Workplace Aggression: 5 Ways Nurses Can Handle Violent Patients

You are usually first in line when a patient or a family member turns aggressive. Anger is almost always an expression of lost control, so it spikes where people feel most powerless: with patients who are mentally unstable, and in the ER, where families are in crisis and surrounded by a strange environment.

Every nurse needs verbal de-escalation skills, for the patient and for your own protection. When you are in the firing line, there is rarely time to wait for a trained responder. A five-minute de-escalation also beats physical restraint, which puts staff at greater risk of injury.

Workplace violence is a serious occupational hazard for nurses. OSHA reports that healthcare and social service settings account for roughly three quarters of all nonfatal workplace assaults, and nurses are among the most frequently targeted. The American Nurses Association treats workplace violence as a priority that demands both clear institutional policy and skills training for every nurse.

The instinctive response to a threat is fight or flight. Neither works in a setting where you have a duty to care. The techniques below usually turn the situation around and cut the need for a crisis team. Practicing them also builds your own confidence in a crisis.

Stay aware that anything you do may de-escalate the situation, make it worse, or do nothing. Read the person's reaction the whole time. If they are calming, keep doing what you are doing. If things are heating up, change tack. Restraint and medication are a last resort, used only when the person is a danger to themselves or others.

1. Find a safe environment

Move the person away from other people to a space where they feel safe and you are safe too.

2. Position yourself correctly

Stand between the person and the doorway, but not directly in front of it, so they keep an escape route. Our instinct as nurses is to move in and offer a comforting touch. With an aggressive person, do the opposite: personal space matters, and crowding it raises anxiety. Stay at least two arms' lengths away. That distance keeps you out of range of a punch or kick and gives you room to evade or block an attack.

Do not square up face to face. A full frontal stance reads as confrontation. Stand slightly to the side and at an angle, posture relaxed, arms at your sides, hands open and visible.

3. Stay calm and respectful

A person who has lost rational control reads your nonverbal cues far more than your words. Even if you are terrified or ready to snap, keep your gestures, expression, movements, and tone calm. Use eye contact and open body language to show you are paying full attention and you take their problem seriously.

4. Use therapeutic communication

This is the moment to put everything you know about therapeutic communication into practice.

Listen for the real reason behind the behavior, not just the words. A relative may be lashing out because they are frightened for someone they love. Allow venting; that is often when the actual issue surfaces.

Validate the feeling. "I understand you are frustrated that your wife hasn't been seen yet, and you are worried her condition could get worse." Show non-judgmental respect. You may think the feeling is unreasonable, but it is completely real to them. Allow silences. They lower the temperature and give the person room to think.

Reflect back what you heard, summarize it, and let them confirm or correct. That signals you want to understand so the problem can be solved.

Ignore personal or institutional jabs like "Who are you to tell me that?" Defending yourself only starts an argument. Steer the conversation back to the issue.

Once things settle and the person can reason again, work toward a resolution. Set clear limits, give concise information, and offer choices where you can, since choice restores some sense of control. "You can't be in the cubicle while we examine your boyfriend, but you can come in the moment we finish, which will be about half an hour. You are welcome to wait here or grab a coffee in the hospital cafe."

5. Practice the skills

De-escalating a live crisis is a skill, and like any skill it takes practice. Role-play with colleagues, and use the steps consciously in everyday disagreements. Push for de-escalation training as inservice education, ideally with role play, video, and feedback. Plenty of organizations offer formal de-escalation courses, and there are good demonstration videos online.