Violence and agitation can be triggered by many different factors. These factors can be categorized in various ways. The list of triggers below is divided by responses to healthcare provider behavior and communication, environmental factors, and symptoms of patient illness. Understanding what causes disruptive behavior can help prevent and de-escalate it.1
Interpersonal Triggers
Disruptive behaviors can be triggered by what you say, how you say it, and how you behave, which can be colored by the patient’s perceptions, for example:2,3,4
What you say
- Giving the patient “bad news”
- Demanding compliance or failing to offer the patient choices
- Reprimanding the patient
How you say it
- Being sarcastic, rude, hostile, patronizing, or untruthful to the patient
- Arguing with the patient
- Interrupting the patient
What you withhold
- Denying cigarettes, food, drinks, medications
- Limiting or prohibiting visitors
- Making a patient wait
- Failing to follow through with promises
- Discharging a patient who wants to stay, or holding a patient who wants to leave
How you behave
- Being inattentive
- Using negative or aggressive body language, for example, eye rolling, pointing, deep sighs, throat clearing, checking your watch, fidgeting, taking a phone call, standing in the doorway, clenching your fists, hiding your hands, folding your arms, turning away
- Getting too close to or touching a patient with physical boundary issues
- Approaching a patient with a needle or other medical device
- Handing off a patient to another clinician or staff member without explanation
Patient Environment
Disruptive behaviors can be triggered by the patient’s environment, for example:2,3,4
- It is too noisy, crowded, bright, hot, or cold for the patient.
- A clinician or staff member looks like someone the patient fears or dislikes, or is a gender or ethnicity the patient dislikes.
- It is a triggering day (for example, the patient’s birthday or holiday) or a triggering time of day (for example, more violent events occur in the evening in the emergency department).
Symptoms of the Patient’s Illness
Disruptive behaviors may be caused by the patient’s current illness or underlying medical condition, for example:2,3,4
- The patient is inebriated or withdrawing from drugs or alcohol, or is psychotic, low-functioning autistic, or suffering from dementia.
- The patient is in pain or otherwise uncomfortable.
- The patient’s low oxygen saturations or oxygenation is causing an agitated state.
- The patient is suffering from medication side effects.
- The patient is suffering from a nervous system disorder (e.g., hepatic encephalopathy).
Nonverbal Cues of Imminent Interpersonal Violence
Knowing when a patient is likely to become violent is ideal, but difficult. Patients may signal they are getting ready to lash out against their healthcare team members through nonverbal communication, including:5,6,7
Body Movements
Pacing, gesturing in an exaggerated or violent manner, assuming a boxer’s stance, removing excess clothing, opening and closing fists, tensing the body, trembling, shaking, stretching to relieve tension, invading your personal space
Facial Expressions
- Jaw clenching, scowling, sneering
Voice Signals
- Speaking loudly, chanting, talking to themself
Eye Contact
- Glaring or avoiding eye contact
Physiological Changes
- Flushing, pallor, sweating, extreme fatigue, rapid breathing, pupil dilation
Of course, all these nonverbal cues may indicate something other than imminent violence. One of the challenges of healthcare violence prevention is successfully anticipating it without unjustly profiling a patient who is not prone to violence; therefore, it is important to judge a situation by the totality of circumstances and not just on nonverbal cues. There are multiple risk assessment tools to help in the early identification of aggressive behavior, which can be paired with early de-escalation intervention. The STAMP (Staring, Tone and volume of voice, Anxiety, Mumbling, and Pacing) Tool8 and the Broset Violence Checklist (BVC)9 have been shown to be effective, and have been validated for reliability in different settings.10
References
1. Judith E. Arnetz, et al. “Understanding Patient-to-Worker Violence in Hospitals: a Qualitative Analysis of Documented Incident Reports.” Journal of Advanced Nursing. 2014; 71(2): 338-48. DOI: 10.1111/jan.12494.
2. Martin Salzmann-Erikson, Lilly Yifter. “Risk Factors and Triggers That May Result in Patient-Initiated Violence on Inpatient Psychiatric Units: An Integrative Review.” Clinical Nursing Research. 2020; 29(7): 504-520. DOI: 10.1177/1054773818823333.
3. California Society for Healthcare Risk Management. “Understanding and Preventing Violence in the Healthcare Environment.”. September 11, 2011. [Webinar] (not available online at the time of publication)
4. U.S. Department of Labor. Occupational Safety and Health Administration. Guidelines for Preventing Workplace Violence for Healthcare and Social Service Workers. OSHA Publication 3148, (2015). [PDF]
5. National Institute for Occupational Safety and Health. Centers for Disease Control and Prevention. “Unit 6: Be Attuned to Patient Behaviors.” Workplace Violence Prevention for Nurses. Last reviewed: February 7, 2020.
6. Canadian Centre for Occupational Health and Safety. “Violence and Harassment in the Workplace – Warning Signs.” Last revised: December 16, 2022
7. Dwan M. Sweet, Rebecca G. Burzette. “Development of the Nonverbal Cues of Interpersonal Violence Inventory: Law Enforcement Officers’ Perceptions of Nonverbal Behavior and Violence.” 2018. Criminal Justice and Behavior. 45(4): 519-540. DOI: 10.1177/0093854817753019.
8. Lauretta Luck, et al. “STAMP: Components of Observable Behavior that Indicate Potential for Patient Violence in Emergency Departments.” Journal of Advanced Nursing. 2007; 59(1): 11-19. DOI: 10.1111/j.1365-2648.2007.04308.x
9. Family Practice Notebook. “Broset Violence Checklist.”
10. Natalie Calow, et al. “Literature Synthesis: Patient Aggression Risk Assessment Tools in the Emergency Department.” Journal of Emergency Nursing. 2016; 42(1): 19-24. DOI: 10.1016/j.jen.2015.01.023
