Issue
Date Log
Copyright (c) 2024 Nasser Ibrahem Nasser Almohaizef, Fatimah Mohammed Ali Hakami, Abdulmajeed Abdulrahman Alanazi, Salha Saeed Alahmari, Arif Mohammed Almotari, Waleed Eid Almutairi, Adel Eid Almutairi, Jawaher Tami H Alkahtani, Khalid Ali Sahhari, Jalilah Adnan Alsaigh, Samar Adnan Alsadah, Layla Jaffar Alkhudear, Norah Shafi Dawi Alghamdi, Saif Allah Atiah Bakri
This work is licensed under a Creative Commons Attribution 4.0 International License.
Beyond Restraint: A Systematic Review of Interprofessional Hospital Emergency Responses to Violence Integrating Security, Clinical, and Sociological Frameworks
Corresponding Author(s) : Nasser Ibrahem Nasser Almohaizef
Saudi Journal of Medicine and Public Health, Vol. 1 No. 2 (2024)
Abstract
Background: Hospital violence, stemming from patients, visitors, or societal conflict spillover, constitutes a critical threat to staff safety, patient care, and institutional integrity. Traditional "Code-Silver" responses often default to security-led containment, potentially escalating situations and neglecting underlying causes. An integrated interprofessional approach is required to address the clinical, psychological, and sociological complexity of in-hospital aggression. Aim: This narrative systematic review synthesizes evidence on interprofessional emergency responses to hospital violence, mapping the roles of health security, emergency medicine, nursing, clinical pharmacy, and sociological frameworks in de-escalation, clinical management, and post-event resilience. Methods: A systematic search of PubMed, CINAHL, PsycINFO, and Scopus (2010-2024) was conducted. Data were analyzed thematically to evaluate models of team integration, intervention efficacy, and systemic learning. Results: Effective responses are characterized by pre-emptive, integrated protocols. Health security personnel trained in trauma-informed de-escalation, supported by nursing-led verbal engagement and rapid clinical assessment, reduce physical restraint use. Clinical pharmacists improve the safety and efficacy of pharmacologic sedation. Incorporating sociological analysis into post-incident reviews uncovers root causes (e.g., systemic inequity, care delays) and informs restorative practices, reducing recurrence. Interdisciplinary simulation training emerged as a key facilitator of team efficacy. Conclusion: Moving from a security-centric "Code-Silver" to a holistic "Code-Social" model necessitates systematic integration of clinical and sociological expertise with security operations. This paradigm shift, supported by joint training and shared mental models, enhances safety, improves patient care, and fosters a resilient institutional culture.
Keywords
Download Citation
Endnote/Zotero/Mendeley (RIS)BibTeX
- Alarfaj, S. J., Jarrell, D. H., & Patanwala, A. E. (2018). Comparison of drug administration logistics between prothrombin complex concentrates and plasma in the emergency department. The American Journal of Emergency Medicine, 36(12), 2182-2186. https://doi.org/10.1016/j.ajem.2018.03.064
- Anderson, E. S., Hsieh, D., & Alter, H. J. (2016). Social emergency medicine: embracing the dual role of the emergency department in acute care and population health. Annals of emergency medicine, 68(1), 21-25. https://doi.org/10.1016/j.annemergmed.2016.01.005
- Arnetz, J., Hamblin, L. E., Sudan, S., & Arnetz, B. (2018). Organizational determinants of workplace violence against hospital workers. Journal of occupational and environmental medicine, 60(8), 693-699. DOI: 10.1097/JOM.0000000000001345
- Arnetz, J. E. (2022). The Joint Commission's new and revised workplace violence prevention standards for hospitals: a major step forward toward improved quality and safety. Joint Commission journal on quality and patient safety, 48(4), 241-245. https://doi.org/10.1016/j.jcjq.2022.02.001
