Workplace Violence Prevention: Behavior De-escalation

Workplace violence is a recognized risk in healthcare facilities. According to the Occupational Health and Safety Administration (OSHA), workplace violence is “any act or threat of physical violence, harassment, intimidation, or other threatening disruptive behavior that occurs at the work site.” In 2020, the Bureau of Labor Statistics (BLS) reported that healthcare workers accounted for 73 percent of all nonfatal workplace injuries and illnesses due to violence in 2018. Many cases go unreported, so the actual rates are likely much higher.

In the hospital setting, the highest risk areas are psychiatric units, emergency departments, waiting rooms, and geriatric units. Nurses and assistants who care directly for patients are at the highest risk for violence, which is most often perpetrated by patients or visitors. These alarming statistics clearly illustrate the need for comprehensive workplace safety programs in hospitals.

According to OSHA’s Guidelines for Preventing Workplace Violence for Healthcare and Social Service Workers, the first step in preventing violence is understanding patient, setting, and organizational risk factors. These factors include working directly with persons with a history of violence, poor environmental design that may block employees from escaping a violent situation, poor lighting, and a lack of means to communicate a situation, such as panic buttons in emergency room settings.

OSHA also identifies the primary organization-based risk factor as being the lack of training for staff members to recognize and manage the escalating hostile and assaultive behaviors of patients, clients, visitors, and/or other staff members.

Violence develops on a continuum. The Department of Labor describes three levels of violence:

• Level One (Early Warning Signs) includes intimidating, uncooperative, and/or disrespectful behavior, and often verbal abuse;
• Level Two (Escalation of the Situation) includes arguing, defiance of rules and regulations, and verbal threats;
• Level Three (Further Escalation) includes physical fights, destruction of property, display of extreme rage, and/or the use of weapons to inflict harm. This level of violence usually requires an emergency response.

The skillful use of behavior de-escalation techniques in the early stages of violence can prevent many of these situations from escalating into dangerous, physical, high-level violence. The Crisis Prevention Institute emphasizes the effective use of 10 behavior de-escalation techniques:

1. Be empathetic and non-judgmental. Try not to discount the person’s feelings even if you feel they are unjustified.
2. Respect personal space. Whenever possible, allow one and one-half to three feet of personal space.
3. Use non-threatening non-verbal communication. Make sure that gestures, movements and tone of voice are neutral.
4. Stay calm and avoid overreacting. Remaining calm, rational and professional to avoid de-escalation of the situation.
5. Focus on feelings. Listen carefully for what the person is really trying to say and be supportive and empathetic.
6. Ignore challenging questions. Defensiveness can lead to a power struggle and increased agitation.
7. Set limits. Make sure directives are clear and simple and set limits that are reasonable.
8. Choose wisely. Carefully consider what you insist upon. Make sure you are clear about what is negotiable and what is not and offer choices when possible.
9. Allow silence for reflection. While periods of silence may seem awkward, it provides the person time to reflect on what is happening.
10. Don’t rush. Stress rises when a person feels rushed so allow time for decisions.

Other tips for de-escalating a potentially violent situation include:

• Do not argue. It is more helpful to show that you heard them and to de-escalate than to be correct.
• Focus on the specific behavior, not the person.
• Do not restrict the person’s movement.
• Do not meet behind closed door if you foresee possible danger.
• Do not touch the person or make sudden moves.
• Do not threaten the person.
• Avoid asking “why” questions-these tend to increase a person’s defenses.
• Do not take the person’s behavior or remarks personally.

The problem of healthcare violence continues to increase. Educating staff members in de-escalating aggression before it becomes violent is a key risk management strategy for providing the safest possible environment for healthcare workers.

Additional resources:

• OSHA workplace violence training and resources
• OSHA workplace violence prevention videos
• CDC: Workplace violence prevention for nurses course
• Crisis Prevention Institute
• MOAB Training International, Inc.