Intensive care units are filled with brave colleagues who care for the sickest patients with a finesse and kindness that are truly admirable. However, in many of my conversations with nurses, executives, and directors of security across the country, violence in health care is a salient concern. In this guest editorial, I explore the increasing incidence of violence in critical care settings and highlight essential strategies for mitigating risks. By using evidence-based practices and fostering a culture of safety, nurses can play a pivotal role in enhancing both their own security and that of their patients.
I am no stranger to violence and its effects. I spent most of my career working in level I trauma centers, witnessing firsthand the high volume of critical injuries caused by violence. I saw the emotional toll that these injuries took on health care providers, colleagues, and friends. I thought these experiences had prepared me to deal with violent incidents; little did I know that an upcoming moment in my career would be life-changing.
About 5 years ago, after a violent attack from a patient seeking emergency care, I faced a terrible adverse patient outcome that challenged me to find better ways to protect myself, my colleagues, and the patients who seek our care. Since then, I have had the privilege of learning from some of the world’s top military leaders, policing experts, and security specialists. This experience has informed a new approach to patient care—one that blends nursing theory and clinical practice guidelines with proven security principles—ultimately paving the way for safe, effective, and professional care delivery in environments increasingly threatened by violence.
We must understand the role that registered nurses play within health care organizations. Nurses are essential in ensuring compliance, patient care, and documentation, all of which are necessary for hospitals to meet the Centers for Medicare & Medicaid Services regulations and secure funding. Recognizing the significance of nurses’ roles from a regulatory and funding perspective should empower nurses to take a more active role in ensuring our safety and the safety of our patients.
The principles of the Occupational Safety and Health Act of 1970 are encapsulated in the Occupational Safety and Health Administration’s (OSHA’s) General Duty Clause.1 If an employer fails to meet the General Duty Clause requirement, workers can report those unsafe conditions to OSHA. This agency can then investigate and impose penalties or require corrective actions, holding employers accountable. Additionally, OSHA’s Whistleblower Protection Program safeguards workers who report violations from retaliation, ensuring their legal right to speak out about unsafe working conditions.2
An upcoming proposed standard from OSHA focuses on requiring health care employers to develop comprehensive programs for preventing workplace violence, conduct regular risk assessments, and provide mandatory training to staff.3 The emphasis on anti-retaliation measures should ensure that nurses can report unsafe conditions without fear of reprisal. This proposed OSHA standard is particularly critical for addressing violence from patients or visitors, a situation that many nurses know too well. Nurses should no longer have to choose between patient care and personal safety. There is a way to do both, but it requires specific training, designed for the clinical environment.
Nurses should be encouraged to take an active role in the design and application of workplace violence prevention training because they collect and assess the patient data needed to recognize early warning signs of agitation or aggression. As described by nursing theorist Ida Jean Orlando,4 assessment is foundational to the nursing process, and when leveraged to evaluate behavioral cues, it becomes a powerful tool in mitigating potential violence in health care settings.
Key elements of workplace violence prevention training should focus on threat assessments. Using threat assessments, one can manage external threats with a concentric layered approach, addressing fixed environmental risks with multiple layers of defense. A fixed environmental risk, as defined by clinical security principles, refers to physical or structural elements in a health care setting that cannot be easily altered but may contribute to safety threats, such as blind corners, unsecured access points, and inadequate lighting. These risks can heighten the likelihood of violent incidents, particularly in high-stress areas like intensive care units or emergency departments. By identifying these risks during routine hazard assessments, nurses trained in clinical security can implement early preventive measures, such as improved surveillance or controlled access, to reduce potential violence in their environment. A concentric layered approach can lead to increased investment in weapons detection systems, camera surveillance, and other security measures.
The measures taken by security professionals to protect health care environments are commendable, yet the management of risk in health care is more dynamic than fixed environmental threats because nurses deal with people. According to Dean Malpass, a renowned consultant specializing in mergers, acquisitions, and operations in mental health care, “[w]hen individuals are ill enough to be hospitalized, they are humans in the exacerbation of the human condition” (D. Malpass, personal communication, June 2024).
Nurses are uniquely positioned to assess rapidly evolving situations or exacerbations in the human condition and to identify not only clinical deterioration but also behavioral cues that signal potential violence. Identifying these cues means looking beyond obvious physical threats and adopting a proactive stance—recognizing early signs of agitation, anxiety, or aggressive behavior before they escalate. Tactical health care emphasizes risk assessment from the inside out, which means that nurses are not only trained to manage the extremes of medical emergencies but also to anticipate human responses to stress, illness, and trauma. Nurses must evaluate environmental, behavioral, and situational factors simultaneously, applying clinical judgment to assess risks such as environmental hazards, patient agitation, and even staff readiness. This approach allows nurses to intervene early and use professionalism and protective measures, ensuring both patient and staff safety.
