Workplace Violence: APNA 2008 Position Statement

Executive Summary Introduction Inpatient Violence in Psychiatric Settings Outpatient Psychiatric Settings
Interventions Appendix Acknowledgments References
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Recommendations for Inpatient and Outpatient Settings

Clinical Practice, Education, and Research

Based on the review of current literature, there are a variety of implications for clinical practice, staff education, and further research in both inpatient and outpatient settings.

Clinical Practice

  • Develop healthy, nurse-client relationships.
  • Use structured assessment tools in combination with traditional assessment techniques to identify risk. Recognize factors that may predispose patients to becoming violent, including
    • history of violence, particularly recent o head injuries, cerebrovascular accidents, cerebral pathology, organic brain dysfunction, or clinical brain injury
    • hypoxia
    • endocrine disorders: hypoglycemia or hyperglycemia
    • seizures: frontal, temporal, or limbic epilepsy
    • psychotic disorders, especially paranoid schizophrenia; hallucinations; depression, especially with history of suicidal tendencies; anxiety; or personality disorders (antisocial or borderline)
    • history of post-traumatic stress disorder
    • side effects of prescribed medication
    • intoxication or drug overdose, or drug or alcohol withdrawal
    • dementia or senility
    • disorders of childhood and adolescence: conduct disorders, hyperactivity, autism, or learning disability
  • Implement preventive measures based on training and education programs.
  • Reduce and/or eliminate positive psychotic symptoms or other symptoms, including confusion and disorganization.
  • Reduce impulsivity through therapeutic methods in conjunction with medication if indicated.
  • Examine incidents of violence in the workplace to identify the underlying causes and the impact of the event on individuals who are involved.
  • Establish protocols to assist staff victims and administrators in navigating complex issues occurring after a violent event.
  • Encourage group discussions for victims of violence.
  • Design intervention strategies to address specific types of violence (physical and nonphysical).
  • Stress the importance of reporting physical and nonphysical incidents of violence in workplace settings.
  • Develop policies and procedures for safety in the event of a weapon threat, such as lockdown procedures, and practice them.
  • Be informed and aware of one’s legal rights related to workplace violence.
  • Take seriously and follow up on all threats, even verbal threats.
  • When transferring to an inpatient facility have each patient checked thoroughly by security or other staff for any contraband items prior to transfer.
  • Have a security guard at outpatient facilities
  • Perform lockdown practice sessions on a regular basis.
  • Familiarize staff with takedown procedures and practice them regularly (even though they are rarely used).
  • Have a system in place for reporting all threats by phone and take immediate measures involving local police if a patient has made a threat and is en route to a clinic.

Clinical practice specific to outpatient practice settings

The following recommendations are based on experience in an outpatient clinic. Research and evidence-based practices are needed in this area:

  • Complete a mental status examination and a risk assessment for each patient and document it. The following risk assessment questions are recommended:
    • Do you have firearms at home?
    • Is there a prior history of violence?
  • Patients at high risk for violence should be seen within a 1- to 2-week timeframe after discharge from the inpatient setting; discuss these patients weekly in an interdisciplinary staff meeting.
  • At interdisciplinary meetings with the high-risk patient present, discuss the ongoing behaviors that have been inappropriate (verbal escalation in the clinic, use of profanity, etc.). Give the patient a copy in writing of what behaviors are inappropriate, the expected behaviors, and the consequences the patient can expect if the behavior continues, such as the termination of services to the patient.
  • Ensure that all staff members know the behavioral expectations of clients and are aware of any behavioral contract.
  • Maintain relationships with local police and use “welfare checks” on high-risk clients.
  • Encourage clients to sign releases of information to facilitate communication regarding the client and improve continuity of care.
  • Teach clients that when there is a risk of harm to others, the Health Insurance Portability and Accountability Act (HIPAA) privacy laws do not apply and staff has a duty to report a realistic threat.
  • All threats should be taken seriously with follow-up with patients, making the patient accountable for such threats.
  • Call police when necessary to an outpatient facility (when possible, have them come in a back entrance to minimize alarm for other patients).
  • A list of patients recently discharged and/or at a high risk for violence and/or with a previous history of violence should be kept. Some computerized systems can even flag these patients; if they are later evaluated as lower risks the “high-risk” status can be changed through a call to the “gatekeeper.”
  • Recommend alarm systems in all outpatient office areas, which are wired to a main desk or to security.
  • Recommend use of regular rounds by security and walkie-talkie connections to security in outpatient clinics when available.
  • Recommend use of visual screening/monitoring devices when available to monitor parking lots, entrances and exits, and remote parts of the facility.
  • Recommend use of visual monitoring systems for areas in and around the clinic when possible.
  • Recommend outpatient facilities have all exits and entrances (except the main entrance) monitored with access only via a fob (electronic system of entry) for staff.

Staff education

  • Define workplace violence and the types, causes, and consequences of violence.
  • Discuss work-related violence prevention and management policies and procedures, including reporting work-related harassment and assault.
  • Recognize the early signs of escalation, identify patient and staff factors that increase risk, and learn structured assessment processes in order to prevent violent episodes.
  • Conduct personal safety training, such as how to operate safety alarms or other safety devices.
  • Address nonphysical and physical techniques that decrease the potential for injury for all individuals (staff and patients), such as conflict management, de-escalation techniques, and effective communication skills.
  • Train in crisis debriefing, coping skills, alternatives to restraint and seclusion, and trauma informed care approaches.
  • Explain legal and ethical concepts related to workplace violence.


