The Pathway to Violence in Australian Healthcare

Targeted violence in healthcare does not usually erupt out of nowhere. It is more often the end point of a progression, a journey marked by observable steps that can be recognised if staff know what to look for. Frederick Calhoun and Steve Weston’s Pathway to Violence model (2003) has become one of the most influential frameworks for understanding this process. While developed in the context of workplace and public-safety environments, its application to healthcare is increasingly clear.

Hospitals and clinics are open spaces charged with emotion, frequently becoming arenas where grievances - personal, political, or ideological - play out. In the current Australian context, with the rise of anti-government sentiment, renewed concerns around terrorism, and the increasingly violent rhetoric of sovereign-citizen movements, the value of this model to healthcare security cannot be overstated.

At its core, the pathway outlines how an individual may progress from grievance to ideation, research and planning, preparation, probing, and finally to attack. It is not always linear; people can stall, regress, or disengage. However, the stages offer a practical lens for interpreting behaviour that might otherwise be dismissed as harmless frustration. A patient who complains bitterly about perceived unfair treatment may be at the grievance stage. A visitor who begins making vague threats online about “teaching them a lesson” has moved into ideation. Someone who starts asking pointed questions about security presence or repeatedly checks locked doors may be in the probing stage. Each of these signals may appear trivial in isolation, but when viewed together, they form part of a recognisable trajectory.

The Australian healthcare environment presents unique challenges for applying this model. Hospitals are designed to be accessible and welcoming. Staff are trained first and foremost to care, not to suspect hostile intent. Yet the reality is that frontline workers like nurses, allied health professionals, or security staff are often the first to notice a patient or visitor moving along the pathway. A muttered racist comment, a fixation on conspiracy theories about government “control,” or repeated frustration at perceived bureaucratic injustice may all be early markers of grievance. If staff are equipped with an understanding of the pathway, they can distinguish between ordinary dissatisfaction and behaviour that may signal an increasing risk of violence.

Of course, recognising behaviour is only part of the challenge. Healthcare is a tightly regulated environment where privacy and confidentiality obligations are deeply embedded in both law and professional ethics. The Privacy Act 1988 and state-based health information laws provide important safeguards for patients, but they also create complexity when information must be shared for safety reasons. A nurse who notices concerning behaviour cannot simply broadcast it to colleagues or discuss it over lunch. Instead, escalation must occur through defined pathways, whether to an internal threat assessment team, to a line manager, or in certain cases, to law enforcement. The principle of “need to know” applies, balancing the duty to protect patient confidentiality with the duty to prevent harm.

The creation of multidisciplinary threat assessment teams in healthcare organisations can provide a practical solution to these tensions. By bringing together clinicians, threat assessment professionals, psychologists, and legal advisers, concerns about behaviour can be assessed with nuance and proportionality. One person’s grievance might be best addressed with patient advocacy and communication support. Another’s fixation on antisemitic conspiracy theories might require closer monitoring and discreet liaison with police. The pathway model provides a common language for these discussions, enabling different disciplines to align around observed behaviours rather than subjective impressions.

Recent trends in Australia make the need for such frameworks urgent. Antisemitism has seen a resurgence, with incidents recorded across universities, schools, and houses of worship. Sovereign-citizen ideology, once fringe, has moved into mainstream awareness and become increasingly violent. The terrorism threat level, recently elevated to “probable,” serves as a reminder that ideologically motivated actors can target public institutions.

In this environment, healthcare settings, because they can be symbols of government authority, multiculturalism, or vulnerability, are not immune. A person who begins with a grievance about the tragic loss of a loved one in hospital care may, under the influence of extremist narratives, move towards planning an act intended to send a wider ideological message. Understanding the pathway allows staff to see these risks in their infancy, before harm occurs.

One such scenario might involve a patient who complains that “the staff here are racist.” Assuming the complaint is ungrounded, this may appear to be little more than irritation. Over time, however, the patient posts online suggesting that staff “need a lesson in respect.” Later, he begins loitering near restricted areas, asking about the security cameras. In the language of Calhoun and Weston, we can trace the progression: grievance, ideation, research, probing. With this awareness, staff can escalate concerns early, activating a multidisciplinary review before the individual reaches the preparation or attack stage. Crucially, the response need not be punitive; it may involve outreach, counselling, or de-escalation strategies. The aim is prevention, not punishment.

For Australian healthcare, the practical application of the pathway to violence model is not about turning clinicians into detectives or security experts. It is about equipping staff with a simple mental map that helps make sense of behaviour that feels “off” and provides a framework for acting early and proportionately. When combined with clear escalation pathways and multidisciplinary review, the model becomes a protective layer woven into the fabric of patient care. In a climate where ideological grievances can so easily spill into public life, recognising that violence is a process rather than an event may be one of the most powerful tools healthcare has to keep its people safe.