If you attended one of my training courses on managing aggression to prevent violence in health and social care settings, you may want to share your doubts, successes or difficulties in applying what we covered. At the end of this article, you can ask questions and suggest ways to help other participants move beyond difficult or stalled situations. Please share your successes too: they can be encouraging!
A few reminders from the training on managing aggression to prevent violence
A useful model offers ways of understanding our responses to stress, aggression and violence: the inhibition-of-action model popularised by Henri Laborit.
Remember the three cages representing three situations:
Cage A: aggression directed towards oneself, an unhelpful response.
Cage B: escape, or creating a way out of the situation. This is the approach to prioritise.
Cage C: aggression directed towards others, an unacceptable response at work.
In a health or social care workplace, the aim is the cage B situation: creating a way out. Avoid turning aggression against yourself, as in cage A. Professional, ethical and legal responsibilities also rule out retaliatory aggression towards another person, as in cage C.
Aggression is a natural response that can serve to defend, assert oneself or express tension. We cannot eliminate all aggression, but we can work to prevent it escalating into violence. Escalation becomes more likely when professional boundaries are unclear, when we lose sight of what we may or must do, or when our responses fuel the aggression.
When faced with stressors, two broad responses are flight or attack.
Aggression is linked to stress. The less control we feel over stressors, the more aggression we may experience. Health and social care settings bring together people and families facing stressors over which they have little control: illness, disability, ageing, dependency or psychiatric symptoms. This helps us understand why distress may sometimes be expressed through aggression or violence.
Aggression and violence are human phenomena, but recognising this does not mean accepting harm. Every society regulates violence. It is generally prohibited, with specific powers granted to those acting under public authority, such as police, the armed forces or the justice system. Public authority claims a monopoly on legitimate force.
The official definitions of violence used in the original French training
The original training referred to French circular DHOS/P1 no. 2005-327 of 11 July 2005 on recording violent incidents in healthcare establishments. It distinguished physical violence, involving acts such as hitting, scratching or biting, from verbal violence, such as insults or threats. These are the two broad categories discussed here:
– Physical violence: hitting, scratching, biting…
– Verbal violence: threats and insults.
Violence may be directed towards people or property.
Do not trivialise violence against objects. Remember the examples we watched during training: damage to property may precede violence towards people.
The difference between aggression and violence
In the framework used in this training, aggression becomes violence when it is acted out, whatever the person’s intention or condition. Violence is aggression expressed through an act.
Why health and social care settings need a strong approach to preventing violence
Some people receiving care have conditions that partly or severely impair judgement, including certain psychiatric or neurological illnesses. Professionals therefore need strategies adapted to the situations they encounter. Organisations and employers must give staff the resources and support needed to prevent and respond to violence.
Responding to aggression
Avoid fuelling it. Remember the role plays and filmed scenes we discussed: there are many ways to escalate aggression. Sometimes passivity contributes; at other times, speaking or acting does. Reflect on your behaviour, discuss it as a team and use reflective practice. When a professional repeatedly responds in a way that fuels aggression, despite feedback and opportunities to improve, the issue needs to be addressed through supervision and professional accountability.
Rudeness or discourtesy may be aggressive without yet amounting to the threats, insults or physical acts discussed above. Stay calm, keep perspective and avoid escalating the situation. At the same time, avoid a submissive response that could reinforce aggression. Stay alert, maintain a safe distance and seek support from colleagues.
Responding to violence
Do not remain isolated. Be careful not to deepen feelings of guilt. Guilt can be an attempt to make sense of something that feels incomprehensible, overwhelming or beyond our control: the mind assumes we must somehow have caused it.
Speak to your manager. Look for improvements together as a team. Do not accept blaming responses from managers or colleagues, such as asking what you did to cause the incident or telling you to find a solution simply because you are a professional. Ask for concrete guidance and for practical demonstrations of how to respond.
If an incident needs to be reviewed with staff or people receiving care, wait until emotions have settled. Otherwise, the discussion may reignite aggression.
Develop shared team strategies. Inconsistent responses can create uncertainty and increase the risk of escalation.
Remember that a shared team decision helps direct frustration towards a clear framework rather than individual staff members. This is why a consistent team approach matters.
People need appropriate ways to express aggression within agreed boundaries. Depending on the individual, this could involve supervised physical activity or learning skills that create distance from aggressive impulses, such as an assertiveness group. The approach must be considered case by case.
Create ways out. Neither individual staff nor the team should remain isolated. Share concerns with management, the wider team, other teams, staff representatives or occupational health. Keeping repeated, unresolved violence hidden within a group can reinforce an aggressor’s sense of impunity. Speak up!
A practical way to improve the response to aggression and violence in care settings
Introduce a system for recording and measuring violent incidents. A structured approach starts with measurement, which helps counter the understandable subjectivity of individual reactions. Without shared information, a team may minimise violence or exaggerate it; the risk is doing too little or too much. The original French training suggested the Ministry of Health incident-reporting form linked to the 2005 circular. It also discussed internal analysis and reporting to the regional health agency, and the role of the then CHSCT workplace health and safety committee. These are historical French references; use the reporting procedures currently applicable to your organisation. Recording incidents improves traceability, supports the prevention of psychosocial risks, and helps improve both staff well-being and the quality of care.
Manage your own stress to respond better to aggression and violence
Remember the value of actively managing stress outside work. To revisit material discussed in training, see these French-language pages on stress and stress management.
When violence occurs despite efforts to prevent escalation
If someone presents an immediate serious danger to themselves or others, staff need an organised response supported by appropriate training. Restrictive interventions must remain a last resort, follow applicable law and clinical protocols, be proportionate and time-limited, and include appropriate monitoring. They must never be used as punishment or as a substitute for adequate staffing or organisation. The French Haute Autorité de Santé guidance on seclusion and restraint in psychiatry explains the safeguards in that specific setting. Regular refresher training with designated staff is important. In the original training, I compared this with airlines rehearsing responses to violent passengers in grounded aircraft: aviation has a strong culture of analysing risks, incidents and near misses. Health and social care organisations can similarly strengthen prevention through structured training, incident analysis and shared learning.