Workplace violence is both highly prevalent and underreported in healthcare settings, according to Melissa Weigel, RN, and Lorina Welper, APRN, CNS, MS, of the Mayo Clinic in Rochester, MN, who spoke during a session on Friday, April 12, 2019, at the ONS 44th Annual Congress in Anaheim, CA.

Scope of the Problem

Three quarters of all the workplace assaults reported annually to the Occupational Safety and Health Administration (OSHA) occur in healthcare settings. OSHA data also show that, compared with workers in private industry, workers in healthcare settings are four times more likely to experience workplace violence. Only 3 out of 10 nurses, however, report incidents of workplace violence. Reasons for nonreporting include not considering verbal abuse to be violence, believing that workplace assault is “part of the job,” and being confronted with systems that make it difficult to report workplace violence.

How to Handle Violent Situations

The ability to de-escalate a violent or potentially violent situation is a key nursing skill. Weigel and Welper suggested several de-escalation strategies that nurses can use.

  • Be empathic.
  • Clarify messages.
  • Respect personal space.
  • Be aware of your body position.
  • Be aware of your verbal cues.
  • Set and enforce reasonable limits.
  • Keep your nonverbal cues nonthreatening.
  • Match your response with the level of agitation.
  • Permit verbal venting when possible.

Dedicated Unit for Aggressive Patients

The speakers described the Complex Intervention Unit (CIU), a specialized unit for the highest-acuity aggressive or violent patients at the Mayo Clinic. Key features include a secure nurses station protected by shatterproof glass, shatter-resistant window inserts in patient rooms, and ligature- and shatter-resistant bathroom materials. CIU is supported by a psychiatrist and a social work team and uses a care model that emphasizes education and empowerment through nonviolent crisis intervention training and simulation drills. 

Since CIU opened, the number of work days restricted or lost because of violent patient incidents has decreased by 96%. Behavioral emergency calls have decreased, staff turnover is low, and CIU staff report high job satisfaction.

Additional Solutions

Facilities without a CIU can implement environment modification and situational awareness strategies to help reduce the incidence of behavioral emergencies. Environment modifications may include installing Plexiglas over windows, removing or securing window blinds, and removing nonessential items (e.g., silverware) from patient rooms. Situational awareness involves being aware of what is on your person and of your location relative to the patient. Patient belongings, including clothing and shoes, should be secured.

Another helpful strategy is to develop a behavior safety plan, an action plan for safe patient care. The behavior safety plan should include details such as patient triggers, calming methods, staff interventions, and limit-setting strategies.

In addition, visual communication tools can be used to identify patients who are at high risk for violent behavior. For example, an “FYI: Violent Patient” flag and a change of header color can be inserted into a patient’s electronic health record and a card placed on the door of a patient’s room to signal that the patient has a history of violence.