The U.S. OSHA proposed a set of guidelines to address and prevent WPV in healthcare and social service sector workers, which guides this current review (OSHA, 2015). These guidelines include five elements to address and prevent WPV. Management commitment and worker participation are critical components necessary for any other element to be effective. The worksite analysis and hazard identification element rely on worksite risk assessment to identify potential employee hazards and risks (OSHA, 2015). Worksite analysis can be conducted using data from several sources, such as employee surveys, patient surveys, job hazard analysis, and incident reports. Hazard prevention and control refers to strategies and actions taken to prevent or mitigate potential risks and hazards in the workplace, which are identified through worksite analysis and hazard identification (OSHA, 2015). These strategies may include substitution (e.g., evicting violent visitors), implementation of engineering controls (e.g., using physical barriers to restrict access to healthcare setting areas), and the use of administrative and work practice controls (e.g., risk assessment, reporting, behavioral emergency response teams). Safety and health training, the most frequent element used in healthcare settings, includes regular worker training on managing aggressive incidents, de-escalation strategies, adoption of WPV policies and procedures, and personal safety training. Finally, the recordkeeping and program evaluation element is vital to evaluate the effectiveness of WPV interventions, such as developing a consistent system for reporting incidents of WPV and regularly reviewing the reports (OSHA, 2015). OSHA’s (2015) guidelines framework guided the research, aims, search process, and interpretation of studies in this review.

This integrative review aims to synthesize the existing literature on effective interventions or strategies aligned with OSHA (2015) guidelines to address and control WPV against nurses.

Whittemore and Knafl’s (2005) five-step methodology provided a structured approach to guide this integrative review. The steps included identifying the research problem (stated earlier), conducting a literature search, evaluating the data, and finally presenting the results. Additionally, this approach enhances rigor and minimizes bias in the analysis, synthesis, and conclusion process.

A comprehensive search strategy was developed and performed by a health sciences librarian. Databases used for the search were PubMed, Embase, CINAHL, and PsycINFO from 2010 to 2023. The starting point for the literature search was set at 2010 to align with significant regulatory updates in WPV prevention, including the OSHA (2015) guidelines, which marked a shift in WPV intervention strategies in healthcare settings. Key terms in the search included “workplace violence,” “occupational violence,” “nurses,” “nursing personnel,” “education,” “training program,” and “educational activity,” among others (see Supplementary Document 1).

Articles that addressed OSHA (2015) guidelines’ key elements, from any type (qualitative, quantitative, and mixed methods), targeted nurses as the main population, published in the English language and peer-reviewed journals, and addressed WPV interventions and strategies aligned with OSHA guidelines were included in the review. However, literature, scoping, integrative or systematic review articles, theses, conferences, eBook chapters, and articles discussing workplace bullying or incivility were excluded.

Records were uploaded to and deduplicated through Rayyan (https://www.rayyan.ai/), a web-based platform used to conduct systematic reviews. After removing the duplicates, the search yielded 834 articles. The initial review process was conducted by two investigators who were blinded to the decisions of the other investigator until both had completed their review. A total of 786 papers were excluded using the title and abstract. Then, the two investigators independently screened the remaining 48 full-text papers against the inclusion/exclusion criteria, and following discussion, a consensus was reached to include 37 papers. The process of this literature review search is demonstrated by the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) (Page et al., 2021) (see Figure 1).

The quality of the reviewed studies was assessed for the level and quality of evidence based on the Johns Hopkins Nursing Evidence-Based Practice Evidence Level and Quality Guide (Dang et al., 2022). This framework categorizes evidence into five levels, from Level I (randomized controlled trials and systematic reviews) to Level V (expert opinions and case reports). Studies were further rated for quality as high (A), good (B), or low (C) based on criteria including study design, sample size, risk of bias, and generalizability.

