Aggression and Violent Behavior 25 (2015) 314322

Contents lists available at ScienceDirect

Aggression and Violent Behavior

Measures for incident reporting of patient violence and aggression

towards healthcare providers: A systematic review
Colleen L. Campbell a,, Mary Ann Burg b, Denise Gammonley b
a
NFL/SG Veterans Health Administration, Geriatrics and Extended Care
b
University of Central Florida, College of Health and Public Affairs

a r t i c l e i n f o a b s t r a c t

Article history: Patient violence and aggression towards healthcare providers is a signicant health and public affairs problem
Received 9 March 2015 receiving international attention. Such violence is found to occur regardless of healthcare setting or provider dis-
Received in revised form 18 September 2015 cipline. However, most of the evidence of a high frequency of incidents perpetrated against providers is anecdotal
Accepted 30 September 2015
and solid data on the prevalence of these incidents is not yet available. Studies have shown that accurate incident
Available online 9 October 2015
reporting remains one of the primary impediments to creating organizational policies and procedures to ensure
Keywords:
the safety of the clinical direct care healthcare provider. Yet there is no clear evidence base currently existing to
Incident reporting suggest what measures are of most utility in remedying this underreporting. This article contributes to the liter-
Patient violence ature by conducting a systematic review of existing instruments designed to measure and report incidents of pa-
Client aggression tient violence against health care workers. It is hoped that this review of existing measures will stimulate health
Measures care agencies to employ routine provider reporting mechanisms in order to increase provider reporting, improve
Systematic review the data on patient violence and consequentially work towards combatting this public affairs problem.
Published by Elsevier Ltd.

Contents

1. Background. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 314
2. Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 315
2.1. Search method . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 315
2.2. Selection criteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 315
3. Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 316
3.1. Literature reviews/conceptual articles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 316
3.2. Researcher developed measures on incident reporting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 316
3.3. Validated instruments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 317
3.4. Unique measures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 318
3.5. Psychometrics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 319
4. Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 321
5. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 321
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 321

1. Background The World Health Organization (World Health Organization, 2002)

In the late 1990's the World Health Assembly acknowledged that
workplace violence is a problematic public health issue and in 2002
Corresponding author at: VHA Geriatrics and Extended Care, Home Based Primary
Care at TVOPC, 8900 SE 165th Mulberry Lane, Room 159A, The Villages FL 32616.
E-mail address: Colleen.Campbell4@va.gov (C.L. Campbell).
began producing the World Report on Violence and Health (Krug,
Mercy, Dalberg, & Zwi, 2002). This international attention informs
both practitioners and scholars that workplace violence warrants atten-
tion. While violence is a well explored phenomenon, exploration of
workplace violence in the healthcare sector remains in its infancy
(Campbell, McCoy, Hoffman, & Burg, 2014; Galinsky et al., 2010). In
2008, this topic began to receive additional attention, with the

