You are on page 1of 37


Final Report
Associate Professor Debra Griffiths
Julia Morphet
Kelli Innes
School of Nursing & Midwifery, Monash University

January 2015
Research report #: 122-0115-R01

This research report was prepared by
Associate Professor Debra Griffiths, Julia Morphet, Kelli Innes
School of Nursing & Midwifery, Monash University
Department of Medicine, Nursing and Health Sciences
Monash University

For Worksafe Victoria

ISCRR is a joint initiative of WorkSafe Victoria, the Transport Accident Commission and Monash University. The
opinions, findings and conclusions expressed in this publication are those of the authors and not necessarily
those of Worksafe or ISCRR.


Table of Contents
EXECUTIVE SUMMARY -------------------------------------------------------------------------------- 1
PREAMBLE ------------------------------------------------------------------------------------------------ 3
INTRODUCTION ----------------------------------------------------------------------------------------- 6
PREVALENCE --------------------------------------------------------------------------------------------- 6
Consequences of violence in health care -------------------------------------------------- 8
Causes and risk factors -------------------------------------------------------------------------- 8
Education ---------------------------------------------------------------------------------------------- 9
Patient risk assessment ------------------------------------------------------------------------ 13
Environmental factors--------------------------------------------------------------------------- 13
Organisational Policy---------------------------------------------------------------------------- 15
Code Grey ------------------------------------------------------------------------------------------ 16
Aggression Management Teams --------------------------------------------------------- 16
Zero Tolerance Policy ------------------------------------------------------------------------ 16
Restraint --------------------------------------------------------------------------------------------- 17
RECORDING INCIDENTS OF VIOLENCE --------------------------------------------------------- 18
CONCLUSION AND RECOMMENDATIONS ------------------------------------------------------ 25
REFERENCES ------------------------------------------------------------------------------------------- 26


This review examines the literature related to occupational violence in health care.
Occupational violence in health care is prevalent, with up to 95% of health care workers
reporting experiencing violence. In health care, patients, family and visitors of patients are
the primary source of violence and aggression, and therefore client-initiated violence is the
focus of this review.

Occupational violence occurs in a wide variety of health care settings. The common types of
violence experienced by health care workers are verbal and physical abuse. There are many
negative consequences of violence in healthcare, including increased incidents of
depression, sleep and anxiety disorders, drug and alcohol problems, Post Traumatic Stress
Disorder (PTSD), and reduced staff retention. Risk factors linked to occupational violence in
health care include patient characteristics, staff characteristics, organisational factors, and
physical design of the workplace and setting.

A number of interventions have been introduced to reduce occupational violence in health
care. These interventions can be broadly grouped under the following headings: education,
patient risk assessment, environmental factors, organisational policy (including zero
tolerance), and restraint. There is a paucity of data evaluating the effectiveness of these

There are low reporting rates for occupational violence with estimates only 20% of events
are reported. Reasons for under-reporting include worker tolerance of violence, violence is
perceived as just part of the job, lack of co-worker and manager support, and lack of

Page 1 of 37

management action. The systems for reporting occupational violence include RiskMan, risk
assessment tools, integrated IT systems and paper based incident reports. There is limited
evaluation of the reporting systems.

The review is presented in three sections; i) prevalence of occupational violence in health
care (including risk factors, and sources of violence), ii) interventions aimed at reducing
occupational violence in health care, and iii) surveillance or reporting of occupational
violence in health care.

Page 2 of 37

This evidence review has been requested by Institute for Safety, Compensation and
Recovery Research (ISCRR) as occupational violence in health care is a problem and is a
priority area for state authorities. ISCRR and WorkSafe Vitoria are keen to understand the
current state of the evidence base in relation to occupational violence in health care. The
review intends to:

1. Identify the evidence concerning prevalence and distribution of occupational violence
across the range of health / social care settings;
2. Seek to identify effective interventions that have reduced occupational violence; and
3. Consider evidence to better inform practice in surveillance from within and outside
the sector.
A thorough search of literature on prevalence of occupational violence in the health care
setting in Australia and the interventions commonly used nationally and internationally was
conducted. Types of studies included peer reviewed research, systematic reviews, metaanalysis, and grey literature including discussion, reports and legal documents published in
English since 2005. Studies were identified from searching electronic databases, references
from articles identified, grey literature and thesis resources. The electronic databases
included Scopus, PubMed, Medline, CINAHL, LexisNexis, AMED, Australian Public Affairs
and Google Scholar. Grey literature was sought from Victorian Government documents,
Work Safe, Australian Nursing Federation, and US Government documents.











Boolean/Proximity Operators, Search phases, Truncation/Wildcards; Subject headings and
particular Database search tips to identify the most relevant publications. The keyword
search terms included occupational violence, workplace violence, workplace aggression,
intervention, prevention, healthcare, report, legislation, and Australia.

Page 3 of 37

The following example illustrates a search strategy conducted in Scopus database:


workplace violence OR occupational violence AND intervention


Article, Conference paper, Article in press, Book chapter, Book


Health Science

Subject areas:

Nursing, Health professions, Social science and Psychology; and


from 2005

The inclusion criteria for this review comprised peer reviewed research based papers related
to patient or family initiated violence, and government reports. Exclusion criteria included
workplace bullying, case studies, opinion papers and papers that only included an abstract.
The screening process started with the publication title and the abstract then the full text to
assess the coverage, objectivity, currency and authority of the identified publications.

Overall, 1301 records were identified within the databases, and other sources of grey
literature provided a further 199 records. After removing 750 duplicate records and 38
inaccessible records, the remaining 712 papers were screened by title and abstract, and 287
removed based on inclusion and exclusion criteria. The remaining 425 full-text articles were
examined and assessed against the inclusion criteria, resulting in the exclusion of a further
345 papers. 80 papers were included in the final review (Figure 1).

