73
Work 51 (2015) 73–77 DOI 10.3233/WOR-141888 IOS Press
Risk assessment for patient perpetrated violence: Analysis of three assaults against healthcare workers Scott Breslera,∗ and Michael B. Gaskellb a
b
Clinical Director of Forensic Psychiatry, University of Cincinnati, Cincinnati, OH, USA Department of Psychology, Xavier University, Cincinnati, OH, USA
Received 12 February 2013 Accepted 24 November 2013
Abstract. Workplace violence in healthcare settings is a complex topic with many different environments in which aggression is sometimes expressed by patients toward those entrusted with providing their healthcare. The assessment of violence risk in a nursing home containing many patients with organic brain syndrome is quite distinct from assessment in forensic psychiatric units, inner city emergency rooms, or outpatient pain clinics. Three cases are presented that are composite summaries of actual assaults which took place across different hospital settings, all within an urban Midwestern city in the United States: (1) an emergency department; (2) a psychiatric emergency services (PES) center; (3) a short stay (typically 72 hours to 5 days) civil psychiatric inpatient unit. These case studies exemplify specific risk factors that violent patients have, depending upon the specific healthcare setting where the patient presents. Research is cited relevant to all three case studies and how one should assess their risk. Lastly, the complexity of this issue is highlighted by a brief discussion of the pitfalls entailed in profiling “the dangerous patient.” It is demonstrated that when violence is expressed by a patient toward a healthcare provider, it is usually a maladaptive response, one in which characteristics of that setting and behavior of those who work within it must be carefully considered when determining what factors precipitated the patient’s violent act. Keywords: Violence risk assessment, workplace violence, patient perpetrated violence
1. Introduction We defined workplace aggression as nonfatal violence against an employed person or persons, occurring while at work or on duty. Using this same definition, the U.S. Department of Justice (DOJ) in their survey of violent incidents in the workplace (2005–2009) found that over 14% of the total violent incidents surveyed were directed against medical (e.g., physicians, nurses, technicians) and mental health workers (e.g., professional and custodial care workers) [1]. Mental ∗ Corresponding author: Scott Bresler, Forensic Psychiatry, 260 Stetson St., Suite 3200, University of Cincinnati, ML 0559, P.O. Box 670559, Cincinnati, OH 45219, USA. Tel.: +1 513 558 3951; Fax: +1 513 558 3823; E-mail: [email protected].
health professionals were found to be at very high risk for assault with 21 reported incidents per 1,000 workers. It is speculated that this rate is a gross under estimation of actual violence in these settings as many medical and mental health professionals consider aggression to be part and parcel of their respective jobs; some simply do not report it. Three incidents of patient perpetrated violence against healthcare workers are discussed below. Following a description of the assault and its precipitating events, each critical incident is analyzed. The first case study highlights how stereotypes of the “typical” violent patient can lead to unpreparedness in the emergency department. When mixed with alcohol and illicit drug intoxication, this unpreparedness may have dangerous consequences. The second case study high-
c 2015 – IOS Press and the authors. All rights reserved 1051-9815/15/$35.00
74
S. Bresler and M.B. Gaskell / Risk assessment for patient perpetrated violence
lights risk factors associated with medication noncompliance and the diagnosis of schizophrenia while showcasing the dangerous consequences of inefficient communication between staff. The third case study describes a patient who, despite lacking typical violence risk factors, perpetrates a sexual assault presumably due to manic excitation.
