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Effectiveness of the interventions against workplace violence suffered by health and support professionals: A meta-analysis

Abstract

Objective:

to assess the effectiveness of the interventions targeted at preventing and reducing the workplace violence suffered by health and support professionals.

Method:

a systematic review with meta-analysis conducted in eight databases and in the gray literature. Risk of bias was assessed by means of the Cochrane tools and certainty of the evidence, through Grading of Recommendations Assessment, Development and Evaluation. The analysis was performed in a descriptive manner and through the meta-analysis, including a heterogeneity assessment.

Results:

a total of 11 randomized and quasi-randomized studies were eligible, of which six (54.5%) implemented individual skills, four used a multiple approach (36.4%) and one (9.1%) resorted to governmental actions. Four studies (36.4%) exerted a positive and significant effect on reducing violence. Risk of bias was classified as high or uncertain. The meta-analysis was performed with two studies that tested individual skill (intervention group) versus individual skill (comparator group), although there was no scientific evidence (95% CI: -0.41 - 0.25, p=0.64) for the violence prevention/reduction outcome.

Conclusion:

this review did not obtain a high level of evidence in the prevention or reduction of workplace violence. The reduced number of randomized trials, the lack of studies with low risk of bias and the high consistency may have been factors that hindered recommending effective interventions.

Descriptors:
Evidence-Based Practice; Systematic Review; Meta-Analysis; Occupational Exposure; Workplace Violence; Health Personnel

Resumo

Objetivo:

avaliar a efetividade das intervenções direcionadas à prevenção e redução da violência no trabalho sofrida por profissionais de saúde e apoio.

Método:

revisão sistemática com metanálise realizada em oito bases de dados e na literatura cinzenta. O risco de viés foi realizado por meio das ferramentas da Cochrane e a certeza da evidência pelo Grading of Recommendations Assessment, Development and Evaluation. A análise foi realizada de forma descritiva e pela metanálise, incluindo avaliação da heterogeneidade.

Resultados:

11 estudos aleatorizados e quasi-aleatorizados foram elegíveis, dos quais seis estudos (54,5%) implementaram habilidades individuais, quatro multiabordagem (36,4%) e um (9,1%) ações governamentais. Quatro estudos (36,4%) tiveram efeito positivo e significativo na redução da violência. O risco de viés foi classificado como alto ou incerto. A metanálise foi realizada com dois estudos que testaram habilidade individual (grupo intervenção) versus habilidade individual (grupo comparador), porém não houve evidência científica (IC 95%: -0,41 a 0,25, p=0,64) para o desfecho prevenção/redução da violência.

Conclusão:

esta revisão não obteve alta evidência na prevenção ou redução da violência no trabalho. O número reduzido de ensaios aleatorizados, a falta de estudos com baixo risco de viés e a alta consistência podem ter sido fatores dificultadores para recomendar intervenções efetivas.

Descritores:
Prática Clínica Baseada em Evidências; Revisão Sistemática; Metanálise; Exposição Ocupacional; Violência no Trabalho; Pessoal de Saúde

Resumen

Objetivo:

evaluar la efectividad de las intervenciones dirigidas a prevenir y reducir la violencia laboral que sufren los profesionales de la salud y de apoyo.

Método:

revisión sistemática con metanálisis realizada en ocho bases de datos y en la literatura gris. El riesgo de sesgo se evaluó mediante herramientas Cochrane y la certeza de la evidencia mediante el Grading of Recommendations Assessment, Development and Evaluation. El análisis se realizó de forma descriptiva y por metanálisis, e incluyó la evaluación de la heterogeneidad.

Resultados:

fueron elegibles 11 estudios aleatorios y cuasialeatorios, de los cuales seis estudios (54,5%) implementaron habilidades individuales, cuatro multienfoque (36,4%) y uno (9,1%) acciones gubernamentales. Cuatro estudios (36,4%) tuvieron un efecto positivo y significativo en la reducción de la violencia. El riesgo de sesgo se clasificó como alto o incierto. El metanálisis se realizó con dos estudios que evaluaron la capacidad individual (grupo de intervención) versus la capacidad individual (grupo de comparación), pero no se encontró evidencia científica (IC del 95 %: -0,41 a 0,25, p = 0,64) para el resultado prevención/reducción de la violencia.

Conclusión:

esta revisión no obtuvo alta evidencia sobre la prevención o reducción de la violencia laboral. El número reducido de ensayos aleatorios, la falta de estudios con bajo riesgo de sesgo y la alta consistencia pueden haber sido factores que dificultaron la recomendación de intervenciones efectivas.

Descriptores:
Práctica Clínica Basada en la Evidencia; Revisión Sistemática; Metaanálisis; Exposición Profesional; Violencia Laboral; Personal de Salud

Highlights

(1) The paper synthesizes the knowledge about the interventions that prevent workplace violence.

(2) The interventions implemented in the studies can benefit health professionals.

(3) The paper raises awareness regarding the theme in health professionals and managers.

(4) It is recommended to conduct new and in-depth randomized clinical trials.

Introduction

Workplace violence is significantly and increasingly present in the world. In the United States of America, a report published in 2017 by the United States Bureau of Labor Statistics revealed that 458 homicides were recorded and committed in the workplace, of which 77 were perpetrated by co-workers or associates11. United States Bureau of Labor Statistics. Injuries, Illnesses, and Fatalities Fact Sheet. Workplace homicides in 2017 [Internet]. Washington, D.C.: U.S. Bureau of Labor Statistics; 2019 [cited 2021 Oct 08]. Available from: https://www.bls.gov/iif/oshwc/cfoi/workplace-homicides-2017.htm
https://www.bls.gov/iif/oshwc/cfoi/workp...
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In 2018, data revealed that health care professionals were five times more likely to experience workplace violence than all other workers, accounting for nearly 73% of all non-fatal work-related accidents and diseases requiring days off22. The Joint Commission. Workplace Violence Prevention Standards [Internet]. Oakbrook Terrace, IL: The Joint Commission; 2021 [cited 2021 Oct. 08]. Available from: https://www.jointcommission.org/standards/r3-report/r3-report-issue-30-workplace-violence-prevention-standards/
https://www.jointcommission.org/standard...
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A systematic review conducted in 2019 revealed that 80% of all the cases of workplace violence affected health professionals from Asia, America, Europe, Middle East, Oceania and Africa33. Yoon YG, Jung-Choi K. Systematic Review on Research Status of Workplace Violence. Ewha Med J. 2019 Jan;42(4):56-64. doi: 10.12771/emj.2019.42.4.56
https://doi.org/10.12771/emj.2019.42.4.5...
. In 2021, a report published by the Joint Commission on sentinel events from 2018 to 2020 revealed that, in relation to the rape of health professionals in the United States of America, 56 events were recorded, in addition to 12 homicides and 260 suicides44. The Joint Commission. Summary Data of Sentinel Events Reviewed by The Joint Commission [Internet]. Oakbrook Terrace, IL: The Joint Commission; 2021 [cited 2021 Oct 08]. Available from: https://www.jointcommission.org/-/media/tjc/documents/resources/patient-safety-topics/sentinel-event/summary-se-report-2020.pdf
https://www.jointcommission.org/-/media/...
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In this study, it is understood that workplace violence consists of intentional acts or aggressive and threatening behaviors that deviate from the expected actions and seek to harm or injure a person during work or as a result of it, including verbal, non-verbal, threatening or demeaning words or actions, bullying, sexual harassment, physical assaults or other intimidating or disruptive behavior involving professionals, patients or visitors22. The Joint Commission. Workplace Violence Prevention Standards [Internet]. Oakbrook Terrace, IL: The Joint Commission; 2021 [cited 2021 Oct. 08]. Available from: https://www.jointcommission.org/standards/r3-report/r3-report-issue-30-workplace-violence-prevention-standards/
https://www.jointcommission.org/standard...
,55. Al-Qadi MM. Workplace violence in nursing: A concept analysis. J Occup Health. 2021;63(1):e12226. doi: 10.1002/1348-9585.12226
https://doi.org/10.1002/1348-9585.12226...
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A systematic review with meta-analysis verified that nearly 2% of the health professionals are victims of workplace violence. Regarding the type of violence, predominance of verbal abuse was evidenced, followed by verbal threats and sexual harassment. In relation to the practice locus, there was higher prevalence in pre-hospital environments66. Liu J, Gan Y, Jiang H, Li L, Dwyer R, Lu K, et al. Prevalence of workplace violence against healthcare workers: a systematic review and meta-analysis. Occup Environ Med. 2019;76(12):927-37. doi: 10.1136/oemed-2019-105849
https://doi.org/10.1136/oemed-2019-10584...
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The aforementioned type of violence has been indicated as a priority area from 2002 to the present day, and political intervention at the international level is a concern, mainly in the health sector, because, among all, it is one of the most affected, exerting negative effects on work productivity, quality of the care provided to the patient and the costs, in addition to the high rates of absenteeism and abandonment of the profession22. The Joint Commission. Workplace Violence Prevention Standards [Internet]. Oakbrook Terrace, IL: The Joint Commission; 2021 [cited 2021 Oct. 08]. Available from: https://www.jointcommission.org/standards/r3-report/r3-report-issue-30-workplace-violence-prevention-standards/
https://www.jointcommission.org/standard...
,77. International Council of Nurses. Public Services International. World Health Organization. International Labor Organization. Framework guidelines for addressing workplace violence in the health sector - the training manual [Internet]. Geneva: International Labor Organization; 2005 [cited 2021 Oct 08]. Available from: https://www.ilo.org/safework/info/instr/WCMS_108542/lang--en/index.htm
https://www.ilo.org/safework/info/instr/...
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A number of studies also reveal that the aforementioned violence in the health sector especially affects female professionals and the Nursing category that practices their profession, especially in hospitals, emergency departments and without another co-worker88. U.S. Department of Labor, Occupational Safety and Health Administration. Guidelines for Preventing Workplace Violence for Healthcare and Social Service Workers [Internet]. Washington, D.C.:U.S. Department of Labor; 2016 [cited 2021 Sept 08]. Available from: https://www.osha.gov/sites/default/files/publications/osha3148.pdf
https://www.osha.gov/sites/default/files...

9. Alsaleem AS, Alsabaani A, Alamri RS, Hadi RA, Alkhayri MH, Badawi KK, et al. Violence towards healthcare workers: A study conducted in Abha City, Saudi Arabia. J Family Community Med. 2018;25(3):188-93. doi: 10.4103/jfcm.JFCM_170_17
https://doi.org/10.4103/jfcm.JFCM_170_17...

10. Simões MRL, Barroso HH, de-Azevedo DSS, Duarte ACM, Barbosa REC, Fonseca GC, et al. Workplace violence among municipal health care workers in Diamantina, Minas Gerais, Brazil, 2017. Rev Bras Med Trab. 2020;18(1):82-90. doi: 10.5327/Z1679443520200425
https://doi.org/10.5327/Z167944352020042...
-1111. Ayasreh IR, Hayajneh FA. Workplace Violence Against Emergency Nurses: A Literature Review. Crit Care Nurs Q. 2021;44(2):187-202. doi: 10.1097/CNQ.0000000000000353
https://doi.org/10.1097/CNQ.000000000000...
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In order to combat this complex phenomenon, several institutions and international bodies have been publishing guidelines to eliminate it with a focus on a zero tolerance culture, addressing measures to minimize or exclude the workplace violence rates and risk. Such measures include commitment by the management, participation of the professional, workplace analysis, safety and health training, risk factor analysis and monitoring records of the violence rates22. The Joint Commission. Workplace Violence Prevention Standards [Internet]. Oakbrook Terrace, IL: The Joint Commission; 2021 [cited 2021 Oct. 08]. Available from: https://www.jointcommission.org/standards/r3-report/r3-report-issue-30-workplace-violence-prevention-standards/
https://www.jointcommission.org/standard...
,77. International Council of Nurses. Public Services International. World Health Organization. International Labor Organization. Framework guidelines for addressing workplace violence in the health sector - the training manual [Internet]. Geneva: International Labor Organization; 2005 [cited 2021 Oct 08]. Available from: https://www.ilo.org/safework/info/instr/WCMS_108542/lang--en/index.htm
https://www.ilo.org/safework/info/instr/...
-88. U.S. Department of Labor, Occupational Safety and Health Administration. Guidelines for Preventing Workplace Violence for Healthcare and Social Service Workers [Internet]. Washington, D.C.:U.S. Department of Labor; 2016 [cited 2021 Sept 08]. Available from: https://www.osha.gov/sites/default/files/publications/osha3148.pdf
https://www.osha.gov/sites/default/files...
.

Thus, actions and implementation of guidelines, laws or public policies to reduce violence should be sought, as it is a preventable problem and an important determinant of physical illness and, above all, mental ailments1212. Dal Pai D, Sturbelle ICS, Santos C, Tavares JP, Lautert L. Physical and psychological violence in the workplace of healthcare professionals. Texto Contexto Enferm. 2018;27(1):e2420016. doi: 10.1590/0104-07072018002420016
https://doi.org/10.1590/0104-07072018002...
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Among the systematic reviews that sought to identify the effect of the interventions, it was verified that there is lack of knowledge in the studies about the effectiveness of the actions that prevent or reduce acts of violence against professionals working in the health services. It should be noted that one study only evaluated a specific intervention at the individual level, including education and training1313. Geoffrion S, Hills DJ, Ross HM, Pich J, Hill AT, Dalsbø TK, et al. Education and training for preventing and minimizing workplace aggression directed toward healthcare workers. Cochrane Database Syst Rev. 2020;9(9):CD011860. doi: 10.1002/14651858.CD011860.pub2
https://doi.org/10.1002/14651858.CD01186...
and another did so at the organizational level, such as work programs and practices1414. Spelten E, Thomas B, O'Meara PF, Maguire BJ, FitzGerald D, Begg SJ. Organisational interventions for preventing and minimising aggression directed towards healthcare workers by patients and patient advocates. Cochrane Database Syst Rev. 2020;4(4):CD012662. doi: 10.1002/14651858.CD012662.pub2
https://doi.org/10.1002/14651858.CD01266...
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In view of the aforementioned considerations, this study is justified, as identifying the scientific evidence on the theme will contribute to the standardization of effective interventions that may curb and prevent acts of violence that affect health and support professionals.

Thus, the objective of this systematic review was to assess the effectiveness of the interventions targeted at preventing and reducing the workplace violence suffered by health and support professionals.

Method

Study design

This study is a systematic review with meta-analysis written according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)1515. Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group. Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. PLoS Med. 2009 July;6(7):e1000097. doi:10.1371/journal.pmed.1000097
https://doi.org/10.1371/journal.pmed.100...

