Threat Assessment Strategies to Mitigate Violence in Healthcare

When investigating a potential threat, there are several key questions that the team should consider:[60]^,[61]

1. What motivated the subject to make the statement or take the action which caused him or her to come to the teams’ attention?
2. Has the subject communicated with anyone concerning his or her intentions?
   Many attackers do not write or communicate a specific threat to the target.  Often, though, they let someone know about their intentions or write their intentions in a diary or journal before they act on violent ideations.  This was a significant finding in the ECSP.  Scrutiny of a subject’s social media communications and posts may provide important information about the subject’s thinking, planning and intentions.  As mentioned previously, many attackers think about an attack in the months and even years before they formulate plans for such an attack. 

3. Has the subject shown inappropriate interest in assassins, weapons, militant ideas or mass murders?
4. Is there evidence that the subject has engaged in attack-related behavior targeting someone in the organization?
   Attack-related behaviors may include having a plan, making efforts to acquire or practice with weapons, casing possible sites for an attack and rehearsing.

5. Does the subject have a history of mental illness involving command hallucinations, delusional ideas, feelings of persecution, etc.?
   Mental illness alone is not a key factor in predicting attacks; however, there are particular mental issues that should raise flags for the TA team.  There does appear to be an increased probability of violence related to substance abuse, particularly alcohol.[62]^,[63]   Additionally, subjects who have command hallucinations with a history of taking action on commands as well as individuals who suffer from paranoid delusions may pose a greater risk.[64] 

6. Does the subject have the ability to plan and execute a violent action?
7. Is there evidence that the subject is experiencing hopelessness, desperation and/or despair?
   Has the subject experienced a recent loss or loss of status? Is the subject now, or has the subject ever been, suicidal? A person who feels hopeless and/or desperate shouldbe viewed with high concern. Major life losses and traumas such as the ending of a relationship, losing a job, failing in an activity of importance, loss of a family member and other life changes may have caused distress or humiliation for the subject.  Subjects may come to believe that an attack will bring an end to their suffering.  A subject who appears to be currently suicidal should be assessed with particular care.
8. Is what the subject says consistent with his or her actions?
9. Is there concern among those who know the subject that he or she might take action based on inappropriate ideas?
10. Are there factors in the subject’s life or environment which might increase or decrease the likelihood of the subject attempting an attack?
    A TA investigation is designed to answer two fundamental questions: does the subject currently pose a threat and are there foreseeable circumstances under which the subject might pose a threat?  The process must be dynamic in that new information may become available and lead to different conclusions.  

There are a variety of commercially-available tools to aid in the TA process, though many are designed for K-12 schools and college campuses specifically.  The National Behavioral Intervention Team (NaBITA) has created several including the Extremist Risk Intervention Scale (ERIS) and the Structured Interview for Violence Risk Assessment (SIVRA-35).  While similarities can be drawn between college campuses and healthcare campuses, there are enough differences that adapting one of these tools to healthcare or workplace violence would be challenging. 

There are no tools available specific to workplace violence in the healthcare setting; however, there is one that is specific to the workplace – The Workplace Assessment for Violence Risk (WAVR-21).  This validated tool is a structured professional judgment guide for the assessment of workplace targeted violence.  The instrument, which was developed beginning in 2004, contains 21 risk factors, both static and dynamic.  The first five risk factors (noted 1 thru 5 in Table 3 on the following page) are considered “red flag indicators due to their proximal, if not causal relationship to targeted violence.”[65]  The instrument is accompanied by a manual with key assessment questions, behavioral risk indicators and additional references for further research.[66]

Table 3 – WAVR-21 Risk Factors

There are also tools specific to evaluating intimate partner violence threats which can affect any workplace, though this may be especially true in healthcare.  According to the Bureau of Justice Statistics, 85% of intimate partner violence is directed toward women and healthcare is a female dominated industry.  In a study that surveyed 1,981 nurses and nursing personnel, just over 25% reported experiencing intimate partner violence.[67]  Intimate partner violence often spills over into the workplace when a victim is harassed, receives threatening phone calls or experiences violence while at work.  According to Workplaces Respond, a national resource center for intimate partner and sexual violence, approximately 24% of workplace violence is related to personal relationships, typically perpetrated by a current or former intimate partner.[68]  According to the U.S. Department of Justice, between four and five women on average are murdered each day by their husbands or boyfriends and nearly 33% of women killed in U.S. workplaces between 2003-2008 were killed by a current or former intimate partner. 

One tool for evaluating the intimate partner violence threats is the Spousal Assault Risk Assessment Guide (SARA).  The SARA is a structured approach to guide and enhance professional judgments about risk.  It is composed of 20 items that were selected based on a review of empirical research and relevant legal and clinical issues. Like the WAVR-21, items evaluated are both static and dynamic in nature. Each of the 20 items is coded on a 3-point scale (0 = absent, 1 = subthreshold, 2 = present), according to detailed criteria.[69] The assessor then determines whether any items are considered critical in that they are sufficient on their own to indicate that the individual poses an imminent risk of harm.   Once complete, the situation is rated as low, moderate or high risk.  There is a limited amount of research on the tool itself, but that which is available indicates it has adequate reliability and validity.[70]

Another tool for assessing intimate partner risk is the Danger Assessment (DA) originally developed in 1985. The DA is an instrument that helps to determine the level of danger an abused woman has of being killed by her intimate partner. There are two parts to the tool: a calendar and a 20-item scoring instrument.  The calendar helps to assess severity and frequency of battering during the past year. The woman is asked to mark the approximate days when physically abusive incidents occurred, and to rank the severity of the incident on a 1 to 5.  The 20-item instrument uses a weighted system to score yes/no responses to risk factors associated with intimate partner homicide. Some of the risk factors include past death threats, partner’s employment status, and partner’s access to a firearm.[71]  A 2005 grant based research project funded through the Department of Justice determined that the DA had the highest correlations with subsequent intimate partner abuse compared with the three other tools that were evaluated.[72] 

[60] Doherty, From protective intelligence to threat assessment, 12

[61] Bryan Vossekuil et. al. Threat Assessment: Assessing the Risk of Targeted Violence, (Journal of Threat Assessment and Management, 2015): 250-252.

[62] Julian Barling, et. al., Predicting Workplace Aggression and Violence, (Annual Review of Psychology, 2009), 677-678.

[63] Randy Borum, et. al., Threat Assessment: Defining an Approach for Evaluating Risk of Targeted Violence, (Behavioral Sciences and the Law, 1999), 333.

[64] Ibid.

[65] Meloy et. al, The Development and Reliability of the WAVR-21*, 1355.

[66] https://www.wavr21.com/

[67] Michelle Irene Bracken, et. al., Intimate Partner Violence and Abuse among Female Nurses and Nursing Personnel: Prevalence and Risk Factors, (Issues with Mental Health Nursing, 2010), 137, 141.

[68] https://www.workplacesrespond.org/resource-library/facts-gender-based-workplace-violence/

[69] http://criminal-justice.iresearchnet.com/forensic-psychology/spousal-assault-risk-assessment-sara/

[70] Ibid.

[71] https://www.dangerassessment.org/DA.aspx

[72] Janice Roehl, et. al., Intimate Partner Violence Risk Assessment Validation Study: The RAVE Study, (National Criminal Justice Reference Service Final Grant Report, 2005), 15.