Causes of workplace violence against nurses and strategies for its prevention in developed countries: a scoping review

Abstract

Introduction

Workplace violence refers to incidents in which individuals are subjected to abuse, misconduct, or threats in professional settings, endangering their health, safety, and well-being. Violence against nurses has reached high levels in recent years. This study aimed to identify the causes of violence against nurses and effective strategies for its prevention in developed countries.

Methods

This scoping review was conducted in 2024 following the PRISMA-ScR guideline. A comprehensive search was performed across international databases of PubMed, Scopus, PsycInfo, and Web of Science that covering studies published between 2003 and 2024. The search strategy combined keywords and MeSH terms related to “nurses” and “violence”. Data extraction was completed using a structured form, and thematic content analysis was employed to synthesize the findings.

Results

From 2658 identified records, 414 duplicates were removed. After screening and reviewing the full-texts, 114 studies were included. The causes of violence against nurses were categorized into five domains: individuals-level factors related to patients and companions, also staff-related factors, organizational factors, social determinants, and political drivers. Interventions for violence reduction were classified across three stages of before, during, and after violent incidents and addressed individual, organizational, social, and policy levels.

Conclusion

The findings demonstrate that workplace violence against nurses is a multifactorial issue driven by individual factors related to patients and healthcare staff, as well as broader organizational, social, and political determinants. In sum, creating safer work environments for nurses requires a coordinated, multi-level approach that addresses both immediate risks and the underlying structural drivers of violence.

Clinical trial number

Not applicable.

Supplementary information

The online version contains supplementary material available at 10.1186/s12912-025-04227-x.

Introduction

Violence is a behavior in which an individual, using physical or non-physical means, attempts to impose their demands on others [1]. Workplace violence includes acts or threats of violence against employees, with uncertain magnitude due to limited surveillance [2]. The World Health Organization (WHO) defines workplace violence as the conscious use of physical force, whether threatened or actual, against oneself, another person, group, or community, which can lead to harm, injuries, or even death. Violence against nurses has become a pandemic [3, 4]. Nurses are three times more likely to experience injuries compared to other healthcare workers [5]. Approximately 8–38% of nurses face some form of violence in their careers; 90% of violent behavior comes from patients and their families; more than 80% of incidents are not formally reported; over 20% of nurses leave their jobs due to violence [6].

Workplace violence is significantly associated with a decline in quality of care and negatively impacts nurse-patient relationships [7]. Violence exposure is strongly associated with increased burnout risk, poor sleep quality, and higher intention to leave the profession, with nurses experiencing multiple types of violence showing 2.12-fold higher odds of personal burnout and 1.95-fold higher odds of poor sleep quality [8]. So, violence against nurses is a global issue that continues to rise, affecting countries worldwide [6].

Hande et al. identified various causes of workplace violence against nurses, including roles of patients, relatives, and health professionals [9]. Different factors can cause the vulnerability of nurses to violence including staff shortages, the employment of temporary and inexperienced personnel, shift work (especially rotating and night shifts), lack of security infrastructure, and etc [10]. Global pandemics like COVID-19 are also among the factors contributing to the occurrence and escalation of violence against healthcare workers, including nurses, as heavy workloads, extreme fatigue, and resource shortages increase tensions between patients, their families, and healthcare staff [11]. These factors are different based on the context and interventions to reduce them in terms of this context. Because nurses often have direct contact with patients and are responsible for management of violence situations, their attitudes and performances are crucial in determining how such incidents are handled [12].

In light of these issues, identifying the causes of violence against nurses and offering strategies can help in preventing such incidents. Given their closer interactions with patients, nurses require additional support to safeguard their physical and mental health in the face of violent encounters. Creating a safe working environment also enables them in providing higher-quality care. Since developed countries generally possess stronger healthcare systems and better nurse-to-patient ratio than developing countries, it is important to explore the frequency of violence in these settings and examine the strategies to address it. Focusing exclusively on developed countries is also relevant because these contexts often have more structured healthcare policies, clearer reporting systems, and greater institutional resources dedicated to staff protection, which provide unique opportunities for intervention and benchmarking. At the same time, the persistence of workplace violence in well-resourced systems highlights the complexity of the issue, suggesting that systemic strength alone is insufficient to eliminate the problem. By examining the causes and interventions in developed countries, this review can shed light on the gaps that remain even under favorable conditions, offering lessons that are both transferable to other settings and essential for improving policy and practice in advanced healthcare system. A review of the existing literature suggests that no scoping review has yet investigated both the causes of violence against nurses and the strategies for its reduction in developed countries [6, 8, 11, 13, 14]. Therefore, objective of this study is to identify the causes of violence against nurses in developed countries and to propose appropriate strategies for its mitigation, through a scoping review.

Methods

Design

This scoping review was conducted in 2024 following the PRISMA Extension for scoping reviews (PRISMA-ScR) guideline [15]. To achieve the study’s main objective, reviewing the causes of violence against nurses and strategies for its reduction in developed countries, a comprehensive search was conducted across major international databases, including PubMed, Scopus, PsycInfo, and Web of Science.

Search strategy

The search strategy utilized a combination of keywords related to “nurses” and “violence,” along with their synonyms in Medical Subject Headings (MeSH). Studies published between 2003 and 2024 were included. An example of the search strategy in PubMed is as follows:

1# = P= (Nurses[Mesh] OR Nurse*[Title/Abstract] OR “Clinical Nurses”[Title/Abstract] OR “Nurse Supervisor”[Title/Abstract] OR “Nurse Manager”[Title/Abstract])

2# = I= (intervention*[Title/Abstract] OR education*[Title/Abstract] OR “inservice training”[Title/Abstract] OR “in-service training”[Title/Abstract] OR “staff development”[Title/Abstract] OR “training program*”[Title/Abstract] OR “prevention program*”[Title/Abstract] OR “organizational policy*”[Title/Abstract] OR “organizational policy*”[Title/Abstract] OR “safety management”[Title/Abstract] OR “security measure*”[Title/Abstract])

3# = Co= (Violence[Mesh] OR Violence[Title/Abstract] OR “workplace violence”[Title/Abstract] OR Harass*[Title/Abstract]) OR aggression*[Title/Abstract] OR Incivility[Title/Abstract] OR “Verbal Abuse”[Title/Abstract] OR “Verbal Harassment”[Title/Abstract] OR “verbal violence”[Title/Abstract] OR “Physical Abuse”[Title/Abstract] OR “Physical Violence”[Title/Abstract] OR “Physical Harassment”[Title/Abstract] OR Bullying[Title/Abstract] OR “Vertical Violence”[Title/Abstract] OR “Horizontal Violence”[Title/Abstract] OR “aggressive behavior”[Title/Abstract] OR “aggressive behaviour”[Title/Abstract] OR assault*[Title/Abstract] OR hostile*[Title/Abstract]) AND (hospital*[Title/Abstract])

1# AND 2# AND 3#

This strategy was translated and adapted for use in other databases, taking into account their specific indexing and search functionalities. Detailed search strategies for each database are provided in Appendix 1. All searches were conducted by F.M. and N.S. Additionally, the reference lists of included studies were manually screened to identify further relevant publications.

Selection criteria

Inclusion criteria

• Research articles, reviews, and gray literature addressing violence against nurses and strategies to reduce it in developed countries,

• Availability of full-text,

• English language of the documents,

• Publication date between 2003 to2024.

Exclusion criteria

• Case studies, letters to the editor, editorials, commentaries, and perspective articles.

