Healthcare organizations suffer from extremely high rates of workplace violence, a phenomenon that continues to grow worse. Yet traditional methods of handling violence against healthcare staff—such as restraint and seclusion—are now framed by many researchers, healthcare workers, and healthcare managers as inflammatory and dangerous. In response, de-escalation strategies have increasingly been recommended as effective and non-violent alternatives to restraint and seclusion. According to the Joint Commission, a U.S. based not-for-profit organization that accredits over 22,000 health care organizations in the United Sates, de-escalation training teaches healthcare staff a “combination of strategies, techniques, and methods intended to reduce a patient’s agitation and aggression,” without having to resort to restraint or seclusion. De-escalation training is lauded for its potential to prevent violent incidents, reduce injuries, and repair patient-staff relationships. Still, the field suffers from a lack of training program evaluation, which is the necessary next step in establishing a de-escalation training gold standard for widespread implementation in healthcare settings.
1.1 Workplace Violence in Healthcare
The National Institute for Occupational Safety and Health (NIOSH) defines workplace violence as “the threat or act of violence, ranging from verbal abuse to physical assaults directed toward persons at work or on duty.” Between 2011 and 2013, it is estimated that between 70–74% of workplace assaults occurred in healthcare or social services settings, despite the sector comprising only 11% of the workforce. , The Occupational Safety and Health Administration (OSHA) states that workplace violence in healthcare is “vastly underreported,” yet occupational injury records indicate that a workplace injury requiring days away from work is still 3.5 times more likely to be due to assault for a healthcare worker than for all other private sector employees. This issue is not confined to the US. The International Labour Office in Switzerland reports that violence in the healthcare sector may account for almost a quarter of all workplace violence. In the Western world, 61% of nurses in Canada reported abuse, harassment, or assault in 2018, 26% of educational and health workers in Europe considered their health or safety to be at risk due to workplace violence in 2000, and 36% of nurses and midwives in Australia experienced violence by patients or their midwives in 2007. Unfortunately, this issue only continues to get worse. Over the nearly 10-year period between 2005 and 2014, violence against healthcare workers increased by 110% in US private industry hospitals. Brous (2018) provides a diagnosis for this trend: “A vicious cycle is set up in which nurses leave the workforce in response to workplace violence. The exodus of providers compromises staffing, and inadequate staffing levels correlate with increased violence.” This hypothesis is validated in a global literature review by Ahmad (2015), who cites lengthy waiting times for patients and visitors as one of the most common risk factors for violence in healthcare.
1.2 Historical Methods of Aggression Management
Restraint is any method, device, or drug that immobilizes or reduces the ability of a patient to move freely. Seclusion is the confinement of a patient alone in a room from which they are physically prevented from leaving. Restraint and seclusion are both typically involuntary for the patient. For this reason, The Joint Commission states that “the use of restraint and seclusion creates a negative response to the situation that can be humiliating to the patient, and physically and emotionally traumatizing to the staff involved.” In a survey of 142 patients, 48% of patients placed in seclusion, 52% of patients put in restraints, and 58% of patients forced to take medication found their experience to be severely distressing. While there is not yet consensus that restraint and seclusion should not be used under any condition, these approaches are recommended largely as a last resort, only to prevent serious injury to the patient or staff. ,
As part of the Nonviolent Crisis Intervention® Training Program, the Crisis Prevention Institute (CPI) outlines the Joint Commission’s standards on seclusion and restraint. Using these guidelines, CPI offers recommendations on how to limit use of the practice, perform it safely when required, and report any resulting injuries or casualties. Several other organizations, however, advocate for the full discontinuation of any restraint or seclusion practices.