2. Case study 1: Aggression in the emergency department Casey is a 22 year old single white female who was “partying” with friends when she became unruly, screaming and singing loudly in the backyard of her girlfriend Melissa’s home, earning the ire of her neighbors. When police were called to the scene late that evening, Casey screamed profanities at the investigating officers. When they attempted to calm her, she ran from the house and slipped on the snow-covered pavement, lacerating her scalp when her head hit the ground. Police transported her to the emergency department (ED). Before leaving the home, Melissa, herself intoxicated, disclosed to police that they had been “drinking beer, smoking marijuana, and snorting cocaine all evening.” At the ED, Casey resisted efforts by police to get her out of the patrol car, biting the hand of one officer who was assisting with the task of removing her from the car. Eventually, they were able to assist Casey to a gurney though she refused to stay still, often attempting to get up and arguing with ED nursing personnel. This lasted for nearly an hour before the physician arrived, demanded that Casey “lie down and be quiet,” and warned her that if she did not do so, they would place her in restraints. At that point, Casey sat up to verbally confront the physician, who reacted by placing his hands on her shoulders to keep her in bed while he called for assistance. A short time later, Casey spat blood in the physician’s face and yelled, “Now you die of AIDS!” It was discovered that she had bitten the inside of her mouth and drawn blood to spit at the attending ED physician. 2.1. Emergency department: Case critical incident analysis When staff was called together to review the assault on the physician, there were specific issues identified accounting for the risk of violence relevant to this case. Like many patients presenting to the ED, Casey was reported to be emotionally labile and disinhibited, in-
toxicated after imbibing alcohol and street drugs in the hours prior to her admission to the ED. Moreover, she was violent toward police (biting) during the transfer to the ED. The strong relationship between community violence and substance abuse is well documented [2] and the DOJ survey discussed above [1] confirmed that nearly 25% of the persons who perpetrated workplace violence were perceived to be intoxicated on alcohol and/or drugs at the time of the violent incident. As well, cocaine abuse has been long associated with physical aggression [3]. This case is rendered even more complicated by other considerations that surfaced after the assault. Nurses admitted that when decisions were being made regarding how much time and resources should be allocated to this ED case upon her admission, they underestimated the risk of violence she posed. They believed that because she was a white woman, she was not at significant risk for violence. Non-white males are typically overestimated as potentially violent, while white females are underestimated [4]. In addition, it was discovered that Casey was admitted to the hospital ED immediately prior to the shift change amongst staff. This calls into question the adequacy of time and resources devoted to this case prior to one shift getting off work, and how well the risks for violence were communicated as this case was passed to the next shift. Lastly, the physician who threatened to restrain Casey admitted to being angry with the previous shift’s attending physician and her staff when he came to work that evening. He felt that this difficult patient should have been better stabilized before transferring care to him. He admitted in retrospect that he may have displaced some of his anger and frustration onto Casey, speaking to her in a confrontational rather than soothing tone, while commanding her to sit still and be quiet. One nurse even complained that the physician was “too aggressive” when he physically restrained Casey by holding down her shoulders. This complaint prompted a formal investigation into the incident by the hospital. A hospital social worker would later discover that unbeknownst to the ED staff at the time, Casey had a long history of being physically and sexually abused stemming back to her formative childhood years, another known risk factor for violence [5]. This may explain her angry, aggressive reaction when physically touched by a male police officer and again later, by the male physician. A post-hoc sentinel event assessment of the assault concluded that the ED staff could have acted more directly and quickly to sedate Casey upon admission. If they had done so, presumably the physician would
S. Bresler and M.B. Gaskell / Risk assessment for patient perpetrated violence
not have “inherited” this volatile case, making it less likely that he would have been assaulted. Further, one is left to wonder how the frustration of the physician may have played some role in precipitating the violent act. Casey was eventually stabilized, her head wound cleaned, stitched and dressed. A CAT scan of her head was negative and she was subsequently transported to jail and formally charged with disorderly conduct, resisting arrest, and assault. The prosecuting attorney would later tell the hospital that this was one of a number of aggressive incidents for which Casey had faced criminal prosecution over the previous year. Of course, a prior history of violence increases significantly one’s risk for future violence [6]. 3. Case study 2: Aggression in the psychiatric emergency service A parole officer was questioning her parolee named Jerome, a 32-year-old single black unemployed male, when he became irate with her after she confronted him about missing their previously scheduled meeting. When she inquired as to whether he had been taking his scheduled antipsychotic drug injections, he stood up in her office, swiped the open file filled with papers off of her desk, yelled profanity, and threw his chair against the wall. Her co-workers responded quickly after hearing the disturbance, and Jerome was subsequently taken into police custody and immediately transported to the local PES. There, he was evaluated by an intake nurse followed by a social worker who was unsuccessful getting a personal history from him; he became more irritable as she asked him questions. The social worker documented in the chart that she terminated her intake interview with Jerome, but she failed to communicate the reason for this termination to Foster, Jerome’s attending psychiatric nurse practitioner, who was entrusted with managing the case. Once placed on the PES observation unit, Jerome was observed pacing nervously for about an hour while PES staff made phone calls to his parole officer and treating psychiatrist to gather more information. Foster met with him and learned that Jerome had been prescribed antipsychotic medications over the last 12 years, diagnosed with schizophrenia. Jerome reluctantly agreed to take emergency medications at the PES. He repeatedly asked different PES staff, “Are you going to keep me here?” Later, when Foster told Jerome that it was decided that he must stay in the hospital for at least “72 hours of observation,” he punched Foster in the right eye. Foster sustained a laceration and required emergent care.
