Continuing Education Activity

Violence in healthcare is a worldwide and critical issue. In 2017, the Bureau of Labor and Statistics reported that healthcare workers are five times more likely to experience violence on the job than the average worker in the United States. Violence is a relatively vague term with several meanings, definitions, and interpretations. In the healthcare setting, violence may present as a verbal or physical attack by patients or visitors. This activity describes the types of violence, indicators of impending violence, and the management of violent patients. It highlights the role of the interprofessional team in ensuring the safe management of these patients.

Objectives:

• Describe indications that a patient may become violent.
• Explain what to do if a patient becomes violent.
• Review strategies for deescalating violent patients.
• Outline interprofessional team strategies for communication to advance the safe management of violent patients and optimize outcomes.

Introduction

Violence in healthcare is a worldwide and critical issue. In a 2017 Assessment of Occupational Injuries and Illnesses, the Bureau of Labor and Statistics reports that healthcare workers are five times more likely to experience violence on the job than the average US worker.

Violence is a relatively vague term with several meanings, definitions, and interpretations. In the healthcare setting, violence may present as a verbal or physical attack by patients or visitors. In this article, topics of discussion will include epidemiology and etiology, indicators of impending violence, repercussions, and management techniques.

Etiology

Violence by patients or visitors can present in different forms. In the most basic of explanations, violence may present in the form of verbal threats, aggressive language, or escalate to physical assault. Verbal harassment includes racial slurs, attacking appearance or perceived sexual orientation, cursing, yelling at, or berating another person. Sexual harassment includes unwelcome sexual advances, insulting gestures, and verbal or physical conduct of a sexual nature. Verbal threats include statements of intent to cause harm, and threatening body language or gestures. Physical violence includes spitting, biting, pulling hair, and any other type of unwanted physical contact intending to cause harm.

When managing a violent patient, it is important to consider the potential etiology. Violent behavior is often perceived as a personal attack by healthcare workers and is an easy source of frustration. However, the etiology of such behavior is quite vast including biological factors, the healthcare setting, and environment, psychological, and socioeconomic influences.

Epidemiology

Violent behavior can happen in all aspects of patient care, regardless of the setting. However, the highest incidences reported are from paramedics, emergency departments, and inpatient psychiatric facilities. In 2016, health care workers made up 69% of all reported workplace violent injuries, according to the Bureau of Labor and Statistics.

Male gender and age are among the strongest predictors of violent behavior. Men younger than the age of 35 are the highest offenders of violence against healthcare professionals.[1]

Socioeconomic factors also play a vital role in regard to violence. The type of community and neighborhood is linked to violent behavior. Patients with exposure to violence as a young child or adolescent have been shown to have reduced educational attainment, below-average intelligence, increased likelihood of lifelong unemployment, increased rates of homelessness, and increased rates of gang involvement. A recent study found that nine factors correctly classified 80% of violent patients at the time of admission. These nine factors include diagnosis of psychosis or bipolar disorder, history of psychiatric disorder, male gender, age younger than 35 years, below-average intelligence, no history of employment, homelessness, and agitated behavior.[2][3][4][5] Overall, multiple studies show a history of exposure to violence leads to a worsened socioeconomic status which in turn increases rates of violent behavior.[6][7][8][9]

Healthcare settings and overall environment is also an important factor that can contribute to violence. Several studies have found a direct correlation with multiple aspects regarding the hospital setting and violent behavior. Hospital policy and staffing play vital roles in properly addressing violence. Long waiting times, lack of security, lack of adequate staff, and patient areas being open to the public are the highest contributing factor to violence, respectively. Other contributing factors include lack of metal detectors, delayed response time by security, working between 7 pm to 7 am, being alone with the patient or visitor, lack of violence prevention training, and working longs hours.[10][11][12]

There are many factors thought to increase the risk of violence among ED workers, including an increased number of patients and visitors using alcohol and drugs, psychiatric disorders, dementia, the presence of weapons, stressful environment, overcrowding, prolonged waiting times, and flow of violence from the community into the ED. Many of these factors are commonly involved in the ambulance and inpatient psychiatric settings as well, corresponding with the increased risk of violence.[10][11][12]

Verbal violence is reportedly highest among paramedics, followed by nurses, and lastly, physicians. Verbal threats are highest among physicians and nurses, 83% and 78%, respectively. Nurses report the highest rates of violence threats by visitors. Among nursing staff, some studies report female nurses are nearly twice as likely to be victims of violence.[13][14]

