Workplace violence (WPV) in psychiatric hospitals and community behavioral health centers remains a significant concern. According to The Joint Commission’s recent EC News and Quick Safety articles, implementing de-escalation techniques plays a critical role in reducing these violent incidents. The Joint Commission’s workplace violence standards emphasize the importance for psychiatric hospitals and behavioral health organizations to be proactive in preventing violence.
Understanding Workplace Violence in Behavioral Health
The frequency and severity of workplace violence in psychiatric hospitals often stem from the inherent volatility of the patient population. Patients may be dealing with mental health crises, substance use disorders, or other stressors that heighten the risk of violence. The Joint Commission’s Quick Safety Issue 47 emphasizes that properly training staff in de-escalation is one of the most effective methods for reducing workplace violence. De-escalation techniques are not only therapeutic interventions but also preventive measures that reduce aggression before it escalates into a full-blown crisis.
Situational Awareness
Situational awareness plays a crucial role in reducing the risk of workplace violence in psychiatric settings by enabling staff to recognize early warning signs of aggression, assess their environment, and respond proactively to potential threats. Here’s how situational awareness helps mitigate violence:
- Recognizing Early Behavioral Cues – allows staff to identify early indicators of agitation or aggression in patients, such as changes in body language, tone of voice, or pacing. By staying alert to these subtle signs, healthcare workers can intervene with de-escalation techniques before the situation escalates. Tools like the STAMP (Staring, Tone/volume, Anxiety, Mumbling, Pacing) model, highlighted by The Joint Commission, help staff maintain awareness of these early aggression markers, enabling timely intervention
- Assessing the Environment – In psychiatric settings, maintaining a clear understanding of the physical environment—such as knowing the location of exits, potential hazards, and security devices—enables staff to respond quickly to emerging threats. Strategic environmental changes, like adding cameras and two-way vision windows, to improve situational awareness make it easier for staff to assess the safety of their surroundings
- Improving Team Communication – Staff who are alert and aware can communicate more effectively with colleagues, ensuring that everyone is on the same page regarding potential threats. This allows for quicker, more coordinated responses, which can de-escalate situations before they become violent.
- Avoiding Overreaction or Underreaction – Being situationally aware helps staff avoid overreacting to minor disturbances that may exacerbate patient stress, while also ensuring that serious threats are addressed immediately. This balance is key in psychiatric settings, where patient behavior can fluctuate rapidly, and inappropriate responses can trigger violence.
Physical Cues of Escalation Towards Violence
Watching out for these physical cues can help reduce workplace violence.
- Changes in Posture: tensed body, rigid posture or leaning forward
- Facial Expressions: clenched jaw or grinding teeth
- Intense staring: Prolonged and focused eye contact, often without blinking
- Flaring nostrils
- Pacing and Restlessness
- Increased pacing
- Inability to stay seated
- Sudden movements
- Aggressive or rapid hand movements: Gestures such as pounding fists, shaking a finger at someone, or other abrupt hand motions often precede violent behavior.
- Throwing objects or pushing furniture: These actions can indicate that the patient is losing control of their impulses and may lead to more serious violence.
- Changes in Tone and Speech: Increased volume or yelling, sudden change in tone, rapid or pressured speech
- Physical Indicators of Anxiety: Mumbling, quiet and incoherent speech or muttering to oneself or sweating and flushed skin
Leveraging Patient Assessment Tools
To further enhance safety, The Joint Commission recommends using standardized assessment tools to predict potential violence. The STAMP tool, which assesses Staring, Tone/volume, Anxiety, Mumbling, and Pacing, helps staff identify early signs of agitation. Other useful tools include the Overt Aggression Scale (OAS) for inpatient settings for children and adults, Broset Violence Checklist (BVC) for inpatient adult psychiatric unit, and Brief Rating Aggression of Children and Adolescents (BRACHA) for use in ED for placement in inpatient psychiatric unit. These tools, combined with de-escalation techniques, form a comprehensive strategy for reducing violent incidents before they escalate.