16. Moher D, Shamseer L, Clarke M, Ghersi D, Liberati A, Petticrew M, et al. Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) 2015 statement. Syst Rev. 2015 Jan;4(1):1-9. doi: 10.1186/2046-4053-4-1
https://doi.org/10.1186/2046-4053-4-1...
-1717. Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021 Mar;372(71):1-9. doi: 10.1136/bmj.n71
https://doi.org/10.1136/bmj.n71...
. The protocol of this review was registered in the International Prospective Register of Systematic Reviews (PROSPERO) platform under number CRD420181113831818. Okubo CVC, Martins JT. Effectiveness of interventions in reducing occupational violence between health workers: systematic review and meta-analysis [Internet]. PROSPERO 2018 CRD42018111383 [cited 2021 June 08]. Available from: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42018111383
https://www.crd.york.ac.uk/prospero/disp...
. This protocols was also published in the BMJ Open Journal1919. Okubo CVC, Silveira RCCP, Galdino MJQ, Fernandes DR, Moreira AAO, Martins JT. Effectiveness of interventions for the prevention of occupational violence against professionals in health services: a protocol for a systematic review. BMJ Open. 2020 Sept [cited 2021 Oct 01];10:e0365582020. doi: 10.1136/bmjopen-2019-036558
https://doi.org/10.1136/bmjopen-2019-036...
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Selection criteria

To search for studies and formulate the guiding question, the PICOS2020. Akobeng AK. Principles of evidence-based medicine. Arch Dis Child. 2005 Aug. [cited 2021 Sept 02];90(8):837-40. doi: 10.1136/adc.2005.071761
https://doi.org/10.1136/adc.2005.071761...
strategy was used, an acronym for “Population” (health and support professionals), “Intervention” (organizational, environmental, individual, multiple approach [organizational, environmental and individual] or governmental [policies/laws]), “Control/Comparison” (no comparison, standard, usual or no intervention is applicable/eligible) and “Outcome” (prevention and reduction of workplace violence or reduction of exposure to this type of violence).

This review had the following guiding question: How effective are the interventions targeted at preventing and reducing the workplace violence suffered by health and support professionals?

The inclusion criteria adopted addressed studies: 1) conducted with health and/or support professionals2121. World Health Organization. Classification of health workforce statistics [Internet]. Geneva: WHO; 2010 [cited 2021 June 21]. Available from: https://www.who.int/hrh/statistics/Health_workers_classification.pdf
https://www.who.int/hrh/statistics/Healt...
; 2) carried out in health services or community health services, such as hospitals, emergency sectors, basic health units or long-term care institutions, in addition to the patient’s home; 3) addressing organizational, environmental, individual, multiple approach (organizational, environmental and individual) or governmental interventions77. International Council of Nurses. Public Services International. World Health Organization. International Labor Organization. Framework guidelines for addressing workplace violence in the health sector - the training manual [Internet]. Geneva: International Labor Organization; 2005 [cited 2021 Oct 08]. Available from: https://www.ilo.org/safework/info/instr/WCMS_108542/lang--en/index.htm
https://www.ilo.org/safework/info/instr/...
; 4) that had reduction and/or prevention of workplace violence perpetrated by patients as primary or secondary outcomes; 5) with randomized or quasi-randomized designs such as randomized clinical trials (level II evidence) and quasi-randomized studies (such as before-and-after type with a control group, level III evidence)2222. Miller CJ, Smith SN, Pugatch M. Experimental and quasi-experimental designs in implementation research. Psychiatry R. 2020 June;283(112452). doi: 10.1016/j.psychres.2019.06.027
https://doi.org/10.1016/j.psychres.2019....

23. Melnyk BM. Level of evidence plus critical appraisal of its quality yields confidence to implement evidence-based practice changes. Worldviews Evid Based Nurs. 2016 Oct;13(5):337-9. doi: 10.1111/wvn.12181
https://doi.org/10.1111/wvn.12181...
-2424. Melnyk BM, Fineout-Overholt E. Evidence-based practice in nursing and healthcare: a guide to best practice. 4a ed. Philadelphia: Wolters Kluwer; 2019.. No restriction was applied in relation to language or year publication.

The exclusion criteria adopted addressed studies: 1) conducted with residents and/or students; 2) with review methodologies, letters, personal opinions, book chapters, institutional manuals, reports, case series, cross-sectional studies (non-comparative as the before-and-after type without control group); and 3) with duplicate data.

Period

Data collection took place during 2020 and 2021. A search in the databases was conducted on August 8th, 2020. Another updated search was performed on June 9th, 2021.

Data collection

The individual search strategies for each electronic database were implemented in PubMed, Scopus, Web of Science, EMBASE, the Cochrane Library, CINAHL, LILACS and Livivo. In addition to that, searches were also conducted in the gray literature, including Google Scholar, OpenGrey and ProQuest. The strategy was prepared by the research team of this review, including PhDs on the theme and on the review method.

It is noted that, prior to carrying out the final searches of the primary studies in the databases selected, several combinations were made employing the controlled descriptors, keywords and the AND and OR Boolean operators. The objective was to identify the highest possible number of publications, first in the PubMed database with adaptation for the others. The MeSH descriptors included the following: “health personnel”, “attitude of health personnel”, “workplace violence”, “exposure to violence”, “physical abuse” and “education”, in addition to synonyms and keywords. The search was conducted by two researchers with PhD degrees on the theme of violence, as well as on the method adopted for the study.

A manual search was also conducted in the references of all the articles included. An expert on the topic of “workplace violence” was identified via a website (http://expertscape.com/), contacted by email and asked to identify the five most important publications on the topic.

The studies were first exported by a PhD to EndNote online2525. Endnote [Software]. 2021 [cited 2021 June 10]. Available from: https://access.clarivate.com/login?app=endnote
https://access.clarivate.com/login?app=e...
, where a detailed screening of all studies and references was performed and duplicates were removed. Subsequently, the citations were exported by the same PhD to the Rayyan QCRI manager2626. Rayyan [Software]. 2022 [cited 2021 June 02]. Available from: https://rayyan.ai/users/sign_in?_ga=2.174315621.619312859.1638400577-1927447999.1629229968
https://rayyan.ai/users/sign_in?_ga=2.17...
, with a new process for removal of duplicates; and selection of the studies, in two phases, was performed by two reviewers.

In the first selection phase, two masked reviewers (one with a Master’s degree and the other with a PhD) independently read and evaluated the titles and abstracts of all studies, applying the eligibility criteria to define the studies to be included. In the second phase, these same reviewers read the full texts to confirm eligibility.

Data extraction and collection was in charge of another two reviewers (with Master’s and PhD degrees, respectively), masked and by means of a form. This form contained a number of study characteristics (author, year, country, study design, objective, locus, study period), population (category, gender, sample size), characteristics of the results (intervention and control groups, including the total sample number of these groups (n) and a description of the intervention and control, randomization, blinding, main results) and main conclusion. A maximum of three attempts were made to contact the authors of the studies to retrieve the information. Subsequently, data accuracy was confirmed between the reviewers.

Any and all disagreements were resolved in a meeting between both reviewers. If no consensus was reached, another two reviewers (PhDs) with expertise in the topic of worker’s health and in the method were contacted to resolve the differences in the aforementioned phases (data collection, selection of the studies and/or extraction).

Data treatment and analysis

Risk of bias of the studies selected was assessed by means of the following Cochrane tools: Revised Cochrane Risk-of-Bias Tool for Randomized Trials (RoB 2), ROB 2 for Cluster - Randomized Trials (RoB 2 CRT) and Risk Of Bias In Non-randomised Studies - of Interventions (ROBINS-I)2727. Eldridge S, Campbell MK, Campbell MJ, Drahota AK, Giraudeau B, Reeves BC, et al. Revised Cochrane risk of bias tool for randomized trials (RoB 2). Additional considerations for cluster-randomized trials (RoB 2 CRT) [Internet]. 2021 Mar 18 [cited 2021 July 0]. Available from: https://sites.google.com/site/riskofbiastool/welcome/rob-2-0-tool/rob-2-for-cluster-randomized-trials
https://sites.google.com/site/riskofbias...

28. Higgins JPT, Savovic J, Page MJ, Sterne JAC, RoB2 Development Group. Revised Cochrane risk-of-bias tool for randomized trials (RoB 2). 2019 Aug 22 [cited 2021 July 04]. Available from: https://sites.google.com/site/riskofbiastool/welcome/rob-2-0-tool/current-version-of-rob-2
https://sites.google.com/site/riskofbias...

29. Sterne JAC, Higgins JPT, Elbers RG, Reeves BC. Risk Of Bias In Non-randomized Studies of Interventions (ROBINS-I): detailed guidance [Internet]. 2016 Oct 20 [cited 2021 July 4]. Available from: https://sites.google.com/site/riskofbiastool/welcome/home/current-version-of-robins-i/robins-i-detailed-guidance-2016
https://sites.google.com/site/riskofbias...
-3030. Sterne JAC, Savovic J, Page MJ, Elbers RG, Blencowe NS, Boutron I, et al. RoB 2: a revised tool for assessing risk of bias in randomised trials. BMJ. 2019 Aug;366:l4898. doi: 10.1136/bmj.l4898
https://doi.org/10.1136/bmj.l4898...
.

Two masked reviewers (master’s degree and PhD) evaluated each domain (selection, performance, detection, attrition and reporting) and classified each study as high risk, low risk or some concerns regarding bias, based on the aforementioned tools.

A synthesis of the results obtained was performed in a descriptive manner and through the meta-analysis. The results of the meta-analysis were presented in a forest plot. The evaluations of the measures of the continuous outcomes adopted provided a general estimate, through the standardized mean difference, weight for the model adopted (random), and with a 95% Confidence Interval (CI). The meta-analysis was performed by means of the Cochrane’s Review Manager (V.5.3) - RevMan Web software3131. Higgins J, Thomas J, Chandler J, Cumpston M, Li T, Page M, et al. Cochrane Handbook for Systematic Reviews of Interventions version 6.2 [Internet]. London: Cochrane; 2021 [cited 2021 Mar 1]. Available from: https://training.cochrane.org/handbook/current
https://training.cochrane.org/handbook/c...
-3232. Cochrane Collaboration. RevMan Web(r). Version 5.4 [Software]. 2021 [cited 2021 July 1]. Available from: https://revman.cochrane.org/#/myReviews
https://revman.cochrane.org/#/myReviews...
. Heterogeneity was also described, by means of the I2statistical test3131. Higgins J, Thomas J, Chandler J, Cumpston M, Li T, Page M, et al. Cochrane Handbook for Systematic Reviews of Interventions version 6.2 [Internet]. London: Cochrane; 2021 [cited 2021 Mar 1]. Available from: https://training.cochrane.org/handbook/current
https://training.cochrane.org/handbook/c...
. No sensitivity analysis was applied due to the limitation of two randomized clinical trials in the meta-analysis.

A summary of the overall certainty of the evidence for the outcome studied (prevention/reduction of workplace violence) was assessed by two masked reviewers (master’s degree and PhD), who grounded their evaluations on the Grading of Recommendations Assessment, Development and Evaluation approach, GRADE)3333. Schünemann H, Brozek J, Guyatt G, Oxman A. GRADE Handbook. Handbook for grading the quality of evidence and the strength of recommendations using the GRADE approach [Internet]. 2013 [cited 2021 July 6]. Available from: https://gdt.gradepro.org/app/handbook/handbook.html#h.svwngs6pm0f2
https://gdt.gradepro.org/app/handbook/ha...
and on the GRADEpro GTD software (Copenhagen, Denmark) provided by the GRADE Working Group, in association with the Cochrane Collaboration3434. Grade Working Group. GRADEPro [Software]. Hamilton: McMaster University/Evidence Prime Inc.; 2021 [cited 2021 July 6]. Available from: https://gradepro.org/
https://gradepro.org...
.

As in the other stages, other reviewers (two PhDs with expertise in systematic reviews and in the review method) were consulted for the disagreements about data treatment and analysis.

Results

In the first phase of this review, 4,909 citations were identified in eight databases, mentioned in the method. Subsequently, after removing the 1,963 duplicate citations, the titles and abstracts of 2,946 articles were assessed to apply the eligibility criteria. Thus, 2,903 studies were included in phase 1. Complementarily, searches were conducted in the gray literature, the reference lists of the articles included were read and the experts were consulted, with addition of another 144 articles to the first phase. Of these, nine were included for the second phase: full-reading.

A total of 52 articles (43 from the databases and 9 found through other methods) were eligible for the second phase. Of these, 41 were excluded after full-reading. An updated search, carried out on 06/09/2021, provided two studies to be screened for full-text reading, but they were excluded after adoption of the eligibility criteria. Therefore, 11 studies were included for the descriptive analysis. Figure 1 presents a detailed flowchart of the process corresponding to the identification, inclusion and exclusion of studies according to the PRISMA guidelines1717. Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021 Mar;372(71):1-9. doi: 10.1136/bmj.n71
https://doi.org/10.1136/bmj.n71...
.

Figure 1
Flowchart of the process corresponding to the identification, inclusion and exclusion of the studies, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Londrina, PR, Brazil, 2021

The main descriptive characteristics of the articles included are presented in Figure 2.

Figure 2
Studies included in the systematic review according to authors, year of publication, method, sample (n), Intervention Group (n), Control Group (n) and main conclusion (n=11). Londrina, PR, Brazil, 2021

The studies included were conducted in five countries: Sweden3535. Arnetz JE, Arnetz BB. Implementation and evaluation of a practical intervention programme for dealing with violence towards health care workers. J Adv Nurs. 2000;31(3):668-80. doi: 10.1046/j.1365-2648.2000.01322.x
https://doi.org/10.1046/j.1365-2648.2000...
, United States of America3636. Gates D, Fitzwater E, Succop, P. Reducing assaults against nursing home caregivers. Nurs Res. 2005 Mar-Apr;54(2):119-27. doi: 10.1097/00006199-200503000-00006
https://doi.org/10.1097/00006199-2005030...

37. Anderson C. Training efforts to reduce reports of workplace violence in a community health care facility. J Prof Nurs. 2006 Sep-Oct;22(5):289-95. doi: 10.1016/j.profnurs.2006.07.007
https://doi.org/10.1016/j.profnurs.2006....
-3838. Casteel C, Peek-Asa C, Nocera M, Smith JB, Blando J, Goldmacher S, et al. Hospital employee assault rates before and after enactment of the California Hospital safety and security act. Ann Epidemiol. 2009 Feb;19(2):125-33. doi: 10.1016/j.annepidem.2008.10.009
https://doi.org/10.1016/j.annepidem.2008...
,4040. Irvine B, Billow MB, Gates DM, Fitzwater EL, Seeley JR, Bourgeois M. An internet training to reduce assaults in long-term care. Geriatr Nurs. 2021 Jan;33(1):28-40. doi: 10.1016/j.gerinurse.2011.10.004
https://doi.org/10.1016/j.gerinurse.2011...

41. 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. J Emerg Nurs. 2014 Mar;40(6):586-91. doi: 10.1016/j.jen.2014.01.003
https://doi.org/10.1016/j.jen.2014.01.00...

