workplace health and safety education programs should be directed toward which employees

An official website of the Department of Health & Human Services

• Search All AHRQ Sites
• Email Updates

1. Use quotes to search for an exact match of a phrase.

2. Put a minus sign just before words you don't want.

3. Enter any important keywords in any order to find entries where all these terms appear.

• The PSNet Collection
• All Content
• Perspectives
• Current Weekly Issue
• Past Weekly Issues
• Curated Libraries
• Clinical Areas
• Patient Safety 101
• The Fundamentals
• Training and Education
• Continuing Education
• WebM&M: Case Studies
• Training Catalog
• Submit a Case
• Improvement Resources
• Innovations
• Submit an Innovation
• About PSNet
• Editorial Team
• Technical Expert Panel

Addressing Workplace Violence and Creating a Safer Workplace

Jones CB, Sousane Z, Mossburg S. Addressing Workplace Violence and Creating a Safer Workplace. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023.

While violence in the workplace can occur across many industries and professions, this issue disproportionately impacts the healthcare workforce. Healthcare workers are five times more likely to sustain a workplace violence injury than other professions. In 2018, 73% of all nonfatal workplace violence-related injuries involved healthcare workers. 1 Even with such a high reported prevalence, the incidence of workplace violence is likely even higher due to underreporting. 2 Workplace violence in healthcare settings has become an increasing problem in recent years, particularly during the COVID-19 pandemic, which presented unique challenges for both patients and providers.

The National Institute for Occupational Safety and Health (NIOSH) defines workplace violence as violent acts, including physical assaults and verbal threats, directed toward persons at work or on duty. 3 Acts of violence against healthcare workers can range from verbal abuse to violent physical assaults. Risk factors for workplace violence in healthcare settings can include (1) unpredictable behaviors of patients and families who are often under emotional stress, as well as (2) organizational and systemic factors such as high-stress work environments, staff shortages, lack of organizational policies and staff training, overcrowding, long wait times, inflexible visiting hours, and lack of information. 4

In addition to violence that healthcare workers may experience from patients, families, or visitors, horizontal violence is also prevalent in healthcare. Horizontal violence can be defined as hostile, aggressive, and harmful behaviors toward coworkers via attitudes, actions, words, or other behaviors such as bullying, incivility, or hazing. 13 While this can occur across all healthcare professions, nurses are especially impacted, with one study estimating that 22% to 44% of nurses experience bullying at some point in their professional careers. 14

Workplace violence can jeopardize the safety of patients and staff. To highlight the importance of addressing this problem, the Joint Commission released a sentinel event alert in 2018 calling attention to the prevalence of violence in the healthcare workplace. The alert noted contributing factors and suggested actions for mitigating violence. 5 The Joint Commission released new workplace violence prevention standards in 2022 to guide hospitals in defining workplace violence and implementing organization-wide strategies to address the issue. 6 Interventions at the systemic, organizational, and individual levels are crucial to prevent workplace violence and better understand incidents when they do occur.

Types of Workplace Violence

The traditional press most often covers workplace violence incidents that yield devastating results, such as gun violence or homicide in healthcare settings. However, it is important to understand that workplace violence can take many forms, ranging from commonplace occurrences of verbal abuse to more serious acts of physical violence. Most incidents of workplace violence are verbal in nature; however, other types of incidents can include assault, battery, stalking, and sexual harassment. 5

Perpetrators of workplace violence can vary, and violence can occur from patients toward healthcare staff or between coworkers. The most common type of violence in healthcare settings is violence from patients, families, or visitors toward healthcare staff. 7 According to a 2019 survey on healthcare crime, about 78% of aggravated assaults and 88% of all assaults that occurred in hospitals were from patients and families toward healthcare workers. 8 Horizontal violence that occurs between coworkers may include personal bullying, job-related bullying, and intimidation. 15 Factors that lead to bullying among staff may include lack of experience or role conflicts, work overload, and insufficient support from management. 14

In addition to varying by type and perpetrator, workplace violence can vary across care settings. For example, emergency departments and psychiatric units are more likely to experience workplace violence than other care settings. 5 While some units or departments may experience a higher incidence of violence than others, workplace violence can impact all healthcare settings and is not limited to one particular area of care.

Trends and Impact

Workplace violence is not a new problem in healthcare. However, the incidence of violence has increased in recent years, particularly during the COVID-19 pandemic. According to the International Association for Healthcare Security and Safety’s 2019 Healthcare Crime Survey, physical assault against healthcare workers in hospitals increased from 7.8 incidents per 100 beds in 2014 to 11.7 incidents per 100 beds in 2018. 8 One study found that violent incidents in emergency departments rose from 1.13 incidents per 1,000 visits in the 3 months preceding the pandemic to 2.53 incidents per 1000 visits during the pandemic. 9 Another study conducted in Italy found that the monthly average of attacks against hospital workers increased from 13.5 events per 1,000 emergency department accesses per month in the pre-COVID-19 era to 27.2 in the pandemic months. 10 This rise in violence during the pandemic has been attributed to increased stress, anxiety, and isolation for patients and providers, as well as ongoing staffing issues and burnout. 9

While it is evident that workplace violence is an ongoing problem, it is also widely underreported. One study conducted at the University of Michigan estimated that the incidence of workplace violence could be up to three times higher than reported rates due to underreporting. 2 Another survey found that over the course of a year, 39% of healthcare workers experienced violence from patients and families (including physical assaults, physical threats, and verbal abuse), but only 19% of events were reported. 12

Underreporting of workplace violence incidents makes it difficult to estimate its true scope and impact. However, it is clear that workplace violence has broad-reaching and long-lasting implications for the healthcare workforce and subsequent effects on patient safety. Exposure to, or fear of, violence in the workplace can lead to negative psychological consequences for healthcare workers such as anxiety, depression, loss of self-esteem, and post-traumatic stress disorder. 4 Horizontal violence among staff can also have negative psychological consequences, such reduced self-esteem and increased risk for stress, anxiety, and depression. 15 These psychological effects can lead to higher rates of absenteeism and burnout , which can have negative downstream effects on quality of care and patient safety. 11 Workforce stress and burnout negatively impact patient safety culture , leading to consequent safety issues including increased errors and potential patient harm.

In addition to implications for patients and healthcare workers, workplace violence of all types negatively impacts healthcare organizations as a whole. Workplace violence is a leading cause of job dissatisfaction among providers, particularly nurses. Annual nurse turnover rates due to workplace violence are estimated to be between 15% and 36%. 11 Workplace violence incidents can lead to increased costs due to staff turnover, costs for treating injuries, and staff time away from work. 11

Strategies to Address Workplace Violence

To effectively address workplace violence to create a safer healthcare environment for patients, families, and providers, it is imperative to implement interventions at both the organizational and individual levels. When reviewing the effectiveness of violence prevention training for nurses, research has found that these trainings lead to increased confidence and improved communication skills. However, the trainings are ineffective as standalone methods to reduce workplace violence without additional organizational interventions. 11

At the organizational level, leaders should take steps to address barriers to reporting workplace violence incidents in order to better understand, address, and prevent problems. Underreporting of workplace violence incidents may be due to healthcare workers’ beliefs that violence is an expected part of the job, beliefs that no action will be taken against perpetrators of violence, fear of negative consequences from reporting, or a lack of easily accessible reporting systems. 3 Implementation of straightforward and easy-to-use reporting systems combined with support and action from leaders can help address these barriers, reduce the burden of reporting for healthcare staff, and prevent further burnout. 7

The Joint Commission recommends that, in addition to addressing barriers to reporting, healthcare leaders should make it clear that it is the organization, rather than the victims of violence, that is responsible for addressing workplace violence. At the organizational level, leaders should cultivate safer work environments by developing clear workplace violence protocols and taking steps to address issues such as staffing shortages and turnover. 5 The Joint Commission also recommends that healthcare organizations capture and track workplace violence incidences from all available sources, including databases used for insurance, security, human resources, and employee surveys, and use this data to inform quality improvement initiatives to reduce incidences of workplace violence. 5 These initiatives may involve changes to the physical work environment, such as enhanced security and better exit routes, as well as changes to work practices or administrative procedures, such as developing workplace violence response teams and providing adequate mental health support on-site. 5

Effective January 2022, the Joint Commission released new and revised standards for the prevention of workplace violence in hospitals. These standards require that hospitals manage safety and security risks by establishing processes for continually monitoring, reporting, and investigating incidents related to workplace violence. They also require that staff participate in ongoing education and training, and that leaders create and maintain a culture of safety and quality throughout the hospital. 6

Creating a culture of safety within organizations is also crucial to addressing horizontal violence and bullying in the healthcare workplace. It is critical for organizations to establish and enforce a zero-tolerance policy towards bullying, as tolerance of bullying at the organizational level is closely related to bullying prevalence. 16 By implementing anti-bullying interventions, such as manager training, teambuilding exercises, and clear reporting systems, organizations can enhance allyship, communication, empowerment, and trust among healthcare staff, thus creating a safer work environment for patients and staff alike. 16

Looking Forward

Workplace violence is a complex issue that affects more than the workers who experience it. Safety leaders recognize workplace violence as a significant patient safety issue; workforce safety is one of four foundational areas in the National Action Plan to Advance Patient Safety . This document, which is focused on improving patient safety at the national level, was created by the National Steering Committee for Patient Safety, an interdisciplinary workgroup of leading healthcare organizations, associations, patient and family advocates, and federal agencies, including AHRQ.

To achieve improved workforce safety, organizations should start with a systems approach, which includes a comprehensive safety program overseen by senior leaders and clinical leader oversight for accountability for physical and psychological safety at the clinical and unit level. Development of programs to prevent and address workplace violence should be complemented by programs that support psychological safety and joy at work. The Implementation Resource Guide of the National Action Plan provides specific tactics and resources that organizations can use as they assess the status of their current initiatives to address workplace violence and develop programs to prevent violence and create safer spaces. By establishing policies and procedures to prevent and address workplace violence incidents on multiple levels, healthcare organizations can take steps toward creating a safer environment for both patients and providers.

• U.S. Bureau of Labor Statistics. Workplace Violence in healthcare, 2018 . Accessed August 23, 2023. https://www.bls.gov/iif/factsheets/workplace-violence-healthcare-2018.htm
• Rosenman KD, Kalush A, Reilly MJ, Gardiner JC, Reeves M, Luo, Z. How much work-related injury and illness is missed by the current national surveillance system? J Occup Environ Med . 2006;48(4):357-365.
• The National Institute for Occupational Safety and Health (NIOSH). Violence: Occupational Hazards in Hospitals . Centers for Disease Control and Prevention; 2002. Accessed October 3, 2023. https://www.cdc.gov/niosh/docs/2002-101/default.html#print
• Lim MC, Jeffree MS, Saupin SS, Giloi N, Lukman KA. Workplace violence in healthcare settings: the risk factors, implications and collaborative preventive measures. Ann Med Surg . 2022;78(78):103727. doi: https://doi.org/10.1016/j.amsu.2022.103727
• The Joint Commission. Physical and Verbal Violence Against Health Care Workers . Issue 59. Sentinel Event Alert. 2018. Accessed August 23, 2023. https://www.jointcommission.org/-/media/tjc/documents/resources/patient-safety-topics/sentinel-event/sea-59-workplace-violence-final2.pdf
• The Joint Commission. Workplace Violence Prevention Standards . R3 Report: Requirement, Rationale, Reference. 2021. Accessed August 23, 2023. https://www.jointcommission.org/-/media/tjc/documents/standards/r3-reports/wpvp-r3_20210618.pdf
• Kim S, Lynn MR, Baernholdt M, et al. How does workplace violence-reporting culture affect Workplace violence, nurse burnout, and patient safety? J Nurs Care Qual . 2023;38(1):11-18. 10.1097/ncq.0000000000000641
• Vellani KH. The 2019 IAHSSF Healthcare Crime Survey . IAHSS Foundation; 2019. Accessed October 3, 2023. https://iahssf.org/assets/2019-Healthcare-Crime-Survey-IAHSS-Foundation.pdf
• McGuire SS, Gazley B, Majerus AC, Mullan AF, Clements CM. Impact of the COVID-19 pandemic on workplace violence at an academic emergency department. Am J Emerg Med . Published online September 2021. doi: https://doi.org/10.1016/j.ajem.2021.09.045
• Brigo F, Zaboli A, Rella E, et al. The impact of COVID-19 pandemic on temporal trends of workplace violence against healthcare workers in the emergency department. Health Policy . 2022;126(11):1110-1116. doi: https://doi.org/10.1016/j.healthpol.2022.09.010
• Somani R, Muntaner C, Hillan E, Velonis AJ, Smith P. A systematic review: effectiveness of interventions to de-escalate workplace violence against nurses in healthcare settings. Saf Health Work . 2021;12(3):289-295. doi: https://doi.org/10.1016/j.shaw.2021.04.004
• Pompeii LA, Schoenfisch AL, Lipscomb HJ, Dement JM, Smith CD, Upadhyaya M. Physical assault, physical threat, and verbal abuse perpetrated against hospital workers by patients or visitors in six U.S. hospitals.  Am J Ind Med . 2015;58(11):1194-1204. doi:10.1002/ajim.22489
• Jaber H, Abu M, Mahmoud Al Kalaldeh, et al. Perceived Relationship Between Horizontal Violence and Patient Safety Culture Among Nurses. Risk Management and Healthcare Policy. 2023;Volume 16:1545-1553. doi: https://doi.org/10.2147/rmhp.s419309
• ‌ Shen Hsiao ST, Ma SC, Guo SL, et al. The role of workplace bullying in the relationship between occupational burnout and turnover intentions of clinical nurses. Applied Nursing Research. Published online August 2021:151483. doi: https://doi.org/10.1016/j.apnr.2021.151483
• Kim Y, Lee E, Lee H. Association between workplace bullying and burnout, professional quality of life, and turnover intention among clinical nurses. Heslop L, ed. PLOS ONE. 2019;14(12):e0226506. doi: https://doi.org/10.1371/journal.pone.0226506
• Jang SJ, Son Y, Lee H. Intervention types and their effects on workplace bullying among nurses: A systematic review. Journal of Nursing Management. 2022;30(6). doi: https://doi.org/10.1111/jonm.13655

In Conversation with... Cheryl Jones about Addressing Workplace Violence and Creating a Safer Workplace

Editor’s note: Cheryl B. Jones is a professor, director of the Hillman Scholars Program, and interim associate dean of the School of Nursing’s PhD program at the University of North Carolina at Chapel Hill. We spoke to her about workplace violence trends in healthcare settings and how we can create a safer work environment for healthcare staff.

Sarah Mossburg: Can you tell us about yourself and your current role?

Cheryl B. Jones: I am a Professor at the University of North Carolina Chapel Hill , and currently I serve as interim associate dean for our PhD program and PhD/post-doctoral programs. I’m also the Director of the Hillman Scholars Program , a BSN through PhD pathway for nurses to be prepared as nurse scientists.

Sarah Mossburg: Can you describe, at a high level, the focus of your research and its intersection with workplace violence?

Cheryl B. Jones: I’ve been studying the healthcare workforce for over 30 years. I began by looking at the cost of nurse turnover, and later I examined the relationship between turnover and the work environment. I have also studied other aspects of the work environment, like staffing, and more recently, workplace violence with my colleague, Dr. Sinhye Kim, with whom I’ve coauthored three papers. My work largely focuses on the organization, delivery, and financing of care, and how the healthcare system and the workforce affect care delivered to patients and their families. I focus on how we can improve the work environment for staff, and, in turn, the care for patients and families.

Sarah Mossburg: What types of violence are healthcare workers experiencing? For example, patient/family to workers, staff to staff? And what forms of violence are we seeing: Is it physical, verbal, something else?

Cheryl B. Jones: Violence can take any of the forms you mentioned. There is certainly violence from patient and family toward staff, but also bullying and other negative behaviors occur between staff, both among the same kinds of professionals and across professional groups. When you’re working in an organization where there are clear power differentials and stressful conditions, there’s always potential for some level of tension, some of which may lead to violence.

Workplace violence has always been present in healthcare. We’ve seen increased reporting coming out of the pandemic, especially violence from patients and families toward healthcare providers. Workplace violence can take a broad spectrum of forms, from verbal abuse to mild and more violent physical acts against healthcare workers. Based on findings from our team’s research, there’s a greater potential for verbal violence, and there is increasing fear about acts of physical violence targeting healthcare providers. 1 We’ve seen recently in the press that shootings have occurred in healthcare organizations, with patients or family members targeting healthcare providers, so workplace violence can have devastating effects.

Sarah Mossburg: You mentioned increased reports of violence during the pandemic. Do you think that the incidence of violence is increasing, or are we just shining a spotlight on it?

Cheryl B. Jones: I think it could be a little of both. In social media and the traditional press, we have seen the public reporting of specific violent events that have occurred. In some cases, it’s hard to discern if the reporting is true, if the incidence of workplace violence has really increased, or if better reporting is shining the spotlight on it. Regardless, this important organizational and patient safety concern deserves focused attention.

Sarah Mossburg: Are there certain types of workplace violence that are more common?

Cheryl B. Jones: We hear more about the verbal and physical violence from patients and families directed toward healthcare workers today. We’re also seeing more about bullying among staff in the workplace. Our findings indicated that verbal violence from patients (e.g., insults, threats, screaming, cursing) occurs most frequently, followed by verbal violence from visitors (including family members) and physical violence from patients (e.g., hitting, grabbing, biting, scratching).

Not always “framed” as violence, bullying may involve some behaviors, such as micro-aggressions, that could be considered violence-like behaviors, especially verbal bullying. I think the most concerning, at least in the immediate sense, is the violence that occurs from patients and family toward healthcare providers because the exposure of clinicians to patients is broad and sometimes longer-term. Also, providers are vulnerable if they lack information about high-risk situations, the processes and systems available to help address them, and the resources needed to respond to an act of violence that may be aimed at them.

Sarah Mossburg: Are there certain settings that have higher incidence of workplace violence?

Cheryl B. Jones: Hospitals are a common setting because they admit large numbers of patients and employ large numbers of healthcare professionals, with opportunities for workplace violence events to occur. Although we think that certain units may have a patient population that may predispose workplace violence to occur, the reality is that we see workplace violence across all types of units, even perinatal care. Opportunities for workplace violence occur in long-term care facilities because of their patient population and the types of care they deliver.

Sarah Mossburg: What are some of the challenges in understanding workplace violence?

Cheryl B. Jones: I think that challenges on multiple levels—societal, systemic, and organizational—give rise to violence. It’s not as simple as one level versus another, but rather it’s a multilevel problem. There are even challenges at a unit level, to some degree, where staff working on certain units within hospitals are more familiar with exposure to violence arising from patients or family members. Patients admitted to the emergency department with problems may predispose them to exhibit aggressive behaviors, or the unit may be short-staffed, or care provided on the unit may be delayed. These and other factors in the emergency department environment could elicit violent behaviors.

At the organizational level, systems may be lacking for staff to safely report incidents of violence, which makes it hard to understand the real magnitude of the problem. There are also issues with staffing. Nurse staffing has been a great challenge to address coming out of the pandemic. If patients and families don’t feel they are receiving proper care or if there are not sufficient staff to care for their loved ones, then they may be more likely to act out violently in some way.

Also, I think it’s important to acknowledge challenges at the societal level. In recent years, in addition to workplace violence events that may occur in healthcare organizations, many violent incidents have been reported across the country. These events threaten the safety of all of us. Patients and families assume that healthcare providers and organizations are safe places—they actually treat victims of physical and psychological violence. But b ecause violence is occurring across the country and workplace violence is occurring in healthcare organizations, patients and families may be hesitant to seek care for fear of being exposed to violence. There should be a consensus at the societal and policy levels that healthcare providers are safe environments for everyone who seeks care.

Sarah Mossburg: You mentioned the potential for underreporting due to the lack of available reporting systems. Are there other factors that may contribute to underreporting?

Cheryl B. Jones: I think there are a few things. For example, some reporting systems that we do have are complicated, difficult to use, or not easily accessible. Clinicians are busy, and it’s hard for them to find time to report, especially if that means taking time away from their patients. It is also one more thing for health professionals to do or to remember to do when they are already stretched. There is fear among healthcare clinicians of potential retribution from reporting. Staff could fear that reporting might negatively affect them, put their jobs at risk, or be shared with family members of, say, a patient exhibiting violent behaviors who could hold it against the clinician.

Staff may also believe that nothing will change or improve, even if they put time and effort into reporting incidents, and this belief discourages them from reporting. The absence or lack of system-level supports after an incident has been reported is also a factor contributing to under-reporting.

There are a number of challenges with reporting and making it easier for clinicians to report acts of violence when they occur. There is interest in electronic apps that would allow patients, families, and staff to report acts of violence more easily, but these solutions are not widely available at this time.

Sarah Mossburg: Do you think healthcare staff may see workplace violence as status quo? Meaning, do you think that staff are so accustomed to workplace violence that the line between verbal incivility and verbal violence is blurred, making it difficult for staff to recognize violence?

Cheryl B. Jones: Let’s face it: Workplace violence is often tolerated by clinicians because they see it as a part of the job. A lot of violence, especially verbal, goes unrecognized or dismissed because clinicians expect it, and therefore they tolerate it on some level until it escalates.

Sarah Mossburg: What kinds of long-lasting impacts do you see on the workforce and individuals related to workplace violence?

Cheryl B. Jones: In some of the work I’ve done with Dr. Kim and other colleagues , we’ve reported a connection between workplace violence and burnout. We know that burnout can lead to an increase in sick time or missed time from work and, ultimately, staff departures from organizations. Right now, there is a shortage of healthcare workers, particularly in certain segments of the workforce, such as nurses. When violence is layered on top of an already stressful work environment, it could potentially escalate problems with burnout, turnover, and staffing shortages.

Sarah Mossburg: How do you think workplace violence impacts patient safety?

Cheryl B. Jones: When workplace violence occurs, it can spill over and make others—patients, visitors, and staff—fearful about what might happen to them. Patients may worry about what could happen to them during their stay, and the uncertainty and at times abrupt occurrences of violence can make both patients and staff feel helpless or psychologically unsafe. The experience of a violent event can linger with a person for a long period of time. The person or persons who experience the event may feel the psychological effects into the future. Nurses, physicians, and other clinicians exposed to violence may experience burnout. With or without burnout, the disturbance of the event could change structures and processes in ways that both disrupt workflows and cause errors in care. Workplace violence can disrupt the patient safety culture and limit leaders’ ability to create a safe patient environment. It can also cause patients, families, and clinicians to worry about their safety in the healthcare environment and erode trust in the organization and system.

Sarah Mossburg: What are some things we should think about at the organizational and systemic levels to reduce workplace violence?

Cheryl B. Jones: I think when addressing the problem of workplace violence, focusing on a provider or organizational level is only one piece of the puzzle. It really is a multilayered problem that starts with policymakers, payers, and providers, including healthcare organizations.

Organizations can create a better work environment that supports better care by addressing the organizational concerns that give rise to unhappy patients, including increasing staffing, addressing clinician burnout, and creating a safety culture for both patients and clinicians. When the healthcare workforce is tired, burned out, and stressed out, it’s really important to address those issues so that the environment for care delivery is safe on a basic level.

Organizations can also think carefully about the organizational actions needed, including evidence from the literature, the Joint Commission, the National Academy of Medicine, and other national groups. 2 A broad organizational approach should include technologies that are needed to address challenges related to the reporting of workplace violence events and the collection of workplace violence event data. These technologies could be available to staff—and to patients and families—to engage those in the environment to report an event.

We hear a lot about de-escalation techniques, and I think those are important when it becomes apparent that a situation is going awry. But in some cases, these techniques are not enough. You probably heard about the recent incident in Oregon, where a security guard suffered a fatal injury from a patient’s family member. At some point, it’s almost too late for de-escalation when a situation reaches the point of reporting. Verbal violence may be a first indicator of potential physical violence, so it’s important to be attuned to those acts when they occur, to take steps toward prevention of a workplace violence event, and to be vigilant about reporting. Reporting systems must be safe, convenient, and not overburdensome for staff. We must also educate workers at all levels to understand workplace violence, to know when and how to take appropriate actions, and to follow accepted organizational procedures and professional standards.

Sarah Mossburg: It sounds like you’re advocating for addressing some of the root causes of an unsafe work environment that may contribute to workplace violence. Organizations should be thinking about staffing, policies around reporting, monitoring, and being alert to the signals they’re seeing in those reports, so that they can identify early indicators of a rise in violence.

Cheryl B. Jones: Absolutely. We know that violence is occurring, so organizations have to be diligent, and situational awareness within an organization is important. Some requirements today, such as those from the Joint Commission, 3 require organizations to be more diligent and have systems and processes in place to protect patients and staff. Basic patient safety activities, which include promoting teamwork, good handoffs, timely responses to patients and families, appropriate sharing of information, and good transitions in care, help build a culture of patient safety. We know that a good patient safety culture is a culture where people feel psychologically safe working, where they can speak up when things are going wrong, and where they want to work.

Sarah Mossburg: What do you see as some of the greatest opportunities for improvement, as it relates to workplace violence?

Cheryl B. Jones: I think there are several opportunities to improve current approaches to addressing workplace violence, such as implementing safer, more convenient, and more user-friendly reporting systems. There is also an opportunity to help organizational leaders and managers improve responses to, and management of, workplace violence events. A recent Health Affairs blog outlined some of these opportunities, 3 and steps have been outlined from other professional and regulatory groups. Management and leadership support can really make a difference. When staff feel psychologically safe, feel heard by their managers and leaders, and believe managers and leaders will act on reported information, they are more likely to report workplace violence when it occurs.

Sarah Mossburg: What reporting methods or strategies would you recommend that organizations use to better understand how, where, and why workplace violence occurs?

Cheryl B. Jones: We should think about how we can leverage technology to address workplace violence and make it easier for clinicians and others to report. The systems that we’ve had in the past are complicated, time consuming, and often onerous to use. Having reporting systems in place that facilitate the reporting of events when they actually occur is important.

Sarah Mossburg: We’ve talked a lot about the big picture of addressing workplace violence at the organizational level. What are some ways on a day-to-day basis that frontline healthcare workers can address the violence that they’re seeing and experiencing?

Cheryl B. Jones: Certainly, if they’re trained on organizational procedures and policies to address workplace violence when it occurs, and in de-escalation techniques, that will be important. I think it’s easy to point to steps that workers can take, but addressing workplace violence is a systemic problem. It’s important that staff know what to do if a situation escalates and what resources are available to them, but that’s only a very small piece of the puzzle. Staff training is important, but organizational supports are critical.

When you look at the statistics, healthcare workers are four to five times more likely to be exposed to workplace violence than any other industry. 4 They operate in high-stress and often unstable environments that can put them in situations that expose them to violence. 5 We need to make workers feel safe and put resources at their fingertips.

You have to think about the people we serve in healthcare. They come in when they themselves or their family members are at their most vulnerable. If the healthcare work environment doesn’t support the delivery of care, and patients and families don’t feel that they and their loved ones are getting the care that they need, I think we can, on some level, understand why they might feel dissatisfied with care and lash out. But if the environment that exists doesn’t give rise to those feelings of dissatisfaction to start with, then there we might see workplace violence decline.

Sarah Mossburg: What you just said makes me think that people are almost in a fight or flight response because they’re just so overwhelmed in some situations. I agree with your point that you can understand, to some extent, where some of that violence comes from.

Cheryl B. Jones: I do understand where patients’ and families’ anger or concern may come from; but I don’t truly understand where the violence comes from. However, the feelings of vulnerability in a system about your health and safety and that of your loved ones, or feelings that care is not delivered safely, could create a sense of urgency that pushes people over the edge at times.

Sarah Mossburg: You seemed to be making the point that we have to be careful not to rely solely on how healthcare workers can fix violence in the moment just because they happen to be the ones experiencing it. That seems to align with the way we often think about patient safety: just because a healthcare worker was at the blunt end of an error, doesn’t mean that they were the cause of that error, and should be able to stop it from occurring next time. Do you agree with that framing?

Cheryl B. Jones: I absolutely agree. Patient safety approaches generally emphasize a “systems” approach to create safe work environments; thinking about workplace violence similarly could help address the root causes of workplace violence. If we give healthcare workers the tools and techniques to deal with workplace violence, as we do with patient safety—such as creating a patient-centered environment, examining the root causes of workplace violence, debriefing with staff when a workplace violence event occur, and creating response teams to address workplace violence events in the moment—then we could move toward creating an environment that is safer for patients, families, and staff. We know that there’s a connection between patient safety culture and healthcare workers feeling like they’re in an environment where they can practice safely. If we viewed workplace violence as part of that patient safety culture, then workers and patients may feel safer when they enter the healthcare setting and receive care.

Sarah Mossburg: You mentioned de-escalation techniques earlier. Are those effective, and are they being used?

Cheryl B. Jones: A lot of training around de-escalation is occurring across the country in hospitals and various healthcare settings. I think de-escalation techniques are necessary but are not sufficient. You need other areas of support, like leadership support, access to security staff, and supportive technologies because de-escalation can help, but it is unlikely to solve the problem entirely. It’s a matter of having a system in place so that resources are available and easily accessible for staff when needed. It gets back to having a safe environment with resources in place in a way that individuals can access the resources, report an event when it happens, and quickly get help when they need it.

Sarah Mossburg: You just mentioned access to security. I’ve seen in the news and heard from colleagues that health systems are increasing security in response to the rise in incidents of workplace violence. Is that correct, and what are your thoughts about that?

Cheryl B. Jones: Yes, I’m reading and hearing about it in the press and on the news as you are. I’ve seen there are systems creating and deploying their own police forces. I think it’s a sad state that we’re here. Patients and families are at their most vulnerable when they come to receive healthcare. They come to us because they want or need our help. When the conditions are such that they don’t get the help they need, don’t get it fast enough, have to wait long periods of time with no response from providers, or come into the emergency department but are sent home only to bounce back again, it creates an environment where people stop trusting the system. It’s a larger, systemic problem, it’s an organizational problem, and then it’s really a problem of public policy.

Sarah Mossburg: You’ve mentioned policy makers as one of the potential shareholders involved in addressing workplace violence. Do you have thoughts about what that might look like?

