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The aggressive and/or violent patient presents unique challenges. Like suicidal patients, aggressive individuals are difficult to treat and they tend to elicit strong negative reactions in hospital personnel ranging from anger to fear.42 Workplace violence is unfortunately commonplace within the health care setting, and is particularly prominent in the inpatient psychiatry ward and emergency department settings.20 Of the approximately 24,000 annual workplace assaults occurring between the years of 2011 and 2013 in the United States, approximately 75% were within the health care and social service settings.37 The prevalence of verbal and physical assaults reported by emergency nurses within a 12-month period is as high as 100% and 82%, respectively.34 Additionally, a survey of emergency physicians within the state of Michigan showed that 25% of emergency physicians reported being a target of physical assault within 12 months.27 These statistics on workplace violence in health care settings are likely underestimates as events are often underreported to health care supervisors and administrators. Workplace violence occurs so frequently that there is a perception among health care workers that violence is “the norm” and an expected part of their job.44

Workplace violence is classified into 4 broad categories that are dependent on the relationship of the perpetrator to the workplace. In type I, which accounts for approximately 80% of workplace homicides, there is not an association between the two. These incidents are generally motivated by theft, with hospitals and pharmacies being susceptible because of their abundance of opioids, equipment, and money. However, this type of violence is no more likely to be experienced in health care settings. Preventive measures include environmental security measures such as metal detectors. In type II, the most common type in the hospital setting, the perpetrator is a patient or customer. In general, these acts of violence occur while workers are performing basic work functions. An example of this would be an intoxicated patient who punches a nurse while obtaining vital signs. In type III, the perpetrator is a current or former employee. In type IV, the perpetrator has a personal relationship with a specific employee but not with the institution.41 The most common types of hospital violence are incidents of aggression against objects in the hospital (57%), violence directed against the hospital staff (28%), and violence directed against other patients (14%).43

In one study of violence in the emergency department, directors of emergency medicine residency programs were surveyed as to the frequency of verbal threats, physical attacks, and the presence of weaponry in the area. Of the 127 institutions surveyed, 74.7% of the residency directors responded; 41 (32%) reported receiving at least one verbal threat each day; 23 (18%) reported that weapons were displayed as a threat at least once each month. Fifty-five program directors (43%) noted that a physical attack on medical staff members occurred at least once a month.29

These studies ...

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