Research demonstrates that among healthcare personnel, nurses are the most likely victims of workplace violence [3]. According to the World Health Organization, up to 38% of healthcare workers have experienced some form of physical violence within their career. Many more are threatened or exposed to verbal aggressions often perpetrated by patients and visitors. The risk factors for violence vary with each healthcare facility, depending on location, size, and type of care. According to Lim et al., risk factors for workplace violence in healthcare settings include attitudes and behaviors of patients, family members, friends, or visitors who are often under intense emotional charge and expectations [4]. Work factors that increase the risk of violence include shortage of staff, inexperienced or anxious staff, poor coping mechanisms, and lack of training. System or environmental factors include overcrowded areas, long waiting hours, and inflexible visiting hours. Factors that may influence the risk for violence in healthcare settings are listed in Table 1.

Workplace violence is destructive and has a profoundly negative impact on healthcare professionals. Healthcare professionals may experience physical injuries, psychological trauma, anxiety, or even death. Feelings such as anger, depression, fear, self-blame, and powerlessness might take over the healthcare professional's life. This can affect the institution by causing loss of job satisfaction, low worker morale, increased job stress, and an increased staff turnover rate [1,6].

Members of the healthcare professional staff need guidelines for dealing with workplace aggression, just as they do for a fire or dangerous situations. These guidelines should be based on a team approach with security staff since both groups have their own unique perspectives and skills to offer. Healthcare professionals who work in long-term care facilities should have training in the management of patients who are potentially aggressive; both the frequency of incidents and the delicate nature of some patients' conditions increase the likelihood of violent incidents. The areas of a hospital where violence is most likely to occur are the emergency department, intensive care units, psychiatric services, and geriatric units [7]. Ideally, all healthcare professionals should receive education on how to handle violence in their workplace.

Healthcare professionals in all healthcare settings should expect training in dealing with patient aggression. Being prepared for situations that may escalate allows healthcare professionals and other staff to defuse potentially violent situations before injuries occur. Areas where patients are most likely to become violent require lower staff-to-patient ratios to decrease incidents of violence. Suggested prevention strategies include (i) substitution by transferring a client or patient with a history of violent behavior to a more suitable secure facility or area; (ii) engineering control measures that include installing barrier protection, metal detectors and security alarm systems, and allocating conducive patients or visitors areas and clear exit routes; (iii) administrative and workplace practice controls that include implementing workplace violence response and zero-tolerance policies, ability to resolve a conflict situation, establishing a mandatory timely reporting system, ensuring employees are not working alone, and a flowchart for assessing and response in emergency situations; (iv) post-incident procedures and services that include trauma-crisis counselling, critical-incident stress debriefing, and employee assistance programs; (v) safety and health training in order to ensure that all staff members are aware of potential hazards and how to protect themselves and their co-workers through established policies and procedures [4,8].

Healthcare professionals should not overlook personal feelings of anxiety during an interaction with a patient. If their intuition gives them a message that a patient may become dangerous or that the situation may be getting out of hand, healthcare professionals should do the following:

A history of previous violence is the highest predictor of future violence. Patients who are at risk for violence often have a history of recent acts of aggression or violence and might exhibit the following behaviors [3]:

The healthcare professional staff should carefully manage patients who are agitated and seem to be at risk for violence. The following steps are important for healthcare professionals to remember in these situations [1,3]:

The healthcare professional staff should carefully manage patients who are agitated and seem to be at risk for violence. The following steps are important for healthcare professionals to remember in these situations [1,3]:

When patients, families, or visitors are experiencing a crisis, a person's ability to think rationally may be diminished. This can lead to unpredictable behavior. Urbanek and Graham suggest when staff are being threatened, they should [10]:

If things begin to escalate further, staff should remove themselves from the situation as quickly as possible and seek further assistance from other staff, the internal response team, Public Safety, or even police if necessary.

