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Violence and aggression towards health care professionals

HG., Stathopoulou

RN, MSc Tzanio General Hospital of Piraeus, Greece

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Workplace violence is a phenomenon that affects every country and every work setting. The conditions of the environment where care is being provided make health care professionals especially vulnerable to assaults. The factors that account for the increased incidence of violence in health care settings include increased stress levels in patients and relatives, long waiting hours, availability of money and drugs on a 24hour basis, unrestricted visitor access, overcrowding. Workplace violence can have a negative impact for both the employee and the hospital. The negative consequences of violence include loss of professional self esteem, loss of job satisfaction, trauma, disability, increased litigation costs, staff absenteeism. Violence prevention focuses on 3 aspects: hospital organization, control of the physical environment, and staff education and development. Some of the measures that can contribute to the prevention of violence include: avoiding overcrowding, enforcing visiting hours, adequate staffing of the Accident and Emergency unit, staff training in handling violent persons.


workplace violence, aggression towards health care workers, assaults to health care providers.


Workplace violence is a phenomenon affecting every country, every workplace and every professional group, to such extent that it can be characterized as an epidemic [1]. In health care areas in particular, all employees are faced with the risk of being a victim of violence [2]. According to international statistic data, nearly 4% of the total employee population has reported that they have suffered physical violence from people outside their workplace [3]. More specifically, in health care areas, violence affects one in two healthcare professionals worldwide, with nurses having three times higher possibility of being exposed to violence than any other professional group [4].

This literature review examines the factors that are related to the manifestation of healthcare violence, analyses the signs of violent behavior and suggests measures for the management and prevention of healthcare violence.

Definitions of Violence and Aggression

As DiMartino [5] points out, it is difficult to provide an accurate definition of violence and aggression, for the following reasons:

• The perception of what constitutes violent behavior varies between cultures and social backgrounds

• There is a wide range of behaviors that can be described by the term ‘violence’

• Often the limits between acceptable and unacceptable behavior can be vague

The term “aggression“describes the behavior that is characterized by the intention to harm another person, while violence refers to the assault to a person with the intent to cause harm [6].

Violence can be physical or psychological [6] and it includes [2,7,8]:

• Threatening behavior (expression of intention to harm, threatening body language, expression of verbal or written threats)

• Verbal abuse

• Verbal abuse

• Destruction of items

• Assault (physical violence, use of weapons, rape, murder)

• Robbery

Workplace violence includes every episode of threat, verbal abuse or assault that happened under circumstances related to the person’s occupation and it involves patients, their relatives, and members of the public [9].

Reasons of Increased Incidence of Workplace Violence toewards Healthcare Personnel

The circumstances under which care is provided in healthcare settings make health care professionals especially vulnerable to occupational violence.

The factors that account for the increased incidence of violence towards healthcare professional can be summarized as it follows:

• Healthcare professionals come into direct contact with a wide range of people who are under stress due to pain or illness [4,10]

• Nursing staff cares for people who are confused or emotionally unstable [11]

• Sometimes, healthcare staff has to provide care in secluded areas eg during diagnostic or therapeutic interventions [12]

• Nursing staff often performs interventions that require close physical contact [13]

• Healthcare staff comes to contact with patients’ families who are often under intense emotional charge due to severe trauma, mental disorder or bereavement [14]

• Areas such as the Accident and Emergency unit are characterized by high stress levels and long waiting hours, a fact that affects negative all individuals [15]

• Healthcare staff, such as ambulance crew, have to intervene in places where violent events are still taking place eg pub riots [16]

• Staff works in shifts, therefore they are exposed into danger having to commute to work during evening and early morning hours [13]

• In hospitals, there is 24 hour availability of money and drugs, making them a target for robberies [12]

• There is often shortage of staff, especially in peak times [11]

• In hospitals, there can be unrestricted movement of visitors across all hospital areas [15]

• Certain settings, such as the Accident and Emergency unit, can be overcrowded [17]

• Staff has the authority to provide or withhold services necessary to the public [7]

• There is lack of staff training in the management and prevention of violence and aggression [15] The healthcare professionals that are in increased risk of being victims of violence and aggression include:

