This is the Author Accepted Manuscript (AAM) of the article published in Safety Science. This version has not undergone journal copyediting, formatting, or typesetting. The final published version is available at: https://doi.org/10.1016/j.ssci.2022.105859

Published Citation
Sheppard, D. M., Newnam, S., Louis, R. M. S., & Perrett, M. S. (2022). Factors contributing to work-related violence: A systematic review and systems perspective. Safety Science, 154, 105859. https://doi.org/10.1016/j.ssci.2022.105859

Abstract

Background & Objectives: Work-related violence is widespread, occurs across industries / occupations, has detrimental effects on physical and mental health of workers and clear implications for the workplace system. Despite this, there is limited understanding of the broad range of contributing factors. This systematic review identifies the factors contributing to WV and adopts a systems thinking framework (Rasmussen’s Risk Management Framework, 1997) to map them across the workplace system.

Methods: A systematic search across 6 databases (MEDLINE, PubMed, AMED, EmCare, SCOPUS, and PsycINFO) was conducted using keywords that specified the setting (workplace), topic (risk factors for WV), and study design of interest. The search was limited to > 18 years, and articles published in English from 2010 to July 2020.

Results: The search retrieved 1,286 articles. Following the application of eligibility criteria, a total of 120 articles were included, the majority of which were rated as moderate methodological quality (59%). The vast majority of articles were within the healthcare sector. When mapped across the workplace system the highest percentage of factors were at the Frontline staff level, followed by Governance and Administration, and Operations Management.

Conclusion: This study represents the first step in gaining a comprehensive understanding of the system of factors contributing to WV. Findings suggest more attention should be given to sectors outside of healthcare such as the public service, with an identified need for WV intervention. The findings of this study can be used to inform the development of targeted intervention to reduce WV through systemic change.

Occupational violence, otherwise known as work-related violence (WV), has been defined as, ‘the infliction, or threat, of harm or injury (either physical or psychological) upon another person’ while carrying out work-related / professional responsibilities (1). WV can range from verbal harassment, abuse and threats to bullying and intimidating behaviours, and in more serious cases intentional physical attacks. In the context of the prevention and regulation of work-related injuries, WV involves an incident in which a person is abused, threatened or assaulted in circumstances relating to their work (2). This definition covers a broad range of actions and behaviours that create a risk to the health and safety of employees.

WV is widespread at a global level. In the UK, WV is said to account for 22% of all violent crime (3).  The Crime Survey for England and Wales (CSEW) in 2013 estimated that there were 649,000 incidents of customer-perpetrated WV, comprising 332,000 assaults and 317,000 threats. Assaults included minor assault, wounding and robbery, and threats including verbal threats and non-verbal intimidation. The most recent (2019-2020) Australian workers compensation statistics (4) indicate that serious claims for being assaulted by a person or persons has more than doubled (up by 128%) since 2000-2001 which represents the largest percentage increase in any mechanism or injury or disease.

A higher prevalence of WV has been reported in occupations involving interpersonal contact with persons who have a tendency for emotional lability or violence, are health-compromised or otherwise vulnerable (5). Work-related claims data from Australia indicate that there is an over representation in the public sector of bullied workers and a higher rate of stress-based compensation claims from victims of bullying (6). Other prevalence data from the United States (7) and Australia (8) indicate that healthcare workers with patient-facing roles are at much higher risk of exposure to WV than those in other professions, including a variety of service or ‘caring’ professions. Other high risk professions are reported to include social, community and personal services (disability, youth, mental health, family protection), frontline emergency services, as well as the education and construction sectors (9-16). To illustrate, self-reported nonfatal violent data from the 2007-2010 ‘National Crime Victimization Survey’ (NCVS) from across the U.S. identified that workers in protective services (police officers, prison guards, security guards) reported the highest rates of violent workplace crimes (101 per 1,000 workers), followed by community and social services (e.g. social workers) (19 per 1,000), and healthcare occupations (5). 

Australian WV statistics also indicate that WV is commonplace, particularly for healthcare workers in the hospital system. One survey conducted in 2010 with a large cohort of nurses and midwives across the state of Victoria found that over half had experienced some form of workplace aggression within their past four working weeks (17). A later study found similar results with two out of three Australian Nursing and Midwifery Federation members of the 5,000 surveyed reporting having experienced WV in the preceding 12 months[1], and nearly one in five being exposed on a weekly or daily basis (18). Further, Australian Workplace Barometer data collected from 2009-2011 placed Australia 6^th highest for work-related bullying in comparison to 31 European countries (6).

WV has detrimental effects on the physical and mental health of the exposed worker. From a work-related injury claims perspective, in the year 2013 there were a total of 890 Australian work-related claims that could be attributed to WV (19) with more than double the number of claims made by females compared with males (11.3 vs 4.7 claims per 100 million hours worked, (19)). Similar to WV prevalence data, compensation claims for mental disorders lodged due to work-related mental stress are thought to underestimate the size of the problem, particularly in lower socio-economic jobs (20). The burden associated with WV captured by a recent framework (21) depends on the severity and type of WV, and can include direct societal (healthcare and non-healthcare related) costs, indirect workplace productivity costs and intangible costs incurred by the individual exposed associated with reduced quality of (personal and working) life (21, 22).

The majority of larger organisations undertake WV prevention activities . Occupational Health and Safety (OHS) laws (e.g. the regulations under the Victorian Occupational Health and Safety Act 2004) require employers to ensure risks to health and safety are eliminated or reduced so far as is reasonably practicable. Local Workers Compensation Boards or state and federal regulatory authorities also provide guidance and information regarding these laws and regulations to assist employers with providing a safe workplace, as is their responsibility. For instance, an employer is responsible for implementing policies that address the risk associated with the behaviour of visitors to the workplace (e.g. client’s friends and family, members of the public), including consequences for inappropriate behaviour. Employers also have a responsibility to ensure that appropriate response measures are in place wherever there are risks of WV. For example, given that a risk has been identified, workers should also be trained to respond to emergency and post-incident responses, including what to do during a WV incident.