Key De-Escalation Techniques
De-escalation relies on creating an environment where patients feel safe and respected. Some of the most effective techniques include:
- Active Listening: Allowing patients to express their frustrations without interruption helps reduce feelings of isolation and powerlessness.
- Calm Demeanor: A calm, empathetic tone from staff can significantly lower a patient’s agitation, making it easier to communicate and de-escalate.
- Respecting Personal Space: Maintaining appropriate physical distance helps prevent patients from feeling threatened, which can trigger aggressive behaviors.
- Non-Threatening Body Language: Open, non-aggressive gestures and postures can help ease the tension in a potentially volatile situation.
The Importance of Comprehensive Training
The experience of Maine Medical Center (MMC) provides an excellent case study on the importance of de-escalation training. According to Joint Commission’s EC News, MMC implemented a comprehensive workplace violence prevention program, which included training staff through the Crisis Prevention Institute to de-escalate potentially violent situations. By tailoring the depth of training to specific roles and work areas, MMC successfully reduced workplace violence (WPV) incidents on average from 423 per month in 2022 to 175 per month in 2024. This targeted training made de-escalation more intuitive and accessible for staff across various departments, resulting in better outcomes for both staff and patients.
Components of the Crisis Prevention Institute Training
The following components collectively aim to reduce workplace violence by equipping staff with skills to prevent, de-escalate, and respond safely to aggressive behavior. The CPI training is commonly used in psychiatric hospitals, behavioral health settings, and other healthcare environments.
1) Preventive Techniques
- Proactive Approaches: The program emphasizes preventing crises before they occur by identifying early signs of distress and potential violence.
- Understanding Behavior: Participants learn to understand the stages of a crisis and recognize verbal and nonverbal cues that indicate someone is escalating toward aggression.
2) Verbal De-escalation
- Empathetic Listening: Staff are trained to actively listen to the person in crisis to validate their feelings and reduce emotional tension.
- Non-Threatening Language: Emphasis is placed on using calm, respectful, and neutral language to defuse anger or frustration.
- De-escalation Phrases: Specific techniques include using short, simple phrases to deflect aggression and give the person in crisis more control over the situation.
3) Nonverbal Communication
- Body Language: Staff learn the importance of maintaining a relaxed posture, using open gestures, and managing personal space to avoid triggering further agitation.
- Positioning: The training also covers strategic positioning, such as standing at an angle rather than directly in front of the individual, to reduce perceived threat.
4) Crisis Development Model
The CPI Crisis Development Model provides a framework for understanding the phases of a crisis and tailoring interventions accordingly:
- Anxiety Phase: Respond with supportive techniques.
- Defensive Phase: Engage with verbal de-escalation.
- Risk Behavior Phase: Focus on safety and limit-setting.
- Tension Reduction Phase: Encourage therapeutic rapport to calm the situation.
5) Physical Intervention (Last Resort)
- Safety Techniques: CPI trains staff in safe, non-harmful physical interventions to protect both staff and patients if de-escalation fails and a violent incident occurs.
- Disengagement Strategies: These techniques are designed to safely remove oneself from harmful situations, if necessary.
6) Post-Crisis Care
- Therapeutic Rapport: After a crisis is resolved, the training emphasizes restoring trust and rapport with the individual.
- Debriefing: Staff are taught to debrief after incidents to reflect on what happened, improve future responses, and support mental well-being.
Environmental and Policy Changes for Enhanced Safety
Creating a safe environment goes beyond training; it involves designing physical spaces and policies that reduce risks. For example, MMC incorporated active shooter training, aligning with run-hide-fight strategies, conducted in real workspaces to help staff mentally prepare for emergencies. Other interventions included adding more cameras, modifying visitor identification systems, and installing two-way vision windows and panic buttons to enhance security.
Additional Resources:
- Joint Commission Workplace Violence Resources
- Joint Commission Workplace Violence R3 Report in Hospitals
- Joint Commission Workplace Violence R3 Report in Behavioral Health Care Settings
- Joint Commission Worksite Analysis
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