Workplace Violence in Healthcare Settings: Risk Factors and Protective Strategies

Abstract

The risk factors and protective strategies associated with workplace violence by patients and visitors against healthcare workers are described. Perpetrator risks factors are patients and visitors having mental health disorders, being under the influence of drugs or alcohol, ineffectively dealing with situational crises, possessing weapons, and being a victim of violence. Worker risk factors are gender, age, years of experience, hours worked, marital status, and previous workplace violence training. Setting/environmental risk factors are the time of day and presence of security cameras. Protective strategies against the negative consequences of workplace violence include carrying a telephone, self-defense, instructing perpetrators to stop their violence, self and social support, and limiting interactions with potential or known perpetrators. Workplace violence is a serious and growing problem and no worker is immune. Strategies need to be in place to prevent workplace violence and manage the negative consequences experienced by healthcare workers following violent events.

Workplace violence is a problem plaguing workers and employers in healthcare settings. Physical violence can result in physical injuries or in the extreme case, the death of a worker (Bergen, Chen, Warner, & Fingerhut, 2008; Hartley, Biddle, & Jenkins, 2005). Verbal violence is another form of workplace violence and has been linked to negative consequences including anxiety, depression, and stress symptoms (Spector, Coulter, Stockwell, & Matz, 2007). Violence affects workers from all disciplines in the healthcare field. DuHart (2001) reported that both physicians and nurses were victims of workplace violence, with physicians being targets of physical violence at 16.2 per 1,000 workers and nurses at 21.9 per 1,000 workers. Other healthcare workers including patient care assistants were assaulted at a rate of 8.5 per 1,000 workers (DuHart, 2001). The purpose of this article is to describe the risk factors and protective strategies associated with workplace violence by patients and visitors against healthcare workers.

Risk Factors for Workplace Violence in Healthcare Settings

Healthcare workers are exposed to a variety of factors that increase their risk for physical and verbal workplace violence from patients and visitors. The National Institute of Occupational Safety and Health (NIOSH, 1996) reported several of these factors: working with the public, handling money, transporting or delivering passengers or items, working with people who are more likely to be violent, working in the community setting, working in high crime areas, working during night time or early morning hours, guarding valuables, and working alone. Details regarding the perpetrator, worker, and setting/environmental risk factors identified in the literature follow.

Perpetrator Risk Factors

Mental health disorders have been linked to perpetrators of workplace violence (Catlette, 2005; Gates, Fitzwater, & Succop, 2003; Gates, Ross, & McQueen, 2006; Gillespie, 2008; James, Madeley, & Dove, 2006; Lee, Gerberich, Waller, Anderson, & McGovern, 1999) from a variety of conditions including dementia, schizophrenia, anxiety, acute stress reaction, suicidal ideation, and alcohol and drug intoxication (American Medical Association, 2007). Patient dementia was identified as a factor in 87% of physical assaults of nursing home assistants (Gates et al., 2003). Mandiracioglu and Cam (2006) further reported on verbal and physical violence in nursing home workers, finding that patient dementia was linked to 11% of the violent events while other psychiatric diseases were linked to another 25% of events. A higher percentage of violence from patients with dementia may have been due to a greater percentage of nursing home residents having dementia in Gates’ et al. (2003) particular study sites.

Research completed by Almvik, Rasmussen, and Woods (2006) compared male and female patients with Alzheimer’s disease and the severity of the physical violence they enacted against healthcare workers using the Staff Observation Aggression Scale – Revised. These researchers determined that the severity of physical violence from male patients was significantly greater compared to female patients (p < 0.01). This may be due to males being more likely to enact physical violence compared to females who may be more likely to enact verbal violence. It may also be due to the physical ability of males to cause more physical injury when hitting, striking, or pushing healthcare workers compared to females who commit physical violence.

Another leading perpetrator risk factor for verbal or physical violence include patients or visitors who were under the influence of drugs or alcohol (Catlette, 2005; Crilly, Chaboyer, & Creedy, 2004; Chaplin, McGeorge, & Lelliott, 2006; Gates et al., 2006; Gerberich et al., 2004; Gillespie, 2008; James et al., 2006; Keely, 2002; Keough, Schlomer, & Bollenberg, 2003; Kowalenko, Walters, Khare, & Comptom, 2005; Lin & Liu, 2005). In one study, 35% of healthcare workers believed that the violent perpetrator was using drugs or alcohol prior to the violent event (DuHart, 2001). In a second study, participants believed that perpetrators were under the influence of drugs or alcohol in half of all verbally violent events and 96% of all physically violent events (Crilly et al., 2004).

