Mitigating the Risk of Violence in the Healthcare Setting

Executive Summary

Violence in the healthcare setting is common, and reducing the chances of it means establishing a culture of intolerance in which acceptable conduct is clearly defined and violations of it have appropriate consequences. Staff training, respectful treatment of patients and a safe office environment can go a long way towards preventing problems. In some cases, termination of care might be necessary to eliminate any danger caused by an individual patient, though it should be the last option for dealing with an aggressive individual. 

Recommended Actions

• Establish and clearly communicate a culture of intolerance of aggressive behavior.
• Train your staff on how to prevent and manage conflict and assess patients for the possibility of aggression.
• Create a patient-provider agreement, including expectations for behavior and consequences for noncompliance, and clearly communicate it to patients when necessary.
• Create a safe physical office environment.
• Prepare for termination of care in extreme cases.

According to the Bureau of Labor Statistics, workers in the healthcare and social service sectors experience the most violence of any industry. A 2018 analysis found that healthcare and social service workers were five times as likely to experience workplace violence than workers overall. Healthcare workers, specifically, made up 73 percent of all nonfatal workplace injuries and illness due to violence.¹

Similarly, a survey of registered nurses completed in August 2021 found that 44 percent experienced physical violence and 68 percent experienced verbal abuse between February and June 2020.²  

The issue of healthcare workplace violence is complex and multi-faceted. This article focuses on the prevention, management and response to healthcare violence specifically involving customers, clients and patients, which, according to the 2021 Healthcare Crime Survey, accounted for 73 percent of aggravated assaults and 86 percent of simple assaults against healthcare workers.³ 

Reducing the Risk of Aggression

Risk mitigation in response to the dangers of aggression and violence in the healthcare industry is not a call for zero tolerance. Although that term sounds strong and effective, it is not the solution, given the varying degrees of fragility, mental stability and vulnerability in our business. We cannot say that everyone gets the same punishment for aggressive behavior, regardless of the etiology. 

Zero tolerance does not allow us to use discretion in managing a situation. For instance, if you have a zero-tolerance policy that states that if patients yell at you, you will discharge them from the practice, there’s no room for discussion.

The following seven strategies will help you establish a consistent and firm approach to threats of violence in your practice. 

Strategy 1: Establish a Culture of Intolerance 

Unlike other industries, healthcare does not have an established culture of intolerance. We all know that there are expected rules of behavior at an airport, for example. We can’t yell; we can’t threaten; we can’t physically act out. If we do, there will be several TSA agents escorting us out the door. In a restaurant, we know we must wear a shirt and shoes if we want to be served. Each culture has its own expectations. But in the healthcare environment, there are no clearly defined rules of conduct.

We, as an industry, must do a better job of educating our patients and the community about the level of violence in healthcare and the consequences of inappropriate or threatening behavior. A culture of intolerance begins at the door of your practice. Just as many organizations post signs that reflect their culture and the lack of tolerance for disruption, so can your medical practice.

When you decide to institute a culture of intolerance, it is important to communicate that change to your patients. Some practices mail letters to all patients; others give written notice to patients during an office visit.

These letters should come from the provider or owner of the practice and educate the patient about the rate of healthcare violence along with an explanation of any new practice protocols to keep everyone safe. This letter should also contain a patient code of conduct for office visits. 

Strategy 2: Meet Patients’ Needs 

Employees of the medical practice have a key role in maintaining a safe environment with a policy of intolerance. Unfortunately, many practices have inadequate employee acquisition, supervision and retention practices along with inadequate training on how to prevent or manage conflict — especially with people who are anxious about medical issues and those with mental health and substance use issues.

Inappropriate attitudes of the staff cause a fair amount of aggressive behavior in patients. To mitigate the risk of aggression, we need to present a consistent attitude of dignified respect and learn to avoid escalation of incidents. This is our first line of prevention. 

Greet patients. No doubt this scene is familiar to you: You arrive at a doctor’s office and stand at the front desk waiting for acknowledgement. You wait while the staff ignores you. You wait and wait and wait. They keep typing, filing, shuffling folders. You wait.

This lack of greeting creates an immediate state of tension and frustration — the groundwork for aggression. Even busy staff members can be trained to look up immediately when a patient enters, make eye contact, say hello with a smile, and give a simple directive to sign in. 

Minimize waits and apologize up front for any delays. Delays happen in the medical field, but failing to communicate that fact is a common reason that patients get angry. Train your staff to give estimated wait times and regular updates.

Apologize for delays and then give options: Do you want to reschedule or do you want to wait? This respects the patients’ time and proactively intercepts the possible angry outburst over waiting too long.  

Provide diversions. Anything that distracts people from their medical worries and from the annoyance of waiting is going to help keep anxiety and agitation down. Have a TV or music in the waiting room; allow cell phone, iPad and computer use; provide magazines; offer coffee or water and snacks. 

Offer integrated services. All healthcare settings should have brochures offering information and resources for substance use and mental health issues such as depression, alcohol use, anxiety, bipolar disorder, PTSD and other challenges.