Despite the legal requirement for risk minimisation activities, there is limited understanding of the broad range of factors contributing to WV events. This is partly due to WV often being underreported due to the stigma associated with reporting and/or a negative organisational reporting culture (23-25). In addition, the literature on WV is diverse, covering a broad range of industries and data capturing methodologies. Research is yet to adopt an integrated approach or framework to facilitate our understanding of the multiplicity of factors contributing to WV. A standardised framework is critical to developing a more comprehensive understanding of the variety of factors contributing to WV, and to then developing targeted interventions to prevent WV.

The goal of this study is to undertake a comprehensive systematic review of the literature to identify the factors contributing to WV. Importantly, this study will also adopt a systems thinking framework to map the factors contributing to WV across the workplace system. The use of system thinking models and methods in understanding incident causation has been well established and such thinking now represents an accepted approach for improving safety (26, 27); with its potential value in the WV domain also recently recognised (9). Systems thinking is underpinned by the understanding that safe system performance is dependent on the propagation of communication across all levels of the system including government, regulators and managers, not only supervisors and frontline staff (28), and that injuries arise from the interaction of multiple components across a system (e.g., 28, 29).

Until very recently, there was very little evidence of the utility of applying systems thinking in practice. The Patient Handling Injury Review of Systems (PHIRES; (30)) was developed as a tool to guide practitioners in identifying the complex system of the factors contributing to patient handling injuries. This tool was underpinned by a systems thinking classification scheme which identified factors contributing to patient handling injuries across all five levels of the healthcare system including the patient handling level (i.e. equipment and surrounding environment), frontline staff, operations management, governance and administration and government regulators and external influencers. The classification scheme was adapted from Rasmussen’s Risk Management Framework (28).

Rasmussen’s (1997) risk management framework is underpinned by the idea that work systems comprise a hierarchy of multiple levels (Figure 1). The actions and decisions of actors within and across the levels interact, and contribute to the control of hazardous processes. Safety is maintained through “vertical integration”, when decisions made at higher levels of the system are reflected in practices occurring at lower system levels, and feedback from the lower levels informs decisions and actions at the higher levels. A lack of vertical integration, and poor feedback across the levels, increases the risk of incidents (27, 31). The framework also describes how work practices constantly adapt in response to various financial and psychological pressures. This process, “migration”, causes incidents when changes in work practices erode risk control measures (28). For example, a lack of policies and procedures for dealing with aggressive clients (i.e., governance & administration level) results in supervisors not being given responsibilities for the safety management of their employees in these situations which, in turn, creates a culture where employees do not report incidence and events of WV is considered accepted practice. This example illustrates how the decisions and actions within and across level interact and contribute to incidence of WV.

Figure 1. Rasmussen’s risk management framework (adapted from Rasmussen, 1997).

Understanding WV, using the lens of systems thinking, is critical to identifying targeted and sustainable intervention and, ultimately, reducing the potential of incidents. WV is the result of interactions between many different individuals, teams, procedures, processes and technologies. The interactions between all of these elements of the system makes workers vulnerable during the normal course of their work. This vulnerability is the consequence of earlier actions and decisions cascading throughout the system which may ultimately result in an adverse event (28). Based on this, it is critical to understand the complex work systems and processes involved in WV incidents to understand incidents and errors, and design better and more resilient systems and processes. Similar to the approach taken in the PHIRES, the first step in achieving this goal is to map the unique risk factors contributing to WV onto a systems thinking classification scheme. This WV classification scheme is intended to underpin development of a tool to help guide OHS practitioners in undertaking system thinking review of an incident involving WV. This study represents the results of the first stage in this process, which involves a review of the academic literature. The end-goal is a tool that will identify the complex system of factors contributing to WV.

The goals of this study are to:

1. Undertake a systematic review of the literature to identify the broad range of factors contributing to WV.
2. Map the factors identified by the systematic review to their relevant workplace system level using an adaptation of Rasmussen’s Risk Management Framework (28).

Methods

Systematic search

The systematic review was guided using the PRISMA guidelines. A comprehensive list of search terms were initially developed to guide the search using the categories (i) primary context of the workplace (i.e. workplace, work-related, occupation*, vocation*) and OHS (Injur*, safety), (ii) outcome of violence / aggression (e.g. violen*, aggress*, verbal abus*, physical abus*, assault, harass*, bullying, threaten*) and (iii) design-related terms to help to limit the scope of the literature to papers with a focus on factors contributing to WV (e.g. caus*, predict*, risk factor, model, etc).

The search was further limited to articles published in English from 2010 to 20^th July, 2020, and included only the adult population (18+ years). Databases that were searched were MEDLINE, PubMed, AMED, EmCare, SCOPUS, and PsycINFO.

Procedure

The systematic search was conducted across the 6 databases, resulting in a total of 1,286 articles. Citations were directly imported into EndNote and 529 duplicates were identified and deleted. A subsequent title and abstract scan was conducted on the 757 remaining articles to eliminate those that were not relevant, using the following eligibility criteria:

Population: Limit to adult population as already applied to the search;Consider also excluding for major cultural differences that render the study irrelevant to the Australian workplace context (e.g. homicides in U.S. law enforcement officers)

Topic: Papers identifying one or more risk factors for WV; or factors associated with WV

Setting: Workplace setting only (exclude non-work-related violence / aggression or studies comparing both that do not differentiate factors)

Studies: Limit to studies providing empirical evidence (i.e. correlational, regression modelling studies) with WV factors as the outcome, i.e.Must show evidence of contributing factors / risk factors (across the system), i.e. exclude books, book chapters, non-empirical papers (e.g. opinion pieces), and qualitative studies. Also exclude papers describing the factor structure of tools or measures being developed for use in the workplace setting to identify contributing factors.

To ascertain the reliability of applying the exclusion criteria to the article titles and abstracts, two raters (DS, RS) applied the above criteria to 15% of the abstracts (n=114). Agreement was obtained for 108 of the 114 papers (94.7% agreement). Of those 108, 25 papers were retained for full text stage, and 83 excluded. Disagreements for the remaining 6 papers were discussed by the research team (DS, RS, SN) and consensus was reached to exclude them all. A single rater (RS) completed the abstract scanning for the remaining articles. A further 41 duplicates were identified. Of the 757 papers, a total of 607 were excluded and 151 were retained for the full text stage.