- Azeem, M., Aujla, A., Rammerth, M., Binsfeld, G., & Jones, R. B. (2017). Effectiveness of six core strategies based on trauma informed care in reducing seclusions and restraints at a child and adolescent psychiatric hospital. Journal of Child and Adolescent Psychiatric Nursing, 30(4), 170-174. https://doi.org/10.1111/jcap.12190
- Brenig, D., Gade, P., & Voellm, B. (2023). Is mental health staff training in de-escalation techniques effective in reducing violent incidents in forensic psychiatric settings?–A systematic review of the literature. BMC psychiatry, 23(1), 246. https://doi.org/10.1186/s12888-023-04714-y
- Buckley, M. S., Roberts, R. J., Yerondopoulos, M. J., Bushway, A. K., Korkames, G. C., & Kane‐Gill, S. L. (2023). Impact of critical care pharmacist‐led interventions on pain, agitation, and delirium in mechanically ventilated adults: A systematic review. Journal of the American College of Clinical Pharmacy, 6(9), 1041-1052. https://doi.org/10.1002/jac5.1778
- Carison, A., Babl, F. E., Hill, A., & O'Donnell, S. M. (2020). Children and adolescents with severe acute behavioural disturbance in the emergency department. Emergency Medicine Australasia, 32(5), 747-755. https://doi.org/10.1111/1742-6723.13515
- Chaffkin, J., Ray, J. M., Goldenberg, M., & Wong, A. H. (2022). Impact of a virtual simulation-based educational module on managing agitation for medical students. Academic Psychiatry, 46(4), 495-499. https://doi.org/10.1007/s40596-021-01521-z
- Ellis, H. A. (2014). Effects of a crisis intervention team (CIT) training program upon police officers before and after crisis intervention team training. Archives of psychiatric nursing, 28(1), 10-16. https://doi.org/10.1016/j.apnu.2013.10.003
- Hallett, N., & Dickens, G. L. (2017). De-escalation of aggressive behaviour in healthcare settings: Concept analysis. International journal of nursing studies, 75, 10-20. https://doi.org/10.1016/j.ijnurstu.2017.07.003
- Ilievski, V., Barrett, T., Lawson, W., Hoyland, S., & Tran, K. (2023). Cognitive impairment and behavioural emergencies within the acute hospital setting. BMJ Open Quality, 12(1), e002034. https://doi.org/10.1136/bmjoq-2022-002034
- Johnston, I., Price, O., McPherson, P., Armitage, C. J., Brooks, H., Bee, P., ... & Brooks, C. P. (2022). De-escalation of conflict in forensic mental health inpatient settings: a Theoretical Domains Framework-informed qualitative investigation of staff and patient perspectives. BMC psychology, 10(1), 30. https://doi.org/10.1186/s40359-022-00735-6
- Kelly, P., Saab, M. M., Hurley, E. J., Heffernan, S., Goodwin, J., Mulud, Z. A., ... & O Donovan, A. (2023). Trauma informed interventions to reduce seclusion, restraint and restrictive practices amongst staff caring for children and adolescents with challenging behaviours: A systematic review. Journal of child & adolescent trauma, 16(3), 629-647. https://doi.org/10.1007/s40653-023-00524-2
- Lenaghan, P. A., Cirrincione, N. M., & Henrich, S. (2018). Preventing emergency department violence through design. Journal of emergency nursing, 44(1), 7-12. https://doi.org/10.1016/j.jen.2017.06.012
- Larson, L. A., Finley, J. L., Gross, T. L., McKay, A. K., Moenck, J. M., Severson, M. A., & Clements, C. M. (2019). Using a potentially aggressive/violent patient huddle to improve health care safety. The Joint Commission Journal on Quality and Patient Safety, 45(2), 74-80. https://doi.org/10.1016/j.jcjq.2018.08.011
- Magnavita, N. (2014). Workplace violence and occupational stress in healthcare workers: A chicken‐and‐egg situation—results of a 6‐year follow‐up study. Journal of nursing scholarship, 46(5), 366-376. https://doi.org/10.1111/jnu.12088
- Mustika, N. W. E., Darma, I. M. W., Kurniawan, I. G. A., & Thapa, N. Y. (2023). Restorative justice settles health disputes between patients and hospitals from an inclusive justice perspective. Jurnal IUS Kajian Hukum dan Keadilan, 11(3), 423-436. https://doi.org/10.29303/ius.v11i3.1293
- Nevels, M. M., Tinker, W., Zey, J. N., & Smith, T. (2020). Who is protecting healthcare professionals? Workplace violence & the occupational risk of providing care. Professional Safety, 65(07), 39-43.
