Management of Non-Physical Violence against Registered Nurses in Hospital Acute Care Setting

Background: The issue of non-physical violence against registered nurses in acute care hospital settings is a pressing concern. As per 2021 CDC figures, there is a prevalence of 38.8 incidents of non-physical violence per 100 nurses annually. Such incidents can lead to serious consequences, including behavioral changes and decreased job effectiveness. Addressing this challenge is essential for ensuring a safe and efficient working environment for healthcare professionals. Aim: The study aims to explore management practices related to non-physical violence against registered nurses (RNs) in hospital acute care (AC) settings. It aims to answer the following main question: What are the effective management practices that can identify the reasons for, and evaluate measures to prevent, non-physical violence against registered nurses in hospital acute care settings? Methodology: The study employed a systematic examination of electronic databases, utilizing sources from ProQuest, PsycINFO, and the Medline library for the period between 2016 and 2022. Six paramount studies that scrutinized non-physical violence against healthcare professionals were included, with relevant articles meticulously analyzed to yield valid conclusions. Thematic analysis was employed to decipher the patterns emerging from the selected studies. Results: Notable themes encompassed the causative factors behind non-physical violence against registered nurses in hospitals and the strategies employed to alleviate such incidents. These factors include high work pressure and stress, inadequate training and professionalism, absence of person-centered care, and unawareness and issues with patient family members. Conclusion: This study affirms that targeted training programs could significantly augment nurses’ capabilities to handle non-physical violence effectively. A heightened level of synergy between healthcare personnel and hospital management is crucial to enable immediate reporting of incidents and pave the way for safer working conditions.

recognized violence as any event that incurs harm to another individual, whether verbal or physical (Rutherford et al., 2007).Such incidents of non-physical violence within hospital settings frequently involve the use of derogatory language, threats, or aggressive behavior towards RNs, leading to psychological trauma (Somani et al., 2021).
This study intends to examine management practices concerning non-physical violence against RNs in hospital AC settings.Primary objectives include identifying the catalysts for non-physical violence and evaluating preventive measures that can be implemented in AC settings.Key topics include the understanding and application of de-escalation techniques, the impact of non-physical violence on RNs, and the necessity of establishing protocols to prevent such incidents (Price et al., 2018).
There is a significant number of non-physical violence incidents against nurses, with 13.2 per 100 nurses facing such encounters annually (CDC, 2021).Consequences of this trend range from heightened levels of depression and anxiety among RNs to compromised job performance and patient care (Ashton et al., 2018;Teoh et al., 2019).This necessitates the development and implementation of effective measures to safeguard nurses against nonphysical violence, which include comprehensive training programs, open communication practices, and enhanced workplace safety (Cheung and Yip, 2017;Pariona-Cabrera et al., 2020).
The current body of research emphasizes the need to foster a positive work environment, improved facilities in the AC settings, and strategies for managing negative reactions from patients and their families (Ashton et al., 2018;Hsu et al., 2022).This exploration provides an essential foundation for subsequent chapters which will delineate the research methodology, review relevant literature, and discuss findings within the context of this pivotal healthcare issue.

Aim and Objectives
The study aims to explore management practices around non-physical violence against RNs in hospital AC settings.To address the aim, the following research aims are framed: • Identify the reasons for non-physical violence against registered nurses in hospital acute care settings • Evaluate measures that can be taken to avoid non-physical violence against nurses in hospital acute care settings

Research Design
This investigation adopts an integrative literature review to assemble evidence on managing non-physical violence against RNs in acute care settings.The method allows a comprehensive evaluation of existing literature, recognizing gaps, and bridging them.The methodology follows Whittemore and Knafl's (2005) five-step process for rigor, including research problem articulation, literature search, data quality evaluation, analysis, and conclusion presentation.The approach also requires a clear definition and elaboration of search terms, databases, and inclusion/exclusion criteria, although no universally accepted standard for evaluating quality exists.Various systematic reviews and primary qualitative sources are synthesized in the analysis.The search strategy ensures reproducibility, including diverse primary research methods and identifying appropriate thesaurus terms for research goals.Inclusion criteria required articles to be recent, English-written, and peer-reviewed.Four key databases were chosen for relevance to the nursing field.The search was structured around 'Management of nonphysical violence against nurses in hospital acute care setting', using relevant keywords and combinations, but excluding the Boolean operator 'NOT' for simplicity.A comprehensive list of the keyword phrases used in the database search is illustrated in Appendix 1.

