APNA Position: Violence Prevention
Position Summary
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Introduction
Violence is a pervasive public health issue that affects individuals and communities across all sectors of society (O’Brien et al., 2024). From interpersonal violence to structural and systemic forms, its impact can be both immediate and long-lasting, contributing to physical harm, psychological trauma, and social disruption (Webb & Penz, 2024). Workplace violence (WPV) is not limited to acute health care settings and can occur in any healthcare setting to anyone present (Meese et al., 2024). Nurses across all specialties and settings are uniquely positioned to recognize, prevent, and respond to violence in its many forms. Whether working in schools, correctional facilities, clinics, homes, or hospitals, nurses routinely encounter individuals impacted by violence and are trusted to intervene with compassion and skill. Psychiatric-mental health nurses, in particular, bring specialized expertise to violence prevention, risk assessment, crisis response, and trauma-informed care. As the largest segment of the healthcare workforce, nurses are essential leaders in multidisciplinary efforts to reduce violence, promote resilience, and improve safety outcomes for individuals, families, and communities.
Definitions
Actual rates of workplace violence may be much higher due to two factors: widespread underreporting and poor quality of data due to lack of universally accepted definitions and standardized reporting measures (Allen et al., 2019; Hauenstein, 2025). Due to the multifaceted etiology and characteristics of violence, rather than relying on one classification of violence, the American Psychiatric Nurses Association recommends the following definitions of violence:
- The World Health Organization (WHO) defines violence as the intentional use of physical force or power, threatened or actual, against oneself, another person, or against a group or community, which either results in or has a high likelihood of resulting in injury, death, psychological harm, mal-development or deprivation (WHO, 2025).
- Workplace violence, referring specifically to violence in the healthcare setting: “Workplace violence is 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” (OSHA, 2025).
- Aggression, an integral component of violence (Allen et al., 2019):
- Physical aggression: Action intended to inflict pain, bodily harm, or death on another.
- Verbal aggression: Verbally hostile statements that seek to inflict psychological harm on another through humiliation, devaluation/degradation, intimidation, social rejection, or threats towards others.
- Aggression against property: Destruction of property, objects, or possessions of others
- Microaggression: A microaggression is a subtle behavior – verbal or non-verbal, conscious or unconscious – directed at a member of a diverse and marginalized group that has a derogatory, harmful effect. (Smith & Griffiths, 2022)
- Autoaggression: Behaviors or actions where an individual directs aggression or harm toward themselves, such as physical injury toward oneself, self-mutilation, or suicide attempt. (Daukantaitė & Jokela, 2024).
Discussion
No matter what type of aggression or circumstances, the issue of violence prevention is complex and requires an interprofessional approach. The U.S. Department of Labor’s Occupational Safety and Health Administration (OSHA) reported that violence in healthcare occupations represented more than 10% of all workplace violence (WPV) incidents (OSHA, 2025). Nurses have the highest rate (40.2%) of workplace violence injuries recorded by participating hospitals and physicians (US Department of Labor, 2023); one estimate is that one in four nurses have experienced violence in the workplace in their career (Bureau of Labor Statistics, 2022.) In one meta-analysis of WPV reports involving nurses, the authors arrived at a pooled prevalence of 0.35 meaning 35% of the RNs experienced aggression from a client/patient. (McLaughlin & Khemthong, 2024). In this study, the mean prevalence of reported workplace violence for emergency department nurses or those who work in corrections or a psychiatric setting was higher, with a pooled prevalence of 0.59. Analysis of healthcare WPV reports echo this finding; while WPV prevalence rates vary, nurses working in psychiatric wards are the professionals most impacted (Rossi et al., 2023).
Violence prevention in the hospital and other healthcare settings relies on a set of interrelated processes involving organizational accountability, risk identification, and prevention strategies that promote positive engagements across all populations (Amara & Hansen, 2024; Michels et al. 2025). Meta analysis of available outcomes on these efforts notes that the evidence supporting any single intervention is limited and that data indicate prevention relies on multicomponent interventions, such as organizational change and training (Daguman, et al., 2024; Munday et al, 2021; Somani et al., 2021) and leadership that cultivates a particular culture marked by inclusivity, support, and respect (Fricke et al., 2022).
The goal of violence prevention is to decrease risk factors and increase protective factors (CDC, 2023). To that end, hospital and other healthcare setting staff should become familiar with potential risk and protective factors associated with violence and solicit specific data on cultural nuances when assessing individuals or communities (Lim et al., 2022; Pagnucci et al., 2022). For instance, agitation (a notable risk factor) often precedes violence. People who present to hospital emergency departments (EDs) often become agitated for a variety of reasons (Doehring et al., 2024). Recognizing early warning signs of agitation can preempt violence, particularly with a patient-centered response (Bowers, 2014; Hallett et al., 2024). Attempts have been made to identify persons at risk for violence through the use of screening tools such as the Broset Violence Checklist (BVC) (Alberhalden et al., 2006; Hvidhjelm, J., 2023; Sarver et al., 2019) and the Dynamic Appraisal of Situational Aggression (DASA) (Ogloff & Daffern, 2006; Simmons, et al., 2023). It is important to remember that the predictive accuracy of violence risk assessment tools vary greatly, can change over time, and are prone to human error (Blair et al., 2025; Gosh, 2019). Other instruments that collect real time data about episodes of violence may be used to guide care plans aimed at preventing further incidents (Mistler & Friedman, 2022).
