Characteristics of International Staff Victims of Psychiatric Patient Assaults: Review of Published Findings, 2017–2022

Psychiatric patient assaults on staff are a worldwide occupational hazard for health care staff that results in medical injury, human suffering, and dollar cost expense. International research through 2000–2017 documented the continued frequency of these assaults and a continuing high risk for nursing personnel. This present paper reviewed the international published literature on staff victims of patient assaults during the next five-year period of 2017–2022. There were 39,034 assaults on 34,679 employee victims. The findings indicate that assaults on staff remain a serious worldwide issue as it has been since the 1990s and that nursing personnel continued to be at greater risk. Aggression management approaches, post-incident interventions, and an updated methodological inquiry are presented. Supplementary Information The online version contains supplementary material available at 10.1007/s11126-022-10008-5.

studies documented 612 assault incidents with 25% of the victims developing PTSD. This study noted the need for better systems of aggression management and post-incident support services for employee victims.
The third review article of 14 studies between 1986 and 2018 [6] focused on methodological issues and noted the 25-85% of health care staff were reported to have been assaulted but that there was a lack of a common definition of workplace violence and no standardized measures across studies, which limited understanding and generalizability across reports. The fourth study was conducted in Italy between 2014 and 2019 [7]. There were 27 studies that documented all types of patient assaults in 20,088 incidents. It noted the need for increased training on the early warning signs and for the development of aggression management skills. The last review article focused on patient assaults in less well-developed countries [8]. The review included 41 studies from 13 countries with health care providers being victims of a wide variety of patient behaviors. This study cited the need for a variety of training programs focusing on aggression management.
The purpose of the present paper is to continue the previous studies in this series [2,3] by reviewing the published findings of the characteristics of staff victims of patient assaults worldwide in studies which presented raw assault data from 2017 to 2022. It was hypothesized patient assaults would continue in spite of recent advances in medications, improved rehabilitation services, and restraint reduction initiatives and that nursing personnel would again remain at higher risk.

Search Procedure
The studies to be reviewed were those of unselected general psychiatric populations where assaults had occurred. These studies were obtained by means of literature searches on Pub Med and PsychINFO with key words such as "psychiatric patients," "assaults," "assaultive psychiatric patients," and "staff victims." Selected studies needed to present the raw data for the total number of assaults and basic victim characteristics in addition to whatever statistical analyses were performed. Selected papers were scanned for additional possible references. Papers cited in the five reviews noted above were not duplicated in this review. No attempt was made to search for unpublished papers.

Inclusion/Exclusion Criteria
The papers that were selected were from international institutions and appeared in English in peer-reviewed journals from June 30, 20,171-June 30, 2022. Inpatient, emergency room, and community studies in all settings were included. Child and adolescent and special populations (e.g. autism) studies and papers primarily validating scales were excluded. Studies with N < 10 were excluded as were studies employing the same data deck to examine different variables.

Results
The literature search yielded 24 studies for this 5-year period that met the inclusion criteria. These papers are presented chronologically from the earliest to the most recent publications and may be found in Table 1. Empty cells indicate that no data for those specific variables were reported in that study. Thus, at times, data do not meet the 100% threshold. Reported assaults included physical assaults, sexual assaults, nonverbal intimidation, damage to property, verbal/racially derogatory threats, and organized healthcare disturbances (15), defined as criminal gang activity to pressure hospitals for compensation.
The papers in Table 1 document 39,034 assaults perpetrated worldwide on 34,679 staff victims in international institutions from 2017 to 2022. In those studies reporting differing assault types, there were 21,250 physical assaults (54%) and 16,458 other assaults (43%). There were 4,046 males (12%) and 30,277 (88%) female staff victims. The victims were primarily nursing personnel (42% studies were nursing personnel exclusively/54% were all clinical staff, including nursing). In the 17 studies reporting age [10-13, 15-24, 28-30] the average staff age was 36.2 years (SD=+/-5.56 years). In the 13 studies reporting years of experience [10-13, 15, 17-23, 30], the average years of experience was 10.3 (SD=+/-2.64. Correlation coefficients revealed statistically significant associations in this population between assaults and male gender (correlation coefficient = 0.4535, p < 0.05) and female gender (correlation coefficient = 0.9141, p < 0.0001). There were no other statistically significant correlation coefficients. The assaults occurred mostly in inpatient settings (74%). The most frequent additional resources requested by staff included being taught various ways to better manage patient aggression (60%) and being offered post-incident crisis counseling services (40%). In these studies, no study made any reference to the various agency policy initiatives in place meant to reduce such patient violence, one study reported staff victims being offered post-incident services, and one study presented metric data on assault severity. The research time frames varied from 1 month to 18 months with the total time of observation and data gathering encompassing 16.53 years.
The small Ns in the studies from other continents precluded further analyses and the small Ns also precluded a meta-analysis. One Asian study (15) raised an additional question as to whether organized healthcare disturbance assaults creates a differing ward culture of fear for employees than is found on wards not experiencing this additional specific form of assault. There is no data as yet addressing this issue.