- Ogonah, M. G., Vega, M. O., Valdearenas, L., Cross, S., & Attoe, C. (2021). Mental health crises in the emergency department: simulation training for interprofessional collaboration and teamwork attitudes. International Journal of Healthcare Simulation, 1(1). https://dx.doi.org/10.54531/owxj2519
- Pariona‐Cabrera, P., Cavanagh, J., & Bartram, T. (2020). Workplace violence against nurses in health care and the role of human resource management: A systematic review of the literature. Journal of advanced nursing, 76(7), 1581-1593. https://doi.org/10.1111/jan.14352
- Prendergast, K. M. (2021). Comparing the effects of two debriefing frameworks: Promoting excellence and reflective learning in simulation (PEARLS) framework and structured and supported debriefing model (GAS) framework. Southern Connecticut State University.
- Riedel, P. L., Kreh, A., Kulcar, V., Lieber, A., & Juen, B. (2022). A scoping review of moral stressors, moral distress and moral injury in healthcare workers during COVID-19. International journal of environmental research and public health, 19(3), 1666. https://doi.org/10.3390/ijerph19031666
- Rossi, M. F., Beccia, F., Cittadini, F., Amantea, C., Aulino, G., Santoro, P. E., ... & Gualano, M. R. (2023). Workplace violence against healthcare workers: an umbrella review of systematic reviews and meta-analyses. Public health, 221, 50-59. https://doi.org/10.1016/j.puhe.2023.05.021
- Rogers, M. S., McNiel, D. E., & Binder, R. L. (2019). Effectiveness of Police Crisis Intervention Training Programs. The journal of the American Academy of Psychiatry and the Law, 47(4), 414-421. https://doi.org/10.29158/jaapl.003863-19
- Sawin, G., Klasson, C. L., Kaplan, S., Larson Sawin, J., Brown, A., Thadaney Israni, S., ... & Gregory, A. (2023). Scoping review of restorative justice in academics and medicine: A powerful tool for justice equity diversity and inclusion. Health Equity, 7(1), 663-675. https://doi.org/10.1089/heq.2023.0071
- Shahjalal, M., Parvez Mosharaf, M., & Mahumud, R. A. (2023). Effect of workplace violence on health workers injuries and workplace absenteeism in Bangladesh. Global health research and policy, 8(1), 33. https://doi.org/10.1186/s41256-023-00316-z
- Shi, J., Wang, S., Zhou, P., Shi, L., Zhang, Y., Bai, F., ... & Zhang, X. (2015). The frequency of patient-initiated violence and its psychological impact on physicians in china: a cross-sectional study. PloS one, 10(6), e0128394. https://doi.org/10.1371/journal.pone.0128394
- Timmins, F., & Timmins, B. (2021). An integrative review of waiting time, queuing, and design as contributory factors to emergency department violence. Journal of Evidence‐Based Medicine, 14(2), 139-151. https://doi.org/10.1111/jebm.12432
- Walter, L. A., Schoenfeld, E. M., Smith, C. H., Shufflebarger, E., Khoury, C., Baldwin, K., ... & Hess, E. P. (2021). Emergency department–based interventions affecting social determinants of health in the United States: a scoping review. Academic Emergency Medicine, 28(6), 666-674. https://doi.org/10.1111/acem.14201
References
Alarfaj, S. J., Jarrell, D. H., & Patanwala, A. E. (2018). Comparison of drug administration logistics between prothrombin complex concentrates and plasma in the emergency department. The American Journal of Emergency Medicine, 36(12), 2182-2186. https://doi.org/10.1016/j.ajem.2018.03.064
Anderson, E. S., Hsieh, D., & Alter, H. J. (2016). Social emergency medicine: embracing the dual role of the emergency department in acute care and population health. Annals of emergency medicine, 68(1), 21-25. https://doi.org/10.1016/j.annemergmed.2016.01.005
Arnetz, J., Hamblin, L. E., Sudan, S., & Arnetz, B. (2018). Organizational determinants of workplace violence against hospital workers. Journal of occupational and environmental medicine, 60(8), 693-699. DOI: 10.1097/JOM.0000000000001345
Arnetz, J. E. (2022). The Joint Commission's new and revised workplace violence prevention standards for hospitals: a major step forward toward improved quality and safety. Joint Commission journal on quality and patient safety, 48(4), 241-245. https://doi.org/10.1016/j.jcjq.2022.02.001
