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Journal of Nursing Administration:
doi: 10.1097/NNA.0b013e31823c16e1
Departments: Spotlight on Leadership

Strategies for Nurse Leaders to Address Aggressive and Violent Events

Hardin, Danielle ACNP, RN, CCRN

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Author Information

Author Affiliation: Student, Graduate School of Nursing, University of Maryland, Baltimore.

The author declares no conflict of interest.

Correspondence: Danielle Hardin, ACNP, CCRN, 8601 East 89th St, Kansas City, MO 64138 (

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According to a 2010 report from the Bureau of Labor Statistics, 48% of all nonfatal injuries from occupational assaults and violent acts occur in healthcare and social service settings. A recent increase in workplace violence has been noted causing a heightened awareness among nurses. Information is scarce both in the literature and in healthcare settings regarding the proper steps to take in the event that violence occurs and de-escalation techniques for aggressive behavior do not work. Nurse leaders should prioritize time to become involved in developing and implementing workplace violence policies including offering education for nurses to deal with aggressive behaviors and violent acts and, learn de-escalation techniques.

In September 2010, Baltimore city police and tactical team rushed to Johns Hopkins Medical Center to subdue a gunman on the eighth floor of the hospital. Patients, nurses, and other healthcare workers in the hospital and vicinity were immediately evacuated when the alert was sounded. The suspect became emotionally distraught after a surgeon updated him on the status of his mother’s grave condition.1 After hearing the news, the gunman allegedly fired a semiautomatic handgun and shot the doctor in the abdomen, seriously wounding him.1

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Recent violent occurrences in hospitals2 have pushed this issue to the forefront of the nursing community and other agencies taxed with ensuring staff and patient safety. As a result, most hospitals have a plan3 to address hostile and violent behavior in the workplace. However, few nurse leaders make it a priority to ensure those plans are properly developed, implemented, and executed.

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Workplace Violence

Forty-eight percent of all nonfatal injuries from occupational assaults and violent acts occurred in healthcare and social service settings3 in 2010. Large numbers of these incidents occurred in hospitals, nursing facilities, and personal care facilities.3 Of those who were injured, nurses, aides, orderlies, and attendants suffered the most nonfatal assaults resulting in injury.3 Nurses were victimized 72% more often compared with medical technicians and more than twice as often as other healthcare workers.3 These issues substantiated by these daunting statistics identify a significant problem and workplace hazard for staff nurses and a major dilemma for nurse leaders and facility administrators.

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Reporting Aggressive Behaviors

According to the National Health Service, violence against nurses is significantly underreported,4 which makes it challenging to quantify the events or develop effective strategies to reduce violent occurrences.3,4

Many nurses are either intimidated to report or concerned that action will not be taken to ensure that the violent or aggressive incident will not be tolerated.5 Others fear that other healthcare staff and leaders will view them as alarmists and inadequate to handle the stress and relationships supporting patient care.5 Lack of consistent definition for violent behavior is also a contributing factor in underreporting.5 The interpretation of what behaviors or actions constitute a violent act can be subjective or situational in nature. A confused elderly patient who attacks a nurse may not be identified as violent but instead confused. The purposeful intention to harm a person is 1 criterion that is subjectively applied in interpretation of these instances. Situations resulting in physical injuries sustained by a nurse in the course of patient care have a tendency to go underreported because of the lack of a standard definition of violence in the workplace.5

Nursing leaders should recognize underreporting of violent behaviors and high-risk situations as an issue. Staff should be encouraged to report violent encounters or behaviors in a confidential manner resulting in swift response by management. This can be supported through a hospital policy mandating documentation of certain types of nonconsensual, nonprofessional physical contact. Included in the hospital policy should be an expectation to delineate a clear and concise description of what constituted physical contact on the part of all persons involved including witnesses.

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Recognizing the Early Stages of Aggression

Many violent situations directed toward nurses could have been avoided by recognizing early signs of aggression. Findings from a study in a rural emergency department involving 20 RNs emphasized the importance of active listening, building rapport, presenting to the patient with a calm demeanor, and being supportive to de-escalate aggression.6 Despite professional knowledge regarding triggers for aggression, most nurses only address violent behaviors when the behavior has escalated.7 Table 1 describes common triggers and suggested actions by the nurse as responses to de-escalate the situation. Nurse leaders should educate nurses and other staff members about early behaviors as signals of aggressive behavior along with reinforcing appropriate responses and actions. Behaviors leading to aggression may be identified at any stage in the care process but should be assessed initially with a thorough admission history (Table 1). Other care providers in addition to nursing should be alert in identifying signs of aggression and must collaborate with nursing to ensure communication is consistent on all levels.

