Mitigating Workplace Violence via De-Escalation Training


Some healthcare staff are more at risk for patient aggression than others. Workplace violence is most likely to occur in acute care settings, behavioral and mental health units, intensive care units, and geriatric care. In terms of staff, mental health professionals and nurses—especially those working in emergency departments and behavioral health units—experience the most violence by patients and family members. However, physicians, social service employees, hospital aides, reception aids, Human Resource employees, and security personnel are also at risk and require unique solutions to remain safe at work. The International Association for Healthcare Security and Safety (IAHSS) provides safety training recommendations specifically for security personnel, given the direct relationship security officers have with workplace violence.

2.1 Emergency Departments and Acute Care

Emergency departments (ED) are widely discussed as hotspots for workplace violence. IAHSS reports that in a survey of 81 hospitals in 2018, 46% of assaults against employees by patients or family occurred in emergency departments. Surveys of ED staff corroborate this evidence. A cross-sectional study surveying 263 emergency medicine residents and attending physicians across the US found that 78% of respondents experienced at least one violent act at work in the past 12 months. In another survey of 242 ED workers at five different hospitals, nearly half of those surveyed said they had been physically assaulted. Moreover, 65% of those assaulted said that they did not report the incident to hospital authorities. Benham (2009) offers several contributing factors for these assaults, including patients coming to the ED in pain, experiencing long wait times, being more likely to be violent because of jail diversion or undiagnosed mental illness, being under the influence of drugs or alcohol, and requiring acute treatment for underlying psychosis or dementia. Moreover, EDs are open 24 hours a day, presenting the opportunity for late-night incidents that would not occur in other departments.

2.2 Behavioral and Mental Health Units

Along with emergency departments, behavioral and mental health units are most at risk for incidents of workplace violence. The Department of Justice National Crime Victimization Survey reports that the victimization rate for mental health professionals was 21 per 1000 people between 2005 and 2009, around three times the rate of medical professionals and twice the rate of bus drivers. This is largely because psychiatric conditions are often associated with increased aggression: people with diagnosable clinical psychiatric conditions are five times as likely to express violence as the general population, according to the National Institute of Mental Health Epidemiologic Catchment Area (NIMH) study. Substance use compounds mental illness, with alcoholism and drug use increasing one’s propensity to be violent to 12 times and 16 times more than the general population, respectively. As a result, the NIMH study reports that 31% of people identified in an initial survey as having both a mental illness diagnosis and substance use committed an act of violence within the following year.

2.3 Geriatric Care Units

Staff working in nursing homes and geriatric care units report frequent verbal and physical assaults, likely due to the confusion, agitation, and aggression caused by age-related cognitive decline. A cross-sectional study of 539 nursing home assistants found that 66% of respondents report experiencing daily physical assault resulting in minor soreness, abrasions, scratches, or bruises. Elderly patients are a uniquely vulnerable population, and nuanced solutions are required to address the high rates of violence in long-term healthcare settings.

2.4 Intensive Care Units

For reasons that overlap with the issues facing emergency departments, intensive care units (ICUs) experience high levels of violence. Patients and their family members are under significant duress, resulting in increased aggression as compared to non-critical care wards. In a survey of intensive care senior nurses in England and Wales, the percentage of ICUs with reports of verbal abuse by patients or relatives was 87% and 74%, respectively. Physical abuse by patients was reported in 77% of ICUs.