Workplace violence experiences of intensive care unit healthcare providers: a qualitative systematic review and meta­-synthesis

Abstract

Objective

Workplace violence (WPV) in intensive care units (ICUs) is a prevalent issue that affects staff well-being and patient care. Although individual studies have explored various facets of WPV, there is a need for a comprehensive synthesis to provide a cohesive understanding of the phenomenon and inform effective interventions. This study aimed to understand its impact on the mental health and work status of ICU staff, identify the coping strategies used by ICU staff to manage WPV and explore the support required by healthcare professionals when facing WPV.

Methods

A systematic literature search was conducted in PubMed, Scopus, Medline, PsycINFO, and Web of Science from the date of inception until June 5, 2024. Only qualitative studies or the qualitative part of mixed methods studies were included in the analysis, with no restrictions on the type of ICU or type or source of violence. This study assessed the risk of bias in the included studies and synthesized the results according to the guidelines of the Joanna Briggs Institute (2024).

Results

Six studies were included. These studies, which were published between 2018 and 2023, were conducted in four countries and involved 91 participants. Six analytical themes and 17 subthemes emerged from the qualitative data. The themes were as follows: Prevalence of ICUs Violence, ICU healthcare perceptions of WPV, The Ripple Effect of WPV in ICU, Practical Strategies for ICU Staff Dealing with WPV, What they need when facing WPV, and Reasons for Not Reporting WPV.

Conclusions

The synthesized findings highlight the pervasive nature of WPV in ICUs and its profound impact on staff members. This review underscores the need for systematic interventions, including comprehensive training, accessible psychological support, and robust reporting mechanisms, to mitigate the effects of WPV.

Other

This study was funded by the Wu Jieping Medical Foundation(320.6750.18526),China. The review protocol was prospectively registered in the Prospective Register of PROSPERO (CRD42024559076).

Relevance to clinical practice

The research findings can provide important evidence for hospital managers and policymakers, helping them develop more effective workplace management policies to enhance the safety and well-being of ICU staff.

Introduction

Workplace violence (WPV) is defined as any form of physical violence, harassment, intimidation, or other disruptive and threatening behaviors occurring within the workplace [1]. WPV is categorized into physical, verbal, and sexual violence. WPV is a serious concern in healthcare settings, with incidents frequently reported across various departments [2], Among these, intensive care units (ICUs) present unique challenges, making them particularly high-risk environments for WPV [3, 4]. Healthcare professionals in the ICU, including physicians, nurses, respiratory therapists, pharmacists, and other support staff, may experience WPV during their duties [5]. Studies indicate that between 44.1 and 99.5% of ICU healthcare professionals have experienced violent incidents at work [1, 6, 7].

The sources of violence in ICUs primarily include patients, family members, and colleagues. Due to severe illness or the effects of medications, ICU patients often exhibit altered mental states that can result in confusion, disorientation, and aggressive behavior [4, 6, 8], which may pose challenges for healthcare workers. High-risk invasive procedures in ICUs are frequently linked to violent reactions. In particular, intubation and physical restraints are among the most significant triggers of WPV in ICU settings due to their highly distressing nature [8, 9]. Intubation, which is required for ICU patients undergoing mechanical ventilation, often causes severe distress and impaired communication, leading to confusion, panic, and combativeness during both the intubation and extubation process [8, 9]. While physical restraints, although used to prevent patients from dislodging life-sustaining equipment, frequently evoke intense feelings of fear, helplessness, and frustration, which may escalate into violent behavior [10]. The unfamiliar and isolated nature of the ICU environment, characterized by frequent monitoring, medical equipment noises, and separation from loved ones, further heightens the anxiety and irritability of both patients and their families [8, 11]. Family members of ICU patients also play a role in the occurrence of WPV. The intense emotional stress and anxiety faced by these families can easily translate into anger and fear, leading to violent actions [12, 13]. Communication issues, such as insufficient or unclear explanations by healthcare staff, often result in misunderstandings and dissatisfaction, escalating conflict [14]. Additionally, the unmet high expectations of ICU staff contribute to perceived inadequacies in patient care, provoking aggressive behavior [13]. WPV has a profound impact on ICU staff, causing severe emotional and physical consequences, such as stress, burnout [15], and even post-traumatic stress disorder (PTSD) [16]. The presence of WPV decreases job satisfaction, increases absenteeism, and leads to high turnover rates among healthcare personnel [17]. Addressing the issue of WPV is crucial for protecting healthcare workers and ensuring patient care quality.