If a patient does not need the help directly, they may know someone who does and may take the information to pass it along. You can get these resources for free from local, state and federal mental health organizations such as the Substance Abuse and Mental Health Services organization at www.samhsa.gov.  

Strategy 3: Assess Patients for Aggression Potential 

Approximately one quarter of the people we treat every day have some form of mental illness or substance use issues.⁴ There are evidence-based tools to predict aggression in our population that would allow for early and proactive intervention. In other words, don’t wait until a situation has exploded. Follow the protocol as soon as staff members observe anxiety and agitation in a patient.

Routinely observe patient behavior. All staff should observe and assess patients for signs of anxiety and agitation, both in the waiting room and the examining room. They’re standing. They’re fidgeting. They’re pacing. They’re walking in and out of the room. They’re obviously nervous. This behavior calls for first-step interventions. Talk to them. Tell them why the doctor is running late. Give them something to distract them. Provide verbal assurance that they are in good hands.

Utilize behavioral health clinicians. In an ideal world, medical providers integrate behavioral health resources into the practice. In this setup, when you identify a patient who could use a behavioral assessment, you can quickly refer them to somebody within the practice who can see them in a timely fashion. This would remove the burden of dealing with behavioral health issues from the shoulders of the office physician and staff. 

Flag the EMR. After an aggressive, threatening, hostile or violent event, be sure to flag the patient’s electronic medical record so that every provider, every nurse, every tech, everyone who’s working with the patient knows that there’s the potential for aggression. The practice should have a written procedure for how the flag is initiated and for how it is taken off the medical record.

Strategy 4: Create a Patient/Provider Agreement 

Because the healthcare community rarely has an established protocol for dealing with angry, demanding, loud and/or threatening behaviors, it is not surprising that the response to these behaviors is weak.

As compassionate healthcare providers, we try to understand the cause of an outburst and make allowances for mental health and substance use factors. We do not make it immediately clear that such behavior is not tolerated. 

Naming the behavior for what it is, regardless of the circumstance surrounding it, is vital to creating a safe working environment. It is aggression. It is not acceptable. When it occurs, it has to be addressed and managed. A patient/provider agreement is a vehicle for doing this in a way that meets the specific needs of specific patients.

The provider and the practice manager, not a nurse or receptionist, should initiate this agreement with a patient. The agreement should not be delivered as a form to read and sign. It is created through dialogue when the provider and the practice manager sit down with the patient and say, “Look, we’re having difficulty. We want to keep treating you, but your aggressive behavior is making it difficult for us to treat you safely.”

Expectations for behavior and consequences if they are not followed should be outlined. “Going forward, this is what you can expect from us and this is what we’re going to expect from you. If you cannot follow these rules of behavior, then we need to figure out what the next step will be in our provider/patient relationship.”

Be sure to add this conversation and the agreement to the patient’s medical record. Give the patient a copy of the signed agreement. Document their words and their responses to whatever your interventions will be. Note if they disagree or refuse to sign the agreement. Note the exact words they use if they refuse intervention or counseling. Flag the record for aggression. 

Strategy 5: Debrief Staff Following Acts of Aggression 

After a disruptive event, it is vital that your team get together and review what happened to prevent future incidents.

Identify what the patient was doing before they escalated. What was our response? What could we have done better? What do we need to do now with this patient? This discussion will help everyone in the office learn something new about either this patient or about how to better manage aggression in the future. The discussion should be routine, constructive and non-blaming. In this way, the debriefing will help you identify opportunities for improvement.

Strategy 6: Create a Safe Office 

No matter how proactive you are in preparing your staff and patients, you still need to be prepared for the worst. For this reason, it is important to conduct an office risk assessment for potential dangers or hazards.

Walk around. Take a fresh look at your office setup, thinking about safety. Look closely at where things are, look where things are easy to grab. Look at the glass at the reception desk; make sure it’s safety glass or plexiglass so that nobody will get harmed in case it’s damaged. 

Look at the furniture layout. Do staff members have immediate egress out of treatment rooms or are they backed up against a wall? If they are, rearrange the room, if you can, so providers and staff are near the door. If the furniture can’t be rearranged, at least practice situational awareness by moving to stand near a door whenever possible. 

Install panic buttons. Contact your local law enforcement officials to find out if you can have a one-touch button installed that would directly alert police to a dangerous situation. Given the number of people who enter your office every day bringing mental health and substance use issues with them, being able to quickly ask for help is vital.  

Secure the entrance to back office/treatment areas. Can an irate patient leave the waiting room and barge into the area where your treatment rooms and offices are located? If so, it is wise to secure that entrance. Only supervised patients would then have access to providers, staff and medical equipment. 

Limit sharing of staff information. The personal information of your staff should be protected. For example, if your staff wears name tags, display first names only. If you list staff names on your website, use first names only. If you post on social media, do not identify staff members by name. In today’s world of digital interconnectedness, it is too easy for a disgruntled patient to track down a staff member off-site. Of course, provider names are known to patients, but limiting staff information gives your employees an additional level of protection. 