One study met the criteria of level I (Chang et al., 2022), 11 studies met the criteria of level II (Al-Ali et al., 2016; Cabilan et al., 2023; Cai et al., 2023; Duncan et al., 2021; Gillespie et al., 2014; Hemati-Esmaeili et al., 2018; Kalbali et al., 2018; Ming et al., 2019; Ramacciati et al., 2021; Sadatmahaleh et al., 2019; Sharifi et al., 2020), 14 studies met the criteria of level III (Al-Natour et al., 2023; Burkoski et al., 2019; Cabilan et al., 2022; Carr & Derouin, 2023; Cordenuzzi et al., 2017; Dadashzadeh et al., 2019; Dafny et al., 2022; Dafny & Muller, 2022; de Barbieri et al., 2022; Gillespie & Berry, 2023; Öztaş et al., 2023; Shea et al., 2018; Tosswill et al., 2023; Xu et al., 2022), and the last 11 articles were level V evidence (Bruccoli, 2023; de la Fuente et al., 2019; Gillespie & Leming-Lee, 2019; Hendrickson, 2022; Lakatos et al., 2019; Senz et al., 2021; Stene et al., 2015; Story et al., 2020; Wong et al., 2015; Yost et al., 2022; Zicko et al., 2017). Almost all reviewed studies are considered good quality (B) due to some limitations regarding the study design, sampling procedures, and generalizability. However, only one study (Gillespie & Berry, 2023) is considered high-quality as it includes a generalizable study sample and recruited study participants by systematic random sampling.

Each study’s data about authors’ names, interventions, methods, and findings were extracted and summarized into an evidence table (see Supplementary Document 2). The table also includes the quality of the studies and the level of evidence. One researcher developed the summary table independently and reviewed it separately with a second investigator. Refinements were made as appropriate.

Data from the evidence table were synthesized and analyzed frequently. Any information related to strategies or interventions to prevent and control WPV aligned with OSHA (2015) guidelines was recorded. Then, data related to strategies or interventions that addressed WPV initiated by patients or visitors were arranged in patterns and themes based on OSHA’s five key elements. This process was performed by the first author under supervision, and another investigator checked for accuracy. In this manner, we determined the interventions and strategies used to prevent and control WPV initiated by patients or visitors that addressed OSHA (2015) guidelines.

Thirty-seven articles were included in this integrative review. The articles used various design methods to collect and analyze data, including qualitative (n=6), quantitative (n=19), and quality improvement methods (n=12). The articles were published between 2010 to 2023 and conducted in the U.S. (Bruccoli, 2023; Carr & Derouin, 2023; de la Fuente et al., 2019; Duncan et al., 2021; Gillespie et al., 2014; Gillespie & Berry, 2023; Gillespie & Leming-Lee, 2019; Hendrickson, 2022; Lakatos et al., 2019; Stene et al., 2015; Story et al., 2020; Zicko et al., 2017), Iran (Dadashzadeh et al., 2019; Hemati-Esmaeili et al., 2018; Kalbali et al., 2018; Sadatmahaleh et al., 2019; Sharifi et al., 2020), Jordan (Al-Ali et al., 2016; Al-Natour et al., 2023), Italy (Ramacciati et al., 2021), Turkey (Öztaş et al., 2023), China (Cai et al., 2023; Xu et al., 2022), Brazil (Cordenuzzi et al., 2017), Canada (Burkoski et al., 2019), Taiwan (Chang et al., 2022; Ming et al., 2019), and Australia (Cabilan et al., 2022, 2023; Dafny et al., 2022; Dafny & Muller, 2022; Senz et al., 2021; Shea et al., 2018; Tosswill et al., 2023). The studies mainly included nurses from several healthcare setting departments (e.g., ED, ICU). The mean age of participants in the included studies ranged from 25 to 43 years. Only three studies did not report age means (Gillespie & Leming-Lee, 2019; Hendrickson, 2022; Stene et al., 2015). Both men and women were included in most of the studies. However, one study involved only male participants (Dadashzadeh et al., 2019), and three studies did not specify gender (Gillespie & Leming-Lee, 2019; Hendrickson, 2022; Stene et al., 2015).

Participants were recruited predominantly through convenience sampling. Only one article used a randomized sample (Gillespie & Berry, 2023), two used a purposeful sample (Al-Natour et al., 2023; Dadashzadeh et al., 2019), and one used a snowball sample (Cabilan et al., 2022). Meanwhile, one study did not mention their sampling plan procedures (Cordenuzzi et al., 2017). Only two studies were guided by a theoretical framework (Chang et al., 2022; Gillespie & Berry, 2023). Thirty-one of the articles used surveys or standardized instruments to collect data. However, only one study used occupational health, security, and employee safety reporting systems to collect and compare data (Lakatos et al., 2019).

Six studies used different qualitative methods to collect data. Three studies used semi-structured focus groups (Burkoski et al., 2019; Cordenuzzi et al., 2017; Dafny & Muller, 2022), two used semi-structured interviews (Al-Natour et al., 2023; Dadashzadeh et al., 2019), and one used mail narrative responses to open-ended structured questions (Gillespie & Berry, 2023).

