Understanding and Managing Assaultive Behavior in Healthcare Settings

Healthcare professionals are no strangers to high-stress, high-stakes environments. Yet, amidst the critical patient care, they also face a concerning trend: assaultive behavior. Nurses, doctors, and support staff often experience various degrees of aggression and violence, ranging from verbal abuse to physical harm. Understanding and managing these incidents is paramount not only for the safety of healthcare workers but for sustaining a culture of patient-centered care.  

In this comprehensive guide, we will explore the nuances of assaultive behavior in healthcare settings, including its definition, epidemiology, and essential strategies for mitigating its impact. 

Defining Assaultive Behavior 

Assaultive behavior in healthcare is not limited to physical altercations. It encompasses a spectrum from non-verbal threats to life-threatening violence. Distinguishing between aggression (a verbal or physical act of a threatening or harmful nature) and violence (behavior involving physical force intended to hurt, damage, or kill someone or something) is essential. 

Types of Assaultive Behavior 
  • Verbal Aggression: Abusive language, shouting, or insult hurling 
  • Physical Aggression: Acts of violence, including scratching, punching, or use of weapons 
  • Sexual Assault: Any sexual act or contact without consent 
  • Psychological Aggression: Intimidation, menacing, or coercion 
Recognizing Warning Signs

Recognizing the signs of potential aggression can aid in preemptive actions. These may include: 

  • Agitation and pacing 
  • Clenched fists or tense posture 
  • History of violent behavior 

Assaultive Behavior Epidemiology 

Assaultive incidents in healthcare can lead to severe consequences, including emotional trauma and physical injuries. 

Prevalence in Healthcare Settings 
  • According to a study conducted in a tertiary care hospital in the USA (Rosenthal), 34.4% of the health workers reported verbal or physical WPV, 31.9% both verbal and 13.5% physical assault.1 
  • According to the World Health Organization (WHO), “between 8 and 38% of nurses suffer from health-care violence at some point of their career.”2 
  • Health care workers are five times as likely to experience workplace violence as other workers, according to government data. In a National Nurses United survey in 2022, 40 percent of hospital nurses said they’d seen an increase in violent incidents.3 
Contributing Factors
  • Understanding the root causes is complex but often linked to: 
  • Long wait times 
  • Overcrowding 
  • Substance abuse 
  • Mental health issues 
Identifying High-Risk Areas 

Certain areas, like emergency departments and psychiatric units, are at a higher risk for assaultive behavior due to: 

  • Understaffing 
  • Increased acuity levels 
  • Diminished environments 

To learn more about assaultive incidents and how to manage them, check out these course: Managing Violent Behavior

Risk Factors and Assessment 

Assessing and managing risk can prevent incidents before they occur. 

Common Risk Factors 
  • Substance intoxication/withdrawal 
  • History of violence 
  • Confrontational situations 
Assessment Tools 

To effectively manage the risk of assaultive behavior in healthcare settings, employing robust assessment tools is crucial. These instruments not only assist in identifying at-risk individuals but also guide the implementation of preventative strategies. Among the most recognized tools are: 

  • The Brøset Violence Checklist (BVC): This tool evaluates the presence of six observable behaviors such as confusion, irritability, boisterousness, physical threats, attacking objects, and verbal threats. A score is assigned based on the behaviors' presence, aiding in the early identification of patients likely to exhibit violence. 
  • The Dynamic Appraisal of Situational Aggression (DASA): DASA offers healthcare professionals a method to assess the likelihood of aggressive incidents within a short timeframe. It focuses on situational factors and patient behavior, providing a structured approach to daily risk assessment. 
  • The Staff Observation Aggression Scale-Revised (SOAS-R): SOAS-R allows for the documentation and analysis of aggressive incidents post-occurrence. It helps in understanding the antecedents, behavior type, and consequences of aggression, which can inform future prevention strategies. 

Incorporating these tools into routine patient assessments and care planning empowers healthcare professionals to preemptively address potential risks.  

Implementing Preventative Strategies 

Implementing preventative strategies is key to mitigating the risk of assaultive behavior in healthcare settings. A proactive approach that encompasses staff training, environmental modifications, and policy implementation can reduce incidents of aggression and violence.  

Staff Training: Comprehensive training programs should be developed to equip healthcare workers with the skills necessary to recognize early signs of aggression, communicate effectively in confrontational situations, and employ de-escalation techniques.  