Data extraction

All identified abstracts were imported into EndNote X8 software. After removing duplicates, titles and abstracts were screened to identify studies addressing the causes of violence against nurses and strategies for its reduction in developed countries. Titles and abstract of relevant studies were reviewed independently by two reviewers. Any disagreements were resolved through discussion with a third reviewer. A data extraction form was developed in Microsoft Word 2021 to capture the following bibliographic and study details: first author, year of publication, study location, research objective, methodology, and the identified causes and strategies related to workplace violence against nurses.

Critical appraisal of the studies

Due to the scoping nature of this review and the methodological diversity of the included studies, no formal critical appraisal was performed.

Data synthesis

Data were synthesized using qualitative thematic content analysis based on Braun and Clarke’s approach [16]. The process involved familiarization with the data, generating initial codes, identification of semantic units, review and refinement of codes, and organization into final themes. The two main categories of causes of violence and strategies for its reduction were identified, with subcategories derived from the documents. Where overlaps existed, similar subcategories were merged. Data extraction and synthesis were performed using Microsoft Word 2021.

Results

Figure 1 illustrates the study selection process. A total of 2658 records were identified, through database searching, of which 414 duplicates were removed. Subsequently, 2244 titles and abstracts were screened according to the inclusion criteria. The primary reason for exclusion was that the studies did not address the causes of violence against nurses or strategies for its reduction. Ultimately, 160 full-text articles were assessed, and 114 studies met the eligibility criteria and were included in the review.

Fig. 1.

Study selection process

Table 1 presents the characteristics of the included studies, focusing on the causes of violence against nurses and main interventions for reducing such violence in developed countries.

Table 1.

Characteristics of the reviewed studies based on the causes of violence against nurses and its reduction interventions in developed countries