42. Glass N, Hanson GC, Anger WK, Laharnar N, Campbell JC, Weinstein M, et al. Computer-based training (CBT) intervention reduces workplace violence and harassment for homecare workers. Am J Ind Med. 2017 July;60(7):635-43. doi: 10.1002/ajim.22728
https://doi.org/10.1002/ajim.22728...
-4343. Arnetz JE, Hamblin L, Russell J, Upfal MJ, Luborsky M, Janisse J, et al. Preventing Patient-to-Worker Violence in Hospitals: Outcome of a Randomized Controlled Intervention. J Occup Environ Med. 2017 Jan;59(1):18-27. doi: 10.1097/JOM.0000000000000909
https://doi.org/10.1097/JOM.000000000000...
, Canada3939. 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. Int J Nurs Stud. 2011 May;48(5):534-9. doi: 10.1016/j.ijnurstu.2010.10.006
https://doi.org/10.1016/j.ijnurstu.2010....
, Iran4444. Sadatmahaleh MM, Khoshknab MF, Rahguy A, Arsalani N, Biglarian A. Effect of Workplace Violence Management Program on the Incidence. Adv Nurs Midwifery [Internet]. 2018 Oct 2 [cited 2021 Nov 3];28(1):27-3. Available from: https://journals.sbmu.ac.ir/en-jnm/article/view/18027
https://journals.sbmu.ac.ir/en-jnm/artic...
and New Zealand4545. Baby M, Gale C, Swain N. Communication skills intervention to minimise patient perpetrated aggression for healthcare support workers in New Zealand: A cluster randomised controlled trial. Health Soc Care Community. 2019 Jan;27(1):170-81. doi: 10.1111/hsc.12636
https://doi.org/10.1111/hsc.12636...
, with most of them (63.7%) from the United States of America. The studies were published between 2000 and 2019.

Regarding the methodology adopted, seven (63.7%) studies3535. Arnetz JE, Arnetz BB. Implementation and evaluation of a practical intervention programme for dealing with violence towards health care workers. J Adv Nurs. 2000;31(3):668-80. doi: 10.1046/j.1365-2648.2000.01322.x
https://doi.org/10.1046/j.1365-2648.2000...

36. Gates D, Fitzwater E, Succop, P. Reducing assaults against nursing home caregivers. Nurs Res. 2005 Mar-Apr;54(2):119-27. doi: 10.1097/00006199-200503000-00006
https://doi.org/10.1097/00006199-2005030...

37. Anderson C. Training efforts to reduce reports of workplace violence in a community health care facility. J Prof Nurs. 2006 Sep-Oct;22(5):289-95. doi: 10.1016/j.profnurs.2006.07.007
https://doi.org/10.1016/j.profnurs.2006....

38. Casteel C, Peek-Asa C, Nocera M, Smith JB, Blando J, Goldmacher S, et al. Hospital employee assault rates before and after enactment of the California Hospital safety and security act. Ann Epidemiol. 2009 Feb;19(2):125-33. doi: 10.1016/j.annepidem.2008.10.009
https://doi.org/10.1016/j.annepidem.2008...
-3939. 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. Int J Nurs Stud. 2011 May;48(5):534-9. doi: 10.1016/j.ijnurstu.2010.10.006
https://doi.org/10.1016/j.ijnurstu.2010....
,4141. 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. J Emerg Nurs. 2014 Mar;40(6):586-91. doi: 10.1016/j.jen.2014.01.003
https://doi.org/10.1016/j.jen.2014.01.00...
,4444. Sadatmahaleh MM, Khoshknab MF, Rahguy A, Arsalani N, Biglarian A. Effect of Workplace Violence Management Program on the Incidence. Adv Nurs Midwifery [Internet]. 2018 Oct 2 [cited 2021 Nov 3];28(1):27-3. Available from: https://journals.sbmu.ac.ir/en-jnm/article/view/18027
https://journals.sbmu.ac.ir/en-jnm/artic...
were classified as quasi-randomized and four (36.3%) studies4040. Irvine B, Billow MB, Gates DM, Fitzwater EL, Seeley JR, Bourgeois M. An internet training to reduce assaults in long-term care. Geriatr Nurs. 2021 Jan;33(1):28-40. doi: 10.1016/j.gerinurse.2011.10.004
https://doi.org/10.1016/j.gerinurse.2011...
,4242. Glass N, Hanson GC, Anger WK, Laharnar N, Campbell JC, Weinstein M, et al. Computer-based training (CBT) intervention reduces workplace violence and harassment for homecare workers. Am J Ind Med. 2017 July;60(7):635-43. doi: 10.1002/ajim.22728
https://doi.org/10.1002/ajim.22728...
-4343. Arnetz JE, Hamblin L, Russell J, Upfal MJ, Luborsky M, Janisse J, et al. Preventing Patient-to-Worker Violence in Hospitals: Outcome of a Randomized Controlled Intervention. J Occup Environ Med. 2017 Jan;59(1):18-27. doi: 10.1097/JOM.0000000000000909
https://doi.org/10.1097/JOM.000000000000...
,4545. Baby M, Gale C, Swain N. Communication skills intervention to minimise patient perpetrated aggression for healthcare support workers in New Zealand: A cluster randomised controlled trial. Health Soc Care Community. 2019 Jan;27(1):170-81. doi: 10.1111/hsc.12636
https://doi.org/10.1111/hsc.12636...
as randomized clinical trials, one of the classic type4242. Glass N, Hanson GC, Anger WK, Laharnar N, Campbell JC, Weinstein M, et al. Computer-based training (CBT) intervention reduces workplace violence and harassment for homecare workers. Am J Ind Med. 2017 July;60(7):635-43. doi: 10.1002/ajim.22728
https://doi.org/10.1002/ajim.22728...
and three of the cluster type4040. Irvine B, Billow MB, Gates DM, Fitzwater EL, Seeley JR, Bourgeois M. An internet training to reduce assaults in long-term care. Geriatr Nurs. 2021 Jan;33(1):28-40. doi: 10.1016/j.gerinurse.2011.10.004
https://doi.org/10.1016/j.gerinurse.2011...
,4343. Arnetz JE, Hamblin L, Russell J, Upfal MJ, Luborsky M, Janisse J, et al. Preventing Patient-to-Worker Violence in Hospitals: Outcome of a Randomized Controlled Intervention. J Occup Environ Med. 2017 Jan;59(1):18-27. doi: 10.1097/JOM.0000000000000909
https://doi.org/10.1097/JOM.000000000000...
,4545. Baby M, Gale C, Swain N. Communication skills intervention to minimise patient perpetrated aggression for healthcare support workers in New Zealand: A cluster randomised controlled trial. Health Soc Care Community. 2019 Jan;27(1):170-81. doi: 10.1111/hsc.12636
https://doi.org/10.1111/hsc.12636...
. Duration of these studies did not present a pattern, but varied between four and 1,440 months, and the intervention took place between one and 360 months after the beginning of the study.

The studies were carried out in different health services, with predominance of hospitals (54.5%)3737. Anderson C. Training efforts to reduce reports of workplace violence in a community health care facility. J Prof Nurs. 2006 Sep-Oct;22(5):289-95. doi: 10.1016/j.profnurs.2006.07.007
https://doi.org/10.1016/j.profnurs.2006....

38. Casteel C, Peek-Asa C, Nocera M, Smith JB, Blando J, Goldmacher S, et al. Hospital employee assault rates before and after enactment of the California Hospital safety and security act. Ann Epidemiol. 2009 Feb;19(2):125-33. doi: 10.1016/j.annepidem.2008.10.009
https://doi.org/10.1016/j.annepidem.2008...
-3939. 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. Int J Nurs Stud. 2011 May;48(5):534-9. doi: 10.1016/j.ijnurstu.2010.10.006
https://doi.org/10.1016/j.ijnurstu.2010....
,4141. 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. J Emerg Nurs. 2014 Mar;40(6):586-91. doi: 10.1016/j.jen.2014.01.003
https://doi.org/10.1016/j.jen.2014.01.00...
,4343. Arnetz JE, Hamblin L, Russell J, Upfal MJ, Luborsky M, Janisse J, et al. Preventing Patient-to-Worker Violence in Hospitals: Outcome of a Randomized Controlled Intervention. J Occup Environ Med. 2017 Jan;59(1):18-27. doi: 10.1097/JOM.0000000000000909
https://doi.org/10.1097/JOM.000000000000...
-4444. Sadatmahaleh MM, Khoshknab MF, Rahguy A, Arsalani N, Biglarian A. Effect of Workplace Violence Management Program on the Incidence. Adv Nurs Midwifery [Internet]. 2018 Oct 2 [cited 2021 Nov 3];28(1):27-3. Available from: https://journals.sbmu.ac.ir/en-jnm/article/view/18027
https://journals.sbmu.ac.ir/en-jnm/artic...
, followed by hospital emergency services3535. Arnetz JE, Arnetz BB. Implementation and evaluation of a practical intervention programme for dealing with violence towards health care workers. J Adv Nurs. 2000;31(3):668-80. doi: 10.1046/j.1365-2648.2000.01322.x
https://doi.org/10.1046/j.1365-2648.2000...
,3838. Casteel C, Peek-Asa C, Nocera M, Smith JB, Blando J, Goldmacher S, et al. Hospital employee assault rates before and after enactment of the California Hospital safety and security act. Ann Epidemiol. 2009 Feb;19(2):125-33. doi: 10.1016/j.annepidem.2008.10.009
https://doi.org/10.1016/j.annepidem.2008...
,4141. 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. J Emerg Nurs. 2014 Mar;40(6):586-91. doi: 10.1016/j.jen.2014.01.003
https://doi.org/10.1016/j.jen.2014.01.00...
,4444. Sadatmahaleh MM, Khoshknab MF, Rahguy A, Arsalani N, Biglarian A. Effect of Workplace Violence Management Program on the Incidence. Adv Nurs Midwifery [Internet]. 2018 Oct 2 [cited 2021 Nov 3];28(1):27-3. Available from: https://journals.sbmu.ac.ir/en-jnm/article/view/18027
https://journals.sbmu.ac.ir/en-jnm/artic...
, psychiatric services3535. Arnetz JE, Arnetz BB. Implementation and evaluation of a practical intervention programme for dealing with violence towards health care workers. J Adv Nurs. 2000;31(3):668-80. doi: 10.1046/j.1365-2648.2000.01322.x
https://doi.org/10.1046/j.1365-2648.2000...
,3838. Casteel C, Peek-Asa C, Nocera M, Smith JB, Blando J, Goldmacher S, et al. Hospital employee assault rates before and after enactment of the California Hospital safety and security act. Ann Epidemiol. 2009 Feb;19(2):125-33. doi: 10.1016/j.annepidem.2008.10.009
https://doi.org/10.1016/j.annepidem.2008...
, home units3535. Arnetz JE, Arnetz BB. Implementation and evaluation of a practical intervention programme for dealing with violence towards health care workers. J Adv Nurs. 2000;31(3):668-80. doi: 10.1046/j.1365-2648.2000.01322.x
https://doi.org/10.1046/j.1365-2648.2000...
,4242. Glass N, Hanson GC, Anger WK, Laharnar N, Campbell JC, Weinstein M, et al. Computer-based training (CBT) intervention reduces workplace violence and harassment for homecare workers. Am J Ind Med. 2017 July;60(7):635-43. doi: 10.1002/ajim.22728
https://doi.org/10.1002/ajim.22728...
, long-term care or geriatric institutions3535. Arnetz JE, Arnetz BB. Implementation and evaluation of a practical intervention programme for dealing with violence towards health care workers. J Adv Nurs. 2000;31(3):668-80. doi: 10.1046/j.1365-2648.2000.01322.x
https://doi.org/10.1046/j.1365-2648.2000...
-3636. Gates D, Fitzwater E, Succop, P. Reducing assaults against nursing home caregivers. Nurs Res. 2005 Mar-Apr;54(2):119-27. doi: 10.1097/00006199-200503000-00006
https://doi.org/10.1097/00006199-2005030...
,4040. Irvine B, Billow MB, Gates DM, Fitzwater EL, Seeley JR, Bourgeois M. An internet training to reduce assaults in long-term care. Geriatr Nurs. 2021 Jan;33(1):28-40. doi: 10.1016/j.gerinurse.2011.10.004
https://doi.org/10.1016/j.gerinurse.2011...
, non-governmental organizations and District Health Councils4545. Baby M, Gale C, Swain N. Communication skills intervention to minimise patient perpetrated aggression for healthcare support workers in New Zealand: A cluster randomised controlled trial. Health Soc Care Community. 2019 Jan;27(1):170-81. doi: 10.1111/hsc.12636
https://doi.org/10.1111/hsc.12636...
.

As for the categories of professionals in the studies included, most of them (n=9; 81.9%) were developed with the Nursing team3535. Arnetz JE, Arnetz BB. Implementation and evaluation of a practical intervention programme for dealing with violence towards health care workers. J Adv Nurs. 2000;31(3):668-80. doi: 10.1046/j.1365-2648.2000.01322.x
https://doi.org/10.1046/j.1365-2648.2000...

36. Gates D, Fitzwater E, Succop, P. Reducing assaults against nursing home caregivers. Nurs Res. 2005 Mar-Apr;54(2):119-27. doi: 10.1097/00006199-200503000-00006
https://doi.org/10.1097/00006199-2005030...
-3737. Anderson C. Training efforts to reduce reports of workplace violence in a community health care facility. J Prof Nurs. 2006 Sep-Oct;22(5):289-95. doi: 10.1016/j.profnurs.2006.07.007
https://doi.org/10.1016/j.profnurs.2006....
,3939. 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. Int J Nurs Stud. 2011 May;48(5):534-9. doi: 10.1016/j.ijnurstu.2010.10.006
https://doi.org/10.1016/j.ijnurstu.2010....

40. Irvine B, Billow MB, Gates DM, Fitzwater EL, Seeley JR, Bourgeois M. An internet training to reduce assaults in long-term care. Geriatr Nurs. 2021 Jan;33(1):28-40. doi: 10.1016/j.gerinurse.2011.10.004
https://doi.org/10.1016/j.gerinurse.2011...

41. 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. J Emerg Nurs. 2014 Mar;40(6):586-91. doi: 10.1016/j.jen.2014.01.003
https://doi.org/10.1016/j.jen.2014.01.00...

42. Glass N, Hanson GC, Anger WK, Laharnar N, Campbell JC, Weinstein M, et al. Computer-based training (CBT) intervention reduces workplace violence and harassment for homecare workers. Am J Ind Med. 2017 July;60(7):635-43. doi: 10.1002/ajim.22728
https://doi.org/10.1002/ajim.22728...

43. Arnetz JE, Hamblin L, Russell J, Upfal MJ, Luborsky M, Janisse J, et al. Preventing Patient-to-Worker Violence in Hospitals: Outcome of a Randomized Controlled Intervention. J Occup Environ Med. 2017 Jan;59(1):18-27. doi: 10.1097/JOM.0000000000000909
https://doi.org/10.1097/JOM.000000000000...
-4444. Sadatmahaleh MM, Khoshknab MF, Rahguy A, Arsalani N, Biglarian A. Effect of Workplace Violence Management Program on the Incidence. Adv Nurs Midwifery [Internet]. 2018 Oct 2 [cited 2021 Nov 3];28(1):27-3. Available from: https://journals.sbmu.ac.ir/en-jnm/article/view/18027
https://journals.sbmu.ac.ir/en-jnm/artic...
, including nurses3535. Arnetz JE, Arnetz BB. Implementation and evaluation of a practical intervention programme for dealing with violence towards health care workers. J Adv Nurs. 2000;31(3):668-80. doi: 10.1046/j.1365-2648.2000.01322.x
https://doi.org/10.1046/j.1365-2648.2000...
,3737. Anderson C. Training efforts to reduce reports of workplace violence in a community health care facility. J Prof Nurs. 2006 Sep-Oct;22(5):289-95. doi: 10.1016/j.profnurs.2006.07.007
https://doi.org/10.1016/j.profnurs.2006....
,4141. 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. J Emerg Nurs. 2014 Mar;40(6):586-91. doi: 10.1016/j.jen.2014.01.003
https://doi.org/10.1016/j.jen.2014.01.00...
,4343. Arnetz JE, Hamblin L, Russell J, Upfal MJ, Luborsky M, Janisse J, et al. Preventing Patient-to-Worker Violence in Hospitals: Outcome of a Randomized Controlled Intervention. J Occup Environ Med. 2017 Jan;59(1):18-27. doi: 10.1097/JOM.0000000000000909
https://doi.org/10.1097/JOM.000000000000...
-4444. Sadatmahaleh MM, Khoshknab MF, Rahguy A, Arsalani N, Biglarian A. Effect of Workplace Violence Management Program on the Incidence. Adv Nurs Midwifery [Internet]. 2018 Oct 2 [cited 2021 Nov 3];28(1):27-3. Available from: https://journals.sbmu.ac.ir/en-jnm/article/view/18027
https://journals.sbmu.ac.ir/en-jnm/artic...
, nursing technicians3535. Arnetz JE, Arnetz BB. Implementation and evaluation of a practical intervention programme for dealing with violence towards health care workers. J Adv Nurs. 2000;31(3):668-80. doi: 10.1046/j.1365-2648.2000.01322.x
https://doi.org/10.1046/j.1365-2648.2000...

