Assessing Patients for Potential Violence as Part of De-Escalation

Laura M. Cascella, MA, CPHRM

Mitigating violence in healthcare is a top concern for all types of settings, from small office practices to large health systems. An important strategy in the toolbox for violence prevention is training staff how to de-escalate aggressive, hostile, and violent patient behaviors. Yet, as patient behavior intensifies and edges closer to violence, de-escalation becomes more challenging and secondary to protecting other patients and staff members. Thus, a crucial aspect of de-escalation is assessing patients for the potential for aggression before it occurs.

First, understanding the factors that might trigger aggression can help healthcare workers potentially identify situations in which violence might arise. These factors might be specific to the patient, the situation, or the environment. Examples include:

• Patients’ histories and personal circumstances (e.g., lack of trust in the healthcare system, poor social support, or financial problems)
• Patients’ conditions and symptoms (e.g., behavioral health disorders, substance use, or pain)
• Patients’ interactions with other patients, staff, and healthcare providers (e.g., conflicts, provocative behavior, or feeling dismissed or disrespected)
• Patients’ perceptions of policies and procedures (e.g., bureaucratic, lacking flexibility, or creating roadblocks)
• Stressors in the physical environment (e.g., crowding, noise, or inability to move freely)¹

Any of these factors, alone or in combination, might send patients into a spiral of anger, frustration, fear, and/or rage that can lead to violence. Different violence prevention methods categorize the progression of violence differently. An early but groundbreaking method identified five phases: the trigger phase, the escalation phase, the crisis phase, the recovery phase, and the postcrisis depression phase.² Another framework noted three key categories: potential violence, imminent violence, and emergent violence.³ A third approach classified the development as: the early warning signs stage, the hostile stage, the threatening stage, and the assaultive stage.⁴

Although the terminology and specifics vary, the common denominator with these classifications is the concept that intervening and de-escalating earlier in the progression of violence is more likely to produce a favorable outcome and prevent harm. However, early intervention requires a capable and alert workforce.

Training staff to assess the potential for violence and recognize red flags is imperative for proactively managing hostile situations. Because no two patients are alike, signs of escalating behavior can vary. While some patients might make outright threats, others might have more nuanced behaviors. Thus, staff should understand both conspicuous and inconspicuous signs of aggression. Examples include:

• Restless movements (e.g., pacing and fidgeting)
• Suspiciousness
• Irritability
• Anxious behavior
• Confusion
• Impulsiveness
• Demands for attention
• Threatening body language (e.g., making fists, pounding on surfaces, disrespecting personal space, etc.)
• Dilated pupils
• Verbal threats (e.g., yelling, making derogatory statements, cursing)
• Staring or glaring at others
• Destroying or defacing objects
• Belligerence
• Rowdy behavior or an inability to calm down
• Outbursts
• Self-harm
• Previous violent or threatening behaviors⁵

This list is not exhaustive, nor do the behaviors listed necessarily indicate that violence will ensue. However, healthcare providers and staff who are attuned to these potential warning signs will be in a better position to initiate de-escalation techniques should the progression toward violence continue.

Various validated tools are available to help healthcare workers assess patients for aggressive and violent behaviors. To learn more about these tools, see the following resources:

• American College of Emergency Physicians: Risk Assessment and Tools for Identifying Patients at High Risk for Violence and Self-Harm in the ED
• IAHSS Foundation: Mitigating Workplace Violence via De-Escalation Training
• Intensive and Critical Care Nursing: Risk Stratification for Violent Behavior in Critically Ill Patients: Current Assessment Tools
• Journal of Emergency Nursing: A Systematic Review of Violence Risk Assessment Tools Currently Used in Emergency Care Settings
• The Joint Commission: Quick Safety Issue 47: De-Escalation in Health Care

For more information on strategies for de-escalation, see MedPro’s article Tips and Strategies for De-Escalating Aggressive, Hostile, or Violent Patients.

Endnotes

¹ Shulman, A. (2020, February 27). Mitigating workplace violence via de-escalation training. IAHSS Foundation. Retrieved from https://iahssf.org/research/mitigating-workplace-violence-via-de-escalation-training/

² Kaplan, S. G., & Wheeler, E. G. (1983). Survival skills for working with potentially violent clients. Social Casework, 64(6), 339–346.

³ Berg, A. Z., Bell, C. C., & Tupin, J. (2001). Clinician safety: Assessing and managing the violent patient. New Directions for Mental Health Services, (91), 107–127. doi: https://doi.org/10.1002/yd.23320019111

⁴ Workplace Safety & Prevention Services. (2023, February 27). De-escalating high-stress situations at work: 4 stages to aggression, 4 responses. Retrieved from www.wsps.ca/resource-hub/articles/de-escalating-high-stress-situations-at-work-4-stages-to-aggression-4-responses

⁵ Shulman, Mitigating workplace violence via de-escalation training; Berg, et al., Clinician safety: Assessing and managing the violent patient.

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