#57454: Violence in the Healthcare Workplace

In the United States each year, there are 20,000 to 30,000 injuries directly related to workplace violence and 450 to 700 victims of workplace homicide; healthcare workers have a much higher risk of experiencing intentional injury by another person than workers in other occupations [34,135,136]. It has been estimated that up to 50% of clinical practitioners, including nurses, social workers, psychologists, psychiatrists, and other human service workers, have been assaulted at their workplace at some time during their professional career [1]. The National Institute for Occupational Safety and Health (NIOSH) estimated that among nonfatal assaults that occur in the workplace, 70% were in the healthcare and social assistance industries and 48% were perpetrated by a patient or client of the service provider [2]. These recent data are similar to data from 2011–2013, which showed that three-quarters of workplace assaults were in healthcare and social assistance settings [137].

The magnitude might be even larger, dependent upon the definition of workplace violence used. In 2000, the U.S. Department of Labor found that the incidence rate of violence in any private sector workplace was 2 per 10,000 full-time workers [7]. Healthcare professionals had a significantly greater incidence rate of 9.3 per 10,000 for injuries resulting from assaults and violent acts. The rate for social service workers was 15 per 10,000, and for nursing and personal care facility workers the rate was 25 per 10,000 [7]. In a 2015 study conducted by the Emergency Nurses Association, 55.6% of emergency department nurses indicated they had experienced physical or verbal violence or both at the workplace [108]. Hospital nurses, physicians, and other staff have reported a significant increase of verbal threats and physical violence throughout the COVID-19 pandemic; almost 70% of emergency nurses reported being hit or kicked at work, while 44% of all registered nurses reported experiencing physical violence on the job [171].

Healthcare professionals are at increased risk due to their contact with patients or clients who have serious mental illnesses and/or history of violence as well as working in occupational environments marked by stress, burnout, and high turnover. In emergency departments, where there is often a large flow of traffic of patients, family members, and other individuals from the general public, 50% of physicians and 70% of nurses report having been physically assaulted [3]. Ultimately, these nonfatal workplace assaults have tremendous economic ramifications to organizations, causing about 876,000 lost workdays and $16 million in lost wages each year [2]. Nationally, workplace violence is estimated to cost $324.9 million annually in staff turnover, disability, and absenteeism [138]. Not surprisingly, there is a relationship between turnover and frequency of exposure of workplace violence. Healthcare professionals who are frequently bullied are three times more likely to resign, even after controlling for age, health, and work conditions [45].

This course will provide an overview of the different types of workplace violence, risk factors, emotional, social, and behavioral ramifications of workplace violence, and specific interventions and policies that have been implemented by organizations to address workplace violence and enhance practitioners' safety.

The definition of workplace violence is complex, multifaceted, and ambiguous. The challenges in establishing tracking and monitoring systems inevitably lead to an under-reporting of workplace violence, which can then have ramifications in developing clear policies in the workplace [4]. The terms used are confusing and can contribute to a lack of consensus regarding an overall definition. For example, terms used in the literature include: workplace bullying, workplace aggression, workplace abuse, workplace harassment, horizontal violence, and mobbing [5]. In this course, a workplace is defined as a location where an employee, whether employed on a temporary or long-term basis, performs tasks related to his or her job description [5].

Although the general public usually equates aggression with violence, there are differences. Aggression constitutes intentional behavior, and the goal is to ultimately harm or injure another party physically or psychologically [139]. Some have further categorized aggression into two types: hostile aggression and instrumental aggression [6]. Hostile aggression refers to aggressive behaviors triggered from feelings of anger or frustration. Instrumental aggression focuses around the intention to hurt someone psychologically or physically to achieve some goal, not merely to inflict pain [6]. The dilemma with these definitions is that nurses, social workers, and other human service professionals deal with clients or patients who may not be fully oriented. In these cases, the question about their intent is raised [6]. However, this does not mitigate the psychologic and emotional consequences of the victims who experience workplace violence [6].