Despite the extensive research on WPV in general medical settings, studies focusing specifically on ICUs are limited. Most existing studies primarily used quantitative methods to measure the prevalence and overall impact of WPV [6, 18]. Although these studies provide valuable statistical data, they often lack the depth required to understand the complex and lived experiences of ICU staff. In this context, qualitative research is particularly valuable, as it allows for an in-depth exploration of the personal experiences and perceptions of healthcare workers. Existing studies have reviewed WPV related to the ICUs [19, 20]. For example, Berger et al. [19] conducted a systematic review focusing on quantitative data, such as WPV prevalence, risk factors, and patient characteristics, but did not delve into the personal experiences of the ICU staff. Filling this qualitative data gap is crucial as understanding the personal experiences of ICU healthcare staffs can provide a comprehensive insight into their mental health status, job satisfaction, and the need for improving the work environment.Similarly, Bass et al. [20] conducted a narrative review on WPV in ICUs, but they did not specify their inclusion and exclusion criteria, nor did they outline the methods for data extraction and analysis. This lack of methodological detail limits the reliability and comprehensiveness of their findings. Therefore, our study aims to fill this gap by employing a qualitative meta-synthesis approach. We will integrate and analyze findings from multiple studies to provide a more comprehensive understanding of the impact of WPV on ICU staff, including their mental health and work status; the relevant experiences they undergo; the coping strategies they employ, and the support they require.

We conducted a preliminary systematic review search using sources, such as Joanna Briggs Institute (JBI) Evidence Synthesis, PubMed, and PROSPERO but did not find a qualitative meta-synthesis specifically focusing on WPV in ICUs, nor were there any ongoing or registered research protocols on the same topic. These findings underscore the importance of the proposed review. Therefore, this systematic review aims to fill the gap in the literature by providing a detailed examination of WPV in ICUs, understanding its impact on the mental health and work status of ICU staff, identifying their coping strategies, and exploring the support needed by healthcare professionals when facing WPV, thereby offering valuable insights for enhancing the safety and well-being of ICU staff.

Methodology

Study design

The study design for this review is a qualitative systematic review using the JBI approach (2024) for critical appraisal, study selection, data extraction, and data synthesis [21]. This qualitative meta-synthesis followed PRISMA reporting guidelines to ensure a systematic and transparent research process. The review protocol was prospectively registered in the Prospective Register of PROSPERO (CRD42024559076).

Objective

This qualitative meta-synthesis review aimed to explore the experiences and perspectives of ICU staff regarding workplace violence and to address the following questions:

• 1. What is the impact of WPV on the mental health and work status of ICU staff?

• 2. What coping strategies do ICU staff employ to address WPV?

• 3. What support do ICU staff need when facing WPV?

Search strategy

To ensure a comprehensive literature review, the search strategy was divided into three stages. Initially, a preliminary search was conducted in PubMed using MeSH terms supplemented by keyword identification through a literature review. Subsequently, comprehensive searches were conducted across multiple databases, including PubMed, Scopus, Medline, PsycINFO, and Web of Science. Specific search strategies were tailored to the unique capabilities of each database (the detailed strategies are provided in Appendix 1. Finally, the reference lists of the included studies were manually searched to identify additional relevant articles. The search was performed from the inception of the databases until June 5, 2024. Language restriction to English publications.

