Violence Prevention

Incidents where persons are abused, threatened, or assaulted in circumstances related to their work, involving a direct or indirect challenge to their safety, wellbeing, and health (BC Provincial Violence Prevention Steering Committee, 2008).

WorkSafeBC defines violence as the attempted or actual exercise by a person, other than a worker, of any physical force so as to cause injury to a worker. Violence also includes any threatening statement or behaviour which gives a worker reasonable cause to believe that the worker is at risk of injury (WorkSafeBC, 2022).

*Remember, your safety is the top priority, and you have the right to refuse unsafe work. If you have reasonable cause to believe that performing a work task puts you or someone else at risk, you must not perform the job or task and notify your supervisor or employer right away.

Occupational Health and Safety Regulation requires employers to perform a violence risk assessment in any workplace where a risk of injury to workers from violence may be present. The risk assessment must consider prior experience at the workplace, experience in similar workplaces, and the location and circumstances of the work.

A violence risk assessment is required at the beginning of operations, when a significant change to operations occurs (i.e., new location or renovation), or following a violent event.

In a medical clinic, the following factors should be considered in a violence risk assessment:

• Number, location, severity and frequency of violent incidents.
• Layout and workplace conditions, including fixtures and equipment, furniture, barriers, lighting and doors.
• Exits and emergency procedures.
• Interactions with patients and the public.
• Age, gender, experience, and skills of staff.
• Enforcing policies with the public (e.g., no public washroom; not accepting patients)
• Staff working alone or in isolation, and the availability of backup staff.

Physician employers must conduct regular inspections to prevent unsafe working conditions. This checklist can support this process by identifying existing controls and areas where additional measures may be needed to prevent workplace violence. While some items are not marked mandatory, they represent best practices for violence prevention in the clinic.

Conduct a risk assessment to determine the nature and type of violent incidents anticipated in the clinic, and the likelihood of occurrence.

The physician employer must create a violence prevention policy that outlines the roles and responsibilities of the employer and staff, standards, and procedures to prevent violence and harassment in the clinic. Staff should receive training on this policy and its procedures. This template can help you establish the violence prevention policy.

Implementing a patient code of conduct in the clinic is not required but is recommended. Posting notices about a zero-tolerance policy for abusive behaviour, enforcing those policies, and promoting a safe workplace are also advisable.

We recommend adding the following language to your recorded phone greeting to inform patients that disrespectful or abusive behaviour will not be tolerated:

“Thank you for calling [Clinic Name]. We are committed to providing a respectful and safe environment for all patients and staff. Disrespectful or abusive behaviour will not be tolerated and will result in the call being ended immediately. We appreciate your support and understanding.”

Community physicians and their teams often face challenging interactions with patients, family members, and other clinic visitors. Despite your best efforts, some situations may escalate to threatening behaviour or violence. Consider implementing these prevention strategies: 

• Code of conduct poster displayed to inform the public about unacceptable behaviour and its consequences. (Example provided in Code of Conduct section above.) 

• Clear sightlines to patients in the reception area (e.g., convex mirrors to improve visibility in blind spots). 

• Controlled access to staff-only areas (e.g., lockable doors). 

• Effective physical barriers between the public and staff in the reception area (e.g., fixed plexiglass above the reception counter, side doors for staff access). 

• Office furniture is arranged to prevent individuals from being cornered and to allow for a quick escape.  

• Clear workspaces free of potential weapons (e.g., removal of small, heavy, or sharp objects from countertops and reception areas). 

• Easy, rapid exit routes for staff (e.g., exit paths kept clear at all times). 

• Emergency alert systems (e.g., an internal duress system to discreetly alert staff, and/or panic buttons to notify police). 

• Adequate lighting at entrances and in parking areas. 

The following violence prevention modules cover topics that may trigger memories of unsafe personal experiences or such experiences of your friends, family, and community. Care has been taken in the creation of this material to reduce harmful impact; however, the content may trigger unpleasant feelings or thoughts of past harm and/or violence. Participants are encouraged to practice good self-care and step away from the material and seek support as needed.