By embedding clinical security into everyday practice, nurses can play a critical role in maintaining a secure, compassionate environment while leveraging tactical health care strategies to manage high-risk situations. The goal is to anticipate, assess, and act in ways that mitigate risks before they manifest into actual harm. This goal underscores the need for robust training in violence prevention, situational awareness, and tactical communication to ensure that nurses are equipped to protect themselves, their colleagues, and their patients in all circumstances.4,5
10 Evidence-Based Approaches to Assessing Violence at the Bedside
Structured clinical judgment tools. Implement structured assessment tools like the Brøset Violence Checklist6 or the Dynamic Appraisal of Situational Aggression7 to systematically evaluate a patient’s risk of violence. In these tools, objective criteria are used to predict the likelihood of violent behavior within a short time frame.
Behavioral observation and documentation. Encourage nurses to use standardized behavioral observation scales8 to document early warning signs of aggression, such as increased motor activity, verbal aggression, or changes in affect. Consistent documentation helps track escalation patterns and improves communication among the health care team.
Trauma-informed care principles. Apply trauma-informed care by recognizing that a history of trauma can influence a patient’s behavior and perception of care. This approach fosters a safe and supportive environment, facilitating the identification of triggers more efficiently. Triggers might include environmental stimuli, such as loud noises, bright lights, or crowded spaces, which can evoke a heightened sense of danger. Personal interactions, such as physical touch or authoritative commands, can also trigger memories of trauma. Additionally, feelings of helplessness, lack of control, or perceived threats during treatment may provoke a fight-or-flight response and can lead to agitation or violence.9,10
Counterbalance training and TACT (Tactical Approach to Caring Training) techniques. Train all bedside staff in evidence-based techniques that focus on caregivers’ abilities to maintain composure and lead negotiations with patients in emotional distress.11 These techniques prioritize verbal communication, calming techniques, and empathy-driven engagement to reduce agitation, along with sensory modulation such as soft lighting and quiet spaces to prevent escalation and ensure a trauma-informed response to behavioral crises without resorting to physical restraints.12,13 Using principles of tactical empathy and emotional regulation provides an effective approach to de-escalation.
Risk communication and team collaboration. Implement regular interprofessional team huddles or safety briefings to discuss current patient risks and mitigation strategies. Clear communication channels among nurses, security, and other staff members are essential for a coordinated response to emerging threats.14
Patient-centered communication. Use tactful silence (ie, the strategic use of pauses in conversation, allowing patients time to process their thoughts and emotions without feeling pressured to respond immediately), tactical empathy (ie, empathy used to achieve a safer and more controlled outcome by fostering trust and guiding the patient toward cooperation), and resonant language (ie, language that resonates with the patient, meeting them where they are emotionally and speaking in a way that reduces defensiveness and anxiety while promoting trust and calm) to build rapport with patients and reduce their anxiety or frustration that could elevate emotional responses. Training nurses in tactical communication skills is crucial for effectively addressing patient concerns and preventing escalation.
Environmental and situational awareness. Educate staff on maintaining situational awareness, including understanding the layout of the environment, potential escape routes, and available support resources. Training staff to adjust the physical environment by removing potential weapons or ensuring sufficient space can help reduce violence risks.5
Personal safety and self-protection strategies. Teach nurses and bedside staff self-protection strategies, such as maintaining a safe distance, positioning themselves between the patient and an exit, and employing environmental tools as barriers. Regular training in least restrictive techniques (ie, using the minimum necessary intervention to manage challenging behaviors while maintaining the dignity and autonomy of the individual, and minimizing physical restraint or force whenever possible) for physical restraint is essential for patient safety when necessary.
Technology and duress systems. Use wearable duress alarms or panic buttons to provide staff with a quick and reliable way to call for help in emergencies.15 Although body-worn cameras have proven effective in reducing workplace violence and providing evidence for de-escalation, they can also present legal risks for nurses if footage reveals improper use of force, especially in cases where hospitals have not provided adequate training in self-defense or protective techniques.16,17 To avoid legal implications that could affect a nurse’s licensure, organizations must implement robust policies and provide comprehensive training on both use of force and ethical camera use, ensuring that cameras are not used punitively or coercively but as part of a broader strategy for staff and patient safety.
Postincident analysis and support. Conduct thorough debriefings following any violent incident to identify contributing factors and adjust protocols and training accordingly. Avoid using terms such as escalation, fault, and improvement ideas until adequate psychological support and counseling have been offered to staff and affected patients and visitors. Cultivating a culture of safety is imperative for maintaining a healthy work environment.
Conclusion
The increasing violence in health care settings necessitates comprehensive training and innovative strategies to protect both staff and patients. As frontline caregivers, nurses must advocate for safety measures that empower them to fulfill their critical roles effectively.
References
Footnotes
To purchase electronic or print reprints, contact the American Association of Critical-Care Nurses, 27071 Aliso Creek Rd, Aliso Viejo, CA 92656. Phone, (800) 899-1712 or (949) 362-2050 (ext 532); fax, (949) 362-2049; email, [email protected].
Financial Disclosures
None reported.
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