Beyond the Code and Why Healthcare Must Rethink Workplace Violence Prevention
Written by Clifford Cartagena, CEO & Founder
Clifford Cartagena, RN, BSN, is a psychiatric nurse, safety trainer, and founder of Gentleway Systems LLC. Co-founder of Arizona Care Horizon Institute, he is completing his PMHNP degree at Walden University. Author of The Gentle Art of Crisis, he advances trauma-informed, dignified approaches to workplace safety.
For more than two decades as a nurse, I have walked into healthcare environments where safety was never guaranteed: psychiatric hospitals, emergency rooms, state hospitals, correctional healthcare facilities, detox units, home health visits, and dementia care settings.
Different buildings. Different patient populations. Different policies. But the same question was always present, "How do we keep both the healthcare worker and the person receiving care safe?"
Throughout my career, I have seen systems that worked remarkably well. I have also seen systems that, despite good intentions, struggled to prevent workplace violence and sometimes unintentionally contributed to frustration, fear, and escalation.
One of the greatest lessons I learned is this, "Workplace violence prevention does not begin when someone becomes aggressive." It begins much earlier. It begins with culture.
The crisis before the crisis
Many behavioral emergencies begin quietly. A person feels ignored. A need remains unmet. Fear develops. Frustration grows. A person begins to feel they are losing control.
Then escalation happens. Often, everyone focuses on the final behavior, the yelling, the threat, the aggression, or the unsafe action.
But perhaps the more important question is not only, “What happened?” The better question may be, “What happened before?”
Understanding the pathway toward crisis allows healthcare teams to intervene earlier, when prevention is still possible.
The power of a 'Yes' Culture
Early in my psychiatric nursing career in the 1990s, I discovered the value of what I call a 'Yes' Culture. Some may misunderstand this idea. A 'Yes' Culture does not mean removing rules, ignoring safety concerns, or allowing inappropriate behavior.
It means changing our first response. Instead of immediately saying “no,” we pause and ask, “Is there a safe, reasonable, and therapeutic way to say yes?”
That simple shift can transform interactions. Sometimes prevention is not complicated. Sometimes it is a warm blanket, a snack, a cup of coffee, a quiet space, a respectful explanation, or allowing someone to make a choice.
These actions may appear small. But for someone experiencing psychiatric distress, dementia, substance withdrawal, fear, or a loss of independence, these moments can restore something extremely important:
A sense of control and dignity. Many crises are not caused by one major event. They are often the accumulation of small moments where a person feels powerless.
Different behaviors require different understanding
Another lesson from working across multiple healthcare settings is that not all challenging behaviors come from the same source.
A person living with dementia who resists care may not be intentionally aggressive. They may be frightened, confused, or responding to a reality that feels very real to them. A person experiencing psychosis or command hallucinations may be overwhelmed by symptoms affecting how they interpret the world around them.
A person experiencing substance withdrawal may be struggling physically and emotionally. A person in a correctional environment may challenge rules, test boundaries, or attempt to manipulate.
The outward behavior may appear similar. The cause may be completely different. Because the cause is different, the response must be different as well.
Compassion does not mean the absence of boundaries. Professional boundaries do not require the absence of compassion. The best healthcare teams understand how to provide both.
Environment shapes cooperation
Throughout my career, I have observed how environments influence behavior. In some voluntary psychiatric settings, I noticed that simple comfort measures and a therapeutic atmosphere encouraged cooperation.
Access to appropriate snacks and warm drinks, along with respectful communication and choices, often contributed to a calmer environment. The lesson was never just about food or comfort items.
The deeper lesson was this, "People are more likely to participate in their own care when they feel respected rather than controlled."
A therapeutic environment does not eliminate all risk, but it can reduce unnecessary conflict.
The words we use during crisis matter
Healthcare has long relied on emergency response codes. Code Gray. Code Green. Code 10. Staff understands what these announcements mean. But what does the patient hear?
For someone already experiencing paranoia, fear, embarrassment, trauma, or emotional distress, the announcement itself can influence their perception. Do they hear, “People are coming to help me” or “People are coming because I am the problem”
Language matters. This is why crisis response language should communicate support whenever possible.
A phrase such as, “Show of support needed” changes the emotional message. The response remains serious. Staff still respond. Safety remains the priority. But the purpose communicated is different. Not confrontation. Support.
The future of workplace violence prevention
Healthcare organizations need policies. They need emergency procedures. They need trained response teams. But policies alone cannot create safety. Culture creates safety.
The future of workplace violence prevention requires healthcare teams to understand human behavior, trauma, communication, environment, and individual needs.
We must measure success not only by how quickly we respond when violence occurs. We must also ask, "How many crises did we prevent from happening?" Because the highest level of crisis management is not controlling someone after escalation.
It is creating a system where fewer people reach that point. The safest crisis will always be the one that never happens.
Read more from Clifford Cartagena
Clifford Cartagena, CEO & Founder
Clifford Cartagena, RN, BSN, is a psychiatric and medical-surgical nurse, hospice provider, safety trainer, and founder of Gentleway Systems LLC. He is also the co-founder of the Arizona Care Horizon Institute. He was authorized by the ADHS (Arizona Department of Health Services) to deliver the Memory Care Services Training in Arizona. Cliff is currently completing his Psychiatric Mental Health Nurse Practitioner (PMHNP) degree at Walden University. He is the author of The Gentle Art of Crisis. With more than 20 years of nursing and leadership experience, he developed the Gentleway System, a trauma-informed approach to preventing and managing assaultive behaviors across healthcare and beyond.
References:
National Institute for Occupational Safety and Health. (2021). Workplace violence prevention strategies and research needs. Centers for Disease Control and Prevention.
Substance Abuse and Mental Health Services Administration. (2023). Practical guide for implementing a trauma-informed approach. U.S. Department of Health and Human Services.
The Joint Commission. (2021). Workplace violence prevention standards.
