Lessons From the Frontline: Compassionate Approaches to Preventing Patient Violence

September/October 2013

Lessons From the Frontline: Compassionate Approaches to Preventing Patient Violence


Healthcare workers, especially nurses on the front line of care, are at risk of being injured by patients who become violent because of their emotionally unstable or clinically agitated condition.

The Department of Labor’s Bureau of Labor Statistics (BLS; n.d.), the Emergency Nurses Association (2011), and others have cited increases in injuries to healthcare providers (and other hospital staff) due to assaults from patients or patients’ visitors. Current BLS statistics show that the healthcare sector leads all other industries with worker injuries resulting in lost work days from “non-fatal assaults.”

The Patient Safety and Quality Improvement Act of 2005 created a framework for healthcare providers to improve patient safety by sharing data with federally certified patient safety organizations (PSOs) that provide analysis and feedback regarding patient safety matters in a protected legal environment. Since it started accepting reports in 2009, ECRI Institute PSO, one of the first federally certified PSOs, has received and reviewed hundreds of reports of patient aggression and violence that have resulted in injury to both patients and healthcare workers. The information from these reports can be used to improve worker and patient safety by helping to raise awareness and identify best practices to prevent and manage patient violence. Because actual data submitted to a PSO is confidential, any case reports used in this article have had all identifying information removed.

Agitation, aggression, and violent behavior are symptoms of underlying conditions that have multiple etiologies. In the PSO event reports involving violent patient behavior, the patient factors are predictable: alcohol and illegal drug intoxication and addiction, drug-seeking behavior, psychosis exhibited by those living at home or by those who are homeless (often refusing to continue their medications), and multiple medical and mental health comorbidities—such as neurological disorders, infections, delirium, post-surgery, adverse prescription drug reactions, and developmental disabilities— combined with behavioral health symptoms (e.g. paranoia, motor agitation, emotional lability) and social dislocation.

Aggressive or agitated behavior signals a high-risk, high-acuity situation that needs immediate clinical attention, comparable to a stroke, cardiac, or respiratory event. The difference, however, is that agitated patients can also pose a threat of injury to hospital staff which, in addition to the patients’ volatile, interfering behavior, creates a barrier to their care that is uncommon with other acute care or emergency patients. Agitated patients are often too overcome by their symptoms to cooperate with medical procedures or to make decisions on their own behalf. Effective therapeutic intervention often requires early recognition of the warning signs of violence and pre-emptive clinical responses, including focused verbal de-escalation strategies and pharmacological therapy to prevent the psychiatrically acute patient from acting out on violent impulses.

ECRI Institute PSO reports of hospital responses to these patients reveal some troubling trends: multiple cases of frontline staff, physicians, technicians, and security officers being assaulted or injured while responding to patients in psychiatric crisis or other clinically agitated states, with very few resources or skills on how to recognize, prevent, and treat these disturbing patient presentations. This suggests that there is not only a significant gap in understanding how to manage patients exhibiting aggressive behavior or psychiatric derangement, but an important need for a more comprehensive organizational response to inform and support patient care in these crisis situations. Otherwise, frontline staff can become quickly overwhelmed with the care of challenging, combative patients, and may feel abandoned and without the resources to do their jobs safely.

Lessons from the reports to ECRI Institute PSO and from the literature suggest that broadening clinical pathways for integrating care between medical and psychiatric services for earlier assessment and treatment of patients at risk of violence merit review and further research on their effectiveness in reducing assault and injury in the hospital.

Recognizing the Early Warning Signs
Recognizing the signals of an impending violent outburst before they happen offers the opportunity for staff teams to intervene much sooner with direct verbal de-escalation. The following case reported to ECRI Institute PSO illustrates what can happen when warning signs are missed and interventions are not used soon enough:

Patient presented to the emergency department (ED) with complaints from his family of erratic behavior. He was placed in a bed, and a toxicity panel and CT scan were ordered. According to the doctor’s notes, the patient did not respond to questions. A suicide risk assessment was performed according to policy. Test results did not indicate any clinical concerns, so the patient was medically cleared for transfer to a psychiatric facility. The patient began pacing, removed hospital gown several times, and seemed to have increasing paranoia. He walked out into an open area of the ED and then tried to run away. A Code Gray was called. A security officer who was standing by did a takedown; an antipsychotic drug was administered while the patient fought. The patient was placed in restraints. Unclear why no medications were given until the patient acted out.

