Emergency Psychiatry: A Review of Assaults by Patients Against Staff at Psychiatric Emergency Centers

Assaults by patients against service staff at psychiatric emergency centers are both a reality and a concern. The effects of violence can be devastating to the employee victim. Some staff rationalize that violence is an occupational hazard and believe that they should be able to cope with it. Despite these beliefs, staff victims suffer from many of the same physical and psychological sequelae as victims of natural disasters or street crime (1,2). In this column, we briefly review the epidemiology and effects of violence on staff victims and describe critical incident stress debriefing as a possible component of treatment for staff members who have been involved in violent incidents.

Epidemiology

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.

Sequelae of violence

As interest in violence against hospital staff has developed over the years, it has been recognized that victims in the medical profession react in ways similar to victims of other traumatic experiences (1,2). Victims of assaults by patients may develop physical or psychological injuries as a result of the assault.

A study by Carmel and Hunter (3) found that about two-thirds of the injuries to staff occurred during containment procedures, and one-third were the result of random assaults by patients. During containment, the most common injuries to staff were to extremities, whereas random assaults were more likely to produce head injuries. The majority of staff who suffered injuries either missed days of work or were assigned to limited duty as a result of the injury (3).

In a survey of 40 nurses who had been randomly assaulted by a patient, 21 percent of the respondents reported suffering life-endangering or multiple injuries, including fractures, lacerations, bruises, and loss of consciousness. Forty-five percent of respondents had taken time off from work as a result of the assault, and of these, 65 percent required one week to one year to fully recover. This study also revealed that at least 30 percent of those surveyed experienced anger, anxiety, and fear as a result of violent encounters. Victims also reported symptoms suggestive of posttraumatic stress disorder (PTSD), such as increased startle response, changes in sleep patterns, increased body tension, and generalized body soreness (4).

These findings were corroborated by a study by Mahoney (8), which found that 52 percent of the more than 1,000 nurses surveyed reported that an assault by a patient had resulted in adverse effects on their job performance. Almost 35 percent of those who were assaulted said that the effects lasted until the end of the shift, 12 percent that they lasted up to one week, 3 percent that they lasted up to one month, and 3 percent that they lasted as long as a year. The predominant emotional responses were anger, anxiousness, a sense of helplessness, loss of control, and increased irritability. Victims reported increased body tension, headaches, and difficulty sleeping. Social repercussions included fear of patients, changes in coworker relationships, and fear of strangers.

In an attempt to determine the incidence of PTSD among staff members who had been victims of violence, Caldwell (1) found that 138 of 224 clinical staff members reported a critical incident, and 137 experienced symptoms such as intrusive thoughts or increased emotional reactivity. Ten percent of the victims would have received a diagnosis of PTSD according to DSM-III-R criteria.

Treatment for the staff victim

A variety of treatment options are available to staff members who have been victims of assault by a patient. Initially, all physical injuries need competent medical attention. In addition, the victims and witnesses, if any, should file incident reports (9). Because an assault may have both long-term and short-term psychological consequences for the victims, prompt psychological intervention may be beneficial (1,9,10). One form of intervention, known as critical incident stress debriefing, aims to assist recovery by reducing the victim's symptoms of distress, enhancing and supporting emotional expression, and encouraging victims to vent their feelings. Evidence suggests that this type of intervention may reduce the detrimental effects of traumatic events (2,11).

Critical incident stress debriefing

Goals

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).

Implementation

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.

Phases

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.

Conclusions

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.

Dr. Erdos is a psychiatric intern at 1 Boston Medical Center Plaza, Dowling 7s, Boston, Massachusetts 02118 (e-mail, [email protected]). Dr. Hughes, who is editor of this column, is associate professor of psychiatry at Boston University School of Medicine and medical director of Dr. Solomon Carter Fuller Hospital in Boston.