First Author/Year/Country of Study	Study Objective	Research Method/Study Sample	Data Collection Method and Instrument
Arnetz (2015, United States) [17]	To identify factors and environmental conditions influencing patient violence against healthcare personnel	Qualitative (staff from a large hospital system consisting of seven hospitals)	Standardized online computerized reporting system
Morphet (2014, Australia) [18]	To identify common causes of perceived violence in the emergency department	Qualitative (nurses); phase 1: 157 participants, phase 2: 132 participants, phase 3: 158 participants	Three-round Delphi technique (interview guide)
Angland (2014, Ireland) [19]	To investigate the causes of violence and aggression experienced by Irish nurses	Qualitative (12 emergency nurses: 3 males and 9 females, aged 36 to 40; purposive sampling)	Semi-structured interviews (interview guide)
Pich (2013, Australia) [20]	To describe the experiences of Australian emergency nurses with patient- and visitor-related violence	Qualitative (emergency department nurses, 11 participants: 7 females and 4 males, average age 44; purposive sampling)	Semi-structured interviews (interview guide)
Fafliora (2016, Greece) [21]	To assess the prevalence and characteristics of violence against nurses working in a healthcare center in Greece	Cross-sectional (80 nurses: 83.3% females, 16.7% males; 53.8% aged 40–49 years; convenience sampling)	Survey (questionnaire)
Pich (2017, Australia) [22]	To determine the prevalence and causes of violence against emergency nurses in Australia	Cross-sectional (537 nurses; average age 44 years)	Survey (questionnaire)
Wolf (2014, United States) [23]	To examine the experiences of emergency nurses who were physically or verbally assaulted while providing patient care	Qualitative (emergency nurses, 46 participants: 8 males [17.4%], 37 females [80.4%], and 1 nurse with unspecified gender [2.2%])	Content analysis of submitted emails
Ramacciati (2018, Italy) [24]	To analyze the characteristics of workplace violence and determine its prevalence in emergency and urgent care departments in Italy	Cross-sectional (emergency and urgent care nurses, 265 participants: 144 females, 119 males, 2 unspecified; average age 42 ± 9 years)	Survey (questionnaire)
Koukia (2013, Greece) [25]	To determine the types and causes of violence experienced by doctors and nurses and to provide solutions	Cross-sectional (250 healthcare staff: 66 males and 184 females; average age 36.3 years; random sampling)	Survey (questionnaire)
Hahn (2010, Switzerland) [26]	To determine nurses’ experiences of violence from patients and visitors in a public hospital in Switzerland	Cross-sectional (nurses working in various clinical departments of four general hospitals, 291 participants: 93.5% females and 6.2% males; 34.4% aged 19–30, 40.5% aged 30–44; non-probability purposive sampling)	Survey (questionnaire)
Pompeii (2015, United States) [27]	To determine the prevalence of violence in six hospitals in the United States	Cross-sectional (5,385 hospital staff: 4290 females and 1021 males [80% female, 20% male]; more than half were over 40 years old)	Survey (questionnaire)
Ramacciati (2019, Italy) [28]	To determine the dimensions and characteristics of violence against emergency nurses	Cross-sectional (816 participants: 480 females [58.8%] and 336 males [41.2%]; average age 41 ± 9 years, age range 20–65)	Survey (questionnaire)
Pelto-Piri (2020, Sweden) [29]	To examine staff perspectives on violent incidents during inpatient psychiatric care	Cross-sectional (entire staff population of ten psychiatric clinics; 283 incidents reported by 181 staff members)	Survey (questionnaire)
Celene Y.L. Yap (2023, Australia) [30]	To identify and compare the attitudes of nurses and patient companions in the emergency department regarding the causes and management of patient aggression	Cross-sectional (nurses, patients, and companions; convenience sampling; 177 participants [65.5% patients and 34.5% patient companions], 102 females [57.6%] and 75 males [42.4%], 41.2% over 60 years old; 222 nurses: 196 females [88.3%] and 26 males [11.7%], 64% aged up to 39 years)	Survey (questionnaire)
Arnetz (2018, United States) [31]	To identify organizational factors influencing violence in hospitals	Cross-sectional (staff from 41 hospital units; 446 participants; 25.6% aged 40–49 years; 81.8% females, 17.7% male)	Survey (questionnaire)
McCann (2014, Australia) [32]	To determine clinical staff attitudes toward the causes and management of aggression in acute inpatient geriatric psychiatric wards	Cross-sectional (85 participants [75 nurses]; 56 females [65.9%] and 29 males [34.1%]; average age 43 years, ranging from 24 to 62 years)	Survey (questionnaire)
Duxbury (2005, United Kingdom) [33]	To report staff and patient perspectives on the causes of patient aggression and its management	Mixed methods study (psychiatric ward nurses and inpatients from three psychiatric inpatient units; convenience sampling; 82 patients [40 males, 42 females], 80 nurses [61 females, 19 males])	Survey (questionnaire) and unstructured in-depth interviews
Gates (2006, United States) [34]	To determine the violence experienced by emergency department staff from patients and companions during the 6 months prior to the survey	Cross-sectional (healthcare staff from five hospitals; 242 participants: 177 females [73.1%], 65 males [26.9%])	Survey (questionnaire)
Gacki-Smith (2009, United States) [35]	To determine nurses’ experiences and perceptions of violence from patients and companions in emergency departments	Cross-sectional (emergency nurses; convenience sampling; 3465 participants: 2910 females [84.4%], 536 males [15.6%]; 38.2% aged 45–54 years)	Survey (questionnaire)
Timmins (2021, Ireland) [36]	To examine the association between emergency waiting times and occurrence of violence	Literature review (25 studies)	Literature review (data extraction form)
Hamrin (2009, United States) [37]	To identify ecological factors influencing workplace violence	Literature review	Literature review (data extraction form)
Magnavita (2011, Italy) [38]	To develop an aggression prevention program in a psychiatric unit and report its impact on violence rates	Quasi-experimental pre-post study (nursing staff and nursing assistants in a psychiatric rehabilitation unit; approximately 82 female staff in 1995 and 94 staff in 2009)	Intervention conducted and questionnaires completed
Henderson (2013, United States) [39]	Designing a safer emergency department to address workplace violence	Quasi-experimental pre-post study (43 emergency department staff)	Intervention implemented and questionnaire completed
McLaughlin (2010, United Kingdom) [40]	Preparing staff to handle verbal aggression: attitude change, increased confidence, enhanced self-regulation coping	Quasi-experimental pre-post study (psychiatric inpatient ward nurses, 18 participants, mean age 33 years, convenience sampling)	Intervention conducted and questionnaires completed
Hahn (2008, Switzerland) [41]	Systematic review of patient and visitor violence	Literature review (31 studies)	Literature review (data extraction form)
Oludare (2024, Scotland) [42]	Synthesis of international evidence on determinants of violence against nurses and its impact on their performance	Literature review (21 studies)	Literature review (data extraction form)
Lau (2004, Australia) [43]	Reviewing the causes of violence against nurses	Literature review	Literature review (data extraction form)
Pich (2010, Australia) [44]	Reviewing the concept of patient violence against emergency nurses	Literature review (53 studies)	Literature review (data extraction form)
Stathopoulou (2007, Greece) [45]	Identifying factors associated with the occurrence of violence in healthcare and proposing solutions	Literature review	Literature review (data extraction form)
Pulsford (2013, United Kingdom) [46]	Determining the causes of violence and the measures taken in response to aggressive and violent incidents	Cross-sectional study (109 nurses: 56 men, 33 women; 89 participants aged 25–54. 26 patients: 23 men, 3 with unspecified gender; 10 participants aged 25–34)	Survey (questionnaire)
Kennedy (2005, Australia) [47]	Determining the impacts and consequences of violence in emergency departments, and to develop and implement strategies to manage violence	Literature review	Literature review (data extraction form)
Papadopoulos (2012, United Kingdom) [48]	Systematic review of types and causes of violence and aggression in psychiatric inpatient settings	Systematic review (71 studies)	Literature review (data extraction form)
Gerdtz (2013, Australia) [49]	Evaluating the impact of an educational program on staff attitudes regarding the prevention and early management of patient aggression	Mixed methods study (Emergency nurses and midwives; convenience sampling; survey: 471 participants, 86.6% female, 33.1% aged 20–29; interviews: 28 nurse managers and educators, 85.7% female)	Survey (questionnaire), semi-structured interviews
Crilly (2004, Australia) [50]	Identifying causes of patient violence against nurses in emergency departments	Cohort study (Emergency nurses from two public hospitals; 71 participants, 50 reported violence: 43 women (86%) and 7 men (14%), average age 37; 21 did not report violence: 17 women (81%) and 4 men (19%), average age 38)	Document review, questionnaire
Antão (2020, Portugal) [51]	Description of physical and verbal violence in a public hospital; suggestions on how to avoid or minimize workplace violence incidents; defining intervention strategies to improve workplace safety	Mixed methods (emergency healthcare staff; quantitative: 28 participants: 20 women and 8 men, mean age 41.64 ± 10.65; qualitative: 6 participants: 1 man and 5 women, age range 34 to 59)	Survey (questionnaire) and semi-structured in-depth interviews
Baby (2016, New Zealand) [52]	Identifying the nature of aggression experienced by healthcare professionals in New Zealand, access to security measures, and training for violence prevention and management in the workplace	Cross-sectional (141 healthcare managers)	Survey (questionnaire)
Fletcher (2021, New Zealand) [53]	Comparing patient and staff perspectives on the causes of aggression and violence in inpatient wards	Literature review (30 studies)	Literature review (data extraction form)
Brophy (2018, Canada) [54]	Exploring the experiences and perspectives of healthcare workers regarding the risk of physical, sexual, and verbal aggression from patients	Qualitative (54 healthcare workers: 41 women and 13 men, average age 47)	Semi-structured interviews (interview guide)
Pich (2011, Australia) [55]	Describing the experiences of a group of triage nurses with workplace violence	Qualitative (6 nurses: 2 men and 4 women, aged 29–53; purposive sampling)	Interviews (interview guide)
Davids (2021, Australia) [56]	Determining the effectiveness of individual and organizational responses to violent incidents in emergency departments	Qualitative (20 emergency department staff from four hospitals)	Semi-structured interviews (interview guide), ethnographic observations
Kafle (2022, United States) [57]	Exploring the concept of violence, its prevalence, consequences, impact on nursing, and developed strategies for prevention	Narrative review (11 studies)	Literature review (data extraction form)
Gates (2011, United States) [58]	Data were collected from emergency department staff, managers, and patients to identify their beliefs about workplace violence and to determine effective strategies	Qualitative study (emergency department personnel: 96 participants: 24 managers [12 men, 12 women], 47 staff members [46% females, 54% male], 25 patients [60% male, 40% female])	Focus group discussions and Haddon matrix framework
Pina (2022, Spain) [59]	Exploring the sources of perceived conflicts among primary healthcare professionals and examined specific measures to reduce such conflicts	Qualitative study (primary healthcare professionals: 44 participants: 30 women [68.2%], 14 men [31.8%]; mean age: 50.3 years)	Focus group discussions
American Organization of Nurse Executives, Emergency Nurses Association (2015, United States) [60]	Review of the guidelines from the American Organization of Nurse Executives (AONE) and the Emergency Nurses Association (ENA) regarding the reduction of workplace violence	Guideline	Guideline
