Assaultive Behaviors in the Healthcare Workplace for CNAs and HHAs

Assaultive behaviors and workplace violence in healthcare facilities are complex and hard to understand. Management and healthcare workers must work together to make the workplace safer. Assaultive behaviors come in many forms:

• Verbal: cursing
• Physical: biting, pinching, slapping, or kicking
• Electronic: cyber bullying
• Psychological threats of brutality: intimidation, threatening, bullying 

The most common type of workplace attack against staff is from patients and family members. It is usually verbal. The second most common is physical violence from that same group. There is also psychological aggression from any person in the workplace. Healthcare staff are more than four times as likely to be hurt at work from hostility than nonmedical workers (BLS, 2020). Workplace suicide is considered workplace violence by some researchers.

There is more to workplace violence than physical damage. Studies show that psychological damage is done over time in small steps. This damage results in time loss at work from burnout, anxiety, depression, and job and occupational changes (De Sio et al., 2020; Jones et al., 2023). Lim et al. (2022) highlight that this happens more commonly in large groups of family and friends in crises, such as a severe injury to a family member. This is mostly seen in the emergency, ICU, and psychiatric units. However, workplace violence occurs in every area of healthcare. An interesting study showed that the typical person without mental or drug issues has just as much of a chance to commit workplace injury (Aljohani et al., 2021). Regular mandatory training for staff to recognize, reduce the damage, and calm down agitation is needed (Oguz et al., 2023).

What makes people agitated and assaultive? There is an imbalance of power in healthcare. Violence of any kind may occur because of this power imbalance. The patients, their families, and friends are on the lower end of the power balance. This perception of a lack of power creates feelings of helplessness and fear. In healthcare, the power balance is higher in the direction of the staff. Staff control everything that is done or happens to the patient.

Care decisions may be shared to a certain extent; however, once that care has begun, any number of changes may occur. For instance, when a person is admitted to the emergency department due to a motor vehicle accident, the patient and family expect the patient to be “put back together” as well as new. They do not expect negative outcomes like kidney damage, cardiac events, or multi-organ failure. The patient and others in this situation have no control over the care, which doctors or nurses do what, or what happens next. They may be removed from the room or cannot see the patient entirely. This loss of control leads to fear, which is closely connected to anxiety (Radomsky, 2022). Poor decisions, anger, and verbal or physical expressions of anxiety may happen. According to Lim et al. (2022), things that can cause assaultive behaviors are:

• Stressful or emotionally charged situations
• Short staffing leading to long wait times
• Unreasonable expectations of service and attitudes
• Training and presentation of staff

Anxiety is an emotional state of mind, almost like fear and loss of control(Pitts & Schaller, 2023). The symptoms of anxiety in a clinical situation are:

• Very high sensitivity to possible threats
• Overreaction of fear because the healthcare environment is not normal for that person
• Persistent and overwhelming worries about future threats
• Poor coping skills
• Poor ability to understand what is happening

There are four types of assaultive behaviors in the workplace.

• Interpersonal is when someone other than the staff is physically assaulting a staff member. Usually, a patient, family, or visitor.
• Horizontal is when physically assaultive behavior is from one staff member to another, such as rape or other battery.
• Verbal abuse against anyone, by staff or non-staff members, such as using foul language, yelling, and threats.
• Psychological use against anyone, by staff or non-staff members, such as intimidation, shaming, coercive power use, incivility, and bullying. 

In any workplace suffering, the final victims are always the patients, as it has been conclusively shown that workplace violence towards the staff is the cause of depression, anxiety, lower morale, missed shifts, job changes, and poorer quality patient care in general (Edmonson & Zelonka, 2019). Part of prevention is anticipating and recognizing anxiety and anger.

Non-verbal behavior indicators:

• Crossed arms, pushed out chest, clenched jaw, or fists, pointing, bowing up
• Abnormal expression for the situation, becoming red in the face
• Stepping into your or someone else’s personal space
• Breathing loudly, big sighs, fast breathing
• Throwing hands up into the air expressively, using larger-than-life movements of limbs
• Sometimes, shutting down and ignoring your words. Suddenly, leaving in the middle of a rant

Verbal behavior indicators:

• Using “You” phrases, “You are going to be sued” and “You people are idiots.”
• Using foul language
• Raised or loud voice
• Growling, muttering, talking to themselves under their breath
• Asking irrational or bizarre questions. “Do you want my mother to die”? “What is this place doing?”

Peers at work are your co-workers. In the case of peer-to-peer bullying and verbal assaults, these are usually due to poor communication skills, jealousy, racism, ageism, and feelings of superiority or inferiority of the perpetrator (Edmonson & Zelonka, 2019).