Cheryl B. Jones: There are different types of policy, including public policy, system policies (like the Joint Commission and other groups), and organizational policies. I think you really need policies at all those levels.

I think on a public policy level, legislation is needed to support and incentivize organizations to report workplace violence more accurately. Congress has introduced a bill called the Workplace Violence Prevention for Health Care and Social Service Workers Act, which has passed the house and is now in the Senate. We need our legislators to take action to protect patients and healthcare workers when they are in healthcare settings.

In healthcare, policies have been created that require organizations to report patient outcomes, including satisfaction with care. P atient satisfaction is an element of healthcare reimbursement. What can happen is that organizations may fear having any reports released that indicates their system may have experienced a workplace violence incident. On a public policy level, attention should be given to supporting systems and organizations in more accurately reporting workplace violence, such as incentivizing them to use reporting systems and technolog ies that enable tracking of events. Thus, interventions are needed—through legislation and industry-wide changes—to address workplace violence. 

Sarah Mossburg: What are some areas for future research in this field?

Cheryl B. Jones: We need to look at how clinicians, nurses, physicians, and others who experience workplace violence are affected. We’ve talked about how similar workplace violence is to quality and patient safety concerns. Research to develop, pilot, implement, evaluate, and modify interventions to address workplace violence, along with the measurement of workplace violence, are areas ripe for study. We can look to theories that come from within and outside of healthcare, including health services research approaches, organizational theory, and organizational psychology, as guides for the theoretical and conceptual framing of research.

We also need to look at the effectiveness of strategies such as technologies, de-escalation techniques, and programs to address workplace safety. We should examine the effectiveness as well as the cost and return on investment of implementing these kinds of programs. Because research on workplace violence is emerging, we need to focus on both the substantive areas associated with workplace violence, as well as the methodological areas to build the science and contribute to generalizable knowledge.

Sarah Mossburg: Are you aware of any promising research exploring ways to prevent workplace violence from occurring?

Cheryl B. Jones: The research emerging from local facilities and systems around the use of technologies, applications, and artificial intelligence (AI) for reporting are intriguing. For example, studies are underway examining the use of apps that allow clinicians and patients to report workplace violence. I’m sure there are potential AI uses and implications for workplace violence and patient safety that we’re not adequately utilizing at this point. The world around technology and the use of AI is ripe for future research.

This focus goes hand in hand with some of the policy work that could be directed at addressing workplace violence, based on research supported through the Agency for Healthcare Research and Quality (AHRQ), the National Institutes of Health (NIH), and private foundations. These efforts are critical. These groups support the implementation of local quality improvement initiatives that could focus on workplace violence.

Sarah Mossburg: Are there any new improvements that have been shown to be impactful on mitigating workplace violence?

Cheryl B. Jones: Organizations now have workplace violence or workplace safety committees, so I think those kinds of things should definitely be supported. We can use strategies we know work in patient safety and quality—such as root-cause analysis, rapid response teams, and event debriefing—to understand what happened during incidents of workplace violence, identify what processes and policies need to change, and determine what levers need to be pulled at the practice level to support quality improvement, and at the policy level to bring about meaningful changes in organizations.

I mentioned management and leadership support earlier. We know that in patient safety, safety champions are needed to support patient safety initiatives. Similarly, we need leaders to champion initiatives that address worker safety, protect and support staff when incidents happen, and ultimately protect patients.

Sarah Mossburg: That’s a great suggestion. It was interesting to hear you talk about workplace safety committees as well. Before we close, is there anything that I didn’t ask you that you think would be important to talk about?

Cheryl B. Jones: I’d like to reinforce the links among workplace violence, the work environment, and the quality and safety of patient care. We know that conditions in the work environment can lead to clinician burnout, feelings of being psychologically unsafe, and potentially to organizational turnover and departures from healthcare organizations and perhaps even the profession. We’re in the midst of a healthcare workforce shortage. If we’re serious about keeping our workforce healthy and in place, we must pay attention to workplace violence. It is one of those things that can tip people over in their decision to leave a unit, leave an organization, and maybe even to leave the workforce. At a time when we critically need healthcare workers, we need to appreciate the importance of addressing the work environment, including workplace violence.

The nature of violence is different in different situations. It can arise from patients and families, as well as among healthcare workers. We need to understand more about the workers themselves and what happens in the work environment, and we need to engage patients and families to understand and address what gives rise to violence, and how workplace violence affects patients and families. We need to understand all angles to identify strategies that address the antecedents, processes, and consequences of workplace violence.

Sarah Mossburg: That was such a perfect call to action for us to end on. Thank you so much for talking to us today.

References :

• Kim S, Kitzmiller R, Baernholdt M, Lynn MR, Jones CB. Patient safety culture: the impact on workplace violence and health worker burnout. Workplace Health Saf . 2023;71(2):78-88. doi:10.1177/21650799221126364
• Beeber L, Delaney KR, Hauenstein E, Iennaco J, Schimmels J, Sharp D, Shattell M. Five urgent steps to address violence against nurses in the workplace. Health Affairs Forefront , August 23, 2023. 10.1377/forefront.20230822.174151. Accessed September 25, 2023. https://www.healthaffairs.org/content/forefront/five-urgent-steps-address-violence-against-nurses-workplace
• Arbury S, Zankowski D, Lipscomb J, Hodgson M. Workplace violence training programs for health care workers: an analysis of program elements.  Workplace Health Saf . 2017;65(6):266-272. doi:10.1177/2165079916671534
• U.S. Bureau of Labor Statistics. Workplace violence in healthcare, 2018. Accessed August 23, 2023. https://www.bls.gov/iif/factsheets/workplace-violence-healthcare-2018.htm
• U.S. Department of Labor. Workplace violence in healthcare: understanding the challenge. Accessed September 25, 2023. https://www.osha.gov/sites/default/files/OSHA3826.pdf

This project was funded under contract number 75Q80119C00004 from the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services. The authors are solely responsible for this report’s contents, findings, and conclusions, which do not necessarily represent the views of AHRQ. Readers should not interpret any statement in this report as an official position of AHRQ or of the U.S. Department of Health and Human Services. None of the authors has any affiliation or financial involvement that conflicts with the material presented in this report. View AHRQ Disclaimers

Perspectives on Safety

Annual Perspective

Perspective

Patient Safety Innovations

Patient and Family Centered I-PASS (Family-Centered Communication Program to Reduce Medical Errors and Improve Family Experience and Communication Processes)

Remote response team and customized alert settings help improve management of sepsis, enhancing support for patients’ social needs to reduce hospital readmissions and improve health outcomes.

Connect With Us

Sign up for Email Updates

To sign up for updates or to access your subscriber preferences, please enter your email address below.

Agency for Healthcare Research and Quality

5600 Fishers Lane Rockville, MD 20857 Telephone: (301) 427-1364

• Accessibility
• Disclaimers
• Electronic Policies
• HHS Digital Strategy
• HHS Nondiscrimination Notice
• Inspector General
• Plain Writing Act
• Privacy Policy
• Viewers & Players
• U.S. Department of Health & Human Services
• The White House
• Don't have an account? Sign up to PSNet

Submit Your Innovations

Please select your preferred way to submit an innovation.

Continue as a Guest

Track and save your innovation

in My Innovations

Edit your innovation as a draft

Continue Logged In

Please select your preferred way to submit an innovation. Note that even if you have an account, you can still choose to submit an innovation as a guest.

Continue logged in

New users to the psnet site.

Access to quizzes and start earning

CME, CEU, or Trainee Certification.

Get email alerts when new content

matching your topics of interest

in My Innovations.

Education and training for preventing and minimizing workplace aggression directed toward healthcare workers

About this resource:.

Source: The Cochrane Collaborative

The last reviewed date indicates when the evidence for this resource last underwent a comprehensive review.

Workgroups: Occupational Safety and Health Workgroup

In this Cochrane systematic review, researchers assessed the effectiveness of education and training interventions to prevent and minimize workplace aggression directed toward health care workers by patients and patient advocates.

Researchers found that education combined with training may not have an effect on workplace aggression directed toward health care workers, even though education and training may increase personal knowledge and positive attitudes. 

Researchers pointed out the need for more and higher quality studies that:

• Focus on specific settings of health care work where exposure to patient aggression is high
• Include other types of health care workers who are also victims of aggression, such as orderlies (health care assistants) 
• Use reports of aggression at an institutional level and rely on multi‐source data while using validated measures 
• Include days lost to sick leave and employee turnover and measure outcomes at one‐year follow‐up 
• Specify the duration and type of delivery of education and use an active comparison to prevent raising awareness and reporting in the intervention group only

Objectives related to this resource (1)

Suggested citation.

Geoffrion S, Hills DJ, Ross HM, et al. (2020). Education and training for preventing and minimizing workplace aggression directed toward healthcare workers. Retrieved from https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD011860.pub2/full .

The Office of Disease Prevention and Health Promotion (ODPHP) cannot attest to the accuracy of a non-federal website.

Linking to a non-federal website does not constitute an endorsement by ODPHP or any of its employees of the sponsors or the information and products presented on the website.

You will be subject to the destination website's privacy policy when you follow the link.

Education and Training are Essential Elements of a Safety and Health Program

Education and training are important tools for informing workers and managers about workplace hazards and controls so they can work more safely and be more productive. Education and training also provide workers and managers with a greater understanding of the safety and health program itself so that they can contribute to its development and implementation.

Effective safety training gives managers, supervisors and workers:

• Knowledge and skills needed to do their work safely and avoid creating hazards
• Awareness and understanding of workplace hazards and how to identify, report and control them
• Specialized training when the work involves unique hazards.

Once a basic safety and health program is developed, employers can take the following steps to help ensure that managers and supervisors fulfill their roles in providing leadership, direction and resources and that workers are actively participating in the program:

• Provide program awareness training
• Train employers, managers and supervisors on their roles in the program
• Train workers on their specific roles in the safety and health program
• Train workers on hazard identification and controls

Upcoming OSHA #7500 Introduction to Safety and Health Management Classes

• Book a Speaker

Lorem ipsum dolor sit amet, consectetur adipiscing elit. Vivamus convallis sem tellus, vitae egestas felis vestibule ut.

Error message details.

Reuse Permissions

Request permission to republish or redistribute SHRM content and materials.

Understanding Workplace Violence Prevention and Response

Introduction.

The  topic of workplace violence tends to dominate the news in the days following a major incident, but not every instance of workplace violence generates national headlines. Each year, an average of nearly 2 million U.S. workers report having been a victim of violence at work, according to the Occupational Safety and Health Administration (OSHA). And the U.S. Bureau of Labor Statistics puts the number of annual workplace homicides at about 400.

A 2022 SHRM survey of U.S. workers found that 28 percent of workers have either witnessed aggressive interactions between coworkers (20 percent) and/or have actually been involved in them personally (8 percent). While no prevention plan is an absolute protection against violence at work, understanding how to prepare for and react to violent conduct is imperative.

Introduction Compliance How to Prepare for Workplace Violence

• Identify the types of violence
• Create a violence prevention plan
• Consider insurance needs
• Know the warning signs
• Recognize risky situations
• Encourage reporting

How to Respond to Workplace Violence

• Active shooters
• Suicidal employees
• Domestic violence
• Bomb or arson threats
• Suspicious mail or packages

HR professionals find themselves in a unique position as both the leaders of workplace violence prevention and sometimes also the targets of employee rage. According to a 2019 SHRM research report, 19 percent of HR professionals are unsure or don't know what to do when they witness or are involved in a workplace violence incident and 55 percent don't know whether their organization has a workplace violence prevention program. See Survey: Half of HR Pros' Workplaces Experienced Violence and SHRM Workplace Violence Research Report .

The National Institute for Occupational Safety and Health (NIOSH) defines workplace violence as the act or threat of violence, ranging from verbal abuse to physical assaults, directed toward people at work or on duty. Workplace violence also may include acts that result in damage to an organization's resources or capabilities. Many employers consider workplace harassment and bullying to be forms of workplace violence. Also included in this context is domestic violence that spills over into the workplace in the form of assaults, threats or other actions by outside parties with whom employees have relationships and that occur at the workplace.

What can employers do to protect their workers from becoming victims of workplace violence? The ultimate goal is to deter disgruntled insiders or nefarious outsiders from violence by making your company a hard target. A secondary goal is to make sure your company and workforce are prepared for violence so you can minimize casualties and respond quickly in the event of a violent incident. If you can save a life—or many—the return on investment will be well worth it.

See : Census of Fatal Occupational Injuries Summary        Occupational Safety and Health Administration (OSHA) Workplace Violence NIOSH Occupational Violence

The federal Occupational Safety and Health (OSH) Act includes a general duty clause requiring employers to "furnish to each of his employees employment and a place of employment which are free from recognized hazards that are causing or are likely to cause death or serious physical harm to his employees." According to OHSA's Enforcement Procedures and Scheduling for Occupational Exposure to Workplace Violence , "employers may be found in violation of the General Duty Clause if they fail to reduce or eliminate serious recognized hazards. Under this Instruction, inspectors should therefore gather evidence to demonstrate whether an employer recognized, either individually or through its industry, the existence of a potential workplace violence hazard affecting his or her employees. Furthermore, investigations should focus on whether feasible means of preventing or minimizing such hazards were available to employers." While there is currently no federal OSHA standard specific to workplace violence, there is potential for such a standard in the future, particularly for the health care industry.

Many states have OSHA-approved plans that must be "at least as effective" as the federal OSH Act and that often have further employee protections. Several states require employers to implement workplace violence prevention programs. For example, in 2017, California health care employers became regulated by the Workplace Violence Prevention in Health Care rule requiring a written workplace violence prevention plan, employee training, state reporting and more.

Common-law principles must also be considered in understanding employer liability for workplace violence, including the following:

• Premises liability is the duty of an employer to keep individuals on the premises safe from injury, including criminal and violent acts of others. Implementing security measures at worksites based on an assessment of potential violence specific to that site is recommended.
• Respondent superior refers to the vicarious liability of an employer for the acts of its employees acting within the course and scope of their employment. This liability is typically very fact-specific and often hinges on whether an employer's actions, or failure to act, contributed to the violent act.
• Negligence in hiring or retention of employees occurs when the employer knew or should have known the potential for violence. Conducting background screens upon hire as well as responding immediately and appropriately to threats of violence in the workplace can reduce this liability.
• Discrimination and harassment claims may arise when workplace violence is motivated by a protected characteristic such as race or religion.

How To Prepare for Workplace Violence

Preparing  for any type of workplace violence is key. Larger companies with robust security departments have the advantages of resources and trained personnel who manage the security effort. But for smaller companies with little or no security measures in place, the responsibility often falls on the general counsel or the head of human resources. See  How to Prepare Your Workforce for Violent Incidents .

As the FBI's Critical Incident Response Group points out in Workplace Violence: Issues in Response , there is no one-size-fits-all plan that employers can download and implement. Every employer will need a plan that is tailored to its particular circumstances and that considers company culture, physical layout, resources, management styles and other factors.

The New York State Department of Labor provides the following examples of employment situations that may pose higher risks of workplace violence:

• Duties that involve the exchange of money.
• Delivery of passengers, goods or services.
• Duties that involve mobile workplace assignments.
• Working with unstable or volatile people in health care, social service or criminal justice settings.
• Working alone or in small numbers.
• Working late at night or during early morning hours.
• Working in high-crime areas.
• Duties that involve guarding valuable property or possessions.
• Working in community-based settings.
• Working in a location with uncontrolled public access to the workplace.

Certain industries are also considered high-risk for workplace violence, including health care , taxi and for-hire drivers , and late-night retail establishments (gas stations, liquor or convenience stores, etc.).

Identify the Different Types of Workplace Violence

The California Division of Occupational Safety and Health, better known as Cal/OSHA, developed a model typology for workplace violence based on the perpetrator's relationship to the victim and/or place of employment that can be used by employers when assessing potential violence in the workplace. When conducting a worksite analysis or threat assessment, each type of perpetrator should be evaluated to determine the likelihood of a violent event and to identify mitigating measures that can be taken to address the particular risk. 

Source: Cal/OSHA.

Create a Workplace Violence Prevention Plan

According to OSHA, the building blocks for developing an effective workplace violence prevention program include:

Management commitment and employee participation. Management commitment, including the endorsement and involvement of top management, will provide the motivation and resources necessary for a successful initiative. Including all levels of employees in the process and soliciting employee feedback allows workers to share their broad range of experience and skills and to provide different perspectives and viewpoints to identify workplace violence hazards and mitigate risks.

• Worksite analysis.  Conducting a needs assessment to evaluate an organization's vulnerability to violence is a vital step in preparing a workplace violence prevention plan. This involves an inspection of the workplace to find existing or potential hazards that may lead to incidents of workplace violence, including an analysis of the physical environment and hazards specific to particular jobs, departments, shifts, etc.  See  Example Evaluation of the Physical Environment  and  Preventing Workplace Violence: 10 Critical Components of a Security lan .
• Substitution of the hazardous practice with a safer work practice such as the use of "buddy systems" when personal safety may be in jeopardy.
• Physical changes that either remove the hazard or create a barrier between the worker and the hazard, such as doors and locks, metal detectors, panic buttons, improved lighting, and accessible exits.
• Changes in work practices and administrative procedures such as a visitor sign-in process or a requirement for home health care workers to contact the office after each in-home visit.
• Safety and health training.  Training should be provided at all levels of the organization upon hire and at least annually thereafter. Suggested topics include an overview of the workplace violence prevention plan, including identified hazards and control measures; risk factors for particular occupations; ways to prevent or diffuse volatile situations; the location and use of safety devices such as alarm systems and panic buttons; and other topics identified by the employer as appropriate to the particular workplace. NIOSH offers a  video  that discusses practical measures for identifying risk factors for violence at work and strategic actions that can be taken to keep employees safe. According to NIOSH, the guidance is based on extensive research, supplemented with information from other authoritative sources.
• Record-keeping and program evaluation.  Maintenance of records is required, including required logs of work-related injuries and illnesses (OSHA Form 300), workers' compensation records, training records, safety committee minutes, and the identification and correction of recognized hazards.

Consider Insurance Needs

Employers should consult with their general liability and workers' compensation insurance providers to ensure adequate coverage. Workplace violence or active shooter insurance policies are available to supplement general liability coverage. According to the International Risk Management Institute, workplace violence insurance provides "coverage for the expenses that a company incurs resulting from workplace violence incidents. The policies cover items such as the cost of hiring independent security consultants, public relations experts, death benefits to survivors, and business interruption (BI) expenses."

Know the Warning Signs

Experts with the Center for Personal Protection & Safety say that when survivors of workplace shootings committed by co-workers remember the incident, they often recall signs that something was wrong—that there were behaviors that should have caused concern. Generally, any behavior that makes employees uncomfortable or leaves them feeling intimidated is cause for alarm.

These behaviors include being disruptive, aggressive and hostile as well as exhibiting prolonged anger, holding grudges, being hypersensitive to criticism, blaming others, being preoccupied with violence and being sad for a long period of time. Experts say what begins as sadness can lead to depression and suicide. Individuals who are contemplating suicide might think about taking their lives and the lives of others as well.

There are other signs. If someone who usually is friendly and outgoing becomes quiet and disengaged, that could be cause for concern. Sometimes people who experience a loss, a death, a reprimand, financial trouble, a layoff or termination can snap. Be mindful, too, of people who are the victims of stalking or domestic violence. Their personal lives might put their colleagues at risk.  See Preventing Workplace Violence Inspired by COVID-19 .

Recognize Risky Situations

There are circumstances in every workplace that increase the risk of a violent incident, including terminating volatile employees and dealing with workers who show signs of potential violence due to a mental illness.

Terminations

According to psychologist Marc McElhaney, CEO of Critical Response Associates, a consulting firm that helps organizations conduct threat assessments, manage crises and separate high-risk workers from the organization safely, there are four general types of problem employees who might cause trouble if they are fired. However, it is important to note that there's no profile of someone most likely to commit violence—anyone is capable of it.

• The Workplace Bully has a history of intimidation. He gets away with bad behavior because no one wants to confront him or make him mad.
• The Disgruntled Employee believes she has been treated unfairly and can't let go of feeling abused by the organization. She is withdrawn, goes to work in a daze, is unhappy and blames the system for her problems. When she is fired, she might take that opportunity to get back at the company.
• The Overly Attached Employee is "the one who won't go away." This person's identity is dependent on his job. He doesn't have many friends or family. Work is his social life, his recreation, his sense of self. If he is fired, he'll feel betrayed, rejected and angry.
• The Nothing-Left-to-Lose Employee is usually in emotional distress because of recent, critical losses in her life. She might be divorced or widowed, have a limited support system, or even seem suicidal. 

Mental Illness

There are times when an employee who is suspected or known by an employer to have a mental illness may seem on the verge of violent conduct. When can, or should, an employer act?

Legally, the federal Americans with Disabilities Act (ADA) and many state laws prohibit discrimination against employees based on an actual or perceived disability, and mental illness is included within the definition of disability. An employer may wish to require a fitness-for-duty exam for a potentially mentally ill employee, but targeting an employee simply due to a real or perceived disability would run afoul of the law, as the ADA generally does not allow medical exams during employment.

However, if such an employee is displaying some of the indicators of potential violence in the checklist above, and the employer has good reason to believe that an employee has a condition that may present a threat of harm to himself or others, requiring an exam would be allowable. The reason must be based on objective facts, not fear or conjecture. The ADA also allows employers to take action if they can show that an employee poses a direct threat to others, defined as "a significant risk to the health or safety of others that cannot be eliminated by a reasonable accommodation." The threat must be based on "an individualized assessment of the [employee's] present ability to safely perform the essential functions of the job" based on a reasonable medical judgment or objective evidence. According to the Equal Employment Opportunity Commission, this assessment must include the following factors:

• The duration of the risk.
• The nature and severity of the potential harm.
• The likelihood the potential harm will occur.
• The imminence of the potential harm.

The availability of any reasonable accommodation that would reduce or eliminate the risk of harm must also be considered.

Employers are encouraged to seek legal counsel prior to taking action or requiring medical exams of employees to avoid violating the ADA.

See  Managing High-Risk Employees  and  Creating a Mental Health-Friendly Workplace .

Encourage Reporting

Employee reports of suspicious or threatening behavior are critical to effective violence prevention programs, and employers should ensure that the internal culture supports such reporting. Workers need to have confidence that their reports will be taken seriously, that their identities won't be divulged unnecessarily and that leaders will take appropriate action. If employees lack confidence in their manager to handle a threatening situation or to report such incidents, employers may want to appoint a more senior person or an HR representative to field concerns.

Furthermore, employers might want to set up a hotline where employees can anonymously report concerns. Whatever method they choose, businesses must make sure employees understand that they must respond immediately and diligently if they perceive a threat. It is a good idea during training to review scenarios that employees might want to report and to explain that they should err on the side of over-reporting.

How to Respond to Workplace Violence

Despite diligent efforts to prevent workplace violence, incidents can and do occur. There is no fail-safe method to eliminate workplace violence entirely, although implementing the prevention strategies recommended by experts and discussed in this toolkit can be very effective. When violence does enter the workplace, employers can be prepared by identifying early the existence of the threat, responding appropriately by involving law enforcement and other professionals, and ensuring that all employees are knowledgeable about effective strategies to reduce the likelihood of injury.

Assess Threats

A threat assessment team is an internal committee of employees from different levels and expertise within an organization whose role is to assess the seriousness and likelihood of a threat once it has been recognized. Training for the threat assessment team should include, at a minimum:

• Behavioral and psychological aspects of workplace violence.
• Identification of concerning behaviors.
• Violence risk screening.
• Investigatory and intervention techniques.
• Incident resolution.
• Multidisciplinary case management strategies.

Most employers will need to engage external specialists with expertise in risk management and workplace violence prevention and intervention to provide the necessary training.

The primary goal of a threat assessment team is to receive and review nonemergency incident reports and recommend appropriate action. In the event of imminent emergency situations, emergency personnel should be contacted immediately.

The threat assessment team can accomplish four goals when it conducts its interview of an employee who has threatened others or acted inappropriately:

• Alert the employee that his behavior has been noticed.
• Give him the opportunity to tell his story.
• Gather information about the person.
• Let him know the behavior is unacceptable.

When internal expertise is not available for certain threats, employers will need to consult with an external professional experienced in threat assessments and crisis management.

Active Shooters

In the event of an active shooter in the workplace, the Department of Homeland Security (DHS) provides guidance employers can use to ensure that their employees know how to respond and understand when to run, hide or fight .

See  Active Shooter – How to Respond .

Suicidal Employees

Suicide threats should always be taken seriously. A human resource professional or the employee's supervisor may be the first person to identify a potentially suicidal employee, so it is critical to recognize the warning signs and encourage at-risk employees to seek help.

If an employee appears to be planning to take action immediately, local emergency authorities should be contacted, since employers usually are not qualified to handle such a situation directly. If there are doubts as to whether the threat is immediate, the HR professional should contact local services, such as an employee assistance program, suicide hotline or hospital. Given the risks of failing to act, it is best to seek professional assistance as soon as possible.

The following are some of the signs you might notice in an employee that may be reason for concern:

• Talking about wanting to die or wanting to kill oneself.
• Making a plan or looking for a way to kill oneself, such as searching online.
• Buying a gun or stockpiling pills.
• Feeling empty, hopeless or like there is no reason to live.
• Feeling trapped or in unbearable pain.
• Talking about being a burden to others.
• Increasing the use of alcohol or drugs.
• Acting anxious or agitated; behaving recklessly.
• Sleeping too little or too much.
• Withdrawing from family or friends or feeling isolated.
• Showing rage or talking about seeking revenge.
• Displaying extreme mood swings.
• Saying goodbye to loved ones; putting affairs in order.

Source: The National Institute of Mental Health.

See NIMH Frequently Asked Questions About Suicide .

Domestic Violence

Domestic violence becomes a workplace issue when the violence follows a victim to work. Employers should avoid dismissing domestic violence as a personal issue as many victims of domestic violence can benefit from the support of their employer. By developing individual and workplace safety plans, employers can prepare for the potential that a domestic situation will escalate in the workplace. According to the Canadian Centre for Occupational and Health Safety, such plans may include the following actions:

• Ask if the victim has already established protection or restraining orders. Help to make sure all the conditions of that order are followed.
• Talk to the employee; work together to identify solutions. Follow up and check on his or her well-being.
• Ask for a recent photo or description of the abuser. Alert others such as security and reception so they are aware of who to look for.
• When necessary, relocate the worker so that he or she cannot be seen through windows or from the outside.
• Do not include the employee's contact information in publicly available company directories or on the company website.
• Change the employee's phone number, have another person screen his or her calls, or block the abuser's calls and e-mails.
• Preprogram 911 on a phone or cellphone. Install a panic button in the employee's work area or provide personal alarms.
• Provide a well-lit parking spot near the building or escort the individual to his or her car or to public transit.
• Offer flexible work scheduling if it can be a solution.
• Call the police if the abuser exhibits criminal activity such as stalking or unauthorized electronic monitoring.
• If the victim and abuser work at the same workplace, do not schedule both employees to work at the same time or location wherever possible.
• If the victim and abuser work at the same workplace, use disciplinary procedures to hold the abuser accountable for unacceptable behavior in the workplace.

[Adapted from: Making It Our Business (2014) from the Centre for Research & Education on Violence against Women & Children]

An Employer's Role in Preventing Partner Abuse

When Domestic Violence Comes to Work

What Employers Can Do When Domestic Violence Enters the Workplace .

Bomb or Arson Threats

Employers should take all bomb or arson threats seriously. The Department of Homeland Security provides a Bomb Threat Checklist employers can use to ensure that all employees know how to handle bomb threats and the procedures to follow.

For threats made via phone, the DHS provides the following guidance:

• Keep the caller on the line as long as possible. Be polite and show interest to keep them talking.
• DO NOT HANG UP, even if the caller does.
• If possible, signal or pass a note to other staff to listen and help notify authorities.
• Write down as much information as possible—caller ID number, exact wording of threat, type of voice or behavior, etc.—that will aid investigators.
• Record the call, if possible.

Suspicious Mail or Packages

All employees with mail-handling responsibilities should be trained in identifying suspicious packages and mail. See  USPS: Handling and Processing Mail Safely .

If a suspicious package or piece of mail is identified, employees should know who to contact internally and when emergency personnel should be contacted. In addition, employees should follow identified procedures, including the following:

• Remain calm.
• Do not open the letter or package.
• Leave the item where it is or place it gently on a flat surface.
• Cover the item using a trash can, article of clothing, etc.
• Shut off fans or equipment in the area that circulate air.
• Alert others to leave the area and keep away from the item.
• Evacuate the area, closing the door and blocking the bottom of the door with a towel, coat, etc.
• Wash hands with soap and water.

Employers may want to post these procedures within the mailroom or provide mail-handling employees with pocket cards or another means to readily access the information.

Related Resources

Preventing Workplace Violence: A Road Map for Healthcare Facilities

Workplace Violence Policy

Workplace Violence Prevention Policy

Weapon-Free Workplace Policy

Available in the SHRM Store:

Give Your Company a Fighting Chance: An HR Guide to Understanding and Preventing Workplace Violence

Workplace Violence: The Early Warning Signs

Example Workplace Violence Prevention Programs and Procedures:

Washington State

State of California

External Resources

There are numerous resources available to employers to assist in preparing a workplace violence prevention program. Federal and state OSHA offices are a good place to start. In addition, NIOSH, the U.S. Department of Labor (DOL) , and other state and federal offices may offer tools and resources to assist employers.

DOL Workplace Violence Program OSHA Workplace Violence Prevention Programs FBI: Workplace Violence: Issues in Response Workplace Violence Prevention Strategies and Research Needs Example Workplace Violence Handbook Online Workplace Violence Prevention Course for Nurses NIOSH Health Hazard Evaluations DHS Interagency Security Committee Violence in the Federal Workplace Guide

Related Content

Why AI+HI Is Essential to Compliance

HR must always include human intelligence and oversight of AI in decision-making in hiring and firing, a legal expert said at SHRM24. She added that HR can ensure compliance by meeting the strictest AI standards, which will be in Colorado’s upcoming AI law.

A 4-Day Workweek? AI-Fueled Efficiencies Could Make It Happen

The proliferation of artificial intelligence in the workplace, and the ensuing expected increase in productivity and efficiency, could help usher in the four-day workweek, some experts predict.

