From fear to safety: Thomas Brownfield, MSN, urges early action against healthcare workplace violence

AAOS’ Committee on Healthcare Safety (CHS) recently hosted a webinar titled “Workplace violence in healthcare — Identifying risks and taking action.” CHS Chair Mary Carnduff, MD, MBA, FAAOS, introduced the session by emphasizing how the committee has shifted focus from solely protecting patients to also safeguarding healthcare staff. She highlighted the alarming rise in workplace violence, citing fatal incidents involving orthopaedic surgeons and recent studies showing that 100% of healthcare workers have experienced verbal abuse. Additionally, 88% of nurses have been physically attacked by a patient, and 37% of physicians have. Healthcare workers are five times more likely to be physically assaulted at work than workers in any other industry.

Dr. Carnduff stressed the urgent need to equip healthcare professionals with tools to recognize and respond to threats. She then introduced special guest Capt. Thomas Brownfield, MSN, RN-BC, who runs the mental health clinic at the Mike O’Callaghan Military Medical Center at Nellis Air Force Base in Nevada. Brownfield has extensive experience in both inpatient and outpatient care. He currently serves as a global adviser and educator on preventing and managing disruptive behavior in healthcare settings. His expertise has helped inform processes to address the escalating risks faced by healthcare workers.

As a military nurse, Brownfield has had the opportunity to care for complex psychiatric patients. He recalled one inpatient care experience: “In three minutes, one of my staff members was beaten enough by a patient to put her in ICU. At that time, I thought, ‘What are we doing that can prevent or minimize these events?’” There was a workplace violence program at the hospital, but it did not provide much in respect to prevention, focusing more on how to respond after an event occurred.

“A lot of times as healthcare workers, we give some extra grace to violence that may not really be permitted,” Brownfield said. “So we are allowing things to happen and perpetuate, and we’re not preventing it at a lower level. That is where my passion comes from — how can I prevent this?”

Brownfield encouraged a proactive, layered approach to preventing violence in clinical settings. His framework centers on four key areas: self-awareness, environmental safety, understanding others, and team coordination.

He urged healthcare professionals to start with themselves, encouraging staff to assess their own body language, tone, and presence. He explained that patients often mirror the emotional energy of healthcare staff, so a calm, supportive demeanor can help de-escalate tense situations.

Environmental awareness was another critical focus. Brownfield pointed out that many clinicians overlook physical risks in their surroundings. “You never put the patient between you and your exit,” he warned, describing how even the placement of a door can become a hazard. He also noted that common items such as cords, call bells, or even eyeglasses can be weaponized in moments of crisis.

When it comes to assessing others, Brownfield emphasized the importance of recognizing risk factors. “The most researched and predictable pattern that we can look at is a history of violence,” he said. Although not all patients with such a history will become violent, it increases the likelihood — especially when combined with pain, cognitive impairment, or psychiatric conditions such as post-traumatic stress disorder, schizophrenia, or dementia. Even urinary tract infections, he noted, can trigger psychosis-like behaviors that elevate risk.

He shared a personal story to illustrate the dangers of high tolerance. He once sat calmly with a frequently readmitted psychiatric patient who was yelling and snarling, demanding that he leave, but Brownfield refused to exit the room. “I said, ‘I am not going to leave,’” he recalled. Although the patient eventually calmed down, Brownfield cautioned against taking the same approach in similar situations. “What I did was not right. … It put me in a very dangerous position,” he said, emphasizing that “our tolerance should be very low” for threatening behaviors. He stressed that clinicians should act early when patients show signs of moderate stress — clenched fists, elevated voices, or aggressive language.

To de-escalate, he recommended using simple, practiced phrases: “Lower your voice. Have a seat. Step back.” These commands are effective because they are automatic. “When it’s a stressful event, I don’t want to have to think about what to say. I just do it. It’s a response that has been conditioned,” he explained.

He also introduced the “Be Nice” framework — Be Negotiable, Inquisitive, Caring, and Empathetic — as a guide for identifying warning signs and managing difficult interactions. “Negotiable” refers to offering a high-quality service experience for patients to avoid a potential power struggle. To be “inquisitive” means to seek out the patient’s true concerns to best assist them. “Caring” means taking responsibility and being vested in the patient’s concerns. To be “empathetic” means trying to understand how the patient’s condition is contributing to their presenting behavior.

“The idea is to be brief and enforce boundaries,” he said. Brownfield warned against overexplaining when patients are escalated, noting, “Most times when people start to get higher and louder, it’s because they don’t feel like they’re being heard.”

On the topic of physical intervention, Brownfield was clear: “The only time that you could or would be able to [put hands on a patient] is in the event that your life is in jeopardy and you are protecting yourself.” He advised involving security early, as they are legally permitted to intervene.

In closing, Brownfield offered three key takeaways:

1. Violence is a natural response to stressful conditions.
2. There must be deliberate planning that focuses on appropriate responses.
3. Noticing warning signs is critical, and the Be Nice framework can help guide those interactions.

Brownfield’s insights underscore the importance of preparation, awareness, and empathy in preventing and managing workplace violence in healthcare. His message was clear: Safety starts with the individual, but it must be supported by team coordination, environmental awareness, and structured training. By engaging our teams early, communicating clearly, and refusing to normalize violence against our staff, we can create a safer environment for our patients and prevent workplace violence before it begins.

To watch the webinar, visit bit.ly/WPVwebinar.