. 2019 Sep 17;9(9):e028465. doi: 10.1136/bmjopen-2018-028465

Table 2.

Summary of selected qualitative studies GRADE-CERQual assessment

Reference	Setting	CERQual	Study design	Intervention	Key findings with respect to review question
Gillespie et al ⁴⁸	3 EDs USA 80 employees ED	Medium	Implementation and evaluation of a sustainable comprehensive department-based ED violence prevention programme. Action research principle: academic researchers partner with clinicians and collaboration with stakeholders	Workplace violence policies and procedures: for example, risk assessment, record-keeping, response to violent events Workplace violence education Environmental changes: for example, panic buttons, lock doors, cameras	Impact on violence rates was not reported. Programme fidelity: variable success in institutionalising and sustaining intervention subcomponents. Mixed overall evaluation of the programme by employees: Employees rated the programme as moderately beneficial. Surveillance and monitoring environmental changes, education and postincident care were rated as very important. Policies and procedures were rated as important. Managers and educators programme evaluation: Most important components were: surveillance, environmental changes, classroom training and postincident care. Workplace violence assessment screening at triage for all patients was evaluated as least effective There was a low participation level of physicians. Underreporting of violent events
Henson¹⁷	EDs Situational crime prevention in EDs	Medium	Preventing interpersonal violence in EDs: practical applications of criminology theory	Increase the effort of criminal activity: for example, secure entrances/exits, metal detectors Increase the risks of getting caught: for example, install CCTV cameras Reduce the rewards of criminal activity: for example, reduce the amount of prescription drugs carried by staff Reduce provocations: for example, appropriate waiting areas, secure and isolate volatile patients Remove excuses for disruptive and violent behaviour: for example, clearly post rules of conduct and consequences for breaking them, streamline the check-in process form, refuse admission to intoxicated visitors	In many EDs these interventions are partially implemented based on the risk assessment and prevention rationale. A systematic test of the proposed prevention techniques is not performed. Remark: Situational crime theory is based on rational choice, however, violence in healthcare is mostly impulsive and unplanned. To deny access to ED if the patient is drunk or intoxicated, is in conflict with the patient’s fundamental right to healthcare and the physician’s duty of care.
Holloman et al ⁴⁹	Emergency Psychiatry Psy	Medium	Overview of Project BETA: Best Practices in Evaluation and Treatment of Agitation: to develop guidelines including all interventional aspects: triage, diagnosis, verbal de-escalation and medicine choices	Five study workgroups Medical evaluation and triage of the agitated patient. Psychiatric evaluation of the agitated patient. Verbal de-escalation of the agitated patient. Psychopharmacological approaches to agitation. Use and avoidance of seclusion and restraint.
Stowell et al ⁵⁰	Emergency Psychiatry	Medium	BETA project Psychiatric evaluation of the agitated patient	Prior to attempting de-escalation, a brief evaluation must be aimed at determining the most likely cause of agitation: Has the patient an acute medical problem ? Has the patient a delirium ? Has the patient a chronic cognitive impairment that is contributing to the current state of agitation ? Is the patient intoxicated or in withdrawal? Is the patient’s agitation due to psychosis caused by a known psychiatric disorder? Is the agitation due to non-psychotic depression or anxiety disorder? Is the patient simply angry or out of control ? Assess the risk of suicide and violence.
