J Occup Health. 2021;63:e12226. | 1 of 11
https://doi.org/10.1002/1348-9585.12226

wileyonlinelibrary.com/journal/joh2

1 | INTRODUCTION

Violence against nurses in their workplace is a major global
problem that has received increased attention in recent years.1
Approximately 25% of registered nurses report being physi-
cally assaulted by a patient or family member, while over 50%
reported exposure to verbal abuse or bullying.2 Nurses, who
are primarily responsible for providing life- saving care to pa-
tients are victimized at a significantly higher rate than other
health- care professionals,3 and it is estimated that workplace
violence causes 17.2% of nurses to leave their job every year.4

In the United States, workplace violence increased by
23% to become the second most common fatal event in
2016,5 accounting for 1.7 million nonfatal assaults and 900
workplace homicides each year.6 In addition, there has been
an increase in workplace violence in US hospitals, increasing
from 2 events per 100 beds in 2012 to 2.8 events per 100 beds

in 2015.5 In 2016, hospitals and health- care facilities invested
$1.1 billion in security and training to prevent violence and
had to spend $429 million on insurance, staffing, and medical
care due to workplace violence.7

The absence of a universal definition for workplace vi-
olence within health- care settings and the ambiguity about
what constitutes a violent event currently compromise re-
search on the prevalence and magnitude of this phenomenon.
Furthermore, varying definitions and unclear criteria may
lead to nurses failing to identify their experience as a form of
workplace violence, which prevents it from being reported.

Applying the concept analysis method to better under-
stand the violence to which nursing staff are subjected in the
workplace will demystify the factors at play, with the under-
lying intention of preventing such violence. Using concept
analysis to address the theoretical background to such vio-
lence will aid the development of an operational definition

Received: 9 December 2020 | Revised: 15 March 2021 | Accepted: 5 April 2021

DOI: 10.1002/1348-9585.12226

R E V I E W A R T I C L E

Workplace violence in nursing: A concept analysis

Mahmoud Mustafa Al- Qadi RN, MSN, MHA

This is an open access article under the terms of the Creative Commons Attribution- NonCommercial- NoDerivs License, which permits use and distribution in any medium,
provided the original work is properly cited, the use is non- commercial and no modifications or adaptations are made.
© 2021 The Authors. Journal of Occupational Health published by John Wiley & Sons Australia, Ltd on behalf of The Japan Society for Occupational Health

University of Connecticut School of
Nursing, Storrs, CT, USA

Correspondence
University of Connecticut School of
Nursing, 231 Glenbrook Rd., Unit 4026,
Storrs, CT 06269- 4026, USA.
Email: [email protected]

Abstract
Objectives: To clarify the concept of workplace violence in nursing and propose an
operational definition of the concept.
Methods: The review method used was Walker and Avant’s eight- step method.
Results: Identification of the key attributes, antecedents, consequences, and empiri-
cal referents of the concept resulted in an operational definition of the concept. The
proposed operational definition identifies workplace violence experienced by nurses
as any act or threat of verbal or physical violence, harassment, intimidation, or other
threatening disruptive behavior that occurs at the worksite with the intention of abus-
ing or injuring the target.
Conclusions: Developing insights into the concept will assist in the design of new
research scales that can effectively measure the underlying issues, provide a frame-
work that facilitates nursing interventions, and improve the validity of future studies.

K E Y W O R D S

concept analysis, harassment, health and safety, nurses and violence, occupational health nursing,
workplace violence

2 of 11 | AL- QADI STUDENT

that increases the validity of the concept. This study aims to
elucidate the nature and form of workplace violence experi-
enced by nurses and develop a precise operational definition
of the concept in conjunction with a set of criteria that can be
used to identify the phenomenon.

2 | BACKGROUND AND
SIGNIFICANCE

Violence is defined by the World Health Organization in the
World Report on Violence and Health as “the intentional
use of physical force or power, threatened or actual, against
oneself, another person, or against a group or community,
that either result in or has a high likelihood of resulting in
injury, death, psychological harm, maldevelopment or dep-
rivation.”8 This definition emphasizes that a person or group
must intend to use force or power against another person or
group for an act to be classified as violent.