Reibmann (2023, Germany) [61]	Examining emergency staff perceptions of existing preventive measures, their effectiveness, and barriers to violence prevention	Qualitative study (emergency physicians and nurses; purposive sampling followed by snowball sampling; 27 participants: 13 physicians and 14 nurses; 15 women and 12 men; age range: 20–59 years)	Semi-structured interviews (interview guide)
Hartley (2015, United States) [62]	Description of the development, content, and qualitative evaluation of a free online course on workplace violence prevention	Qualitative study (9 nurses)	Focus group discussion (data collection form)
Corinne Peek-Asa (2009, United States) [63]	Comparison of workplace violence prevention programs in psychiatric units and facilities in California and New Jersey	Mixed-method study (53 hospitals in California and 30 hospitals in New Jersey; random sampling)	Semi-structured interviews (interview guide) and survey (questionnaire)
Marquez (2020, United States) [64]	Examining hospital staff perceptions of organizational safety one year after a workplace violence intervention	Quasi-experimental pre-post study (343 employees across 41 hospital units)	Intervention implementation and survey (questionnaire)
Kelley (2014, United States) [65]	Implementation of a Rapid Response Team (RRT) approach in the emergency department to reduce incidents of violence and aggression toward healthcare staff and to improve overall workplace safety and security	Cross-sectional study (conducted in a social hospital with an emergency center handling over 90,000 patients annually)	Survey (questionnaire)
Christensen (2022, United States) [66]	Improvement of clinical safety in acute inpatient care settings through healthcare teams at a large academic medical center and the Emergency Behavioral Response Team (BERT) program	Quasi-experimental pre-post study involving 302 hospital staff members. Baseline group and final outcome included 43 nursing staff: 42 males in baseline group and 8 in pilot group; 255 females in baseline group and 34 in pilot group. Age range from under 20 to over 50 years. Conducted in two acute inpatient care units	Intervention and survey (questionnaire)
Okundolor (2021, United States) [67]	Development, implementation, and evaluation of a multifaceted approach to reduce physical assaults on staff	Quasi-experimental pre-post study involving 42 nursing staff and 230 patients	Intervention and survey (questionnaire)
Story (2020, United States) [68]	Evaluation of the impact of workplace violence prevention in hospitals and the effect of the Workplace Violence Prevention (WVP) training program on nurses’ perception and confidence regarding aggression and violence	Quasi-experimental pre-post study with 43 participants; 39 (91%) completed both pre- and post-test surveys, and 22 (51%) completed the full intervention. Participants were 77% females and 23% males, with a mean age of 39.8 years	Intervention and survey (questionnaire)
Mitchell (2020, Australia) [69]	Design, implementation, and evaluation of a group-based simulation training program for health professionals	Quasi-experimental pre-post study involving 182 health professionals	Intervention and survey (questionnaire)
Buterakos (2020, United States) [70]	Enhancing emergency nurses’ knowledge about the importance of reporting workplace violence and training on new assertive de-escalation techniques as well as self-protection methods	Quasi-experimental pre-post study (Phase 1: 25 participants (18 nurses; 72% female, 28% male), mostly aged 31–40 years (40%) Phase 2: 34 participants (26 females, 8 males; 76.5% female; age not reported)	Intervention and survey (questionnaire)
Krull (2019, United States) [71]	Improving staff perceptions of knowledge, skills, abilities, confidence, and preparedness in managing violent patient behaviors through inter professional simulation training	Quasi-experimental pre-post study with 90 participants (67 females and 23 males), including 55% registered nurses; 74% female overall	Intervention and survey (questionnaire)
de la Fuente (2019, United States) [72]	Determining the impact of behavior management training on nurses’ confidence in handling aggressive patients	Quasi-experimental pre-post study with 21 nurses initially surveyed (20 females, 95%), 29% aged 20–30 years and 29% aged 51–60 years; 17 completed the post-survey and 13 completed both pre- and post-surveys	Intervention and survey (questionnaire)
Sanchez (2018, United States) [73]	The objective of the active shooter program for the emergency department was to improve staff knowledge, confidence, and response to active shooter situations	Quasi-experimental pre-post study involving 204 emergency department staff	Intervention and survey (questionnaire)
Lamont (2018, Australia) [74]	Determining the effects of a workplace violence training program related to risk assessment and management strategies, de-escalation skills, separation techniques, and confidence levels in an acute hospital setting	Quasi-experimental pre-post study with 78 emergency nurses (56 females and 22 males), mean age 41.7 ± 10.9 years, 72% female and 28% male, with a mean experience of 16.6 ± 10.7 years	Intervention and survey (questionnaire)
Risor (2017, Denmark) [75]	Evaluation of an intervention involving patient handling equipment aimed at improving nursing staff’s use of patient transfer devices, enhancing overall health, reducing musculoskeletal problems, aggression episodes, absenteeism, and work-related incidents	Quasi-experimental pre-post study (181 staff in the intervention group and 113 staff in the control group; 93% female and 7% male in both groups. 43% were aged 25–34 years, 20% were 35–44 years, and 19% were 45–54 years old)	Intervention and survey (questionnaire)
Adams (2017, Australia) [76]	Evaluation of the effectiveness of clinical training to identify patients at high risk of violence and reduce the frequency of violent incidents	Quasi-experimental pre-post study (65 participants before intervention, 73 after; all over 30 years old)	Intervention and survey (questionnaire)
Koller (2016, United States) [77]	Explaining the necessity of training emergency department nurses in violence prevention to identify and reduce violent incidents before they occur	Literature review	Literature review (data collection form)
Nikstaitis (2014, United States) [78]	Determining the effect of an educational intervention on awareness of violence and its incidence among nurses in the adult intensive care unit	Quasi-experimental pre-post study (Before the intervention: 26 participants [4 men and 22 women], 58% aged 30–39; After the intervention: 21 participants [3 men and 17 women, 1 missing], 52% aged 30–39)	Intervention and survey (questionnaire)
Louden (2014, United States) [79]	Determining whether healthcare staff can improve their performance and minimize personal risk when confronted with an active shooter in a hospital emergency department through formal training and scenario-based education	Quasi-experimental pre-post study (32 emergency department staff: 3 medical students, 27 emergency medicine residents, 2 nurses)	Intervention and survey (questionnaire)
Lanza (2009, United States) [80]	Confirmation of the effectiveness of a new nurse-supervised treatment, the comprehensive Violence Prevention Case Management (VPCM) session, for reducing patient violence in an acute inpatient psychiatric unit	Quasi-experimental pre-post study (nursing staff included 13 women and 8 men; all patients were male with a mean age of 42.6 years)	Intervention and survey (questionnaire)
Needham (2005, Switzerland) [81]	Determining the effectiveness of an aggression management training program on nurses’ perception and attitude towards patient aggression	Randomized controlled clinical trial (58 nurses; intervention group: 30 participants [18 women and 12 men, mean age 36.47 years], control group: 28 participants [14 men and 14 women, mean age 39.21 years])	Intervention and survey (questionnaire)
Cowin (2003, Australia) [82]	Assessing nurses’ knowledge and the use of stress management, as well as providing a valuable resource for nursing education	Quasi-experimental pre-post study (19 mental health ward nurses and 30 emergency nurses)	Intervention and survey (questionnaire)
Casteel (2009, United States) [83]	Determining changes in the incidents of violent events among hospital staff before and after the passage of the California Hospital Safety and Security Law in 1995	Cohort (95, California hospital emergency departments and 46 hospitals in New Jersey (control))	Passing the California hospital safety and security law
Kling (2011, Canada) [84]	Determining the effectiveness of a risk assessment tools, along with existing violence prevention training for nurses, on the risk of patient violence in a major acute care hospital in British Columbia, Canada	Quasi-experimental pre-post study (807 high-risk patients (n = 473), a large acute care hospital)	Intervention and survey (questionnaire)
Hamblin (2017, United States) [85]	Describing the implementation of a data-driven and unit-based intervention to reduce workplace violence risk	Randomized controlled trial (supervisors and staff of 21 hospital units across seven hospitals)	Intervention and survey (questionnaire)
Anderson (2006, United States) [86]	Evaluation of the effectiveness of a 3-hour online workplace violence education program by counting reports of violence among various healthcare staff in a small rural community hospital	Quasi-experimental pre-post study (43 nurses; 42.2% of the intervention group and 42.9% of the control group were aged 41–50. In the intervention group, 72.7% (16 individuals) were female, while in the control group, 95% (19 individuals) were female).	Intervention and survey (questionnaire)
Gillespie (2014, United States) [87]	Evaluation of the effectiveness of a comprehensive program to reduce the incidence of physical assaults and threats against emergency care providers by patients and visitors	Quasi-experimental pre-post study (209 emergency department healthcare personnel: 149 women (71.3%) and 60 men (28.7%); mean participant age was 37.3 years (SD = 10.5; range: 20–65 years); 56% were nurses; stratified sampling)	Intervention and survey (questionnaire)
Arnetz (2017, United States) [88]	Evaluation of the impact of an intervention aimed at reducing hospital violence by prospectively tracking the incidence of patient-to-worker violence and related injuries	Quasi-experimental pre-post study (2,863 participants; intervention group: n = 1,612 and control group: n = 1,251. Staff in the intervention group were younger, with 54% under 40 years old compared to 48% in the control group)	Intervention and survey (questionnaire)
Inoue (2011, Japan) [89]	Evaluation of the effectiveness of a group intervention approach aimed at improving the mental health of psychiatric nurses exposed to verbal violence	Randomized controlled trial (62 nurses: 30 in the intervention group and 32 in the control group)	Intervention and survey (questionnaire)
Wong (2015, United States) [90]	Development of an inter professional curriculum focused on improving teamwork and staff attitudes toward patient violence using simulation-based training for emergency department personnel, and evaluation of attitudes toward patient aggression before and after curriculum implementation	Quasi-experimental pre-post study (106 emergency department staff; 41% were nurses, 58% were women (44 men and 62 women), and 34% were aged between 26 and 30 years)	Intervention and survey (questionnaire)
Baby (2019, New Zealand) [91]	Determining the impact of an intervention (communication skills training) on reducing the experience of aggression among healthcare support staff	Randomized controlled trial (127 healthcare support staff from 14 non-governmental organizations (NGOs) and District Health Boards (DHBs))	Intervention and survey (questionnaire)
Cahill (2008, United States) [92]	Evaluation of the effectiveness of the ACT–SMART training program through self-reported improvements by emergency nurses in managing aggression and workplace violence	Quasi-experimental pre-post study (65 participants; intervention group: 16% male and 84% female, mean age 38; control group: 9 female participants, mean age 41)	Intervention and survey (questionnaire)
