Keeping Clinicians Safe When Responding to Combative Patients

Violence against healthcare workers has always posed a challenge, but post-COVID-19, the problem has marginally increased, with a recent survey revealing 40% of healthcare employees experiencing an incident of violence over the last two years. However, even for facilities with formal incident reporting systems, many acts of violence go unreported due to a lack of faith in the process or a fear of retaliation.

“It starts at the top with fostering an environment of not only swift responsiveness but one that is proactive. To achieve this encompasses strong leadership and support from the c-suite and department heads of each discipline to promote and foster a strong culture of safety. This includes, but is not limited to, having a robust workplace violence program and sound protocols to specifically address different types of violence,” said Alleen Wilson, Senior Risk Services Manager at Safety National. “Regardless of what is in place, it is important that every incident is investigated and documented. This is particularly important in specialty care facilities, home healthcare and nursing homes where patients should be assessed on intake including screening for risk of violence/aggression and their precursors to violent tendencies are well documented with tailored protocol to address said violent patient.”

What might cause a patient to become combative?

Patients can become violent for a multitude of reasons, ranging from medications, alcohol and drug abuse, and psychiatric conditions. Drug reactions outside of illicit use, like anti-anxiety and anti-seizure medications and sedation, can cause a shock to a patient’s system where they respond aggressively after extubation or anesthesia. Individuals being treated for alcoholism or drug abuse can have extreme reactions due to the effects of detox. Mental illnesses, Alzheimer’s, and dementia can also significantly contribute to a patient’s overall aggression and combative behavior

Environmental conditions and poor communication can also trigger violent behaviors. Ongoing staffing shortages mean healthcare employees are continuously overworked, leading to miscommunication in care where a patient may feel disrespected or unheard. This can also extend to family members and visitors acting as advocates, especially since violent incidents occur most frequently in emergency and psychiatric treatment settings, waiting rooms, and geriatric settings.

What common mistakes are made when handling combative patients?

First and foremost, a healthcare setting lacking a proper procedure for violent incidents puts everyone involved at risk. Without de-escalation or crisis prevention training, an employee may over or underreact, without any understanding of how to assess the degree of threat posed. For example, involving law enforcement can provide helpful support, but their presence can also be intimidating in patient encounters, causing an adverse reaction. Balancing the need for provider security and patient comfort can be complicated. In the most dangerous situations, restraint may be required, but healthcare employees should never attempt this alone, ensuring that all facility and local protocols are met.

How do you create an environment that responds appropriately to these incidents?

An appropriate, written workplace violence prevention program will involve management commitment and employee participation. Because workplace violence within healthcare settings has been an increasing trend, some hospitals have specific workplace violence committees. Leadership should provide full support for developing comprehensive programs in conjunction with employee involvement. Worksite analysis and hazard identification of high-risk areas should be performed with a step-by-step assessment conducted involving a team that consists of managers, supervisors, and employees. Following the worksite analysis, all stakeholders should take appropriate steps to control identified hazards.

Staff training and education should be prioritized, focusing on reiterating written policies, procedures and training such as de-escalation and self-defense. All facilities need routine recordkeeping and program evaluation. This is important in identifying trends and patterns of assaults that could be prevented or reduced through appropriate risk control measures. Consistent evaluation is necessary to determine the effectiveness of programs. When possible, obtaining records of a patient’s violent history can prepare for them, particularly when a patient may be transferred to a new facility.

For more expertise, guidance or resources on this topic, please contact [email protected].