Peer Reviewed Scholarly Articles Workplace Violence in Hospitals
Workplace violence and health in human service industries: a systematic review of prospective and longitudinal studies
Abstract
Objectives To provide systematically evaluated show of prospective associations between exposure to physical, psychological and gender-based violence and health amongst healthcare, social care and educational activity workers.
Methods The guidelines on Preferred Reporting Items for Systematic Reviews and Meta-Analyses were followed. Medline, Cinahl, Spider web of Scientific discipline and PsycInfo were searched for population: human service workers; exposure: workplace violence; and study type: prospective or longitudinal in articles published 1990–Baronial 2019. Quality cess was performed based on a modified version of the Cochrane's 'Tool to Assess Risk of Bias in Accomplice Studies'.
Results After deduplication, 3566 studies remained, of which 132 manufactures were selected for full-text screening and 28 were included in the systematic review. A majority of the studies focused on healthcare personnel, were from the Nordic countries and were assessed to have medium quality. Nine of 11 associations betwixt physical violence and poor mental health were statistically significant, and 3 of 4 associations between physical violence and sickness absence. Ten of thirteen associations between psychological violence and poor mental health were statistically pregnant and 6 of 6 associations betwixt psychological violence and sickness absenteeism. The merely study on gender-based violence and health reported a statistically non-significant clan.
Conclusion There is consistent testify mainly in medium quality studies of prospective associations betwixt psychological violence and poor mental health and sickness absence, and between concrete violence and poor mental wellness in human service workers. More than research using objective outcomes, improved exposure assessment and that focus on gender-based violence is needed.
- mental health
- longitudinal studies
- sickness absence
- violence
- healthcare workers
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- mental health
- longitudinal studies
- sickness absenteeism
- violence
- healthcare workers
Key letters
What is already known near this discipline?
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Workplace violence is prevalent in human being service industries, and associations between workplace violence and health outcomes have been reported. Even so, a synthesis of results based on prospective or longitudinal information of associations between different forms of workplace violence and health outcomes in human being service industries is lacking.
What are the new findings?
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The results of the systematic review indicate consistent evidence mainly in medium quality studies of prospective associations between psychological violence and poor mental wellness and sickness absenteeism, and betwixt physical violence and poor mental health in homo service workers. More research with objective outcomes, improved exposure assessment and that focus on gender-based violence is needed.
How might this bear on on policy or clinical practice in the foreseeable future?
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The bear witness of the present review supports the demand to develop guidelines for readily detecting and dealing with workplace violence in the human service industries.
Introduction
Workplace violence has been acknowledged every bit a major workplace take a chance and has been studied for at least 30 years,1–3 only the research on its antecedents and consequences has expanded and avant-garde methodologically primarily during the past 15 years. There is no consensus in the literature on a definition of workplace violence, and a large variation of definitions is plant across studies. The almost recent definition was presented in the Violence and Harassment Convention 20194 by the International Labour Organization (ILO):
Violence and harassment in the globe of work refers to a range of unacceptable behaviours and practices, or threats thereof, whether a single occurrence or repeated, that aim at, result in, or are probable to result in physical, psychological, sexual or economic impairment, and includes gender-based violence and harassment.