Patients’ and visitors’ inability to deal with a crisis situation is another perpetrator risk factor for workplace violence (Catlette, 2005; Gates et al., 2006; Gillespie, 2008). For example, the stress experienced during an emergency department (ED) visit may lead patients or visitors into a state of crisis where they are no longer able to deal with a situation as they normally would (Broering, Campbell, Favand, Galvin, & Holleran, 2007). This stress may increase their chance of becoming verbally or physically violent. Crisis situations can occur when there are disagreements with the medical plan, denial of a service or request, conflict with healthcare workers, excessive waiting for assessments and interventions, inability to focus beyond oneself, perceptions of a healthcare worker as rude or uncaring, grief over the death of a child, and a lack of control over the ability to change a healthcare outcome (Badger & Mullan, 2004; Catlette; Committee on Pediatric Emergency Medicine, 1997; Ergün & Karadakovan, 2005; Gates et al.; Gillespie; James et al., 2006; Keely, 2002; Lin & Liu, 2005; McAneney & Shaw, 1994).

Gerberich et al. (2004) identified that the gender and age of a perpetrator are associated with violence against healthcare workers. The researchers found that the majority of verbally violent perpetrators were men (73%, n = 1,594) and between the ages of 35–65 (54%, n = 1,186). Physical violence was most often enacted by men (59%, n = 386) and persons 66 years or older (64%, n = 423). Children 17 years and younger represented the smallest group of perpetrators; 5.3% (n = 35) for physical violence and 5.7% (n = 122) for verbal violence. James et al. (2006) reported similar findings for gender when studying safety event reports from a hospital in the United Kingdom. Males (66%, n = 97) and younger patients between 16 to 35 years (55%, n = 82) were most likely to be perpetrators of violence.

The sheer volume of weapons being brought into the healthcare setting today may increase the potential for violence against healthcare workers. Peek-Asa, Cubbin, and Hubbell (2002) noted that patients were more likely to carry guns and knives when being treated in the healthcare setting in 2000 compared to 1990 data. Sixteen years ago, McAneney and Shaw (1994) found that over half of pediatric ED directors had already begun confiscating weapons from pediatric patients. DuHart (2001) reported that 11% of perpetrators used a weapon during the commission of violent events against healthcare workers. While some EDs instituted a weapon screening system in triage, patients arriving by ambulance were not routinely checked for the presence of weapons (McAneney & Shaw).

Being a victim of violence, particularly when the violence resulted from a firearm injury, is a perpetrator factor significantly linked to enacting violence against others (Bingenheimer, Brennan, & Earls, 2005; Cunningham, et al., 2009). Bingenheimer et al. tracked 1,517 Chicago adolescents longitudinally. The researchers revealed that the adolescents who had seen or been victims of violence were significantly more likely than adolescents with no violence exposures to self-report impulsivity (p < 0.0001), aggression towards others (p < 0.0001), and committing violent offenses (p < 0.0001). These behaviors increase the likelihood that the patient who is a victim of violence may enact violence at some point to the healthcare workers providing the patients’ care.

Worker Risk Factors

Certain characteristics have been found to increase the risk of workers being a target of workplace violence in the healthcare setting. These risk factors include workers’ gender, age, years of experience, hours worked, marital status, and previous workplace violence training.

There was contradictory evidence about a worker’s gender as a risk factor for being verbally or physically assaulted by patients and visitors. One group of researchers ascertained that women experienced a higher percentage of verbally and physically violent events as compared to males although the difference was not significant (Ayranci, Yenilmez, Balci, & Kaptanoglu, 2006). The majority of researchers though identified that men experienced workplace violence significantly more often than women (Anderson & Parish, 2003; Camerino, Estryn-Behar, Conway, van Der Heijdend, & Hasselhorn, 2008; Ferrinho et al., 2003; Hegney, Plank, & Parker, 2003; Hegney, Eley, Plank, Buikstra, & Parker, 2006; James et al., 2006; Miedema, Easley, Fortin, Hamilton, & Tatemichi, 2009; Thomas et al., 2006). In contrast, Tolhurst, Baker, Murray, Bell, Sutton, and Dean (2003) determined that there was no significant difference between the overall frequency of verbally and physically violent events between a group of male and female physicians; however, the percentage of men who experienced at least one violent event compared to women was greater during the preceding 12 months. Privitera, Weisman, Cerulli, Tu, and Groman (2005) noted that there was no significant difference in gender for the number of verbally or physically violent events against clinical and non-clinical mental health workers. However, a greater percentage of female physicians had a fear of future violence compared to male physicians (Tolhurst, Talbot, et al., 2003).