Secure pictures and other items hanging on the wall. Interestingly, when patients get angry and look around for something to throw, they often go for things on the wall. Make sure that all pictures are secured, particularly when they include glass, and consider reframing pictures with plexiglass.  

Secure the office environment. Most practices do a good job of securing syringes, needles and sample medication. You might go one step further and remove needle boxes from treatment rooms, instead using portable, disposable needle boxes. Of course, secure prescription pads, especially if you now write scrips electronically and have old pads that may still be lying around. Also, encourage your patients to pay with credit cards so you can reduce the amount of cash in the office that tempts robbery. 

Identify a safe place for staff. Given the recent number of active shooter events, staff members need a safe place to go if somebody comes in the front door with a weapon.

Build good working relationships with local law enforcement. Like healthcare providers, police want to help people in distress, so they too may hesitate to arrest someone with a mental health issue who is acting aggressively in your office. We need to educate local law enforcement personnel and work collaboratively with them to enforce the policy of intolerance. 

Invite officers into your practice. Show them the intolerance policy you have given to all your patients. Explain that you will be calling 911 if a patient becomes aggressive, violent or threatening. Explain that, when necessary, you plan to press charges and/or obtain restraining orders and work with law enforcement to keep your staff and patients safe.

Consider asking officers to look around your office for safety or security issues. Ask if you can be trained in how to conduct security drills. Creating a partnership with local law enforcement officials will help you get the word out in your community that you will not tolerate aggressive or violent actions in your practice.

Strategy 7: Prepare for Termination of Care 

Termination of care is the last resort for serious aggression or violence. You protect your liabilities by taking every step possible before termination to address the problem and reduce the danger. Discuss the provider-patient agreement. 

Thoroughly document all conversations and hostile events. If the patient came to you as a referral from another physician, you can advise that physician that you are sending the patient back to them, and the patient will need a new provider. You might refer the patient out to an integrated clinic that can better handle their mental health and physical needs.

Prevention Is Key

The best way to mitigate the risk of violence and the need to terminate a patient is to prevent the escalation of aggression from the beginning. Do not tolerate even minor instances of aggression. Do not make excuses for the patient who yells at your staff. Do not look the other way. Ever.

Know, in advance, exactly how you will handle the most common complaints from your patients. Be sure your staff feels comfortable making this statement: “I cannot continue to speak with you if you continue to raise your voice. I want to resolve this with you, but we have to be able to talk calmly.” 

And, as a provider, do not hesitate to clearly state: “This is the treatment plan, and this is the best practice. It’s all evidence-based medicine. If you don’t agree with it, maybe you should investigate other providers who may be willing to do what you are asking.” 

A policy of intolerance requires the provider and staff to relate a firm and consistent message. You will find that most patients respond positively to firm limits and will be grateful that you have procedures in place to keep them safe — as well as healthy. 

Lessons Learned

• The healthcare industry needs to better educate patients and the community about the level of violence in healthcare and the consequences of inappropriate or threatening behavior.
• Providers aren’t at the mercy of aggressive patients; there are many effective steps that can help prevent and mitigate violence in their offices, including training staff, implementing patient-provider agreements and establishing a safe physical environment.
• While termination of care needs to be done thoughtfully and carefully to avoid liability, it might be necessary in ongoing cases of patient aggression.

Additional Reading 

• Addressing Workplace Violence in Healthcare Settings | Medical Group Management Association 
• Guidelines for Preventing Workplace Violence for Healthcare and Social Service Workers | Occupational Health & Safety Administration 
• The Persistent Pandemic of Violence Against Health Care Workers | The American Journal of Managed Care
• Preventing Workplace Violence in Healthcare | American Association of Critical-Care Nurses 
• Promoting Policy Standards for Workplace Violence Prevention and Management | American College of Physicians 

Monica Cooke, BSN, MA, RN, PMH-BC, CPHQ, CPHRM, DFASHRM, is a certified psychiatric mental health nurse and the Founder of Quality Plus Solutions. 

1 U.S. Bureau of Labor Statistics. (2020, April). Fact sheet: Workplace violence in healthcare, 2018. www.bls.gov/iif/oshwc/cfoi/workplace-violence-healthcare-2018.htm. 

2 Byon, H. D., Sagherian, K., Kim, Y., Lipscomb, J., Crandall, M., & Steege, L. (2021, August). Nurses’ experience with type II workplace violence and underreporting during the COVID-19 pandemic. Workplace Health & Safety. https://journals.sagepub.com/doi/10.1177/21650799211031233. 

3 International Association for Healthcare Security and Safety. (2022, May 18). 2021 Healthcare crime survey. https://iahssf.org/assets/2022-IAHSS-Foundation-Crime-Survey.pdf. 

4 Congressional Research Service. (2018, January 19 [updated]). Prevalence of mental illness in the United States: Data sources and estimates. https://crsreports.congress.gov/product/pdf/r/r43047/14.