“It’s all your fault,” the man yelled at the nurse huddled on the concrete.

“Freeze!” The security guard warned. “Take your hand out, slowly! Put your hands behind your head!”

Ten minutes later, the shaking nurse rested on an ED stretcher talking to the police. She had contusions and abrasions on her elbows and knees, but wasn’t injured otherwise.

A day-shift nurse, ready to go off duty, spoke to another officer. “I should have done something about that guy this morning,” she said half in tears. 

“You know him?” The officer asked.

She nodded yes. “A woman came in DOA this morning. I called her son,” she pointed toward the man in the police cruiser parked outside the ED doors. “He was so upset, repeating over and over that we should have called him sooner. I tried to explain the situation, but he didn’t get it. He mumbled something about it being my fault, but then walked out. I didn’t make a big deal of it. I mean, his mother had just died.” 

If she had known a little more about violence and how to prevent it, would she have handled the situation differently? She resolved to notify security and seek out information that would broaden her options the next time something like this occurred. Even if she couldn’t avoid potential harm, she vowed to be better prepared the next time — if it ever came.

Experts not only agree on the extent of the problem, they also concur on its best treatment — education and prevention. Nurses heighten their awareness and expertise in dealing with violence in their professional settings by learning to identify risk factors and warning signs, and by applying interventions that could shield their patients and themselves from harm.

A turbulent workplace

Violent occurrences in healthcare reflect the chaos of a broader work environment. Workplace violence has become a serious occupational risk resulting in more than 1.7 million nonfatal assaults and 900 deaths each year in the United States.¹ The Department of Justice Survey’s most recent data identified the average annual rate for nonfatal violent crime for all occupations to be 12.6 per 1,000 workers.² As if these statistics aren’t bad enough, they are much worse for healthcare workers. The same DOJ survey reports an average rate of 16.2 for physicians, 21.9 for nurses, a staggering 68 for mental health professional workers, and 69 for mental health custodial workers. Put another way, 2 million people die each year as a result of violence, and nurses are three times more likely to experience violence than any other professional group.³

While the numbers suggest a much higher incidence of violence in the healthcare sector, the frequency may be even larger. Accurate statistics from healthcare settings are difficult to obtain because of underreporting. The International Council of Nurses estimated that as little as 20% of violent incidents are even reported, mirroring statistics that suggest that only 25% of all crime is ever reported.⁴ Extra paperwork, time spent explaining the incident, and fear of being blamed are a few of the reasons some have avoided alerting anyone of an incident. Combative, threatening behavior that deescalates and does not result in actual assault may not be reported at all, making the problem seem less significant than it is.

Nevertheless, a high prevalence of violence has been reported in healthcare settings. On the global scene, data from several organizations, including the World Health Organization (WHO) and the International Labor Office (ILO), report that almost 25% of workplace violence worldwide occurs in the healthcare sector, with more than half of all healthcare workers reporting having come under attack.⁵ Studies indicate that violence often takes place during times of high activity and interaction with patients, such as meal times and during visiting hours and patient transportation. Additionally, assaults may occur when service is denied, a patient is involuntarily admitted, or a healthcare worker attempts to set limits.⁶ Violence occurred most frequently in psychiatric and ED waiting rooms and geriatric units.

In a 2002 survey of ED, ICU, and general floor nurses in a 770-bed acute care medical center, 88% reported being verbally assaulted, and 74% reported being physically assaulted while at work in the past year by patients and family members or visitors. The assaults were perpetrated most often by patients with cognitive dysfunction (79.1%), patients with substance abuse (60.5%), and persons who were angry because of the patient’s condition (55.8%).⁷ The problem is not limited to patients and visitors, however. A survey of 551 nursing students reported that 34% had experienced other nurses being rude, verbally abusive, humiliating, or unjustly critical.⁸

Violence in hospitals is usually precipitated by patients or family members who feel out of control, frustrated, and vulnerable with their circumstances, which differs from the circumstances of workplace violence in general, which often is related to  robberies.⁹