Eligibility criteria

The eligibility criteria were developed according to the PICO framework (Table 1). The population (P) comprised ICU staff, encompassing physicians, nurses, administrative personnel, therapists, and other support staff. The phenomenon of interest (I) focused on studies that delved into the experiences and perceptions of WPV. The context (C) included any ICU setting for the scope of the review. There were no restrictions on the type of ICU or violence type or source. For mixed settings (ICU and others), we extracted only the results related to ICU personnel. For studies with mixed-method designs (including qualitative data), we extracted only the qualitative components.

Table 1 Eligibility criteria

Assessment of methodological quality

The quality of the included studies was independently assessed by two authors using the JBI Critical Appraisal Checklist for Qualitative Research (JBI-QARI) [21]. The JBI-QARI includes ten criteria: philosophical perspective, methodology, data collection, representation and analysis of data, interpretation of results, researcher reflexivity, ethical approval, and data analysis. Each criterion offers response options of “yes,” “no,” “unclear,” or “not applicable.” Discrepancies were resolved through discussion between the two researchers to reach a consensus. In cases where a consensus could not be reached, the third researcher was consulted.

Data extraction

Qualitative data from the included studies were independently extracted by two reviewers using the JBI SUMARI. The extracted data included specific details regarding populations, contexts, cultures, geographical locations, study methods, and phenomena relevant to the review questions and findings. Any discrepancies in the extracted data were resolved by consultation with a third reviewer until a consensus was reached.

Data synthesis

This study utilized the meta-aggregation approach recommended by the JBI to integrate the findings from qualitative studies [22]. Initially, two researchers (WJY, LM) independently reviewed the included studies, gaining a deep understanding of the background, methodology, and study findings. Subsequently, the researchers conducted independent preliminary coding of participants’ quotes from the 6 included studies, categorizing textual data into manageable codes and tags to precisely capture the essence of the data. Concurrently, each finding was assigned a credibility rating based on the strength of the evidence: definitive, credible, or unsupported. Following the preliminary coding phase, two researchers (WJY, LM) employed Atlas.ti software to categorize the data, forming subthemes based on the similarities and differences of each code. In the categorization process, we engaged in critical reflection, continuously revising and refining the categories. Any discrepancies were resolved through consultation with a third researcher (XMF), the third researcher thoroughly reviewed and referenced the original data during the contextualization of themes. In the final stage, three researchers collaboratively reviewed and contextualized the derived themes, ensuring they accurately reflected the original intent of the data.

Results

Search outcome

All the references were imported into EndNote 20 to check for duplicates and their relevance. Two researchers independently screened the relevant literature. Initially, titles and abstracts were reviewed for preliminary screening, followed by a full-text assessment for secondary screening. Any discrepancies between the researchers were resolved through discussion, and a third researcher was consulted when a consensus could not be reached.

In total, 4592 studies were identified from the five databases. Following the removal of duplicates (n = 1080), title and abstract screening was performed on the remaining 3512 articles. Screening of titles and abstracts resulted in the exclusion of 3490 articles, leaving 22 studies for full-text review. After full-text review, a total of 7 studies were excluded for not meeting qualitative research criteria, 1 study was excluded due to being in a language other than English, 3 studies were excluded due to irrelevance to the research topic, and 5 studies were excluded because the study setting was not an intensive care unit (ICU). Ultimately, six studies met the inclusion criteria for the meta-synthesis (Fig. 1).

Fig. 1

Flowchart of the identification and selection of studies

Methodological quality

Overall, the methodological quality of the included studies was high. However, two studies did not clearly state their philosophical perspectives [6, 8], merely reporting the use of qualitative methods or methodologies. Additionally, three studies did not explicitly state the researcher’s cultural or theoretical positioning [6, 11, 13]. Furthermore, three studies did not report the influence of the researcher [6, 11, 13]. For further details, please refer to Appendix 2.

Characteristics of included studies

The included studies were published between 2018 and 2023, involving four countries: Korea [6] (n = 1), Australia [8, 18] (n = 2), Mexico [23] (n = 1), and China (n = 2) [11, 13]. In total, there were 91 participants in all studies. Five studies used qualitative research methods, and one employed a mixed-method approach. Except for one study conducted in a psychiatric ICU [8] and another conducted in an ICU during the COVID-19 pandemic [11], all the other studies were performed in general ICUs. Appendix III presents the specific characteristics of the study methodology, participants, and findings can be found in Table 2.