• Nurses and nurse assistants: they are at higher risk of assault compared with doctors [18]

• Ambulance crues [2,6]

• Staff working in Accident and Emergency units [6]

• Nursing students [11]

• Hospital security staff [2]

• Members of ethic minorities [10]

A number of factors is believed to relate with the demonstration of violent behavior. These factors include:

• Alcohol abuse – use of illicit drugs [19]

• Long waiting hours [19]

• Irritating or inappropriate staff attitude [10,19]

• High levels of stress in patients and their relatives [19]

• Suspicion that priority order has been violated [18]

• Lack of information concerning the estimated waiting time [18]

• Difference of language and culture, that can give rise to misunderstandings between staff, patients and their relatives [18]

• Inappropriate physical environment eg lack of sufficient seats, limited waiting room space, inadequate lighting [2]

• Access to guns [2]

Additionally, violent events can occur when hospital staff is attempting to enforce limits on food or drink consumption or smoking in hospital areas.

There appears to be high risk of assault during night and early morning hours, during holidays and during pay days [20].

Warning Signs of Violence and Aggression

Despite the fact that there are not definite indications about the form a violent event is going to take, indeed, it is possible to recognize several warning signs of the manifestation violent behavior. These warning signs can be summarized as it follows [6,7]:

• Vivid walking, nervous movements and gestures

• Approaching very closely to the other person

• Raised voice tone

• Hitting walls or items, or hitting themselves in the head or chest

• Inappropriate laughter

• Excessive sarcasm

• Sudden pause of activity that follows a period of agitation. Such a pause may signal that the person is planning a violent action

Management of Violent Events in Hospital Settings

The way in which each person responds when they become victims of violent behavior depends upon a number of factors, including [18,21,22]:

• Personality type

• Defense mechanisms (conscious or unconscious)

• Physical environment

• Social and professional limitations

• High workload

• Increased stress levels

• Ambiguity

• Self confidence

• Professional expertise

The recommendations that follow can prove themselves useful in the safe and effective management of assaults towards health care staff:

• Always try to maintain a calm attitude, using a calm but directive voice tone6

• Set limits in a calm but firm manner [7]

• Do not teat patients in a humiliating manner [17]

• Do not give orders [2]

• Do not try to speak while the aggressive person is yelling [2]

• Do not use threats [2]

• Maintain adequate distance from the aggressive person, it is safer for you and also, it is unlikely to make the other person feel threatened [7]

• Always stay alert when dealing with aggressive persons and ensure that there is an open route of escape [2]

• Try to recognize the underlying cause of aggression [23]

• No matter how aggressive a person is, you should attempt to listen to it and try to figure out their needs

• Show compassion [24]

• Check your body language, in case it transmits aggressive messages [17]

• To avoid confusion, it is preferable to follow one on one dialogue with the aggressive person.[15]

• Aggressive persons should be kept away from other patients, to avoid expansion of tension [17]

• Trust your intuition, if you feel that a person is about to attack, take appropriate action before the assault occurs [2]

• Do not ignore threats [17]

• Do not touch aggressive persons, or point toward them [24]

• If you realize you cannot handle the situation effectively, it is safer to retire from the situation and alert security staff or report to your supervisor [2]

Impact of Violence and Aggression

The manifestation of violence in healthcare settings can have a profound impact, both for the person receiving it and for the hospital. The victims of violence experience the following negative consequences:

• Loss of self confidence and self esteem, loss of trust to his own professional abilities and expertise [10]

• Loss of job satisfaction [22]

• Elevated stress levels [2]

• Trauma [2]

• Permanent or temporary inability [2]

• Death

• Cost of litigation against the perpetrators of violence [25]

• Feelings of anger, fear, depression and guilt [13]

• Negative impact on interpersonal relationships [13]

At the hospital level, violence can have the following impact:

• Increased absenteeism and use of sickness leave [14]

• Loss of employee morale and motivation [10]

• Avoidance behavior, which can have an adverse impact on employee performance [10]

• Increased costs for installation and maintenance of security equipment [25]

Prevention of Violence

Hospitals are areas at high risk for manifestation of violence and aggression towards health care professionals; therefore, it is essential that a series of measures are taken to prevent violent events. The preventive measures focus around 3 areas:

• Hospital organization

• Arrangement of the physical environment

• Staff training and development

Concerning hospital organization, the following measures could be useful:

• Timely and effective management even of minor violence events, to prevent expansion of the tension [19]

• Formation of “crash teams” that will rush to the point where violence is taking place, so that no employee will attempt to manage violent events on his own [19]

• Restriction on entry to the Accident and Emergency Unit [14]

• Establishment of visiting hours and provision of visitor identification [14]

• Avoidance of crowding [10]

• Development of protocols that will be applied in the management of violent people, especially in the Accident and Emergency Unit [26]

• Installation of closed circuit television [16]

• Liaison with the local police station [15]

• Establishment of criteria for requesting police assistance and ensuring that all hospital staff is aware of the procedure that must be followed in order to request police assistance [9]

• Sufficient staffing of hospital reception to reduce tension and waiting time [9]

• Provide as accurate information as possible on waiting times and make every effort to reduce it [15]

• Sufficient staffing at the Accident and Emergency Unit [9]

• Caution the public that violence against staff shall not be tolerated and that anyone who commits assaults against staff shall be prosecuted [10]

• Establishment of written policies for the protection of hospital staff against violent actions, creation of a reference manual and distribution to all hospital staff [15]

• Establishment of a reporting system for violent actions against staff. Employees should be encouraged to report violent events without fear of reprimand on behalf of hospital management

Additionally, proper arrangement of the physical environment of the hospital can assist in the prevention of hospital violence. A number of measures can be taken to achieve this goal, for example:

• Sufficient lighting in all hospital areas [15]

• Placement of curved mirrors in corridors to allow better visibility [15]

• Placement of sufficient seats in the waiting room of the Accident and Emergency unit to ensure that no one will be waiting standing up [9]

• Provision of distraction material eg magazines, television to reduce boredom which often spurs aggression [9]

• Hospital Reception desk should be placed in the main entrance, in a highly visible place, easily accessible by all patients and visitors [10]

• Hospital Security Services should be placed in the main entrance [10]

• Single main entrance to the hospital [21]

• Proper setting of temperature, ventilation, humidity in all hospital areas to ensure comfort [10]

• Ensure that access to staff rest rooms and lockers is restricted to the public

Staff training and development

As the European Committee [26] points out, workplace violence is a risk factor that the employer has the duty to assess, prevent or minimize, by taking a series of measures.

A training program for the prevention and management of hospital violence could include the following:

• Medical, psychiatric and social conditions that could be a cause of violent behavior

• Recognition of potentially violent persons and of every situation where staff safety is endangered [25,27]

• Effective use of communication skills and de‐escalation techniques [25]

• Methods for handling violent persons [25]

• Techniques for crisis intervention and conflict resolution [28]

• Available services for violence prevention and management [14]

• Reporting and documentation of all violent events towards health care staff [27]

• Application of physical restraints [27]

Additionally, Hospital Reception staff should receive training in the management of violent people, in handling tension and in effective communication and information giving.


Health care professionals suffer from the social tolerance of violence and from the perception that the practice of their profession implies the acceptance of violence and aggression.

The exact extent of violent events towards health care professionals is not fully known, due to under reporting of such events and due to insufficient documentation and record keeping. The factors that prevent health care professionals from reporting such events include fear of stigmatization, fear that involvement in a violent event may be perceived as an indication of poor performance or negligence and lack of support from hospital administration [8,14].

International organizations, such as American College of Emergency Medicine [26] and the International Council of Nurses [21] have condemned hospital violence and maintain that the only way in which health professionals can provide effective care is by working in an environment free form the threat of violence.

It is important that nurses are knowledgeable of the fact that every patient or visitor can be a potential perpetrator of violence under circumstances that favor escalation of violence. Therefore, it is important that nurses know and make every effort to eliminate all circumstances that can fuel violence, that they recognize the warning signs of violence and that they deal with violent persons in an effective and professional manner.

Finally, s number of changes in the structure and organizational culture of the hospital are required. All hospital employees, employers, patients and their families share responsibility for the creation of a safe workplace.


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