Advertisement

Artificial Intelligence in the Workplace

​An organization run by AI is not a futuristic concept. Such technology is already a part of many workplaces and will continue to shape the labor market and HR. Here's how employers and employees can successfully manage generative AI and other AI-powered systems.

HR Daily Newsletter

News, trends, analysis and breaking news alerts to help HR professionals do their jobs better each business day.

Success title

Success caption

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings

Preview improvements coming to the PMC website in October 2024. Learn More or Try it out now .

• Advanced Search
• Journal List
• Cochrane Database Syst Rev

Education and training for preventing and minimizing workplace aggression directed toward healthcare workers

Workplace aggression constitutes a serious issue for healthcare workers and organizations. Aggression is tied to physical and mental health issues at an individual level, as well as to absenteeism, decreased productivity or quality of work, and high employee turnover rates at an organizational level. To counteract these negative impacts, organizations have used a variety of interventions, including education and training, to provide workers with the knowledge and skills needed to prevent aggression. 

To assess the effectiveness of education and training interventions that aim to prevent and minimize workplace aggression directed toward healthcare workers by patients and patient advocates.

Search methods

CENTRAL, MEDLINE, Embase, six other databases and five trial registers were searched from their inception to June 2020 together with reference checking, citation searching and contact with study authors to identify additional studies.

Selection criteria

Randomized controlled trials (RCTs), cluster‐randomized controlled trials (CRCTs), and controlled before and after studies (CBAs) that investigated the effectiveness of education and training interventions targeting aggression prevention for healthcare workers.

Data collection and analysis

Four review authors evaluated and selected the studies resulting from the search. We used standard methodological procedures expected by Cochrane. We assessed the certainty of evidence using the GRADE approach.

Main results

We included nine studies—four CRCTs, three RCTs, and two CBAs—with a total of 1688 participants. Five studies reported episodes of aggression, and six studies reported secondary outcomes. Seven studies were conducted among nurses or nurse aides, and two studies among healthcare workers in general. Three studies took place in long‐term care, two in the psychiatric ward, and four in hospitals or health centers. Studies were reported from the United States, Switzerland, the United Kingdom, Taiwan, and Sweden.

All included studies reported on education combined with training interventions. Four studies evaluated online programs, and five evaluated face‐to‐face programs. 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). Seven studies were rated as being at "high" risk of bias in multiple domains, and all had "unclear" risk of bias in a single domain or in multiple domains.

Effects on aggression

Short‐term follow‐up

The evidence is very uncertain about effects of education and training on aggression at short‐term follow‐up compared to no intervention (standardized mean difference [SMD] ‐0.33, 95% confidence interval [CI] ‐1.27 to 0.61, 2 CRCTs; risk ratio [RR] 2.30, 95% CI 0.97 to 5.42, 1 CBA; SMD ‐1.24, 95% CI ‐2.16 to ‐0.33, 1 CBA; very low‐certainty evidence).

Long‐term follow‐up

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 have an effect on 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).

Measurements of these concepts showed high heterogeneity.

Authors' conclusions

Education combined with training may not have an effect on workplace aggression directed toward healthcare workers, even though education and training may increase personal knowledge and positive attitudes. Better quality studies that focus on specific settings of healthcare work where exposure to patient aggression is high are needed. Moreover, as most studies have assessed episodes of aggression toward nurses, future studies should include other types of healthcare workers who are also victims of aggression in the same settings, such as orderlies (healthcare assistants). Studies should especially use reports of aggression at an institutional level and should rely on multi‐source data while relying on validated measures. Studies should also include days lost to sick leave and employee turnover and should measure outcomes at one‐year follow‐up. Studies should specify the duration and type of delivery of education and should use an active comparison to prevent raising awareness and reporting in the intervention group only.

Plain language summary

Do education and training programs reduce aggressive behavior toward healthcare workers?

What is aggressive behavior?

The International Labour Organization uses the term "workplace violence" defined as "any action, incident or behaviour that departures from reasonable conduct in which a person is threatened, harmed, injured in the course of, or as a direct result of, his or her work". Experiencing aggressive behavior at work can affect people's ability to do their job well, can cause physical and mental health problems, and can also affect home life. Aggressive behavior may lead to absences from work; some people might leave their job if they experience aggressive behavior.

Why we did this Cochrane Review

Aggressive behavior exhibited by patients and their families, friends, and carers is a serious problem for healthcare workers. It may affect the quality and safety of the care that healthcare workers can provide.

Education and training programs have been developed to try to reduce—or eliminate—aggressive behavior at work. These programs are intended to teach and train healthcare workers about:

• their organization's policies and procedures;

• how to assess risks; and

• strategies to control or reduce the chances—and effects—of experiencing aggressive behavior.

What did we do?

We searched for studies that investigated how well education and training programs prevented or reduced aggression toward healthcare workers.

We included randomized controlled studies, in which the programs that people received were decided at random and studies in which effects of a program were measured before and after among people who completed the program and in another group of people who did not take part.

We wanted to know if education and training programs could:

• reduce the number of incidents of aggressive behavior in healthcare workplaces;

• improve healthcare workers' knowledge, skills, and attitudes toward aggressive behavior; and

• reduce any personal adverse (unwanted or negative) effects noted among healthcare workers who experienced aggressive behavior.

Search date: we included evidence published up to June 2020.

What we found

We found nine studies including 1688 healthcare workers (including healthcare support staff, such as receptionists) who worked with patients and patients' families, friends, and carers. These studies compared the effects of receiving an education and training program to the effects of not receiving such a program.

Studies were conducted in hospitals or healthcare centers (four studies), in psychiatric wards (two studies), and in long‐term care centers (three studies) in the United States, Switzerland, the United Kingdom, Sweden, and Taiwan.

All programs combined education with training provided either online (four studies) or face‐to‐face (five studies). In eight studies, the people taking part were followed for up to three months (short‐term), and in one study for over one year (long‐term).

What are the results of our review?

Education and training programs did not reduce the number of reports of aggressive behavior toward healthcare workers (five studies), possibly because these programs made healthcare workers more likely to report these incidents.

An education and training program might improve healthcare workers’ knowledge of aggressive behavior in the workplace in the short term (one study), but we are uncertain whether this would be a long‐term effect (one study).

Education programs might improve healthcare workers' attitudes toward aggressive behavior in the short term (five studies), although these results varied depending on the type and length of the program provided.

Education programs might not affect healthcare workers' skills in dealing with aggressive behavior (two studies) and might not affect whether unwanted or negative personal effects were noted after healthcare workers experienced aggressive behavior (one study).

How reliable are these results?

We are not confident in the results of our review because these results were reported from a small number of studies—some with small numbers of participants—and because some studies showed large differences in results. We identified problems involving the ways some studies were designed, conducted, and reported. Our results are likely to change if further evidence should become available.

Key message

Although an education and training program might increase healthcare workers' knowledge and positive attitudes, such a program might not affect the number of incidents of aggressive behavior that healthcare workers experience.

More studies are needed, particularly in healthcare workplaces with high rates of aggressive behavior.

Summary of findings

Aggression in the workplace.

Aggression commonly occurs within the interactional context of work. It is a surprisingly prevalent phenomenon across the globe, with data from the United States, Australia, Japan, Saudi Arabia, and Malaysia indicating that large numbers of working people, in a range of occupations, experience aggression from multiple sources at work ( di Martino 2005 ). The International Labour Organization uses the term "workplace violence" defined as "any action, incident or behaviour that departures from reasonable conduct in which a person is threatened, harmed, injured in the course of, or as a direct result of, his or her work" ( ILO 2003 ). As such, this definition includes different forms of aggression such as physical assault, verbal abuse, bullying, mobbing, and sexual, racial, and psychological harassment. Therefore, in this study, workplace aggression will refer to any episode of aggression toward healthcare workers that resulted in no harm or injury, psychological harm or injury, or physical harm or injury. Workplace aggression may be employed by people external to the workplace (customers/clients and other members of the public) or internal to the workplace (supervisors and other coworkers) to express more immediate distress, frustration, or hostility, or to more deliberately and systematically coerce, intimidate, discriminate, or exert power. Overall, however, aggression from external sources is more prevalent than aggression from coworkers ( Cookson 2012 ; Harrell 2011 ; LeBlanc 2002 ; LeBlanc 2006 ; Packham 2011 ). We found a large body of evidence related to exposure to workplace aggression from a range of sources and subsequent adverse consequences for individuals and organizations. These include relatively short‐lived feelings of distress, fear, and shame; longer‐term impact on physical and mental health for individuals ( Briggs 2003 ; Brown 2011 ; Flannery 2001 ; Hershcovis 2010 ; Hills 2014 ; Hinduja 2007 ; Hogh 2005a ; Hogh 2005b ; LeBlanc 2002 ; Mayhew 2007 ; Niedhammer 2009 ; Wieclaw 2006 ); and impact on their home lives ( Lewis 2005 ). Workplace aggression exposure is also associated with adverse work‐related outcomes, including those related to job satisfaction, organizational commitment, and workforce participation intentions ( Dupré 2014 ; Heponiemi 2014 ; Hills 2014 ; Lanctôt 2014 ; Lapierre 2005 ; LeBlanc 2002 ). In the healthcare sector, some evidence indicates that exposure of health workers to workplace aggression also impacts the quality and safety of health care provided ( Arnetz 2001 ; Laschinger 2014 ; Paice 2009 ; Rosenstein 2008 ). In their systematic review, Piquero 2013 reported that healthcare workers are among the workers most likely to experience workplace aggression.

Description of the condition

Aggression in health care.

The process of delivering health care often comprises complex interactions with patients, their advocates, coworkers, and a range of other people peripherally associated or completely unconnected with service delivery (e.g. intruders). It is often stressful work, typically involving working with people who are experiencing distressing conditions or circumstances and suboptimal cognition, affect, or arousal. Consequently, it would be expected that aggression is likely to be an unwelcome feature of healthcare work. Indeed, people working in health care are at high risk of experiencing workplace aggression, second only to people working in protection and security services ( Cookson 2012 ; di Martino 2002 ; Estrada 2010 ; Packham 2011 ; Parent‐Thirion 2007 ). Furthermore, health workers can be exposed to other occupational conditions associated with higher risk for experiencing workplace aggression, including working alone or in small numbers, working at night, and working in acute care community‐based settings ( Bulatao 1996 ; Chappell 2006 ; Mayhew 2000 ; Wiskow 2003 ).

Workplace aggression in health care has become a widely researched phenomenon. This is important because a good deal of evidence suggests that poor reporting practices are the norm rather than the exception in healthcare settings ( Farrell 2006 ; Judy 2009 ; Mayhew 2001 ; Parker 2010 ). Organizational data are dependent on voluntary reporting by staff, yet there is a significant problem with under‐reporting of incidents due to lack of clarity about what is a reportable incident, organizational culture, or inadequate support for staff reporting incidents of workplace aggression ( Atawneh 2003 ; Gates 2011 ; Gerberich 2004 ; Kvas 2014 ). Aggression may be viewed by staff and employers as just part of the job, further contributing to under‐reporting ( Child 2010 ; Ventura‐Madangeng 2009 ). Consequently, survey research may be the most reliable method of estimating the extent of workplace aggression in healthcare settings, despite the likely limitations of recall bias and response bias.

Prevalence of aggression in health care

A major feature of workplace aggression in healthcare research published since 2000 is that most studies have focused on nurses, with a smaller body of research focused on medical practitioners or mixed populations of health workers, among which nurses are typically the majority of respondents. Most of this research has been exploratory and descriptive in nature, and most studies have estimated 6‐month, 12‐month, or career prevalence, using cross‐sectional, retrospective, self‐report survey designs with customized instruments unique to individual studies ( Hahn 2008 ; Hills 2013 ; Hills 2018 ; Taylor 2010 ). Such study‐specific variations render efforts to establish broadly based prevalence rates extraordinarily challenging. Furthermore, the rates of different forms and sources of aggression vary considerably between nations ( Camerino 2008 ; di Martino 2002 ; Spector 2014 ). Thus, a systematic review on workplace aggression has estimated that between 7% and 83% of healthcare workers have been the target of violent acts ( Piquero 2013 ).

A further complication associated with establishing prevalence rates relates to the imprecision with which workplace aggression is conceptualized and defined in different studies, if explicated at all. Alternative terms include "occupational aggression," "occupational violence," and "counterproductive work behaviour." The terms "aggression" and "violence" are often interchanged. Of greatest concern is the highly problematic use of the term "violence" to include less extreme and non‐physical forms of aggression, even though verbal or written expressions of aggression may include highly disturbing threats of violence. Additionally, it has been argued that it is important to distinguish "resistance to care" behavior from aggressive behavior. While appearing similar, the behavioral intentions and the therapeutic responses required are clinically significantly different, with the primarily defensive "resistance to care" frequently exhibited by people with some form of cognitive impairment ( Kable 2012 ). This differentiation appears not to be explicitly considered in much of the health profession workplace aggression literature.

Despite the challenges of defining and establishing the extent of workplace aggression in health care, patients have been identified as the most common source of aggression, with 10% to 95% of respondents reporting that they experienced verbal or physical forms of aggression from patients. Aggression from patients' advocates was reported by 20% to 50% of respondents. Studies assessing episodes of aggression typically relied on self‐reporting of experiences over the previous 6, 12, or 24 months, suggesting that episodes of aggression are experienced commonly—not rarely—during healthcare practice ( Arnetz 2001 ; Campbell 2011 ; Carluccio 2010 ; Farrell 2006 ; Frank 1998 ; Gascón 2009 ; Gerberich 2004 ; Guay 2014 ; Hahn 2010 ; Hegney 2006 ; Hills 2012 ; Hills 2013 ; Hills 2018 ; Hodgson 2004 ; Martínez‐Jarreta 2007 ; O'Brien‐Pallas 2009 ; Roche 2010 ; Spector 2014 ; Viitasara 2003 ). When aggression from supervisors and other coworkers has been investigated, it was usually the third most common source, experienced by 3% to 70% of survey respondents ( Arnetz 2001 ; Camerino 2008 ; Campbell 2011 ; Farrell 2006 ; Farrell 2010 ; Hegney 2006 ; Hills 2012 ; Hills 2013 ; Hills 2018 ; Hodgson 2004 ; O'Brien‐Pallas 2009 ; Roche 2010 ).

Prevention and minimization of workplace aggression in health care

As a consequence of existing evidence on the prevalence of workplace aggression and the wide range of consequences affecting individuals and organizations, there is broad agreement that a diversity of integrated approaches are required to effectively prevent and mitigate aggression and its impact within organizations ( ILO 2002 ; ILO 2003 ; Mayhew 2000 ; Mayhew 2004 ; McCarthy 2004 ; OSHA 2004 ; Viitasara 2002 ). Education and training in the prevention and mitigation of workplace aggression is a key component of any workplace aggression prevention program but can be considered only one of a necessary range of approaches required to address this work health and safety concern. Education and training interventions are unlikely to resolve organizational systems' environmental or cultural challenges. In any case, education and training interventions based on clearly identified needs are lacking ( Anderson 2010 ).

Description of the intervention

Education and training for prevention and minimization of workplace aggression may comprise any of a broad range of techniques to enhance knowledge and understanding of organizational policies and procedures, legal responsibilities, risk assessment, and control strategies. Further, specific interpersonal skills and behavior management techniques may be tailored to the specific work roles of personnel in the context of the workplace ( Chappell 2006 ; Farrell 2005 ; ILO 2002 ; ILO 2003 ; Mayhew 2000 ; Mayhew 2001 ; OSHA 2004 ).

In this review, education is defined as "the process of imparting knowledge and understanding of organizational policies and procedures, legal responsibilities, and risk assessment and control strategies, including in relation to specific techniques that may be employed in one's work environment, to prevent and mitigate the likelihood and consequences of exposure to workplace aggression." Training is defined as "the process of education about, and rehearsal and simulated or in vivo practice of, cognitive and behavioral skills that may be implemented in one's work to prevent and minimize the likelihood and consequences of exposure to workplace aggression." Thus, healthcare workers should acquire a set of knowledge, attitudes, and skills that aim to prevent aggression in several ways such as de‐escalation techniques, effective communication, conflict management, self‐defense, evasion methods, and so on ( Spencer 2018 ).

How the intervention might work

As highlighted above, education and training interventions, in isolation, are unlikely to resolve systemic, environmental, or cultural challenges that may impact the likelihood and consequences of incidents of workplace aggression in health service organizations. Nonetheless, by improving the knowledge, attitudes, and skills of individuals and groups of healthcare workers related to prevention and minimization of workplace aggression directed toward them by patients and their advocates, it would be expected that the overall number of episodes of aggression, including those resulting in psychological or physical harm or injury, would be reduced. It would also be expected that the number of adverse personal and organizational outcomes attributable to incidents of workplace aggression (e.g. leave days taken, alterations to workforce participation including changing work patterns or attrition, litigation and rehabilitation costs) would be reduced.

Why it is important to do this review

The capacity to deliver purposeful, safe, and effective responses to potential and escalating aggression is essential for people engaged in any form of human service delivery, including health care, where human interactions are prominent and the risk of aggression may be more prevalent. Unfortunately, there has been a poor history of evaluating education and training programs for aggression minimization and prevention ( Beech 2006 ). Furthermore, available evidence on the impact and outcomes of workplace aggression minimization education and training programs in diverse settings typically shows indeterminate or poor results ( Bowers 2006 ; Gerdtz 2013 ; Hahn 2013 ; Heckemann 2015 ; Hills 2008 ; Hodgson 2004 ; Kansagra 2008 ; Laker 2010 ; Livingston 2010 ; Nachreiner 2005 ; Needham 2005 ; Price 2015 ). Nonetheless, clinicians and support personnel recognize its value ( Arimatsu 2008 ; Ceramidas 2010 ; HEPRU 2003 ; HEPRU 2008 ; Judy 2009 ). It is important to note that the relative absence of evidence for the effectiveness of education and training is no reason to assume that it is ineffective ( Richter 2006 ). Indeed, in the absence of an evidence base, beneficial and possibly life‐saving training may be neither sought nor provided ( NICE 2006 ), highlighting the ongoing need for more rigorous evaluation of education and training programs for preventing and minimizing workplace aggression directed toward health workers.

Although reasons for the lack of evidence regarding the protection afforded by education and training are unclear, they may relate in part to necessary plasticity in the application of these techniques for specific situations as they arise. Despite these ongoing concerns, education and training is likely to remain an important component of any structured workplace aggression prevention and minimization program. Precisely what constitutes the key components of effective education and training in workplace aggression prevention and minimization however is unclear.

In this systematic review, we will examine research evidence showing the effects of all types of education and training interventions used by employers in the healthcare sector to build knowledge or skills of healthcare workers as one means of reducing the incidence and adverse outcomes of aggression directed toward healthcare workers by patients or their advocates. This review will exclude organizational interventions, application of physical devices, or the introduction of environmental design or re‐design features including physical structures. Such structural approaches have been addressed in separate reviews ( Spelten 2020 ; Spencer 2018 ).

Criteria for considering studies for this review

Types of studies.

We considered all published and unpublished randomized controlled trials (RCTs) and controlled before and after studies (CBAs) as eligible for inclusion in this review. 

Types of participants

We included healthcare workers who interact with patients, patient advocates, or both, in any public or private healthcare facility regardless of worker age, gender, or profession. These included:

• physicians and physician assistants;
• nurses and midwives;
• allied health professionals (e.g. physiotherapists, occupational therapists, speech pathologists, pharmacists, respiratory therapists, medical imaging technicians, oral hygienists, podiatrists, dieticians, opticians); and
• healthcare support personnel (e.g. reception staff, healthcare aides or assistants, healthcare security personnel).

Types of interventions

We included any educational or training intervention undertaken with healthcare workers to improve their knowledge, attitudes, and skills in preventing and minimizing verbal or physical aggression directed toward them and their workplace peers from patients or their advocates. These included interventions designed to enhance knowledge and understanding of legal responsibilities, organizational policies and procedures, and specific risk assessment and control strategies. Interventions included education and training in specific communication and behavior management techniques targeting the diffusion and de‐escalation of aggression, violence avoidance and breakaway strategies, and physical restraint of aggressive people.

We included interventions that were mandatory or voluntary; delivered all at once or over multiple sessions; and delivered face‐to‐face, online, or in blended form and including synchronous or asynchronous components. We included interventions delivered in workplace, educational, and other professional settings. We included stand‐alone programs as well as those offered in conjunction with other organizational interventions, but only when such interventions were "controlled for" in the analysis of impact or outcomes, or when they could be determined not to have confounded or biased results of the education and training intervention study. 

Types of outcome measures

Outcome measures included reported clinical events and participant‐reported outcomes.

Primary outcomes

We included studies that evaluated the effects of an education or training intervention among staff in the healthcare sector on the number of episodes of aggression.

Secondary outcomes

Personal knowledge about workplace aggression.

• Attitudes toward workplace aggression

Skills related to workplace aggression

• Adverse personal and organizational outcomes attributable to incidents of workplace aggression (e.g. leave days taken, alterations to workforce participation including changing work patterns or attrition, litigation, and rehabilitation costs)

Search methods for identification of studies

We conducted a systematic search of the literature to identify all published and unpublished RCTs and CBAs that could be considered eligible for inclusion in this review. The literature search identified potentially eligible studies in all languages. If we would have encountered foreign language studies, non‐English language papers would have been translated and fully assessed for potential inclusion in the review as necessary.

Electronic searches

We searched the following electronic databases from their inception to the date of the search specified to identify potential studies. 

• Cochrane Central Register of Controlled Trials (CENTRAL), in the Cochrane Library (June 2020).
• MEDLINE (PubMed, June 2020).
• Embase (June 2020).
• Cumulative Index to Nursing and Allied Health Literature (CINAHL) (EBSCO, June 2020).
• PsycINFO (ProQuest, June 2020).
• US National Institute for Occupational Safety and Health bibliographic database of literature on occupational safety and health (NIOSHTIC) (OSH‐UPDATE, June 2020).
• NIOSHTIC‐2 (OSH‐UPDATE, June 2020).
• HSELINE (OSH‐UPDATE, June 2020).
• ISDOC (OSH‐UPDATE, June 2020).

We used keywords selected from the search strategies supplied in Appendix 1 .

Searching other resources

We also conducted a search of the following. 

• ClinicalTrials.gov (www.ClinicalTrials.gov) and the World Health Organization (WHO) trials portal (www.who.int/ictrp/en/).
• WorkSafe Australia.
• Canadian Centre for Occupational Health and Safety (CCOHS).
• The Campbell Collaboration and social, psychological, educational, and criminological trials register.

We checked the reference lists of all primary studies and review articles for additional references. Finally, we contacted experts in the field to identify additional unpublished materials. 

Selection of studies

Four review authors (JP, AH, SR, SGe) independently screened titles and abstracts of all potentially eligible studies identified as a result of the search and coded them as "retrieve" (eligible or potentially eligible/unclear) or "do not retrieve." We retrieved the full‐text study reports/abstracts/publications, and five review authors (HR, TD, SG, BM‐J, SGe) independently screened the full text and identified studies for inclusion. When a study was identified as ineligible for inclusion in the review, we recorded the reason(s) for its exclusion. We resolved disagreements by consensus or by consultation with another person from the review team (DH, SGe). We identified and excluded duplicates and collated multiple reports of the same study, so that each study, rather than each report, is the unit of interest in the review. We recorded this selection process in sufficient detail to complete a PRISMA flow diagram and Characteristics of excluded studies table.

Data extraction and management

We used a study‐specific data collection form for collection of study characteristics, intervention details, and outcome data ( Appendix 2 ). All review authors piloted this form on one study in the review. Four review authors (HR, AH, SG, SGe) extracted study characteristics from the identified included studies. 

Using the study‐specific data collection form, we extracted the following study characteristics.

• Publication details: authors, email address of corresponding author, date of publication, title, journal name, volume, issue, pages.
• Methods: study design (e.g. RCT/cluster RCT/CBA), including sampling, group allocation and treatment of missing data, study location/s, study setting/s, withdrawals.
• Participants: health worker type/s, total number of participants, number of health worker type sub‐populations and proportions (%), mean age or age range, gender, workplace/s (e.g. mental health, emergency department), work setting/s (e.g. hospital inpatient, hospital outpatient, community), work sector/s (e.g. public, private, non‐government), inclusion and exclusion criteria.
• Interventions: description of interventions and co‐interventions, targeted knowledge, attitudes and skills, comparison, content of both intervention and control condition, and co‐interventions (especially noting if bundled with other organizational interventions), duration, intensity, number commencing, number completing, adherence to protocol.
• Outcomes: description of primary and secondary outcomes specified and collected, measurement instruments used and validation status (e.g. reported/not reported), at which time points reported, controlling for biasing or confounding effects of co‐interventions.
• Length of follow‐up: time points at which primary and secondary outcomes were collected; categorization to short‐term, medium‐term, and long‐term follow‐up (see further details below in Assessment of heterogeneity ).
• Notes: funding for study, notable conflicts of interest of trial authors.

Upon preparation of the final included list of studies, three review authors (DH, SR, SGe) independently extracted data from these study reports. We noted in the Characteristics of included studies table if outcome data were not reported in a usable way. One review author (TD) transferred data into Review Manager 5 ( RevMan 5.3 .) Another (SGe) made the migration toward Review Manager Web ( RevMan Web 2019 ). We double‐checked that data were entered correctly by comparing data presented in the systematic review with information provided in the study reports. Two review authors (JP, SGe) spot‐checked study characteristics for accuracy against the study report.

Assessment of risk of bias in included studies

Four authors of the present review (DH, TD, BM‐J, SGe) independently assessed risk of bias for each study using the criteria outlined in the Cochrane Handbook for Systematic Reviews of Interventions ( Higgins 2011 ). Disagreements were resolved by discussion or by consultation with another review author (AH, HR, JP, SG, or SR). Risk of bias of the included RCTs was assessed according to the following domains. 

• Random sequence generation.
• Allocation concealment.
• Blinding of participants and personnel.
• Blinding of outcome assessment.
• Incomplete outcome data.
• Selective outcome reporting.
• Other biases.

Each potential source of bias was graded as high, low, or unclear. Further, a quote from the study report was provided together with a justification for the assessment in the "Risk of bias" table. The risk of bias judgment is summarized across different studies for each of the domains listed. Blinding was considered separately for different key outcomes when necessary (e.g. for unblinded outcome assessment, risk of bias for all‐cause mortality may be very different than for a participant‐reported pain scale). However, blinding was not found to be necessary for evaluation of risk of bias of the included studies. When information on risk of bias was related to unpublished data or correspondence with a trialist, this was noted in the "Risk of bias" table.

For CBAs, we used a combination of the applicable domains for risk of bias determination for RCTs and elements of the Downs and Black checklist ( Downs 1998 ), as described in Chapter 13 of the Cochrane Handbook for Systematic Reviews of Interventions ( Higgins 2011 ).

Assessment of bias in conducting the systematic review

We conducted the review according to this published protocol and reported any deviations from it in the Differences between protocol and review section of the systematic review.

Measures of treatment effect

Outcome data for each study were entered into the data tables in Review Manager Web to calculate treatment effects ( RevMan Web 2019 ). We used risk ratios (RRs) for dichotomous outcomes and standardized mean differences (SMDs) for continuous outcomes, or other types of data as reported by study authors. When only effect estimates and their 95% confidence intervals (CIs) or standard errors were reported in studies, we entered these data into Review Manager Web using the generic inverse‐variance method. We ensured that higher scores for continuous outcomes have the same meaning for the particular outcome, explained the direction to the reader, and reported when the directions were reversed, if this was necessary. When results could not be entered either way, we described them in the Characteristics of included studies table, or we entered the data into Additional tables. 

Unit of analysis issues

For studies that employed a cluster‐randomized controlled trial (CRCT) design and that reported sufficient data for inclusion in the meta‐analysis but did not make an allowance for the design effect, we calculated the design effect based on a fairly large assumed intracluster correlation of 0.10 ( Appendix 3 ). We based this assumption of 0.10 as a realistic estimate by analogy to studies about implementation research ( Campbell 2001 ). We followed the methods stated in the Cochrane Handbook for Systematic Reviews of Interventions to perform the calculations ( Higgins 2011 ).

Dealing with missing data

We contacted investigators or study sponsors to verify key study characteristics and obtain missing numerical outcome data when possible (e.g. when a study is identified as an abstract only). When this was not possible and the missing data were thought to introduce serious bias, we explored the impact of including such studies in the overall assessment of results by conducting a sensitivity analysis. 

If numerical outcome data such as standard deviations or correlation coefficients were missing and we could not obtain these from trial authors, we calculated them from other available statistics such as P values, according to the methods described in the Cochrane Handbook for Systematic Reviews of Interventions  ( Higgins 2011 ).

Assessment of heterogeneity

We assessed the homogeneity of the results of all included studies based on similarity of study design, intervention types, outcomes, and follow‐up. We considered interventions to be different when they included education only or education combined with training. RCTs and CBAs were considered separately.

We categorized studies based on mode of delivery (online or face‐to‐face) and on their duration (short for less than a week, long for one week or longer, and self‐paced). We did not assume that these differences could cause differences in the effect estimates. Still, we did run subgroup analysis to check for any differences in both mode of delivery and length of interventions. We reported the results of this analysis both combined and separated when subgroup differences were found.

Further, follow‐up times were categorized into short‐term (six months and less), medium‐term (between six months and 12 months), and long‐term (12 months and longer) follow‐up and were regarded as different.

Statistical heterogeneity was assessed using the I² statistic (Higgins 2011), based on the following as a rough guide for interpretation: 0% to 40% might not be important; 30% to 60% may represent moderate heterogeneity; 50% to 90% may represent substantial heterogeneity; 75% to 100% considerable heterogeneity. In cases of substantial heterogeneity (defined as I² ≥ 50%), we explored the data further, including subgroup analyses, in an attempt to explain the heterogeneity.

Assessment of reporting biases

Because we were not able to pool 10 or more trials in any single meta‐analysis, we did not explore possible small‐study biases via funnel plot examination. 

