Workplace Violence
A White Paper Developed by the
MNA Practice and Education Committee.

Background
Part I - Violent Patients – How to Cope
Part II - Documentation and Reporting of Violence
Part III - Employee/Co-Worker Violence
Part IV - Employer Responsibilities when Violence Occurs

Part I - Violent Patients - How to Cope

By Carol A. Distasio, RN, MSN, MPH, C, CS-P, CS-HH

Violence is a major public health problem in the United States (1). We are inundated with media reports of road rage, air rage, violent crime, random violence, school shootings, home invasions, sports violence, child/spousal/elder abuse, etc. and the catastrophic sequelae often associated with such events.

In healthcare, re-engineering, mergers and acquisitions, shifting roles and functions, regulatory and reimbursement changes, etc. have resulted in nurses-indeed, all healthcare providers-doing more with less, which induces stress in both staff and patients.

Some patients respond with aggression to situationally or environmentally inducted stresses, e.g. limit setting; invasive procedures; loss or control/privacy; lost of, or absence of choices; perceived disrespect or other affronts to one’s dignity; etc.

Confusion, impaired communications, low frustration tolerance levels, and a history of responding to negative feelings or anger with aggression are all associated with violence potential. Further, multicultural diversity may contribute to misunderstandings and misperceptions that precipitate anger and aggression in patients.

Although the highest rates of assaults on nursing staff occur on inpatient psychiatric units, assaults on nurses are increasing across care settings, including home health, where such occurrences used to be rare (2,3,4). Given these realities, how can nurse recognize and respond effectively to potentially violent patients? This article focused on patient factors associated with workplace violence; early risk identification; and effective interventions that prevent the occurrence, or minimize the damaging effects of, patient violence in the healthcare workplace.

Violence Defined

Violence is any physically or verbally assaultive behavior, with or without a weapon, against persons or property. Violence has emotional components for the out-of-control); patient (who may be frightened by his loss of control); staff confronted with the escalating, potentially violent patient; and anyone else who witness the patient’s threatening, abusive, or violent behaviors.

Violence As Process

Violence is not an isolated act but a process that occurs in stages or phases and seldom occurs without warning (there are exceptions, et. Patients with intermittent explosive disorders (5). Reduced to its elements, violence essentially has three stages: the baseline (calm) stage; the pre-assaultive stage (which may be as brief as a few minutes or as long as a few days or longer, e.g. the patient whose anger continues to build); and the acute excitement (assalutive) stage (Exhibit 1).

Exhibit 1: The Process of Violence

Stages: Calm Window of Opportunity: Pre-Assaultive Acute Excitement: Assaultive

Time Period

Minutes: Recognize Hours: Assess Days: Intervene

The pre-assaultive stage is the stage at which both patients and staff have the most options, because the pre-assalutive stage presents staff with a window of opportunity in which to initiate interventions to defuse the patient’s emotional volatility, de-escalate the situation, and redirect and assist the patient to return to a calmer personal state. The goals of intervention are to enable the patient to maintain self-control, interrupt and reverse the escalating process, and minimize risks for all concerned.

Risk Assessment: Patient Factors Associated With Violence

There are four reliable predictors of patient violence: diagnosis, history, legal status on admission, and presence or absence of dementia. Patients with certain psychiatric diagnoses, a history of violence, those admitted by court order, and those with dementia all present potential safety risks. Exhibit 2 depicts only some of the general clinical conditions associated with violent behaviors. There are many other subdiagnoses, clinical conditions and research findings that are also associated with patient violence, the discussion of which is beyond the scope and purpose of this article.

Exhibit 2: General Patient Factors Associated With Violence

Pyschosis Affective Disorders Chronic Organic Brain Syndromes Anxiety Disorders Impulse Dyscontrol Disorders Conduct Disorders Personality Disorders Substance Abuse/Toxicity Acute Confusional States History of Violence

A history of violence is a significant predictor of future violence, regardless of diagnosis. Violence occurs most often in the young and the elderly, and although males are more violent than females in younger age groups, this gender difference disappears in long-term demented, elderly inpatients (5).

Early Recognition: The Key To Effective Intervention

The keys to violence prevention is early recognition of warning signs that a patient is escalating, which vary by patient but may include:

• Increased Motor Agitation - Pacing, inability to sit still, clenching or pounding fists, jaw clenching, gritted teeth, increased or rapid respirations
• Verbal Indicators – Threats; visual hallucinations; loud, pressured, rapid speech; paranoid thinking; command hallucinations (the voices are telling me to do bad thing) etc.
• Level of Consciousness – Worsening disorientation; sudden change in mental status
• Increasing Generalized Anxiety – Hand-wringing, finger-pulling, anxious expression
• Other Indicators – Reddened or flushed face; nostrils flaring in rage; property damage; inability to be redirected.