75
3.1. Psychiatry emergency services: Case critical incident analysis Medication noncompliance and a history of being diagnosed with schizophrenia are significant risk factors for violence in the community [4,7,8]. These must be carefully considered by staff when a mentally ill patient enters the PES directly from the community. Jerome came into PES with these risk factors along with a criminal history (he was known to be a parolee). There were reports of recent acts of aggression with objects and verbal aggression toward an authority figure (the behavior in his parole officer’s office). Specific symptoms observed on the PES unit were reactive irritability with the social worker, which was not communicated to Foster. A breakdown in communication amongst staff has been determined to contribute to an environment in which patient violence is greatly potentiated [9]. In addition, Jerome’s hyperkinetic behavior (pacing) on the unit suggested pent up energy, perhaps fueled by akathisia sometimes brought on by prescribed antipsychotic medications [10]. Further, the repeated questioning by Jerome as to whether he would be forced to stay in the hospital clearly showed a nearly obsessive preoccupation with loss of his civil liberties. In fact, one is left to speculate that when Foster delivered the “bad news” that Jerome seemed to fear, that he would be required to stay in the hospital, Jerome retaliated by attacking the messenger, Foster. This aggressive act may have been fueled by Jerome’s psychotic paranoid demeanor, but also may have been driven largely by sociopathic personality traits.
4. Case study 3: Aggression in the civil psychiatric inpatient unit Sidney is in his second year at a local college where he studies architecture, a very competitive and demanding academic program requiring long hours in the studio working on assigned projects. About two weeks ago, Sidney’s roommate went to their dormitory “RA” (resident assistant) and complained that Sidney was “not sleeping hardly at all,” and kept talking about a new building design that would “revolutionize” utilization of space while attaining “remarkable” energy efficiency ratings. The roommate further disclosed that Sidney has been uncharacteristically frequenting local bars and drinking to excess. He had also gotten into verbal confrontations with other males at the bars after “hitting on” their female acquaintances. After one
76
S. Bresler and M.B. Gaskell / Risk assessment for patient perpetrated violence
such disturbance, police transported him to a local PES where he flatly refused to take any medications offered to him. He was subsequently admitted to the inpatient adult psychiatric unit. He saw “nothing wrong” with his behavior. On the inpatient unit, the attending nurse interviewed him and attempted to complete a physical exam, at which point he broke off the meeting and accused her of trying to steal his “revolutionary ideas.” Later that day, a young female nursing student spoke with Sidney as part of her educational requirements on the unit. That meeting was immediately terminated by her when Sidney pinched her buttocks, touched her breast by brushing up against her blouse, and showed her a condom in his possession while commenting jocularly that he knew what she needed to “round out her education.” He was immediately placed in seclusion and administered emergency medications. 4.1. Civil psychiatric inpatient unit: Case critical incident analysis Sidney was diagnosed as suffering from an acute episode of bipolar mania, a “first break” likely brought on by the stress of his academic requirements and complicated by his more recent alcohol consumption patterns. Bipolar patients are prone to acting out aggressively in both manic and mixed episodes [11], and disinhibited sexual behavior (hypersexuality) is one identified symptom of persons who carry this diagnosis (DSM-IV-TR criteria for Bipolar I Disorder). In addition, Sidney was observed to be sleeping few hours, obsessing about projects to which he attributed excessive (grandiose) importance, intrusively entering into others’ personal space, and having hypersexual attraction to females on the unit, both staff and patients. Having a female nursing student meet with him one-onone while in this state was clearly poor management of both Sidney and the victimized nursing student. Sometime later after Sidney reluctantly agreed to take his prescribed medications, he even expressed genuine remorse and embarrassment for his behavior, writing a formal apology to the nursing student. Interestingly, other risk factors for violence that are typically considered for psychiatric inpatients [12] were not relevant to this case. Sidney had no known previous history of violent behavior or aggressive sexualized acts. His history of substance abuse was circumscribed to a few weeks prior to his psychiatric inpatient hospital stay. He had no known prior history of being traumatized physically and/or sexually. He was reared in a middle class, religious, conservative supportive family, not in poor socioeconomic conditions with unstable parental support or exposure to violence.
5. Discussion and conclusions There is a complex relationship between the characteristics of the patient, treatment staff, and the milieu of the unit (e.g., its “culture,” staffing patterns, physical layout) across emergency departments, psychiatric emergency services, and civil psychiatric inpatient settings [9,13,14]. Risk factors for violence in the community may not be salient considerations once a patient enters the ED or PES, as their reliance on injectable forms of major tranquilizers and benzodiazepines can successfully quell imminent aggression in most patients. Once on an inpatient unit, different concerns may emerge including a patient’s response to medications, and interpersonal factors such as personality traits which may be maladaptive, reaching personality disorder proportions. Consideration of patient risk for violence will reveal both static (i.e., historical variables) and fluid (e.g., expressed symptoms) factors. Attempting to predict who will or who will not become violent will only produce many false positives and some false negatives, a somewhat futile academic exercise. Identifying the risk factors that can be addressed across patients, staff, and the treatment milieu, and implementing patient specific interventions to lower the risk of violence is the evidence-based, recommended course of addressing this vexing problem. These composite case studies were presented to highlight problems often encountered by treatment staff across a continuum of care settings (ED, PES, Civil Psychiatric Inpatient Unit). Systematic approaches for the assessment of risk early in the process are strongly advised. There are tools specifically designed to remind staff what to look for (memory aids) in patient behavior which may indicate that a patient is escalating, at risk for violence [see 15 for an overview of such tools]. Once in the hospital, a systematic observation of the patient’s behavior should continue. Tools such as the Nurses’ Observation Scale for Inpatient Evaluation (NOSIE) [16] and the Overt Aggression Scale (OAS) [17] are designed for this purpose. Most importantly, after a violent incident, a meeting of interested and knowledgeable persons including physicians, nurses, and front line staff must be called. An open discussion about what may have been the antecedents to the violent event (e.g., Root Cause Analysis), the specific nature of the violence, and an assessment of the response to the aggressive incident should ensue. It is known that experiencing violence directly or indirectly in a healthcare setting takes a considerable emotional toll on patients and caregivers alike [18–20].