Page 4 of 37


Figure 1: Flow Diagram of study selection

Records identified through
database searching
(n = 1301)

Additional records identified
through other sources
(n = 199)




Records after duplicates (n = 750) & inaccessible papers (n = 38) removed
(n = 712 remaining)

Records screened
(n = 712)

Records excluded
(n = 287)

Full-text articles assessed
for eligibility
(n = 425)

Full-text articles excluded,
with reasons
(n = 345)

Studies included in
literature review
(n = 80)

Page 5 of 37

In the past decade an expansive body of research has been published on occupational
violence and the health professions. In an effort to standardise the definition of occupational
violence in health care, the International Labour Organization, International Council of
Nurses, World Health Organization, and Public Service International developed the following
definition; “Incidents where staff are abused, threatened or assaulted in circumstances
related to their work including commuting to and from work, involving an explicit or implicit
challenge to their safety, wellbeing or health”.(1)

Occupational violence in health care is often classified by source or perpetrator type,

external violence, perpetrated by people outside of the organisation with a criminal

client-initiated violence, initiated by patients, or patients’ families against health care
providers; and

horizontal or internal violence, perpetrated by co-workers, supervisors and other
health care workers.(2)

In health care, patients and family / visitors of patients are the primary source of violence
and aggression, and therefore client-initiated violence is the focus of this review. The review
is presented in three sections; i) prevalence of occupational violence in health care
(including risk factors, and sources of violence), ii) interventions aimed at reducing
occupational violence in health care, and iii) surveillance or reporting of occupational
violence in health care.

Studies show that occupational violence in health care is prevalent and is a recurrent
phenomenon. The research comprises a range of studies, with many focussing on nurses

Page 6 of 37

and to a lesser extent other groups of health workers. The literature does nevertheless
examine most areas of work health professionals undertake including: acute care in both

(3, 4)

and remote


settings, mental health,(6,


aged care,(8) and community

environments including general practice (GP) clinics,(9-11) paramedics,(12,



care,(14, 15) and pharmacies.(16) The common types of violence experienced by health care
workers include: verbal abuse,(5, 9, 10, 12, 14, 16, 17) physical abuse,(5, 6, 10, 12, 17) and less commonly
sexual harassment,(5, 9, 12) intimidation,(12) stalking,(5, 9, 12, 17) and property damage.(5, 17)

There are numerous studies conducted in workplaces where high levels of occupational
violence are deemed to occur. One survey of Australian medical practitioners showed that
occupational violence ranged from 2%-29% for physical aggression from patients, and 15-75%
for verbal aggression from patients.(11) Another Australian study reported that there were 5.5
Code Blacks per 1,000 patients in the emergency department (ED).(4) A Code Black is a
hospital-wide internal security response to actual or potential aggression involving a weapon
or a serious threat to personal safety.(18) A study of varied health professionals found 10-95%
of respondents reported experiencing violence from patients, and 20-40% of respondents
reported the source from relatives or carers of patients.(19)

The literature reflects research studies with enormous variation in focus, aim, definitions and
study design. Many studies rely on self-reporting of occupational violence where definitions
and perceptions vary. Studies are frequently explorative and descriptive in character.
Therefore, the manner in which prevalence is measured differs immensely from the
identification of health workers’ perceptions to the physical lodgement of workers
compensation claims. Despite these data, which show a high rate of occupational violence
in health care, the International Council of Nurses estimates that only one in five incidents
(20%) of occupational violence in health care is reported.(20)

Page 7 of 37

Consequences of violence in health care
There are many negative consequences of violence in healthcare. These include increased
incidents of depression, sleep and anxiety disorders, drug and alcohol problems and Post
Traumatic Stress Disorder (PTSD).(21) While injuries caused by physical violence may be
obvious, injury caused by verbal abuse may not be obvious. There is increasing evidence to
suggest that verbal abuse has long term harmful consequences.(22) Workers exposed to
repeated episodes of violence were more likely to suffer from poor psychological health as a
consequence.(23) It has been reported that psychological injuries are not necessarily related
to the severity of the violence but the frequency of exposure.(23) In addition, these authors
assert that those who witness violence have a greater risk of developing mental health
issues. Finally, studies reveal that many staff had resigned from their position due to verbal
or physical abuse,(16, 24) and a further 24% of staff had considered resigning for the same

Causes and risk factors
A number of risk factors have been linked to occupational violence in health care. These can
be divided into four categories: patient characteristics, staff characteristics, organisational
factors, and physical design of the workplace and setting. Patient characteristics that have
frequently been linked with occupational violence in health care include being male, (11) drug
and alcohol toxicity,(11) mental illness,(4, 11) and organic illness or confusion.(4, 25) One study
also reported that 50% of violence in hospital wards comes from patients aged more than 70
years,(8) however this may reflect the demographics of the hospitalised patient population,
more than the age itself.

Staff characteristics that have been linked with violence include being young and

9, 11)



or being an international medical graduate,(10) while

increasing age(11) and increasing experience(9) were found to be protective.

Page 8 of 37

Organisational factors linked to occupational violence in health care include understaffing,
the culture and the climate of the work environment. (2) The physical design of the workplace,
including level of security (locked doors, blind spots, lighting, surveillance cameras), (2, 26-29)
and accessibility(2, 29) have been found to influence the prevalence of violence. Finally, the
hospital setting also influences the prevalence of occupational violence in health care, with
violence more common in public hospitals than private hospitals,(30) and more common in
emergency departments(31-33) and mental health units

(7, 26, 34)

than other hospital wards.(11, 35)

Occupational violence is also more prevalent at night (1800 – 0600) than during the day.(4)

A number of interventions have been introduced to reduce occupational violence in health
care. In Victoria, several reports have been prepared for or by Government Departments,
outlining the prevalence of violence in health care,(35,


and ways in which it can be

prevented or managed.(36-40) These interventions can be broadly grouped under the following
headings: education, patient risk assessment, environmental factors, organisational policy
(including zero tolerance), and restraint. In the following section, the literature examining
each group of interventions will be presented.

Education and training of health care staff is the most frequently reported component of
occupational violence prevention programs. This approach to managing or reducing
occupational violence is typically comprised of educating health care staff on:

Situational awareness and risk assessment, i.e. methods for recognising and
identifying potentially violent situations;(7, 39-49)

Conflict management, i.e. de-escalation strategies and communication strategies for
defusing or preventing potentially violent situations;(7, 33, 37, 39, 40, 42, 44, 45, 47-54)

Page 9 of 37

Physical self-defence techniques including break-away (escape) training and patient
restraint methods;(34, 55, 56)

Familiarising staff with organisational policies and procedures, i.e. reporting systems,
security systems, and the right and ability to withdraw to safety at any time.(40, 45-47, 49)

Several reports were also located in which a focus was on public awareness and patient
education in relation to acceptable behaviours.(29, 35, 37, 38, 40) These projects aimed to reduce
occupational violence in health care by informing patients about hospital processes and
appropriate behaviour.

