Violence Prevention in a Small-scale Psychiatric Unit: Program Planning and Evaluation NICOLA MAGNAVITA Aggression against nurses and ancillary personnel is a major—overall under-reported—occupational problem in sociomedical facilities for psychiatric and demented patients. The frequency of violent incidents against workers in a residential rehabilitation unit was assessed during medical examinations in the workplace between 1996 and 2009. The majority of the workers had been subjected to physical aggression over time. A violence prevention program that included educational, organizational, and medical measures was implemented in 2002. Interrupted time series analysis showed that the aggression trend prior to intervention was flat (␤1 = –0.004; SD = 0.003; P = 0.241), while there was a significant drop in aggressions after the intervention (␤2 = –0.149; SD = 0.018; P < 0.0001). No late increase in trend was observed in the post-intervention period (␤3 = –0.006; SD = 0.004; P = 0.175). The program contributed to reducing violence in the workplace. Key words: aggression; health care workers; prevention; risk management; violence; occupational health; workplace; intervention studies; psychiatric inpatients; psychiatric nurses I N T J O C C U P E N V I R O N H E A LT H 2 0 1 1 ; 1 7 : 3 3 6 – 3 4 4 INTRODUCTION Patient-perpetrated violence in the health care working environment is increasingly recognized as a preventable occupational risk,1 both in developed and developing countries.2–11 The nurse aides have the highest rate of assault and the perpetrator is most often an elderly patient, often with dementia.12 Mental health staff experience high assault rates ranging for physical violence from 10% to 35.1% in a 12-months period.13–21 In 2007, the Italian Ministry of Health issued a recommendation specifically requiring health care units to initiate violence prevention programs.22 Italian health care institutions have failed to comply with this recommendation, and most do not have policies, strategies, and administrative or behavioral measures to counteract workplace violence. Received from: Institute of Occupational Medicine, Università Cattolica del Sacro Cuore, Roma, Italy. Send correspondence to: Nicola Magnavita, Institute of Occupational Medicine, Università Cattolica del Sacro Cuore, Largo Gemelli 8, 00168 Roma, Italy; email: <nicolamagnavita@gmail.com>; <nmagnavita@rm.unicatt.it>. Disclosures: The author declares no conflict of interest. 336 Poor awareness of the problem by nursing staff and managers in health care facilities is probably the first obstacle to preventive action. Scarcity of economic and human resources may be another obstacle, especially in small enterprises. Physicians in charge of medical surveillance of health care workers may play a leading role in eliciting awareness, promoting preventive measures, and teaching safe behaviors in small facilities. This study summarizes a prevention plan developed in a small, nonintensive psychiatric unit and reports its effects on assault rates. It specifically focuses on aggression, defined as “action using physical force intended to hurt, damage, or kill.” Verbal abuse, sexual harassment, and other types of violence, were not specifically addressed. Background The studied facility was a nonintensive psychiatric rehabilitation unit near Rome, Italy. The Institute, situated in a 17th-century convent, was founded in the 1960s to accommodate mentally retarded female patients. Initially, its mission was the internment and custody of patients. After the adoption of Law 180/1978 (the socalled “Basaglia Law,” which reformed mental care), the Institute gradually changed its objective to provide more modern interventions designed to improve or eliminate patients’ mental illness. This change of perspective required better trained staff; however, the hospital failed to implement programs to retrain existing employees. In 1996, the Institute accommodated 120 female persons, randomly subdivided into groups of 15, each with an assistant. The staff was comprised of 82 female workers. Unskilled assistants were directly responsibile for patient care for most of the daytime. The Institute had an injury register; however, before 1996 in only two cases were formal injury reports made, suggesting severe underreporting of patient aggression.23 From 1996 on, workers underwent medical surveillance in the workplace. During each periodical medical visit, the occupational health physician asked workers to report violent accidents that had occurred in the previous 12 months. Workers were asked to give details of each accident, using a self-completed questionnaire. We tested the effectiveness of a workplace violence prevention program, as measured by a reduction of frequency of assaults before and after implementation. TABLE 1 