http://dx.doi.org/10.1016/j.avb.2015.09.014
1359-1789/Published by Elsevier Ltd.
 C.L. Campbell et al. / Aggression and Violent Behavior 25 (2015) 314322
convening of the International Conference on Violence in the Health
Sector and the WHO acknowledgment that workplace violence occur-
ring in the healthcare setting is an international problem (Needham
et al., 2008).
The WHO denes workplace violence as incidents where staff are
abused, threatened or assaulted in circumstances related to their
work... involving an explicit or implicit challenges to their safety, well-
being or health (O'Brien-Pallas, Wang, Hayes, & Laporte, 2008). The Na-
tional Institute of Health and Safety denes workplace violence as vio-
lent acts, including physical assaults and threats of assault, directed
towards person at work or on duty (1996, p. 1). Within the overarching
umbrella of workplace violence in the healthcare sector, there exist
three main forms of violence: lateral violence (worker on worker vio-
lence), provider towards patient violence and patient or client violence
towards the provider. It is this nal form of violence that is the target of
this review.
The terms client violence and workplace violence are used inter-
changeably in the literature to describe the phenomenon of acts of ag-
gression (verbal and physical) by the client towards the provider.
Looking specically at this form of workplace violence, the National
Task Force on Violence against Social Care Staff denes client violence
as incidents where persons are abused, threatened or assaulted in cir-
cumstances relating to their work, involving an explicit or implicit chal-
lenge to their safety, well-being or health (Department of Health, 2000,
p. 7). Complimenting denitions have been found in scholarly literature
dening client violence as any incident in which a helping professional
is harassed, threatened, or physically assaulted by a client in circum-
stances emerging for the course of the professionals' work with the cli-
ent (Macdonald & Sirotich, 2001, p. 109) and as actual physical
assault, threats, or any other event the individual worker may deem as
violent. The violent incident may also be dened by the worker's per-
ceptions and the context in which the incident occurred. (Spencer &
Munch, 2003, p. 534).
For the purposes of this review, patient violence and aggression are
dened as verbal assault and/or physical assault. Verbal assault includes
expressions of intent to cause harm, cussing, yelling, sexual advances,
and sexual gestures. Physical assault is dened as hitting with body,
hitting with object, slapping, kicking, being punched, being scratched,
being bit, hair pulled, object thrown, spit at, pushed, pulled, squeezed
and the existence of sexual contact. In this study, violence and
aggression of the patient towards the healthcare provider were used
interchangeably.
Healthcare workers are among a group of workers that are subject to
some of the highest rates of these violent incidents (Janocha & Smith,
2010); studies have found that as many as 92% of healthcare workers
have experienced abuse or violence by patients, including threats, as-
sault and sexual harassment (Franz, Zeh, Schablon, Kuhnert, &
Nienhaus, 2010). The research overwhelming suggests that health
care workers are at a heightened risk of experiencing client violence
compared to other helping profession, estimated 16 times higher for
health care workers than for any other service profession (Hinson &
Shapiro, 2003; Kingma, 2001; Smith-Pittman & McKoy, 1999). Conse-
quentially, the National Institute of Occupational Safety and Health
(NIOSH) and the Occupational Safety and Health Administration
(OSHA) have dened guidelines for workplace violence prevention
and response protocols in healthcare organizations, with evidence that
an integrated organizational perspective is required. Such an ap-
proach should incorporate explicit workplace violence monitoring
tools, differentiated training for staff and a predetermined response pro-
tocol (Leather, Lawrence, Beale, Cox, & Dickson, 1998). However, mech-
anisms for these recommended monitoring tools for reporting patient
violence and aggression are often lacking, resulting in extensive under
reporting of incidents (Campbell et al., 2014; Franz et al., 2010;
Macdonald, Lang, & MacDonald, 2011).
Highlighting this neglected research area, Franz et al. (2010) assert
that systematic research of the causes and consequence of aggression
315
and violence towards employees in the health care system... are still
being neglected (p. 52). They underscore that without accurate fre-
quency and prevalence statistics, prevention and policies are complete-
ly hindered. Despite the current national and international attention
focused on patient violence and aggression in healthcare settings, pa-
tient aggression and violence towards healthcare workers remains
under reported (Fernandes et al., 1999; Gates, Ross, & McQueen, 2005;
Hesketh et al., 2003; Hutchings, Lundrigan, Mathews, Lynch, &
Goosney, 2011; Pawlin, 2008; Taylor & Rew, 2010; Zuzelo, 2010) and
that healthcare workers often fail to report incidents of client violence
(Erickson & Williams-Evans, 2000; Hutchings et al., 2011; Taylor,
2000). Accurate information on prevalence and factors contributing to
patient violence and aggression is needed to develop effective and ef-
cient interventions to combat this public affairs problem and to begin
developing policies and effective and efcient procedures to increase
reporting and to prevent such occurrences.
An evidence base is currently lacking for choosing valid and
reliable monitoring and reporting tools for healthcare providers. As
such, it is the goal of this article to contribute to the literature and
ll this gap by conducting a systematic review of existing incident
reporting tools and measures. It will provide researchers and policy
makers with an evidence based foundation for the development of
tools for incident reporting of patient violent and aggressive behaviors
towards healthcare providers and the future development of violence
prevention programs and policies to enhance the safety of healthcare
workers.
2. Methods
2.1. Search method
A systematic review of the literature over the last 20 years was con-
ducted by searching the following databases: Academic Search
Premiere, Cumulative Index to Nursing and Allied Health Literature
(CINAHL), Health & Psychosocial Instruments (HaPI), Medline,
PsycINFO, Proquest & PubMed. Keywords utilized for the search includ-
ed measures, scales, incident reporting, violence, healthcare, patient and
provider. The search was limited to articles published in English be-
tween August 1994 and August 2014. In addition to articles obtained
from this search strategy, the references of included articles were also
searched for relevance and inclusion in this review. To prevent the
search from producing articles regarding incident reporting of medical
errors and patient falls, the terms medical errors, patient safety and falls
prevention were used as exclusionary criteria in the search.
2.2. Selection criteria
Those articles which meet criteria for inclusion in this review are
those that identify and examine scales and measures examining the
constructs of patient perpetrated violence or aggression in healthcare
settings. Full text article reviews were conducted for those articles
that were questionably related to this search via only title and abstract.
Both conceptual and systematic research articles were utilized for this
review and no exclusion criteria were applied based upon type of
healthcare setting. As such, those articles included this systematic re-
view of the literature captured incident reporting measures utilized
both in inpatient hospital and institutional care settings as well as
those utilized in non-institutional, such as homecare, settings. Articles
examining lateral violence (worker on worker violence), violence per-
petrated by patient visitors in healthcare settings, and intimate partner
violence were excluded as they did not meet the specic foci required to
measure the unique form of violence perpetrated against healthcare
providers by patients. Additionally articles were excluded which were
not published in peer reviewed journals.
316 C.L. Campbell et al. / Aggression and Violent Behavior 25 (2015) 314322

3. Results Summary ndings included characteristics of harmed healthcare staff,

In total, 62 articles were included for review, 53 obtained during a
systematic review of the aforementioned databases and nine articles
obtained through inclusion of studies referenced in the originally locat-
ed literature. Fifteen of the articles focused specically on institutional
healthcare settings, including inpatient psychiatric settings (N = 5)
and hospital settings including emergency departments (N = 14); six
articles utilized a non-institutional healthcare setting. Only 11 articles
specically focused on creation of and testing of reliable and valid in-
strumentation or measures related to the concept under investigation.
Additionally three literature reviews were located, specically evaluat-
ing the conceptual and theoretical underpinnings of incident reporting
measures and rationale for use of measures with various healthcare
populations.
3.1. Literature reviews/conceptual articles
Of the conceptual articles located in this systematic search of the lit-
erature, three related literature reviews were found (see Table 1) the
most recent being the meta-analysis by Spector, Zhou, and Che (2014)
examining exposure rates to workplace violence.
The meta-analysis found that violence in nursing is an international
problem; two-thirds of nurses internationally have been assaulted or
injured by patients either physically or emotionally. The literature re-
view conducted by Pompeii et al. (2013) found that there is a greater
need for the development of improved incident reporting systems.
Pompeii et al. articulated their intent to capture what is known about
non-fatal patient and visitor violence towards healthcare workers
(articulated as Type II Work Place Violence) in hospital settings. Within
this review, the authors explored patient and provider characteristics
surrounding violence in hospital settings using Department of Health
and Human Services existing databases for capturing incidents resulting
in workplace injuries; the authors conducted a review of the DHHS Safe-
ty Reporting System (SRS), workers compensation claims and OSHA
logs. This review found the violence reporting varied by health care dis-
ciplines, with nurses contributing most reports (51%) contrasted with
nurses' aides (10%). Additionally the authors found signicant gender,
age and work experience differences in reporting: reported violence is
higher among males and younger, less experienced workers. Another
noteworthy nding of this review was that most reported violence
was physical violence resulting in injury, no events that involved verbal
abuse and/or threat of assault were captured in hospital reported data
(p. 61). The authors of this review acknowledged that their ndings
were probably limited by under reporting of incidents that occurred
since workplace violence events are not captured thoroughly (Pompeii
et al., 2013, p. 58).
Another systematic review also examining patient violence in hospi-
tal settings, was conducted four years prior, by Hahn et al. (2008).
similar to those found in the Pompeii review; males report more vio-
lence in average than women and that less experienced staff report
more PVV. The review also found that most studies distinguish two sep-
arate forms of abuse, verbal and physical abuse. Specically applicable
to this review, however, is that the review examining violence towards
the provider perpetrated by patients and visitors (patient and visitor vi-
olence PVV) suggested overwhelmingly that existing measurements to
capture PVV are often limited to researcher developed questionnaires
with questionable validity and generalizability. This is a nding sup-
ported through this systematic review as well, whereby Hahn et al., in
a later study articulated that PVV is the most dangerous occupational
hazard that healthcare providers must contend with (Hahn et al.,
2013).
3.2. Researcher developed measures on incident reporting
A limited number of the articles in this review specically identied
provider incident reporting as the study outcome of interest. Those
which do often offer researcher developed measurements and use of in-
strumentation which has not been evaluated for reliability, validity or
precision (see Table 2).
While these studies do offer signicant contributions to existing lit-
erature, they lack the rigorous evaluation of instrumentation which re-
mains lacking in this eld. One example is the cross-sectional survey of
six acute hospitals in Japan conducted by Sato et al. (2013). These au-
thors utilized a researcher developed questionnaire to examine incident
reporting with the intent of capturing incidents that were not typically
viewed by nurses as violence. The instrument that was developed by
these authors used a Likert scale to capture aggressive behavior by
type (physical/mental) and was tested for face-validity. Findings of
this review were consistent with existing literature: under reporting is
a common occurrence, is related to the form of abuse, provider charac-
teristics and patient characteristics. However, this study raises ques-
tions of generalizability due to the convenience sampling method and
lack of construct validity and concurrent validity utilized by the study.
While these shortcomings are acknowledged by the authors, this ap-
pears to be a general theme found in the literature examining patient vi-
olence: researcher developed tools to measure patient violence and
aggressive behavior are not rigorously examined prior to use.
Other examples of studies based on non-validated instruments are
common. Studies by Gacki-Smith et al. (2009), Dvir et al. (2012), Pejic
(2005), Kowalenko et al. (2013) and Kvas and Seljak (2014) have the
same shortcomings of the Sato et al. (2013) study utilizing researcher
developed measures. As an example, the 2009 study by Gacki-Smith
et al. utilized a convenience sampling method to conduct an online sur-
vey of the providers experience with patient violence and reporting in-
cidents. The 69-item researcher developed survey was developed
through the use of survey software (Survey Select Expert version 5.6),

Table 1
Articles with a conceptual focus

Authors Measures Population Type of Findings Limitations

Article

Hahn Survey of violence experienced by
et al. staff, German version revised
(2008) (SOVES-G-R). Perception of
Aggression Scale, Shortened (POAS-S)
Pompeii SRS (Safety Reporting System) and
et al. OSHA logs and Workers
(2013) Compensation claims (all
incorporated within Department of
Health and Human Services)
Spector No specic measures. Articles
et al. included ve types of violence:
(2014) physical, bullying, sexual harassment,
non-physical and other.
University hospital in
Switzerland
Examined patient against
provider (type II) WPV
within hospital settings.
Provider characteristics
were explored.
Review of nursing literature. Meta-Analysis Violence against nurses is an international Examines only exposure rates
Included 136 articles.
Systematic Most studies distinguish two forms of Limited only to inpatient
Review hospital systems. No inclusion
abuse: verbal and physical. Provider and
patient demographics impact reporting. of sexual abuse as a form of
violence.
Systematic Reporting of violence varies by discipline, This captures only reported
Review gender, age and work experience. Form of incidents and offers no micro or
violence also impacts reporting. There is a mezzo level system for
need for development of improved reporting or increasing
incident reporting systems. unreported events
problem. 2/3 of nurses have been assaulted of violence, not accounting for
or injured by patients. those unreported incidents.
 C.L. Campbell et al. / Aggression and Violent Behavior 25 (2015) 314322 317

Table 2
Studies Utilizing Researcher Developed Measures

Authors Measures Psychometrics Population Design Limitations

Chiang, Hsiao, Lin, Incident Reporting Culture
and Lee (2011) Questionnaire (IRCQ) in Taiwan
Dvir, Crisp-Han, Researcher developed
and Coverdale questionnaire examining
(2012) prevalence of threats and
assaults by patients. Qualitative
data included.
Gacki-Smith et al. 69-item online survey with
(2009) questions developed using
Survey Select Expert (version
5.6) software
Kowalenko, Gates, Safety Scale, researcher
Gillespie, developed instrument.
Succop, and Condence Scale, researcher
Mentzel (2013) developed instrument.
Researcher developed violent
event surveys followed by
Stanford Acute Stress Reaction
Questionnaire (SASRQ).
Healthcare Productivity Survey
(HPS).
Kvas and Seljak Researcher developed
(2014) questionnaire.
Pejic (2005) Researcher developed
questionnaire adapted from
Verbal Abuse Scale.
Sato, Wakabayashi, Assess barriers to reporting.
Kiyoshi-Teo, and Researcher developed
Fukahori (2013) questionnaire to examine ve
domains of incident reporting.
Factorial construct,
criterion-related validity,
homogeneity and stability of
IRCQ and perceptions of IRCQ
None offered.
No validity or psychometric of
survey questions used
Safety and Condence
instruments reported face and
content validity. Content and
construct validity, internal
consistency reliability and test
retest reliability were reported
for the HPS.
None offered
Focus group of 10 nurses for
content validity. 21 nurses
participated in test-retest
evaluation of the measure.
Face validity only. Noted no
construct or concurrent validity
of instrument
Examines perceived N = 1064 nurses, Conducted in Chinese, possible
incident reporting response rate 83% concerns regarding validity
culture. Hospital and reliability of translations.
nurses in Taiwan Focuses on all forms of
incidents
Examined psychiatric N = 204, response rate Very low response rate.
residents from 13 39% Limited scope with sole focus
psychiatry programs. on physical assaults.
Emergency Nurses Convince sampling of Sampling methodology, no
Association (ENA) professional associationrestriction of multiple
members were membership. submissions, lack of validation
offered online survey of instrument.
Healthcare workers in Longitudinal Limited to institutional
emergency repeated-methods design settings, specically
departments. with monthly data emergency departments. No
collection at rigorous psychometrics were
6 emergency offered on the researcher
departments. N = 213 developed instruments.
health care workers
completing monthly
reports.
Nurses and midwives 3-level stratied sampling Very limited response rate
in Slovenia from national registry of
nurses and midwives.
Survey, N = 692 out of
3756 provided with
questionnaire
Registered periodic Descriptive study Limited to descriptive
nurses working on N = 35 examination of verbal abuse
pediatric units. among pediatric nurses in
limited geographic area. Small
sampling size and
non-randomized sampling
technique.
6 acute care hospitals N = 1953, response rate hospital setting only.
in 2 regions of Japan. 76.7%, 1385 nal sample. Convenience sampling,
Nurses (Hospital, Questionnaire based researcher developed
Nursing, Reporting) cross sectional study instrument