One definition of workplace violence includes physical assaults and threats of physical assault aimed at employees in their occupational setting or while on duty [7]. Other definitions address not only physical violence but also psychologic violence, abuse, bullying, harassment (racial, sexual, and psychologic), obscene phone calls, and/or verbal assault [7,8]. The Occupational Safety and Health Administration (OSHA) defines workplace violence as "any act or threat of physical violence, harassment, intimidation, or other threatening disruptive behavior that occurs at the work site. It ranges from threats and verbal abuse to physical assaults and even homicide. It can affect and involve employees, clients, customers, and visitors" [109]. The U.S. Department of Labor defines workplace violence as "an action (verbal, written, or physical aggression) that is intended to control or cause, or is capable of causing, death or serious bodily injury to oneself or others, or damage to property" [110]. Other instances that may be overlooked are incidents in which there are unintended victims. Such a case, as described by Keyes and Keim, is one in which an employee who is berated in front of co-workers later sabotages equipment, resulting in personal injury and damage to property [4]. While many equate the term "violence" with physical force or physical injury, for the purposes of this course, workplace violence will refer to any act of aggression, physical or nonphysical, that takes place while the victim is working. The term "workplace aggression" is often used in the mental health literature, while the term "workplace violence" is preferred in the healthcare literature [139]. For the purposes of this course, the two terms are used interchangeably.

Some experts have posited that workplace violence falls into three categories: internal violence (i.e., the perpetrator and victim are employees), external violence (i.e., the perpetrator is a stranger and the victim is an employee), and client initiated (i.e., the perpetrator is a patient and the victim is an employee) [87]. Of these types, client-initiated workplace violence is the most frequently encountered in the healthcare setting [91].

Overall, these incidences of workplace violence are characterized as specific, time-limited, and unanticipated. They may also trigger feelings of loss of personal safety and emotional well-being [9]. Workplace violence ultimately consists of persistent, offensive, unwanted, and intimidating behaviors that are used to control or exert power over an individual [5].

It is important to identify the different types of workplace violence. Lipscomb et al. highlighted four distinct types of workplace violence perpetrators [13,14]:

These perpetrator types parallel the categories identified by OSHA. OSHA has differentiated workplace violence perpetrated by strangers (Type I), co-workers (Type II), or service recipients (Type III) [7].

In addition to perpetrator types, workplace violence may also be categorized by the quality of the behaviors. Workplace violence may be classified according to the type of behavior and manner in which harm is inflicted [16,140]:

Part of the difficulty in developing a consensus regarding the definition of workplace violence, or even the related terms, is that the criteria for acceptable behavior is based on implicit and unwritten assumptions that vary across organizations, contexts, and individuals [17]. These perceptions are influenced by a host of factors on individual, organizational, cultural, and social levels [18]. The challenge of establishing a definitional consensus is problematic for policy makers, researchers, and workers [139].

Another type of violence that may occur in the workplace is domestic violence, also referred to as intimate partner violence. Domestic violence is a worldwide problem and predominantly affects women. Although women can be perpetrators of domestic violence and violence does occur in some same-sex relationships, the World Health Organization (WHO) confirms that the overwhelming burden of partner violence is borne by women at the hands of men [88]. Therefore, this section of the course will focus on domestic violence against women. Results of 50 different population surveys around the world show that, at some point in their lives, 10% to 50% of women experience physical violence perpetrated by an intimate male partner [32]. Worldwide, the World Health Organization reports lifetime domestic violence rates ranging from 25% to 75% [148]. In 2010, the Centers for Disease Control and Prevention (CDC) conducted a large-scale survey and found that 35.6% of women and 28.5% men in the United States had been raped, stalked, or physically abused by an intimate partner [97]. Among victims of rape and sexual assault in the workplace, 80% are female and 20% are male. In 2003, homicide was the second leading cause of death on the job for women [35]. Overall, domestic violence incidents account for slightly more than one-quarter of all workplace violence incidents [35].

