Recognize Threatening Behavior to Prevent Workplace Violence

By understanding the signs of potential violence and knowing how to intervene, nurses can create a safer work environment.

Editor’s Note: This is an excerpt from Preventing Emergency Department Violence: Tips, Tools, and Advice to Keep Your Facility Safe, by Lisa Pryse Terry, CHPA, CPP.

The clock is ticking. The risk of a loved one not being treated quickly enough before her condition worsens causes great anxiety for a family member who begins pacing and becomes increasingly angry (potential risk). Seeing the crowded emergency department and assuming the staff are too busy to provide immediate attention for his family member triggers the perpetrator to seek immediate medical attention by commandeering staff to assist him (stimulus). An unattended door with a restricted access sign for employees only provides an opportunity for the perpetrator to grab and force a clinician to help now (opportunity to act). Violent behavior erupts, nurses are terrified, and chaos ensues.

The theoretical situation above could have been avoided with proper training and ability to recognize threats early. Understanding how perpetrators behave is key to managing threats. There are some commonalities among individuals who pose a threat. Recognizing threatening behaviors allows resources to intervene at the earliest possible stage.

Most all perpetrators consider, plan, prepare, and then act. This allows intervention at multiple points along the violence spectrum. But effective intervention to decrease threats is dependent on training and experience that enable security officers, public safety, and police officers to fully recognize and identify the early signals. Intervention also relies on nurses and healthcare staff understanding the signs of pending violence.

Collaboration is Key to Safety

Nursing by nature requires staff to be physically close to patients who can quickly become agitated or violent. Close contact increases the likelihood that a nurse or other clinician will become the victim of physical violence, especially if the signs of violence are not recognized early. This increases the need for clinical staff training on the violence spectrum as well as related security training, de-escalation techniques, and personal safety training.

A collaborative effort and integrated training for healthcare security staff and clinicians increases safety for everyone. It also helps define roles and responsibilities if an event occurs. Collaboration reinforces what to expect if an event occurs and how resources can be quickly assimilated.

Security and healthcare staff who are able to proactively deal with threats and/or threatening behavior early—detecting threats early, evaluating them, and knowing how to address them—may be the single most important key to preventing and managing violence.

Recognizing Potential Violence

So how do security and healthcare professionals identify the signs to decrease threats?

In Chapter 3, we discussed the impact of the violence spectrum and the importance of managing threats of violence. All staff should be trained on the components of anger and impending violence, which present in three primary ways:

• Physical reactions—These reactions include an individual’s response to anger, frustration, and potential violence such as an adrenaline rush, increased heart rate and blood pressure, and tightening of muscles for the “fight or flight”
   
• Cognitive Experience—This involves how an individual perceives he or she is being treated. If he believes he is being treated unfairly, prejudicially, or in any negative way, the risk of becoming angry and violent escalates.
   
• Behavior Changes—Individuals considering a violent action or response will display behavioral changes such as change in demeanor, verbal or voice changes, and nonverbal cues of agitation and frustration such as tapping fingers, rapid eye movement, or pacing.
   

Security and healthcare staff must understand the significance of verbal and nonverbal cues. Key threat management strategies focus as much on nonverbal communication as they do on verbal communication. According to various researchers, body language is thought to account for between 50 to 70% of all communication.

For example:

• In a crowded waiting area, a family member feels claustrophobic and becomes agitated.
   
• A worried parent continually reaches out for the nurse’s arm in hopes of getting more attention.
   
• An agitated spouse paces back and forth in front of the doors leading to restricted treatment areas.
   
• The eyes of a frustrated patient dart back and forth continually.
   
• An anxious spouse believes it is taking way too long to get an updated report on his wife, and begins clenching his jaw.
   
• A forensic patient visually scours the treatment room for a weapon of opportunity.
   

These are all signs of potential violence. Space, touch, body movement, and perception of time are all ways people express their frustration and anxiety. Proactively identifying these particular behaviors of concern can help reduce the risk of violence in the ED and contribute to a better patient experience.

Responding to nonverbal cues may be as simple as:

• Providing a brief update on the status of a loved one
   
• Giving a person a reassuring smile and greeting
   
• Explaining that it’s important to conduct thorough testing to provide the best treatment possible
   
• Acknowledging a person’s feelings
   
• Offering to get an anxious parent a cup of water while she waits
   

Eye contact can also indicate genuine interest and concern for a person and alleviate anxiety. In an overcrowded ED, speaking to the agitated person and offering to help him find a more comfortable place to wait can defuse anger.

Verbal communication is also an important indicator of agitation, frustration, and pending violent actions. Tone of voice, loudness, inflection, intonation, and rapid speech are red flags. Once verbal communication escalates to cursing, threats, and disrespectful language, rapid de-escalation is critical to lessen risks.

STEP(s) to Managing Threats

Working together, security and healthcare professionals can decrease or minimize threats to safety and block opportunities to act. They can integrate case management into the security management strategy to lessen the threats.

Effective threat management strategies incorporate the STEP process:

S: De-escalate, contain, or control the subject who may take violent action
T: Decrease vulnerabilities of the target
E: Modify physical and cultural environment to discourage escalation
P: Prepare for precipitating events that trigger adverse reactions

Utilizing the STEP Process is an effective means of managing threats. Some questions to ask in the process include:

• What is motivating the individual to become a threat?
   
• Has the individual communicated his/her intentions as a threat?
   
• Is the individual demonstrating physical actions of threat?
   
• Does the individual have access to weapons?
   
• Are there unusual objects that could be used as weapons?
   
• Are there bystanders to consider and remove from harm’s way?
   
• Has the person taken aggressive action (pushing, striking)?
   
• Is the person argumentative?
   
• Is he/she displaying unwarranted anger?
   
• What is the stimulus for action and how can it be removed?
   

Responding positively to verbal signs of anxiety is extremely important in the ED environment.  Keep your voice calm, repeat what you hear to reassure the person you understand, look the person in the eye when she is speaking, and seek to understand the underlying cause of agitation. People who visit the ED are usually nervous and fearful of a diagnosis or treatment process. Many things in the ED environment can put that fear into overdrive and then violence occurs. Watching for the earliest signs of violence and utilizing strategies to overcome fear and anxiety are an essential part of the healthcare security team’s job.