Assault in the Medical Setting: 3 Stages of Violence

April 28, 2017

Bruce Fage, MD

When clinicians work without ready access to a security team or environmental safety protocols, early recognition is crucial to preventing or avoiding those rare occasions when behavior problems escalate.

View the slides in PDF format.

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.