The definition of workplace violence is complex, multifaceted, and ambiguous. The challenges in establishing tracking and monitoring systems inevitably lead to an under-reporting of workplace violence, which can then have ramifications in developing clear policies in the workplace [4]. The terms used are confusing and can contribute to a lack of consensus regarding an overall definition. For example, terms used in the literature include: workplace bullying, workplace aggression, workplace abuse, workplace harassment, horizontal violence, and mobbing [5]. In this course, a workplace is defined as a location where an employee, whether employed on a temporary or long-term basis, performs tasks related to his or her job description [5].

These perpetrator types parallel the categories identified by OSHA. OSHA has differentiated workplace violence perpetrated by strangers (Type I), co-workers (Type II), or service recipients (Type III) [7].

In addition to perpetrator types, workplace violence may also be categorized by the quality of the behaviors. Workplace violence may be classified according to the type of behavior and manner in which harm is inflicted [16,140]:

Studies have not yielded definitive conclusions about the magnitude of workplace violence when service workers provide care in the homes of patients. It is believed to be more prevalent than other sectors because, although workplace violence is a hidden problem in general, it is even less visible for caregivers working in residential care settings or in private homes. It has been estimated that nursing home workers experience more aggressive incidents while caring for their patients, leading to more lost workdays compared with human service professionals in other sectors [24]. The "behind closed doors" nature of the work for homecare workers can exacerbate the sense of isolation, fear, and anxiety for those who experience workplace violence, and working in patients' homes offers no immediate organizational structure or available support [6,25]. However, a study conducted by Büssing and Höge in Germany offered a different picture [6]. A total of 1,314 surveys were mailed out to 105 home care services. From this initial contact, 721 questionnaires were returned from 97 home care services, which represented a response rate of 55%. Compared with studies conducted among other healthcare sectors, the majority did not rate high agreement to experiencing general workplace violence and aggression. The authors speculated that perhaps their definitions of workplace violence affected the results. Furthermore, there is a possibility that the higher degree of autonomy among patients living at home compared with a hospital or residential setting might minimize the amount of violence perpetrated.

Another type of violence that may occur in the workplace is domestic violence, also referred to as intimate partner violence. Domestic violence is a worldwide problem and predominantly affects women. Although women can be perpetrators of domestic violence and violence does occur in some same-sex relationships, the World Health Organization (WHO) confirms that the overwhelming burden of partner violence is borne by women at the hands of men [88]. Therefore, this section of the course will focus on domestic violence against women. Results of 50 different population surveys around the world show that, at some point in their lives, 10% to 50% of women experience physical violence perpetrated by an intimate male partner [32]. Worldwide, the World Health Organization reports lifetime domestic violence rates ranging from 25% to 75% [148]. In 2010, the Centers for Disease Control and Prevention (CDC) conducted a large-scale survey and found that 35.6% of women and 28.5% men in the United States had been raped, stalked, or physically abused by an intimate partner [97]. Among victims of rape and sexual assault in the workplace, 80% are female and 20% are male. In 2003, homicide was the second leading cause of death on the job for women [35]. Overall, domestic violence incidents account for slightly more than one-quarter of all workplace violence incidents [35].

Extensive literature reviews have highlighted reasons that workplace violence is under-reported [40,99,122,151]:

Characteristics associated with a specific job are correlated to risk of experiencing workplace violence. Research indicates that employees who work nighttime hours (e.g., 3 p.m. to 11 p.m.) are more likely to experience all types of workplace violence than those working daytime hours (e.g., 7 a.m. to 3 p.m.) [44,119,153,154]. Findings of another study of emergency departments in Turkey also indicated that working a night shift increased the risk for experiencing violence [28]. Periods of increased activities and less surveillance, such as visiting hours or mealtimes, are another risk marker. Working in a geographically isolated area is also a risk factor [155].

Lack of security is also a risk factor [154]. In a focus group study with 22 nurses, the participants identified the presence of security as instrumental in preventing workplace violence [55]. The nurse participants emphasized the importance of security staff who were specifically hired by the organization (and not by an outside organization) and trained to the unique issues related to the grounds of the organization. Other security-related factors include unsecured doors, areas with poor visibility or lighting, and non-functioning alarms [155]. Overall, environments that are vulnerable to patient-perpetrated workplace violence are those with easy public accessibility, high noise levels contributing to the perceived chaos of the environment, and long waiting times [91].

Long wait times are another predictor to violence perpetrated by patients and family members. In one study, researchers found that freestanding emergency departments have fewer incidents of workplace violence compared with hospital-based emergency departments. Hospital-based emergency departments take in more patients, which then creates longer wait times and leads to higher levels of patient anxiety and frustration [156].

Finally, health and mental health professionals' work often entails having one service provider solely assessing or providing a service to a client/patient. This in itself increases the risk of violence or assault [7].

Other researchers have similarly categorized injustices into two categories: procedural injustices and interactional injustices. Procedural injustices refer to the perceived fairness of the organization's decision making, formal procedures, and other mechanisms to determine outcomes [50]. Interactional injustices refer to the employees' perceptions about the quality of the interpersonal treatment they received when policies and procedures are carried out [50].