Ayranci et al. (2006) learned that healthcare workers under age 40 had the greatest prevalence of violence perpetrated against them. This finding was supported by other researchers who observed that older workers experience significantly less violence than younger workers (Camerino et al., 2008; Hegney, Eley, Plank, Buikstra, & Parker, 2006; Hegney et al., 2003; Lawoko, Soares, & Nolan, 2004; Thomas et al., 2006). Gates, Fitzwater, Telintelo, Succop, and Sommers (2002) provided a similar finding with the age of nursing home assistants. As the age of the caregiver increased, the incidence of violence against them decreased. Gates et al. posited that this relationship may be due to older nursing home assistants being more adaptable, patient, empathetic, and slower during their interactions with the elderly. As with gender, not all research findings for age were consistent. In contrast, Ergün and Karadakovan (2005) provided evidence that nurses reporting physical violence were significantly older than nurses who denied an event of physical violence. Anderson and Parish (2003) noted no relationship between age and the occurrence of violence among Hispanic nurses. This may be due to researchers studying lifetime incidence for workplace violence versus a 12-month period for workplace violence. Findings for lifetime incidence of violence will likely always be greater for older workers compared to younger workers because as each year passes, the accumulative number of violent events will increase. In contrast, when studying the number of violent events over a single 12 month period, the number of violent events per person per year will likely be less for older workers.

Ergün and Karadakovan’s (2005) research yielded a significant and positive accumulative relationship between the number of violent events and years of nursing experience. Anderson and Parish (2003) found no relationship between years of experience and the occurrence of violence; however, they also limited their study population to Hispanic nurses working in Texas. It is possible that there may be geographical or ethnic differences between Hispanic Texan nurses and nurses from other cultures and states or countries. In addition, while the accumulative number of violent events over a career span may be greater with each successive year, the incidence per each successive year may be decreasing. This would explain why newer nurses have a greater number of events per year but more experienced nurses have a greater lifetime number of violent events.

When comparing years of experience and the occurrence of violent events, Kowalenko et al. (2005) stated the opposite of Ergün and Karadakovan (2005). Kowalenko et al. determined that less experienced physicians incurred violence more often than more experienced physicians. The difference in findings is likely to again be due to differences in data analysis; for example Ergün and Karadakovan studied cumulative incidence of violence compared to Kowalenko et al. who studied violence incidence over a 12-month period.

Additional worker characteristics associated with the occurrences of violence are the number of hours worked per week and worker’s marital status. Part time staff had a reduced odds of being physically assaulted compared to full time staff (O.R. = 0.35, p < 0.001) (Thomas et al., 2006), even though part time workers had a significant (p < 0.01) increase in violent events from 2001 to 2004 (Hegney et al., 2006). Lin and Liu (2005) discovered that non-married workers were significantly (p < 0.01) more likely to experience violence compared to married workers. Married workers may experience less violence because they are used to working with another person to come to a mutual understanding or agreement when there is a misunderstanding or disagreement.

There is contradictory evidence about the role of violence prevention training in reducing the risk of workplace violence. One group of researchers found that participants who never attended violence prevention training were at greater risk for workplace violence than workers who did attend training (Ergün & Karadakovan, 2005). However, Nachreiner et al. (2005) reported that violence training increased the odds of being a victim of physical violence. Specific training components increasing the odds for violence were training on managing assaultive or violent patients (O.R. 1.551; p = 0.03), reporting work-related physical assault (O.R. 1.639, p > 0.05), self defense (O.R. 1.393, p > 0.05), and recognizing risk factors of violence (O.R. 1.314, p > 0.05). Lee et al. (1999) stated that the relative risks for physical violence against a nurse increased when the nurse had received assault prevention training with a previous employer (R.R. 2.57), when the training occurred with their current employer (R.R. 4.64), and when the nurse’s employer accepted assault as being part of the job (R.R. 8.14). Data from these studies obviously go against logic. Four possible explanations for the contradiction were provided by the researchers. First, workplace violence training may only be provided in settings where violence is more common (Lee et al.). Second, workplace violence training may raise awareness for the need to report violent events (Lee et al.). Third, victims of violence may be more likely to recall receiving violence training (Lee et al.). Fourth, workers who receive violence training may be more likely to intervene during physical violence whereas their untrained counterparts may be more likely to remain passive (Nachreiner et al.).