Data synthesis

We pooled the data from studies judged to be homogeneous using Review Manager Web software ( RevMan Web 2019 ). If more than one study provided usable data for any single comparison, we performed meta‐analysis. When studies were statistically heterogeneous, we used a random‐effects model. Otherwise, we used a fixed‐effect model. When using the random‐effects model, we conducted a sensitivity check by using the fixed‐effect model to reveal differences in results. We included a 95% confidence interval for all estimates. 

When multiple trial arms were reported in a single trial, we included only the relevant arms. If two comparisons were combined in the same meta‐analysis, we halved the control group to avoid double‐counting.

Subgroup analysis and investigation of heterogeneity

The original protocol intended to carry out subgroup analyses if a sufficient number of studies were found based on types of delivery and length of intervention. As such, we carried out subgroup analyses when a sufficient number of studies with substantial heterogeneity (I² > 50%) were found among the included studies based on:

• types of delivery (face‐to‐face or online); and
• duration of intervention (short, long, or self‐paced). 

Sensitivity analysis

We originally planned to carry out sensitivity analysis to test the robustness of our meta‐analysis results by omitting studies that we judged to be at high risk of bias. However, we did not find a sufficient number of studies to perform sensitivity analyses. 

Summary of findings and assessment of the certainty of the evidence

A "Summary of findings" table was created for each of the following outcomes.

• Episodes of aggression.
• Changes in personal knowledge, attitudes, and skills related to workplace aggression.
• Adverse personal and organizational outcomes attributable to incidents of workplace aggression.

We evaluated the quality of available evidence using the GRADE approach. We generated a "Summary of findings" table that provides outcome‐specific information concerning the overall quality of evidence from studies included in the comparison, the magnitude of effect of the interventions examined, and the sum of available data on outcomes considered. We included information on the primary and secondary outcomes of our review. We assessed the quality of evidence using several factors.

• Limitations in study design and implementation of available studies.
• Indirectness of evidence.
• Unexplained heterogeneity or inconsistency of results.
• Imprecision of effect estimates.
• Potential publication bias.

For each outcome, we classified the quality of evidence according to the following categories.

• High quality: further research is very unlikely to change our confidence in the estimate of effect.
• Moderate quality: further research is likely to have an important impact on our confidence in the estimate of effect, and may change the estimate.
• Low quality: further research is very likely to have an important impact on our confidence in the estimate of effect, and is likely to change the estimate.
• Very low quality: we are very uncertain about the estimate.

We used the five GRADE considerations (study limitations, consistency of effect, imprecision, indirectness, and publication bias) to assess the quality of a body of evidence as it relates to the studies that contributed data to meta‐analyses for the pre‐specified outcomes. We adhered to the methods and recommendations described in Section 8.5 and Chapter 12 of the Cochrane Handbook for Systematic Reviews of Interventions, using GRADEpro software ( GRADEPro 2014 ; Higgins 2011 ). We justified all decisions to downgrade the quality of RCTs or to upgrade the quality of CBAs using footnotes, and we made comments to aid the reader's understanding of the review when necessary. Criteria for upgrading included a large effect size, a reported dose‐response gradient, and the effects of all plausible confounding factors working against the intervention.

Reaching conclusions

We based our conclusions only on findings from the quantitative or narrative synthesis of studies included in this review. We avoided making recommendations for practice based on more than just the evidence, such as values and available resources. Our implications for research suggest priorities for future research and outline remaining uncertainties in this area.

Description of studies

See Characteristics of included studies  and Excluded studies tables.

Results of the search

Results of the search strategy are presented in Figure 1 . Through the search, we found a total of 4803 references, 37 of which we deemed potentially eligible for inclusion. We then accessed the full‐text articles of these studies and, upon closer examination, excluded 28 manuscripts ( Table 2 ). Finally, we decided that nine studies met the inclusion criteria, and we included them in the review ( Anderson 2006 ; Arnetz 2000 ; Fitzwater 2002 ; Irvine 2007 ; Irvine 2012a ; Irvine 2012b ;  Ming 2019 ;  Needham 2005 ; Whittington 1996 ). We tried twice to contact the authors of an included study to obtain more information about the data, but without success. We therefore available data provided in the published articles for all included studies.

Figure 1. Prisma flow diagram of search and screening results.

Included studies

Study design.

Five studies reported on the number of episodes of aggression directed toward healthcare workers: three CRCTs ( Arnetz 2000 ; Fitzwater 2002 ; Irvine 2012b ), and two CBAs ( Anderson 2006 ;  Whittington 1996 ). In addition, three RCTs— Irvine 2007 ; Irvine 2012a ; Ming 2019 —and three CRCTs— Arnetz 2000 ; Irvine 2012b ;   Needham 2005 —reported on secondary outcomes.

Participants

Two RCTs— Irvine 2007 ; Irvine 2012a —and one CRCT— Irvine 2012b —were conducted among nurse aides working in long‐term care facilities (N = 62, 159, and 103, respectively). Participants for Irvine 2007 and Irvine 2012a were drawn from people in the United States who answered Internet advertising. Participants for Irvine 2012b were drawn from two long‐term care facilities in Cincinnati, Ohio, USA. Another CRCT was conducted among 20 certified nurse assistants working at two nursing homes in midwestern United States ( Fitzwater 2002 ).

One CRCT— Needham 2005 —and one CBA— Whittington 1996 —were carried out among psychiatric ward nurses and included a sample size of 58 nurses and 155 nurses, respectively, at follow‐up. Whittington 1996 was conducted in London, United Kingdom. Needham 2005 was conducted in German‐speaking portions of Switzerland.

One CBA— Anderson 2006 —investigated effects of a training program among 43 hospital workers in a small community hospital in the United States. One RCT examined effects of simulation training among 392 nurses working at a medical center in Taipei, Taiwan ( Ming 2019 ). Finally, one CRCT— Arnetz 2000 —examined the effects of a practical intervention program at 47 healthcare workplaces in Stockholm, Sweden, representing a total of 686 workers at follow‐up.

Types of Interventions

See Table 3 .

CBA: controlled before and after study.

CRCT: cluster‐randomized controlled study.

RCT: randomized controlled study.

Four studies evaluated online programs and five studies evaluated face‐to‐face programs. All studies provided education combined with training.

Online education programs—short duration

Participants who received training in Anderson 2006 underwent a three‐hour online training program comprising five modules, completed within a 30‐day period. The training program covered material such as identifying triggers for violence and exploring why violence happens and provided resources and suggestions for diffusing anger and for debriefing/follow‐up after an episode of violence.

Online education programs—long duration

Two of the included studies— Irvine 2012a  and  Irvine 2012b —consisted of two online training sessions offered one week apart. Study authors did not specify the length of each training session, although they did mention that the training was based on Irvine 2007 , which was self‐paced. The first session was dedicated to de‐escalation skills, and the second taught situation‐specific advanced skills (e.g. pulling hair). 

Online education programmes—self‐paced

The intervention used by Irvine 2007 consisted of 155 Web pages, 11 video vignettes, 16 narrator video clips, 71 voiceover clips, and 3 video testimonials. These interventions aimed to provide skills on how to approach agitated long‐term care residents and how to de‐escalate situations, and were to be completed in a one‐day self‐paced online training session. Study authors did not specify the length of the training program, which is somewhat variable due to its self‐paced nature, but they reported that participants normally completed the program within a single day.

Face ‐ to‐face program—short duration

Fitzwater 2002 provided participants in the intervention group with two assault prevention sessions, each lasting two hours. These training sessions were provided by a master’s level psychiatric nurse. The intervention was designed to prevent and reduce violent incidents and involved topics such as reasons for violence, effective communication, signs of impending violence, and how to protect their own as well as residents’ safety.

The intervention used in Whittington 1996 was based on a cyclical model of violence in psychiatric units and consisted of two components. The first dealt with prevention of imminent violence, and the second addressed dealing with possible psychological consequences of the assault. Training took place over a seven‐hour period in a single day.

Participants in  Ming 2019  received a three‐hour teaching session, which included an hour‐long discussion on the topic of workplace violence, review of case videos, demonstrations of workplace violence prevention, treatment, self‐defense and evasion methods, and role‐playing of situational simulations. 

Face‐to‐face program—long duration

The intervention described for Needham 2005 was a training program that consisted of 20 lessons, with each lesson lasting 50 minutes. It was delivered by trained psychiatric nurses over five consecutive days. The lessons covered topics such as causes and types of aggression, conflict management, communication, behavior during aggression, prevention of aggression, and post‐aggression procedures. 

Face‐to‐face program—extended duration

The intervention used by Arnetz 2000 consisted of contact between project co‐ordinators and workers who registered a violent incident. These incidents were later presented at regular staff meetings and were discussed within the group.

Primary outcome—episodes of aggression

Fitzwater 2002  and Irvine 2012b measured the effectiveness of training in reducing aggression using an Assault Log, which was a record‐keeping process to document and describe physical assaults by patients. Workers completed this form after each workday.  Fitzwater 2002  reported the mean total number of reported events for participants at each site in the two weeks before the intervention and in the two weeks following the intervention. Irvine 2012b  reported the mean number of daily occurrences of aggression. In both studies, participants in the control group were compared to participants who received the intervention. For these studies, we used the change between baseline and follow‐up in the mean number of daily occurrences of aggression for the intervention and control groups to determine standard mean differences (SMDs).

Whittington 1996 evaluated the effectiveness of a training intervention among nurses using the number of notified assaults on staff during the 28 days preceding training and the 28 days immediately following training, determined by contacting all available staff in participating wards every day about any notifiable aggression that had occurred over the past 24 to 48 hours. This was used by study authors to compute the percentages of workers in intervention and control groups who had been the target of an aggression at baseline (i.e. in the 28 days before the intervention) and at follow‐up (i.e. in the 28 days following the intervention). We used these percentages to estimate the number of events (i.e. the number of staff that had been the target of aggression) and to calculate a risk ratio (RR) for intervention and control groups at follow‐up.

Anderson 2006 assessed the effectiveness of a training intervention using the Workplace Violence Questionnaire and Demographics Tool, a self‐report questionnaire that documented the frequency and type of workplace violence events. This instrument was developed by the study author based on the Conflict Tactics Scale ( Straus 1979 ), as well as the Wyatt Sex History questionnaire ( Wyatt 1995 ). The questionnaire lists multiple events of aggression. Participants were instructed to indicate which of these events had occurred to them over the past six months. This questionnaire documented the frequency and type of events of aggression. For the current analysis, the mean number of events per participant was calculated at baseline and at follow‐up for intervention and control groups. The SMD in change in mean number of events between baseline and follow‐up (six months) was used to determine the efficacy of the intervention in reducing the frequency of episodes of aggression.

Arnetz 2000 asked participants if they had been the target of aggression over the past year at two times: at baseline—before the intervention—and at follow‐up one year later—at the end of the intervention. The percentage of participants who answered "yes" to this question was determined by adding together the percentages of participants who answered "yes, once or twice" with those who answered "yes, several times." This combined percentage was then used to estimate the number of participants who reported having been the victim of aggression at follow‐up, at the end of one‐year intervention. We then calculated an RR based on these estimates.

Irvine 2007 tested participants' personal knowledge about workplace aggression by presenting three video vignettes demonstrating an example of workplace aggression (e.g. a patient in a wheelchair swinging his arms violently). At the end of each vignette, participants were asked a single multiple choice question about what to do in the previously depicted situation. Participants indicated their responses by selecting the option that corresponded to what they thought was the correct response. Participants were tested before intervention and again, at the end of the self‐paced intervention. Study authors reported the mean proportions of correct responses both before intervention and at follow‐up for intervention and control groups. For the present analyses, we used the SMD in the proportion of correct responses.

Arnetz 2000 assessed the effects of intervention on worker knowledge by asking participants three questions regarding whether the project had given them better knowledge of (1) risk situations for aggression toward staff; (2) how potentially dangerous situations could be avoided or attenuated; and (3) how best to handle a patient or another person who became aggressive toward them in the workplace. We selected the first measure (i.e. risk situations for aggression toward staff) to be included in the analysis as it fitted the definition of personal knowledge about workplace aggression and it better encompassed the general aspect of this outcome. For this measure, we estimated the number of respondents who answered "yes" based on the percentages reported by study authors and the number of participants who answered at 12 months' follow‐up. These data were then used to calculate RRs for the present analyses.

Attitudes toward patient aggression

Irvine 2007 assessed the effects of intervention on worker attitudes toward aggression using a 13‐item unspecified scale. Each item evaluated participants' agreement with the importance of certain behavioral responses to aggression and asked participants to indicate their level of agreement on a 7‐point Likert scale (1 = completely agree; 7 = completely disagree). For each participant, attitude was measured as the mean of response across these 13 items at each testing interval. Assessments were made before intervention and again at follow‐up, at the end of the self‐paced intervention. Study authors reported the mean attitude response for cohorts both before intervention and at follow‐up—one business day after the end of the self‐paced intervention. For the present analysis, we used the SMD in change in attitude scores at one‐day follow‐up to assess the efficacy of the intervention in improving worker attitudes toward aggression.

Irvine 2012a used an unspecified five‐item questionnaire to assess effects of intervention on worker attitudes. Respondents were asked to indicated their level of agreement/disagreement using a 7‐point Likert scale (1 = completely disagree; 7 = completely agree). The score was the mean value across these five items. For the present analysis, we used the SMD in mean score changes between baseline and eight‐week follow‐up assessments to determine the efficacy of the intervention in improving worker attitudes toward violence.

Irvine 2012b evaluated attitudes toward aggression using a single item. Participants were asked the extent to which they agreed or disagreed with the statement, "I believe that residents act aggressively because they have unmet needs." Participants were asked to indicate their level of agreement/disagreement on a 7‐point Likert scale (1 = completely disagree; 7 = completely agree). Study authors reported the mean values for control and intervention groups before intervention and at eight weeks' follow‐up. For the present analyses, we used the SMD in change in scores between baseline and follow‐up scores to evaluate the efficacy of intervention in changing worker attitudes for them to be more understanding of the causes of aggression.

Ming 2019 measured the effects of intervention on worker attitudes using seven items from the Management of Aggression and Violence Attitude Scale ( Duxbury 2002 ; Duxbury 2008 ). Each of these items contains a statement regarding the causes of aggression (e.g. "It is largely situations that can contribute toward the expression of aggression by patients"). Participants were asked to indicate their level of agreement/disagreement with each item using a 5‐point Likert scale ranging from 1 (i.e. "strongly disagree") to 5 (i.e. "strongly agree"). For each participant, individual test item response values were summed to yield a global score from 7 to 35. Study authors reported the mean global score values for intervention and control groups at baseline and at follow‐up three months later. We calculated the SMD in change in scores between intervention and control groups to establish the effectiveness of the intervention in improving attitudes toward patient aggression.

Needham 2005 assessed effects of an intervention on worker attitudes using the short version of the Perception of Aggression Scale and the Tolerance Scale, respectively ( Needham 2004 ; Whittington 2002 ). Each of the 12 items on the short Perception of Aggression Scale asks participants to indicate their level of agreement with a statement (e.g. "aggression is an emotional outlet") on a 5‐point Likert scale (1 = strongly disagree; 5 = strongly agree). The Tolerance Scale is derived from the long version of the Perception of Aggression Scale ( Jansen 1997 ). Because this scale stemmed from the Perception of Aggression Scale, we retained only the short version of the Perception of Aggression Scale for this review. Needham 2005 reported mean Perception of Aggression (POAS‐S) "positive" scale results for intervention and control groups at baseline and at follow‐up 90 days later. Individual scores were calculated by adding the response value of the items on each scale. For the present analyses, we calculated the SMD in change in scores between intervention and control groups to establish the effectiveness of the intervention in changing workers' attitudes toward patient aggression.

Irvine 2012a used four items from the Personal Accomplishment Scale to assess effects of intervention on the empathy of participants toward residents ( Ray 1994 ). Irvine 2012b assessed caregiver empathy with a single item from the Personal Accomplishment Scale ( Ray 1994 ): "even if a resident sometimes is verbally or physically aggressive toward me, I can easily understand how he/she feels about things." In both studies, participants were asked to rate their level of agreement/disagreement using a 7‐point Likert scale (1 = completely disagree; 7 = completely agree). Irvine 2012a calculated a composite score for each participant by computing the average response across the four test items. In both studies, study authors reported the group mean for participants in control and intervention groups before intervention and at follow‐up eight weeks later. For the present analysis, the SMD in the change in mean between baseline and follow‐up was compared for participants in intervention and control groups to assess effectiveness of the intervention.

Adverse personal outcomes

Needham 2005 examined the impact of the intervention in mitigating adverse outcomes of aggression using the Impact of Patient Aggression on Carers Scale ( Needham 2005a ). Each item on this 10‐item instrument starts with the statement "After dealing with patient aggression ..." followed by a reaction that could occur following aggression (e.g. "I avoid contact with this patient"). Participants were instructed to give their response using a 5‐point Likert scale indicating frequency of their reaction to aggression (i.e. "never," "rarely," "sometimes," "often," and "always"). This instrument was used to measure adverse outcomes before intervention and at follow‐up 90 days later. Study authors reported the mean score on the three subscales (i.e. adverse moral reactions; adverse feelings to external sources; and impairment of the relationship between patient and carer) of this instrument for intervention and control group participants. For the present analyses, we selected "adverse moral reactions" as this reflected median scores across the three scales and fitted better the definition of personal outcome. We used the SMD in changes in this score between baseline and follow‐up for control and intervention groups to assess the efficacy of an intervention in preventing or mitigating the adverse outcomes of aggression.

Follow‐up

These included studies provided short‐term follow‐up: Anderson 2006 (six months); Fitzwater 2002 (two weeks); Irvine 2007 (one day); Irvine 2012a (eight weeks); Irvine 2012b (two weeks for aggression outcomes, eight weeks for other reported outcomes); Ming 2019 (three months); Needham 2005 (90 days); and Whittington 1996 (28 days).

Medium term

No included studies provided medium‐term follow‐up.

Only one study in the present review was considered to provide long‐term follow‐up ( Arnetz 2000 ; one‐year follow‐up).

Excluded studies

Following screening of search results, review authors excluded 28 articles from the systematic review. Some studies were excluded due to research design considerations. Eleven studies were excluded because they did not include a control group ( Beech 2006 ; Beech 2003 ; Cailhol 2007 ; Casalino 2015 ; Fernandes 2002 ; Gerdtz 2012 ; Gertz 1980 ;  Lipscomb 2004a ; Meehan 2006 ; Peek‐Asa 2002 ; Shah 1998 ). In addition, two studies were excluded because they included no control groups and the education/training interventions were part of a multi‐intervention program ( Gillespie 2013 ; Gillespie 2014 ). One study was excluded because it did not have a concurrent control group, with control group participants selected after the intervention ( Ore 2002 ). One study was excluded because control group measures were taken only once, as opposed to measures both before and after intervention ( Ishak 2002 ).

One study was excluded because it used "a before and after study" research design with no comparison group ( Adams 2017 ). One study was excluded because it was reported as an abstract duplicating other material ( Kowalenko 2014 ). One publication was excluded because it described a grant application for a multi‐program intervention, and its results were reported elsewhere ( Gates 2013 ). Two studies were excluded because the education/training intervention was only one component of a multi‐component intervention, and the contribution of education component effects could not be assessed in the analysis ( Lipscomb 2004b ; Lipscomb 2006 ).

Another reason for exclusion was lack of relevance of the study to the objective of the present study. One study was excluded because it investigated effects of an intervention aimed at patients rather than at healthcare workers ( Cooper 2006 ). Another study was excluded because it investigated effects of an intervention on aggression between colleagues ( Kang 2017 ). One study was excluded because its reported outcomes were not deemed relevant to the present review ( McIntosh 2003 ).

Finally, some studies were excluded because they provided no data pertaining to an intervention. Two studies were excluded because they did not report on an intervention ( Kim 2018 ; Li 2018 ). One study was excluded because it did not report on an intervention and did not appear to provide any data ( McElaney 2008 ). One paper was excluded because it was a literature review ( Rittenmeyer 2013 ). Finally, one paper was rejected because it was a descriptive report rather than a report on an intervention study ( Vousden 1987 ). 

Risk of bias in included studies

The risk of bias of the included studies as assessed by the authors of this review is shown in Figure 2  and on an individual study basis in Figure 3 . Details are provided in the section  Characteristics of included studies . 

Figure 2. Review author's judgement about Risk of bias by Cochrane Collaboration's tool for assessing risk of bias within and across randomized trials. Risk of bias across studies.

Figure 3. Review author's judgement about Risk of bias by Cochrane Collaboration's tool for assessing risk of bias within and across randomized trials. Risk of bias within studies.

Three studies were judged to have high risk of selection bias due to lack of allocation concealment ( Anderson 2006 ;  Fitzwater 2002 ;  Whittington 1996 ). Two studies did not provide enough details about allocation concealment to allow determination of risk of selection bias ( Arnetz 2000 ; Needham 2005 ). Finally, four studies were found to have taken enough precautions regarding allocation concealment to represent low risk of introducing bias ( Irvine 2007 ; Irvine 2012a ; Irvine 2012b ; Ming 2019 ). 

Three of the included studies were deemed to be at high risk for selection bias due to lack of random assignment ( Anderson 2006 ; Fitzwater 2002 ; Whittington 1996 ). One study performed random assignment of participants in the experimental and control groups and thus was assessed to have low risk of selection bias ( Ming 2019 ). The risk of selection bias due to lack of randomization was deemed unclear for the remaining included studies because they did not provide enough information to permit this assessment ( Arnetz 2000 ; Irvine 2007 ; Irvine 2012a ; Irvine 2012b ; Needham 2005 ).

Performance bias

Two studies were deemed to have high risk of performance bias due to lack of blinding of participants ( Fitzwater 2002 ; Whittington 1996 ). Two studies did not blind participants regarding which cohort they belonged to, but we did not deem this to be a likely source of bias as education interventions were delivered online ( Irvine 2007 ; Irvine 2012a ). The other included studies did not provide enough information to permit determination of the risk of performance bias ( Anderson 2006 ; Arnetz 2000 ; Irvine 2012b ; Ming 2019 ; Needham 2005 ).

The research design of the included studies involved comparing those who underwent intervention with those who did not. As a result, there was no blinding of the person(s) giving the intervention in face‐to‐face interventions ( Arnetz 2000 ; Fitzwater 2002 ; Ming 2019 ; Needham 2005 ; Whittington 1996 ). Lack of blinding of research personnel in studies that used an online intervention was not deemed an issue, given the absence of interactions between people delivering the intervention and those receiving it ( Anderson 2006 ; Irvine 2007 ; Irvine 2012a ; Irvine 2012b ).

Detection bias

The included studies relied primarily on self‐assessment to determine the effects of education and training interventions on outcome measures, thereby potentially inserting a source of bias inherent to these methods. For instance, participants in Arnetz 2000 were asked questions regarding changes in their awareness of high‐risk situations of aggression. A number of other factors may contribute to a report on increased awareness, including underestimation of one's prior awareness, overestimation of one's awareness at the time responses were provided, and social desirability bias leading participants to respond in a manner that would be viewed favorably. This poses a significant risk of bias for studies in which participants were not blinded ( Fitzwater 2002 ; Irvine 2007 ; Irvine 2012a ; Whittington 1996 ). The risk of bias for the remaining studies was deemed unclear due to insufficient information about blinding ( Anderson 2006 ; Arnetz 2000 ; Irvine 2012b ; Ming 2019 ; Needham 2005 ).

Incomplete outcome data

Five studies detailed loss of participants and were deemed to be at low risk of attrition bias ( Arnetz 2000 ; Irvine 2012a ; Irvine 2012b ;  Ming 2019 ;  Whittington 1996 ). Two studies reported high attrition rates and thus were determined to be at high risk for attrition bias ( Anderson 2006 ; Needham 2005 ). Finally, two studies did not provide sufficient information to permit assessment of the risk of attrition bias ( Fitzwater 2002 ; Irvine 2007 ).

Selective reporting

Four studies were judged to have low risk of reporting bias ( Arnetz 2000 ; Irvine 2012a ; Ming 2019 ;  Needham 2005 ). The risk of selective reporting bias was deemed unclear for the remainder of the studies due to insufficient information to permit judgment ( Anderson 2006 ; Fitzwater 2002 ; Irvine 2007 ; Irvine 2012b ; Whittington 1996 ). 

Other potential sources of bias

Categorization of interventions based on duration and types of delivery may have an impact on study results as they are considered to have the same potential for effect. The categorization of follow‐up may also hinder time to detect differences between short‐ and long‐term effects.

Effects of interventions

See: Table 1

Summary of findings 1

Education only

No studies reported on an education only program.

Education combined with training

Short‐term follow‐up crcts.

Evidence provided by CRCTs was very uncertain concerning effects of education and training on episodes of aggression at short‐term follow‐up. Results of two CRCTs were combined in a meta‐analysis (Fitzwater 2002; Irvine 2012b), which did not show a statistically significant effect of the intervention on the number of episodes of aggression (SMD ‐0.33, 95% CI ‐1.27 to 0.61; Analysis 1.1 ). No significant subgroup differences between these studies based on type and duration of the intervention were found (P = 0.18; I² = 44.4%).

Comparison 1: Number of episodes of aggression, Outcome 1: CRCT short‐term follow‐up

Short‐term follow‐up CBAs

The two CBAs provided very uncertain evidence about effects of education and training on the number of workers reporting episodes of aggression at short‐term follow‐up. Whittington 1996 did not find a statistically significant effect of intervention on the risk ratio of aggression against workers (RR 2.30, 95% CI 0.97 to 5.42; Analysis 1.2 ).

Comparison 1: Number of episodes of aggression, Outcome 2: CBA short‐term follow‐up

Anderson 2006 reported a significant reduction in the mean number of reported episodes of aggression at follow‐up (SMD ‐1.24, 95% CI ‐2.16 to ‐0.33; Analysis 1.3 ).

Comparison 1: Number of episodes of aggression, Outcome 3: CBA short‐term follow‐up

Long‐term follow‐up (CRCTs)

Low‐certainty evidence suggests that education and training does not reduce the number of workers reporting episodes of aggression at short‐term follow‐up. A long‐term follow‐up CRCT revealed no statistically significant effect of an extended face‐to‐face education intervention on the probability of reporting being the target of aggression (RR 1.14, 95% CI 0.95 to 1.37; Analysis 1.4 ) ( Arnetz 2000 ).

Comparison 1: Number of episodes of aggression, Outcome 4: CRCT long‐term follow‐up

Secondary outcome—personal knowledge about aggression

Short‐term follow‐up (rct).

See Analysis 2.1 .

Comparison 2: Personal knowledge about aggression, Outcome 1: Knowledge about aggression (RCT/CRCT)—short‐term follow‐up

Low‐certainty evidence suggests that education and training interventions improved knowledge about aggression at short‐term follow‐up. One RCT reported short‐term follow‐up data regarding knowledge about aggression following an online education intervention (Irvine 2007). Analysis revealed a statistically significant effect favoring the intervention group (SMD 0.86, 95% CI 0.34 to 1.38).

Long‐term follow‐up (CRCT)

See Analysis 2.2

Comparison 2: Personal knowledge about aggression, Outcome 2: Knowledge about aggression (RCT/CRCT)—long‐term follow‐up

Low‐certainty evidence suggests that education and training interventions did not improve knowledge about aggression at long‐term follow‐up. Arnetz 2000 assessed the impact of an education intervention on enhancing awareness of risk situations and found no statistically significant effect of training on personal knowledge about aggression (RR 1.26, 95% CI 0.90 to 1.75).

Secondary outcome—attitudes

Short‐term follow‐up (rct/crtc)—general attitudes.

See Analysis 3.1 .

Comparison 3: Attitudes, Outcome 1: Attitudes (RCT/CRCT)—short‐term follow‐up

Very low‐quality evidence suggests that education/training interventions improved attitudes among healthcare workers at short‐term follow‐up. Two CRTCs and three RCTs measured effects of education interventions on the attitudes of participants toward patient aggression in short‐term follow‐up ( Irvine 2007 ; Irvine 2012a ; Irvine 2012b ; Ming 2019 ; Needham 2005 ). Results of the meta‐analysis revealed a statistically significant small effect on attitudes favoring the education group (SMD 0.59, 95% CI 0.24 to 0.94).

Subgroup differences were statistically significant (P < 0.001; I² = 78.3%), suggesting that type and duration of an intervention accounted for different effects. Ming 2019 found a statistically significant moderate effect favoring the education group (SMD 0.78, 95% CI 0.58 to 0.99). Irvine 2007 found a statistically significant large effect favoring the education group (SMD 1.23, 95% CI 0.69 to 1.78). Irvine 2012a and Irvine 2012b found a statistically significant small effect favoring the education group (SMD 0.33, 95% CI 0.05 to 0.61).  Needham 2005  found no statistically significant effect of intervention on attitudes toward aggression (SMD ‐0.03, 95% CI ‐0.68 to 0.73).

Secondary outcome—skills

Short‐term follow‐up (rct/crct)—empathy.

See Analysis 4.1 .

Comparison 4: Skills, Outcome 1: Skills (RCT/CRCT)—short‐term follow‐up

Very low‐quality evidence suggests that healthcare workers who underwent education interventions did not show more empathy than those in the control group at follow‐up. One RCT and one CRCT assessed the impact of an online education intervention on workers' empathy toward patients ( Irvine 2012a ; Irvine 2012b ). Combined results of short‐term follow‐up revealed a small effect favoring the intervention that was not statistically significant (SMD 0.21, 95% CI ‐0.07 to 0.49).

Secondary outcome—adverse impact

Short‐term follow‐up (crct)—adverse personal impact.

See Analysis 5.1 .

Comparison 5: Adverse personal outcomes, Outcome 1: Adverse personal (RCT/CRCT)—short‐term follow‐up

Very low‐quality evidence suggests that education and training interventions did not help mitigate the adverse outcomes of patient aggression for healthcare workers. One CRCT tested the impact on adverse moral reactions at short‐term follow‐up ( Needham 2005 ). These results revealed a small negative effect in favor of the control group that was not statistically significant (SMD ‐0.31, 95% CI ‐1.02 to 0.40).

