Skip to main content

Dealing with aggression in the healthcare setting

Healthcare safety and security expert Steven Wilder offers important guidance on how to recognize potential workplace violence and some simple de-escalation steps that can work in any healthcare setting

As healthcare providers, you know that the risk of healthcare violence is real. OSHA guidelines state that if an employer recognizes and identifies an unsafe condition in the workplace that puts an employee at risk for illness or injury, then that employer is obligated to put the appropriate safeguards in place to minimize the risk.1

Climbing the “aggression continuum” ladder

Typically, people do not go directly from a state of calm to a state of being physically violent. According to Wilder, there are six behavioral changes that a person goes through that lead up to physical violence (known as the “Aggression Continuum”). The six steps, similar to climbing a ladder, range from calm (the bottom rung) up to physically violent (the top rung). “The goal is always to get the person back down to a state of calm,” says Wilder.

Step 1: Calm

Most everyone you have contact with is going to be in a state of calm. This could be a co-worker at the nurses’ station, a supervisor-subordinate relationship, or a patient or resident. The person states his/her concerns in a calm, polite, and non-agitated way. This person’s presence is not threatening to you. Your presence is not threatening to them.

How should you respond:

  • Listen to their concerns – “I’m here to help you”

  • Demonstrate compassion and a caring/helpful approach

  • Focus on what that person’s needs are and work on continuing to build that relationship

Step 2: Verbally agitated

Verbally agitated is “a good person having a bad day,” says Wilder. This person is expressing verbal anger, but their anger is not directed at you. This is “non-directed anger.” They’re not mad at you, they’re mad about something. Non-directed anger is not a threat to you.

How should you respond:

  • Do not take it personally or become defensive

  • Listen and acknowledge them. Letting them vent and showing respect for their feelings helps save the person’s self-esteem

Step 3: Verbally hostile

Verbally hostile equals verbally agitated plus the element of emotion. The person’s behavior is very similar to when they are verbally agitated, but they’re now at a point where they’re oblivious to any efforts to calm them down. Their anger is still generalized and non-directed. They may start to use generalized statements, “This blankety-blank place, you blankety-blank people,” “This always happens,” or “You never let me.”

How should you respond:

  • Watch their level of emotion – tearing up, voice cracking, and changes in breathing are all signs that the person has transitioned from verbally agitated to verbally hostile

  • Use non-confrontational body language. Don’t make fists and keep your hands in front of your chest

  • Respect the individual’s personal zone, even for residents lying in their bed

  • Keep instructions minimal. Ask questions and use inclusive, collaborative statements such as “Steve, tell me how I can help you” to help them make the right choices

  • Never lie to them or agree to anything you can’t provide. Keep it focused to the here and now

Step 4: Verbally threatening

When a person is verbally threatening, they begin to focus their anger on a specific person. It can be directed at you or it can be directed at a different person. This is called “directed anger.” They may call you by name or use the word “you”, or they may point to you. They may make a demand for action and then make a threat of what’s going to happen if you don’t do it.

How should you respond:

  • Maintain eye contact and avoid cornering the person. A person that is cornered will likely try to fight their way out

  • Anticipate violence. Call for help immediately

  • Limit the number of people interacting with the aggressor to three (the Triangle Approach)

  • The person closest to the aggressor is in charge and they are the only one that talks

Step 5: Physically threatening

There are recognizable physical signs that indicate when a person is becoming physically threatening. They get into an aggressive stance, or they start looking around for potential weapons, which can include common, everyday items such as a letter opener, pens, stapler, telephone or a scalding hot cup of coffee.

How should you respond:

  • Discreetly go into a defensive stance

  • Position yourself on the individual’s weak side, if possible

Step 6: Physical violence

The last step on the ladder is when the person becomes physically violent. They physically attack you or another person.

How should you respond:

  • Your response should change to a self-defense and survival mode. Protect yourself, but the goal is not to fight, but rather to control the situation

  • When that person starts to raise their voice level, start lowering yours

Self defense vs. patient control

Self defense involves any and all means of self protection.

  • Force used must be reasonable and necessary

  • Tactics aid in the escape of an individual from an attacker without regard for the attacker

  • Used only in emergency situations to protect the provider from harm or injury

Patient control

  • Tactics to maximize patient management while minimizing injury to patients and other providers

  • Professional responsibility to protect and defend

Don'ts & Dos

Don’t give orders instead of choices Do demonstrate self confidence
Don’t over stare Do stay calm and relaxed
Don’t make threats or lie to the individual Do keep voice pitch and volume down
Don’t argue Do offer honest options
Don’t turn your back or walk away Do allow individual to make choices
Don’t become emotional Do allow individual to save self esteem
Don’t corner the individual or invade his space Do maintain safe personal distance
  Do take your time


Resources for healthcare providers

OSHA guideline 3148, subtitled “The Guideline for the Prevention of Workplace Violence for Healthcare and Social Service Workers,” sets forth guidelines for putting in place workplace violence prevention programs in healthcare facilities.