The anatomy of violence is being dissected by both hands-on safety officers and academic scholars, revealing that both common sense and research can point a path to prevention.

Violence at some level is intrinsically unpredictable, but there are practical methods and techniques workers can be trained in to prevent events — and minimize the effect of events that do occur.

The phrase that captures a lot of this approach is “situational awareness,” says Cory Worden, MS, CSHM, CSP, CHSP, ARM, REM, CESCO, manager of system safety at Memorial Hermann Health System in Houston.

“With workplace violence in any industry, whether it’s healthcare, firefighters, or EMTs, you have to have a zero-tolerance policy,” he says. “That goes without saying. We are not going to tolerate people being injured, but then the question becomes ‘How do you prevent these injuries?’”

One obvious answer is constant vigilance to prevent workplace violence, but that may do little good if resources are not provided and the worker response is not engrained by training and understanding of the policies and procedures.

“You want to first make sure you are providing people with the proper resources so they know the procedures, the codes, where the panic buttons are,” Worden says. “And you want to make sure all the equipment is operational. The last thing you want to find out is that the panic button does not work when you hit it.”

Once those protections are in place, an important adjunct is honing an awareness of potential factors that could contribute to violence or make healthcare workers more vulnerable if it occurs.

“With our nurses — especially in the emergency department — one of the things we always discuss with them is, for example, if you are pushing a work cart in an examination room you don’t want to place it between the patient and the door,” Worden says. “If you have a patient that suddenly acts out, you don’t want to find yourself barricaded in the room.”

The same logic applies in building workstations into existing rooms, as access to an exit should be considered in the layout, he says.

“Also, when you go into work with a tray of needles and sharps, make sure you are not placing them right in front of the patient where they might be tempted to grab one,” he says. “Everything has to be thought through. This is called situational awareness.”

Healthcare workers who have a background in police work, military, or EMT personnel likely have picked up this skill, but it must be emphasized in training for most people.

“Many people have not been in these types of situations, and we don’t want them to find out what happens in the real world with a violent, combative patient,” Worden says. “We want to make sure people are conditioned and ready to execute these procedures.”

Arguably the most important part of situational awareness is being able to recognize when it is a “go time,” he adds.

“For example, a person is raising their voice and using a lot of profanity or they are here to see their dying mother and they are starting to get really upset,” Worden says. “We want to make sure we’re prepared to start the response as early in the game as possible. The first goal is to prevent it, and if we can’t prevent we need to make sure our response is as good as possible.”

Healthcare workers can be taught — through a combination of didactic lecture and role-playing — how to recognize potentially violent patients and de-escalate situations and interactions, the author of a recently published study1 reports.

“Many violence prevention and de-escalation programs will blend some lectures and content on the risk factors, triggers, and causes of violence,” says Margo Halm, RN, PhD, NEA-BC, director of nursing research and professional practice at Salem Hospital in Portland, OR. “Then, they will break out and have some case scenarios. It’s best if they are built on likely scenarios that a nurse might see in their unit. They have an opportunity to role-play, so one person would act as the aggressor — a patient, a family member, or another employee; you could have a variety of scenarios. Nurses then practice how they would defuse the situation.”

In a review of research papers published in the last 10 years on violence prevention in healthcare, Halm found some similarities and recurring themes. For example, verbal abuse typically is reported three times more often that physical assaults, and ED nurses are at higher risk than nurses in other departments.

Risk factors in violent patients include a history of aggression, psychiatric disorders, substance abuse, feeling powerless, and the perception that violence is tolerated.

In terms of content, aggression management education may include an “interpersonal style using effective communication, including less reliance on avoidant, hostile, or critical behaviors that may provoke escalation,” Halm notes in the paper.

According to Halm, the behavioral skills needed to achieve some of this desired tone include de-escalation techniques that include the following outwardly expressed traits and emotions by healthcare workers:

• open, honest, genuine;

• self-aware, confident but not arrogant;

• non-judgmental;

• non-threatening, non-authoritarian manner;

• calm appearance, despite inner anxiety, to convey control of situation;

• awareness of body language like eye contact, facial cues, posture, proximity, and touch to ensure it expresses concern;

• actively listen to understand what the aggressor is saying;

• use soft tone of voice that is calm and gentle;

• use short sentences and simple vocabulary; provide aggressor time to respond before sharing more information;

• repeat messages when making requests, setting limits, offering choices, or proposing alternatives.

“Many healthcare workers may already have some of these skills and behaviors, but aggression management education really brings them to the forefront,” Halm says. “It really helps people by heightening their awareness of these characteristics.”

Those not naturally inclined to these de-escalation strategies can learn to adopt some of them to dial down volatile situations.

“Some people may need to work on being non-threatening, non-authoritarian,” she says. “Maybe that is not somebody’s normal persona in the way that they work. It’s a way to really think about the way you interact with patients. There could be some cues that you are sending out; for example, if you get defensive in response to needs the patient is bringing forward, that can feed into the cycle. These all are key attributes that nurses can be taught.”


1. Halm M. Aggression Management Education for Acute Care Nurses: What’s the Evidence? American Association of Critical-Care Nurses 2017: