A Literature Review

Angel Johann Solorzano Martinez, MSN, MBA, RN

ABSTRACTWorkplace violence in health care settings

is an occupational issue concerning nurses

and other health care professionals. Patient

aggression against nurses is often the most

common form of violence in clinical set-

tings, occurring in emergency departments,

inpatient psychiatric settings, and nursing

homes. Physical and verbal assaults are the

major forms of workplace violence encoun-

tered by nurses. Current research has iden-

tified staff, environmental, and patient risk

factors as the major precursors of workplace

violence initiated by patients. Nurses often

experience significant physical and psycho-

logical negative consequences after an epi-

sode of workplace violence. A review of the

evidence was conducted to identify current

evidence-based interventions that can help

nurses minimize the incidence of workplace

violence. [Journal of Psychosocial Nursing and

Mental Health Services, 54(9), 31-36.]

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31Journal of Psychosocial nursing • Vol. 54, no. 9, 2016

(International Council of Nurses, 2009). Moreover, nonfatal injuries that require health care practitioners to take time away from work are pri-marily related to incidents of assault in the workplace (Wolf, Delao, & Perhats, 2014). Workplace violence incidents occur more frequently in emergency departments, nursing homes, and psychiatric settings (Ed-ward, Ousey, Warelow, & Lui, 2014). Phillips (2016) reported that nurses are victimized at higher rates than other health care professionals be-cause the assault rates are strongly correlated with patient contact time. Client-initiated violence is often the most frequent type of workplace vio-lence encountered by nurses (Child & Mentes, 2010). Physical and verbal assaults are the major types of work-place violence incidents experienced by nurses (Taylor & Rew, 2011). At times, as many as 80% of nurses re-port feeling unsafe in their workplace (Child & Mentes, 2010). Nurses often experience significant physical and psychological effects after an incident of workplace violence (Edward et al., 2014). Consequently, nurses may choose to leave their workplaces and some even the nursing profession due to workplace violence incidents (Ed-ward et al., 2014).

The current article presents a re-view of evidence-based interventions that can help nurses minimize the in-cidence of workplace violence.

SEARCH STRATEGYCINAHL and PubMed were the

online databases selected for the liter-

ature review. Search terms included workplace violence, interventions to manage workplace violence, physical as-saults by patients, violence, nurses, and patients. These terms were selected to locate journal articles discussing workplace violence incidents against nurses perpetrated by patients. Ar-ticle types were limited to academic journals, systematic reviews, peer-reviewed articles, abstracts, and full text. To obtain the most current lit-erature on workplace violence, the publication date limit was 2009-2016. Another limit used in the search was articles written in English. After ap-plying these limits, CINAHL yielded 64 articles and PubMed yielded 41 articles. Articles were further col-lated by selecting a specific journal abstract in conjunction with qualita-tive, quantitative, and systematic re-view articles.

Systematic reviews were given pri-ority because of their value in current content and evidence on the subject. Randomized controlled trials and meta-analyses were not found during the literature search. Quantitative studies containing specific interven-tions to manage workplace violence and nurses’ experiences were also se-lected. Qualitative studies that includ-ed data on nurses’ experiences with workplace violence and suggestions for managing those incidents in nursing settings were also included. A journal abstract containing an evidence-based intervention presented at a nursing meeting was also given consideration. Furthermore, to maintain the main fo-cus of the research, articles discussing

assaults perpetrated by patients specifi-cally against nurses were also included. Articles that mentioned assaults per-petrated by visitors, violence against nursing students, and assaults against personnel other than nurses were ex-cluded because the main focus of the current research was client-related violence toward nurses. Articles that were unrelated to the main topic were also excluded. Unpublished theses and dissertations were not considered during the literature search. Eleven articles/abstracts were used in the cur-rent review (Table).