Richmond et al ³¹	Emergency Psychiatry	Medium	BETA project Verbal de-escalation of the agitated patient	The authors detail the proper foundations for appropriate training for de-escalation using the 10 domains of de-escalation: Respect the patient and your personal space: maintain at least two arms’ length of distance. Do not be provocative: avoid iatrogenic escalation. Body language and tone of voice should be congruent with what the clinician is saying. Establish verbal contact: Only one person verbally interacts with the patient. Introduce yourself to the patient and provide orientation and reassurance, explain that you are there to keep him safe and make sure no harm comes to him or anyone else. Be concise and keep it simple, use short sentences, give the patient time to process and respond. Repetition is essential to successful de-escalation, repeat your message until it is heard, set limits and offer choices, listen actively to the patient and agree with his position whenever possible. Identify wants and feelings: use free information to identify wants and feelings. Listen closely to what the patient is saying, use active listening and Miller’s law: you must assume that what the other person is saying is true and try to imagine what it could be true of, this makes you less judgemental and the patient will sense that you are interested in what he is saying and this will improve your relationship. Agree with the patient as much as possible or agree to disagree. Lay down the law and set clear limits: establish basic working conditions: communicate these in a matter-of-fact way and not as a threat. This requires that both patient and clinician treat each other with respect. Limit setting must be reasonable and done in a respectful manner. Coach the patient in how to stay in control. Offer choices and optimism. Be assertive and propose alternatives to violence. Offer realistic things that will be perceived as acts of kindness such as blankets, drinks. Broach the subject of medication when needed and offer choices to the patient. The goal is not to sedate but to calm down. Debrief the patient and staff.³¹
Wilson et al ⁵¹	Emergency Psychiatry	Medium	Psychopharmacology of agitation BETA project	’Pharmacologic treatment of agitation should be based on an assessment of the most likely cause for the agitation. If the agitation is from a medical condition or delirium, clinicians should first attempt to treat this underlying cause instead of simply medicating with antipsychotics or benzodiazepines. Oral medications should be offered over intramuscular injections if the patient is cooperative and no medical contraindications to their use exist. Antipsychotics are indicated as first-line management of acute agitation with psychosis of psychiatric origin. When an antipsychotic is indicated for treatment of agitation, certain SGAs (such as olanzapine, risperidone or ziprasodone), with good evidence to support their efficacy and lack of adverse events, are preferred over haloperidol or other FGAs. Agitation secondary to intoxication with a CNS depressant, such as alcohol, may be an exception in which haloperidol is preferred owing to few data on second-generation antipsychotics in this specific clinical scenario. If haloperidol is used, clinicians should consider administering it with a benzodiazepine to reduce extrapyramidal side effects unless contraindications to use of this medication exist.’⁵¹
Price and Baker²⁶	Process of de-escalating violence and aggression excluding patients with dementia	High	Key components of de-escalation techniques Qualitative research Thematic synthesis	Seven themes Staff skills: Characteristics of effective de-escalators: open, honest, supportive, self-aware, coherent, non-judgmental and confident without being arrogant. Maintaining personal control: calmness conveys that the member of the staff is in control of the situation whereas fear can increase anxiety, make the patient feel either unsafe or that they have gained the upper hand. Verbal and non-verbal skills: calm, gentle, soft tone of voice. Process of intervening: Engaging with the patient: establish a bond. When to intervene. Ensuring safe conditions for de-escalations. Strategies for de-escalation autonomy confirming interventions: Shared problem solving Facilitating expression Offering alternatives to aggression limit setting and authoritative interventions: knowing when to exert control and implement. ²⁶
Morken et al ⁵²	Emergency Primary Healthcare, Norway, 15 nurses and 22 physicians	Medium	Focus group study, qualitative design Dealing with workplace Violence in emergency primary care focusing on organisational factors.	Organisational strategies for workplace violence prevention: Minimising the risk of working alone: Having an efficient alarm system with adequate response time to summon someone. Regular turning up of colleague. Being prepared: obtain information prior to the consultation, take precautions when facing warning signs, alerting colleagues or police in advance. Resolving mismatch between patient expectations and services offered: for example, clear and consistent procedures on not handing out drugs to patient and communicate these to the public. Supportive manager response in follow-up of a violent episode.
Moylan, 2017	General practice, Australia	Not applicable	Discussion on practical measures to manage the risk of occupational violence based on guidelines from RACGP and WorkSafe Victoria.	Multilevel response: workplace design. policies and work practices. training. Before consultation: Is there a quick exit route? Do you have an alarm mechanism or call for assistance? Are there patient flags for previous violence? Are there other client risk factors present? Is a chaperone required? During consultation: Are warning signs of violence present ? De escalate versus end consultation ? After the consultation: Has the patient left safely ? Are others in practice safe? Documentation of event ?