Azeem, M., Aujla, A., Rammerth, M., Binsfeld, G., & Jones, R. B. (2017). Effectiveness of six core strategies based on trauma informed care in reducing seclusions and restraints at a child and adolescent psychiatric hospital. Journal of Child and Adolescent Psychiatric Nursing, 30(4), 170-174. https://doi.org/10.1111/jcap.12190
Brenig, D., Gade, P., & Voellm, B. (2023). Is mental health staff training in de-escalation techniques effective in reducing violent incidents in forensic psychiatric settings?–A systematic review of the literature. BMC psychiatry, 23(1), 246. https://doi.org/10.1186/s12888-023-04714-y
Buckley, M. S., Roberts, R. J., Yerondopoulos, M. J., Bushway, A. K., Korkames, G. C., & Kane‐Gill, S. L. (2023). Impact of critical care pharmacist‐led interventions on pain, agitation, and delirium in mechanically ventilated adults: A systematic review. Journal of the American College of Clinical Pharmacy, 6(9), 1041-1052. https://doi.org/10.1002/jac5.1778
Carison, A., Babl, F. E., Hill, A., & O'Donnell, S. M. (2020). Children and adolescents with severe acute behavioural disturbance in the emergency department. Emergency Medicine Australasia, 32(5), 747-755. https://doi.org/10.1111/1742-6723.13515
Chaffkin, J., Ray, J. M., Goldenberg, M., & Wong, A. H. (2022). Impact of a virtual simulation-based educational module on managing agitation for medical students. Academic Psychiatry, 46(4), 495-499. https://doi.org/10.1007/s40596-021-01521-z
Ellis, H. A. (2014). Effects of a crisis intervention team (CIT) training program upon police officers before and after crisis intervention team training. Archives of psychiatric nursing, 28(1), 10-16. https://doi.org/10.1016/j.apnu.2013.10.003
Hallett, N., & Dickens, G. L. (2017). De-escalation of aggressive behaviour in healthcare settings: Concept analysis. International journal of nursing studies, 75, 10-20. https://doi.org/10.1016/j.ijnurstu.2017.07.003
Ilievski, V., Barrett, T., Lawson, W., Hoyland, S., & Tran, K. (2023). Cognitive impairment and behavioural emergencies within the acute hospital setting. BMJ Open Quality, 12(1), e002034. https://doi.org/10.1136/bmjoq-2022-002034
Johnston, I., Price, O., McPherson, P., Armitage, C. J., Brooks, H., Bee, P., ... & Brooks, C. P. (2022). De-escalation of conflict in forensic mental health inpatient settings: a Theoretical Domains Framework-informed qualitative investigation of staff and patient perspectives. BMC psychology, 10(1), 30. https://doi.org/10.1186/s40359-022-00735-6
Kelly, P., Saab, M. M., Hurley, E. J., Heffernan, S., Goodwin, J., Mulud, Z. A., ... & O Donovan, A. (2023). Trauma informed interventions to reduce seclusion, restraint and restrictive practices amongst staff caring for children and adolescents with challenging behaviours: A systematic review. Journal of child & adolescent trauma, 16(3), 629-647. https://doi.org/10.1007/s40653-023-00524-2
Lenaghan, P. A., Cirrincione, N. M., & Henrich, S. (2018). Preventing emergency department violence through design. Journal of emergency nursing, 44(1), 7-12. https://doi.org/10.1016/j.jen.2017.06.012
Larson, L. A., Finley, J. L., Gross, T. L., McKay, A. K., Moenck, J. M., Severson, M. A., & Clements, C. M. (2019). Using a potentially aggressive/violent patient huddle to improve health care safety. The Joint Commission Journal on Quality and Patient Safety, 45(2), 74-80. https://doi.org/10.1016/j.jcjq.2018.08.011
Magnavita, N. (2014). Workplace violence and occupational stress in healthcare workers: A chicken‐and‐egg situation—results of a 6‐year follow‐up study. Journal of nursing scholarship, 46(5), 366-376. https://doi.org/10.1111/jnu.12088
Mustika, N. W. E., Darma, I. M. W., Kurniawan, I. G. A., & Thapa, N. Y. (2023). Restorative justice settles health disputes between patients and hospitals from an inclusive justice perspective. Jurnal IUS Kajian Hukum dan Keadilan, 11(3), 423-436. https://doi.org/10.29303/ius.v11i3.1293
Nevels, M. M., Tinker, W., Zey, J. N., & Smith, T. (2020). Who is protecting healthcare professionals? Workplace violence & the occupational risk of providing care. Professional Safety, 65(07), 39-43.