36. Gates D, Fitzwater E, Succop, P. Reducing assaults against nursing home caregivers. Nurs Res. 2005 Mar-Apr;54(2):119-27. doi: 10.1097/00006199-200503000-00006
https://doi.org/10.1097/00006199-2005030...
-3737. Anderson C. Training efforts to reduce reports of workplace violence in a community health care facility. J Prof Nurs. 2006 Sep-Oct;22(5):289-95. doi: 10.1016/j.profnurs.2006.07.007
https://doi.org/10.1016/j.profnurs.2006....
,4141. 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. J Emerg Nurs. 2014 Mar;40(6):586-91. doi: 10.1016/j.jen.2014.01.003
https://doi.org/10.1016/j.jen.2014.01.00...
,4343. Arnetz JE, Hamblin L, Russell J, Upfal MJ, Luborsky M, Janisse J, et al. Preventing Patient-to-Worker Violence in Hospitals: Outcome of a Randomized Controlled Intervention. J Occup Environ Med. 2017 Jan;59(1):18-27. doi: 10.1097/JOM.0000000000000909
https://doi.org/10.1097/JOM.000000000000...
, nursing assistants3737. Anderson C. Training efforts to reduce reports of workplace violence in a community health care facility. J Prof Nurs. 2006 Sep-Oct;22(5):289-95. doi: 10.1016/j.profnurs.2006.07.007
https://doi.org/10.1016/j.profnurs.2006....
,4040. Irvine B, Billow MB, Gates DM, Fitzwater EL, Seeley JR, Bourgeois M. An internet training to reduce assaults in long-term care. Geriatr Nurs. 2021 Jan;33(1):28-40. doi: 10.1016/j.gerinurse.2011.10.004
https://doi.org/10.1016/j.gerinurse.2011...
-4141. 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. J Emerg Nurs. 2014 Mar;40(6):586-91. doi: 10.1016/j.jen.2014.01.003
https://doi.org/10.1016/j.jen.2014.01.00...
,4343. Arnetz JE, Hamblin L, Russell J, Upfal MJ, Luborsky M, Janisse J, et al. Preventing Patient-to-Worker Violence in Hospitals: Outcome of a Randomized Controlled Intervention. J Occup Environ Med. 2017 Jan;59(1):18-27. doi: 10.1097/JOM.0000000000000909
https://doi.org/10.1097/JOM.000000000000...
and homecare - nursing assistants4242. Glass N, Hanson GC, Anger WK, Laharnar N, Campbell JC, Weinstein M, et al. Computer-based training (CBT) intervention reduces workplace violence and harassment for homecare workers. Am J Ind Med. 2017 July;60(7):635-43. doi: 10.1002/ajim.22728
https://doi.org/10.1002/ajim.22728...
. The studies were also carried out with physicians4141. 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. J Emerg Nurs. 2014 Mar;40(6):586-91. doi: 10.1016/j.jen.2014.01.003
https://doi.org/10.1016/j.jen.2014.01.00...
, paramedics4141. 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. J Emerg Nurs. 2014 Mar;40(6):586-91. doi: 10.1016/j.jen.2014.01.003
https://doi.org/10.1016/j.jen.2014.01.00...
, health managers4343. Arnetz JE, Hamblin L, Russell J, Upfal MJ, Luborsky M, Janisse J, et al. Preventing Patient-to-Worker Violence in Hospitals: Outcome of a Randomized Controlled Intervention. J Occup Environ Med. 2017 Jan;59(1):18-27. doi: 10.1097/JOM.0000000000000909
https://doi.org/10.1097/JOM.000000000000...
, health support workers - security, secretaries3939. 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. Int J Nurs Stud. 2011 May;48(5):534-9. doi: 10.1016/j.ijnurstu.2010.10.006
https://doi.org/10.1016/j.ijnurstu.2010....
,4343. Arnetz JE, Hamblin L, Russell J, Upfal MJ, Luborsky M, Janisse J, et al. Preventing Patient-to-Worker Violence in Hospitals: Outcome of a Randomized Controlled Intervention. J Occup Environ Med. 2017 Jan;59(1):18-27. doi: 10.1097/JOM.0000000000000909
https://doi.org/10.1097/JOM.000000000000...
,4545. Baby M, Gale C, Swain N. Communication skills intervention to minimise patient perpetrated aggression for healthcare support workers in New Zealand: A cluster randomised controlled trial. Health Soc Care Community. 2019 Jan;27(1):170-81. doi: 10.1111/hsc.12636
https://doi.org/10.1111/hsc.12636...
, rehabilitation/physiotherapy workers, laboratories and radiology3737. Anderson C. Training efforts to reduce reports of workplace violence in a community health care facility. J Prof Nurs. 2006 Sep-Oct;22(5):289-95. doi: 10.1016/j.profnurs.2006.07.007
https://doi.org/10.1016/j.profnurs.2006....
, in addition to health workers that were not specified3838. Casteel C, Peek-Asa C, Nocera M, Smith JB, Blando J, Goldmacher S, et al. Hospital employee assault rates before and after enactment of the California Hospital safety and security act. Ann Epidemiol. 2009 Feb;19(2):125-33. doi: 10.1016/j.annepidem.2008.10.009
https://doi.org/10.1016/j.annepidem.2008...
.

The total number (n) of professionals described above was 4,790. There was predominance of the female gender in eight studies (72.8%), although three (27.2%) surveys3535. Arnetz JE, Arnetz BB. Implementation and evaluation of a practical intervention programme for dealing with violence towards health care workers. J Adv Nurs. 2000;31(3):668-80. doi: 10.1046/j.1365-2648.2000.01322.x
https://doi.org/10.1046/j.1365-2648.2000...
,3838. Casteel C, Peek-Asa C, Nocera M, Smith JB, Blando J, Goldmacher S, et al. Hospital employee assault rates before and after enactment of the California Hospital safety and security act. Ann Epidemiol. 2009 Feb;19(2):125-33. doi: 10.1016/j.annepidem.2008.10.009
https://doi.org/10.1016/j.annepidem.2008...
-3939. 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. Int J Nurs Stud. 2011 May;48(5):534-9. doi: 10.1016/j.ijnurstu.2010.10.006
https://doi.org/10.1016/j.ijnurstu.2010....
did not report the prevailing gender. Some studies reported the total mean age and others did so by group or predominant age interval, thus hindering presentation of these results.

The study sample for composition of the Intervention Group (IG) and Control Group (CG) varied across professionals, departments and patients, with five (45.5%) studies3636. Gates D, Fitzwater E, Succop, P. Reducing assaults against nursing home caregivers. Nurs Res. 2005 Mar-Apr;54(2):119-27. doi: 10.1097/00006199-200503000-00006
https://doi.org/10.1097/00006199-2005030...
-3737. Anderson C. Training efforts to reduce reports of workplace violence in a community health care facility. J Prof Nurs. 2006 Sep-Oct;22(5):289-95. doi: 10.1016/j.profnurs.2006.07.007
https://doi.org/10.1016/j.profnurs.2006....
,4242. Glass N, Hanson GC, Anger WK, Laharnar N, Campbell JC, Weinstein M, et al. Computer-based training (CBT) intervention reduces workplace violence and harassment for homecare workers. Am J Ind Med. 2017 July;60(7):635-43. doi: 10.1002/ajim.22728
https://doi.org/10.1002/ajim.22728...
,4444. Sadatmahaleh MM, Khoshknab MF, Rahguy A, Arsalani N, Biglarian A. Effect of Workplace Violence Management Program on the Incidence. Adv Nurs Midwifery [Internet]. 2018 Oct 2 [cited 2021 Nov 3];28(1):27-3. Available from: https://journals.sbmu.ac.ir/en-jnm/article/view/18027
https://journals.sbmu.ac.ir/en-jnm/artic...
-4545. Baby M, Gale C, Swain N. Communication skills intervention to minimise patient perpetrated aggression for healthcare support workers in New Zealand: A cluster randomised controlled trial. Health Soc Care Community. 2019 Jan;27(1):170-81. doi: 10.1111/hsc.12636
https://doi.org/10.1111/hsc.12636...
having the professionals as sample, another five (45.5%)3535. Arnetz JE, Arnetz BB. Implementation and evaluation of a practical intervention programme for dealing with violence towards health care workers. J Adv Nurs. 2000;31(3):668-80. doi: 10.1046/j.1365-2648.2000.01322.x
https://doi.org/10.1046/j.1365-2648.2000...
,3838. Casteel C, Peek-Asa C, Nocera M, Smith JB, Blando J, Goldmacher S, et al. Hospital employee assault rates before and after enactment of the California Hospital safety and security act. Ann Epidemiol. 2009 Feb;19(2):125-33. doi: 10.1016/j.annepidem.2008.10.009
https://doi.org/10.1016/j.annepidem.2008...
,4040. Irvine B, Billow MB, Gates DM, Fitzwater EL, Seeley JR, Bourgeois M. An internet training to reduce assaults in long-term care. Geriatr Nurs. 2021 Jan;33(1):28-40. doi: 10.1016/j.gerinurse.2011.10.004
https://doi.org/10.1016/j.gerinurse.2011...
-4141. 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. J Emerg Nurs. 2014 Mar;40(6):586-91. doi: 10.1016/j.jen.2014.01.003
https://doi.org/10.1016/j.jen.2014.01.00...
,4343. Arnetz JE, Hamblin L, Russell J, Upfal MJ, Luborsky M, Janisse J, et al. Preventing Patient-to-Worker Violence in Hospitals: Outcome of a Randomized Controlled Intervention. J Occup Environ Med. 2017 Jan;59(1):18-27. doi: 10.1097/JOM.0000000000000909
https://doi.org/10.1097/JOM.000000000000...
, the departments and only one (9%)3939. 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. Int J Nurs Stud. 2011 May;48(5):534-9. doi: 10.1016/j.ijnurstu.2010.10.006
https://doi.org/10.1016/j.ijnurstu.2010....
, the patients.

The IG interventions covered three criteria: individual skills development, multiple approach (organizational, environmental and individual) and governmental actions (law/policy implementation), while the CG covered individual skills, governmental action and no intervention. Both classifications were defined based on the International Labor Organization recommendations77. International Council of Nurses. Public Services International. World Health Organization. International Labor Organization. Framework guidelines for addressing workplace violence in the health sector - the training manual [Internet]. Geneva: International Labor Organization; 2005 [cited 2021 Oct 08]. Available from: https://www.ilo.org/safework/info/instr/WCMS_108542/lang--en/index.htm
https://www.ilo.org/safework/info/instr/...
.

In the IG, six studies (54.5%) implemented interventions for the development of individual skills3535. Arnetz JE, Arnetz BB. Implementation and evaluation of a practical intervention programme for dealing with violence towards health care workers. J Adv Nurs. 2000;31(3):668-80. doi: 10.1046/j.1365-2648.2000.01322.x
https://doi.org/10.1046/j.1365-2648.2000...

36. Gates D, Fitzwater E, Succop, P. Reducing assaults against nursing home caregivers. Nurs Res. 2005 Mar-Apr;54(2):119-27. doi: 10.1097/00006199-200503000-00006
https://doi.org/10.1097/00006199-2005030...
-3737. Anderson C. Training efforts to reduce reports of workplace violence in a community health care facility. J Prof Nurs. 2006 Sep-Oct;22(5):289-95. doi: 10.1016/j.profnurs.2006.07.007
https://doi.org/10.1016/j.profnurs.2006....
,4040. Irvine B, Billow MB, Gates DM, Fitzwater EL, Seeley JR, Bourgeois M. An internet training to reduce assaults in long-term care. Geriatr Nurs. 2021 Jan;33(1):28-40. doi: 10.1016/j.gerinurse.2011.10.004
https://doi.org/10.1016/j.gerinurse.2011...
,4242. Glass N, Hanson GC, Anger WK, Laharnar N, Campbell JC, Weinstein M, et al. Computer-based training (CBT) intervention reduces workplace violence and harassment for homecare workers. Am J Ind Med. 2017 July;60(7):635-43. doi: 10.1002/ajim.22728
https://doi.org/10.1002/ajim.22728...
,4545. Baby M, Gale C, Swain N. Communication skills intervention to minimise patient perpetrated aggression for healthcare support workers in New Zealand: A cluster randomised controlled trial. Health Soc Care Community. 2019 Jan;27(1):170-81. doi: 10.1111/hsc.12636
https://doi.org/10.1111/hsc.12636...
, four (36.4%) resorted to the multiple approach3939. 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. Int J Nurs Stud. 2011 May;48(5):534-9. doi: 10.1016/j.ijnurstu.2010.10.006
https://doi.org/10.1016/j.ijnurstu.2010....
,4141. 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. J Emerg Nurs. 2014 Mar;40(6):586-91. doi: 10.1016/j.jen.2014.01.003
https://doi.org/10.1016/j.jen.2014.01.00...
,4343. Arnetz JE, Hamblin L, Russell J, Upfal MJ, Luborsky M, Janisse J, et al. Preventing Patient-to-Worker Violence in Hospitals: Outcome of a Randomized Controlled Intervention. J Occup Environ Med. 2017 Jan;59(1):18-27. doi: 10.1097/JOM.0000000000000909
https://doi.org/10.1097/JOM.000000000000...
-4444. Sadatmahaleh MM, Khoshknab MF, Rahguy A, Arsalani N, Biglarian A. Effect of Workplace Violence Management Program on the Incidence. Adv Nurs Midwifery [Internet]. 2018 Oct 2 [cited 2021 Nov 3];28(1):27-3. Available from: https://journals.sbmu.ac.ir/en-jnm/article/view/18027
https://journals.sbmu.ac.ir/en-jnm/artic...
and only one (9.1%) to governmental actions (state law)3838. Casteel C, Peek-Asa C, Nocera M, Smith JB, Blando J, Goldmacher S, et al. Hospital employee assault rates before and after enactment of the California Hospital safety and security act. Ann Epidemiol. 2009 Feb;19(2):125-33. doi: 10.1016/j.annepidem.2008.10.009
https://doi.org/10.1016/j.annepidem.2008...
.