The National Crime Victimization Survey conducted by the Department of Justice reports the annual rate of violence against staff in psychiatric facilities is 68.2 per 1000 workers.[15] Medical staff in psychiatric departments have the highest rates of being victims of repeated physical violence.[2] As many as 1.7 million medical ED contacts per year involve agitated and violent patients.[2] A study performed by the American Journal of Emergency Medicine followed 213 healthcare providers over 9 months. A total of 827 violent events were reported, with an average of 4.15 violent encounters per provider.[11] Many other studies also show a concerning trend of under-reporting incidents of violence. Common causes of under-reporting include lack of organizational policy, the categorization of violence as a criminal act, or because health care providers attribute the behavior to an unpreventable event secondary to the patient's underlying medical conditions.[11] Therefore, current numbers likely underestimate the prevalence and severity of violent behavior in the healthcare setting.

Pathophysiology

Origins of violent behavior may be complex and must be determined to address and manage these encounters properly. It is important to remember that patients with violent tendencies often have poor coping mechanisms and suppress anger and rage due to societal norms. When under duress, it becomes more difficult to suppress these urges. These patients may become violent against healthcare workers due to pain or the stressful nature of the emergency department or inpatient psychiatric unit. The cause of violent behavior can involve a multitude of factors including biological factors, distress from underlying pathology, brain structure abnormality, medications, alcohol, illicit drugs, and many types of psychiatric conditions.

History and Physical

Although it may be more difficult to perform a thorough history and physical in a violent patient, every attempt must be made to do so. This may lead to a better understanding of the patient’s behavior and, therefore, more appropriate and efficient management of the behavior with improved opportunities for de-escalation. A proper review of past medical and surgical history, medications, alcohol use, illicit drug use, family history, psychiatric history, and mental status exam can provide critical information as to potential exacerbating factors and predictors of violent behavior. Therefore, it is important to obtain this information early, even when a patient is escalating aggressive or violent behavior, such as threats or verbal violence. If the patient is already engaged in any violent, physical behavior, immediate interventions must be made.

Evaluation

Determining the origin of a patient's violent behavior will guide proper evaluation in any healthcare setting: tailor laboratory and radiographic workup around the suspected sources of violent behavior. If the healthcare provider cannot perform a thorough history and physical exam, the differential diagnosis must be broad, and further evaluation performed accordingly.

Treatment / Management

After obtaining a history, the healthcare provider may find the source of violence is due to a biological source such as described above. In these instances, treating the underlying medical condition may lead to a quick resolution of the violent behavior.

If the source of violence is undetermined or the violent behavior must be addressed urgently, first-line management should be through de-escalation. However, safety precautions should be implemented before making any attempts at de-escalation. This includes calling security and others to assist, remove untrained individuals from the room to decrease the risk of injury to medical staff, and eliminating potential weapons from the room. Seclusion to a private room with decreased stimuli will provide a sense of calm. While still assuring a safe exit from the room, staff should either sit or stand with an open stance. The healthcare provider should make every effort to establish a good report and make the patient feel respected. Asking open-ended questions and repeating the patient's concerns will help the patient feel that all complaints have been adequately addressed. If the patient's aggression improves with these techniques, medications should be discussed before administration to prevent the re-escalation of violent behavior. If de-escalation techniques are unsuccessful, pharmacological intervention may be necessary.[16][17]

After failed attempts at de-escalation in the undifferentiated or acutely violent patient, pharmacological treatment regimens may be tailored optimally to the situation.

Patients with mild agitation and mild verbal violence may benefit most from oral medications. In patients with moderate agitation and escalating violent behavior, intranasal or intramuscular administration will likely be necessary. The American College of Emergency Physicians (ACEP) recommends the use of typical antipsychotics (haloperidol 2 to 5 mg orally, intramuscularly, or intravenously [PO/IM/IV] and droperidol 5 mg IM) or benzodiazepines (lorazepam 2 mg PO/IM/IV or midazolam 2 to 5 mg IM) for violent patients requiring rapid management. These medications may be administered intranasally, intramuscularly, or intravenously.[18] Patients early in pregnancy can be treated with diphenhydramine.

