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Violence is increasing both in society at large(1) and in worksite settings.(2) Health care settings are not exempt from this trend.(1,2) While acts of homicide, hostage taking, physical and sexual abuse, and verbal and nonverbal intimidation have been committed against caregivers by patients,(1-3) patient assault on staff members is the most frequent form of inpatient violence toward health care providers.(1-4) Patient assault is a serious problem, and rates of injuries to nursing staff from assaults appear to exceed the rate of injuries to workers in construction, currently considered the most hazardous occupation in the United States.(5)
These acts of patient violence toward staff members or other patients may result in symptoms associated with psychological trauma, and Post-Traumatic Stress Disorder (PTSD).(6-8) While prediction of violence remains problematic,(9) the human suffering, medical expense, and lost productivity(10) associated with patient assault suggests the need to review the risk factors associated with violence to guide assessment and intervention procedures. While these tasks have traditionally been the responsibility of clinical staff, in an era of managed care and cost containment, such models should prove of equal importance to mental health administrators who must continually respond to an evolving mental health care delivery system.
At least five recent studies(11-15) have begun to explore possible models for predicting patient assault. These papers have relied primarily on patient predictor variables, however. They have not included the growing literature on the characteristics of staff victims and the patient care sites where such assaults occur,(1,4,6-8) variables that are responsive to mental health administration.
The purpose of the present article is to provide a comprehensive review of the human risk factors associated with psychiatric inpatient assaults. These factors are not a model for predicting violence but are guidelines for administrators and clinicians in developing clinically efficacious, cost-effective strategies for containing the violence and its aftermath. The review includes a detailed presentation of the characteristics of patients who assault, the characteristics of assaulted staff members, and the characteristics of the context in which these assaults occur.
The present article outlines a multifactorial Person X Event X Environment approach(16) that provides an extended base for providing policy initiatives.
CHARACTERISTICS OF PATIENTS WHO ASSAULT
Several investigators(4,7,17-27) have studied psychiatric patients who have been assaultive. Comparing data from these studies...