Participants who require emotional support can contact:

• B. C. Physician Health Program: call 1-800-663-6729, available 24/7.
• 310 Mental Health support: dial 310, available 24/7.
• Crisis Centre: call or text 9-8-8, available 24/7.
• WorkSafeBC Crisis Support Line: call 1-800-624-2928, available 24/7.

First Nations, Inuit, and Métis peoples who require emotional support can contact the First Nations and Inuit Hope for Wellness Help Line and On-line Counselling Service toll-free at 1-855-242-3310 or through hopeforwellness.ca. The Métis Crisis Line is available 24 hours a day at 1-833-MétisBC (1-833-638-4722). And the KUU-US Crisis line is available 24/7 at 1-800-588-8717 to provide support to Indigenous people in B.C. For more information, visit: kuu-uscrisisline.ca.

When behaviour becomes threatening—such as abusive language or threats of violence—consider the following immediate actions: 

• Clearly state that the behaviour is unacceptable and outline the consequences if it continues. Remind patients the Patient Code of Conduct.  

• Involve support resources, including other clinic personnel, or call 9-1-1.  

• If faced with imminent violence or threats, including sexual harassment, move to safety and prioritize protecting yourself, staff, and others in the clinic. 

• Call the police: Always make sure you are in a safe place before you call 9-1-1. It is important to recognize when it’s time to back away and get help. If you or someone else is being assaulted or threatened with a weapon, leave immediately and call 9-1-1. When reporting to police, provide only essential information (e.g., the individual’s name and the nature of the incident) and avoid disclosing medical details to protect patient privacy. 

• Document any relevant statements or behaviours in patient’s medical records using clear, factual language. Include verbatim statements in quotation marks. Also, document the incident using the clinic’s Incident Report Form, including the incident details and contributing factors, to support internal tracking and team communication. 

•  Physicians: If efforts to address a patient’s aggressive behaviour fail and trust cannot be rebuilt Contact the Canadian Medical Protective Association (CMPA) for medico-legal advice. ⁠  

What is de-escalation? De-escalation is a way to decrease the intensity of a situation. The goal is to settle the person so that discussion and problem-solving become possible (Provincial Violence Prevention Curriculum, 2025).

Benefits of strengthening your skills in patient de-escalation:

• Reduce stress: Staff will feel more prepared and confident in handling challenging situations, helping to reduce cumulative stress.
• Minimize absenteeism: Staff may feel more empowered to stay at or return to work following a stressful event.
• Improve patient relationships: Using calm, clear communication will enhance patient satisfaction.
• Maintain a safe environment: By preventing situations from escalating, staff will help ensure a safer, more welcoming clinic atmosphere, while enhancing workplace health and safety.
• Increase overall efficiency: With effective communication, staff will have more time to focus on care.

Violence prevention is everyone’s responsibility. It is important to build relationships with patients and colleagues, as well as communicate in a respectful manner that avoids contributing to potential escalation. Review what you can do to be open to others’ perspectives, lived experiences around trauma and violence, and culture in preventing violence:

• Understand cultural influences on behaviour.
• Avoid stereotypes and microaggressions.
• Identify and be aware of your own biases.
• Respect diversity and inclusivity.
• Address cultural barriers.

Throughout this module, we provide a variety of tools developed to strengthen de-escalation skills. The de-escalation tools presented were developed with valuable input from a diverse and representative group of Medical Office Staff and Physicians across British Columbia. We extend our sincere thanks to those who shared their feedback and expertise.

Below we have provided some dos and don’ts for communication on the phone and in-person to help prevent and decrease patient escalation. Review these frequently to increase your familiarity and decrease your reliance on the poster during an incident. We recommend printing the posters and posting them somewhere visible to you (and not the patient) at your workstation. Poster size may be adjusted before printing to tailor to your clinic’s needs.

The HEARD+D method is a structured approach to manage heated situations calmly and effectively. The tools provided below are not meant to be relied on “in the moment” during interactions with escalated patients but rather are designed to help build your skills in de-escalation. Review the tools frequently to increase your familiarity with the HEARD+D method.

