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Safety Alert

Protecting yourself and others from violence

Davis, Charlotte BSN, RN, CCRN; Landon, Denise BSN, RN, CMSC; Brothers, Kandie MSN, RN, CNL

doi: 10.1097/01.NURSE.0000454955.88149.e4

Review the red flags outlined here, then brush up on best practices for defusing a dangerous situation.

Charlotte Davis is a CCU/CVICU staff nurse at Heritage Medical Center in Shelbyville, Tenn., and Alvin C. York VA Medical Center in Murfreesboro, Tenn. Denise Landon is an MICU staff nurse at Olin Teague Veterans Medical Center in Temple, Tex. Kandie Brothers is nursing clinical faculty/prevention and management of disruptive behavior coordinator at the Department of Veterans Affairs Medical Center in Nashville, Tenn.

The authors have disclosed that they have no financial relationships related to this article.



IN 2012, 27,380 U.S. healthcare workers were injured in nonfatal workplace injuries. According to the Bureau of Labor Statistics, healthcare facilities with more than 1,000 employees have an average of 5.5 nonfatal injuries annually.1 Between 2009 and 2011, eight RNs were fatally injured at work.2 (See Startling statistics.)

Many nurses are routinely exposed to violent behavior such as shouting, cursing, spitting, biting, pulling, pushing, scratching, threats to themselves and their loved ones, and actual physical assaults with hands, fists, weapons, or objects within the assailant's reach.3 All too often, nurses fail to report these episodes of violence because they erroneously consider it to be “part of the job.” Consequently, managers and administrators may be unaware of the extent of risk to nurses and fail to initiate corrective action.

For their personal safety and the protection of patients, visitors, and other staff, nurses must recognize signs of behavior escalating toward violence. This article discusses how to recognize signs of escalating behavior and what to do to defuse the situation effectively and safely.

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Violence: Getting down to basics

Violence is the intentional act of aggression, verbal abuse, threatening behavior, and/or physical assault. The intended goal is to threaten, control, coerce, intimidate, humiliate, silence, ostracize, demean, or otherwise emotionally or physically injure the victim.3,4 The focus of this article is threatened or actual physical violence within healthcare facilities.

Although anyone can be a victim of violence, people in certain healthcare positions, such as clinical nurses and unlicensed assistive personnel, may be routinely exposed to acts of violence. Nursing personnel who work in the ED, ICU, and psychiatric or long-term care units are most at risk for experiencing routine episodes of violence on the job from patients, family members, or visitors.3 Patient substance abuse and cognitive impairment can increase the risk of violence for staff.

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Identifying levels of stress

The Veterans Administration Health Care 2014 Prevention and Management of Disruptive Behavior (PMDB) program teaches that potentially violent behavior escalates through four levels of stress: normal, moderate, severe, and panic level.3,4 In some circumstances, a person can transition rapidly from a normal stress level to panic level. This potential requires nurses to refine their escalation assessment skills and to develop a plan with the employer and coworkers to safely manage the perpetrator's escalating behavior and ensure everyone's safety. See Four levels of stress: Assessment and intervention for warning signs and interventions appropriate for each stress level.

When confronted with signs of moderate escalation, avoid arguing with the agitated patient or visitor. Raising your voice to match the tone and volume of the other person's voice can trigger escalation to a higher stress level and increase the likelihood of physical violence. If the person seems to perceive you as a threat, remove yourself from the situation. If you can safely do so, introduce a neutral party to speak with the person and try to deescalate the behavior.

If a patient's family or visitor becomes disruptive in the patient's room, consider asking the person to step outside the room or press the call light to signal the need for assistance, depending on the situation. Don't remain in the room with the hostile individual because of the risk of physical injury.

Follow facility safety policies and procedures if the person's behavior continues to escalate. For example, most facility policies include a provision for notifying security or a house supervisor or management team member immediately; that designated person may then call law enforcement if needed. Nurses should program their healthcare facility's security office and 911 into their cell phone speed dial.

Consider developing a code word, such as “purple,” that signifies a need for assistance because of an escalating situation. All staff members should be educated on what the code word is and what actions to take in response.

If you're isolated and in imminent danger, find alternative ways to draw attention to the location, such as activating a panic button, yelling for assistance, and pulling a fire alarm or accessing an automated external defibrillator (AED). When accessed, some AEDs activate an alarm to locate the emergency. Check to see if this is an option where you work.

Report and document all incidents of potential or actual violence according to facility policy. This information will help managers and administrators take action to maintain the culture of safety that staff, patients, and staff are entitled to.

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Minimizing risks: Watch for weapons

Some healthcare facilities allow staff to review and itemize a patient's personal possessions upon admission. If permitted to itemize possessions by facility policy, the nurse can look for obvious and potential weapons at this time. Guns, stun guns, knives, and other items that could be used to penetrate the skin should be confiscated and locked in a secure location until the patient's discharge per your facility's policy.

Be aware that some innocent-looking items can be used as weapons; for example:

  • a cane can be modified to make a sword with a potentially long, lethal blade.
  • both flashlights and cell phones can be modified to make a gun or stun gun.5
Table F

Table F

Nurses should be suspicious if an object seems heavier than it should be or shows signs of alteration, such as screws or reinforcement at joints, and contact the security team to have the item inspected.