In the case of cyberbullying, the damage to the victim may be much worse than face-to-face bullying. The results are anonymous, cannot be walked away from, and may be shared around the world. Possible types of cyberbullying are emails, texts, photos, rumors, deep-faked information, stalking, and identity theft (Ikeda et al., 2022; La Regina et al., 2021; Oguz et al., 2023). This exposes the target over and over on social media, emails, and texts. It destroys the feeling of privacy and security, leading to the same or more severe reactions physiologically and psychologically (La Regina et al., 2021). A combination of face-to-face bullying and cyberbullying is much more devastating to the target (Ikeda et al., 2022). Training in coping skills and communication skills, such as non-violent communication and therapeutic communication, can decrease the damage of peer-to-peer assaultive behaviors in the workplace.

Reporting workplace violence is necessary. Bullying, peer-to-peer insults, and harassment should not be treated as expected or as part of the initiation to a job (International Labour Organization [ILO], 2024). No one is excluded from reporting, bystanders included. As per Oguz et al. (2023), who regard cyberbullying as a crime, administrators, supervisors, and managers should protect the targeted employee from cyberbullying through electronic device controls, policy making, and vigilance.

To prevent patient violence, there are several things staff can do:

• Do not surprise patients. A bad start to a patient encounter sets the tone for the entire meeting.
• Ask permission to touch patients.
• Let them know what you are going to do at every step and what they can do to help.
• Be on the same level for conversation, though out of arm’s reach. If they are lying down, sit down to speak with them. If they are standing, stand up also.
• Keep your voice calm even if they do not comply with directions.
• Ask what you can do to help them today. Do the best you can to make it happen. Keep them informed of the results of your efforts.
• Show compassion and empathy. Listen to them. Sometimes, that is all they want.
• Take someone with you, as this may stop or help you in case of a problem.
• Do not share your workload or frustrations with them. It is not about us. It is about them.
• Smile, use a relaxed stance, keep your arms loose at your sides, and only touch when assured they are open to a pat on the arm or hand holding.

Melanie had been working at a healthcare facility for 6 months when she overheard one nurse tease another nurse who had just started employment there. She noticed that the nurse told the new nurse that she “Would not last long, thank goodness” because the new nurse had commented that she was tired. Later, she heard the same nurse reporting to the supervisor that she thought the new nurse “Might be thinking of quitting already.” She remembered that this same nurse had acted that same way towards her when she first started and still did sometimes. At first, Melanie developed an “I do not want to go to work” attitude.

Her facility had an Employee Assistance Program, which she called to find out what to do. The program counselor invited her to journal her feelings and try to find one good or helpful thing every day. The counselor made several suggestions to increase her resiliency, such as meditation, self-affirmation, and positive coping ideas. She encouraged her to call back regularly until she felt she had a good outcome. Melanie talked to the counselor several times and put many of her suggestions in place. She journaled her feelings and decided she could ignore the poor behavior of the other nurse since the bills had to be paid. She felt lucky to have a good job.

However, she felt she could not report the bullying for several reasons. She had not reported it because she heard the supervisor say early on, “You girls work it out; you are adults.” Melanie had looked at the policy for poor behaviors on the job and learned that the supervisor was not following the policy. Then, she felt she could do nothing about this co-worker's incivility without getting her supervisor in trouble. She did not want to be pointed out as a troublemaker. Besides, who would the administration believe if it came down to it? Melanie thought to herself, “It is not my monkey and not my circus.” She felt that maybe the other nurse had to learn like she did. Despite Melanie’s friendly attention and occasional advice to her, the new nurse quit after just a few weeks.

Things to consider:

• Were Melanie’s feelings and inaction reasonable?
• What made Melanie able to endure the incivility?
• What would you have done?
• Was the supervisor’s response to the bullying avoidance and distancing herself from accountability?

If you agree with the supervisor in this case, you should know that that method of curbing bullying among staff is not successful. Over 50% of staff report at least one case of bullying in the last week!

You might be a bully if…

According to psychologist Chantal Gautier (2019), you might be a bully if you make people angry or cry often or if you cannot understand why when you have upset someone. Sometimes, you shout or complain about one person's errors in front of others, including patients and family. If you seem to thrive around insecure people and find that you feel good when you point out others' errors, you enjoy telling others about real or made-up things about someone. You deliberately ignore others and leave them out of events or important bits of information that are important to their job performance. Alternatively, you use your occupational power to remove or pile responsibilities onto someone without an excuse or explanation.

