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Assaultive Behavior and Workplace Violence

2.5 Contact Hours
This course is applicable for the following professions:
Advanced Registered Nurse Practitioner (ARNP), Certified Nursing Assistant (CNA), Certified Registered Nurse Anesthetist (CRNA), Clinical Nurse Specialist (CNS), Home Health Aid (HHA), Licensed Nursing Assistant (LNA), Licensed Practical Nurse (LPN), Licensed Vocational Nurses (LVN), Medical Assistant (MA), Midwife (MW), Registered Nurse (RN), Respiratory Therapist (RT)
This course will be updated or discontinued on or before Sunday, February 23, 2020
Course Description
The purpose of this activity is to enable the learner to understand how workplace violence affects nurse and which how to prevent and minimize the effects of workplace violence. A thorough review of the etiology of workplace violence and understanding its classification. By the end of this activity, nurses will be able to describe and implement effective strategies in preventing and managing workplace violence. Also nurses will be able to understand and start implementing strategies set forth by both the ANA and OSHA in their different clinical settings.
CEUFast Inc. did not endorse any product, or receive any commercial support or sponsorship for this course. The Planning Committee and Authors do not have any conflict of interest.

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To earn of certificate of completion you have one of two options:
  1. Take test and pass with a score of at least 80%
  2. Reflect on practice impact by completing self-reflection, self-assessment and course evaluation.
    (NOTE: Some approval agencies and organizations require you to take a test and self reflection is NOT an option.)
Author:    Berthina Coleman (MD, BSN,RN)


After completing this course, the learner will be able to:

  1. Definition of workplace violence
  2. Identify which populations are most at risk for workplace violence
  3. Understand the classification of workplace violence
  4. Understand interventions used to prevent workplace violence
  5. Review Occupational Safety and Health Administration recommendations for preventing workplace violence
  6. Discuss the ANA’s “zero tolerance” policy
  7. Understanding verbal de-escalation techniques

Definition of Workplace Violence

Violence was declared a public health emergency in 1992 by Koop et al and ever since then several agencies including the WHO have been striving to prevent and decrease the incidence of violence. However, several factors have contributed to the rising incidence of violence in our communities in general and in the healthcare community in particular.

The World Health Organization (WHO) defines workplace violence as “the intentional use of power, threatened or actual, against another person or against a group, in work-related circumstances, that either results in or has a high degree of likelihood of resulting in injury, death, psychological harm, mal-development, or deprivation”.  

Unfortunately, our reality today is workplace violence can occur in any work setting especially in a clinical setting and clinicians must anticipate and remain vigilant at all times to effectively manage and cope with aggressive patients with the potential to become violent. Today, with the media sensationalizing every incident of violence and with the advent of social media, reports of violence are ever present seeking to grab our attention. More specifically, violence in a clinical setting can have debilitating results affecting not just the patient being violent but the clinical staff as well as other patients. There are financial ramifications as well with the cost of workplace violence estimated at $120 billion per year.

According to the United States department of Labor; bureau of labor statistics, in 2014 there were three private sector industries which had more than 100,000 days-away-from-work incidents in 2014. These 3 included health care and social assistance (164,440), manufacturing (125,990), and retail trade (120,640). As evidenced above, health care and social assistance are ranked as the number one industry in the private sector with the highest number of days-away-from-work incidents. Incidents from violence in the healthcare and social assistance industries was more than three times greater than the violence rate for all private industries. Of all the professionals in the health care and social assistance industry, nurses and nursing assistants were amongst the groups most affected by violence.

The California Occupational Safety and Health Administration defined and classified workplace violence into three types. Namely:

Type I: The aggressor has no legitimate employment relationship to the worker or the workplace and, usually, the main object of the violence is obtaining cash or valuable property, or demonstrating power. Examples are robbery, mugging and road rage.

Type II: The aggressor is someone who is the recipient of a service provided by the affected workplace or by the worker. Examples are assault or verbal threats by patients, caregivers or relatives of the patient.

Type III: The aggressor is another employee, a supervisor, or a manager. Examples are bullying and harassment.

Which Population is Most at Risk of Experiencing Workplace Violence?

