SummaryA voluntary, peer-assisted crisis intervention program known as the Assaulted Staff Action Program helps hospital or community facility staff who are victims of patient assaults cope with the psychological aftermath of these incidents. Specially trained, on-call staff who have volunteered to be first responders provide immediate support and comfort following the assault, including crisis counseling, looking for symptoms of trauma, and professional counseling services as needed. The program has significantly reduced trauma-related symptoms among victims, the number of patient assaults on staff, staff turnover due to patient assaults, and associated turnover-related costs.Moderate: The evidence consists of long-term retrospective studies of the program's impact on various trauma-related symptoms; pre- and post-implementation comparisons of assaults and staff turnover related to assaults; and estimates of cost savings from program-induced reductions in staff turnover.
Developing OrganizationsMetropolitan State Hospital
Metropolitan State Hospital (now closed) was located in Waltham, MA. Dr. Raymond B. Flannery designed the Assaulted Staff Action Program while he worked in the hospital.
Use By Other OrganizationsOver its 22-year history, 1,700 ASAP team members at 40 sites in 7 states have volunteered 1.75 million hours of time in responding to approximately 4,750 assaults. Some teams have been lost to facility downsizings and closures. As of June 2012, ASAP is being used in six sites in New York, one in Ohio, one in New Hampshire, and two in Connecticut. Adopting organizations include state and private psychiatric inpatient facilities, outpatient clinics, homeless shelters, day programs, residential housing programs, and other organizations in which employees might face traumatic situations.
Date First Implemented1990
Vulnerable Populations > Mentally ill
Problem AddressedPatient-perpetrated violence and abuse directed at staff occur often in health care settings, with incidents involving individuals in psychiatric care settings being particularly common. Although crisis intervention programs can help victims of violence cope and prevent future incidents, relatively few facilities offer such support.
- A common occurrence: Nearly 15 percent of health care workers have been the victim of patient-perpetrated physical violence in the past year, while nearly 40 percent have been the victim of verbal assaults or abuse.1 Nursing personnel remain most susceptible to such violence and abuse, particularly in psychiatric settings.2 One study found that, over a 1-week period, more than 20 percent of psychiatric nurses had been the victim of a physical assault, while more than half had been verbally assaulted.3 An Occupational Safety and Health Administration study found that between 46 and 100 percent of nurses, psychiatrists, and therapists in psychiatric facilities have been assaulted at some point during their career.4
- Unrealized potential of crisis intervention: Many health care workers view patient-perpetrated violence as an occupational hazard that they must cope with on their own. Crisis intervention programs can reduce the impact of violence-related trauma on health care providers and in some cases reduce the likelihood of violent episodes, yet relatively few health care facilities offer such programs to staff.4
Description of the Innovative ActivityA voluntary, peer-assisted crisis intervention program known as the Assaulted Staff Action Program (ASAP) helps psychiatric hospital or community facility staff who are victims of patient assaults cope with the psychological aftermath of these incidents. Specially trained, on-call staff who have volunteered to be first responders provide immediate support and comfort following the assault, including crisis counseling, looking for symptoms of trauma, and professional counseling services as needed. Key program elements include the following:
- Initiating service by paging on-call team member: Staff members who have volunteered to serve as ASAP first responders (including clinicians, managers, administrators, social workers, and mental health workers) rotate call duty, with someone on call 24 hours a day, 7 days a week. When an assault occurs, a charge nurse or residential house manager pages the ASAP responder on call.
- Introducing victim to services: The ASAP team member arrives at the scene within 20 minutes. He or she assesses safety and any medical issues first. The responder meets with the staff victim and assures the victim that the incident will remain confidential unless the victim reports a patient-related crime, in which case the first responder notifies the appropriate authorities. The responder then offers ASAP services to the victim (approximately 85 percent accept the service). Victims who decline services receive a card with the team member’s contact information in case they change their mind—of the 15 percent of victims who initially decline services, about half call later for services.
