Recognition and Prevention of Hospital Violence : Dimensions of Critical Care Nursing

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Recognition and Prevention of Hospital Violence

Keely, Beth R. PhD, MSN, RN

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Dimensions of Critical Care Nursing 21(6):p 236-241, November 2002.
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Crime in the United States is increasing at an alarming rate. Women, children, and the elderly are most often the victims of violence. In the workplace, however, any employee can be the victim. Any patient or visitor within the hospital setting can become violent when under extreme mental and physical stress. Physical confrontations and verbal abuse involving families and staff in the emergency department (ED) are well documented, and violence against doctors and nurses in critical care settings is a matter of particular concern. 1

According to the International Council of Nurses, two million people die each year as the result of violence. Nurses are three times more likely to experience violence than any other professional group. Although males have experienced abuse and violence in the workplace, most violent acts are committed against female nurses, both in the workplace and at home.

Violence is the second leading cause of death in the workplace. 2 The literature is filled with studies that have documented injuries and deaths related to the rise of violence. Yet, most cases of violence in the healthcare setting go unreported. Critical care nurses must be prepared to deal with these tragedies. Although the data on violence in hospitals is limited, current statistics have demonstrated that, for both male and female nurses, significantly increased numbers of lost-time claims are the direct result of violence. 3 Furthermore, violence can lead to the overall decrease in job performance and lead to legal implications for the institution.


There are two forms of violence that commonly occur in hospital settings. 4 The first form is an act of physical violence that is intentional and directed at causing injury to another person. It can also include purposeful damage to hospital property. The second form of violence is an act of aggression, including verbal or physical actions directed toward creating fear. Apprehension in employees can be created through inappropriate and rude behavior specifically intended to disrupt routine organizational operation.

Nurses often think they are immune from violent situations. Given the crisis-oriented nature of critical care and emergency nursing, however, nurses who work in these settings are at a higher risk for encountering violence. 5 A recent study showed that 68% of all nurses surveyed reported both an increase in the incidence and severity of violence. 1 This included verbal abuse, witnessing physical threats or assaults, and personal physical assault.

Many situations can lead to violence in the workplace (see Figure 1). Anyone who is confronted with stress can become violent. These individuals include co-workers, visitors, volunteers, and patients. Stressful life events such as divorce, death, and domestic abuse evoke a range of reactions, often leaving individuals overwhelmed, distressed, and out of control. 6 Too often in today’s environment, violent acts may be seen as normal and appropriate in some situations. 7 In some countries, violence against women is tolerated. Violence may be seen as a legitimate means to resolve conflict.

Predictors of violence.

People bring who they are into a healthcare setting. We often know little at the beginning about their personality, behavior, and tolerance for frustration. This demands increased communication among healthcare providers to help assess and resolve stressful situations before they become violent. Aggression can be fueled by inaccurate perceptions, intolerance, misunderstandings, and lack of control. Early stress behaviors such as use of profanity, rapid speech, or increased speaking volume, boasting of prior violence, pacing, or frequent alteration of body position can be clues that the individual is very agitated.

Situational factors can also contribute to increased risk of violence in critical care areas. Violence in healthcare settings is frequently precipitated by drug and/or alcohol use, homelessness, domestic disputes, frustration from crowding and lengthy waits, as well as worries about medical expenses. 7 Societal changes in the mental health system, increased gang activity, and changes in family and community support systems also contribute to workplace violence in hospitals. Understanding these risks can help nurses recognize situations that can lead to violence, so they can take appropriate action before a violence act occurs.

The volume of patients and family members within many critical care areas, the acuity of illness, and the perceived lack of efficient healthcare delivery can create environmental stress. The media and other factors have contributed to an expectation of service delivery in the hospital setting that may or may not be realistic. Several recent publications have cited nine primary expectations of health care consumers: (1) provision of information, including keeping the family informed; (2) accessibility to a wide variety of services; (3) good discharge planning; (4) a caring and compassionate approach; (5) provision of adequate time to be heard; (6) quality and timely care; (7) involvement in decision making; (8) respect for privacy; and (9) adequate pain management. In a very volatile environment where demands from patients, families, physicians, and coworkers can be conflicting, it can be difficult to meet expectations. When patients’ needs or perceived wants are not met, verbal abuse and violent outbursts can occur. These actions are directed toward those individuals in the immediate area. 8

Aggression and violence is a culmination of a process. Episodes of violence progress through stages. The violence begins with a change in activity, such as pacing or restlessness, and then proceeds to verbal outbursts. If no intervention is done or if the attempt fails, the individual may progress to aggressive behavior such as throwing things or pushing furniture. When this type of behavior is exhibited, the individual may be losing control.