REVIEW OF THE EVIDENCERisk Factors Associated With Workplace Violence

Staff, environmental, and patient risk factors are the major precursors associated with workplace violence incidents initiated by patients (Tay-lor & Rew, 2011). Taylor and Rew (2011) conducted a systematic re-view using MEDLINE, CINAHL, and PsycINFO databases to obtain journal articles as well as dissertations and theses from full text databases. A total of 16 articles were used and included qualitative and quantita-tive studies testing an intervention. A limitation of their review was the specific articles used pertained solely to the emergency department. Poor security, delays in service, and work-ing closely with potentially dangerous individuals were found to be the most common environmental risk factors. Patient risk factors included access to guns and substance abuse. Staff risk factors included inadequate or nonex-istent training on the management of assaultive behaviors, understaffing, and working alone (Taylor & Rew, 2011).

Nurses’ Perceptions of Workplace Violence

Many nurses often view workplace violence as part of the job (Child & Mentes, 2010). In some instances, when nurses work in settings where vi-olent incidents occur frequently, a cul-ture of acceptance of violence persists (Wolf et al., 2014). Blando, O’Hagan,

is a phenomenon affecting nurses worldwide

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Casteel, Nocera, and Peek-Asa (2013) evaluated whether nurses’ perceptions of violence and safety were influenced by their work environments and also identified whether their perceptions were correlated with actual risk. The study was a cross-sectional survey that was administered to 314 emer-gency department and 143 psychiatric nurses working in various hospitals in California and New Jersey. In addition, incidence of workplace violence, re-sponse of security guards, and appropri-ate training were found to play a role in nurses’ perceptions of violence and safety in the workplace. The authors noted that perceptions of violence vary among nurses, and they are affected by existing conditions in the workplace. Differences between emergency de-partment and psychiatric nurses were significant. Emergency department nurses were more likely to report feel-ing unsafe and more threatened when they were verbally assaulted compared to psychiatric nurses. Moreover, psy-chiatric nurses were more tolerant of abusive behavior and had more train-ing in de-escalation practices. Fur-thermore, Blando et al. (2013) used a univariate logistic regression statisti-cal analysis to identify the major vari-ables that measured the outcome of the emergency department nurses’ percep-tions of safety. A multivariate logistic regression was further performed on those variables showing that response time by security personnel, appropri-ate security equipment, and frequent verbal abuse were significant in the emergency department nurses’ percep-tions of safety. The researchers reported that nurses’ perceptions of violence and safety may not correlate with the actual risk, as statistical analyses showed dif-ferences between the perceptions and actual rates of assault that occurred in the emergency department (Blando et al., 2013).

Underreporting of Workplace ViolenceUnderreporting of incidents of

workplace violence often occur in nursing settings (Child & Mentes, 2010). Gacki-Smith et al. (2009) con-

ducted a cross-sectional study survey-ing RNs (n = 3,465) of the Emergency Nurses Association to explore their perceptions and experiences with vio-lence perpetrated by patients and visi-tors in U.S. emergency departments. Major barriers that contributed to the phenomenon of underreporting workplace violence incidents included nurses’ fear of retaliation by their em-ployers and little support from admin-istration (Gacki-Smith et al., 2009). Kvas and Seljak (2014) conducted a study about the issue of underreport-ing of workplace violence incidents using a survey method to obtain the responses of 692 nurses working in hospital settings in Slovenia. Study findings included nurses’ fear of losing their jobs and their belief that report-ing those incidents would not change any current practices against work-place violence (Kvas & Seljak, 2014). Although the study was conducted in a foreign country, the results concurred with the qualitative findings reported by Gacki-Smith et al. (2009), increas-ing the generalization of the results.

