Violence can be described as any exertion of physical or verbal force with the intention of abusing or injuring the target. Physical abuse includes pushing, smashing, throwing objects, preventing individuals from leaving the room, pulling, spitting, biting or scratching, striking, or kicking. While verbal abuse includes swearing, threatening behavior, non-serious threats, or sexual intimidation . The purpose of the literature review is to determine and understand the causes of patient-instigated workplace violence in the emergency departments.
Violence in health care was defined “as any incidents where the staff are abused, threatened or assaulted in circumstances relating to their work involving an explicit or implicit challenge to their safety, well-being or health” . This definition includes “any threatening statement or behavior which gives a worker reasonable cause to believe they are at risk” . It also includes a broad type of behaviors , from physical assault or direct violence to non-physical forms of violence such as verbal abuse and sexual harassment .
Types of Violence
Verbal abuse. Verbal abuse is the most common type of abuse against nurses in healthcare settings. It is three times more likely to occur than physical violence . Verbal abuse is reported to be the most common type of abuse with 82% of nurses , and an average of 63.9% of them , being subjected to some form of verbal abuse from patients. Of these behaviors, swearing, shouting, or cursing has been identified as the most common  and is reported to be the most violent type of verbal aggression .
Physical abuse. Physical abuse often co-exists with verbal abuse, suggesting that the latter might act as a warning sign for potential physical abuse [15, 18]. Of these behaviors, “being pushed or hit” identified as the most common type of physical abuse , while the use of lethal weapons mostly occurs during the night hours .
The risk factors can be grouped into five categories. They are as follows: substance and alcohol abuse, medical diagnosis and treatment, waiting times, and time of day.
Substance and alcohol abuse. Substance abuse of alcohol and drugs has been reported to be associated with an increased risk of violent behavior by patients . It is reported to be 98%  of all violent episodes being attributed in some way to alcohol use.
Medical diagnosis and treatment. There is a relationship between mental illnesses and an increased risk of violence, with sufferers being up to two-to-three times more likely to act violently than the general population . In addition, alcohol and drug abuse in patients with a mental illness increases the possibility for violent behavior . Many emergency nurses lack mental health nursing experience and skills, which has the possibility to trigger potentially violent events  because ED nurses classified mental health patients as the most likely to display physical violence . In addition, the environment in ED is noisy, open, crowded and busy, and no privacy for patients with mental health problems and these patients need less noise and privacy to generate an environment in which they feel safe . Matters that are associated with the patients have a very high level of anxiety, tension, and lingering negative impression of bad treatment as well as lack of medical insurance and high hospital bills are common in the ED and these factors can predispose a patient to violent behavior [4, 20, 27, 28].
Waiting times. Many patients holding unrealistically high expectations of the nurses , but when these expectations are not met, the consequent anger usually is directed towards the nurses . In addition, patients place the blame of delayed treatment, if so happens, on the nurses .
Time of day. Nurses are more vulnerable to patient-related violence in the afternoon shifts (after 4 p.m.) [22, 31]. This was validated when crime statistics on hospital assaults in Australia showed that the most common time for violent events is between 2 p.m. and 9 p.m. .
Causes of Under-Reporting
Many studies indicate that violence against nurses goes underreported, e.g., more than 72% of the nurses suffer from violence at their workplace . Emergency departments have been highlighted as locations where violent incidents are likely to be significantly under-reported and the reasons are: a) nurses not satisfied with the way their previous events of violence was handled because some of these cases are not treated with the seriousness they deserve , b) the belief that violence is part of the job [16, 33], c) nurses are discouraged from coming forward to report such event because even if they do, there are no policies that will guarantee justice [16, 27], d) insufficient time , e) nurses do not report due to the belief that no harm was inflicted on them and they can handle it , f) nurses can defend themselves by changing the way they treat that particular patient .
Cultural issue. Some countries are male-dominant, which means the culture block women from complaining or questioning a man’s acts against them or other issues in the society. Many female nurses do not come forward to report physical abuse against them in the workplace due to the absence of any ability to defend themselves . For example, the male nurse will be more likely to report physical attack than the female nurses and less likely than female nurses to report being verbally abused.
Previous studies reported that nurses feel the absence of assertive legislations, poor management of violent incidents, and lack of resources like insufficient equipment, medical errors, and poor environment contribute significantly to workplace violence [4, 5]. Also, shortage of nursing staff lack of proper communication skills, lack of experience, and lack of quality care could lead to workplace violence as well [4, 27].
Consequences of Violence
Experienced and older nurses are reported to be at less risk of violent behavior than their less experienced colleagues . The majority of nurses who get hurt in physical violent incidences tend to go on leave , but some of them also react by saying they cannot make it to work because they are sick . Furthermore, the majority of nurses who are abused physically and verbally think of leaving their profession and believe that their competence has decreased significantly as a result .
Workplace violence that is targeted at nurses is a rapidly growing problem that effects nurses throughout the world. There is a severe underreporting of violent occurrences and, due to this, the lack of empirical data supporting this phenomenon are not the only barriers that prevent accurate reporting of violence targeted at nurses. Patients’ violent behaviors have deleterious consequences, not only for the nurses but for the patients themselves as they undermine the quality of care that is ultimately delivered to the patient. There is currently a global shortage of qualified nurses  and reported instances of workplace violence are negatively correlated with rates of recruitment and retention. Consequently, it is of vital importance that nurses are both encouraged to enter the profession and are provided with a work environment in which they are supported and protected. The provision of such an environment will ultimately increase the quality of care nurses deliver.