6.4 Workplace Violence

Nurses may encounter aggressive behaviors at work from clients, their family members or visitors, or coworkers. Up to 50 percent of health care professionals are victims of violence during their careers.^[1] Common client situations that carry a risk of unpredictability and volatility are delirium, dementia, psychosis, substance intoxication or withdrawal, and acute exacerbations of severe mental illnesses like schizophrenia. Nurses and nursing students must recognize signs of impending violence and know how to use de-escalation techniques to reduce their risk of injury.^[2]

Violence typically erupts after a period of mounting tension, although it can also erupt without warning. Observe the attitude of an individual’s hands as an indicator of tension. Other signs of impending violence may include the following^[3]:

• Confrontational behavior
• Angry demeanor
• Loud, aggressive, or mumbling speech
• Threatening to leave
• Tense posturing (e.g., gripping arm rails tightly or clenching fists)
• Frequently changing body position or pacing
• Aggressive acts (e.g., pounding walls, throwing objects, or hitting oneself)

Clients who are agitated but cooperative may respond to verbal de-escalation techniques. They should be moved into a quiet area to prevent escalation, such as a room with video monitoring. Actively violent or severely agitated clients who exhibit signs of impending violence require immediate assistance and possibly behavioral restraints per agency policy. Assume that all violent clients are armed until proven otherwise, especially those presenting to an emergency department.^[4]

Verbal De-Escalation Techniques

If clients demonstrate agitation but are cooperative, nurses can attempt to build trust and comfort by friendly gestures like offering food or drink and a place to sit. However, hot beverages should not be offered because they can be used to cause injury. If the client sits, the nurse can sit, and if the client stands, the nurse should stand as protection for the nurse.^[5]

A nonconfrontational, attentive, and receptive demeanor without conveying weakness or vulnerability is optimal. The nurse should use a calm and soothing tone of voice and avoid direct eye contact, which can be seen as a challenge. The nurse should not approach the client from behind or move suddenly, and they should stand at least two arm’s length away from the client.^[6] Stethoscopes and badge holders should not be worn around the neck to prevent strangulation risks.

In some cases, an agitated client may be aware of their impulse control problem and may welcome limit-setting behavior by the nurse (e.g., “I can help you with your problem; I cannot allow you to continue threatening me or the emergency department staff.”). However, nurses must avoid making threats. It is difficult to predict which clients will respond to this limit-setting approach. Some clients may interpret such statements as confrontational and escalate their behavior.^[7] See examples of threats and limit-setting in the following box.

When interviewing an agitated or potentially violent individual, address potential violence directly by asking questions, such as, “Do you feel like hurting yourself or someone else?” and “Do you carry a gun?” Stating the obvious like “You look angry” may help them to begin sharing their emotions.^[8]

If the client becomes more agitated, speak in a conciliatory manner and offer supportive statements to diffuse the situation, such as, “You obviously have a lot of willpower and are good at controlling yourself.”^[9]

A consensus statement from the American Association for Emergency Psychiatry De-escalation Workgroup recommends ten key elements for verbal de-escalation^[10]:

• Respect personal space: Maintain a distance of two arm’s lengths and provide space for easy exit for either party.
• Do not be provocative: Keep your hands relaxed, maintain an open body posture, and do not stare at the client.
• Establish verbal contact: The first person to contact the client should take the lead in communicating.
• Use concise, simple language: Avoid elaborate and technical terms because they are hard for an impaired person to understand.
• Identify feelings and desires: “What are you hoping for?”
• Listen closely to what the client is saying: After listening, restate what the client said to improve mutual understanding (e.g., “Tell me if I have this right…”).
• Agree or agree to disagree: Agree with clear specific truths or agree in general (e.g., “Yes, everyone should be treated respectfully.”).
• Set clear limits: Inform the client that violence or abuse cannot be tolerated.
• Offer clear choices and optimism: Clients feel empowered if they have some choice in matters.
• Debrief the client and staff.

Nurses should not lie to the client, and they should take all threats seriously. If verbal de-escalation techniques are unsuccessful, the nurse should excuse themselves from the area and summon help.

Restraints

Clients who are violent or displaying severe agitation with the potential for impending violence may require physical or chemical restraints per agency policy to maintain safety for themselves and others. Nurses must be aware of agency policies, procedures, and required documentation regarding restraints.