S. Bresler and M.B. Gaskell / Risk assessment for patient perpetrated violence
It certainly cannot be ignored or taken for granted as there are important lessons that can be learned thereby creating safer treatment settings for all.
[10]
[11] [12]
References [1]
[2]
[3]
[4]
[5] [6]
[7]
[8] [9]
Harrel, E. Workplace violence, 1993-2009. Washington, DC: US Department of Justice, Bureau of Justice Statistics; March 2011. 17 p. Report No.: NCJ 233231. Mulvey EP, Odgers C, Skeem J, Gardner W, Schubert C, Lidz C. Substance Use and Community Violence: A Test of the Relation at the Daily Level. Journal of Consulting and Clinical Psychology 74, 4:743-754. Brody SL. Violence associated with acute cocaine use in patients admitted to a medical emergency department. NIDA Res Monogr 1990; 103:44-59. McNeil DE, Binder RL. Correlates of accuracy in the assessment of psychiatric inpatients’ risk of violence. J of Psychiatry 1995; 152:901-906. Pollock NL, Accounting for predictions of dangerousness. Int J Law Psychiatry 1990; 13(3):207-215. Quinsey VL, Harris GT, Rice ME, Cromier CA. Violent offenders: Appraising and managing risk. 2nd ed. Washington, D.C.: American Psychological Association Press; 2006. Swartz MS, Swanson JW, Hiday VA, Borum R, Wagner HR, Burns BJ. Aggression and severe mental illness: The effects of substance abuse and nonadherence to medication. Am J psychiatry 1998; 155:226-231. Omerov M, Edman G, Wistedt B. Incidents of violence in psychiatric inpatient care. Nordic J Psychiatry 2002; 56:207-213. Bowers L, Stewart D, Papadopoulos C, Dack C, Ross J, Khanom H. Inpatient violence and aggression: A literature review. London: Institute of Psychiatry King’s College; May 2011.
[13]
[14]
[15]
[16]
[17]
[18]
[19]
[20]
77
Raja M, Azzoni A, Lubich L. Aggressive and violent behavior in a population of psychiatric inpatients. Soc Psychiatry and Psychiatric Epidemiology 1997; 32:428-434. Binder RL, McNiel DE. Effects of diagnosis and context of dangerousness. Am J Psychiatry 1988; 145:728-732. Lee MR, Galynker II. Violence in bipolar disorder: What role does childhood trauma play? Psychiatric Times 2010; 27(11): 1-7. Hamrin V, Iennaco J, Olsen D. A review of ecological factors affecting inpatient psychiatric unit violence: Implications for relational and unit cultural improvements. Issues in Mental Health Nursing 2009; 30:214-226. Cornaggia CM, Beghi M, Pavone F, Barale F. Aggression in psychiatry wards: A systematic review. Psychiatry Research 2011; 189:10-20. Kennedy J, Bresler S, Whitaker A, Masterson B. Risk management special report-Assessing violence risk in psychiatric inpatients: Useful tools. Psychiatric Times 2007; 24(8): 30-34 Honigfeld G, Klett CJ. The nurse’s observation scale for inpatient evaluation. A new scale for measuring improvement in chronic schizophrenia. Journal of Clinical Psychology 1965; 21(1): 65-71. Yudofsky SC, Silver JM, Jackson W, Endicott J, Williams D. The overt aggression scale for the objective rating of verbal and physical aggression. The American Journal of Psychiatry 1986; 143(1): 35-39. Gates DM, Gillespie GL, Succop P. Violence against nurses and its impact on stress and productivity. J Nursing Econ 2011; 29(2): 59-66. Gates DM, Ross CS, McQueen L. Violence against emergency department workers. Journal of Emergency Medecine 2006; 31(3):331-337. Gillepsie GL, Bresler S, Gates DM & Succop P. Symptoms of posttraumatic stress in emergency workers following workplace aggression. In press.