Not unlike victims' experiences with other types of violence, such as family violence, domestic violence, or witnessing a traumatic act of violence, there are a host of emotional, somatic, and psychologic reactions associated with experiencing workplace violence. Research also indicates that secondary victims of all types of violence (i.e., those who do not experience the violence directly but who hear about or witness it) experience similar stress responses. Fear reactions are common, and these responses can then lead to more serious psychologic disorders, such as depression and anxiety, and an array of somatic symptoms, such as sleep and gastrointestinal disturbances [58]. Suicidal ideation is also twice as likely to occur among those who have experienced workplace bullying compared with those who have not experienced workplace violence [161]. In a systematic review of 137 studies, sadness, shock, embarrassment, and stress symptoms were common in the short term [128]. On a longer-term basis, avoidance of the workplace was common, which also resulted in loss of work days as well as loss of confidence and good working relationships with peers and colleagues. In a longitudinal study, those who had been exposed to physical workplace violence were 1.67 times more likely to have an increased number of visits to a physician after seven years compared with those who were not exposed to physical workplace violence [162].

Post-traumatic stress disorder (PTSD) and acute stress symptoms are also common. Interestingly, Rogers and Kelloway found that fear symptoms surrounding future workplace experiences appear to play a role in triggering a host of mental health and physical symptoms [59]. There also appears to be an association between nurses' productivity levels and exposure to patient violence. Although nurses indicate that they are generally able to continue working at their usual pace after the violence, they have more difficulty remaining focused after the incident [102].

Confidentiality and the limits it imposes are key ethical issues that emerge when discussing the topic of workplace violence. Generally, healthcare professionals and other clinicians cannot disclose information learned in a clinical setting. Yet, the question is: Should protecting the privacy and maintaining the confidence of a patient's disclosure outweigh the greater social good?

Borum and Reddy argue for the need to have a fact-based line of inquiry when clinicians work with patients who may be a risk to others [63]. They maintain that clinicians should consider: Is the client on the path towards violence? If the answer is affirmative, how fast is the client moving and where can one intervene? Although this line of inquiry was not specifically developed for the workplace, it can be applied to workplace violence perpetrated by patients or clients. To help answer these two questions, further assessment may be conducted and information garnered in six areas, which may be remembered by the acronym ACTION [63]:

Many experts maintain that the occurrence of any type of violent or abusive incident, including workplace violence, is not necessarily a single incident but can be conceptualized as a chain of events [64]. In terms of healthcare workplace violence, this cycle is most applicable to violence perpetrated by patients/clients or service recipients (OSHA's classification Type III). Understanding the phases and stage-specific characteristics of violence or aggressive behaviors can assist clinicians and other helping professionals to determine the appropriate tasks and interventions for each stage of the crisis. It may also help to reduce the tendency to pathologize the perpetrator, ultimately promoting autonomy and dignity.

The first phase of the perpetrator's cycle of violence involves experiencing rising emotions. This phase is characterized by a sense of unspecified panic or anxiety. The perpetrator may not necessarily be able to name his or her feelings or associate these emotions to the event (whether real or imagined) [64]. The goal in this phase is to help the individual identify and discuss the problem. If the perpetrator is unable to identify and address the problem in the first stage, he/she then enters the second stage.

The second phase is characterized by an escalation of inner anxiety and a mounting feeling of loss of control. This causes the individual to attempt to regain control through the use of threats, abuse, and/or verbal intimidation [64]. During this phase, clinicians should assist perpetrators in redirecting their feelings toward arenas in which they feel some degree of control. Practitioners often miss or fail to recognize anxiety and stress cues [152]. Work should also be continued in identifying and discussing the problem. At this point, staff and other relevant persons should be alerted to the situation [64].

The third phase of the cycle of violence is called the crisis stage. In this phase, the individual uses aggressive behaviors to regain a sense of control. McAdams and Foster note that this may also symbolize a "primitive plea for external intervention" [64]. Clinicians should take steps to ensure the individual's safety as well those around him/her. Interventions must be clear and firm in regards to what is needed and expected [64].

The fourth stage is recovery and involves a decline in the individual's crisis symptoms. However, the individual may continue to feel angry or frustrated and may be resistant to interventions. Therefore, clinicians should continue working to ensure the individual's safety and to identify a resolution [64].

After a critical incident, it is imperative for agencies to help in the victim's recovery by providing support, education, and referral services. A critical incident is defined as the acute stress response normally experienced after a traumatic event. During a crisis, the range of physical and psychologic responses is often so overwhelming and intense that it taxes the individual's normal coping experiences; anxiety and numbness often follow [9]. Debriefing is a crisis intervention that aims to reduce stress symptoms [65]. This, along with defusing (e.g., giving the traumatized individual an opportunity to vent emotions about an event) may be helpful for many victims [104]. However, debriefing is not considered a replacement for psychotherapy [9]. The debriefing and defusing process should begin within 24 to 72 hours of the incident [66,104].