Risk factors

Risk factors have been proposed for providers and patients. One small study found no significant association between assault and staff members’ age, length of employment, history of working with the mentally ill, gender, body size, organizational position, or amount of time spent in certain patient care activities, such as bathing and feeding. However, more than half of the staff who reported assault experiences also reported being victims of childhood or adult abuse.⁹

There are also several employee behaviors that have been identified as warning signs of potential violence. They are excessive grievances, deterioration in work performance, depression, expressed desire to harm coworkers, drug and/or alcohol dependence, defensiveness when criticized, fascination with weapons, and low tolerance for frustration.³

The National Institute of Health program CIVIL states that educated leaders can help decrease the risks of workplace violence involving staff. Leaders place the harmony of the work environment at risk when they allow inappropriate conduct by an employee, or act inconsistently or unpredictably, fail to resolve conflicts as they arise, or make decisions without employee input or participation, which can lead to employees feeling undervalued and frustrated.¹⁰

The likelihood of violent occurrences has also been linked to certain patient diagnoses, work situations, and geographical areas. However, all nurses need to anticipate trouble by accurately assessing risk factors and changes in patients’ behaviors. When patients exhibit acute, unexplained changes in behavior, look for an underlying physiological cause. Metabolic abnormalities, drug toxicity, and acute pulmonary or neurological impairment may trigger combative or agitated conduct. Neurological damage to the cerebral cortex, as well as abusing drugs, such as benzodiazepines, can have a paradoxical disinhibiting effect that can result in uncharacteristically violent behavior. Patients with complex partial or complex absence seizures may also become defensively combative during the seizure. They may not understand a command or recognize a familiar face and uncharacteristically push someone away, such as a loved one or police officer, who may only be trying to protect them from injury. Later, the patient may not remember the event and be quite embarrassed to hear about it. Without an electroencephalogram (EEG), some types of seizures are easily mistaken for behavior problems.

Understanding and treating any underlying cause may prevent future occurrences. Violence may still be difficult to predict when precipitated by situational factors. A patient’s visitor, such as a bereaved loved one or a member of an opposing street gang, may become unexpectedly aggressive in a healthcare facility. Nurses need to be vigilant for clues, which indicate that friction may lie ahead, for instance, clothing worn by visitors indicating gang allegiance or rivalry. Establish effective communication early on and avoid problems later.

Prevention

No single strategy is appropriate for all workplaces. Employers need to assess the environment’s risks, develop relevant policies and procedures that address prevention and intervention, and monitor the effectiveness of these standards. Employers also need to create an environment of open communication between staff and management that emphasizes the importance of reporting an incident and the actions that were taken.

Communicating clear standards, providing clear rationales underlying decisions, ensuring employees have adequate resources and training to do their jobs, and addressing misconduct promptly will establish a workplace where employees feel valued, even under stressful conditions from outside sources.¹⁰

Additionally, employers must recognize that a rested staff who has adequate time away from the work environment is more likely to have the energy and patience to manage difficult patients, family, and visitors.

Staff can often prevent the violent behavior of patients by systematically applying recommendations derived from sound research. A reduction in serious assault has been linked to training staff to take appropriate preventative measures. A staff training program for the prevention and management of violence directed at nurses and other healthcare workers in mental health services and EDs conducted in New Zealand concluded that staff education and training can reduce violence, but adds that evidence is far from conclusive http://nzhta.chmeds.ac.nz/publications/staff_training.pdf. Since so few studies and statistics are available, more research is needed in the area of prevention.

Take care of the environment. Manipulating physical surroundings can alter the frequency of violent acts. Pleasant, comfortable surroundings can make a difference. High-risk areas, such as waiting areas in EDs, should be spacious and well lit with adequate seating and access to refreshments, restrooms, and telephones. Security guards, surveillance cameras, panic buttons with silent alarms, metal detectors, and bulletproof glass may be necessary precautions. Objects that can be used as weapons, such as pictures and tables, should be affixed to the wall or floor. High-risk units and departments should be well lit with enclosed nurses’ stations, staff-only restrooms, and emergency exits. These areas should also be designed to ensure high visibility of staff, patient, and visitor activity.