Interventions

Common sense is the core of effective intervention. Intervention involves the therapeutic use of self; acknowledgement to the patient that his escalating behaviors have been recognized and his feelings are respected; and communication to the patient and the expectation that he can and will maintain self-control, and that staff will help him to do so (the generic term “he” refers to both male and female patients).

Don’t ignore the escalating patient. Alter all staff that the patient is escalating. The escalating patient is a threat to everyone and is everyone’s problem, not just the nurse assigned to care for him.

Before you approach the patient, calm yourself. Escalating patients are highly sensitive and will discern your stress. Remove all jewelry, stethoscopes or other items that may dangling from your ears, neck, waist, etc. as these items could cause injury if grabbed by the escalating patient.

Always approach the patient from the front and gain eye contact before you begin speaking. Use a calm tone. Maintain a neutral facial expression. Do not smile. Paranoid or confused patients may think you/re laughing at them, which could be a provocation. Be empathetic to the patient’s issue.

Always position yourself near an exit and let nothing obstruct your quick assess to that exit. Let coworkers know that you are going to try and de-escalate (defuse) the patient. Stay within sight or hearing of coworkers. Don’t approach the patient in an isolated, crowded, or overstimulating area. Be aware of objectives in the patient’s vases.

Ask the patient what is wrong using open ended statements and questions. You need to learn what is upsetting the patient from his perspective. Listen and respond to the patient’s issues. Meet his needs if possible. Offer fluids (not hot) and finger foods (social components that mitigate stress). Offer medication to calm the patient (if there’s no order for this, follow institutional protocols, but in any case, get orders promptly for sedating medication by both oral and injectible routes).

Watch you posture. Don’t stand facing the patient directly (could be viewed as confrontational). Don’t cross your arms over your chest (closed communication position). Stand in a relaxed posture with one foot at a 45 degree angle and slightly in front of your body (evenly distributes your weight and gives you better balance) at an angle to the patient. Communicate at eye level (avoids intimidation): if the patient sits, you sit, if he stands, you stand. In some situations, it is necessary and therapeutic to tell the patient that there will be legal consequences if he injures others.

What Not To Do

Never turn your back on an escalating patient (it’s not only foolhardy, it’s an affront). Don’t argue, threaten, yell, curse, or respond with anger to the patient. Don’t defend staff to a patient ventilating anger against staff. Don’t relate to the patient in an overbearing, arrogant manner. Don’t “save” the patient for the next shift (when there may be less staff) or make promises the next shift will have to honor. Don’t lie about what is possible relative to meeting the patient’s needs or demands. Don’t be inflexible. Be creative. Think of how the patient’s needs could be met.

Assaultive State ( Out-of-Control State)

At this stage staff must gain rapid control of the patient. Follow institutional protocols to insure that the patient does not injure self or others. Such protocols vary but usually include: crisis intervention team (or some variant of this intervention); sedating medications; restraints; seclusion; removal of patients who are too dangerous to other settings, and involvement of law enforcement authorities if necessary, per organizational protocol.

Summary

This article provides general introductory guidelines for coping with patient violence. Future articles will address organizational and supervisory responsibilities in violence prevention and caring for employees involved in a violent incident; documentation and report guidelines; staff factors associated with violence, and employee violence.

References

(1) Healthy People, 2000. U.S. Department of Health and Human Services, Public Health Service (1990).

(2) Distasio, C.A. Violence in Healthcare: Institutional Strategies to Cope with the Phenomenon. The Health Care Supervisor 12:4. (1194) 1-34.

(3)Neurath, P. Violence Stalks the Healthcare Field. Puget Sound Business Journal (1996), 9-16.

(4)Scott, A. Protecting Home Health Nurses on the Job. Advances for Nurses. 1:2 (Jan 25, 1999), 17-18.

(5) Tardiff, T. The Current State of Psychiatry in the Treatment of Violent Patients. Archives of General Psychiatry. 49 (June 1992), 493-499.

(6) Harris, D. and Morrison, E. Managing Violence Without Coercion. Archives of Psychiatric Nursing. 9:4 (1995), 203-210.

About the Author:
Carol A. Distasio is a Maryland board certified Nurse Psychotherapist who is also a Certified Specialist in Home Health Nursing and is Certified in Gerontological Nursing.