Inclusion and Exclusion Criteria
Inclusion Criteria for this review encompassed non-physical violence against healthcare professionals, specifically registered nurses in the acute care setting of hospitals, including urgent medical conditions and recovery from surgery.Only English-written, peer-reviewed articles published within the last five years were considered.Exclusion Criteria were applied to omit non-relevant studies such as physical violence, violence among staff or patients outside hospital premises, studies not involving RNs and duplicates.Also excluded were articles not in English and those with inaccessible full text (Appendix 2).

Quality Appraisal of the Included Studies
Quality appraisal plays a crucial role in the literature review process.It helps us mitigate information overload by excluding insignificant papers and focusing on the most relevant ones.Additionally, it enables us to distinguish facts from assumptions or opinions, assess the validity and usefulness of a study, and identify potential biases (Williams et al., 2018).
The quality appraisal of an integrative literature review is a significant factor in assessing the authenticity, accuracy, and credibility of the studies included.It ensures that only the highest-quality papers are incorporated, thereby enhancing the overall quality of the review (James et al., 2022).
Quality appraisal is carried out using specified tools that allow for a reliable evaluation process.Whittemore and Knafl (2005) suggest that some studies argue the futility of quality assessment due to the complexity involved in such an evaluation.Nevertheless, the studies selected for this review underwent a rigorous quality appraisal using various critical appraisal instruments (Whittemore & Knafl, 2005).
In the qualitative studies by Ashton et al. (2017) and Price et al. (2017) identified in the database screening process, the Critical Appraisal Skills Programme (CASP) tool for qualitative studies was employed (Hoh et al., 2019).The CASP checklist examined what the cohort study results represented, the validity of these results, and their relevance to this study (Anon., 2020).Following the application of this tool, the papers selected for inclusion in the review demonstrated a high level of quality, featuring comprehensive methodologies, appropriate sample sizes, and a high degree of relevancy to the research question about superior approaches to addressing and managing patient violence in critical care facilities (Appendix 3).
Similarly, the 'systematic review' CASP tool was applied to assess the quality of the selected systematic reviews that had been selected from this database search.The checklist illustrated below consists of ten questions covering the major elements.This includes the validity of study outcomes, study significance, and local implications that could be applied.
All of the papers that were examined as part of the integrative literature review were found to be critical in examining the issue of patient violence.Again based on Anon.( 2020), Appendix 4 shows the CASP process for systematic review studies and the considerations taken into account for each paper.

Ethical Considerations
The studies that have been included in this review all followed appropriate ethical considerations.These include the proper level of research data confidentiality, appropriate consenting before the study, privacy protection, making sure no level of harm occurs to participants, avoidance of misleading information, honest communication, and declaration of sources of funding or conflicts of interest (Zhou et al., 2020).

Results
The findings from this systematic review are presented in this chapter.The search results and an overview of the selected articles are presented in the first section of the chapter.This chapter is extremely important since it enables in-depth investigation into the articles chosen for analysis.Then, each paper will be presented narratively with a summary of its objectives, findings, and methodological strength.Due to the homogeneous character of this research, a synthesis of the evidence is given for the seven qualitative articles that looked at non-physical violence against RNs in hospital AC settings of previous discharge procedures and their preferences for upcoming ones.

Results from Search
During the search, a total of 334 studies were identified.The number of studies found on Medline, ProQuest, CINAHL, and PsycINFO were 125, 118, 49, and 42, respectively.Out of the 334 studies, 190 articles were found to be duplicates and were therefore excluded.This meant that only the remaining 144 abstracts needed screening.
During the screening process, 45 articles were eliminated from the search due to irrelevance.After excluding these irrelevant articles, only 99 relevant studies needed to be retrieved.However, upon trying to retrieve these articles, six studies failed to be retrievable.The remaining 93 were successfully retrieved and passed on for the application of the inclusion/exclusion criteria (Figure 1).

