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Staying safe

Responding to violence against healthcare staff

Strickler, Jeffery, DHA, RN, NEA-BC

doi: 10.1097/01.NURSE.0000545021.36908.28

Abstract: This article takes a look at the incidence of verbal or physical violence nurses face on a daily basis and examines the importance of preparedness in handling potentially violent situations in the workplace.

Nursing must overcome a culture of acceptance or tolerance of violence in the workplace. Follow these guidelines to defuse potentially violent situations and protect patients and staff alike.

Jeffery Strickler is a vice president at University of North Carolina Hospitals in Chapel Hill, N.C., and a member of the Nursing2018 editorial board.

The author has disclosed no financial relationships related to this article.



VIOLENCE AGAINST healthcare workers remains an epidemic in the US and throughout the world. Unfortunately, workplace violence is often underreported and/or tolerated. As such, it remains a persistent problem that has only recently garnered attention.1 Nursing must overcome a culture of acceptance regarding such behavior to address this national problem. This article examines the incidence and indicators of verbal or physical violence from patients, family members, or visitors and describes how healthcare professionals can prepare to handle potentially violent incidents in the workplace.

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Incidence of violence

According to the Bureau of Labor Statistics, healthcare workers are five times more likely to be victims of nonfatal assaults than any other profession.2 At this rate, the number of violent injuries in healthcare alone is nearly equal to that of every other industry combined.3

The CDC reports that injuries from workplace violence doubled between 2012 and 2014. Between 2011 and 2013, workplace assaults averaged 24,000 per year in healthcare professions.4

A 2009 survey specific to ED violence noted that more than 50% of participating nurses had experienced physical violence that year and 70% had experienced verbal abuse.5 Another study supported by the Emergency Nurses Association (ENA) showed that more than half of nurses feel unsafe and unprepared to handle a violent encounter.6 In a July 2015 statement on incivility, bullying, and workplace violence, the American Nurses Association stated that 43% of nurses have been verbally or physically threatened and 24% have actually been assaulted.7

These data show that violent encounters are ubiquitous in the healthcare industry, but the risk is higher in certain specialties. According to a 2013 survey, 80% of violent incidents in the healthcare setting took place in the ED, but professionals working in labor and delivery, pediatric, and psychiatric units are also at a higher risk.8 An Australian study demonstrated that staff at long-term-care facilities and government-funded hospitals are at risk as well.9 Regardless of the practice setting, nurses and managers need to be prepared to address the potential for workplace violence.

Data suggest that up to 70% of violent incidents are underreported.4 This may be part of the reason for the healthcare industry's inadequate response to this problem. Many employers had no protocol for responding to potentially violent situations, which is concerning because the ENA study showed that hospitals without workplace violence policies reported an incidence rate of 18% compared with only 8% at those with zero-tolerance policies.5

A lack of institutional preparedness leads to significant personal costs as well as lost time, lower productivity, and higher turnover.4 From a financial perspective, staff turnover alone costs healthcare organizations between $60,000 and $100,000 for RN replacement, while other factors such as increased length of stay, decreased patient satisfaction, increased lawsuits for malpractice and negligence, and declining facility reputation cost organizations over $500,000 annually.5,10

Besides the economic costs, violent or abusive behavior takes an emotional toll on staff. Nurses who encounter aggression in the workplace experience feelings of anger, frustration, and hopelessness and may experience hypervigilance, posttraumatic stress disorder, depression, and anxiety. These factors drive some nurses to leave the profession and contribute to burnout and high turnover rates.11 Encouraging staff to report violent incidents is key to understanding the full scope of the problem, performing an in-depth root cause analysis, and making the necessary organizational changes.

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Underlying factors

Many factors can precipitate violent situations in a healthcare setting, including long wait times in the ED, unrestricted public movement in the facility, decreased availability of mental health beds, increased patient acuity, more patients with law enforcement escorts, and an overall lack of adequate staffing.12 Certain situations or times of the day have also been associated with increased risk, such as periods of understaffing, medication administration times, and visiting hours.6

Social underpinnings of violence include poverty, homelessness, hopelessness, underemployment, unemployment, and lack of education. A shortage of economic opportunities and educational inequality may lead to fractured families and fragmented services, which compound the problem.12 Additionally, state reductions in mental health funding have sent more psychiatric patients to the ED, where the staff is often unprepared to deal with violent outbursts.3

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Practical strategies

As a guiding principle, nurses must acknowledge that violence can and does happen anywhere and recognize that healthy work environments promote safety and positive patient outcomes.13 Commitment and collaboration among healthcare professionals is necessary to create a lasting change.

