No one should have to deal with aggression within his or her occupation, but healthcare professionals often do.
You may have recently seen in the media public awareness advertisements reinforcing that violence towards healthcare workers is NOT ok and that there should be zero tolerance for it.
Violent incidents are more likely to occur around staff who are directly involved in patient care, namely nurses, emergency room staff and paramedics. The regularity of aggressive or violent episodes will generally depend on what area of healthcare you work in; aggressive and violent situations can either be a regular occurrences (e.g. in mental health), or something completely out of the ordinary (e.g. a day procedure unit.) (WHO 2018).
Statistically, 8-38% of healthcare workers around the world experience some form of physical violence in their career. And that’s just physical violence; many more are exposed to verbal aggression coming from not only patients but visitors too.
These numbers vary significantly due to the underreporting of violent episodes (Mayhew & Chappell 2003; WHO 2018).
Violence in the workplace can have many negative effects on the individual. It can affect their physical health, as well as their psychological and emotional wellbeing resulting in decreased motivation, anxiety and depression (WHO 2018).
Safe Work Australia (2017) has found that females are more than twice as likely to experience workplace violence than males, and that 15% of all mental disorder claims by workers are caused by exposure to workplace violence.
There are different strategies that can be used in order to protect healthcare workers against violence.
These approaches can be in the form of hospital policies such as codes, as well as training for those workers who are more at risk of experiencing some form of violence in their day to day work.
One of the aims to decrease violent and aggressive situations is to try and prevent them from occurring in the first place. This can include the use of risk assessments to identify those higher at risk of becoming aggressive and violent, as well as ensuring a calm and supportive environment is provided for the patient, especially psychiatric patients (Gaynes et al. 2016).
It is also important to remember that certain medical conditions can potentially cause an individual to become aggressive. These can include:
- Cerebral insults such as stroke, tumour, seizure, encephalitis, meningitis or trauma
- Conditions with a cognitive impairment such as dementia
- Metabolic disturbances such as hyponatraemia, thiamine deficiency and hypercalcaemia
- Organ failure (commonly liver or renal failure)
- Withdrawal from alcohol, benzodiazepines or illicit drugs
- Drug effects from medications and potential medication interactions.
(Fulde & Preisz 2011)
Responding to Aggression and Violence
If you are faced with an aggressive or threatening patient or visitor, here are some important points to consider:
Remember that your safety is the number one priority
- It is always important to remember your own safety. Call for help and remove yourself from the situation. If you are interacting with a potentially violent person, make sure you have an unblocked exit route.
Call for help
- A Code Grey is a coordinated response to actual or potential aggression or violence whereas a code black involves a weapon or serious threat to personal safety, however, it is important to note that these codes can vary from state to state in Australia. Always be familiar with the code criteria within the setting in which you are working. With any code, it is always better to call a code early and for it be a false alarm, then to call it too late. A code that is called late often causes a situation that is a lot harder to get under control again. If there is any doubt about your safety, it is always safer to call for help early and then remain at a safe distance until that help arrives (ANMF 2017).
Treat any suspected or identified medical problems
- Any medical problems that leave the individual as either a danger to themselves or others needs to be treated prior to treating the behavioural disturbance. This advice is mostly relatable to those who have a suspected mental illness, however it is also important to address medical issues in non-psychiatric patients which can include pain and discomfort (Fulde & Preisz 2011)
- Listen to the person. Active listening can be an important component in the de-escalation process. The individual may be aggressive due to fear of their situation, or even due to the fact they have lost control of the situation, so listening to them is an important element of the communication process. And remember when you are listening, you also should avoid giving opinions on issues that are beyond your control (Fulde & Preisz 2011; Lowry 2016).
Acknowledge their anger
- Use reflective comments, and use the words that are spoken by the aggressive individual, but keep these comments brief. Don’t use statements that can be perceived as devaluing the patients such as ‘you shouldn’t be angry’, instead use statements like ‘I can see you are angry’. This type of statement can also be a good opening to explore their feelings, giving them a chance to speak about how the are feeling. Often when an individual has an opportunity to express their anger, it can assist in lowering their levels of anger and therefore decrease the risk of a violent outburst (Lowry 2016).
- Resist the temptation to fill silences with words… it can be hard! A good strategy to implement is if the silence feels uncomfortable, slowly count down to ten, by doing this you will often find the other person will break the silence (Lowry 2016).
- Make sure you maintain eye contact that is appropriate for the individual as well as ensure your body language is open and relays both your interest and engagement to the person. For example, a slightly inclined head can show that you are interested, as well as be a non-threatening posture to have in these types of situations (Lowry 2016).
- With the use of empathy, make sure it is kept brief. Paraphrasing can be a way to express empathy to the patient, and this also shows the patient that their concerns are being listened to and being taken seriously. This can also be a strategy to ensure the information the nurse is gathering from the patient is accurate (Lowry 2016).
- Offer food and drink and a place to sit (Fulde & Preisz 2011).
- Avoid excessive stimulation (Fulde & Preisz 2011).
- Remember that you can utilize the person’s family and friends to help if required (Fulde & Preisz 2011).
- Medication management
- In some cases, the individuals’ aggression and violence may need to be managed medically by sedation. This will be dependent on the patient and their situation and medication will be used as a last resort in these situations (Fulde & Preisz 2011).
Following any sort of incident that involves violence and aggression, it is important that any staff involved in the situation attend a debriefing session as well as be followed up to monitor their physical, psychological and emotional wellbeing. It is also important that the incident is reported to ensure accurate data collection and for quality improvement purposes (Lowry 2016; Department of Health & Human Services 2017).
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- Australian Nursing & Midwifery Federation 2017, New violence response policy clears up grey areas, 27 September, viewed 4 September 2018, https://www.anmfvic.asn.au/news-and-publications/news/2017/09/27/codegrey
- Fulde, G & Preisz, P 2011, ‘Managing aggressive and violent patients,’ Australian Prescriber, vol. 34, no. 4, viewed 4 September 2018, https://www.nps.org.au/australian-prescriber/articles/managing-aggressive-and-violent-patients
- Gaynes, BN, Brown, C & Lux, LJ 2016, ‘Strategies To De-escalate Aggressive Behavior in Psychiatric Patients [Internet].’, Agency for Healthcare Research and Quality (US), viewed 4 September 2018, https://www.ncbi.nlm.nih.gov/books/NBK379388/
- Mayhew, C & Chappell, D 2003, ‘Workplace violence in the health sector: A case study in Australia’, The Journal of Occupational Health and Safety: Australia and New Zealand, vol. 19, no. 6, viewed 4 September 2018, http://www.who.int/violence_injury_prevention/violence/en/wpv_australia.pdf?ua=1&ua=1
- Safe Work Australia 2017, Workplace violence, viewed 4 September 2018, https://www.safeworkaustralia.gov.au/workplace-violence
- Department of Health & Human Services 2017, Code Grey Standards, Victoria State Government, viewed 4 September 2018, https://www2.health.vic.gov.au/about/publications/policiesandguidelines/code-grey-standards
- World Health Organization 2018, Violence and Injury Prevention, WHO, viewed 4 September 2018, http://www.who.int/violence_injury_prevention/violence/workplace/en/
Sally is a Rehabilitation Clinical Nurse Specialist and Nurse Educator teaching the Diploma of Nursing. She is passionate about education in nursing so we can become the best nurses possible. Sally has experience in many nursing sectors including rehabilitation, medical, orthopaedic, neurosurgical, day surgery, oncology, emergency, aged care and general surgery. Sally's Blog.