A nurse confronted with an escalating person who's armed with any type of weapon should immediately evacuate the area and retreat to a safe place, then notify hospital security and/or call 911. The nurse should never try to intervene with someone armed with a weapon.

Besides obvious weapons, many items found within a healthcare facility can be used as a weapon because of convenience and proximity. These include telephone cords, hole-punch devices, examination lamps, plants, electrical devices, pens, tables, and chairs. When the nurse observes escalating behavior, he or she should begin to calmly remove these items out of sight or away from the person's reach, if this can be done safely.

Many items nurses wear or carry are also potential weapons; for example, a stethoscope, pen, eyeglasses, dangling jewelry, and lanyards. Even lanyards with breakaway clasps can be used to strangle a nurse if the aggressor grasps the breakaway clasp.

During periods of panic-level escalation, nurses with long hair should put their hair up in a ponytail, twist their hair into a bun, or tuck long hair underneath the back of their shirt. An agitated person can grasp loose long hair and use it to control the nurse's head, resulting in a whip-lash injury, blunt force trauma to the head, or even strangulation.

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Control the environment

By managing the environment, nurses can help defuse potentially dangerous behavior or minimize the consequences. Following these guidelines can help prevent escalation of aggressive behavior and minimize the risk of injury.

  • Pay attention to early signs of escalation and intervene at the lowest level of stress. (See Making “GAINS” against escalating behavior.)
  • Remove unnecessary staff, patients, and visitors to minimize the “audience.” Some aggressors will calm down without an audience.
  • Remove any excess furniture, plants, and decorative items that could be used as a weapon or thrown.
  • Decrease the noise level and other environmental stimuli in patient-care areas. Increased environmental stimuli and high noise levels can trigger anxiety attacks and posttraumatic stress disorder exacerbations.3,4
  • Reduce overcrowding in waiting areas if possible. Offer patients, staff, and visitors the option to take a break in a quiet area, such as a chapel, outside sitting area, or a less crowded waiting room.
  • Don't multitask when you're assisting patients, staff, and visitors who are exhibiting signs of moderate or severe stress. Give them your full attention. Multitasking may give them the impression that you're not fully invested in solving their problem.
  • Pay attention to gut feelings! Immediately leave any situation if you feel uncomfortable or unsafe.

Nurses should take advantage of any training that their employers offer, such as Crisis Prevention and Intervention training, the Veterans Administration's PMDB program, and self-defense classes that teach hands-on techniques to minimize the risk of injury to self or others during potentially violent situations.

Help reduce the risk of violence by assisting people who appear lost, answering questions, and conveying your commitment to helping to resolve their problems. Avoid making comments such as “that's not my job,” which can escalate an agitated person's stress level. Like patient and staff safety, customer service is everyone's business.

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Startling statistics

Results of the Emergency Nurses Association's 2011 Emergency Department Violence Surveillance Study revealed that almost 70% of respondents had been physically threatened, 52% had been physically assaulted, and 40% had been involved in a violent situation at their job in which a weapon was utilized. Of those routinely exposed to physical violence, about 17% experienced the behavior more than four times a week. Nurses failed to report physical violence in 66% of these cases because they believed that violence was just “part of the job.”6

Failure to file a timely formal incident report may allow the perpetrator to victimize others and place the nurse at risk for uncompensated medical treatment for any injuries suffered during the violent incident. Underreporting also can prevent the facility's administrative and safety and quality management teams from recognizing and addressing the presence and severity of staff members' routine exposure to violence. Employers may be cited by the Occupational Safety and Health Administration if they fail to “prevent or abate a recognized violence hazard in the workplace.”7

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Making “GAINS” against escalating behavior3

Both verbal and nonverbal indicators signal escalating, potentially violent behavior, as suggested by the GAINS mnemonic:

Gestures of anger, such as shaking a fist, prolonged staring, slamming a door, throwing objects

Acting suspicious, anxious, fearful, or hostile toward staff

Incongruent behavior that doesn't match the words; for example, a person stating that he or she is “fine” while pacing and becoming increasingly agitated

Noticeable signs and symptoms of stress, such as diaphoresis, flared nares, jugular vein distension, and elevated heart rate and BP

Systematically pacing, tapping feet, shaking knees, sighing, running fingers through the hair repeatedly, rubbing the forehead.

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1. United States Department of Labor. Bureau of Labor Statistics. Economic News Release. 2012.
2. American Nurses Association. Workplace Violence. 2014.
3. Bullard D. Prevention and management of disruptive behavior. Veterans Administration Healthcare System {Conference}. Nashville, Tennessee. 2014.
4. Williams J. Improvised weapons and other safety concerns. Los Angeles County Sherriff's Department. 2013.
6. Emergency Nurses Association. Emergency Department Violence Surveillance Survey. 2011.
7. Occupational Safety and Health Administration. OSHA fact sheet: workplace violence.
© 2015 by Wolters Kluwer Health | Lippincott Williams & Wilkins.