Description of Included Studies
After applying the exclusion/inclusion criteria, a further 87 studies were omitted.This was because 36 papers were excluded due to their coverage of physical types of violence.Another 25 studied non-physical violence that occurred outside the premises of AC settings.A further 21 papers studied causes that could trigger violence in the healthcare sector, and five studies involved healthcare staff in general with no specification towards RNs.That left six studies to be screened in full text.
The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) concern the significant items that are associated with sources of information, selection process, presentation of the search flow, summarising findings, research limitations, and interpretation.
As such, for method evaluation, the PRISMA diagram was used.This is to allow a transparent process for data extraction from a systematic database search.This is illustrated in Figure 1.

Mitigation of Non-Physical Violence towards Registered Nurses in Hospital Acute Care Environments
Six qualitative studies exploring the triggers of non-physical violence towards registered nurses in hospital acute care (AC) settings are divided into two thematic categories: experiences and preferences.Despite their distinct foci, these studies bear significant parallels, thus their findings are synthesized, replacing experiences and preferences.An exhaustive catalog of the studies, inclusive of their authors, publication year, location, objectives, sample size, data collection methods, results, recommendations, and CASP tool score is provided in Appendix 1 (Stambler, 2017).

Triggers of Non-Physical Violence Towards Registered Nurses in Hospital Acute Care Settings
Late appraisals by medical authorities often result in staff demotivation, potentially leading to aggressive behavior towards patients, and instigating non-physical violence in AC settings.Lack of adequate measures such as robust reporting mechanisms also catalyzes violence (Wirth et al., 2021).Furthermore, depression among staff, poor psychological situations of patients and their families, and a shortage of professionals exacerbate non-physical violence (Houston, 2019;Hsu et al., 2022).Additionally, receiving bad news may distress patients or their relatives, further stimulating violence.

Countermeasures Against Non-Physical Violence Towards Registered Nurses in Hospital Acute Care Settings
Workplace health and safety (WHS) programs are instrumental in mitigating non-physical violence against healthcare professionals (HCPs) (Wirth et al., 2021).The World Health Organization underscores the responsibility of organizations to safeguard their staff while also instituting remedial measures for post-violence incidents (Dixon, 2019).Adopting a zero-tolerance policy against workplace violence and facilitating open communication channels to report such incidents can foster a safer work environment (Hsu et al., 2022).Enhancing awareness about workplace violence and streamlining reporting processes can also help combat violence (Price et al., 2018).

Inadequate Training and Knowledge
Insufficient skills and professionalism provoke non-physical violence.Hospital management must ensure training (Hsu et al., 2022).

Absence of Person-Centered Care
Lack of patient-oriented services leads to dissatisfaction and escalates violence.Effective regulations are needed (Somani et al., 2021).

Zero-Tolerance Policy and Open Communication
Development of a zero-tolerance policy and open communication to resolve issues (Wirth et al., 2021).

Raising Awareness and Training
Awareness about WPV and its impact, identifying abuse patterns, and implementing online training to augment knowledge.