Table 2 Detail characteristics of included studies

Findings of the review

We extracted and coded the study contents of the six articles, assigning a level to each finding, as detailed in Appendix 3. Finally, we identified six analytical and 17 subthemes from the analysis of the six eligible papers. Appendix 4 illustrates the representation of subthemes across various studies. The themes were as follows: prevalence of ICUs Violence, ICU healthcare perceptions of WPV, the ripple effect of WPV in ICU, practical strategies for ICU staff dealing with WPV, what they need when facing WPV, and reasons for not reporting WPV.

Theme 1: prevalence of ICUs violence

Studies have reported that WPV is highly prevalent in ICU settings [18]. Healthcare professionals frequently encounter violent incidents that have become a routine part of their work environment. As one participant expressed,“It comes from patients all the time. In fact, we get to the stage where we are quite complacent about it because I think it has happened so regularly it is a day-to-day thing and I am a bit worried about it. We have patients who are quite violent towards us and aggressive” [18].

Theme 2: ICU healthcare perceptions of WPV

This analytical theme explored the diverse perceptions of WPV among ICU healthcare professionals and categorized them into two subthemes: “Emotional Distress” and “Empathy”.

Emotional distress

The emotional distress experienced by ICU staff due to WPV is profound and multifaceted. Many victims feel that they invest significantly in patient care, yet they often encounter violence, which leaves them feeling misunderstood and angry. As one nurse articulated, “I’m hurt when I’m told ‘How can a person like you be a nurse?’… It lingers in my mind because it is related to my identity. I begin to think, ‘What did I do that was wrong enough to be told this? ” [6].

Furthermore, some victims also begin to experience fear or stress after encountering WPV. These complex emotions include shock, disrespect, stress, upset, fear, and anger. One participant shared, “I had never imagined violence from patients or their families before working in an ICU. it was a great shock to me at first” [6]. Another nurse recounted, “Last year was my most frightening moment and I have been in nursing all this time, I have been smacked by everybody including geriatric [patients] and I have been verbally abused…said to me (luckily, I had witnesses) but he said to me, ‘I will be waiting for you in the car park’. I have never felt safe after that. That was really, really scary” [18].

Empathy

Despite the significant emotional toll, some ICU staff demonstrated empathy for their patients. Empathy reveals the complex emotional dynamics in ICU settings, where staff balance their emotional challenges with an understanding of their patients’ difficult circumstances. As one nurse expressed, “The patient was forced to be hospitalized and separated from his family because of COVID-19, so it is understandable that the patient was in a bad mood, and the patient was only agitated for a while. I think psychological care is very important here” [11].

Theme 3: the ripple effect of WPV in ICU

This theme delves into the repercussions of WPV on ICU healthcare professionals, focusing on three key areas: avoidance behavior, personal impact, and professional burnout.

Avoidance behavior

WPV profoundly affects interpersonal dynamics between healthcare professionals and their patients [6]. One striking consequence is the development of avoidance behaviors among staff members. This shift from a familial, compassionate approach to a more detached, defensive stance is driven by the need for self-preservation. The protective distance maintained by healthcare professionals serves as a coping mechanism to mitigate further harm. As one healthcare staff poignantly shared,“I treated them like my family but they offered verbal and physical violence on me in return, so I came to think that I only got hurt and kept distance from them in spite of myself. While I nursed them like my family before, I find myself working, keeping a step from them now” [6].

Personal impact

Personal ramifications of WPV extend beyond the immediate workplace, affecting healthcare professionals’ broader well-being. One participant shared, “You no longer come to work happily for the working day” [23]. Another said “I feel like I am always stressed and in a bad mood” [23]. These statements underscore the persistent fear and stress caused by WPV, which diminishes healthcare workers’ joy and satisfaction derived from their work.

Professional burnout

Professional burnout is a significant consequence of WPV and is characterized by decreased motivation and enthusiasm for work [11]. One participant noted, “After being abused by the patient, I did not act as actively as before” [11]. This decline in proactive engagement marks the onset of burnout, with repeated exposure to violence leading to emotional and physical exhaustion, thereby undermining the willingness and ability of healthcare workers to perform their duties effectively.

Theme 4: practical strategies for ICU staff dealing with WPV

This theme highlights the coping strategies employed by ICU healthcare workers to manage and mitigate the effects of WPV. Strategies were categorized into four subthemes: tolerance and acceptance, seeking support, preventive communication, and direct confrontation.

Tolerance and acceptance

Healthcare professionals often adopt tolerance and acceptance as coping mechanisms against WPV. They understand and empathize with patients and their families, even when they exhibit violent behavior [6]. One ICU staff member explained this perspective, stating, “They can visit an ICU just twice a day… I think if we feel empathy with families in the environment unique to an ICU, or at the last moment of deathbed, we need to accept even their violent emotions, so I try to tolerate and accept it” [6]. Another ICU staff highlighted the personal discipline involved, noting, “Once violence occurs, I control myself. I don’t know the permitted limit of tolerance for violence. I just thought I have to accept and tolerate it because I’m a nurse. I think I didn’t try to get angry or express my anger because they were patients or were families of patients” [6].

Seeking support

Seeking support from colleagues and superiors is crucial. One participant stated, “When a visitor was likely to become aggressive, I called a security guard, and when he arrived, I became relieved because I didn’t need to settle the situation by myself. I think I have a system to protect myself and they can immediately come to help me when I call any time” [6].

Another participant mentioned, “After experiencing a violent incident, I felt very depressed and talked to a department manager who sympathized with me and regretted that I was in a violent situation. The manager saw it as a problem in itself, which was a great comfort to me” [6].

Support from colleagues also played a significant role. One participant stated, “Even though we experience violence from patients or their families, they rarely apologize. It only helps when other nurses listen to me. When I experienced violence, my colleagues listened to me and comforted me, saying that I did well despite the difficulties, which healed and helped me” [6].

Preventive communication

Preventive communication is considered a strategy for mitigating WPV. One participant emphasized, “Most attacks are completely preventable; talk to the patients, find out what they want, and then take steps to address it” [13].

Direct confrontation

In some cases, healthcare workers adopt direct confrontation as a coping mechanism. One participant expressed, “It was so infuriating. I couldn’t control my emotions and ended up arguing with the patient” [11].

Theme 5: what they need when facing WPV

This theme discusses the recommendations for improving WPV handling in ICU settings. The subthemes included education and training, psychological counseling, and reporting systems for violence.

Education and training

Healthcare workers expressed a need for formal education and training to cope with violence. One participant noted, “The current method of coping with violence is not what we have learned from an official manual but from our experience. I think that if we get education about violence on the basis of simulation to learn how to cope with it or how to communicate, it will be really helpful” [6].

Psychological counseling

Access to effective psychological counseling is another key suggestion. One participant stated, “We have stress management education or counseling, but it seems formal. I have to apply for it personally after exposure to violence, but I could not come to the education due to schedule problems… We need counseling we can easily access to console us without temporal limitations” [6].

Reporting systems for violence

The need for systematic reporting of violence has also been highlighted. One participant mentioned, “(After exposure to violence) I think simply drawing empathy from seniors through a talk but violence is being repeated. So, a manager needs to make an active intervention… I think a system for making a report of any PVV and keeping it systematically is useful” [6].

Theme 6: reasons for not reporting WPV

Healthcare workers in ICU settings do not report WPV for various reasons. This section provides a detailed analysis of the main reasons for this.

Acceptance of violence as part of the job

Many healthcare workers view violence as an integral part of their jobs, believing it to be unavoidable. One participant mentioned, “Maybe we just take it as everyday stuff. I think it is part of our job. It is part of day-to-day. He was septic, he was confused, so we let him pass” [18]. This perspective increases their tolerance of violent incidents and reduces their willingness to report them. They may see violence as an unavoidable part of their work, thus deeming it unworthy of reporting.