The US Bureau of Labor Statistics reported more than 23,000 significant injuries due to assault at work in 2013. More than 70 percent of these assaults were in healthcare and social service settings. Workers in health care and social services are approximately four times more likely to be injured as a result of violence than other private sector workers. In 2013, 25% of all fatalities in healthcare and social services were due to assaults and violent acts. Recent research has shown that workplace violence is underreported by health care workers making the real estimates much higher.

A 2011 study by Campbell et al at the Johns Hopkins hospital school of nursing which included a total of 2166 nurses and nursing personnel, examined the prevalence of workplace violence as well as the risk factors for workplace violence. The results showed that approximately 30 percent of nurses and nursing personnel experienced workplace violence.  Of those affected, 19.4% experienced physical violence and 19.9% psychological violence. The risk factors identified by the study include; being a nurse, white, male, working in the emergency department, older age, longer employment, childhood abuse, and a history of intimate partner violence.

A study conducted by Sang Woo Tak et al in 2010 noted a total of 34% of nursing assistants reported experiencing physical injuries from assaults by residents during the year before their interview, including 12% who reported injuries from human bites during the past year. Non-Hispanic White nursing assistants reported the highest proportion of physical assault injuries (43.5%) and human bites (15.6%).

A cross sectional study by Ching-Yao et al, 2015 which sample almost 27,000 nurses sought to identify the prevalence of workplace violence and noted that 49.6% of the nurses had experienced at least one episode of violence in the past year. Of those, 19.1% had been exposed to physical violence and 46.3% had experienced non-physical violence. They also looked at the prevalence of violence based on the work setting and noted that prevalence varied greatly based on the work environment. ICU or emergency room nurses reported the highest prevalence up to 55.5% of all nurses had experienced workplace violence. Another interesting finding was the fact that nurses between the ages of 55-65 years had the lowest prevalence of workplace violence (28.3%). Overall after adjusting for other confounders, they concluded that younger nurses were more at risk to being exposed to violent threats. 

Cycle of Violence

Abuse tends to occur in cycles. It does not just go away and tends to get worse over time. Research suggests the more severe the violence, the more chronic it is and the more likely it is to worsen over time. The cycle of violence has the following stages:

1. Tension Building

2. Battery incident

3. Calm, then continues back to stage one

Risk Factors Which Increase the Propensity to Experience Workplace Violence

The etiology of workplace violence is multifactorial with myriad causes contributing to the root cause. These include the environment or setting in which violence occurs, a patient's social and medical history, interpersonal relations, genetics, neurochemistry and endocrine function, and substance abuse (Volavka, 1999).

According to the guidelines for Preventing Workplace Violence for Healthcare and Social Service Workers published by the Occupational Safety and Health Administration (OSHA) risk factors for workplace violence can be divided into two main categories: Patient, client or setting related risk factors and Organizational related risk factors.

Client, patient or setting related risk factors include: 

  • Working directly with people who have a history of violence, abuse drugs or alcohol, gang members, and relatives of patients or clients
  • Transporting patients and clients
  • Working alone in a facility or in patients’ homes
  • Poor environmental design of the workplace that may block employees’ vision or interfere with their escape from a violent incident
  • Poorly lit corridors, rooms, parking lots and other areas
  • Lack of means of emergency communication
  • Prevalence of firearms, knives and other weapons among patients and their families and friends
  • Working in neighborhoods with high crime rates 

Organizational Risk Factors:

  • Lack of facility policies and staff training for recognizing and managing escalating hostile and assaultive behaviors from patients, clients, visitors, or staff
  • Working when understaffed—especially during mealtimes and visiting hours
  • High worker turnover
  • Inadequate security and mental health personnel on site
  • Long waits for patients or clients and overcrowded, uncomfortable waiting rooms
  • Unrestricted movement of the public in clinics and hospitals
  • Perception that violence is tolerated and victims will not be able to report the incident to police and/or press charges

Other studies focused on violence in specific settings such as the emergency department noted that, significant illness, prolonged waiting times, and confusion often found in busy emergency departments (ED) creates a stressful atmosphere that can potentiate feelings of agitation among patients and their families. Other factors that compound the issue of workplace violence in the emergency department setting include the accessibility of drugs and weapons in today’s society, the 24-hour open door policy of emergency departments and the availability and accessibility of potential hostages (Behnam, 2011).

