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Crisis Intervention in the Workplace

Vol. 6 •Issue 23 • Page 32
Crisis Intervention in the Workplace

Responding to potentially violent situations in the workplace requires a systems approach

Jane, the charge nurse on the 3-11 p.m. shift in a 22-bed psychiatric unit of a tertiary hospital, receives an intake call from the ED informing her she will receive an admission in about 30 minutes, after the patient is cleared medically.

Jane listens to the report about this patient from the triage nurse in the ED. Robert is a 30-year-old white male with a diagnosis of paranoid schizophrenia. He has a high-risk potential for violence. A treatment plan has been initiated in the ED with the primary goal being to decrease the potential for violence to him and others.

Further information included: police were called to the partial hospitalization program the patient attends after he struck a nurse on her arm. A patient in the partial program for 5 months, Robert became angry when denied a cigarette break. His anger escalated quickly despite attempts by staff to remove him from the group and redirect him. After he hit the nurse, he was found outside smoking and left the facility with the police without further incidents.

In the ED, Robert was assessed as being agitated, pacing frequently; he says he is hearing voices, but does not reveal what the voices say. He barely is maintaining control with admission procedures. He lacks insight into his immediate needs and, therefore, doesn't see the need for admission.

Pre-Planning for Admission

As soon as Jane finishes talking to the ED triage nurse, she begins pre-planning for Robert's admission, recognizing that providing a safe environment for Robert, the other patients and staff is the No. 1 goal now. Fortunately, this unit has a plan in place that provides training for staff that includes the knowledge and skills to appropriately respond to crisis situations that may involve violence.

Crisis intervention skills are a necessity on any nursing unit; it is imperative you know the basics of how to assess, plan and intervene if the potential for workplace violence threatens. Most healthcare employees are acutely aware of incidents in their practice that resulted in actual or threatened violence with patients, families of patients and even staff. Too often in the past, these situations, which create fear and panic among healthcare providers, are viewed as only occurring sporadically or considered part of the job. How to intervene was put on the backburner until the next incident occurred. Today, we recognize these incidents occur much more frequently.

Escalating Workplace Violence

OSHA cites the incidence of violence is higher among healthcare facilities and healthcare workers compared to other workplace settings and groups of workers. For example, from 1996-2000, there were 69 homicides in health services, and in 2000, 48 percent of all non-fatal injuries in the workplace occurred in healthcare and social services (OSHA, 2004).

Regulatory Agencies

The National Institute for Occupational Safety and Health defines workplace violence as "violent acts, including physical assaults, directed toward persons at work or on duty."

In the past several years, OSHA, the Department of Justice, the FBI, JCAHO, states and professional organizations have mandated strict guidelines and standards to decrease the incidence of workplace violence. For employers, the legal standard for protecting patients/ families is clearly stated: It is a "breach of legal duty if reasonable care is not used to prevent a foreseeable risk of injury to others."

Effective Prevention Program

An effective violence prevention program in the workplace starts with committed and involved administration, management and staff. Before any plan is initiated, a work-site analysis must be done with all team members participating. For example, the team should determine what the risk factors for violence are for their specific community, hospital and unit/department within the hospital.

Primary risk factor assessments for violence include: prevalence of handguns/weapons in community; acutely disturbed, violent individuals treated annually in hospital (ED/psych, detox units); prevalence of mentally ill in the community without follow-up; and patient population of gang members, substance abusers and trauma victims treated.

Of course, the workplace analysis must include a careful assessment of the high-risk violence potential for each unit/department/personnel within the hospital. For example, such practices as isolated work areas during exams and treatments must be assessed, as well as other environmental/architectural issues. Staffing ratios are critical during increased activity periods.

This assessment also identifies the resources, strengths and skills of each department and its personnel – critical information when developing the hospital's plan. For example, if a hospital has a large psychiatric unit that frequently admits patients with the potential for violence, the unit staff can be the experts in teaching other staff about how to assess and intervene with hostile patients.

Safety and Health Training

Once the work-site analysis is completed and administration and staff have identified risk factors for violence, it is time to develop a safety and health-training prevention and intervention program for workplace violence. To be time- and cost-effective, the program should be individualized to each unit. Training for all staff in violence prevention should be mandatory. However, units that have a documented incidence of violent acts, such as the ED and psych units, will receive more training on the use of teams, de-escalation techniques and restraints.

Certainly, this training must be ongoing with staff competency evaluated periodically.

The last element of an effective violence-prevention program must include record-keeping and evaluation of the program's effectiveness.

Potential for Violence

Who is a potentially violent patient, neighbor, relative or co-worker? For individuals who have not had experience with someone who becomes hostile and then exhibits verbal or physical violent behavior, this is always a central question.

Accounts in the media involving a violent event frequently report neighbors reporting the perpetrator as a quiet person who rarely bothered anyone. However, almost always there are overt and covert signs of the person's potential for violence.