In summary, identifying the worker most at risk for violence based on the worker’s characteristics is difficult due to the lack of consistency with the research findings in the literature. Although most researchers state that men are more likely to be a victim of workplace violence, it is possible that women may actually be more frequently targeted with men intervening thereby men becoming the victims of workplace violence. Although older and more experienced workers report a greater number of violent events over the course of their work life, younger and less experienced workers report a greater number of recent violent events. Training has also been associated with risks for workplace violence. It is not known if violent work environments were identified after implementation of violence training programs or if the programs were implemented as a result of workplace violence events. What is consistent in the evidence is that all workers are at risk for some degree of workplace violence despite their gender, age, work experiences, and training opportunities.

Setting/environmental Risk Factors

Environmental factors identified to reduce the odds of physical assault against healthcare workers include controlled access to patient areas, reduced wait times, security presence, and escort service to walk the worker to his or her vehicle (Catlette, 2005; Crilly et al., 2004; Gates et al., 2006; Gerberich et al., 2005; Gillespie, 2008; Lee et al., 1999; Nachreiner et al., 2005). Lee et al. and Ayranci et al. (2006) provided evidence that the odds of a nurse being physically assaulted at work were reduced when there was a security presence, video monitors present, and organizational policies that addressed assault prevention and repeat violent offenders. In contrast, Gerberich et al. ascertained that the odds of nurses being physically assaulted were actually greater when video monitors, metal detectors, or panic buttons were used. Gerberich et al. did not provide an explanation for this finding, but it is possible that it may be due to an increased awareness of violence leading to increased reporting or due to an actual increase in the number of violent events with the employer making the environmental changes in an effort to provide for worker safety.

In addition, other researchers have identified that violence is more likely to occur during certain times of the day. Ergün and Karadakovan (2005) found that 70% of violent events took place between 4 p.m. and 8 a.m. This finding was supported by other researchers (AbuAlRub, Khalifa, & Habbib, 2007; Crilly et al., 2004; Gates et al., 2006; Gillespie, 2008). The higher rates for violence during the evening and night hours may be due to the types and conditions of patients that seek treatment during later hours such as intoxicated patients and those with injuries due to violence (McAneney & Shaw, 1994). Almvik et al. (2006) further stated that violent events in long-term care were most likely to occur during the day and evening hours with few events during nighttime hours. This difference may be due to the setting; long term care patients that are aggressive may be asleep during the nighttime hours, therefore not enacting violence against others.

Protective Strategies for Workplace Violence

When violent events occur, it is likely that some workers will experience negative consequences. However, it is possible that some healthcare workers will respond in ways that minimize the negative consequences.

Personal protection was one protective factor identified in the literature when violence occurred. In a sample of 116 Iraqi hospital nurses, 27% (n = 13) of those who reported physical violence took no actions during the event while 49% (n = 24) who reported physical violence tried to defend themselves during the event (AbuAlRub et al., 2007). Defending oneself may be an effective strategy to prevent being injured until able to receive help from others or escape from the patient room. Gerberich et al. (2005) determined that hospital nurses who carried some form of personal protection or carried their personal cellular telephone on themselves had a greatly reduced odds ratio for being assaulted compared to nurses who did not (0.30 to 1.00); yet the effect was not seen when workers used an employer’s cellular telephone or personal alarm system (1.03 to 1.00). This may be a result of the nurse not knowing how to use the equipment at the time of the event. It may also be due to workers who carried some form of personal protection were more cognizant to the potential of violence relying on themselves for protection while those who used employers’ measures relied on the employer for protection. Tolhurst, Talbot, et al. (2003) found that 15% (n = 47) of rural physicians started carrying a cellular telephone with them to use in the event of a violent emergency. Kowalenko et al. (2005) reported that 16% (n = 27) of Michigan physicians in their study carried a concealed weapon as a form of protection due to the fear of or prior experience with workplace violence.