Aggressions toward Workers per Year Year Number of Assaults Number of Workers Assault Rate 1995 1996 1997 1998 1999 2000 2001 21 22 18 20 22 18 19 82 82 83 82 83 83 83 0.26 0.27 0.22 0.24 0.27 0.22 0.23 2002 2003 2004 2005 2006 2007 2008 2009 P 9 4 5 3 0 3 1 2 86 88 87 90 92 92 92 94 0.1 0.05 0.06 0.03 0 0.03 0.01 0.02 Mean Rate (+s.d.) Mean Number of Reported Consequences 0.24 (± .02) 2.4 (± 1.2) 0.04 (± .03) 1.6 (± 1.1) < 0.001* < 0.002* Note: *Student’s t test, comparison between pre-intervention and post-intervention. METHODS Subjects The study is based on retrospective review of violent incident reports. Periodical medical examination of workers is compulsory in Italy; so the workers were informed and reminded at least once a year of the opportunity to complete a questionnaire concerning violent accidents. Workers were asked to complete the visits, but were free to report or not report events. We used a revised Italian version of the Violent Incident Form (VIF),a validated questionnaire proposed by Arnetz J. E., to simplify the registration of violent events.24 The survey tool elicited information about violent incidents, how each incident was managed, and the outcome. The workers described the activity that preceded the incident (e.g., conversation, patient transfer/ lift/physical assistance, patient-made demands, examination/treatment/physical care); the characteristics of the aggression (e.g., spitting, biting, kicking, scratching/pinching, slapping/hitting, punching, pushing, restraining); and the consequences (e.g., fear, anger, distress, anxiety, humiliation, guilt, helplessness, disappointment, physical injury, no reaction). The number of consequences reported after each violent episode can be added, giving a rough estimate of the impact of the assault on worker’s health. The Italian version, as amended by excluding questions not applicable to the specific job, had a one-month test–retest SpearmanBrown split-half reliability coefficient of 0.91.2 We analyzed data on outcomes including the number and character of assaults at yearly intervals from review of the VIF. For each year, we calculated the rate of assaults by dividing the number of reported VOL 17/NO 4, OCT/DEC 2011 • www.ijoeh.com events by the number of workers employed in the corresponding year (Table 1). During the observation period, the employee number slowly increased from 82 to 94 female workers. The Catholic University of Rome Institutional Ethics Committee gave ethical approval for this study. Intervention Planning In 2000, an aggression-minimization program was developed as part of a wider program of total quality management (TQM), and it was progressively implemented in 2002 (Table 2). The principles of TQM in health care activities call for a global organizational commitment to enhancement of quality. The TMQ focused on problem solving by those directly affected by the problem. The importance of customer feedback, the value of interdisciplinary teams, and data-driven problem and evaluation are stressed.25 A small interdisciplinary team of five members, including the occupational health physician, the head manager, the sanitary director (a psychiatrist), one psychologist, and one nurse, were selected to work on the project. All team members participated in the program development and implementation. The primary objective was to decrease the total number of patient assaults against workers. The secondary objective was to reduce or eliminate restraint and seclusion measures. Objectives targeting safety and quality improvement were selected through a consensual decision-making process. The team used the FADE (focus, analyze, develop, and execute) cycle, part of the ASIA (assessment, surveillance, information, audit) model,26 to manage the project. In the first phase of the program, the team tried to identify causes of violence. In the analysis phase of the Violence Prevention in a Small-Scale Psychiatric Unit • 337 project, before 1998, data were drawn from VIFs. Fishbone analysis revealed a number of factors contributing to violence, concerning the structure (crowded rooms, lack of safety exits), the procedures (working alone, noisy rooms, and disorganized environment), the people (insufficient staff coverage, poorly qualified staff, insufficient activity planning for patients leading to inactivity and boredom), the equipment (lack of alarms, insufficient lighting) and the lack of written policies and procedures. Researchers noted the hierarchical social structure of this closed community. Older workers were called “Madam,” in Italian “Donna,” corresponding to the Latin “Domina,” (i.e., she who dominates). Younger workers were called “Miss.” Patients were called “baby.” Collaborative patients were employed in many strenuous and unfair tasks, such as manual handling and cleaning, and