Full text screen

The purpose of the full text screen was to confirm eligibility criteria (as above). The full text for two articles could not be obtained, resulting in 150 articles for the full text screen.

Again, to ascertain the reliability of applying the exclusion criteria, two raters (DS, RS) applied the criteria to 30% of articles (n=50). Raters agreed on 44 of 50 papers (88% agreement), and a consensus meeting regarding the final 6 papers led to an additional exclusion criterion: studies focused on non-contracted “sole traders” where law prevents such work in the majority of developed countries (e.g. sex workers).

Of the 150 total articles considered at full text stage, a further 30 were excluded, including those that lacked contextual relevance (i.e. inconsistent laws / regulations RE workplace conditions), studies that included workers younger than 18 years, and those not identifying any risk factors per se, or examining risk factors from a qualitative perspective only. A total of 120 articles remained for the data extraction and quality appraisal phase.

[DS1]

Quality appraisal

A quality appraisal of the final 120 articles was conducted using Downs and Black’s (32) checklist, listed in the Cochrane Handbook (2011) as adaptable and relevant for non-RCT studies (32). The checklist items address study reporting, external validity, internal validity (bias, confounding) and power. The quality index of the checklist has high criterion validity (r = 0.90), high internal consistency (KR-20 = 0.89), test–retest (r = 0.88) and inter-rater (r = 0.75) reliability (32). As has been done by previous studies (33), the original checklist of 27 items was modified to fit the purpose of the current study. A total of 12 items relevant only to randomised controlled trials were removed from the checklist in order to fit the design of the studies relevant to the current non-RCT systematic review. The scoring paradigm of the original Downs and Black checklist was modified accordingly. Finally, as per Prang et al.(2015), the scoring for the final power-related question was modified from a scale of 0–5 to a dichotomous score of 0 (no) or 1 (yes), where a score of 1 was given if a power or sample size calculation was present.

The final checklist consisted of a total of 15 items with each item coded as either ‘yes’, ‘no’, or ‘undetermined’. In applying the criteria, if sufficient information was available and bias was considered unlikely, the item was rated as ‘yes’. If information was available and bias was considered likely, the item was rated as ‘no’. When information was not given or the information given was unclear, the item was reported as ‘undetermined’. Criteria that were coded as ‘yes’ received one point and those that were coded ‘no’ or ‘undetermined’ were allocated zero points. A simple sum over the 15 items (i.e. total of ‘yes’ responses) determined the overall quality of score, with a higher score indicating higher methodological quality. As per Downs and Black (31), studies scoring 85–100% were categorised as high quality, those scoring 60–84% were moderate quality, and those scoring 59% and below were low quality. A single rater (SN) consistently applied the criteria across the 120 articles.

Data Extraction

Data extracted from each of the 120 articles in the final sample included: type of WV (where specified); industry (e.g. healthcare, emergency services, education, public services); country / region; specifics of workplace setting / sample; and risk factors (mapped onto systems thinking classification scheme).

Mapping the identified WV risk factors onto a systems thinking OHS classification scheme

The authors used an adapted version of Rasmussen’s Risk Management Framework (27) to classify the risk factors identified within the literature at their relevant level of the system. Table 1 describes each of the five hierarchical levels of the classification scheme adapted to the WV context. Stakeholder meetings with representation from industry and work-related injury regulators were instrumental in developing the WV systems thinking classification scheme outlined below.

Table 1: WV systems thinkingclassification scheme levels and definitions (adapted from Rasmussen’s Risk Framework Framework (28))

Government, Regulators & External Influences	Factors external to the organisation such as Government and other regulatory body influences, unions and employer associations, suppliers, and other external influencers (media reporting, social media, community attitudes, emergency management response)
Governance & Administration	Conceptualised as high level, intra-organisational governance and administration influences, including management (e.g. change management, consultation, human resources, risk management, policies and procedures, incident reporting system), resources (level of funding), and leadership (e.g. safety and reporting culture, senior management commitment, key performance indicators (KPIs) / organisation priorities, communication, OHS strategies).
Operations Management	The management of operations within an organisation, including supervision (e.g. supervisor communication, quality and support, cooperation between areas), client management (e.g. risk management, care plans, records), work scheduling (e.g. rostering, staff ratios, workload, time pressure), and work systems (e.g. training, education and development, role expectations, budgets, equipment maintenance).
Frontline Staff	Individual worker and role-related factors, including work design (job control, demands, role conflict, clarity, lone worker conditions, work-related physical demands), staff / worker characteristics (e.g. communication, experience, perceptions of risk, physical or emotional fatigue, co-worker support, job satisfaction), client / consumer characteristics (e.g. behavioural / cognitive factors, communication, care- / service-related expectations, access to social support). Also includes communication, expectations of care, demands and level of support provided by worker or client family / social support networks.
Equipment & Surroundings	Includes characteristics of the on-site workplace environment (e.g. furniture, layout / design, lighting, temperature, isolation, crowding, obstructions), and off-site workplace environment (i.e. urban/regional, socioeconomic status (SES) / cultural demographic, state of disaster / emergency), as well as equipment used by the worker to carry out their duties (i.e. availability, design, maintenance, suitability).

Results

Description of the studies

The application of the systematic search criteria resulted in a range of dependent variables coming under the umbrella of workplace violence (Table 2).

Table 2: WV variables represented in the final sample of n=120 articles

WV variable	Percentage of studies captured by review
Workplace violence (non-specific)	41%
Workplace violence (physical and non-physical)	23%
Workplace bullying & harassment	15%
Work-related physical assault	11%
Workplace aggression (not limited to physical)	5%
Injuries stemming from WV	3%
Work-related verbal abuse	2%

The majority of studies adopted a broad definition of WV that was otherwise unspecified and included both physical and non-physical violence (e.g. verbal, bullying). A minority of studies (3%) that were primarily interested in WV incidents resulting in injuries were included as they also examined the factors contributing to these incidents.