Psychiatric personnel are very familiar with the signaling behaviors displayed by this agitated ED patient, but medical nursing staff may not be aware of the following signs of psychiatric emergency (Tishler et al., 2012):

  • Raised voice/cursing/sexualized language
  • Pacing or other physical agitation
  • Removal of clothing, intravenous lines, bandages/tape, etc.
  • Threats to clinicians or others
  • Paranoid ideation
  • Aggressive use of objects in the environment (e.g., pulling, grabbing, throwing)

Attentive intervention without delay when these early signs appear can often preclude shouts and threats from becoming physical altercations (Tishler et al., 2012). Reports to ECRI Institute PSO indicate that these signals are often missed altogether or that nursing staff attempt to hand off patients whose behavior becomes disruptive—very likely to diminish their own reasonable anxiety in treating these patients. Predictably, the outcome is undesirable for both patients and staff.

Verbal De-escalation: A Select Skill Set
Verbal de-escalation can often deter violent outbursts in all but the most intently aggressive patients (Richmond et al., 2012). De-escalation training, by raising awareness of one’s own responses to fear and anxiety and teaching alternative behavior modes, contributes to creating a culture of safety in which providers and security staff develop confidence in their communication and crisis management skills. But it cannot be a one-off approach if the skills are to remain robust and durable.

Conveying verbal awareness of patients’ distress without being defensive or authoritarian shows empathetic concern for their welfare—indeed, maintaining a positive attitude toward patients displaying repulsive or oppositional behavior demonstrates respect for the patient and self (Richmond et al., 2012), but rarely does this “come naturally.” More common are confrontational or dismissive statements and behaviors that aggravate an already unstable situation.

Verbal de-escalation skills must be learned through training and practice, along with the skills to know when and how to use them. In many healthcare organizations, developing de-escalation competencies outside of the psychiatric care unit remains on their “wish list” for resources, rather than a “must-have” list unless there has been a serious assault (Tishler et al., 2012). This relatively small investment in time and resources, however, is a way that healthcare organizations can improve safety on many levels: reducing coercion and empowering staff to engage rather than avoid patients with undifferentiated agitation, while ensuring safe conditions. It may prove to be more cost-effective than use of untrained, low-wage “sitters,” who often appeared in event reports as the targets (or sometimes the instigators) of attacks by patients. In-house or outpatient mental health professionals may be able to offer excellent resources to clinical care professionals in this process, but need support from a culture of openness and collaboration across medical and psychiatric services to succeed. Knowledgeable de-escalation intervention is a simple way to increase overall awareness and competency, reduce injuries to healthcare professionals (Tishler et al., 2012), and cultivate compassion for all concerned.

Use of Medications and Restraints
While pharmacological management of the violent or agitated patient is nearly always required to relieve the patient’s symptoms and permit further evaluation and therapy to proceed, medication to the point of sedation precludes the patient’s ability to participate in their psychiatric examination and is not recommended (Richmond et al., 2012; Zun, 2012). It is beyond the scope of this article to review or recommend specific drug therapies; however, clinical policies that define algorithms, standing orders, and order sets for such drugs as benzodiazepines and typical or atypical antipsychotics (some institutions add antihistamines to forestall allergic reaction) should be available for activation by a physician on the scene to medicate violent patients to help them regain conscious control of themselves (Richmond et al., 2012) if verbal de-escalation has been insufficient or inappropriate. Physician-led behavioral code teams for urgent response, for example, can be a way to implement these standing protocols. Active monitoring of psychotropically medicated patients should be ongoing.



Security personnel often have a significant role in helping clinicians manage patient aggression. They are dedicated officers, often with law enforcement training, whose responsibilities can encompass everything from parking lot safety to patient security functions. In many cases, though, hospital security officers do not have sufficient training in clinical interactions, which can pose difficulties when they are mobilized to help medical staff defuse a potentially (or actively) volatile patient encounter.

While many security officers respond quickly and effectively, there are reports of others responding to violent patients as if they were criminals, or who engage them at the same affective level, which exacerbates the problem and makes it more difficult for the medical team to intervene appropriately to care for the patient. ECRI Institute PSO has reviewed reports in which security officers, while well-intentioned, escalated the situation by their comments or actions:

“We can either do this the easy way or the hard way” [officer’s comments in attempting to reason with an agitated patient refusing treatment].

“I’m a God-fearing man, and you are no God!” [officer’s comments to a delusional patient needing management by four nurses].

Patient’s wrist was broken by a security officer responding to combative, schizophrenic patient.