Fear of retaliation

The fear of retaliation is another significant reason. One participant stated, “I have often seen how they shout at colleagues for different reasons but the truth is I am afraid to interfere with the bosses because they would do the same to me after” [23]. This fear stems not only from patients but also from potential retaliation by colleagues and superiors. Healthcare workers are concerned that reporting violence can negatively affect their career prospects.

Prioritizing patient safety over personal safety

Healthcare workers in ICU settings often prioritize patient safety over their own. One participant noted, “My safety is not secured, but the first thing is to settle the situation. So I have to keep patients safe by maintaining endotracheal tubes, arterial lines, and central lines, instead of sparing myself, though patients spit at me. I come to think about my experience of violence only after I confirm patients’ safety due to concerns about their safety at that time” [6]. This dedication leads them to focus on stabilizing the patient’s condition during violent incidents, rather than immediately reporting or addressing the violence.

Discussion

To the best of our knowledge, this is the first review to systematically aggregate, synthesize, and interpret qualitative evidence to explore ICU staff experiences with WPV. This study employed a meta-synthetic approach to review six studies on ICU staff’ experiences and perceptions of WPV. Through repeated reading, analysis, and discussion, we identified six analytical themes: “prevalence of ICUs Violence”, “ICU healthcare perceptions of WPV”, “the ripple effect of WPV in ICU”, “practical strategies for ICU staff dealing with WPV”, “what they need when facing WPV”, and “reasons for not reporting WPV”. These themes offer valuable insights into the profound impact of WPV on ICU staff and their coping mechanisms and provide recommendations for improving ICU environments and ensuring the safety of ICU staff.

Multiple studies included in this review indicate that WPV is frequent in ICUs [8, 18, 23], with healthcare personnel often subjected to verbal and physical abuse, which is consistent with previous research [1, 7]. The widespread occurrence of WPV profoundly affects ICU staff, leading to psychological effects, such as fear and stress [6, 23]. This aligns with prior findings, where some study revealed that individuals experiencing WPV are prone to depression, anxiety, and PTSD [15, 16]. Additionally, ICU staffs frequently suppress their emotions to maintain a professional demeanor when faced with violence from patients and their families [6, 23]. This emotional suppression can lead to long-term mental health issues, further affecting their job performance [17].

WPV also negatively impacts healthcare providers’ work performance, WPV can lead to burnout and decreased job satisfaction among healthcare providers [17]. One meta-analysis indicated that individuals experiencing WPV had an adjusted odds ratio (AOR) for reporting burnout that was two times higher compared to their counterparts without any exposure [16]. Burnout may lead to increased turnover rates, which not only raises human resource costs for healthcare institutions but also affects team stability and work efficiency [1, 7]. Furthermore, burnout can negatively impact the quality of healthcare services [1], highlighting the urgent need to address the effects of WPV on ICU staffs. Despite the frequent and severe consequences of WPV, ICU staffs have reported that existing resources are insufficient to adequately address WPV from various sources [24].

Preventive measures are crucial in mitigating WPV. In our study, many participants indicated that they needed WPV-related training from the hospital to enhance their skills in handling WPV [6, 8]; however, a survey found that only a small number of ICU healthcare workers had received WPV training and education [3]. Therefore, hospitals should implement relevant training and education programs to enhance healthcare workers’ skills in managing WPV [25]. These programs should cover early signs of violent behavior, techniques for recognizing potential threats, and methods for de-escalation and response [26]. Different types of structured education programs have been utilized, including cognitive rehearsal programs [27, 28], civility, respect, and engagement in the workplace) [29], and clinical aggression management-rapid emergency department intervention [30], most of which yielded positive outcomes. These programs employ various methods and techniques to enhance the ability of nurses and other healthcare workers to cope with WPV, demonstrating positive effects in terms of improving job satisfaction, enhancing coping mechanisms, and fostering better interpersonal relationships [26]. However, these studies were not specifically conducted for the ICU. Therefore, training and education should be designed and implemented based on the unique context of the ICU.