According to Harrell et al, in the United States, racial/ethnic differences have been noted in the prevalence of workplace violence with increased prevalence noted among Whites (78%), when compared to Blacks (13%) and Hispanics (15%) (Harrell, 2011).

A recent study by Sabri et al (2015) examined whether different racial or ethnic groups differed in their vulnerability to workplace violence. It also examined the ability to utilize the resources available in the workplace to prevent and manage workplace violence. They noted that childhood physical abuse played a role in significantly increasing the risk of workplace violence amongst all races. However, they noted that amongst Asians and Whites intimate partner violence was a significant factor. In addition, they noted that Blacks and Asians were less knowledgeable about resources within the workplace used in preventing and addressing workplace violence.  In conclusion their study showed a significant difference in resource utilization amongst minority worker groups. This exemplifies the need for mandatory training and education programs designed for new employees and annual training and education programs targeting current employees in efforts to increase awareness of workplace violence in all populations including minority groups.  

The Heart of the Matter: A Summary on the Etiology of Workplace Violence.

Current research on threat management has shown that violence directed towards a specific target is usually due to progressively worst behaviors rather than single impulsive occurrence. In most cases of Type III violence; that is violence caused by a coworker, the incident is usually secondary to a buildup of anger, not a sudden denigration in behavior. This implies that identifying and assessing an employee’s change in behavior is paramount to preventing violence in the workplace (Huston, 2013).

In determining whether or not an employee or patient may become violent, one must identify warning behaviors and assess the threat of violence over time. In order to monitor behavior over time, the employers must strive to create a culture of safety and open communication where employees can freely report warning behaviors observed without fear of retaliation. Then, the employer must also be committed to track those behaviors over time and take appropriate interventions.

The key behaviors identified by Huston et al (2011) include; leakage which is the revealing of intentions to be violent to a third party. Secondly, identifying with violent offenders and preparation for attack. Third is fixation on one person or a cause. And lastly, a deep desire for retaliation. 

Another barrier identified in the prevention of workplace violence is the issue of under-reporting. Some studies have estimated under reporting to be as high 16% amongst nurses. Chapman et al (2010) identified reasons for not reporting included the belief that workplace violence was just part of the job. Also identified were cultural beliefs such as Asian cultural values which placed high emphasis on workplace performance as opposed to individual performance thereby fostering an environment workplace bullying is acceptable (Power et al, 2013).

Studies have shown that divorced workers experienced higher rates of workplace violence than married workers (Harrell, 2011). Gillespie et al (2010) suggested that this was likely secondary to the fact that married workers were more likely to work towards agreement with their spouse or partners and therefore were using those same skills in the workplace to aid in conflict resolution.

A careful analysis of the literature shows that violence against nurses is not just a problem limited to the United States. Several studies have shown worldwide reports of violence against nurses.  A few examples include studies from Japan (Fujita et al., 2012), Italy (Maonavitra et al., 2011) and Egypt (Samir et al., 2012). 

Coping and Aftermath of Violent Assault

According to the Bureau of Labor Statistics, the consequences of violence include acute stress disorder, post traumatic disorder, decreased productivity at work, physical injury and death (Bureau of Labor Statistics, 2012).

In 2013, Kowalenko et al., (2013) noted that in the emergency department, the rate of physical assaults against nurses was 1.8 assaults per nurse per year. Other studies have also identified nurses in the emergency department being at increased risk of experiencing workplace violence compared to nurses in other departments.

Again, the sequelae of physical violence is not limited to psychological stress but can cause significant distress with those affected manifesting signs and symptoms of post-traumatic stress disorder such as flashbacks, avoidance of similar patients or situations. Ultimately, nurses have been shown to have difficulty to cognitively focus on their work after experiencing physical violence thereby affecting their performance (Succop, 2011).

Iennaco, et al (2013) conducted a study focused on observing aggression exposure in emergency room nurses. They identified 3,000 randomly selected emergency room nurses with a recent experience of physical violence, f which 85.8% were female, 90.9% were Caucasian and almost half worked in hospitals in an urban setting (47.5%). Participants were asked to describe in their own words the factors that contributed to the violent event and their reactions to these violent events. They categorized their findings into 4 main categories which were: personal worker factors, workplace factors, aggressor factors and assault situation.

