Psychiatric Patient Assault and Staff Victim Gender: Fifteen-year Analysis of the Assaulted Staff Action Program (ASAP)
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- Flannery, R.B., Marks, L., Laudani, L. et al. Psychiatr Q (2007) 78: 83. doi:10.1007/s11126-006-9029-4
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Extensive, largely cross-sectional research has documented the continued occurrence of patient assaults on male and female staff. Different studies report either male or female staff to be at highest risk. Studies of same/different gender assaults which might more fully answer this question have been few. In these latter studies both male and female staff were at high risk for same gender assaults. In community settings males were at risk from same gender assaults but females were at risk from assaults by both patient genders. The present 15-year longitudinal retrospective study examined same/different gender assaults over time. Since the health care system under study experienced several major policy changes during these years, data were also examined at 5-year intervals to assess the stability of findings across time. Male and female staff were at increased risk from same gender assaults over time in both inpatient and community settings. The findings and their implications are discussed. In addition, a cost-effective, comprehensive risk management strategy for containing assaults is outlined.
KeywordsAssaultsGenderPsychiatric PatientRisk ManagementStaff Victim
During the past forty years, levels of assault in the United States have increased over six fold . Health care settings have not been exempt from this violence, as reviews of studies of staff victims have demonstrated [2–5]. It is estimated that the risk of injury from patient assaults in public sector psychiatric hospitals exceeds the rate of injury from construction, agriculture, mining, manufacturing, and transportation combined . Assaults on staff remain a serious public health concern .
Although the patient assailant characteristics literature is extensive [2–5] less attention has been directed to the role of staff victim gender in these assaults. A recent review of the gender victim literature  found inpatient male staff to be at increased risk during restraint procedures and inpatient and community female staff to be at increased risk for random assaults. Subsequent research in a variety of settings has reported mixed findings. For example, some studies have reported male staff at increased risk . Others have reported female staff at high risk  and still others studies have found no gender differences at all . The role of victim gender appears to be multifaceted.
Some of these apparent conflicting results might be more fully understood by examining the same/different gender of assailants and staff victims at the same time in the same study. However, the literature assessing same gender/different gender staff victim assault patterns (male patient/male, female staff; female patient/male, female staff) within the same study is very limited. To date, there appear to be only four studies [12–15] that have addressed this issue. In nine cases, Kalogerakis  reported a higher rate of same gender assaults (male patient/male staff, female patient/female staff) than different gender assaults. Harris and Rice  reported male staff at increased risk for assault from male patients. In the two remaining studies, Flannery and his colleagues reported in their first two-year study  that both male and female staff were at increased risk for same gender assaults in inpatient settings and that female staff were at risk for different gender assaults in community settings. In their second, six-year study , male and female staff remained at the same risk for same-gender assaults but female staff in community settings were at increased risk from both male and female patients.
The purpose of the present study is to retrospectively examine same gender/different gender assaults in one public health care system during a fifteen-year continuous period. This health care system included both inpatient and community settings. Since this health care system underwent several major initiatives at various points during this time interval (e.g., managed care initiatives, downsizings and closures, outsourced vendor services, reductions in force, patient transfers from correctional facilities, etc.), this study further examined these assaults at five-year intervals to assess whether the fifteen-year pattern remained consistent through the various change initiatives.
The subjects were 1,047 male and 1,056 female child and adult assaultive patients of the Massachusetts Department of Mental Health (DMH) who received care in 7 state hospitals and 9 DMH state or DMH-vendored community programs from April 2, 1990 through March 31, 2005. There were 806 male and 766 female assaultive inpatients and 241 male and 290 female assaultive community patients. Their average age was 36 years (SD = 11.74). Primary diagnoses included schizophrenia (48%), affective disorders (15%), and personality disorders (19%) and other (16%). They were predominantly Caucasian (74%), Black (16%), Asian (2%), and other (8%).
During this fifteen-year period, there were 1,071 male and 1,049 female staff victims across all disciplines. Assaulted staff included mental health workers (64%), nurses (25%), clinicians (8%) and other groupings (3%). Employees ranged in experience from new hires to seasoned staff.
During the period of this study, this health care system experienced reductions in the workforce due to downsizings, closures, layoffs, and the utilization of contracted services. Reductions in staff by gender, job classification, and experience were proportionally equal. No statistically significant differences emerged in the reductions in force in 1990, 1995, or 1999.