Although there is no standard requirement for training of hospital security officers, according to the International Association for Healthcare Safety and Security, many healthcare organizations require training and ensure that it is available. Crisis management training for the clinical setting is available from several private vendors or may be developed by behavioral health specialists within a healthcare system or facility. Emergency overhead codes for violence may be of limited utility because they often signal a security officer response when the situation may require an urgent clinical response as well.

Because their role is vital in support of the clinical care team, security officers should be trained alongside clinical and ancillary staff in de-escalation, clinical crisis management, and the legal processes to facilitate care.

Restraints should also be used with caution and never as punishment or for staff convenience, e.g., when the census is high. Hospitals should be guided by collaborative policy and research, as well as the experience of frontline psychiatric and medical physicians, nurses, specialists, security leadership, and management to ensure compliance with federal and state requirements as well as applicable standards, such as accreditation standards from The Joint Commission. Invariably there will be times when restraint use is needed to prevent serious injury to a patient or others during a crisis, but this forceful approach may increase patient resistance and anger and may not help clinicians to get to the root of the medical and psychological problems that brought the patient to the hospital. The objective of any intervention is to assure safe, therapeutic care that proceeds as medically indicated for the patient’s condition. A confrontational “takedown” exceeds this goal and should be avoided.

Medical Clearance or Medical Stability?
Procedures that constitute the “medical clearance” process vary widely among hospitals. There is no clear consensus of which medical procedures should be routinely performed in EDs to rule out medically acute factors contributing to a patient’s behavioral distress prior to a psychiatric evaluation (Zun, 2012; Lukens et al., 2006), which can lead to prolonged ED boarding of an agitated patient, as in the following report to ECRI Institute PSO:

The patient came in in crisis and the psychiatrist did not come when he said he would, and has not seen the patient in 3 days.

Attempts to perform medical tests, obtain lab specimens, transport the patient, and prepare for impending transitions of care have emerged in event reports submitted to ECRI Institute PSO as occasions for the exacerbation of aggressive and agitated states. Information from medical assessments are important for making admission and transfer decisions, although some emergency physicians find that many medical test results in patients with psychiatric symptoms are clinically insignificant (Zun, 2012).

The American College of Emergency Physicians’ clinical policy guideline on the management of adult psychiatric patients in the ED suggests that most behavioral health patients’ medical status can be ascertained with a history, physical examination, and vital signs sufficient to determine if the patient has the cognitive awareness for a psychiatric interview (Lukens et al., 2006). Documenting physical and cognitive findings to establish “medical stability” (Zun, 2012; Lukens et al., 2006) for psychiatric treatment may be preferable to medical clearance procedures that delay treatment until results from the lab, radiology, and other departments are returned. This can optimize patient flow, even for intoxicated patients (Zun, 2012; Lukens et al., 2006), and more importantly, ensure therapeutic relief to patients before they decompensate (Zun, 2012). Collaborative, critical review of a healthcare organization’s medical clearance policies and procedures, combined with review of assaultive and restraint-use incidents in that setting, could yield important information for revising clinical pathways for the assessment of uncooperative or behaviorally acute patients.

Reduce Boarding With Early Psychiatric Assessment and Intervention

The patient remained in our ED for 33 hours when beds were immediately available and more definitive care could have been established much earlier.

Boarding of acutely ill patients in the ED without assessment or treatment of their illness would rarely happen for other medical populations (Zun, 2012), so why does it happen to patients who have psychiatric illnesses or co-morbidities, as in the incident above reported to ECRI Institute PSO? If the patient safety reports to ECRI Institute PSO are any indication, this question merits serious consideration.

The Emergency Medical Treatment and Active Labor Act (EMTALA) obligates providers to address the emergency conditions of all patients, including those with behavioral health emergencies, regardless of whether the facility provides mental health services. Strategies to increase access to psychiatrists and mental health specialists are needed to provide assessment and guide intervention for underlying behavioral issues during the pre-admission stage in the ED. Studies of technologies that improve access to care, such as telemedicine, to provide focused psychiatric encounters, have been available for over a decade (McLaren, 2003; Janca, 20000; Ermer, 1999). Telepsychiatry can be a safe, successful, cost-effective option in this resource-challenged area of medicine (Zun, 2012), with positive implications for ED patient flow. Additionally, telepsychiatry may reduce the risk of patient roaming, elopement, or other irrational and potentially dangerous behavior affecting the patient and others in the care environment.