  • Develop consensus-based definitions so that research findings can be compared and replicated.
  • Determine the effect of relationships on reducing the incidence of violence in inpatient settings.
  • Review legal issues and responsibilities of addressing violence in clinical practice.
  • Evaluate outcomes related to staff training (recognizing early signs of escalation and the effectiveness of techniques used in de-escalation).
  • Assess outcomes of the use of structured assessment tools in combination with traditional assessment techniques to identify risk
  • Identify which techniques help contain the violent individual with the greatest degree of safety.
  • Examine staff characteristics and environmental factors that increase the risk of aggression and violence.
  • Explore the effect of nurse-patient relationships on reducing the incidence of violence.
  • Develop a uniform standard instrument or instruments for measuring aggression and violence that will identify the type and mode (direct or indirect) of aggression and the severity of the impact (physical, psychological, and/or emotional).
  • Test the effectiveness of proactive strategies such as establishment of work environments that are not conducive to violent behavior.
  • Include longer follow-up periods in studies.

Horizontal (Lateral) Violence

Clinical practice

  • Help create a work environment that facilitates and supports collegiality and effective communication and interpersonal skills.
  • Develop clear organizational guidelines regarding the responsibility of all leaders and employees to be accountable for workplace behavior and implement measures for reporting, documenting, and addressing bullying.
  • Inform all staff about the existence of such guidelines during orientation and annual review, and via EAP programs.
  • Intervene when witnessing victimization and bullying of colleagues.
  • Change a culture of horizontal violence by:
    • observing for verbal and nonverbal cues of horizontal violence in the behavior of your staff;
    • raising the issue at staff meetings and allowing staff members to tell their stories of horizontal violence;
    • being responsive when staff members bring concerns of horizontal violence to your attention;
    • engaging in self-awareness activities and reflective practice to ensure that your leadership style does not support horizontal violence.

Staff education

  • Educate newly graduated nurses on horizontal violence, and provide cognitive rehearsal techniques (role modeling and rehearsal in an interactive session using cue cards with a script and professional behaviors for each of the identified types of horizontal violence).
  • Coach nurses to develop their conflict management and conflict resolution skills.
  • Provide ongoing education to reinforce the organization’s commitment to ensuring a caring and respectful environment.

Nursing education

  • Teach students that horizontal violence is not acceptable.
  • Educate about horizontal violence, including how to identify it and appropriately confront it. Include cognitive rehearsal techniques.
  • Mentor students, building their self-esteem and self worth.
  • Equip students with assertiveness tools and with conflict resolution and healthy communication techniques.


  • Determine whether zero tolerance policies or sanctions against aggressive behavior are effective in preventing aggression.
  • Evaluate the effectiveness of organizational training programs aimed at preventing aggressive behaviors.
  • Assess whether emotional or other support from organizational insiders (e.g., peers, supervisors) and outsiders (e.g., family members, friends) lessens the negative effects of workplace aggression on victims.
  • Examine which leadership styles promote assertiveness and lessen bullying.
  • Identify which strategies most effectively reduce horizontal violence in the workplace.

Organizational Recommendations

Professional nursing organizations

  • Continue to advocate for a safe work environment for all nurses.
  • Continue to recommend research and education in this area.
  • Acknowledge horizontal violence, including bullying, as a very real problem in the workplaces of nurses.
  • Increase awareness of this issue among nurses, nurse researchers, employers, and the general public.
  • In all publications use the standard definitions for workplace aggression and violence, as outlined in this document.
  • Lobby for legislation that would increase assault of a health care worker to felony status.
  • Request that OSHA guidelines become mandatory for health care workplaces.

Employers of nurses

  • Establish and maintain a comprehensive program for prevention and management of all types of workplace violence.
  • Analyze workplace security and perform risk assessments of the physical environment.
  • Improve screening of potential employees.
  • Select staff preceptors who will support workplace violence policy and who will intervene if they observe other staff demonstrating any horizontally violent behaviors.
  • Make ongoing formal education about workplace violence compulsory.
  • Reward outstanding role models.
  • Track all assaults no matter who was the victim or where or when in the organization they occurred, and use performance improvement strategies as indicated.
  • Ensure anonymity in reporting through the use of occupational health or human resources.
  • Modify administrative practices to ensure the following:
    • time-out areas and quiet places
    • adequate staffing
    • specialist security staff
    • covert distress messages and coded responses
  • Provide environmental security features such as
    • personal alarms and panic-button alarms
    • bulletproof glass
    • adequate lighting
    • metal detectors
    • two-way communication systems
    • closed-circuit television
    • controlled access to, and security monitoring of entrances, exits, and highrisk areas of the facility.
Executive Summary Introduction Inpatient Violence in Psychiatric Settings Outpatient Psychiatric Settings
Interventions Appendix Acknowledgments References
Download the full PDF
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