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Assault in the Medical Setting: 3 Stages of Violence

Assault in the Medical Setting: 3 Stages of Violence

  • When clinicians work without ready access to a security team or environmental safety features, it is important to employ a standard process and screening tools to appropriately triage and anticipate violence. Clinicians who work alone, or who see patients after hours and on weekends, are particularly vulnerable. Early recognition of agitation is crucial to preventing or avoiding escalating behavior problems. This slideshow outlines the stages of violence (see Reference 8 here) and the levels of intervention required. View the slides in PDF format.

  • The risk of violence in psychiatric practice is a frightening aspect of our work. Violent events are uncommon and hard to predict. However, clinicians must guard against complacency and institute universal precautions that emphasize prevention. One way to do this is to understand the stages of violence, know what to look for, and enact appropriate levels of intervention in case of emergency. Noticing and acting on early warning signs such as pacing and frustrated affect can mitigate danger and open the door to help patients feel safe and stay in control.

  • Signs to look for: Nervous, angry, frustrated, or suspicious affect; pacing, restless, foot tapping, clenched fists; loud and fast speech with angry demands or profanity.
    Level of intervention: In medicine, safety is paramount. As a specialty, psychiatry seeks to help those experiencing extreme psychological distress and vulnerability. Although providers may be hopeful and well intentioned in their clinical encounters, violence against health care professionals is an unfortunate and disturbing reality. Provide space and a sense of safety. Call for back-up. Terminate the assessment if necessary. Providers might anticipate violence in the emergency department or an inpatient setting, but violence can occur anywhere.

  • Signs to look for: Clenched fists or jaw, glaring, sweating; menacing, posturing, invading space; swearing and demanding; specific threats and personal attacks
    Level of intervention: Use verbal de-escalation techniques; contact emergency services or security; if available. When prevention fails, clinicians can try to reason with patients in distress. Validate the patient’s experience. Establish a collaborative relationship. Find solutions to ensure the patient’s needs are met.

  • Signs to look for: A wide range of behaviors, including hitting, kicking, biting, or spitting; damage to property; patients may use weapons or objects in the environment as weapons
    Level of intervention: Terminate the interview; contact security and/or emergency services. The patient may need to be escorted to the emergency department. Where applicable and possible, consider physical and chemical restraint. Seeking criminal prosecution is a personal and complicated decision. It may be beneficial to discuss the decision with colleagues to ensure objectivity is maintained. Refraining from pressing charges may not always be the ethical choice.

  • For more on this topic, see Practical Tips for Managing the Agitated Patient: Avoiding Violence in the Clinical Setting, by Jodi Lofchy, MD and Bruce Fage, MD, on which this slideshow is based.

View the slides in PDF format.


I'm a psychiatric nurse who trained in Ireland in 1979 in St Patrick's hospital, Dublin an old institution built in the 18th century by the great satirist Johnathan Swift. Apologies I digress. While attaining my BSN in Mercy college, Dons Ferry, NY, my research proposal was to establish the content validity of the Norwegian Broset Violence-Checklist as an accurate instrument to predict aggressive behavior within a 24 hour time frame. It has proven itself to be very effective as a predictor of violent behavior. These tools are of paramount importance if caregivers are to target interventions to lesson this risk. The behaviors measures on this checklist are confusion, irritability, boisterousness, verbal threats, physical threats and attacks on objects. They are seen as being present or absent. If an individual displays two or more of these behaviors, he/she is more likely to be violent in the next 24 hour period. Each of the behaviors is scored numerically for their existence; 1 or nonexistent 0, producing a possible maximum grade of 6. The risk of violence is insignificant with a grade of 0; moderate with a grade of 1-2, where preventative measures should be utilized and the risk is high with a grade above 2, where management plans for violent behavior should be utilized. No harm in looking at this checklist. Thank you, Myles Hurley BSN

Myles @

First: assure patient safety. Second: assure staff safety. If staff safety cannot be assured walking away and calling law enforcement is a good plan. Physicians arming themselves is not.

Ingrid @

This was all well in good but somewhat unrealistic.What about the physician in a private practice.Are we now at a point where mace should be in our pocket?The office setting is much different than clinic or hospital setting at times getting to the phone can be impossible and time response to 911 is too long.Have we reached the point that the office nurse etc should "pack heat"? or should all mental health care be removed from traditional office setting to institutions?

