In the health care setting, workplace violence directed by patients against clinicians or other staff (eg, verbal or physical assaults) is common.1-3 Factors that contribute to violent incidents within mental health settings include communication problems, substance use, patients’ noncompliance with medications, procedural failures (administrative and legal), and a lack of resources.4
Being verbally or physically assaulted, stalked, or threatened by a patient is a reality for mental health professionals, especially in outpatient settings with limited resources and a lack of onsite security.5 Addressing the concerns outlined in this article can enhance your safety in outpatient settings. These steps should be customized for your practice with the possible assistance of legal counsel, risk management, and/or law enforcement.5
Plans and policies to mitigate the risk of violence. Assess for hazards within and around the workplace.5 Learn to assess your patient’s violence risk level in pre-screening interviews before their first appointment. Create a violence prevention and response plan, which may involve calling law enforcement if you fear for your safety or the safety of others.5 The confidentiality clauses of the Health Insurance Portability and Accountability Act make an exception to allow for disclosure to prevent or reduce a serious and substantial threat to the health or safety of an individual or society (you should limit your disclosure to pertinent nonclinical information).5,6 Develop policies and procedures to identify, communicate, track, and document patients’ concerning behaviors as well as policies and procedures to terminate care of patients who display these concerning behaviors.5 These plans and policies should include informing patients that neither violence nor threats of any kind will be tolerated. Frequently review these plans and policies with clinic personnel; these documents should be easily accessible to everyone (eg, posted on a board).
Communication and education. Keep open lines of communication with all clinic personnel, and encourage them to promptly report incidents and any concerning patient behaviors. Frequently check in with them about any safety concerns they have, and encourage them to suggest ways to reduce risks.7 Include discussions about safety during clinic meetings. Educate clinic personnel about the nonverbal warning signs of behavior escalation, and provide de-escalation and response training.5 Hold simulation drills so clinic personnel can become more familiar with the violence prevention and response plan.
Office safety. Install a security barrier between the waiting room and office spaces so that patients cannot easily barge into the office spaces. Ensure access to the office areas is restricted to clinic personnel using access card readers, electronic locks, locks with deadbolts, etc.5 Escort patients within the office and ensure that individuals who are not associated with the clinic are not permitted to enter any area of the office alone.5 Install video surveillance cameras at entrances, exits, and other strategic locations and post signs signaling their presence.5 Post signs stating that concealed weapons are not allowed on the premises. Install panic buttons in each office, at the reception desk, and other areas (eg, restrooms).5 Develop a code word or phrase that will allow front desk staff to know that you are in trouble when they call your office. Have a designated room in which staff can gather and lock themselves if they are not able to escape.5 Provide law enforcement with floor plans of the clinic to help expedite their response.2
Personal safety. During patient visits, position yourself so you can exit a room quickly if needed, and avoid having your back to the exit.5,7 Ensure the patient is not blocking the exit. Avoid wearing attire that can be used as a weapon against you, such as a tie or necklace, or can impede your escape, such as high heels.7 Avoid wearing valuable accessories that can be damaged or destroyed during a “take down.”7 Wear an audible alarm.5 Avoid posting personal information that is publicly accessible (eg, in the office or online) and may reveal your habits.5 Insist upon a “buddy system” in which no one works alone, including outside normal business hours, or goes to their car alone.5