Workplace Violence in Healthcare Settings: A Scoping Review of Guidelines and Systematic Reviews

Abstract

Workplace violence in healthcare settings is alarmingly common and represents significant financial and human cost. The aim of this scoping review was to identify and summarize evidence on strategies to prevent and/or manage workplace violence in healthcare settings. Searches were limited to evidence-based clinical practice guidelines and systematic reviews published between 2015 and 2021. Multiple databases were searched and screened. Quality of the included guidelines and reviews was also assessed. Three guidelines and 33 systematic reviews were included. Both the Occupational Safety and Health Administration 2015 and Registered Nurses’ Association of Ontario 2019 guidelines provided useful recommendations for building a comprehensive prevention program. Evidence-based risk assessment, prevention and management, and education and training are all central components. Regular reassessment and adjustment is required. Included reviews (n = 33) were grouped into five main categories: violence toward nurses (n = 10); violence toward healthcare workers in general (n = 8); violence in the emergency department (n = 5); violence related to mental health (n = 5); and measurement related to workplace violence (n = 5). Multicomponent interventions were often more effective than those applied in isolation. We found consistent support for certain strategies including education and training, post-incident debriefing, multidisciplinary rapid response teams, and environmental modifications; however, the strength of evidence and certainty of conclusions were limited across reviews. This scoping review found that strong leadership that cultivates and enforces a culture of inclusivity, support, and respect is a prerequisite for a successful workplace violence prevention program. Rigorous comparative effectiveness research testing interventions are needed.

Keywords

workplace violence violence exposure vicarious trauma

Introduction

Workplace violence is a persistent, endemic problem causing both significant financial and human cost. The Occupational Safety and Health Administration (OSHA), a part of the U.S. Department of Labor, defines workplace violence as “any act or threat of physical violence, harassment, intimidation, or other threatening disruptive behavior that occurs at the work site” (Workplace Violence, n.d.) and ranges from threats and verbal abuse to physical assaults and even homicide. Workplace violence in healthcare is alarmingly common and may affect and involve employees, clients, customers, and visitors. Data from the U.S. Bureau of Labor Statistics (2020) shows that in 2018, healthcare and social service workers were 5 times more likely to experience workplace violence than all other workers, comprising 73% of all nonfatal workplace injuries and illnesses requiring days away from work in the U.S. The incidence of violence-related healthcare worker injuries has steadily increased for more than a decade. Actual rates are arguably higher, as workplace violence events are characteristically underreported (Arnetz et al., 2015). Notably, healthcare is an incredibly diverse environment. There is well-documented variation in the exposure to workplace violence among healthcare workers based on job role and individual characteristics (i.e., gender and race) (Liu, 2019). In response to the increasing incidence of workplace violence, The Joint Commission published new and revised workplace violence prevention standards for all accredited and critical access hospitals in the United States, effective January 2022. Considering these updated standards, Penn Medicine started an initiative to standardize workplace violence prevention efforts across the health system. To support this initiative, we conducted a scoping review to identify guidelines and systematic reviews on strategies to prevent and manage workplace violence in healthcare settings. This review will guide workplace prevention efforts at Penn Medicine and can inform interventions at other institutions by consolidating and appraising available guidelines and systematic reviews.

Methods

Guided by the methodological framework set by Arksey and O’Malley (2005) and the PRISMA reporting standards for scoping reviews, this scoping review was conducted in five stages: (1) developing research questions, (2) identifying relevant studies, (3) selecting relevant literature, (4) charting data, and (5) collecting and summarizing results.

Eligibility Criteria and Search Strategies

A protocol was developed a priori to this review, which outlined eligibility criteria using the PICOTS framework. Any evidence-based clinical practice guideline or systematic review published in English between 2015 and2021 that evaluated workplace violence prevention and/or management strategies in inpatient or outpatient settings was eligible for inclusion. Outcomes of interest included process outcomes such as frequency, severity, recording, and reporting of workplace violence events; patient outcomes including hospital length of stay, readmission, and mortality (HARM) score; and personal and occupational well-being reflective of provider outcomes. Multiple databases, including Medline, EMBASE, CINAHL, Cochrane Library, NICE Evidence Search, ECRI Guidelines Trust, ECRI HTA, and INAHTA were searched in September 2021 using three main axes: violence, healthcare, and prevention/management. Websites of relevant professional organizations were also searched. The Medline search strategy that was constructed and translated across select databases can be found in Appendix A.

Extraction and Quality Appraisal

After screening was completed in Covidence using the PICOTS eligibility criteria, relevant recommendations and data were extracted into Word tables and synthesized narratively. Screening and extraction was completed by a single reviewer. Quality of included guidelines was assessed using the Center for Evidence-based Practice (CEP) Trustworthy Guideline scale. Quality of included systematic reviews was assessed using the CEP modified AMSTAR scale. CEP scales for evidence quality assessment are found in the “Methods” section of the CEP website (https://www.med.upenn.edu/CEP/methods.html).

Results

Guidelines

Three guidelines were included. Guideline recommendations were clear that prevention programs should be comprehensive, program components are interdependent, and require regular reassessment and adjustment. Included guidelines are listed in Table 1 and their quality assessed in Table 2.

Table 1.

Published Guidelines.

Guideline	Relevant Recommendations
OSHA (2015)	Violence prevention programs: A written program for workplace violence prevention, incorporated into an organization’s overall safety and health program, offers an effective approach to reduce or eliminate the risk of violence in the workplace. The building blocks for developing an effective workplace violence prevention program include: • Management commitment and employee participation • Worksite analysis ○ Records analysis and tracking ○ Job hazard analysis ○ Employee and client/patient surveys • Hazard prevention and control ○ Substitution ○ Engineering controls and workplace adaptations to minimize risk ○ Administrative and work practice controls ○ Post-incident procedures and services ○ Investigation of incidents • Safety and health training ○ Training for all workers, supervisors/managers, and security personnel ○ Training topics ○ Evaluation of training • Recordkeeping and program evaluation A workplace’s violence prevention program should have clear goals and objectives for preventing workplace violence, be suitable for the size and complexity of operations, and be adaptable to specific situations and specific facilities or units. The components are interdependent and require regular reassessment and adjustment to respond to changes occurring within an organization, such as expanding a facility or changes in managers, clients, or procedures. As with any occupational safety and health program, it should be evaluated and reassessed on a regular basis. Those developing a workplace violence prevention program should also check for applicable state requirements.
NICE (2015)	Anticipating and reducing the risk of violence and aggression: • Health and social care provider organizations should train staff who work in services in which restrictive interventions may be used in psychosocial methods to avoid or minimize restrictive interventions. De-escalation: • Health and social care provider organizations should give staff training in de-escalation that enables them to recognize the early signs of agitation, irritation, anger, and aggression; understand the likely causes of aggression or violence, both generally and for each service user; use techniques for distraction and calming, and ways to encourage relaxation; recognize the importance of personal space; and respond to a service user's anger in an appropriate, measured, and reasonable way and avoid provocation. • Establish a close working relationship with service users at the earliest opportunity and sensitively monitor changes in their mood or composure that may lead to aggression or violence. Post-incident debrief and review: • The service user experience monitoring unit or equivalent service user group should undertake a formal external post‑incident review as soon as possible and no later than 72 hours after the incident. Managing violence and aggression in emergency departments: • If a service user with a mental health problem becomes aggressive or violent, do not exclude them from the emergency department. Manage the violence or aggression in line with recommendations 1.4.1–1.4.45 and do not use seclusion. Regard the situation as a psychiatric emergency and refer the service user to mental health services urgently for a psychiatric assessment within 1 hour. Managing violence and aggression in community and primary care settings: • Health and social care provider organizations, including ambulance trusts, should consider training staff working in community and primary care settings in methods of avoiding violence, including anticipation, prevention, de‑escalation and breakaway techniques, depending on the frequency of violence and aggression in each setting and the extent to which staff move between settings.
RNAO (2019)	Risk assessment: 1.1: Health service organizations establish an implementation plan for integrating a violence risk assessment tool for persons (strong recommendation). This plan should include the following: • Selection of a risk assessment tool that is applicable to the clinical population and setting • Education and training on the chosen tool for all health workers who provide direct care 1.2: Health workers conduct a violence risk assessment on all persons using a validated tool (strong recommendation). Recommendation addressing harassment and bullying from formal leaders, other health workers, or students: 1.3: Health service organizations and academic institutions support the use of validated risk assessment tools to measure and develop a quality improvement plan to address horizontal and/or vertical violence (conditional recommendation). Prevention and management: 2.1: Health service organizations provide education and training to health workers on addressing violent behaviors from persons (strong recommendation). 2.2: The expert panel recommends that health service organizations implement protective and security measures, such as the following (strong recommendation): • Documentation and communication of a person’s previous incident(s) of violence • Equipment to protect against violent behaviors, and a standardized approach for deciding what, when, and how to use these • Environmental security measures, including locked doors, closed-circuit cameras, and alarm systems • Formal reporting systems that are simple to use 2.3: Formal leaders within health service organizations support health workers in preventing and addressing workplace violence by doing the following (strong recommendation): • Understanding and implementing policies against workplace violence • Reviewing and acting on reported workplace violence incidents 2.4: Health service organizations implement a process for formal incident reviews immediately following a violent event to discuss the details of what occurred, the approach that was used, and the strategies for violence prevention in the future (strong recommendation). 2.5: Health service organizations and academic institutions provide education and training to health workers and students on addressing workplace harassment and bullying (conditional recommendation). 2.6: Health service organizations and academic institutions implement appropriate policies and codes of conduct to address harassment and bullying in the workplace and learning environment (strong recommendation). 2.7: Formal leaders in health service organizations and academic institutions be actively involved in preventing and addressing harassment and bullying to support health workers and students by doing the following (strong recommendation): • Understanding and reinforcing policies that address harassment and bullying • Providing mentorship and role modelling of professional behavior Education and training programs: 3.1: Health service organizations provide education to health workers on the risk factors and triggers for violent behaviors from persons (strong recommendation). 3.2: Health service organizations provide training to health workers on de-escalation techniques, including communication and redirection strategies, to prevent and/or reduce violent incidents within their organizations (strong recommendation). 3.3: The expert panel recommends that health workers are provided training in breakaway techniques and when to safely use breakaway techniques in violent incidents (strong recommendation). 3.4: Health service organizations provide education to health workers on how to identify harassment and bullying, understand the impact of harassment and bullying, and use effective communication strategies (conditional recommendation). 3.5: As part of an interactive learning approach, students learn to use guided communication responses to address harassment and bullying from multiple sources within an academic institution or clinical learning environment (strong recommendation).

Note. RNAO = Registered Nurses’ Association of Ontario; OSHA = Occupational Safety and Health Administration; NICE = National Institute for Health and Care Excellence.

Table 2.

Guideline Appraisal.

Guideline Issuer	OSHA	NICE	RNAO
1: Transparency	C	A	A
2. Conflict of interest	NR	A	A
3. Development group	B	A	A
4. Systematic review	NR	A	A
5. Supporting evidence	C	A	A
6. Recommendations	C	A	A
7. External review	A	A	A
8. Currency and updates	C	A	A

Note. RNAO = Registered Nurses’ Association of Ontario; OSHA = Occupational Safety and Health Administration; NICE = National Institute for Health and Care Excellence.

Color explanations vary for each aspect of the guideline/review. The scales for the quality assessment are found on the CEP website and the link is provided in the Methods section.

In 2015, OSHA published updated guidance for prevention of workplace violence for healthcare and social service workers. OSHA recommendations emphasized the value of a comprehensive written workplace violence prevention program. Also included were recommendations for developing policies and procedures to eliminate or reduce workplace violence in a range of healthcare and social service settings. Five different settings were identified: hospital, residential treatment, nonresidential treatment/service, community care, and field work. However, recommendations were not specific to these locations and employers were encouraged to use OSHA recommendations to develop appropriate, tailored prevention programs. Recommendations were not formally listed or graded, and supporting evidence was not provided or evaluated. OSHA also developed a roadmap to assist healthcare employers and employees interested in establishing a workplace violence prevention program or strengthening an existing program.

Also in 2015, the National Institute for Health and Care Excellence (NICE) published a guideline on short-term management of violence and aggression in mental health, health, and community settings. This guideline updated and replaced NICE guideline CG25 (2005). Evidence was last reviewed in 2019. The updated guideline included recommendations on six key areas for managing violence and aggression: anticipating and reducing the risk of violence and aggression; preventing violence and aggression; using restrictive interventions in inpatient psychiatric settings; managing violence and aggression in emergency departments, and community and primary care settings; and managing violence and aggression in children and young people. The wording used in the recommendations denotes the certainty with which the recommendations were made (the strength of the recommendation). Notably, this guidance only applied to adults, young people, and children with a mental health problem who were currently service users within mental health, health, and community settings, as well as their caregivers. As such, it is not generalizable to entire health systems, but may be indirectly pertinent in practice. Due to the volume of recommendations in the NICE guideline, an exhaustive list is not provided in this review. Instead, relevant recommendations highlighted as priorities for implementation are outlined in Table 1.

In 2019, the Canadian Registered Nurses’ Association of Ontario (RNAO) published an updated best practice guideline (BPG) on preventing violence, harassment, and bullying against healthcare workers (RNAO, 2019). This BPG replaced the previous RNAO BPGs on preventing and managing violence in the workplace (2009) and workplace health, safety, and well-being of the nurse (2008). The 2019 RNAO guideline was designed to support health service organizations and academic institutions in creating and sustaining positive work environments and focused on six main areas: risk assessment tools and strategies; organizational policies, procedures, requirements, and responsibilities; educational approaches and strategies; implementation strategies and tools for organizations; evaluation criteria; and future research opportunities and gaps in knowledge. RNAO BPGs are developed using the Grading of Recommendations Assessment, Development and Evaluation and Confidence in the Evidence from Reviews of Qualitative Research methods. Recommendations were formulated as strong or conditional. A conditional recommendation reflects the guideline panel’s confidence that while some uncertainty exists, desirable effects probably outweigh undesirable effects or undesirable effects probably outweigh desirable effects. The RNAO BPG recommended implementation as part of a multi-intervention, organizational strategy for the prevention and management of workplace violence, harassment, and bullying. Also included in the guideline is a conceptual model for healthy work environments for nurses. Interventions to promote healthy work environments must target multiple levels and components within the system, as well as the system itself.

Reviews

Thirty-three systematic reviews were included. Most included reviews focused on a specific population, such as nurses, or individual settings, like the emergency department. Only one review evaluated violence prevention specifically in the outpatient setting. No reviews reported HARM scores. In general, there was a clear lack of high-quality evidence to evaluate intervention effectiveness. However, interventions such as staff education, de-escalation training, and multidisciplinary violence rapid response teams, may be more beneficial when they are part of a multimodal strategy and not adopted in isolation. Included reviews were grouped for synthesis into five categories based on their primary focus: violence toward nurses; violence toward healthcare workers in general; violence in the emergency department; violence related to mental health; and violence measurement. Occasionally, overlap among reviews occurred because of this categorization method (e.g., a nurse-focused review that included multiple settings). And not all included settings in every review were applicable.

Violence toward nurses

Ten reviews evaluated interventions to prevent violence experienced by nurses (Armstrong, 2018; Bordignon & Monteiro, 2019; Crawford et al., 2019; Martinez, 2016; Olsen et al., 2020; Pereira et al., 2019; Rutherford et al., 2019; Somani et al., 2021; Tölli et al., 2017; Zhang et al., 2021). These reviews encompassed multiple settings. Most interventions focused on educational strategies, including simulation training, online platforms, and hybrid models. Reviews are summarized in Table 3 and their quality assessed in Table 4.

Table 3.

Systematic Review Findings: Nurses.

Reviewer	Setting	Violence	Primary Studies	Intervention	Outcomes
Armstrong (2018)	Healthcare	Incivility toward nurses, other healthcare team members, and nursing students	N = 10 Descriptive (n = 8) Controlled trials without randomization (n = 2)	Education; communication training; active learning strategies	In several studies, the outcome of reported confidence in handling incivility or in their ability to manage incivility was directly assessed, with participants reporting improvements after the interventions. The review provided evidentiary support that education about workplace incivility, training related to effective responses to uncivil behaviors in the workplace, and active learning exercises to practice responses to incivility are appropriate and research-supported for use in training nurses in the management of incivility.
Bordignon and Monteiro (2019)	Healthcare; psychiatric facility	Violence toward nurses, nursing students, and emergency department and psychiatric facility staff	N = 9 Quasi-experimental (n = 6) Qualitative (n = 3)	Simulation training	Simulation was found to be a resource capable of helping nursing students and professionals to deal with cases of workplace violence, preventing it to occur or reducing damage. Also, there are several simulation resources that can be used to train nursing students and professionals regarding violence at work and point out that it is possible to approach different manifestations or situations of violence with the simulation, depending on the interest of the learning proposal. The settings with patients or aggressors and violence starting with the patient were the most frequent. The studies pointed out benefits of the simulation, but not all results were consistent.
Crawford et al. (2019)	Acute care	Nurse-to-nurse bullying, incivility, lateral violence Included students, new graduates, experienced, and academic faculty	N = 21 Integrative review (n = 1) RCT (n = 1) Qualitative survey (n = 6) Quantitative survey (n = 8) Concept analysis (n = 1) Mixed-methods (n = 3) Theory/model testing (n = 1)	Structural strategies	The review provided structural strategies for a civil culture. Using regular assessments of practices, perceptions, and policies, executive leaders can create a workspace of civility and respect. Processes to increase a culture of acceptance and understanding include open discussion of the issues and a clear outline of how managers/directors are to respond to unacceptable behaviors. Engaging HR, nurse leaders, and staff in exploring current resources and autonomy of nursing practice are central to establishing an empowering practice environment. Implementing new graduate transition programs could potentially decrease stress and acculturate novice nurses. Nurse leaders who harness these strategies can provide support for frontline staff to feel engaged and confident, and potentially improve communication and clinical competencies—all essential elements for excellent patient care.
Martinez (2016)	Hospitals; psychiatric facilities	Patient-to- nurse violence	N = 11	Response teams; quality improvement initiative; community meetings; metal detectors; hybrid educational model	Overall conclusions were not drawn, only narrative descriptions of the interventions. A response team (a charge nurse, security personnel, and the physician and primary nurse) managing a potentially violent event resulted in successful resolution of violent incidents using verbal de-escalation skills and noncoercive medication administration. Nurse-led community meetings in inpatient psychiatric facilities reduced violent incidents. The comprehensive qualitative improvement project implemented in an inpatient psychiatric facility, which included posting universal precautions, resulted in fewer staff injuries. A hybrid education model may have a positive effect on the information being taught when used in conjunction with a web-based program to enhance knowledge attainment among nurses.
Olsen et al. (2020)	Healthcare (n = 23); academic settings (n = 16)	Incivility and bullying experienced by nurses and nursing students	N = 39	Education; administrative strategies, including policy changes	Six outcome themes emerged from the findings and were used to examine intervention strategy effectiveness: recognizing incivility, empowering participants, impacting job satisfaction and turnover, increasing civility, improving relationships, and decreasing contributing factors. In healthcare settings, four outcome themes were prominent: empowering participants, increasing civility, impacting job satisfaction and turnover, and recognizing incivility. Policy-related strategies included development of a policy to address incivility, as well as policy that required intervention attendance (but this was most common in academic settings). All the studies used multiple strategies as part of the intervention. Therefore, the effectiveness of individual intervention strategies for attaining specific outcomes could not be determined. Most studies reported at least some positive results, providing clear support for multicomponent incivility interventions with both nursing students and practicing nurses.
Pereira et al. (2019)	Hospitals; emergency departments; outpatient settings; psychiatric facilities	Violence toward nurses	N = 14	Institutional strategies	Specific actions prevailed (57%) over programs underlying institutional policies (43%). There are effective measures to curb nursing workplace environment; however, these are still focused on three countries: the United States, Canada, and Sweden. The programs, when implemented as an institutional policy, proved to be able to significantly reduce violence, and most of them are well evaluated and can serve as a model for the development and dissemination of policies, according to the needs of each location. From the United States, two programs have been well evaluated: the BE NICE and VAT programs. The BE NICE program was developed to train nurses to identify and counteract bullying. It involved three classroom sessions of three to four hours, in addition to printed materials posted in the units. The VAT program was a comprehensive emergency department violence prevention program that adopted a hybrid educational model with online and classroom activities. The intervention allowed for implementing risk assessment, safe environment maintenance, risk communication, response to violent events, record maintenance, surveillance, and monitoring.
Rutherford et al. (2019)	Healthcare	Bullying against nurses and nursing students	N = 22	Education; nurse leaders; policy	Educational interventions, such as curriculum integration and courses within healthcare settings, to address bullying are key components to eliminate the behaviors and actions. Educational endeavors are needed to teach and implement change within the nursing culture. To implement change in nursing culture, nursing leaders need to be willing and able to address concerns when nursing staff report negative behaviors irrespective of the individuals involved. Leadership must assume an active role in decreasing bullying behaviors and work toward a safe and healthy workplace by following evidence-based practices. Policies alone have been analyzed to mitigate bullying behaviors. Viewing the relative success of the Hospital Consumer Assessment of Healthcare Providers, researchers proposed that a similar system needs to be designed to penalize healthcare institutions where bullying behaviors have been reported. No research has been performed due to the lack of instrumentation to measure the outcomes. One descriptive study used several components including visual reminders and increased managerial involvement to change the notion that any level of violence was not acceptable and needed to be reported. Despite the multiple layered educational endeavors, formal documentation of workplace aggression decreased from 53% to 47% (p = .06).
Somani et al. (2021)	Healthcare	Violence toward nurses	N = 26 RCT (n = 5) Quasi-experimental (n = 10) Pre-post (n = 12)	Stand-alone education; structured education; multicomponent	Stand-alone training and structured education programs can have a positive impact, the impact is unfortunately limited. To effectively combat workplace violence against nurses, healthcare organizations must implement multicomponent interventions. Stakeholders should also be involved.
Tölli et al. (2017)	Psychiatric facilities (n = 6); emergency departments (n = 4); community care (n = 2); other (n = 4)	Patient-to-nurse violence	N = 17 RCT (n = 4) CBA (n = 2) ITS (n = 11)	Training	Competence, rates of violent incidents, and use of restraints were measured. Training interventions were classified into four key themes based on the way the challenging behavior was managed: disengagements, communication, controlling behavioral symptoms, and restrictive measures. Interventions were more likely to decrease violent incident rates and increase staff confidence than change staff attitudes or increase knowledge. The elements of competence used to manage challenging behavior were measured unilaterally. The evidence provided by studies was largely weak.
Zhang et al. (2021)	Psychiatric wards (n = 3); emergency departments (n = 2); triage areas (n = 2); trauma units (n = 3)	Patient or relative or visitor-to-nurse violence	N = 10 Qualitative (n = 10)	Support following violence: investigated nurses’ experiences or feelings regarding patient-related workplace violence (n = 9); explored nurses’ perceptions about management support after workplace violence (n = 1)	Concerning the support, two key themes were identified: “informal support needs” and “formal support needs.” Informal support: Having support made it easier for nurses to return to work and endure tough situations. The nurses needed various types of informal support, including encouragement from friends and family, empathetic understanding from colleagues, and cooperation from their medical team. Peer support was considered an effective, and the most common, support strategy. Formal support: Nurses need personal support and emotional input from managers after any violent incident. An open and blame-free atmosphere is significant in making nurses feel comfortable about reporting violence; nurses need managers to be concerned about them from a victim’s perspective, rather than how it adversely affects the hospital, such as the police report or patient feedback. Facilities (e.g., security cameras and panic buttons) and assistance to secure nurses’ safety are essential, including security personnel. Training was also considered vital, but nurses felt that it should focus on competence, rather than knowledge, and be practical, not theoretical. It is also necessary to establish postaccident support. Reporting was the most common management strategy, but it is important to consider reporting from the nurses’ perspective. It was suggested that policies and guidelines could protect them in the event of violence and ease the conflict between balancing professional roles and self-protecting behaviors. In addition to psychological support, nurses wanted legal departments to provide advice to staff.

Note. CBA = controlled before and after; ITS = interrupted time series; RCT = randomized controlled trial.

Table 4.

Systematic Review Appraisal: Nurses.