All studies reported at least one strategy aligned with key elements of the OSHA (2015) guidelines framework. After reviewing the articles, several interventions and strategies were found to mitigate and eliminate WPV in healthcare settings.

Administrative commitment and leadership engagement are consistently identified as essential in mitigating workplace violence (WPV) in healthcare settings. Such involvement is crucial for ensuring adequate resource allocation, visible safety measures, and enforcement of anti-violence policies (Al-Natour et al., 2023; Bruccoli, 2023; Burkoski et al., 2019; Cabilan et al., 2022; Carr & Derouin, 2023; Dafny & Muller, 2022; de Barbieri et al., 2022; Gillespie & Berry, 2023; Hemati-Esmaeili et al., 2018; Öztaş et al., 2023; Shea et al., 2018; Xu et al., 2022). Leadership engagement, primarily through the implementation of anti-WPV policies and structured follow-up procedures, enhanced staff trust and safety perceptions (Hendrickson, 2022; Gillespie et al., 2014). Security presence emerged as a core component of this leadership commitment to mitigate violent incidents and increase nurses’ perception of safety (Al-Natour et al., 2023; Cabilan et al., 2022; Dafny & Muller, 2022; de Barbieri et al., 2022; Gillespie & Berry, 2023). Nurses described the presence of trained security personnel as vital in deterring aggressive behaviors and facilitating timely interventions during escalating situations (Cabilan et al., 2022). In some cases, involving law enforcement was also necessary to remove highly aggressive individuals (Cabilan et al., 2022).

Post-incident psychological support was another key leadership-supported strategy shown to enhance recovery and resilience. Post-incident debriefings and access to mental health services were described as effective strategies to promote recovery and restore a sense of safety among nursing staff (Al-Natour et al., 2023; Bruccoli, 2023; Cabilan et al., 2022; Dafny & Muller, 2022; Gillespie & Berry, 2023; Shea et al., 2018). In a quality improvement study, Bruccoli (2023) reported a 35.5% increase in staff safety perception following the implementation of post-incident debriefings. Likewise, Shea et al. (2018) found that hospitals with mandatory WPV training had a 40% higher rate of post-incident debriefing adoption compared to those without formal training. However, several studies’ results reported the absence of institutional emotional support systems, which forces staff to rely on personal coping mechanisms and increases the risk of long-term psychological distress (Gillespie & Berry, 2023; Öztaş et al., 2022; Xu et al., 2022).

Technological safety interventions, such as personal duress alarms, also represent a growing area of administrative investment intended to support real-time response during violent incidents. While these systems have been linked to increased staff confidence (Burkoski et al., 2019), their effectiveness may be compromised by issues related to training and usability (Carr & Derouin, 2023). In their study, Carr and Derouin (2023) found that the duress alarm system usage rates were low among nurses, and this was due to device design issues (e.g., bulky or uncomfortable badges), insufficient training, and unreliable security response times. Additionally, many staff members lacked adequate knowledge of how to operate the alarm. Finally, empowering staff through direct participation in prevention efforts also is essential for strengthening their commitment to workplace safety, enhancing engagement, and ensuring the sustainability of WPV interventions. Hemati-Esmaeili et al. (2018) took an innovative approach by involving nurses directly in prevention efforts and designed a new role for violence prevention nurses. This initiative empowered nurses to perform their duties in a safe environment, and the study results indicated that nurses’ satisfaction with incident follow-ups improved significantly.

Two research studies emphasized walkthrough assessment as a critical strategy for identifying and addressing hazards related to WPV in healthcare settings. In a quality improvement study, Gillespie and Leming-Lee (2019) applied a failure modes and effects analysis (FMEA) framework during a walkthrough assessment of an ED to evaluate weaknesses in the WPV reporting process. Through structured discussions with frontline healthcare workers, primarily nurses, they identified multiple failure modes and systematically assessed each one based on its severity, frequency of occurrence, and likelihood of detection. These three factors were used to calculate a risk priority number (RPN) for each failure mode, where higher scores indicate more significant risk and urgency for intervention. Notably, the failure to report incidents to leadership received the highest RPN. The staff believed that reporting WPV incidents to leadership would not result in any real action, which was a sign of a lack of trust and poor administrative response. Similarly, Gillespie et al. (2014) integrated walkthrough assessments into a multi-component WPV intervention project implemented in six EDs (three intervention and three control groups) across different hospitals. Their intervention included environmental redesign, development and revision of institutional policies, and delivery of training programs focused on WPV prevention. These assessments enabled dynamic refinements to policies, training, and physical layout based on staff feedback and real-time observations. Employees were actively involved in the iterative development of prevention strategies, which fostered a sense of improved compliance.