Know your patients. Identify potentially violent patients and their triggers. Staff needs to get to know these patients well enough to recognize what triggers negative behaviors so that staff can communicate this to other coworkers and eliminate antecedents to violence. Typical triggers include crowding; noise; irritating patients and staff; boredom; unstructured activity; and tasks that a patient may not want to perform, such as physical therapy. Whenever possible, redirect patients’ attention to focus on things that do not agitate them, or take them to a quieter place. Staffing patterns should also be designed to prevent personnel from working alone and to minimize patient waiting times.

Handle patients with care. Approach patients with a calm, even-tempered attitude. Caregivers who appear angry, fearful, frustrated, or disinterested can create new problems as well as escalate existing ones. Nurses can convey an impression of interest and caring, while eliminating fear of the unknown, by frequently communicating in an honest and respectful manner with patients, their families, and other visitors.

Using an “I” message is a calming technique that can help to avoid an escalating confrontation between patients or family and staff. Phrases such as “I can hear the distress in your voice” or “I can see that you’re angry” help to let the other person know you understand how they feel while conveying what you perceive.¹²

Keep in mind that a quiet, gentle response with a smile can deescalate an agitated person. Control your own behavior. Don’t take insults personally, which could escalate your own anger. Speak in a soft, calm, but firm tone, allowing patients to express what bothers them. If you become quieter, while acknowledging their complaints, they may do the same. For example, “I know this must be difficult for you, how can I make it easier?” spoken in a soft voice may deescalate a potentially difficult situation, while a frustrated sounding “Just wait until I have a few minutes” may fuel anger. Patients need to believe that caregivers want what is best for them. If they are convinced that nurses are on their side and not working against them, they will be more amenable to their suggestions. Similar approaches when working with difficult staff members will be effective as well; the key is to control yourself and your own responses.⁸

Patients sometimes feel angry because they believe they have lost control over their situation. Keep patients and their families informed and involved in decisions regarding their care whenever possible. Respect patients’ personal space and right to privacy. Rigid, unfair, or overly strict rules and regulations, especially regarding visitors, can trigger anger and need to be avoided whenever possible. Maintaining and updating policies and procedures ensure consistency and take the burden off the staff member for individual decisions.

Adopting a preventative approach to workplace violence will enhance safety for employees. Early detection methods and developing procedures to threats, physical assaults, and surprise encounters assist in offering staff choices and chances of deescalating potentially violent situations. Having immediate interventions in place that personnel have read and become familiar with before a crisis occurs is one prevention strategy.¹³

So is reinforcing desired behaviors. Techniques to reduce violence can be applied in many inpatient settings, such as psychiatric and brain injury rehabilitation facilities, where staff have longer periods of time to get to know patients and establish therapeutic relationships. Reinforcement schedules concentrate on rewarding patients for the absence of physical confrontations, rather than focusing on disruptive behaviors.

The use of time outs has become another strategy for controlling potentially injurious episodes in neurological rehabilitative settings. Time outs involve placing patients in a quiet, undisturbed environment immediately after undesirable behavior. The place for a time out is established beforehand, and the patient is kept in the restricted area for a specified period of time. Elaborate discussion about the precipitating event is avoided to discourage reinforcement; the patient is told why the time out is being used and then taken straight to the new environment. Staff should not attempt this alone, and security officers may need to be contacted for assistance. Most healthcare settings do not have designated time out areas, and more research is needed to evaluate this strategy’s effectiveness in a variety of settings.

Take care of yourself. Staff must ultimately look after their own personal safety first. The staff, as a group, need to agree upon which patient behaviors will be unacceptable, to recognize them when they occur, and to obtain immediate assistance when necessary. While sensitivity to “gut feelings” and common sense are important adjuncts, the most effective strategy for dealing with violence is knowing what to do before it transpires.