Work 51 (2015) 73–77 DOI 10.3233/WOR-141888 IOS Press
Risk assessment for patient perpetrated violence: Analysis of three assaults against healthcare workers Scott Breslera,∗ and Michael B. Gaskellb a
b
Clinical Director of Forensic Psychiatry, University of Cincinnati, Cincinnati, OH, USA Department of Psychology, Xavier University, Cincinnati, OH, USA
Received 12 February 2013 Accepted 24 November 2013
Abstract. Workplace violence in healthcare settings is a complex topic with many different environments in which aggression is sometimes expressed by patients toward those entrusted with providing their healthcare. The assessment of violence risk in a nursing home containing many patients with organic brain syndrome is quite distinct from assessment in forensic psychiatric units, inner city emergency rooms, or outpatient pain clinics. Three cases are presented that are composite summaries of actual assaults which took place across different hospital settings, all within an urban Midwestern city in the United States: (1) an emergency department; (2) a psychiatric emergency services (PES) center; (3) a short stay (typically 72 hours to 5 days) civil psychiatric inpatient unit. These case studies exemplify specific risk factors that violent patients have, depending upon the specific healthcare setting where the patient presents. Research is cited relevant to all three case studies and how one should assess their risk. Lastly, the complexity of this issue is highlighted by a brief discussion of the pitfalls entailed in profiling “the dangerous patient.” It is demonstrated that when violence is expressed by a patient toward a healthcare provider, it is usually a maladaptive response, one in which characteristics of that setting and behavior of those who work within it must be carefully considered when determining what factors precipitated the patient’s violent act. Keywords: Violence risk assessment, workplace violence, patient perpetrated violence
1. Introduction We defined workplace aggression as nonfatal violence against an employed person or persons, occurring while at work or on duty. Using this same definition, the U.S. Department of Justice (DOJ) in their survey of violent incidents in the workplace (2005–2009) found that over 14% of the total violent incidents surveyed were directed against medical (e.g., physicians, nurses, technicians) and mental health workers (e.g., professional and custodial care workers) [1]. Mental ∗ Corresponding author: Scott Bresler, Forensic Psychiatry, 260 Stetson St., Suite 3200, University of Cincinnati, ML 0559, P.O. Box 670559, Cincinnati, OH 45219, USA. Tel.: +1 513 558 3951; Fax: +1 513 558 3823; E-mail: [email protected].
health professionals were found to be at very high risk for assault with 21 reported incidents per 1,000 workers. It is speculated that this rate is a gross under estimation of actual violence in these settings as many medical and mental health professionals consider aggression to be part and parcel of their respective jobs; some simply do not report it. Three incidents of patient perpetrated violence against healthcare workers are discussed below. Following a description of the assault and its precipitating events, each critical incident is analyzed. The first case study highlights how stereotypes of the “typical” violent patient can lead to unpreparedness in the emergency department. When mixed with alcohol and illicit drug intoxication, this unpreparedness may have dangerous consequences. The second case study high-
c 2015 – IOS Press and the authors. All rights reserved 1051-9815/15/$35.00
74
S. Bresler and M.B. Gaskell / Risk assessment for patient perpetrated violence
lights risk factors associated with medication noncompliance and the diagnosis of schizophrenia while showcasing the dangerous consequences of inefficient communication between staff. The third case study describes a patient who, despite lacking typical violence risk factors, perpetrates a sexual assault presumably due to manic excitation.