The reported prevalences of workplace violence vary greatly. For example, in a research review the percent of hospital employees exposed to verbal violence from patients varied betwixt 22% and 90% beyond studies, exposure to threats of violence and actual violence between 12% and 64%, and exposure to physical assault between 2% and 32%.5 When comparing different labour marketplace sectors, information technology is however evident that employees in some sectors are more exposed to violence than others. The prevalence of physical violence has, in international reviews, been reported to exist particularly high in healthcare, teaching, public prophylactic, retail and justice industries.1 half-dozen 7 According to a recent systematic review and meta-analysis, 61.9% of healthcare personnel reported exposure to physical or non-concrete workplace violence by patients and visitors in the past year.8
Human service industries include healthcare, social care and education, providing care and education to patients, children, elderly or clients, and employ a big part of the workforce, particularly the female 1, in most countries. The risk of mental ill-health and sickness absence among employees in these industries, as compared with other industries, is higher and has increased in later years.nine–13 Poorer working weather condition, not least exposure to workplace violence by patients and clients, have been suggested every bit major explanations.x 14 Employees in these industries are not, in dissimilarity to, for example, protection workers that are besides exposed to workplace violence, as well educated or prepared to handle violence. Professions with frequent contact with people in general, for example, within the retail industry, were not included considering they have not been institute to accept elevated risks of mental ill-health13 or sickness absence,9 and workplace violence is less prevalent.13
To date, there is no synthesis of the evidence of associations betwixt exposure to workplace violence and health outcomes amidst employees working in the human service industries. A large corporeality of review manufactures of workplace violence has focused on the healthcare manufacture.5 6 15–18 For case, Lanctôt and Guay published a review of cross-sectional and longitudinal studies of consequences of workplace violence by patients and visitors against healthcare workers, without distinctions between the different forms of violence (physical, psychological or gender-based).sixteen Because also the social care and education industries are highly exposed to workplace violence,1 vi 7 a more comprehensive focus on these industries is well motivated. Merely one review article of workplace violence among staff inside the didactics system was identified by the authors.19 However, but employees within higher education were included in the review. The lack of prospective or longitudinal studies examining health consequences of workplace violence has been identified as a major enquiry gap.16 Furthermore, workplace violence is a very wide concept, including exposures ranging from harassment to concrete attack, with potentially different health outcomes, and distinctions between unlike forms of violence thus announced necessary. A systematic review of published prospective or longitudinal studies seems warranted to clarify the state of the prove regarding health effects of various forms of workplace violence in the human service sectors.
Aim
Our aim was to provide systematically evaluated evidence of the prospective or longitudinal associations between exposure to concrete, psychological and gender-based violence respectively past whatsoever perpetrator confronting human service workers, and health-related outcomes. The aim was furthermore to identify gaps in the research literature and provide guidelines for hereafter inquiry within the field.
Methods
The guidelines on Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA, run across www.prisma-statement.org) were followed and a review protocol was registered (PROSPERO registration number: CRD42019128442). The literature searches were conducted by professionals at the University Library at Karolinska Institutet in Stockholm, Sweden, in February and Baronial 2019. The review team consisted of a principal investigator (AN) and three additional researchers (GK, LMH and KR).
Search strategy and study selection
The strategy was developed by the review team in collaboration with the librarians. The databases Medline (OVID), Cinahl (EBSCO), Web of Science (Clarivate) and PsycInfo (OVID) were searched for articles published from 1990 until August 2019. The search was based on a combination of terms identifying exposure (workplace violence), population (employees in human service occupations and industries) and written report type (prospective or longitudinal study). The full search strategy is given in online supplementary appendix A.
Supplemental material
The inclusion criteria for the present study were (ane) language: English; (2) population: employees in the human service industries healthcare, social care, and education; (3) exposure: workplace violence; (4) outcome: mental health, physical health, sickness absence and other health-related outcome; and (5) study type: study based on quantitative data and prospective or longitudinal study design with at least thirty participants exposed to workplace violence (if measured as a binary variable) or the level of exposure assessed in at least 30 participants (if measured on a continuous calibration). Nosotros selected but original articles published in peer-reviewed journals; no book chapters, doctoral theses or other scientific reports were included.
Beginning, the titles and abstracts identified past the search were screened against our inclusion criteria by the principal investigator and one more researcher in the review team. Discrepancies or uncertainties were discussed and resolved in the team. In case the titles and abstracts did non provide enough information, the articles were moved forrard to the next step. Next, the research squad worked in pairs and read total texts. Discrepancies well-nigh eligibility of studies were resolved within the pairs or if necessary discussed and decided on in the review team. Reasons for exclusion were noted. When the article selection process had been completed, the reference lists of the selected articles were searched for further studies coming together our inclusion criteria. The software tool Covidence (www. covidence.org) was used to facilitate the selection of abstracts and total-text articles.
Quality assessment
A quality cess of the selected studies was also conducted in pairs. It was based on the Cochrane's 'Tool to Assess Risk of Bias in Cohort Studies' (see methods.cochrane.org) which we modified to better correspond to the topic of this review. 8 dimensions were used: (1) How representative was the sample of the population under written report?; (two) Can nosotros exist confident in the cess of exposure?; (3) Tin can nosotros be certain that the issue was not present at get-go of study?; (4) Were all relevant confounders adjusted for in the analyses?; (5) Can we be confident in the assessment of confounders?; (6) Can we be confident in the assessment of upshot?; (vii) Was the follow-up of cohorts acceptable?; and (8) Were the statistical methods used adequate? Quality assessment scores ranged between one and 2 for the kickoff dimension and between 1 and 4 for the following ones. Lower scores indicated college quality. Ratings were first done individually by both researchers in the couple. The ratings were then discussed and agreed on within the couple. Disagreements were resolved in the full team. A total quality assessment score ranging between 8 and 30 was given each study. If several exposures or outcomes were measured in one written report, each association was evaluated separately. We considered quality assessment scores 8–12 equally indicating high quality, scores xiii–sixteen indicating medium quality and scores 17–30 indicating low quality.
