Authors: Fatemeh Mahmoudi, Gholamreza Garmaroudi, Nadia Saniee, Narjes Razavi, Ali Mohammad Mosadeghrad, Mahnaz Ashoorkhani
Categories: Research, Nurses, Workplace violence, Prevention, Interventions, Scoping review
Source: BMC Nursing
Authors: Fatemeh Mahmoudi, Gholamreza Garmaroudi, Nadia Saniee, Narjes Razavi, Ali Mohammad Mosadeghrad, Mahnaz Ashoorkhani
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.
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.
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 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.
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.
Not applicable.
The online version contains supplementary material available at 10.1186/s12912-025-04227-x.
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.
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.
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
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.
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.
Case studies, letters to the editor, editorials, commentaries, and perspective articles.
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 first author, year of publication, study location, research objective, methodology, and the identified causes and strategies related to workplace violence against nurses.
Due to the scoping nature of this review and the methodological diversity of the included studies, no formal critical appraisal was performed.
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.
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. 1Study 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 1Characteristics of the reviewed studies based on the causes of violence against nurses and its reduction interventions in developed countriesFirst Author/Year/Country of StudyStudy ObjectiveResearch Method/Study SampleData Collection Method and InstrumentArnetz (2015, United States) [17]To identify factors and environmental conditions influencing patient violence against healthcare personnelQualitative (staff from a large hospital system consisting of seven hospitals)Standardized online computerized reporting systemMorphet (2014, Australia) [18]To identify common causes of perceived violence in the emergency departmentQualitative (nurses); phase 157 participants, phase 132 participants, phase 158 participantsThree-round Delphi technique (interview guide)Angland (2014, Ireland) [19]To investigate the causes of violence and aggression experienced by Irish nursesQualitative (12 emergency 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 violenceQualitative (emergency department nurses, 11 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 GreeceCross-sectional (80 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 AustraliaCross-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 careQualitative (emergency nurses, 46 8 males [17.4%], 37 females [80.4%], and 1 nurse with unspecified gender [2.2%])Content analysis of submitted emailsRamacciati (2018, Italy) [24]To analyze the characteristics of workplace violence and determine its prevalence in emergency and urgent care departments in ItalyCross-sectional (emergency and urgent care nurses, 265 144 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 solutionsCross-sectional (250 healthcare 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 SwitzerlandCross-sectional (nurses working in various clinical departments of four general hospitals, 291 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 StatesCross-sectional (5,385 hospital 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 nursesCross-sectional (816 480 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 careCross-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 aggressionCross-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; 222 196 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 hospitalsCross-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 wardsCross-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 managementMixed 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 interviewsGates (2006, United States) [34]To determine the violence experienced by emergency department staff from patients and companions during the 6 months prior to the surveyCross-sectional (healthcare staff from five hospitals; 242 177 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 departmentsCross-sectional (emergency nurses; convenience sampling; 3465 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 violenceLiterature review (25 studies)Literature review (data extraction form)Hamrin (2009, United States) [37]To identify ecological factors influencing workplace violenceLiterature reviewLiterature review (data extraction form)Magnavita (2011, Italy) [38]To develop an aggression prevention program in a psychiatric unit and report its impact on violence ratesQuasi-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 completedHenderson (2013, United States) [39]Designing a safer emergency department to address workplace violenceQuasi-experimental pre-post study (43 emergency department staff)Intervention implemented and questionnaire completedMcLaughlin (2010, United Kingdom) [40]Preparing staff to handle verbal attitude change, increased confidence, enhanced self-regulation copingQuasi-experimental pre-post study (psychiatric inpatient ward nurses, 18 participants, mean age 33 years, convenience sampling)Intervention conducted and questionnaires completedHahn (2008, Switzerland) [41]Systematic review of patient and visitor violenceLiterature 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 performanceLiterature