and not subjected to any pilot testing or rigorous psychometric
methods. Nonetheless, under reporting was one of the ndings of this
study, and barriers to incident reporting were discussed.
Kvas and Seljak (2014) also utilized a researcher developed ques-
tionnaire to survey 629 nurses and midwives in Slovenia. While this
study supported prior ndings that there is an association with age, ed-
ucation and experience of healthcare providers and their reporting inci-
dents of patient aggression and that there is a difference in reporting
based upon the form of abuse perpetrated and characteristics of the ag-
gressor, the study also failed to use rigorously tested and validated mea-
sures to collect this data.
Chiang et al. (2011) surveyed 1064 nurses in ten teaching hospitals
in Taiwan, Chiang et al. (2011) with a researcher developed scale, enti-
tled the Incident Reporting Culture Questionnaire (IRCQ). However, this
study includes extensive testing of the measure's psychometric proper-
ties. Developed by the authors from interviews with expert panels, the
IRCQ consists of 20 items using a 5-point Likert scale format to measure
cultural elements, such as perceptions of need for personal space and
language barriers, which contribute to reporting incidents. Testing of
construct validity for this measure indicates 49.3% of the variance of
the outcome is explained using this measure. Criterion-related validity
(r = 0.42), reliability (Cronbach's alpha =0.83) and stability (interval
correlation r = 0.80) were all tested at the = 0.001 signicance
level. Despite the rigorous testing of this measurement, no additional
studies or conceptual articles were located in this review which utilized
this tool. The IRCQ focuses on all forms of incident reporting (including
incidents of medical errors and adverse events), and inquired into
reasons for failure to report incidents which include fear of negative
consequences to patients, belief no actions will be taken, and concerns
about perceptions of worker's competency.
3.3. Validated instruments
While studies located in this review that focus specically on inci-
dent reporting lack rigorous studies of the incident reporting measures,
in stark contrast, those studies which focused on the broader public af-
fairs problem of violence in the healthcare workplace were found to use
rigorously studied and examined scales and measures (see Table 3).
One such example is the Polish study by Merecz et al. (2006). This
study examined violence perpetrated against psychiatric nurses versus
nurses in other elds. With a high response rate (92%), the authors
found that the specic setting and area of specialization of nursing
staff does inuence patient perpetrated violence. However, the study
sampled only nurses and those participating in voluntary professional
development and training seminars which may have been a selective
sample of nurses. Multiple existing scales such as the Stress at Work
Scale were used in this study, and each of the measures used were
discussed in detail. The study provided a detailed report of the measures
utilized to examine prevalence of violence at work, but did not offer any
contributions regarding reported versus unreported incidents.
Similar ndings were obtained in additional studies of work place vi-
olence, such as in the study by Kitaneh and Hamdan (2012) study of
workplace violence perpetrated against physicians and nurses in Pales-
tinian hospitals. The cross sectional study (N = 271) utilized a
318 C.L. Campbell et al. / Aggression and Violent Behavior 25 (2015) 314322

Table 3
Examination of Existing and Studied Measures

Authors Measures Population Design Limitations

Hahn et al. (2013) Survey of violence experienced by staff,
German version revised (SOVES-G-R).
Perception of Aggression Scale, Shortened
(POAS-S)
Joa and Morken (2012) Use measures developed by Magin, Adams,
Ireland, et al. (2005), Magin, Adams,
Sibbritt, et al. (2005). Contributes to use of
Magin et al. questionnaire and inclusion of
patient/provider factors
Kitaneh and Hamdan Used survey developed by di Martino
(2012) (2002) where extensive focus groups were
used to develop a survey.
Magin, Adams, Sibbritt, 60-item questionnaire developed after
Joy, and Ireland Magin, Adams, Ireland, et al., 2005
(2005) qualitative study. Focused on
demographics of provider, experience and
form of violence
Magnavita (2014) Violent Incident Form (VIF) developed by
Arnetz and Arnetz (1998)
Merecz, Rymaszewska, Stress at Work Scale, General Health
Moscicka, Kiejna, and Wuestionnaire, Maslach Burnout
Jarosz-Nowak (2006) Inventory, Work Satisfaction Scale. Stress professional trainings
at Work Scale
Talas, Kocaoz, and 36-item questionnaire on types of violence, Emergency Department of 6 N = 270 hospital ED staff
Akguc (2011) adapted from Senol-Celik and Baraktar's
(2004) questionnaire
University hospital in
Switzerland
Primary Care after hours.
20 PC clinics, all providers
RNs and MDs in 5 public
hospitals Stratied random
sample N = 240, 88%
response rate
Urban GPs in Australia
20033009 HCWs from a
public health care unit
reporting aggression
Nurses sampled from
participants at voluntary
(psychiatric vs. non
psychiatric nurses)
hospitals in Ankara Turkey
Retrospective cross Limited to patient and visitor violence and
sectional survey (detailed risk factors, not to indecent reporting. Also
in Hahn et al., 2008) questions of generalizability due to language
utilized.
Cross-sectional. Mailed Findings consistent with Magin, Adams,
survey. N = 536, 75% Ireland, et al., 2005; Magin, Adams, Sibbritt,
response rate et al., 2005 studies, add provider discipline as
factors. Does not examine incident reporting.
Cross-sectional, Institutional setting,
self-administered
questionnaire
mail and f/u mail of Examined violence, but not specic incident
questionnaires of 1085 reporting. Urban setting only
members of 3 urban
divisions of GPs.
N 698, 96.5% response Examined WPV, did not evaluate incident
rate. Providers surveyed reporting nor determine prior actions. Did
during routine medical not capture those not receiving exams.
examinations
N = 446, District Limited discipline examined and also not
Chamber of Nurses and examine specically incident reporting.
Midwives in Poland.
More than 1/2 of the survey respondents
indicated they had never reported the
violence. Small number of respondents does
not examine formal incident reporting
structures.

