NEW YORK (Reuters Health) – It's common for patients to come into a hospital with injuries, but too often they’re the ones inflicting injury on nurses, technicians and security guards, according to a new study.

Researchers analyzed incident reports of patient violence to identify the situations most likely to lead to a physical conflict, in the hope of training hospital staff to avert the attacks.

“This study is contributing to knowledge about how we can develop (patient violence) prevention,” Judith Arnetz told Reuters Health. “This is a project that is very much in collaboration with hospital stakeholders and that means both labor and management,” said Arnetz, a researcher with the Wayne State University School of Medicine in Detroit who led the new study.

“Compared with workers in other industries, hospital workers have high rates of non-fatal workplace assault injuries,” Arnetz and her colleagues write in the Journal of Advanced Nursing.

Among hospital workers, nurses, mental health professionals and security staff are most at risk, they point out, but hospitals’ efforts to reduce workplace violence are hampered by a lack of information about the reasons violence flares.

To learn more about what triggers patient violence, Arnetz and her colleagues looked at electronic reports of patient-to-employee violence during a one-year period in a Midwestern hospital system that includes a pediatric hospital, a rehabilitation hospital and five specialty hospitals. The system has 15,000 employees, two of the hospitals are located in the suburbs and five are in cities. Employees are required to report details of all adverse incidents in a centralized computer reporting system.

A total of 214 incidents of patient violence were entered over the year, with 90 percent involving physical violence directed toward employees. Nurses reported about 40 percent of the incidents. Another 16 percent were reported by security staff and 14 percent by nursing assistants called patient care associates.

Incidents happened at all seven hospitals, “ranging from eight at a suburban specialty hospital to 64 at an inner city acute care hospital,” according to the authors.

“In order to know what's happening you really do have to look at incident reports,” Arnetz said. “After reading and rereading all of these incidents we came up with what we saw as three main themes or categories.”

The study team further broke those patterns down into sub-themes, which were very specific types of situations that represented risk situations for violence. Within the first overall category of patient behavior and characteristics, which accounted for 40 percent of incidents, the researchers identified cognitive impairment (such as dementia or intoxication) and times when patients were demanding to leave as recurring sub-themes in the incident reports.

For example, one registered nurse recounted, “I was sitting at bedside of a confused patient. She had been laying down, got up quickly and punched me in the left side of the face.”

A patient care associate also reported, “Was comforting confused patient and he put his hand around my neck and tried to choke me.”

A psychiatric social worker entered, “Patient was at the nurses’ station demanding discharge, abruptly started striking at me, hitting and scratching my face and neck.”

A second category of incidents was related to delivering care and tended to happen when workers were in close proximity to patients, such as using needles and otherwise causing discomfort, or physically moving patients from one place to another.

For example, a registered nurse wrote, “Patient needed lab work drawn and became very hostile, aggressive and violent with staff. He was verbally abusive with profanity and physically abusive by hitting, biting, scratching and pushing. Attempted to grab patient’s arm to prevent him from hitting the ER (emergency room) tech who was drawing his blood and the patient hit me in the left side of my face . . . patient hit my eye, ear, cheek and head. Patient then tried to bite me, but could only get my clothing.”

And a patient care associate entered, “Employee was hooking up tube feeding, patient got agitated and kicked employee in the face.”

The third category, dubbed situational events, involved transitions such as admission or discharge, use of restraints, redirecting patients back to their beds or hospital rooms and intervening with a violent patient.

A patient care associate wrote, “I was trying to keep the patient from leaving the room and going to the elevator by standing in front of her room door. She got mad and scratched my face. I grabbed her hands to keep her from scratching me again and then she bit my thumb.”

And a security guard’s supervisor wrote, “Security officer was injured while attempting to control patient. Patient was disruptive and threatening medical staff. Security officer was kicked to the chest area by patient while attempting to place her in a wheelchair.”

“I think each of these subthemes are specific enough that it would be possible to educate staff to be aware of the risk situations,” Arnetz said. “I think that is the importance of this study.”

Arnetz said another general theme that emerged from the analysis was that healthcare workers were often taken by surprise by the patient outbursts.

“It may be that staff are missing signals, or they need to be educated so that they know that these things could happen,” she said.

By Shereen Lehman

SOURCE: Journal of Advanced Nursing, online August 4, 2014.