Streamlining the Reporting Process
Creating an uncomplicated reporting system allows notification of any violence, promoting a safer workplace (Hsu et al., 2022).This narrative presentation synthesises the literature providing context and a discussion of recurring ideas.From the review's objectives and findings, two primary themes emerged, namely: the causes of non-physical violence against Registered Nurses (RNs) in acute care (AC) settings and the measures taken to mitigate such violence, each with three subthemes.
Non-physical violence against RNs in AC settings often originates from high work pressure.According to Pariona-Cabrera et al. (2020), stressful environments and intense workloads render nurses vulnerable to non-physical violence and internal conflicts.Furthermore, job-related stress can distract nurses from their duties, leading to patient dissatisfaction and resulting in non-physical violence.
Inadequate training and knowledge of nurses present another trigger for non-physical violence, with patient behavior playing a significant role.Insufficient skills and professionalism in handling patients can provoke nonphysical violence in AC settings (Hsu et al., 2022).Hospital management has a responsibility to ensure appropriate staff training and professional behavior to reduce such incidents.
The absence of person-centered care also contributes to non-physical violence.The inability to provide patientoriented services leads to patient dissatisfaction and escalates non-physical violence in AC settings.Hospital management should provide high-quality and patient-centered care, and an absence of effective regulations to this end often makes nurses the target of non-physical violence in AC settings (Somani et al., 2021).
With an increase in non-physical violence against nurses in AC settings globally, several countermeasures have been proposed.Unawareness and patient family members' issues contribute to the escalating violence, emphasizing the role of human resource management in managing job-related anxiety through organizational support (Wirth et al., 2021).
One such measure is developing a zero-tolerance policy, entailing a workplace code of conduct with strict action against violators (Wirth et al., 2021).Maintaining open lines of communication enables effective issue resolution and allows employees to report casualties promptly.
Raising awareness about workplace violence (WPV), its impact, and its repercussions can aid in its reduction.Identifying patterns of abuse within different sectors of an organization can foster safety awareness among employees and facilitate proactive countermeasures.Online training can be implemented to augment employees' knowledge and response to violent situations.
Streamlining the reporting process is another effective measure.Establishing an uncomplicated reporting system allows workforce members to notify leaders about any violence in the organization, promoting a safer workplace (Hsu et al., 2022).Hence, these strategies can significantly reduce non-physical violence in AC settings, fostering a safe working environment.Wirth et al. (2021) discussed that staff appraisals are considered the major causes of aggression of the staff members or the RNs.Medical staff members may feel disheartened when they do not get timely appraisals, which makes them feel irritated, and sometimes, as a result, they do not give proper responses to patients.This quickly increases the violent episodes in the AC setting (Wirth et al., 2021).When the staff members have to deal with difficult patients, it may create difficult situations for the RNs.However, Niu et al. (2019) found that there is a need to have an adequate level of clinical management and a strong commitment toward the RNs so that nonphysical violence in the AC setting can be controlled.This reveals the critical importance of recognizing and addressing the emotional needs of staff members to promote a more harmonious AC setting.

Discussion
The findings from the above review indicate that medical authorities are not paying attention to managing aggressiveness and violence at hospitals.Many staff members are unaware of their role; therefore, they fail to interact with the families of patients effectively.In such conditions, the family members may react loudly to staff members (Hsu et al., 2022).This emphasizes the importance of clear role definition and effective communication with patient families to prevent unnecessary confrontations.It is found that truly exhausted staff members in AC are unable to control their behavior.In these circumstances, such RNs are unaware of their role, hence they fail to deal with different problematic situations effectively.The six intervention studies showed that non-physical violence is the result of a high level of stress, aggression, and lack of awareness of the role of RNs (Pariona-Cabrera et al., 2020).This needs a more robust examination to implement such outcomes into practice in AC settings.Cheung et al. (2019) found that clinical violence causes big trouble for nurses as they fail to perform their duties well.
The review was done from the perspective of RNs working in AC settings.Therefore, it is difficult to compare the actual conclusion to the current research (Wang et al., 2019).Many mixed methods were used to conduct this research and the perspective of the patient's family members was excluded because there was a lack of clarity on it.The exclusion of this perspective underscores the necessity to broaden the scope of future research to capture a more comprehensive view of the problem.Understanding the experiences of the patient's family members and the patient themselves was outside the scope of the review (Somani et al., 2021).However, the study reinforced findings from the systematic review that non-physical violence results in aggression, improper communication, and lack of clarity for the job role.One review paper highlighted that the introduction of a WPV reporting system can help in controlling such kinds of violent episodes in the AC setting.This finding aligns with the identified need for more efficient reporting and monitoring systems within the AC environment.There is a need to give training to the RNs so that they can handle critical situations effectively.One review paper highlighted that lack of staff respect, ward rules, and patient factors are increasing the non-physical violence for RNs (Husted and Dalton, 2021).The paper discussed that the provision of prevention needs to be there to protect the RNs from non-physical violence.Enhancing workplace training, respect, and clear guidelines can lead to better preparedness and less violence.Workplace training must be encouraged so that nurses can ensure offering high-quality nursing care to the patients and thus such violence can be avoided in the hospital AC (Hsu et al., 2022).It can be said that violence and aggression in AC are inevitable experiences and there is a need to boost the organizational commitments to control such violent episodes.However, interventions must be taken to protect the nurses.Effective training and strong commitment can help nurses avoid such violent conditions (Bayraktar et al., 2020).The study's objectives thus highlight the necessity of multi-faceted approaches, including training, policy development, and increased organizational commitment to curb non-physical violence in AC settings.