previously developed scale with researcher adaptations to meet the
specic needs of their study. Magnavita (2014) also utilized a previously
developed scale to measure the existence of workplace violence, the Vi-
olent Incident Form (VIF), created by Arnetz and Arnetz, 1998. The VIF
has been found to have good reliability (Spearman-Brown coefcient =
0.91). Similarly, Talas et al. (2011) utilized a 36-item questionnaire,
based on the 1998 Arnetz study, to measure and dene workplace vio-
lence and the sources of such.
Examining workplace violence targeted at urban general practi-
tioners, Magin, Adams, Sibbritt, et al. (2005) offer another example of
the development and utilization of a well-studied measure. These au-
thors utilized a 60-item questionnaire that had been developed through
the results of a qualitative study two years prior (Magin, Adams, Ireland,
Heaney & Darab, 2005). The developed measure examined provider de-
mographics, provider experience, form of violence and patient charac-
teristics to assess the contribution of each of these factors to the
experience of occupational violence. This measure of occupational vio-
lence was further examined as recently as 2012, examining the associa-
tions between specic provider characteristics and form of violence (Joa
& Morken, 2012). Using rigorous statistical analysis methods, Joa &
Morken utilized the Magin questionnaire and with a 75% response
rate, the authors found that variance exists among the provider's disci-
pline and years of experience and a correlation with the severity and
form of violence perpetrated. This study added that the existence of
mental health and substance abuse by the patient further contributed
to this phenomenon.
Other instruments utilized in the literature to examine workplace vi-
olence are the Survey of Violence Experienced by Staff (SOVES) and the
Perception of Aggression Scale (POAS) (Hahn et al., 2013). The SOVES
examines the interaction between provider and patient characteristics
and reporting patient perpetrated violence whereas the POAS examines
provider attitudes towards the aggression. These instruments were also
tested for reliability and validity, and the Hahn et al., 2013 study found
that provider characteristics (demographics and experience) and
patient characteristics (diagnosis and demographics) both contribute
to the perception of and occurrence of patient perpetrated violence.
The ndings in these aforementioned studies that there is a strong
relationship between patients with mental health and substance related
diagnoses and the perpetration of violence, and the ndings that pro-
vider discipline, gender and years of experience all contribute to the
likelihood of having experienced violence. The Magin, Adams, Ireland,
et al. (2005), Magin, Adams, Sibbritt, et al. (2005), Joa and Morken
(2012), Hahn et al. (2013) and Magnavita (2014) studies tell us that
both provider and patient characteristics inuence the perpetration of
violence by patient towards provider and by inference that such ele-
ments should be included when examining patient violence towards
health care workers. However, none of these studies examined or re-
ported whether such incidents were reported in any formal ways in
the workplace.
3.4. Unique measures
There were three studies located in this systematic review that were
conducted on a larger scope, examining the issue of workplace violence
at national and international levels (see Table 4).
Two studies on prevalence and prevention of workplace aggression
were conducted on the national level in Australia (Hills et al., 2011,
2013) and one international study was conducted surveying health
care workers in Brazil, Bulgaria, Lebanon, Portugal, South Africa,
Thailand and Australia (di Martino, 2002). These studies are unique in
that they captured data on much greater scales than that conducted
by the aforementioned studies with smaller samples sizes and limita-
tions of generalizability.
The Hills et al. studies utilized an Australian national database
consisting of responses to an annual survey (the Medicine in
Australia: Balancing Employment and Life, MABEL) of the Australian
healthcare workforce. Measuring the frequency and prevalence of
workplace aggression experienced by doctors, the survey obtains
 C.L. Campbell et al. / Aggression and Violent Behavior 25 (2015) 314322
Table 4
Unique Measures
Authors Measures Population
di Martino (2002) Synthesis report of country case studies None offered, extensive focus
(Brazil, Bulgaria, Lebanon, Portugal, groups to develop the survey
South Africa, Thailand and Australia
Hills, Joyce, and Humphreys Uses MABLE, a national survey of GPs in None offered
(2011, 2013) Australia
information on experiences perpetrated by patients, patient family and
visitors, coworkers, and others. Findings from the MABEL survey indi-
cate that greater than 70% of GPs experience verbal aggression and al-
most one-third have experienced physical aggression over the past
year. While no information was provided about the psychometrics
of the national survey used to collect this data, which the authors ac-
knowledge as a current limitation of ndings, the Hills et al. (2011,
2013) research is the only study located in this review that presents a
national approach to examining the public affairs problem of workplace
violence.
The international study surveying healthcare workers was conduct-
ed in collaboration with the International Labor Ofce (ILO), the Inter-
national Council of Nurses (ICN), the WHO, and Public Services
International (PSI) was obtained. Summarized by di Martino (2002),
the international review examined workplace violence in seven coun-
tries (Brazil, Bulgaria, Lebanon, Portugal, South Africa, Thailand and
Australia) to develop a cross cultural understanding of violence in the
healthcare sector and identify underlying themes. The review conduct-
ed surveys of workplace violence, dening the issue as incidents where
staff are abused, threatened or assaulted in circumstances related to
their work... involving an explicit or implicit challenge to their safety,