Under the category of personal worker factors, three main sub categories arose namely; nursing role, nursing experience and nursing practice. In regards to the nursing role, most of the nurses were providing direct patient care. However, charge nurses were more likely to respond to a volatile situation that became violent. Majority of the nurses declined to report their years of nursing experience. A plethora of nursing practice task were reported to have been occurring at the time of attack ranging from performing a nursing assessment or triage versus performing an invasive procedure.

Workplace factors had several sub categories including; location of violence, workplace design, security devices and personnel, wait times and policies. Of those listed above, workplace design was noted to be a major factor affecting the risk of being victimized in the emergency department. Wait time was also noted to play a significant role in provoking physical violence from patients and visitors. Enforcement of certain workplace policies were noted to contribute to physical violence while the lack of policy enforcement was also noted to be contributory. In an example provided the writers described a situation where parents were not allowed to see a deceased child because the body was considered a crime scene. This is an example where enforcing a visitor policy contributed to a violent event.

In their discussion of aggressor factors, the patient’s chief complaint played a major role especially those with mental health crises, pain and substance abuse. When addressing situational context, they noted that patients in police custody, patients with a history of violence and situations involving patient death were all high risk factors contributing to violent events.

Finally, assault situation assessment noted that 74% of the assaults were physical assaults with examples ranging from chocking and biting to brandishing firearms and knives. Verbal threats of physical violence were reported by 33.3% of the nurses and intimidation was reported by 11.9% of all nurses in the study.


 Restraining a patient should be considered a last resort. There are three types of restraints –physical, chemical and seclusion.  The use of restraints can be a dangerous intervention if not done properly and by qualified staff. Improper use of restraints can cause death and serious injury. The Center for Medicare and Medicaid defines a physical restraint as any manual, physical or mechanical device attached or adjacent to the patient that cannot be easily removed and restricts movement. This may include vests, straps, wrist ties, belts, bed-side rails and Geri-Chairs. Also, holding a patient to restrict their movement is considered a restraint Chemical restraints consist of the use of drugs for the purpose of controlling behavior or movement. Seclusion, on the other hand, is when the patient is in a locked room involuntarily. Restraints and seclusion are used for various reasons including aggression, violence or self-harm (such as pulling out medically needed devices or causing self-injury).

All standards and guidelines state that first and foremost restraints are use only when necessary and when all other forms of interventions have failed. The least restrictive methods of controlling behavior must be tried first before restraints are initiated. Restraints are to be time limited, have documented indications, and be re-evaluated frequently. It is important to note that a restraint is in place when the patient is not able to free themselves from the restraint. This includes soft restraint and bed rails. However, an important distinction is that some forms of restraints such as bed rails can be used to help the patient get in and out of bed and may not be considered restraints.  It is up to the prescriber to make the use very clear in the documentation. Furthermore, unless the patient is being violent toward himself or others or places himself in danger, the patient can refuse restraints.

Making the decision to use restraints or seclusion should not be taken lightly. The decision should be based on the assessment and the ability to pick up on cues related to the patient’s behavior. The nurse must then consider all alternatives prior to administering restraints or seclusion. Cues and assessment should center around the patient’s speech, mood and content of thought. Furthermore, the nurse must assess if safety to the patient or to the staff is likely to occur. Patients who are restrained and/or in seclusion for violent behaviors or self-destructive behaviors are to be monitored on a one to one or face to face status by a trained staff member. This can be done via video and audio equipment as well by a staff member trained in this area.  The staff member must document the patients condition, any attempts at less restrictive intervention with results, a behavioral and medical evaluation, the response to the restraints and the reason to continue the restraints.

Preventing Assault

A common sense strategy to prevent being assaulted identified was maintaining a safe distance from a potential aggressor. It appeared that violence may have been perceived to be more distressful when it occurred in unexpected situations. In addition, nurses reported system limitations such as the fact they did not know patients had a history of violence prior to interacting with them. A 2012 study by Zuzelo et al suggested that emergency departments should have procedures set in place in order to communicate to colleagues that patients may be violent.