Measures of assault
The four types of assaults included in this study remained the same as they have been since the program was fielded in 1990. Physical assaults were defined as unwanted contact with another person with intent to harm, including punching, kicking, slapping, biting, spitting, and throwing objects directly at staff. Sexual assaults were unwanted sexual contacts and included rape, attempted rape, fondling, forced kissing, and exposing. Nonverbal intimidation referred to actions intended to threaten and/or frighten staff, such as pounding on the staff office door, random throwing of objects, and destruction of property. Verbal threats were statements meant to frighten or threaten staff, and included threats against life and property as well as racial slurs and other derogatory comments.
Data on patient assailants and staff victims were recorded on Assaulted staff Action Program (ASAP)  report forms from 1990–2005 in DMH state and vendored facilities that had fielded an ASAP team. ASAP  is a voluntary, peer-help, system-wide, crisis intervention program to assist staff victims to address the psychological sequelae of patient assaults. ASAP offers individual, group and victims’ family crisis intervention services as well as staff victim support groups and referrals to individual therapists who specialize in treating trauma victims, if indicated. ASAP has strong empirical support for its efficacy in providing needed support to staff victims and is associated reductions in overall assaultiveness in several facilities that have fielded ASAP teams [16, 17].
All ASAP team members had practiced completing ASAP report forms, including the sections on patient precipitants, until acceptable levels of reliability were obtained. To guard against underreporting , each facility was required to fill out a DMH report form for each incident, to call the ASAP person on duty, and to review the incident at daily staff meetings. At times, the total numbers do not equal 100% because of occasional missing data when staff victims declined ASAP services, declined to identify the patient assailant, or when the patient’s record did not include sufficient documentation of the study’s variables. This analysis assumes that all staff were at equal risk for the full period, except for some brief hospitalizations during which community patients were absent from residential placements. All data are reported as assault incidents.
During this fifteen-year time period, ASAP teams responded to 2,152 patient assaults on staff. ASAP was accepted in 1,862 incidents (87%) and declined in 290 others (13%). There were 1,068 male (50%) and 1,055 female (49%) victims. Of these, 824 were male (51%) and 764 female (47%) staff victims in inpatient settings. Community settings reported 240 male (45%) and 290 female (54%) staff victims. Staff victims declined ASAP services in 187 inpatient (12%) and 108 community (20%) incidents.
Gender Differences at 15 years: total, inpatient, community findings
Assaults by Gender
Male patients against
Female patients against
Gender differences at 5 and 10 years: totals, inpatient, community findings
Assaults by gender
5 year: totals (inpatient)
10 year: totals
Male patients against
Female patients against
The present study’s findings are consistent with most previously published research in documenting patient assaults on staff as a serious occupational hazard in health care settings [1–10, 12–15]. Unlike the earlier mixed findings studies [9, 10], this study found both men and women to be at increased risk in patient care settings. The same/different gender variable findings at both the ten- year and fifteen-year periods are also consistent with previously published findings [12–15]. Male and female staff were at higher risk of assault from same gender assailants in both inpatient and community settings. This study’s findings differ from the previous two studies from this same data base because the data were examined for two- and six-year periods and these time spans did not adequately represent the actual findings over time [12, 13]. These mixed findings within the same data base at different points in time suggests the importance of longitudinal studies in assessing assault trends.
Although the overall rate of assaults in society as a whole has been increasing , a recent detailed review of violence by males and females  suggests that violence by men has been decreasing since 1986 where as violence by women has been increasing during this same period. The present data confirm these findings. After the first 5-year period, female staff in this study became increasingly likely to be assaulted by female patients. This finding could be an artifact of this data base as managed care vendor initiatives in the second five-year period resulted in an increase of residential housing staffed primarily by female staff. However, there was a similar increase female same gender violence in inpatient settings. Thus, it appears that, while privatization of community services increased the total pool of female staff at risk, the increased risk appears to reside with the female patients themselves in whatever setting they may be receiving services.
Violence by males is often instrumental in nature and force is often utilized to solve problems . As we have become a more equalitarian culture in the past decade, perhaps female patients have begun modeling male patient behavior in terms of using force to solve problems. Research has also suggested that females become aggressive when they perceive resources to be limited . It may be that female patients perceive female staff as the gatekeepers of health care resources and benefits. It may also be that female staff have more contact with patients in general, are more likely to utilize verbal de-escalation strategies, and be less included to utilize restraint procedures early on. With the exception of an increased pool of female staff as an outgrowth of vendoring community services, it is noteworthy that the other major policy initiatives of this time period, such as managed care, downsizings, reductions in force, appear to have had little or no apparent impact on reductions in patient assaults. This finding may be an artifact of this study in that the changed outcomes have not been adequately delineated. However, it is equally plausible that patient assaults are inherent within the patients and their serious mental illnesses. The later explanation would imply the need for renewed research into the nature of these seemingly treatment-resistant assaults.