well-being or health including both physical and psychological vio-
lence (di Martino, 2002, ix). Findings from this study are consistent
with others in the literature: violence at work is a signicant public
health problem, healthcare workers have some of the highest rates
of violence perpetrated against them and violence is chronically
underreported. The ILO/ICN/WHO/PSI study found that incidents of vio-
lence in the healthcare sector are extremely under reported, to a much
greater degree than was previously identied.
In Bulgaria, in two-thirds of the cases of physical violence, the re-
spondents... did not report the incident to anybody In Thailand,
38% of victims pretended that nothing had happenedIn South
Africa, particularly in the case of psychological violence, many inci-
dents were unreported and when reported, the vast majority of
cases no action was taken... In Portugal, only 17% of the victims re-
ported the incident in writing... In Australia, only between 8 and 12%
of all incidents were reported (di Martino, 2002, p. 2930).
What was unique of this study, aside from the extremely large sam-
ple size (N = 6099) and international collaboration in development of
the survey, is that the instrumentation utilized encompassed both
quantitative and qualitative measures and was widely adapted to ac-
count for cross-cultural differences by multiple focus groups: four
focus groups in Brazil, six focus groups in Bulgaria, three focus groups
in Lebanon, twenty-eight semis structured interviews with 28 stake-
holders in Portugal, 18 focus groups in South Africa and 15 focus groups
in Thailand. While the publication does not offer further details or any
psychometrics of this rigorously developed measurement instrument,
other studies, on a smaller scale, do provide such evaluations of their
instrumentation.
3.5. Psychometrics
There were a limited number of articles (totaling 12) in this
review that were either solely dedicated to examining existing
319
Design Limitations
N = 6099 in multiple countries, stratied random
healthcare providers in all levels. sampling across
countries
Doctors practicing in Australia Annual national survey of
providers
instrumentation, including psychometrics (N = 7), (Altinbas, Altinbas,
Turkcan, Oral, & Walters, 2011; Douglas & Belfrage, 2014; Douglas
et al., 2014; Franz et al., 2010; Nijman, Bowers, Oud, & Jansen, 2005;
Yudofsky, Kopecky, Kunik, Silver, & Endicott, 1997) and developing re-
visions or new instruments (Hallsteinsen, Kristensen, Dahl, &
Eilersten, 1998; Maguire & Ryan, 2007; Nijman et al., 1999; Ryan &
Maguire, 2006; Yudofsky, Silver, Jackson, Endicott, & Williams, 1986)
(N = 5) (see Table 5).
One example of an instrument utilized solely to report incidents of
patient aggression or violence is the Overt Aggression Scale (OAS). The
OAS has been used to register and rate patient violence, specically
within secured inpatient psychiatric units (Altinbas et al., 2011;
Hallsteinsen et al., 1998; Yudofsky et al., 1986). The objective of the
OAS is to allow providers to objectively rate acts of patient aggression.
The measure examines four areas of aggression: verbal aggression,
physical aggression towards inanimate objects, physical aggression to-
wards others and physical aggression towards oneself (Altinbas et al.,
2011). The tool has been found to be a parsimonious tool of utility for
rating events of both children and adults (Yudofsky et al., 1986).
While this instrument has been found both reliable and valid, only
two of the four components of the measure are applicable in the in-
stance of patient aggression or violence towards the provider.
Taking the OAS one step further, Yudofsky et al. (1997) developed
and examined the Overt Agitation Severity Scale (OASS). The OASS ex-
pands the scope of the OAS, to examine not only the form, but the sever-
ity of the patient aggressive incident. The OASS has twelve categories of
aggressive behavior, consisting of 47 observable patient characteristics,
where healthcare provider may rate the existence of behaviors on a
4-point Likert-type scale from mild symptoms to very severe symp-
toms. Validity of the instrument was tested by the researchers, as
were multiple measures of reliability. While the instrument was found
to have internal consistency reliability (ranging from 0.880.69) equiv-
alence reliability (r = 0.90, p-value b 0.001) and convergent construct
reliability (r = 0.81, p-value b 0.001), the OASS was found to have ex-
tremely low reliability at the 8-h mark (0.10). The authors attribute
this unexpected low reliability to the eight-hour mark being when the
effects of administered psychiatric medications were at their peak. De-
spite the strong potential for measuring observable aggressive and agi-
tated behaviors, this instrument was developed and tested only on
geriatric patients within a sole inpatient psychiatric unit. Therefore the
question of whether elements of the OASS could be extrapolated to
measure the forms and severities of aggressive behaviors in varying set-
tings and among patients with heterogenetic characteristics remains
unresolved. Indeed, evaluations of the OAS and OASS found that these
measures lacked reliability and validity when translated into formats
that could be easily lled out by staff while still clearly separate physical
and non-physical forms of aggression (Hallsteinsen et al., 1998).
Another well studied instrument identied during this systematic
review whereby scholars examined the reliability and validity of the
measure is the Historical-Clinical Risk Management-20 (HCR-20)
(Douglas & Belfrage, 2014; Douglas et al., 2014). The HCR-20, rst devel-
oped in 1995 and since revised to the 3rd version, is widely used to as-
sess risk for violence. Douglas and Belfrage (2014) assert that this
measure is in fact the most widely used instrument for assessing risk
for violence when utilizing a structured professional judgment ap-
proach to violence risk assessment. The HCR-20 identies 20 risk factors
320 C.L. Campbell et al. / Aggression and Violent Behavior 25 (2015) 314322