Touzet (2019, France) [93]	Evaluation of the impact of a comprehensive prevention program aimed at preventing rudeness and verbal violence against healthcare professionals in the ophthalmic emergency department of a university hospital	Quasi-experimental pre-post study (30 healthcare staff; 23% nurses, 23% residents)	Intervention and survey (questionnaire)
Aladwan (2022, United States) [94]	Development of a “zero-tolerance” culture, an educational program, and a new reporting tool in an urban community hospital in Westchester to reduce the incidence of workplace violence among emergency nurses	Quasi-experimental pre-post study (emergency department staff)	Intervention and survey (questionnaire)
Gillespie (2012, United States) [95]	Evaluation of learning outcomes following a four-module workplace violence management training program	Quasi-experimental pre-post study (315 emergency department staff; 47.9% were unlicensed assistive personnel; 220 participants were in the blended learning group and 95 in the web-based learning group)	Intervention and survey (questionnaire)
Gillespie (2014, United States) [96]	Evaluation of learning outcomes from a blended (online and classroom) training program for workplace violence prevention, tailored to the needs of emergency services staff	Quasi-experimental pre-post study (120 staff members; 71.7% registered nurses, 86.7% female)	Intervention and survey (questionnaire)
Deans (2004, Australia) [97]	Determining the effectiveness of a one-day training program for emergency nurses in preventing and managing workplace violence, and its impact on nurses’ knowledge, skills, and attitudes toward managing aggressive behavior	Quasi-experimental pre-post study (before the intervention: 30 participants: 24 women (80%) and 6 men (20%), aged 20–59; after the intervention: 22 participants: 20 women and 2 men, aged 20–59)	Intervention and survey (questionnaire)
Lee (2020, South Korea) [98]	Development and evaluation of a violence prevention program for nursing students aimed at improving communication self-efficacy, problem-focused coping style, emotion-focused coping style, and the ability to cope with violence	Quasi-experimental pre-post study (45 nursing students, all female; mean age of the intervention group: 22.4 years, control group: 24 years)	Intervention and survey (questionnaire)
Ferrara (2017, United States) [99]	Determining the effectiveness of de-escalation training using a ten-item evidence-based de-escalation practice tool	Quasi-experimental pre-post study (34 participants; 71% had less than five years of experience, and 50% were aged between 30 and 49)	Intervention and survey (questionnaire)
Lamont (2012, Australia) [100]	Evaluation of “seclusion technique” training among neuroscience nursing staff as a measure to increase confidence and safety in managing aggression	Quasi-experimental pre-post study (22 participants: 5 men and 17 women; age range 21 to 55 years, mean age 33)	Intervention and survey (questionnaire)
Kontio (2013, Finland) [101]	Determining the impact of an e-learning course on the professional competence of psychiatric nurses in the use of seclusion and restraint, as well as on their job satisfaction and general self-efficacy	Randomized controlled trial (158 participants; in the intervention group, 45% were men and 55% women; in the control group, 48% were men and 52% women. The mean age was 43 years in the intervention group and 45 years in the control group)	Intervention and survey (questionnaire)
Grenyer (2004, Australia) [102]	Development and evaluation of a new aggression reduction program for public health service staff at risk of violence, aimed at helping employees achieve a safer workplace	Quasi-experimental pre-post study (63 participants: 48 healthcare staff members: 33 women and 15 men, mean age 39.15 years; 15 trainers: 9 men and 6 women, mean age 45.1 years)	Intervention and survey (questionnaire)
Guay (2016, Canada) [103]	Determining the impact of the Omega training program on psychological well-being (including staff psychological distress, confidence in skills, and perceived exposure to violence)	Quasi-experimental pre-post study (89 participants: 40 women and 49 men; 56% were aged 46 years or older)	Intervention and survey (questionnaire)
Hahn (2006, Switzerland) [104]	To determine the effect of a systematic aggression management training course on the attitudes of mental health nurses regarding the causes of patient aggression and its management	Quasi-experimental pre-post study (63 participants: 40 women and 23 men, mean age 36 years, age range 24–58 years)	Intervention and survey (questionnaire)
Bowers (2015, United Kingdom) [105]	To determine the effectiveness of a complex intervention (Safewards) aimed at reducing the rates of conflict and containment in acute psychiatric wards	Randomized controlled trial (31 acute psychiatric wards; staff age group 40–49 years (33.7%), majority female (59.4%))	Intervention and survey (questionnaire)
Björkdahl (2012, Sweden) [106]	To determine the effect of the Bergen educational intervention on the prevention and management of violence by nurses in psychiatric wards	Quasi-experimental pre-post study (85 staff members: 58% female, 42% male; 68% over the age of 40 156 patients: 49% female, 51% male; 62% over the age of 40)	Intervention and survey (questionnaire)
Geoffrion (2018, Canada) [107]	To evaluate the impact of the Omega program for managing aggressive behaviors on the use of seclusion and restraint	Quasi-experimental pre-post study (880 staff members)	Intervention and survey (questionnaire)
Senz (2021, Australia) [108]	To evaluate the impact of a new approach for identifying and responding to occupational violence and aggression (OVA) on staff knowledge, perceptions, and confidence regarding OVA in the emergency department, as well as the number of OVA-related security incidents	Quasi-experimental pre-post study (Survey 1: 76 nurses, 83% female; Survey 2: 83 nurses, 81% female; age group 20–50 years, majority in the 20–30 range)	Intervention and survey (questionnaire)
Cowling (2007, Australia) [109]	To evaluate staff experiences of violence and perceptions of safety in the emergency department after the introduction of a Behavioral Assessment Room (BAR), and to determine the satisfaction level of staff responsible for patient management using this method	Quasi-experimental pre-post study and cohort study (117 patients managed in the BAR: 76 men, 38 women; mean age 36.4 years; cohort: 80 emergency department staff)	Intervention and survey (questionnaire)
Cailhol (2007, Switzerland) [110]	To determine the effect of a critical staff education intervention (SECI) on reducing violent behaviors in patients admitted to emergency departments after drug overdose suicide attempts	Quasi-experimental pre-post study and cohort study (478 patients: before intervention 254, after intervention 224; age and gender not reported)	Intervention and survey (questionnaire)
Gillam (2014, United States) [111]	To determine the impact of a non-violent crisis intervention training on reducing violent incidents in the emergency department and educational investment	Quasi-experimental pre-post study (75, 246 emergency department visits with 111 emergency purple code events from November 2012 to October 2013)	Intervention and survey (questionnaire)
Gillespie (2016, United States) [112]	To evaluate the effect of an intervention aimed at increasing the reporting of workplace aggression by patients and their companions	Quasi-experimental pre-post study (101 emergency staff before intervention and 49 after intervention, majority female, mean age approximately 35 years)	Intervention and survey (questionnaire)
Kotora (2013, United States) [113]	To create a comprehensive educational experience to better prepare healthcare staff for an active shooter using didactic lectures and scenario-based methods	Quasi-experimental pre-post study (32 physicians and nurses)	Intervention and survey (questionnaire)
Somani (2021, Canada) [114]	To identify and consider various interventions aimed at reducing the prevalence of workplace violence against nurses	Systematic review (26 studies)	Literature review (data extraction form)
Geoffrion (2022, Canada) [115]	To determine the effectiveness of educational interventions aimed at preventing and minimizing aggression by patients and their companions against healthcare workers	Systematic review (9 studies)	Literature review (data extraction form)
Heckemann (2015, Netherlands) [116]	A systematic review of evidence on the impact of aggression management training on nurses and nursing students working in general hospitals, with recommendations for further research	Systematic review (9 studies)	Literature review (data extraction form)
Anderson (2010, Australia) [117]	A review of interventions aimed at minimizing workplace violence against emergency department nurses	Systematic review (10 studies)	Literature review (data extraction form)
Swain (2014, New Zealand) [118]	To deliver a communication skills training package aimed at reducing experiences of aggression in the workplace for healthcare staff	Quasi-experimental pre-post study (56 healthcare staff: 46 women and 10 men, with a mean age range of 45–54 years)	Intervention and survey (questionnaire)
Martinez (2016, United States) [119]	A review of evidence-based interventions that can help nurses minimize the occurrence of workplace violence	Literature review	Literature review
Arbury (2017, United States) [120]	A review of 12 training programs using criteria developed from the Occupational Safety and Health Administration (OSHA) guidelines for workplace violence prevention for healthcare and social service workers	Literature review	Literature review
Wirth (2021, Germany) [14]	A review of methods for preventing violence by patients and their companions against emergency staff, aimed at reducing violent incidents and increasing emergency personnel’s knowledge, skills, or awareness related to such events	Systematic review (15 studies)	Literature review (data extraction form)
Ramacciati (2016, Italy) [121]	A narrative overview of current approaches to reducing workplace violence in emergency departments, with a special focus on evaluating the effectiveness of emergency response programs	Literature review (10 studies)	Literature review (data extraction form)
Spelten (2020, Australia) [122]	To determine the effectiveness of organizational interventions aimed at preventing and minimizing workplace aggression	Systematic review (7 studies)	Literature review (data extraction form)
Weiland (2017, Australia) [123]	Systematic review of the effectiveness of non-pharmacological strategies for managing acute behavioral disorders in emergency departments, including changes in environment, architecture, policy, and practice	Systematic review (8 studies)	Literature review (data collection form)
Kowalenko (2012, United States) [124]	A review of studies on violence prevention in emergency departments and practical measures to reduce it	Literature review (32 studies)	Literature review (data collection form)
Mundey (2023, Australia) [125]	Evaluation of non-pharmacological interventions to prevent violence by patients and companions against healthcare workers in hospital settings	Systematic review (12 studies)	Literature review (data collection form)
Recsky (2023, Canada) [126]	A review of published evidence on the effectiveness of interventions to reduce violence against hospital emergency department staff	Literature review (24 studies)	Literature review
Gillespie (2013, United States) [127]	Development, implementation, and evaluation of a workplace violence prevention program Mixed methods	Mixed methods (97 healthcare professionals, 66% nurses)	Survey (questionnaire), qualitative (expert panel)
Wassell (2009, United States) [128]	Determining the effectiveness of interventions for workplace violence prevention and proposing interventions to reduce it	Systematic review (100 studies)	Literature review (data collection form)
Wand (2006, Australia) [129]	Review of methods for reducing and managing aggression and violence in healthcare, especially in emergency departments	Literature review	Literature review