No tolerance for violence was another strategy exhibited by healthcare workers. Findorff, McGovern, Wall, and Gerberich (2005) who randomly sampled 4,166 hospital workers found that some workers told perpetrators to stop their verbally violent acts. Workers who told perpetrators to stop their verbal violence were more than three times as likely to report the violence compared to workers who did not tell the perpetrator to stop. Even though Findorff et al. did not report if the perpetrator stopped the verbal assault, the worker’s simple act of setting a limit on what is not acceptable behavior may prove to protect the worker against a more long term negative effect of violence related stress.

Self support has been used by some healthcare workers to protect themselves against negative effects of violence after violent events (Gillespie, 2008). Catlette (2005) interviewed eight trauma nurses about their workplace violence experiences. Catlette stated that the nurses discussed the use of self support through humor, venting, and leisure time but did not report whether the participants believed that the interventions were effective. Gillespie discovered during qualitative interviews of pediatric emergency workers that drinking a cold beverage and taking a short break were effective for decreasing the stress following a violent event.

Support from others after a violent event was identified as a third protective factor in the literature. Schat and Kelloway (2003) found that social support (e.g., showing concern for the victim, listening to the victim tell his or her story) from coworkers and managers in a Canadian healthcare system had a positive effect on study participants who were primarily nurses, patient care assistants, laboratory and technical assistants, counselors, and social workers. The support reduced their negative physical and psychological symptoms, and their negative attitude towards their work. Gillespie (2008) concluded that the informal debriefing should occur during the same shift as the violent event in order to prevent the intrusive thoughts that later affected the worker’s sleep when reflecting back onto the violent event.

Although Schat and Kelloway (2003) identified social support as a protective factor for suffering the negative consequences of violence, they also found that the support had no effect on a worker’s fear for a future workplace violence event. The researchers concluded that to increase the social support of a worker, the fear for a future violent event must be addressed through interventions such as formal debriefings or professional counseling sessions.

A fifth protective factor identified in the literature included efforts to make changes to current practices and decreasing availability to patients. Magin, Adams, Ireland, Heaney, and Darab (2005) found that urban general practitioner physicians documented their after hours’ destinations, checked in with spouses at predetermined periods, and quit making house calls to patients they were not familiar with or lived in areas of low socioeconomic status. Female physicians in their study were more likely to take their spouse with them during home visits. Tolhurst, Talbot, et al. (2003) stated that 30% of general practitioners made changes to their after hours’ practice due to the risk of workplace violence such as limiting which patients they will visit or taking someone else with them. The most significant change included the instruction of patients they didn’t know or patients who had a history of violence to seek healthcare with a different provider when requesting to be seen after hours. In fact, five percent of the physicians quit home visits altogether.

Summary

Perpetrator, worker, and setting/environmental factors have been shown to relate to the risk for workplace violence. Factors related to the perpetrator that increased the risk of violence were gender, age, the presence of weapons, and patients with mental disorders including dementia and being under the influence of drugs or alcohol. Worker factors that were related to a lower risk of violence were being older, more experienced, working fewer hours, and being married. There was conflicting evidence related to the effect of gender and workplace violence training as risk factors for workers being assaulted. Setting/environmental factors related to violence risk, although not definitive, were the time of the day (day time versus evening and night time hours) and changes to the environment such as having security systems or cameras.

Not all violence can be prevented in the healthcare setting. Healthcare workers use several strategies to protect themselves against the negative consequences of workplace violence. First, some victims of workplace violence carry concealed weapons or personal cellular telephones and defend themselves physically to protect themselves against the consequence of physical violence. Second, workers may instruct perpetrators to stop their violent acts. Third, healthcare workers provide their own self care when they use effective coping mechanisms and receive support from colleagues and employers. A final protective mechanism used is limiting the availability for medical care to patients after hours or to patients that resembled prior perpetrators.

Implications to Rehabilitation Nursing

Strategies need to be implemented by both rehabilitation nurses and organizations to reduce the risks associated with workplace violence. Strategies should take into account that all verbally and physically abusive, threatening, and harmful acts need to be considered violent despite the intent or cognitive accountability of the perpetrator. Even with cognitively impaired patients, violent acts can leave a healthcare worker physically debilitated or psychologically harmed (Badger & Mullan, 2004; Brock, Gurekas, Gelinas, & Rollin, 2009; Rose & Cleary, 2007). As a result, the strategies depicted in this section are universal regardless the patient intent or cognitive accountability for committing a violent act.