Table 5
Measures with Validated Psychometrics

Authors Measures Psychometrics Elements Limitations

Altinbas et al. (2011), Overt Aggression Scale Instrument has been found both measures four areas of aggression: Used almost exclusively within
Hallsteinsen et al. (OAS). reliable and valid verbal aggression, physical aggression secured inpatient psychiatric
(1998), Yudofsky towards inanimate objects, physical settings. Measure lacked reliability
et al. (1986) aggression towards others and physical and validity in formats that could
aggression towards self be easily lled out by staff
Douglas and Belfrage Historical-Clinical Risk Inter-rater reliability on clinical items of Uses a structured professional judgment Fails to have translation for
(2014), Douglas et al. Management-20 the HCR-20 Version 3 averaged .86, approach to violence risk assessment. measuring violence and aggression
(2014) (HCR-20) single item reliability ranged in the Identies 20 risk factors for the after its
high to excellent ranges; Concurrent perpetration of violence, including 10 occurrence and does not offer
validity, signicant at p b .001 at .76 historical items, 5 clinical items and 5 measures for incident reporting
risk management items
Franz et al. (2010) Review of Staff The SOAS-R was found to have a Cross-sectional retrospective survey of Used almost exclusively in
Observation Aggression moderate relationship to the ndings of 123 individuals employed in two inpatient psychiatric settings. Sole
Scale (SOAS) and Staff the SOAS correlation 0.62. nursing homes, one psychiatric clinic study of measure in alternate
Observation Aggression and individuals participating in a settings. Low response rate, 38%
Scale- Revised (SOAS-R) disabilities workshop from low sample size.
Maguire and Ryan Scale of Aggressive and SAVE psychometrics remain lacking The SAVE modied POPAS by limiting Psychometrics are lacking with
(2007), Ryan and Violent Experiences timeframe to 1 month (from 12 months) revisions from the POPAS.
Maguire (2006) (SAVE), adapted from recall and expanding sources of
POPAS perpetrators of violence to include
potential perpetrators
Nijman et al. (1999, Staff Observation SOAS: Fair to good inter-rater reliability POPAS: Categorizes 15 forms of Further psychometrics on POPAS
2005) Aggression Scale (SOAS) found; intraclass correlation of 0.96; aggression and violence. Respondents beyond internal consistency
Prevalence of Aggression inter-rater reliability recall the over prior 12 months. Uses a remain lacking.
Scale (POPAS) Cohen's js, 0.61 and 0.74; Pearson's r 5-point Likert scale.
0.87. POPAS: high internal consistency,
cronbach's = 0.86.
Woods, Ashley, Kayton, Broset Violence Checklist Reliable in predicting violence within Uses six items to evaluate the presence BVC studied extensively; found to
and Heusdens (2008) (BVC) 24 h period: 64% sensitivity and 94% or absence of a behavior be an excellent predictor of patient
specicity and reliability, ranges from violence and aggression. Yet
r = 0.64 to 1.0. Inter rater reliability measure fails to measure incident
kappa values ranging from k = 0.481.0 reporting
Yudofsky et al. (1997) Overt Agitation Severity Internal consistency reliability (ranging OASS has 12 categories of aggressive Low reliability at the 8-h mark
Scale (OASS); extension of from 0.880.69); equivalence reliability behavior, consisting of 47 observable (0.10). Instrument developed
the OAS, expands measure (r = 0.90, p-value b 0.001); convergent patient characteristics, provider rates and tested only on geriatric
to include form and construct reliability (r = 0.81, p-value b behaviors on a 4-point Likert-type scale patients within one inpatient
severity incident 0.001) from mild symptoms to very severe psychiatric unit
symptoms