Many strategies and procedures can be taken to prevent WPV and control the situation during the incident. The studies discussed different types of hazard prevention and control strategies, including substitution, implementation of engineering controls, and the use of administrative and work practice controls.

Safety training programs on topics such as de-escalation techniques, WPV procedures, and crisis prevention were the most common interventions across the reviewed studies. Al-Ali et al. (2016) conducted a quasi-experimental study that included a five-session in-person training program for nurses on WPV prevention and management. The program significantly improved nurses’ performance in handling WPV incidents but had less impact on attitudes toward legal and safety protocols. In a similar study targeting ED nurses, Kalbali et al. (2018) introduced a hybrid model that combined a four-hour in-person anger management training with two months of virtual reinforcement. This more intensive approach led to a notable reduction in exposure to physical and sexual WPV. In another study, Hemati-Esmaeili et al. (2018) found that the three-day educational seminar training paired with the introduction of a violence prevention nurse role positively affected the verbal abuse rates but not the physical violence rates. In contrast, Story et al. (2020) took a shorter, more general approach in their study by performing a two-hour WPV prevention training for nurses from different units. The researchers noted improved nurse confidence in managing WPV after the intervention. (Calow et al., 2016)

Simulation-based training was another prominent method that helped staff practice real-life conflict scenarios, which enhanced their preparedness and reduced aggression-related incidents. Ming et al. (2019) found beneficial results from the simulation-based WPV training targeted nurses at different nursing units. After a pretest was given to participants, a 3-hour literature-based simulation educational intervention program of real-world scenarios focused on coping with violent conflict situations was introduced, followed by a posttest after the intervention. Researchers noted that nurses’ confidence in their ability to manage WPV incidents was increased after the educational intervention. Similarly, Duncan et al. (2021) showed that simulation-based de-escalation training significantly improved participants’ capabilities in handling patient aggression. Cai et al. (2023) took a long-term approach by performing a 10-month training program grounded in situational prevention theory. The training involved classroom teaching and scene simulation for nurses from different hospital units. The results indicated a reduction in WPV incidence and severity at three-time points post-training (3-, 6-, and 9-months) compared to baseline. In addition, nurses reported an enhanced ability to anticipate and cope with WPV three- and nine-months post-training. In contrast, Wong et al. (2015) noted that the simulation-based training conducted for ED staff did not affect their attitudes toward management strategies.

Behavior management training also demonstrated strong efficacy in preparing nurses for WPV. De la Fuente et al. (2019) implemented a four-hour behavior management training for nurses to protect themselves from injury and control patients’ and visitors’ aggressive behavior to decrease harm. Scores for nurses who received the training indicated increased confidence in managing patient/visitor aggression after the intervention compared with pre-intervention. Similarly, Yost et al. (2022) conducted a 60-minute behavior management training program that included evidence-based de-escalation techniques. After training, the results indicated increased staff confidence in managing aggressive situations and reduced WPV rates. Chang et al. (2022) expanded on this by implementing a 12-month training program. Researchers found that their multifaceted training intervention, which involved conflict management, communication, and problem-solving skills, significantly improved nurses’ confidence and coping self-efficacy in managing WPV incidents. Lakatos et al. (2019) further contributed to the field by developing the S.A.F.E. Response program, which integrated behavior management training with de-escalation techniques, clinical responses to threats, and structured post-incident debriefing. Data from employee safety, security, and occupational health reporting systems were compared, and the results showed a significant 40% reduction in staff injuries related to WPV after the intervention.

