What is Violent Patients?
Violence in healthcare is a significant problem worldwide. According to a study in 2017 examining job-related injuries and illnesses, the Bureau of Labor and Statistics found that healthcare workers are five times more likely to face violence at work compared to other jobs in the US.
The term ‘violence’ can be a little unclear as it can have different meanings and interpretations. In the context of a healthcare setting, it can refer to verbal or physical attacks by patients or visitors. We’re going to talk about where and why this violence takes place, how to recognize signs that violence may be about to happen, what the consequences are and how best to manage these challenging situations.
What Causes Violent Patients?
Violence from patients or visitors can take many forms. In the simplest terms, violence may show up as verbal threats, aggressive language, or even progress to physical attack. Verbal harassment can include racial insults, personal attacks on someone’s appearance or assumed sexual orientation, rude language, shouting at, or belittling another person. Sexual harassment involves unwanted sexual attention, offensive actions, and any verbal or physical behavior with a sexual connotation. Verbal threats include statements of plans to hurt someone and menacing body language or gestures. Physical violence includes actions like spitting, biting, pulling hair, and any other type of physical contact meant to cause harm.
When dealing with a violent patient, it’s crucial to think about what might be the root cause of their behavior. Health care workers often perceive violent behavior as a personal attack, and understandably it can be a source of stress. However, there could be a number of reasons for such behavior including biological factors, the hospital setting and conditions, psychological and economic influences.
Risk Factors and Frequency for Violent Patients
Violent behavior can occur in any healthcare setting but is often reported most by paramedics, emergency departments, and psychiatric facilities. In 2016, it was reported that 69% of all reported workplace violent injuries occurred among health care workers.
The likelihood of violent behavior increases with certain factors. Men under the age of 35 tend to be the highest offenders of violence against healthcare professionals. Social factors such as community, exposure to violence at a young age and low socioeconomic status are also linked to violent behavior. Individuals with these factors tend to have lesser educational achievements, high chances of remaining unemployed, become homeless, and/or gang involvement. In a study, nine factors were found that could classify 80% of violent patients at the time of admission:
- Diagnosis of psychosis or bipolar disorder
- Past history of psychiatric disorder
- Male gender
- Age under 35 years
- Below-average intelligence
- Unemployment
- Homelessness
- Agitated behavioral display
Another important aspect is hospital policy and staffing. Violent behavior can be directly linked to long waiting times, lack of security, insufficient staff, and unrestricted public access. Other contributing factors may include lack of metal detectors, slow security response times, working in isolated conditions, inadequate violence prevention training, and long work hours.
Emergency department (ED) workers face an increased risk of violence due to factors such as more patients and visitors using alcohol or drugs, presence of weapons, stressful environment, overcrowding, and long waiting times. Paramedics reportedly experience the highest verbal violence, followed by nurses, and lastly physicians. Among these, female nurses are almost twice as likely to become victims of violence.
Violence against staff in psychiatric facilities is reported at a rate of 68.2 per 1000 workers annually. Repeated physical violence victimization is highest among the medical staff in psychiatric departments. Emergency department visits involving agitated and violent patients are estimated to number 1.7 million per year. It’s important to note that these statistics may not paint the full picture as incidents of violence are often under-reported due to reasons such as lack of organizational policy, defining violence as a criminal act, or attributing violent behavior to a patient’s medical condition.
Signs and Symptoms of Violent Patients
Dealing with a violent patient can be challenging, but it’s crucial to try and understand their history and current condition. This approach may help ascertain why the patient is behaving violently and guide the appropriate care and management processes necessary to calm them down. Important information might be gleaned from their past medical and surgical records, current medications, alcohol and illicit drug use, family history, mental health background, and their current mental status. All of these factors may contribute to their violent behavior. Therefore, it is essential to gather this information as early as possible, even if the patient’s behavior is escalating, such as threats or verbal violence. If the patient is physically violent, immediate action must be taken.
Testing for Violent Patients
Knowing the cause of a patient’s violent behavior is crucial for healthcare professionals to provide the right treatment. This understanding will shape the kind of lab tests and imaging studies needed to identify the source of such behavior. If the healthcare provider isn’t able to carry out a detailed review of the patient’s medical history and a physical exam, they’ll need to consider a wide range of possible causes (a broad differential diagnosis) and carry out more evaluations as needed.
Treatment Options for Violent Patients
If a healthcare provider observes violent behavior in a patient, one possibility they’ll consider is that the behavior might be caused by an underlying medical condition. If that’s the case, treating this condition could help reduce the violent behavior.
