Violence against nurses is practically an endemic in the United States. According to a study from the U.S. Bureau of Labor and Statistics, those in healthcare and social services are five times more likely to experience workplace injuries than those in other industries. Moreover, the rate of workplace injuries has consistently increased since 2011.
One study found that violent events cause 12.2% of all registered nurse injuries, and the rate of violence against registered nurses (RN) is 12.7 per 10,000 full-time workers. Another estimated that the rate of violence against RNs was 16.2 per 10,000 full-time workers. And while healthcare providers have always had to deal with angry and volatile patients, the number of nurses experiencing violence or feeling threatened in their workplace has also increased in recent years.
A 2021 study from the American Association of Critical Care Nurses (AACN) found that only 47% of respondents agreed with the statement “My organization values my health and safety,” which was a steep drop from the 68% agreement rate in 2018. Unsafe, threatening, or violent behavior can come from both patients and visitors.
Nurses must know what they can do to spot potential threats, get help, and protect themselves as needed. While each facility has unique policies, a few practices can help nurses identify threats and stay safe.
Know That It’s Not Your Fault
First, we want to address this: Nurses are never at fault for the violence or threats they experience while working.
Beth Hawkes, the owner of Nursecode, stressed that violence could be unpredictable in the healthcare industry.
“There is numerous news through social media of physical attacks against nurses. Patients and families in high-stress settings with little or no coping skills can constitute a significant hazard to the safety of nursing personnel. It is not always feasible to predict a person’s triggers or reactions.”
That’s true for new and seasoned nurses alike. You may sometimes have a gut feeling but aren’t entirely sure what’s triggering it. Trust your gut feeling. Know that your safety is always the priority if a patient or visitor’s behavior seems to be escalating quickly.
Nothing you did deserves a violent, threatening, or unsafe reaction.
Always Have an Escape Route
All three of the experts we spoke to shared the same tip: Always have a way out of every room.
“Never let anybody stand between you and the door,” said Hawkes. “Always provide yourself an escape route. If you are uncomfortable with a situation, retreat and leave the room— do not turn around.”
John*, who oversees security at a large hospital in the southwest, expressed the same sentiment. “Nurses and CNAs need to always have a clear and direct path to the door, and if you don’t have one, get one. The second someone starts to react in a way that raises the alarm bells, back out, slowly if possible to avoid escalation but go fast if you need to for your safety. Do not turn around— if a patient or visitor is ready to get violent, you do not want to have your back turned to them.”
Kate*, a charge nurse who had a team member experience workplace violence, said something similar. “If you get red flags or are worried about escalation, get out of the room before anything escalates. It’s always important to have a clear path to the door for an immediate exit if needed. If you have any equipment with you, like a point-of-care mobile cart or even an IV bag, you can position it in front of you and drag it out. This allows you to never turn your back on the patient without giving a reason, and it also puts something between your body and the threatening person.”
Get Backup ASAP
Even though nurses and CNAs are often alone in the room with patients and their families, they should never have to deal with a threatening situation alone.
“If something doesn’t feel right, come up with a reason to leave the room if you can, especially if the patient is stable, and go get help,” said Kate. “My team all knows that if they don’t feel safe, even if there hasn’t been any intense action yet, they should come get me. Having another person in the room to ‘assist’ or ‘check equipment’ or ‘learn’ can sometimes be enough to dissuade threatening behavior— now there’s a witness and another body. And if there’s clear threatening behavior, a security team member will be involved if needed, even if they’re just standing at the doorway.”
John stressed that it’s never too early to sound the alarms and notify security of potential problem patients. “Some hospitals I’ve worked at had an annoyed attitude if nurses called for anything other than actual physical assault, but fortunately that’s changed. I’ve made sure that all of my team members know that it’s better that we get notified long before a potential assault happens than need to go in after. Even if we get a few false alarms that’s better than an injured nurse, so get backup right away.”
It’s also important to get backup if you feel threatened or harassed by another team member, contractor, or vendor, even if other team members initially dismiss your concern.