According to Table 1, a total of 114 studies examined the causes of violence against nurses in hospitals and healthcare centers in developed countries and effective strategies to reduce it. Among these studies related to causes of violence, the highest number of studies were conducted in Australia (11 studies) and the United States of America (9 studies). Most of these studies were conducted in 2014 with six studies and in 2013 with five studies. The majority of these studies were conducted using the cross-sectional method (11 studies) and literature reviews (11 studies). Among studies that mentioned intervention for reducing violence against nurses in developed countries, 42 studies were conducted in the United States and 21 in Australia, representing the highest number of studies. Most of these studies were published in the years 2014 (11 studies) and 2020 (8 studies). In terms of study design, the majority were interventional (47 studies), followed by literature reviews (22 studies).

Causes of violence against nurses in developed countries

Table 2 outlines the main causes of violence against nurses in developed countries. These were categorized into five overarching domains: individual causes of patients and companions (29 themes), individual causes of staff (23 themes), organizational causes (26 themes), social causes (6 themes), and political causes (7 themes).

Table 2.

Main causes of violence against nurses in developed countries

Main Category	Themes
Individual Causes (Patient and Companion)	Unstable mental state and psychiatric disorders
	Unmet needs of patients and companions
	Death of the patient
	Dissatisfaction with the treatment process
	Personal problems
	Dissatisfaction with the arrangement of medical staff
	Male gender
	Low level of education
	Very young or very old age
	Pain and discomfort
	Lack of trust in medical staff and the hospital
	Increased patient awareness of their rights
	Substance and alcohol abuse
	Lack of awareness of medical and hospital procedures
	Disrespectful behavior
	Non-compliance with rules
	history of violence
	Receiving distressing news
	Conflict between patient and companion
	Emergency or critical condition
	High cost of treatment
	Lack of effective communication staff
	Deprivation from or forced use of medication
	Restriction on personal activities
	Inability to leave the ward
	Sexual abuse
	Low socioeconomic status
	Ethnic and cultural characteristics
	Use of weapons
Individual Causes – Staff	Ineffective communication with the patient
	Negative attitude about nursing
	Lack of compassion and empathy
	Limited clinical skills or work experience
	Staff conflicts
	Feeling of insecurity in the workplace
	Fear and vulnerability of nurses
	High workload
	Time constraints
	Lack of skills in managing violence
	Failure to deliver appropriate care
	Being alone during the shift
	Staff marital status
	Cultural and religious background
	Age
	Low resilience
	Nursing error
	Lower educational level
	Transfer of physician-patient conflicts to nurse
	Employment in emergency or intensive care units
	Evening shifts
	Lack of teamwork
	Failure to report incidents of violence
Organizational causes	Long waiting time
	Being big hospital
	High treatment cost
	Low service quality
	Delays in admission or discharge
	Insufficient security infrastructure
	staff shortages
	Overcrowding and noise
	Lack of space
	Lack of privacy
	Absence of risk assessment mechanisms
	Limited visiting hours
	Tobacco bans
	Shift changes of nurses
	Enforcement of regulations
	Limited access to background information on the high-risk behaviors of patients and their attendants
	Lack of empowerment and violence prevention training programs for hospital staff
	Heavy workload
	Delayed security or police response
	No scheduled rest breaks
	Inadequate post-violence support
	Lack of violence reporting
	Poor monitoring of visitors
	Evening shift
	Limited financial resources
	Lack of financial and psychological support after incidents of violence
Social causes	Negative media portrayal
	Lack of public appreciation for healthcare workers
	Specific cultural behaviors
	Social conflict
	Gender discrimination
	Marginalization of ethnic and immigrant minorities
Political causes	Insufficient government investment
	Poor hospital oversight
	Ineffective legal system
	Weak health insurance coverage
	Restrictive regulations
	Lack of strict visitation policies
	Absence of legal frameworks for penalizing offenders

The main causes of violence against nurses in developed countries are multifactorial, spanning individual, organizational, social, and political levels. At the individual level, patient- and companion-related factors such as psychiatric disorders, unmet needs, dissatisfaction with care, pain, substance abuse, and demographic characteristics (e.g., age, gender, socioeconomic status) were frequently reported. Staff-related factors included ineffective communication, lack of empathy or clinical skills, high workload, insecurity, shift timing, and work in high-risk units such as emergency or intensive care. Both patient and staff characteristics highlight how interpersonal interactions and situational stressors contribute to workplace aggression.

