Introduction

In 2002, the World Health Organization recognized violence as a global health priority with significant health, social, and economic consequences. It’s no wonder. Anger, aggression, and violence permeate every aspect of our culture—including healthcare organizations (Liss & McCaskell, 1994).

In a 2014 survey of registered nurses and nursing students, 21% of respondents reported being physically assaulted at work during a 12-month period, and more than 50% reported being verbally abused. Experts also estimate that fewer than half of all such incidents are actually reported (Occupational Safety and Health Administration [OSHA], 2015).

The same year, the Bureau of Labor Statistics reported that 52% of reported workplace violence incidents occurred in healthcare settings. Indeed, a violent incident is over four times more likely to occur in a healthcare setting than in any other professional workplace. As for injuries suffered by healthcare professionals at work, 80% of these are caused by patients (OSHA, 2015)—although healthcare workers must also contend with agitated family members of patients and stressed-out coworkers. Experts estimate that 50% of healthcare workers will encounter violence at least once in their healthcare careers (Findorff, McGovern, Wall, Gerberich, & Alexander, 2004).

The number of violent incidents in healthcare settings has continued to rise (The Joint Commission, 2018). There are various reasons for this. One is that our chaotic modern world fosters considerable stress and conflict, which naturally seeps into the healthcare environment. Here are several other reasons:

• A lack of organizational policies regarding de-escalation

• A lack of training of healthcare staff in de-escalation

• The stressful environments of many medical facilities (due to crowding, long waits, receiving bad news, and so on)

• Increased gang activity and crime that invade the healthcare workplace with the traumatic results of violence

• Increased alcohol and substance use or addiction (The Joint Commission, 2018)

• Large numbers of domestic disputes among patients and visitors

• The increasing presence of firearms and weapons brought into healthcare facilities by patients and visitors

• Inadequate security at healthcare facilities

• A lack of availability of mental health personnel to resolve conflicts that arise

• Frequent understaffing of healthcare facilities (meaning fewer available staff to provide care and safety)

• Healthcare facilities in which staff work in isolation

• Healthcare facilities in which staff can be easily trapped by an aggressive patient or other party

• Poor lighting in corridors, rooms, and parking lots that allow for easy assault

• Healthcare facilities that lack emergency communication tools such as cellphones or call bells to obtain emergency assistance

• Unrestricted public access to hospitals and clinics allowing for the entry of criminal elements

There is also a shortage of community mental health centers—leaving traditional medical facilities to provide access to these services. The de-institutionalization of the mentally ill has caused large numbers of the chronically mentally ill to enter the mainstream community without access to adequate mental healthcare.

All this has taken a growing financial and human toll on the nation’s 15 million healthcare workers and on the hospitals, long-term care centers, and other facilities that employ them. Too many healthcare professionals feel unsafe at work. Indeed, this lack of safety has driven many nurses and other healthcare professionals to leave the industry entirely (The Joint Commission, 2018). Often nurses stay in nursing for about as long as it took them to obtain their professional education before leaving nursing permanently (Blegen, Spector, Lynn, Barnsteiner, & Ulrich, 2017).

This has the unfortunate effect of adding to the existing nurse shortage; and, as nurse-to-patient ratios fall, the risk of violence continues to increase, and the cycle continues.

The growing problem of violence in the healthcare setting has prompted many healthcare executives, providers, and policymakers to take action in myriad ways. Unfortunately, these efforts have proven largely ineffective, insofar as the number of violent incidents has yet to decrease. That means nurses and other front-line providers must identify effective tactics and tools to handle aggressive patients (and others).

The first and most beneficial technique to prevent healthcare violence is de-escalation training. De-escalation is the process of helping others regain self-control by using therapeutic communication and interventions to lower the emotional tension. De-escalation is a nonpharmacological approach for preventing violence—in healthcare facilities and anywhere else. Safety begins with assessment and early intervention with effective violence prevention tools (OSHA, 2016).

Research shows that when a situation involving an aggressive person is effectively de-escalated, violence is reduced. De-escalation can also help healthcare facilities avoid containment (takedown) episodes, which can lead to patient and staff injuries, as well as avoid using tranquilizers, restraints, or seclusion to ensure the safety of agitated patients and those around them. De-escalation is the least restrictive intervention recommended by the Joint Commission on Accreditation (2018) to prevent aggression/violence. It also decreases patient stress and anxiety and allows agitated patients to feel understood. De-escalation as a first response is key to reducing violent incidents in healthcare facilities.

De-escalation doesn’t just happen. Training in de-escalation techniques is essential. That’s where this book comes in. It serves as a comprehensive guidebook of therapeutic de-escalation techniques for nurses and other healthcare professionals to improve safety in healthcare facilities.

Readers will explore the concepts of aggression (including risk factors), de-escalation, and therapeutic communication. They will also learn how to perform mental status assessments, manage and even prevent aggressive behavior, practice conflict resolution, and—when faced with individuals with depressive disorders, suicidal ideation, or self-injurious behavior—engage in crisis intervention. Specific therapeutic interventions for difficult behavioral issues associated with schizophrenia, dementia, bipolar disorder, cognitive impairment, anxiety, and panic disorders are also covered, as are stress- management techniques to help patients cope, tips for creating a caring and healing environment to stop violence before it starts, and a framework for building a healthcare violence prevention program. Nursing students and healthcare professionals of all educational levels will find this book to be immensely valuable.

De-escalation is one of the most valuable skills a healthcare worker can possess. Indeed, all healthcare workers need this vital skill to help ensure their safety in the healthcare environment. It’s not uncommon for healthcare professionals to encounter an agitated or aggressive person. How that healthcare worker responds will dictate whether the situation is defused or escalated—perhaps even resulting in physical violence. The goal of this book is to ensure the result is the former— to prevent healthcare violence, and to foster a safe healthcare workplace that benefits all and promotes peace and safety for everyone.