even in the surveillance of aggressive patients (“bad babies”). This structure appeared to contribute to frequent episodes of conflict between patients that were suppressed by threats and punishments (such as the denial of cigarettes and coffee). The violent reactions of the patients were suppressed by means of restraint and medication. These measures were rarely reported in medical records, and there was a clear difference between the few sedatives under the treatment plan for each patient and the high consumption of drugs in the clinic. The first and most difficult task of the prevention team was to remove patients from monitoring tasks and to give each worker her appropriate job. The team observed and analyzed assistance operations. The mix of patients with different impairment levels in the same assistance group was thought to be the main obstacle to targeted rehabilitation programs. The team believed that violence might be reduced if patients were engaged in therapeutic activities. The team stated that structural changes were necessary to improve the quality of care and the safety of workers. The lack of appropriate financial resources delayed the plan until 2000, when it was possible to proceed to the execution phase. Based on analysis of VIFs and operation, a plan was developed to control hazards by modifying the environment, changing work practices, and responding to incidents. Workplace analysis was considered an ongoing process evaluating the effectiveness of the program. Team members periodically conducted walk-throughs for a comprehensive evaluation of the physical environment. The environmental surveys focused on territoriality, such as the ability of subjects to work or inhabit the space safely, and attention to design features that encourage safe behavior (e.g., lighting, space layout, sharp objects, furniture, blind spots). A debriefing transpired at the conclusion of each walkthrough. If a violent incident occurred, the victimized employee received immediate treatment, including 338 • Magnavita medical assistance, specific debriefing, community meeting, and peer support. The team regularly revised the process and evaluated the results at least yearly. Intervention Architecture/Work Organization (2000–2001). Working rooms were enlarged to contain an increased number of patients, who were treated by a team of assistants. Through architectural rearrangement of the building, patients were divided into three assistance areas, depending upon the severity of mental illness: (1) profound/severe impairment, with associated motor impairment (patients permanently confined to bed); (2) severe/mild impairment and mental retardation; and (3) slight impairment (self-sufficient patients). Each group of patients was given a team of health care workers, who developed specific therapeutic objectives. Increased and more adequate nurse-to-patient ratios and qualified staff coverage was ensured at all times. In addition, the hospital adopted other minor interventions, improving the security of the premises. Lighting was improved and areas where employers worked alone were eliminated. Safety alarms were introduced. Education (2000–2001). At the same time, an educational program was initiated. A training course was devised to increase worker awareness of the problem and to teach coping skills. Four hours of training were divided into specific modules addressing: general aggression and violence minimization competence; conflict resolution and effective communication strategies; identification of violence-prone subjects; specific prevention strategies and handling of violent events; and self-protection strategies. From 2000 to 2001, courses were held. A reporting procedure for aggressive incidents and near-miss events was developed and implemented. Regular feedback from employees about their work-related concerns was obtained during periodical medical visits. Short-duration refresher courses were periodically held, as part of workers’ continuing education programs, to maintain accreditation and competency. These collegial meetings were also used to diffuse news about the evolution of the program, and to obtain regular feedback from employees about their work-related concerns. Statistics An interrupted time series (ITS) analysis was used to ascertain the intervention’s effectiveness. The ITS approach is based on the use of time-series regression models, correcting for the time trend and considering any autocorrelations between individual observations. The method provides the analysis of change in level www.ijoeh.com • INT J OCCUP ENVIRON HEALTH 0.30 0.25 Rate 0.20 0.15 0.10 0.05 0.00 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 Year Figure 1—Assault rates per year and slope, so giving information about the immediate impact of the intervention and its