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How Do We Keep Our Residents Safe? An Educational Intervention.

Tobias Wasser, MD

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While psychiatric training programs devote a great deal of focus to teaching residents how to assess a patient’s risk of suicide, often there is significantly less attention paid to training how to assess for a patient’s risk of violence. Despite the fact that most individuals with mental illness do not act out violently and the severely mentally ill are significantly more likely to be victims of violent crime than they are to be perpetrators, a significant number of psychiatry residents are the victims of assault by their patients and few are sufficiently trained in violence risk assessment and management. In a 1999 national survey, one third of psychiatry residents reported receiving no training in this area and another third described their training as inadequate. This is particularly concerning given that 73% of these residents had been threatened and 36% had been physically assaulted by a patient. More recent evidence suggests that this trend is not improving and psychiatric trainees are not alone, though they may be the most affected.

From a resident health and well-being perspective, one area for concern is the significant psychological impact patient assaults have on trainees. The adverse psychological consequences include anger, fear, anxiety, post-traumatic stress symptoms, guilt, self-blame, shame, believing that being assaulted is inherent to the profession and a change in career interest. This is especially concerning given that residents are a group already faced with the challenges of long work hours, sleep deprivation, and loss of autonomy, and well known to be subsequently more vulnerable to depression.

Given the high rates of assaults and insufficient safety training for residents, it is crucial to refocus our attention on this area. Numerous efforts have been made to delineate how we might improve resident education in this area. In 1993, the American Psychiatric Association (APA) published an outline for residency training in managing patient violence. Others have added to these recommendations, delineating recommendations for training of 5-10 hours in duration. However, little work has been done to assess the effectiveness of these trainings in improving clinical practice.

Toward this end, we designed and implemented a brief (2 hour) educational intervention at our institution focused on improving residents’ ability to recognize violence risk and increase their attention to safety in the psychiatric interview. Our core learning objectives were that residents would recognize the characteristics of patients and situations which elevate the risk for violence, increase their efforts to be cognizant of their own internal state while sitting with patients and make appropriate adjustments to the interview milieu to attend to their safety. We then assessed whether such a brief intervention could be effective in increasing residents’ attention to safety in their clinical care, given prior recommendations in the literature for 5-10 hours of training.

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