For the CG, the majority, seven studies (63.6%), did not implement any intervention3535. Arnetz JE, Arnetz BB. Implementation and evaluation of a practical intervention programme for dealing with violence towards health care workers. J Adv Nurs. 2000;31(3):668-80. doi: 10.1046/j.1365-2648.2000.01322.x
https://doi.org/10.1046/j.1365-2648.2000...

36. Gates D, Fitzwater E, Succop, P. Reducing assaults against nursing home caregivers. Nurs Res. 2005 Mar-Apr;54(2):119-27. doi: 10.1097/00006199-200503000-00006
https://doi.org/10.1097/00006199-2005030...
-3737. Anderson C. Training efforts to reduce reports of workplace violence in a community health care facility. J Prof Nurs. 2006 Sep-Oct;22(5):289-95. doi: 10.1016/j.profnurs.2006.07.007
https://doi.org/10.1016/j.profnurs.2006....
,3939. 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. Int J Nurs Stud. 2011 May;48(5):534-9. doi: 10.1016/j.ijnurstu.2010.10.006
https://doi.org/10.1016/j.ijnurstu.2010....
,4141. 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. J Emerg Nurs. 2014 Mar;40(6):586-91. doi: 10.1016/j.jen.2014.01.003
https://doi.org/10.1016/j.jen.2014.01.00...
,4343. Arnetz JE, Hamblin L, Russell J, Upfal MJ, Luborsky M, Janisse J, et al. Preventing Patient-to-Worker Violence in Hospitals: Outcome of a Randomized Controlled Intervention. J Occup Environ Med. 2017 Jan;59(1):18-27. doi: 10.1097/JOM.0000000000000909
https://doi.org/10.1097/JOM.000000000000...
-4444. Sadatmahaleh MM, Khoshknab MF, Rahguy A, Arsalani N, Biglarian A. Effect of Workplace Violence Management Program on the Incidence. Adv Nurs Midwifery [Internet]. 2018 Oct 2 [cited 2021 Nov 3];28(1):27-3. Available from: https://journals.sbmu.ac.ir/en-jnm/article/view/18027
https://journals.sbmu.ac.ir/en-jnm/artic...
, three (27.3%) developed individual skills as a control4040. Irvine B, Billow MB, Gates DM, Fitzwater EL, Seeley JR, Bourgeois M. An internet training to reduce assaults in long-term care. Geriatr Nurs. 2021 Jan;33(1):28-40. doi: 10.1016/j.gerinurse.2011.10.004
https://doi.org/10.1016/j.gerinurse.2011...
,4242. Glass N, Hanson GC, Anger WK, Laharnar N, Campbell JC, Weinstein M, et al. Computer-based training (CBT) intervention reduces workplace violence and harassment for homecare workers. Am J Ind Med. 2017 July;60(7):635-43. doi: 10.1002/ajim.22728
https://doi.org/10.1002/ajim.22728...
,4545. Baby M, Gale C, Swain N. Communication skills intervention to minimise patient perpetrated aggression for healthcare support workers in New Zealand: A cluster randomised controlled trial. Health Soc Care Community. 2019 Jan;27(1):170-81. doi: 10.1111/hsc.12636
https://doi.org/10.1111/hsc.12636...
and only one (9.1%) implemented governmental intervention (federal policy/guideline)3838. Casteel C, Peek-Asa C, Nocera M, Smith JB, Blando J, Goldmacher S, et al. Hospital employee assault rates before and after enactment of the California Hospital safety and security act. Ann Epidemiol. 2009 Feb;19(2):125-33. doi: 10.1016/j.annepidem.2008.10.009
https://doi.org/10.1016/j.annepidem.2008...
. Of them, four (36.4%) exerted a positive and significant effect on reducing violence3737. Anderson C. Training efforts to reduce reports of workplace violence in a community health care facility. J Prof Nurs. 2006 Sep-Oct;22(5):289-95. doi: 10.1016/j.profnurs.2006.07.007
https://doi.org/10.1016/j.profnurs.2006....
-3838. Casteel C, Peek-Asa C, Nocera M, Smith JB, Blando J, Goldmacher S, et al. Hospital employee assault rates before and after enactment of the California Hospital safety and security act. Ann Epidemiol. 2009 Feb;19(2):125-33. doi: 10.1016/j.annepidem.2008.10.009
https://doi.org/10.1016/j.annepidem.2008...
,4040. Irvine B, Billow MB, Gates DM, Fitzwater EL, Seeley JR, Bourgeois M. An internet training to reduce assaults in long-term care. Geriatr Nurs. 2021 Jan;33(1):28-40. doi: 10.1016/j.gerinurse.2011.10.004
https://doi.org/10.1016/j.gerinurse.2011...
,4343. Arnetz JE, Hamblin L, Russell J, Upfal MJ, Luborsky M, Janisse J, et al. Preventing Patient-to-Worker Violence in Hospitals: Outcome of a Randomized Controlled Intervention. J Occup Environ Med. 2017 Jan;59(1):18-27. doi: 10.1097/JOM.0000000000000909
https://doi.org/10.1097/JOM.000000000000...
.

Figure 3 presents the result of the risk of bias assessment corresponding to the randomized clinical trials through the RoB 2 and RoB 2 CRT tools2727. Eldridge S, Campbell MK, Campbell MJ, Drahota AK, Giraudeau B, Reeves BC, et al. Revised Cochrane risk of bias tool for randomized trials (RoB 2). Additional considerations for cluster-randomized trials (RoB 2 CRT) [Internet]. 2021 Mar 18 [cited 2021 July 0]. Available from: https://sites.google.com/site/riskofbiastool/welcome/rob-2-0-tool/rob-2-for-cluster-randomized-trials
https://sites.google.com/site/riskofbias...
-2828. Higgins JPT, Savovic J, Page MJ, Sterne JAC, RoB2 Development Group. Revised Cochrane risk-of-bias tool for randomized trials (RoB 2). 2019 Aug 22 [cited 2021 July 04]. Available from: https://sites.google.com/site/riskofbiastool/welcome/rob-2-0-tool/current-version-of-rob-2
https://sites.google.com/site/riskofbias...
.

Figure 3
Risk of bias assessment corresponding to the randomized clinical trials in each domain of the Revised Cochrane Risk-of-Bias Tool for Randomized Trials and for Cluster - Randomized Trials tools Londrina, PR, Brazil,2021

In relation to the randomized clinical trials, of the four studies included, three (75%) were classified as (un)certain risk4040. Irvine B, Billow MB, Gates DM, Fitzwater EL, Seeley JR, Bourgeois M. An internet training to reduce assaults in long-term care. Geriatr Nurs. 2021 Jan;33(1):28-40. doi: 10.1016/j.gerinurse.2011.10.004
https://doi.org/10.1016/j.gerinurse.2011...
,4242. Glass N, Hanson GC, Anger WK, Laharnar N, Campbell JC, Weinstein M, et al. Computer-based training (CBT) intervention reduces workplace violence and harassment for homecare workers. Am J Ind Med. 2017 July;60(7):635-43. doi: 10.1002/ajim.22728
https://doi.org/10.1002/ajim.22728...
-4343. Arnetz JE, Hamblin L, Russell J, Upfal MJ, Luborsky M, Janisse J, et al. Preventing Patient-to-Worker Violence in Hospitals: Outcome of a Randomized Controlled Intervention. J Occup Environ Med. 2017 Jan;59(1):18-27. doi: 10.1097/JOM.0000000000000909
https://doi.org/10.1097/JOM.000000000000...
, while one (25%) was categorized as high risk4545. Baby M, Gale C, Swain N. Communication skills intervention to minimise patient perpetrated aggression for healthcare support workers in New Zealand: A cluster randomised controlled trial. Health Soc Care Community. 2019 Jan;27(1):170-81. doi: 10.1111/hsc.12636
https://doi.org/10.1111/hsc.12636...
due to concerns about deviations from the intended intervention (domain 2), missing data (domain 3) and measurement of outcomes (domain 4).

Regarding the seven quasi-randomized studies analyzed by means of ROBINS-I2929. Sterne JAC, Higgins JPT, Elbers RG, Reeves BC. Risk Of Bias In Non-randomized Studies of Interventions (ROBINS-I): detailed guidance [Internet]. 2016 Oct 20 [cited 2021 July 4]. Available from: https://sites.google.com/site/riskofbiastool/welcome/home/current-version-of-robins-i/robins-i-detailed-guidance-2016
https://sites.google.com/site/riskofbias...
-3030. Sterne JAC, Savovic J, Page MJ, Elbers RG, Blencowe NS, Boutron I, et al. RoB 2: a revised tool for assessing risk of bias in randomised trials. BMJ. 2019 Aug;366:l4898. doi: 10.1136/bmj.l4898
https://doi.org/10.1136/bmj.l4898...
, five (71.4%) were classified as serious risk3434. Grade Working Group. GRADEPro [Software]. Hamilton: McMaster University/Evidence Prime Inc.; 2021 [cited 2021 July 6]. Available from: https://gradepro.org/
https://gradepro.org...
,3737. Anderson C. Training efforts to reduce reports of workplace violence in a community health care facility. J Prof Nurs. 2006 Sep-Oct;22(5):289-95. doi: 10.1016/j.profnurs.2006.07.007
https://doi.org/10.1016/j.profnurs.2006....
,3939. 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. Int J Nurs Stud. 2011 May;48(5):534-9. doi: 10.1016/j.ijnurstu.2010.10.006
https://doi.org/10.1016/j.ijnurstu.2010....
,4141. 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. J Emerg Nurs. 2014 Mar;40(6):586-91. doi: 10.1016/j.jen.2014.01.003
https://doi.org/10.1016/j.jen.2014.01.00...
,4444. Sadatmahaleh MM, Khoshknab MF, Rahguy A, Arsalani N, Biglarian A. Effect of Workplace Violence Management Program on the Incidence. Adv Nurs Midwifery [Internet]. 2018 Oct 2 [cited 2021 Nov 3];28(1):27-3. Available from: https://journals.sbmu.ac.ir/en-jnm/article/view/18027
https://journals.sbmu.ac.ir/en-jnm/artic...
, one (14.3%) as moderate risk3838. Casteel C, Peek-Asa C, Nocera M, Smith JB, Blando J, Goldmacher S, et al. Hospital employee assault rates before and after enactment of the California Hospital safety and security act. Ann Epidemiol. 2009 Feb;19(2):125-33. doi: 10.1016/j.annepidem.2008.10.009
https://doi.org/10.1016/j.annepidem.2008...
and another one (14.3%) as uncertain risk3636. Gates D, Fitzwater E, Succop, P. Reducing assaults against nursing home caregivers. Nurs Res. 2005 Mar-Apr;54(2):119-27. doi: 10.1097/00006199-200503000-00006
https://doi.org/10.1097/00006199-2005030...
. These studies presented significant biases in domain 1 (confounding factors), domain 3 (classification of the intervention) and domain 6 (measurement of the outcomes).

In order to assess the possibility of meta-analysis, the first step was to group the studies according to the PICOS acronym. Thus, the (methodologically and clinically) homogeneous studies were combined, resulting in the meta-analysis of two studies4040. Irvine B, Billow MB, Gates DM, Fitzwater EL, Seeley JR, Bourgeois M. An internet training to reduce assaults in long-term care. Geriatr Nurs. 2021 Jan;33(1):28-40. doi: 10.1016/j.gerinurse.2011.10.004
https://doi.org/10.1016/j.gerinurse.2011...
,4242. Glass N, Hanson GC, Anger WK, Laharnar N, Campbell JC, Weinstein M, et al. Computer-based training (CBT) intervention reduces workplace violence and harassment for homecare workers. Am J Ind Med. 2017 July;60(7):635-43. doi: 10.1002/ajim.22728
https://doi.org/10.1002/ajim.22728...
. Heterogeneity was considered important (I2=88%). The estimate corresponding to the mean of the random effect of the studies was -0.08 and the meta-analysis diamond 95% CI varied from -0.41 to 0.25, with p=0.64.

Therefore, no scientific evidence was found for the mean difference of the effect of the IG when compared to the GC (individual skills versus individual skills), according to the forest plot shown in Figure 4.

Figure 4
Forest plot corresponding to the meta-analysis of the individual skills (intervention) versus the individual skills (comparator) in the prevention and reduction of workplace violence. Londrina, PR, Brazil, 2021

In Figure 5, certainty of the evidence of the results evaluated by means of the GRADE system was classified as very low for the outcome analyzed (violence prevention/reduction).

Figure 5
Synthesis of the assessment corresponding to certainty of the evidence, according to Grading of Recommendations Assessment, Development and Evaluation. Londrina, PR, Brazil, 2021

Source: Chart elaborated in and extracted from the GRADEpro® software3434. Grade Working Group. GRADEPro [Software]. Hamilton: McMaster University/Evidence Prime Inc.; 2021 [cited 2021 July 6]. Available from: https://gradepro.org/
https://gradepro.org...
. *Two levels decreased due to uncertain risk of bias in both studies, in the “intervention deviation” and “general” domains; Two levels decreased, as I2=88%; One level decreased due to the difference in the direction of the effect of the confidence intervals of both studies; §CI = Confidence Interval; ||MD = Mean Differences

Discussion

The studies found in this review reveal that most of them (63.7%) were carried out in the United States of America, which may show that there is greater effort to implement guidelines and strategies to combat violence at work in this country. This can be due to the efforts by the Occupational Safety and Health Administration (OSHA) of the United States of America, which was created in 1970 and had its first bulletin published in 2002 warning about zero-tolerance policies for workplace violence, including programs to prevent it. The documents were gradually updated and the last one was published in 201688. U.S. Department of Labor, Occupational Safety and Health Administration. Guidelines for Preventing Workplace Violence for Healthcare and Social Service Workers [Internet]. Washington, D.C.:U.S. Department of Labor; 2016 [cited 2021 Sept 08]. Available from: https://www.osha.gov/sites/default/files/publications/osha3148.pdf
https://www.osha.gov/sites/default/files...
.

The data of this study, with most of the surveys being carried out in hospital units (54.5%), followed by hospital emergency units (36.4%), specifically with the Nursing team (81.9%), and a majority of females (72.8%), are similar to the existing guidelines and studies, as they assert that workplace violence has predominantly affected the female Nursing team members working in hospitals88. U.S. Department of Labor, Occupational Safety and Health Administration. Guidelines for Preventing Workplace Violence for Healthcare and Social Service Workers [Internet]. Washington, D.C.:U.S. Department of Labor; 2016 [cited 2021 Sept 08]. Available from: https://www.osha.gov/sites/default/files/publications/osha3148.pdf
https://www.osha.gov/sites/default/files...
-99. Alsaleem AS, Alsabaani A, Alamri RS, Hadi RA, Alkhayri MH, Badawi KK, et al. Violence towards healthcare workers: A study conducted in Abha City, Saudi Arabia. J Family Community Med. 2018;25(3):188-93. doi: 10.4103/jfcm.JFCM_170_17
https://doi.org/10.4103/jfcm.JFCM_170_17...
,4747. Mishra S, Chopra D, Jauhari N, Ahmad A, Kidwai NA. Violence against health care workers: a provider's (staff nurse) perspective. Int J Community Med Public Health. 2018 Ago;5(9):4140-8. doi: 10.18203/2394-6040.ijcmph20183609
https://doi.org/10.18203/2394-6040.ijcmp...
-4848. Aljohani B, Burkholder J, Tran QK, Chen C, Beisenova K, Pourmand A. Workplace violence in the emergency department: a systematic review and meta-analysis. Public Health. 2021 July;196:186-97. doi: 10.1016/j.puhe.2021.02.009
https://doi.org/10.1016/j.puhe.2021.02.0...
.