The foremost strategy is an effective workplace violence program focused on preventing violence before it occurs, safely managing violent events, and coping with the psychological consequences that occur after violent events are over. Violence prevention training needs to take place at hiring with updates on an annual or semiannual basis. Educational components may include a description of factors linked to violent events such as patients or visitors experiencing a situational crisis or being under the influence of drugs or alcohol. Additional training components may include training specific to rehabilitation settings such as identifying and intervening early for patients with signs of substance use withdraw or new physical limitations such as the inability to perform their normal activities of daily living. Another training possibility is the development of case studies based on actual violent events reported by rehabilitation healthcare workers thereby increasing the personal relevance of the educational program. The case studies may allow rehabilitation workers to discuss why the patient or visitor escalated to verbal or physical violence and what could be done during a future encounter to yield a more positive outcome between the patient and caregiver.

Special strategies can be used for patients that are victims of violence: limiting visitor access and using a pseudonym for the actual names of patients that are victims of violence (e.g., patients suffering gunshot firearm injuries, stabbings, and gang assaults). These two strategies may be necessary to prevent an exposure to the same stressor that led up to the original violent event. Registering the patient using a pseudonym will reduce the likelihood that persons who may escalate the patient’s behavior towards workplace violence will find the patient within the hospital or rehabilitation center. Limiting visitor access to two predetermined individuals (e.g., spouse, parents) reduces the chance that a room full of visitors who are anxious and stressed will escalate towards an event of workplace violence.

It is important for healthcare workers to recognize that the reported risks for violence are not all-inclusive and that every patient and visitor should be considered as potentially violent. When signs of escalation towards violence are identified, interventions need to be immediately implemented especially de-escalation techniques such as active listening to the patient or visitor, attempting to identify concerns and reasons for the escalation, answering patient and visitor questions honestly, permitting visitors to the patient bedside who may have a calming effect, and providing comfort measures including warm blankets, beverages, snacks, and medications for pain, anxiety, and agitation control.

Organizational policies addressing workplace violence should include a component for what steps are to be taken after a weapon is found on a patient or visitor. For example, the worker should calmly leave the patient’s room, notify security personnel that a weapon was discovered, and make no attempts to remove the weapon from the patient. Homecare workers should instruct their patients to remove all firearms from the house before home visits take place or keep the firearm in a lock box with the bullets removed and stored separately. Care plans should indicate that a firearm is on the premises. Healthcare workers need to be informed and follow the organizational policies as well as provide input in keeping the policies up-to-date. Experienced workers can provide mentoring and guidance to lesser experienced colleagues in communication strategies and care delivery that may have a calming and de-escalation effect for patients and visitors before a violent event escalates to the use or showing of weapons.

Limited evidence is available on empirically tested protective factors for when a workplace violent event has already occurred. It is important for all workers to recognize the signs of stress and when they themselves are experiencing that stress. Workers experiencing stress need to request or be offered a break away from the patient care environment. It is important that all workers have a plan for dealing with workplace violence, the means to call for help when needed (e.g., personal alarms, cellular telephones, radios), and know how to use the technology (e.g., activating a personal alarm). It may not be feasible to limit hours of service such as with inpatient rehabilitation units or on-call homecare services nor be able to refuse patients to particular home care agencies. However, plans should be in place to identify patients with a prior history of workplace violence such as chart flagging and specifically soliciting this information during shift change reports and the during the new referral intake process. Patients with a known violent encounter to a particular healthcare worker should be reassigned to another healthcare worker when feasible. This may not be possible when the worker (e.g., registered nurse, physical therapist) is the only provider within a geographic area that includes the residence of the violent patient. To provide additional protections, healthcare workers need to communicate their whereabouts at regular intervals with a unit coordinator or home care office and have a plan that will be activated when they fail to communicate at predetermined intervals. Home care workers may need a chaperone or conduct home care visits in pairs to increase personal safety.

Conclusion

A review of the literature reflected a number of risks and protective factors associated with workplace violence by patients and visitors against healthcare workers. Based on the published literature, it is concluded that workplace violence is a serious and growing problem in today’s healthcare settings and no worker is immune. In addition, while protective factors were identified to reduce negative consequences of workplace violence, it is imperative that rigorous studies be conducted to determine which factors provide the greatest protection and in what combination. It is important that healthcare workers and employers recognize that the only strategy ensured to prevent the negative consequences of workplace violence is an effective violence prevention program. Healthcare workers have a right to be safe while on duty, and workers should be proactive in conjunction with their employers to create that safe work environment (Occupational Safety and Health Administration, 2004).