When domestic violence extends into the workplace, it becomes a concern for businesses and other organizations. A large-scale Canadian study examined the level of awareness of domestic violence in the workplace among 8,429 men and women [120]. Approximately 40% of participants recognized someone at their workplace as being a domestic violence victim, based on identification of at least one warning sign. Of these participants, half believed that it had an adverse impact on their colleagues' work. In a 2018 survey study involving 1,390 employees at 32 companies, more than 50% of female workers and almost 25% of male employees disclosed having experienced intimate partner violence [149]. In total, 16% of all employees surveyed had experienced partner abuse in the past year [149]. On an annual basis, lost productivity and healthcare costs due to domestic violence are estimated to be $8 million in the United States alone, translating to 7.9 million lost workdays annually [36,150]. Injuries stemming from domestic violence are approximated to yield healthcare expenses of about $4.1 billion, most of which is paid by employers [37]. Among employees who reported lifetime intimate partner violence, 41% acknowledged it negatively affected their work performance (resulting in late arrivals, absenteeism, and disruption/violence at the workplace) [149]. Other workers may also be reluctant to work near the affected individual(s), which may then result in additional indirect costs on the organization [35]. Domestic violence in the workplace is also a liability issue for employers. It is estimated that, in the United States, $1.2 million have been awarded to individuals as the result of civil lawsuits regarding lack of workplace security [36]. Legal cases associated with domestic violence in the workplace have included charges of negligent security, failure to warn when an employer is aware of a specific threat made to an employee, or violations of OSHA and Title VII of the Civil Rights Act [38].

Domestic violence victims do have legal rights that affect the workplace. In some states, there are statutes that provide guaranteed leave from the workplace, albeit unpaid, so victims can seek medical, legal, and social services due to domestic violence [98]. However, in some states, the employer has the right to ask for certification of their need to take a leave [98].

Other victims may utilize the Family and Medical Leave Act, a federal law that offers job-guaranteed leave. Although it was created specifically for domestic violence victims, it may be used by victims who require time to heal from the consequences of violence, deal with child care issues, or to obtain legal services [98]. States may also have specific laws protecting victims from workplace discrimination. For example, in California, an employer is not allowed to terminate an employee who is a domestic violence victim for taking time off (as much as 12 weeks) to obtain medical, counseling, and/or legal services, in accordance with the California Survivors of Domestic Violence Employment Leave Act [121].

As noted, the magnitude of workplace violence in various human service sectors may be underestimated because incidences of workplace violence are typically under-reported. Ergün and Karadakovan's study with nurses who have experienced workplace violence indicated that the majority opted not to report the incident [28]. In the United States, approximately 50% of workplace violence incidences are not reported [99]. In some cases, reporting is done informally and verbally instead of via a formal procedure [100]. The most common process for those who did report the incidents was submission of a formal, written statement to the administration. Results of a study conducted by Rowett, who examined social workers' views about reporting client violence, showed that only 5% of incidents of physical violence against social workers were reported to management [39]. Rowett speculates that lack of disclosure may be due to stereotypes of social workers who are assaulted by their clients, stating [39]:

Both assaulted and non-assaulted social workers painted a common picture of the typical assaulted social worker as someone who sought out riskier situations, confronted the client, challenged unnecessarily, was more demanding and less flexible, and less able to detect potentially violent situations and handle them once they had arisen.

Extensive literature reviews have highlighted reasons that workplace violence is under-reported [40,99,122,151]:

It has also been speculated that the ideology of various helping professions might influence reporting behaviors. For example, it has been suggested that the pervasive ideology in the field of social work has been client-driven, which is reinforced by the emphasis of consumerism in our society, and this might explain why social workers are reluctant to disclose and report incidents of client violence [41].

Perceived time constraints can also contribute to the under-reporting of incidences of workplace violence. If it is perceived that reporting is a laborious process and will take a significant amount of time in addition to a practitioner's heavy workloads, reporting may be avoided [100].