for the perpetration of violence, including 10 historical items, 5 clinical
items and 5 risk management items. Revised from Version 2, Version
3 of the HCR-20 was developed through analysis of the literature,
beta-testing of HCR-20 users and empirical testing of reliability and va-
lidity (Douglas et al., 2014). Despite the strengths of the HCR-20 in ex-
amining twenty risk factors for violence, this instrument also fails to
have translation for measuring violence and aggression after its occur-
rence and does not offer measures for incident reporting. What this
measure does offer, however, is measures of patient characteristics
(mental disorder, substance use and traumatic experiences). The
inter-rater reliability on the clinical items of the HCR-20 Version 3 aver-
aged .86, and single item reliability of the ve clinical risks also ranged in
the high to excellent ranges (Douglas & Belfrage, 2014). Concurrent va-
lidity on these items was also found, signicant at p b .001 at .76. It is
these specic items, which can be included in future developed mea-
sures when examining patient violence and providers' incident
reporting by inclusion of questions involving patient characteristics as
one of the factors contributing to provider's reporting or failing to report
the incident.
The Scale of Aggressive and Violent Experiences (SAVE), adapted
from the Perception of Prevalence of Aggression Scale (POPAS), is an-
other instrument recently developed and utilized in the literature to
measure workplace violence (Maguire & Ryan, 2007; Ryan & Maguire,
2006). Encompassing a description of types of experience which catego-
rize aggression and violence, the SAVE asks respondents to recall violent
experiences perpetrated against them in the prior month. This is the
sole noted difference between the SAVE and the POPAS, where the
POPAS requests recall over a 12-month period and the SAVE over a
1 month period. The POPAS, developed boy Oud (2001), categorizes
fteen forms of aggression and violence and asks respondents to recall
the events which were perpetrated by patients over the prior twelve
months. The POPAS, well studied within psychiatric settings, utilizes
5-point Likert scale questions ranging from never to frequently, to
have psychiatric staff estimate their experience with various forms of
patient aggression. The scale has been found to have high internal con-
sistency (Cronbach's = 0.86); what remains requiring investigation is
the validity of the POPAS assessments (Nijman et al., 2005). While the
POPAS focuses solely on patient aggression and recall of such events
over a one year period, Ryan & Maguire study modied the POPAS by
limiting the timeframe to a one month recall and expanding the sources
of perpetrators of violence to include all potential perpetrators. Psycho-
metrics on both of these measures remain lacking.
The most frequently cited and researched measure of violence and
aggressive behavior towards healthcare staff discovered during this re-
view is the Staff Observation Aggression Scale (SOAS), with 3 articles
obtained in this systematic review specically dedicated to examining
this instrument (De Neit, Hutchemaekers, & Lendemeijer, 2005;
Woods et al., 2008. The SOAS was initially developed by Palmstierna
and Wistedt in 1987 (Nijman et al., 2005) and has undergone multiple
revisions over the past 25 years to include the Staff Observation Scale
Revised (SOAS-R) and the Staff Observation Scale Extended
(SOAS-E). The original instrument was utilized to monitor patient ag-
gression with psychiatric institutional healthcare settings and to aid
staff in predicting and reporting such behaviors (De Neit et al., 2005;
Hallsteinsen et al., 1998; Woods et al., 2008). Consisting of ve columns,
the scale allows healthcare staff to record the provocation for the violent
event, the methods used by the patient, the target of the aggression, the
consequences of the incident and the measures used to stop repetitions
 C.L. Campbell et al. / Aggression and Violent Behavior 25 (2015) 314322
or exacerbations of the aggressive incident. As the original SOAS did not
allow healthcare providers to identify precursors to the violent or ag-
gressive act, the SOAS-E was developed in 1998 to include this missing
element. The SOAS-E was developed and tested, also on inpatient psy-
chiatric units, and found to have inter-rater reliability of this added ele-
ment 0of 0.78 (Hallsteinsen et al., 1998). Following the SOAS-E was the
SOAS-Revised (SOAS-R). The addition of this revision was the develop-
ment of a standardized scoring method to interpret the results pro-
duced by the SOAS. Developed and tested within six-secured inpatient
units of three psychiatric hospitals, 677 respondents completed the ini-
tial SOAS with severity scores (Nijman et al., 1999; Woods et al., 2008).
The SOAS-R was found to have a moderate relationship to the ndings
of the SOAS (correlation 0.62).
A review of the SOAS and SOAS-R was conducted 15 years after the
introduction of the SOAS, and found that the instrument continues to
be a well utilized measure of monitoring aggression (Nijman et al.,
2005). Regardless of the utility of this instrument and its revisions and
evaluations of reliability and validity of the measure, it has only been
used almost solely in inpatient psychiatric settings. Only one study lo-
cated in this review utilized this measure in alternate settings (Franz
et al., 2010). A cross-sectional retrospective survey of nurses and health
care workers was conducted in Germany, surveying 123 individuals
employed in two nursing homes, one psychiatric clinic and individuals
participating in a disabilities workshop. While the ndings of Franz
et al. offer valid and reliable ndings of the prevalence and form of pa-
tient aggression, the generalizability of the use of the SOAS in this
study is however lacking, as the authors received only a 38.8% response
rate with a low sample size.
Another measure utilized in existing literature whereby psychomet-
rics are provided is the Broset Violence Checklist (BVC) (Woods et al.,
2008). Developed in 1995, the BVC was designed to predict violent be-
havior in inpatient psychiatric units. Consisting of six items being eval-
uated for the presence or absence of a behavior, the BVC has been found
to be highly reliable in predicting patient violence within a 24 h period
with 64% sensitivity and 94% specicity and reliability on this measure
ranges from r = 0.64 to 1.0 with inter rater reliability kappa values
ranging from k = 0.481.0 (Woods et al., 2008). While the BVC has
been studied extensively and found to be an excellent predictor of pa-
tient violence and aggression, it fails to measure the construct under in-
vestigation in this review of incident reporting. What the Woods study
did contribute applicable to this review is the continued nding that
healthcare staff were underreporting instance of violence.
4. Discussion
Research suggests that ensuring accurate incident and prevalence
reporting is a key element in the prevention of client violence against
healthcare workers (Franz et al., 2010; Freyne & Wrigley, 1996;
Geiger-Brown, Muntaner, McPhaul, Lipscomb, & Trinkoff, 2012; Schulte,
Nolt, Williams, Spinks, & Hellsten, 1998). Accurate information on prev-
alence and factors contributing to patient violence and aggression is
needed to develop effective and efcient interventions to combat this
public health problem. However, under reporting of incidents of client
violence is problematic, resulting in not only a paucity of evidence of cli-
ent aggression, but also difculty in measuring the size of the phenom-
enon and trends in patient violence and subsequently contributes to the
lack of ability to devise interventions to address the safety concerns
(Bussing & Hoge, 2004; Macdonald & Sirotich, 2001).
In summary, this review suggests that the use of well-studied mea-
sures for recording instances of patient abuse or violence remains insuf-
cient. The majority of the studies were cross-sectional and utilized
researcher developed tools and measures which lacked testing on reli-
ability and validity of the instrumentation and lacked standardization
of measures. Those studies which did include discussions of validity
and reliability of measures tended to focus on the larger themes of
workplace violence, and less on the areas of interest of this study,
321
specically incident reporting. Finally, those articles which did offer
psychometrics regarding reliable and valid instrumentation also lacked
a specic focus on incident reporting.
While it is beyond the scope of this study to examine the theoretical
underpinnings of patient perpetrated violence, the articles examined
within this systematic review identify possible areas for future research
from a theoretical perspective, to include broken windows theory and
the theory of reasoned action. Also resulting from this review, inherent
in the limitations of this review, specically the exclusion of articles
which were published in a language other than English and the exclu-
sion of violence perpetrated by patient visitor, is the identication of
areas where further research is warranted. Extrapolating from the nd-
ings of this review, further research may also be of benet exploring if
the instruments and measures examined in this review are applicable
to both the institutional healthcare setting, as well as non-institutional
healthcare settings. For practicing clinicians, future studies, which col-
lect primary data from healthcare clinicians experiencing patient vio-
lence and aggression would further add to the gaps in the existing
knowledge base, to examine which of the measures examined within
this review are of the most practical utility to providers.
5. Conclusion
The problem of patient violence towards health care workers is ac-
knowledged by national and international health care organizations as
a serious workplace issue and one that requires a standardized and
comprehensive response. To date our understanding of the prevalence
of this problem and the conditions under which violence occurs is not
conclusive, although anecdotal evidence and the ndings of indepen-
dent and un-validated studies strongly suggest it is widely prevalent
and under reported. This type of workplace violence may have serious
implications for health care workers' quality of life, their work satisfac-
tion and their workforce commitment; however, to date we have no
routine reporting approaches to assess the magnitude of the problem,
to indicate targets for prevention or to inform workplace policies.
This review has conrmed that the collection of data on patient vio-
lence towards health care workers is awed by the lack of standardized
measures of patient violence and standardized workplace reporting
schemes. This appears to be a particular problem in the U.S. health
care setting since some of our international health care colleagues are
able to produce data from national incident reporting databases
allowing for large scale collection of reported incidents of patient vio-
lence. We will need a federal-level response to increase routine and
valid data collection on the problem of patient violence. Federal atten-
tion to the problem will require advocacy from health professionals
and health care organizations to push for the value of routine methods
to screen employees about their experiences with patient violence
and to create an environment wherein reporting incidents of violence
is supported by the organization. More conrmatory research is also
needed to conrm how patient initiated violence affects health care
workers' lives, including how it factors in the prediction of psychological
health, risk for burnout, work commitment, and employee relations.
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