Interventions to Reduce Workplace Violence

Dilman (2015) presented the use of a code green response team (CGRT)

as an evidence-based intervention implemented in 2013 in a Pennsyl-vania hospital. The CGRT comprised a charge nurse, security personnel, and the physician and primary nurse managing the potentially violent situation. The major functions of the CGRT included using the least re-strictive measures, such as verbal de-escalation skills and noncoercive use of medications, to control violent or escalating situations. Data were col-lected for 1 year using a post-violence debriefing tool and an incident report form to measure the rates of restraints applications and de-escalation of po-tentially violent patients. The results demonstrated that 85% of code green calls resulted in successful resolution of the violent incidents using verbal de-escalation skills and noncoercive medication administration, and a decrease of restraints application in nursing units by 11% compared with restraint data obtained in 2012. The effectiveness of the evidence-based intervention showed a reduction of patient restraints and effective man-agement of aggression using least restrictive measures in a hospital (Dilman, 2015).

Hill, Lind, Tucker, Nelly, and Daraiseh (2015) implemented a qual-

TABLE

STUDIES BY TYPE INCLUDED IN CURRENT LITERATURE REVIEW

Study TypeAnderson, FitzGerald, & Luck (2010) Systematic review

Taylor & Rew (2011) Systematic review

Edward, Ousey, Warelow, & Lui (2014) Systematic review

Kvas & Seljak (2014) Qualitative

Wolf, Delao, & Perhats (2014) Qualitative

Gacki-Smith et al. (2009) Quantitative

Lanza, Rierdan, Forester, & Zeiss (2009) Quantitative

Gillespie, Gates, & Mentzel (2012) Quantitative

Blando, O’Hagan, Casteel, Nocera, & Peek-Asa (2013)

Quantitative

Hill, Lind, Tucker, Nelly, & Daraiseh (2015) Quantitative

Dilman (2015) Journal abstract

33Journal of Psychosocial nursing • Vol. 54, no. 9, 2016

ity improvement initiative in an Ohio hospital to decrease staff injuries in an inpatient psychiatric unit specialized in treating children and adolescents with developmental disabilities and other co-occurring psychiatric disor-ders. Hill et al. (2015) employed the Plan, Do, Study, Act (PDSA) rapid interventions testing process to in-vestigate the interventions and con-tinue decision making. Occupational Safety and Health Administration (OSHA) reportable injury standards were used to record the types of inju-

ries that occurred in the unit during the initiative. A major intervention used was the creation and implemen-tation of universal precautions posted in the unit for clinical staff members, including nurses and unlicensed per-sonnel. Universal precautions in-cluded the following: be aware that patients have the potential to strike-out; wear appropriate clothing; rear-range environments in the setting to minimize the risk of injury with objects during crisis; maintain appro-priate positioning when approaching patients; keep a safe distance; sustain the proper stance (i.e., show one third of the body when working with patients); use protective personal equipment, such as gloves and fore-arm and knee pads; and learn and use de-escalation techniques and active listening (Hill et al., 2015).

Moreover, other interventions used included standardized team meetings to increase awareness of potentially violent patients and plan for crisis; bedside handoff to review patients’ problematic behaviors and approaches taken; patient informa-

tion binders and boards identifying high-risk behaviors; critical incident reviews; leadership rounds conducted by directors of nursing, psycholo-gists, quality managers, and other supportive members to assess the in-terventions used by staff; proper use of protective personal equipment; and conducting risk identification (Hill et al., 2015). The quality im-provement initiative showed a 65% reduction of staff injuries, from 2.2 per week to 0.77 per week, during the 1-year intervention period. In

addition, the days in between occur-rences of OSHA-reportable injuries increased from 26.5 days to 124 days (Hill et al., 2015).

Lanza, Rierdan, Forester, and Zeiss (2009) conducted a pilot study to as-sess the efficacy of a violence preven-tion community meeting (VPCM) in decreasing the prevalence of workplace violence in an acute in-patient psychiatric setting. The ma-jor intervention of the VPCM was a 30-minute meeting that focused on violence prevention topics in psychi-atric settings, which was conducted twice per week by nursing staff dur-ing the day shift and attended by pa-tients.