This new generation of studies would need to include several enhancements in research design. First, researchers in the field would need to agree upon a basic set of patient characteristics to be measured in each study. Additional characteristics could be added in individual studies but the agreed upon base would need to be included in very study. Second, researchers would need to develop some standardized scale of incident severity, again to be included across studies. Third, these new studies should develop a common assessment procedure. The current mix of incident reports, staff inferences, chart reviews, self-reports, and videotaped incidents that are rated some time later is unwieldy and ineffectual in comparing different study outcomes. Fourth, single incident assailants versus repeat offenders should be routinely differentiated and examined across studies. Finally, as the present study suggests, longitudinal studies across lengthy time spans would likely yield a richer yield than one-point-in-time cross-sectional research. New generation research on patient assailants, including the same/different gender issue, that follows the suggested standardized procedures noted above should yield enhanced generalizability across studies so that the more important components of patient assaults are more fully clarified in the person x event x environment mix.
Risk management implications
Having examined the implications of the present study’s findings, attention is now turned to risk management strategies to address assaults such as those reported on in this study. Facilities presently have at their discretion a number of risk management strategies to reduce such patient violence. These can be incorporated into a comprehensive strategy to strengthen patient and staff safety and enhance clinical care. The Occupational Safety and Health Administration (OSHA)  has outlined some preliminary workplace violence prevention considerations. Outlined below is a fully detailed approach that includes organizational, staff, and patient initiatives. These strategies are drawn from OSHA , published research and clinical practice.
As a first step, each facility will want to create its own detailed quality management data base for assessing assaultive patient and staff victim characteristics [5, 16]. This is especially important information to know about repetitively violent patients. This data base would provide information for managing resources for staffing, hiring, and training as well as indicating clinical services needed by assaulting patients. Each facility needs to clearly define assaults and have adequate reporting systems to avoid the issue of underreporting .
Next, the facility will want to put in place clear policies on guns, substance use, and threats for both staff and patients. Patient violations of these polices will need to be understood within clinical context but the fact of a policy illustrates the seriousness of the issue and its links to potential violence.
Facilities will benefit from creating restraint-free environments that are rooted in trauma-informed care. Patients with a past history of personal victimization may encounter triggers or symbolic reminders of that victimization during restraint procedures and impulsively become violent. The publications of the National Association of State Mental Health Policy Directors outline the steps for trauma-informed care in detail . No nurse or physician should be alone with a patient during an intimate exam.
As noted above, organizations will want to review the general federal guidelines for preventing workplace violence  and work to improve police liaison links, especially in community settings where a great many female staff are employed. Lastly, facilities should have post-incident crisis counseling services for both patients and staff, as these have been shown to reduce violent assaults facility-wide .
Staff need to be trained in basic mental health safety skills. These would include some system of nonviolent self-defense, restraint and seclusion procedures, alternatives to restraint and seclusion, psychological trauma, and de-escalation skills. Although not all episodes of patient violence are preceded by warning signs, the majority are and staff should be trained in the appearance and behavioral warning signs of impending loss of control. Staff should further be taught anger management and verbal-conflict resolution skills to further enhance their own coping skills in addressing agitated patients. Staff should also be trained in taking a violence history routinely with each admission.
Facility violence may also be reduced by addressing patient clinical issues directly. Staff should freely utilize forensic, behavioral, psychopharmacological, and patient-at-risk consults as indicated. In addition, patient issues that my result in violence may be addressed through traditional treatment approaches. The published literature [2–21] suggests individual or group treatments may prove of assistance in the following areas: anger management and verbal-conflict resolution, substance use disorder, posttraumatic stress disorder, interpersonal skill deficiencies, and community living skills. Lastly, utilization of the courts may prove to be of assistance in some incidents of extensive and/or very serious harm or destruction of persons and property .
Patient and staff safety is a primary goal in all health care facilities. The technology to enhance safety and care exists. It is easily implemented and is cost-effective. Facilities are now able to design a` program tailored to their individual needs.
Raymond B. Flannery, Jr., Ph.D.
is Senior Psychologist, Massachusetts Department of Mental Health, Worcester State Hospital, Worcester, MA, and Director of the Assaulted Staff Action Program (ASAP). Dr. Flannery is on the faculties of Harvard Medical School and the University of Massachusetts Medical School.
Louise Marks, L.I.C.S.W.
was an ASAP team leader and is now Director of Housing, The Metro Boson Area, the Massachusetts Department of Mental Health, Boston, MA.
Lisa Laudani, M.A.
is an ASAP team leader, and senior staff counselor at the Vinfen Corporation, Boston, MA.
Andrew P. Walker, B.A.
is an Automated Information Technology specialist, at the Massachusetts Department of Mental Health, Boston, MA.