency and types of aggressive and violent behavior encountered in a psychiatric acute care setting. During the seven-month study, 174 patients perpetrated 1,289 incidents, of which staff members rated 58 percent as serious. Of the incidents rated as serious, 78 percent were committed against members of the nursing staff, 4 percent against physicians, and 2 percent against psychologists. The authors determined that the risk of violence by patients increased with the number of patients on the ward, the presence of patients with a history of violence, the number of female staff, and the number of staff with little or no psychiatric training.
In a survey of assaultive behavior in Veterans Health Administration facilities, Lehmann and colleagues (
+6) found that over a one-year period, a total of 24,219 incidents were reported at 166 treatment facilities. Physical assault accounted for more than a third of the incidents (N=8,552). Forty-three percent of the incidents occurred on inpatient psychiatric units; long-term-care units accounted for 19 percent of the cases and triage or admitting areas for 14 percent. Again, most of the injuries that were reported were sustained by nursing personnel.
A one-year study of emergency department staff found that 55 percent of 106 employees had been physically assaulted, 21 percent had witnessed physical threat or assault, 12 percent had experienced verbal abuse, and 10 percent had been physically threatened. Nurses and security personnel suffered the greatest number of incidents (
+7). A study of emergency department nurses found that 98 percent of the 1,209 nurses surveyed had experienced some type of victimization during their careers. The most frequently reported incident was verbal abuse, followed by threats and physical assault. Nurses in urban settings and male nurses were at highest risk (
+8).
Overall, the data indicate that the staff members who spend the most time with patients are at the greatest risk of experiencing an assault. However, every staff member who has contact with patients is a potential target of patient violence.
Although some studies have suggested that stress debriefing may increase the level of intrusive thoughts and avoidance in victims who are not ready to confront the incident, other evidence suggests that the availability of such programs and voluntary attendance are generally effective in reducing stress (
+2,
+9,
+10,
+11,
+12). Conceptually, the goals of debriefing are to help victims cope with the event by decreasing their feelings of helplessness and fear and to provide a supportive emotional atmosphere until the event can be effectively integrated (
+12,
+13).
For debriefing to be effective, a response team must be in place to assess victims after a critical incident. The team is an integrated group that consists of at least one mental health professional—a psychologist, a social worker, a psychiatric nurse, a psychiatrist, or a mental health counselor—who is specially trained in crisis intervention, stress, and PTSD. Peer counselors are also used to further ease the victims' burden. A team is usually deployed at the request of the service or department involved in the incident.
Debriefing is indicated after major disasters, unusual violent events, serious injury to a coworker, or other particularly difficult or stressful situations. Optimally, defusing occurs within one to two hours after the critical incident (
+11), but it should definitely occur within three days of the incident.
The process of critical incident stress debriefing usually comprises six phases, which typically are implemented over a three-hour period (
+11,
+12).
• Introduction: the group facilitator explains the purpose of the debriefing session and ensures confidentiality.
• Fact phase: the participants are introduced, and they describe their role in the incident. In this phase, an overall picture of the incident is provided; the individual participants' performances during the incident are not critiqued.
• Feeling phase: the participants discuss their feelings about the incident; emotional reactions are identified and shared.
• Symptom phase: the participants describe their physical and psychological symptoms, and their stress response is analyzed.
• Teaching phase: the group facilitator describes symptoms that the participants should look for in themselves and in others. Stress response and recovery are discussed further. Printed material about recovery and stress is provided.
• Reentry phase: the group facilitator provides final assurances to the participants, answers any remaining questions, reemphasizes the confidentiality of the meeting, and provides follow-up plans. Referral to further therapy may be provided.
The best approach to staff assault in the medical workplace is prevention. However, in high-risk areas such as emergency departments and inpatient psychiatric units there is no guarantee against patient violence. Direct caregivers are assaulted most often, but all members of the health care team are at risk. Evidence suggests that when assaults occur, the victims suffer not only physical injury but psychological trauma as well. Effective response teams and critical incident stress management programs may help reduce the long-term sequelae, worker burnout rate, and development of PTSD that can result from violent incidents. More research on the efficacy of debriefing is needed to determine its relative advantages and limitations.