General Safety Measures

Don't get cornered: If the person who is angry, agitated and threatening is between you and the only exit, you could be in physical danger. You won't be able to get past the person to get to the door. Keep an exit available. Position yourself so you can leave the room safely and go for help. At the same time, be careful not to corner someone who is angry or paranoid.

Allow enough space: If you stand over or within reach of someone who is angry, agitated or threatening, you put yourself in danger. If possible, position yourself so the door is accessible to both of you. Keep your distance and position yourself so you can't be hit or kicked if the person takes one step. Do not stand over the person or make persistent direct eye contact; this can be perceived as threatening to people who are paranoid. Give the person plenty of personal space to help him feel less threatened and allow enough space to help keep you safe. Additionally, scan the perimeter; are there weapons of opportunity within reach?

Keep your hands free: When someone is angry, agitated or threatening, you are more vulnerable if your hands are in your pockets, behind your back or on your hips. You also may seem more threatening to someone who's paranoid if they can't see your hands. Keep your hands relaxed, bend your arms slightly at the elbows and keep your hands in front of your thighs. This position will help you protect yourself quickly if needed. It also makes your hands visible so you're less threatening to someone who's paranoid.

Balance and angle: Standing so you completely face a person who is angry, agitated or threatening makes you an easy target to hit or kick. Standing with your weight on one foot can slow you down if you need to get out of the way quickly. Stand so that your body is at an angle. This will make it harder for the other person to hit or kick you. Keep your weight balanced on both feet so that you can move in any direction in a hurry. If you position yourself this way, you'll be able to respond more quickly and you'll be safer.

Setting limits: Angry feelings are natural, but when they are expressed inappropriately, they need to be addressed. However, remember, appropriate anger should be validated and permitted.

When an angry outburst occurs, react with calmness. An angry reaction from the nurse will only escalate the situation. You must not mirror the client's inappropriate behavior. Remember, when you lose your temper, you lose.

Model how to be assertive rather than aggressive. Remember, the assertive comment says what you need and explains how you feel. It is delivered calmly. Example: "Mr. Jones, I understand this is very upsetting and I truly want to help, but I am getting concerned that something might happen to injure me or someone else. I am concerned about my and your safety."

The use of "I" (versus "you") statements will share your serious concerns with Mr. Jones without sounding like you are blaming him for a situation where he might already feel out of control.

Who Is At Risk?

All of us are at risk.

There is a higher risk for those who directly deal with agitated patients or families, particularly if they are intoxicated or otherwise emotionally impaired. Most importantly, there is a particularly high risk for everyone when someone hears a threat (overt or veiled) and tells no one, disbelieves it or takes a "watch and wait" approach.

If your facility has a zero tolerance for violence policy, it is important to know exactly to whom to report what form of threat or violence and how to do so. Are you clear about what is deemed as violence or an increased risk for violence in your facility?

The importance of vulnerability risk assessment can be invaluable. When conducting a successful assessment, it's important to do it during a non-crisis time when you can:

• seriously examine your environment;

• be clear about what places you at risk for violence or injury; and

• to be certain about your facility's policy and procedure on violence in the workplace.

Unfortunately, a significant violent episode may only need to happen once to forever change the life of the nurse, and truly supports the age old adage: "an ounce of prevention is worth a pound of cure."

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References
1. National Institute for Occupational Safety and Health. (2009, May 28). Multi-city study of the magnitude and risk factors of workplace violence among health care workers and pharmacists. Retrieved June 29, 2009 from the World Wide Web: http://cdc.gov/NIOSH/topics/violence/traumaviol_research.html#pharmacists
2. Occupational Safety and Health Administration. (2004). Guidelines for preventing workplace violence for health care & social service workers. Retrieved June 29, 2009 from the World Wide Web: http://osha.gov/Publications/OSHA3148/osha3148.html

Paul Clements is an associate clinical professor at the Drexel University College of Nursing and Health Professions, Philadelphia. A psychiatric/forensic specialist, he also is a certified gang specialist.