2. Case study 1: Aggression in the emergency department Casey is a 22 year old single white female who was “partying” with friends when she became unruly, screaming and singing loudly in the backyard of her girlfriend Melissa’s home, earning the ire of her neighbors. When police were called to the scene late that evening, Casey screamed profanities at the investigating officers. When they attempted to calm her, she ran from the house and slipped on the snow-covered pavement, lacerating her scalp when her head hit the ground. Police transported her to the emergency department (ED). Before leaving the home, Melissa, herself intoxicated, disclosed to police that they had been “drinking beer, smoking marijuana, and snorting cocaine all evening.” At the ED, Casey resisted efforts by police to get her out of the patrol car, biting the hand of one officer who was assisting with the task of removing her from the car. Eventually, they were able to assist Casey to a gurney though she refused to stay still, often attempting to get up and arguing with ED nursing personnel. This lasted for nearly an hour before the physician arrived, demanded that Casey “lie down and be quiet,” and warned her that if she did not do so, they would place her in restraints. At that point, Casey sat up to verbally confront the physician, who reacted by placing his hands on her shoulders to keep her in bed while he called for assistance. A short time later, Casey spat blood in the physician’s face and yelled, “Now you die of AIDS!” It was discovered that she had bitten the inside of her mouth and drawn blood to spit at the attending ED physician. 2.1. Emergency department: Case critical incident analysis When staff was called together to review the assault on the physician, there were specific issues identified accounting for the risk of violence relevant to this case. Like many patients presenting to the ED, Casey was reported to be emotionally labile and disinhibited, in-
toxicated after imbibing alcohol and street drugs in the hours prior to her admission to the ED. Moreover, she was violent toward police (biting) during the transfer to the ED. The strong relationship between community violence and substance abuse is well documented [2] and the DOJ survey discussed above [1] confirmed that nearly 25% of the persons who perpetrated workplace violence were perceived to be intoxicated on alcohol and/or drugs at the time of the violent incident. As well, cocaine abuse has been long associated with physical aggression [3]. This case is rendered even more complicated by other considerations that surfaced after the assault. Nurses admitted that when decisions were being made regarding how much time and resources should be allocated to this ED case upon her admission, they underestimated the risk of violence she posed. They believed that because she was a white woman, she was not at significant risk for violence. Non-white males are typically overestimated as potentially violent, while white females are underestimated [4]. In addition, it was discovered that Casey was admitted to the hospital ED immediately prior to the shift change amongst staff. This calls into question the adequacy of time and resources devoted to this case prior to one shift getting off work, and how well the risks for violence were communicated as this case was passed to the next shift. Lastly, the physician who threatened to restrain Casey admitted to being angry with the previous shift’s attending physician and her staff when he came to work that evening. He felt that this difficult patient should have been better stabilized before transferring care to him. He admitted in retrospect that he may have displaced some of his anger and frustration onto Casey, speaking to her in a confrontational rather than soothing tone, while commanding her to sit still and be quiet. One nurse even complained that the physician was “too aggressive” when he physically restrained Casey by holding down her shoulders. This complaint prompted a formal investigation into the incident by the hospital. A hospital social worker would later discover that unbeknownst to the ED staff at the time, Casey had a long history of being physically and sexually abused stemming back to her formative childhood years, another known risk factor for violence [5]. This may explain her angry, aggressive reaction when physically touched by a male police officer and again later, by the male physician. A post-hoc sentinel event assessment of the assault concluded that the ED staff could have acted more directly and quickly to sedate Casey upon admission. If they had done so, presumably the physician would
S. Bresler and M.B. Gaskell / Risk assessment for patient perpetrated violence
not have “inherited” this volatile case, making it less likely that he would have been assaulted. Further, one is left to wonder how the frustration of the physician may have played some role in precipitating the violent act. Casey was eventually stabilized, her head wound cleaned, stitched and dressed. A CAT scan of her head was negative and she was subsequently transported to jail and formally charged with disorderly conduct, resisting arrest, and assault. The prosecuting attorney would later tell the hospital that this was one of a number of aggressive incidents for which Casey had faced criminal prosecution over the previous year. Of course, a prior history of violence increases significantly one’s risk for future violence [6]. 3. Case study 2: Aggression in the psychiatric emergency service A parole officer was questioning her parolee named Jerome, a 32-year-old single black unemployed male, when he became irate with her after she confronted him about missing their previously scheduled meeting. When she inquired as to whether he had been taking his scheduled antipsychotic drug injections, he stood up in her office, swiped the open file filled with papers off of her desk, yelled profanity, and threw his chair against the wall. Her co-workers responded quickly after hearing the disturbance, and Jerome was subsequently taken into police custody and immediately transported to the local PES. There, he was evaluated by an intake nurse followed by a social worker who was unsuccessful getting a personal history from him; he became more irritable as she asked him questions. The social worker documented in the chart that she terminated her intake interview with Jerome, but she failed to communicate the reason for this termination to Foster, Jerome’s attending psychiatric nurse practitioner, who was entrusted with managing the case. Once placed on the PES observation unit, Jerome was observed pacing nervously for about an hour while PES staff made phone calls to his parole officer and treating psychiatrist to gather more information. Foster met with him and learned that Jerome had been prescribed antipsychotic medications over the last 12 years, diagnosed with schizophrenia. Jerome reluctantly agreed to take emergency medications at the PES. He repeatedly asked different PES staff, “Are you going to keep me here?” Later, when Foster told Jerome that it was decided that he must stay in the hospital for at least “72 hours of observation,” he punched Foster in the right eye. Foster sustained a laceration and required emergent care.