Do not attempt a hands-on approach with a person who is an active threat, unless required by your role and trained to do so.

Healthcare professionals should always seek assistance in an emergency. They should get help from the security staff, other available healthcare professionals, or any other facility personnel. A patient who has a weapon should be disarmed by persons who are trained to do so. If the patient cannot be disarmed easily, the safety of healthcare personnel and that of others in the area must be considered. Shields and barriers may protect against knives but not against a patient with a loaded gun. Other patients and visitors should be moved to safe and secure areas, and local police should be engaged in such a situation.

The healthcare professional responsibilities involved in handling a violent episode by mechanically restraining a patient include the following [5]:

Inviolability is the fundamental right of every individual to be left alone. The U.S. Constitution and Bill of Rights are based on this principle. The individual has authority over what happens to their body. In practice, however, the situation is not always so clear. In some instances, individual rights may interfere with the rights of others. In addition, fluctuations in public sentiment may affect the decisions made by practitioners and institutions.

Psychological and cognitive factors influence adherence to treatment. To be able to comply, patients must understand the information presented to them. Teaching should be brief and focused. Complex information should be broken into smaller and more understandable parts whenever possible. It is helpful to simplify teaching material as much as possible. Use of written materials that reflect a fourth or fifth grade reading level is appropriate so that the patient's level of health literacy is not overestimated.

Manipulation, learned early in life, is a process that occurs consciously or unconsciously in virtually all interpersonal interactions. When manipulation is used in an adaptive sense, it is just one of many behaviors that a person can call on to ensure that their needs are fulfilled. It is neither the only need-gratifying behavior nor the dominant one. For manipulation to be considered maladaptive, it depends on the:

Manipulation, learned early in life, is a process that occurs consciously or unconsciously in virtually all interpersonal interactions. When manipulation is used in an adaptive sense, it is just one of many behaviors that a person can call on to ensure that their needs are fulfilled. It is neither the only need-gratifying behavior nor the dominant one. For manipulation to be considered maladaptive, it depends on the:

Patients who use manipulation are often charming, entertaining, and intelligent. They rarely see themselves as having a problem and are unlikely to seek help on their own. In fact, many individuals who demonstrate manipulative behaviors are loathe to change, even when confronted, because these behaviors get their needs met [5]. When the harmful effect on others is pointed out, these patients may feign guilt or remorse because they are aware that these are the socially acceptable responses. They will not actually feel those feelings, however. Patients with dominant manipulative traits do not have a superego (concerned with moral behavior) strong enough for pangs of conscience to be genuine.

Gaining the patient's trust, although difficult, and sometimes not possible, is something the healthcare professional should work toward. Trust-building behavior includes being on time for treatments or other appointments with the patient, never promising something that cannot be delivered, and remembering things the patient has related. In addition, healthcare professionals must accept that patients may say hurtful things and not take them personally; patients who use manipulation make such remarks to everyone. Self-confidence on the part of the healthcare professional is important because patients who use manipulative behaviors will try their best to gain power by undermining the healthcare professional's knowledge, skill, and competence.

Intentionally developing social maturity, which includes the emotional strength and ego to recognize and deflect manipulation, is an important goal for healthcare professionals. Healthcare professionals' benefit from learning to recognize intrinsic rewards such as knowing they have made a difference and helped someone else transcend to a higher level of functioning. For patients who use manipulation, healthcare professionals must clearly set the healthcare professional-patient relationship with appropriate professional boundaries and maintain those boundaries [28].

Intentionally developing social maturity, which includes the emotional strength and ego to recognize and deflect manipulation, is an important goal for healthcare professionals. Healthcare professionals' benefit from learning to recognize intrinsic rewards such as knowing they have made a difference and helped someone else transcend to a higher level of functioning. For patients who use manipulation, healthcare professionals must clearly set the healthcare professional-patient relationship with appropriate professional boundaries and maintain those boundaries [28].