When the cause of violence isn’t immediately clear or the violent behavior needs to be addressed quickly, the first steps usually involve trying to calm the situation down. It’s crucial to prioritize safety when doing so. The healthcare team might call security for assistance, ask other people to leave the room to reduce the chance of injury and remove anything that could be used as a weapon from the room. They might also move the patient to a quiet, private room to create a calmer environment. Staff members should communicate in a respectful and open way, which can help build a good relationship with the patient and can help the patient feel heard and understood. If these de-escalation efforts successfully improve the patient’s aggression, medications might be discussed and given to keep the situation from escalating again. If these efforts are unsuccessful, it might be necessary to use medications to help manage the situation.
What type of medications and how they are used can depend on the patient’s behavior and situation. For example, someone with mild agitation and mild verbal aggression might benefit from oral medications. However, if someone has moderate agitation and their violent behavior is escalating, it might be necessary to use medications that are given in the nose or muscle. Certain types of medication such as antipsychotics or benzodiazepines are often considered for rapid treatment of violent behavior. These medications might be administered in different ways, depending on the situation.
If a patient is severely violent, medications that work more quickly like olanzapine or ziprasidone can be given in a muscle injection, though they may need to be given more frequently compared to other alternatives. For patients who are intoxicated, going through withdrawals, or violent, the first treatment option is usually benzodiazepines. Antipsychotics might be used in addition if the violent behavior isn’t sufficiently managed with benzodiazepines alone.
Safeguards may need to be put in place for specific patients. For instance, individuals with dementia or delirium might respond differently to antipsychotics or benzodiazepines, and much lower doses are recommended for them when these medications are necessary. Certain antipsychotics should be avoided with patients with a history of dementia due to the increased risk of stroke and death.
It’s also important to remember the risks associated with these medications. Antipsychotics can cause side effects like sleepiness, lengthened heart rhythm, low blood pressure when standing, seizures, and muscle symptoms, which might worsen a patient’s agitation and increase the risk of breathing difficulties and heart issues. Benzodiazepines can sometimes lead to disinhibition, which can intensify violent behavior. These medications also heighten the risk of over sedation and respiratory depression when used in high doses or combined with other sedatives, alcohol or illicit drugs.
As a last resort, physical restraints may be necessary. If applied, they should be used in a safe, effective, and comfortable manner. Regular reassessments need to be made, and once the patient begins to cooperate and is no longer a threat, the restraints should be removed.
What else can Violent Patients be?
Several biological factors can contribute to violent behavior, and these can be quite varied. Common causes could include alcohol or drug abuse, toxins, stress from an existing health condition like heart disease or lung disease, prescribed or over-the-counter drugs, and hormonal imbalances. Even a person’s age, gender, brain structure, and neurotransmitter balance can play a role. Understanding a patient’s history and mental state can be crucial in assessing violent patients to understand their decision-making capacity and their level of awareness.
The structure of the brain and its neural connections also have a notable impact on behavior. The prefrontal cortex, a key area of the brain, is in charge of planning complex behavior, personality expression, decision-making, and moderating social behavior. If this part of the brain is damaged because of illnesses like Alzheimer’s disease or because of growths such as tumors, aggression can become uncontrolled. The balance of neurotransmitters, chemical messengers in the brain, also plays a crucial role. For instance, both an excess and a deficiency of serotonin have been associated with violent behavior. Other neurotransmitters like GABA and dopamine can also influence violence patterns when their levels are thrown off.
Substance abuse, particularly alcohol abuse, has a well-established connection with violent behavior. Studies have shown that among patients receiving treatment for substance misuse, over 75% had committed violent acts while under the influence. Alcohol, in particular, is known to greatly contribute to violence in healthcare settings by lowering inhibitions and emotional control. Symptoms of alcohol withdrawal can also lead to violent acts.
Other drugs like cocaine, methamphetamine, PCP, and ecstasy can also result in violent behavior due to their effects on the brain and the body. In large doses, they can cause a series of symptoms like rapid heartbeat, high blood pressure, tremors, and delusions which can eventually lead to violent acts especially in high-stress environments like hospitals. These drugs not only alter the perception of pain and reality but can also cause distressing hallucinations that can induce violence.
Several mental or personality disorders listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM–5) can also lead to violence. These include bipolar disorder, certain personality disorders, intellectual delays, adolescent disorders, dementia, schizophrenia, and post-traumatic stress disorder (PTSD). People affected by these conditions can exhibit violent behavior, especially during manic phases or situations of stress.