review (21 studies)Literature review (data extraction form)Lau (2004, Australia) [43]Reviewing the causes of violence against nursesLiterature reviewLiterature review (data extraction form)Pich (2010, Australia) [44]Reviewing the concept of patient violence against emergency nursesLiterature review (53 studies)Literature review (data extraction form)Stathopoulou (2007, Greece) [45]Identifying factors associated with the occurrence of violence in healthcare and proposing solutionsLiterature reviewLiterature review (data extraction form)Pulsford (2013, United Kingdom) [46]Determining the causes of violence and the measures taken in response to aggressive and violent incidentsCross-sectional study (109 56 men, 33 women; 89 participants aged 25–54.26 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 violenceLiterature reviewLiterature review (data extraction form)Papadopoulos (2012, United Kingdom) [48]Systematic review of types and causes of violence and aggression in psychiatric inpatient settingsSystematic 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 aggressionMixed methods study (Emergency nurses and midwives; convenience sampling; 471 participants, 86.6% female, 33.1% aged 20–29; 28 nurse managers and educators, 85.7% female)Survey (questionnaire), semi-structured interviewsCrilly (2004, Australia) [50]Identifying causes of patient violence against nurses in emergency departmentsCohort study (Emergency nurses from two public hospitals; 71 participants, 50 reported 43 women (86%) and 7 men (14%), average age 37; 21 did not report 17 women (81%) and 4 men (19%), average age 38)Document review, questionnaireAntão (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 safetyMixed methods (emergency healthcare staff; 28 20 women and 8 men, mean age 41.64 ± 10.65; 6 1 man and 5 women, age range 34 to 59)Survey (questionnaire) and semi-structured in-depth interviewsBaby (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 workplaceCross-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 wardsLiterature 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 patientsQualitative (54 healthcare 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 violenceQualitative (6 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 departmentsQualitative (20 emergency department staff from four hospitals)Semi-structured interviews (interview guide), ethnographic observationsKafle (2022, United States) [57]Exploring the concept of violence, its prevalence, consequences, impact on nursing, and developed strategies for preventionNarrative 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 strategiesQualitative study (emergency department 96 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 frameworkPina (2022, Spain) [59]Exploring the sources of perceived conflicts among primary healthcare professionals and examined specific measures to reduce such conflictsQualitative study (primary healthcare 44 30 women [68.2%], 14 men [31.8%]; mean 50.3 years)Focus group discussionsAmerican 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 violenceGuidelineGuidelineReibmann (2023, Germany) [61]Examining emergency staff perceptions of existing preventive measures, their effectiveness, and barriers to violence preventionQualitative study (emergency physicians and nurses; purposive sampling followed by snowball sampling; 27 13 physicians and 14 nurses; 15 women and 12 men; age 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 preventionQualitative 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 JerseyMixed-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 interventionQuasi-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 securityCross-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) programQuasi-experimental pre-post study involving 302 hospital staff members. Baseline group and final outcome included 43 nursing 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 unitsIntervention and survey (questionnaire)Okundolor (2021, United States) [67]Development, implementation, and evaluation of a multifaceted approach to reduce physical assaults on staffQuasi-experimental pre-post study involving 42 nursing staff and 230 patientsIntervention 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 violenceQuasi-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 yearsIntervention and survey (questionnaire)Mitchell (2020, Australia) [69]Design, implementation, and evaluation of a group-based simulation training program for health professionalsQuasi-experimental pre-post study involving 182 health professionalsIntervention 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 methodsQuasi-experimental pre-post study (Phase 25 participants (18 nurses; 72% female, 28% male), mostly aged 31–40 years (40%)Phase 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 trainingQuasi-experimental pre-post study with 90 participants (67 females and 23 males), including 55% registered nurses; 74% female overallIntervention and survey (questionnaire)de la Fuente (2019, United States) [72]Determining the impact of behavior management training on nurses’ confidence in handling aggressive patientsQuasi-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-surveysIntervention 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 situationsQuasi-experimental pre-post study involving 204 emergency department staffIntervention 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 settingQuasi-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 yearsIntervention 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 incidentsQuasi-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 