Organizational factors further exacerbate the risk, with issues such as long waiting times, overcrowding, insufficient staffing, inadequate security, high treatment costs, poor infrastructure, and lack of violence-prevention training creating environments conducive to conflict. Limitations in reporting mechanisms, post-incident support, and risk assessment protocols also reinforce systemic vulnerabilities. Social factors including negative media portrayals, low public appreciation, cultural norms, gender discrimination, and marginalization of minority groups undermine respect for healthcare workers and increase the likelihood of aggression. Political and policy-level factors play a critical role as well. Weak government investment, limited oversight, ineffective legal enforcement, inadequate insurance coverage, restrictive regulations, and absence of clear legal frameworks for penalizing offenders contribute to a culture of impunity.

Interventions to reduce violence against nurses in developed countries

Table 3 outlines the subcategories of violence management strategies implemented in developed countries for nurses.

Table 3.

Interventions for reducing violence against nurses in developed countries

Topic	Main Category	Subcategory	Themes
Strategies to Reduce Violence Against Nurses	Prevention Strategies (Before the Occurrence of Violence)	Individual Interventions of Patient and Companion	Separating high-risk patients from other patients
			Administering sedatives to high-risk patients
			Paying special attention to patients’ needs
			screening for history of substance and alcohol use
			Restricting companion movement
			Involving patients in treatment plans
			Reducing patients stress and frustration
		Individual Interventions of Staff	Recruiting skilled healthcare staff
			Training in communication and mindfulness
			Violence management
			Interdepartmental collaboration
			Stress and anger management
			Clinical assessment skills
			Psychological and behavioral training
			Promoting staff health
			Strengthening critical thinking
		Organizational Interventions	Improving patient comfort infrastructure
			Hospital-police collaboration
			Comprehensive violence attention
			Developing violence management protocols
			Visiting hours restriction
			Routine managerial rounds
			Staff support from leadership
			Violence risk assessment procedures
			Security implementations of (e.g., codes, ID systems)
			Reducing wait times
			Providing security infrastructure
			Assessment of patient violence risk
		Social Interventions	Enhancing healthcare access in the community
			Public education on healthcare use
			Raising public awareness on alcohol/substance abuse
			Promoting respect for healthcare staff
			Improving health literacy
		Political Interventions	Conducting action research
			Expanding insurance coverage
			Shifting toward preventive violence management
			Enacting violence management laws
	Interventions During Violent Incidents	Individual Interventions of Patient and Companion	Isolation of high-risk patients and companion
		Individual Interventions of Staff	-
		Organizational Interventions	Presence of police and security personnel
		Social Interventions	-
		Political Interventions	-
	Interventions After the Occurrence of Violence	Individual Interventions (Patient and Companion)	-
		Individual Interventions (Staff)	Reporting incidents of violence
		Organizational Interventions	Medical, psychological, and financial staff support
			Addressing violent incidents
		Social Interventions	-
		Political Interventions	Implementing evidence-based strategies
			Legal action against perpetrators

According to Table 3, the most important interventions for reducing violence against nurses in developed countries were categorized into three levels: before the occurrence of violence, during the occurrence of violence, and after the occurrence of violence. At each level, the interventions were further classified into individual interventions (patient/companion), individual interventions (staff), organizational interventions, social interventions, and political interventions. At the pre-violence level, there were 7 individual interventions (patient/companion), 9 individual interventions (staff), 12 organizational interventions, 5 social interventions, and 4 political interventions. At the violence-occurrence level, there was only 1 intervention related to patients/companions and 1 organizational intervention. At the post-violence level, there was 1 staff-related intervention, 2 organizational interventions, and 2 political interventions.

Discussion

This scoping review sought to identify the underlying causes of violence against nurses in developed countries and to propose strategies for mitigating this growing concern. The findings indicate that violence arises from a multifaceted interaction of individual, organizational, social, and political factors. Notably, the greatest concentration of them was associated with patient- and companion-related contributors, underscoring the immediacy and emotionally charged nature of patient-nurse encounters. Factors such as psychiatric disorders, unmet expectations, dissatisfaction with the quality or timeliness of care, and substance abuse significantly heighten the risk of aggressive behaviors. Multiple studies reveal key risk factors including psychiatric disorders, substance abuse, unmet patient expectations, and dissatisfaction with care [130, 131]. Align with these results, Feruglio et al. [132] found that violence from patients and caregivers causes significant psychological and physical health consequences for nurses, including gastrointestinal symptoms, headaches, and sleep problems. So, it needs for evidence-based, nurse-centered approaches combining training, organizational support, and zero-tolerance policies. These results underscore the need for a holistic approach to preventing violence against nurses.

This review highlights the essential role of nurses’ communication skills, empathy, and professional competence in reducing violence. These findings emphasize the need for continuous training, supportive supervision, and structured de-escalation programs. Individual characteristics such as age or cultural background also influence how nurses experience aggression, while persistent underreporting points to organizational barriers and the need for confidential reporting systems and stronger protective policies. The increased risk in high-pressure units underscores the importance of targeted measures like additional staffing, security presence, and specialized training. In line with these results, Brien et al. [11] pointed out that growing burden of workplace violence is driven by unmet patient expectations, poor communication, long wait times, and organizational factors such as inadequate resourcing such as providing adequate personnel and infrastructure. Despite decades of research, few prevention strategies have demonstrated sustained effects, highlighting the complexity of factors driving violence against healthcare workers [133–135].

The structural weaknesses within healthcare institutions create conditions that enable violence against nurses. Overcrowding, long wait times, staff shortages, inadequate security, and poor infrastructure heighten patient frustration and increase the risk of aggression. Persistent underreporting driven by fear, lack of institutional support, and normalization of violence further prevents organizations from addressing the problem effectively that similar with results of the study of Buterakos et al. [70]. Establishing confidential and supportive reporting systems, backed by clear organizational policies, can also encourage nurses to report incidents. Overall, creating a safer work environment requires institutional commitment, adequate resources, and a proactive safety culture. Improving reporting culture such as anonymous reporting systems, legal protection, post-incident debriefing must be considered by hospital’s management. The absence of clear violence management protocols, delayed security responses, and lack of visitor control were especially problematic [136].

On the other hand, negative media portrayals of healthcare workers, persistent gender discrimination, and the marginalization of staff from cultural or ethnic minority groups collectively erode public trust and respect. This erosion, in turn, heightens the likelihood of violent incidents against healthcare personnel. Insufficient governmental investment in the health sector, poor enforcement of existing protective laws, and weak legal repercussions for perpetrators all contribute to an environment where violence can occur with little fear of accountability. Taken together, these findings suggest that both social narratives and political frameworks play a critical role in shaping the prevalence of workplace violence against nurses, emphasizing the need for comprehensive, multi-level interventions. In line with these results, Gonzalez et al. [137] pointed out that because of different causes of violence against nurses, effective prevention and management strategies require multidimensional approaches including institutional leadership promoting zero-tolerance cultures, comprehensive training programs, de-escalation techniques, resilience building, and enhanced security measures.