John @

Very good article. Employers need to be aware and provide resources All staff need debriefing on regular basis. The violence is not about you per se and should not be personalized. Team work and never work at lone without someone knowing where you are. Your best defender is the relationship you develop with your client .

Brenda E @

Early detection through accurate and close observation may preventing the risk of violence toward self or health team as much as we can

mona @

Physical or chemical restraint should often be used as a last resort-if at all-as it is often perceived as degrading and humiliating by patients and robbing them of their dignity.
Experiences of restraints often retraumatise patients,which is ironic,considering that the point of Psychiatry is to heal them of any traumas.
Instead of building rapport,it rapidly erodes trust of the Mental Health system and Clinicians and cause effected patients to avoid seeking help in future.

In my experience,violence or threats of violence occur in the Hospital setting under three circumstances:

1.Violence due to the disorder itself -ie:the patient may misperceive a situation as being a threat or due to paranoia.

2.Violence due to the patient simply having an aggressive and unreasonable nature (ie:a character flaw).This instance is more likely to occur in a general hospital setting and not by patients other a Psychiatric disorder.

3.Violence due to interpersonal difficulties between the doctor and the patient.Frankly speaking,an aggressive doctor who is expectant that their "orders" will followed without thought,discrimination or use of own judgment by the patient/s are more likely to attract aggression from patients because the patients are often vulnerable and unable to modulate their emotions when in difficult circumstances and ironically these types of doctors have poor emotional regulation too.

The third type of violence is not fixed through involving security or pressing charges as this is a bandaid solution.
It is solved by better training affected doctors of the importance of treating patients with respect and dignity,changing their expectations that patients will state "how high" when they say jump just because they are a doctor,teaching them empathy and better communication skills and also go to regulate their own emotions.

m @

Typo,should state "......This instance is more likely to occur in a general hospital setting and not by patients *WITH* a Psychiatric disorder..."

m @

As someone who works in a high-acuity psychiatric facility, I am puzzled to see "invading personal space," and "posturing" classified as "verbal threats." These behaviors are non-verbal signals of more imminent risk for assault and are generally less likely to respond to verbal de-escalation techniques alone, especially if the patient is being seen in an isolated or after-hours situation.

Although our profession has an obligation to help de-stigmatize mental illness, I think we do our patients no favors by minimizing the risk that some of them present for violence in the community and in clinical settings. Educating the public and our colleagues in a straightforward fashion about these risks, and helping to develop reliable and effective strategies for minimizing harm, also benefits our patients by preventing them from exposure to the legal consequences that result from their having assaulted others.

G. @

I agree completely. The line has already been crossed once a patient, or anyone else for that matter, invades one's space in an aggressive manner.

Mary @

well said! My psychiatric hospital has had multiple episodes involving aggressive or psychotic patients injuring staff (myself included). Little has been done to improve the environment. All staff are well educated in least restraint policy and self defense in our setting. The Ministry of Labor has sued and criminal charges have been brought upon the hospital. They must have a loaded legal team! Changes are needed.

Sandi @

There is an unrealistic expectation by some Hospital staff members that they should be protected from all instances,however,some workplaces,by the very nature of the work,we have to be realistic that occasionally instances will occur.
It would be akin to an employee wishing to get a job as a Corrections officer/prison guard but expecting there would be no risks involved and then complaining that they were forced to deal with dangerous criminals.
People should choose careers with "eyes wide open" and be realistic about what those jobs will involve.
If a person wants an extreme low risk job then they should choose to be a hairdresser or an admin worker-not a nurse.
There are certain potential hazards that come with being a nurse and you do have to interact with people that may be in a state of Psychosis or misinterpret things.
Nurses have to be able to show compassion for these patients seeking out help,have great interpersonal skills,not be fearful,defensive or aggressive in turn, and see that those patients actions are not often an "act of the will" but rather illness induced.
Pressing charges often does nothing more than turn our prison systems into mental health institutions.
When a vet is bitten by a rabid animal he sees "past the behaviour" and doctors and nurses dealing with human patients should have the emotional intelligence to be able to do so likewise.

m @

Thank you for this. I also work in such a facility, and people are too prone to being polite to the point of ignoring threats. We don't want to be involved in violence, and so we ignore the signs. Which often leads to escalation, rather than helping.

Michael @

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