sustained impact over time.27 ITS was calculated with the ARIMA (autoregressive moving average models) statistics in PAWS/SPSS 15.0 software. A first order autoregressive model was defined as: Y = ␤0 + ␤1 ⫻ T + ␤2 ⫻ (T – P) ⫻ I(T > P) + ␤3 ⫻ I(T > P) + e Where T is time, e is Normal (0, s2) and I(T > P) is the characteristic function equal to 1 if T is greater than the intervention time (P), and 0 otherwise. The intervention time was established as 2002. The time period considered began on January 1, 1995, and ended January 1, 2010. RESULTS Workers reported 167 assaults from patients in the period from 1995 to 2009. Most assaults (140, 84%) occurred before the intervention (2002). Upon completion of the program, the assault rate was significantly reduced (Figure 1). The average number of aggressions dropped from a range of 18–22 cases per year in the period from 1995 to 2001, to a range of 0–5 cases per year in the period following the intervention (Table 1). Mean assault rate was reduced from 0.24 (SD 0.02) per year in the period before the VOL 17/NO 4, OCT/DEC 2011 • www.ijoeh.com intervention, to 0.04 (SD 0.03) per year after the intervention (Student’s t-test = 14.4, P < 0.0001). Following the ITS model, we estimated four coefficients. A first one (␤1 = –0.004; SD = 0.003; P = 0.241) represents the trend of the phenomenon prior to intervention; a second one (␤2 = –0.149; SD = 0.018; P < 0.0001) expresses the difference between the postintervention and pre-intervention period; and a third coefficient (␤3 = –0.006; SD = 0.004; P = 0.175) represents the difference between the rate observed in the first post-intervention period and the predicted rate if no intervention had been provided. Finally, a model intercept (␤0 = 0.260; SD = 0.015; P < 0.0001) was given. Trend prior to intervention was flat, not changing. There was a significant drop in aggression rate after the intervention. There was no change in trend after the intervention, with a stable decline over time in assaults after the intervention. The intervention appeared to reduce both the frequency and severity of assaults. No severe violent event was reported after the intervention. In the postintervention period, attacks consisted mainly of pushing workers or tearing their clothes, and the workers’ reactions are less intense and do not include anxiety and fear. The average number of consequences reported after each assault dropped from 2.4 (SD 1.2) in the pre-intervention, to 1.6 (SD 1.1) in the postintervention period (Student’s t-test = 3.3; P < 0.002) (Table 1). Violence Prevention in a Small-Scale Psychiatric Unit • 339 TABLE 2 Synthetic Overview of the Prevention Plan Year Action Before 1996 An Institute for the internment and custody of mentally retarded female patients accommodated 120 patients. The staff is comprised of 82 unskilled workers; each of them has direct responsibility for 15 patients with mixed clinical problems. 1996 Beginning of the health surveillance of workers During medical examinations workers report frequent assaults from patients. Most of these assaults are not reported on the firm’s injury register. 1997–1999 Planning the prevention plan; the causes of violence were identified through analysis of VIF and observing and analyzing operations. Assessment of costs and definition of a ranking of priorities 2000–2001 Architectural intervention: room enlargement, improved lighting, alarms, and others Marked improvement of environmental quality Patients are accommodated in spacious and comfortable rooms. Rehabilitation services are renewed. 2000–2001 Training courses on violence Workers have increased awareness of workplace violence. Workers’ coping skills and satisfaction are increased. Reporting procedure in place 2001–2002 Work organization changes: patients are divided into different assistance areas, workers are arranged in teams. Patients perform specific therapeutic paths. Patients are rarely inactive and less bored. Workers never work alone. 2004 Electronic storage of clinical data Real-time control of therapies 2002–2009 Periodical walk-through Analysis of workplaces Elaboration and implementation of safety measures 2002–2009 Short-duration refresher courses during collegial meetings Maintaining workers’ skills and attention toward violence The form of physical assault ranged from punching, to scratching or hair pulling, and to slapping or pushing, spitting, or restraining. The most violent attacks, with significant physical damage, occurred before the intervention. In a minority of cases, all before the intervention, assaults had caused permanent physical impairment to the assaulted person. After the intervention, changes in health care organization significantly improved both the quality of delivered care, increasing the number of patients who could be discharged, and the