The SCAHRM SOURCE Newsletter

COVERYS – Workplace Violence Prevention: Behavior De-Escalation

November 2023

Please note: This article was provided by COVERYS. Embedded hyperlinks may not be accessible in this format.  Additional information can be found at

Workplace Violence Prevention: Behavior De-Escalation

By Solveig Dittmann, RN, BA, BSN, CPHRM

Workplace violence (WPV) is a recognized risk in healthcare settings. According to the Occupational Health and Safety Administration (OSHA), WPV is “any act or threat of physical violence, harassment, intimidation, or other threatening disruptive behavior that occurs at the work site.”(1) In 2017, the Bureau of Labor Statistics (BLS) reported that 18,400 people were WPV victims and suffered injuries serious enough to require time away from work.(2) Many more cases go unreported,(1) so the actual rates are likely much higher.

Healthcare workers account for approximately 10% of the workforce3 but experience 70% of all violence-related injuries,(4) and the number of reported incidents is on the rise. Nurses and assistants who care directly for patients are at the highest risk for violence, which is most often perpetrated by patients or visitors.(5) These alarming statistics clearly illustrate the need for comprehensive workplace safety programs in healthcare settings.

According to OSHA, the first step in preventing violence is understanding patient, setting, and organizational risk factors. These risk factors include face-to-face interaction with persons with a history of violence, environmental design that may block employees from escaping a violent situation, inadequate lighting, and a lack of means to communicate in volatile situations, such as panic buttons in emergency room settings. OSHA also identifies the primary organization-based risk factor as the lack of training for staff members to recognize and manage escalating hostile and assaultive behaviors of patients, clients, visitors, and/or other staff members.(6)

Violence develops on a continuum. The Department of Labor describes three levels of violence:

  • Level One (Early Warning Signs) includes intimidating, uncooperative, and disrespectful behavior, often involving verbal abuse.

  • Level Two (Escalation of the Situation) includes arguing, defiance of rules and regulations, and/or verbal threats.

  • Level Three (Further Escalation – Usually Requiring an Emergency Response) includes physical fights, destruction of property, display of extreme rage, and/or the use of weapons to inflict harm.(7)

The skillful use of behavior de-escalation techniques in the early stages of violence can prevent many of these situations from escalating into dangerous, physical, high-level violence. The Crisis Prevention Institute (CPI) emphasizes the effective use of 10 behavior de-escalation techniques:

  1. Be empathetic and nonjudgmental: Try not to discount the person’s feelings, even if you think the feelings are unjustified.
  2. Respect personal space: Whenever possible, allow 1 ½ to 3 feet of personal space.
  3. Use non-threatening nonverbal behaviors: Keep your gestures, facial expressions, tone of voice, and movements neutral.
  4. Avoid overreacting: Remain calm, rational, and professional.
  5. Focus on feelings: Listen carefully to what the person is trying to say, and be supportive and empathetic.
  6. Ignore challenging questions: Defensiveness can lead to a power struggle and increased agitation.
  7. Set limits: Make sure directives are clear, simple, and enforceable.
  8. Choose wisely what you insist upon: Make sure you are clear about what is negotiable and what is not; give choices when possible.
  9. Allow silence for reflection: Even though this may seem awkward, it provides the person time to reflect on what is happening.
  10. Allow time for decisions: Stress rises when a person feels rushed.(8)

Other tips for de-escalating a potentially violent situation include:

  • Let another staff member know you are meeting with an angry person in private in case you need help.
  • Paraphrase your understanding of the person’s situation.
  • Validate their feelings.
  • Be specific and clear about behaviors that you will not tolerate.
  • Do not argue.
  • Address the person’s behaviors, not their attributes.
  • Do not position yourself so the person is between you and the door.
  • Remember to take deep breaths, especially if you are anxious.(9)

The problem of healthcare violence continues to increase. Educating staff members in de-escalating aggression before it becomes violent is a key risk management strategy for providing the safest possible environment for healthcare workers.


The following tools are available to Coverys policyholders:

To access these tools, Coverys policyholders may visit Policyholder Online Services, register for the Policyholder Resources Portal, log in, select Resources, and then select Tool Chest – Physicians and Practice Groups.

OSHA offers a free, online Workplace Violence Training video.

OSHA also offers Workplace Violence Program Checklists in

Guidelines for Preventing Workplace Violence for Healthcare and Social Service Workers.

The Centers for Disease Control and Prevention (CDC) also offers a free, interactive course titled Workplace Violence Prevention for Nurses.

Full, on-site staff training programs that include de-escalation techniques and intervention strategies are available for purchase from CPI and MOAB (Management of Aggressive Behavior) Training International.

We hope you found this RisKey helpful. If you have questions or would like further resources on this topic, please contact your Coverys Risk Management Consultant.


  1. United States Department of Labor (DOL), Occupational Safety and Health Administration (OSHA).  Workplace violence. OSHA website. Accessed          March 20, 2019.
  2.  United States Department of Labor Bureau of Labor Statistics. Table R4. Number of nonfatal occupational injuries and illnesses involving days away from work by industry and selected events or exposures leading to injury or illness, private industry, 2017. Available at Accessed April 11, 2019.
  3. Henry J Kaiser Family Foundation. Health Care Employment as a Percent of Total Employment. currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22 sort%22:%22asc%22%7D. Published May 2017. Accessed March 20, 2019.
  4. The National Institute for Occupational Safety and Health (NIOSH). Occupational Violence Fast Facts. Reviewed March 28, 2018. Accessed March 20, 2019.
  5. Centers for Disease Control and Prevention (CDC). Violence occupational hazards in hospitals. CDC website. Published April 2002. Reviewed June 6, 2014. Accessed March 20, 2019.
  6. United States Department of Labor (DOL), Occupational Safety and Health Administration (OSHA). Guidelines for Preventing Workplace Violence for Healthcare and Social Service Workers. OSHA 3148-06R 2016. Available at: Accessed March 20, 2019.
  7. United States Department of Labor (DOL). DOL workplace violence program. DOL website. Accessed March 20, 2019.
  8. Crisis Prevention Institute (CPI). CPI’s Top 10 De-Escalation Tips. Available at: Revisited Published October 2017. Accessed April 11, 2019.
  9. San Jose State University (SJSU), Division of Student Affairs, Counseling and Psychological Services. De-escalating aggressive behaviors. SJSU website. Reviewed March 20, 2015. Accessed March 20, 2019.