One of the most accurate predictors of violence is past behavior. This is particularly true if the perpetrator has been involved in violent activity within the previous few hours. 9 Nurses must be alert for potential clues to help avoid violent situations.

Societal changes, such as the decline in community and family support, have contributed to increased violence. The prevalence of handguns and easy access to weapons poses even more risk. Patients who come into the hospital after a prior confrontation and who are armed can pose a significant threat to employees, other patients, and visitors.

Recognize Possible Gang Members

Gangs are not strictly an urban, inner-city problem. Healthcare workers often minimize the fact that gangs are present in their community. Gang members have a standardized style and behavior and may adhere to a strict code of rules. Younger, nontraditional gangs have fewer rules and fewer adherences to a code of conduct. Members of these nontraditional gangs tend to act quickly and irrationally and are more likely to cause injury to nursing personnel. 10

Common identifiers can help nurses recognize possible gang members. Most gang members are male and travel in the company of their peer group. They frequently keep their heads down, focusing on the floor. They are aware of individuals in the area. When gang members wear sunglasses, baseball caps, jackets or vests, or scarves over their faces, they may be in combat gear. This situation increases the potential of violence.

Matching clothing, such as shirts, caps, and bandanas, are common group symbols identifying which members belong to which gang. Each gang has unique symbols, hand signs, colors, dress, and jewelry to promote solidarity and indicate affiliation with the gang. 10

Assess for Mental Illness

Poor impulse control due to neuropsychiatric deficits is one of the top five factors that can precipitate violent behavior in critical care settings. 11 Several studies have reported that patients with mental disorders and comorbid substance abuse had the highest probability of violent behavior. Both men and women hospitalized at least once with major mental disorder are more likely to have a history of violent crime. 12

Whenever behavior leads to a suspicion of mental illness, the critical care or ED nurse should obtain a history of any violent behavior. This information is often best obtained from the family or friends. In addition, an accurate medication history can help give insight into possible mental abnormalities. Knowledge of the patient’s current medications is important to identify any adverse reactions that could lead to violence.

Assess for Physical Abuse

When a victim of abuse is admitted to the ED or critical care unit, it is essential to determine the identity of the perpetrator. One group at increased risk for abuse is the older person who lives with others. Stress, financial independence, and isolation of the caregiver can lead to mistreatment. 13 A family history of violence is also a major variable, and many abused older persons come from mutually abusive relationships, similar to child abuse. If the nurse suspects that an older person has been abused and begins asking questions, the abuser could turn their aggression towards the nurse. Caution is needed.

Domestic violence is another cause for trauma leading to hospital admission. Domestic violence is a health threat that spans all socioeconomic classes, professions, cultures, religions, ages, and gender. A study showed as many as 35% of women visiting emergency departments for trauma care were injured in domestic disputes. 14 Because many violent acts are accompanied by heavy alcohol intake, the risk to healthcare professionals is increased when the perpetrator accompanies the victim seeking care.

Employees should also be assessed for physical abuse. An employee who wears sunglasses when it is not sunny or shows up with bruises that are not easily explained may be exhibiting clues to difficulty outside the workplace. Sudden or frequent address changes or possession of self-defense items also could be clues. Many violent acts are committed by a former husband, wife, boyfriend, or girlfriend. However, men are more likely to commit acts of violence. The situation can become more volatile if the victim is leaving the abuser.


Numerous studies of organizational violence show that violence can occur from employees, acquaintances of employees, contractors, vendors, patients, and family members. One of the most common perpetrators of workplace violence is the disgruntled employee. Figure 2 lists the causes of healthcare violence.

Causes of workplace violence.

Concerns over job security and professional identity have been stressful for many healthcare workers. The more an employee’s identity is related to their job, the more likely they are not connected to family or other support. If brought on by economic conditions, violent acts are more likely to occur when the employee feels that he or she has little or no control.

Fairbourne identifies 13 behaviors that can be warning signs of potential violence with hospital staff members. 15 They are (1) excessive grievances; (2) deterioration in work performance; (3) history of suicide attempts or aggression; (4) depression; (5) expressed desire to harm coworkers or managers; (6) blaming coworkers or managers for their problems; (7) dependence on drugs and/or alcohol; (8) obsession with a particular person; (9) dependent on work for self-esteem and identity; (10) low tolerance for frustration; (11) defensive when criticized; (12) history of interpersonal conflict; and (13) fascination with weapons.

Vendors can also be a potential threat. Most delivery people and contractors have timetables and schedules. They may not have extra time to spend in a single institution. If the vendor appears to ask a lot of questions, particularly if they are not relevant to the service, be alert. Furthermore, if the vendor targets a particular employee for attention, this could be a sign of potential problems.