climate at the workplace. The clinical homogeneity of patient working groups led to an improvement in the interpersonal relationship between patients and toward workers. The improvement in communication between therapists (psychiatrist, neurologist, psychologist, general physician) and other workers led to the early identification and control of aggressive patients, without restraints or seclusion. Since 2004, electronic storage of patients’ clinical data has allowed better monitoring of therapy. From 340 • Magnavita Effect this date, no cases of aggression required the use of restraints or isolation, and sedation is now rare. In this sample, both pre- and post-intervention, workers perceived violence as occurring principally in connection with unmet demands for such things as prescriptions and referrals and worker-to-patient interaction for washing, dressing, or eating (80 events, 48%), or with worker’s attempt to counteract aggressive behavior on the part of the patient (40 cases, 24%). The majority of incidents (156, 93%) occurred when health care staff was working alone. For this reason, assistants often had to manage the aggression by themselves, without the assistance of fellow workers. A retrospective analysis showed that, in the pre-intervention period, workers identified lack of aggression-management training as a potential cause of incidents (82, 59%), while after training, this complaint was virtually absent. At the end of the learning courses on prevention and management of aggressions, staff members were satisfied and reported increased confidence for dealing with www.ijoeh.com • INT J OCCUP ENVIRON HEALTH aggressive behavior. Eighty-eight percent of workers said that the training significantly improved their skills. Even after the introduction of the prevention program, periodical surveys and workers’ suggestions, collected during medical visits and meetings, led to progressive improvements of environmental safety. Materials-related issues, including open-hinged doors providing pinch-points, and sharp objects and furniture that could be used as a weapon, were carefully checked and eliminated. Nursing activities were configured so as to make observations of and access to patients easy. At the end of the present study, the team group identified a number of future administrative interventions addressing organizational risk factors, and suggested increasing staff size to reduce worker frustration, stress, and isolation. DISCUSSION We tested the efficacy of a violence intervention program in a psychiatric unit. Using a pre-post design, we found that the intervention resulted in a statistically significant reduction in the frequency of assaults against workers. Interrupted time-series analysis is the strongest, quasi-experimental approach for evaluating longitudinal effects of interventions; even without a control group, it allows analysts to control for prior trends in the outcome and to study the dynamics of change in response to an intervention, showing whether the effect is immediate or delayed, abrupt or gradual, and whether or not it persists over time.28 Two parameters define each segment of a time series: level and slope. In our study, the marked drop in assault level, measured from the difference between the last point pre-intervention and the first point post-intervention, demonstrates an abrupt effect of the program. The absence of change in slope after the intervention in comparison with the slope before the intervention demonstrates that the improvement lead to lasting reductions in violence against workers. The reduction of frequency and gravity of assaults improved workers’ safety and health. Furthermore, the associated drop in the use of restraint improved patients’ safety.29 This study adopted a quasi-experimental approach. A critical review of the published literature on administrative and behavioral interventions directed at addressing workplace violence in the health care industry showed that none used experimental designs, and the results were often inconclusive.30 A more recent review confirmed that few aggression-management programs were based on a systematic evaluation of their outcomes, and most of them appear not to address the psychological and organizational costs associated with aggression in the workplace.31 In contrast to previous programs, we adopted a participatory approach, which encouraged workers to VOL 17/NO 4, OCT/DEC 2011 • www.ijoeh.com change and maintain safe behavior in the short, medium, and long term. Managerial commitment to reducing violence in the workplace was another key factor in the success of the program. This study has several limitations. Much of the information was collected through self-report, which could lead to reporting bias and misclassification. Workers may have exaggerated the importance