Synthesis of study results
Because there was a large heterogeneity in exposures, outcomes and types of effect estimates in the studies that met the inclusion criteria, information technology was not possible to acquit a meta-analysis. The analyses were divided according to exposure type into physical (physical violence and threats thereof), psychological (eg, bullying, harassment) or gender-based (violence towards people based on their gender, including sexual harassment) violence. We synthesised the evidence based on the quality and gamble estimates of the included studies and considered the bear witness as consistent if (one) several associations between a specific exposure and outcome (mental health, sickness absenteeism or physical health) were like with respect to management, strength and statistical significance; and (2) about of these studies were assessed to be of at least medium quality.
Results
In the literature search, 5461 hits were recorded, of which 3566 remained later deduplication. Titles and abstracts of these articles were screened for eligibility, and 129 articles were selected for full-text screening. During full-text screening, additional 99 manufactures were excluded (primarily because of incorrect written report blazon or population) and 30 were passed on to the stage of quality assessment and synthesis. In the reference lists of our selected studies, boosted 3 eligible articles were detected. During quality cess, boosted five studies were excluded because of wrong population (three) or effect (ii). Finally, 28 manufactures were included (come across figure 1).
Physical violence
Physical violence and mental health outcomes
As shown in table 1, nosotros identified nine studies20–28 investigating associations between physical violence and mental health outcomes, of which two studies23 25 included two outcomes, respectively. Six studies20–22 24 27 28 were from the Nordic countries, two23 26 from other European countries and one25 from the USA. Five of them20 21 23–25 focused on healthcare personnel, three26–28 on employees within social care and one22 on teachers. One28 was given a high quality assessment, six20–23 25 27 were given medium quality assessments and two24 26 low quality assessments. Of the 11 effect estimates presented in the ix studies, ix indicated statistically significant associations.
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Table 1
Included studies examining physical violence every bit a predictor of mental health outcomes, sickness absence and physical health outcomes in employees in health care, social intendance or education
Physical violence and sickness absence
We identified iii studies of medium quality from Kingdom of denmark and Norway investigating associations between threats and physical violence and sickness absence in health and social workers.29–31 In one report,30 exposure to threats and violence were estimated separately, resulting in a full of four hazard estimates. Two studies29 30 used annals-based data on sickness absence and one31 self-reports; one29 did not detect a statistically significant clan between concrete violence and sickness absence, whereas three studied associations were statistically significant.
Physical violence and physical wellness outcomes
Two studies were identified, one from the Us and ane based on a sample from eight European countries, investigating other wellness and wellness-related outcomes among health and social workers.32 33 Both were assessed to exist of medium quality. Results indicate a statistically significant association betwixt physical violence and musculoskeletal pain,33 just non betwixt physical violence and perceived health.32
Psychological violence
Psychological violence and mental health outcomes
As shown in table 2, we identified 10 studies of associations between psychological violence, primarily workplace bullying and poor mental health,20 21 23 34–twoscore of which 3 studies23 34 38 included ii outcomes, respectively. All studies focused on employees within healthcare (nurses, physicians and intendance workers), and most of them were from Northern Europe. Two of the studies38 forty were given loftier quality assessments, seven20 21 23 34–37 medium quality and one39 a low quality assessment. Of the 13 chance estimates presented in the 10 studies, xi showed statistically significant associations with poor mental health. In that location were 2 studies of the association with insomnia/poor sleep, of which the one of loftier quality40 showed that bullying predicted insomnia and the one of medium quality20 reported that exposure to bullying was associated with lower odds of sleep issues.
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Table two
Included studies examining psychological violence as a predictor of mental health outcomes, sickness absence or physical health outcomes in employees in wellness care, social care or education
Psychological violence and sickness absenteeism
We identified five studies that investigated associations between workplace bullying and sickness absence,29 xxx 41–43 of which one41 studied associations with both medically and cocky-certified sickness absenteeism. Sickness absenteeism was in five of the 6 risk estimates based on register-data. The studies were all from the Nordic countries and focused on employees in health and social intendance. In total, four medium quality assessments, and two high quality assessments were given. All the six studied associations were statistically significant in the expected direction.