In this study, nearly all the reviewed literature mentioned the significance of security [6, 8, 11]. The immediate presence of security staff, when needed, can offer healthcare workers a substantial sense of safety [31]. Security measures can be primarily addressed in two ways: first, through the hardware environment, and second, through the deployment of security personnel. Keys et al. [32] conducted a qualitative study aimed at exploring and describing nurses’ perceptions of their safety and security in the ICU. The findings presented several safety enhancement recommendations from the nurses’ perspective, including restricting visitor access, installing emergency call systems, deploying security personnel, equipping the area with surveillance cameras and metal detectors, utilizing U-shaped layouts to improve visibility, and incorporating glass windows and low windows to enhance monitoring effectiveness.

In this study, we found that many victims choose not to report the violent incidents they experienced [6, 11, 18]. A survey conducted among 1,033 ICU staff from five European countries revealed that when asked, “Have you reported the incidents?”, 46% stated they had not reported any incidents, 54% reported some incidents, and 30% reported all the incidents [33]. Failure to report WPV over an extended period prevents management and violence prevention agencies from understanding the full scope of the issue and taking targeted measures, thereby allowing WPV to persist [34, 35], along with its adverse effects [36, 37]. Therefore, it is crucial to encourage healthcare workers to report WPV and promptly address these issues to ensure timely resolution and management. Hospitals can address this phenomenon by establishing a simple and clear mechanism for reporting WPV incidents, enabling victims to report violent incidents promptly [6, 38]. Additionally, after an incident is reported, relevant agencies should follow up and handle the cases in a timely manner to protect victims’ rights. Finally, each case should be thoroughly analyzed and reported by institutions to identify the causes and processes of incidents [39], learn from them, and make improvements to reduce the recurrence of similar events [40].

Although our qualitative data did not yield direct accounts of suicidal ideation, it is crucial to acknowledge established research indicating a significant link between WPV and suicidal ideation among healthcare professionals. For example, a study conducted in China has specifically confirmed a correlation between WPV and suicidal ideation in medical staff. This body of evidence suggests that WPV can contribute to suicidal thoughts in medical personnel [41]. Therefore, it is crucial to provide immediate psychological support to victims of WPV [42]. Healthcare institutions should organize professional counseling teams to offer one-on-one psychological support, help victims cope with trauma, and alleviate psychological stress [6]. Research has focused on various psychological interventions to aid ICU staff in managing stress, such as risk perception interventions [43], Comprehensive Active Resilience Education (CARE) [44], and CopeColumbia [45]. These interventions can be used to validate psychological relief from WPV.

Although we did not limit the search by date, all studies included were relatively recent (from 2018 onwards). This phenomenon may reflect the evolving research trends in the field. It could be associated with the development of critical care medicine, as the number of patients admitted to ICUs has gradually increased alongside a rising incidence of WPV related to ICUs, prompting researchers to conduct more relevant studies. Additionally, during the COVID-19 pandemic, the continuous rise in ICU admissions may have further accelerated research advancements in this area.

Limitations

This study has certain limitations. First, it was confined to studies published in English, which may have led to a linguistic bias. Additionally, this review did not restrict the type of ICU; therefore, the types and causes of WPV may vary across ICUs. The diversity of these settings may have affected the generalizability of the results. Lastly, this study included only six papers, primarily because existing research on WPV in hospital settings is largely concentrated in emergency and psychiatric departments, with less focus on ICUs. Future research should consider other languages and investigate the occurrence of WPV in different environments to enhance comparability.

Conclusion

This review highlights the significant psychological and emotional impacts of WPV on ICU healthcare providers, emphasizing the urgent need for institutional support and comprehensive anti-violence policies. Future research should prioritize the development of standardized measures for the prevention and management of WPV, along with an evaluation of the effectiveness of various intervention strategies. These endeavors will facilitate the creation of safer working environments and enhance the physical and mental well-being of ICU staff.