TABLE Common Trigger...
TABLE Common Trigger...
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Aggression Management Training Programs

Aggression management training has received mixed support in the literature. Sparse evidence exists supported by research or included in routine hospital orientation regarding the proper steps to take in the event that de-escalation of aggressive behavior does not work.2,4,7,8

Regardless of a lack of conclusive evidence, many organizations implement training programs as a strategy to address and decrease workplace violence.9 A study of 650 nurses in Australia demonstrated no differences in the number of violent exposures to the group who had been trained in aggressive management versus those who had no formal training.10

Nursing leaders should assist in the evaluation of aggression management training programs and help identify outcomes to validate competence and effectiveness. Implementing a program without substantiated actions can increase organizational cost while yielding little positive effect on the ability of the staff to manage aggression.3,4,5,11

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Management of the Late Stage of Aggression

An initial reaction to impending aggression may be a physical restraint or a reaction supporting physical restraint. The use of restraints should be minimized to promote patient safety.2 This is especially true with staff members that are not trained appropriately to implement and monitor restraints and restraint use. Inappropriately applied restraints may result in death, physical injury, emotional stress, and extra work for the staff to monitor accordingly.12,13 There is also a strong correlation between aggression violence and lost work productivity.4 The cost of work-related violent incidents is estimated at $283 million a year.4

Titrated sedation may be necessary with patients who are unable to be calmed down with de-escalation techniques including physical restraint but may be counted as chemical restraints.14 In nonemergency settings, aggressors have the right to refuse medications, including antipsychotics; however, in emergency situations, this right may not override safety for the patient and staff.14 Staff nurses and nurse leaders should investigate and be aware of organizational policy in this area. Breakaway techniques and physical restraint training effectiveness are controversial and must be carefully taught and monitored for appropriateness.9

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An abundance of literature exists regarding prevention strategies that nurses can use to de-escalate aggressive situations; however, there is a shortage of information regarding management steps to take in the event that de-escalation interventions do not work. Future studies should be conducted to identify optimal content to be included in staff education regarding the handling of aggressive behaviors. Because of the rising incidence of aggressive and violent behaviors in the healthcare setting, this information should be included in orientation for all care providers.

Nursing leaders play a significant role in the planning and implementation of aggression management techniques and the development of policies to support implementation. As part of education, scenarios need to be identified to prepare staff when de-escalation techniques do not work. Nursing leaders should collaborate with organization leaders, staff nurses, law enforcers, and risk managers to develop effective plans to prepare nurses for the unfortunate event of aggressive and/or violent behaviors directed towards the nurse. This collaboration should include coordinated and rapid response to support the care provider. In collaboration with human resources, risk management, and nursing leaders, systems should be put in place to facilitate the reporting and support and protect the nurse after reporting aggressive and violent incidents.

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Thanks to Jocelyn Farrar, DNP, ACNP, RN, instructor, University of Maryland School of Nursing, for all of her support and guidance in the development of this article.

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1. Friedman E. John Hopkins Hospital: gunman shoots doctor, then kills self and mother. ABC News/US. Available at Published September 16, 2010. Accessed August 13, 2011.

2. The Joint Commission. Sentinel Event Alert: preventing violence in the health care setting. Available at Published June 3, 2010. Accessed January 15, 2011.

3. US Department of Labor Occupational Safety and Health Administration. Guidelines for preventing workplace violence for health care & social service workers Available at Accessed November 12, 2010.

4. Comptroller and Auditor General. A safer place to work. Protecting NHS and hospital staff from violence and aggression. Available at Published March 27, 2003. Accessed January 24, 2011.

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11. Needlham I, Abderhalen C, Halfens RJ, Fischer JE, Dassen T. Nonsomatic effects of patient aggression on nurses: a systematic review. J Adv Nurs. 2005; 49(3): 283–296.

12. Stubbs B. The manual handling of aggressive patient: a review of the risk of injury to nurses. J Psychiatr Ment Health Nurs. 2009; 16(4): 395–400.

13. Hahn S, Muller M, Needham I, Dassen T, Kok G, Halfens R. Factors associated with patient and visitor violence experienced by nurses in a general hospital in Switzerland: a cross sectional survey. J Clin Nurs. 2010; 19(23): 3535–3546.

14. Kao L, Moore G. The violent patient: clinical management, use of physical and chemical restraints, and medico-legal concerns. Emerg Med Pract. 1999; 1 (6): 1–24.

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