In a study conducted by Macdonald and Sirotich, of 171 social workers in Ontario, Canada, a large majority (88%) reported that they had been verbally abused by a client during their careers [42]. Additionally, 66% reported being threatened with physical assault, and 28% experienced a physical assault by a client. The top three reasons social workers in this study gave for not reporting incidents of violence were:

There is a culture of acceptance of violence in many workplaces [152]. For example, emergency department nurses who are victims of workplace violence are often discouraged by hospital administrators from pursue legal action, or administrators may be reluctant to implement steps to mitigate risk factors for workplace violence (e.g., disruptive patients, long wait times). Similar conclusions were found in a 2015 study with 538 nurses in an international university-based hospital. The nurses in the study reported that the responses from superiors were not always supportive. They also tended to believe that reporting was useless, with no formal reporting mechanism and no system for following up legally [123].

In an interesting qualitative study that sought to examine the process by which individuals, specifically women, label and identify workplace bullying, Lewis interviewed 10 women from a range of professional fields (e.g., teacher, counselor, nurse, police officer, university lecturer) [18]. Nine of the 10 participants reported being bullied by their managers. Lewis found that when they initially experienced various forms of workplace bullying, the victims tended to minimize the behaviors [18]. Although the study participants perceived the behaviors as stressful, they framed them as an interpersonal problem and did not recognize the patterns of bullying. All of the women acknowledged that the behaviors escalated. Because the definition of workplace bullying is ambiguous, the women felt they could resolve the problem on their own. In part, this was related to preserving their sense of self and sense of professional competence.

Similar results were found in a qualitative study conducted by van Heugten [43]. The 17 social workers in the study who had experienced workplace bullying reported having attempted to minimize the seriousness of the bullying. Similar to Lewis' study, these participants also did not recognize the negative behaviors they experienced as workplace bullying. When they were finally able to put a name to the behaviors, the shame gradually ebbed. Prior to the behaviors being identified as workplace bullying, the social workers reported experiencing negative physical health symptoms [43]. These studies are very small, and generalized conclusions about the profession should not be made based on the results. However, they do provide some insight into how individuals respond to and report perceived violence.

Not unlike victims' experiences with other types of violence, such as family violence, domestic violence, or witnessing a traumatic act of violence, there are a host of emotional, somatic, and psychologic reactions associated with experiencing workplace violence. Research also indicates that secondary victims of all types of violence (i.e., those who do not experience the violence directly but who hear about or witness it) experience similar stress responses. Fear reactions are common, and these responses can then lead to more serious psychologic disorders, such as depression and anxiety, and an array of somatic symptoms, such as sleep and gastrointestinal disturbances [58]. Suicidal ideation is also twice as likely to occur among those who have experienced workplace bullying compared with those who have not experienced workplace violence [161]. In a systematic review of 137 studies, sadness, shock, embarrassment, and stress symptoms were common in the short term [128]. On a longer-term basis, avoidance of the workplace was common, which also resulted in loss of work days as well as loss of confidence and good working relationships with peers and colleagues. In a longitudinal study, those who had been exposed to physical workplace violence were 1.67 times more likely to have an increased number of visits to a physician after seven years compared with those who were not exposed to physical workplace violence [162].

Post-traumatic stress disorder (PTSD) and acute stress symptoms are also common. Interestingly, Rogers and Kelloway found that fear symptoms surrounding future workplace experiences appear to play a role in triggering a host of mental health and physical symptoms [59]. There also appears to be an association between nurses' productivity levels and exposure to patient violence. Although nurses indicate that they are generally able to continue working at their usual pace after the violence, they have more difficulty remaining focused after the incident [102].

With more insidious examples of workplace violence, such as workplace bullying or mobbing, similar physical and psychologic responses are also common. Leymann has identified potential effects that mobbing may have on the victim(s) [11]:

This categorization offers a context to understand the consequences of workplace violence, bullying, or mobbing. In a qualitative study of 10 women who experienced bullying behaviors, the symptoms associated with workplace bullying were initially attributed to other factors [18]. The symptoms were attributed to individual health, ultimately pathologizing the symptoms and causing the participants to feel even more inadequate.