The industry represented in the vast majority of articles was healthcare (n=82), with 47 of those being hospital-based (Table 3). This was followed by 14 articles for which the industry sector was not specific (i.e. sample was across a number of industries). There were 9 articles from the education sector, 4 from aged care, another 4 from human or social services, 3 from the public sector or civil service, and 2 from the emergency services sector. Notably absent from the final sample of articles were the retail, hospitality and construction sectors. Of note, several of the industry non-specific articles specifically mentioned the construction industry as a high risk injury for WV.

Table 3: Industry sectors represented across final sample of articles (n=120)

Industry sector	Number of articles	%
Healthcare	82 studies (47 hospital-based, 13 emergency medicine, 12 community health, 7 psychiatry)	68.3%
Education	9 studies	7.5%
Aged care	4 studies	3.3%
Human / social services	4 studies	3.3%
Public sector / civil service	3 studies	2.5%
Emergency services	2 studies	1.7%
Other	2 studies (maritime, taxi service)	1.7%
Not specific to a given sector	14 studies	11.7%

Over one-third of the articles were from the United States (n=47), followed by Europe & UK (n=28), Asia (n=18), the Middle East (n=10) and Australia / New Zealand (n=8).  A small number of studies within the final sample were from Africa, Canada, and South America (Table 4).

Table 4: Regions represented across final sample of articles (n=120)

Industry sector	Number of articles	%
United States	47 studies	39.2%
Europe & UK	28 studies	23.3%
Asia	18 studies (including 6 from China, 3 from Japan)	15.0%
Middle East	10 studies	8.3%
Australia / New Zealand	8 studies	6.7%
Africa	4 studies	3.3%
Canada	2 studies	1.7%
South America	2 studies	1.7%
Not specific	1 study	0.8%

Finally, a number of studies reported worker demographics as predictors of workplace violence (n=46). While worker characteristics are predictors of WV, this study has exclusively focused on modifiable factors, or those of consideration when developing preventative interventions. The most commonly reported were age and gender as significant predictors, and less often education level, marital status or cultural background / ethnicity. In general, risk of WV decreased with increased worker age, while male gender, higher education level and unmarried marital status increased risk.

Quality Assessment

A total of six of 120 studies were rated as high quality (Mean score of 13.0/15), 71 as moderate quality (Mean score of 10.0/15) and 43 as low quality (Mean score of 6.6/15).

WV risk factors as mapped onto the systems thinking classification scheme

Systems thinking classification scheme of factors contributing to WV

The process of mapping each risk factor from the 120 studies onto the levels of the systems thinking risk management framework saw the highest percentage (46.5%) mapped onto the frontline staff level and very few, in contrast, at the government, regulators and external influences level (Table 5).

Table 5: Percentage of risk factors identified by the systematic review at each of the 5 levels of an adapted version of Rasmussen’s risk management framework

Industry sector	%
Government, regulators & external influences	1.5%
Government & administration	22.7%
Operations management	23.1%
Frontline staff	46.5%
Equipment & surroundings	6.2%

Government regulators and other external influences

The highest level of the classification scheme includes factors external to the organisation (Table 5). Very few studies (only 1.5% of factors identified by 3 studies within this systematic review) explored potential contributing factors to workplace violence at this level (see Table 6).

Table 6: Risk factors and examples identified at the Government, regulators and external influences level of the systems thinking classification scheme[2]

Level of system	Risk factors and examples	References
Government regulators and external influences	Political instability: unstable state of the government/political parties	Kitaneh & Hamdan(33)
	Economic conditions: poor state of the economy	Kitaneh & Hamdan(33)
	Politically motivated violence: environment is politically charged	Nayyer-ul  et al.(34)
	Timeliness of security response: security or police not responding in an appropriate time frame	Schnapp et al.(35)

Of the studies exploring predictors at this level, there were 3, all Healthcare sector-based, reporting a significant influence of factors including political instability and economic conditions (33), politically-motivated violence (34), and timeliness of security response / police (35). These findings suggest that uncertainty in political agendas and the economy, as well as societal unrest and slow response from enforcement agencies are factors that contribute to incidents of WV. Of note, the latter two articles were also of low quality as judged by the quality appraisal.

Governance and administration

There was a total of 45 articles reporting 59 different WV risk factors within the Governance and Administration level. This corresponded to 22.7% of factors identified within this systematic review (Table 5). Eighteen of the 45 articles reported WV risk factors within the ‘management systems’ sub-category (9, 33, 35-50) (see Table 7). These included several reporting security and general staff management as risk factors, with  studies identifying OHS meetings and policies / procedures / guidelines as risk factors, and a few identifying the incident reporting system as a risk factor (37, 38). These findings suggest that management of WV through strategies such as policies and procedures, risk management, reporting and security systems are critical in the prevention of WV.

Table 7: Risk factors and examples identified at the Governance and Administration level of the systems thinking classification scheme