Recordkeeping and program evaluation are crucial to assess the extent of the issue, appraise various strategies for managing risks, and recognize training requirements. Stene et al. (2015) introduced a simplified reporting tool in their quality improvement study to encourage real-time documentation and help staff and nursing leadership complete the formal WPV incident report later, outside of the actual WPV event. Alongside the tool, the researcher provided a training program on the nature of WPV behaviors, the reporting tool, and how to report WPV incidents. Following the creation and implementation of the reporting tool, each incident reported was addressed by a special committee. The purpose of the reporting tool creation was to establish a database for WPV incidents, which will help identify the problem’s severity (Stene et al., 2015). After the intervention, physical and verbal violence was reduced during the year between the first and second surveys. Nurses’ perceptions of WPV as part of their job were reduced, and the reporting of WPV incidents increased. Additionally, nurses’ knowledge about WPV behaviors and which behaviors should be reported to the police was increased (Stene et al., 2015). Ramacciati et al. (2021) further supported these findings by introducing a smartphone-based application for reporting WPV among ED nurses. The application simplified the WPV reporting process and increased engagement in reporting WPV events. Although there was a modest but significant increase in reporting rates post-intervention, Ramacciati et al. (2021) concluded that technological solutions alone are insufficient to address underreporting.

The review revealed a broad spectrum of interventions aligned with OSHA’s (2015) guidelines. However, their differential effectiveness revealed important distinctions in how various strategies influence WPV outcomes and organizational safety culture. To begin with, administrative commitment and leadership engagement emerged as critical components in fostering a culture of safety within healthcare settings. Interventions that involved visible leadership support (i.e., security personnel), enforcement of anti-WPV policies, and the active inclusion of nurses in prevention planning were consistently associated with increased staff perceptions of safety and organizational trust (Al-Natour et al., 2023; Cabilan et al., 2022; Hemati-Esmaeili et al., 2018; Hendrickson, 2022; Gillespie et al., 2014). However, these efforts alone are often insufficient to reduce WPV incidents unless they are accompanied by concrete operational systems and follow-up mechanisms. One such complementary strategy involved the provision of psychological support, including post-incident debriefings and access to mental health services, which played a significant role in promoting staff recovery after WPV events (Al-Natour et al., 2023; Bruccoli, 2023; Cabilan et al., 2022; Dafny & Muller, 2022; Gillespie & Berry, 2023; Shea et al., 2018). However, the effectiveness of these psychological interventions was notably diminished in environments where coordinated administrative support, and structured emotional support systems were lacking (Bruccoli, 2023; Gillespie & Berry, 2023; Öztaş et al., 2022; Shea et al., 2018; Xu et al., 2022). In such cases, even when leadership initiatives were present, the absence of formal support mechanisms often left staff relying on personal coping strategies, limiting both recovery and trust in the system (Öztaş et al., 2022; Xu et al., 2022).

Another foundational strategy identified was worksite analysis, particularly through walkthrough assessments. These approaches did not directly prevent WPV but played a vital diagnostic role by identifying latent systemic risks effectively and enabling targeted interventions aligned with frontline realities (Gillespie et al., 2014). Such participatory analyses fostered staff engagement and provided data-driven direction for institutional reforms. Although worksite analysis alone may not reduce WPV incidents, its value lies in informing targeted, context-sensitive interventions that can enhance long-term system responsiveness.

In contrast, hazard prevention and control interventions, particularly administrative mechanisms such as BERTs and electronic flagging systems, demonstrated a more direct and measurable impact on WPV outcomes. Studies showed that the implementation of BERTs and automated alerts improved staff preparedness, confidence, and coordination during violent incidents (Hendrickson, 2022; Burkoski et al., 2019). Similarly, structured risk assessment tools, especially when integrated into patient management systems, enabled early identification of high-risk individuals and increased staff engagement in documentation and intervention processes (Cabilan et al., 2023). However, these approaches were limited by technical constraints and staff reluctance to engage with new digital tools; thus, these approaches should be reinforced by education and incentives to enhance greater adoption of these tools (Cabilan et al., 2023).

Engineering controls also made a notable contribution, with environmental modifications such as CCTV installation, improved lighting, and de-escalation rooms supporting WPV prevention and rapid intervention in high-risk zones (Cabilan et al., 2022; de Barbieri et al., 2022; Sadatmahaleleh et al., 2019). However, these modifications required high financial investment and site-specific customization. Substitution strategies (i.e., relocating violent patients, using physical and chemical restraints) provided immediate control in crisis scenarios but raised ethical concerns and were often constrained by clinical regulations requiring physician authorization (Dafny & Muller, 2022; de Barbieri et al., 2022; Gillespie & Berry, 2023).