Studies have shown that the presence of social support for victims can alleviate some psychologic and somatic symptoms. In a survey study of 229 workers in a healthcare setting, researchers found that instrumental support, defined as support available from coworkers, supervisors, and management after the violent event, was a positive factor in alleviating psychologic problems (e.g., loss of well-being) and somatic symptoms (e.g., sleep disturbance, gastrointestinal problems) [85]. In another study, coworker support was found to be a protective buffer against workplace bullying and psychologic distress, albeit relatively small [163]. Instrumental and emotional support have been suggested to moderate burnout stemming from workplace bullying [164].

It is important to note that feelings of isolation are typical in the aftermath of a traumatic event. The victim may feel that no one understands what he/she is going through regardless of the amount of support available. In one study, for example, some nurses revealed that they did not want to disclose to their family members for fear of worrying them nor did they feel comfortable talking to co-workers [55]. It is therefore vital that instrumental support, having a network at the work setting that provides a formal and informal venue for the victim to express their feelings, be made available.

Providing training on how to deal with workplace violence, also referred to as informational support, has been associated with a decreased level of somatic symptoms and negative feelings [85]. However, social support does not appear to influence the fear of future violence or neglect of one's job duties [85]. Fear of future violence has not been found to affect an individual's level of commitment to their workplace and organization [59]. These findings are a bit perplexing; however, it is important to note that workplace violence was not categorized in these studies to differentiate aggression perpetrated by a stranger and aggression initiated by co-workers. When LeBlanc and Kelloway took this into account, they found that aggression perpetrated by co-workers adversely affected emotional and psychosomatic well-being and level of organization commitment; however, it did not influence fear of the future or intent to quit [60]. Workplace aggression perpetrated by a stranger or patient increases the likelihood of future violence, as individuals are then more likely to bring weapons to work for self-defense [44]. Finally, public-initiated aggression also increased the likelihood of an employee leaving the organization [60].

The studies presented here demonstrate the complex dynamics of workplace violence and how it can result in adverse emotional and health consequences. There are also economic ramifications of workplace violence. Figures vary depending upon how one defines workplace violence and how one calculates "cost." In 1994, it was approximated that 1.751 million workdays were lost, resulting in $55 million in lost wages [61]. However, this does not take into account litigations filed against the organizations, medical expenses incurred, and negative morale, which may influence job satisfaction, triggering future attrition and turnover.

Confidentiality and the limits it imposes are key ethical issues that emerge when discussing the topic of workplace violence. Generally, healthcare professionals and other clinicians cannot disclose information learned in a clinical setting. Yet, the question is: Should protecting the privacy and maintaining the confidence of a patient's disclosure outweigh the greater social good?

The duty to protect is related to the Tarasoff legislation. Although the act of violence that resulted in the Tarasoff Law did not occur in the healthcare workplace, it has clear implications for any case in which a practitioner suspects an individual is capable of violence. This law resulted from a case in 1968, involving a male student, Prosenjit Poddar. Poddar met Tatiana Tarasoff at a school function, where she declined his romantic interests. Poddar had a history of depression and had visited the university's health services. Soon after meeting Tarasoff, his depression worsened. He disclosed to his counselor that he had thoughts of harming and even killing a girl whom he met, and Poddar's description clearly matched Tarasoff. Poddar was committed to a hospital, and the police were contacted. However, when the police interviewed Poddar, they found him lucid and issued a warning. Ultimately, the hospital where Poddar was sent did not commit him. Two months later, he shot and killed Tarasoff after missing several counseling appointments [62]. Tarasoff's parents sued, which resulted in the Tarasoff Law. This law states that therapists, clinicians, and other mental health counselors have the duty to protect third parties from harm. The case was reheard in 1976, resulting in a change in terminology, from "duty to warn" to "duty to protect" [63]. As a result of this legislation, clinicians have a duty to protect the third party by warning the targeted victim or others who can then warn the intended victim, notifying law enforcement, and implementing other steps to protect the potential victim [63].