Workplace violence will continue. However, when critical care and emergency nurses learn prevention strategies, they can detect potential violent situations and intervene in a therapeutic manner.

Provide Education for All Employees

The major prevention strategy for any organization is the education of all employees. Every employee should be able to recognize the signs of workplace violence and know the proper steps to report potential problems. This demands that hospitals have clear policies and procedures for employees to follow. Hospital administrators must make a deliberate commitment to the safety and security of all employees. Annual training must be mandatory. Figure 3 presents suggested educational content.

Suggested Educational Content.

Workplace violence should also be discussed in nursing schools. Inexperienced student nurses can be targets for potential assault. 7 They should be taught to recognize situations that could put them at risk. Nurses are often the ones who have the greatest opportunity to identify and assess violence in victims. If nurses are to function effectively in preventing violence through assessment and interventional strategies, the educational system must provide the opportunity for students to learn these skills.

Improve Employee Identification

The healthcare industry is unique in that it operates 24 hours a day, 365 days a year. Healthcare institutions typically have multiple points of entry with a free flow of traffic. Most healthcare administrators are implementing photo identification and departmental badges to better identify employees and increase security. Other facilities have added electronic access control to certain areas. This is accomplished by adding a barcode or magnetic strip to the employee’s identification card or name badge.

Implement Strict Policies to Protect Personal Information

Training all healthcare employees to ensure that both client and employee personal information is kept confidential can help reduce the incidence of violence. Access to personal information, including work schedules and telephone numbers, opens the possibility of this information being used in a threatening manner. Security personnel must be informed if threats are made. Counseling may be conducted to help identify concerns and possible solutions.

Check Previous Employment

Although most companies will only verify the dates of a person’s employment, some states allow previous employers to reveal whether or not a person was terminated for cause. Another option is to try to speak directly with the potential employee’s previous supervisor.

Develop a Drug Screening Program

Most authorities agree that if a drug-screening program is implemented, all potential employees should be tested. Tests should not be done selectively, nor should they be done on current employees unless the person’s job performance is affected and documentation can be provided to support the claim. Because drug screening involves major political and legal issues, it is always important to know the current state laws. Some states do not allow pre-employment testing.

Develop a Family Advocate Program

Critical care units can become hostile very quickly. Family advocates work with hospital security and can intervene in crisis situations when the hospital staff must focus on the care of the patient. The advocates can help provide information and direction to distraught family members who may otherwise feel abandoned. Having an individual available to provide a liaison between hospital personnel and families can significantly reduce the feeling of alienation as well as increase the security in the critical care area. Decreasing the level of anxiety can reduce the potential for violence.

Work With the Security Department to Assess Access

There are many tools that can be used to help increase security. Cameras, controlled access via card readers, locked storage and medication areas, magnetic door locks, and bulletproof glass are examples of things that can improve security for the employees. But remember, clients may not welcome the increased security.

Many urban hospitals have introduced security systems that include manned security checkpoints and metal detectors. Most studies have demonstrated that use of these devices significantly increases the seizure of weapons that would otherwise enter the critical care area. Although confiscation of weapons may not dramatically reduce the number of assaults, it can reduce the severity of those assaults and increase the safety of patients, families, and staff.

Because most hospitals no longer restrict visiting hours and do not require visitors to check in, facilities are more open to potential danger. Moreover, competition between facilities has increased due to managed care, so hospitals are trying to be more open and inviting to the public. This can create a real conflict with security issues. Working in collaboration with security personnel, nurses can be influential in implementing low-key security programs that will increase safety while keeping the environment patient and family friendly.

Hospital security departments can also play a role in supporting and protecting victims of domestic violence. Involvement of security personnel can be a major step in helping develop comprehensive resources to support hospital personnel in their efforts to prevent and manage aggression.

Random acts of violence cannot be entirely prevented. However, most acts of violence within the workplace are not random, and follow a pattern of behavior that had led to a violent act. Because it is often the employee or patient who feels little or no control over the situation, the critical care nurse can often recognize these behaviors and implement a plan to protect all individuals involved and minimize the potential for violence.


Workplace violence in healthcare settings is increasing. Through education, critical care nurses can learn to identify the risks and help minimize the negative consequences through early intervention. The critical care area is particularly susceptible to acts of violence due to the natural stresses in this environment. By accepting the need to create frameworks for effective assessment and response plans, critical care nurses can begin to take the first steps in deterring workplace violence.


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© 2002 Lippincott Williams & Wilkins, Inc.