A Brazilian survey carried out in 2017 with municipal professionals confirms that violence predominantly affects women (47.9%) in relation to men (22.0%), including community agents and nurses, among others1010. Simões MRL, Barroso HH, de-Azevedo DSS, Duarte ACM, Barbosa REC, Fonseca GC, et al. Workplace violence among municipal health care workers in Diamantina, Minas Gerais, Brazil, 2017. Rev Bras Med Trab. 2020;18(1):82-90. doi: 10.5327/Z1679443520200425
https://doi.org/10.5327/Z167944352020042...
.

A systematic review with meta-analysis revealed that female nurses are more likely (21%) to being victims of verbal harassment than their male counterparts4949. Edward KL, Stephenson J, Ousey K, Lui S, Warelow P, Giandinoto JA. A systematic review and meta-analysis of factors that relate to aggression perpetrated against nurses by patients/relatives or staff. J Clin Nurs. 2016 Feb;25(3-4):289-99. doi: 10.1111/jocn.13019
https://doi.org/10.1111/jocn.13019...
. In relation to another review, it was verified that there are more chances for women being victims of sexual harassment when compared to men5050. Liu J, Gan Y, Jiang H, Li L, Dwyer R, Lu K, et al. Prevalence of workplace violence against healthcare workers: a systematic review and meta-analysis. Occup Environ Med. 2019 Dec;76(12):927-37. doi: 10.1136/oemed-2019-105849
https://doi.org/10.1136/oemed-2019-10584...
.

Therefore, there is consensus in the studies found on workplace violence in the health sector, which infer that this type of violence, especially cases of verbal and sexual harassment, predominantly affect women and female nurses.

The high prevalence of workplace violence among female health service professionals, as in this systematic review, can be explained by the lack of knowledge about the different forms of this type of violence and to the naturalization of this violence and of the sexist culture, in addition to the preponderance of female professionals in health services.

In this context, measures to combat the prevalence of workplace violence among women are essential, such as awareness campaigns, training sessions, work groups, referral based on established flows in cases of violence, mandatory records of violence, action plans, and implementation of these actions and local and national laws.

Among the existing theories that seek to explain the phenomenon of workplace violence, an interactive and theoretical model shows that it has a multifaceted nature and that it can be understood through the interaction of several interrelated factors such as individual, social, environmental and occupational ones5151. Chappell D, Di Martino V. Violence at work [Internet].3rd ed. Geneva: International Labour Office; 2006 [cited 2021 July 12]. Available from: https://www.ilo.org/wcmsp5/groups/public/%40dgreports/%40dcomm/%40publ/documents/publication/wcms_publ_9221108406_en.pdf
https://www.ilo.org/wcmsp5/groups/public...
. This theory reveals that the victim’s gender, age, task situation and working without any other colleague (from home) can exert an influence on the occurrence of violence.

Together, other risk factors such as individual issues inherent to the aggressor (e.g., use of illegal substances) and social and contextual factors (e.g., violence in society, negative culture of violence and insecurity at work) can influence the outcome of violence (physical and/or psychological) both for the workers, including stress, diseases and health problems, high costs and suicide, and for the employing institution, including absenteeism and the quality of the care provided to the patients5151. Chappell D, Di Martino V. Violence at work [Internet].3rd ed. Geneva: International Labour Office; 2006 [cited 2021 July 12]. Available from: https://www.ilo.org/wcmsp5/groups/public/%40dgreports/%40dcomm/%40publ/documents/publication/wcms_publ_9221108406_en.pdf
https://www.ilo.org/wcmsp5/groups/public...
-5252. Barrios-Casas S, Paravic-Klijn T. Aplicación del modelo de violencia laboral de Chappell y Di Martino adaptado al usuario hospitalizado. Aquichan [Internet]. 2011 Apr [cited 2021 July 28];11(1):77-93. Available from: http://www.scielo.org.co/scielo.php?script=sci_arttext&pid=S1657-59972011000100007&lng=en&nrm=iso
http://www.scielo.org.co/scielo.php?scri...
.

A fact that furthers aggravates the magnitude of the problem of the aforementioned type of violence is its under-reporting22. The Joint Commission. Workplace Violence Prevention Standards [Internet]. Oakbrook Terrace, IL: The Joint Commission; 2021 [cited 2021 Oct. 08]. Available from: https://www.jointcommission.org/standards/r3-report/r3-report-issue-30-workplace-violence-prevention-standards/
https://www.jointcommission.org/standard...
,5353. Arnetz JE, Hamblin L, Ager J, Luborsky M, Upfal MJ, Russell J, et al. Underreporting of Workplace Violence: Comparison of Self-Report and Actual Documentation of Hospital Incidents. Workplace Health Saf. 2015 May;63(5):200-10. doi: 10.1177/2165079915574684
https://doi.org/10.1177/2165079915574684...
. A study carried out in a North American hospital system with approximately 15,000 employees concluded that 88% of the professionals had not recorded any incidents in the electronic system that is used in the United States of America for notification, where incidents that caused injuries were mainly reported5353. Arnetz JE, Hamblin L, Ager J, Luborsky M, Upfal MJ, Russell J, et al. Underreporting of Workplace Violence: Comparison of Self-Report and Actual Documentation of Hospital Incidents. Workplace Health Saf. 2015 May;63(5):200-10. doi: 10.1177/2165079915574684
https://doi.org/10.1177/2165079915574684...
. Thus, under-reporting is even more alarming in cases of harassment and abuse, possibly due to the culture of trivializing violence in the workplace, considered by many to be common in the health sector5151. Chappell D, Di Martino V. Violence at work [Internet].3rd ed. Geneva: International Labour Office; 2006 [cited 2021 July 12]. Available from: https://www.ilo.org/wcmsp5/groups/public/%40dgreports/%40dcomm/%40publ/documents/publication/wcms_publ_9221108406_en.pdf
https://www.ilo.org/wcmsp5/groups/public...
.

Notification of violence still needs to advance to determine the extent and depth of this problem, including preventive measures and interventions that can support health professionals so that they report violence and are protected against reprisals, both at work and from the aggressor5454. García-Pérez MD, Rivera-Sequeiros A, Sánchez-Elías TM, Lima-Serrano M. Workplace violence on healthcare professionals and underreporting: Characterization and knowledge gaps for prevention. Enferm Clin. 2021 Nov-Dec;31(6):390-5. doi: 10.1016/j.enfcle.2021.05.001
https://doi.org/10.1016/j.enfcle.2021.05...
.

The quasi-randomized methodology, that is, studies with two pre- and post- non-equivalent groups (IG and CG), found in most of the studies (63.7%), even without randomization, can answer questions and estimate the success of a health intervention implemented rather than estimating the health effects of this intervention, as in randomized clinical trials2222. Miller CJ, Smith SN, Pugatch M. Experimental and quasi-experimental designs in implementation research. Psychiatry R. 2020 June;283(112452). doi: 10.1016/j.psychres.2019.06.027
https://doi.org/10.1016/j.psychres.2019....
. Thus, the low percentage of randomized studies (36.3%) exerted an influence on the estimation of the global effect of the studies presented, which may be improved with a greater number of this methodology.

A research study verified that the clinical outcomes can improve, especially after 12 months of study2222. Miller CJ, Smith SN, Pugatch M. Experimental and quasi-experimental designs in implementation research. Psychiatry R. 2020 June;283(112452). doi: 10.1016/j.psychres.2019.06.027
https://doi.org/10.1016/j.psychres.2019....
. Thus, a study3737. Anderson C. Training efforts to reduce reports of workplace violence in a community health care facility. J Prof Nurs. 2006 Sep-Oct;22(5):289-95. doi: 10.1016/j.profnurs.2006.07.007
https://doi.org/10.1016/j.profnurs.2006....
published in 2006 was significant, although only for data on verbal abuse, with a study period of 12 months, 6 months post-intervention (online training). In another study3838. Casteel C, Peek-Asa C, Nocera M, Smith JB, Blando J, Goldmacher S, et al. Hospital employee assault rates before and after enactment of the California Hospital safety and security act. Ann Epidemiol. 2009 Feb;19(2):125-33. doi: 10.1016/j.annepidem.2008.10.009
https://doi.org/10.1016/j.annepidem.2008...
published in 2009, with 108 months of study, implementation of the policy was able to significantly increase the health professionals’ safety 72 months after the intervention.

For the randomized clinical trials, a study4343. Arnetz JE, Hamblin L, Russell J, Upfal MJ, Luborsky M, Janisse J, et al. Preventing Patient-to-Worker Violence in Hospitals: Outcome of a Randomized Controlled Intervention. J Occup Environ Med. 2017 Jan;59(1):18-27. doi: 10.1097/JOM.0000000000000909
https://doi.org/10.1097/JOM.000000000000...
published in 2017 was also effective and significant in reducing the risks of patient-worker violence and related injuries after the 24-month period since implementation of the intervention, with a 60-month study period. In another randomized clinical trial4242. Glass N, Hanson GC, Anger WK, Laharnar N, Campbell JC, Weinstein M, et al. Computer-based training (CBT) intervention reduces workplace violence and harassment for homecare workers. Am J Ind Med. 2017 July;60(7):635-43. doi: 10.1002/ajim.22728
https://doi.org/10.1002/ajim.22728...
, computer-based training also reduced incidents of violence and harassment in the workplace, although with no significant difference between the groups. In this study4242. Glass N, Hanson GC, Anger WK, Laharnar N, Campbell JC, Weinstein M, et al. Computer-based training (CBT) intervention reduces workplace violence and harassment for homecare workers. Am J Ind Med. 2017 July;60(7):635-43. doi: 10.1002/ajim.22728
https://doi.org/10.1002/ajim.22728...
, time corresponded to 6 months, and the intervention took place 2 months after initiating the study. Thus, it is inferred that monitoring time can be related to the significance of the effect of the intervention.

A systematic review conducted with nine randomized and quasi-randomized studies concluded that the diverse scientific evidence is extremely uncertain about the effects of education and training on aggression in the short-term follow-up when compared to no intervention. In the long-term, education was not able to reduce the violence rates in relation to no intervention (low certainty of the evidence)1313. Geoffrion S, Hills DJ, Ross HM, Pich J, Hill AT, Dalsbø TK, et al. Education and training for preventing and minimizing workplace aggression directed toward healthcare workers. Cochrane Database Syst Rev. 2020;9(9):CD011860. doi: 10.1002/14651858.CD011860.pub2
https://doi.org/10.1002/14651858.CD01186...
.

The interventions classified in this study were defined according to the International Labor Organization77. International Council of Nurses. Public Services International. World Health Organization. International Labor Organization. Framework guidelines for addressing workplace violence in the health sector - the training manual [Internet]. Geneva: International Labor Organization; 2005 [cited 2021 Oct 08]. Available from: https://www.ilo.org/safework/info/instr/WCMS_108542/lang--en/index.htm
https://www.ilo.org/safework/info/instr/...
, namely: development of individual skills, environmental and organizational approach, multiple approach (individual, environmental and organizational skills) and governmental actions (implementation of laws/policies/guidelines) at the prevention level and. in this systematic review, the majority (54.5%) corresponded to individual skills, followed by the multiple approach (36.4%).

These data allow inferring that governmental interventions are still incipient and scarce, revealing a weakness in the development of public policies and regulations that prevent workplace violence and, in turn, reduce it worldwide.

Among the randomized clinical trials, two studies4040. Irvine B, Billow MB, Gates DM, Fitzwater EL, Seeley JR, Bourgeois M. An internet training to reduce assaults in long-term care. Geriatr Nurs. 2021 Jan;33(1):28-40. doi: 10.1016/j.gerinurse.2011.10.004
https://doi.org/10.1016/j.gerinurse.2011...
,4343. Arnetz JE, Hamblin L, Russell J, Upfal MJ, Luborsky M, Janisse J, et al. Preventing Patient-to-Worker Violence in Hospitals: Outcome of a Randomized Controlled Intervention. J Occup Environ Med. 2017 Jan;59(1):18-27. doi: 10.1097/JOM.0000000000000909
https://doi.org/10.1097/JOM.000000000000...
exerted significant effects on the violence rates. A study4040. Irvine B, Billow MB, Gates DM, Fitzwater EL, Seeley JR, Bourgeois M. An internet training to reduce assaults in long-term care. Geriatr Nurs. 2021 Jan;33(1):28-40. doi: 10.1016/j.gerinurse.2011.10.004
https://doi.org/10.1016/j.gerinurse.2011...
published in 2012 implemented an individual skill approach, including an Internet training session designed to teach strategies through courses with videos demonstrating behaviors, in a one-week period, to nursing assistants, in both groups, IG and CG, but with different intervention times, in order to deal with, prevent or reduce aggressive behaviors by institutionalized aged individuals. In the IG, training was performed immediately after the beginning of the study, while in the CG, it was conducted after 8 weeks, with the study lasting 6 months.

Another research study4343. Arnetz JE, Hamblin L, Russell J, Upfal MJ, Luborsky M, Janisse J, et al. Preventing Patient-to-Worker Violence in Hospitals: Outcome of a Randomized Controlled Intervention. J Occup Environ Med. 2017 Jan;59(1):18-27. doi: 10.1097/JOM.0000000000000909
https://doi.org/10.1097/JOM.000000000000...
conducted during 60 months implemented an action-research (Plan-Do-Study-Act). No intervention was implemented in the CG, whereas the IG did undergo interventions. The unit supervisors were instructed to record all the violent events reported in the electronic system up to 24 hours after receiving the notification. Thus, by means of focus groups, the units were presented their violence rates as related to the hospital system of the United States West region. Secondly, an action plan was developed among the professionals, researchers and supervisors, including the implementation and change of this action plan, not only in terms of individual or behavioral factors (focus groups, training sessions), but also of an environmental and organizational nature (records of the workplace violence data, feedback of these data to the units). In the third place, the IG and CG units were monitored 36 months after applying the interventions in order to determine whether measures and improvements were implemented in the units.

This participant research method is widely accepted in health care and consists of a scientific method to test changes in complex environments5555. Taylor MJ, McNicholas C, Nicolay C, Darzi A, Bell D, Reed JE. Systematic review of the application of the plan-do-study-act method to improve quality in healthcare. BMJ Qual Saf. 2014 Apr;23(4):290-8. doi: 10.1136/bmjqs-2013-001862
https://doi.org/10.1136/bmjqs-2013-00186...
. A systematic review found that this methodology can be effective, as shown by a study4343. Arnetz JE, Hamblin L, Russell J, Upfal MJ, Luborsky M, Janisse J, et al. Preventing Patient-to-Worker Violence in Hospitals: Outcome of a Randomized Controlled Intervention. J Occup Environ Med. 2017 Jan;59(1):18-27. doi: 10.1097/JOM.0000000000000909
https://doi.org/10.1097/JOM.000000000000...
included in this review, although it needs to be implemented rigorously5555. Taylor MJ, McNicholas C, Nicolay C, Darzi A, Bell D, Reed JE. Systematic review of the application of the plan-do-study-act method to improve quality in healthcare. BMJ Qual Saf. 2014 Apr;23(4):290-8. doi: 10.1136/bmjqs-2013-001862
https://doi.org/10.1136/bmjqs-2013-00186...
.