One important sign of bullies is that they do not have empathy for others. They do not understand and cannot imagine that what makes the bully feel good may have a very real and lasting negative effect on the person they are bullying. But then, if they have no empathy, they may not care.

No single way of calming down a situation is more successful than any other. However, regular and repeated training in calming down techniques has helped with overall reports of assaults of all kinds. One of the things most of these programs have in common is ways to decrease the damage or calm down agitation in patients and other consumers. Ways to prevent workplace violence include:

Compassion: Have compassion for the person acting out. They believe what they are upset about. They are anxious and are not thinking clearly.

Personal space: Provide space for either party to exit safely. People who feel threatened or angry feel safer if not approached too closely. Keep the exit clear. Do not allow yourself to be trapped by a desk, for instance.

Be Calm; do not allow yourself to take anything said or done personally. Emotional reactions are likely to increase violent behaviors. Keep an open stance.

Listen to the complaint with great attention. Attempts to understand what the person needs are seen as calming. Rephrase what the person has said for clarity. Try empathizing when you think you understand, such as “I see that worried (scared, troubled) you” or “That would make anyone feel that way.” Do not interrupt, as this is seen as discounting their feelings.

Apologize for what you can honestly be apologetic for. “I am sorry you feel so uncomfortable.”

If the person starts to wander verbally, try to keep to the point. “What can I do to help you with this right now?”

Keep it simple: Do not use medical jargon or “You” phrases (“You need to…, You should…”). Provide choices; people with little to no weight in the healthcare power balance need to feel they have control over something. This is especially true for patients. Use therapeutic communication when you can.

Silence: Allow silent breaks in the conversation. This decreases stress, does not feel rushed, and gives the perpetrator time to think about what you have said.

Report what happened, as this is how managers can track whether training is working as it is, if it needs to be repeated, or if an enhanced program is called for.

Mrs. Lura Rahim is a 90-year-old patient who experienced a fall at home 3 days ago and has been bed-bound since then. She broke her hip, which cannot be repaired due to her medical problems and age. She is completely incontinent of bowel and bladder and has pain in her hip during any movement. She refuses food and medications. She refuses to answer questions and turns her head away whenever anyone tries to talk to her. She will say “No” and loudly scream about being turned or cared for in any way that requires movement. She is assaultive to staff by pinching, slapping, and throwing food and other items. Everyone has been warned to watch out in her room. Some of the staff think she is angry that her son has put her in rehabilitation and that she just wants to die.

On the third day, the supervisor called the son, Najir, to discuss his mother and her needs. He reports that since she came from their home country, she has not adapted well; she does not like the food and does not speak English. He further states that she had servants in their country and her own home. He brought her here because his father passed away just a month ago, and her health was poor. He is the only living child. He had not hired servants for her here yet because he could not find any that spoke the language and that was acceptable to both him and his mother. He reports that this town does not have a large community of Middle Eastern people. But at the same time, he remains optimistic that she will be fine when she adjusts to it here.

He is encouraged to visit often, bring traditional, native, home-cooked meals to supplement what she tells him she will eat, and help her understand that her pain and other illnesses can be treated with medications. He is also urged to ask her to treat the staff respectfully without trying to hurt them.

When an incident happens, whether it is a minor incident or a major crisis, a debriefing by trained personnel is needed(Strid et al., 2021). This helps the abused staff member(s) to learn to deal with the issue and not take it personally. Emotional, negative coping skills such as self-blame, feelings of unfairness, avoidance, and anger are not helpful.Positive coping skills such as seeing the incident from a different perspective, talking it out, journaling, learning resiliency and adaptability, setting boundaries, recognizing self-worth, adequate rest, holistic self-care, and spiritual time are more successful in any psychologically difficult situation(Janzarik et al., 2022). Reporting the incidents and seeing results is also helpful to the victims.

Katella (2022) collected a list of ways to become a more resilient person. Those more likely to have positive outcomes used these eight ideas often:

1. Acknowledge and accept what you cannot do and figure out what you can do.
2. Learn to see things from a more positive point of view, such as practicing gratitude for what you do have.
3. Build your social connections, say help, and say goodbye. Develop deeper connections in your close social circle.
4. Do something for yourself that makes you feel fulfilled.
5. Do things that uplift your spirits on purpose. Walk outside, paint a picture, sew a toy, or do whatever you enjoy.
6. What can you do to make your job a better place for you to be?
7. Make family and friends’ emotional health a priority.
8. Avoid dwelling on the negative, such as not watching the news channel for hours, and avoid the strictly pessimistic people who want to expound on it.