Ogonah, M. G., Vega, M. O., Valdearenas, L., Cross, S., & Attoe, C. (2021). Mental health crises in the emergency department: simulation training for interprofessional collaboration and teamwork attitudes. International Journal of Healthcare Simulation, 1(1). https://dx.doi.org/10.54531/owxj2519
Pariona‐Cabrera, P., Cavanagh, J., & Bartram, T. (2020). Workplace violence against nurses in health care and the role of human resource management: A systematic review of the literature. Journal of advanced nursing, 76(7), 1581-1593. https://doi.org/10.1111/jan.14352
Prendergast, K. M. (2021). Comparing the effects of two debriefing frameworks: Promoting excellence and reflective learning in simulation (PEARLS) framework and structured and supported debriefing model (GAS) framework. Southern Connecticut State University.
Riedel, P. L., Kreh, A., Kulcar, V., Lieber, A., & Juen, B. (2022). A scoping review of moral stressors, moral distress and moral injury in healthcare workers during COVID-19. International journal of environmental research and public health, 19(3), 1666. https://doi.org/10.3390/ijerph19031666
Rossi, M. F., Beccia, F., Cittadini, F., Amantea, C., Aulino, G., Santoro, P. E., ... & Gualano, M. R. (2023). Workplace violence against healthcare workers: an umbrella review of systematic reviews and meta-analyses. Public health, 221, 50-59. https://doi.org/10.1016/j.puhe.2023.05.021
Rogers, M. S., McNiel, D. E., & Binder, R. L. (2019). Effectiveness of Police Crisis Intervention Training Programs. The journal of the American Academy of Psychiatry and the Law, 47(4), 414-421. https://doi.org/10.29158/jaapl.003863-19
Sawin, G., Klasson, C. L., Kaplan, S., Larson Sawin, J., Brown, A., Thadaney Israni, S., ... & Gregory, A. (2023). Scoping review of restorative justice in academics and medicine: A powerful tool for justice equity diversity and inclusion. Health Equity, 7(1), 663-675. https://doi.org/10.1089/heq.2023.0071
Shahjalal, M., Parvez Mosharaf, M., & Mahumud, R. A. (2023). Effect of workplace violence on health workers injuries and workplace absenteeism in Bangladesh. Global health research and policy, 8(1), 33. https://doi.org/10.1186/s41256-023-00316-z
Shi, J., Wang, S., Zhou, P., Shi, L., Zhang, Y., Bai, F., ... & Zhang, X. (2015). The frequency of patient-initiated violence and its psychological impact on physicians in china: a cross-sectional study. PloS one, 10(6), e0128394. https://doi.org/10.1371/journal.pone.0128394
Timmins, F., & Timmins, B. (2021). An integrative review of waiting time, queuing, and design as contributory factors to emergency department violence. Journal of Evidence‐Based Medicine, 14(2), 139-151. https://doi.org/10.1111/jebm.12432
Walter, L. A., Schoenfeld, E. M., Smith, C. H., Shufflebarger, E., Khoury, C., Baldwin, K., ... & Hess, E. P. (2021). Emergency department–based interventions affecting social determinants of health in the United States: a scoping review. Academic Emergency Medicine, 28(6), 666-674. https://doi.org/10.1111/acem.14201