Similarly, two quasi-randomized studies included in this review proved to be effective and significant. A study3737. Anderson C. Training efforts to reduce reports of workplace violence in a community health care facility. J Prof Nurs. 2006 Sep-Oct;22(5):289-95. doi: 10.1016/j.profnurs.2006.07.007
https://doi.org/10.1016/j.profnurs.2006....
found that a three-hour online training session (individual skills development), focusing on violence risk assessment, assertiveness techniques, legal issues and monitoring after an incident, was significant, although only for verbal abuse rates; whereas another study3838. Casteel C, Peek-Asa C, Nocera M, Smith JB, Blando J, Goldmacher S, et al. Hospital employee assault rates before and after enactment of the California Hospital safety and security act. Ann Epidemiol. 2009 Feb;19(2):125-33. doi: 10.1016/j.annepidem.2008.10.009
https://doi.org/10.1016/j.annepidem.2008...
, published in 2009, which implemented governmental intervention (California state law rules), with a period of three years prior to the violence prevention policy and six years of follow-up, inferred that the state law/policy can be an effective method to increase health care workers’ safety. The assault rates among emergency department workers was reduced by 48% in California after enactment of the State Law, when compared to the rates for the New Jersey emergency department, which had only federal guidelines, in this case, from OSHA.

It is therefore understood that the guidelines are essential, but a regulatory norm, with a mandatory character, has greater coercive conditions for the implementation of preventive measures against workplace violence.

The implementation of governmental interventions, including legal aspects or public policies, at the local, municipal, regional, state or national level is an effective strategy with high potential to address workplace violence in the health services in a collective and sustainable way5656. Bordignon M, Trindade LL, Cezar-Vaz MR, Monteiro MI. Violência no trabalho: legislação, políticas públicas e possibilidade de avanços para trabalhadores da saúde. Rev Bras Enferm. 2021;74(1). doi: 10.1590/0034-7167-2020-0335
https://doi.org/10.1590/0034-7167-2020-0...
. Such being the case, governmental interventions and efforts must be implemented so that a safe and decent work environment is promoted.

Despite the efforts in different countries or locations, many places do not yet have legislation or public policies that ensure specific strategies to prevent workplace violence against health professionals5656. Bordignon M, Trindade LL, Cezar-Vaz MR, Monteiro MI. Violência no trabalho: legislação, políticas públicas e possibilidade de avanços para trabalhadores da saúde. Rev Bras Enferm. 2021;74(1). doi: 10.1590/0034-7167-2020-0335
https://doi.org/10.1590/0034-7167-2020-0...
. In the Brazilian context, an infographic of Nursing photography, performed in 2020, concluded that there are no preventive measures against violence for health professionals in Brazil5757. Conselho Regional de Enfermagem do Paraná. Fotografia da enfermagem no Brasil [Internet]. 2020 [cited 2022 Mar 24]. Available from: https://www.corenpr.gov.br/portal/noticias/1141-fotografia-da-enfermagem-no-brasil
https://www.corenpr.gov.br/portal/notici...
.

Therefore, it can be asserted that both individual skills and the multiple approach (individual, organizational and environmental) and the implementation of governmental interventions (legislation) can minimize the violence rates and risk, as well as they can improve monitoring of the workplace violence notification systems5858. Ramacciati N, Guazzini A, Caldelli R, Rasero L. User-friendly system (a smartphone app) for reporting violent incidents in the Emergency Department: an Italian multicenter study. Med Lav. 2021 Feb;112(1):68-81. doi: 10.23749/mdl.v112i1.9984
https://doi.org/10.23749/mdl.v112i1.9984...
.

It is noted that the different periods of the interventions implemented in the studies described above can interfere with their effectiveness. In addition to that, effectiveness can also be affected by the follow-up time of the studies, as research has found that the outcomes can improve with increased study follow-up times2222. Miller CJ, Smith SN, Pugatch M. Experimental and quasi-experimental designs in implementation research. Psychiatry R. 2020 June;283(112452). doi: 10.1016/j.psychres.2019.06.027
https://doi.org/10.1016/j.psychres.2019....
.

In relation to the risk of bias, no studies were identified with low risk, only with uncertain risk or high risk for a classification of five domains in randomized clinical trials and seven domains in quasi-randomized trials, influencing the final estimate of the effect.

In randomized clinical trials, the concerns, especially in domain 2 (deviations from the intended intervention) and domain 4 (measurement of the outcomes), can be mainly related to blinding of the participants and to incomplete data about the results in the outcome. While in the quasi-randomized trials, the studies had concerns mainly in domain 1 (confounding factors), domain 3 (intended intervention or classification of the intervention) and domain 6 (measurement of the outcomes).

Thus, both methodologies presented problems both in the intended intervention and in measurement of the outcomes. It is emphasized that workplace violence is complex and often requires the professional’s report; therefore, it can be difficult to adopt masking of the participants.

The meta-analysis allowed inferring that there was no improvement in the outcome of the intervention (individual skills) versus the comparator (individual skills) for the random effect model, with individual skills including training sessions, programs and courses. Such being the case, there was no scientific evidence that the individual skills intervention may prevent or reduce workplace violence (95% CI: -0.41 - 0.25, p=0.64, I2=88%), when compared to the control condition.

The lack of scientific evidence and the high heterogeneity between the meta-analysis studies can be explained by the difference in the direction of the effect of the confidence intervals of the studies included. Another explanation can be due to the fact that the same strategy was implemented in the intervention and control groups (individual skills). Consequently, it was not possible to infer which intervention was more effective for the outcome evaluated.

A systematic review without meta-analysis carried out with 15 studies revealed that most of them exerted a positive effect on preparing the team to deal with violent situations or on reducing the number of violent incidents, although the evidence is still scarce5959. Wirth T, Peters C, Nienhaus A, Schablon A. Interventions for Workplace Violence Prevention in Emergency Departments: A Systematic Review. Int J Environ Res Public Health. 2021 Aug;18(16):8459. doi: 10.3390/ijerph18168459
https://doi.org/10.3390/ijerph18168459...
.

In this same aspect, a systematic review with meta-analysis carried out with nine studies (clinical trials and quasi-randomized studies) found that the evidence from the studies is still extremely uncertain about the effects of education and training against aggression when compared to no intervention1313. Geoffrion S, Hills DJ, Ross HM, Pich J, Hill AT, Dalsbø TK, et al. Education and training for preventing and minimizing workplace aggression directed toward healthcare workers. Cochrane Database Syst Rev. 2020;9(9):CD011860. doi: 10.1002/14651858.CD011860.pub2
https://doi.org/10.1002/14651858.CD01186...
.

Similarly, certainty of the evidence of the outcome evaluated in this review by means of the GRADE system was classified as very low, as the risk of bias of the studies found (uncertain) and the inconsistency (I2=88%) or high statistical heterogeneity were the main factors that determined certainty of the evidence of the studies evaluated as very low.

The lack of recent studies stands out among the limitations of this systematic review, as only four studies were published in the last three years, 2017-2019, revealing the need to carry out new randomized clinical trials and quasi-randomized studies. In addition, non-standardization of the analysis of the age of the samples of the studies, as some of them evaluated the total mean or the mean per group, while others assessed the predominant age group; and omission of the participants’ gender in three studies also represented a limitation.

The reduced number of randomized clinical trials was also a limitation, in addition to the fact that only two of these studies were homogeneous in terms of PICO, which may have hindered generalizing the findings and replicating the evidence for the practice. The quasi-randomized studies found may have reduced the chances of showing effectiveness of the implemented interventions due to interrupted time series and poorly controlled confounding variables.

Thus, this study contributed in an attempt to deepen knowledge and respond to the study object, aiming to contribute to filling the gap in the literature on this theme. Systematic reviews with meta-analysis are useful to determine the knowledge synthesis and the effectiveness of the interventions. The results found provide subsidies for workers, managers and public policy makers to implement interventions for the prevention and reduction of workplace violence.

That said, this study collaborated and advanced to deepen knowledge about the effectiveness of preventive actions and that reduce acts of violence against health and support professionals, contributing to filling the gap in the literature on this theme. It also provides subsidies for workers, managers and public policy makers to implement interventions for the prevention and reduction of the workplace violence suffered by health and support professionals.

Conclusion

This review did not reveal high scientific evidence for the outcomes of prevention and reduction of workplace violence in relation to the interventions (individual skills, multiple approach and governmental actions) implemented, mainly due to the high and uncertain risk of bias in the studies, in addition to the high statistical heterogeneity.

Due to the impossibility of a precise scientific judgment in this meta-analysis, it is recommended to conduct more randomized clinical trials with standardization of the interventions, low risk of bias and low consistency, so that the most effective interventions can be replicated in the practice and provide a safe and decent work environment for health and support professional.