Sometimes, a friend or a family member can help, but a counselor, preacher, psychologist, or other non-invested professional can feel better. There are also artificial intelligence-guided cognitive behavioral therapy programs that can be accessed via apps on a smartphone or computer.

Another situation that may cause hostility in the healthcare facility is when staff are judgmental towards patients. Febres-Cordova et al. (2023) report that abuse from staff toward substance-using, abusing, or addicted patients is also a workplace aggression problem. The report states that this abuse of power is verbal and physical in that these patients are often considered to be “drug-seeking” and, as such, are not always treated for pain or anxiety. These patients are often verbally abused, and their accounts of pain are not believed. Febres-Cordova et al. (2023) also report that staff can make this injustice better for patients who are illicit drug users by:

• Providing care based on respect for the person rather than judging
• Not attempting to punish the user verbally or physically
• Not bullying, withholding care, or coercion

Racism, ageism, and other prejudices that may be different due to cultural or socioeconomic levels cannot interfere with care. Staff must be aware of their core values before delivering care.

It is never acceptable to harm a patient deliberately and without provocation. How can healthcare workers reduce the amount of harm caused by assaultive behaviors from patients, family members, visitors, and other staff? There is a lot of agreement on that.

Whether the aggression is verbal, physical, or psychological, from patients, family members, or other staff, certain actions will be useful. To decrease the lasting psychological harm that, if ignored, can lead to depression, leaving the job or even the profession, consider these interventions.

• Treating each other with kindness and respect
• Believing the reporter, not holding the reporter responsible for mistreatment
• Debriefing the victims and bystanders where possible
• Mandatory counseling for the victim or victims
• Paid time off to get care without retaliation
• Training should include meditation, mindfulness teaching, and positive coping skills
• Management must actively seek and address feedback (Strid et al., 2021).
• Environmental changes made, such as large, comfortable waiting areas without blind spots
• Increasing staffing to avoid long wait times
• Increasing security staff in public entry points and on floors with higher instances of workplace violence

In the case of peer-to-peer incivility, peer group support is needed when standing up for what is right. Having a well-defined policy and transparent follow-through from a perpetrator's direct supervisor will also help (Edmonson & Zelonka, 2019).

Mr. Jacks is a 43-year-old man who had a motorcycle accident while riding with his club. He is a very large man weighing 280 pounds and standing 5’11”, dressed in a t-shirt and jeans cut off at the knee on his left leg, with a leather jacket covered in club patches. The ER staff considered his appearance to be dirty; scruffy, and scary. His “brothers” in the club are also large, long-haired, bearded and dressed in leather. They explained that a deer ran out of the roadside brush and hit him broadside. His leg was lacerated open through the entire calf. Due to the trauma of the event and the size of the laceration, his skin could not be closed over his calf muscles and associated structures. The physicians used an area of skin on his opposite hip and lower back to harvest skin for an allograft. However, daily care of the two operative sites was very painful. His club always left a member in his room to be his advocate. When one of his club brothers complained that his treatment should be preceded with pain medications, he was told by the charge nurse that the hospital was not interested in feeding Mr. Jack’s drug habit. There was a record of an overdose in the past. The “brother” reported to the hospital administrator that if his brother was not sufficiently treated for pain before daily treatments, he would purchase something on the streets to help him. The administrator saw the earnest caring of the “brother” and visited the patient, spoke with the physician, and discovered that there was a PRN order for opioids to decrease the severe pain already written and had been ignored due to the stigma of this patient’s medical history and motorcycle club affiliation.

Things to consider:

• Was kindness or caring employed by the nurses in this case?
• If the person had been clean-cut and without a substance abuse history, would this have happened?
• What if this man had no “brothers” or anyone else to advocate for his needs?
• Does this rise to the level of workplace violence prevention toward this patient?

Training is a very specific tool that is easy to put in place. Nurse educators and counselors are usually already present in most organizations. Workplace violence prevention training should encompass all areas.

Staff need to be aware of the area and situation where they work. What to look for and what policy allows you to do about it. If you must defend yourself, keep in mind that you must stop force only through your actions. Anticipation and avoidance may be the easiest and best answer (ANA, n.d.). Remember, in the case of safety restraint use, we are bound to use the least restrictive method possible to protect the patient and others from harm. Policy and procedures will be directed by the facility for restraint types, the timing of restraint use, nurse checks, documentation, and removal. Patients and family members are less likely to react to anxiety if they understand what is going on.