In comparison, the implementation of technological safety measures such as personal duress alarms represents a more reactive form of intervention designed to enable immediate response once a violent incident is underway. While these systems have been associated with increased staff confidence (Burkoski et al., 2019), their real-world effectiveness has been inconsistent. Common challenges limiting the efficacy of these alarms include low rates of staff utilization, insufficient training on device operation, delayed or unreliable security responses, and poor design features (Carr & Derouin, 2023). In contrast to more integrated approaches like BERTs, duress alarms rely heavily on individual activation and functional infrastructure, which makes them vulnerable to failure without strong usability and organizational support.

Training interventions were among the most widely implemented strategies that demonstrated the most consistent improvements in participants’ de-escalation skills, situational confidence, and overall preparedness when they were scenario-specific, theory-driven, and reinforced over time (Duncan et al., 2021; Cai et al., 2023; Ming et al., 2019). In contrast, brief or generic training sessions yielded limited influence on behavioral change or attitudes toward WPV reporting (Story et al., 2020; Wong et al., 2015). Lastly, while recordkeeping tools improved incident reporting and awareness (Stene et al., 2015; Ramacciati et al., 2021), they were most effective when embedded in systems that encouraged follow-up and continuous learning.

Jointly, the evidence indicates that the success of WPV interventions is closely tied to their structure, integration, and level of institutional support. Multi-component programs that combined administrative leadership, environmental controls, real-time response mechanisms, training, reporting systems, and diagnostic tools like worksite analysis were the most effective in reducing WPV incidents and fostering long-term cultural change (Gillespie et al., 2014). Conversely, standalone strategies, whether focused solely on policy, training, or technology, demonstrated limited efficacy when implemented in isolation. This comparative analysis affirms the need for a coordinated and context-sensitive approach to WPV prevention.

The findings of this review consistently highlight the critical role of administrative commitment and leadership engagement in addressing WPV against nurses. This aligns with the previous research indicating that administrators’ support can decrease the long-term adverse emotional impacts of WPV incidents on nurses’ well-being (Han et al., 2021). However, the review also revealed inconsistencies in how such support is delivered across institutions. While some settings implemented structured post-incident protocols, others failed to respond adequately, with nurses’ reports of neglect or even blame experienced by leadership following WPV incidents (Dafny et al., 2022; Vogel, 2016). These disparities underscore the urgent need to cultivate organizational cultures in which psychological safety and staff advocacy are prioritized (Christie, 2015). This inconsistency highlights a systemic gap in how leadership translates policy into practice. Future studies should investigate leadership training programs focused on trauma-informed care and evaluate their impact on both staff recovery and incident reporting.

A related and equally important factor is the role of security personnel in enhancing nurses’ perceptions of safety. This review confirms that a consistent and visible security presence contributes to faster incident resolution and increased feelings of protection among nursing staff (Gillespie et al., 2019; Christie, 2015). However, the effectiveness of security personnel appears to vary widely depending on their training, visibility, and integration into clinical workflows. For example, Gillespie et al. (2012) found that while some ED nurses viewed security officers as helpful, others reported delayed responses, limited authority to intervene, and poor coordination between security and clinical teams. These findings suggest that the presence of security personnel alone is insufficient. Instead, hospitals must ensure that security staff are trained in de-escalation, familiar with clinical environments, and fully integrated into WPV prevention protocols. Practical steps include establishing joint protocols between nursing and security leadership, providing routine training, and involving frontline clinicians in the evaluation of security practices.

Another key finding demonstrated by the review is the importance of involving nurses directly in WPV prevention planning. Interventions co-designed with nurses were more acceptable, sustainable, and contextually relevant (Hemati-Esmaeili et al., 2018). Despite this, current practices in developing WPV interventions predominantly rely on theoretical models, expert recommendations, or literature synthesis (Gillespie et al., 2019). While this approach is valuable, researchers may overlook the lived experiences of nurses who regularly face WPV and understand the practical realities of frontline care (Liu et al., 2019). Without integrating nurses’ insights into WPV prevention efforts, interventions may be less likely to achieve long-term success. Therefore, future research should explore the impact of participatory WPV intervention models in terms of their effectiveness in improving safety culture, enhancing nurse morale, and ensuring timely incident resolution.

