Table 2.

Summary of theoretical frameworks identified in our literature review for understanding WPV

Theory	Theory description	Category of risk factor	Non-modifiable factors within hospitals	Modifiable factors within hospital	Quality improvement initiatives
Ecological occupational health model of workplace assault [23, 24]	• A model depicting the factors and consequences of WPV in Long Term Care • It considers the complex interactions between individual worker, interpersonal, organizational environment, and societal factors. • Factors included the individual worker, the workplace, the external environment, and the assault situation • Assaults have an impact on the workers, workplace and quality of care	• Clinical risk factors • Societal risk factors • Organizational risk factors	• Societal changes  • crime rates  • substance abuse  • lack of mental health care • Staffing levels • Global affairs/wars	• Individual worker sense of safety in their workspace	• Environmental indicators • Debriefing Improved • Incident Reporting • Interviews, pulse surveys
				• Training and education	• Educational intervention
Broken Windows Theory [25]	• Criminology based • Tolerance of smaller crimes leads to more larger crimes occurring • Tolerance of verbal abuse can lead to more severe forms of abuse, such as physical abuse, being tolerated	• Organizational risk factors	• Societal changes  • crime rates  • substance abuse  • lack of mental health care  • world events	• WPV Policies Managing • WPV Data and statistics	• Identifying and implementing tailored quality indicators on WPV
Cultural care theory [26]	• Uses Holistic Culture Care Theory • Identifies 4 subcultures of those involved in ED WPV  • ED Nurses  • Institution’s administration departments  • Clients with violent behaviours  • Clients without violent behaviours • Three prominent themes  • Policies often lack sufficient contribution to a safe ED environment  • Administration often value hospital/organizational reputation over ED staff well-being  • Anxiety, fear, and negative emotions caused by WPV impact nurses’ quality of care	• Clinical risk factors • Societal risk factors • Organizational risk factors	• Clients with violent behaviours Clients without violent behaviours	• WPV culture • Support for ED staff	• Educational interventions • Environmental indicators • Debriefing • Improved Incident Reporting • Interviews, pulse surveys • Clinical representation in leadership decisions
Routine Activity Theory [27]	• Criminology based • A person’s daily activities can increase or decrease the opportunities for victimization • A person with one or more of the following is likely to be a victim of WPV;  • greater exposure to aggressor  • lower levels of protection over possible targets  • repeated engagement with potential aggressor  • greater closeness to potential aggressor	• Organizational risk factors • Societal risk factors • Clinical risk factors • Economical risk factors	• Patient behaviour upon arrival • Staff exposure to patients with aggressive behaviours	• Societal perspectives on hospital staff • Increased protection for staff	• Environmental indicators • Increased security presence • Wearable devices such as body cameras • Personal alarm buttons • Environmental awareness training
Situational Crime Prevention Theory [28]	• Criminology based • Situational crime prevention theory is based on rational choice theory  • Offenders consider the perceived risks and rewards associated with crime   • in healthcare, attacking a nurse could prevent the pain associated with medical interventions such as drawing blood • Need to emphasize the punishment and risk for violent behaviour in ED in environment to reduce the rewards	• Organizational risk factors		• Emphasizing WPV policies in hospital	• Environmental indicators • Policy review
Framework of cultural aspects of violence in the ED [29]	• Cultural themes related to WPV in the ED were categorized into the following three groups;  • Problems and solutions   • Staffs perceptions of violence   • Indicators or warning signs of violence   • Diverse staff responses to violence  • Them and us   • Patient/relative behaviour   • Nurses’ behaviour  • Requests and demands   • Rejected request of patients/relative   • Long waiting times or waiting times perceived as long contributing to requests and demands of patients and relatives	• Organizational risk factors • Societal risk factors • Clinical risk factors • Economical risk factors	• Wait times • Patient and relative behaviour • Number of staff	• Nurses behaviour • Perceptions of violence • Knowledge of violence • Response to violence • Patient/visitor requests	• Education • Support • Outreach to staff • Trauma informed approach • Behavioural emergency response team
Honneth’s theory of struggle for recognition [30, 31]	• Three themes that describe the experiences of patients in WPV situations;  • Unmet needs  • Involuntary assessment  • Unsolicited touch • Violence felt as a demand for rights and recognition as a person	• Societal risk factors • Clinical risk factors	• Previous patient experiences and traumas	• Trauma-informed approach	• Education for staff
Psychological frameworks [32]: Psychoanalytical model [33], personality theories [34–39], frustration-aggression hypothesis [40]	• Aggressive behaviours may be innate and unconscious forces due to certain personality types • Frustration when patient can’t get what they want • We have no control over who enters ED so nurses must be calm and prepared	• Societal risk factors	• Patient population	• Calm and prepared HCPs	• Education interventions • Support for staff • Pulse survey, check ins • Behavioural emergency response team