Referências

  • 1
    United States Bureau of Labor Statistics. Injuries, Illnesses, and Fatalities Fact Sheet. Workplace homicides in 2017 [Internet]. Washington, D.C.: U.S. Bureau of Labor Statistics; 2019 [cited 2021 Oct 08]. Available from: https://www.bls.gov/iif/oshwc/cfoi/workplace-homicides-2017.htm
    » https://www.bls.gov/iif/oshwc/cfoi/workplace-homicides-2017.htm
  • 2
    The Joint Commission. Workplace Violence Prevention Standards [Internet]. Oakbrook Terrace, IL: The Joint Commission; 2021 [cited 2021 Oct. 08]. Available from: https://www.jointcommission.org/standards/r3-report/r3-report-issue-30-workplace-violence-prevention-standards/
    » https://www.jointcommission.org/standards/r3-report/r3-report-issue-30-workplace-violence-prevention-standards
  • 3
    Yoon YG, Jung-Choi K. Systematic Review on Research Status of Workplace Violence. Ewha Med J. 2019 Jan;42(4):56-64. doi: 10.12771/emj.2019.42.4.56
    » https://doi.org/10.12771/emj.2019.42.4.56
  • 4
    The Joint Commission. Summary Data of Sentinel Events Reviewed by The Joint Commission [Internet]. Oakbrook Terrace, IL: The Joint Commission; 2021 [cited 2021 Oct 08]. Available from: https://www.jointcommission.org/-/media/tjc/documents/resources/patient-safety-topics/sentinel-event/summary-se-report-2020.pdf
    » https://www.jointcommission.org/-/media/tjc/documents/resources/patient-safety-topics/sentinel-event/summary-se-report-2020.pdf
  • 5
    Al-Qadi MM. Workplace violence in nursing: A concept analysis. J Occup Health. 2021;63(1):e12226. doi: 10.1002/1348-9585.12226
    » https://doi.org/10.1002/1348-9585.12226
  • 6
    Liu J, Gan Y, Jiang H, Li L, Dwyer R, Lu K, et al. Prevalence of workplace violence against healthcare workers: a systematic review and meta-analysis. Occup Environ Med. 2019;76(12):927-37. doi: 10.1136/oemed-2019-105849
    » https://doi.org/10.1136/oemed-2019-105849
  • 7
    International Council of Nurses. Public Services International. World Health Organization. International Labor Organization. Framework guidelines for addressing workplace violence in the health sector - the training manual [Internet]. Geneva: International Labor Organization; 2005 [cited 2021 Oct 08]. Available from: https://www.ilo.org/safework/info/instr/WCMS_108542/lang--en/index.htm
    » https://www.ilo.org/safework/info/instr/WCMS_108542/lang--en/index.htm
  • 8
    U.S. Department of Labor, Occupational Safety and Health Administration. Guidelines for Preventing Workplace Violence for Healthcare and Social Service Workers [Internet]. Washington, D.C.:U.S. Department of Labor; 2016 [cited 2021 Sept 08]. Available from: https://www.osha.gov/sites/default/files/publications/osha3148.pdf
    » https://www.osha.gov/sites/default/files/publications/osha3148.pdf
  • 9
    Alsaleem AS, Alsabaani A, Alamri RS, Hadi RA, Alkhayri MH, Badawi KK, et al. Violence towards healthcare workers: A study conducted in Abha City, Saudi Arabia. J Family Community Med. 2018;25(3):188-93. doi: 10.4103/jfcm.JFCM_170_17
    » https://doi.org/10.4103/jfcm.JFCM_170_17
  • 10
    Simões MRL, Barroso HH, de-Azevedo DSS, Duarte ACM, Barbosa REC, Fonseca GC, et al. Workplace violence among municipal health care workers in Diamantina, Minas Gerais, Brazil, 2017. Rev Bras Med Trab. 2020;18(1):82-90. doi: 10.5327/Z1679443520200425
    » https://doi.org/10.5327/Z1679443520200425
  • 11
    Ayasreh IR, Hayajneh FA. Workplace Violence Against Emergency Nurses: A Literature Review. Crit Care Nurs Q. 2021;44(2):187-202. doi: 10.1097/CNQ.0000000000000353
    » https://doi.org/10.1097/CNQ.0000000000000353
  • 12
    Dal Pai D, Sturbelle ICS, Santos C, Tavares JP, Lautert L. Physical and psychological violence in the workplace of healthcare professionals. Texto Contexto Enferm. 2018;27(1):e2420016. doi: 10.1590/0104-07072018002420016
    » https://doi.org/10.1590/0104-07072018002420016
  • 13
    Geoffrion S, Hills DJ, Ross HM, Pich J, Hill AT, Dalsbø TK, et al. Education and training for preventing and minimizing workplace aggression directed toward healthcare workers. Cochrane Database Syst Rev. 2020;9(9):CD011860. doi: 10.1002/14651858.CD011860.pub2
    » https://doi.org/10.1002/14651858.CD011860.pub2
  • 14
    Spelten E, Thomas B, O'Meara PF, Maguire BJ, FitzGerald D, Begg SJ. Organisational interventions for preventing and minimising aggression directed towards healthcare workers by patients and patient advocates. Cochrane Database Syst Rev. 2020;4(4):CD012662. doi: 10.1002/14651858.CD012662.pub2
    » https://doi.org/10.1002/14651858.CD012662.pub2
  • 15
    Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group. Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. PLoS Med. 2009 July;6(7):e1000097. doi:10.1371/journal.pmed.1000097
    » https://doi.org/10.1371/journal.pmed.1000097
  • 16
    Moher D, Shamseer L, Clarke M, Ghersi D, Liberati A, Petticrew M, et al. Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) 2015 statement. Syst Rev. 2015 Jan;4(1):1-9. doi: 10.1186/2046-4053-4-1
    » https://doi.org/10.1186/2046-4053-4-1
  • 17
    Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021 Mar;372(71):1-9. doi: 10.1136/bmj.n71
    » https://doi.org/10.1136/bmj.n71
  • 18
    Okubo CVC, Martins JT. Effectiveness of interventions in reducing occupational violence between health workers: systematic review and meta-analysis [Internet]. PROSPERO 2018 CRD42018111383 [cited 2021 June 08]. Available from: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42018111383
    » https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42018111383
  • 19
    Okubo CVC, Silveira RCCP, Galdino MJQ, Fernandes DR, Moreira AAO, Martins JT. Effectiveness of interventions for the prevention of occupational violence against professionals in health services: a protocol for a systematic review. BMJ Open. 2020 Sept [cited 2021 Oct 01];10:e0365582020. doi: 10.1136/bmjopen-2019-036558
    » https://doi.org/10.1136/bmjopen-2019-036558
  • 20
    Akobeng AK. Principles of evidence-based medicine. Arch Dis Child. 2005 Aug. [cited 2021 Sept 02];90(8):837-40. doi: 10.1136/adc.2005.071761
    » https://doi.org/10.1136/adc.2005.071761
  • 21
    World Health Organization. Classification of health workforce statistics [Internet]. Geneva: WHO; 2010 [cited 2021 June 21]. Available from: https://www.who.int/hrh/statistics/Health_workers_classification.pdf
    » https://www.who.int/hrh/statistics/Health_workers_classification.pdf
  • 22
    Miller CJ, Smith SN, Pugatch M. Experimental and quasi-experimental designs in implementation research. Psychiatry R. 2020 June;283(112452). doi: 10.1016/j.psychres.2019.06.027
    » https://doi.org/10.1016/j.psychres.2019.06.027
  • 23
    Melnyk BM. Level of evidence plus critical appraisal of its quality yields confidence to implement evidence-based practice changes. Worldviews Evid Based Nurs. 2016 Oct;13(5):337-9. doi: 10.1111/wvn.12181
    » https://doi.org/10.1111/wvn.12181
  • 24
    Melnyk BM, Fineout-Overholt E. Evidence-based practice in nursing and healthcare: a guide to best practice. 4a ed. Philadelphia: Wolters Kluwer; 2019.
  • 25
    Endnote [Software]. 2021 [cited 2021 June 10]. Available from: https://access.clarivate.com/login?app=endnote
    » https://access.clarivate.com/login?app=endnote
  • 26
    Rayyan [Software]. 2022 [cited 2021 June 02]. Available from: https://rayyan.ai/users/sign_in?_ga=2.174315621.619312859.1638400577-1927447999.1629229968
    » https://rayyan.ai/users/sign_in?_ga=2.174315621.619312859.1638400577-1927447999.1629229968
  • 27
    Eldridge S, Campbell MK, Campbell MJ, Drahota AK, Giraudeau B, Reeves BC, et al. Revised Cochrane risk of bias tool for randomized trials (RoB 2). Additional considerations for cluster-randomized trials (RoB 2 CRT) [Internet]. 2021 Mar 18 [cited 2021 July 0]. Available from: https://sites.google.com/site/riskofbiastool/welcome/rob-2-0-tool/rob-2-for-cluster-randomized-trials
    » https://sites.google.com/site/riskofbiastool/welcome/rob-2-0-tool/rob-2-for-cluster-randomized-trials
  • 28
    Higgins JPT, Savovic J, Page MJ, Sterne JAC, RoB2 Development Group. Revised Cochrane risk-of-bias tool for randomized trials (RoB 2). 2019 Aug 22 [cited 2021 July 04]. Available from: https://sites.google.com/site/riskofbiastool/welcome/rob-2-0-tool/current-version-of-rob-2
    » https://sites.google.com/site/riskofbiastool/welcome/rob-2-0-tool/current-version-of-rob-2
  • 29
    Sterne JAC, Higgins JPT, Elbers RG, Reeves BC. Risk Of Bias In Non-randomized Studies of Interventions (ROBINS-I): detailed guidance [Internet]. 2016 Oct 20 [cited 2021 July 4]. Available from: https://sites.google.com/site/riskofbiastool/welcome/home/current-version-of-robins-i/robins-i-detailed-guidance-2016
    » https://sites.google.com/site/riskofbiastool/welcome/home/current-version-of-robins-i/robins-i-detailed-guidance-2016
  • 30
    Sterne JAC, Savovic J, Page MJ, Elbers RG, Blencowe NS, Boutron I, et al. RoB 2: a revised tool for assessing risk of bias in randomised trials. BMJ. 2019 Aug;366:l4898. doi: 10.1136/bmj.l4898
    » https://doi.org/10.1136/bmj.l4898
  • 31
    Higgins J, Thomas J, Chandler J, Cumpston M, Li T, Page M, et al. Cochrane Handbook for Systematic Reviews of Interventions version 6.2 [Internet]. London: Cochrane; 2021 [cited 2021 Mar 1]. Available from: https://training.cochrane.org/handbook/current
    » https://training.cochrane.org/handbook/current
  • 32
    Cochrane Collaboration. RevMan Web(r). Version 5.4 [Software]. 2021 [cited 2021 July 1]. Available from: https://revman.cochrane.org/#/myReviews
    » https://revman.cochrane.org/#/myReviews
  • 33
    Schünemann H, Brozek J, Guyatt G, Oxman A. GRADE Handbook. Handbook for grading the quality of evidence and the strength of recommendations using the GRADE approach [Internet]. 2013 [cited 2021 July 6]. Available from: https://gdt.gradepro.org/app/handbook/handbook.html#h.svwngs6pm0f2
    » https://gdt.gradepro.org/app/handbook/handbook.html#h.svwngs6pm0f2
  • 34
    Grade Working Group. GRADEPro [Software]. Hamilton: McMaster University/Evidence Prime Inc.; 2021 [cited 2021 July 6]. Available from: https://gradepro.org/
    » https://gradepro.org
  • 35
    Arnetz JE, Arnetz BB. Implementation and evaluation of a practical intervention programme for dealing with violence towards health care workers. J Adv Nurs. 2000;31(3):668-80. doi: 10.1046/j.1365-2648.2000.01322.x
    » https://doi.org/10.1046/j.1365-2648.2000.01322.x
  • 36
    Gates D, Fitzwater E, Succop, P. Reducing assaults against nursing home caregivers. Nurs Res. 2005 Mar-Apr;54(2):119-27. doi: 10.1097/00006199-200503000-00006
    » https://doi.org/10.1097/00006199-200503000-00006
  • 37
    Anderson C. Training efforts to reduce reports of workplace violence in a community health care facility. J Prof Nurs. 2006 Sep-Oct;22(5):289-95. doi: 10.1016/j.profnurs.2006.07.007
    » https://doi.org/10.1016/j.profnurs.2006.07.007
  • 38
    Casteel C, Peek-Asa C, Nocera M, Smith JB, Blando J, Goldmacher S, et al. Hospital employee assault rates before and after enactment of the California Hospital safety and security act. Ann Epidemiol. 2009 Feb;19(2):125-33. doi: 10.1016/j.annepidem.2008.10.009
    » https://doi.org/10.1016/j.annepidem.2008.10.009
  • 39
    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. Int J Nurs Stud. 2011 May;48(5):534-9. doi: 10.1016/j.ijnurstu.2010.10.006
    » https://doi.org/10.1016/j.ijnurstu.2010.10.006
  • 40
    Irvine B, Billow MB, Gates DM, Fitzwater EL, Seeley JR, Bourgeois M. An internet training to reduce assaults in long-term care. Geriatr Nurs. 2021 Jan;33(1):28-40. doi: 10.1016/j.gerinurse.2011.10.004
    » https://doi.org/10.1016/j.gerinurse.2011.10.004
  • 41
    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. J Emerg Nurs. 2014 Mar;40(6):586-91. doi: 10.1016/j.jen.2014.01.003
    » https://doi.org/10.1016/j.jen.2014.01.003
  • 42
    Glass N, Hanson GC, Anger WK, Laharnar N, Campbell JC, Weinstein M, et al. Computer-based training (CBT) intervention reduces workplace violence and harassment for homecare workers. Am J Ind Med. 2017 July;60(7):635-43. doi: 10.1002/ajim.22728
    » https://doi.org/10.1002/ajim.22728
  • 43
    Arnetz JE, Hamblin L, Russell J, Upfal MJ, Luborsky M, Janisse J, et al. Preventing Patient-to-Worker Violence in Hospitals: Outcome of a Randomized Controlled Intervention. J Occup Environ Med. 2017 Jan;59(1):18-27. doi: 10.1097/JOM.0000000000000909
    » https://doi.org/10.1097/JOM.0000000000000909
  • 44
    Sadatmahaleh MM, Khoshknab MF, Rahguy A, Arsalani N, Biglarian A. Effect of Workplace Violence Management Program on the Incidence. Adv Nurs Midwifery [Internet]. 2018 Oct 2 [cited 2021 Nov 3];28(1):27-3. Available from: https://journals.sbmu.ac.ir/en-jnm/article/view/18027
    » https://journals.sbmu.ac.ir/en-jnm/article/view/18027
  • 45
    Baby M, Gale C, Swain N. Communication skills intervention to minimise patient perpetrated aggression for healthcare support workers in New Zealand: A cluster randomised controlled trial. Health Soc Care Community. 2019 Jan;27(1):170-81. doi: 10.1111/hsc.12636
    » https://doi.org/10.1111/hsc.12636
  • 46
    Cochrane Collaboration. Robvis tool(r) [Internet]. 2021 [cited 2021 June 1]. Available from: https://www.riskofbias.info/welcome/robvis-visualization-tool
    » https://www.riskofbias.info/welcome/robvis-visualization-tool
  • 47
    Mishra S, Chopra D, Jauhari N, Ahmad A, Kidwai NA. Violence against health care workers: a provider's (staff nurse) perspective. Int J Community Med Public Health. 2018 Ago;5(9):4140-8. doi: 10.18203/2394-6040.ijcmph20183609
    » https://doi.org/10.18203/2394-6040.ijcmph20183609
  • 48
    Aljohani B, Burkholder J, Tran QK, Chen C, Beisenova K, Pourmand A. Workplace violence in the emergency department: a systematic review and meta-analysis. Public Health. 2021 July;196:186-97. doi: 10.1016/j.puhe.2021.02.009
    » https://doi.org/10.1016/j.puhe.2021.02.009
  • 49
    Edward KL, Stephenson J, Ousey K, Lui S, Warelow P, Giandinoto JA. A systematic review and meta-analysis of factors that relate to aggression perpetrated against nurses by patients/relatives or staff. J Clin Nurs. 2016 Feb;25(3-4):289-99. doi: 10.1111/jocn.13019
    » https://doi.org/10.1111/jocn.13019
  • 50
    Liu J, Gan Y, Jiang H, Li L, Dwyer R, Lu K, et al. Prevalence of workplace violence against healthcare workers: a systematic review and meta-analysis. Occup Environ Med. 2019 Dec;76(12):927-37. doi: 10.1136/oemed-2019-105849
    » https://doi.org/10.1136/oemed-2019-105849
  • 51
    Chappell D, Di Martino V. Violence at work [Internet].3rd ed. Geneva: International Labour Office; 2006 [cited 2021 July 12]. Available from: https://www.ilo.org/wcmsp5/groups/public/%40dgreports/%40dcomm/%40publ/documents/publication/wcms_publ_9221108406_en.pdf
    » https://www.ilo.org/wcmsp5/groups/public/%40dgreports/%40dcomm/%40publ/documents/publication/wcms_publ_9221108406_en.pdf
  • 52
    Barrios-Casas S, Paravic-Klijn T. Aplicación del modelo de violencia laboral de Chappell y Di Martino adaptado al usuario hospitalizado. Aquichan [Internet]. 2011 Apr [cited 2021 July 28];11(1):77-93. Available from: http://www.scielo.org.co/scielo.php?script=sci_arttext&pid=S1657-59972011000100007&lng=en&nrm=iso
    » http://www.scielo.org.co/scielo.php?script=sci_arttext&pid=S1657-59972011000100007&lng=en&nrm=iso
  • 53
    Arnetz JE, Hamblin L, Ager J, Luborsky M, Upfal MJ, Russell J, et al. Underreporting of Workplace Violence: Comparison of Self-Report and Actual Documentation of Hospital Incidents. Workplace Health Saf. 2015 May;63(5):200-10. doi: 10.1177/2165079915574684
    » https://doi.org/10.1177/2165079915574684
  • 54
    García-Pérez MD, Rivera-Sequeiros A, Sánchez-Elías TM, Lima-Serrano M. Workplace violence on healthcare professionals and underreporting: Characterization and knowledge gaps for prevention. Enferm Clin. 2021 Nov-Dec;31(6):390-5. doi: 10.1016/j.enfcle.2021.05.001
    » https://doi.org/10.1016/j.enfcle.2021.05.001
  • 55
    Taylor MJ, McNicholas C, Nicolay C, Darzi A, Bell D, Reed JE. Systematic review of the application of the plan-do-study-act method to improve quality in healthcare. BMJ Qual Saf. 2014 Apr;23(4):290-8. doi: 10.1136/bmjqs-2013-001862
    » https://doi.org/10.1136/bmjqs-2013-001862
  • 56
    Bordignon M, Trindade LL, Cezar-Vaz MR, Monteiro MI. Violência no trabalho: legislação, políticas públicas e possibilidade de avanços para trabalhadores da saúde. Rev Bras Enferm. 2021;74(1). doi: 10.1590/0034-7167-2020-0335
    » https://doi.org/10.1590/0034-7167-2020-0335
  • 57
    Conselho Regional de Enfermagem do Paraná. Fotografia da enfermagem no Brasil [Internet]. 2020 [cited 2022 Mar 24]. Available from: https://www.corenpr.gov.br/portal/noticias/1141-fotografia-da-enfermagem-no-brasil
    » https://www.corenpr.gov.br/portal/noticias/1141-fotografia-da-enfermagem-no-brasil
  • 58
    Ramacciati N, Guazzini A, Caldelli R, Rasero L. User-friendly system (a smartphone app) for reporting violent incidents in the Emergency Department: an Italian multicenter study. Med Lav. 2021 Feb;112(1):68-81. doi: 10.23749/mdl.v112i1.9984
    » https://doi.org/10.23749/mdl.v112i1.9984
  • 59
    Wirth T, Peters C, Nienhaus A, Schablon A. Interventions for Workplace Violence Prevention in Emergency Departments: A Systematic Review. Int J Environ Res Public Health. 2021 Aug;18(16):8459. doi: 10.3390/ijerph18168459
    » https://doi.org/10.3390/ijerph18168459
  • Paper extracted from doctoral dissertation “Prevenção e redução da violência no trabalho sofrida por profissionais de saúde: revisão sistemática com metanálise”, presented to Universidade Estadual de Londrina, Londrina, PR, Brazil.

Edited by

Associate Editor

Maria Lúcia Zanetti

Data availability

Data citations

World Health Organization. Classification of health workforce statistics [Internet]. Geneva: WHO; 2010 [cited 2021 June 21]. Available from: https://www.who.int/hrh/statistics/Health_workers_classification.pdf

Publication Dates

  • Publication in this collection
    12 Aug 2022
  • Date of issue
    2022

History

  • Received
    16 Dec 2021
  • Accepted
    27 Apr 2022
Escola de Enfermagem de Ribeirão Preto / Universidade de São Paulo Av. Bandeirantes, 3900, 14040-902 Ribeirão Preto SP Brazil, Tel.: +55 (16) 3315-3451 / 3315-4407 - Ribeirão Preto - SP - Brazil
E-mail: rlae@eerp.usp.br