- Providing counseling and support: The ASAP team member provides any of a variety of support services depending on the patient's needs, as outlined below:
- Evaluation of safety and medical need: The team member ensures that the victim is safe and that medical issues have been addressed, and then gathers facts about the incident from the victim and witnesses.
- Crisis counseling: The team member performs crisis counseling, helps the victim cope with the immediate psychological trauma, identifies a network of supportive individuals, and (if the victim wishes) reviews the traumatic event to understand why it happened. The team member monitors the victim for symptoms associated with psychological trauma (e.g., helplessness, hypervigilance, exaggerated startle response), explains to the victim what symptoms may occur, and reviews general coping mechanisms. The team member and victim also jointly develop a plan to help the victim return to a precrisis level of functioning.
- Documenting incident and injury: After the first interview, the ASAP team member records the victim’s demographic characteristics, injuries, trauma symptoms, assailant characteristics, and any possible precipitants to the incident.
- Referral to support group and professional counselors: The ASAP team member makes the victim aware of ASAP's victim support group, led by the ASAP team leader. This group meets weekly to enable victims to discuss their incidents and gain support from peers. If requested, the ASAP team member arranges professional counseling services for the victim.
- Counseling for family members and/or unit staff: If necessary, the ASAP team member provides crisis intervention for staff at the site of the assault and/or for the victim’s family.
- Followup with victim: With the victim’s permission, the ASAP team member contacts the victim by phone or in person within 3 days of the event, and then again in 10 days, to check on the victim's progress and determine the need for possible additional ASAP services.
Context of the InnovationDr. Raymond Flannery developed ASAP in 1990 while working in Metropolitan State Hospital, a 400-bed inpatient psychiatric facility in Waltham, MA. At least one patient assault of a staff member occurred every day in the facility, which employed 800 individuals, including 500 with direct care responsibilities. The director of nursing asked Dr. Flannery, who had significant experience working with victims of psychological trauma, to help clinicians traumatized and frightened by patient assaults. After the hospital closed due to state budget cuts, the commissioner of the state Department of Mental Health asked Dr. Flannery to implement ASAP in other state inpatient facilities.
ResultsThe program has significantly reduced trauma-related symptoms among victims, the number of patient assaults on staff, staff turnover due to patient assaults, and associated turnover-related costs.
Moderate: The evidence consists of long-term retrospective studies of the program's impact on various trauma-related symptoms; pre- and post-implementation comparisons of assaults and staff turnover related to assaults; and estimates of cost savings from program-induced reductions in staff turnover.
- Fewer trauma-related symptoms: A retrospective study of all people served by the program in both inpatient facilities and community settings over the past 20 years found that the program has significantly reduced trauma-related symptoms associated with patient-initiated attacks, as outlined below:
- Fewer problems coping: Victims of violence often experience residual negative effects on their coping skills related to managing work and relationships. The study found that inpatient victims served by the program experienced a roughly 65-percent decline in the number of such disruptions (from 1,634 to 574).
- Fewer problems making attachments: After a traumatic event, victims may withdraw from other people, and other people—not knowing how to help—may withdraw from them out of fear or awkwardness. The study found that the program has made this problem less severe, with the number of such attachment problems declining by more than 50 percent, from 759 to 360.
- Less questioning of one's purpose in life: Victims of assault often lose their interest in daily activities of life. In particular, health care clinicians attacked by patients often begin questioning why they work to help these patients. The study found that the frequency of such thoughts among victims served by the program fell by roughly 50 percent, from 1,401 to 705.
- Fewer physical symptoms: The number of physical symptoms due to trauma fell by almost 75 percent in victims served by the program, from 998 to 252.
- Fewer avoidant behaviors and intrusive thoughts: The frequency of avoidant behaviors (such as taking sick leave to avoid the site of the trauma or avoiding people who witnessed the event) fell by more than 80 percent (from 425 to 73) among victims served by the program, while intrusive thoughts (defined as unbidden thoughts about the event) declined by more than 75 percent (from 484 to 113).