University of Iowa Injury Prevention Research Center9
classified workplace violence into four basic types: Type I,
Type II, Type III, and Type IV. Type I involves “criminal in-
tent.” In this type of workplace violence, “individuals with
criminal intent have no relationship to the business or its em-
ployees.” Type II involves a customer, client, or patient. In
this type, an “individual has a relationship with the business
and becomes violent while receiving services.” Type III in-
volves a “worker- on- worker” relationship and includes “em-
ployees who attack or threaten another employee.” Type IV
involves personal relationships. It includes “individuals who
have interpersonal relationships with the intended target but
no relationship to the business.” Types II and III are the most
common in the health- care industry.

Verbal abuse is the most common type of abuse directed
toward nurses in health- care settings. It is three times more
likely to occur than physical violence.10 In one study, 82%
of nurses reported verbal abuse as being the most common
type of abuse,11 while 63.9% of nurses had been subjected
to some form of verbal abuse by patients.12 Behaviors such
as swearing, shouting, or cursing have been identified as the
most common form of verbal abuse13 and have also been re-
ported as the most violent type of verbal aggression.14 Data
collected from 349 nurses indicated that 79.5% had been sub-
jected to verbal violence, while 28.6% had been exposed to
physical violence.15 Physical abuse often co- exists with ver-
bal abuse, suggesting that the latter might act as a predictor
for potential physical abuse.10 Of these behaviors, “being
pushed or hit” has been identified as the most common type
of physical abuse,13 while the use of lethal weapons has been
shown to occur mostly during night hours.16

Many studies indicate that violence against nurses is under-
reported.17 Emergency departments have been highlighted as
locations where violent incidents are likely to be significantly

underreported; the reasons given are: (a) nurses are not satis-
fied with how their previous violent events were handled as
some cases were not treated with appropriate seriousness15;
(b) nurses’ belief that violence is part of the job18; (c) nurses
are discouraged from reporting such events as even if they do,
there are no policies guaranteeing justice19; (d) insufficient
time20; (e) nurses’ belief that no harm was inflicted on them
and they can handle it21; and (f) nurses’ ability to defend them-
selves by changing how they treat that particular patient.12

Previous studies have reported that nurses consider the
absence of assertive legislation, poor management of violent
incidents, a lack of resources, such as insufficient equipment,
medical errors, and a poor environment to contribute signifi-
cantly to workplace violence.22 Also, a lack of proper com-
munication skills, lack of experience, lack of quality care,
and shortage of nursing staff can also lead to workplace vio-
lence.15 The shortage of nursing staff is a pertinent issue that
has affected the majority of countries. The reviewed literature
underlines how health- care settings have witnessed high turn-
over rates among nurses.23

The experience of workplace violence has physical, per-
sonal, emotional, professional, and organizational conse-
quences that impact individuals and organizations. We argue
that a definition to aid the recognition of workplace violence
and the understanding of its attributes, antecedents, and con-
sequences will assist in optimizing recognition and facilitate
the formation of strategies to address the problem.

3 | CONCEPT ANALYSIS METHOD

This study used Walker and Avant’s24 eight- step method, which
is commonly applied in the nursing context (see Table 1). The
concept analysis process helps to validate current nursing un-
derstanding, as well as support strategies for nursing interven-
tions. Hence, this approach was utilized to analyze the current
understanding of the workplace violence to which nurses are
subjected as it offers an interactive process that can facilitate
the development of an operational definition of a concept.

4 | DATA SOURCES

Walker and Avant24 suggest that all data sources should be
fully utilized to ensure a thorough inventory of the relevant
characteristics and variables is compiled. Studies were iden-
tified via a search of four key databases: Cumulative Index of
Nursing and Allied Health Literature (CINAHL), PubMed,
PsycINFO, and Scopus using the following single and/or
combined keywords: “nurses”; “nursing”; “nurse”; “vio-
lence”; “workplace violence”; “abuse”; and “assault.”

The eligibility of the studies was assessed based on the
aims of the concept analysis. The following inclusion criteria

| 3 of 11AL- QADI STUDENT

were utilized: (a) studies published in peer- reviewed journals
between 2000 and 2020; (b) studies that are relevant to the
topic and fit with the content of the analysis; (c) studies that
included nurses experience of workplace violence; and (d)
studies published in English. Papers were excluded if the
study primarily focused on violence against nurses working
in mental health settings on the basis that these had different
and unique considerations (see Figure 1).

Initially, 383 papers were identified. Once duplicates
were removed, the titles and abstracts of the papers were re-
viewed. This resulted in 227 papers, which were reviewed in
full against the inclusion criteria, after which a further 193
papers were excluded. Thus, a total of 34 papers met the in-
clusion criteria and were included in the concept analysis;
see Figure 1 for a Preferred Reporting Items for Systematic
Reviews and Meta- Analyses (PRISMA) flow diagram of the
process.25

5 | RESULTS

The results of the concept analysis are presented according to
the eight steps of Walker and Avant’s24 method.

5.1 | Select a concept

According to Walker and Avant,24 before a concept is selected
its significance should be scrutinized across a variety of set-
tings. The selected concept should reflect the area of interest

T A B L E 1 Walker and Avant’s24 eight- step method

Step # Walker and Avant’s step

1 Select a concept.

2 Determine the purpose of analysis.

3 Identify all uses of the concept.

4 Determine the defining attributes.

5 Construct a model case.

6 Construct borderline and contrary cases.

7 Identify antecedents and consequences.

8 Define empirical referents.

F I G U R E 1 PRISMA diagram of search strategy adapted for use from Moher et al25

4 of 11 | AL- QADI STUDENT

addressed in the research question. Workplace violence experi-
enced by nurses is the selected concept for this analysis.

5.2 | Purpose of the analysis

The aims of the current analysis were to (a) clarify the con-
cept of workplace violence experienced by nurses by defin-
ing its essential attributes, antecedents, consequences, and
empirical referents; and (b) propose an operational definition
of workplace violence.

5.3 | Identifying uses of the concept

Under the next step in Walker and Avant’s24 method, the
available literature is searched to outline the primary attrib-
utes of the concept and identify how it is used. Reviewing the
existing studies generates an evidence base in relation to the
essential attributes underpinning the concept; hence, it facili-
tates and validates the outcomes of the analysis.

5.3.1 | Literature definitions

Violence in health care has been defined “as any incidents
where the staff are abused, threatened, or assaulted in circum-
stances relating to their work involving an explicit or implicit
challenge to their safety, well- being, or health.”26 This defini-
tion includes “any threatening statement or behavior which
gives a worker reasonable cause to believe they are at risk.”27
It also encompasses a broad range of behaviors28 from physical
assault or direct violence to nonphysical forms of violence such
as verbal abuse and sexual harassment.29 Workplace violence
can be defined as any physical assault, threatening behavior, or
verbal abuse that occurs in a work setting.30

The Center for Disease Control and Prevention,31 World
Health Organization,32 and Occupational Safety and Health
Administration33 define workplace violence as any act occur-
ring in the workplace with the intention to harm someone
physically or psychologically including attacks, verbal abuse,
and both sexual and racial harassment.34 Also, workplace
violence is defined as, “Incidents where staff are abused,
threatened, or assaulted in circumstances related to their
work, including commuting to and from work, involving an
explicit or implicit challenge to their safety, well- being, or
health.”31- 33

5.4 | Defining attributes

The defining attributes are those critical qualities and charac-
teristics that often emerge within a concept. Such attributes

differentiate the concept from closely related notions, and
elucidate its meaning. The literature review revealed that the
three distinguishing qualities of the workplace violence expe-
rienced by nursing staff can be classed in distinct categories:
(a) working relationship; (b) power and powerlessness; and
(c) behavior.