The 2011 Inquiry into Violence and Security Arrangements in Victorian Hospitals and, in
particular, Emergency Departments, listed 39 recommendations for managing violence in
health care, including nine that specifically focused on staff communication, education and
training.(36) Since then projects have examined staff training programs to address prevention
and management of aggression and violence in Victoria’s hospitals, and organisation wide
responses to patient aggression and violence.(39) However there is great variability in the
effect of education and training on occupational violence management. One important issue
with this relates to the methods used to evaluate training. Many of the studies evaluated the
outcomes of the educational intervention using self-reported knowledge,(48,

56, 58)

or self-efficacy to deal with aggressive patients,(42,

52, 56)



rather than

quantifiable changes in acts of occupational violence. One important finding identified that
the training was found to reduce distress among community healthcare workers, and
increase general mental wellbeing.(52)

A small number of studies used pre and post tests to measure quantitative differences in
knowledge.(45, 48, 50, 55) For example, in one study, 104 participants were filmed in simulated
settings using de-escalation techniques. Each participant completed a pre and post training
simulation, and experts in de-escalation (who were blind to which scenario was pre and post)

Page 10 of 37

scored performance using the De-escalating Aggressive Behaviour Scale. The mean deescalation score rose from 2.74 to 3.65 (p<0.001) after training.(50)

An educational program that combined online education with a table top exercise was
reported to result in an immediate increase in knowledge, and a further knowledge increase
six months after the event.(45) However despite a demonstrated increase in knowledge about
the causes of violence, participants in one study did not feel any more confident to manage
or reduce occupational violence following the training.(48)

Break-away (escape) training has been mandatory for staff working in mental health in the
National Health Service in the United Kingdom.(55,


Several studies have examined the

efficacy of break-away training.(55, 56, 59, 60) Evaluation of break-away training has identified
challenges, with too much content delivered in a short period of time. One study found that
21 different techniques were demonstrated in a 7.5 hour training day, with a mean average
time of just over 13 minutes for each participant to observe and practice each skill. (59) Other
studies examining the outcomes of the break-away training found that many participants who
had previously completed break-away training, were unable to apply those skills in scenarios
on the ward, and were unable to break-away from potentially life threatening holds.(55, 60)

Few studies examined the frequency of violent incidents pre and post the educational
intervention.(7, 43, 49, 54, 57, 61, 62) Four of those studies identified a reduction in the number of
reported violent incidents following the training.(7, 54, 61, 63) One study, in which de-escalation
techniques were taught, examined the frequency with which the hospital emergency
response security team were called, both before and after the introduction of the training. (54)
The authors reported an increase in the frequency of calls to security staff, from 0.78 per
1,000 ED patient visits, to 1.76 per 1,000 ED patient visits, in a 12 month period. However,
the authors used correlations to examine the number of trained staff per call-out, and found
a significant reduction in hospital emergency response calls, when a higher proportion of

Page 11 of 37

trained staff were on shift. They concluded that the training was effective at reducing the
frequency of violence, and subsequent calls to security staff.(54)

Two other studies found that training in communication, de-escalation and situational
awareness resulted in a reduction in the frequency of violent incidents. (7, 61) It is important to
note however that in one of these studies, environmental changes were implemented
concurrently with the training, and it is unclear therefore if the reduction in violence was a
result of the education, environmental changes, or a combination of both.(7)

Perhaps the most effective education programs reported in the literature were based on
group debriefing after aggressive or violent incidents in the workplace.(63, 64) In one study
during the debrief, staff would identify the motivations underlying the aggressive or violent
behaviour, and discuss strategies that could be used in future situations. This program was
reported to reduce the rate of violent incidents over a one year period,(63) and was reportedly
an effective means of alleviating psychosocial impact of stress on nurses who were exposed
to violence.(64)

One concern that has been raised in relation to an emphasis on education and training as a
form of occupational violence prevention, is that it places the burden of minimising and
managing violence onto the health care staff who have completed the training, rather than
on organisations to make changes to environmental and staffing issues.(2)

Training in the identification and management of patients at risk of violence seems a natural
and appropriate measure.(65) However, studies demonstrate mixed results.(66) Research is
needed to identify the essential components of a training program, the frequency of refresher
programs, and to investigate effects of training on the number, type and severity of
aggressive incidents. While education and training programs are a common component of
occupational violence prevention programs, and have been shown to increase knowledge
regarding risk factors associated with occupational violence, and self-confidence to manage

Page 12 of 37

occupational violence, there are scant large-scale, well-designed studies that can strongly
support their effectiveness in reducing the incidence of occupational violence.

Patient risk assessment
Risk assessment tools have been introduced in both community and hospital settings in
Canada(67, 68) and USA.(8, 68) The purpose of the risk assessment tools was to identify patients
who might be at risk of violence toward staff and then flag the risk with other staff, either
through the patient notes(8,


or a patient wrist band.(67) Kim et al.(8) found that the

‘Aggressive Behaviour Risk Assessment Tool’ was predictive of future violence on the wards,
had good inter-rater reliability, and was simple to use.(8) The authors did not report if this
intervention reduced the incidence of occupational violence. ‘The Alert System’ was also
found to be easy to use, and predictive of violence, however the authors reported that, while
the rate of violent incidents did reduce in the immediate post intervention period, they
returned to pre intervention levels six months after the intervention was introduced


. This

implies that while staff may be able to identify predictors of violence, they are not adequately
prepared to manage or de-escalate occupational violence.