Ultimately, everyone in an organization should be held accountable for upholding foundational behavior standards, regardless of his or her position or discipline. When members of the healthcare team identify an issue contributing to violence in the workplace, they have an obligation to address it. We must address all potential sources of violence (patients, family, coworkers) through a multidisciplinary approach that includes patients and their families.

Despite the challenges, nursing does not need to adopt a victim mentality. A few core strategies can empower nurses and employers to address this problem proactively. (See Proactive approaches.)

  • Each organization should perform a worksite analysis and create a comprehensive organizational violence prevention program. An essential element of this program is the establishment of a zero-tolerance policy to ensure ownership and accountability.5 The program should include a reporting and documentation system, policies that address how to handle violent occurrences, a postevent review, and key outcome metrics.6,14
  • Healthcare workers must receive proper training and education on the necessary foundational behaviors related to recognition and communication skills in verbal de-escalation. In potentially violent situations, nurses must recognize escalating behavior, respond in ways that diffuse anger, and know the steps to take if the situation cannot be diffused.14

For example, nurses should be aware that the best indicator of future violence is a history of violent actions. Be alert for body language signals such as anxiety, pacing, defensiveness, and other physical means of acting out, and use caution with those under the influence of alcohol or illicit drugs.6,15 (See DANGEROUS behavior screening guide for higher risk of violent behavior and STAMP mnemonic for violent behavior.)

  • Healthcare organizations should have an identified response team trained in verbal de-escalation and noncoercive medication administration.11

In potentially violent interactions, always maintain a safe distance of at least 3 ft and sustain the proper positioning with a supportive stance recommended by the Crisis Prevention Institute that communicates respect and honors personal space, but still allows for defensive moves or escape.15,16 Because any patient or visitor has the potential for violent behavior, staff should be familiar with precautions they can take to protect themselves, such as not wearing clothing or jewelry that present grabbing and choking hazards and, where possible, rearranging the unit environment according to International Association for Healthcare Security and Safety's Security Design Guidelines for Healthcare Facilities.17 These include:

  • – restricted access during nonvisiting hours
  • – screened public areas
  • – areas for designated staff with appropriate clearance
  • – staff-only entry and circulation points
  • – physical separations between general public visiting areas
  • – electronic security systems and video surveillance.

Educating the staff about de-escalation and active listing techniques should include practice in simulated scenarios. Simply instructing the person to stop being violent can sometimes be effective.18 These classes should focus on defensive skills related to de-escalation, protection, and escape rather than offensive techniques taught in self-defense courses. Basic self-defense courses aren't adequate in a clinical setting.

  • Because the presence of others is a deterrent to violent behavior, working in isolation is another risk factor.6 Units should have standardized team huddles to increase individual awareness of potentially violent patients.11 As part of the organization response plan, healthcare professionals should have the ability to flag dangerous behaviors on electronic health records to provide coworkers with the proper situational awareness.12 Other individual protective strategies include making sure that members of the staff always carry a telephone or other communication device.
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Advocate for safety

Nurses must advocate within hospitals and professional groups for policies and procedures that better equip staff to prevent or handle violent incidents. As a society, we all must work to address circumstances, such as poverty, homelessness, hopelessness, and a lack of educational and employment opportunities, that contribute to the risk of violence in our hospitals.12

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Proactive approaches5,6,11,12,14,15,17

  • Adopt a zero-tolerance policy to address workplace violence systemically.
  • Create metrics tools and communicate awareness about violent behavior through electronic health records.
  • Establish official standards of practice for these situations.
  • Identify an incident response team with training in defusion and de-escalation.
  • Incorporate general staff training on precautionary techniques.
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DANGEROUS behavior screening guide for higher risk of violent behavior14,19

D-deviant thinking


N-negative home environment

G-gang affiliation

E-exposure to or history of violence

R-rebellion and poor socialization skills

O-obsession with violence


S-substance abuse.

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STAMP mnemonic for violent behavior20,21


T-tone of voice




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de-escalation; incivility; physical violence; verbal violence; workplace violence; zero-tolerance policy

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