Psychological violence and physical health outcomes
4 studies were identified, one39 of low and three32 35 44 of medium quality, investigating furnishings of workplace bullying on self-reported cardiovascular affliction,35 fibromyalgia,44 psychosomatic complaint39 and perceived health32 among healthcare workers. Workplace bullying predicted fibromyalgia but not cardiovascular disease in Finnish hospital employees, and social harassment did not predict psychosomatic complaints in Canadian nurses. In a study32 focusing nurses in eight European countries, harassment from colleagues but non from superiors was establish to predict poorer perceived health.
Gender-based violence
As shown in tabular array 3, nosotros identified one Danish study, estimated to be of medium quality, that investigated effects of unwanted sexual attending on long-term sickness absenteeism among care workers.xxx No significant clan was found.
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Table 3
Included studies examining gender-based and not-specific violence as predictors of mental health outcomes, sickness absence and physical health outcomes in employees in health care, social intendance or teaching
Not-specific violence
As also shown in tabular array iii, we found ii articles that measured violence either without specification with regard to physical, psychological or gender-based violence,45 or studied violence equally a composite measure of verbal, concrete and sexual aggression.46 1 Dutch study46 of mental health nurses found a statistically significant association between patient aggression and burnout symptoms, and one Australian study47 of medical doctors found no statistically significant clan between workplace aggression from coworkers, patients or relatives and self-rated health. Both studies were found to exist of medium quality.
Synthesis of study results
As shown in table 4, summarising data from all 28 studies and 44 hazard estimates, prospective associations between physical and psychological violence, on the 1 manus, and mental health outcomes, on the other manus, have been rather extensively studied in human service professionals, especially in employees in health and social care in the Nordic countries. A prospective clan betwixt physical violence and poor mental wellness was indicated by 9 of xi take chances estimates and an association between psychological violence (primarily bullying) and poor mental wellness by 10 of thirteen hazard estimates. Based on these findings of primarily medium quality studies, we consider that the evidence for an association betwixt physical and psychological violence respectively and poor mental health is consequent. The association between physical and psychological violence, on the one hand, and sickness absence, on the other hand, has been less extensively studied. Notwithstanding, with statistically significant associations between psychological violence (bullying) and sickness absence establish in six of half-dozen risk estimates in studies of medium to high quality, we consider the show to be consistent. Studies of medium quality furthermore indicate an clan between physical violence and sickness absence among healthcare personnel in the Nordic countries, but to date nosotros consider the testify to be likewise express to describe conclusions from. Finally, nosotros consider the testify to be insufficient regarding gender-based violence.
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Table 4
Summary of the included studies (n=28)
Discussion
To the best of our cognition, this is the first systematic review of health consequences of workplace violence used by whatsoever perpetrator confronting employees in the female person-dominated human service industries. Nosotros include a wide spectrum of health outcomes due to physical, psychological and gender-based violence, respectively, in studies with prospective or longitudinal study designs. We conclude that the show is consequent for an association between, on the ane manus, physical and psychological violence and, on the other hand, negative mental wellness outcomes. The evidence is also consistent for an association between psychological violence and non-specific long-term sickness absence, and accumulating regarding an association between physical violence and non-specific long-term sickness absence. Various self-reported physical health outcomes have been studied in relation to concrete and psychological violence, but more enquiry is needed. Finally, there is insufficient evidence of prospective associations betwixt gender-based violence and health outcomes.
Overall strengths of the evidence
Many studies of medium quality, using prospective study designs and big sample sizes, accept investigated mental health furnishings of concrete and psychological violence in the man service industries. In well-nigh of the studies, the blueprint is well described and relevant confounders take been taken into account in many of them. Near studies have as well ascertained that the outcome of interest was non present at baseline. In some studies, samples that were nationally representative of specific profession(s) were used. Frequency or severity of the exposure has been taken into account in some studies and some have used validated self-written report instruments for measurement of exposure and outcome. The studies investigating associations with sickness absenteeism accept in most cases used register-based data and in one the sickness absence was specific by diagnosis.