Lewis, Coursol, and Wahl have recommended bibliotherapy for victims of violence, which involves providing educational information, such as books and pamphlets about workplace violence [67]. Information regarding available sources for this information is provided later in this course. Bibliotherapy is done within the context of the therapeutic experience.

Environmental assessment entails service providers evaluating the work environment, such as office spaces, cars, and for those professionals who conduct home visits, their clients' residences and neighborhoods, for violence risks and potential opportunities for self-defense [56]. For example, when healthcare or human service professionals conduct patient interviews in their offices or interview rooms, several questions regarding the environment should be raised. This includes determining the most effective room layout so the professional can exit quickly if there are visual cues that the patient is getting angry or violent. The office should be scanned for items that can easily be used by a potentially violent patient to cause harm; for example, books, ashtrays, and furniture can potentially be used as weapons [69]. It is also important to determine the extent of which the interviewing or evaluation office is visible to others. This requires a delicate balance, because it is important to promote the privacy and confidentiality of the client, but simultaneously, it is also important for the clinician to be safe [69].

The environment of waiting rooms can be potential breeding grounds for patient violence [131]. Organizations should evaluate the mechanisms in place to manage patients' emotions and safety. For example, what can be done to keep the environment peaceful and calm? What mechanisms are in place to reduce waiting times or to communicate waiting times most effectively [131]? What security measures are in place (e.g., cameras, patrols) [132]?

Workers' vehicles are often taken for granted. However, maintenance issues are important, particularly for staff who work late at night or who conduct home visits in unfamiliar neighborhoods [56]. Staff members should have their keys readily available when they walk to their cars, and they should check the back seats before getting in their vehicles. Items that place a car at risk of being vandalized, such as a supply of psychotropic medication, should be put away or not left in the vehicle.

Verbal strategies to de-escalate tension in cases in which clients have weapons can also be effective. When clinicians talk to clients in a calm and rational manner, both clinicians and the clients suffer less physical injury or property damage than when clinicians opt to use verbal or physical aggression [74]. Active listening skills are helpful and involve appropriate eye contact and body language, empathizing, and paraphrasing to convey understanding [69]. Clinicians should also be aware of their tone, volume, rate, and rhythm of speech, also referred to as paraverbals. If not careful, paraverbals can convey the opposite of what is communicated verbally [75]. Empathetic listening and communication can help to de-escalate violent situations [105]. Instead of trying to suppress emotions, listening and talking through the frustration can help mitigate potentially violent anger.

For some practitioners who witness workplace violence, compassion fatigue, secondary traumatization, and burnout are typical consequences. Compassion fatigue is a relatively new term, coined in 1992, and is meant to convey a nonpathologic concept [77]. It is a natural consequence of the emotions that stem from either witnessing or knowing about a traumatic event or daily continual contact with those who are suffering [77]. Secondary, or vicarious, traumatization is defined as "transformation of the inner experience of the therapist that comes about as a result of empathic engagement with clients' trauma material" [78]. Vicarious traumatization can cause emotional and cognitive arousal symptoms, such as increased emotional sensitivity, lack of well-being, intrusive thoughts, and difficulty concentrating [79]. Finally, burnout has been defined as physical and emotional symptoms that are linked to the workplace experience, ranging from working with clients to environmental components of the workplace [79]. The practitioner experiencing burnout feels exhausted and, at times, emotionally detached from clients [79]. In one study, Levine, Hewitt, and Misner found that nurses withdrew from their patients after an incident of workplace violence [55].

It is important to view occupational policies regarding workplace violence in the context of the range of different types of organizational responses to incidents of workplace violence or bullying. Ferris divided organizational responses into three categories: "See no evil, hear no evil, and speak no evil" [80]. Organizations that fall into the "see no evil" category acknowledge the existence of workplace violence or bullying but normalize the behavior. When affected staff members approach the employer, they are told to toughen up and to learn how to deal with the behaviors [80]. Organizational responses identified as "hear no evil" acknowledge the problem but frame it as an interpersonal conflict. The victim is often blamed for somehow triggering the negative behaviors due to his or her personality [80]. The third and final response is classified as "speak no evil." These organizations acknowledge the problem and its deleterious effects. Consequently, they take allegations seriously, follow up with an investigation, and take action against the bullying or violent individual. Ferris noted that the "speak no evil" organizations had learned from previous encounters of workplace violence that had resulted in lawsuits [80]. Organizations may ask where their current policies would be categorized based on this system.

Mandates for the development of zero-tolerance violence policies have been set for healthcare organizations [7]. This sends a clear message to employees that all types of workplace violence, including harassment, are not tolerated [66]. Such behaviors should be followed up with the appropriate disciplinary action [81]. The main premise of zero-tolerance policies is that workplace violence is reduced by promoting open communication of acceptable behaviors [81]. However, it is crucial for organizations to remember that a zero-tolerance policy itself does not prevent workplace violence [167].

It is recommended that an interview be conducted with the victim and witness(es) as soon as possible after the event. The American Federation of State, County, and Municipal Employees recommends questions covering [83]: