Here's an overview of motivation for assaults by chronically aggressive inpatients and steps to de-escalate.
Rape, assault, and murder of health care staff are reportable sentinel events.1 In January 2015, the Occupational Safety and Health Administration (OSHA) revised its Guidelines for Preventing Workplace Violence, noting that “Health care and social service workers face an increased risk of work-related assaults resulting primarily from violent behavior of their patients, clients, and/or residents.”2
According to the OSHA guidelines, assaults against health care workers comprise 10% to 11% of workplace injuries involving days away from work compared with 3% of injuries of all private sector employees. Workplace violence in the medical occupations represents 10.2% of all workplace-violence incidents. In addition, violence toward staff tends to be underreported.
The OSHA guidelines identify multiple patient, setting-related, and organizational risk factors for patient violence toward health care staff and provide suggestions for violence prevention programs. OSHA emphasizes that systems must be improved to mitigate patient-on-staff violence risk.
The Department of Veterans Affairs (VA) has created one such systems improvement by adding a “behavioral flag” to the electronic record of patients who have committed violence against a staff member within the past 2 years. This allows the VA to take extra measures in dealing with high-risk patients, including security standby, searching for weapons, and patient confinement to one area of the hospital. This measure has led to a 90% reduction in patient-on-staff assaults.3
In a study that looked at motivation for assaults on staff by chronically aggressive inpatients, Quanbeck and colleagues4 classified assaulters’ motives into 3 categories:
1.Reactive assaulters were most likely to target staff and to lash out after limits were set by staff. Their behavior tended to be impulsive, aggressive, and explosive. They perpetrated 72% of all inpatient assaults against staff.
2.Instrumentally aggressive inpatients used pre-mediated violence to achieve an end. Their violence tended to be coercive, predatory, and psychopathic. They perpetrated 16% of inpatient assaults against staff.
3.Psychotically motivated patients perpetrated only 12% of inpatient assaults against staff. They acted on delusions and hallucinations to protect themselves from perceived persecutors.
Reactive assaulters can be de-escalated by the following:
• Read the situation
• Verbally connect to the patient with a calm voice
• Listen to the patient and try to empathize
• Avoid an authoritarian stance
• Try to give the patient a sense of control
• Ask permission to speak with the patient
• Give the patient choices
• Increase personal space between you and the patient
The risk of violence due to psychotic motivation can best be managed by correct diagnosis and psychopharmacologic treatment of the underlying psychosis. Instrumental predatory violence is perhaps the most difficult to manage on an inpatient unit. Consideration should be given to criminally charging such patients and discharging them from inpatient treatment.
Also in this Special Report:
Depressive Symptoms Associated With Aggression
The Role of Psychiatrists in Countering Violent Extremism
Strategies to Reduce and Prevent Restraint and Seclusion in Pediatric Populations
Practical Tips for Managing the Agitated Patient: Avoiding Violence in the Clinical Setting
Dr. Janofsky is Director, Psychiatry and Law Program, and Associate Professor of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD.
1. The Joint Commission. CAMH, January 2013, Sentinel Events. http://www.jointcommission.org/assets/1/6/CAMH_2012_Update2_24_SE.pdf. Accessed January 3, 2017.
2. Occupational Safety and Health Administration. Guidelines for Preventing Workplace Violence for Health Care and Social Service Workers. http://www.osha.gov/Publications/osha3148.pdf. Accessed January 3, 2017.
3. Drummond DJ, Sparr LF, Gordon GH. Hospital violence reduction among high-risk patients. JAMA. 1989;261:2531-2534.
4. Quanbeck CD, McDermott BE, Lam J, et al. Categorization of aggressive acts committed by chronically assaultive state hospital patients. Psychiatr Serv. 2007;58:521-528.