We included nine studies—four cluster‐randomized controlled trials (CRCTs), three randomized controlled trials (RCTs), and 2 controlled before and after studies (CBAs)—with a total of 1688 participants. Five studies reported episodes of aggression, and six studies reported secondary outcomes. Seven studies were conducted among nurses or nurse aides, and two studies among healthcare workers in general. Three studies took place in long‐term care, two in the psychiatric ward, and four in hospitals or health centers. Studies were reported from the United States, Switzerland, the United Kingdom, Taiwan, and Sweden.

All included studies reported on education combined with training interventions. Four studies evaluated online programs, and five evaluated face‐to‐face programs. Five studies were of long duration (up to 52 weeks), and four studies were of short duration. Eight studies provided short term follow‐up (< 3 months) and one study long‐term follow‐up (> 1 year). Seven studies were rated as being at "high" risk of bias in multiple domains, and all had "unclear" risk of bias in a single or multiple domains. Effects of education and training interventions in aggression prevention in healthcare settings are shown in Table 1 .

Summary of main results

Effects of education and training interventions in aggression prevention on reduction of episodes of aggression.

The evidence is very uncertain about effects of education and training interventions on aggression, compared to no intervention, at short‐term follow‐up (standardized mean difference [SMD] 0.33, 95% confidence interval [CI] ‐1.27 to 0.61, 2 CRCTs; risk ratio [RR] 2.30, 95% CI 0.97 to 5.4, 1 CBA; SMD ‐1.24, 95% CI ‐2.16 to ‐0.33, 1 CBA; very low‐quality evidence). Education may not have an effect on aggression compared to no intervention in the long term (RR 1.14, 95% CI 0.95 to 1.37, 1 RCT; low‐quality evidence). The primary outcome findings of this review may be explained by different factors. First, increased knowledge about aggression may lead to increased awareness of aggression incidents, thereby offsetting actual reductions in aggression. As such, participants may have been more willing to report these episodes, which are normally under‐reported ( Arnetz 2015 ). Further, the self‐reported nature of data on the number of aggression incidents in some studies complicates interpretation, as it is unclear whether the increases are due to greater awareness of aggression or willingness to report it, or whether they represent a genuine increase in the number of events of aggression. Another possible explanation is that training healthcare workers in aggression management and raising their self‐efficacy in dealing with such situations renders them more willing to engage in, instead of avoiding, situations in which there is high risk of aggression. Second, the heterogeneity of the ways in which episodes of aggression were recorded and reported made it impossible to combine all included studies into a single measure. Moreover, the use of dichotomous measures in some included studies may not have captured effects of the intervention, as they represent only the proportion of healthcare workers who experienced aggression before and after the intervention—not the reduction or increase in the number of episodes of aggression for each participant. For example, a participant may experience fewer episodes of aggression at follow‐up compared to baseline but would still answer "yes" if asked a dichotomous question, thereby not reducing the proportion of workers who experience these acts. Third, the statistical power of certain studies may not have been sufficient to reject the null hypothesis. Thus, we cannot determine whether education and training interventions in aggression prevention result in reduction of episodes of aggression toward healthcare workers.

Effects of education and training interventions in aggression prevention on secondary outcomes

Education may result in increased personal knowledge about workplace aggression at short‐term follow‐up (SMD 0.86, 95% CI 0.34 to 1.38, 1 RCT; low‐quality evidence) but may not be effective at long‐term follow‐up (RR 1.26, 95% CI 0.90 to 1.75, 1 RCT; very low‐quality 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‐quality evidence) and the type and duration of interventions produced effects of different sizes. The evidence is very uncertain about effects on skills related to workplace aggression (SMD 0.21, 95% CI ‐0.07 to 0.49, 1 RCT and 1 CRCT; very low‐quality evidence) or on adverse personal outcomes (SMD ‐0.31, 95% CI ‐1.02 to 0.40, 1 RCT; very low‐quality evidence). Still, the heterogeneity of measurements of the concepts made it impossible to combine outcomes in a single measure, and the statistical power for some secondary outcomes was low.

Overall completeness and applicability of evidence

The search strategy that we used to find studies for the present review sought to detect as many relevant articles as possible. To do this, we used several terms that are semantically close or related to aggression, such as violence and assault. We also did not restrict the search to any single category of healthcare worker nor filter out search results based on language. We included several types of research design assessing effects of education and training interventions that allowed comparison between those who received intervention and those who did not. This included RCTs, CRCTs, and CBAs. We also searched a wide array of databases to maximize the number of hits. This search returned 4744 potential articles for us to screen for the present review. We pursued additional search results from the reference sections of retrieved papers and sought papers from experts in the field. Given this search strategy, we are confident that we did not miss many studies investigating the outcomes of education and training interventions for dealing with aggression among healthcare workers.

Participant occupations included certified nurse assistants or nurse aides ( Fitzwater 2002 ; Irvine 2007 ; Irvine 2012a ; Irvine 2012b ), nurses ( Needham 2005 ;  Ming 2019 ;  Whittington 1996 ), and non‐specific healthcare workers ( Anderson 2006 ; Arnetz 2000 ). The settings in which these studies took place include a small community hospital ( Anderson 2006 ), psychiatric wards ( Needham 2005 ; Whittington 1996 ), long‐term care facilities or nursing homes ( Fitzwater 2002 ; Irvine 2007 ; Irvine 2012a ; Irvine 2012b ), a medical center ( Ming 2019 ), and healthcare workplaces ( Arnetz 2000 ). All of these studies were conducted in high‐income countries, namely, Great Britain, the United States, Taiwan, and Sweden. Thus, several healthcare workers were missing in studies from low‐ and middle‐income countries, as were other types of healthcare workers such as physicians and first aid workers.

Our search failed to find any study investigating organizational outcomes such as absenteeism or employee turnover. Further, the studies on individual outcomes focused on variables such as knowledge, attitudes, and self‐efficacy regarding aggression. No study was found that investigated effects of intervention on physical and mental health issues, nor professional difficulties. 

Another obstacle to the generalizability of review findings is the fairly short follow‐up period reported by most of the included studies. Consequently, caution must be exercised in extrapolating the long‐term impact of education and training programs in aggression prevention based on currently available data. 

Quality of the evidence

We found the quality of evidence for primary and secondary outcomes to be very low to low due to the bias implicit in self‐reporting and the heterogeneity of outcome measurement approaches across the small body of included studies. In light of the very low to low quality of the existing research, additional research findings from high‐quality studies are likely to have a significant impact on our confidence related to the effects of education and training programs in aggression prevention and minimization.

Potential biases in the review process

One of the limitations of this review is the scarcity of studies on the topic, as the lack of studies did not allow us to perform sensitivity analyses to evaluate optimal intervention parameters (e.g. face‐to‐face, online, duration) to reduce the frequency of episodes of aggression and mitigate their impact. Adjustment of the sample size in CRCTs reduced the statistical power of the analysis, thereby increasing the chance of type II error. Effects on episodes of aggression became insignificant for Fitzwater 2002 and Irvine 2012b , and effects on personal knowledge became insignificant for Arnetz 2000 .

Categorization of interventions based on duration and type of delivery may also have biased this review and impacted the results. Because we found no evidence on differences in effectiveness of online or face‐to‐face programs, short to long duration, or single to multiple sessions, we started with the assumption that they have the same effect on our outcomes. Still, we computed subgroups to assess differences according to duration and type of delivery. In the same vein, our categorization of follow‐up may have hindered our capacity to detect differences between short‐term and long‐term effects.

Agreements and disagreements with other studies or reviews

Our search revealed one review related to the effectiveness of education and training for preventing workplace aggression in healthcare settings ( Rittenmeyer 2013 ). The scope of the review was limited to workplace aggression between healthcare workers. We did not discover any studies that examined the effectiveness of interventions aimed at preventing workplace violence or ameliorating its effect.

Implications for practice

• Education may not have an effect or may have an inconsistent effect on preventing workplace aggression, compared to no intervention, at short‐term follow‐up on prevention 
• Education may not have an effect on preventing workplace aggression compared to no intervention in the long term
• Education may increase healthcare workers' personal knowledge about patient aggression
• Education may increase healthcare workers' positive attitudes toward patient aggression
• Education may not have an effect on skills related to patient aggression
• Education may not have an effect on adverse personal outcomes of patient aggression

Implications for research

According to the PICO framework, future studies on education and training interventions that aim to prevent and minimize workplace aggression directed toward healthcare workers by patients and patient advocates should:

• focus on specific settings of healthcare work where exposure to patient aggression is high (e.g. mental health workers). As such, a reduction in episodes of aggression following training may be significant only for workers who are highly exposed. Moreover, as most studies have assessed episodes of aggression toward nurses, future studies should include other types of healthcare workers who are also victims of aggression in the same settings, such as orderlies (healthcare assistants);
• benefit from the ability to track reports of aggression at an institutional level and rely on multi‐source data (combining subjective and objective measures) and validated measures. Studies should also incorporate an active comparison to prevent raising awareness and reporting in the intervention group only;
• specify the duration and type of delivery to provide insight as to the method that is most effective to reduce episodes of aggression against healthcare workers; and
• incorporate variables such as days lost to sick leave and employee turnover into their outcome measures. In addition, care should be taken to study the longer‐term outcomes of these education and training programs. Further, given that several interventions did not specify their assessment tools, future studies should endeavor to disclose their instruments and use the same well‐established, validated questionnaires. In addition, measures of episodes of aggression should be reported as frequencies rather than as the number or proportion of workers who have been the target of aggression, as the former is more sensitive due to the fact that a worker can experience multiple episodes of aggression over an assessment period.

Protocol first published: Issue 9, 2015 Review first published: Issue 9, 2020

Acknowledgements

We wish to acknowledge the contributions of Dr Maya Guest, formerly of the University of Newcastle, Australia (now retired), who originally conceived the protocol and led its early development, including in relation to the search strategy design, in conjunction with the University of Newcastle librarians; and the contributions of Associate Professor Ashley Kable and Professor Michael Hazelton from the University of Newcastle, Australia, to early development of the protocol.

We thank Jani Ruotsalainen, former Managing Editor of the Cochrane Work Review Group, for providing administrative and logistical support for the conduct of the current review; and Kaisa Neuvonen, Trials Search Co‐ordinator, Cochrane Work Review Group, for developing and testing the search strategies, which were subsequently employed for the conduct of this review.

We acknowledge the contributions of Murray Turner, Librarian, University of Canberra, in completing the initial search of the literature. We also acknowledge the contributions of Catelyn Richards, Research Assistant, Nursing and Midwifery; and Anne Young, Librarian; both of Monash University, for their efforts in updating the literature search to 31 March 2018. We additionally thank Dr Louisa Lam, Deputy Dean, Federation University, for assistance in translating a Chinese language manuscript for the review paper.

 We would also like to thank the Cochrane Work Review Group's Co‐ordinating Editor Jos Verbeek, Managing Editor Julitta Boschman, and Editors Thais Morata and Anneli Ojajärvi and external peer referees Joy Duxbury and Sabine Hahn for their comments. Last but not least, we thank copy editor Dolores Matthews and plain language summary writer Carolyn Hughes for copyediting the text.

Appendix 1. Search strategies

Campbell Collaboration Library of Systematic Reviews

• aggress* OR violen* OR bully* OR harass* OR mob*

Canadian Centre for Occupational Health and Safety

• ‘Violence’
• ‘Violent’
• ‘Aggression’
• ‘Aggressive’ 

ClinicalTrials.gov

• education and training in "aggression OR violence"
• aggression OR aggressive; intervention: education OR training
• violent OR violence: intervention: education OR training
• aggression OR aggressive OR violence OR violent OR bullying OR harassment OR mobbing | completed | interventional studies | education OR training

World Health Organization International Clinical Trials Registry

• “aggress* OR violen* OR bully* OR mobb* OR harass* OR Assault* OR disrupt OR abuse AND harass* OR assault* OR disrupt OR abuse”
• "Workplace Violence"[Mesh] OR "Violence/prevention and control"[Mesh] OR violence[tw] OR violent[tw] OR "Aggression"[Mesh] OR aggression*[tw] OR angry[tw] OR "Hostility"[Mesh] OR hostil*[tw] OR "inappropriate behavior"[tw] OR "Agonistic Behavior"[Mesh] OR "Bullying"[Mesh] OR bully*[tw] OR mob*[tw] OR harass*[tw] OR pester*[tw] OR disrupt*[tw] OR incivility[tw] OR "emotional‐verbal abuse"[tw] OR abus*[tw] OR assault*[tw]
• work‐related OR at work[tw] OR "Work"[Mesh] OR work[tw] OR worke*[tw] OR workplace*[tw] OR work place*[tw] OR work site*[tw] OR occupation*[tw] OR "Occupations"[MeSH] OR "Occupational Groups"[MeSH] OR job*[tw] OR "Occupational Health"[MeSH] OR "occupational health"
• #1 AND #2         
• "Health Personnel"[Mesh] OR "Personnel, Hospital"[Mesh] OR "health care worker"[tw] OR "health care workers"[tw] OR "health care personnel"[tw] OR "health personnel"[tw] OR "health‐personnel"[tw] OR "health provider"[tw] OR "health providers"[tw] OR "health care provider"[tw] OR "health care providers"[tw] OR "health staff"[tw] OR "health care staff"[tw] OR "healthcare staff"[tw] OR "health professional"[tw] OR "health care professional"[tw] OR "healthcare professional"[tw] OR "health worker"[tw] OR "medical staff"[tw] OR "medical personnel"[tw] OR "medical professional"[tw] OR "medical worker"[tw] OR "medical workers"[tw] OR "medical provider"[tw] OR "military‐medical personnel" [tw] OR "Physicians"[Mesh] OR "physician"[tw] OR "physicians"[tw] OR "doctor"[tw] OR "practitioner"[tw] OR "clinician"[tw] OR "nursing staff"[tw] OR "Nurses"[Mesh] OR "nurse"[tw] OR "nurses"[tw] OR "nursing assistant"[tw] OR "nursing assistants"[tw] OR "Nurses' Aides"[Mesh] OR "Nurse Midwives"[Mesh] OR "midwife"[tw] OR "midwives"[tw] OR "dental personnel"[tw] OR "dental staff"[tw] OR "Dentists"[Mesh] OR "dentist"[tw] OR "dentists"[tw] OR "dental assistant"[tw] OR "dental assistants"[tw] OR "Dental Assistants"[Mesh] OR "Pharmacists"[Mesh] OR "pharmacist"[tw] OR "Physical Therapists"[Mesh] OR "physical therapist"[tw] OR "physical therapists"[tw] OR "physiotherapist"[tw] OR "physiotherapists"[tw] OR "therapist"[tw] OR "therapists"[tw] OR "Physical Therapist Assistants"[Mesh] OR "technician"[tw] OR "technicians"[tw] OR "radiographer"[tw] OR "radiographers"[tw] OR "emergency medical services"[tw] OR "Emergency Medical Services"[MeSH] OR "transporting patients"[tw] OR "patient transport"[tw] OR "Ambulances"[Mesh] OR "Allied Health Personnel"[Mesh] OR "paramedic"[tw] OR "paramedics"[tw] OR "paramedical personnel"[tw] OR "health manager"[tw] OR "health care manager"[tw] OR "healthcare manager"[tw] OR "clinical officer"[tw] OR "reception"[tw]
• "Health Personnel/education"[Mesh] OR "Nursing Staff, Hospital/education"[Mesh] OR "Health Occupations/education"[Mesh] OR education[tw] OR "Inservice Training"[Mesh] OR training[tw] OR inservice[tw] OR in‐service[tw] OR "Staff Development"[Mesh] OR program* OR "aggression management" (372143)
• ("Comparative Study" [Publication Type] OR effectiveness OR program OR intervention OR reduction OR effect*[ti] OR evaluation OR decrease* OR "prevention and control" OR measures OR improve*[tiab])
• #7 AND #8 
• #9 NOT ("Child Abuse"[Mesh])
• (randomized controlled trial [pt] OR controlled clinical trial [pt] OR randomized [tiab] OR randomised [tiab] OR placebo [tiab] OR clinical trials as topic [mesh: noexp] OR randomly [tiab] OR trial [ti] NOT (animals [mh] NOT humans [mh]))
• #10 AND #11    
• "Controlled Before‐After Studies"[Mesh] OR "controlled before‐after study"[tw] OR "controlled before‐after studies"[tw] OR "CBA study" OR "CBA studies" OR "before‐after study"[tw] OR "before‐after studies"[tw] OR "Prospective Studies"[Mesh] OR prospective study OR "longitudinal studies"[MeSH]
• #10 AND #13 
• 'workplace violence'/de OR 'violence'/de OR 'violence' OR 'violent' OR 'aggression'/de OR aggression* OR 'angry' OR 'hostility'/de OR hostil* OR 'inappropriate behavior' OR 'agonistic behavior'/de OR 'bullying'/de OR bully* OR mob* OR harass* OR pester* OR disrupt* OR incivility OR 'emotional‐verbal abuse' OR abus* OR assault*
• 'work related' OR 'at work' OR 'work'/de OR 'work' OR worke* OR workplace* OR work NEAR/1 place* OR work NEAR/1 site* OR occupation* OR 'occupations'/de OR 'occupational groups'/de OR job* OR 'occupational health'/de OR 'occupational health'
• 'health care personnel'/de OR 'hospital personnel'/de OR 'hospital personnel' OR 'health care worker' OR 'health care workers' OR 'health care personnel' OR 'health personnel' OR 'health‐personnel' OR 'health provider' OR 'health providers' OR 'health care provider' OR 'health care providers' OR 'medical staff' OR 'medical personnel' OR 'medical professional' OR 'medical worker' OR 'medical workers' OR 'dental personnel' OR 'dental staff' OR 'dentist' OR 'dentists' OR 'dental assistant' OR 'dental assistants' OR 'nursing staff' OR 'nurses'/de OR 'nurse' OR 'nurses' OR 'nursing assistants' OR 'nursing assistant'/de OR 'nursing assistant' OR 'nurse midwife'/de OR 'nurse midwife' OR 'midwife' OR 'midwives' OR 'military‐medical personnel' OR 'physician'/de OR 'physician' OR 'physicians' OR 'emergency medical services' OR 'transporting patients' OR 'patient transport' OR 'ambulance'/de OR 'ambulance' OR 'paramedical personnel'/de OR 'paramedical personnel' OR paramedic OR paramedics OR 'health manager' OR 'health care manager' OR 'healthcare manager' OR 'clinical officer' OR 'reception'
• 'inservice training'/de OR 'in service training' OR 'in service' OR 'inservice' OR 'training' OR 'allied health education' OR 'staff development'/de OR 'personnel management'/de OR aggression NEAR/1 management OR program* OR 'health personnel' NEAR/5 education OR nurse NEAR/5 education OR 'medical profession' NEAR/5 education OR 'interprofessional education'
• 'comparative study':it OR 'comparative study'/exp OR 'intermethod comparison'/exp OR effectiveness OR program OR intervention OR reduction OR effect*:ti OR evaluation OR decrease* OR 'prevention and control'/de OR measures OR improve*:ab,ti
• #9 NOT 'child abuse'/de
• #10 AND [embase]/lim
• #11 NOT [medline]/lim
• 'randomized controlled trial'/exp OR 'controlled study'/exp OR 'randomization'/exp OR 'double blind procedure'/exp OR 'single blind procedure'/exp OR 'clinical trial'/exp OR 'crossover procedure'/exp OR 'follow up'/exp OR 'prospective study'/exp OR (singl* OR doubl* OR trebl* OR tripl*) NEXT/5 (mask* OR blind* OR method*) OR clinical NEXT/3 trial* OR 'placebo'/exp OR placebo*:ab,ti OR random*:ab,ti OR latin NEXT/3 square OR 'comparative study'/exp OR ((control* OR prospective* OR volunteer*) NEAR/3 (trial* OR method* OR stud*)):ab,ti OR crossover* OR cross NEXT/1 over* NOT ('nonhuman'/exp NOT 'human'/exp)
• #12 AND #13
• #14 AND ‘clinical trial’/de
• workplace violence/ OR violen*.sh. OR aggressive behavior/ OR aggression.sh. OR anger.sh. OR hostility.ti. OR hostility.ab. OR inappropriate behavio*.ti. OR inappropriate behavio*.ab. OR agnostic behavior*.af. OR bullying/ OR bully.sh. OR mob.sh. OR harass*.ti. OR harass*.ab. OR pester*.sh. OR disrupt*.sh. OR incivility.sh. OR emotional abuse/ OR verbal abuse/ OR abus*.sh. OR assault*.sh.
• Work‐related.sh. OR work.sh. OR worke*.sh. OR work site*.af. OR occupation*.sh. OR occupations/OR job*.sh. OR occupational health.sh. OR occupational health.af.
• health personnel/ OR allied health personnel/ OR medical personnel/ OR mental health personnel/ OR counsellors/ OR counselor*.sh. OR home care personnel/ OR social workers/ OR nurses/ OR nurses.sh. OR dentists/ OR therapists.sh. OR optometrists/ OR pharmacists/ OR physicians/ OR physicians.sh. OR general practitioners/ OR gynaecologists/ OR internists/ OR neurologists/ OR obstetricians/ OR pathologists/ OR paediatricians/ OR surgeons/ OR psychiatric hospital staff/ OR psychiatric aides/ OR psychiatrists/ OR attendants/ OR clinicians/
• #3 AND #4
• inservice training/ OR personnel training/ OR on the job training/ OR professional development/ OR education.sh. OR training.sh. OR inservice.sh. OR in‐service.af. OR staff development.af. OR health personnel education.af. OR training program.af. OR aggression management.af. OR staff education.af.
• comparative study.ti. OR comparative study.ab. OR effectiveness.af. OR program.af. OR intervention.af. OR reduction.af. OR effect.af. OR evaluation.af. OR decrease*.af. OR prevention and control.af. OR measures.af. OR improve*.ti. OR improve*.ab
• treatment outcome.af. OR clinical trial.af. OR randomized.ti. OR randomized.ab. OR placebo.ti. OR placebo.ab. OR clinical trials/ OR randomly.ti. OR randomly.ab. OR trial.ti. NOT animals/ NOT animals.sh.
• #9 AND #10
• longitudinal study.af. OR controlled before‐after stud*.af. OR CBA stud*.af. OR before‐after stud*.af. OR prospective studies/ OR prospective study.md. OR prospective stud*.af.
• (MH "Workplace Violence") OR (MH "Violence/PC") OR (MW violence) OR (MW violent) OR (MH "Aggression") OR (MW aggression*) OR (MW angry) OR (TI hostility) OR (AB hostility) OR (TI "inappropriate behavior") OR (AB "inappropriate behavior") OR (TX "agnostic behavior") OR (MH Bullying) OR (MW bully) OR (MW mob*) OR (MW harass*) OR (MW pester*) OR (MW disrupt*) OR (MW incivility) OR (MW "emotional‐verbal abuse") OR (MW abus*) OR (MW assault*)
• (MW work‐related OR “at work”) OR (MH work) OR (MW work) OR (MW worke*) OR (MW workplac*) OR (MW “work site*”) OR (MW occupation*) OR (MH "occupations and professions") OR (MH "named groups by occupation") OR (MW job*) OR (MH "occupational health") OR (TX “occupational health”)
• (MH "health personnel") OR (MH "personnel, health facility") OR (MW "health care worker") OR (MW "health care workers") OR (MW "health care personnel") OR (MW "health personnel") OR (MW "health‐personnel") OR (MW "health provider") OR (MW "health providers") OR (MW "health care provider") OR (MW "health care providers") OR (MW "health staff") OR (MW "health care staff") OR(MW  "healthcare staff") OR (MW "health professional") OR (MW "health care professional") OR (MW "healthcare professional") OR (MW "health worker") OR (MW "medical staff") OR (MW "medical personnel") OR (MW "medical professional") OR (MW "medical worker") OR (MW "medical workers") OR (MW "medical provider") OR (MW "military‐medical personnel") OR (MH "physicians") OR (MW "physician") OR (MW "physicians") OR (MW "doctor") OR (MW "practitioner") OR (MW "clinician") OR (MW "nursing staff") OR (MH "nurses") OR (MW "nurse") OR (MW "nurses") OR (MW "nursing assistant") OR (MW "nursing assistants") OR (MH "nursing assistants") OR (MH "nurse midwives") OR (MW "midwife") OR (MW "midwives") OR (MW "dental personnel") OR (MW "dental staff") OR (MH "dentists") OR (MW "dentist") OR (MW "dentists") OR (MW "dental assistant") OR (MW "dental assistants") OR (MH "dental assistants") OR (MH "pharmacists") OR (MW "pharmacist") OR (MH "physical therapists") OR (MW "physical therapist") OR (MW "physical therapists") OR (MW "physiotherapist") OR (MW "physiotherapists") OR (MW "therapist") OR (MW "therapists") OR (MH "physical therapist assistants") OR (MW "technician") OR (MW "technicians") OR (MW "radiographer") OR (MW "radiographers") OR (MW "emergency medical services") OR (MH "emergency medical services") OR (MW "transporting patients") OR (MW "patient transport") OR (MH "ambulances") OR (MH "allied health personnel") OR (MW "paramedic") OR (MW "paramedics") OR (MW "paramedical personnel") OR (MW "health manager") OR (MW "health care manager") OR (MW  "healthcare manager") OR (MW "clinical officer") OR (MW "reception")
• (MH "Health Personnel/ED") OR (MH "Nursing Staff, Hospital/ED") OR (MH "Health Occupations/ED") OR (MW education) OR (TX “inservice training”) OR (MW training) OR (MW inservice) OR (MW in‐service) OR (MH "Staff Development") OR program* OR (TX “aggression management”)
• (TI “comparative study”) OR (AB “comparative study”) OR effectiveness OR program OR (TX intervention) OR (TX reduction) OR (TI effect*) OR (TX evaluation) OR (TX decrease*) OR (TX "prevention and control") OR (TX measures) OR (TI improve*) OR (AB improve*)
• (PT “randomized controlled trial”) OR (PT clinical trial) OR (TI randomized) OR (AB randomized) OR (TI placebo) OR (AB placebo) OR (MM “clinical trials”) OR (TI randomly) OR (AB randomly) OR (TI trial) NOT (MH animals NOT MH human)
• (MH "Controlled Before‐After Studies") OR (TX "controlled before‐after study") OR (TX "controlled before‐after studies") OR (TX "CBA study") OR (TX "CBA studies") OR (TX "before‐after study") OR (TX "before‐after studies") OR (MH "Prospective Studies") OR (TX “prospective study”)

Appendix 2. Data extraction form

Appendix 3. Calculation of total number of participants in cluster RCTs

Appendix 4. GRADE table

CI: confidence interval.

OR: odds ratio.

RCT: randomized controlled trial.

SMD: standardized mean difference.

Data and analyses

Comparison 1.

Comparison 2

Comparison 3

Comparison 4

Comparison 5

Characteristics of studies

Characteristics of included studies [ordered by study id].

CNA: certified nursing assistant.

DT: delayed treatment.

IMPACS: I.mpact of Patient Aggression on Carers Scale

KMO: Kaiser‐Meyer‐Olkin test.

LTC: long‐term care.

LVN: licensed vocational nurse.

NA: nursing assistant.

POAS‐S: Perception of Aggression Scale.

RN: registered nurse.

SD: standard deviation.

VIF: violent incident form.

VST: video situation test.

WPV: workplace violent incident.

Characteristics of excluded studies [ordered by study ID]

Differences between protocol and review

• Steve Geoffrion was added to the team to compute the analyses and to co‐ordinate writing and submission of the review. He also updated the search for new publications since the time the protocol was published
• Authorship was modified given the implications of all authors. Steve Geoffrion became first author as he led analyses and writing and submission of the review. Stéphane Guay became last author as he acted as the senior author and has authored the most publications on workplace aggression

Contributions of authors

Co‐ordinating the review: SGe, DH.

Designing the protocol: DH, HR, JP, AH, TD, SR.

Designing search strategies: DH, TD, in collaboration with Kaisa Neuvonen, formerly Trials Search Co‐ordinator of the Cochrane Occupational Safety and Health Group.

Writing the protocol: DH, HR, JP, AH, TD, SR, SG, BM‐J

Providing general advice on the protocol: DH, HR, JP, AH, TD, SR, SG, BM‐J.

Undertaking the meta‐analyses: SGe, TD, DH

Writing the review: SGe, DH, HR, TD, JP, AH, SR, SG, BM‐J

Sources of support

Internal sources.

A career grant awarded to the first author by the Fonds de recherche du Québec–Institut Robert‐Sauvé en Santé et Sécurité au Travail

External sources

No external source of support

Declarations of interest

Steve Geoffrion: none known.

Danny Hills: none known.

Heather Ross: none known.

Therese Dalsbø: none known.

Jacqueline Pich: none known.

April Hill: none known.

Sanaz Riahi: none known.

Begoña Martínez‐Jarreta: none known.

Stephane Guay: none known.

References to studies included in this review

Anderson 2006 {published data only}.

• Anderson C. Training efforts to reduce reports of workplace violence in a community health care facility . Journal of Professional Nursing 2006; 22 ( 5 ):289-95. [DOI: 10.1016/j.profnurs.2006.07.007] [ PubMed ] [ CrossRef ] [ Google Scholar ]

Arnetz 2000 {published data only}

• Arnetz JE, Arnetz BB. Implementation and evaluation of a practical intervention programme for dealing with violence towards health care workers . Journal of Advanced Nursing 2000; 3 ( 3 ):668-80. [ PubMed ] [ Google Scholar ]

Fitzwater 2002 {published data only}

• Fitzwater EL, Gates DM. Testing an intervention to reduce assaults on nursing assistants in nursing homes: a pilot study . Geriatric Nursing 2002; 23 ( 1 ):18-23. [ PubMed ] [ Google Scholar ]

Irvine 2007 {published data only}

• Irvine AB, Bourgeois M, Billow M, Seeley JR. Internet training for nurse aides to prevent resident aggression . Journal of the American Medical Directors Association 2007; 8 ( 8 ):519-26. [ PMC free article ] [ PubMed ] [ Google Scholar ]

Irvine 2012a {published data only}

• Irvine AB, Billow MB, Gates DM, Fitzwater EL, Seeley JR, Bourgeois M. Internet training to respond to aggressive resident behaviors . The Gerontologist 2012; 52 ( 1 ):13-23. [DOI: 10.1093/geront/gnr069] [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]

Irvine 2012b {published data only}

• Irvine B, Billow MB, Gates DM, Fitzwater EL, Seeley JR, Bourgeois M. An internet training to reduce assaults in long-term care . Geriatric Nursing 2012; 33 ( 1 ):28-40. [ PMC free article ] [ PubMed ] [ Google Scholar ]

Ming 2019 {published data only}

• Ming JL, Tseng LH, Huang HM, Hong SP, Chang CI, Tung CY. Clinical simulation teaching program to promote the effectiveness of nurses in coping with workplace violence [臨床情境模擬教學促進護理人員因應職場暴力之成效研究]. Journal of Nursing 2019; 66 ( 3 ):59-71. [ PubMed ] [ Google Scholar ]

Needham 2005 {published data only}

• Needham I, Abderhalden C, Halfens RJ, Dassen T, Haug HJ, Fischer JE. The effect of a training course in aggression management on mental health nurses' perceptions of aggression: a cluster randomised controlled trial . International Journal of Nursing Studies 2005; 42 ( 6 ):649-55. [DOI: 10.1016/j.ijnurstu.2004.10.003] [ PubMed ] [ CrossRef ] [ Google Scholar ]

Whittington 1996 {published data only}

• Whittington R, Wykes T. An evaluation of staff training in psychological techniques for the management of patient aggression . Journal of Clinical Nursing 1996; 5 ( 4 ):257-61. [ PubMed ] [ Google Scholar ]

References to studies excluded from this review

Adams 2017 {published data only}.