75
3.1. Psychiatry emergency services: Case critical incident analysis Medication noncompliance and a history of being diagnosed with schizophrenia are significant risk factors for violence in the community [4,7,8]. These must be carefully considered by staff when a mentally ill patient enters the PES directly from the community. Jerome came into PES with these risk factors along with a criminal history (he was known to be a parolee). There were reports of recent acts of aggression with objects and verbal aggression toward an authority figure (the behavior in his parole officer’s office). Specific symptoms observed on the PES unit were reactive irritability with the social worker, which was not communicated to Foster. A breakdown in communication amongst staff has been determined to contribute to an environment in which patient violence is greatly potentiated [9]. In addition, Jerome’s hyperkinetic behavior (pacing) on the unit suggested pent up energy, perhaps fueled by akathisia sometimes brought on by prescribed antipsychotic medications [10]. Further, the repeated questioning by Jerome as to whether he would be forced to stay in the hospital clearly showed a nearly obsessive preoccupation with loss of his civil liberties. In fact, one is left to speculate that when Foster delivered the “bad news” that Jerome seemed to fear, that he would be required to stay in the hospital, Jerome retaliated by attacking the messenger, Foster. This aggressive act may have been fueled by Jerome’s psychotic paranoid demeanor, but also may have been driven largely by sociopathic personality traits.
4. Case study 3: Aggression in the civil psychiatric inpatient unit Sidney is in his second year at a local college where he studies architecture, a very competitive and demanding academic program requiring long hours in the studio working on assigned projects. About two weeks ago, Sidney’s roommate went to their dormitory “RA” (resident assistant) and complained that Sidney was “not sleeping hardly at all,” and kept talking about a new building design that would “revolutionize” utilization of space while attaining “remarkable” energy efficiency ratings. The roommate further disclosed that Sidney has been uncharacteristically frequenting local bars and drinking to excess. He had also gotten into verbal confrontations with other males at the bars after “hitting on” their female acquaintances. After one
76
S. Bresler and M.B. Gaskell / Risk assessment for patient perpetrated violence
such disturbance, police transported him to a local PES where he flatly refused to take any medications offered to him. He was subsequently admitted to the inpatient adult psychiatric unit. He saw “nothing wrong” with his behavior. On the inpatient unit, the attending nurse interviewed him and attempted to complete a physical exam, at which point he broke off the meeting and accused her of trying to steal his “revolutionary ideas.” Later that day, a young female nursing student spoke with Sidney as part of her educational requirements on the unit. That meeting was immediately terminated by her when Sidney pinched her buttocks, touched her breast by brushing up against her blouse, and showed her a condom in his possession while commenting jocularly that he knew what she needed to “round out her education.” He was immediately placed in seclusion and administered emergency medications. 4.1. Civil psychiatric inpatient unit: Case critical incident analysis Sidney was diagnosed as suffering from an acute episode of bipolar mania, a “first break” likely brought on by the stress of his academic requirements and complicated by his more recent alcohol consumption patterns. Bipolar patients are prone to acting out aggressively in both manic and mixed episodes [11], and disinhibited sexual behavior (hypersexuality) is one identified symptom of persons who carry this diagnosis (DSM-IV-TR criteria for Bipolar I Disorder). In addition, Sidney was observed to be sleeping few hours, obsessing about projects to which he attributed excessive (grandiose) importance, intrusively entering into others’ personal space, and having hypersexual attraction to females on the unit, both staff and patients. Having a female nursing student meet with him one-onone while in this state was clearly poor management of both Sidney and the victimized nursing student. Sometime later after Sidney reluctantly agreed to take his prescribed medications, he even expressed genuine remorse and embarrassment for his behavior, writing a formal apology to the nursing student. Interestingly, other risk factors for violence that are typically considered for psychiatric inpatients [12] were not relevant to this case. Sidney had no known previous history of violent behavior or aggressive sexualized acts. His history of substance abuse was circumscribed to a few weeks prior to his psychiatric inpatient hospital stay. He had no known prior history of being traumatized physically and/or sexually. He was reared in a middle class, religious, conservative supportive family, not in poor socioeconomic conditions with unstable parental support or exposure to violence.
5. Discussion and conclusions There is a complex relationship between the characteristics of the patient, treatment staff, and the milieu of the unit (e.g., its “culture,” staffing patterns, physical layout) across emergency departments, psychiatric emergency services, and civil psychiatric inpatient settings [9,13,14]. Risk factors for violence in the community may not be salient considerations once a patient enters the ED or PES, as their reliance on injectable forms of major tranquilizers and benzodiazepines can successfully quell imminent aggression in most patients. Once on an inpatient unit, different concerns may emerge including a patient’s response to medications, and interpersonal factors such as personality traits which may be maladaptive, reaching personality disorder proportions. Consideration of patient risk for violence will reveal both static (i.e., historical variables) and fluid (e.g., expressed symptoms) factors. Attempting to predict who will or who will not become violent will only produce many false positives and some false negatives, a somewhat futile academic exercise. Identifying the risk factors that can be addressed across patients, staff, and the treatment milieu, and implementing patient specific interventions to lower the risk of violence is the evidence-based, recommended course of addressing this vexing problem. These composite case studies were presented to highlight problems often encountered by treatment staff across a continuum of care settings (ED, PES, Civil Psychiatric Inpatient Unit). Systematic approaches for the assessment of risk early in the process are strongly advised. There are tools specifically designed to remind staff what to look for (memory aids) in patient behavior which may indicate that a patient is escalating, at risk for violence [see 15 for an overview of such tools]. Once in the hospital, a systematic observation of the patient’s behavior should continue. Tools such as the Nurses’ Observation Scale for Inpatient Evaluation (NOSIE) [16] and the Overt Aggression Scale (OAS) [17] are designed for this purpose. Most importantly, after a violent incident, a meeting of interested and knowledgeable persons including physicians, nurses, and front line staff must be called. An open discussion about what may have been the antecedents to the violent event (e.g., Root Cause Analysis), the specific nature of the violence, and an assessment of the response to the aggressive incident should ensue. It is known that experiencing violence directly or indirectly in a healthcare setting takes a considerable emotional toll on patients and caregivers alike [18–20].