- Fewer assaults: A study conducted at the first ASAP site (a 400-bed state mental institution) found that the number of patient assaults on staff fell from 30 to 11 per month after implementation of the program. A second study in an institution historically experiencing more than 11 patient assaults on staff each quarter found that such assaults basically ended after program implementation. Studies in two additional state hospitals, an acute care emergency department, and a community mental health center also found dramatic declines in assaults after implementation. These declines appear to stem from the program's ability to improve collegiality and cohesion among staff (due to the strong message of support it sends), which leads to staff feeling less tense. (Early anecdotal evidence suggests that staff tension and discord often agitates patients, thus leading to assaults. Dr. Flannery and his research colleagues are currently gathering data to address this issue.)
- Less staff turnover: The program has reduced staff turnover related to assaults. For example, at the initial ASAP site, an average of 15 staff resigned during the 2 years before program implementation for reasons directly related to patient assaults. Only one staff member resigned for assault-related reasons during the 2 years after implementation.
- Lower costs: The program reduces the costs associated with assaults, staff turnover, absenteeism and presenteeism, industrial accident claims, and legal and medical expenses. Estimated cost savings related to lower staff turnover alone total $268,000 biennially for the typical 350- to 400-bed psychiatric hospital experiencing roughly 30 assaults per month.
Planning and Development ProcessThe five steps required for ASAP adoption (each of which requires approximately 1 month) include the following:
- Document magnitude of problem: Program adopters should track the annual number of patient assaults on staff, using both incident report data and anecdotal information from administrative leaders and staff. ASAP has special forms developed for this purpose.
- Obtain leadership and (if necessary) union support: In a hospital, the chief executive officer, medical director, director of nursing, head of psychiatry, head of social work, and other administrative leaders should be contacted to share data on the size of the problem, introduce the ASAP program, and confirm their support for it. Senior managers must also agree to respect the confidentiality of ASAP conversations, using only facility incident reports and/or other administrative (non-ASAP) procedures to investigate incidents. In unionized facilities, union leaders must pledge their support for the program and be involved in its development, because ASAP team members volunteer their time after work hours.
- Select team: Program leaders need to select ASAP team leaders and members. (See the Resources Used and Skills Needed section for information on staffing requirements and skill sets of team members.)
- Train team: Team members attend a 1-day training program that provides information about the program and reviews psychological trauma, crisis intervention, and interactive skills training. Team supervisors attend a half-day program that briefly covers team member training and how to conduct support groups and provide backup support to first responders when necessary. Potential adopters can train the team internally using the ASAP manual (see the Tools and Related Resources section for more information) or by contracting with Dr. Flannery, who conducts such trainings and holds bimonthly team leader conference calls for the teams he has trained.
- Initiate and market program to staff: Program adopters should choose a date for initiation and advertise the team to the workforce via flyers, emails, and/or newsletters. Communications should explain the concept behind ASAP, introduce team members, assure confidentiality, and provide contact information.
Resources Used and Skills Needed
- Staffing: The program requires no new staff, as existing staff incorporate it into their daily routines. The number of ASAP volunteers needed depends on institution size and experience with violence. For example, a mental health facility with approximately 400 employees may need one team leader, three team supervisors, and 10 first responders. Team leaders should be interested in psychological trauma and helping others; be willing to commit to a 2-year term; and be able to run a team effectively, set up a call schedule, and perform other activities related to overseeing the program. Team members should have at least 1 or 2 years' tenure at the facility and also be interested in trauma and helping others. As a group, ASAP volunteers should reflect the diversity of the workforce. Team members with more experience often end up becoming team leaders.
- Costs: The program requires little financial outlay. Upfront costs might include $27 for the ASAP training manual and/or payments to outside consultants to conduct the initial training. Ongoing costs consist of cell phones or beepers for team members and supervisors. Typically, facilities offer team members compensatory time off in lieu of overtime pay. However, in the 20 years that the program has operated at multiple sites, no team member has ever taken his or her earned compensatory time off.
Funding SourcesThe program is funded internally by institutions that adopt it.