The limitations of the Huang and Glenn’s study include a selection bias; given that the participants had to self-report in order to participate. Also, the sample was extremely homogenous consisting mostly of Caucasian females limiting its applicability. In conclusion, they suggested screening all patients for violence as part of the emergency department triage process. Also providing support for nurses who had experienced workplace violence to help them cope with the aftermath of experiencing physical violence in the workplace.

There are several challenges involved in measuring aggression including; the reluctance by victims to report the incident, use of indirect measures and finally the lack of information (Huang & Glenn, 2016). They also suggested using a handheld counter as a tool to accurately measure aggression exposure. 

Occupational Safety and Health Administration Recommendations for Preventing Workplace Violence

Occupational Safety and Health Administration (OSHA) recommends reviewing records to identify patterns of assault and reviewing near misses to identify things that helped prevent the violent event.

Most of the questionnaire respondents who self-reported a violent event in the past year had not documented an incident in the electronic system (88%). However, more than 45% had reported violence informally, for example, to their coworkers and supervisors. They noted that employees who got injured or lost time from work were more likely to formally report a violent event. If hospitals got a better understanding of the magnitude of underreporting and the factors that cause health care workers to underreport, they will be more knowledgeable about where to focus violence education and prevention resources.

In its Guidelines for preventing workplace violence for healthcare and social services workers, the Occupational Safety and Health Administration organization recommends all hospitals perform a program evaluation which focuses on reviewing their safety and security measures.

OSHA goes on to spell out the elements of an effective evaluation system which include:

  • Establishing a uniform violence reporting system and regular review of reports.
  • Reviewing reports and minutes from staff meetings on safety and security issues.
  • Analyzing trends and rates in illnesses, injuries or fatalities caused by violence relative to initial or “baseline” rates.
  • Measuring improvement based on lowering the frequency and severity of workplace violence.
  • Proper patient confidentiality must be maintained.
  • Keeping up-to-date records of administrative and work practice changes to prevent workplace violence to evaluate how well they work.
  • Surveying workers before and after making job or worksite changes or installing security measures or new systems to determine their effectiveness.
  • Tracking recommendations through to completion.
  • Keeping abreast of new strategies available to prevent and respond to violence in the healthcare and social service fields as they develop.
  • Surveying workers periodically to learn if they experience hostile situations in performing their jobs.
  • Complying with OSHA and state requirements for recording and reporting injuries, illnesses, and fatalities.
  • Requesting periodic law enforcement or outside consultant review of the worksite for recommendations on improving worker safety.

The American Nurses Association, the professional organization which represents the 3.4 million registered nurses, recently issue a position statement with recommendations to prevent and mitigate violence (August, 2015). The statement included the position that nurses will no longer tolerate violence of any kind from any source. The ANA essentially issued a “zero tolerance” policy with respect to violence against nurses in the workplace. The ANA recommendations include:

  • Establishing a shared and sustained commitment by nurses and their employers to a safe and trustworthy environment that promotes respect and dignity.
  • Encouraging employees to report incidents of violence, and never blaming employees for violence perpetrated by non-employees.
  • Encouraging RNs to participate in educational programs, learn organizational policies and procedures, and use “situational awareness” to anticipate the potential for violence.
  • Developing a comprehensive violence prevention program aligned with federal health and safety guidelines, with RNs’ input.
  • Employers must provide a mechanism for RNs to seek support when feeling threatened
  • Employers also have a responsibility to inform employees about available strategies for conflict resolution and respectful communication.
  • Employers are urged to offer education sessions on incivility and bullying, including prevention strategies.

How to Diffuse Tense Situations Using Verbal De-Escalation Techniques

When obtaining a history and implementing the care plan, with agitated patients, clinicians must learn how to quickly assess when a patient is amenable to verbal calming techniques and when they realize that they are not working, they must quickly excuse themselves and go get help. Often times when approaching a patient, one has no idea how the interaction will play out. However, the American Association for emergency psychiatry has provided 10 key elements for verbal de-escalation (Richmond et al, 2012).