Consistent with the previous literature, our review highlighted that walkthroughs can lead to the identification of WPV risks and a measurable reduction in WPV rates (Hamblin et al., 2017). However, the effectiveness of walkthroughs is highly dependent on their depth and quality. In some settings, they are reduced to superficial, checklist-driven tasks with limited staff engagement and follow-up, which undermines their potential. For walkthroughs to achieve meaningful outcomes, they must go beyond passive observation to promote open dialogue, foster psychological safety, and lead to timely, actionable interventions. Challenges to walkthrough implementation include time constraints and the absence of formal cost-benefit analyses, which limit organizational commitment to routine assessments (Hamblin et al., 2017). Despite these barriers, walkthroughs offer a proactive means to uncover latent hazards such as underreporting, breakdowns in protocol adherence, and environmental triggers of aggression (Gillespie et al., 2019). Recognizing their importance, The Joint Commission (2021) recommends that healthcare organizations conduct formal worksite analyses at least annually to identify WPV risks and tailor targeted prevention strategies systematically. When designed and executed with intention, walkthrough assessments can enhance institutional learning, build staff trust, and reinforce the sustainability of WPV prevention efforts.

This review highlights several WPV prevention strategies, each with distinct advantages and limitations. Aligning with previous literature, substitution strategies such as physical, chemical, and mechanical restraints are commonly employed to manage violent behavior when the safety of staff or patients is compromised (Vieta et al., 2017; Cunha et al., 2016). Although they are effective for immediate control, these interventions carry significant risks, including patient injury, agitation escalation, and ethical concerns (Chou et al., 2020; Arnetz et al., 2015). In addition, their use is often delayed (especially chemical restraints) due to physician authorization requirements; thus, preemptive orders have been suggested to address this (Dafny & Muller, 2022). These findings underscore that while restraints may offer short-term control, they should remain a last-resort option, used only within a clearly defined clinical and ethical framework. A practical alternative includes creating safe, low-stimulation spaces, such as padded rooms free of objects, where patients can de-escalate without physical force (Gillespie & Berry, 2023).

Environmental modifications also emerged as effective preventive measures. Design features such as de-escalation rooms, CCTV, controlled access points, and improved lighting have been shown to reduce WPV by increasing surveillance and limiting sensory overload for high-risk patients (Braitberg et al., 2018; Morphet et al., 2018). However, such infrastructure improvements can be cost-prohibitive, especially in resource-limited settings (Blando et al., 2015). Future research should prioritize identifying cost-effective environmental modifications that can be feasibly adopted in low-resource environments.

Consistent with existing literature, administrative and work practice controls, such as risk assessment tools, were also widely reported as effective strategies for WPV prevention. These tools were used to identify patients at high risk of aggression and enable early de-escalation and proactive safety planning (Calow et al., 2016; Daniel, 2015; Sammut et al., 2023). In addition, their use was associated with a reduction in both restraint application and WPV-related injuries, while enhancing nurse preparedness and the overall quality of care (Daniel, 2015). However, the effectiveness of these tools relies heavily on the adequacy of staff training and consistency in use (Cabilan et al., 2023). To enhance utility, future research should focus on the development of electronic risk assessment systems that are user-friendly, embedded into electronic health records, and capable of generating real-time alerts.

In line with the literature, BERTs were found to be a promising strategy designed to respond rapidly to behavioral crises and have been shown to improve staff safety, reduce the need for restraints and security involvement, and enhance staff satisfaction and confidence in managing behavioral symptoms (Lopez, 2019; Rajwani et al., 2022). In contrast, Kim et al. (2024) found that while signage for high-risk patients reduced WPV incidents, the addition of proactive BERT huddles (pre-incident planning meetings) did not significantly improve outcomes beyond what was achieved through standard administrative measures. These discrepancies suggest that while BERTs can enhance preparedness, the value of their proactive components may vary depending on context and available resources. Future studies should examine how organizational factors such as leadership support, team structure, and integration with other WPV protocols influence the effectiveness of BERT implementation.

Training nurses to manage WPV is widely recognized as a foundational component of any effective prevention strategy. The majority of studies included in this review reported positive outcomes, suggesting that training interventions increase nurses’ confidence and ability to respond to violent incidents (Al-Ali et al., 2016; Cai et al., 2023; Chang et al., 2022; de la Fuente et al., 2019; Duncan et al., 2021; Hemati-Esmaeili et al., 2018; Kalbali et al., 2018; Lakatos et al., 2019; Ming et al., 2019; Sadatmahaleh et al., 2019; Story et al., 2020; Wong et al., 2015; Yost et al., 2022). These findings are consistent with broader literature that affirms the role of training in enhancing nurses’ skills to recognize, de-escalate, and respond appropriately to WPV (Portela Dos Santos et al., 2022). However, despite the overall positive trends, inconsistencies were noted in the reported effectiveness of different training formats and durations. For instance, while some simulation-based and multi-session interventions demonstrated substantial improvements in nurses’ confidence and de-escalation skills (Duncan et al., 2021; Cai et al., 2023), others, particularly those of shorter duration or generic content, showed limited impact on behavior change or long-term outcomes (Story et al., 2020; Wong et al., 2015). These disparities may be attributed to variations in content relevance, instructional design, delivery methods, and participant engagement. Moreover, several studies relied on self-reported outcomes measured immediately after training, which raises questions about the sustainability of learning over time. A further complicating factor is the limited use of validated assessment tools and the absence of control groups in many training evaluations, which weakens the evidence base.