Environmental factors
Changes to environmental structure have been commonly believed to reduce occupational
violence in health care. Features commonly described in the literature include:

locked doors,(27, 28, 35, 40, 47)

surveillance cameras,(28, 29, 35, 47)

duress alarms,(7, 26, 35, 40, 47)

flexiglass as a barrier between patients and staff, while ensuring a line of site,(26, 27)

removal of blind spots,(7, 26)

secure observation rooms,(69) and

metal detectors.(33)

Page 13 of 37

Yet there are few studies evaluating the effect of these interventions. Most of the studies that
have been undertaken, examined staff perceptions of safety, and found that staff felt safer
when rooms were secure,(7, 26, 27, 47, 69) and duress alarms and surveillance cameras were
present or metal detectors were in place.(33)
However, despite staff rating environmental safety as “very important”, (47) and reporting that
they felt safer following changes to environmental security, there is scant evidence that
environmental changes reduce the frequency of occupational violence in health care. Further,
it must be acknowledged that most occupational violence in health care is verbal. While
environmental changes can act as a barrier to physical violence, therefore reducing the
severity of violence, they are unlikely to reduce verbal violence.(27, 33)

One study of three emergency departments, that examined the effect of duress alarms,
surveillance cameras, locked doors, as well as non-environmental changes such as asking
each patient if they were carrying a concealed weapon, found that these interventions did
not reduce the frequency of violence.(31) Another study examined three mental health
facilities in which environmental changes were made. Changes included replacing solid
panel doors with transparent flexiglass to improve line of site, securing wardrobes to the floor
so they could not be picked up and used as a weapon, installing personal alarm systems,
and carpeting floors to reduce noise and therefore stimuli.(26) Focus groups and surveys
were conducted with staff in the facilities, who reported feeling “safer”, however no
evaluation of the rate of occupational violence was reported.(26)

The only study of environmental changes that reported a reduction in the frequency of
violent incidents was conducted in an aged care psychiatric rehabilitation centre.


authors reported that patients in single rooms were more likely to be violent toward staff, and
so the building was restructured, to enlarge room size and provide all patients with shared
rooms.(7) This allowed treatment by a team, rather than an individual health care worker,
ensuring no staff member was working in isolation. The authors reported a reduction in the

Page 14 of 37

frequency of violent incidents from 18-22 per year in the preceding six years, to 0-5 incidents
following the environmental changes.(7) These structural changes were supported with
education, so it is not clear if the reduction in violent incidents was a result of the
environmental changes, the education, or a combination of both.

The effectiveness of the environmental structure as a means to reducing occupational
violence in health care has not been appropriately evaluated, however staff perceptions of
safety are an important consideration for staff mental well-being. In light of this,
environmental security measures should be considered in high risk health care settings.
There is a need for future research to examine the effect of environmental security features
on the incidence of occupational violence in health care.

Organisational Policy
Organisational policies related to occupational violence in health care need to clearly identify
unacceptable behaviours, and should include a statement of support from management, the
processes for reporting violent incidents, and expectations for staff training.(2) Several reports
in the grey literature highlight the importance of organisational policy in the prevention and
management of workplace violence.(35, 40) These papers suggest that health services must
clearly communicate that aggression and violence will not be tolerated, and that appropriate
action be taken when such behaviour occurs. Further, they suggest a staged approach to
the management of aggression and violence, that includes warnings, sanctions such as
restriction of visiting rights, alternate treatment arrangements, contracts of acceptable
behaviour, conditional treatment rights, refusal of service (except in life threatening
conditions), and prosecution.(40) Examples of organisational policies aimed at reducing
workplace violence and aggression in health care include the integration of Code Grey,
aggression management teams, and the zero tolerance policy, as described below.

Page 15 of 37

Code Grey
A Code Grey is a hospital-wide coordinated clinical and security response to actual or
potential aggression or violence (unarmed threat). When a Code Grey is called, an internal
alert or emergency response is activated.(18) The 2011 policy framework for preventing
occupational violence in health care recommended the introduction of Code Grey throughout
Victorian hospitals,(37) but they were only mandated in Victoria in 2014.(18)

Aggression Management Teams
Aggression management teams (AMT) have been recommended as one way to manage
aggressive or violent behaviour.(35, 69) AMT members may be drawn from any area of the
health service, and receive specific additional training in de-escalation of violence and
aggression. AMT members respond to Code Grey (or Code Black) calls, and support the
local team members to care for the patient or visitor.(35)

Zero Tolerance Policy
Zero tolerance policies were first introduced in the United Kingdom in 1997, and were later
introduced in NSW, Australia in 2003. The premise of a zero tolerance policy is the
understanding that “specified behaviour will not be tolerated under any circumstances, and
that there will be a non-negotiable sanction imposed whenever that behaviour occurs”.(70)
The zero tolerance policy aims to change the attitudes and acceptance of violence in the
health care setting, and send a message to patients and families about their obligations
toward those who provide care.(2) Under a zero tolerance policy, staff are encouraged by
management to press charges against individuals who are violent towards them, and those
patients known to be aggressive or violent are blacklisted and denied treatment.(70)
Prosecutions of patients and relatives for attacks on health care staff increased significantly
following the introduction of the zero tolerance policy in Britain.(2)
While advocated in many health care settings,(17, 71) there are many detractors to the zero
tolerance policy. Zero tolerance policies fail to discriminate between different causes of

Page 16 of 37

violence. For example, under the zero tolerance policy, the confused elderly patient who
strikes out in fear, is treated in the same way as the violent young male who is frustrated by
the waiting time. Zero tolerance policies rely on the use of external teams of security staff to
respond to episodes of violence, and remove the violent individual from the health care
setting. However, it has been suggested that use of external teams to manage occupational
violence can have a negative effect on staff confidence to manage occupational violence.(2) It
has also been reported that zero tolerance policies have a negative effect on staff
confidence to manage violence and aggression,(53) with staff attitudes toward violence
becoming increasingly rigid following their zero tolerance training. (53) Finally, zero tolerance
policies can have a negative effect on patients’ ability to make genuine complaints or to
express appropriate annoyance or irritation with inadequate service.(2) It has been suggested
that causal factors of violence must be addressed, and support and training provided to
health care staff, rather than the impositions of sanctions.(72)

A small number of studies examined the use of chemical or physical restraint in the violent or
aggressive patient.(58, 62, 73, 74) One systematic review of restraint and seclusion found that
seclusion and restraint are ineffective means of reducing violent behaviour in adult inpatient
psychiatric settings.(74) Another study found that training in de-escalation did not reduce the
frequency of violent incidents, or the need for restraint. (62) However, other outcomes focused
on the most effective drug for chemical sedation, or best way to physically restrain a patient,
rather than the incidents of restraint, or ways to avoid restraint.(58, 73) These papers will not be
discussed in further detail.