Healthcare workers and other helping professionals are obligated to promote good and avoid harm (i.e., adhere to the ethical principle of beneficence). Demeaning, threatening, and humiliating are often the underlying motivations in bullying behaviors, all of which violate the principle of beneficence [165]. The codes of ethics of various professions explicitly discuss the relationship practitioners are to have with their colleagues. For example, the Code of Ethics for Nurses outlines the necessity for extending respect and integrity for all individuals—colleagues as well as patients [129]. In the Code of Ethics of the National Association of Social Workers, the respectful relationships social workers are to have with their colleagues and how to resolve disputes are outlined [130].

Borum and Reddy argue for the need to have a fact-based line of inquiry when clinicians work with patients who may be a risk to others [63]. They maintain that clinicians should consider: Is the client on the path towards violence? If the answer is affirmative, how fast is the client moving and where can one intervene? Although this line of inquiry was not specifically developed for the workplace, it can be applied to workplace violence perpetrated by patients or clients. To help answer these two questions, further assessment may be conducted and information garnered in six areas, which may be remembered by the acronym ACTION [63]:

Another violence assessment tool has been created to assist in specifically identifying potentially violent patients in emergency departments [103]. Cues that indicate a patient is more likely to resort to violence include [103]:

None of these behaviors above are definitive indicators of a violent patient, but if taken as part of the holistic assessment, they can be used to alert practitioners of potential at-risk situations.

Administrators should assess the work environment for factors that might make the workplace more vulnerable to violence by asking the following questions [166]:

The U.S. Department of Labor recommends using the Workplace Violence Checklist to evaluate workplaces for potential risks [135]. A copy of the checklist may be accessed at https://www.osha.gov/SLTC/etools/hospital/hazards/workplaceviolence/checklist.html.

Many experts maintain that the occurrence of any type of violent or abusive incident, including workplace violence, is not necessarily a single incident but can be conceptualized as a chain of events [64]. In terms of healthcare workplace violence, this cycle is most applicable to violence perpetrated by patients/clients or service recipients (OSHA's classification Type III). Understanding the phases and stage-specific characteristics of violence or aggressive behaviors can assist clinicians and other helping professionals to determine the appropriate tasks and interventions for each stage of the crisis. It may also help to reduce the tendency to pathologize the perpetrator, ultimately promoting autonomy and dignity.

The first phase of the perpetrator's cycle of violence involves experiencing rising emotions. This phase is characterized by a sense of unspecified panic or anxiety. The perpetrator may not necessarily be able to name his or her feelings or associate these emotions to the event (whether real or imagined) [64]. The goal in this phase is to help the individual identify and discuss the problem. If the perpetrator is unable to identify and address the problem in the first stage, he/she then enters the second stage.

The second phase is characterized by an escalation of inner anxiety and a mounting feeling of loss of control. This causes the individual to attempt to regain control through the use of threats, abuse, and/or verbal intimidation [64]. During this phase, clinicians should assist perpetrators in redirecting their feelings toward arenas in which they feel some degree of control. Practitioners often miss or fail to recognize anxiety and stress cues [152]. Work should also be continued in identifying and discussing the problem. At this point, staff and other relevant persons should be alerted to the situation [64].

The third phase of the cycle of violence is called the crisis stage. In this phase, the individual uses aggressive behaviors to regain a sense of control. McAdams and Foster note that this may also symbolize a "primitive plea for external intervention" [64]. Clinicians should take steps to ensure the individual's safety as well those around him/her. Interventions must be clear and firm in regards to what is needed and expected [64].

The fourth stage is recovery and involves a decline in the individual's crisis symptoms. However, the individual may continue to feel angry or frustrated and may be resistant to interventions. Therefore, clinicians should continue working to ensure the individual's safety and to identify a resolution [64].

The fifth and final stage is characterized by the perpetrator feeling emotionally and physically exhausted. Feelings of guilt may also be evident, with the perpetrator wanting to make reparations to victims. The task of clinicians in this phase is to assist the individual in making reparations and to discuss the triggers for aggression. It may then be possible to identify prosocial mechanisms to deal with frustrations in the future [64].