Sub-level of system	Risk factors and examples	References
Management systems	Policies and procedures: presence of violence prevention policies and procedures to enforce policy	Al-Azzam et al.(36); Alyaemni & Alhudaithi(37); Feda et al.(42); Kitaneh & Hamdan(33); Xing et al.(50)
	Risk management: strategies utilized by administration to take corrective/preventive measures against assault	Al-Azzam et al.(36, 40); Bayram et al.; Gadegaard et al.(44); Gerberich et al. (2014)(45);  Kitaneh & Hamdan(33); Schnapp et al. (2016)(35)
	Incident reporting system: mechanism to report violence and efficacy of reporting	Alyaemni & Alhudaithi(37); Anand et al.(38); Hartley et al.(46)
	Security systems / staff: use of security guards within the workplace to prevent/respond to violence	Bayram et al.(40); Çıkrıklar et al.(51); Darawad et al.(41);  Folgo & Iennaco(43); Ori et al.(48)
Resources	Funding model: funds and resources available for adequate staffing/security, etc.	Bayram et al.(40); Darawad et al.(41); Fafliora et al.(52); Folgo & Iennaco(43); Gerberich et al. (2014); Sage et al.(13);  Welch et al.(53)
	Sector resources: differing levels of violence dependent upon public or private designation of organisation	Lo et al.(54); Shea et al.(49); Wei et al. (2013)(14)
Leadership	Reporting culture: environment that encourages/discourages reporting of violence	Al-Turki et al.(55); Anand et al.(38); Chipps et al.(56); Feda et al.(42); Gadegaard et al.(44);  Xing et al.(50); Zelnick et al.(15)
	OHS meetings/safety climate: perceptions of the effectiveness of guidelines to prevent violence/violence prevention culture of the organisation	Lipscomb et al.(47); Shea et al.(49)
	Effectiveness of administration: ability of organisation to ensure a safe environment	Ori, J., et al.(48)
	Administrative support: perceived support from management	Snyder et al.(57)
	Organisational justice: perceptions of fairness in treatment of workers	Andersen et al.(58); Bentley et al.(8)
	Workplace / organisational culture, including psychosocial and violence prevention / safety climate:   the shared assessments of safety policies, procedures, and practices, and the perceptions and expectations workers have of workplace safety	Arnetz et al. (2018)(39); Arnetz et al. (2019)(59); Cavalcanti et al.(60); Çıkrıklar et al(51); Claybourn(61); De Cieri et al.(62); Enosh & Tzafrir(63); Gadegaard et al.(44); Gerberich et al. (2014)(45); Gimeno et al(64); Hahn et al.(65); Spector, Yang, & Zhou(66); Wu et al.(67)
	Management commitment: level of managerial adherence to safety and violence prevention	De Cieri et al.(62); Lipscomb et al.(47); McLinton et al.(11);  Shea et al.(49)
	Psychosocial climate:  shared perceptions of organizational policies, practices and procedures for the protection of worker psychological health, that stem largely from management practices	Arnetz et al. (2019)(59); Law et al.(68); Nguyen et al.(69)
	OHS strategies	Folgo & Iennaco(43)

A further 10 studies reported ‘financial and administrative resourcing’ limitations as risk factors for WV, including a few that specifically distinguished between publicly- and privately-owned organisations within a particular sector (healthcare or education). This finding suggests that a sufficient allocation of financial and human resources is critical to optimise the management the WV.

A further 31 studies identified ‘organisational leadership’ characteristics as risk factors. These factors encompassed a number of safety climate-related variables, including senior management commitment, incident reporting culture, psychosocial safety climate (e.g. perceptions of organisational support, safety prioritisation, violence prevention climate). These findings suggest that organisational leaders play a key role in creating a culture were safety and reporting is valued and prioritised.

Operations Management

There was a total of 55 articles reporting 60 different WV risk factors within the Operations Management level (Table 5). This corresponded to 23.1% of factors identified within this systematic review. Twelve studies described risk factors that came under the ‘supervision’ sub-category of the Operations Management level (see Table 8). The factors identified included supervisor / management support, quality of supervision, communication and one study only reporting leadership style. One additional study reported care plan quality as a risk factor under client management. These findings suggest that the role and responsibilities of supervisors in the management of WV is critical in preventing incidence of WV.

Table 8: Risk factors and examples identified at the Operations Management level of the systems thinking classification scheme

Sub-Level of system	Risk factors and examples	References
Supervisors	Supervisor quality: effectiveness of supervisor in leading and managing employees	Andersen et al.(58); Sharipova et al.(70); Sturbelle et al.(71);  Tsuno & Kawakami (2015)(72); van der Velden et al.(73)
	Supervisor support: direct managerial support for employee safety	Andersen et al.(58); Chambers et al.(74); De Cieri et al.(62); Gadegaard et al.(44); Shea et al.(49); Tsuno & Kawakami (2016)(75)
	Communication: quality of interpersonal communication with supervisors	Bentley et al.(8); Snyder et al.(57); Sturbelle et al.(71); van der Velden et al.(73)
	Management style:  supervisors’ characteristics and behavioural patterns when managing groups of people	Nielsen(76); Tsuno & Kawakami (2015)(72)
	Perceptions of support: employees perceive supervisors are responsive to concerns and provide on the job support	Snyder et al.(57)
Client management	Unsatisfactory care plan: unclear plan for care delivery	Karlsson et al.(77)
Work scheduling	Work shift (late/night/extra hours/time of day/shift work): differences in shift and time of day impact risk of violence	Abbas et al.(78); Al-Azzam et al.(36); Al-Turki et al.(55); Bayram et al.(40); Burgel et al.(79); Ferri et al.(80); Hartley et al.(46); Li et al. (2019)(81); Maguire & O’Neill(10); Pai & Lee(82); Schnapp et al.(35); Sun et al.(83); Terzoni et al.(84); Unruh & As(85)i;  Vaez et al.(86); Welch et al.(53); Zeng et al.(87)
	Unpredictable and reduced hours:  variability in scheduling and shifts worked, and working part time	David et al.(88); Hahn et al.(65); Karlsson et al(77); Li et al. (2019)(81)
	Workload: excessive work hours/duties and/or busyness of specific shift	Bentley et al.(8); Çıkrıklar et al.(51); Darawad et al.(41); Enosh & Tzafrir(63); Fafliora et al.(52); Huang et al.(89); Ori et al.(48); Shea et al.(49); Stutte et al.(90); Tak et al.(91)
	Time pressure: working at a high speed/on tight deadlines	van den Bossche et al.(92)
	Higher caseload: increased contact with patients	Bride et al.(93)
	Staff to patient/client/student ratio: lack of adequate staff/number of patients/clients per worker, including implications such as long wait times	Bizzarri et al.(94); Folgo & Iennaco(43); Gerberich et al. (2014)(45); Ridenour et al.(95); Schnapp et al.(35); Staggs (2013, 2015, 2016)(96-98); Wei et al. (2013)(14, 86); Vaez et al.
	Emotional load: emotional health of worker, i.e. exhaustion	Stutte et al.(90)
	Flexible workers: working on holidays	Terzoni et al.(84)
Work systems	Training: prevalence and quality of formal learning to gain skills to deal with patients / clients and manage crises	Alyaemni & Alhudaithi(37); Byon et al.(99); Folgo & Iennaco(43)

The majority of WV risk factors identified at the Operations Management level came under ‘work scheduling’ (n=42 factors). Among those studies, shift work (i.e. late shifts, additional hours) was the most commonly cited risk factor associated with WV, with rostering and staff-to-patient ratios also reasonably common. Time pressure, workload and emotional load were also identified as risk factors in this sub-category. Also of note, under the ‘work systems’ sub-category, staff training was identified by three studies as a risk factor for WV (37, 43, 99). These findings suggest that the system of work and the effective management of the employee experience within this system is critical in mitigating the risk of WV.

