The ability to de-escalate violence in healthcare settings is a skill that nurses need to master. Unfortunately, it is necessary since violence in healthcare occurs at higher rates than in other workplaces, and it’s rising.

Registered nurses experience intentional injuries at a rate of 8.8 per 10,000 employees compared to 1.9 across all occupations. In addition, one in four nurses will be assaulted throughout their careers, and one in 4,000 healthcare workers will be hit monthly. The highest rates of violence occur in the emergency department, geriatric and psychiatric settings.

The Covid-19 pandemic has not made things safer. According to an article published in The Lancet, more than 600 incidents of violence, harassment, or stigmatization occurred against healthcare workers, patients, and medical infrastructure concerning the Covid-19 pandemic between February 1st and July 31st, 2020.

What’s more, many healthcare employees have little to no education about strategies on how to de-escalate violence in healthcare settings or how to report it if it does happen. “Many people think it’s okay to spit at a nurse or be hollered at or have a bedpan flung across a room,” explains Margaret Morales, APRN, ACNS, NEA-BC, VP at Mount Sinai Hospital in New York City. “Especially in our emergency room, we found [the attitude was,] ‘That’s just the way our patients are,’”

That’s why Morales, along with two colleagues, Lydia Lopez, RN, NEA-BC, and Taina Rivera, RN, MS, spoke at American Nurses Credentialing Center’s Magnet Conference about how they successfully reduced violence in several units, including psychiatry. These are some strategies they used, supplemented with information from a Quick Safety note released by the Joint Commission in January 2019.

What is de-escalation?

Like conflict resolution, conflict management, crisis resolution, talking down, and defusing, de-escalation combines strategies, techniques, and methods to reduce a patient’s agitation and aggression.

Such strategies include communication, self-regulation, assessment, and safety maintenance. Restraints and seclusion fall into these categories but should be a last resort performed only to protect the patient and others nearby from physical injury. “Using a restraint is a failure to us, and we’ve taken that seriously,” Rivera notes.

‍How to de-escalate violence in the healthcare setting.

The Mount Sinai team relies heavily on the Brøset Violence Checklist (BVC) to assess this risk. As Lopez explains: “It can’t be just a gut sense. Back in the day, as nurses, we used to say, ‘Watch that guy in room 10. Something’s not right about him.’ But now we have true, evidence-based tools to talk to each other shift to shift to know what’s going on with a patient.”

Lopez says that the BVC is not a long-term assessment; instead, it’s most effective for “in the moment” interventions. It assesses patients based on six variables:

• Confused, irritable, boisterous, physical threats
• Verbal threats (explicit and implicit)
• Attacking objects

Any presence earns a score of 1; if it’s not present, mark 0. If a patient earns a 1-2, assess them regularly throughout your shift—a rating of 3 or higher merits taking preventative measures.

Consider using the BVC in the same way you would a pain rating. Perform it at the beginning of your shift and endeavor to hand off the patient at 0.

The Joint Commission also recommends STAMP for use in the ED, OAS in inpatient settings for children and adults, and the BRACHA in the ED to determine the need for placement in an inpatient psychiatric unit.

‍How to prevent a patient from acting violently.

In addition to using the BVC, the Mount Sinai team recommends collaborating with the patient on an individual crisis prevention plan (ICPP) when they enter the hospital. The ICPP aims to understand the patient’s triggers, early warning signs of aggression, and interventions that will effectively calm the individual.

To gather this information, ask simple questions like, “What makes you feel upset? What frightens you? What helps you feel calm?” Lopez explains that doing so promotes interventions that reduce the risk of trauma to the patient.

When a patient exhibits warning signs of violence per the BVC or their ICPP, address what’s causing it as soon as possible. For example, updating the whiteboard might help a confused patient.

“When somebody’s having difficulty breathing or chest pain, we know the steps we must follow,” Lopez says. “The same applies when someone’s having a behavioral crisis … You can’t just leave and deal with the guy down the hall instead. You have to look at both and figure out what your priorities are.”

‍What to do when a patient is acting aggressively.

While individualized interventions based on a pre-determined ICPP are some of the most effective, the Joint Commission offers general communication tips for defusing aggression:

• Be clear, calm, and non-confrontational. Avoid using abbreviations or healthcare terms.
• Use non-threatening body language.
• Be respectful and understanding of the patient’s concerns.
• Address the patient’s concerns as best you can. This creates a sense of trust.
• Set clear limits for the patient to follow.
• Consider implementing environmental controls, such as minimizing lighting, noise, and loud conversations.

The Crisis Prevention Institute also offers the top 10 de-escalation tips in healthcare settings. In addition, the Joint Commission recognizes the efficacy of the following de-escalation models:

• Dix and Page revolves around assessment, communication, and tactics (ACT).
• Turnbull et al. emphasizes trying different de-escalation tactics and constantly monitoring the aggressor’s response to each.
• Safewards begins by moving the patient to a safe area and maintaining a safe distance, asking what’s prompting the anger, and resolving the problem by finding a mutually agreeable solution.

‍What to do if a patient acts violently towards you.

Despite best efforts, violence in healthcare settings can still occur. The Mount Sinai team encourages clinicians to “tap out” or leave the situation if a patient’s behavior makes them uncomfortable or impedes their ability to provide quality care. If you see a fellow provider struggling, ask the individual if they would like to “tap out.”

Reporting violence can also improve the safety of your unit. The Joint Commission says every episode or threat warrants notification to leadership, internal security, and law enforcement, if appropriate. You should also take the time to fill out an incident report.

Even though healthcare workers risk violent encounters daily, the good news is that people are finally starting to pay attention.