5.4.1 | Working relationship

One of the considered attributes is the working relationship,
which is one of the contributors to violence against nurses. It
involves the relationship between nurses and patients, nurses
and the patient’s family, physician and nurses, management
and nurses, and nurses and other nurses, any of which can
trigger violence.35 Human beings differ in their response to
emotions,36 and dealing with them requires a certain level of
discipline.

5.4.2 | Power and powerlessness

Power is another defining factor. In any normal working en-
vironment, there should be someone superior who guides and
directs the normal operations of the day.37 However, misuse
of this power can result in conflicts within the organiza-
tion.38,39 For example, conflicts tend to arise when multiple
people want to wield power or when a superior rule in an
unjust manner. Similarly, there may be others within the or-
ganization who intend to disempower the one bestowed with
power. Such an intention results in organizational politics,
which can have serious consequences for workplace perfor-
mance.40 Moreover, when members of one gender believe
that they should rule over others, this destabilizes the unity
within a health facility. In general, unequal power relation-
ships contribute to violence against nurses.41

5.4.3 | Behavior

The final attribute is the behavior of the perpetrator. Behavior
is defined as how a person acts or does things, whereby in
this context the causative agent of the violence comes from
an outside source. It can be in the form of physical or emo-
tional violence.42

6 | CONSTRUCTED CASES

The defining attributes identified within the concept analy-
sis can also be narrowed down through the identification
of model, borderline, contrary, illegitimate, and invented
cases.24 The constructed cases facilitate efforts to delineate

| 5 of 11AL- QADI STUDENT

between the characteristics that represent key attributes and
those that do not.

7 | MODEL CASE

The model case should be a real example that, ideally, pre-
sents all the critical attributes.24 Sarah went to see Julia, the
charge nurse in her unit. Sarah reported that the workload
in her assignment was becoming unsafe and unacceptable
for practice and quality of care. Julia became defensive
saying that Sarah was over- dramatic and her noncompli-
ance with following policies and procedures in the unit
contributed to unsafe practice within the unit. This case is
an example containing all the defining attributes of work-
place violence: That is, a formal working relationship ex-
ists between Sarah and Julia, with Julia in a position of
power. Julia’s response to verbal abuse and horizontal vio-
lence professionally degraded Sarah and is again consistent
with workplace violence.

8 | BORDERLINE CASE

Borderline cases are those that present some, but not all, of
the key attributes associated with the concept. They shed
light on ideas related to the main attributes of the concept
of interest by providing insights into how often it is mis-
construed.24 John was due for his surgery and was observed
continuously pacing throughout the corridor looking very
agitated and anxious. Jessica, a nurse, asked him if he was
alright. John did not say anything and went back to his
room but showed signs of autonomic arousal by continuing

pacing throughout the hallway. However, while anxious
and agitated, he has not acted abusively toward Jessica (the
nurse), and therefore this cannot be considered workplace
violence.

9 | CONTRARY CASE

A contrary case is one that does not represent the defining
attributes of the concept. In addition, it represents attributes
that are not features of the concept.24 A contrary case can
give insights into the primary characteristics of the concept
by highlighting contrary ideas.

9.1 | Antecedents

Walker and Avant24 describe antecedents as events or inci-
dents that precede the concept’s occurrence (see Figure 2).
These can be defined as the fundamental and underlying
factors that initialize violence against nurses.43 For any
form of violence to occur, there must be two parties; one
party is the perpetrator, who aims to harm the other party,
and the other is the recipient, who is on the receiving end
of the act. Other contributors are the internal factors and
the external factors.

9.1.1 | Two parties (perpetrators and nurses)

Two parties must be present in order for violence to occur,
namely the perpetrator and the recipient. In this study, the
recipient is the nurse, while the perpetrator could be a family

F I G U R E 2 Antecedents, empirical referents, attributes, and consequences of workplace violence

6 of 11 | AL- QADI STUDENT

member of the patient, the patient, management, other nurses,
or even a physician.