S. Bresler and M.B. Gaskell / Risk assessment for patient perpetrated violence
It certainly cannot be ignored or taken for granted as there are important lessons that can be learned thereby creating safer treatment settings for all.
[10]
[11] [12]
References [1]
[2]
[3]
[4]
[5] [6]
[7]
[8] [9]
Harrel, E. Workplace violence, 1993-2009. Washington, DC: US Department of Justice, Bureau of Justice Statistics; March 2011. 17 p. Report No.: NCJ 233231. Mulvey EP, Odgers C, Skeem J, Gardner W, Schubert C, Lidz C. Substance Use and Community Violence: A Test of the Relation at the Daily Level. Journal of Consulting and Clinical Psychology 74, 4:743-754. Brody SL. Violence associated with acute cocaine use in patients admitted to a medical emergency department. NIDA Res Monogr 1990; 103:44-59. McNeil DE, Binder RL. Correlates of accuracy in the assessment of psychiatric inpatients’ risk of violence. J of Psychiatry 1995; 152:901-906. Pollock NL, Accounting for predictions of dangerousness. Int J Law Psychiatry 1990; 13(3):207-215. Quinsey VL, Harris GT, Rice ME, Cromier CA. Violent offenders: Appraising and managing risk. 2nd ed. Washington, D.C.: American Psychological Association Press; 2006. Swartz MS, Swanson JW, Hiday VA, Borum R, Wagner HR, Burns BJ. Aggression and severe mental illness: The effects of substance abuse and nonadherence to medication. Am J psychiatry 1998; 155:226-231. Omerov M, Edman G, Wistedt B. Incidents of violence in psychiatric inpatient care. Nordic J Psychiatry 2002; 56:207-213. Bowers L, Stewart D, Papadopoulos C, Dack C, Ross J, Khanom H. Inpatient violence and aggression: A literature review. London: Institute of Psychiatry King’s College; May 2011.
[13]
[14]
[15]
[16]
[17]
[18]
[19]
[20]
77
Raja M, Azzoni A, Lubich L. Aggressive and violent behavior in a population of psychiatric inpatients. Soc Psychiatry and Psychiatric Epidemiology 1997; 32:428-434. Binder RL, McNiel DE. Effects of diagnosis and context of dangerousness. Am J Psychiatry 1988; 145:728-732. Lee MR, Galynker II. Violence in bipolar disorder: What role does childhood trauma play? Psychiatric Times 2010; 27(11): 1-7. Hamrin V, Iennaco J, Olsen D. A review of ecological factors affecting inpatient psychiatric unit violence: Implications for relational and unit cultural improvements. Issues in Mental Health Nursing 2009; 30:214-226. Cornaggia CM, Beghi M, Pavone F, Barale F. Aggression in psychiatry wards: A systematic review. Psychiatry Research 2011; 189:10-20. Kennedy J, Bresler S, Whitaker A, Masterson B. Risk management special report-Assessing violence risk in psychiatric inpatients: Useful tools. Psychiatric Times 2007; 24(8): 30-34 Honigfeld G, Klett CJ. The nurse’s observation scale for inpatient evaluation. A new scale for measuring improvement in chronic schizophrenia. Journal of Clinical Psychology 1965; 21(1): 65-71. Yudofsky SC, Silver JM, Jackson W, Endicott J, Williams D. The overt aggression scale for the objective rating of verbal and physical aggression. The American Journal of Psychiatry 1986; 143(1): 35-39. Gates DM, Gillespie GL, Succop P. Violence against nurses and its impact on stress and productivity. J Nursing Econ 2011; 29(2): 59-66. Gates DM, Ross CS, McQueen L. Violence against emergency department workers. Journal of Emergency Medecine 2006; 31(3):331-337. Gillepsie GL, Bresler S, Gates DM & Succop P. Symptoms of posttraumatic stress in emergency workers following workplace aggression. In press.
