WARNING WARNING! 2 Patient Factors Indicating Pending Violence

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A new patient care associate (PCA) from an agency is assigned to work the evening shift in a skilled nursing care facility.

The PCA is unfamiliar with the facility, as well as the patients, and has just met the nursing employee for the first time in hand-off report. Shortly after she enters the room of a 90-year old male patient, she emerges, hugging her abdomen and states, ‘He just kicked me in the stomach!

Could this attack have been prevented?


  • The American Nurses Association Health Risk Appraisal Survey of registered nurses and nursing students found that 25% had been physically assaulted at work by a patient or patient’s family member.
  • According to OSHA, from 2002 to 2013, incidents of serious workplace violence were approximately four times more common in healthcare than in private industry.
  • In a recent study, The New England Journal of Medicine reported 75% of workplace assaults occur in a healthcare setting.


Violence against healthcare employees is on the rise to the point where healthcare organizations are now being held accountable to protecting their employees. Recently, in their April 2018 Sentinel Alert, The Joint Commission put forth recommendations to prevent the escalation of verbal and physical violence in the workplace. In October 2017, the Magnet Recognition Program® added to their required documents, “supporting evidence of an improved workplace safety outcome specific to physical or psychological violence, and threats of incivility workplace.”

Everyone is noticing that healthcare employees aren’t safe and are finally holding organizations accountable!

[Tweet “Everyone is noticing that #healthcare employees aren’t safe and are finally holding organizations accountable!”]

After an incident of violence occurs, employees often ask what could have been done to prevent the violence.

  • Were there warning signs?
  • Was there something in the patient’s history that could have indicated the potential for violence?
  • How did we miss it?
  • Or, was this just a random single act of unprovoked violence?


Human behavior is complicated at best, however, there are a few things we can do to at least heighten our awareness for potential violence.

Research has shown, to determine what went wrong, we need to take a multilevel approach, including examination of employee and patient factors, available resources, unit design and unit workflow factors, and organizational structure and function. Each set of factors impacts the others and can contribute to or help to prevent violence in the workplace.


Let’s explore 2 patient factors:


Does your patient have a history of controlling or violent behaviors?

Research has indicated the single best predictor of violence is a patient history of violence.

In the above scenario, it would have been essential for the PCA to know whether the patient had a history of domestic abuse, assaultive behaviors, or charges related to violent crimes. A second patient contributor to risk for aggressive behavior centers on patient diagnoses of disorders that may underlie aggression, such as certain personality disorders, cognitive disorders, Oppositional Defiant Disorder, Impulse Control Disorder, traumatic brain injury, and some medical conditions.

The personality trait for hostile-dominance was the strongest predictor for aggression in patients on mental health units. Hostile-dominance is “a pattern of relating to others that is hostile and domineering”.

Remember, having a history of violent behavior is the single best predictor of violence.


Next, pay attention to how a patient presents him or herself.

Become more aware when you first encounter a patient.

Are there non-verbal cues of anxiety or agitation, such as a clenched jaw, a frown or grimace, a tense or fixed facial expression, a rigid posture, or repetitive, rapid movements, such as finger tapping, banging on the side rails, or pacing?

Is the patient muttering under his breath or mumbling to himself? Is he short of breath, holding his breath, diaphoretic or flushed? Is he verbally aggressive, loud, profane, verbally abusive, or demanding with the PCA? Perhaps, he was sitting in stony silence?

Is the elderly patient drowsy, disoriented, confused, or disorganized in his thinking? Is his current behavior a sudden change for him? Is he already presenting as irritated, anxious, fearful, impatient, worried, depressed, or preoccupied? Does he appear to be responding to internal stimuli or “hearing things,” or experiencing tactile or visual hallucinations? Does he present with signs of being over- or under-medicated, paranoid, delusional, or manic? Could he be hungry, thirsty, in pain or discomfort, or in need of toileting, cleansing, or repositioning? Is he overstimulated by bright lights, television, alarms, chatter in the hallway, uncomfortable room temperature, noisy equipment, noxious smells, or sounds made by other patients, like crying or moaning?

Other signs of potential for violence in other patients might include intoxication or effects of illicit drugs.


Many cues were present in the scenario above, which, if heeded, could have prevented the assault.

In the debriefing following the incident, it was discovered that the patient had a history of dementia and combative behavior, which had not been shared with the agency PCA during the hand-off report. The PCA also reported in the debriefing that the elderly gentleman had looked irritated, tense, and restless and had told her  ‘he wasn’t going for a shower, because it’s too cold in here.’

She had admitted to feeling time pressure at that time, and reported she had encouraged the patient to ‘come along anyway, because it will make you feel so much better.’ She states the patient, then, had begun punching and rattling the bed rails in anger, so she had reached in to lower the bed rail ‘to keep him from hurting himself.’ It was, then, that the patient had reportedly kicked the PCA in the stomach.

All of the non-verbal and verbal cues above combine to present a picture of a patient at risk of becoming violent.

Here are a few handy tips to remind you of signs to watch for in patients or visitors.


  • Violent behavior (single best predictor of violence)
  • A diagnosis of:
    • Substance abuse
    • Personality disorder
    • Cognitive disorder
    • Conduct disorder
    • Traumatic Brain Injury


  • Overstimulation
  • Intoxication
  • Psychosis, especially with command auditory hallucinations
  • Paranoia
  • Mania
  • Increasing anxiety or agitation
  • Verbal aggression (cursing, yelling, etc.)
  • Stony silence
  • Change in mental status

To ensure patient and employee safety, employees in any patient care setting, should be taught to recognize these clues. In addition, the caregivers should be encouraged to work in pairs or teams with patients with an established history of aggression.

[Tweet “To ensure #patientsafety and #employeesafety, employees in any patient care setting, should be taught to recognize the warning signs of patient violence.”]

Finally, employees should be taught precautionary measures concerning appropriate (safe) dress, therapeutic communication skills, crisis intervention skills, and other safety measures to help prevent an assault.

The Healthy Workforce Institute Team works with healthcare organizations to cultivate professional workforces by addressing workplace violence, bullying, and incivility. The HWI offers a cadre of services from online programs, workshops, and leadership coaching, to onsite and virtual assessments and deep dive consulting. 

If you would like more information about keeping your employees safe, contact the team at the Healthy Workforce Institute.

This article was written by Diane Feldhausen, a Healthy Workforce Institute Content Writer and Workplace Violence Specialist. 

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