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Book excerpt: Be prepared to prevent healthcare violence

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Book excerpt: Be prepared to prevent healthcare violence

The following is an excerpt from the HCPro book, Preventing Workplace Violence: Handbook for Healthcare Workers, published in March 2015. Reviewed by Tony York, CPP, CHPA, MBA, CEO and senior vice president of security for HSS in Denver, the handbook explores the causes of violence in the healthcare environment and offers techniques to help workers reduce violence and keep themselves safe at work. Visit for more information.


Why do some people become violent? The key word is recognition. By knowing who is in your waiting rooms, and being able to recognize the signs of impending violence, most episodes of violence can be prevented.


Change the environment

If your waiting room is busy, perhaps it's a good time to send a staffer out with some coffee, or to explain to your patients why their wait is taking so long. Sometimes, a simple explanation is all that is needed to de-escalate a brewing confrontation. Plus, it gives you a chance to monitor potential threats and remove potential weapons from the situation.

Sometimes, despite best efforts to de-escalate, patients will become violent. Security experts say the best first strategy is to stay calm, reason with the person, and try to talk them down rather than get into a verbal confrontation. Walking with the person or removing them to another, less-crowded environment can also lessen anxiety.


Remove opportunity for weapons

Managing threats of violence involves recognizing potential weapons and taking a proactive approach to minimizing use of those items. Manage the overall environment and accessibility to possible weapons as part of the threat management plan.

In addition to typical weapons such as guns and knives, there are other less obvious weapons in healthcare environments:

  • Fists/hands/fingernails
  • Feet/legs
  • Teeth/mouth
  • Head
  • Body fluids
  • Medical supplies/instruments
  • Food/utensils/meal tray
  • Furniture
  • Floor/door/wall/window


Securing potential items and being aware of the surroundings enables security staff and clinicians to minimize threats. Keeping harmful objects out of sight and out of reach is a deterrent to violence.

Removing all items in the healthcare environment that could potentially be used as weapons is not possible. But it's important to minimize the risks. Removing the potential risk and stimulus can eliminate and block the opportunity to act.

During an emergency, maintaining a safe and secure facility can be a major challenge. With an influx of patients comes an influx of problems. In addition to the higher patient volume, you will have people trying to gain access to your facility for nefarious purposes?such as stealing, hiding, kidnapping, drug diversion, or gaining access to patients (think lawyers and members of the press).

You will need to work with your superiors and coworkers (which may include nurse managers, security and safety officers, and hospital administrators) to help control movement into and within the facility. This will be a daunting task with limited resources and little, if any, help from outside agencies, at least during the initial response to a disaster.


Know your facility's emergency plan

You will need to know your facility's emergency management plan, which should be covered in full during a new employee orientation and ongoing training sessions. This emergency management plan may require plans for a full facility lockdown and posting of personnel at every external door and outside of common areas where you will allow the public, such as the cafeteria and family waiting rooms. The plan will likely include color codes, which indicate a particular type of event when broadcast over the facility's loudspeakers.

Examples of common emergency color codes are:

  • Code Blue: Cardiac arrest or medical emergency
  • Code Red: Fire
  • Code Pink: Infant/child abduction
  • Code Orange: Hazardous spill
  • Code Gray: Weather emergency (tornado, etc.)
  • Code Black: Bomb threat/active shooter


During an emergency, account for your own mental health as well as that of your patients. Remember that anxious people can sometimes become violent, and if you can calm them down, you may be able to prevent violence later.

In some emergencies, especially public health emergencies involving infectious diseases, some security experts talk about a group known as the "worried well." These are people who, having witnessed an event, are now convinced they were affected by the event, even though they were not. In a major emergency, the numbers of worried well are expected to outnumber those actually injured by as many as five to one.


Verbal and nonverbal signs

As much as 70% of communication is nonverbal, so there's a good chance that if someone is going to get aggressive, you'll see it in his or her actions first.

The pathway to violence begins with so-called "behaviors of concern," which may be obvious but can sometimes be very subtle. For the untrained individual, these signs of pending violence can go unnoticed, especially in the busy healthcare environment.

In most cases of imminent violence, there are plenty of warning signs. Look for some of the following:

  • Rapid, uneasy eye movements that dart back and forth, or a wide-open, focused stare.
  • Constant questioning. This is often an attempt to gain understanding of the situation.
  • Pacing in the hallway. This can be a way to work off anxiety.
  • Rapid breathing?usually a reaction to stress.
  • Clenching of jaws and fists, another common stress reaction.
  • Verbalized threats of aggression. These should never be ignored, as verbal threats can be the last sign that physical violence is about to occur.


Environmental factors that affect security

Hospitals are also paying more attention to the physical design of treatment areas and the emergency room itself as a deterrent to violence. Instead of one large open space, ER design is moving toward compartments that can be isolated from one another with protective walls and doors, depending on the intended use of the space. A behavioral ward, for instance, might have patients that could pose a potential threat, and therefore many hospitals have instituted a card-access system that restricts entry. Some hospitals have even installed video monitoring systems not unlike those in retail stores that will give visitors a view of themselves, so they know they are being watched.

Keep these environmental factors in mind to help you safely perform your job while preventing violence from occurring:

  • Know where the cameras are. New ER designs give staff members an open view of every patient room from the large central area. Some facilities even include closed-circuit cameras. By positioning yourself in front of these cameras when treating patients, it can help security monitor what is going on and leave a digital footprint.
  • Use objects to create separation. Reception desks are being built with glass tops and a sloping design that can hinder attempts to climb over them and put more space between visitors and staff. A simple locked door or glass partition separating the reception staff, as well as an alarm alerting staff in the back areas, could help keep a violent individual from getting to you.
  • Don't prop open doors. When the weather gets warm and sunny, it's only human to want to open the door and let in some of that fresh air. But before you do, consider how it compromises the safety of your facility. An open door or window is a breach in your building's defenses against an intruder, especially in the evening hours when darkness provides extra concealment.
  • Maintain physical space/distance. You should never allow yourself to be alone, especially with high-risk patients. At the very least, make sure you have plenty of room between you and the patient to allow you space to defend yourself and see a potential attack coming. Always give yourself an escape route by placing yourself between a potentially violent person and a door.
  • Keep calm and direct. Be firm but kind when talking to patients and visitors, as it can convey the message that you mean business. Try saying things like, "We have some rules on the unit that all patients need to abide by. Not abiding by the rules causes confusion."
  • Ask an offending patient/visitor to accept personal responsibility. Say something like, "Continuing to smoke in the bathroom jeopardizes the safety of you and everyone else on the unit. If you smoke again, our only recourse is to call security or discharge you."
  • Know how to call for help. You should always have a way to call for help, whether a colleague or security officer, if necessary. Most hospitals have a system in place for calling for help, and some even have panic buttons installed in patient rooms.