If a family is large, ask them to appoint a spokesperson for you to communicate patient updates. This reduces the number of people you deal with and sometimes takes you out of being the bearer of bad news.  It would be best if you attempted to have enough places for the families to sit comfortably. Designate a waiting area for them if possible. This increases comfort and reduces negative feelings. Let the security people know you have a large family who may become hostile if you see any signs. Know your facility’s policy ahead of time. Be aware of the people around you. Who can you count on in an emergency? The locations of exits and your safety status.

Be alert to places to hide if the situation devolves into a live shooter situation. Know when to shelter in place, bar the door, and call 911 in a live shooter situation. In this situation, if you must defend yourself, stopping the force may mean producing similar or greater power with whatever weapon you have at hand. Dunsford (2022) reports that staff can defend themselves from patients and others when avoidance is not achievable or successful. Facility policy will not support unreasonable self-defense measures. Protect yourself first, then patients if necessary. Any animosity in the workplace can lead to lasting psychological problems for everyone exposed to it. Workplace violence prevention training should include:

• How to recover from an event such as assaultive behavior without having lasting emotional issues, such as post-traumatic stress disorder.
• Learning and using positive coping skills to become a more resilient person. Knowledge is power.

The International Labor Organization (ILO) authored a world treaty that each member country would:

• Ensure that relevant policies address violence and hostility.
• Adopt a comprehensive strategy to prevent and combat violence and hostility.
• Establish or strengthen enforcement and monitoring.
• Ensure access to remedies and support for victims.
• Provide sanctions.
• Develop tools, guidance, education, and training and raise awareness in accessible formats as appropriate; and
• Ensure effective means of inspection and investigation of cases of violence and hostility through labor inspectors and other competent bodies (ILO, 2024).

Worldwide, discrimination for whatever reason is often the base of assaultive behavior, sexual harassment, and vertical and horizontal violence (ILO, 2024).

Not all assaultive behavior is caused by reality. There are situations where unprepared healthcare workers are simply surprised, such as the incident in Dallas, TX, in October 2022. A man was visiting his girlfriend who had just had their baby. No one knew, except his parole officer and his girlfriend, that this visitor was on parole after a violent aggravated robbery conviction and released with orders from the court to wear an ankle monitor. No one except her and his parole officer knew at the time that he had a history of violent criminality and had previously removed his ankle monitor four times. He had permission from his parole officer to visit his new baby at the maternity ward. He was intoxicated on arrival and irrationally became jealous, thinking a man was hiding somewhere in the room. He pulled out a gun and beat his girlfriend on the face and head several times while she held the baby. He shot and killed a nurse and a social worker who came in or near the room to care for the mother and baby. The mother recovered, and the baby was not harmed. The security officer arrived as the perpetrator was holding the mother hostage and shot the man in the leg (Osibamowo, 2023). It is unclear whether the hospital was aware of the man’s record and, if so, what steps they took to address the risk.

Points to Consider:

• What could the hospital have done if they had known his status?
• If you had known of the father’s record, what steps might you have taken to address the risk?
• What will the long-term psychological problems be for the rest of the staff (Jones et al.,2023)?
• Could any of this be prevented?

The World Health Organization defines workplace violence as “The deliberate use of physical force or power threatened or actual, against oneself, another person, or against a group or community, which has consequences or has a high probability of resulting in injury, death, mental distress, mal-development, or deprivation” (World Health Organization [WHO], 2022, pg. 1).

To address assaultive behaviors in the healthcare workplace, a big solution is needed. Continuing workplace violence prevention training regularly is helpful. Personal training and keeping the staff’s knowledge current is one way to be prepared (ElHadidy & El-Gilany, 2020; Lim et al., 2022). Language interpretation, therapeutic communication techniques, and self-defense training may also be helpful (Jeong & Lee, 2020). A safe and supportive work environment for reporting workplace violence, which supports judgment and emotional well-being, is important. Reporting verbal and physical conflict should be easy and not weighed against the reporter (Edmonson & Zelonka, 2019).

Post-incident debriefing meetings are necessary for all involved staff to help them cope with the incident (Strid et al., 2021). Most workplace violence occurs during highly emotional stressful situations where family groups are involved(Lim et al., 2022). The incidence of physical and verbal hostility is higher in emergency departments, ICUs, and psychiatric units (Cabilan & Johnson, 2019). Any medical setting where people are stressed, feel slighted, or ignored, such as long wait times or being refused pain medication, can become a place for abuse by the healthcare workers present(ElHadidy & El-Gilany, 2020; Khalid et al.,2020). A shared responsibility exists between staff and administration to put workplace violence prevention interventions in place (Lim et al., 2022). It is accepted in the healthcare industry that happy, healthier nurses make happy, healthier patients (Edmonson & Zelonka, 2019).

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