  • Respect personal space – Maintain a distance of two arm's lengths and provide space for easy exit for either party.
  • Do not be provocative – Keep your hands relaxed, maintain a non-confrontational body posture, and do not stare at the patient.
  • Establish verbal contact – The first person to contact the patient should be the leader.
  • Use concise, simple language – Elaborate and technical terms are hard for an impaired person to understand.
  • Identify feelings and desires – "What are you hoping for?"
  • Listen closely to what the patient is saying – After listening, restate what the patient said to improve mutual understanding.
  • Agree or agree to disagree – (a) Agree with clear specific truths; (b) agree in general: "Yes everyone should be treated respectfully; (c) agree with minority situations: "There are others who would feel like you."
  • Lay down the law and set clear limits – Inform the patient that violence or abuse cannot be tolerated.
  • Offer choices and optimism – Patients feel empowered if they have some choice in matters.
  • Debrief the patient and staff.

Some have purported reporting using well established business techniques in dealing with agitated patients such as the three Fs and the philosophy of yes can be helpful (Morgan, 2002).

The three Fs (feel, felt, found) approach provides a framework for responding to the patient's emotional needs: "I can understand how you could feel that way. Others in a similar situation have felt that way, too. Most have found that doing ‘this’ can be helpful."

The philosophy of yes encourages the clinician to respond to the patient affirmatively. Examples of initial clinician responses using this approach might include: “Yes, but first we should do”, “Okay we will as soon as” or “I truly understand what you want done but in my experience it is more effective to do it another way”.

It is important to know that physical restraints can be used when unable to calm a combative patient using other techniques. When restrained, a patient must be carefully and frequently monitored. If rapid tranquilization is required, typical antipsychotics and benzodiazepines can be utilized. 

What Not To Do

There are certain things clinicians must never do and they include: arguing, being condescending, and commanding the patient. Also interestingly, a threat to call security is often an invitation to aggression. Other potential mistakes include criticizing or interrupting the patient, responding defensively or taking the patient's insults personally, and not clarifying what the patient meant before responding. Finally, never lie to a patient, especially about wait times.

Do not take any threats lightly. Respond to all threats seriously and report them as appropriate. Downplaying violent behavior places all the staff at increased risk.

Putting our knowledge to practice

Clinical Scenario 1:

You are nurse in a busy emergency room in a large urban city. You are the triage nurse and you are assessing patients deciding who should be seen first. You are in the process of triaging a 28-week pregnant woman presenting with frank vaginal bleeding when an inebriated patient with a 3 inch cut on his hands he sustained from a bar fight approaches you in the waiting room. He is demanding to be seen first since he arrived before the pregnant patient. He doesn’t understand why he should have to wait just because she is pregnant. 


First, acknowledge him then ask to be excused while you get a coworker’s attention to assist you in promptly processing the pregnant patient. The pregnant patient must be processed expeditiously given that her symptoms could potentially be life threatening. Allow your coworker to take over caring for the pregnant patient since you established first contact with the agitated patient. Be sure that you come back as soon as possible to assess whether or not the patient is a threat and at risk for becoming violent. Be mindful you should be gleaning from your interaction with the patient within a couple of minutes whether or not he is amenable to de-escalation using verbal techniques. If he is, calmly give him a reasonable expectation about when he should expect to be admitted. If he is not amenable to de-escalation, calmly excuse yourself and get security. Regardless of his reaction, you should not turn your back on the patient, always maintain a safe exit and set clear limits. Be sure to brief other staff members about your interactions with the patient. 

Clinical Scenario 2:

You are a nurse working on pediatric floor where you are taking care of a 6-year-old girl who sustained burn injuries a few days ago. The police visited the floor that morning and informed the nursing staff that her father was a person of interest in their investigation but they are having some trouble locating him. The mother reports that she is estranged from her husband and has been so for the past 4 days. Now the father arrives on the floor, appears inebriated, and demands to see his daughter stating he would never try to hurt her knowingly. 


Calmly excuse yourself, immediately call security and notify the police as soon as possible. Do not allow him in to see his daughter until assured it is safe to do so by law enforcement. Remain calm and be sure to notify other staff members. Do not turn you back on the agitated parent and keep a safe distance, allowing space for exit. Do not try to detain him if he tries to leave on his own. Just be sure to report his route of exit to security as well as to the police. Do not disclose that he is wanted by the police as this could incite a violent reaction. 

Select one of the following methods to complete this course.

Take TestPass an exam testing your knowledge of the course material.
Reflect on Practice ImpactDescribe how this course will impact your practice.   (No Test)


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