• Adams J, Knowles A, Irons G, Roddy A, Ashworth J. Assessing the effectiveness of clinical education to reduce the frequency and recurrence of workplace violence . Australian Journal of Advanced Nursing 2017; 34 ( 3 ):6-15. [ Google Scholar ]

Beech 2003 {published data only}

• Beech B, Leather P. Evaluating a management of aggression unit for student nurses . Journal of Advanced Nursing 2003; 44 ( 6 ):603-12. [ PubMed ] [ Google Scholar ]

Beech 2008 {published data only}

• Beech B. Aggression prevention training for student nurses: differential responses to training and the interaction between theory and practice . Nurse Education in Practice 2008; 8 ( 2 ):94-102. [DOI: 10.1016/j.nepr.2007.04.004] [ PubMed ] [ CrossRef ] [ Google Scholar ]

Cailhol 2007 {published data only}

• Cailhol L, Allen M, Moncany AH, Cicotti A, Virgillito S, Barbe RP, et al. Violent behavior of patients admitted in emergency following drug suicidal attempt: a specific staff educational crisis intervention . General Hospital Psychiatry 2007; 29 ( 1 ):42-4. [DOI: 10.1016/j.genhosppsych.2006.10.007] [ PubMed ] [ CrossRef ] [ Google Scholar ]

Casalino 2015 {published data only}

• Casalino E, Choquet C, Thomas S, Erhel S, Cossard P. Violence in the emergency department: evaluation of a policy to reduce violence in one university emergency department in the Paris area . Annales Francaises de Medecine d'Urgence 2015; 5 ( 4 ):226-37. [ Google Scholar ]

Cooper 2006 {published data only}

• Cooper C, Eslinger DM, Stolley PD. Hospital-based violence intervention programs work . Journal of Trauma 2006; 61 ( 3 ):534-7. [DOI: 10.1097/01.ta.0000236576.81860.8c] [ PubMed ] [ CrossRef ] [ Google Scholar ]

Fernandes 2002 {published data only}

• Fernandes CM, Raboud JM, Christenson JM, Bouthillette F, Bullock L, Ouellet L, et al. The effect of an education program on violence in the emergency department . Annals of Emergency Medicine 2002; 39 ( 1 ):47-55. [ PubMed ] [ Google Scholar ]

Gates 2013 {published data only}

• Gates DM. A multi-site intervention to reduce violence in hospital emergency departments: final grant report. Grant Number R01-OH-009544 . National Institute for Occupational Safety and Health 2013. [http://www.cdc.gov/niosh/nioshtic-2/20045211.html]

Gerdtz 2012 {published data only}

• Gerdtz MF, Daniel C, Dearie V. An evaluation of a novel training program for preventing occupational violence in emergency departments. Abstract from the 14th International Conference on Emergency Medicine . Academic Emergency Medicine 2012; 19 ( 6 ):751-2. [ Google Scholar ]

Gertz 1980 {published data only}

• Gertz B. Training for prevention of assaultive behavior in a psychiatric setting . Hospital and Community Psychiatry 1980; 31 ( 9 ):628-30. [ PubMed ] [ Google Scholar ]

Gillespie 2013 {published data only}

• Gillespie GL, Gates DM, Mentzel T, Al-Natour A, Kowalenko T. Evaluation of a comprehensive ED violence prevention program . Journal of Emergency Nursing 2013; 39 ( 4 ):376-83. [DOI: 10.1016/j.jen/2012.12.010] [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]

Gillespie 2014 {published data only}

• Gillespie GL, Gates DM, Kowalenko T, Bresler S, Succop P. Implementation of a comprehensive intervention to reduce physical assaults and threats in the emergency department . Journal of Emergency Nursing 2014; 40 ( 6 ):586-91. [DOI: 10.1016/j.jen/2014.01.003] [ PubMed ] [ CrossRef ] [ Google Scholar ]

Ishak 2002 {published data only}

• Ishak M, Christensen M. Achieving a better management for patients' aggressive behaviour: evaluation of a training program . Journal of Occupational Health and Safety–Australia and New Zealand 2002; 18 ( 3 ):231-7. [ Google Scholar ]

Kang 2017 {published data only}

• Kang J, Kim JI, Yun S. Effects of a cognitive rehearsal program on interpersonal relationships, workplace bullying, symptom experience, and turnover intention among nurses: a randomized controlled trial . Journal of Korean Academy of Nursing 2017; 47 ( 5 ):689-99. [ PubMed ] [ Google Scholar ]

Kim 2018 {published data only}

• Hyejin K, Ji-Su K, Kwisoon C, Yeunhee K, Jae-seok S. Mediating effects of workplace violence on the relationships between emotional labour and burnout among clinical nurses . Journal of Advanced Nursing 2018; 74 :2331-9. [ PubMed ] [ Google Scholar ]

Kowalenko 2014 {published data only}

• Kowalenko T, Gates D, Gillespie G, Succop P. Implementation of a comprehensive intervention to violence against health care workers in the emergency department. Abstract from the 2014 Society for Academic Emergency Medicine Annual Meeting . In: Academic Emergency Medicine . Vol. 21(Suppl S1). 2014:S306.

Li 2018 {published data only}

• Li P, Xing K, Qiao H, Fang H, Ma H, Jiao M, et al. Psychological violence against general practitioners and nurses in Chinese township hospitals: incidence and implications . Health and Quality of Life Outcomes 2018; 16 ( 1 ):117-26. [ PMC free article ] [ PubMed ] [ Google Scholar ]

Lipscomb 2004a {published data only}

• Lipscomb JA, Rosen J, McPhaul K. Violence prevention in the mental healthcare setting: evaluation of an intervention based on OSHA guidelines . In: Presentation to the American Public Health Association 132nd Annual Meeting and Exposition, Washington, DC . 2004. [http://apha.confex.com/apha/132am/techprogram/paper_88020.htm]

Lipscomb 2004b {published data only}

• Lipscomb JA, Soeken K, Rosen J, McPaul K, Choi M, Geiger B, et al. Evaluation of OSHA violence prevention guidelines in mental health. Final report. Grant-Number-R01-OH-004051 . National Institute for Occupational Safety and Health 2004. [http://www.cdc.gov/niosh/nioshtic-2/20029678.html]

Lipscomb 2006 {published data only}

• Lipscomb J, McPhaul K, Rosen J, Brown JG, Choi M, Soeken K, et al. Violence prevention in the mental health setting: the New York State experience . Canadian Journal of Nursing Research 2006; 38 ( 4 ):96-117. [ PubMed ] [ Google Scholar ]

McElaney 2008 {published data only}

• McElaney LA. Workplace violence training for nurses. Final report. Grant-Number-R43-OH-009180 . National Institute for Occupational Safety and Health 2008. [http://www.cdc.gov/niosh/nioshtic-2/20044849.html]

McIntosh 2003 {unpublished data only}

• McIntosh D. Testing an intervention to increase self-efficacy of staff in managing clients perceived as violent [PhD thesis]. . Cincinnati (USA): University of Cincinnati, 2003. [ Google Scholar ]

Meehan 2006 {published data only}

• Meehan T, Fjeldsoe K, Stedman T, Duraiappah V. Reducing aggressive behaviour and staff injuries: a multi-strategy approach . Australian Health Review 2006; 30 ( 2 ):203-10. [ PubMed ] [ Google Scholar ]

Ore 2002 {published data only}

• Ore T. Workplace assault management training: an outcome evaluation . Journal of Healthcare Protection Management 2002; 18 ( 2 ):61-93. [ PubMed ] [ Google Scholar ]

Peek‐Asa 2002 {published data only}

• Peek-Asa C, Cubbin L, Hubbell K. Violent events and security programs in California emergency departments before and after the 1993 Hospital Security Act . Journal of Emergency Nursing 2002; 28 ( 5 ):420-78. [ PubMed ] [ Google Scholar ]

Rittenmeyer 2013 {published data only}

• Rittenmeyer L, Huffman D, Hopp L, Block M. A comprehensive systematic review on the experience of lateral/horizontal violence in the profession of nursing . JBI Database of Systematic Reviews and Implementation Reports 2013; 11 ( 11 ):362-468. [ Google Scholar ]

Shah 1998 {published data only}

• Shah A, De T. The effect of an educational intervention package about aggressive behaviour directed at the nursing staff on a continuing care psychogeriatric ward . International Journal of Geriatric Psychiatry 1998; 13 ( 1 ):35-40. [ PubMed ] [ Google Scholar ]

Vousden 1987 {published data only}

• Vousden M. Are you safe? Nursing Times 1987; 83 ( 26 ):28-30. [ PubMed ] [ Google Scholar ]

Additional references

Anderson 2010.

• Anderson L, FitzGerald M, Luck L. An integrative literature review of interventions to reduce violence against emergency department nurses . Journal of Clinical Nursing 2010; 19 ( 17-18 ):2520-30. [ PubMed ] [ Google Scholar ]

Arimatsu 2008

• Arimatsu M, Wada K, Yoshikawa T, Oda S, Taniguchi H, Aizawa Y, et al. An epidemiological study of work-related violence experienced by physicians who graduated from a medical school in Japan . Journal of Occupational Health 2008; 50 ( 4 ):357-61. [ PubMed ] [ Google Scholar ]

Arnetz 2001

• Arnetz JE, Arnetz BB. Violence toward health care staff and possible effects on the quality of patient care . Social Science & Medicine 2001; 52 ( 3 ):417-27. [ PubMed ] [ Google Scholar ]

Arnetz 2015

• Arnetz JE, Hamblin L, Ager J, Luborsky M, Upfal MJ, Russell J, et al. Underreporting of workplace violence: comparison of self-report and actual documentation of hospital incidents . Workplace Health & Safety 2015; 63 ( 5 ):200-10. [DOI: ] [ PMC free article ] [ PubMed ] [ Google Scholar ]

Atawneh 2003

• Atawneh F, Zahid M, Al-Sahlawi K, Shahid A, Al-Farrah M. Violence against nurses in hospitals: prevalence and effects . British Journal of Nursing 2003; 12 ( 2 ):102-7. [ PubMed ]
• Beech B, Leather P. Workplace violence in the health care sector: a review of staff training and integration of training evaluation models . Aggression and Violent Behavior: A Review Journal 2006; 11 ( 1 ):27-43. [DOI: 10.1016/j.avb.2005.05.004] [ CrossRef ] [ Google Scholar ]

Bowers 2006

• Bowers L, Nijman H, Allan T, Simpson A, Warren J, Turner LR. Prevention and management of aggression training and violent incidents on UK acute psychiatric wards . Psychiatric Services 2006; 57 ( 7 ):1022-6. [ PubMed ]

Briggs 2003

• Briggs F, Broadhurst D, Hawkins R. Violence, threats and intimidation in the lives of professionals whose work involves child protection. A report on a research project funded by the Australian Criminology Research Council. CRC 15/01-02, 2003 . crg.aic.gov.au/reports/200102-15.pdf (accessed August 2, 2015).
• Brown LP, Rospenda KM, Sokas RK, Conroy L, Freels S, Swanson NG. Evaluating the association of workplace psychosocial stressors with occupational injury, illness, and assault . Journal of Occupational and Environmental Hygiene 2011; 8 ( 1 ):31-7. [ PMC free article ] [ PubMed ]

Bulatao 1996

• Bulatao EQ, VandenBos GR. Workplace violence: its scope and issues. In: VandenBos GR, Bulatao EQ, editors(s). Violence on the Job: Identifying Risks and Developing Solutions . Washington, DC: American Psychological Association, 1996:1-23. [ Google Scholar ]

Camerino 2008

• Camerino D, Estryn-Behar M, Conway PM, Der Heijden BIJM, Hasselhorn H-M. Work-related factors and violence among nursing staff in the European NEXT study: a longitudinal cohort study . International Journal of Nursing Studies 2008; 45 ( 1 ):35-50. [ PubMed ]

Campbell 2001

• Campbell MK, Mollison J, Grimshaw JM. Cluster trials in implementation research: estimation of intracluster correlation coefficients and sample size . Statistics in Medicine 2001; 20 ( 3 ):391-9. [ PubMed ] [ Google Scholar ]

Campbell 2011

• Campbell JC, Messing JT, Kub J, Agnew J, Fitzgerald S, Fowler B, et al. Workplace violence: prevalence and risk factors in the safe at work study . Journal of Occupational & Environmental Medicine 2011; 53 ( 1 ):82-9. [ PubMed ]

Carluccio 2010

• Carluccio A, Knychala V, Marshall C. Violence against frontline NHS staff: research study conducted for COI on behalf of the NHS Security Management Service . London: NHS Security Management Service, 2010 .

Ceramidas 2010

• Ceramidas DM, Parker R. A response to patient-initiated aggression in general practice: Australian professional medical organisations face a challenge . Australian Journal of Primary Health 2010; 16 ( 3 ):252-9. [ PubMed ]

Chappell 2006

• Chappell D, di Martino V. Violence at Work . 3rd edition. Geneva: International Labour Office, 2006. [ Google Scholar ]
• Child RJ, Mentes JC. Violence against women: the phenomenon of violence against nurses . Issues in Mental Health Nursing 2010; 31 ( 2 ):89-95. [DOI: 10.3109/01612840903267638] [ PubMed ] [ CrossRef ] [ Google Scholar ]

Cookson 2012

• Cookson H, Buckley P. Violence at Work: Findings From the 2010/11 British Crime Survey . London: Health Service Executive, 2012. [ Google Scholar ]

di Martino 2002

• di Martino V. Workplace violence in the health sector. Country case studies in Brazil, Bulgaria, Lebanon, Portugal, South Africa, Thailand and an additional Australian study. Synthesis report . Geneva: International Labour Office, International Council of Nurses, World Health Organization and Public Services International. Joint Programme on Workplace Violence in the Health Sector, 2002 .

di Martino 2005

• di Martino V. A cross-national comparison of workplace violence and response strategies. In: Bowie V, Fisher BS, Cooper CL, editors(s). Workplace Violence: Issues, Trends, Strategies . Cullompton, UK: Willan Publishing, 2005:15-36. [ Google Scholar ]
• Downs SH, Black N. The feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non-randomised studies of health care interventions . Journal of Epidemiology and Community Health 1998; 52 ( 6 ):377-84. [ PMC free article ] [ PubMed ] [ Google Scholar ]

Dupré 2014

• Dupré KE, Dawe KA, Barling J. Harm to those who serve: effects of direct and vicarious customer-initiated workplace aggression . Journal of Interpersonal Violence 2014; 29 ( 13 ):2355-77. [DOI: 10.1177/0886260513518841] [ PubMed ] [ CrossRef ] [ Google Scholar ]

Duxbury 2002

• Duxbury J. An evaluation of staff and patient views of and strategies employed to manage inpatient aggression and violence on one mental health unit: a pluralistic design . Journal of Psychiatric and Mental Health Nursing 2002; 9 ( 3 ):325-37. [ PubMed ] [ Google Scholar ]

Duxbury 2008

• Duxbury J, Hahn S, Needham I, Pulsford D. The Management of Aggression and Violence Attitude Scale (MAVAS): a cross‐national comparative study . Journal of Advanced Nursing 2008; 62 ( 5 ):596-606. [DOI: 10.1111/j.1365-2648.2008.04629.x] [ PubMed ] [ CrossRef ] [ Google Scholar ]

Estrada 2010

• Estrada F, Nilsson A, Jerre K, Wikman S. Violence at work—the emergence of a social problem . Journal of Scandinavian Studies in Criminology and Crime Prevention 2010; 11 ( 1 ):46-65.

Farrell 2005

• Farrell G, Cubit K. Nurses under threat: a comparison of content of 28 aggression management programs . International Journal of Mental Health Nursing 2005; 14 :44-53. [ PubMed ]

Farrell 2006

• Farrell GA, Bobrowski C, Bobrowski P. Scoping workplace aggression in nursing: findings from an Australian study . Journal of Advanced Nursing 2006; 55 ( 6 ):778-87. [ PubMed ]

Farrell 2010

• Farrell GA, Shafiei T, Salmon P. Facing up to ‘challenging behaviour’: a model for training in staff-client interaction . Journal of Advanced Nursing 2010; 66 ( 7 ):1644-55. [ PubMed ]

Flannery 2001

• Flannery RB. The employee victim of violence: recognizing the impact of untreated psychological trauma . American Journal of Alzheimer's Disease and Other Dementias 2001; 16 ( 4 ):230-3. [ PMC free article ] [ PubMed ]
• Frank E, Brogan D, Schiffman M. Prevalence and correlates of harassment among US women physicians . Archives of Internal Medicine 1998; 158 ( 4 ):352-8. [ PubMed ]

Gascón 2009

• Gascón S, Martínez-Jarreta B, González-Andrade JF, Santed Mlod Y, Rueda MA. Aggression towards health care workers in Spain: a multi-facility study to evaluate the distribution of growing violence among professionals, health facilities and departments . International Journal of Occupational and Environmental Health 2009; 15 ( 1 ):29-35. [ PubMed ] [ Google Scholar ]
• Gates DM, Gillespie G, Smith C, Rode J, Kowalenko T, Smith B. Using action research to plan a violence prevention program for emergency departments . Journal of Emergency Nursing 2011; 37 ( 1 ):32-9. [ PubMed ]

Gerberich 2004

• Gerberich SG, Church TR, McGovern PM, Hansen HD, Nachreiner NM, Geisser MS, et al. An epidemiological study of the magnitude and consequences of work related violence: the Minnesota Nurses' Study . Occupational and Environmental Medicine 2004; 61 ( 6 ):495-503. [ PMC free article ] [ PubMed ]

Gerdtz 2013

• Gerdtz MF, Daniel C, Dearie V, Prematunga R, Bamert M, Duxbury J. The outcome of a rapid training program on nurses' attitudes regarding the prevention of aggression in emergency departments: a multi-site evaluation . International Journal of Nursing Studies 2013; 50 ( 11 ):1434-45. [DOI: 10.1016/j.ijnurstu.2013.01.007] [ PubMed ] [ CrossRef ] [ Google Scholar ]

GRADEPro 2014 [Computer program]

• McMaster University GRADEpro [Computer program on www.gradepro.org] . Hamilton, ON: McMaster University, 2014.
• Guay S, Goncalves J, Jarvis J. Verbal violence in the workplace according to victims' sex—a systematic review of the literature . Aggression and Violent Behaviour 2014; 19 ( 5 ):572-8. [DOI: 10.1016/j.avb.2014.08.001] [ CrossRef ] [ Google Scholar ]
• Hahn S, Zeller A, Needham I, Kok G, Dassen T, Halfens RJG. Patient and visitor violence in general hospitals: a systematic review of the literature . Aggression and Violent Behavior 2008; 13 ( 6 ):431-41.
• Hahn S, Müller M, Needham I, Dassen T, Kok G, Halfens RJ. Factors associated with patient and visitor violence experienced by nurses in general hospitals in Switzerland: a cross-sectional survey . Journal of Clinical Nursing 2010; 19 ( 23-24 ):3535-46. [DOI: 10.1111/j.1365-2702.2010.03361.x] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Hahn S, Müller M, Hantikainen V, Kok G, Dassen T, Halfens RJ. Risk factors associated with patient and visitor violence in general hospitals: results of a multiple regression analysis . Journal of International Nursing Studies 2013; 50 ( 3 ):374-85. [DOI: 10.1016/j.ijnurstu.2012.09.018] [ PubMed ] [ CrossRef ] [ Google Scholar ]

Harrell 2011

• Harrell E. Workplace Violence, 1993-2009: National Crime Victimization Survey and the Census of Fatal Occupational Injuries. NCJ 233231 . Washington: Bureau of Justice Statistics, 2011 .

Heckemann 2015

• Heckemann B, Zeller A, Hahn S, Dassen T, Schols JM, Halfens RJ. The effect of aggression management training programmes for nursing staff and students working in an acute hospital setting. A narrative review of current literature . Nurse Education Today 2015; 35 ( 1 ):212-9. [DOI: 10.1016/j.nedt.2014.08.003] [ PubMed ] [ CrossRef ] [ Google Scholar ]

Hegney 2006

• Hegney D, Eley R, Plank A, Buikstra E, Parker V. Workplace violence in Queensland, Australia: the results of a comparative study . International Journal of Nursing Practice 2006; 12 ( 4 ):220-31. [ PubMed ]

Heponiemi 2014

• Heponiemi T, Kouvonen A, Virtanen M, Vänskä J, Elovainio M. The prospective effects of workplace violence on physicians' job satisfaction and turnover intentions: the buffering effect of job control . BMC Health Services Research 2014; 14 ( 19 ):1-8. [DOI: 10.1186/1472-6963-14-19] [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Health Policy and Economic Research Unit, British Medical Association. Violence at Work: The Experience of UK Doctors . London: British Medical Association, 2003 .
• Health Policy and Economic Research Unit, British Medical Association. Violence in the Workplace: The Experience of Doctors in Great Britain . London: British Medical Association, 2008 .

Hershcovis 2010

• Hershcovis MS, Barling J. Toward a multi-focal approach to workplace aggression: a meta-analytic review of outcomes from different perpetrators . Journal of Organizational Behavior 2010; 31 ( 1 ):24-44.

Higgins 2011

• Higgins JPT, Green S (editors). Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 (updated March 2011). Cochrane, 2011 . Available from www.cochrane-handbook.org .
• Hills D. Relationships between aggression management training, perceived self-efficacy and rural general hospital nurses' experiences of patient aggression . Contemporary Nurse 2008; 31 ( 1 ):20-31. [ PubMed ]
• Hills D, Joyce C, Humphreys J. A national study of workplace aggression in Australian clinical medical practice . Medical Journal of Australia 2012; 197 ( 6 ):336-40. [ PubMed ]
• Hills D, Joyce C. A review of research on the prevalence, antecedents, consequences and prevention of workplace aggression in clinical medical practice . Aggression and Violent Behavior: A Review Journal 2013; 18 ( 5 ):554-69.
• Hills D, Joyce C. Workplace aggression in clinical medical practice: associations with job satisfaction, life satisfaction and self-rated health . Medical Journal of Australia 2014; 201 ( 9 ):535-40. [ PubMed ] [ Google Scholar ]
• Hills D, Lam L, Hills S. Workplace aggression experiences and responses of Victorian nurses, midwives and care personnel . Collegian 2018; 25 ( 6 ):575-82. [DOI: 10.1016/j.colegn.2018.09.003] [ CrossRef ] [ Google Scholar ]

Hinduja 2007

• Hinduja S. Workplace violence and negative affective responses: a test of Agnew's general strain theory . Journal of Criminal Justice 2007; 35 ( 6 ):657-66. [0047-2352]

Hodgson 2004

• Hodgson MJ, Reed R, Craig T, Murphy F, Lehmann L, Belton L, et al. Violence in healthcare facilities: lessons from the Veterans Health Administration . Journal of Occupational & Environmental Medicine 2004; 46 ( 11 ):1158-65. [ PubMed ]
• Hogh A, Henriksson M, Burr H. A 5-year follow-up study of aggression at work and psychological health . International Journal of Behavioral Medicine 2005; 12 ( 4 ):256-65. [1070-5503] [ PubMed ]
• Hogh A, Viitasara E. A systematic review of longitudinal studies of nonfatal workplace violence . European Journal of Work & Organizational Psychology 2005; 14 ( 3 ):291-313. [1359432X]
• Joint Programme on Workplace Violence in the Health Sector. Framework Guidelines for Addressing Workplace Violence in the Health Sector . Geneva: International Labour Office, 2002 .
• International Labour Organization Sectoral Activities Programme. Code of Practice on Workplace Violence in Services Sectors and Measures to Combat This Phenomenon . Geneva: International Labour Organization, 2003 .

Jansen 1997

• Jansen G, Dassen T, Moorer P. The perception of aggression . Scandinavian Journal of Caring Sciences 1997; 11 ( 1 ):51-5. [ PubMed ] [ Google Scholar ]
• Judy K, Veselik J. Workplace violence: a survey of paediatric residents . Occupational Medicine 2009; 59 ( 7 ):472-5. [ PubMed ]
• Kable A, Guest M, McLeod M. Resistance to care: contributing factors and associated behaviours in healthcare facilities . Journal of Advanced Nursing 2012; 69 ( 8 ):1747-60. [ PubMed ]

Kansagra 2008

• Kansagra SM, Rao SR, Sullivan AF, Gordon JA, Magid DJ, Kaushal R, et al. A survey of workplace violence across 65 U.S. emergency departments . Academic Emergency Medicine 2008; 15 ( 12 ):1268-74. [1553-2712] [ PMC free article ] [ PubMed ]
• Kvas A, Seljak J. Unreported workplace violence in nursing . International Nursing Review 2014; 61 ( 3 ):344-51. [DOI: 10.1111/inr.12106] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Laker C, Gray R, Flach C. Case study evaluating the impact of de-escalation and physical intervention training . Journal of Psychiatric and Mental Health Nursing 2010; 17 ( 3 ):222-8. [ PubMed ]

Lanctôt 2014

• Lanctôt N, Guay S. The aftermath of workplace violence among healthcare workers: a systematic literature review of the consequences . Aggression and Violent Behavior 2014; 19 ( 5 ):492-501. [DOI: 10.1016/j.avb.2014.07.010] [ CrossRef ] [ Google Scholar ]

Lapierre 2005

• Lapierre LM, Spector PE, Leck JD. Sexual versus nonsexual workplace aggression and victims' overall job satisfaction: a meta-analysis . Journal of Occupational Health Psychology 2005; 10 ( 2 ):155-69. [ PubMed ] [ Google Scholar ]

Laschinger 2014

• Laschinger HK. Impact of workplace mistreatment on patient safety risk and nurse-assessed patient outcomes . Journal of Nursing Administration 2014; 44 ( 5 ):284-90. [DOI: 10.1097/NNA.0000000000000068] [ PubMed ] [ CrossRef ] [ Google Scholar ]

LeBlanc 2002

• LeBlanc MM, Kelloway EK. Predictors and outcomes of workplace violence and aggression . Journal of Applied Psychology 2002; 87 ( 3 ):444-53. [ PubMed ]

LeBlanc 2006

• LeBlanc MM, Dupre KE, Barling J. Public-initiated violence. In: Kelloway EK, Barling J, Hurrell Jr JJ, editors(s). Handbook of Workplace Violence . Thousand Oaks: Sage Publications, Inc, 2006:261-80. [ Google Scholar ]
• Lewis SE, Orford J. Women's experiences of workplace bullying: changes in social relationships . Journal of Community & Applied Social Psychology 2005; 15 ( 1 ):29-47.

Livingston 2010

• Livingston JD, Verdun-Jones S, Brink J, Lussier P, Nicholls T. A narrative review of the effectiveness of aggression management training programs for psychiatric hospital staff . Journal of Forensic Nursing 2010; 6 ( 1 ):15-28. [ PubMed ]

Martínez‐Jarreta 2007

• Martínez-Jarreta B, Gascón S, Santed MA, Goicoechea J. Medical-legal analysis of aggression towards health professionals. An approach to a silent reality and its consequences on health [Análisis médico-legal de las agresiones a profesionales sanitarios. Aproximación a una realidad silenciosa y a sus consecuencias para la salud]. Medicina Clínica 2007; 128 ( 8 ):307-10. [ PubMed ] [ Google Scholar ]

Mayhew 2000

• Mayhew C. Preventing Client Initiated Violence: A Practical Handbook . Canberra: Australian Institute of Criminology, 2000 .

Mayhew 2001

• Mayhew C, Chappell D. Prevention of occupational violence in the health workforce. Working paper series 140 . Taskforce on the Prevention and Management of Violence in the Health Workplace, Discussion Paper No. 2. Sydney: School of Industrial Relations and Organizational Behaviour and Industrial Relations Research Centre, University of New South Wales, 2001 .