Page 17 of 37

There is a need for occupational violence to be reported. Reporting is the only accurate
method of establishing the risk factors, extent, patterns, contributing and precipitating factors
associated with occupational violence. Reporting allows for reflection and the ability to learn
from incidents of occupational violence, including the evaluation of any interventions
implemented.(75, 76) WorkSafe also highlight the importance of reporting violence, to ensure
that information regarding a risk of potential violence that may pose a threat to health and
safety be provided to staff who may come into contact with the client or to another health
service to which the client is referred.(40) WorkSafe recommend that this is done through alert
systems or ‘file flagging’.

Despite the identified need, there are low formal reporting rates for occupational violence.
According to the International Council of Nurses, only 20% of occupational violence is
reported.(20) Reasons for underreporting of assaults and other types of violence include a
tolerance for occupational violence in practice environments, the perception of violence as
“part of the job”, lack of co-worker and manager support, including a lack of management
action and follow up, perceptions of incompetence for being unable to manage a combative
client and variations in terminology and definitions.(2, 3, 6, 77, 78)

Patient risk assessment tools are a mechanism for reporting potential occupational violence.
Examples of patient risk assessment tools, as previously discussed, include ‘Aggressive
Behaviour Risk Assessment Tool’(8) and ‘The ALERT System’.(67) The tools allow staff to
assess patients for risk of perpetrating violence, if patients display a risk it is noted or
‘flagged’ in their history or via wrist band.(8,


Risk assessment tools provide rapid

identification and communication to colleagues of potential for occupational violence. The
reporting of potential risk may result in a decrease in actual incidents of occupational
violence as staff can initiate appropriate preventative measures.

Page 18 of 37

A key strategy described in the 2011 Victorian Government report on preventing workplace
violence in health care included the development of an effective reporting and monitoring
system, that would enable health services to report, monitor and compare the incidence of
violence.(37) Despite this, another contributing factor for the low reporting rate

(75, 79)

is the

lack of a systematic, continuous comprehensive and easy to use, monitoring and reporting
system.(80) Worker’s compensation claim data are one method used for measuring
workplace violence,(37) however these data are only collected when there is an injury
associated with the event. In Victoria, RiskMan was introduced in 2012 to collect
standardised data on occupational violence in all public hospitals. The Victorian Health
Incident Management System (VHIMS) is incorporated into the RiskMan database to collect
data on multiple occupational hazards.(37, 38) RiskMan collects data related to: the type of
incident, date and time of incident, site of incident, people involved, the outcome of the
incident, injuries sustained, and contributing factors (clinical, workplace design). It was
intended that VHIMS and RiskMan would enable the collation and analysis of data across
health services, to monitor trends and assess the impact of the implementation of
recommendations aimed at reducing violence.(37)

It was intended that RiskMan and VHIMS be formally evaluated twelve months after their
introduction (i.e. 2013), and a comprehensive evaluation again three years later, (37) however
there is no evidence that RiskMan has been formally evaluated, and evidence suggests it is
not being used effectively.(77)

One recent study found that RiskMan was not user friendly, was difficult to use, and time
consuming.(77) The system was viewed by study participants as rigid and offered no flexibility.
Participants were restricted to selecting categories, with no option for free text data.
Furthermore, the study found that despite acknowledging the importance of reporting
occupational violence, participants often had insufficient time to complete all of the RiskMan
requirements.(77) Instead, participants reported that they used the patient electronic file to

Page 19 of 37

‘flag’ patients who were violent, therefore warning their colleagues for future visits. (77) This
finding is in keeping with the recommendation by WorkSafe, who have highlighted the
importance of sharing information regarding risk for potential violence with colleagues. (40)
Despite being widely utilised to collect data on occupational violence in Victorian public
healthcare settings, there is a paucity of literature evaluating the effectiveness of RiskMan.

It has been suggested that the retrospective collection of data related to violence and
aggression in health care is challenging, because it only measures incidents that have
occurred, and does not reflect the prevention of incidents.(38,


Therefore rather than

measuring positive outcomes, the tools used measure only negative outcomes. Arnetz et
al.,(80) propose that occupational violence should be treated like any other occupational
hazard such as needle stick injuries. Rather than retrospectively collecting information after
an incident, there should be a regular monitoring and surveillance. In response to this the
authors developed a reporting system that was integrated with other hospital databases
including human resources and occupational surveillance system. Relationships between
data, such as staff demographic data and occupational hazards, could be identified with
linked databases.(80)

In this reporting system staff completed an incident report, either paper based or
electronically, that was then submitted to the Occupational Health Services (OHS)
department. The details collected on the incident report are outlined in Table 1 Summary of
reporting systems. All data were then entered into the database and categorised by an OHS
analyst. Table 1 Summary of reporting systems, presents the categories. The integrated
system allowed for analysis of occupational violence to occur. The OHS department were
able to calculate incidence rates, characteristics of occupational violence, incidence by job
category, characteristics of employees reporting, incidence rates by worksite and
consequences of occupational violence.(80)

Page 20 of 37

An increase in reporting was noted after the introduction of this integrated system. There
was a rise in reporting from 1.84 incidents/100 full time equivalents in 2003, to 4.32
incidents/100 full time equivalents in 2005. The authors did note that it was difficult to
ascertain if the increase in reporting was due to the introduction of the system or an increase
in violence being perpetrated in hospitals. However, reporting was consistent over a six year
period demonstrating sustainability of the integrated system in reporting occupational

In another study, in an effort to gauge the level of occupational violence in their emergency
department, staff developed an ‘Abuse data recording tool’.(81) The paper based tool was
approved by hospital management and piloted over a six month period. Staff designed the
tool to be simple, comprehensive and accurate in collecting data on occupational violence.
Visual analogue and numeric scales were used as staff were familiar with recording patient
data using such tools. Data collected in this tool is presented in Table 1 Summary of
reporting systems. Over the trial period there was a rise in reported incidents. A 33 fold
increase in reported incidents of occupational violence was seen during the trial period,
compared to the previous 18 months (4 vs. 44).(81)

Another challenge widely recognised in the literature is the under-reporting of workplace
violence. To improve the accuracy in reporting the incidence of violence in healthcare, one
study analysed monthly reports of all calls to hospital security.(54) There were two reported
advantages to this method of data collection. Firstly, this measurement did not place an
additional burden on any staff, as security staff were already required to prepare a monthly
report of all call-outs. Secondly, this method avoided under-reporting of workplace violence,
which is widely acknowledged in health care.(54)

From the limited literature available, reporting systems for occupational violence need to be
centralised, user friendly and quick to complete.