“Harassment isn’t really what we’re talking about here I guess,” Kate said, “But a dark reality of working in the hospitals is that all kinds of harassment happen against nurses from every direction. Patients, obviously, but also vendors, other nurses, security, and doctors, too. If you’re being harassed, go to your charge nurse or nurse manager. If they don’t believe you, keep going until you find someone who does. It’s bad enough what we deal with with the patients; you shouldn’t be dealing with that from your own team.”
Know Signs of Potential Violence
Identifying a high-risk patient or visitor is essential because if dangers are spotted early, it may be possible to mitigate risk. A few different methods can be used to identify high-risk patients and visitors.
One is STAMP, which looks for the following indicators, especially in Emergency Room (ER) environments where you need to assess patients quickly:
- Staring
- Tone and volume of voice that’s aggressive, agitated, or hostile
- Anxiety
- Mumbling
- Pacing
The Overt Aggression Scale can be used for both pediatric and adult inpatient care, which considers cues from verbal aggression (like cursing at staff), property aggression (slamming doors or kicking furniture), auto aggression (intensive scratching and picking, or self-harm), and physical aggression (threatening movements or intended violence against others).
The Broset Violence Checklist is also a good option for inpatient psychiatric facilities, which can track patient risk during each shift by looking at factors like confusion, verbal threats, and boisterous behavior.
Use De-escalation Tactics
If nurses feel they are in danger, they must get away as soon and safely as possible.They can also use deescalation tactics if they feel that an individual can be managed, or if they’re trying to keep things calm long enough to stabilize the patient or get out of the room. De-escalation techniques are designed to calm a patient so that you can reduce the agitation that may trigger aggression.
Examples of de-escalation techniques nurses can use include the following:
- Having non-threatening body language. Loosen your posture, walk slowly, and smile at the patient.
- Empathize right away. when you ask how they’re doing, express real empathy and say that you’re sorry they’re experiencing those symptoms and how hard that must be, and that you’re going to talk to the doctor to see what can be done right away.
- Don’t make any sudden movements, and explain what you’re going to do before you do it. getting verbal confirmation from the patient that they understand and consent can go a long way with an agitated individual.
- Stay calm yourself. Even when patients are frustrating, rude and alarming, it’s important to stay calm. So much as an ounce of reactivity or anger from the nurse— even when justified— can cause the situation to escalate.
- Control environmental factors. The environment around the agitated individual can directly impact behavior, especially since hospital settings are stressful enough to be in. Dimming the lights, turning off beeping alarms, and offering extra blankets to keep the patient comfortable can all help reduce discomfort and soothe them.
Make Changes at the Management Level
There are some strategies that nurses can use to protect themselves, which we’ve discussed so far in this post. There are some changes, however, that management must implement to allow nurses to protect themselves.
“Too many hospitals I’ve worked at discourage nurses from taking action,” Kate said. Her frustration was evident. “This endangers nurses because they wait too long to get help, they don’t want to report when something does happen, and all of this makes them more prone to experience violence.”
She said management needs to stress that their team’s safety is the most important thing. Safety training for nurses should be mandatory for all new hires, and it should be reiterated at least once per year at minimum.
“Management also needs to encourage nurses to report when something happens to them and to support them when they do. No more of this bullshit where we say ‘report!’ and then management dismisses those reports or even is hostile about them,” she said. “We need to encourage our teams to report anything and everything.”
According to the AACN, a lack of reporting is a significant barrier to research, regulatory action, and legal action surrounding violence against nurses. Three commonly-given reasons for not reporting violent incidents were:
- Fear of retaliation
- Lack of a clear reporting method
- A belief that nothing will be done.
Therefore, having a transparent reporting process in place and an environment meant to support patient-facing team members is crucial.
Final Thoughts
No one should have to go to work wondering if they’ll be safe. And while nurses have always had a hard job, they should not be worried about their safety. Mental illness, pain-induced confusion, substance abuse and withdrawal, general aggression, and predatory behavior can all drive threatening or dangerous behavior in healthcare facilities. While nurses and CNAs are never at fault, it does put them directly in harm’s way.
Safety must be a priority, so ensure there’s intensive safety training at your facility that includes understanding and identifying high-risk indicators and what to do if they’re spotted. In addition, train your nurses, management, and security on handling dangerous events when they happen, and support nurses that report.