In practice, while theoretical and skills-based instruction can raise awareness and promote preparedness, nurses often report barriers to applying these skills, such as time constraints, competing clinical priorities, and organizational culture (Goodman et al., 2020). These conditions may lead some nurses to perceive training as a procedural requirement rather than a valuable, practice-enhancing resource, especially when institutional leadership fails to reinforce WPV prevention priorities. Therefore, WPV training must be integrated into routine workflows and tailored to reflect the realities of high-stress clinical environments to improve real-world applicability. Interactive, scenario-based methods that mirror actual clinical situations and foster reflection and dialogue are more likely to be internalized and applied. Moreover, while the studies in the review support short-term benefits, there remains a lack of longitudinal data examining whether nurses’ knowledge, confidence, and behavioral changes persist over time. Future long-term follow-up research that assesses sustained impact on staff behavior, incident reporting, and patient outcomes is needed.

The review results highlighted the importance of establishing a standardized reporting system to accurately measure the frequency, nature, and severity of WPV incidents. While several studies emphasize the value of reporting in identifying trends and guiding institutional responses (Stene et al., 2015; Al-Turki et al., 2016), empirical evidence suggests that such systems are often underutilized in practice. For example, Cai et al. (2024) reported a prominently low WPV reporting rate of only 16.1% among nurses, despite institutional mandates. Similarly, Elsharkawy et al. (2025) found that nurses often refrained from reporting due to emotional distress, normalization of WPV, and the absence of meaningful managerial follow-up. Nurses’ lack of knowledge about reporting procedures, concerns about time consumption, or fear of reprisal further exacerbate underreporting (Gillespie & Leming-Lee, 2019; Elsharkawy et al., 2025). These findings highlight that the success of reporting systems is not solely dependent on their technical features but also on broader institutional dynamics and staff perceptions. On the other hand, evidence suggests that digital tools, such as mobile or integrated electronic health record (EHR) systems, can streamline the reporting process and improve compliance, particularly when they are designed with usability and time-efficiency in mind (Ramacciati et al., 2021). Thus, allocating financial resources is crucial for managers to adopt an innovative reporting system in their facilities. In addition, leadership must actively promote a non-punitive reporting culture, provide timely feedback, and demonstrate that reports are met with substantial action to encourage WPV reporting.

This review has several limitations that should be considered when interpreting the findings. A key limitation is the lack of long-term follow-up data in many of the included studies, which restricts our understanding of the sustainability and enduring effectiveness of the reported interventions. Additionally, methodological heterogeneity, such as differences in study design, outcome measures, and tools used to assess WPV, complicated cross-study comparisons and limited the ability to draw consistent conclusions.

Another notable limitation is related to the search strategy. Although it was developed in collaboration with a health sciences librarian and included Medical Subject Headings (MeSH) and controlled vocabulary terms to maximize comprehensiveness, the search did not explicitly include terms such as “strategies.” While intervention-related terms like “training,” “education,” and “program” were used and yielded relevant results, the absence of the word “strategy” could have led to the omission of some pertinent studies. This highlights the importance of continuously refining search terms in future systematic reviews to ensure broader coverage of the literature. The review also was limited to English-language publications, which may have excluded relevant studies from non-English-speaking countries and potentially reduced the global generalizability of the findings. Although the included studies were conducted across a range of geographic settings, this language restriction may have introduced bias. Furthermore, the review relied solely on database searches, which may have resulted in the exclusion of gray literature, such as unpublished studies or organizational reports that might contain valuable data on WPV interventions. Despite these limitations, this review offers a comprehensive synthesis of WPV interventions aligned with OSHA’s (2015) framework. It contributes valuable insights to inform policy, practice, and future research in diverse healthcare settings.