Page 21 of 37

Page 22 of 37

Table 1 Summary of reporting systems

Reporting Format/

Information collected

Process post completion

Arnetz et al.



workplace violence

location & work shift

incident reports

Demographic data

Categorise report as


Incident date, time,


Type I - criminal intent with no legitimate
relationship with the organisation


Type II – perpetrator is a client for who services
are being provided

injury, illness, exposure, and/or
any form of verbal or physical


Type III – between employees (current or former)

violence (workplace conflict)


Type IV – perpetrator has a relationship with an

Activity preceding event

Any injury that occurred

Description of any

employee of the organisation

object or substance that
caused harm
Details of witnesses

Violent incidents further categorised based

on the nature of the incident:



combative patient


combative person






sexual harassment




unprofessional behaviour

Page 23 of 37



Abuse data

Date, time

recording tool

Who was being abused

Form of abuse

How did abuse leave

you feeling

Assailant details

Police called

Outcomes of incident

Visual analogue scales

Numeric rating scales

Page 24 of 37

This review confirms the prevalence of occupational violence across all health care
environments. Whilst a wide variety of interventions aimed at preventing or reducing violence
in health care have been implemented, few have been shown to reduce the incidence of
occupational violence. Further, there is evidence that the state-wide reporting system used
in Victoria to identify the frequency of occupational violence is burdensome and underutilised. The effectiveness of this reporting system has not been formally evaluated. Based
on the data in this literature review, the following recommendations are proposed:

Evaluation of the RiskMan reporting system – exploring usability and obstacles to

Introduction of a standardised data collection system to collect and evaluate incidents
involving hospital security staff;

Investigate the development of software to import patient medical record ‘alert data’
with hospital violence data collection systems (RiskMan);

Introduction of a state-wide patient management data system, which enables sharing
of patient files between health care providers, thus enabling the provision of informed
health care and increasing awareness of patients at risk of potential violence;

Evaluation of the efficacy of education programs in reducing the incidence of violence;

Evaluation of the effectiveness of environmental changes in reducing the incidence of

Page 25 of 37


International Labour Office, International Council of Nurses, World Health

Organisation, Public Services International. Framework Guidelines for Addressing
Workplace Violence in the Health Sector. Geneva: International Labour Office, 2002.

Wang S, Hayes L, O’Brien-Pallas L. A Review and Evaluation of Workplace Violence

Prevention Programs in the Health Sector. Toronto: Nursing Health Services Research Unit.

Chapman R, Styles I, Perry L, Combs S. Nurses' experience of adjusting to

workplace violence: A theory of adaptation. International Journal of Mental Health Nursing.

Downes MA, Healy P, Page CB, Bryant JL, Isbister GK. Structured team approach to

the agitated patient in the emergency department: Original Research. EMA - Emergency
Medicine Australasia. 2009;21(3):196-202.

Opie T, Lenthall S, Dollard M, Wakerman J, MacLeod M, Knight S, et al. Trends in

workplace violence in the remote area nursing workforce. Australian Journal of Advanced
Nursing. 2010;27(4):18-23.

McKinnon B, Cross W. Occupational violence and assault in mental health nursing: A

scoping project for a Victorian Mental Health Service. International Journal of Mental Health
Nursing. 2008;17(1):9-17.

Magnavita N. Violence prevention in a small-scale psychiatric unit: Program planning

and evaluation. International Journal of Occupational and Environmental Health.

Kim SC, Ideker K, Todicheeney-Mannes D. Usefulness of Aggressive Behaviour Risk

Assessment Tool for prospectively identifying violent patients in medical and surgical units.
Journal of Advanced Nursing. 2012;68(2):349-57.

Magin PJ, Adams J, Sibbritt DW, Joy E, Ireland MC. Experiences of occupational

violence in Australian urban general practice: A cross-sectional study of GPs. Medical
Journal of Australia. 2005;183(7):352-6.

Hills DJ, Joyce CM, Humphreys JS. A national study of workplace aggression in

Australian clinical medical practice. Medical Journal of Australia. 2012;197(6):336-40.

Page 26 of 37


Hills D, Joyce C. A review of research on the prevalence, antecedents,

consequences and prevention of workplace aggression in clinical medical practice.
Aggression and Violent Behavior. 2013;18(5):554-69.

Boyle M, Koritsas S, Coles J, Stanley J. A pilot study of workplace violence towards

paramedics. Emergency Medicine Journal. 2007;24(11):760-3.

Chappell D, Mayhew C. Ambulance officers: The impact of exposure to occupational

violence on mental and physical health. Journal of Occupational Health and Safety Australia and New Zealand. 2009;25(1):37-49.

Campbell CL, McCoy S, Burg MA, Hoffman N. Enhancing Home Care Staff Safety

Through Reducing Client Aggression and Violence in Noninstitutional Care Settings: A
Systematic Review. Home Health Care Management & Practice. 2014;26(1):3-10.

Galinsky T, Feng HA, Streit J, Brightwell W, Pierson K, Parsons K, et al. Risk Factors

Associated with Patient Assaults of Home Healthcare Workers. Rehabilitation Nursing.

Peterson GM, Tan SI, Jackson SL, Naunton M. Violence in community pharmacy in

Australia: Incidence and implications. International Journal of Clinical Pharmacy.

Morphet J, Griffiths D, Plummer V, Innes K, Fairhall R, Beattie J. At the crossroads of

violence and aggression in the emergency department: Perspectives of Australian
emergency nurses. Australian Health Review. 2014;38(2):194-201.

Victorian Department of Health. Better responses, safer hospitals: Standards for

Code Grey responses. Melbourne: 2014.