Overall research gaps
In that location is a lack of prospective or longitudinal studies on health consequences of gender-based violence and a lack of inquiry focusing the educational industry. Gender-based violence, such equally sexual harassment, is known to be widespread in the homo service industries, not to the lowest degree from patients in the health and social services.48 49 The only study on wellness effects of gender-based violence that we identified30 investigated the association between unwanted sexual attention and sickness absenteeism. The exposure, which was not clearly defined, may be understood every bit relatively mild, while the length of the sickness absence, viii or more sequent weeks, indicates a rather astringent illness. With regard to the educational manufacture, there is a large trunk of inquiry on school social climate and bullying among pupils, in which teachers are regarded as resources to hinder negative acts. However, violence against the teachers themselves is too highly prevalent, at least in the Swedish educational system,l 51 and health consequences for the teachers need further attention.
Limitations in the current evidence
A articulate limitation in the literature on health effects of workplace violence is the assessment of the exposure. The challenges of capturing the exposure to workplace violence and of refining these measures differ depending on blazon of violence. For case, physical violence has oftentimes been measured as a blended measure of threats of violence and actual physical violence. Furthermore, information technology is often not clear from the measure out who exerts the violence, for case, patients, next-of-kin, collaborators or others. The severity, elapsing or frequency of the violence is also oftentimes unclear from the published studies. For psychological violence, such every bit bullying, at that place are other aspects to consider when it comes to measurement. The most common measure in the reviewed studies is the 'self-labelling method',52 meaning that the respondent is asked if he or she is currently or have over a defined menstruum of time been exposed to bullying. This question is sometimes accompanied by a definition of bullying. Another, supposedly better method, is that the respondent is presented with a listing of behaviours that betoken bullying and asked if he or she currently is or has been exposed to these behaviours, for example, the Negative Acts Questionnaire.53 A third method, not often used in the literature but suggested by Nielsen et al,52 used to measure to what extent an individual is exposed to behaviours that would betoken bullying, concerns the perspective of several individuals in the workgroup. Although the subjective perception of being bullied is crucial, we argue that it would strengthen the research field to complement this with other measures than the self-labelling one to get a broader picture of the exposure and its relation to outcomes. When it comes to gender-based violence, only one written report met our inclusion criteria. General discussions in the research field of sexual and gender-based harassment is that questions of sexual harassment are often narrowly formulated, existence close to the legal definition of the concept, and that because many people do not categorise exposures that they have experienced every bit the narrowly defined concept of sexual harassment, in that location is an under-reporting in the literature.2 The research on wellness effects of sexual and gender-based violence is still very limited. It is, yet, reasonable to believe that some of the threats, physical and psychological violence reported in the current review are in fact gender based, although this has not been given plenty attention in the studies. Future inquiry should disentangle to what extent the victim perceives his or her gender or other personal characteristics to be a target for the violence.
Another clear limitation is the employ of self-reported data on mental health outcomes. The measures are often not validated against diagnostic criteria. This limitation as well concerns the physical wellness outcomes, which in the reviewed studies were all cocky-reported. In order to further strengthen the evidence regarding health effects of workplace violence, more outcome measures based on register information on diagnoses are needed. Nigh data on sickness absence were based on registries, in most cases withal with the limitation of being non-specific.
Another limitation is that the time between exposure assessment and the consequence measurement is not motivated and shows considerable variation between the studies. Ane example is the timeframe for retrospective self-labelling–how long back is such a measurement reliable or relevant? It is furthermore non theoretically outlined in the included studies how long it may take for various negative wellness outcomes to develop in response to exposure to the diverse forms of workplace violence.
Our overall determination is that the evidence is consistent regarding an association betwixt psychological violence and poor mental health in human service workers. However, it should be noted that some of the risk estimates were loftier and the CIs were rather wide, indicating poor precision. At that place are besides studies that do non find an association between psychological violence and mental sick-health. One study of medium quality20 furthermore reported the unexpected finding that exposure to bullying was associated with lower odds of sleep problems. The authors of the study advise selection mechanisms to explain the finding, that is, that employees remaining in a work situation in which they are existence bullied may be more resilient, and also have fewer symptoms of poor slumber, than others. The variations across studies may partly be due to incertitude in the exposure assessment, different time perspectives and cocky-reported outcome measures that have not been validated against diagnostic criteria, as discussed previously. Poor statistical power for some groups is another possible explanation. In the studies assessed to exist of loftier quality, statistically significant associations between psychological violence and poor mental health were found in two of 3 studies (66.seven %), and in the studies of medium quality, the corresponding number was seven of 9 (77.8 %), suggesting that more studies of high quality are needed before business firm conclusions well-nigh prospective associations tin be drawn.