During the 9-week pilot study, nursing staff led community meet-ings in the inpatient psychiatric unit, encompassing a number of topics to prevent workplace violence, includ-ing, but not limited to: establishing unit rules, importance of safety in the unit, what to do if losing control, modeling problem solving, discus-sions of violence reduction, discus-sions of reactions regarding assaults,

and discussion of accepted alterna-tives to violence (Lanza et al., 2009). Nursing staff adjusted the topics dis-cussed during the meetings according to the acuity in the unit. The record-ing of workplace violence events in the unit was conducted by nurses and researchers in real time during the course of the study. The VPCM program was effective, reducing in-cidents of violence by 85% among all shifts throughout the duration of the study. The study presented a validated evidence-based interven-tion with promising results to man-age workplace violence that can be implemented in inpatient psychiatric settings (Lanza et al., 2009).

Anderson, FitzGerald, and Luck (2010) conducted a literature review to evaluate interventions aimed at de-creasing violence against emergency department nurses. The authors used MEDLINE, CINAHL, and the Co-chrane Library to conduct their lit-erature research. The authors cited the study by Meyer, Wrenn, Wright, Glaser, and Slovis (1997) that imple-mented the use of a metal detector under the continuous surveillance of a security guard as a major interven-tion addressing environmental risk factors in the emergency department (Anderson et al., 2010). The study by Meyer et al. (1997) evaluated the patrons’ and emergency department nurses’ perceptions regarding the use of a metal detector in this setting. The study results showed that 80% of patrons and 85% of employees liked the idea of having a metal detector in the emergency department; 90% of patrons and 73% of employees felt safer (Meyer et al., 1997). The study presented an intervention that was implemented in one emergency de-partment, which can be implemented in other emergency departments and nursing units.

Gillespie, Gates, and Men-tzel (2012) conducted a quasi-experimental study to evaluate the effectiveness of delivering an educa-tional program on workplace violence for 315 nurses using web-based and

Nurses must advocate for themselves by voicing concerns and possible solutions to administrators

to reduce the incidence of workplace violence.

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classroom-/web-based hybrid pro-grams. The study results showed that the classroom-based program may have a positive effect on the informa-tion being taught when used in con-junction with a web-based program to enhance knowledge attainment among nurses (Gillespie et al., 2012).

Negative Consequences of Workplace Violence Against Nurses

Nurses often experience psycho-logical and physical effects after an incident of workplace violence, which may impact their careers and personal lives. Edward et al. (2014) conducted a systematic review about workplace violence against nurses to understand the types of aggression, effects on nurses, and coping strategies used by nurses. The authors used MEDLINE, CINAHL, and PsycINFO databases to conduct their literature search. They found that nurses who encountered aggression in the workplace may ex-perience anger, frustration, feelings of hopelessness, hyper-vigilance, post-traumatic stress disorder, develop de-pression or anxiety, and even leave the nursing profession (Edward et al., 2014). Taylor and Rew (2011) noted that physical assaults may cause fa-tal and nonfatal injuries and reduce nurses’ ability to perform job require-ments.

Increasing Nurses’ Awareness of Workplace Violence

Educating nursing personnel on the appropriate management of ag-gressive behaviors is vital to decrease the incidence of workplace violence and promote safety for staff and pa-tients (Martindell, 2012). Nurse man-agers should make the availability and inclusion of appropriate training programs a priority for nursing staff to prevent and effectively manage inci-dents of workplace violence. Train-ing programs to manage workplace violence should include specific and practical skills, such as recognition of aggressive cues and behaviors, build-ing therapeutic rapport, enhancing communication skills, using verbal

de-escalation skills, and using team approaches for managing assaultive behaviors in clinical nursing settings (Casella, 2015; Dilman, 2015; Gacki-Smith et al., 2009; Hill et al., 2015).