SAFETY TRAINING FOR EMPLOYEES/STAFF

Several experts emphasize the importance of safety training for healthcare and human service professionals [56,68]. Training must be ongoing, beginning at new employee orientations and continuing at staff meetings and in-service training. By raising staff's awareness of their immediate surroundings, training can increase professionals' sense of competence and control and lessen feelings of helplessness. Some topics that have been recommended as part of safety training are environmental assessment, techniques for de-escalation of violence, and self-awareness.

Environmental Assessment

Environmental assessment entails service providers evaluating the work environment, such as office spaces, cars, and for those professionals who conduct home visits, their clients' residences and neighborhoods, for violence risks and potential opportunities for self-defense [56]. For example, when healthcare or human service professionals conduct patient interviews in their offices or interview rooms, several questions regarding the environment should be raised. This includes determining the most effective room layout so the professional can exit quickly if there are visual cues that the patient is getting angry or violent. The office should be scanned for items that can easily be used by a potentially violent patient to cause harm; for example, books, ashtrays, and furniture can potentially be used as weapons [69]. It is also important to determine the extent of which the interviewing or evaluation office is visible to others. This requires a delicate balance, because it is important to promote the privacy and confidentiality of the client, but simultaneously, it is also important for the clinician to be safe [69].

The environment of waiting rooms can be potential breeding grounds for patient violence [131]. Organizations should evaluate the mechanisms in place to manage patients' emotions and safety. For example, what can be done to keep the environment peaceful and calm? What mechanisms are in place to reduce waiting times or to communicate waiting times most effectively [131]? What security measures are in place (e.g., cameras, patrols) [132]?

Workers' vehicles are often taken for granted. However, maintenance issues are important, particularly for staff who work late at night or who conduct home visits in unfamiliar neighborhoods [56]. Staff members should have their keys readily available when they walk to their cars, and they should check the back seats before getting in their vehicles. Items that place a car at risk of being vandalized, such as a supply of psychotropic medication, should be put away or not left in the vehicle.

When going on home visits, knowledge of neighborhoods is a prerequisite to safety. The following questions may be helpful in determining the risk associated with certain neighborhoods [7,56,57]:

• Do workers know which neighborhoods or areas are unsafe at night?

• Do workers know where to find secure parking and easy exits?

• Are workers apprised of recent incidents of violence or drug-related activities in the neighborhood?

• Is it possible for a worker to be accompanied by another staff person on home visits or rounds?

• Is there a clear plan for workers who conduct home visits to communicate their whereabouts and a protocol to follow if a worker does not report as expected?

• Is it possible for workers in the field to carry hand-held alarms or noise devices?

Twenty-three social workers participated in a study conducted in rural areas in Australia. The study consisted of a forum to identify safety concerns and for workers to convey their experiences with abuse and violence with clients while working [70]. A prominent theme that emerged was the risk involved in conducting home visits and transporting clients from one location to another. In some cases, agencies did not have the resources for radios, mobile phones, security papers, and duress alarms. Even when the equipment was available, it was unreliable in remote locations. As a result, issues of personal safety were a paramount concern for many of these rural social workers.

Techniques for De-Escalating Violence

De-escalation involves defusing potentially agitated patients and reducing maladaptive behaviors using conflict resolution methods, limit-setting, and calm and empathic verbal strategies [71,167]. Ultimately, this depends upon the clinician's ability to negotiate and use conflict resolution [71,72]. One of the goals of de-escalating potentially aggressive patients is to promote autonomy and dignity by providing options [73]. To achieve this goal, clinicians must learn to recognize the warning signs of agitation. Behavioral cues may include increased pacing, increased volume and tempo of voice, flushed face, or agitated body movements [71].

Verbal de-escalation strategies can be effective. The National Association of Therapeutic Schools and Programs recommends that clinicians remain calm and convey an attitude of respect by listening to the patient [72]. Next, it is important to identify what is provoking the individual, and then to assist the individual to use prosocial means to express his/her feelings. Clinicians should approach the client calmly [69]. It is important not to convey any cues that may be perceived as confrontational. For example, clinicians should not maintain unrelenting or persistent eye contact. Permission should be given to express feelings of frustration and anger without interruption.

