While the ED is still the point of the spear in terms of healthcare violence, a new study supports the idea that the threat to workers is becoming more general and less unit-based. A survey of roughly 1,000 nurses in Canada found that the majority “believe that high-risk pockets of violence are being replaced by widespread and systemic workplace violence.”1

The researchers conducted a survey from March 2017 to January 2018 in British Columbia, netting responses from 771 medical-surgical nurses and 189 nurses in mental health settings.

“For medical-surgical and mental health nurses, greater perceptions of workplace safety were related to employers listening to them with respect to violence prevention strategies,” the researchers found. “Nurses in both settings were more likely to feel safe when they were not expected to physically intervene during a ‘code white’ situation.”

Mental health nurses felt safer with a sufficient number of trained code white responders on their unit. Medical-surgical nurses were more likely to feel safe when reviews of incidents were conducted and with fixed alarms in place throughout the workstation.

To delve deeper in the findings, Hospital Employee Health interviewed lead author Farinaz Havaei, RN, PhD, a post-doctoral fellow at the University of British Columbia School of Nursing in Vancouver.

HEH: You found that nurses in general feel safer when they are not expected to physically intervene during a violent incident. Has there been some historical perception that nurses would be expected to go to these lengths in code white incidents?

Havaei: Unfortunately, this is not just a historical perception. It is the reality. About one-third of medical-surgical nurses and two-thirds of mental health nurses indicated they were expected to physically intervene during code white incidents. And there are probably many explanations for this, including history, finite financial and human resources, rising violence, etc.

But the most important issue is that this has got to stop now because it is not safe. Nurses are not educated or prepared to physically respond to violence. It is not part of their job or scope of practice.

HEH: We know EDs are at risk of incidents, but you report a growing sense that violence can occur on any unit and in any patient population.

Havaei: Yes. According to evidence, workplace violence is difficult to eliminate or effectively manage because it is so deeply embedded within organizations’ structures and cultures irrespective of the workplace specialization and the patient population. Structural violence is the source of discrimination based on, for example, gender, race, and sexual orientation, and can happen in any context.

HEH: You found that only about 30% of medical-surgical nurses and about 53% of mental health nurses reported having enough properly trained code white responders on their unit. Was this a general subjective feeling that there were not enough responders?

Havaei: These data reflect nurses’ perceptions. But, previous research2,3 has found a strong relationship between nurse reports and institutional reports of events. Although these studies are not focused on nurse violence, they provide sufficient evidence around the validity and reliability of nurses’ perceptions. Perceptions and self-reports of events are a useful proxy, especially when administrative data are lacking or access is limited.

HEH: You found about 66% of medical-surgical nurses had never observed a code white drill on their unit as opposed to 50% of mental health nurses. The lack of visible drilling seems like it could feed into an overall narrative of vulnerability and lack of preparation. Is part of violence prevention making it visibly apparent that efforts are indeed in place to prevent violence?

Havaei: Absolutely. Drills are important as they familiarize nurses and other healthcare providers with the part they ought to play should a violent incident occur. I think it is really important to prepare nurses and provide them with the opportunity to practice what to do during a code white incident before it actually happens. Both hospitals and educational institutions can play a part in preparing nurses and nursing students.

HEH: Regarding violence prevention strategies, you found some positives in terms of nurses reporting that facilities took action as a result of incidents. Can you comment on this finding, which runs counter to the weak administrative reactions some nurses report?

Havaei: We found nurses had higher workplace safety perceptions when they believed employers listened to them. This finding was consistent across both medical-surgical and mental health settings. Unfortunately, some administrators fail to actively engage nurses in problem-solving. Organizational empowerment research shows participatory decision-making enables nurses to provide better patient care more effectively and efficiently. Nurses can play key roles in identifying gaps in workplace safety and co-developing prevention strategies because they are at the forefront of patient care.

HEH: Given current trends, perceptions of threats of healthcare violence may continue to increase. Are there one or two take-home points you can recommend for hospitals to address this problem?

Havaei: I would say the key message is that promoting a safe workplace is everyone’s responsibility; e.g., clients and families who interact with healthcare staff in a respectful, nonviolent manner; nurses who recognize that violence is not part of the job and report actual and potential violence incidents to the responsible authority; employers who value and invest in an organizationwide culture of safety and comply with legislative and contractual requirements to ensure workplace safety; and health authorities and governments who mandate organizations to enforce policies and procedures to prevent violence in the workplace.


  1. Havaei F, MacPhee M, Lee SE. The effect of violence prevention strategies on perceptions of workplace safety: A study of medical-surgical and mental health nurses. J Adv Nurs. 2019 Jan 15. doi: 10.1111/jan.13950. [Epub ahead of print]
  2. Purdy N, Laschinger HKS, Finegan J, et al. Effects of work environments on nurse and patient outcomes. J Nurs Manag. 2010;18(8):901-13. doi: 10.1111/j.1365-2834.2010.01172.x.
  3. McHugh MD, Stimpfel AW. Nurse reported quality of care: a measure of hospital quality. Res Nurs Health 2012;35(6):566-575.