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

Abstract

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.

Review articles of data-based research from 1995 to 2017 document the continuing occurrence of assaults by psychiatric patients in health care staff [1–3]. It is a worldwide problem [2, 3]. The most common assailants were patients with schizophrenia and substance abuse and the most common staff victims have been nursing personnel with sequelae that included medical injury, depression, anxiety, posttraumatic stress disorder (PTSD), lost productivity, and impaired morale.

Since 2017, there have been five review articles that have focused on select aspects of this staff victim literature. These reviews are based on 71,262 patient assaults on staff. The first review was an international study of psychological trauma experienced by forensic nurses from 2000 to 2019 [4]. Sixteen studies of 18,602 abuse incidents documented psychological distress with formal psychological support being offered in only 298 incidents. A second review article also focused on the presence of psychological trauma as sequelae to psychiatric patient assaults among psychiatric nurses from 1980 to 2019 [5]. Nineteen 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.

Method

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.

Table 1.

Characteristics of Staff Victims

	Duration in months	N	Total Assaults Physical	Discipline	Average Age	Gender M/F	Years Experience	Setting	Training Needs	Country
Abdellah et al., 2017 [9]	2	134	80	MDs Nursing		65/69		ER	Better Reporting, Aggression Management	Egypt
Partridge et al., 2017 [10]	12	330	432	Clinical Staff	37.5	93/231	13.3	ER	More Security	Australia
Pekurinen et al., 2017a [11]	12	758	1,047	Nursing	44	200/ 558	9.1	Inpt Psych		Finland
Pekurinen et al., 2017b [12]	12	5,288	4,345	Nursing	42.3	476/ 4,812	12.6	Various	Staff Support	Finland
Shafran-Tikva et al., 2017 [13]	6	678	966	Clinical Staff	41	270/ 407	11	Medical Center	Better Reporting, Aggression Management	Israel
Shi et al., 2017 [14]	12	15,970	12,891	Clinical Staff		377/ 15,593		Tertiary Inpt	Staff Support, Aggression Management	China
Zhang et al., 2017 [15]	5	3,004	2,052	Nursing	29.4	89/ 2,915	8	Public Hospital Sites	Aggression Management Staff Support	China
Alhassan et al., 2018 [16]	1	296	73	Nursing		105/191		Hospitals	Aggression Management	Ghana
Olashore et al., 2018 [17]	12	179	79	All Staff	32	72/107	4	Inpt Psych	Violence Prevention, Staff Support	Botswana
Rosenthal et al., 2018 [18]	12	802	276	All Staff		169/ 630	10.9	Tertiary Inpt	Staff Support	USA
Yang, 2018 [19]	12	245	563	All Staff	31.4	82/163	9.7	Inpt Psych	Aggression Management	China
Akamni et al., 2019 [20]	12	145	38	All Staff	39.7	44/101	8.2	Inpt Psych	Violence Prevention	Nigeria
Ezeobele, 2019 [21]	2	143	4,356	Clinical Staff	32.4	59/84	12.2	Inpt Psych	Aggression Management	USA
Kelly et al., 2019 [22]	12	348	242	Clinical Staff		108/239	9.9	Forensic Psych	Staff Support	USA
Lu et al., 2019 [23]	12	1,906	4,061	Nursing	32.4	308/ 1,598	11.1	Inpt Psych	Security, Staff Support	China
Pekurinen et al., 2019 [24]	12	923	1,317	Nursing	44	234/289		Inpt Psych	Better Leadership	Finland
Puzzo et al., 2019 [25]	6	111	54	All Staff				Inpt Psych	Staff Support	Britain
Pelto, Wang, Kjellen, 2020 [26]	6	181	238	Nursing				Inpt Psych	Aggression Management Victim Support Services	Sweden
Zoleo et al., 2020 [27]	6	171	178	Nursing		4/130		ER	Aggression Management	Italy
Atinga et al., 2021 [28]	4	501	1,329	Clinical Staff	29.9	213/288		Inpt. Psych	Aggression Management	Ghana
Pereira-Sanchez et al., 2021 [29]	18	827	691	Psych Trainees	30.9	566/260		ER Inpt	Aggression Management	European Countries
Schlup et al., 2021 [30]	8	1,128	1,181	Nursing	40	332/786	13.9	Inpt Psych	Aggression Management Staff Support	Switzer-land
Horn et al., 2022 [31]	2.4	611	3,373	Health Care Staff		180/426		Psych Hospitals	Aggression Management Staff Wellness	Canada

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 studies in Table 1 were further arranged by continents and included 3 from North America, 8 from Europe, 2 from the Middle East, 4 from Africa, and 5 from Asia. The 8 European studies [11, 12, 24–28, 30] documented 10,862 assaults on 9,387 staff victims. Again, victims were predominantly nursing personnel on inpatient units with 75% of the studies being conducted on nursing staff. There were 5,704 physical assaults (53%) and 5,158 other assaults (47%). There were 1,821 male (20%) and 7,235 female (80%) staff victims. The average age was 40.24 years (SD=+/- 4.89) [11, 12, 24, 27–30]. The average years of experience were 11.87 years (SD= +/- 2.48) [11, 12, 30]. There was a statistically significant correlation between assaults and female gender (correlation coefficient = 0.9878, p < 0.05). No other statistically significant correlations were obtained. The European staff victims requested additional resources for aggression management (44%) and staff support (44%). The research time frame for these studies ranged from 12 months to 18 months for a total observation period of 6.67 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 [9–31]. This study’s data, as well as the five review articles [4–8], 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.

Table 2.

Characteristics of Staff Victims, 2000–2022

Year	2012 (2)	2017 (3)	2022
Female Gender	8%	71%	88%
Age	37	37.9	36.2
Years of Experience	7	10.02	10.3

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 post-incident 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.

Electronic Supplementary Material

Below is the link to the electronic supplementary material.

Biographies

Raymond B. Flannery, Jr., Ph.D., FACLP

designed and directs the Assaulted Staff Action Program (ASAP). Dr. Flannery is Adjunct Assistant Professor of Psychiatry, Department of Psychiatry, The University of Massachusetts Chan Medical School, Worcester, MA and Member of Board of Directors, American Mental Health Foundation, New York, NY.

Georgina J. Flannery, M.S.

is Reference Librarian in private practice, and Research Associate, The Assaulted Staff Action Program (ASAP), Boston, MA.

Funding

The authors have no funding from any public or private sources, no conflicts with property rights or any holdings by the author or any family members. The authors have no commercial gain from this study and did not receive any honoraria, stocks, paid consultations, or referrals for this review.

Declarations

Conflict of interest

The authors declare no conflicts of interest.

Consent

This is a review of the literature article only. There were no human subjects and therefore no need for an IRB review, nor informed consent, nor committee involvement, and no need to obtain consent to publish. Similarly, there were no animals involved in this review with no need to discuss and present a statement and review of animal welfare in this project.