Elston and Gabe²	General practice 1300 GPs 13 focus groups 19 in-depth interviews English National Health Service UK	Medium	Survey, in-depth interviews, focus group discussions Gender differences in risk of violence and prevention measures	No gender difference in overall risk of violence. Increased risk for physical assaults within younger, male GPs. Women were more likely to express concerns about violence. Women consistently adopted more preventive measures than men. Male and female GPs downplayed the impact of any violence. Male and female GPs spoke of fear and being vulnerable. Fear and the impact of violence: differences in terms and tone between men and women GPs, higher emotional intensity in terms used by women GPs. Sexual assault and harassment: male and female GPs are confronted with this. Women GPs explicitly suggested their professional standing protected them. Reducing risk and minimising harm: GPs strongly opposed to so-called ‘fortress medicine’. GPs emphasising importance of professionalism and good communication skills to reduce risk and harm. Leaving visit schedule with someone. Check patient notes in advance. Policy adapted such that GPs use at their discretion the opportunity to be accompanied during home visits.
Sim et al ²²	General practice, Australia	Not applicable	Aggressive behaviour: prevention and management in the general practice environment	Strategies to prevent aggression: Staff: friendly, patient-focused approach, demonstrating willingness can reduce stimuli for aggressive behaviour. System approach to reduce long waiting times: for example, include emergency appointment slots, courtesy message systems to alert patients about delays, rescheduling late patients… Management of aggression: Recognizing aggressive behaviour. De-escalating early aggression. Limit setting and follow-up of incidents. Use of verbal or written behaviour contracts. Systems approach by applying the Plan-Do-Check-Act approach. Establish a roadmap to follow when faced with aggressive behaviour.
Magin⁵³	General practice, Australia practice receptionists	Medium	Semistructured interviews Experiences and perceptions of GP receptionists with Perspex and lockdown system	Perspex and lockdown system implemented or not implemented	Experiences and perceptions of GP receptionists: Positive perception about the safety measures for reducing risks. Concern to compromise the feeling of a practice being patient-centred by alienating patients from staff and paradoxically increasing the levels of patient violence and staff fearfulness. Respondents from low prevalence practices did not see the need for these measures.
Magint et al ¹⁸	General practice, Australia GP	Medium	Focus group discussions (18 GPs) and questionnaire (154 GPs) Underlying and proximate causes of violence	Risk factors: see discussion. Implementation of overt measures to deter violence such as security guards or barricades between staff and patients might impair doctor-patient trust and antagonise therapeutic relationships with mutual suspicion and misunderstanding spiralling into violence.
Magin et al ⁵⁴	General practice, Australia	Not applicable	Occupational violence in general practice	Risk factors: see discussion. Planning and training. Referral of patients to hospitals or other public facilities during out-of-hours service. Selective restriction of practice is perceived to compromise the equality of access to care principle and may lead to stigmatisation and discrimination. RACGP recommendations’ summary of recommendation.⁵⁵ RACGP recognises as well as GPs right to feel and be safe as the willingness of the GP to take care of people who may have a propensity for violence rather than the zero tolerance policy.
Naish et al ³⁴	General practice London	Medium	30 interviews and 5 focus groups (44 people)	Strategies for incident management and team organisation: Immediate response: Containment and cooperation. Aimed at managing immediate incident, preventing escalation and preserving patient-staff relationship. Medium-term strategies: What lessons can a team learn from an aggressive incident? Adequate incident recording mechanism with agreed threshold for reporting and good support system with opportunities for individual and team debriefing. Long-term strategies: Improved security for protection of staff, balanced with a welcoming environment for patients. Communication skills training and improved whole team communication. Arrange primary care team-specific workshops to review experiences, identify systematic weaknesses and formulate solutions on an inclusive multidisciplinary basis. Collective formulation of protocols for managing threatening encounters.