The National Institute for Health and Care Excellence asserts that if a service user becomes agitated or angry, a staff member should take the primary role in communicating with them. That staff member should assess the situation for safety, seek clarification with the service user and negotiate to resolve the situation in a non-confrontational manner. Emotional regulation and self-management techniques should be used to control verbal and nonverbal expressions of anxiety or frustration (e.g., body posture, eye contact) when carrying out de-escalation.

(https://www.nice.org.uk/guidance/ng10 Last Accessed: July 26, 2022)

Strength of Recommendation: Expert Opinion/Consensus Statement

Verbal strategies to de-escalate tension in cases in which clients have weapons can also be effective. When clinicians talk to clients in a calm and rational manner, both clinicians and the clients suffer less physical injury or property damage than when clinicians opt to use verbal or physical aggression [74]. Active listening skills are helpful and involve appropriate eye contact and body language, empathizing, and paraphrasing to convey understanding [69]. Clinicians should also be aware of their tone, volume, rate, and rhythm of speech, also referred to as paraverbals. If not careful, paraverbals can convey the opposite of what is communicated verbally [75]. Empathetic listening and communication can help to de-escalate violent situations [105]. Instead of trying to suppress emotions, listening and talking through the frustration can help mitigate potentially violent anger.

Redirection is another effective de-escalation strategy [76]. In some cases, this may simply involve changing the topic. Alternately, it can be as concrete as offering a patient a glass of water or cup of coffee. This conveys to patients that the clinician is aware of and sensitive to their needs [76].

The use of de-escalation techniques as early intervention results in more therapeutic gains for patients as opposed to using more restrictive management techniques to deal with aggressive behaviors [71]. Clinicians who successfully use de-escalation techniques report improved relationships with patients and increased feelings of self-efficacy, which can lead to greater job satisfaction [71]. It is vital that the environment supports patient self-management of anxiety [168]. Facilities can promote this by providing access to massages, relaxing sounds, aromatic oils, comforting blankets, guided imagery, and other soothing techniques.

Training to Increase Self-Efficacy and Confidence

Workers should be given an arsenal of tools to increase their sense of confidence and self-efficacy. Practitioners who work with patients who can become highly volatile and violent should be aware of the warning signs of potential violence. They should also be taught calming communication approaches and restraining techniques and when to use them [91,131,167]. For example, tone of voice and use of eye contact can be employed to calm potentially violent or aggressive patients [91]. Using traditional and simulated trainings, practitioners can also learn how to prepare for violent situations and learn self-defense techniques [169].

Clinician Self-Awareness

Clinicians should also be attuned to their own feelings and reactions. If they sense that a client will be violent, a safety plan should be implemented immediately. Not only should clinicians be aware of their feelings, but they must be aware of how their body language and facial expressions mirror their feelings. For example, if they feel fear and anxiety, these reactions should be masked so as not to communicate the fear to their patients [69]. If patients sense fear, open communication, trust, and rapport can be negatively impacted [69].

When employees are trained to assess their environment, encouraged to listen and be aware of their feelings and reactions toward patients and their environment, and to report potentially violent incidences, their responses will differ dramatically compared with those who have not been trained [106]. According to a 2011 study, employees who have been educated will initially express a startled reaction/response to a violent incident, but they are more likely to prepare themselves and others to address the act appropriately than untrained employees, who are more likely to panic, deny the incident, and feel helpless.

The following resources are offered to provide more information about workplace violence. As discussed, education is vital in order to ensure that workplace violence is identified and reported.

Workplace violence is primarily a hidden social problem, with negative ramifications for victims and other employees. These ramifications also extend to organizations and agencies in the form of lost productive work days, increased sick time, decreased staff morale, and staff turnover. Workplace violence is a social problem that warrants attention from employees, researchers, and policy-makers.