Mayhew 2004

• Mayhew C. Occupational violence/bullying in the health industry. In: McCarthy P, Mayhew C, editors(s). Safeguarding the Organization Against Violence and Bullying: An International Perspective . Houndmills, UK: Oalgrave Macmillan, 2004:110-28. [ Google Scholar ]

Mayhew 2007

• Mayhew C, Chappell D. Workplace violence: an overview of patterns of risk and the emotional/stress consequences on targets . International Journal of Law and Psychiatry 2007; 30 ( 4-5 ):327-39. [ PubMed ]

McCarthy 2004

• McCarthy P. The safeguarding challenge. In: McCarthy P, Mayhew C, editors(s). Safeguarding the Organization Against Violence and Bullying: An International Perspective . Houndmills, UK: Oalgrave Macmillan, 2004:1-16. [ Google Scholar ]

Nachreiner 2005

• Nachreiner NM, Gerberich SG, McGovern PM, Church TR, Hansen HE, Geisser MS, et al. Impact of training on work-related assault . Research in Nursing & Health 2005; 28 ( 1 ):67-78. [ PubMed ]

Needham 2004

• Needham I, Abderhalden C, Dassen T, Haug HJ, Fischer JE. The perception of aggression by nurses: psychometric scale testing and derivation of a short instrument . Journal of Psychiatric and Mental Health Nursing 2004; 11 ( 1 ):36-42. [ PubMed ] [ Google Scholar ]

Needham 2005

• Needham I, Abderhalden C, Halfens RJ, Dassen T, Haug HJ, Fischer JE. The effect of a training course in aggression management on mental health nurses' perceptions of aggression: a cluster randomised controlled trial . International Journal of Nursing Studies 2005; 42 ( 6 ):649-55. [ PubMed ] [ Google Scholar ]

Needham 2005a

• Needham I, Abderhalden C, Halfens RJG, Dassen T, Haug H-J, Fischer JE. The Impact of Patient Aggression on Carers Scale: instrument derivation and psychometric testing . Scandinavian Journal of Caring Sciences 2005; 19 ( 3 ):296-300. [ PubMed ] [ Google Scholar ]
• National Institute for Health and Clinical Excellence. Violence Clinical Practice Guidelines: The Short-Term Management of Disturbed/Violent Behaviour in In-Patient Psychiatric Settings and Emergency Departments . London: Royal College of Nursing, 2006 . [ PubMed ]

Niedhammer 2009

• Niedhammer I, David S, Degioanni S, Drummond A, Philip P. Workplace bullying and sleep disturbances: findings from a large scale cross-sectional survey in the French working population . Sleep 2009; 32 ( 9 ):1211-9. [ PMC free article ] [ PubMed ]

O'Brien‐Pallas 2009

• O'Brien-Pallas L, Wang S, Hayes L, Laporte D. Creating work environments that are violence free . World Hospitals and Health Services 2009; 45 ( 2 ):12-8. [ PubMed ]
• Occupational Safety and Health Administration, US Department of Labor. Guidelines for Preventing Workplace Violence for Health Care & Social Service Workers . Washington: US Department of Labor, 2004 .

Packham 2011

• Packham C. Violence at Work: Findings From the 2009/10 British Crime Survey . London: Health Service Executive, 2011 .
• Paice E, Smith D. Bullying of trainee doctors is a patient safety issue . The Clinical Teacher 2009; 6 ( 1 ):13-7. [DOI: 10.1111/j.1743-498X.2008.00251.x] [ CrossRef ] [ Google Scholar ]

Parent‐Thirion 2007

• Parent-Thirion A, Marcias EF, Hurley J, Vermeylen G. Fourth European Working Conditions Survey . Dublin: European Foundation for the Improvement of Living and Working Conditions, 2007 .

Parker 2010

• Parker RM, Ceramidas DM, Forrest LE, Herath PM, McRae I. Patient initiated aggression and violence in the Australian general practice setting . Canberra: The Australian Primary Health Care Institute, 2010 .

Piquero 2013

• Piquero NL, Piquero AR, Craig JM, Clipper SJ. Assessing research on workplace violence, 2000–2012 . Aggression and Violent Behavior 2013; 18 ( 3 ):383-94. [ Google Scholar ]
• Price O, Baker J, Bee P, Lovell K. Learning and performance outcomes of mental health staff training in de-escalation techniques for the management of violence and aggression . British Journal of Psychiatry 2015; 206 ( 6 ):447-55. [DOI: 10.1192/bjp.bp.114.144576] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Ray EB, Miller KI. Social support, home/work stress, and burnout: Who can help? Journal of Applied Behavioral Science 1994; 30 ( 3 ):357-73. [ Google Scholar ]

RevMan 5.3 [Computer program]

• The Nordic Cochrane Centre, The Cochrane Collaboration Review Manager (RevMan). . The Nordic Cochrane Centre, The Cochrane Collaboration, Version 5.3. Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration, 2014.

RevMan Web 2019 [Computer program]

• Review Manager Web . Cochrane, 2019. Available at revman.cochrane.org.

Richter 2006

• Richter D, Needham I, Kunz S. The effects of aggression management training for mental health care and disability care staff: a systematic review. In: Richter D, Whittington R, editors(s). Violence in Mental Health Settings . New York: Spring Science and Business Media, LLC, 2006:211-27. [ Google Scholar ]
• Roche M, Diers D, Duffield C, Catling-Paull C. Violence toward nurses, the work environment, and patient outcomes . Journal of Nursing Scholarship 2010; 42 ( 1 ):13-22. [ PubMed ]

Rosenstein 2008

• Rosenstein AH, O'Daniel M. A survey of the impact of disruptive behaviors and communication defects on patient safety . Joint Commission Journal on Quality and Patient Safety 2008; 34 ( 8 ):464-71. [ PubMed ] [ Google Scholar ]

Spector 2014

• Spector PE, Zhou ZE, Che XX. Nurse exposure to physical and nonphysical violence, bullying, and sexual harassment: a quantitative review . International Journal of Nursing Studies 2014; 51 :72-84. [ PubMed ]

Spelten 2020

• Spelten  E, Thomas  B, O'Meara  PF, Maguire  BJ, FitzGerald  D, Begg  SJ. Organisational interventions for preventing and minimising aggression directed towards healthcare workers by patients and patient advocates. . Cochrane Database of Systematic Reviews 2020; 4 :E-pub. [DOI: DOI: 10.1002/14651858.CD012662.pub2.] [ PMC free article ] [ PubMed ] [ Google Scholar ]

Spencer 2018

• Spencer S, Johnson P, Smith I. De‐escalation techniques for managing non‐psychosis induced aggression in adults . Cochrane Database of Systematic Reviews 18 July 2018, Issue 7 . Art. No: CD012034. [DOI: 10.1002/14651858.CD012034.pub2] [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]

Straus 1979

• Straus MA. Measuring intrafamily violence and conflict: the Conflict Tactics (CT) Scale . Journal of Marriage and Family 1979; 41 :75-88. [ Google Scholar ]

Taylor 2010

• Taylor JL, Rew L. A systematic review of the literature: workplace violence in the emergency department . Journal of Clinical Nursing 2010; 20 :1072-85. [ PubMed ]

Ventura‐Madangeng 2009

• Ventura-Madangeng J, Wilson D. Workplace aggression experienced by registered nurses: a concept analysis . Nursing Praxis in New Zealand 2009; 25 ( 3 ):37-50. [ PubMed ] [ Google Scholar ]

Viitasara 2002

• Viitasara E, Menckel E. Developing a framework for identifying individual and organizational risk factors for the prevention of violence in the health-care sector . Work 2002; 19 ( 2 ):117-23. [ PubMed ]

Viitasara 2003

• Viitasara E, Sverke M, Menckel E. Multiple risk factors for violence to seven occupational groups in the Swedish caring sector . Industrial Relations 2003; 58 ( 2 ):202-31.

Whittington 2002

• Whittington R, Higgins L. More than zero tolerance? Burnout and tolerance for patient aggression amongst mental health nurses in China and the UK . Acta Psychiatrica Scandinavica 2002; 106 :37-40. [ PubMed ] [ Google Scholar ]

Wieclaw 2006

• Wieclaw J, Agerbo E, Mortensen PB, Burr H, Tüchsen F, Bonde JP. Work related violence and threats and the risk of depression and stress disorders . Journal of Epidemiology and Community Health 2006; 60 ( 9 ):771-5. [ PMC free article ] [ PubMed ]

Wiskow 2003

• Wiskow C. Guidelines on Workplace Violence in the Health Sector. Comparison of Major Known National Guidelines and Strategies: United Kingdom, Australia, Sweden, USA (OSHA and California) . Geneva: World Health Organization, 2003 .
• Wyatt GE, Riederle M. The prevalence and context of sexual harassment among African American and White American women . Journal of Interpersonal Violence 1995; 10 ( 3 ):309-21. [ Google Scholar ]

Jump to navigation

• Bahasa Malaysia

Do education and training programs reduce aggressive behavior toward healthcare workers?

What is aggressive behavior?

The International Labour Organization uses the term "workplace violence" defined as "any action, incident or behaviour that departures from reasonable conduct in which a person is threatened, harmed, injured in the course of, or as a direct result of, his or her work". Experiencing aggressive behavior at work can affect people's ability to do their job well, can cause physical and mental health problems, and can also affect home life. Aggressive behavior may lead to absences from work; some people might leave their job if they experience aggressive behavior.

Why we did this Cochrane Review

Aggressive behavior exhibited by patients and their families, friends, and carers is a serious problem for healthcare workers. It may affect the quality and safety of the care that healthcare workers can provide.

Education and training programs have been developed to try to reduce—or eliminate—aggressive behavior at work. These programs are intended to teach and train healthcare workers about:

• their organization's policies and procedures;

• how to assess risks; and

• strategies to control or reduce the chances—and effects—of experiencing aggressive behavior.

What did we do?

We searched for studies that investigated how well education and training programs prevented or reduced aggression toward healthcare workers.

We included randomized controlled studies, in which the programs that people received were decided at random and studies in which effects of a program were measured before and after among people who completed the program and in another group of people who did not take part.

We wanted to know if education and training programs could:

• reduce the number of incidents of aggressive behavior in healthcare workplaces;

• improve healthcare workers' knowledge, skills, and attitudes toward aggressive behavior; and

• reduce any personal adverse (unwanted or negative) effects noted among healthcare workers who experienced aggressive behavior.

Search date: we included evidence published up to June 2020.

What we found

We found nine studies including 1688 healthcare workers (including healthcare support staff, such as receptionists) who worked with patients and patients' families, friends, and carers. These studies compared the effects of receiving an education and training program to the effects of not receiving such a program.

Studies were conducted in hospitals or healthcare centers (four studies), in psychiatric wards (two studies), and in long-term care centers (three studies) in the United States, Switzerland, the United Kingdom, Sweden, and Taiwan.

All programs combined education with training provided either online (four studies) or face-to-face (five studies). In eight studies, the people taking part were followed for up to three months (short-term), and in one study for over one year (long-term).

What are the results of our review?

Education and training programs did not reduce the number of reports of aggressive behavior toward healthcare workers (five studies), possibly because these programs made healthcare workers more likely to report these incidents.

An education and training program might improve healthcare workers’ knowledge of aggressive behavior in the workplace in the short term (one study), but we are uncertain whether this would be a long-term effect (one study).

Education programs might improve healthcare workers' attitudes toward aggressive behavior in the short term (five studies), although these results varied depending on the type and length of the program provided.

Education programs might not affect healthcare workers' skills in dealing with aggressive behavior (two studies) and might not affect whether unwanted or negative personal effects were noted after healthcare workers experienced aggressive behavior (one study).

How reliable are these results?

We are not confident in the results of our review because these results were reported from a small number of studies—some with small numbers of participants—and because some studies showed large differences in results. We identified problems involving the ways some studies were designed, conducted, and reported. Our results are likely to change if further evidence should become available.

Key message

Although an education and training program might increase healthcare workers' knowledge and positive attitudes, such a program might not affect the number of incidents of aggressive behavior that healthcare workers experience.

More studies are needed, particularly in healthcare workplaces with high rates of aggressive behavior.

Education combined with training may not have an effect on workplace aggression directed toward healthcare workers, even though education and training may increase personal knowledge and positive attitudes. Better quality studies that focus on specific settings of healthcare work where exposure to patient aggression is high are needed. Moreover, as most studies have assessed episodes of aggression toward nurses, future studies should include other types of healthcare workers who are also victims of aggression in the same settings, such as orderlies (healthcare assistants). Studies should especially use reports of aggression at an institutional level and should rely on multi-source data while relying on validated measures. Studies should also include days lost to sick leave and employee turnover and should measure outcomes at one-year follow-up. Studies should specify the duration and type of delivery of education and should use an active comparison to prevent raising awareness and reporting in the intervention group only.

Workplace aggression constitutes a serious issue for healthcare workers and organizations. Aggression is tied to physical and mental health issues at an individual level, as well as to absenteeism, decreased productivity or quality of work, and high employee turnover rates at an organizational level. To counteract these negative impacts, organizations have used a variety of interventions, including education and training, to provide workers with the knowledge and skills needed to prevent aggression. 

To assess the effectiveness of education and training interventions that aim to prevent and minimize workplace aggression directed toward healthcare workers by patients and patient advocates.

CENTRAL, MEDLINE, Embase, six other databases and five trial registers were searched from their inception to June 2020 together with reference checking, citation searching and contact with study authors to identify additional studies.

Randomized controlled trials (RCTs), cluster-randomized controlled trials (CRCTs), and controlled before and after studies (CBAs) that investigated the effectiveness of education and training interventions targeting aggression prevention for healthcare workers.

Four review authors evaluated and selected the studies resulting from the search. We used standard methodological procedures expected by Cochrane. We assessed the certainty of evidence using the GRADE approach.

We included nine studies—four CRCTs, three RCTs, and two CBAs—with a total of 1688 participants. Five studies reported episodes of aggression, and six studies reported secondary outcomes. Seven studies were conducted among nurses or nurse aides, and two studies among healthcare workers in general. Three studies took place in long-term care, two in the psychiatric ward, and four in hospitals or health centers. Studies were reported from the United States, Switzerland, the United Kingdom, Taiwan, and Sweden.

All included studies reported on education combined with training interventions. Four studies evaluated online programs, and five evaluated face-to-face programs. 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). Seven studies were rated as being at "high" risk of bias in multiple domains, and all had "unclear" risk of bias in a single domain or in multiple domains.

Effects on aggression

Short-term follow-up

The evidence is very uncertain about effects of education and training on aggression at short-term follow-up compared to no intervention (standardized mean difference [SMD] -0.33, 95% confidence interval [CI] -1.27 to 0.61, 2 CRCTs; risk ratio [RR] 2.30, 95% CI 0.97 to 5.42, 1 CBA; SMD -1.24, 95% CI -2.16 to -0.33, 1 CBA; very low-certainty evidence).

Long-term follow-up

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 have an effect on 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).

Measurements of these concepts showed high heterogeneity.

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings
• My Bibliography
• Collections
• Citation manager

Save citation to file

Email citation, add to collections.

• Create a new collection
• Add to an existing collection

Add to My Bibliography

Your saved search, create a file for external citation management software, your rss feed.

• Search in PubMed
• Search in NLM Catalog
• Add to Search

Education and training for preventing and minimizing workplace aggression directed toward healthcare workers

Affiliations.

• 1 École de psychoéducation, Université de Montreal, Montreal, Canada.
• 2 School of Health, Federation University, Ballarat, Australia.
• 3 Edson College of Nursing and Health Innovation, Arizona State University, Phoenix, AZ, USA.
• 4 Faculty of Health, University of Technology Sydney, Ultimo, Australia.
• 5 College of Nursing and Health Innovation, Arizona State University, Phoenix, AZ, USA.
• 6 Norwegian Institute of Public Health, Oslo, Norway.
• 7 Ontario Shores Centre for Mental Health Sciences, Whitby, Canada.
• 8 Department of Psychiatry, University of Toronto, Toronto, Canada.
• 9 Faculty of Medicine, University of Zaragoza, Zaragoza, Spain.
• 10 School of Criminology, University of Montreal, Montreal, Canada.
• PMID: 32898304
• PMCID: PMC8094156
• DOI: 10.1002/14651858.CD011860.pub2

Background: Workplace aggression constitutes a serious issue for healthcare workers and organizations. Aggression is tied to physical and mental health issues at an individual level, as well as to absenteeism, decreased productivity or quality of work, and high employee turnover rates at an organizational level. To counteract these negative impacts, organizations have used a variety of interventions, including education and training, to provide workers with the knowledge and skills needed to prevent aggression. OBJECTIVES: To assess the effectiveness of education and training interventions that aim to prevent and minimize workplace aggression directed toward healthcare workers by patients and patient advocates.

Search methods: CENTRAL, MEDLINE, Embase, six other databases and five trial registers were searched from their inception to June 2020 together with reference checking, citation searching and contact with study authors to identify additional studies.

Selection criteria: Randomized controlled trials (RCTs), cluster-randomized controlled trials (CRCTs), and controlled before and after studies (CBAs) that investigated the effectiveness of education and training interventions targeting aggression prevention for healthcare workers.

Data collection and analysis: Four review authors evaluated and selected the studies resulting from the search. We used standard methodological procedures expected by Cochrane. We assessed the certainty of evidence using the GRADE approach.

Main results: We included nine studies-four CRCTs, three RCTs, and two CBAs-with a total of 1688 participants. Five studies reported episodes of aggression, and six studies reported secondary outcomes. Seven studies were conducted among nurses or nurse aides, and two studies among healthcare workers in general. Three studies took place in long-term care, two in the psychiatric ward, and four in hospitals or health centers. Studies were reported from the United States, Switzerland, the United Kingdom, Taiwan, and Sweden. All included studies reported on education combined with training interventions. Four studies evaluated online programs, and five evaluated face-to-face programs. 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). Seven studies were rated as being at "high" risk of bias in multiple domains, and all had "unclear" risk of bias in a single domain or in multiple domains. Effects on aggression Short-term follow-up The evidence is very uncertain about effects of education and training on aggression at short-term follow-up compared to no intervention (standardized mean difference [SMD] -0.33, 95% confidence interval [CI] -1.27 to 0.61, 2 CRCTs; risk ratio [RR] 2.30, 95% CI 0.97 to 5.42, 1 CBA; SMD -1.24, 95% CI -2.16 to -0.33, 1 CBA; very low-certainty evidence). Long-term follow-up 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 have an effect on 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). Measurements of these concepts showed high heterogeneity.

Authors' conclusions: Education combined with training may not have an effect on workplace aggression directed toward healthcare workers, even though education and training may increase personal knowledge and positive attitudes. Better quality studies that focus on specific settings of healthcare work where exposure to patient aggression is high are needed. Moreover, as most studies have assessed episodes of aggression toward nurses, future studies should include other types of healthcare workers who are also victims of aggression in the same settings, such as orderlies (healthcare assistants). Studies should especially use reports of aggression at an institutional level and should rely on multi-source data while relying on validated measures. Studies should also include days lost to sick leave and employee turnover and should measure outcomes at one-year follow-up. Studies should specify the duration and type of delivery of education and should use an active comparison to prevent raising awareness and reporting in the intervention group only.

Copyright © 2020 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

PubMed Disclaimer

Conflict of interest statement

Steve Geoffrion: none known.

Danny Hills: none known.

Heather Ross: none known.

Therese Dalsbø: none known.

Jacqueline Pich: none known.

April Hill: none known.

Sanaz Riahi: none known.

Begoña Martínez‐Jarreta: none known.

Stephane Guay: none known.

Figure 1. Prisma flow diagram of…

Figure 1. Prisma flow diagram of search and screening results.

Figure 2. Review author's judgement about…

Figure 2. Review author's judgement about Risk of bias by Cochrane Collaboration's tool for…

Figure 3. Review author's judgement about…

Figure 3. Review author's judgement about Risk of bias by Cochrane Collaboration's tool for…

1.1. Analysis

Comparison 1: Number of episodes…

Comparison 1: Number of episodes of aggression, Outcome 1: CRCT short‐term follow‐up

1.2. Analysis

Comparison 1: Number of episodes of aggression, Outcome 2: CBA short‐term follow‐up

1.3. Analysis

Comparison 1: Number of episodes of aggression, Outcome 3: CBA short‐term follow‐up

1.4. Analysis

Comparison 1: Number of episodes of aggression, Outcome 4: CRCT long‐term follow‐up

2.1. Analysis

Comparison 2: Personal knowledge about…

Comparison 2: Personal knowledge about aggression, Outcome 1: Knowledge about aggression (RCT/CRCT)—short‐term follow‐up

2.2. Analysis

Comparison 2: Personal knowledge about aggression, Outcome 2: Knowledge about aggression (RCT/CRCT)—long‐term follow‐up

3.1. Analysis

Comparison 3: Attitudes, Outcome 1:…

Comparison 3: Attitudes, Outcome 1: Attitudes (RCT/CRCT)—short‐term follow‐up

4.1. Analysis

Comparison 4: Skills, Outcome 1:…

Comparison 4: Skills, Outcome 1: Skills (RCT/CRCT)—short‐term follow‐up

5.1. Analysis

Comparison 5: Adverse personal outcomes,…

Comparison 5: Adverse personal outcomes, Outcome 1: Adverse personal (RCT/CRCT)—short‐term follow‐up

• doi: 10.1002/14651858.CD011860

Similar articles

• Organisational interventions for preventing and minimising aggression directed towards healthcare workers by patients and patient advocates. Spelten E, Thomas B, O'Meara PF, Maguire BJ, FitzGerald D, Begg SJ. Spelten E, et al. Cochrane Database Syst Rev. 2020 Apr 29;4(4):CD012662. doi: 10.1002/14651858.CD012662.pub2. Cochrane Database Syst Rev. 2020. PMID: 32352565 Free PMC article.
• Training healthcare providers to respond to intimate partner violence against women. Kalra N, Hooker L, Reisenhofer S, Di Tanna GL, García-Moreno C. Kalra N, et al. Cochrane Database Syst Rev. 2021 May 31;5(5):CD012423. doi: 10.1002/14651858.CD012423.pub2. Cochrane Database Syst Rev. 2021. PMID: 34057734 Free PMC article.
• Individual-level interventions for reducing occupational stress in healthcare workers. Tamminga SJ, Emal LM, Boschman JS, Levasseur A, Thota A, Ruotsalainen JH, Schelvis RM, Nieuwenhuijsen K, van der Molen HF. Tamminga SJ, et al. Cochrane Database Syst Rev. 2023 May 12;5(5):CD002892. doi: 10.1002/14651858.CD002892.pub6. Cochrane Database Syst Rev. 2023. PMID: 37169364 Free PMC article. Review.
• Workplace interventions for increasing standing or walking for decreasing musculoskeletal symptoms in sedentary workers. Parry SP, Coenen P, Shrestha N, O'Sullivan PB, Maher CG, Straker LM. Parry SP, et al. Cochrane Database Syst Rev. 2019 Nov 17;2019(11):CD012487. doi: 10.1002/14651858.CD012487.pub2. Cochrane Database Syst Rev. 2019. PMID: 31742666 Free PMC article.
• Behavioural interventions to promote workers' use of respiratory protective equipment. Luong Thanh BY, Laopaiboon M, Koh D, Sakunkoo P, Moe H. Luong Thanh BY, et al. Cochrane Database Syst Rev. 2016 Dec 7;12(12):CD010157. doi: 10.1002/14651858.CD010157.pub2. Cochrane Database Syst Rev. 2016. PMID: 27925149 Free PMC article. Review.
• Organizational characteristics of highly specialized units for people with dementia and severe challenging behavior. van Voorden G, Koopmans RTCM, Strik-Lips MM, Smalbrugge M, Zuidema SU, van den Brink AMA, Persoon A, Oude Voshaar RC, Gerritsen DL. van Voorden G, et al. BMC Geriatr. 2024 Aug 14;24(1):681. doi: 10.1186/s12877-024-05257-x. BMC Geriatr. 2024. PMID: 39143456
• Critical Care Nurses' Perceptions of Abuse and Its Impact on Healthy Work Environments in Five European Countries: A Cross-Sectional Study. Friganović A, Slijepčević J, Režić S, Cristina Alfonso-Arias C, Borzuchowska M, Constantinescu-Dobra A, Coțiu MA, Estel Curado-Santos E, Dobrowolska B, AGutysz-Wojnicka A, Hadjibalassi M, Laurado-Serra M, Sabou A, Georgiou E. Friganović A, et al. Int J Public Health. 2024 May 10;69:1607026. doi: 10.3389/ijph.2024.1607026. eCollection 2024. Int J Public Health. 2024. PMID: 38800831 Free PMC article.
• Behavioral skills training for teaching safety skills to mental health service providers compared to training-as-usual: a pragmatic randomized control trial. Lin E, Malhas M, Bratsalis E, Thomson K, Hargreaves F, Donner K, Baig H, Boateng R, Swain R, Benadict MB, Busch L. Lin E, et al. BMC Health Serv Res. 2024 May 17;24(1):639. doi: 10.1186/s12913-024-10994-1. BMC Health Serv Res. 2024. PMID: 38760754 Free PMC article. Clinical Trial.
• Guardians of health under fire: Understanding and combating violence against doctors. Yücel Özden KB, Sarıca Çevik H, Asenova R, Ungan M. Yücel Özden KB, et al. Aten Primaria. 2024 Apr 27;56(9):102944. doi: 10.1016/j.aprim.2024.102944. Online ahead of print. Aten Primaria. 2024. PMID: 38678853 Free PMC article.
• Understanding context of violence against healthcare through citizen science and evaluating the effectiveness of a co-designed code of conduct and of a tailored de-escalation of violence training in Eastern Democratic Republic of Congo and Iraq: a study protocol for a stepped wedge randomized controlled trial. Ferrari G, Lwamushi SM, Balaluka GB, Lafta RK, Schindler C, Bugugu D, Lurhangire E, Tediosi F, Mendoza JR, Merten S. Ferrari G, et al. Trials. 2023 Dec 19;24(1):814. doi: 10.1186/s13063-023-07839-3. Trials. 2023. PMID: 38110997 Free PMC article.

References to studies included in this review

Anderson 2006 {published data only}.

• Anderson C. Training efforts to reduce reports of workplace violence in a community health care facility. Journal of Professional Nursing 2006;22(5):289-95. [DOI: 10.1016/j.profnurs.2006.07.007] - DOI - PubMed

Arnetz 2000 {published data only}

• Arnetz JE, Arnetz BB. Implementation and evaluation of a practical intervention programme for dealing with violence towards health care workers. Journal of Advanced Nursing 2000;3(3):668-80. - PubMed

Fitzwater 2002 {published data only}

• Fitzwater EL, Gates DM. Testing an intervention to reduce assaults on nursing assistants in nursing homes: a pilot study. Geriatric Nursing 2002;23(1):18-23. - PubMed

Irvine 2007 {published data only}

• Irvine AB, Bourgeois M, Billow M, Seeley JR. Internet training for nurse aides to prevent resident aggression. Journal of the American Medical Directors Association 2007;8(8):519-26. - PMC - PubMed

Irvine 2012a {published data only}

• Irvine AB, Billow MB, Gates DM, Fitzwater EL, Seeley JR, Bourgeois M. Internet training to respond to aggressive resident behaviors. The Gerontologist 2012;52(1):13-23. [DOI: 10.1093/geront/gnr069] - DOI - PMC - PubMed

Irvine 2012b {published data only}

• Irvine B, Billow MB, Gates DM, Fitzwater EL, Seeley JR, Bourgeois M. An internet training to reduce assaults in long-term care. Geriatric Nursing 2012;33(1):28-40. - PMC - PubMed

Ming 2019 {published data only}

• Ming JL, Tseng LH, Huang HM, Hong SP, Chang CI, Tung CY. Clinical simulation teaching program to promote the effectiveness of nurses in coping with workplace violence [臨床情境模擬教學促進護理人員因應職場暴力之成效研究]. Journal of Nursing 2019;66(3):59-71. - PubMed

Needham 2005 {published data only}

• Needham I, Abderhalden C, Halfens RJ, Dassen T, Haug HJ, Fischer JE. The effect of a training course in aggression management on mental health nurses' perceptions of aggression: a cluster randomised controlled trial. International Journal of Nursing Studies 2005;42(6):649-55. [DOI: 10.1016/j.ijnurstu.2004.10.003] - DOI - PubMed

Whittington 1996 {published data only}

• Whittington R, Wykes T. An evaluation of staff training in psychological techniques for the management of patient aggression. Journal of Clinical Nursing 1996;5(4):257-61. - PubMed

References to studies excluded from this review

Adams 2017 {published data only}.

• Adams J, Knowles A, Irons G, Roddy A, Ashworth J. Assessing the effectiveness of clinical education to reduce the frequency and recurrence of workplace violence. Australian Journal of Advanced Nursing 2017;34(3):6-15.

Beech 2003 {published data only}

• Beech B, Leather P. Evaluating a management of aggression unit for student nurses. Journal of Advanced Nursing 2003;44(6):603-12. - PubMed

Beech 2008 {published data only}

• Beech B. Aggression prevention training for student nurses: differential responses to training and the interaction between theory and practice. Nurse Education in Practice 2008;8(2):94-102. [DOI: 10.1016/j.nepr.2007.04.004] - DOI - PubMed

Cailhol 2007 {published data only}

• Cailhol L, Allen M, Moncany AH, Cicotti A, Virgillito S, Barbe RP, et al. Violent behavior of patients admitted in emergency following drug suicidal attempt: a specific staff educational crisis intervention. General Hospital Psychiatry 2007;29(1):42-4. [DOI: 10.1016/j.genhosppsych.2006.10.007] - DOI - PubMed

Casalino 2015 {published data only}

• Casalino E, Choquet C, Thomas S, Erhel S, Cossard P. Violence in the emergency department: evaluation of a policy to reduce violence in one university emergency department in the Paris area. Annales Francaises de Medecine d'Urgence 2015;5(4):226-37.

Cooper 2006 {published data only}

• Cooper C, Eslinger DM, Stolley PD. Hospital-based violence intervention programs work. Journal of Trauma 2006;61(3):534-7. [DOI: 10.1097/01.ta.0000236576.81860.8c] - DOI - PubMed

Fernandes 2002 {published data only}

• Fernandes CM, Raboud JM, Christenson JM, Bouthillette F, Bullock L, Ouellet L, et al. The effect of an education program on violence in the emergency department. Annals of Emergency Medicine 2002;39(1):47-55. - PubMed

Gates 2013 {published data only}

• Gates DM. A multi-site intervention to reduce violence in hospital emergency departments: final grant report. Grant Number R01-OH-009544. National Institute for Occupational Safety and Health 2013. [ http://www.cdc.gov/niosh/nioshtic-2/20045211.html ]

Gerdtz 2012 {published data only}

• Gerdtz MF, Daniel C, Dearie V. An evaluation of a novel training program for preventing occupational violence in emergency departments. Abstract from the 14th International Conference on Emergency Medicine. Academic Emergency Medicine 2012;19(6):751-2.