Other limitations to consider is that almost of the studies included in the present review are prospective, with data on the exposure available only at baseline, and caution needs to be taken regarding conclusions about causality. More longitudinal studies, measuring both exposure and issue at two or several fourth dimension points, in which reverse causality tin be taken into account, are needed to strengthen the prove. Intervention studies targeting exposure to workplace violence with evaluation of possible changes in wellness have, to the best of our noesis, not been conducted and would add to the current state of evidence. For case, clear and well-communicated workplace policies regarding how incidents of violence should exist handled, and better grooming among staff in handling incidents could lead to a greater sense of preparedness and command, which in turn could moderate the negative impact of violence amongst staff. Furthermore, even if many of the reviewed studies included several relevant confounders in the analyses, few studies applied statistical methods that accept into account unmeasured confounding, such every bit personality. Another limitation is that convenience samples were used in most studies, with consequences for generalisability to the written report population.
Strengths and limitations of the current review
Strengths of the present review include the focus on the human service industries that are highly exposed to workplace violence, a distinction between different forms of workplace violence, the inclusion of a wide spectrum of wellness outcomes and the inclusion of only prospective or longitudinal studies. Through the assessment of the quality of evidence, we identified methodological strengths and limitations in the current best quality studies and pointed out factors that could meliorate the show fifty-fifty farther.
At that place are, however, also several limitations. Afterwards the literature searches had been finalised, nosotros detected an additional three eligible manufactures when checking reference lists in our selected studies. They were nearly likely not detected in the main search because several piece of work exposures were measured, and violence may non have appeared conspicuously in the text that was searched. Nosotros cannot dominion out that other studies were missed for the same reason. Furthermore, if the occupational groups were non conspicuously stated, but but included in sensitivity analyses or the like, such associations may have been missed in the current review. We cannot rule out the hazard of publication bias. Also, due to the low number of studies, nosotros categorised the health outcomes into broad groups. For example, concrete health outcomes include a wide range of outcomes with perchance very dissimilar underlying mechanisms. Perceived general health furthermore does not only embrace perceived physical merely also psychological health. This all ways that while broad, the health outcomes are also unspecific. Also, much of the evidence derived from the developed world (primarily the Nordic European countries) and generalisability could be limited. The overall aim of the present review was to highlight potential health effects of various forms of workplace violence in the human service industries. We therefore included a large variety of workplace violence types and wellness outcomes, but on the other paw a restricted population. Although it is ofttimes recommended to bear meta-analyses to summarise results, as stated in the protocol registered in PROSPERO, it was never intended hither. We believe a meta-analysis would have been of limited added value due to big heterogeneity of the exposure and health outcomes.54–56 Instead, nosotros presented the results carefully and transparently in several exhaustive tables.54
Implications for futurity research
At that place is a full general demand to clarify concepts of workplace violence, to better distinguish between different types of violence and to improve exposure assessment. Theories regarding how dissimilar forms of workplace violence may affect employee wellness over time should be adult and empirically tested, with adequate timeframes taken into business relationship. Other aspects that would move the enquiry field forward is the utilize of register-based diagnoses of disease equally outcome, representative samples and the application of statistical methods that take unmeasured misreckoning such as personality into account.
Conclusion
There is consistent evidence mainly in medium quality studies of prospective associations between psychological violence and poor mental wellness and sickness absence, and between physical violence and poor mental health in human service workers. More inquiry using objective outcomes, improved exposure cess and that focus on gender-based violence is needed.
Practical implications
It is stated in the ILO convention4 and recommendation57 that everyone has the right to a working life free from workplace violence and that member states should adopt advisable measures of prevention in sectors that are more exposed. The evidence of the nowadays review supports the need to develop guidelines for readily detecting and dealing with workplace violence in the human service industries.
Acknowledgments
We would like to thank Sabina Gillsund and Susanne Gustafsson at the Karolinska Academy Library in Stockholm for their professional support in developing the search strategy, conducting the database searches and delivering the selected studies to the review team. Nosotros would too like to thank Tom Sterud at the National Institute of Occupational Health (STAMI) in Oslo, Norway, for valuable comments that improved this written report.
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