Alexander C, Fraser J. Occupational violence in an Australian healthcare setting:

Implications for managers. Journal of Healthcare Management. 2004;49(6):377-92.

International Council of Nurses. Guidelines on coping with violence in the workplace.

Geneva: ICN, 2007.

Gates D, Gillespie G, Smith C, Rode J, Kowalenko T, Smith B. Using Action

Research to Plan a Violence Prevention Program for Emergency Departments. Journal of
Emergency Nursing. 2011;37(1):32-9.

Child RJH, Mentes JC. Violence against women: The phenomenon of workplace

violence against nurses. Issues in Mental Health Nursing. 2010;31(2):89-95.

Page 27 of 37


Mayhew C, Chappell D. The occupational violence experiences of 400 Australian

health workers: An exploratory study. Journal of Occupational Health and Safety - Australia
and New Zealand. 2003;19(6):3-43.

Farrell GA, Bobrowski C, Bobrowski P. Scoping workplace aggression in nursing:

findings from an Australian study. Journal Of Advanced Nursing. 2006;55(6):778-87.

Arnetz JE, Hamblin L, Essenmacher L, Upfal MJ, Ager J, Luborsky M. Understanding

patient-to-worker violence in hospitals: a qualitative analysis of documented incident reports.
Journal of Advanced Nursing. 2014:n/a-n/a.

Lipscomb J, McPhaul K, Rosen J, Brown JG, Choi M, Soeken K, et al. Violence

prevention in the mental health setting: The New York State experience. Canadian Journal
of Nursing Research. 2006;38(4):96-117.

Magin P, Joyce T, Adams J, Goode S, Cotter G. General practice as a fortress:

Occupational violence and general practice receptionists. Australian Family Physician.

McPhaul KM, London M, Lipscomb JA. A framework for translating workplace

violence intervention research into evidence-based programs. Online journal of issues in
nursing. 2013;18(1):4.

Touzet S, Cornut PL, Fassier JB, Le Pogam MA, Burillon C, Duclos A. Impact of a

program to prevent incivility towards and assault of healthcare staff in an ophtalmological
emergency unit: Study protocol for the PREVURGO On/Off trial. BMC Health Services
Research. 2014;14(1).

Farrell G, Cubit K. Nurses under threat: A comparison of content of 28 aggression

management programs. International Journal of Mental Health Nursing. 2005;14(1):44-53.

Gillespie GL, Gates DM, Kowalenko T, Bresler S, Succop P. Implementation of a

Comprehensive Intervention to Reduce Physical Assaults and Threats in the Emergency
Department. Journal of Emergency Nursing. 2014.

Kowalenko T, Cunningham R, Sachs CJ, Gore R, Barata IA, Gates D, et al.

Workplace violence in emergency medicine: Current knowledge and future directions.
Journal of Emergency Medicine. 2012;43(3):523-31.

Anderson L, FitzGerald M, Luck L. An integrative literature review of interventions to

reduce violence against emergency department nurses. Journal of Clinical Nursing.

Page 28 of 37


Mott A, Walton J, Harries L, Highfield P, Bleetman A, Dobson P. Personal defence

training in a medium secure unit - a pilot study. The Journal of Mental Health Training,
Education, and Practice. 2012;7(4):200-13.

Victorian Government. Victorian taskforce on violence in nursing: Final report. In:

Branch DoH-NP, editor. Victoria2005.

Parliament of Victoria. Inquiry into violence and security arragements in Victorian

hospitals and, in particular emergency department. In: committee DaCP, editor. Victoria2011.
p. i-241.

Victorian Goverment. Preventing occupational violence: A policy framework including

principles for managing weapons in Victorian health services. In: Health Do, editor.
Victoria2011. p. 1-37.

Victorian Goverment. Progress on Occupational Violence Prevention in Victorian

Health Services: Including a snapshot of the work arising from the Taskforce on Violence in
Nursing. In: Health Do, editor. Victoria2012.

Knott J, Gerdtz M, Daniel C, Dearie V, Holsheimer A. Violence prevention and

management: Standards for development of training and organisational responses in
Victorian health services. In: Health Do, editor. Victoria2011.

WorkSafe Victoria. Prevention and management of aggression in health services. In:

Project MHaNHWsAPaM, editor. Victoria2008.

Weeks SK, Barron BT, Horne MR, Sams GP, Monnich AB, Alverson LD. Responding

to an active shooter and other threats of violence. Nursing management. 2014;45(6):42-5.

Oostrom JK, Van Mierlo H. An evaluation of an aggression management training

program to cope with workplace violence in the healthcare sector. Research in Nursing and
Health. 2008;31(4):320-8.

Nachreiner NM, Gerberich SG, McGovern PM, Church TR, Hansen HE, Geisser MS,

et al. Impact of training on work-related assault. Research in Nursing & Health.

Hartley D, Ridenour M, Craine J, Costa B. Workplace violence prevention for

healthcare workers - An online course. Rehabilitation Nursing. 2012;37(4):202-6.

Gillespie GL, Farra SL, Gates DM. A workplace violence educational program: A

repeated measures study. Nurse Education in Practice. 2014;In Press(0).

Phillips S. Countering workplace aggression: An urban tertiary care institutional

exemplar. Nursing Administration Quarterly. 2007;31(3):209-18.

Page 29 of 37


Gillespie GL, Gates DM, Mentzel T, Al-Natour A, Kowalenko T. Evaluation of a

Comprehensive ED Violence Prevention Program. Journal of Emergency Nursing.

Gerdtz MF, Daniel C, Dearie V, Prematunga R, Bamert M, Duxbury J. The outcome

of a rapid training program on nurses’ attitudes regarding the prevention of aggression in
emergency departments: A multi-site evaluation. International Journal of Nursing Studies.

Anderson C. Training Efforts to Reduce Reports of Workplace Violence in a

Community Health Care Facility. Journal of Professional Nursing. 2006;22(5):289-95.

Nau J, Halfens R, Needham I, Dassen T. Student nurses' de-escalation of patient

aggression: A pretest-posttest intervention study. International Journal of Nursing Studies.

Forster JA, Petty MT, Schleiger C, Walters HC. kNOw workplace violence:

developing programs for managing the risk of aggression in the health care setting. The
Medical Journal Of Australia. 2005;183(7):357-61.