Discussion
The data in Table 1 supports its hypothesis that patient assaults on staff would continue and that nursing personnel would be at higher risk . This study's data, as well as the five review articles [4][5][6][7][8], continue to document that patient assaults are a worldwide occupational hazard. This includes the current papers from developing countries as well [16,17,20,28]. Since the findings from the European studies are generally similar to the findings as a whole, they are included below.
The basic characteristics of age and years of experience in internationally assaulted staff have remained generally stable from 2000 to 2022. As can be seen in Table 2, victims were primarily female nurses with an average age of 37.2 years and 10.3 years of experience. However, the number of female assault victims appears to be increasing over time. Nurses spend more time on the units and have more patient interactions. They are taught the early warning signs of loss of control, restraint procedures, and the profiles of high risk patients, but they may habituate to these ward abilities over time and/or be distracted by budget cuts, loss of programming, mandatory overtime, reductions in force, and/or staffing shortages on the units at various points with a resultant increased risk.
There may be other interacting variables as well. First, there may be design artifacts. These could include the specific institutions that published assault data during this five-year period and who may employ more female staff as a matter of course. There are also more studies.
from African and Asian countries and this may be introducing cultural differences in hiring practices. This recent uptick in female assaults may also be reflecting other societal shifts. Many women are seeking career opportunities with good working conditions, benefits, and opportunities for advancement. Nursing careers offer such possibilities. In addition, the cost of living began to increase during the covid-19 pandemic due to supply chain shortages and worsened during the continuing subsequent inflation period. Women, especially those with children, may have returned to the work force for needed additional income. Any combination of these factors may result in more women in the nursing workforce and, thus, a higher probability of female nursing victims.
However, there are available interventions to lessen this rate of assault. Nurses could be provided with additional and more detailed refresher trainings as well as being provided with additional needed staffing on units. The risk may be further addressed with more male staff on the units, the presence of facility security on high risk units such as the emergency room or acute forensic services, and a support group for staff victims. Nursing unions usually have contacts with the media around labor issues and could begin to raise this matter with their media contacts.
Seventeen of this review's studies review requested assistance with aggression management [9, 10, 13-17, 19-21, 23, 26-31]. Every facility should have a written policy of zero tolerance for violence. Recent research [32] has developed a zero assault procedure that includes increased behavioral response drills, shift handoff summaries, screening for risk of violence, past violence signage, mitigating counter measure, and post-incident support services. This package of interventions could be adapted and implemented in a variety of psychiatric settings.
Some of the requests for aggression management have been voiced by the developing countries where resources for aggression management may be fewer. It would be helpful if there were an online website as a repository for training manuals in the public domain for signs of loss of control, de-escalation, trauma informed carte, and nonviolent self-defense approaches. Facilities worldwide could access needed materials and adapt them for their own needs.
Eleven of the studies in this review also noted the need for post-incident services for victims [12,14,15,17,18,22,23,25,26,30,31]. As Psychiatry has learned more about psychological trauma/PTSD and its impact on human functioning, clinicians also realized the potential negative impact on employees that could result in medical absences, lost productivity, human suffering, and weakened morale. Complicating this basic issue in many facilities were factors such as weak environmental safety issues, unsupportive managers, staff victim stigma, and the failure to report incidents. However, the need for such postincident services remains.
There are a variety of possible options for these support services. This could include counseling services, time off of the unit for paperwork, family victim outreach, and in severe cases transfer of either patient or staff victim to another unit. There is also a data-based crisis intervention system for employee victims that has been treating employee victims for 32 years. Known as the Assaulted Staff Action Program (ASAP) [33,34], it provides crisis counseling in a clinically efficacious, cost effective approach. It includes individual and group crisis counseling, a staff victim support group, family victim outreach, and referrals for long term counseling as indicated. ASAP has treated over 10,000 staff victims. Facilities that have fielded an ASAP team have reported less use of sick leave, less industrial accident claims, and sustained productivity and morale. In some instances, fielding an ASAP team is associated with reductions in violence facility-wide. ASAP has been chosen as a best practice by the Province of Ontario, Canada and by the United States government. The need for post-incident support services is increasing; ASAP may be readily fielded by an interested agency.
Methodological Update. The first two reviews in this series [2,3] noted several flaws in the basic demographic information gathered and fundamental flaws in research design. Since this area has been recently reviewed in detail in 2021 [7], a short summary is provided here.
There has been methodological progress in the past two decades. Research papers on the topic have increased significantly, including papers from developing countries. The majority of papers now define physical assaults as some form of unwanted physical contact with intent to harm. Increasingly assault data is recorded at the time of the incident on some type of incident report form, which minimizes memory decay and selection bias. Basic demographics now include gender, and age.
Future studies will need to include verbal and nonverbal assaults that are operationally defined. and the basic demographics gathered needs to be expanded to include job block and years of experience. The impact of organized healthcare disturbances needs to be addressed. Research designs currently are mostly retrospective or cross-sectional in general. Rare is the prospective study and the problems of underreporting and severity assessment remain.  Whatever the cause(s), nursing victims' needs can be easily overlooked as patient assaults usually occur one at a time, are often daily incidents, are not taken up by the courts, are not usually reported in the media, and garner little attention from politicians. Every year these assaults on staff result in medical expense, lost productivity, and human suffering. More rigorous research designs will result in a deeper understanding of these events and better ways to prevent assaults and improve post-incident victim supports.