Between 2010-2020, the rate of non-fatal workplace violence against healthcare workers has more than doubled, and nearly 400 healthcare professionals were killed in their workplaces. Hospital workers are 6 times more likely to encounter workplace violence resulting in injury than other professions. Workplace violence is most common in emergency rooms and critical care units, but also occurs in geriatric and psychiatric units with a concerning frequency.  The violence can include physical aggression, verbal abuse, sexual harassment, and racial discrimination and can be perpetrated by patients, family members, or even colleagues.  In one survey, 90% of the respondents reported that the incidence of violence could have been prevented.  

If we are one of the most respected professions in existence, then why are nurses the target of violence?  We’re going to talk about that and more importantly, what you can control in your everyday routines to help prevent becoming a statistic.

First, why is this violence happening?  We are seeing a societal shifts to instant gratification and concierge service.  For instance, I was leading a cardiac arrest when a visitor for a stable patient walked into the room to ask when we would be around to take lunch orders because she would like a tray.  Like most nurses, my mouth probably had something nicer to say than may face did.  But this illustrates the lack of situational awareness that can lead to dissatisfaction and the impression that because one patient is receiving immediate care that others are not receiving adequate care. Expectations are not aligned, which creates a gap that is difficult to fill in the moment, particularly in short staffing situations.  This can lead to emotional interactions from both sides.

Other factors that can lead to nurses or other staff being the target of violence include:

• Patient or family behavior can be unpredictable when under emotional stress, which can lead to violence
• Healthcare settings (including home care) can be high stress work environments
• Nurses provide the most direct patient care, making them more vulnerable
• Lack of effective communication
• Short staffing
• Lack of facility controls and support staff (such as security)
• Lack of training in de-escalation

So, how can nurses protect themselves in an escalating situation? First, we return to situational awareness.  What are your egresses for escape?  What doors lock creating a place of refuge?  Are there panic buttons or other emergency notification devices?  These are important to know when you float to other units, too.

A notable hostage negotiator, Chris Voss, has some great suggestions on negotiation. Why mention negotiation?  It is an art of physical and verbal language which can many times deescalate a situation.  Out own reaction to the situation can greatly influence the outcome in many cases (but not all).  At the same time, important to know when the time has come to abandon efforts to deescalate and remove yourself from potential violence. 

When attempting to deescalate a situation, Voss mentions: “words, music, and dance.” The words are what is being said, the music is how it is being said, and the dance is the body language you are using.

• The Words.  Repeat what is being said.  Use those open-ended questions we were all taught in nursing school to gain as much information as possible. Mirror what they are saying, as this demonstrates not only that you are listening, but also understand correctly.
• The Music. Keep the focus on the other person, avoid drawing the attention to yourself.  For instance, instead of saying “I think you are afraid your mother is going to die,” revert the statement to say, “it sounds like you are afraid your mother is going to die.”  This does two things: keeps the attention on the other person keeping you out of the equation and acknowledges their feelings behind the behavior.  Use an even, calm tone to avoid inflections that may be perceived negatively.
• The Dance. With everything happening, this could be the hardest to accomplish. Attempt to keep your hands and arms relaxed. If safe, attempt to sit at eye level with the person, but never allowing them to block your egress.  Relax your jaw, breathe, and show genuine interest in their concern. 

Above all, if the interaction become physically violent, the escalation continues, or there is open brandishment of a weapon, you may best utilize the active shooter protocol (escape, hide, fight). It is important to continue monitoring the other person’s “dance,” observing signs of aggression or escalation such as tightened fists, teeth grinding, pacing, etc.

We are seeing many shifts in nursing today, including short staffing and long hours that can contribute to higher risks for escalation and workplace violence. The goal is to provide nurses tools to use in practice to help avoid injuries and violence when possible. What other thoughts do you have about keeping nurses and other healthcare staff safe?