Patient-centered, relationship-based, trauma-informed, recovery-oriented practices are an integral element of violence prevention (Brewer & Lewis , 2025; Edegman-Levitan, 2022; Goldstein, et al., 2024; Koloroutis, 2022; SAMHSA, 2025). Richmond and the Emergency Psychiatry Group BETA position statement (2012) recommended the replacement of restrictive methods of treating agitated patients with non-coercive interventions that include engagement, collaboration, and de-escalation. Connecting with people in distress via therapeutic relationship strategies and focusing on meeting each individual’s unmet needs may prevent unnecessary frustration and anger that often trigger violence (Amara & Hansen, 2024; Munday et al., 2023). Moreover, coercive measures based on control are in direct conflict with patient-centered, trauma-informed care. Len Bowers (2014) found that there is a correlation between using controlling interventions and violence; units which use controlling interventions often have more violence, resulting in increased risk to staff and patients. As imposition of restrictions usually exacerbates the problem of violence, an approach that is sensibly cautious, yet not overly reactive or controlling, may be most effective (Blair, et al.,2025). Thus, a critical violence prevention strategy is one that develops culturally relevant communication techniques that decrease controlling and coercive interactions and increase staff use of positivity, empathy, softer words, conflict resolution, and reassurance (Amara & Hansen, 2024; Bowers, 2025; Janzen et al., 2022; Mullen, 2022).
Violence prevention in mental health care requires a multifaceted strategy that includes therapeutic engagement, environmental safety, clinical protocols, and organizational leadership. Psychiatric-mental health (PMH) nurses play a central role in this approach by building relationships that foster trust, de-escalate distress, and support recovery. Evidence-based strategies — ranging from trauma-informed communication, early risk screening, and individualized care planning to environmental modifications and debriefing practices — are all part of a violence prevention toolbox (APNA, 2022; Beeber, Delaney & Martinez, 2025; The Joint Commission, 2022). At the heart of these interventions lies the therapeutic relationship: a dynamic and healing connection that empowers patients to manage impulses, reduce isolation, and develop hope. PMH nurses are trained to recognize early warning signs of agitation or suicidal ideation and to partner with patients through de-escalation, coping skill development, and collaborative care planning (Amara et al., 2024; Blair et al., 2025; Harrington et al., 2019). This person-centered engagement is essential – not only in acute care, but also in schools, correctional facilities, long-term care, and community mental health settings, where preventive interactions can interrupt trajectories of harm. Aligning with the APNA Key Components of Safety, interventions that emphasize space and design, structured milieu, staff preparedness, and ongoing assessment support this relational work while mitigating structural risks.
Sustained violence prevention also depends on a supportive and accountable organizational culture (Sheppard et al., 2023). Leaders must champion safety by advancing collaborative care models that are rooted in dignity, equity, and psychological safety. This includes adopting culturally humble practices; ensuring adequate staffing; investing in staff training on violence prevention, risk assessment, and trauma-informed care; and promoting consistent reporting mechanisms (Beeber, Delaney & Martinez, 2025; Fricke et al., 2022). Policies must be aligned with practice to ensure nurses are supported not only in responding to violence but in proactively preventing it. Data-informed systems that track exposure and outcomes, environmental reviews that identify hazards, and peer support for those impacted by violence (Dean, Butler & Cuddigan, 2021) are integral to this process. When therapeutic engagement is integrated with policy, environment, and leadership strategies, violence prevention becomes not just an intervention, but a culture.
Position
The American Psychiatric Nurses Association (APNA) believes that psychiatric-mental health nurses at all levels of practice are crucial in developing policies and strategies that enhance safety across healthcare settings for both patients and staff (Beeber et al., 2023; Finn et al., 2024).
With expertise in interpersonal relationships, conflict resolution, and violence prevention, PMH nurses can educate individuals on violence, its prevention, and related risk and protective factors in various contexts. Positioned to work with individuals, systems, and families from diverse backgrounds, PMH nurses play a key role in helping identify and address intolerable emotions in non-violent ways, utilizing evidence-based best practices.
Conclusion
Trusting relationships between PMH nurses and individuals, families, and members of the community are essential elements in the effort to prevent violence. Through these relationships, PMH nurses are positioned to be at the forefront of violence prevention efforts by assessing risk factors, providing counseling and education, and acting as role models while actively working to identify and acknowledge cultural norms related to violence. PMH nurses have an ethical and best practice responsibility to facilitate and implement interventions and strategies to reduce and ultimately prevent violence (Healthy People, 2030). Additionally, the American Nurses Association (ANA) outlines standards of practice that guide nurses in promoting safety and well-being. These standards support the role of PMH nurses in facilitating and implementing violence prevention strategies as part of their professional responsibilities (ANA, 2025).
As psychiatric-mental health nursing leaders, caregivers, educators, and members of one of the most trusted professions in America, PMH nurses have the opportunity to teach and promote violence prevention approaches and strategies, as well as cultural humility approaches and strategies, when they interface with diverse individuals, families, and communities in an equitable manner.
Approved by the APNA Board of Directors July 12, 2016. Revised November 2020, April 2022, August 2025
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Approved by the APNA Board of Directors July 12, 2016.
Revised and approved November 10, 2020, October 2022, August 2025.