Gertz 1980 {published data only}

• Gertz B. Training for prevention of assaultive behavior in a psychiatric setting. Hospital and Community Psychiatry 1980;31(9):628-30. - PubMed

Gillespie 2013 {published data only}

• Gillespie GL, Gates DM, Mentzel T, Al-Natour A, Kowalenko T. Evaluation of a comprehensive ED violence prevention program. Journal of Emergency Nursing 2013;39(4):376-83. [DOI: 10.1016/j.jen/2012.12.010] - DOI - PMC - PubMed

Gillespie 2014 {published data only}

• Gillespie GL, Gates DM, Kowalenko T, Bresler S, Succop P. Implementation of a comprehensive intervention to reduce physical assaults and threats in the emergency department. Journal of Emergency Nursing 2014;40(6):586-91. [DOI: 10.1016/j.jen/2014.01.003] - DOI - PubMed

Ishak 2002 {published data only}

• Ishak M, Christensen M. Achieving a better management for patients' aggressive behaviour: evaluation of a training program. Journal of Occupational Health and Safety–Australia and New Zealand 2002;18(3):231-7.

Kang 2017 {published data only}

• Kang J, Kim JI, Yun S. Effects of a cognitive rehearsal program on interpersonal relationships, workplace bullying, symptom experience, and turnover intention among nurses: a randomized controlled trial. Journal of Korean Academy of Nursing 2017;47(5):689-99. - PubMed

Kim 2018 {published data only}

• Hyejin K, Ji-Su K, Kwisoon C, Yeunhee K, Jae-seok S. Mediating effects of workplace violence on the relationships between emotional labour and burnout among clinical nurses. Journal of Advanced Nursing 2018;74:2331-9. - PubMed

Kowalenko 2014 {published data only}

• Kowalenko T, Gates D, Gillespie G, Succop P. Implementation of a comprehensive intervention to violence against health care workers in the emergency department. Abstract from the 2014 Society for Academic Emergency Medicine Annual Meeting. In: Academic Emergency Medicine. Vol. 21(Suppl S1). 2014:S306.

Li 2018 {published data only}

• Li P, Xing K, Qiao H, Fang H, Ma H, Jiao M, et al. Psychological violence against general practitioners and nurses in Chinese township hospitals: incidence and implications. Health and Quality of Life Outcomes 2018;16(1):117-26. - PMC - PubMed

Lipscomb 2004a {published data only}

• Lipscomb JA, Rosen J, McPhaul K. Violence prevention in the mental healthcare setting: evaluation of an intervention based on OSHA guidelines. In: Presentation to the American Public Health Association 132nd Annual Meeting and Exposition, Washington, DC. 2004. [ http://apha.confex.com/apha/132am/techprogram/paper_88020.htm ]

Lipscomb 2004b {published data only}

• Lipscomb JA, Soeken K, Rosen J, McPaul K, Choi M, Geiger B, et al. Evaluation of OSHA violence prevention guidelines in mental health. Final report. Grant-Number-R01-OH-004051. National Institute for Occupational Safety and Health 2004. [ http://www.cdc.gov/niosh/nioshtic-2/20029678.html ]

Lipscomb 2006 {published data only}

• Lipscomb J, McPhaul K, Rosen J, Brown JG, Choi M, Soeken K, et al. Violence prevention in the mental health setting: the New York State experience. Canadian Journal of Nursing Research 2006;38(4):96-117. - PubMed

McElaney 2008 {published data only}

• McElaney LA. Workplace violence training for nurses. Final report. Grant-Number-R43-OH-009180. National Institute for Occupational Safety and Health 2008. [ http://www.cdc.gov/niosh/nioshtic-2/20044849.html ]

McIntosh 2003 {unpublished data only}

• McIntosh D. Testing an intervention to increase self-efficacy of staff in managing clients perceived as violent [PhD thesis].. Cincinnati (USA): University of Cincinnati, 2003.

Meehan 2006 {published data only}

• Meehan T, Fjeldsoe K, Stedman T, Duraiappah V. Reducing aggressive behaviour and staff injuries: a multi-strategy approach. Australian Health Review 2006;30(2):203-10. - PubMed

Ore 2002 {published data only}

• Ore T. Workplace assault management training: an outcome evaluation. Journal of Healthcare Protection Management 2002;18(2):61-93. - PubMed

Peek‐Asa 2002 {published data only}

• Peek-Asa C, Cubbin L, Hubbell K. Violent events and security programs in California emergency departments before and after the 1993 Hospital Security Act. Journal of Emergency Nursing 2002;28(5):420-78. - PubMed

Rittenmeyer 2013 {published data only}

• Rittenmeyer L, Huffman D, Hopp L, Block M. A comprehensive systematic review on the experience of lateral/horizontal violence in the profession of nursing. JBI Database of Systematic Reviews and Implementation Reports 2013;11(11):362-468.

Shah 1998 {published data only}

• Shah A, De T. The effect of an educational intervention package about aggressive behaviour directed at the nursing staff on a continuing care psychogeriatric ward. International Journal of Geriatric Psychiatry 1998;13(1):35-40. - PubMed

Vousden 1987 {published data only}

• Vousden M. Are you safe? Nursing Times 1987;83(26):28-30. - PubMed

Additional references

Anderson 2010.

• Anderson L, FitzGerald M, Luck L. An integrative literature review of interventions to reduce violence against emergency department nurses. Journal of Clinical Nursing 2010;19(17-18):2520-30. - PubMed

Arimatsu 2008

• Arimatsu M, Wada K, Yoshikawa T, Oda S, Taniguchi H, Aizawa Y, et al. An epidemiological study of work-related violence experienced by physicians who graduated from a medical school in Japan. Journal of Occupational Health 2008;50(4):357-61. - PubMed

Arnetz 2001

• Arnetz JE, Arnetz BB. Violence toward health care staff and possible effects on the quality of patient care. Social Science & Medicine 2001;52(3):417-27. - PubMed

Arnetz 2015

• Arnetz JE, Hamblin L, Ager J, Luborsky M, Upfal MJ, Russell J, et al. Underreporting of workplace violence: comparison of self-report and actual documentation of hospital incidents. Workplace Health & Safety 2015;63(5):200-10. [DOI: ] - PMC - PubMed

Atawneh 2003

• Atawneh F, Zahid M, Al-Sahlawi K, Shahid A, Al-Farrah M. Violence against nurses in hospitals: prevalence and effects. British Journal of Nursing 2003;12(2):102-7. - PubMed
• Beech B, Leather P. Workplace violence in the health care sector: a review of staff training and integration of training evaluation models. Aggression and Violent Behavior: A Review Journal 2006;11(1):27-43. [DOI: 10.1016/j.avb.2005.05.004] - DOI

Bowers 2006

• Bowers L, Nijman H, Allan T, Simpson A, Warren J, Turner LR. Prevention and management of aggression training and violent incidents on UK acute psychiatric wards. Psychiatric Services 2006;57(7):1022-6. - PubMed

Briggs 2003

• Briggs F, Broadhurst D, Hawkins R. Violence, threats and intimidation in the lives of professionals whose work involves child protection. A report on a research project funded by the Australian Criminology Research Council. CRC 15/01-02, 2003. crg.aic.gov.au/reports/200102-15.pdf (accessed August 2, 2015).
• Brown LP, Rospenda KM, Sokas RK, Conroy L, Freels S, Swanson NG. Evaluating the association of workplace psychosocial stressors with occupational injury, illness, and assault. Journal of Occupational and Environmental Hygiene 2011;8(1):31-7. - PMC - PubMed

Bulatao 1996

• Bulatao EQ, VandenBos GR. Workplace violence: its scope and issues. In: VandenBos GR, Bulatao EQ, editors(s). Violence on the Job: Identifying Risks and Developing Solutions. Washington, DC: American Psychological Association, 1996:1-23.

Camerino 2008

• Camerino D, Estryn-Behar M, Conway PM, Der Heijden BIJM, Hasselhorn H-M. Work-related factors and violence among nursing staff in the European NEXT study: a longitudinal cohort study. International Journal of Nursing Studies 2008;45(1):35-50. - PubMed

Campbell 2001

• Campbell MK, Mollison J, Grimshaw JM. Cluster trials in implementation research: estimation of intracluster correlation coefficients and sample size. Statistics in Medicine 2001;20(3):391-9. - PubMed

Campbell 2011

• Campbell JC, Messing JT, Kub J, Agnew J, Fitzgerald S, Fowler B, et al. Workplace violence: prevalence and risk factors in the safe at work study. Journal of Occupational & Environmental Medicine 2011;53(1):82-9. - PubMed

Carluccio 2010

• Carluccio A, Knychala V, Marshall C. Violence against frontline NHS staff: research study conducted for COI on behalf of the NHS Security Management Service. London: NHS Security Management Service, 2010.

Ceramidas 2010

• Ceramidas DM, Parker R. A response to patient-initiated aggression in general practice: Australian professional medical organisations face a challenge. Australian Journal of Primary Health 2010;16(3):252-9. - PubMed

Chappell 2006

• Chappell D, di Martino V. Violence at Work. 3rd edition. Geneva: International Labour Office, 2006.
• Child RJ, Mentes JC. Violence against women: the phenomenon of violence against nurses. Issues in Mental Health Nursing 2010;31(2):89-95. [DOI: 10.3109/01612840903267638] - DOI - PubMed

Cookson 2012

• Cookson H, Buckley P. Violence at Work: Findings From the 2010/11 British Crime Survey. London: Health Service Executive, 2012.

di Martino 2002

• di Martino V. Workplace violence in the health sector. Country case studies in Brazil, Bulgaria, Lebanon, Portugal, South Africa, Thailand and an additional Australian study. Synthesis report. Geneva: International Labour Office, International Council of Nurses, World Health Organization and Public Services International. Joint Programme on Workplace Violence in the Health Sector, 2002.

di Martino 2005

• di Martino V. A cross-national comparison of workplace violence and response strategies. In: Bowie V, Fisher BS, Cooper CL, editors(s). Workplace Violence: Issues, Trends, Strategies. Cullompton, UK: Willan Publishing, 2005:15-36.
• Downs SH, Black N. The feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non-randomised studies of health care interventions. Journal of Epidemiology and Community Health 1998;52(6):377-84. - PMC - PubMed
• Dupré KE, Dawe KA, Barling J. Harm to those who serve: effects of direct and vicarious customer-initiated workplace aggression. Journal of Interpersonal Violence 2014;29(13):2355-77. [DOI: 10.1177/0886260513518841] - DOI - PubMed

Duxbury 2002

• Duxbury J. An evaluation of staff and patient views of and strategies employed to manage inpatient aggression and violence on one mental health unit: a pluralistic design. Journal of Psychiatric and Mental Health Nursing 2002;9(3):325-37. - PubMed

Duxbury 2008

• Duxbury J, Hahn S, Needham I, Pulsford D. The Management of Aggression and Violence Attitude Scale (MAVAS): a cross‐national comparative study. Journal of Advanced Nursing 2008;62(5):596-606. [DOI: 10.1111/j.1365-2648.2008.04629.x] - DOI - PubMed

Estrada 2010

• Estrada F, Nilsson A, Jerre K, Wikman S. Violence at work—the emergence of a social problem. Journal of Scandinavian Studies in Criminology and Crime Prevention 2010;11(1):46-65.

Farrell 2005

• Farrell G, Cubit K. Nurses under threat: a comparison of content of 28 aggression management programs. International Journal of Mental Health Nursing 2005;14:44-53. - PubMed

Farrell 2006

• Farrell GA, Bobrowski C, Bobrowski P. Scoping workplace aggression in nursing: findings from an Australian study. Journal of Advanced Nursing 2006;55(6):778-87. - PubMed

Farrell 2010

• Farrell GA, Shafiei T, Salmon P. Facing up to ‘challenging behaviour’: a model for training in staff-client interaction. Journal of Advanced Nursing 2010;66(7):1644-55. - PubMed

Flannery 2001

• Flannery RB. The employee victim of violence: recognizing the impact of untreated psychological trauma. American Journal of Alzheimer's Disease and Other Dementias 2001;16(4):230-3. - PubMed
• Frank E, Brogan D, Schiffman M. Prevalence and correlates of harassment among US women physicians. Archives of Internal Medicine 1998;158(4):352-8. - PubMed

Gascón 2009

• Gascón S, Martínez-Jarreta B, González-Andrade JF, Santed Mlod Y, Rueda MA. Aggression towards health care workers in Spain: a multi-facility study to evaluate the distribution of growing violence among professionals, health facilities and departments. International Journal of Occupational and Environmental Health 2009;15(1):29-35. - PubMed
• Gates DM, Gillespie G, Smith C, Rode J, Kowalenko T, Smith B. Using action research to plan a violence prevention program for emergency departments. Journal of Emergency Nursing 2011;37(1):32-9. - PubMed

Gerberich 2004

• Gerberich SG, Church TR, McGovern PM, Hansen HD, Nachreiner NM, Geisser MS, et al. An epidemiological study of the magnitude and consequences of work related violence: the Minnesota Nurses' Study. Occupational and Environmental Medicine 2004;61(6):495-503. - PMC - PubMed

Gerdtz 2013

• Gerdtz MF, Daniel C, Dearie V, Prematunga R, Bamert M, Duxbury J. The outcome of a rapid training program on nurses' attitudes regarding the prevention of aggression in emergency departments: a multi-site evaluation. International Journal of Nursing Studies 2013;50(11):1434-45. [DOI: 10.1016/j.ijnurstu.2013.01.007] - DOI - PubMed

GRADEPro 2014 [Computer program]

• McMaster University GRADEpro [Computer program on www.gradepro.org ]. Hamilton, ON: McMaster University, 2014.
• Guay S, Goncalves J, Jarvis J. Verbal violence in the workplace according to victims' sex—a systematic review of the literature. Aggression and Violent Behaviour 2014;19(5):572-8. [DOI: 10.1016/j.avb.2014.08.001] - DOI
• Hahn S, Zeller A, Needham I, Kok G, Dassen T, Halfens RJG. Patient and visitor violence in general hospitals: a systematic review of the literature. Aggression and Violent Behavior 2008;13(6):431-41.
• Hahn S, Müller M, Needham I, Dassen T, Kok G, Halfens RJ. Factors associated with patient and visitor violence experienced by nurses in general hospitals in Switzerland: a cross-sectional survey. Journal of Clinical Nursing 2010;19(23-24):3535-46. [DOI: 10.1111/j.1365-2702.2010.03361.x] - DOI - PubMed
• Hahn S, Müller M, Hantikainen V, Kok G, Dassen T, Halfens RJ. Risk factors associated with patient and visitor violence in general hospitals: results of a multiple regression analysis. Journal of International Nursing Studies 2013;50(3):374-85. [DOI: 10.1016/j.ijnurstu.2012.09.018] - DOI - PubMed

Harrell 2011

• Harrell E. Workplace Violence, 1993-2009: National Crime Victimization Survey and the Census of Fatal Occupational Injuries. NCJ 233231. Washington: Bureau of Justice Statistics, 2011.

Heckemann 2015

• Heckemann B, Zeller A, Hahn S, Dassen T, Schols JM, Halfens RJ. The effect of aggression management training programmes for nursing staff and students working in an acute hospital setting. A narrative review of current literature. Nurse Education Today 2015;35(1):212-9. [DOI: 10.1016/j.nedt.2014.08.003] - DOI - PubMed

Hegney 2006

• Hegney D, Eley R, Plank A, Buikstra E, Parker V. Workplace violence in Queensland, Australia: the results of a comparative study. International Journal of Nursing Practice 2006;12(4):220-31. - PubMed

Heponiemi 2014

• Heponiemi T, Kouvonen A, Virtanen M, Vänskä J, Elovainio M. The prospective effects of workplace violence on physicians' job satisfaction and turnover intentions: the buffering effect of job control. BMC Health Services Research 2014;14(19):1-8. [DOI: 10.1186/1472-6963-14-19] - DOI - PMC - PubMed
• Health Policy and Economic Research Unit, British Medical Association. Violence at Work: The Experience of UK Doctors. London: British Medical Association, 2003.
• Health Policy and Economic Research Unit, British Medical Association. Violence in the Workplace: The Experience of Doctors in Great Britain. London: British Medical Association, 2008.

Hershcovis 2010

• Hershcovis MS, Barling J. Toward a multi-focal approach to workplace aggression: a meta-analytic review of outcomes from different perpetrators. Journal of Organizational Behavior 2010;31(1):24-44.

Higgins 2011

• Higgins JPT, Green S (editors). Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 (updated March 2011). Cochrane, 2011. Available from www.cochrane-handbook.org .
• Hills D. Relationships between aggression management training, perceived self-efficacy and rural general hospital nurses' experiences of patient aggression. Contemporary Nurse 2008;31(1):20-31. - PubMed
• Hills D, Joyce C, Humphreys J. A national study of workplace aggression in Australian clinical medical practice. Medical Journal of Australia 2012;197(6):336-40. - PubMed
• Hills D, Joyce C. A review of research on the prevalence, antecedents, consequences and prevention of workplace aggression in clinical medical practice. Aggression and Violent Behavior: A Review Journal 2013;18(5):554-69.
• Hills D, Joyce C. Workplace aggression in clinical medical practice: associations with job satisfaction, life satisfaction and self-rated health. Medical Journal of Australia 2014;201(9):535-40. - PubMed
• Hills D, Lam L, Hills S. Workplace aggression experiences and responses of Victorian nurses, midwives and care personnel. Collegian 2018;25(6):575-82. [DOI: 10.1016/j.colegn.2018.09.003] - DOI

Hinduja 2007

• Hinduja S. Workplace violence and negative affective responses: a test of Agnew's general strain theory. Journal of Criminal Justice 2007;35(6):657-66. [0047-2352]

Hodgson 2004

• Hodgson MJ, Reed R, Craig T, Murphy F, Lehmann L, Belton L, et al. Violence in healthcare facilities: lessons from the Veterans Health Administration. Journal of Occupational & Environmental Medicine 2004;46(11):1158-65. - PubMed
• Hogh A, Henriksson M, Burr H. A 5-year follow-up study of aggression at work and psychological health. International Journal of Behavioral Medicine 2005;12(4):256-65. [1070-5503] - PubMed
• Hogh A, Viitasara E. A systematic review of longitudinal studies of nonfatal workplace violence. European Journal of Work & Organizational Psychology 2005;14(3):291-313. [1359432X]
• Joint Programme on Workplace Violence in the Health Sector. Framework Guidelines for Addressing Workplace Violence in the Health Sector. Geneva: International Labour Office, 2002.
• International Labour Organization Sectoral Activities Programme. Code of Practice on Workplace Violence in Services Sectors and Measures to Combat This Phenomenon. Geneva: International Labour Organization, 2003.

Jansen 1997

• Jansen G, Dassen T, Moorer P. The perception of aggression. Scandinavian Journal of Caring Sciences 1997;11(1):51-5. - PubMed
• Judy K, Veselik J. Workplace violence: a survey of paediatric residents. Occupational Medicine 2009;59(7):472-5. - PubMed
• Kable A, Guest M, McLeod M. Resistance to care: contributing factors and associated behaviours in healthcare facilities. Journal of Advanced Nursing 2012;69(8):1747-60. - PubMed

Kansagra 2008

• Kansagra SM, Rao SR, Sullivan AF, Gordon JA, Magid DJ, Kaushal R, et al. A survey of workplace violence across 65 U.S. emergency departments. Academic Emergency Medicine 2008;15(12):1268-74. [1553-2712] - PMC - PubMed
• Kvas A, Seljak J. Unreported workplace violence in nursing. International Nursing Review 2014;61(3):344-51. [DOI: 10.1111/inr.12106] - DOI - PubMed
• Laker C, Gray R, Flach C. Case study evaluating the impact of de-escalation and physical intervention training. Journal of Psychiatric and Mental Health Nursing 2010;17(3):222-8. - PubMed

Lanctôt 2014

• Lanctôt N, Guay S. The aftermath of workplace violence among healthcare workers: a systematic literature review of the consequences. Aggression and Violent Behavior 2014;19(5):492-501. [DOI: 10.1016/j.avb.2014.07.010] - DOI

Lapierre 2005

• Lapierre LM, Spector PE, Leck JD. Sexual versus nonsexual workplace aggression and victims' overall job satisfaction: a meta-analysis. Journal of Occupational Health Psychology 2005;10(2):155-69. - PubMed

Laschinger 2014

• Laschinger HK. Impact of workplace mistreatment on patient safety risk and nurse-assessed patient outcomes. Journal of Nursing Administration 2014;44(5):284-90. [DOI: 10.1097/NNA.0000000000000068] - DOI - PubMed

LeBlanc 2002

• LeBlanc MM, Kelloway EK. Predictors and outcomes of workplace violence and aggression. Journal of Applied Psychology 2002;87(3):444-53. - PubMed

LeBlanc 2006

• LeBlanc MM, Dupre KE, Barling J. Public-initiated violence. In: Kelloway EK, Barling J, Hurrell Jr JJ, editors(s). Handbook of Workplace Violence. Thousand Oaks: Sage Publications, Inc, 2006:261-80.
• Lewis SE, Orford J. Women's experiences of workplace bullying: changes in social relationships. Journal of Community & Applied Social Psychology 2005;15(1):29-47.

Livingston 2010

• Livingston JD, Verdun-Jones S, Brink J, Lussier P, Nicholls T. A narrative review of the effectiveness of aggression management training programs for psychiatric hospital staff. Journal of Forensic Nursing 2010;6(1):15-28. - PubMed

Martínez‐Jarreta 2007

• Martínez-Jarreta B, Gascón S, Santed MA, Goicoechea J. Medical-legal analysis of aggression towards health professionals. An approach to a silent reality and its consequences on health [Análisis médico-legal de las agresiones a profesionales sanitarios. Aproximación a una realidad silenciosa y a sus consecuencias para la salud]. Medicina Clínica 2007;128(8):307-10. - PubMed

Mayhew 2000

• Mayhew C. Preventing Client Initiated Violence: A Practical Handbook. Canberra: Australian Institute of Criminology, 2000.

Mayhew 2001

• Mayhew C, Chappell D. Prevention of occupational violence in the health workforce. Working paper series 140. Taskforce on the Prevention and Management of Violence in the Health Workplace, Discussion Paper No. 2. Sydney: School of Industrial Relations and Organizational Behaviour and Industrial Relations Research Centre, University of New South Wales, 2001.

Mayhew 2004

• Mayhew C. Occupational violence/bullying in the health industry. In: McCarthy P, Mayhew C, editors(s). Safeguarding the Organization Against Violence and Bullying: An International Perspective. Houndmills, UK: Oalgrave Macmillan, 2004:110-28.

Mayhew 2007

• Mayhew C, Chappell D. Workplace violence: an overview of patterns of risk and the emotional/stress consequences on targets. International Journal of Law and Psychiatry 2007;30(4-5):327-39. - PubMed

McCarthy 2004

• McCarthy P. The safeguarding challenge. In: McCarthy P, Mayhew C, editors(s). Safeguarding the Organization Against Violence and Bullying: An International Perspective. Houndmills, UK: Oalgrave Macmillan, 2004:1-16.

Nachreiner 2005

• Nachreiner NM, Gerberich SG, McGovern PM, Church TR, Hansen HE, Geisser MS, et al. Impact of training on work-related assault. Research in Nursing & Health 2005;28(1):67-78. - PubMed

Needham 2004

• Needham I, Abderhalden C, Dassen T, Haug HJ, Fischer JE. The perception of aggression by nurses: psychometric scale testing and derivation of a short instrument. Journal of Psychiatric and Mental Health Nursing 2004;11(1):36-42. - PubMed

Needham 2005

• Needham I, Abderhalden C, Halfens RJ, Dassen T, Haug HJ, Fischer JE. The effect of a training course in aggression management on mental health nurses' perceptions of aggression: a cluster randomised controlled trial. International Journal of Nursing Studies 2005;42(6):649-55. - PubMed

Needham 2005a

• Needham I, Abderhalden C, Halfens RJG, Dassen T, Haug H-J, Fischer JE. The Impact of Patient Aggression on Carers Scale: instrument derivation and psychometric testing. Scandinavian Journal of Caring Sciences 2005;19(3):296-300. - PubMed
• National Institute for Health and Clinical Excellence. Violence Clinical Practice Guidelines: The Short-Term Management of Disturbed/Violent Behaviour in In-Patient Psychiatric Settings and Emergency Departments. London: Royal College of Nursing, 2006. - PubMed

Niedhammer 2009

• Niedhammer I, David S, Degioanni S, Drummond A, Philip P. Workplace bullying and sleep disturbances: findings from a large scale cross-sectional survey in the French working population. Sleep 2009;32(9):1211-9. - PMC - PubMed

O'Brien‐Pallas 2009

• O'Brien-Pallas L, Wang S, Hayes L, Laporte D. Creating work environments that are violence free. World Hospitals and Health Services 2009;45(2):12-8. - PubMed
• Occupational Safety and Health Administration, US Department of Labor. Guidelines for Preventing Workplace Violence for Health Care & Social Service Workers. Washington: US Department of Labor, 2004.

Packham 2011

• Packham C. Violence at Work: Findings From the 2009/10 British Crime Survey. London: Health Service Executive, 2011.
• Paice E, Smith D. Bullying of trainee doctors is a patient safety issue. The Clinical Teacher 2009;6(1):13-7. [DOI: 10.1111/j.1743-498X.2008.00251.x] - DOI

Parent‐Thirion 2007

• Parent-Thirion A, Marcias EF, Hurley J, Vermeylen G. Fourth European Working Conditions Survey. Dublin: European Foundation for the Improvement of Living and Working Conditions, 2007.

Parker 2010

• Parker RM, Ceramidas DM, Forrest LE, Herath PM, McRae I. Patient initiated aggression and violence in the Australian general practice setting. Canberra: The Australian Primary Health Care Institute, 2010.

Piquero 2013

• Piquero NL, Piquero AR, Craig JM, Clipper SJ. Assessing research on workplace violence, 2000–2012. Aggression and Violent Behavior 2013;18(3):383-94.
• Price O, Baker J, Bee P, Lovell K. Learning and performance outcomes of mental health staff training in de-escalation techniques for the management of violence and aggression. British Journal of Psychiatry 2015;206(6):447-55. [DOI: 10.1192/bjp.bp.114.144576] - DOI - PubMed
• Ray EB, Miller KI. Social support, home/work stress, and burnout: Who can help? Journal of Applied Behavioral Science 1994;30(3):357-73.

RevMan 5.3 [Computer program]

• The Nordic Cochrane Centre, The Cochrane Collaboration Review Manager (RevMan).. The Nordic Cochrane Centre, The Cochrane Collaboration, Version 5.3. Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration, 2014.

RevMan Web 2019 [Computer program]

• Review Manager Web. Cochrane, 2019. Available at revman.cochrane.org .

Richter 2006

• Richter D, Needham I, Kunz S. The effects of aggression management training for mental health care and disability care staff: a systematic review. In: Richter D, Whittington R, editors(s). Violence in Mental Health Settings. New York: Spring Science and Business Media, LLC, 2006:211-27.
• Roche M, Diers D, Duffield C, Catling-Paull C. Violence toward nurses, the work environment, and patient outcomes. Journal of Nursing Scholarship 2010;42(1):13-22. - PubMed

Rosenstein 2008

• Rosenstein AH, O'Daniel M. A survey of the impact of disruptive behaviors and communication defects on patient safety. Joint Commission Journal on Quality and Patient Safety 2008;34(8):464-71. - PubMed

Spector 2014

• Spector PE, Zhou ZE, Che XX. Nurse exposure to physical and nonphysical violence, bullying, and sexual harassment: a quantitative review. International Journal of Nursing Studies 2014;51:72-84. - PubMed

Spelten 2020

• Spelten E, Thomas B, O'Meara PF, Maguire BJ, FitzGerald D, Begg SJ. Organisational interventions for preventing and minimising aggression directed towards healthcare workers by patients and patient advocates.. Cochrane Database of Systematic Reviews 2020;4:E-pub. [DOI: DOI: 10.1002/14651858.CD012662.pub2.] - PMC - PubMed

Spencer 2018

• Spencer S, Johnson P, Smith I. De‐escalation techniques for managing non‐psychosis induced aggression in adults. Cochrane Database of Systematic Reviews 18 July 2018, Issue 7. Art. No: CD012034. [DOI: 10.1002/14651858.CD012034.pub2] - DOI - PMC - PubMed

Straus 1979

• Straus MA. Measuring intrafamily violence and conflict: the Conflict Tactics (CT) Scale. Journal of Marriage and Family 1979;41:75-88.

Taylor 2010

• Taylor JL, Rew L. A systematic review of the literature: workplace violence in the emergency department. Journal of Clinical Nursing 2010;20:1072-85. - PubMed

Ventura‐Madangeng 2009

• Ventura-Madangeng J, Wilson D. Workplace aggression experienced by registered nurses: a concept analysis. Nursing Praxis in New Zealand 2009;25(3):37-50. - PubMed

Viitasara 2002

• Viitasara E, Menckel E. Developing a framework for identifying individual and organizational risk factors for the prevention of violence in the health-care sector. Work 2002;19(2):117-23. - PubMed

Viitasara 2003

• Viitasara E, Sverke M, Menckel E. Multiple risk factors for violence to seven occupational groups in the Swedish caring sector. Industrial Relations 2003;58(2):202-31.

Whittington 2002

• Whittington R, Higgins L. More than zero tolerance? Burnout and tolerance for patient aggression amongst mental health nurses in China and the UK. Acta Psychiatrica Scandinavica 2002;106:37-40. - PubMed

Wieclaw 2006

• Wieclaw J, Agerbo E, Mortensen PB, Burr H, Tüchsen F, Bonde JP. Work related violence and threats and the risk of depression and stress disorders. Journal of Epidemiology and Community Health 2006;60(9):771-5. - PMC - PubMed

Wiskow 2003

• Wiskow C. Guidelines on Workplace Violence in the Health Sector. Comparison of Major Known National Guidelines and Strategies: United Kingdom, Australia, Sweden, USA (OSHA and California). Geneva: World Health Organization, 2003.
• Wyatt GE, Riederle M. The prevalence and context of sexual harassment among African American and White American women. Journal of Interpersonal Violence 1995;10(3):309-21.

Publication types

• Search in MeSH

Related information

• Cited in Books

LinkOut - more resources

Full text sources.

• Europe PubMed Central
• PubMed Central

• Citation Manager

NCBI Literature Resources

MeSH PMC Bookshelf Disclaimer

The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). Unauthorized use of these marks is strictly prohibited.