Nurses are more vulnerable to violence as they commu-
nicate directly with patients and their families.44 Sometimes,
physicians use violence to achieve power, maintain their
prestige, and abuse nurses to force them to perform better
in their handling of not only patients but also the physicians
themselves.12

9.1.2 | External factors (policies and
workplace environment)

Some policies that are imposed within health- care settings
lead to nurses being subject to stress and can even affect pa-
tients negatively. For example, in some instances, nurses are
expected to work long hours without rest45; however, increas-
ing the working hours impairs the performance of nurses.
Similarly, restricting the visitation hours makes patients’
family members experience distress and resentment. They
feel alienated and unvalued by the administration. A stressful
situation also arises when patients are involved in painful in-
vasive procedures.46 All these situations can precipitate vio-
lence against nurses. Hence, the physical setting is important
when it comes to health care, whereby the accessibility of
working instruments and a good working atmosphere play a
key role. If there is not enough medicine or if staffing levels
are low, both nurses and patients may be negatively affected.
The working environment can also discourage patients and
even staff from being associated with the health facility as
they feel that the quality of services is being compromised.
Moreover, there is a lack of well- structured policies, which
contributes significantly to the violence experienced by
nurses.23 The result is conflict among different parties.

9.1.3 | Internal factors (perpetrator or recipient
characteristics)

Anything that causes stress can serve as a contributor to vio-
lence against nurses. These factors are not contributed ex-
ternally but rather emanate from the thinking of individuals.
Some of the causes for such behaviors are substance and drug
abuse, feelings of powerlessness, frustration, fear, disorder,
mental illness, and others.44 These can affect the minds of
individuals, which in turn impairs individual judgments. A
perpetrator can become directly violent toward a recipient
if he or she falls into one of the identified categories. The
above behaviors are associated with perpetrators, who in
this context are generally patients or their relatives.47 On the
other hand, the recipients, who are nurses, may display poor
communication and a failure to perform, making them more
vulnerable to violence.22 For example, a nurse who fails to

accomplish his or her task is prone to verbal violence from a
senior nurse.

9.2 | Consequences

Walker and Avant24 refer to consequences as events or in-
cidents which follow the occurrence of workplace violence.
These consequences can be psychological, emotional, physi-
cal, organizational, or professional.

9.2.1 | Emotional and psychological
consequences

The emotional and psychological consequences are largely
experienced by nurses, whereby psychological violence is
the most common type of abuse reported by nurses in health-
care facilities.48 They include, but are not limited to, stress,
lack of sleep, and anger. Emotional and psychological con-
sequences are more prevalent than physical consequences
and represent the highest percentage of experienced conse-
quences. Such consequences eventually affect the quality of
work performed as a stressed nurse will not deliver as per
the expected standards.49 Violence also evokes feelings of
humiliation, which can lead to an increase in absenteeism.50

9.2.2 | Physical consequences

Physical consequences are the result of an assault on nurses
from external sources and include broken bones, headaches,
wounds, and other injuries that are associated with physical
harassment.35 Nurses in the health- care setting have reported
being subjected to incidents of physical abuse, including the use
of weapons, whereby most of the perpetrators of these violent
incidents were patients.3 Physical attacks on nurses within the
health- care setting have been reported to include lethal weap-
ons, and most of these attacks occur between the afternoon and
night time.16 This is due to the fact that the majority of clin-
ics do not accept patients after 4 PM, and the managers and
administrators also finish work at that time. This results in a
large number of patients visiting hospitals and requiring atten-
tion from nurses.47 Pushing and hitting have been reported to be
the most common forms of physical attacks.13

9.2.3 | Organizational consequences

Workplace violence is associated with a high turnover rate, lack
of proper communication skills, lack of experience, and lack of
quality care,15 and thus it incurs additional operating costs.7 It is
expensive to replace a nurse as the new staff needs to be trained

| 7 of 11AL- QADI STUDENT

so that they can become acquainted with the normal operations
of the health- care setting.51 The organization is thus negatively
affected in terms of running costs. Furthermore, it can be dif-
ficult for the administration to source new and skilled nurses.