incidentsQuasi-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 occurLiterature reviewLiterature 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 unitQuasi-experimental pre-post study (Before the 26 participants [4 men and 22 women], 58% aged 30–39; After the 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 educationQuasi-experimental pre-post study (32 emergency department 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 unitQuasi-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 aggressionRandomized controlled clinical trial (58 nurses; intervention 30 participants [18 women and 12 men, mean age 36.47 years], control 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 educationQuasi-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 1995Cohort (95, California hospital emergency departments and 46 hospitals in New Jersey (control))Passing the California hospital safety and security lawKling (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, CanadaQuasi-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 riskRandomized 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 hospitalQuasi-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 visitorsQuasi-experimental pre-post study (209 emergency department healthcare 149 women (71.3%) and 60 men (28.7%); mean participant age was 37.3 years (SD = 10.5; 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 injuriesQuasi-experimental pre-post study (2,863 participants; intervention n = 1,612 and control 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 violenceRandomized controlled trial (62 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 implementationQuasi-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 staffRandomized 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 violenceQuasi-experimental pre-post study (65 participants; intervention 16% male and 84% female, mean age 38; control 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 hospitalQuasi-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 nursesQuasi-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 programQuasi-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 staffQuasi-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 behaviorQuasi-experimental pre-post study (before the 30 24 women (80%) and 6 men (20%), aged 20–59; after the 22 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 violenceQuasi-experimental pre-post study (45 nursing students, all female; mean age of the intervention 22.4 years, control 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 toolQuasi-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 aggressionQuasi-experimental pre-post study (22 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-efficacyRandomized 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 workplaceQuasi-experimental pre-post study (63 48 healthcare staff 33 women and 15 men, mean age 39.15 years; 15 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 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 managementQuasi-experimental pre-post study (63 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 wardsRandomized 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 wardsQuasi-experimental pre-post study (85 staff 58% female, 42% male; 68% over the age of 40156 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 restraintQuasi-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 incidentsQuasi-experimental pre-post study (Survey 76 nurses, 83% female; Survey 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 methodQuasi-experimental pre-post study and cohort study (117 patients managed in the BAR: 76 men, 38 women; mean age 36.4 years; 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 attemptsQuasi-experimental pre-post study and cohort study (478 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 investmentQuasi-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 companionsQuasi-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 methodsQuasi-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 nursesSystematic 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 workersSystematic 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 researchSystematic review (9 studies)Literature review (data extraction form)Anderson (2010, Australia) [117]A review of interventions aimed at minimizing workplace violence against emergency department nursesSystematic 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 staffQuasi-experimental pre-post study (56 healthcare 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 violenceLiterature reviewLiterature reviewArbury (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 workersLiterature reviewLiterature reviewWirth (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 eventsSystematic 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 programsLiterature 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 aggressionSystematic 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 practiceSystematic 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 itLiterature 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 settingsSystematic 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 staffLiterature review (24 studies)Literature reviewGillespie (2013, United States) [127]Development, implementation, and evaluation of a workplace violence prevention programMixed methodsMixed 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 itSystematic 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 departmentsLiterature reviewLiterature 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).