Swain N, Gale C. A communication skills intervention for community healthcare

workers reduces perceived patient aggression: A pretest-postest study. International Journal
of Nursing Studies. 2014;51(9):1241-5.

Middleby-Clements JL, Grenyer BFS. Zero tolerance approach to aggression and its

impact upon mental health staff attitudes. Australian and New Zealand Journal of Psychiatry.

Gillam SW. Nonviolent crisis intervention training and the incidence of violent events

in a large hospital emergency department: an observational quality improvement study.
Advanced emergency nursing journal. 2014;36(2):177-88.

Dickens G, Rogers G, Rooney C, Mc Guinness A, Doyle D. An audit of the use of

breakaway techniques in a large psychiatric hospital: a replication study. Journal of
Psychiatric and Mental Health Nursing. 2009;16(9):777-83.

Lamont S, Brunero S, Bailey A, Woods K. Breakaway technique training as a means

of increasing confidence in managing aggression in neuroscience nursing. Australian Health
Review. 2012;36(3):313-9.

Gates D, Fitzwater E, Succop P. Reducing assaults against nursing home caregivers.

Nursing Research. 2005;54(2):119-27.

Page 30 of 37


Kynoch K, Wu CJ, Chang AM. Interventions for preventing and managing aggressive

patients admitted to an acute hospital setting: A systematic review. Worldviews on EvidenceBased Nursing. 2011;8(2):76-86.

Rogers P, Gail M, Brodie P, Clive B, Peter T, Sue B, et al. Is breakaway training

effective? Examining the evidence and the reality. The Journal of Mental Health Training,
Education and Practice. 2007;2(2):5-12.

Rogers P, Ghroum P, Benson R, Forward L, Gournay K. Is breakaway training

effective? An audit of one medium secure unit. Journal of Forensic Psychiatry & Psychology.

Jones CD, Manno MS, Vogt B. Tier one alert! A psychiatric rapid response team.

Nursing Management. 2012;43(11):34-40.

Laker C, Gray R, Flach C. Case study evaluating the impact of de-escalation and

physical intervention training. Journal of Psychiatric and Mental Health Nursing.

Arnetz JE, Arnetz BB. Implementation and evaluation of a practical intervention

programme for dealing with violence towards health care workers. Journal of Advanced
Nursing. 2000;31(3):668-80.

Inoue M, Kaneko F, Okamura H. Evaluation of the effectiveness of a group

intervention approach for nurses exposed to violent speech or violence caused by patients: a
randomized controlled trial. ISRN Nursing. 2011:1-8.

Wassell JT. Workplace violence intervention effectiveness: A systematic literature

review. Safety Science. 2009;47(8):1049-55.

Richter D, Needham I, Kunz S. The Effects of Aggression Management Training for

Mental Health Care and Disability Care Staff: A Systematic Review. In: Richter D,
Whittington R, editors. Violence in Mental Health Settings: Springer New York; 2006. p. 21127.

Kling RN, Yassi A, Smailes E, Lovato CY, Koehoorn M. Evaluation of a violence risk

assessment system (the Alert System) for reducing violence in an acute hospital: A before
and after study. International Journal of Nursing Studies. 2011;48(5):534-9.

Lundrigan E, Hutchings D, Mathews M, Lynch A, Goosney J. A Risk Assessment

Screening Tool for Community Health Care Workers. Home Health Care Management &
Practice. 2010;22(6):403-7.

Page 31 of 37


Cowling SA, McKeon MA, Weiland TJ. Managing acute behavioural disturbance in an

emergency department using a behavioural assessment room. Australian Health Review.

Holmes CA. Violence, zero tolerance and the subversion of professional practice.

Contemporary Nurse. 2006;21(2):212-27.

Occupational Safety & Health Administration [OSHA]. Guidelines for Preventing

Workplace Violence for Health Care & Social Service Workers. In: Administration
USDoLOSaH, editor. US2004. p. 1-28.

Johnson P. Staff injury arising from the use of physical intervention. Journal of

Learning Disabilities & Offending Behaviour. 2012;3(1):35-43.

Isaacs KJ. The Effectiveness of Interventions to Prevent and Manage Aggressive

Behaviours in Patients Admitted to Acute Care. HNE Handover: For Nurses and Midwives.

Nelstrop L, Chandler-Oatts J, Bingley W, Bleetman T, Corr F, Cronin-Davis J, et al. A

Systematic Review of the Safety and Effectiveness of Restraint and Seclusion as
Interventions for the Short-Term Management of Violence in Adult Psychiatric Inpatient
Settings and Emergency Departments. Worldviews on Evidence-Based Nursing.

Brooks B, Staniford A, Dollard M, Wiseman R. Risk Factors, Consequences, and

Management of Aggression in Healthcare Environments. In: Leka S, R. SR, editors.
Contemporary Occupational Health Psychology: Global Perspectives on Research and
Practice: John Wiley & Sons, Ltd; 2014. p. 329-53.

Benveniste KA, Hibbert PD, Runciman WB. Violence in health care: The contribution

of the Australian Patient Safety Foundation to incident monitoring and analysis. Medical
Journal of Australia. 2005;183(7):348-51.

Hogarth K. Nurses' attitudes toward the reporting of workplace violence in the

emergency department: Monash University; 2013.

Mayhew C, Chappell D. Occupational violence: types, reporting patterns and

variations between health sectors. University of New South Wales Sydney: School of
Industrial Realtions and Organisational Behaviour and the Industrial Relations Research
Centre, 2001.

Page 32 of 37


Gilligan T, Alamgir H. Bridging the Knowledge Gap: An Innovative Surveillance

System to Monitor the Health of British Columbia's Healthcare Workforce. Canadian Journal
of Public Health / Revue Canadienne de Sante'e Publique. 2008;99(6):478-82.

Arnetz JE, Aranyos D, Ager J, Upfal MJ. Development and application of a

population-based system for workplace violence surveillance in hospitals. American Journal
of Industrial Medicine. 2011;54(12):925-34.

Pawlin S. Reporting violence: the introduction to an emergency department of a new

recording tool has increased the frequency of reports of abusive incidents and revealed why
some staff do not report abuse by patients. Emergency Nurse. 2008 2008/07//:16+.

Page 33 of 37