If IV access has not yet been established, intranasal administration will have the quickest onset and is most likely to reduce the need for further escalation of treatment. In patients with acute psychosis, antipsychotics are considered first-line. Benzodiazepines may also be used independently or in addition to antipsychotics. Using a combination of antipsychotics and benzodiazepines has a synergistic effect and theoretically lower dosing requirements. However, studies have not consistently shown improved control of agitation or violent behavior.

If a patient is imminently violent, medications with faster peak plasma levels such as olanzapine (5 to 10 mg IM) or ziprasidone (10 to 20 mg IM) can be injected intramuscularly but will likely require more repeated dosing in comparison to other alternatives.[19]

In patients with acute psychosis, antipsychotics are considered first-line. Benzodiazepines may also be used independently or in addition to antipsychotics.

The first-line treatment for intoxicated, violent patients as well as violent patients going through withdrawals is benzodiazepines. Antipsychotics may be used in conjunction with benzodiazepines if violent behavior is not adequately controlled.

Patients with dementia or delirium have an increased risk of severe side effects when given antipsychotics or benzodiazepines. If necessary, lower doses should be used with recommendations of 25% to 50% of standard adult doses.[20] Certain antipsychotics, such as olanzapine or ziprasidone, should be avoided in patients with a history of dementia due to increased risk of stroke and death.[2][20]

The risks of antipsychotics and benzodiazepines should be considered before being used in violent patients. Common risks associated with antipsychotics include sedation, prolongation of the QT interval, postural hypotension, seizures, neuromuscular effects, and cardiovascular and respiratory suppression or collapse. Typical antipsychotics can cause akathisia, dyskinesia, Parkinsonian-like tremors, muscular dystonia, including oculogyric crisis. Akathisia may often be mistaken as increased agitation. Providing more antipsychotics will cause these symptoms to worsen and will increase the risk of respiratory and cardiovascular collapse. The most common side effect of benzodiazepines is disinhibition which can exacerbate unanticipated agitation and violent behavior. Higher doses of benzodiazepines, or when used in combination with other sedatives, alcohol, or illicit drugs, increases the risk of oversedation and respiratory depression.

Anticholinergic medications are often used for their sedative properties as well. They may also be used to counteract the neuromuscular effects of antipsychotic medications but are not without risk. Common side effects include dry mouth, dry eyes, and constipation. One potentially serious side effect includes acute closed-angle glaucoma and should be recognized if the patient complains of eye pain or vision changes and demonstrated associated conjunctiva erythema and mydriasis.

Physical restraints should be the last resort. If restraints are necessary, they should be applied in an optimally safe and comfortable yet effective position. After restraints are implemented, frequent reassessments should be made. Restraints should be removed as soon as possible once the patient has become cooperative and no longer poses a threat of self-harm or harm to medical staff.

Differential Diagnosis

Biologic factors may contribute to violent behavior and are extensive. Common contributing factors include alcohol, illicit drugs or abused substances, toxins, distress secondary to an underlying medical condition (i.e., acute coronary syndrome [ACS], respiratory distress from chronic obstructive pulmonary disease [COPD] or pulmonary embolism [PE]), prescribed or over-the-counter medications, and endogenous or exogenous hormone effects. The patient’s age, gender, brain structure, and neurotransmitter balance can all play a role as well. It is of vital importance to complete a thorough HPI in agitated or violent patients and attempt to determine a patient’s level or orientation and capacity for decision-making. Violence may be a presentation of altered mental status.[21]

Aggressive behavior is also correlated with certain brain structures, neuronal connections, and neurotransmitters. The prefrontal cortex controls executive functioning such as planning complex cognitive behavior, personality expression, decision making, and moderating social behavior. Lesions (tumors) or neuronal changes, such as in Alzheimer disease, will impede the proper functioning of the prefrontal cortex resulting in unchecked aggressive behavior. Excess or deficiency of neurotransmitters has been correlated with aggression and violence. Serotonin, both excess and deficiency, has been linked to violent behavior. Other neurotransmitter sources of violent behavior include deficiency of GABA and excess dopamine. GABA serves as an inhibitory neurotransmitter. Deficiency of GABA, as seen in patients with depression, anxiety, insomnia, allows other neurotransmitters (dopamine) to function in excess. Dopamine excess, such as in patients with Parkinson disease treated with dopaminergic medications or schizophrenia, has also been linked to increased aggression and risk of violent behavior.[22] Seizures, particularly epilepsy, originated in the temporal or frontal lobes have also been associated with violent behavior.