Limitations of Study
The limitations of the present study are integral to understanding and interpreting the findings, especially in the context of nursing management in AC settings.First and foremost, the sample selection may have been confined to specific hospitals or regions, limiting the generalizability of the findings across various settings or countries.This restriction could affect the broader application of the study's conclusions.Secondly, the methodological constraints, including reliance on certain data collection methods such as interviews or surveys and the potential subjective bias from self-reported data, might have led to a skewed or incomplete view of non-physical violence against Registered Nurses (RNs).Thirdly, the study's focus solely on the RNs' perspective without incorporating the viewpoints of other stakeholders, such as patients' families or hospital management, could limit a comprehensive understanding of the issue.A fourth limitation pertains to the time constraints of the study, which may have restricted the ability to capture the full complexity or trends of non-physical violence over a more extended period.Lastly, the study might have suffered from insufficient emphasis on organizational culture and policies, neglecting an essential aspect that can significantly impact the effectiveness of preventive measures.These limitations necessitate careful consideration in applying the study's findings to nursing management and underline the need for future research to adopt a more inclusive, methodologically robust, and context-sensitive approach.

Conclusion
The present study can be summarised by stating that non-physical violence incidents are increasing in hospitals in the AC setting.The family members of patients have a high concern for their loved ones and when they find that no one is responding to them about the condition of patients or if they listen to any kind of bad news then they become highly aggressive.This kind of threat to AC nurses affects their emotional and psychological state to a great extent.These findings should guide nursing management in formulating comprehensive strategies tailored to the specific challenges faced in AC settings.The medical authorities must take corrective measures to overcome such kinds of critical incidents in the AC setting.
Workplace training programs are the most significant action that may help in avoiding such kinds of events in AC.Such training programs concentrate on improving the capability of nurses to deal with family members and patients effectively in AC.This ensures that nurses provide high-quality nursing care to the patients and try to improve their conditions promptly.From a nursing management perspective, these training programs must be an integral part of continuous professional development, fostering skills that align with real-world challenges.
The authorities need to adopt multi-component intervention strategies to control the prevalence of non-physical violence against RNs.Positive management support and creating a healthy workplace environment, along with open communication, may support enhancing the confidence of the nurses so they can deal with critical situations effectively without affecting their performance.Nurses need to behave confidently and must report these violent incidents to the relevant authorities.Nursing management plays a pivotal role here, as they must actively facilitate open communication and ensure that reporting mechanisms are transparent and responsive.This may help those authorities to become aware of the issues and they may take serious action to punish the perpetrator.Organizations need to create effective protective guidelines for medical staff members.A safe environment must be created for healthcare workers in which they can execute their job of providing quality care to patients effectively.
Many healthcare organizations are concentrating more on improving safety policies and creating a safer environment for medical staff members.Great interventions and a strong collaboration between the hospital management and the nurses can work well in minimizing violent incidents and in raising the confidence of RNs in the hospitals.This underscores the importance of nursing management's proactive involvement in shaping policies and cultivating a collaborative culture.In such conditions, they would work well and would be more committed to the healthcare setting.Medical staff members have to play the role of victim in the violent incidents and this impacts their care setting as well.The organization needs to be committed to reducing violence and aggression in the AC setting.Staff training and close clinical supervision must be ensured.The active engagement of nursing management in supervision and training is vital in translating these strategies into practical, effective interventions.This is the best way through which such incidents of non-physical violence can be minimized and nurses can execute the best care to the patients in the AC setting.The hospital authority needs to prepare the RN to deal with such kinds of incidents carefully.By promoting WPV prevention interventions and increasing the knowledge of AC staff members the hospital can protect its medical workers and promote good care to its patients.In conclusion, the application of these research findings within nursing management can lead to more targeted and effective measures to safeguard both the well-being of nurses and the quality of patient care.

Table 1 .
Causes and Countermeasures of Non-Physical Violence Towards Registered Nurses in Hospital AC Settings Stressful environments and intense workloads lead to nonphysical violence(Pariona-Cabrera et al., 2020).Job-related stress can lead to patient dissatisfaction.