Table 2 outlines the main causes of violence against nurses in developed countries. These were categorized into five overarching 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 2Main causes of violence against nurses in developed countriesMain CategoryThemesIndividual Causes (Patient and Companion)Unstable mental state and psychiatric disordersUnmet needs of patients and companionsDeath of the patientDissatisfaction with the treatment processPersonal problemsDissatisfaction with the arrangement of medical staffMale genderLow level of educationVery young or very old agePain and discomfortLack of trust in medical staff and the hospitalIncreased patient awareness of their rightsSubstance and alcohol abuseLack of awareness of medical and hospital proceduresDisrespectful behaviorNon-compliance with ruleshistory of violenceReceiving distressing newsConflict between patient and companionEmergency or critical conditionHigh cost of treatmentLack of effective communication staffDeprivation from or forced use of medicationRestriction on personal activitiesInability to leave the wardSexual abuseLow socioeconomic statusEthnic and cultural characteristicsUse of weaponsIndividual Causes – StaffIneffective communication with the patientNegative attitude about nursingLack of compassion and empathyLimited clinical skills or work experienceStaff conflictsFeeling of insecurity in the workplaceFear and vulnerability of nursesHigh workloadTime constraintsLack of skills in managing violenceFailure to deliver appropriate careBeing alone during the shiftStaff marital statusCultural and religious backgroundAgeLow resilienceNursing errorLower educational levelTransfer of physician-patient conflicts to nurseEmployment in emergency or intensive care unitsEvening shiftsLack of teamworkFailure to report incidents of violenceOrganizational causesLong waiting timeBeing big hospitalHigh treatment costLow service qualityDelays in admission or dischargeInsufficient security infrastructurestaff shortagesOvercrowding and noiseLack of spaceLack of privacyAbsence of risk assessment mechanismsLimited visiting hoursTobacco bansShift changes of nursesEnforcement of regulationsLimited access to background information on the high-risk behaviors of patients and their attendantsLack of empowerment and violence prevention training programs for hospital staffHeavy workloadDelayed security or police responseNo scheduled rest breaksInadequate post-violence supportLack of violence reportingPoor monitoring of visitorsEvening shiftLimited financial resourcesLack of financial and psychological support after incidents of violenceSocial causesNegative media portrayalLack of public appreciation for healthcare workersSpecific cultural behaviorsSocial conflictGender discriminationMarginalization of ethnic and immigrant minoritiesPolitical causesInsufficient government investmentPoor hospital oversightIneffective legal systemWeak health insurance coverageRestrictive regulationsLack of strict visitation policiesAbsence 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.
Table 3 outlines the subcategories of violence management strategies implemented in developed countries for nurses.Table 3Interventions for reducing violence against nurses in developed countriesTopicMain CategorySubcategoryThemesStrategies to Reduce Violence Against Nurses****Prevention Strategies (Before the Occurrence of Violence)****Individual Interventions of Patient and CompanionSeparating high-risk patients from other patientsAdministering sedatives to high-risk patientsPaying special attention to patients’ needsscreening for history of substance and alcohol useRestricting companion movementInvolving patients in treatment plansReducing patients stress and frustrationIndividual Interventions of StaffRecruiting skilled healthcare staffTraining in communication and mindfulnessViolence managementInterdepartmental collaborationStress and anger managementClinical assessment skillsPsychological and behavioral trainingPromoting staff healthStrengthening critical thinkingOrganizational InterventionsImproving patient comfort infrastructureHospital-police collaborationComprehensive violence attentionDeveloping violence management protocolsVisiting hours restrictionRoutine managerial roundsStaff support from leadershipViolence risk assessment proceduresSecurity implementations of (e.g., codes, ID systems)Reducing wait timesProviding security infrastructureAssessment of patient violence riskSocial InterventionsEnhancing healthcare access in the communityPublic education on healthcare useRaising public awareness on alcohol/substance abusePromoting respect for healthcare staffImproving health literacyPolitical InterventionsConducting action researchExpanding insurance coverageShifting toward preventive violence managementEnacting violence management lawsInterventions During Violent Incidents****Individual Interventions of Patient and CompanionIsolation of high-risk patients and companionIndividual Interventions of Staff-Organizational InterventionsPresence of police and security personnelSocial Interventions-Political Interventions-Interventions After the Occurrence of Violence****Individual Interventions (Patient and Companion)-Individual Interventions (Staff)Reporting incidents of violenceOrganizational InterventionsMedical, psychological, and financial staff supportAddressing violent incidentsSocial Interventions-Political InterventionsImplementing evidence-based strategiesLegal action against perpetrators
According to Table 3, the most important interventions for reducing violence against nurses in developed countries were categorized into three 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.
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 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.
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.
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.
Below is the link to the electronic supplementary material.
Supplementary Material 1