of aggression in order to enhance their role or to obtain environmental and organizational improvements, or may have minimized the risk, considering it “part of the job.” For this reason, we tried to get confirmation events through interviews with other workers and/or patients. Because this study was conducted in one small health care organization, caution must be exercised before generalizing the results. Nevertheless, our findings showed that aggression could be efficiently prevented by implementing a multilevel program, even in a small-scale facility with very limited resources. To the best of our knowledge, no previous study has been conducted with as long a longitudinal outcome evaluation design. Violence against health care workers is not a new phenomenon. Nurses and ancillary personnel have been subjected to physical assaults for many years. In this type of context, assistants in the psychiatric unit we observed had to cope with frequent physical aggression, and felt they were powerless to avoid it. A number of theories have been developed that endeavor to explain the causes of patient aggression in mental health settings. The first is the “internal model,” which explores the association between aggression and the mental illness of patients. Nursing staff working for many hours with patients affected by epilepsy, psychiatric diseases, and dementia are more likely to be caring for agitated, incompliant individuals, and therefore, may be at greater risk of sustaining physical injuries during manual handling procedures. Patients’ behavior (active affect, passive affect, aggression toward oneself, and patient confusion) and psychosocial issues (isolation and withdrawal from relationships, noninvolvement in treatment, and wide mood variability) may significantly predict violent behavior.14,32,33 The second is the “external model,” which claims that environmental factors greatly contribute to the incidence of aggression and that both the work climate and structural aspects of work may be important in promoting workplace violence.34 Next, there are other studies that support the view that negative staff and patient relationships lead to patient aggression, and the personality, stress, and burnout of nursing staff are predictive of incidents.35 Finally, the other explanatory factor is the approach used to manage patient aggression. It has been observed that student nurses are likely to experience hostility and abuse in clinical situations, due to their lack of training in confrontation techniques.36 In our study, workers’ reports showed that all of these factors exerted a role in the occurrence of violent episodes. Violence Prevention in a Small-Scale Psychiatric Unit • 341 Another important factor was most likely the architectural inadequacy of the building, which led the assistants to work alone and without clear therapeutic objectives. The enlargement of rooms allowed the redesign of assistance tasks that were targeted specifically to the clinical needs of each group of patients. It was also apparent that most violent incidents contained an intentional element. Many assaults were precipitated directly by the delivery of care, frustration of a patient’s wishes, an assistant’s actions perceived as aggressive by a patient, or situations in which staff set limits on a patient’s behavior. The informal hierarchy of the community contained obvious aspects of social psychopathology that had to be eliminated. Focusing on perpetrators of violence was helpful in predicting many cases of aggression. In the training program, assistants were instructed to assess adequately and formally document patient treatment difficulties, thereby helping in violence prevention. Before our intervention, workers were not trained in the management of violent behavior because it was presumed they already knew how to handle violence. The study showed that workers did not routinely try to de-escalate or diffuse a situation, but rather used force to control violence. The training program was specifically devoted to changing this situation. CONCLUSION At the beginning of this study, the psychiatric unit had no clear policy concerning violence at work. Our study undoubtedly contributed to creating a shared conviction regarding the need for such a policy. Assistants tended to deal with the effects of violence and cope with aggression intrapersonally. Frequently, aggressive incidents were managed in a reactive way, with reliance on containment methods such as restraints, compulsory medication, and seclusion. Violence was tolerated, ignored, and scarcely reported. The assurance that reporting of violent incidents would be kept confidential, and that measures would be taken to counteract perpetrators of violence, gradually changed the behavior and attitude of workers toward workplace violence. In