Kowalenko et al ⁶	ED USA Physical assault	Low	Review workplace violence in emergency medicine: current knowledge and future directions focus on physical assault	Training of staff Modifications in ED physical structure and security Changes to policies	Training leads to increased knowledge and confidence to deal with violence, however a reduction in assaults is not demonstrated. Modification in environment: metal detectors, security dogs, panic buttons, alarm systems, visibility, cameras, physical barriers are commonly used but there is no clear evidence on reduction of violence. Policies such as zero-tolerance policies, management commitment, reporting of incidents and risk assessment are commonly used but there is no clear evidence on reduction of violence. Specific action plan for ED based on guidelines and recommendations from OSHA. No evidence-based policies and interventions.
Garriga et al ³⁰	Agitation in psychiatry International Psy	High	Systematic Review Assessment and management of agitation in psychiatry expert consensus among most cited authors using Delphi method. 124 included studies	22 recommendations: Identify possible medical cause. First choice: verbal de-escalation and environmental modification. Physical restraint: last resort. Pharmacological treatment: calm without oversedation. Agitation with no provisional diagnosis or with no available information should be presumed to be from a general medical condition until proven otherwise. The routine medical examination in an agitated patient should include a complete set of vital signs, blood glucose measurement (finger stick), determination of oxygenation level, and a urine toxicology test. After treating agitation, systematic assessment of sedation levels should be performed. The initial approach to a patient with agitation should always start with verbal de-escalation, environmental modifications and other strategies that focus on the engagement of the patient and not on physical restraint. Verbal de-escalation should be always used in cases of mild-to-moderate agitation, thus avoiding the need for physical restraint. Physical restraint should only be used as a last resort strategy when it is the only means available to prevent imminent harm. In front of risk of violence, the safety of patient, staff and others patients should be presumed. If restraint and seclusion are necessary, proper monitoring and the use of quality indicators should be also undertaken. In the case of physical restraint, vigilant documented monitoring should be mandatory. Vital signs should be measured every 15 min for 60 min and then every 30 min for 4 hours or until awake. Physical restraint should be removed as soon as the patient is assessed not to be dangerous anymore for him/herself and/or others. Non-invasive treatments should be preferred over invasive treatments whenever possible. Agitated patients should be involved as much as possible in both the selection of the type and the route of administration of any medication. The main goal of pharmacological treatment should be to rapidly calm the agitated patient without oversedation. When planning involuntary pharmacological treatment team consent should be reached and the action carefully prepared. Oral medications, including solutions and dissolving tablets, should be preferred to the intramuscular route in mildly agitated patients. A rapid onset of the effect and the reliability of delivery are the two most important factors to consider in choosing a route of administration for the treatment of severe agitation. In the case of agitation secondary to alcohol withdrawal, treatment with benzodiazepines should be preferred over treatment with antipsychotics. In the case of agitation associated with alcohol intoxication, treatment with antipsychotics should be preferred over treatment with benzodiazepines. In mild-to-moderate agitation, and when rapid effects of medication are needed, inhaled formulations of antipsychotics may be considered. The concomitant use of intramuscular olanzapine and benzodiazepines should be avoided, due to the possible dangerous effects induced by the interaction of the two medications in combination (hypotension, bradycardia, and respiratory depression). Intravenous treatment should be avoided except in cases where there is no alternative. Elderly agitated patients should be treated with lower doses: usually between a quarter and a half of the standard adult dose.³⁰