The best predictor of violence is the individual's history of previous violent acts. Certainly, if the person has a known psychiatric history that includes psychosis with delusions, substance abuse and/or personality disorders — antisocial, borderline or narcissistic — he should be considered a threat.

'I Get So Mad Man'

Besides the psychiatric causes for aggression, there are a number of social and medical causes. Domestic abuse and homelessness are just two social causes that may contribute to violence. There are numerous underlying medical causes that can trigger aggressive behavior. The mnemonic, I GET SO MAD MAN, details 12 medical causes that can provoke violent behavior. They are infection, geriatric, epilepsy, trauma, strokes/infarcts, organic/tumors, medications, acidosis, delirium, metabolic (e.g., electrolytes and renal), alcohol and neurological (e.g., Huntington's chorea, MS).

As a nurse, a quick assessment to determine an individual's potential for disruptive behavior is to focus on what the individual's immediate experience is, then explore what influence the environment adds to his current behavior and then factor in what you know about his physical, cultural and emotional factors.

Anger Diffusion

Nurses and all allied healthcare workers need to have a working knowledge on how to diffuse anger once they've assessed a high-risk situation. For example, a situation may develop when a patient or their visitor confronts you and becomes verbally assaultive. It begins simply as excessive questioning by the person, which may escalate, particularly if they don't receive the answers they want. Eventually this individual threatens, "If I don't get my way, I will É"

How will you handle this situation? Early de-escalation behaviors include: remain calm; listen attentively; always treat the person with respect and dignity; isolate the situation; set clear enforceable limits — and if necessary use backup resources. Realize control issues are at the root of this confrontation.

What you don't want to do in this situation is: personalize the client complaints; argue with the client; overreact; make false promises — and definitely not threaten the individual. If possible, try to negotiate "yes" responses.

Safety and Security

As you attempt to diffuse this individual's anger, you recognize his anger is escalating. Some of the assessments you may note at this time are increased motor agitation, more verbal threats, gestures toward real or imagined objects and behavior reaching a crescendo quickly. You also may have a history or detect signs indicating possible use of alcohol or drugs

While waiting for the team, it is important to remain with the patient. Additionally, as the primary person providing intervention, you want to make sure you model calmness, both verbally and non-verbally. For example, you want to allow sufficient personal space between you and the aggressor; convey a posture that indicates you will help the individual gain control of his behavior without aggression. Your verbal exchanges should connote caring and authority. Do not speak too loudly, too rapidly or with a demanding inflection in your voice. Reply to the patient's demands with simple, clear, direct answers. Approach with the attitude that you know this individual is struggling and wants help to regain control. The goal is to defeat the problem, not the person.

Initially, you want to remove the person to a quiet, calm environment, free of environmental hazards. Your concern here is to meet the patient's safety and security needs since he is unable to do this independently. However, it is essential at this point to make sure you communicate to the rest of the staff that the team approach for violence prevention is now in effect.

If you are able to grant reasonable requests for this escalating individual, this may mean the difference between de-escalation and violent behavior. For example, if the patient requests a cigarette on a non-smoking unit when his anger escalates, what is your policy? Types of interventions like this should be spelled out clearly in the unit plan. These policies should influence how the care plan is developed and implemented.

Team Approach

When an individual's anger continues to escalate and aggressive behavior is imminent, the team plan must be implemented quickly and smoothly with all members knowing their respective roles. The short-term goals now are to control the disturbed behavior, suppress the symptoms and effect a rapid return to the best level of functioning for the patient — and to protect other patients and the staff.

At this point, the need for an external control system becomes evident. Medication management of the disruptive symptoms is key. Physical restraints may be necessary. Implementing the violence prevention plan now would call for the leader to call the code, according to the hospital policy. Generally, unit staff are aware of the crisis, but additional staff from other units respond to the call as well as hospital security. The leader manages the code; she designates a licensed nurse to serve as the medication nurse, staff to intervene with physical restraint. For example, perhaps two staff are responsible for the patient's upper extremities; another two for the lower extremities. Promotion of staff safety in a code (takedown) is always considered paramount in any intervention. Staff is delegated to provide environmental support that includes maintaining privacy for the patient; other staff is needed to support other patients and visitors.

Post-Aggression Briefing

After a code for aggressive behavior, a debriefing should occur. This allows opportunity for the team to "defuse" themselves as well as review clinical and written interventions to validate nursing practice and review areas for improvement.

Workplace violence can be decreased significantly when an ongoing plan to prevent and intervene during these situations is implemented, evaluated and updated on an ongoing basis. However, if any link in the management chain is broken, the plan will be ineffective.


Occupational Safety and Health Administration, U.S. Department of Labor. (2004). Guidelines for preventing workplace violence for healthcare and social service workers. Washington, DC: OSHA 3148-01R.

Marianne Howard-Siewers is director of behavioral health nursing at Coney Island Hospital, Brooklyn, NY.


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