the reporting process, the emphasis was posed on staff safety rather than the prosecution of aggressors. The Violent Incident Form checklist proved to be a reliable and easy tool that could be used to complement an official work injury report. We recommend supporting its implementation during periodical medical examinations at the workplace. A summary of the violent incident, including the victim’s reactions, provides a useful focus for organized discussion among staff. The objective of group discussion should be to remove self-blame, fear of criticism from fellow staff, and any other stigma that might be attached to violent incidents. Future studies need to address the broad array of circumstances in which violence occurs, and to carefully evaluate interventions with appropriate design. 342 • Magnavita Although it is not possible to prevent all violence against assistants in this type of work environment, hospital managers and administrators have a legal and moral responsibility to develop action plans to minimize violence and deal with the effects of violence on staff. There is a clear need for training and educational strategies to diffuse and prevent the rise in violent assaults in the health care setting. Violence against health care workers can no longer be expected, tolerated, or accepted. 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Verbal abuse experienced by nursing students. J Adv Nurs. 2009;65(12):2678–2688. APPENDIX Violent incident form (VIF) (modified Italian inpatient version) (see the enclosed PDF file) This questionnaire contains questions on violence in the workplace. The content is confidential and will be reviewed only by the Doctor. It is not necessary to identify themselves. If necessary, ask your doctor. Please answer all questions. Profession: Age: ❑ physician ❑ 29 or less ❑ registered nurse ❑ 30–39 ❑ practical nurse ❑ 40–49 ❑ other ❑ 50–59 ❑ 60 or older 1. Over the past 12 months have you been in a physical assault while you were working? (Physical assault means an attack, with or without weapons, that could cause or not cause physical damage.) ❑ NO ❑ YES 2. Over the past 12 months have you been threatened while you were working? (A threat refers to the intention of causing physical damage.) ❑ NO ❑ YES 3. Over the past 12 months have you been harassed while you were working? (Harassment is any act—words, attitudes, actions—annoying or unpleasant, that creates a hostile work environment.) ❑ NO ❑ YES Description of a violent event. Violent Incident Form (Arnetz) The following describes a specific incident of violent or threatening behavior directed toward a staff member. Only the person who experienced the violent event should answer these questions. Fill out a separate form for each event you wish to report. Place an ‘X’ in the appropriate box(es). In what year was the accident: _____________ VOL 17/NO 4, OCT/DEC 2011 • www.ijoeh.com Violence Prevention in a Small-Scale Psychiatric Unit • 343 1. Who showed aggression or violence toward you? ❑ patient ❑ patient’s relative/companion ❑ staff ❑ other _____________________________________________________________________________________ 2. In your estimation, was the aggressor: ❑ mentally ill ❑ senile dement/mentally retarded ❑ affected by heavy medication ❑ under the influence of alcohol/narcotics ❑ don’t know 3. The aggressor’s sex: ❑ male ❑ female 4. The aggressor’s age: ❑ under 18 ❑ 19–30 ❑ 31–50 ❑ 51–65 ❑ over 65 5. Activity that preceded the incident: ❑ conversation ❑ patient made demands ❑ patient transfer/lift/physical assistance ❑ examination/treatment/physical care ❑ no activity ❑ other _____________________________________________________________________________________ 6. Did you have a feeling in advance that something was about to happen? ❑ NO, it came as a complete surprise ❑ YES 7. Did you working alone when the incident occurred? ❑ NO ❑ YES 8. Violent incident: ❑ punching ❑ kicking ❑ biting ❑ spitting ❑ slapping/hitting ❑ scratching/pinching ❑ restraining/jerking ❑ hair pulling ❑ pushing ❑ use of object or weapon (describe) ___________________________________________________________ ❑ verbal threat/aggression ❑ other (describe) ___________________________________________________________________________ 9. Action: ❑ called for help/activated alarm ❑ handled the situation myself ❑ other(s) came to assist ❑ no action necessary 10. Result: ❑ physical injury (describe) ___________________________________________________________________ ❑ fear ❑ anger ❑ distress ❑ anxiety ❑ humiliation ❑ guilt ❑ disappointment ❑ helplessness ❑ no reaction ❑ other (describe) ___________________________________________________________________________ 11. Have you filed a report? ❑ NO ❑ YES, to the Insurance 344 • Magnavita ❑ YES, to the police www.ijoeh.com • INT J OCCUP ENVIRON HEALTH