Workplace Violence: APNA 2008 Position Statement

Executive Summary Introduction Inpatient Violence in Psychiatric Settings Interventions
Recommendations for Inpatient and Outpatient Settings Appendix Acknowledgments References
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Outpatient Psychiatric Settings

Mental health regulatory agencies and public policies over the past several decades have emphasized the use of community-based treatment settings rather than inpatient settings for patients with psychiatric needs. The major national movement to deinstitutionalize mental health services about 25 years ago has led to a vast growth of outpatient mental health services. Despite the push to deinstitutionalize mental health services, very little research exists in regard to violence in outpatient psychiatric settings. Part of the reason may be that researchers tend to focus on physical violence, rather than nonphysical violence.

Violence in outpatient care settings such as psychiatric clinics and partial hospitalization programs have been steadily increasing. Ambulatory patients often are in crisis, have recently left the hospital or prison with a history of violence, or have a substance abuse problem, which also increases the risk of physical violence.


Often security is not present in outpatient clinics, so mental health staff is vulnerable. Repeatedly violent patients in outpatient psychiatric units are more likely to assault staff than fellow patients (Blow et al., 1999).

One study of outpatient service settings found that employees identified clients, frequently mentally impaired clients, as the perpetrators in physical aggression and violence, whereas other employees were frequently the perpetrators of nonphysical violence (Findorff, McGovern, & Sinclair, 2005). In another study, medical and nursing colleagues were the second most common perpetrators of workplace aggression after patients/clients or their visitors (Farrell, Bobrowski, & Bobrowski, 2006).

When patients are the victims, females are found to be at greater risk of suffering assault than male patients (Flannery, Fisher, & Walker, 2000).

Risk Factors

Otto (2008) classified violence risk factors in outpatient settings as static or dynamic. Static risk factors are those that either cannot be changed, such as age and gender, or those that are not particularly amenable to change, such as psychopathic personality structures (Otto, 2008). Dynamic risk factors are those that are amenable to change, such as substance use/abuse or psychotic symptoms. There are two types of dynamic risk factors: acute and stable. The acute dynamic risk factors refer to client conditions, such as alcohol intoxication, that can change rapidly and tend to pose imminent risk. Stable dynamic risk factors refer to client conditions, such as alcoholism, that do not pose imminent risk but are amenable to change over time.

Static risk factors that Otto (2008) identified include the following:

  • history of violence (significantly increased risk if the violence began before age 12 years)
  • victim of and/or witness to domestic violence
  • low IQ score or neurological impairment
  • antisocial personality disorders and traits

Dynamic risk factors include (Otto, 2008):

  • substance abuse
  • poor medication compliance
  • psychotic symptoms that induce perceptions of threat or perceptions that external forces are controlling one’s actions
  • stressors such as environmental, health, financial, or interpersonal
  • command hallucinations, especially if the internal voice was familiar
  • current symptoms and/or history of anger, impulsivity, irritability, and poor judgment related to underlying mental illness or disorder

Client Factors

Rew and Ferns (2005) examined the current literature and identified the following patient/client factors that may trigger aggression or violence:

  • fear and anxiety
  • past experiences of personal and/or workplace violence
  • lack of self-confidence and self-esteem
  • personal problems
  • misunderstandings or lack of communication
  • troublesome journey to the hospital or clinic
  • pain, disease, or conditions that affect an individual’s mood and behavior
  • use of drugs or alcohol
  • perceived loss of control or autonomy over a situation
  • a feeling of depersonalization

Flannery, Fisher, Walker, Kolodziej, and Spillane (2000) examined assaultive behavior directed toward staff of community-based residential facilities. Their long-term results are consistent with other research findings, which indicate that in assaultive patients with a diagnosis of schizophrenia, gender does not play a role in the number of assaults. However, unlike some recent findings of younger age and a high frequency of personality disorder among assaultive patients, the assaultive patients in this study were on average older, and most did not have a personality disorder diagnosis.

A diagnosis of schizophrenia was present in 47% of repeat assaulters in a study by Blow and associates (1999) of multiple assaults in VA medical centers and freestanding outpatient clinics.

Staff Factors

In the study by Blow and colleagues (1999) of multiple assaults on staff and other patients, nursing staff members were the typical targets of attack. This study found that most assaults occurred during the day shift (7 a.m. to 3 p.m.), a finding that the authors stated is in agreement with earlier studies, including those in non-VA settings (Blow et al., 1999).

Flannery, Fisher, and Walker (2000) examined patient assaults toward other patients and staff in community residences during the first 12 months after hospitalization for a group of patients who had not been violent as inpatients. They found lack of experience by staff to be a risk factor for assault.

Consequences of Workplace Violence

The consequences to staff of workplace violence in the outpatient setting are similar to those in the inpatient setting. For example, in a study of the prevalence of workplace aggression among 6,326 nurses in Tasmania, Australia, the consequences of workplace violence influenced the nurses’ level of distress, their desire to stay in nursing, productivity, ability to meet patient needs, and potential to make errors (Farrell, Bobrowski, & Bobrowski, 2006). Despite the negative effects that violence had on the nurses, they were reluctant to make official reports.

Executive Summary Introduction Inpatient Violence in Psychiatric Settings Interventions
Recommendations for Inpatient and Outpatient Settings Appendix Acknowledgments References
Download the full PDF
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