Frontline Staff

Risk factors identified at the frontline staff level were many, with a total of 84 articles reporting 121 different WV risk factors within this level (Table 5). This corresponded to 46.5% of factors identified within this systematic review. This included 37 studies identifying ‘work design’ risk factors (see Table 9). Of those, the most commonly cited was having a patient- or client-facing role usually in the context of patient handling / mobility support in the hospital, psychiatric or aged care settings. Job demands (unspecified) was also a commonly cited risk factor, with lone worker conditions also identified by a few studies (100, 101). These findings suggest that the roles and responsibilities of workers and the environment in which they operate plays a key role in the incidence of WV.

Table 9: Risk factors and examples identified at the Frontline Staff level of the systems thinking classification scheme

Sub-Level of system	Risk factors and examples	References
Work design	Client/patient-facing role: workers that have direct interaction with clients/patients	Al-Azzam et al.(36); Arnetz et al. (2011)(102); Arnetz et al. (2018)(39); Campbell et al.(103); Enosh & Tzafrir(63); Ferri et al.(80); Gormley et al.(104); Groenewold et al.(105); Kim et al.(101); Li et al.(2017)(106); Ogenler & Yapıci(107); Rasmussen et al.(12); Shea et al.(49); Sun et al.(83); Taylor et al.(108); Terzoni et al.(84); van den Bossche et al.(92); Welch et al.(53); Xing et al.(50); Yenealem et al.(109); Zelnick, et al.(15)
	High level client contact: time spent directly interacting with patients	Folgo & Iennaco(43); Hahn et al.(65)
	Managerial responsibilities: supervisory duties as part of job role	Edwards & Buckley(110)
	Job demands:  physical, psychological, social or organisational aspects of a job that require continuous physical and/or psychological (i.e., cognitive or emotional) effort	Andersen et al.; Chambers et al.; Chipps et al.; Çıkrıklar et al.; Folgo & Iennaco;  Li et al.(2019); McLinton et al.; Unruh & Asi; van den Bossche et al.; van der Velden et al.; Wu et al.
	Rewards: recognition for effort	Andersen et al.(58)
	Role conflict: employees have different and incompatible roles concurrently/role overlaps with another worker	Andersen et al.(58)
	Job control: autonomy in job role	Andersen et al.(58); van den Bossche et al.(92)
	Role clarity: uncertainty about/frequent changes to tasks and work standards	Andersen et al.(58)
	Working alone: direct contact with patients and/visitors while alone	Folgo & Iennaco(43); Houdmont et al.(100); Kim et al.(101)
	Roles/duties: nature of contact with client	Enosh et al.(111); Enosh & Tzafrir(63); Sharipova et al.(70)
	Patient function: ability of patient to conduct activities of daily living/less mobile need more assistance	Karlsson et al.(77)
	Job strain: high job demand with low job control	Magnavita(112)
Staff	Communication skills: importance of interpersonal communication to reduce or avoid workplace aggression	Al-Azzam et al.(36); Anand et al.(38); Darawad et al.(41); Friis et al.(48, 113); Ori et al.; Zhou et al.(114)
	Worker-client communication (language barrier): miscommunication due to an inability to speak a common language	Byon et al.(99)
	Conflict resolution: skills to de-escalate a situation and resolve the issue	Anand et al.(38)
	Staff interaction (interpersonal conflict/co-worker conflict): strength of relationships between co-workers	Arnetz et al. (2018)(39); van der Velden et al.(73)
	Co-worker support: prevalence and strength of relationships with peers	Chambers et al.(74);  Gadegaard et al.(44); Snyder et al.(57); Tsuno & Kawakami (2016)(75)
	Work efficiency:  employees’ perceptions of how well work processes function at their workplace	Arnetz et al. (2018)(39)
	Job satisfaction: the extent to which an employee feels self-motivated, content and satisfied with their job	Berlanda et al.(115); Claybourn(61)
	Experience / exposure: length of time working in a specific field/role	Bizzarri et al.(94); Burgel et al.(79); DeSouza(116); Gerberich et al. (2011)(117); Gormley et al.(104); Hahn et al.(65); Lepping et al.(118); Li et al.(2017)(106); Mollayeva et al.(119); Obeidat et al.(120);  Rodríguez-Acosta et al.(121); Sadrabad et al.(122); Sharipova et al.(70); Terzoni et al.(84); Unruh & Asi(85); Yenealem et al.(109); Zeng et al.(87)
	Worker characteristics: soft skills such as individual stress reactivity to social conflict, past exposure to victimisation, level of anxiety about WV	Kelly et al.(123); Nachreiner et al.(124); Pai & Lee(82)
	Safety performance: varying levels of staff safety compliance, safety motivation and safety participation	Shea et al.(49)
	Worker time management /  perceptions of support and resourcing:  the degree to which the employees perceived that they had enough time and staff resourcing to carry out their tasks efficiently	Snyder et al.(57); Sturbelle et al.(71); Stutte et al.(90)
	Risk perceptions: perceptions of the violence prevention climate	Yang et al.(125)
	Social support: availability of or actual assistance provided to an employee by co-workers	Magnavita(112)
Clients / consumers	Client expectations: feelings, needs, and ideas that clients/patients have toward the service they are receiving	Azodo et al.(126); Belayachi et al.(127); Bernaldo-De-Quiros et al.(9); Çıkrıklar et al.(51);  El-Gilany et al.(128); Enosh et al.(111); Fafliora et al.(52); Li et al.(2017)(106); Nayyer-ul, et al.(34); Ramacciati et al.(129); Speroni et al.(130); Tak et al.(91)
	Client behaviour/characteristics:  the way in which a client/patients acts toward others; can be influenced by mental health, drugs, or alcohol	Al-Azzam et al.(36); Anand et al.(38); Azodo et al(126); Belayachi et al.(127); Bride et al.(93); Campbell et al.(103); Cavalcanti et al.(60); Chambers et al.(74); Darawad et al.(41); Edwards & Buckley(110); El-Gilany et al.(128); Enosh & Tzafrir(63); Fafliora et al.(52); Farrell & Shafiei(16);  Ferri et al.(80); Folgo & Iennaco(43); Friis et al.(113); Gerberich et al. (2014)(45); Karlsson et al.(77); Lachs et al.(131); Lipscomb et al.(47); Ori et al.(48); Schnapp et al.(35); Speroni et al.(130); Staggs (2016)(98); Sun et al.(83); Terzoni et al.(84); Vaez et al.(86); Wei et al. (2013)(14);  Wei et al. (2016)(132); Welch et al.(53); Wu et al.(67); Yenealem et al.(109)
	Relatives: having family members of the patient present	Karakas et al.(133)
	Communication: difficulties in doctor-patient interaction due to miscommunication with patient (language barrier)	Ori et al.(48)
	Client type/type of health service provision: risk of violence varies by hospital unit and type of service provision (includes MH treatment type)	Ridenour et al.(95); Rodríguez-Acosta et al.(121)

