A nurse at Nemours Alfred I. du Pont Hospital for Children, Brecher said the problems were not confined to emergency departments. "This happens in every unit in the hospital," she said.
Her group's most recent survey of nurses, published in 2011, found that 54 percent had experienced physical or verbal violence in the previous week.
Patricia Eakin, a Philadelphia nurse who leads the Pennsylvania Association of Staff Nurses and Allied Professionals (PASNAP), said nurses endure "run-of-the-mill constant abuse" that includes "a lot of kicking," punches, contact with knives and teeth, and loud, vile language.
According to the American College of Emergency Physicians (ACEP), nearly 60 percent of all nonfatal assaults and violent acts at work occur in health-care and social-assistance settings.
'A daily risk'
Local hospitals try to protect employees and visitors with no-guns policies, metal detectors in danger zones like ERs, strategically placed panic buttons, extra attention for agitated patients, and, of course, security guards.
"Violence in the emergency department is a daily risk," said Gary Goodman, a Florida emergency physician and ACEP member. He was punched recently. One of his patients - a man infected with two dangerous viruses - cut himself and threatened the staff with his blood. One day after work, a carload of "gangbangers" asked how a gunshot victim he had treated that night was doing.
"Either this was his buddies," Goodman thought, "or they're going to go back and do him. I just turned and ran."
In the incident at the Mercy Fitzgerald wellness center, patient Richard Plotts has been charged with the murder of caseworker Theresa Hunt. Plotts also wounded Lee Silverman, a psychiatrist he had known for 20 years, before Silverman pulled his own gun and shot Plotts.
Mix of measures
Doctors said most mentally ill patients are not violent. Many aggressive patients are under the influence of drugs or alcohol.
Experts said preventing violence in medical settings involves a complex mix of security measures, risk assessment, training, attitude adjustment, customer service, and knowing how to deal with agitated people.
Arming staff with guns is not a popular option.
"I don't think that's the answer, although it clearly was in this case," said Eakin, referring to the Mercy Fitzgerald incident.
The danger is that impulsive patients or visitors will grab a gun and use it against its owner. Or that workers could shoot wildly and injure bystanders.
"Very few people are proficient enough to hit what they're aiming at, especially in a crisis," said Joel Dvoskin, a University of Arizona psychologist who works with the Threat Assessment Group, a national organization specializing in preventing workplace violence.
Mercy Fitzgerald prohibits firearms but has declined to say whether Silverman had permission to carry his gun at work. . Hospital security officers are unarmed, and signs tell visitors: "If you have any type of weapon, please inform staff or security immediately."
The hospital is reviewing its security policies. Since the shootings, hospital spokeswoman Bernice Manallo Ho said there had been an "increased security presence on our campus" and restrictions at some public entrances.
Main Line Health, Temple University Health System, and Thomas Jefferson University Hospital all have no-firearms policies, although Temple University police officers are allowed to keep their guns.
Temple, Crozer-Chester Medical Center, and Cooper University Hospital all have metal detectors in their emergency departments. Crozer-Keystone Health System security officers are armed with pepper spray, and security supervisors carry stun guns. Cooper offers training quarterly to staff on how to handle an "active shooter."
The Hospital of the University of Pennsylvania declined to discuss its security policies.
Brecher, the du Pont nurse, is not convinced metal detectors make emergency departments safer. The real problem, she said, is a "culture of acceptance" that starts with nurses. "We kind of feel it's part of our job," she said. That attitude goes all the way up to judges, and has to change, she said.
"Workplace violence is not acceptable" for nurses or anyone else, she said.
Brecher said the most effective deterrent is to adopt a zero-tolerance policy. Her hospital just did that. Main Line Health hospitals plan to.
For three years, PASNAP has been pushing a bill in the Pennsylvania legislature that would require hospitals to establish violence-prevention committees to assess and mitigate risks, track violent incidents, and train staff, Eakins said.
William Dubin, chief of psychiatry at the Temple University School of Medicine, said past violent behavior was the best predictor of future violence. "Substance abuse exponentially increases the risk," he said. Other risk factors include having experienced physical or sexual abuse, brain damage that reduces impulse control, chronic anger, persecutory delusions, hearing voices that give commands, and weapon collecting.
John R. Lion, a Baltimore psychiatrist who edited a book with Dubin on violence in medical settings, said dangerously disgruntled patients often blame medical professionals for their problems. "They blame you for the death of their mother or father," he said. "They blame you for not curing them."
He thinks psychiatrists should receive more training in how to deal with such patients.
Dubin said a trick was recognizing that aggressive patients often feel helpless, humiliated, or powerless. "The one thing you don't want to do is increase those feelings," he said.
Instead of playing the tough guy, Dubin suggests, say something like this: "You're really frightening me. . . . I really want to help you, but when I'm this scared, it's hard to help."
If that doesn't work, patients should be referred to more secure settings, Dubin said.
'Late is bad'
Other experts say it is key to head off problems early.
Dvoskin makes people who attend his seminars chant, "Early is good and late is bad." Identify troubled people and get them help. The "combination of anger and despair is the problem," he said.
While security is important, he said, "the most important thing is to improve customer service. The more enraged people are, the more likely they are to engage in violence. Some of what's infuriating about medical care is unnecessary."
Matthew Hurford, a psychiatrist who is chief medical officer for the Philadelphia Department of Behavioral Health and Intellectual Disability Services, agreed that treating patients with respect and support - establishing a "strong therapeutic alliance" - can head off many problems.
He said the Delaware County case should remind treatment providers to make sure their strategies to avoid violence are up-to-date.
"Without safety, there can be no healing," he said.