Environmental Stimuli theories [32]	• Negative affect escape model [41]  • Unpleasant environmental stimuli increasing in intensity can often lead to aggression • Excitation-transfer theory [42]  • Stimuli add up and can result in triggering an aggressive behaviour	• Environmental risk factors	• Patient population with environmental triggers • Physical layout of hospital	• Limiting stimuli • Comfortability of patients and visitors	• Seclusion rooms • Limiting noise • Regulating temperature • Creating calm atmosphere
Rational Choice Theory [43]	• Makes choice based on rational calculation of costs and benefits or pain versus enjoyment with the aim of maximizing pleasure • Perception and understanding of potential pain caused by the punishment drives the choice • If you don’t follow through with protecting you workers, then likely to commit more violence as no costs, only benefits	• Clinical risk factors • Organization risk factors	• Patient population with prior negative experiences and traumas with healthcare • Patient population with knowledge of medicine	• Trauma-informed approach • Supported staff • Policy to protect staff	• Education interventions • Debriefs • Improved culture with regards to WPV • Environmental indicators • Policy change
Terror Management Theory [44]	• Addresses how individuals cope with anxiety and fear associated with their awareness of mortality • If a person consciously believes that a world event such as the • Covid-19 virus could result in death, fear of death will play a role in a person’s attitude and behaviours regarding the topic Covid-19 disrupts the feeling of calmness, causes a feeling of threat, terror management takes over and responds in distress or disorderly manners • Awareness of death creates a potential for existential terror to due survival instincts • Anxiety buffering systems related to cultural worldviews, self-esteem and close interpersonal relationships play a role in this • Fear of death may be conscious or unconscious	• Clinical risk factors • Organization risk factors	• Patient population with prior negative experiences and traumas with healthcare • Patient population with knowledge of medicine	• Trauma-informed approach • Supported staff	• Education interventions • Debriefs • Improved culture with regards to WPV • Increased security guard presence
Psychology Model for Understanding Violence [45]	• Psychobiological theories of violence include brain dysfunction, autonomic functioning, hormones, neuropsychology, and temperament • Evolutionary psychology states that due to natural selection, humans have evolved adaptations enabling them to harm other humans in order to reproduce and survive, which still exists • The death instinct states that a defence system controls our anger but when we no longer feel like they keep us safe, we may react with violent behaviour	• Societal risk factors	• Biological factors affecting patient population	• Trauma-informed approach • Culture change	• Education intervention • Environmental indicators
Sociological perspectives on WPV [46]	• Violence is a resource used to obtain a result • Violence is a reaction to a crisis situation • Culture of violence from either, friends, family, community or society leads to more violence	• Societal risk factors	• Patient population	• Trauma-informed approach	• Education intervention
Psychosocial Risk Factors [47]	• Biological vulnerability for aggression in combination with psychosocial factors contribute to aggressive behaviours, factors include  • Proximal factors, present psychological state  • Developmental and environmental factors influencing an individual’s personality and cognition	• Societal risk factors	• Patient population	• Agitation management	• Education Intervention
Minority Stress Model [48]	• A model based on multiple sociological and social psychological theories that describes the stigma, prejudice, and discrimination that minority communities encounter and the impact that these negative experiences have on individuals’ physical and mental health • Negative encounters stemming from discrimination and stigmatization may lead individuals to anticipate rejection and discrimination in social contexts, prompting the development of defensive coping mechanisms that could be perceived as confrontational • Marginalized communities can include ethnic minorities, the 2SLGBTQIA+ community, individuals with disabilities • Model argues that minority stress can only be managed through systemic changes that address social inequalities and providing the necessary supports and resources that marginalized communities require	• Societal risk factors	• Societal inequalities that result in marginalization, discrimination and stigma towards minority communities	• Trauma-informed approach • Culture change within hospital	• Education interventions • Improved culture with regards to WPV
Intersectional Identities [49]	• Intersectional identities outlines the power and control individuals experience in society due to different intersecting aspects of their identity including sex, gender, age, sexual orientation, ethnicity, race, religion, language, culture, education, presence of disability, geography, income, marital status, immigration status and indigenous status • Whether an individual experiences power or discrimination in their society is determined through the way their different identities are interpreted by the society they live in and the way their identities intersect, for example a person that identifies with multiple marginalize communities is more likely to experience discrimination than a person that identifies mainly with the identities in power • Individuals with marginalized identities possess more lived experiences of trauma are likely to feel less safe in social situations	• Societal risk factors	• Societal inequalities that result in marginalization of identities	• Trauma-informed approach • Culture changes within hospital	• Education interventions • Improved culture with regards to WPV