A large number of articles (n=41) also identified ‘staff-related factors’ at the frontline level as a key risk factor for WV. The most commonly identified risk factor in this sub-category was staff experience. Interestingly, depending on the setting, experience or tenure could either increase or decrease risk of WV. This finding suggests that the incidence of WV is not solely dependent on the knowledge, skills, or attitudes of the worker. Other staff-related factors including communication and/or interaction, co-worker / social support or conflict, and job satisfaction were also identified as factors that support or constrain the incidence of WV.

A further 43 studies identified client / consumer factors as risk factors for WV. The most frequently identified risk factor across all levels was client behaviour (n=31 articles). This encompassed a variety of clients / patients with aggressive tendencies including those exposed to alcohol or other substances, those experiencing acute psychiatric episodes, dementia-related confusion/aggressive behaviour, and individuals with special needs. A related risk factor was the urgency / complexity of the behavioural issues such as the behaviours presenting at Emergency departments.  Client expectations (general unmet needs, expectations of care, wait times) were also found to predict WV quite often. These findings suggest that factors, outside the control of the worker, contribute to WV.

Equipment and surroundings

A total of 6.2% of factors identified within this systematic review were mapped onto the equipment and surroundings level (Table 5) of the classification scheme.

On-site, the most commonly identified workplace factor predicting WV was the busyness or crowding of the environment (n=11 articles). Poor working conditions (generally) and poor temperature control were the only other two factors identified as contributors from this sub-category. These findings suggest that the operating environment needs to account for not only the needs of clients/patients etc., but to avoid the development and escalation of aggressive behaviour. Only 4 articles identified off-site variables as predictors of WV, including two studies that suggested SES was a risk factor, and another that suggested characteristics of an urban environment increased risk. Perhaps similarly, another study suggested that the public accessibility of the environment increases risk (35) (see Table 10).

Finally, one study identified infrequent use of equipment (i.e., assistive devices for patient handling) as a risk factor for WV at this level.

Table 10: Risk factors and examples identified at the Equipment and surroundings level of the systems thinking classification scheme

Sub-Level of system	Risk factors and examples	References
Equipment	Assistive devices: physical tools to help workers perform their job	Pihl-Thingvad et al.(134)
On-site environment	Security systems: adequacy of the measures in place to maintain safety of workers, including security personnel on site	Çıkrıklar et al.(51)
	Busyness / crowding: interacting with many clients/patients, too many  clients/patients for the number of workers to provide efficient service	Abbas et al.(78); Alyaemni & Alhudaithi(37);  Anand et al.(38); Bayram et al.(40); Darawad et al.(41); El-Gilany et al.(128); Farrell & Shafiei(16); Folgo & Iennaco(43);  Medley et al.(135); Ramacciati et al.(129)
	Poor working conditions: circumstances of the physical working environment	Anand et al.(38)
	Poor temperature control: inability to regulate temperature of workplace	Folgo & Iennaco(43)
Off-site environment	Urban environment: dense community with >75,000 people	Gormley et al.(104)
	Socioeconomic status:  measure of a person’s economic and social position in relation to others	Lange et al.(136); Tsuno et al.(2015)(137)
	Limited work space: small work space, as in a client’s home	Karlsson et al.(77)
	Public accessibility of area: patient areas open to the public	Schnapp et al.(35)
	Environmental factors (lack of  police presence): no security or police protection	Schnapp et al.(35)

Discussion

The aims of this study were to conduct a systematic review of the literature to identify the factors contributing to WV, and to subsequently map the factors identified by the systematic review to their relevant system level using an adaptation of Rasmussen’s Risk Management Framework. This research was designed to address an identified gap in the literature regarding understanding the system of factors contributing to WV. This information is critical to being able to design targeted prevention activities and methods (e.g., investigation tools; 26, 50) to best learn from incidence of WV. 

Consistent with previous research (139, 140), this study found that most of the factors (50%) contributing to risk were identified at the Frontline Staff level. This finding is consistent with past research which has identified that workplace safety often takes a reductionist lens, primarily focused on the behaviour of frontline staff (30, 138-140). This means that the complexity and interaction of risk factors operating at various levels within the overarching system is overlooked. This finding is concerning given that research is often used to inform the development of interventions. For example, isolated changes within systems, such as the use of body armour and body cameras, and training in de-escalation and dealing with aggressive customers, are unlikely to create sustainable change in the prevention of violent and aggressive behaviour.  Change that is systemic, such as the development of guidance material in managing violent and aggressive behaviour, policies and procedures that guide the management of behaviour and identifying roles and responsibilities of leaders in the management of WV, is needed to mitigate pressures at lower levels of the system.

Approximately 1% of the factors identified were at the highest level of the system, Government, Regulators and other external influences. The factors that were identified at this level included political climate, economic conditions and timeliness of security response. These findings offer recommendations for research and practice in the review and revision of existing controls and the development of new intervention to better manage WV. Examples of systemic intervention were identified in this study. For example, in the Australian state of Victoria, there has been joint lobbying of the Police Association Victoria and the Victorian Ambulance Union to successfully influence ongoing legislative changes and public awareness campaigns to help protect emergency workers from violence, and the introduction of harsher penalties for offenders who attack emergency workers (141). There has also been evidence to support the effectiveness of this type of intervention. Furthermore, a report from the Victorian Auditor-General’s Office (142) on WV in the public health sector has influenced positive changes in the sector’s approach to WV prevention, including increased accountability for public health service providers to government regulators.