9.2.4 | Professional consequences

The professional consequences of workplace violence are re-
lated to the delivery of services, manifested through increased
sick leave, decreased job satisfaction, a high turnover rate,
very low productivity, and an increase in error frequency by
staff.23 A nurse who feels threatened will not be inspired to
work better. Instead, their motivation to work will decrease
and they may opt to venture into other areas to find safety.35
In addition, violence by perpetrators disrupts teamwork,
thereby reducing the efficiency of service delivery.

9.3 | Empirical referents

Empirical referents are categories of actual phenomena that
may indicate the occurrence of the concept in its contextual
framework and enable one to recognize or measure the defin-
ing attributes of the concept.24 Although empirical referents
are not themselves instruments for measuring the concept,
they can be employed in the development of new measure-
ment instruments or evaluation of existing ones. Empirical
referents can be correlated to the theoretical foundations of
the concept and contribute to the content and construct valid-
ity of the new measurement tool.

These are symptoms signifying that violence has oc-
curred or might occur at any time and can be combined to
form a tool that is used as part of the concept under discus-
sion. Such observable cues are (a) humiliation, (b) verbal
abuse, (c) physical abuse, and (d) horizontal violence and
bullying.23

9.3.1 | Humiliation

Humiliation is an act aiming to belittle an individual as well
as a failure to acknowledge achieved success. It may be pre-
sented in the form of words or actions directed at the victim.
This mostly happens when a member of staff fails to appre-
ciate the role of another or when someone is the subject of
malicious rumors circulated by their colleagues.13

9.3.2 | Verbal abuse

Verbal abuse is also a sign of impending danger.52 Patients
or other staff members can decide to use abusive language

against nurses. Family members of a patient can also become
perpetrators by subjecting a nurse to verbal abuse.

9.3.3 | Physical abuse

Physical abuse refers to the use of physical force, such as
wounding a nurse or inflicting other forms of injury. This
indicates the presence of violence. As stated earlier, this can
come from patients who are angry with the nurse or even
from the family members. The worst- case scenario involves
the use of weapons and the throwing of objects.20

9.3.4 | Horizontal violence and bullying

Horizontal violence can be an indicator of violence. This is
mostly directed at vulnerable groups within the health- care
setting,53 for example, when these are sidelined from major
activities and are not consulted. Horizontal violence might
involve the withholding of resources, exclusion from the or-
ganization’s activities, and the belittling of nurses.

10 | PROPOSED OPERATIONAL
DEFINITION

The following is a proposed operational definition of work-
place violence generated from the current concept analysis:

Workplace violence is any act or threat of physical vio-
lence (beating, slapping, stabbing, shooting, pinching, push-
ing, smashing, throwing objects, preventing individuals
from leaving the room, pulling, spitting, biting or scratching,
striking, or kicking; including sexual assault), harassment
(unwanted behavior that affects the dignity of an individ-
ual), intimidation, or other threatening disruptive behavior
that occurs at the worksite with the intention of abusing or
injuring the target. It ranges from threats and verbal abuse
(swearing, shouting, rumors, threatening behavior, nonseri-
ous threats, or sexual intimidation) to physical assaults and
even homicide that creates an explicit or implicit risk to the
health, well- being, and safety of an individual, multiple indi-
viduals, or property.

11 | DISCUSSION AND
IMPLICATIONS

It is important to keep the working environment safe, cooper-
ative, and respectful.47 The relationships experienced among
nurses, patients, and family members have a significant im-
pact on cases of violence.35,54 Failure to have a good working
environment makes the professionals suffer, which can affect

8 of 11 | AL- QADI STUDENT

the organization negatively. Physical, emotional, and verbal
violence are the most prevalent forms in health- care set-
tings.46 Of the three, verbal abuse is the most frequent one and
primarily affects the emotional strength of nurses. The con-
sequences of workplace violence are classified as physical,
professional, or organizational. Organizational consequences
are by far the most detrimental to the running of a health- care
facility16 because they range from cutting staffing levels to
affecting the finances of the organization. They also result in
an increased turnover rate and low retention of employees.