Review	Armstrong	Crawford	Bordignon	Martinez	Olsen	Pereira	Rutherford	Somani	Tölli	Zhang
1: Search terms described	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y
2. Two or more databases	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y
3. Inclusion/exclusion criteria	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y
4. Number of included/excluded	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y
5. Two independent screeners	NR	NR	Y	N	Y	NR	NR	N	Y	Y
6. Two independent reviewers	NR	NR	Y	N	Y	NR	NR	Y	Y	Y
7. Study quality assessed	Y	Y	N	Y	Y	N	Y	Y	Y	Y
8. Heterogeneity assessed	N	N	N	N	N	N	N	N	N	NA
9. Publication bias assessed	N	N	N	N	N	N	N	Y	Y	N
10. Studies described in evidence table	N	N	N	N	N	N	N	N	N	N
11. Funding described; no conflict	Y	Y	Y	Y	Y	N	Y	Y	Y	Y

Color explanations vary for each aspect of the guideline/review. The scales for the quality assessment are found on the CEP website and the link is provided in the Methods section.

One high-quality review found that to effectively combat workplace violence against nurses, healthcare organizations must implement multicomponent interventions that include both organizational changes and training (Somani et al., 2021). Another two reviews found support for multicomponent incivility interventions that incorporated educational, administrative, and learning strategies for staff and/or nursing students (Armstrong, 2018; Olsen et al., 2020). Two additional reviews evaluated training interventions for staff and/or nursing students (Bordignon & Monteiro, 2019; Tölli et al., 2017). Three of the 10 reviews evaluated structural or institutional strategies for violence prevention (Crawford et al., 2019; Pereira et al., 2019; Rutherford et al., 2019). These interventions focused on creating a workspace of respect, in addition to supporting and training nurses. One high-quality review of qualitative studies discussed the support nurses need after a violent event (Zhang et al., 2021). To highlight, nurses wanted personal support and emotional input from managers after any violent incident; facilities and assistance to secure nurses’ safety, especially security personnel; training that was practical and focused on competence; and policies and guidelines that protected them in the event of violence and eased the conflict between balancing professional roles and self-protecting behaviors. One additional review evaluated multiple strategies to reduce violent incidents in hospitals and psychiatric facilities (Martinez, 2016).

Violence toward healthcare workers

Eight reviews evaluated strategies to prevent violence experienced by healthcare workers in general (Geoffrion et al., 2020; Leach et al., 2019; MohammadiGorji et al., 2021; Morphet et al., 2018; Pompeii et al., 2020; Raveel & Schoenmakers, 2019; Safwan & Ariffin, 2019; Spelten et al., 2020). All the reviews included multiple settings except for one that assessed violence prevention practices in outpatient care (Pompeii et al., 2020). Five of the eight reviews focused specifically on aggression prevention and/or management (Geoffrion et al., 2020; Spelten et al., 2020; MohammadiGorji et al., 2021; Morphet et al., 2018; Raveel & Schoenmakers, 2019). Reviews are summarized in Table 5 and their quality assessed in Table 6.

Table 5.

Systematic Review Findings: Healthcare Workers.

Reviewer	Setting	Violence	Primary Studies	Intervention	Outcomes
Geoffiron et al. (2020)	Long-term care (n = 3); psychiatric ward (n = 2); hospitals or health centers (n = 4)	Aggression toward healthcare workers (nurse aids n = 7; general healthcare workers n = 2)	N = 9 RCT (n = 3) CRCT (n = 6) n = 1,688 total participants	Education and training (online programs n = 4; face-to-face programs n = 5). Five studies were of long duration (up to 52 weeks), and four studies were of short duration. Eight studies had short-term follow-up (< 3 months), and one study long-term follow-up (>1 year).	Effects on aggression: The evidence is very uncertain about effects of education and training on aggression at short-term follow-up compared to no intervention (SMD: −0.33, 95% CI −1.27 to −0.61, 2 CRCTs; RR: 2.30, 95% CI: 0.97–5.42, 1 CBA; SMD: -1.24, 95% CI: −2.16 to −0.33, 1 CBA; very low-certainty evidence). Education may not reduce aggression compared to no intervention in the long term (RR: 1.14, 95% CI: 0.95 to 1.37, 1 CRCT; low-certainty evidence). Effects on knowledge, attitudes, skills, and adverse outcomes: Education may increase personal knowledge about workplace aggression at short-term follow-up (SMD: 0.86, 95% CI: 0.34 to 1.38, 1 RCT; low-certainty evidence). The evidence is very uncertain about effects of education on personal knowledge in the long term (RR: 1.26, 95% CI: 0.90 to 1.75, 1 RCT; very low-certainty evidence). Education may improve attitudes among healthcare workers at short-term follow-up, but the evidence is very uncertain (SMD: 0.59, 95% CI: 0.24 to 0.94, 2 CRCTs and 3 RCTs; very low-certainty evidence). The type and duration of interventions resulted in different sizes of effects. Education may not influence skills related to workplace aggression (SMD: 0.21, 95% CI: −0.07 to 0.49, 1 RCT and 1 CRCT; very low-certainty evidence) nor on adverse personal outcomes, but the evidence is very uncertain (SMD: −0.31, 95% CI: −1.02 to 0.40, 1 RCT; very low-certainty evidence).
Leach et al. (2019)	Emergency departments (n = 4); social care (n = 1); psychiatric hospitals (n = 4); policing (n = 5); healthcare (n = 5)	Violence toward healthcare workers	N = 19	De-escalation training	The evidence indicates that individual staff training programs, such as in de-escalation, do not reduce violent incidents. However, there is some evidence that de-escalation training can help staff to manage patient aggression. The current evidence is inconclusive on the effectiveness of de-escalation training for reducing staff injuries. However, interventions are more likely to be effective when they are not adopted in isolation but instead rely on multimodal approaches. There is some anecdotal evidence on common content within de-escalation programs that include verbal and nonverbal strategies, control and restraint skills, and prediction and prevention of aggression. There is no consistent evidence on the efficacy of training, but staff and managers tend to believe that multimodal approaches combining program elements and recurring programs that extend over a long period of time are more effective than other methods.
Mohammadi-Gorji et al. (2021)	Emergency departments (n = 10); psychiatric facilities, including addiction treatment centers (n = 4); pediatric emergency department (n = 1)	Patient or visitor-to-healthcare worker aggression	N = 15	Environmental strategies, including interventions (n = 4)	Findings were organized according to four categories identified in the literature regarding CPTED including natural surveillance, access control, territoriality, and other CPTED elements. Physical environment attributes (i.e., layout, location, ambient conditions, equipment) were among the factors affecting violent incidents and staff security. Design-focused recommendations, such as providing a second door in a triage room and a sub-waiting area inside the treatment zone, were summarized according to CPTED categories.
Morphet et al. (2018)	Healthcare	Consumer-to-healthcare worker aggression	N = 20	Environmental strategies; consumer risk management; education; management of incidents	Environmental risk management included increasing visibility, reducing access to weapons, safe assessment rooms; education included recognizing risk behaviors, communication and de-escalation, self-defense; and management of violent incidents included aggression management teams and post-incident support. Interventions which reduced workplace violence included consumer risk assessment, staff education, and aggression management teams. Increasing visibility, in conjunction with other measures, also reduced the incidence of workplace violence. Post-incident support, in the form of group debriefing, increased the incidence of violent incidents, but this may be due to increased awareness of the importance of reporting. No evidence was found in relation to the use of duress alarms, incident reporting, or zero tolerance policies.
Pompeii et al. (2020)	Outpatient physician clinics	Patient- or patient relative-to-healthcare worker violence	N = 18 Quantitative (n = 13) Qualitative (n = 5)	Training; policy; environmental strategies	Various workplace violence prevention practices were mentioned across studies. Two studies examined the type of training healthcare workers had undergone pertaining to prevention. In the study by Bayman (2007), 92% of respondents received training in the role of a physician’s receptionist, and 78% received training on how to deal with violent or difficult behavior from patients and their companions. Receptionists who did undergo training felt significantly safer at work, but there were still receptionists that worried about being threatened while at work (27%) or being physically attacked (22%). In the study by Chambers and Kelly (2006), 28% of their practices surveyed had a policy in place for managing workplace violence and 13% of receptionists had received education that taught them how to deal with violence at work. In a small study of receptionists in the United Kingdom, verbal, threatening, and physical violence were examined before and after the implementation of a national zero tolerance campaign in the United Kingdom; the researchers observed no changes in violent events post-implementation. A response seen from physicians as secondary measures to prevent violence involved changes in the built environment of the clinic to prevent verbal abuse from escalating, for example, physical boundaries.
Raveel and Schoenmakers (2019)	Healthcare	Patient- or patient relative-to-healthcare worker aggression	N = 44 Quantitative (n = 15) Qualitative (n = 15) Systematic reviews (n = 7) Reviews (n = 7)	Pre, during, and post-incident strategies	One RCT provided moderate evidence that a violence prevention program was effective in decreasing risks of violence. Major risk factors are long waiting times, discrepancy between patients’ expectations and services, substance abuse by the patient and psychiatric conditions. Appropriate workplace design and policies aim to reduce risk factors but there is no hard evidence on the effectiveness. One RCT provided evidence that a patient risk assessment combined with tailored actions decreased severe aggression events in psychiatric wards. Applying de-escalation techniques during an aggressive event is highly recommended. Post-incident reporting followed by root cause analysis of the incident provides the basic input for review and optimization of violence prevention programs.
Safwan and Ariffin (2019)	Hospitals; emergency departments; community care	Violence toward healthcare workers	N = 12 RCT (n = 2) Quasi-experimental (n = 5) CBA (n = 5)	Education and training	Most of the studies included multiple modules, including de-escalating techniques, assessing risk of violence, communication skills, workers’ responsibility, notification and post-incident procedure, and legal aspect of workplace violence. Recognizing the early signs of violence was used in 8 out of 12 studies, while communication skills training was used in 9 out of 12. Most studies also used combined modes of delivery for the interventions, such as computer-based learning and lectures/discussions. Studies showed improvement in knowledges, attitude, confidence, and coping, but strength of evidence was weak.
Spelten et al. (2020)	Nursing homes (n = 4); psychiatric wards (n = 2); emergency department (n = 1)	Patient- or patient advocates-to-healthcare worker aggression	N = 7 Cross-over RCT (n = 2) CRCT (n = 3) CBA (n = 2)	Organizational strategies Two studies focused on prevention of aggression in the pre-event phase (n = 398 nursing home residents; n = 597 psychiatric patients); Two studies compared interventions to minimize aggression by the vector in the event phase to practice as usual (n = 87 residents); One intervention focused on the vector, pre-event phase, and event phase and compared culture change to practice as usual (n = 101 residents). Two studies evaluated multicomponent interventions that focused on the vector, the victim, and the environment during the pre-event and the event phase (n = 564 psychiatric staff; n = 209 emergency department staff)	Pre-event phase: Humor therapy in one study in a nursing home setting did not have clear evidence of a reduction of overall aggression (MD: 0.17, 95% CI: 0.00 to 0.34; very low-quality evidence). A short-term risk assessment in the other study showed a decreased incidence of aggression (RR: 0.36, 95% CI: 0.16 to 0.78; very low-quality evidence) compared to practice as usual. Vector in the event phase: Two studies provided low-quality evidence that bathing interventions may result in a medium-sized reduction of overall aggression (SMD: −0.49, 95% CI −0.93 to −0.05; 2 studies), and physical aggression (SMD: −0.85, 95% CI: 1.46 to −0.24; 1 study; very low-quality evidence), but not in verbal aggression (SMD: −0.31, 95% CI: −0.89 to 0.27; 1 study; very low-quality evidence). Vector, pre-event phase, and the event phase: One study provided very low-quality evidence that culture change may result in a medium-sized reduction of physical aggression (MD: 0.51, 95% CI: 0.11 to 0.91), but there was no clear evidence that it reduced verbal aggression (MD: 0.76, 95% CI: −0.02 to 1.54). Pre-event phase and the event phase: There was no clear evidence that multicomponent psychiatry interventions may result in a reduction of overall aggression (OR: 0.85, 95% CI: 0.63 to 1.15; low-quality evidence), compared to the control condition. The emergency department study did not result in a reduction of aggression (MD = 0) but provided insufficient data to test this.

Note. CBA = controlled before and after; CI = confidence interval; CRCT = cluster randomized controlled trial; MD = mean difference; OR = odds ratio; RCT = randomized controlled trial; RR = risk ratio; SMD = standardized mean difference; CPTED = crime prevention through environmental design.

Table 6.

Systematic Review Appraisal: Healthcare Workers.

Review	Geoffiron	Leach	M-G	Morphet	Pompeii	Raveel	Safwan	Spelten
1: Search terms described	Y	Y	Y	Y	Y	Y	Y	Y
2. Two or more databases	Y	N	Y	Y	Y	Y	Y	Y
3. Inclusion/exclusion criteria	Y	Y	Y	Y	Y	Y	N	Y
4. Number of included/excluded	Y	Y	Y	Y	Y	Y	Y	Y
5. Two independent screeners	Y	Y	N	NR	Y	NR	NR	Y
6. Two independent reviewers	Y	Y	Y	NR	Y	NR	NR	Y
7. Study quality assessed	Y	N	N	N	N	Y	N	Y
8. Heterogeneity assessed	Y	N	N	N	N	N	N	Y
9. Publication bias assessed	Y	N	N	N	N	Y	N	Y
10. Studies described in evidence table	Y	N	N	N	N	N	N	Y
11. Funding described; no conflict	Y	Y	Y	Y	Y	Y	N	Y

Color explanations vary for each aspect of the guideline/review. The scales for the quality assessment are found on the CEP website and the link is provided in the Methods section.

Two reviews that assessed aggression toward healthcare workers performed meta-analyses: one evaluated education and training interventions (Geoffrion et al., 2020) and one evaluated organizational strategies (Spelten et al., 2020). However, increased risk of bias of the underlying primary studies prevented either review from drawing any conclusions with high certainty. One low-quality review also evaluated educational training interventions for healthcare staff (Safwan & Ariffin, 2019). One scoping review assessed interventions to prevent patient-to-healthcare worker aggression (Morphet et al., 2018). Interventions that reduced incidents of workplace violence included consumer risk assessment, staff education, and aggression management teams. Increasing environmental visibility, in conjunction with other measures, also reduced the incidence of workplace violence. Similarly, one review evaluated environment strategies to prevent patient aggression and provided design-focused recommendations, such as providing a second door in a triage room and a sub-waiting area (MohammadiGorji et al., 2021). An additional review assessed strategies to prevent patient- or patient relative-to-healthcare worker aggression during different phases of a violent event (Raveel & Schoenmakers, 2019). Evidence supported violence prevention programs that addressed risk factors, such as waiting times and substance abuse, in addition to tailored strategies, such as de-escalation techniques and post-incident reporting. A RAND commissioned rapid review assessed individual skills-based training with an emphasis on de-escalation tactics (Leach et al., 2019). Evidence regarding the efficacy of training was inconsistent, but staff tended to believe that multimodal approaches combining program elements and recurring programs that extend over a long period of time were more effective than other methods.

Violence in the emergency department

Five reviews evaluated violence prevention interventions tailored to the emergency department (Elder et al., 2020; Ramacciati et al., 2016; Wirth et al., 2021; Timmins & Timmins, 2021; Weiland et al., 2017). More than any other setting, violence in the emergency department was recognized as an environmental issue. All but one review evaluated environmental strategies for violence prevention (Elder et al., 2020). There was evidence for environmental interventions, such as specialized behavioral rooms, security upgrades, and emergency department modifications, but effectiveness was difficult to establish considering the lack of high-quality evidence. Like the previously discussed review categories, reviews identified the benefits of utilizing comprehensive, multicomponent approaches for violence prevention that included behavioral, organizational, and environmental strategies. Additionally, targeted interventions, like educational programs and mindfulness/relaxation techniques, may improve burnout, stress, and other provider-related outcomes reported by emergency department staff (Elder et al., 2020). Reviews are summarized in Table 7 and their quality assessed in Table 8.

Table 7.

Systematic Review Findings: Emergency Department.