Know the procedures set up for your working environment. Deal with issues, such as threats or harassment or obscene phone calls in the workplace, as they occur rather than writing them off as idle talk. The American Nurses Association released its Bill of Right for Registered Nurses in 2001, which states nurses have the right to a safe and nonthreatening environment in which to care for patients. Still, the awareness that a violent situation may be pending can go unnoticed if nurses are not educated on how to address the problem. Hesitating to act or ignoring signs may mean a missed opportunity to deescalate a situation. Report violent or threatening behavior. Adopt a zero tolerance for workplace violence.¹³

Never attempt to deal with a physically aggressive patient alone. If necessary, remove yourself from danger. Take three slow deep breaths and count to 10 before returning to the situation. If you are dealing with patients who are known to the staff, confer with coworkers for techniques that have been helpful in dealing with this person in the past. Someone may be able to give you a better perspective.

When confronted by an agitated patient, try to calm your own feelings first, and maintain a relaxed but concerned appearance. Smile at the person to show you care. Stay calm and controlled, but firm; the appearance of being fearful or condescending can be dangerous. Assume a nonthreatening, nondefensive posture with one side turned toward the patient to protect vital organs in the event that a punch or kick is thrown. Keep your arms and hands open, and avoid the appearance of making a fist. Avoid sudden changes or surprises. And never turn your back on an angry person, corner an individual, or allow a person to get between you and the door or an escape route.

Offer to walk around the unit with a restless person who is physically stable and ambulatory. This activity often dissipates energy, which otherwise might be channeled into aggressive behaviors, and it also keeps you visible to coworkers in the event you need their assistance. Avoid topics that fuel agitation, redirecting conversation to more pleasant subjects. However, never make promises that cannot be kept, such as, “If you sit quietly, you will not have to have any blood tests drawn today.”

Although talking yourself out of a dangerous situation is best, it’s not always possible. Nurses need to know how to defend themselves once a patient has made contact. Nurses can learn to perform releases from wrist grabs, chokeholds, hair pulls, and bites as well as other methods of self-defense to protect themselves and others. They can also become familiar with strategies to escort agitated patients to a holding room or to position aggressors for an intramuscular injection. However, these techniques are best acquired in a training situation that allows practice to maintain proficiency. The goal is to protect yourself without harming the attacker.

A joint research study conducted by the ICN, ICO, WHO, and Public Services International highlighted that both psychological and physical violence are reported by healthcare workers who report that violence in the streets is spilling over to the hospital. Research indicates that of healthcare workers who experienced workplace violence, two-thirds suffer from post-traumatic stress disorder, which can lead to higher levels of stress. That stress itself then becomes a risk factor for violence in the workplace.¹¹

Healthcare workers who have been physically abused may experience a variety of harmful effects — fear and anger, depression, sleeping difficulties, headaches, or a desire to leave an otherwise rewarding job or career. They may even have to deal with the blame that colleagues often assign to victims rather than perpetrators. Although many nurses who have been assaulted have not lost time from work, others have required from one week to more than a month to fully recover from the physiological, emotional, and social effects of the experience. Employee assistance programs and extensive counseling may be necessary to recover. Facilities can supplement aftercare measures with education that prepares workers to recognize and prevent violence before it occurs.

Worldwide workplace violence is a threat to healthcare workers and in some places threatens the delivery of care. Not only can issues of workplace violence diminish the quality of care to individual patients who may be perceived as a threat, but the availability of healthcare in general is threatened due to a decrease in qualified nurses and the higher healthcare costs when, nurses leave the profession to avoid the violence.¹¹

Although violence continues to plague healthcare settings, financial constraints may sometimes force reductions in security personnel. However, under the general duty clause of the Occupational Safety and Health Act, employers are obligated to provide safe workplaces.² And staff can provide information necessary to establish trends that may justify the retention or the addition of personnel. All violent occurrences, even those resulting in no injuries, should be reported to risk management departments through mechanisms such as incident reports.

Violence may be difficult to predict and prevent. Sometimes there is nothing healthcare providers can do to avoid its occurrence, which is why additional research is needed to identify more strategies that can effectively prevent and reduce violence in the work setting. Nurses can anticipate violence and use tested interventions to prevent it or at the least, reduce its ill effects by learning to recognize risk factors and warning signs.