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10 Ways to Protect Nurses From Active Shooters

Analysis  |  By Jennifer Thew RN  
   November 29, 2018

Experiencing violence shouldn't be 'part of the job.' Here's how healthcare executives can promote workplace safety.

A month after Chicago's Mercy Hospital & Medical Center held an active shooter drill, a gunman killed an emergency department physician, pharmacy technician, and police officer on the hospital's campus.  

Just over a year ago, a man walked into New Hampshire's Dartmouth-Hitchcock Medical Center and shot his mother, who was a patient in the intensive care unit.

Workplace violence is a serious issue in healthcare. It was a topic of conversation among nurse executives at the HealthLeaders 2018 CNO Exchange in November, and, through its Sentinel Event Alert 59, the Joint Commission has called on healthcare organizations to better protect employees from abuse.

Don't wait for something bad to happen. Nurse leaders and other healthcare executives can act now to create a safe workplace though training, communication, and creating physical barriers.

In an article for Patient Safety & Quality Healthcare, contributing writer John Palmer shares some strategies to help healthcare organizations prevent and prepare for violent incidents.  Below is an excerpt outlining ways to improve safety. It can be read in its entirety here.

1. Know your patients, and talk to coworkers. 

People who commit violent acts against healthcare facilities are usually well-known to the people who work there. Offenders may be furious at a [healthcare provider] for being unable to save the life of a loved one, angry about a large bill, or upset at an estranged spouse who works there.

Whatever the case, know who is coming into the facility and communicate with them. If a patient or family member is known for having anger issues or makes threats against employees, communicate and document it. Hospital personnel and security officers should know who they are dealing with, and in extreme cases, the police should be notified. Consider banning the person from the facility, but remember that decision may also make the person angry. 

2. Recognize the warning signs.  

Experts on healthcare safety say nonverbal body language known as “behaviors of concern” can precede actual violence. If caught early, de-escalation tactics can be used to intervene and keep the situation from becoming violent. 

Be on alert for the telltale signs of stress and anxiety, including raised voices or fast talking, clenched fists and teeth, glaring eyes, and fixed or darting stares. These behaviors of concern can usually be defused with simple tactics such as calming talk, offering a glass of water, or allowing the person to sit in a quiet area to relax. 

3. Communicate "zero-tolerance."  

Letting people know violence will not be tolerated is a deterrent in itself. Many facilities have a “zero-tolerance” approach to violence and have informed those working inside their walls. You should also let patients and visitors know that violent or aggressive acts will be taken seriously and reported to the police.  

4. Install locks and barriers.

This sounds like a no-brainer, but many nurses' stations and intake areas are still very vulnerable because they do not have proper locks installed. Exterior doors should latch when closed. Install glass or plastic partitions (bulletproof is best) that enclose front-desk personnel and protect them from violent individuals. Lastly, instruct staff members to always keep exterior doors shut.

5. Secure furniture. 

Many waiting areas and patient rooms have lightweight furniture, lamps, tables, and other items that could be wielded as weapons. Tie or clamp down waiting room furniture, or purchase weighted furniture that is harder to lift and does not contain glass or sharp edges. 

6. Establish safe rooms. 

If violence does break out, there should be a designated room where staff and patients can go to escape. Staff should be trained to run, look for a room in which to barricade themselves and their patients, and lock the door to keep out violent individuals. Also, designate an area outside the facility where employees can meet if necessary.

7. Check your phone lines.  

Regularly update lists of emergency contact numbers and communication plans. If a violent incident occurs, who should staff call for help? Is there an alarm or code to alert others about the situation? Staff may know to call 911, but would they know what to say? Consider writing a short script for callers to follow when calling for help. Also, many police and fire departments will send representatives to a healthcare facility to talk about security.

8. Fight as a last resort. 

Many facilities have turned to government agencies such as the FBI and the Department of Homeland Security to teach participants to run, hide, and fight during a violent incident. But in a healthcare setting, that sort of training won’t work, since most physicians and nurses would not leave a patient’s side during a shooting. 

"Avoid, Deny, Defend, and Treat" is an alternative shooting response plan in use at Carolinas Medical Center in Charlotte, North Carolina, says David Callaway, MD, FACEP, director of operational and disaster medicine at the organization.

Here’s a breakdown of how it works: 

  • Avoid. Hospital staff need to develop habits to help raise situational awareness and avoid a shooter situation in the first place. They should know their location’s access points and take time to check them (e.g., making sure doors are locked). They also need to engage people and observe whether visitors' hands are in their pockets, they are hiding something, or if they will exchange a handshake if one is offered. By engaging people, it may be possible to prevent a shooter incident from occurring. 
  • Deny. Almost half of active shooter incidents end within five minutes, and victims are usually chosen at random. Staff members need to be trained to quickly recognize when an incident is about to get violent and to find a safe room where they can quietly hide with patients, barricading the entrance with things such as beds, chairs, or other objects. 
  • Defend. Only as a last resort should a staff member in a healthcare setting fight back. Even then it’s a personal decision that should be made deliberately. Staff should always understand that it is never a job requirement to put their life in jeopardy.
  • Treat. This is where a hospital’s response plan differs from a typical shooting scene, Callaway says. Because the hospital is where shooting victims will be treated, staff members cannot flee after an incident.

9. Get rid of jewelry. 

Necklaces can be a choking hazard, rings can be a hard weapon, and earrings can be used to stab at someone’s eyes. Instruct staff members to leave jewelry at home or keep it in a locker. 

10. See something, say something.  

One of the reasons accurate statistics on patient violence and worker injuries are not available is because most incidents go unreported. Recent campaigns from nurses’ associations and healthcare worker advocates encourage healthcare staff to report incidents to their supervisors and keep good paperwork. Incident reports should always be filled out and kept on file for accurate reporting. 


Jennifer Thew, RN, is the senior nursing editor at HealthLeaders.


Violence against healthcare workers is unacceptable.

Provide de-escalation training to staff.

Frequently review the facility's active shooter plan.

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