Wright et al ¹⁹	General practice, UK	Medium	Systematic Review Prevalence and management of violence in primary care	‘ Management of violence in primary care should focus on structural risk factors and interaction at individual level between patient and clinician. Establish a collaborative practice approach. Be aware of the specific risks for verbal abuse and threats of violence towards the receptionists. Risk factors are not static but vary according to time, place and situation. GPs should use their knowledge of the patient to form part of risk assessment. Perceived risk of violence can exceed the real absolute risk. Balance the risk of excluding patients from primary care versus staff safety. Do: Provide panic alarms. Use a critical incident recording system. Ensure that waiting area can be seen from the reception desk. Provide a means of escape that does not involve the path of the patient. Consult with another team member if conflict is anticipated. Call the police if an abusive situation seems likely to become violent. Reflect on one’s own behaviour after each critical incident. Remove a patient from the list only as a last resort. Encourage all team members to ‘own’ the potential problem of violence. Do not: Use grills, barriers or glass screens inappropriately. Leave it to someone else to attend to the problem. Use physical force to restrain. Always see yourself as ‘right’ and the other party as ‘wrong’.¹⁹
Phillips²⁰	Healthcare different settings, USA	Medium	Review article Prevalence of type II workplace violence. Non-hospital setting. Hospital setting. Barriers to reporting. Risk factors. Metal detectors. Guidelines. Potential solutions.	Although metal detectors may theoretically mitigate violence in the healthcare workplace, there is no concrete evidence to support this expectation. Lack of supporting evidence on efficacy of preventive measures. Difficulty in designing experiments to test hypothetical interventions. A multifaceted, multidisciplinary approach is necessary and any prevention programme requires individualisation and customisation. Recommendations that have been proposed: Training in de-escalation techniques and training in self-defence. Target hardening of infrastructure: security cameras, fences, metal detectors, hiring of guards. Healthcare organisations: improve staffing levels during busy periods to reduce crowding and wait times, decrease worker turnover and provide adequate security and mental health personnel on site. Reporting and redress: verbal assault has been shown to be a risk factor for battery. ‘The broken window principle’: criminal justice theory that apathy towards low-level crimes creates a neighbourhood conducive to more serious crime also applies to workplace violence. ‘Zero tolerance policy’ may prevent escalation.²⁰
Wax et al ⁵⁶	Healthcare USA	Not applicable	Review Workplace Violence in Healthcare: It's Not ‘Part of the Job’.	Prevalence: healthcare workers comprise only 13% of the US workforce but experience 60% of all workplace assaults. Types of workplace violence. Contributors to workplace violence: see discussion on risk factors. Consequences of workplace violence in healthcare. Guideline summary: OSHA.⁵⁷ Responding to active shooter incident: ‘run, hide, fight’ approach. The human, societal and economic costs of healthcare workplace violence are enormous and unacceptable. There are opportunities for professional physician organisations to establish clear policy statements on workplace violence, to support education on workplace violence and to assist collaborative state legislative efforts.
Gillespie et al ²¹	Healthcare workers USA	Medium	Literature review: workplace violence in healthcare settings: risk factors and protective strategies	Environmental risk factors: controlled access to patient areas, reduced wait times, security presence, escorting workers to vehicle, security presence, video monitors, cell phone or personal alarm. Organisational policies, zero-tolerance policy. After a violent event: support from co-workers, management, debriefing, professional counselling, re-assigning patients when feasible. General practitioner: documentation of after-hours destination, no house calls to unfamiliar patients. Instructing unknown patients or patients with history of violence to seek healthcare with a different provider. Communication of location at regular intervals with a unit coordinator and a plan to be activated on failure to do so. Violence-prevention training on hiring and regular updates; including recognising stress in oneself or in patients, de-escalation techniques. Effective violence-prevention programme. Limiting visitor access to two persons.
Robson et al ³⁷	General OHSAS system effectiveness Different industrial sectors	Medium	Systematic review The effectiveness of occupational health and safety management system interventions 13 selected studies	See discussion. Relatively small quantity of published peer-reviewed evidence involving occupational health and safety management system interventions. Synthesis of evidence showed mostly favourable results, there were a few null findings but no findings of negative effects. All but one of the studies included had moderate methodological limitations. Despite the generally positive results on effectiveness of occupational health and safety management system interventions, the evidence is insufficient to make recommendations either in favour or against.

ED, emergency department; GP, general practitioner; OSHA, Occupational Safety and Health Administration.