Workplace violence against nurses has been likened to
other forms of violence like domestic violence and child
abuse, although the element of sexual harassment does
not feature greatly in workplace violence,55 unlike in child
abuse. Nevertheless, the consequences of the two are similar.
Furthermore, the effects felt by the nurse due to humiliation
are the same as those elicited by domestic violence,49 indicat-
ing that there is a strong relationship between the two. Some
scholars even argue that workplace violence is an extension
of domestic violence.

Much has been written on horizontal violence, which re-
fers to nurses exposing other nurses to violence. Power strug-
gles largely contribute to this form of violence. Nurses often
use abusive language to insult other nurses with the intention
of lowering their morale.51 Horizontal violence is also ap-
plied when there is a need to implement certain strategies.
For instance, senior nursing staff impart a lot of pressure on
juniors if they want certain standards to be attained,36 and
this trend is often maintained once the achievement has been
made.

Workplace violence affects not only nurses but also the
entire health- care system. It may cause stress among the
staff, which affects their performance, which in turn results
in poor services. This also has an effect on recruitment as it
becomes more difficult for the health- care service provider to
attract suitably skilled workers. Furthermore, the effects of
workplace violence are sometimes felt directly or indirectly.
Nurses who have experienced violence report symptoms re-
lated to stress, whereby some experienced trauma while oth-
ers had difficulty sleeping. In addition, the majority of nurses
who report their violent incidents are not satisfied with the
way these are handled by their employers, with some of these
cases not being treated with appropriate seriousness, meaning
the nurses’ claims are often swept under the carpet in favor of
the patients and their families.15 Identifying the factors that
contribute to violence is necessary for policymakers as well
as health- care center administrators as this would help them
develop strategies to address this phenomenon. To do so, they
would also need to be aware of the concerns of the staff, who
are in the firing line and thus subject to the consequences of
workplace violence.

Violence against nurses can be reduced by addressing the
factors contributing to the occurrence of this violence. For

instance, researchers suggest that when there are enough staff
and adequate training programs, abuse and violence can be
greatly reduced by adding facilities like beds and other med-
ical equipment, encouraging teamwork, and assigning work
fairly.15 They also recommend controlling the access of the
public and limiting visitation hours, which would stabilize
the situation in the hospitals and thereby ensure the safety of
nurses. Implementing certain policies and legislation would
also minimize workplace violence. For example, some of the
studies reviewed here showed that withholding information
from the family of a patient can trigger violence.10,12,13,16,23

Some of the studies considered in this paper argue that the
absence of legislation is one of the major contributing fac-
tors in violence against nurses. Most of the nurses who were
asked why they did not come forward when abused reported
that they are aware that nothing would be done. In other
words, the absence of policies means the absence of justice.
The weakness in this argument, however, is that there is no
clear reason for the lack of policies on the abuse of nurses
in health- care settings. Hence, more research is necessary
to determine why such policies are not being implemented.
Enforcing security measures has also been suggested as one
of the solutions to curb violence against nurses.48

The proposed operational definition can be used in nurs-
ing research addressing the concept of workplace violence.
The outcomes of this concept analysis could facilitate future
research by providing insights that prompt new research ave-
nues. Researchers need to conduct mixed- method, qualitative
studies to discern relationships between the concept and real-
life events as a means of better understanding the relation-
ships between the key attributes in various nursing specialties
which experience violence in the workplace.

One of the limitations of Walker and Avant’s24 concept
analysis method is that it does not recommend a specific strat-
egy to identify multiple uses of a given concept. The breadth
of the articles studied in the literature review increased the
rigor of the current analysis and was an attempt to overcome
this limitation by enabling consideration of numerous exam-
ples of the concept. A further limitation associated with the
concept analysis carried out for this study was that the cases
presented were artificially constructed, which may limit their
application in a real- world setting. However, this concept
analysis had many strengths. At the time this paper was writ-
ten, the concept analysis presented herein was, to the best of
the author’s knowledge, the first of its type to use Walker and
Avant’s24 method to assess workplace violence in the nursing
setting.