Environmental Modifications: The design of healthcare facilities can influence the occurrence of assaultive behavior. Simple changes, such as increasing visibility across units, implementing secure access points, and optimizing layout to minimize crowding, can create a safer environment for both patients and staff. 

Policy Implementation: Establishing clear policies regarding the management of assaultive behavior is crucial. These policies should define what constitutes unacceptable behavior, outline the steps for reporting incidents, and describe the consequences for those who engage in aggression.  

Strategies for managing aggressive behavior 

Managing aggressive behavior requires a multi-faceted approach that begins with comprehensive training and is sustained by organizational policies and resources. 

Training and Certification 

Specialized courses, like Management of Assaultive Behavior (MAB), equip healthcare workers with the skills to de-escalate and manage potentially violent situations. 

The Management of Assaultive Behavior certification represents a critical component in preparing healthcare workers to effectively handle and de-escalate potentially violent situations. The certification process encompasses a comprehensive curriculum, covering various aspects of assaultive behavior management, including but not limited to, understanding the psychology of aggression, legal and ethical considerations in managing violent incidents, and physical techniques for personal defense in extreme situations. By obtaining the MAB certification, healthcare professionals demonstrate their commitment to maintaining a safe and secure environment, reinforcing the importance of proactivity and preparedness in confronting challenges associated with assaultive behavior. 

If you’re interested in learning more about training and certification, check out our course, Managing Violent Behavior

De-escalation Techniques 

De-escalation techniques are vital for healthcare professionals to handle aggressive behavior. These methods aim to lessen confrontation by using effective verbal and non-verbal communication, empathy, and understanding. Key strategies: 

  • Active Listening: Demonstrating genuine, nonjudgmental attention to the individual's concerns can help alleviate their frustration and aggression.  
  • Maintaining Calm Demeanor: Healthcare workers should strive to remain calm and composed, regardless of the provocations. A calm demeanor can have a soothing effect on agitated individuals, reducing the likelihood of escalation. 
  • Space and Privacy: Giving the individual some space can prevent feelings of being trapped or overwhelmed. Whenever possible, addressing concerns in a private area away from an audience can also help de-escalate tensions. 
  • Use of Non-Threatening Body Language: Body language plays a significant role in communication. Adopting a non-threatening stance by avoiding direct eye contact and keeping a safe distance can help reduce perceived aggression. 
  • Offering Choices and Alternatives: Providing individuals with options gives them a sense of control, reducing feelings of helplessness or frustration. However, it’s crucial to ensure that the choices offered are feasible and safe. 
  • Setting Clear Limits: Clearly communicated boundaries help define acceptable behavior. Be honest and consistent about the consequences of aggressive behavior and enforce these boundaries with compassion. 
  • Seeking Assistance When Needed: Recognize when to seek help. If de-escalation efforts are unsuccessful, or if the situation escalates further, involving security personnel or law enforcement may be necessary. 
Post-Incident Procedures 

Post-incident procedures are critical components in the management of assaultive behavior within healthcare settings. They provide a structured approach for responding to aggressive incidents, supporting affected staff, and preventing future occurrences. These procedures typically include immediate reporting, documentation, staff debriefing, support and counseling, review and reflection, and follow up when possible. 

Organizational Support 

Ensuring adequate staffing levels, providing security measures, and offering counseling services all form part of comprehensive support that guards staff well-being. 

Understanding and managing assaultive behavior in healthcare settings is an ongoing effort that demands the attention and action of every healthcare stakeholder. By implementing proactive strategies, healthcare organizations can enhance their safety measures, protect their personnel, and maintain an environment that prioritizes patient care at every level. 

If you are interested in learning more about managing assaultive behavior in healthcare, consider this course: Managing Violent Behavior


1. Rosenthal LJ, Byerly A, Taylor AD, Martinovich Z. Impact and Prevalence of Physical and Verbal Violence Toward Healthcare Workers. Psychosomatics. 2018. Nov;59(6):584–90. doi: 10.1016/j.psym.2018.04.007 

2. World Health Organization. Workplace Violence. Geneva, Switzerland: World Health Organization; [Accessed 2024 March 7].  

3. What’s behind an alarming rise in violent incidents in health care facilities. (2023, September 17). PBS NewsHour. 

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