QUALITY APPRAISAL OF THE EVIDENCE

The Johns Hopkins Nursing Evidence-Based Practice Non-Research Evidence Appraisal Tool (access http://www.hopkinsmedicine.org/evidence-based-practice/_docs/appendix_f_nonresearch_evidence_appraisal_tool.pdf) was used to evalu-ate the evidence provided in the ar-ticles included in the current review because randomized controlled trials or meta-analyses were not found. The quality of evidence can be assessed using a rating scale of high (A), good (B), and low/major flaw (C). System-atic reviews were evaluated using levels I-IV. Intervention studies were evalu-ated using the tool’s section on clinical practice guidelines. Qualitative studies were evaluated using the tool’s sec-tion on organizational experience. All articles included in the current article obtained scores ranging from A to B.

IMPLICATIONS FOR PRACTICEEducation and Clinical Practice

Nurses should be aware of the availability of training programs to manage workplace violence in their health care settings. Nurses must advocate for themselves by voicing concerns and possible solutions to ad-ministrators to reduce the incidence of workplace violence. Furthermore, nurses should increase their knowl-edge and awareness of evidence-based interventions by reading peer-reviewed journal articles analyzing interventions and approaches to manage workplace violence. Nurses should also implement evidence-based interventions learned in their training programs at their facilities to minimize violent events.

Nursing ManagementThe role of nursing administration is

critical to combat the phenomenon of

workplace violence in clinical settings. Nurse managers can assess the staff and environmental risk factors in their nurs-ing units and implement appropriate in-terventions to reduce risk factors. Nurse administrators should heed nurses’ con-cerns about safety in the workplace, listen to their suggestions to manage violent events, and address those issues with the implementation of evidence-based interventions to decrease the prevalence of workplace violence.

Nursing ResearchMore research studies preventing

and managing workplace violence with evidence-based interventions are critical to reduce the prevalence of such events in clinical settings. Re-searchers should create and validate more evidence-based interventions and approaches in future studies that could be implemented across nursing settings to reduce the incidence of ag-gression against nurses.

LIMITATIONSThe current review has two major

limitations. Three of the quantitative studies discussed interventions used to manage workplace violence pri-marily in emergency department and psychiatric settings, which may affect the generalizability and transferability of interventions outside those specific milieus. Qualitative studies used in the current literature review evaluat-ed nurses’ experiences with workplace violence incidents. The types of inci-dents nurses experienced ranged from verbal, physical, or a combination of those forms of violence. As a result, nurses’ self-reported answers collected as data may demonstrate a potential for bias, as some nurses may have ex-perienced only verbal assault and oth-ers may have experienced physical or both forms of violence.

CONCLUSIONThere is substantial evidence

regarding workplace violence pre-vailing in clinical nursing settings. Workplace violence can significantly affect nurses’ physical and psycho-

35Journal of Psychosocial nursing • Vol. 54, no. 9, 2016

logical well-being. Implementation of evidence-based interventions can help decrease the incidents of work-place violence, as demonstrated by Dilman (2015), Lanza et al. (2009), and Hill et al. (2015). More research studies focusing on creating and test-ing evidence-based interventions aimed to prevent and manage work-place violence are needed to decrease the prevalence of this unwanted phe-nomenon in clinical settings.

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Mr. Solorzano Martinez is Psychiatric Nurse, Inpatient Adult Psychiatric Unit, Saint Fran-cis Memorial Hospital and California Pacific Medical Center; and Psychiatric Nursing Clini-cal Instructor, Samuel Merritt University, San Francisco State University, and University of San Francisco, San Francisco, California.

The author has disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Angel Johann Solorzano Martinez, MSN, MBA, RN, Psychiatric Nurse, Inpatient Adult Psychiatric Unit, Saint Francis Memorial Hospital and California Pacific Medical Center, and Psychiatric Nursing Clinical Instructor, Samuel Merritt University, San Francisco State University, and University of San Francisco, 1600 Holloway Avenue, San Francisco, CA 94132; e-mail: onlyjohann@hotmail.com.

Received: January 22, 2016Accepted: June 15, 2016doi:10.3928/02793695-20160817-05

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