“Nursing personnel play the vital role by together with
other workers in the field of health, in the protection and im-
provement of the health and welfare of the population, and
emphasize the need to expand health services through co-
operation between governments and employers’ and workers’
organizations concerned in order to ensure the provision of

| 9 of 11AL- QADI STUDENT

nursing services appropriate to the needs of the community,
and recognizing that the public sector as an employer of nurs-
ing personnel should play a particularly active role in the im-
provement of conditions of employment and work of nursing
personnel and noting that the present situation of nursing per-
sonnel in many countries, in which there is a shortage of qual-
ified persons and existing staff are not always utilized to best
effect, is an obstacle to the development of effective health
services, and recalling that nursing personnel are covered by
many international labor Conventions and Recommendations
laying down general standards concerning employment and
conditions of work, such as instruments on discrimination, on
freedom of association and the right to bargain collectively,
on voluntary conciliation and arbitration, on hours of work,
holidays with pay and paid educational leave, on social secu-
rity and welfare facilities, and on maternity protection and the
protection of workers’ health, and considering that the special
conditions in which nursing is carried out make it desirable to
supplement the above- mentioned general standards by stan-
dards specific to nursing personnel, designed to enable them
to enjoy a status corresponding to their role in the field of
health and acceptable to them.”56

Finally, social learning theory57 is a theoretical frame-
work that suggests that new behaviors are learned from other
people. The theory is based on the hypothesis that people
learn new behaviors through imitation and observation.58 It
is applied in understanding social behavior and learning pro-
cesses. The social learning theory can also be used to under-
stand health behaviors among individuals or members of a
group.59

Social learning theory indicates that responses to social
stimuli or situations are motivated by prior experience.60
Thus, nurses who appreciate social learning theory are likely
to engage actively in collaborative learning and teamwork,
which develop values such as participative decision- making,
communication, and cooperation in promoting the interests
of patients.61 According to the social learning theory, learn-
ing occurs best within social environments.57

12 | CONCLUSION

Workplace violence can take multiple guises and can be de-
fined in a myriad of ways. In light of this, the objective of
this paper was to delineate a clear definition of workplace
violence that is derived from its prevailing characteristics.
Acts of workplace violence can take various forms, including
verbal and physical abuse, bullying, harassment, exclusion,
and intimidation, and can be targeted at and perpetrated by a
range of individuals, including patients, colleagues, patients’
family and friends, and management. Regardless of the form
it takes, workplace violence can have far- reaching emotional,
professional, physical, and psychological consequences. The

extant studies highlight the extent to which workplace vio-
lence remains an issue for members of the nursing workforce.
However, addressing this issue will require a collaborative
effort that involves a range of stakeholders, including admin-
istrators, nurses, leaders, educators, and other practitioners
at both the community and national levels. The failure to ad-
dress the prevalence of workplace violence in health- care set-
tings will have major ethical, legal, and moral implications
for the industry and will ultimately undermine the quality of
care provided.

The outcomes of this analysis provide the conceptual
basis and standardized language required to develop and
implement effective interventions in workplace violence as
well as valuable insights that can guide future studies. As the
main goal of the concept analysis was to develop an opera-
tional definition, the next step involves developing study in-
struments that accurately reflect the primary attributes of the
concept. This will add to the validity of future studies.

ACKNOWLEDGMENTS
N/A

DISCLOSURE
Approval of the research protocol: N/A. Informed Consent:
N/A. Registry and the Registration No. of the study/trial:
N/A. Animal studies: N/A. Conflict of Interest: N/A.

ORCID
Mahmoud Mustafa Al- Qadi  https://orcid.
org/0000-0001-5191-2542

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How to cite this article: Al- Qadi MM. Workplace
violence in nursing: A concept analysis. J Occup
Health. 2021;63:e12226. https://doi.
org/10.1002/1348- 9585.12226