Involuntary Petition: Consider Earlier Use
The emergency petitioning and certification process may be an underused tool in the clinical management of patient violence in emergency and acute care settings, as illustrated by the following report to ECRI Institute PSO:

Patient became violent, hitting and kicking the bedside RN [resisting treatment]. Patient spit in my direction and began kicking and hitting with force. She [landed] blows to my chest, shoulders, abdomen, and thorax. Several other team members rushed into the room to restrain the patient, who was still combative. Patient was able to free her right arm and hit a paramedic in the face. The patient was put in 4-point restraints and medicated to the point of sedation.

Often viewed as an intervention of last resort, the petition and certification for involuntary treatment is not intended to sanction the use of force or coercion but to enable providers to help their patients reach psychiatric stability with earlier, therapeutically appropriate interventions. Earlier use of emergency petitioning procedures, in accordance with applicable state law, to treat some patients involuntarily may enable them to return to a conscious ability to allow further medical intervention to take place, before an injurious confrontation with healthcare workers and security officers occurs.

If used as a means to foster compassionate care for critically distressed mentally ill or dual-diagnosis patients who find themselves in the ED because they have few medical options available to them in the outpatient setting, then petitioning and certifying for involuntary treatment can offer providers the legal authority to treat patients whose symptoms make them incapable of cooperating with their treatment—comparable to patients presenting with trauma. The acute symptoms that demonstrate a patient’s inability to participate in his/her care should not be misinterpreted or responded to as unwillingness, however.

Although physicians may hesitate to invoke an emergency petition for care of a patient for many sound reasons, the purpose of emergency petitioning for care is to enable doctors and other professionals to act on the patient’s behalf during an acute episode to relieve the patient’s distress and to enable the patient to cooperate with treatment. The National Alliance on Mental Illness (NAMI), an advocacy group for patients, families, and professionals, has published extensively about the appropriate use of emergency petitioning for patients who otherwise would elope and endanger themselves and their families (NAMI, 1995). If it is considered and used at the earliest signs of agitated and aggressive behavior that does not respond to verbal de-escalation, emergency petitioning can be an effective, temporary method to make treatment available to patients who are unable to act in their own best medical interests.

Understanding Legal Status as a Component of Care
Training in understanding and communicating the legal status of mental health patients is fundamental to appropriate intervention in situations in which violent behavior has escalated. This training should be directed by risk management and legal counsel and should include all personnel who work with agitated patients. Documentation and communication of a patient’s legal status is essentially the same as any high-risk clinical situation and should be treated with the same priority for maintaining safe care as medication reconciliation, for example.

State legal requirements and restrictions for petitioning and certifying patients in medical settings should be required knowledge for clinical managers. Clarifying this information in policies and procedures is an important responsibility of the healthcare organization. This is a challenging area for clinicians because state law determines the threshold for what constitutes “danger to self or others” and other conditions that warrant emergency petitioning and its duration. Frontline clinicians need to be absolutely certain of the treatment plan for every case of agitation that threatens (or is already disruptive of) a patient’s care, and know specifically when and how therapeutically indicated medication or restraint may legally take place without the patient’s consent.

Delivering Compassionate Care in a Compassionate Workplace
To decrease incidents of patient violence and injury to healthcare workers, there are actions within an organization’s control that not only can facilitate delivery of compassionate care to patients in acute distress, but also demonstrate compassion and respect for the providers who must discharge their duties under challenging and sometimes threatening conditions. Putting these techniques and tools at their disposal gives them the means to keep themselves and their patients safe. Increased access to professional training in verbal de-escalation and recognition of early signals of impending violence, ready availability of psychoactive medications per protocol (and reconciliation with medically active drugs), reduction in restraint use, evaluation of medical clearance practices (including options such as telemedicine) to obtain psychiatric care sooner, improved training for and the number of security professionals, and earlier use of emergency petitioning and certification are suggestions that warrant further review, development, and measurement to evaluate their impact.

Patient violence is a human problem that resists technical solutions alone. Rather, a partnership approach for resources and support throughout the hospital and community that integrates care among medical, psychiatric, and emergency professionals, management and frontline staff, and leaders from other important departments, including risk management, patient safety, security, pharmacy, and legal counsel, can diminish risk of assault and injury and ensure safe, appropriate care for the urgent needs of this vulnerable patient population.

Ruth Ison is a patient safety analyst/consultant with the ECRI Institute PSO in Plymouth Meeting, Pennsylvania, and works with the Patient Safety Organization and INsight Assessment Services. With a background in academic medicine, clinical research, and medical ethics, Ison has written and presented on human research ethics, qualitative research, and regulatory affairs. She may be contacted at rison@ecri.org.

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