How to use the HEARD+D tool:

1. Review and understand the HEARD+D steps.
2. Review and practice physical and verbal responses to a patient who is frustrated, angry, aggressive, or threatening.
3. At any time during a patient interaction, if you sense escalation, assess whether the patient is frustrated, angry, aggressive, and/or threatening.
4. Follow the HEARD+D method when communicating with the patient. If the patient becomes aggressive, or threatening, go to STEP 5.
5. Ensure you document the incident and alert your manager (STEP 6) if you interacted with an aggressive or threatening patient.

We also recommend printing the HEARD+D Reference Card and having it at your desk station for quick reference.

Every interaction with an aggressive or threatening patient should be documented in the patient’s medical record in an objective, clear, and non-judgmental manner to alert other staff and help prevent future incidents. Any encounter involving a physician requires the physician to document the incident firsthand/directly. 

Additionally, if you, as an MOA, interact with an aggressive or threatening patient, you should notify your manager immediately and complete the clinic’s incident report form to support internal tracking and appropriate follow-up actions.  

The Incident Report Form should be used to document an incident that caused an injury (e.g., psychological, physical, or both) or had the potential to cause an injury (near-miss) to staff while at work.

When documenting a violent incident in the clinic’s incident report form: 

• Describe the person’s behaviour clearly, and in an objective, factual, and non-judgmental way. If subjective judgements are ever included, ensure to record all objective facts and observations that informed your judgement.
• Include date, time, location, context, contributing factors, and any de-escalation actions. Indicate what you did in each step of the HEARD tool.
• Consider the 5 W’s: Who, What, Where, When, and Why.
• Consider and note down how you felt during the interaction and after.
• When reporting to the police, do not include patient medical information (unless there is a public safety risk).

Example of Incident Report Description:

At 10:15 a.m. on April 28, 2025, an incident occurred in the reception area. The patient entered the clinic to a full waiting room and appeared uncomfortable. The patient introduced themselves and expressed to me that they’ve had neck pain for two days, and it has not gone away. They requested to see a doctor today. I listened and remained calm (HEARD+D Step 1). Upon checking the schedule, there was no availability today. I gently informed the patient that the earliest they can see a doctor is tomorrow morning at 9:00 a.m. The patient became visibly agitated with clenched fists and loudly said, “Why can’t you slot me in today? I only need 10 minutes with the doctor. I don’t want to wait another day. I’m in pain!” (classified as angry using the HEARD+D tool). I remained calm, professional, and empathized, “I hear your frustration. We care about your health and want to be able to help.” (HEARD+D Step 2 and 3). The patient yelled, “Well then, do something about it!”. I said, “Here’s what I can do. I can book you for an appointment tomorrow at 9:00 a.m. and put you on the cancellation list for today. If an appointment opens today, I will give you a call right away. Does that work for you?” (HEARD+D Step 4). The patient raised their voice, slammed their hand on the counter, and yelled, “No! You people are f***ing useless! Why is it so hard to see a doctor?! I’ve had enough of this garbage!” All the while pointing their finger at my face (escalated to Aggressive classification using the HEARD+D tool). I immediately stepped away to increase distance from the patient, remained behind the reception desk, signalled for assistance from other staff using the clinic’s duress system, and kept the exit path in sight. I did not engage further and was a little rattled. The patient immediately stormed out the door, and no further defuse was required. No injuries were reported. Ashley was working near me and witnessed the incident. I immediately reported the incident to the clinic manager. In addition to documenting it in the patient’s medical records, I also completed the internal incident report form (HEARD+D Step 6).

Review the scenario-based examples below to better understand how to use the HEARD+D method in practice.

Select a scenario from the drop-down menu below to review an example of the HEARD+D tool being used to de-escalate a patient in a community-based clinic.

The provided scenarios are examples. Any particular outcome of using the HEARD+D tool cannot be guaranteed.

Listen to the three examples of the on-phone HEARD+D tool being used to de-escalate a patient over the phone, option to review transcripts available.

Note: Medimap is free and available in B.C.