Tools and Other ResourcesThe ASAP training manual is available for $27 from Chevron Publishing (Ellicott City, MD) at:
Telephone: (410) 418-8002
Getting Started with This Innovation
- Win leadership and union support through education about impact of trauma: Some senior leaders in psychiatric settings believe that patient violence “comes with the territory.” Education about ASAP and its results can help convince them that supporting the program will have tangible benefits for the staff and institution. In addition, multiple levels of administrative leaders should be involved in planning discussions so that leadership turnover will not derail the program. Similarly, union leaders may initially resist ASAP adoption but usually become convinced fairly quickly that ASAP will reduce suffering for their members.
- Expect initial resistance from staff: Staff may express concerns that the information they discuss with an ASAP team member will be used against them during the employee evaluation process. Typically, such concerns evaporate after an initial traumatic event occurs, as staff see firsthand that the program can be quite helpful and will not violate their privacy.
Sustaining This Innovation
- Continually remind employees about team's availability: The ASAP team should continually be “advertised” on bulletin boards and via e-mail. For example, the ASAP team leader can send out a bimonthly memo that provides information about psychological trauma and updates about program activities.
- Select team leaders carefully: Energetic team leaders ensure that team members provide services in a high-quality, timely manner, which helps maintain enthusiasm and support for the program over time.
- Provide ongoing support to team leaders: Team leaders can benefit from bimonthly group telephone calls that provide a forum for sharing advice and best practices with peers.
- Keep team leaders engaged after their term ends: Team leaders should be allowed to apply for a second 2-year term if they so desire. Those ready to relinquish their oversight role after 2 years but who still want to be part of the program should be allowed to continue as a “team leader emeritus.” In this role, they can still participate in team meetings and provide advice and suggestions, but no longer have responsibility for overseeing team operations.
Additional ConsiderationsASAP has been designated as a “best practice” by both the U.S. Occupational Safety and Health Administration and the Canadian Ministry of Health.
Contact the InnovatorRaymond B. Flannery, PhD, FAPM
Associate Clinical Professor of Psychology, Harvard Medical School
7 Westchester Road
Newton, MA 02458
Innovator DisclosuresDr. Flannery receives financial compensation related to the ASAP training manual and for providing training services to interested ASAP adopters.
References/Related ArticlesFlannery RB Jr, Rego S, LeVitre V, et al. Characteristics of staff victims of psychiatric patient assaults: Twenty-year analysis of the Assaulted Staff Action Program. Psychiatr Q. 2011;82:11-21. [PubMed]
Flannery RB Jr, Farley EM, Rego S, et al. Characteristics of staff victims of psychiatric patient assaults: Fifteen-year analysis of the Assaulted Staff Action Program (ASAP). Psychiatr Q. 2007;78:25-37. [PubMed]
Flannery RB Jr, Stone P, Rego S, et al. Characteristics of staff victims of patient assault: Ten year analysis of the Assaulted Staff Action Program (ASAP). Psychiatr Q. 2001;72:237-248. [PubMed]
Assaulted Staff Action Program (ASAP). Public Health Agency Of Canada. Canadian Best Practices Portal.
Flannery RB. The Assaulted Staff Action Program: coping with the psychological aftermath of violence. Ellicott City, MD: Chevron Publishing, 1998.
Flannery RB. Program Development: critical incident stress management and the Assaulted Staff Action Program. Int J Emerg Ment Health. 1999;2:103-108.
Gerberich SG, Church TR, McGovern PM, et al. An epidemiological study of the magnitude and consequences of work related violence: the Minnesota Nurses' Study. Occup Environ Med. 2004;61(6):495-503. [PubMed]
Lanza ML, Rierdan J, Forester L, et al. Reducing violence against nurses: the violence prevention community meeting. Issues Ment Health Nurs. 2009;30:745-750. [PubMed]
Hesketh KL, Duncan SM, Estabrooks CA, et al. Workplace violence in Alberta and British Columbia hospitals. Health Policy. 2003;63(3):311-21. [PubMed]
4 Morton T. ASAP: a workplace violence prevention program. In: Volpe R, Lewko J. Best practices in the prevention of reinjury. July 2009.
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Original publication: December 07, 2011.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: February 06, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.
Date verified by innovator: November 19, 2012.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.