1. Boston-Fleischhauer, Carol JD, MS, BSN
  2. Herleth, Anne MPH, MSW
  3. Langr, Madeleine MA


Despite deeper investment in security measures, the rate of violence and point-of-care safety threats in healthcare settings is rising. As a result, nurses do not always feel safe while delivering care. In this article, the authors describe strategies for addressing point-of-care violence. This is the 2nd article of a series. The 1st article of this series, Cracks in the Foundation of the Care Environment Undermine Nurse Resilience, in the December 2018 issue (volume 48, issue 12) of The Journal of Nursing Administration, the authors explained how nursing leaders can reduce frontline nurse stress and burnout by addressing 4 "cracks in the foundation" of the care environment that can undermine nurse resilience. This article aims to help leaders address 1 of the foundational cracks: that violence and point-of-care safety threats are now commonplace in healthcare settings.


Article Content

Between 2005 and 2014, there was a 110% increase in incidents of violence against healthcare workers.1 Despite growing investments in facility security, frontline staff are dealing with disruptive, aggressive, and violent behavior from patients and families.2 One primary cause of increasing point-of-care violence is a growing number of patients with behavioral health or substance abuse disorders. Factors contributing to this trend include an aging population and an increased number of patients struggling with drug addiction.3 These patients often have acute clinical needs along with cognitive impairment, confusion, or anxiety. As a result, patient or family behaviors are more prone to escalation, which often lead to verbal or physical violence directed at the nurse. In addition to directly jeopardizing staff safety, point-of-care aggression and violence can undermine nurse resilience and can lead to burnout.


Strategies for Improving Response Time to Point-of-Care Safety Threats

To address point-of-care violence and safeguard nurse resilience, organizations need to reduce response time to safety threats. However, timely response can be challenging for healthcare organizations for 2 reasons. The 1st reason is that nurses underreport disruptive or aggressive behaviors. Many nurses believe that violence is part of the job and do not know which behaviors are appropriate to report. This means that security or other responders often are not alerted of disruptive behavior until after it escalates into violence.


To address underreporting of concerning behaviors, leaders should give frontline staff clear guidelines on when and how to ask for help when patients and family members display disruptive or aggressive behavior. For example, an acute care hospital in California developed an easy-to-use tool that assesses a patient's or family members' likelihood for behavior escalation.4 The assessment tool categorizes behaviors into 3 levels based on severity-from least to most severe-and includes specific interventions for each level. If a patient exhibits highly disruptive behavior, a behavioral treatment plan is put in place and follows the patient across their stay. This ensures all frontline staff know if a patient has a history of disruptive behavior. By providing a behavior assessment tool, the organization helps nurses better identify early warning signs, and security can intervene before behavior escalates. This resulted in a 68% decrease in staff injuries due to combative patients from 2015 to 2017.4


The 2nd reason why a timely response to point-of-care violence is challenging is that behavioral health patients need a specialized response when in acute crisis. However, many organizations have a limited number of clinicians qualified to respond-and they may not be available in the moment to help de-escalate threatening behaviors.


Some organizations have developed behavioral health emergency response teams, which are rapid response teams staffed by behavioral health clinicians from an inpatient psychiatric unit. When called, these teams quickly respond and provide clinical care for behavioral health patients while also managing disruptive or aggressive behavior.4


The key to creating an effective behavioral health emergency response team is access to clinicians with the right clinical and de-escalation expertise, such as staff from an inpatient psychiatric unit. But in the absence of an inpatient psychiatric unit, healthcare organizations should think strategically about how to build a team with upskilled clinical staff. A large, academic medical center in the Midwest without an inpatient psychiatric unit recently created a nurse-led behavioral health emergency response team. They trained select nurses in specific clinical competencies and behavioral management for the organization's most common behavioral health scenarios: delirium, substance abuse, acute psychosis, and admitted psychiatric patient. By upskilling frontline staff, the organization now deploys responders who are equipped to safely manage or intervene with behavior health patients. As a result, frontline staff feel safer providing care to behavioral health patients.4


The Chief Nursing Officer's Call to Action

At a time when healthcare leaders have multiple strategic priorities to advance, they must not overlook the critical need to address environmental factors eroding nurse resilience, including point-of-care violence. Nurse executives play an important role in ensuring the entire C-suite appreciates the magnitude of the challenge at their own organization. In addition to the 2 practices detailed in this article, Nursing Executive Center researchers identified several other strategies nurse leaders should consider. For example, broaden the definition of point-of-care violence to include any type of inappropriate behavior, encourage security personnel to collaborate more closely with nurse managers on each unit, and provide all staff with de-escalation training. By implementing a suite of strategies, nurse leaders ensure that frontline staff not only feel safe, but are safe.


For more information, JONA readers can request a copy of the Nursing Executive Center's publication, Rebuild the Foundation for a Resilient Workforce.




1. Campbell AF. Why violence against nurses has spiked in the last decade. The Atlantic. December 1, 2016. Accessed December 14, 2018. [Context Link]


2. "2016 Hospital Security Survey report," Health Facilities Management, October 5, 2016. Available at: Accessed: December 14, 2018 [Context Link]


3. Weiss AJ, et al. 4Trends in Emergency Department Visits Involving Mental and Substance Use Disorders, 2006-2013. Agency for Healthcare Research and Quality, HCUP Statistical Brief. 2016;216. Available at: Accessed: December 14, 2018. [Context Link]


4. Herleth A. Rebuild the Foundation for a Resilient Workforce. Washington, DC: Nursing Executive Center, The Advisory Board Company; 2018. [Context Link]