Workplace Violence Training and Prevention in Hospital-Based Healthcare: Implications for Nursing and the Interdisciplinary Team in the Hospital


The integrative review addresses two review questions:

  1. Do workplace violence prevention education and training programs reduce incidents of workplace violence in the hospital setting?
  2. Do workplace violence prevention programs help improve staff perception of and confidence in managing workplace violence incidents?


This integrative review will utilize the Whittemore and Knafl (2005) approach and design. An integrative review method of design was chosen for this project due to the acceptance of a variety of methodologies. Integrative reviews are often thought of as the gold standard for nursing-based evidence-based studies. This integrative review will undertake several key steps prior to publication. These steps include problem identification, literature search, data evaluation, data analysis, and finally presentation (Whittemore & Knafl, 2005).

This integrative review will utilize the Kennesaw State University Database and Google Scholar, in combination with gray literature from the American Nurses Association, Emergency Nurses Association, and political publications. All articles utilized in the review are published from January 2015- January 2020, allowing for the most up to date literature to be reviewed. Key search terms will include healthcare, workplace violence, emotional violence, physical violence, verbal violence, sexual violence, assault, prevention training, de-escalation, nurse, physician, healthcare worker, and hospitals. The key search terms will allow for variations of tense and spelling to account for a larger sample size review.

The articles will be reviewed based on title and abstract to ensure the appropriate include and exclusion criteria are met in the preliminary review. The inclusion criteria will include global studies, research studies, qualitative studies, mixed method studies, quantitative studies, healthcare workers, pre and post-test comparisons, published in English, primary sources, hospital-based departments, de-escalation training program implementation or education. The exclusion criteria will be limited to research articles in non-hospital settings, non-patient facing healthcare workers, studies without pre and post comparisons, and psychiatric units. As previously mentioned, each article will be reviewed based on a set of steps. The review will include the title, abstract, key terms, inclusion and exclusion criteria, and finally the entire article for inclusion into the final selected integrative review articles.

The management of selected articles will be maintained in an excel spreadsheet. The excel spreadsheet will include the management of bibliographies, the Johns Hopkins Nursing Evidence Based Practice Research Appraisal Tool and pertinent article details. The spread sheet includes several subsections for each article under review. The subsections for the bibliographies will include the APA reference, article title, authors, journal title, ISSN, publication date, volume, issue, first page, page count, accession number, DOI, and publisher. The subsections for the article details will include key terms, abstract, research study type, healthcare setting, sample size, de-escalation strategy or education, aim, methods, results, conclusions, and the Johns Hopkins Nursing Evidence Based Practice Research Appraisal Tool. Each article will be apprised for a level and quality of literature utilizing the Johns Hopkins Nursing Evidence based Practice Research Appraisal Tool. Finally, a PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) approach will be utilized to show the steps leading to the final included articles and studies. The PRISMA will guide readers in understanding how the final included articles are selected (Moher, Liberati, Tetzlaff, & Altman, 2009).

The Johns Hopkins Nursing Evidence Based Practice Research Appraisal tool will be used to evaluate the overall quality of the articles. The Johns Hopkins Nursing Evidence Based Practice Research Appraisal tool categorized articles first by level of evidence then by quality. There are three levels. The first is level one, which includes randomized control trial and experimental studies. The second level consists of quasi-experiments, this will be the primary level chosen for this integrative review. Finally, the third level is non-experimental. This integrative review will primarily consist of levels one and two. Next the Johns Hopkins Nursing Evidence Based Practice Research Appraisal tool evaluates the quality through a series of questions. There are three quality rating scores. High quality, good quality, and low quality or major flaws. This integrative review will only utilize articles with high quality and good quality scores. Evaluating the level and quality of articles allows for the integrative review to establish “authenticity, methodological quality, informational value, and representativeness of available primary sources is considered and discussed in the final report” (Whittemore & Knafl, 2005).


A PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flow diagram was chosen for the data collection framework to display the search results (Moher, Liberati, Tetzlaff, & Altman, 2009). Figure 1 shows the progression of how articles were excluded and included.

The search resulted in 87 articles identified through the Kennesaw State University Library and 10 additional articles through Google Scholar, American Nurses Association, Emergency Nurses Association, and political news publications. Duplicate articles were removed resulting in 64 potential articles to be included in the integrative review. Articles were then screened by title, where 38 were then excluded. Finally, the author assessed the full articles for eligibility. Articles of poor quality, those that did not assess the effectiveness of implemented training to reduce workplace violence or assess the confidence level, and articles that consisted of incomplete trials were excluded. This resulted in a total of 10 articles to be synthesized for the integrative review. Three of the articles consist of qualitative studies, four are quantitate, and three are mixed method studies.

The integrative review was designed to evaluate current literature and review two key questions pertaining to workplace violence in healthcare. The first is the effectiveness of various training or education in the reduction of workplace violence. The second is effectiveness of various training or education in conjunction with staff’s perception or confidence level in managing workplace violence. Each of the ten articles addresses at least one of the key questions, if not both.

The author created a methodological matrix from the reviewed research articles (see table 1). The matrix is divided into five columns:

  1. Study and location
  2. Purpose
  3. Level of evidence, quality, and design
  4. Training methods
  5. Major findings.

The research articles are then separated into three subgroups: qualitative, quantitative, and mixed methods. The matrix is utilized to synthesize the key areas in each research article.


The selected research articles had to address at least one of the two integrative review questions for the integrative review. Three out of the ten articles selected in the integrative review discuss the effectiveness of various training and education programs to reduce workplace violence in the hospital setting. In reviewing the four articles, two used mixed methods of both training and education in their programs, while one research article only utilized education. The two articles that utilized mixed methods were from Arnetz, et al., (2017) and Baig, et al., (2018). Adams, et al., (2017) is the only article to utilize one method of education to reduce workplace violence rates.

Arnetz, et al., (2017), structured their research in reducing workplace violence in hospitals by utilizing a randomized controlled intervention on selected hospital units then compared the results to similar controlled units. The design was structured to give the intervention units pertinent information and data related to previous violence on their unit then develop individual action plans. The action plans covered three distinct strategic categories: environmental strategies, administrative strategies, and behavioral strategies. Many of the action plans indicated increased education to frontline staff in the behavioral and administrative strategies. The results of the research article indicate decreased rates of patient to staff violent incidences in the intervention units as compared to the control units.

Baig, et al., (2018), utilized mixed methods of training and education to reduce incidents of workplace violence in the hospital setting. Training and education in the research article included education and scenario-based role-playing simulation learning. The education and training were conducted over a single four-hour session. Baig, et al., (2018), found that the de-escalation training and education did not prove scientifically significant in the reduction of the frequency of violence as compared to the control group.

Ramacciati & Giusti (2020) identified the need for training and partnership with nursing and security personnel to partner to improve WPV incidents in the Emergency room. Education and training to increase knowledge and promote partnership of nursing and security staff has the potential to reduce WPV incidents. In addition, education can provide clarity in roles and responses to WPV for nursing and security which will support a safer environment.

Adams, et al., (2017), only utilized an education approach to reduce workplace violence events in the hospital setting. The education was provided daily in-person on the units over the course of four months in 2013. All staff were educated at the same times each day, one session for day shift, one session for night shift staff. The education had four main focuses: assessment, planning, implementation, and post incident. A comparison of pre-intervention and postintervention showed a reduction in the frequency of workplace violence events on the units.


The other aim of this integrative review was to determine staff’s confidence level in managing workplace violence and the perception of workplace violence in healthcare. Of the ten research articles, nine articles speak to confidence and/or perception of workplace violence. Seven of the eight research articles utilized workplace prevention programs that incorporated multiple education techniques: simulation, video, power points, etc. Only one workplace violence prevention program utilized one educational method.

Six articles showed evidence of improved confidence in managing and coping with workplace violence after an intervention. These six articles are from Baig, et al., (2018), de la Fuente & Schoenfisch, (2019), Heckemann, et al., (2016), Jeong & Lee, (2020), Mitchell, et al., (2020), and Story, et al., (2020). Four of these articles utilized a standardized coping scale developed by Michael Thackrey in 1987 (Thackrey, 1987). The coping scale is frequently referred to as Confidence in Coping with Patient Aggression Instrument (CCPAI) or Self- Confidence in Coping with Patients’ Assault Scale. Baig, et al., (2018), de la Fuente & Schoenfisch, (2019), and Story, et al., (2020), utilized the Coping with Patient Aggression Instrument. Jeong and Lee, (2020), utilized the Self-Confidence in Coping with Patients’ Assault Scale to standardize the results. All six articles utilized multiple educational methods to improve confidence in managing and coping with workplace violence.

The articles by Heckermann, et al., (2016), Coneo, et al., (2019), and Adams, et al., (2017), indicated no scientific improvement to staff perception or attitude in the management of workplace violence post intervention training. Heckerman, et al., (2016), Coneo, et al., (2019), and Adams, et al., (2017), implemented aggression management training courses to determine staff’s perceptions to the effectiveness of aggression training. Overall, the aggression management courses indicated that staff’s attitudes did not improve with training, nor did staff’s ability to emotionally cope with aggression in the workplace.