The pharmacological properties and link between alcohol or other substance abuse and violent behavior have been well documented in the medical field. The Journal of Substance Abuse Treatment noted among patients receiving treatment for substance abuse, more than 75% had reported a history of committing violent acts while under the influence.[5][4] Alcohol is the highest contributing factor to violent behavior in the healthcare setting.[23][24] Alcohol intoxication can lower inhibitions, including repressive barriers of emotions, including anger and violent tendencies. It is also important to consider alcohol withdrawal as a source of violent behavior.

Sympathomimetic drugs may also lead to violent behavior. Illicit drugs such as Cocaine, Methamphetamine, PCP, and 3,4-methylenedioxymethamphetamine (MDMA, ecstasy) result in a blockade of presynaptic catecholamine uptake. In large doses, this may lead to tachycardia, HTN, hyperthermia, tremors, pressured speech, and flight of ideas. These symptoms may be exacerbated when combined with a high-stress environment such as the ED and ultimately lead to violent behavior. Phencyclidine (PCP, angel dust) is of particular importance when discussing violent behavior in the healthcare setting. PCP has both sympathomimetic and hallucinogenic properties. The dissociative properties alter the perception of pain, nearly making users impervious to painful stimuli. This altered perception of pain in combination with potentially frightening hallucinations and sympathomimetic effects is a common cause of violence against healthcare workers. Other hallucinogens, including DMT, peyote, LSD, and ecstasy, can precipitate fear and agitation. This may lead to violent behavior due to a sensation of lack of control during a frightening hallucination. Several other drugs may lead to euphoria or agitation, including Spice, Whippets, Khat, Synthetic Cathinones (bath salts), Kratom. Agitation in a stressful setting such as the emergency department may exacerbate violent behavior. Withdrawal from illicit drugs often causes severe agitation and may result in violence.

There are numerous diagnoses in the Diagnostic and Statistical Manual of Mental Disorders (DSM–5) with aggression and violent behavior listed as a component of the disease or personality disorder. The most common include bipolar affective disorder, Cluster B personality disorders, intellectual or cognitive delay, adolescent disorders, dementia, schizophrenia, and post-traumatic stress disorder (PTSD). Patients with bipolar affective disorder during the manic phase develop grandiose delusions and can easily become aggressive and violent, especially if their delusions are not being acknowledged. Personality disorders listed as Cluster B include antisocial, borderline, narcissistic, and histrionic personality disorders. Antisocial and borderline are the most likely to become violent. Antisocial personality disorder individuals are egocentric and lack empathy, often with a history of violence as an adolescent. Individuals with Bipolar personality disorder can become aggressive if they fail at manipulating others to fit their desires. An intellectual or cognitive delay may lead to violence as a coping mechanism during times of stress. Adolescents with increased rates of violent behavior include attention deficit hyperactivity disorder (ADHD), oppositional defiant disorder, conduct disorder, and diagnoses along the autism spectrum disorder due to impulsiveness and communication difficulties.[25][26][27]

Pearls and Other Issues

Violence against healthcare workers is a complex and growing issue across the world. Although difficult, a thorough history and physical exam are of vital importance to properly evaluate violent patients. Disposition is highly variable depending on the origin of violent behavior. Common pitfalls are becoming angry at aggressive or violent patients, poor team response, and failure to report incidences of violence. Remaining calm and understanding that violent behavior often stems from a multitude of contributing factors. Approaching patients with an open stance and de-escalation is the key component to prevent aggressive behavior from becoming violent. Team training and a team-based response to violent behavior reduce episodes of violent behavior resulting in injury to both healthcare workers and patients.

Enhancing Healthcare Team Outcomes

As awareness of violence against healthcare professionals continues to improve, so must the approaches to management. Proper training is of utmost importance when managing violent patients, and any training activities should include personnel in hospital administration and security in addition to all healthcare professionals with direct patient contact. There are many organizations with thorough training seminars available to all healthcare staff. Violence prevention and management training involving both discussion and role-playing seminars have the best outcomes. Studies have found these types of training seminars have both a cascade-type direct and indirect effect on violent behavior outcomes. In these sessions, healthcare professionals practice violence prevention and management, safety precautions, de-escalation techniques, and restraint techniques. Training in this environment produces improved confidence among staff, improved management of violent patients, decreased rates of physical violence, and decreased need for sedation and restraints. Overall, training seminars improve both patient outcomes and provider safety.[28][13][28][14]