These examples support the argument that systemic change is more likely to optimise efforts in the prevention of WV as opposed to isolated changes focused on frontline behaviour and changes to equipment.

Organisational leadership type factors were also identified as contributors to WV, including general workplace / organisational culture, safety climate and reporting culture. In support of previous research (e.g., Zohar, 2002; Griffin & Neal, 2000; Newnam et al., 2008), creating a safety and reporting culture within organisations should be a clear priority in the prevention of WV. To do this, management and leaders at all levels need to create an environment where workers are confident that the organisation is committed to their health and safety, that workers feel safe and supported when reporting incidents of WV, and that the information provided to management by workers will lead to positive change. As supported by the results of this study, change could be achieved through management initiatives such as the development of policies and procedures relating to WV, as well as allocated financial and human resources to the prevention of WV. At the operations management level, WV prevention could also be optimised through the review and revision of work schedules, including shift types and variability of shift, caseload / workload), and staff to patient or client ratio.

Consistent with the principles underpinning Rasmussen’s risk management framework (28), these changes are likely to increase consultation and improve the flow of information at lower levels of the system.

The findings of this study also identified that client characteristics were a significant risk factor to WV for staff, particularly for those with a client- / patient-facing role as well as factors operating on-site including busyness or crowding of the environment. It is acknowledged that direct contact with unpredictable, potentially volatile individuals and poor working environments is commonplace for many staff across healthcare and community service-related organisations. This study identified that system thinking changes could mitigate the risk. For instance, work design-related factors such as the level and nature of client contact and the presence of co-worker support could be considered within work roles and staff could be provided professional development in conflict resolution skills. Furthermore, the use of assistive devices is a clear opportunity for intervention in this context, assuming organisational support and resources, particularly when workers are exposed to high risk off-site environments, including those already mentioned as well as the public accessibility of the area, SES and lack of (external) security or police presence (35, 136). As evidenced in the findings of this study, these prevention strategies will only be optimised if managed within a system which supports these activities.

Future research and practical implications

The findings of this study have identified two pronounced gaps in existing knowledge regarding risk factors contributing to WV. The first is that there is a predominance of research focused on the healthcare sector despite employees from many other sectors being commonly exposed to WV. The public service sector, including local government employees, is an example of a sector that has received little attention in the academic literature despite an identified need (146). It has been well documented that employees are exposed to WV, particularly those in positions issuing parking fines and other local authority regulatory services such as animal management, public health administration, planning scheme enforcement, and building surveying.  There were only three articles identified by this review that examined WV risk factors for employees in this sector (69, 72, 113), with none of these articles examining local government specifically despite its prominence as a front-line community service provider. This gap identifies a need for research to be undertaken to explore the prevalence of WV within other high-risk sectors, such as local government.

Secondly, the findings of this study indicate that there is opportunity to better learn from WV incidents.  Based on methods used in previous research (28, 138), there is an opportunity to develop a system thinking investigation tool to guide practitioners in the review of WV incidents. The goal of such a tool would be to better understand the system of factors contributing to these incidents so that systemic change can be achieved in prevention efforts. The findings of this study support the idea of the development of a classification scheme (see 30, 138) that could be used to guide practitioners in considering factors that contribute to incidents under review. The next step would involve consulting with key stakeholders to ensure the tool is feasible and practicable in its implementation. This step is critical in ensuring that the findings of any investigation clearly inform the review and revision and development of intervention capable of creating systemic change within the system.  

This classification scheme could also be valuable in assisting practitioners with pre-incident risk assessment and risk profiling at all levels of the system.  Results from incident investigations could also be included in risk profiling data.  Data captured from risk profiling could be support a business case for systemic change.  These changes may include organisational system changes such as WV policy and procedure development and implementation, adequate provision human and other resources in high-risk areas, review of job design and job control, investment in new technology, and the education, training and development of actors at all levels of the organisational in WV prevention, response and recovery.

This study also highlights an opportunity for City Councils to influence change in the Government Regulator and External Influencers level of the system.  This could be achieved by City Councils either individually or collectively through regional groups, local government associations, employer associations, and unions to partner with research institutions and regulators to conduct further WV-related research in to systemic factors that exist at the higher, less researched levels of the system.

Limitations

A limitation of the current study is the proportion of articles from the healthcare sector relative to those from other occupations and sectors which reflects a current bias in the academic literature. As mentioned above, it is important to develop intervention that is tailored to the context of the working environment. That is, the factors contributing to WV in healthcare may be different to those in other sectors, such as the public service sector, and in particular, local government or city councils. A second limitation is that the systematic review was limited only to the academic literature and did not include the grey literature. Moreover, it only considered research focusing on adult employees (18 years and over). This may have resulted in excluding studies of the younger workforce in sectors such as retail and hospitality. This establishes a clear future research priority. Finally, approximately one-third of the studies included in this review were rated as low quality, with only six rated as high quality by the Quality Assessment. Research of higher quality is not only necessary to confirm the findings of this study but, more broadly, to better understand and subsequently address critical issues to improve workplace violence prevention efforts.

Concluding remarks

WV is a significant issue for many sectors of the workforce.  This study was one of the first to examine factors contributing to WV using a systems thinking lens. Although this study shows that academic research on WV is currently reductionist, the findings present an opportunity for future research to understand the prevalence of WV across multiple sectors and inform development of a tool to better inform practitioners on the system of factors contributing to WV. These opportunities provide a clear direction to inform the review and revision of risk controls and to develop new and targeted intervention to mitigate the risk of WV.

Acknowledgements

This review was conducted as part of a project funded by WorkSafe Victoria, through the Institute for Safety, Compensation and Recovery Research.

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[1] Data collection dates were not specified

[2] Studies of moderate-high quality (27) have been bolded in this and subsequent tables

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