Reviewer	Violence	Primary Studies	Intervention	Outcomes
Elder et al. (2020)	Violence toward healthcare workers	N = 31	Individual and organizational strategies to reduce stress or improve coping	Exposure to or impact of occupational stress and workplace violence were common foci. A range of outcomes (such as burnout levels, stress levels, and quality of life) were measured in the included studies. All studies demonstrated some improvement in outcomes measured, although most were evaluated for relatively short duration. Quality of evidence varied. Emotional exhaustion, depersonalization, and compassion fatigue were reported to decrease with targeted interventions, such as educational programs focusing on compassion fatigue and programs focusing on communication skills, conflict, emotional skill, and working skills. Strategies, such as mindfulness and relaxation techniques, aimed at the individual to help improve coping also reportedly improved self-reported levels of burnout, stress, and anxiety. Knowledge, confidence, and ability to manage workplace violence also improved with strategies such as implementing tools designed to aid in reporting workplace violence, and tailored training programs. Most included studies were low level methodological design; therefore, true effectiveness cannot be established based on these findings alone. Understanding the effectiveness of strategies is an important early step in improving the working environment for emergency department clinicians in an evidence-informed manner.
Ramacciati et al. (2016)	Violence toward healthcare workers	N = 10 Guideline (n = 1) Literature review (n = 1) Descriptive (n = 1) Pre-post (n = 1) Mixed-methods (n = 2) Quasi-experimental (n = 2) Qualitative (n = 2)	Sectoral (n = 7) and comprehensive approaches (n = 3)	The few studies that have attempted to evaluate the effectiveness of interventions, such as educational training and rapid response teams, have shown weak evidence to date. Further research is needed to identify effective training content, best practices, and security measures designed to promote a safe work environment in the emergency department.
Timmins and Timmins (2021)	Violence toward healthcare workers	N = 25 Quantitative (n = 14) Qualitative (n = 6) Mixed-methods (n = 2) Literature review (n = 2) Delphi study (n = 1)	Environmental strategies	The literature revealed three emerging themes: the nature of emergency department violence, environmental contributory factors, and its management and control, all of which contributed to the understanding of violence as an environmental issue. Emergency department design is important. More is needed in terms of implementation of more far-reaching, practical, and effective management solutions to promote health care workers’ safety and adequately support vulnerable patients.
Weiland et al. (2017)	Acute behavioral disturbances	N = 8 ITS (n = 5) Cohort (n = 2) NRCT (n = 1)	Environmental strategies	Studies reporting interventions for managing acute behavioral disturbances within the emergency department are limited in number and quality. The level of evidence for efficacy is low, requiring caution in conclusions. While there is preliminary evidence for environmental change in the form of specialized behavioral rooms, security upgrades and emergency department modifications, these are not supported by evidence from controlled studies. Many of these “common sense” environmental changes recommended in many guidelines have been widely implemented in emergency departments.
Wirth et al. (2021)	Patient- and patient relative-to-healthcare worker violence and aggression	N = 15 Quasi-experimental (n = 10) ITS (n = 1) Mixed-methods (n = 1) Observational (n = 1) Cross-sectional (n = 3)	Training (n = 11); multicomponent (n = 4), including organizational environmental strategies	Most studies showed that interventions had a positive effect in the form of a reduction of violent incidents or an improvement in how prepared staff were to deal with violent situations by increasing staff knowledge, skills, and confidence. However, due to the limited number of studies, heterogeneity of methods, and the limited methodological quality of studies, this result will need to be verified in future research.

Note. ITS = interrupted time series; NRCT = nonrandomized controlled trial.

Table 8.

Systematic Review Appraisal: Emergency Department.

Review	Elder	Ramacciati	Timmins	Weiland	Wirth
1. Search terms described	Y	Y	Y	Y	Y
2. Two or more databases	Y	Y	Y	Y	Y
3. Inclusion/exclusion criteria	Y	Y	Y	Y	Y
4. Number of included/excluded	Y	Y	Y	Y	Y
5. Two independent screeners	N	NR	NR	Y	N
6. Two independent reviewers	Y	NR	NR	Y	Y
7. Study quality assessed	Y	N	Y	Y	Y
8. Heterogeneity assessed	N	N	N	N	Y
9. Publication bias assessed	Y	N	N	N	N
10. Studies described in evidence table	N	N	N	N	N
11. Funding described; no conflict	Y	Y	Y	Y	Y

Color explanations vary for each aspect of the guideline/review. The scales for the quality assessment are found on the CEP website and the link is provided in the Methods section.

Violence related to mental health

Five reviews focused on violence related to patients with psychiatric disorders and/or mental health settings (Ganyes et al., 2020; Gaynes et al., 2017; Gudde et al., 2015; Mangaoil et al., 2020; Price et al., 2015). Three of five reviews evaluated de-escalation strategies (Ganyes et al., 2020; Gaynes et al., 2017; Price et al., 2015). One of these three reviews was an Agency for Healthcare Research and Quality (AHRQ) commissioned comparative effectiveness review on strategies to de-escalate aggressive behavior in patients admitted to psychiatric settings with a length of stay (LOS) fewer than 35 days (Ganyes et al., 2020). For prevention, risk assessment reduced both aggression and use of seclusion and restraint (low strength of evidence [SOE]), and multimodal interventions reduced the use of seclusion and restraint (low SOE). SOE for all other interventions, whether aimed at preventing or de-escalating aggression, and for modifying characteristics, was insufficient. A separate, follow-up review evaluated patients admitted to psychiatric settings regardless of LOS (Gaynes et al., 2017). Results were comparable to the initial AHRQ review. One qualitative review assessed service users’ views on aggressive situations and preventive strategies (Gudde et al., 2015). The findings highlighted the importance of staffs’ knowledge and skills in communication for development of relationships based on sensitivity, respect, and collaboration with service users to prevent aggressive situations. This echoes the sentiment from nurses (described above) that a supportive and cooperative environment is necessary for violence prevention. Relatedly, immediate staff debriefing following seclusion or restraint events may also lend to a supportive environment (Mangaoil et al., 2020). Reviews are summarized in Table 9 and their quality analyzed in Table 10.

Table 9.

Systematic Review Findings: Mental Health.

Reviewer	Setting	Violence	Primary Studies	Intervention	Outcomes
Gaynes 2017	Acute care	Aggression in patients with psychiatric disorders or severe psychiatric symptomology	N = 29 Controlled trials (n = 11) Pre-post (n = 18)	De-escalation strategies Grouped into five categories: staff training interventions; risk assessment interventions; multimodal interventions; environmental interventions (including group psychotherapeutic options); and medication protocols versus other medication protocols or alternative strategies	Included patients had a length of stay of less than 35 days. Evidence was limited for benefits and, especially, for harms; information about modifying characteristics was completely absent. No key questions had data supporting SOE grades better than low, indicating limited confidence that the estimate of effect lies close to the true effect for these outcomes. Of the 11 trials eligible for SOE assessment, all but 1 had medium (or high) risk of bias. Risk assessment had low SOE for decreasing subsequent aggression and reducing use of seclusion and restraint, but only when applied in a preventive manner (e.g., as unit-wide programs). SOE for all other interventions, whether aimed at preventing aggression or de-escalating aggressive behavior, was insufficient.
Gaynes et al. (2017)	Acute care	Aggression in patients with psychiatric disorders or severe psychiatric symptomology	N = 17 RCT (n = 8) CRCT (n = 5) NRCT (n = 2) Retrospective cohort (n = 2)	De-escalation strategies	Included patients regardless of length of stay duration. Evidence was limited for benefits and harms; information about characteristics that might modify the interventions’ effectiveness, such as race or ethnicity, was especially limited. All but one study had a medium or high risk of bias and thus presented worrisome limitations. For prevention, risk assessment reduced both aggression and use of seclusion and restraint (low SOE), and multimodal interventions reduced the use of seclusion and restraint (low SOE). SOE for all other interventions, whether aimed at preventing or de-escalating aggression, and for modifying characteristics was insufficient. More research is needed on how best to prevent and de-escalate aggressive behavior in acute care settings.
Gudde et al. (2015)	Mental health facilities	Aggressive situations experienced by adult psychiatric patients	N = 13 Qualitative (n = 10) Mixed-methods (n = 3)	Aggression prevention	Service users recognized that both their own mental state and negative aspects of the treatment environment affected the development of aggressive situations. Themes were derived from experiential knowledge and included calls to be involved in questions regarding how to define aggression and relevant triggers, and how to prevent aggressive encounters effectively. The findings suggested that incidents are triggered when users experience staff behavior as custodial rather than caring and when they feel ignored. The findings highlighted the importance of staffs’ knowledge and skills in communication for developing relationships based on sensitivity, respect, and collaboration with service users to prevent aggressive situations. An important factor is a treatment environment with opportunities for meaningful activities and a preponderance of trained staff who work continuously on the development of conditions and skills for collaborative interaction with users.
Mangaoil et al. (2020)	Inpatient mental health facilities	Violence requiring seclusion or restraint	N = 42 Reviews (n = 6) Retrospective cohort (n = 3) Qualitative (n = 7) RCT (n = 1) Case study (n = 3) Quality improvement initiative (n = 11) Grey literature (n = 11)	Immediate staff de-briefing	The analysis identified several core components of immediate staff debriefing, such as terminology, type, critical reflection, iterative process, training, documentation, and monitoring. While these components were regarded as vital to the implementation of debriefing, they remain inconsistently described in the literature. Immediate staff debriefing is an important intervention not only to prevent future episodes of seclusion and restraint use, but as a forum for staff to support each other emotionally and psychologically after a potentially distressing event. The core components identified in this review should be incorporated into the organization’s policies, practice guidelines, and training modules to ensure consistent conceptualization and implementation of the debriefing process. They also should be routinely evaluated.
Price et al. (2015)	Mental health facilities	Violence and aggression in adult patients with mental health problems	N = 38 Uncontrolled cohort (n = 23) Controlled cohort (n = 12) Case–control (n = 3)	De-escalation training (direct skills-teaching n = 26; influenced either de-escalation performance or reduce violence and aggression through modification of staff attitudes (n = 6); used a combination of both approaches (n = 6)	The strongest impact of training appeared to be on de-escalation-related knowledge, confidence to manage aggression, and de-escalation performance (although limited to artificial training scenarios). No strong conclusions could be drawn about the impact of training on assaults, injuries, containment, and organizational outcomes owing to the low quality of evidence and conflicting results.

Note. CRCT = cluster randomized controlled trial; NRCT = nonrandomized controlled trial; RCT = randomized controlled trial; SOE = strength of evidence.

Table 10.

Systematic Review Appraisal: Mental Health.

Review	Gaynes 2016	Gaynes 2017	Gudde	Mangaoil	Price
1 Search terms described	Y	Y	Y	Y	Y
2. Two or more databases	Y	Y	Y	Y	Y
3. Inclusion/exclusion criteria	Y	Y	Y	Y	Y
4. Number of included/excluded	Y	Y	Y	Y	Y
5. Two independent screeners	Y	Y	N	Y	N
6. Two independent reviewers	Y	Y	Y	Y	Y
7. Study quality assessed	Y	Y	Y	N	Y
8. Heterogeneity assessed	Y	N	NA	N	Y
9. Publication bias assessed	Y	Y	N	N	N
10. Studies described in evidence table	Y	N	N	N	N
11. Funding described; no conflict	Y	Y	Y	Y	Y

Color explanations vary for each aspect of the guideline/review. The scales for the quality assessment are found on the CEP website and the link is provided in the Methods section.

Violence measurement

Five reviews assessed methods of measurement related to workplace violence (Anderson & Jenson, 2019; Campbell et al., 2015; Layne et al., 2020; Ramesh et al., 2018; Serafin et al., 2020). One review and meta-analysis examined the predictive accuracy of nine violence risk assessment instruments for inpatient violence in forensic psychiatric hospitals (Ramesh et al., 2018). The median area under the curve (AUC) value was higher for imminent (within 24 hours) tools (AUC 0.83; interquartile range [IQR]: 0.71–0.85) compared with longer term tools (AUC 0.68; IQR: 0.62–0.75). Other performance measures indicated variable accuracy for imminent and longer term tools. The Brøset Violence Checklist (BVC) and the Dynamic Appraisal of Situational Aggression were recommended for use in clinical practice. Similarly, one review evaluated violence risk-assessment screening tools for acute mental health settings (Anderson & Jenson, 2019). The two included BVC RCTs reported a higher AUC (0.93 and 0.85) than the two included V-RISK-10 RCTs (0.82 and 0.84). And the V-RISK-10 values were favorable for violence risk prediction in sensitivity, specificity, positive predictive value, and negative predictive value. One additional review and meta-analysis synthesized empirical studies that used the Negative Acts Questionnaire–Revised (NAQ-R) to assess bullying among nurses (Serafin et al., 2020). Usability of the instrument was supported by a high reliability reported in most studies (Cronbach’s α range = 0.74–0.95). Two meta-analyses were conducted. The first meta-analysis included studies that calculated the sum of the Likert-type scale item scores (n = 5; 1,495 participants). The mean NAQ-R score was 39.46 (95% CI: 31.69–47.23). The second meta-analysis included studies that calculated a mean score for the entire NAQ-R scale (n = 7; 2,284 participants). The mean NAQ-R score was 1.55 (95% CI: 1.51–1.60). Both analyses were considered heterogeneous, and no publication bias was detected. The NAQ-R was determined to be a useful and reliable tool for measuring bullying among nurses. The other two reviews did not identify optimal tools for measurement. One of these two reviews assessed incident reporting of patient violence and aggression toward healthcare providers (Campbell et al., 2015). The other review identified tools to measure negative behaviors among healthcare workers (Layne et al., 2020). Reviews are summarized in Table 11. Quality appraisal of these reviews was less applicable and not conducted.

Table 11.

Systematic Review Findings: Measurement.

Reviewer	Setting	Measurement	Primary Studies	Outcomes
Anderson and Jenson (2019)	Acute mental health	Violence risk–assessment screening tools	After examining 8 violence risk–assessment screening tools, 4 were chosen for further detail: the BVC, V-RISK-10, DASA-IV, and START.	The BVC and V-RISK-10, provided enough statistical information to be considered for use in acute care mental health settings. The two BVC studies reported a higher AUC (i.e., discrimination) (0.93 and 0.85) than the two V-RISK-10 studies (0.82 and 0.84), and the V-RISK-10 values were favorable for violence risk prediction in sensitivity, specificity, positive predictive value, and negative predictive value (i.e., calibration).
Campbell et al. (2015)	Healthcare	Incident reporting of patient violence and aggression toward healthcare providers	Most of the studies were cross-sectional and utilized researcher developed tools and measures which lacked testing on reliability and validity of the instrumentation and lacked standardization of measures.	This review suggests that the use of well-studied measures for recording instances of patient abuse or violence remains insufficient. Those studies which did include discussions of validity and reliability of measures tended to focus on the larger themes of workplace violence, and less on the areas of interest of this study, specifically incident reporting. Articles which did offer psychometrics regarding reliable and valid instrumentation also lacked a specific focus on incident reporting.
Layne et al. (2020)	Healthcare	Negative behaviors among healthcare workers	22 instruments were evaluated. The 22 instruments measured 9 negative behaviors: incivility, violence, bullying, abuse, conflict, aggression, work environment, lack of cohesion, and disruptive behavior.	The following key principles of measuring negative behaviors emerged during this review: frequency, severity, and sources of the behaviors. Most existing instruments often included one or two of these key principles. Violence, incivility, and bullying are the most frequently measured behaviors in healthcare workers, and a robust number of valid and reliable instruments are available. To date, a comprehensive review of psychometric properties and feasibility of administration is lacking. This review synthesizes the instruments measuring these behaviors, providing a resource for future research focused on mitigation and intervention strategies.
Ramesh et al. (2018)	Psychiatric hospitals	Violence risk-assessment screening tools	43 publications provided information on tool accuracy in the form of AUC statistics. These provided data on 78 individual samples, with information on 6,840 patients. Of these, 35 samples (3,306 patients from 19 publications) provided data on all performance measures.	9 instruments were examined: BVC, the Classification of Violence Risk, the DASA, the Psychopathy Checklist Revised, the Psychopathy Checklist Screening Version, the Violence Risk Appraisal Guide, and the Violence Risk Scale. Structured professional judgement tools included the Historical Clinical Risk Management-20 and the START. The median AUC value for the wider group of 78 samples was higher for imminent tools (AUC 0.83; IQR: 0.71–0.85) compared with longer term tools (AUC 0.68; IQR: 0.62–0.75). In clinical practice, consideration should be given to the use of the BVC and the DASA.
Serafin et al. (2020)	Healthcare	NAQ-R to assess bullying in nursing	N = 31 (n = 13 included in the meta-analysis)	Usability of the instrument was supported by a high reliability reported in most studies (Cronbach’s α range = 0.74–0.95). Two meta-analyses were conducted. The first meta-analysis included studies that calculated the sum of the Likert-type scale item scores (n = 5; 1,495 participants). The mean NAQ-R score was 39.46 (95% CI: 31.69–47.23). The Cochrane test showed moderate heterogeneity (Q = 399.25; p < .001) with 4 degrees of freedom and the Paule-Mandel method showed τ² = 778,825 and I² = 99.0%). The second meta-analysis included studies that calculated a mean score for the entire NAQ-R scale (n = 7; 2,284 participants). The mean NAQ-R score was 1.55 (95% CI: 1.51–1.60). The Cochrane test allowed the rejection of the null hypothesis (Q = 19.26; p = .004) with 6 degrees of freedom and the Paule-Mandel method showed τ² = 0.0023 and I² = 68.8%). Both analyses were considered heterogeneous, and no publication bias was detected. The good quality of the NAQ-R in determining variables related to bullying is endorsed. Variables related to bullying identified in this review could be used to map out a model of a potential bullying victim for preventative measures.

Note. AUC = area under the curve; CI = confidence interval; NAQ-R = Negative Acts Questionnaire–Revised; START = Short-term Assessment of Risk and Treatability; DASA-IV = Dynamic Appraisal of Situational Aggression–Inpatient Version; BVC = Brøset Violence Checklist; V-RISK-10 = Violence Risk Screening-10; IQR = interquartile range.

Discussion

This scoping review is the first to consolidate and appraise the available high-level evidence related to workplace violence prevention and management in healthcare settings. It provides a systems-level perspective on evaluated approaches and catalogues an extensive, multifaceted body of literature. Additionally, the review categorizes the included studies into distinct groups to highlight specific topic areas and to increase the readability of the results. However, the review is not without limitations. Although the methods were systematic, screening and extraction were not performed in duplicate. Also, the included studies were restricted to those published in English between 2015 and 2021.

Three guidelines and thirty-three systematic reviews were included. Included reviews (n = 33) were grouped into five main categories: violence toward nurses (n = 10); violence toward healthcare workers in general (n = 8); violence in the emergency department (n = 5); violence related to mental health (n = 5); and measurement related to workplace violence (n = 5). For nurses, most reviews evaluated educational strategies, including simulation training, online platforms, and hybrid models. One qualitative review highlighted that nurses wanted personal support and emotional input from managers after any violent incident; facilities and assistance to secure nurses’ safety; training that was practical and focused on competence; and policies and guidelines that protected them in the event of violence (Zhang et al., 2021). Most reviews for general healthcare workers focused specifically on aggression prevention and/or management strategies, while most reviews for the emergency department and mental health settings evaluated environmental interventions and de-escalation strategies, respectively.

Quality of the reviews varied. Nine of the reviews failed to conduct a quality appraisal. Heterogeneity and publication bias was rarely assessed. The category with the highest quality reviews was violence related to mental health. It was clear that workplace violence prevention in healthcare should be addressed comprehensively and that multicomponent interventions were preferred to those applied in isolation. Both OSHA and RNAO guidelines provided useful recommendations for building a thorough violence prevention program. Evidence-based risk assessment, prevention and management, and education and training are all necessary components. Regular reassessment and adjustment is required. We found consistent support for certain strategies, including education and training, post-incident debriefing, multidisciplinary rapid response teams, and environmental modifications; however, the strength of evidence and certainty of conclusions were limited across reviews.

Diversity

Issues related to diversity were not considered in any of the reviews. This lack of attention to diversity is particularly troubling given the varied healthcare environment and the known variation in the exposure to workplace violence among healthcare workers based on job role and individual characteristics (Liu et al., 2019). A recent systematic review explored workplace discrimination toward physicians of color and found no study that assessed an intervention to reduce discrimination among this population (Filut et al., 2020). Researchers (especially those that work within healthcare institutions) should endeavor to be inclusive and responsive to diverse cultures, populations, and groups (Tajima, 2021). Specific, evaluated strategies to address workplace violence for those at increased risk (e.g., minority providers) are urgently needed, both at the individual and institutional level.

Conclusion

Based on this scoping review, strong leadership that cultivates and enforces a culture of inclusivity, support, and respect is a prerequisite for a successful workplace violence prevention program. While direct comparison of different programs is not available to support the efficacy of one intervention over another, healthcare leaders can adapt and apply the evidence presented here that is best suited to their environment. Further research should focus on comparative effectiveness of interventions and the effects of strong leadership and workplace diversity on the experience, frequency, and severity of workplace violence. This future research and implementation of results is urgently needed as workplace violence will likely remain an ongoing and pressing problem for the future of the healthcare industry.

Critical Findings

Three guidelines were included. Both The Occupational Safety and Health Administration 2015 and Registered Nurses’ Association of Ontario 2019 guidelines provided useful recommendations for building a comprehensive prevention program. Evidence-based risk assessment, prevention and management, and education and training are all necessary components. Regular reassessment and adjustment is required.

Thirty-three systematic reviews were included. The reviews were grouped into five main categories: violence toward nurses (n = 10); violence toward healthcare workers in general (n = 8); violence in the emergency department (n = 5); violence related to mental health (n = 5); and methods of measurement related to workplace violence (n = 5).

Multicomponent interventions were often preferred over those applied in isolation.

There was consistent support for certain strategies including education and training, post-incident debriefing, multidisciplinary rapid response teams, and environmental modifications; however, the strength of evidence and certainty of conclusions were limited across reviews.

Strong leadership that cultivates a culture of support and respect is a prerequisite for a successful workplace violence prevention program.

Implications for Policy, Practice, and Research

The review will guide workplace prevention efforts at Penn Medicine and can inform interventions at other institutions by consolidating and appraising high-level evidence.

While direct comparison of different programs is not available to support the efficacy of one intervention over another, healthcare leaders can adapt and apply the evidence presented here that is best suited to their environment.

Further research should focus on comparative effectiveness of interventions and the effects of strong leadership and workplace diversity on the experience, frequency, and severity of workplace violence.

Supplemental Material

sj-docx-1-tva-10.1177_15248380221126476 – Supplemental material for Workplace Violence in Healthcare Settings: A Scoping Review of Guidelines and Systematic Reviews

Supplemental material, sj-docx-1-tva-10.1177_15248380221126476 for Workplace Violence in Healthcare Settings: A Scoping Review of Guidelines and Systematic Reviews by Julie Fricke, Shazia Mehmood Siddique, Caryn Douma, Alicia Ladak, Christian N. Burchill, Ryan Greysen and Nikhil K. Mull in Trauma, Violence, & Abuse

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

Julie Fricke

Christian N. Burchill

Supplemental Material

Supplemental material for this article is available online.

Author Biographies

Julie Fricke, PhD, MSc, is a research analyst at the Center for Evidence-based Practice within the University of Pennsylvania Health System. She has years of experience conducting evidence synthesis in a variety of contexts, including a Cochrane-affiliated group within the Department of Epidemiology at Johns Hopkins University and a health economics consultancy.

Shazia Mehmood Siddique, MD, MSHP, is a gastroenterologist and assistant professor of medicine at the University of Pennsylvania Perelman School of Medicine. She is a health services researcher with expertise in observational dataset analyses, systematic reviews, guideline development, and implementation science.

Caryn Douma, MS, RN, IBCLC, CPPS, is corporate director of patient safety for the University of Pennsylvania Health System. She is an innovative quality and patient safety leader with a focus on cultural transformation. Her career has included a variety of staff nursing and progressive leadership roles providing oversight for clinical practice and quality and safety initiatives.

Alicia Ladak MPH, MSN, BSc, RN, CNOR, CPPS, is senior project manager in the Clinical Effectiveness and Quality Improvement Department for the University of Pennsylvania Health System. Her healthcare career includes a diverse background in community health, public health, patient care, leadership, patient/employee safety, education, and quality improvement.

Christian N. Burchill, PhD, MSN, RN, CEN, is director, Nursing Research and Science, Penn Medicine Lancaster General Hospital, Lancaster, PA. He has over 26 years of experience as a stretcher-side emergency nurse and has worked with the American Nurses Association revising their workplace violence position statement and End Nurse Abuse campaign.

Ryan Greysen, MD, MHS, MA, is chief of the section of hospital medicine, executive director for the Center for Evidence-based Practice, and a practicing hospitalist within both Penn Medicine and the Veterans Affairs health systems. His NIH and VA-funded research focuses on improving systems of care and the quality of care, particularly for vulnerable populations.

Nikhil K. Mull, MD, is medical director for the Penn Medicine Center for Evidence-based Practice and senior associate director of the ECRI-Penn AHRQ EPC. He has extensive experience with rapid review, systematic review, and other health technology assessment methodologies. He is a practicing hospitalist that leverages his clinical role to effectively implement many evidence-based interventions.

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