The emphasis on prevention particularly at the pre-violence stage suggests that proactive measures are seen as the most viable and effective approach. Patient-focused interventions emphasized early identification, separation, patient engagement, and management of underlying issues such as substance abuse. These strategies target known triggers of aggression and aim to de-escalate tensions before violence occurs. Fletcher et al. [53] noted that the patient-staff relationship plays a key role in aggression, with patients often perceiving staff behavior as coercive, while staff attribute violence to patients’ mental states. Early identification of high-risk patients, management of underlying issues (e.g., substance abuse or psychiatric conditions), and structured engagement to reduce unmet expectations and frustration appear highly effective in preventing escalation.

Staff-oriented interventions centered on capacity building through communication, emotional regulation, mindfulness, and violence de-escalation skills. These efforts acknowledge the psychological burden faced by nurses and emphasize the importance of resilience and critical thinking in high-pressure environments. This is consistent with prior studies advocating early risk assessment, interdisciplinary collaboration, and effective communication strategies as essential elements of prevention [138]. Training nurses in communication, emotional regulation, mindfulness, and de-escalation skills causes to have consistent effectiveness, especially in high-stress units such as emergency and intensive care.

Organizational interventions targeted structural reforms. Leadership support and regular engagement from hospital managers were also emphasized as critical to fostering a safety-oriented culture. This aligns with findings by Spelten et al. [122], who advocated for multilevel violence prevention strategies ranging from intrapersonal to structural interventions and noted their potential to affect change across systems. A systematic review demonstrated that while standalone training programs have limited impact, multicomponent interventions involving organizational changes and all stakeholders are most effective in combating workplace violence against nurses [114]. Social interventions aim to reduce public entitlement and aggression through a broader societal shift in perception. Political interventions though fewer are crucial for long-term change. Legal reforms, insurance policies, and paradigm shifts from reaction to prevention are necessary to ensure systemic accountability and protection for healthcare workers. Consistent with prior recommendations, such interventions must span personal, organizational, and policy levels. While some evidence suggests these interventions may reduce aggression, more high-quality research is needed, particularly in emergency care settings, to establish their effectiveness and standardize outcomes.

Despite the emphasis on prevention, acute-phase interventions during violent incidents were notably underdeveloped. Only two strategies were identified: isolating high-risk individuals and the deployment of on-site security personnel. This gap underscores the urgent need for real-time incident response protocols and staff preparedness. While preventive strategies are ideal, they do not eliminate the need for effective crisis management. Wirth et al. [14] concluded that emergency departments face particularly high levels of workplace violence, and while some behavioral and environmental strategies exist, the evidence for their effectiveness remains limited. The limited evidence underscores the urgent need for robust real-time response protocols, including crisis management training, rapid security response, and structured de-escalation procedures. Future research should prioritize evaluating the effectiveness of these acute-phase interventions, especially in emergency and psychiatric settings where violent incidents are most frequent.

The post-violence phase emerges as a crucial period for both the recovery of affected staff and for organizational learning. While interventions such as psychological support, financial compensation, proper documentation of incidents, and legal follow-up are essential, the fact that only one intervention centered on staff responsibility for reporting underscores the ongoing challenge of underreporting. This gap suggests that cultural norms, institutional constraints, and social stigma continue to discourage nurses from reporting violent incidents, ultimately hindering accurate surveillance and meaningful system-level change. Although the existence of legal frameworks and political commitments to protect healthcare workers is encouraging, their effectiveness is often undermined by limited scope and weak enforcement. Similar to our findings, prior reviews have emphasized the need for clear reporting systems, visible security presence, and interdepartmental collaboration to improve healthcare worker safety [13, 139]. Ultimately, the effectiveness of interventions varies depending on the quality of implementation and the healthcare system in which they are applied. High-quality, multi-site, interdisciplinary research is urgently needed to strengthen the evidence base and support tailored solutions.

Research limitations

Although this scoping review offers a comprehensive synthesis of the causes and interventions related to violence against nurses in developed countries, several limitations must be acknowledged. First, due to the nature of scoping reviews, no formal quality assessment of the included studies was conducted. As a result, the strength of evidence supporting each identified cause or intervention may vary considerably, and some findings may be based on studies with limited methodological rigor. This means that the conclusions drawn should be interpreted with caution, as they reflect breadth rather than depth of evidence. Second, the exclusive focus on developed countries limits the generalizability of findings to low- and middle-income countries (LMICs). Third, the definitions and measurements of workplace violence varied widely across studies from verbal abuse to physical assault making direct comparisons difficult. Additionally, many included studies were cross-sectional or narrative reviews, which limited the availability of high-quality longitudinal or interventional evidence. A significant number of studies acknowledged the issue of underreporting, with nurses often reluctant to report incidents due to fear of retaliation, normalization of violence, or perceived institutional inaction. This systemic problem likely resulted in an underestimation of the actual prevalence of workplace violence, particularly in high-stress environments such as emergency departments. Furthermore, few studies used validated assessment tools or provided long-term follow-up data, making it difficult to evaluate the sustainability or broader impacts of the interventions. Another limitation was the geographic concentration of studies, with a large proportion originating from the United States and Australia. This may over represent healthcare systems, cultural contexts, and policy environments in these countries, while underrepresenting those in other developed nations. Lastly, although several studies addressed individual demographic factors such as age, gender, and educational background, few explored how intersecting identities such as ethnicity, immigrant status, or socioeconomic background may compound nurses’ vulnerability to violence or affect the success of interventions. Pandemics and infectious disease outbreaks, such as COVID-19, can further elevate the risk of violence, highlighting the importance of adequate staffing, financial support, and social and psychological assistance for healthcare workers. However, this review did not consider the effects of pandemics or natural disasters as primary factors contributing to violence against healthcare workers, particularly nurses. Therefore, it is essential to conduct studies, ideally scoping reviews, examining the impact of pandemics and natural disasters on the incidence of violence against nurses.

Conclusion

This scoping review of 114 studies highlights that workplace violence against nurses in developed countries is a multifactorial issue driven by patient-related factors (e.g., psychiatric disorders, unmet needs, dissatisfaction), staff-related factors, and broader organizational, social, and political determinants. Interventions were categorized into pre-violence, during-violence, and post-violence phases, with most focusing on prevention through staff training, risk assessment, protocols, and public awareness. Few strategies addressed real-time responses or post-incident recovery, revealing gaps in emergency preparedness and long-term support. Key recommendations include strengthening acute-phase responses via de-escalation training and rapid security measures, enhancing post-incident recovery with reporting systems, counseling, and legal/financial support, fostering organizational culture change with zero-tolerance policies and adequate staffing, and promoting legislative enforcement and inter-sectorial collaboration. Overall, empowering nurses through education, resilience-building, and institutional commitment is essential to protect staff and sustain quality patient care. Future research should focus on high-risk settings like emergency and psychiatric departments to evaluate and optimize intervention effectiveness.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Author contributions

Conception and design: Fatemeh Mahmoudi, Gholamreza Garmaroudi, Narjes Razavi, Ali Mohammad Mosadegh Rad, Mahnaz Ashoorkhani; Data collection: Fatemeh Mahmoudi; Analysis and interpretation: Fatemeh Mahmoudi, Nadia Saniee; Draft manuscript preparation: Fatemeh Mahmoudi, Gholamreza Garmaroudi, Nadia Saniee, Narjes Razavi, Ali Mohammad Mosadegh Rad, Mahnaz Ashoorkhani. All authors reviewed the results and approved the final manuscript.

Funding

This research was supported by a grant No: 64211 from the Vice-Chancellor for Research and Technology at Tehran University of Medical Sciences.

Data availability

The data supporting the findings of this study are in the article.

Declarations

Ethics approval and consent to participate

This study was approved by the Ethics Committee of Tehran University of Medical Sciences (code number: IR.TUMS.SPH.REC0.1401.258). The consent to participate in the research was not applicable.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.