NU 515 Assignment 3 Hierarchy of Evidence: Three Articles on Violence Against Nurses in the Workplace

NU 515 Assignment 3 Hierarchy of Evidence: Three Articles on Violence Against Nurses in the Workplace

Hierarchy of Evidence: Three Articles on Violence Against Nurses in the Workplace

Hierarchy of evidence is a framework designed to offer healthcare practitioners and researchers the opportunity to consider evidence and their effectiveness in addressing a nursing problem. The rating of evidence allows medical professionals to determine the reliability, unbiased and effectiveness of research studies. The pyramid developed by researchers ranks studies in distinct levels; right from level I to VIII based on the strengths and vigor of the research. Level I is considered to be the most dependable source of evidence and consists mainly of systematic reviews of experimental research articles (Polit & Beck, 2017). The implication is that using this pyramid is essential in getting clear aspect of research articles and their importance in an identified nursing or healthcare issue.

Critiquing evidence presented in research articles based on their level as per the pyramid of evidence hierarchy is important in understanding the issue of violence against nurses in health care settings. Violence against nurses is an incivility that impacts their ability to deliver care and may cause adverse events that include medication administration errors (Faghihi et al., 2021). The purpose of this paper is to review three research articles to determine if these studies on violence against nurses in healthcare are reliable and offer the best evidence by utilizing the traditional hierarchy of evidence.

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Level of Article One

The first article is by d’Ettore et al. (2018) who carried out systematic review of articles about workplace violence

NU 515 Assignment 3 Hierarchy of Evidence Three Articles on Violence Against Nurses in the Workplace

NU 515 Assignment 3 Hierarchy of Evidence Three Articles on Violence Against Nurses in the Workplace

against healthcare workers practicing in emergency departments (EDs) in different areas in the world. Using a qualitative review, the authors identify predictors of violence against healthcare workers caused by patients. They highlight health conditions like anxiety and depression and substance abuse as the main causes of these assaults. The article also provides solutions to manage the problem that include training courses, development of better interactions and relationship among healthcare workers and patients and effective communication. The article shows the need to have a multifaceted approach in tackling violence against healthcare workers emanating from patients like workplace designs that mitigate stressful conditions in waiting areas since a majority of the assaults on the healthcare workers occur in these rooms.

NU 515 Assignment 3 Hierarchy of Evidence Three Articles on Violence Against Nurses in the Workplace

NU 515 Assignment 3 Hierarchy of Evidence Three Articles on Violence Against Nurses in the Workplace

Based on the pyramid hierarchy, the article’s level is one since it is a systematic review of randomized control trials by the researchers. Well done systematic reviews, either having meta-analyses or not, offer the best evidence for all questions types since they are founded on findings from multiple studies. These studies are not only comprehensive but also emanate from systematic literature searches. Systematic reviews also comprise of several qualities that include addressing a focused and clearly formulated question and uses systematic and explicit approaches in identification, selection and critical appraisal of relevant research and collect and analyze data from studies included in the review.

In this case, the authors collect data and analyzes it from different areas to gain understanding of the issues that lead to violence against healthcare workers in emergency departments. The article demonstrates strong evidence since it shows that using reviews from several randomized and non-randomized control trials allows researchers to identify various aspects connected to the issue of violence in health care settings against nurses. The article is strong given the setting it focuses on, emergency departments (EDs) in various parts of the world.

Level of Article Two

The second article is by Kremic et al. (2017) and evaluates the effects of encouraging healthcare employees to report verbal violence in primary care in Belgrade, Serbia. The authors use a cross-sectional study that comprises of 1526 employees chosen using a multi-stage sampling to assess the prevalence and characteristics of violence in primary health care setting. The article shows that effective reporting can reduce and motivate employees to find solutions to the problem. The authors assert that the primary form of violence against healthcare workers is verbal coming from patients. The authors assert that a majority of nurses, close to 56% never report the events with about 75% attributing their choice of not making reports to no solution being provided by the management. The authors conclude by emphasizing the need for better interventions to protect HCWs by organization’s management, especially encouraging reporting of such events.

The article is a cross-sectional study with a specific population and carried out at a certain time. Insight attained from cross-sectional studies provides a foundation to using more effective design to substantiate the early findings. Cross-sectional studies don’t need numerous resources, can be carried out fast, and assess multiple interventions and outcomes at the same time. while they may present bias, they are used in determining the number of cases in a certain population at a particular moment.

The level of evidence from cross-sectional studies may appear not robust but based on the hierarchy of evidence be considered at the seventh rank or scale. The evidence in this article is from a single qualitative study and does not contain more views but from similar area though in different settings. Cross sectional studies offer primary information based on the number of those selected to participate in the research. In this case, healthcare workers in Belgrade were interviewed on reporting violence against them by patients or clients. The study shows the need to identify reasons for failure of reporting despite the negative effects on nurses and other health professionals

Level of Article Three

The third article is by Heckermann et al. (2020) which is a qualitative study to get nurses’ perspective about their learning from aggression management training course. The study places emphasis on the importance of these interventions in mitigating aggressive behaviors among nurses and those visiting healthcare facilities. The authors conclude that such trainings improve nurses’ awareness of their settings and enables them to recognize initial signs of offending by patients and other visitors. Nurses also improve the confidence in handling potential aggressive situations.

The article demonstrates the need to find meaning to understanding aggression in the workplace by nurses. The article is a qualitative descriptive study implying that it is level of evidence is seven. The evidence from this qualitative study allows practitioners and organizations to develop effective interventions to raise awareness about aggression and ways that nurses can prevent them. As posited by Polit and Beck, evidence from descriptive or qualitative studies are essential as they provide critical and foundational information to implement certain interventions to enhance quality care. The evidence from the article shows the effects of confidence levels and how they affect nurse’s attitude towards quality care delivery.


The hierarchy of evidence helps researchers in nursing to identify the types of studies that are reliable. The best evidence denotes to findings that demonstrate appropriate, and rigorous methodology and are relevant clinically in answering persistent questions and concerns. While systematic reviews may offer the best and robust level of evidence, there are situations where such evidence may not be the most effective or best. The implication is that researchers can be innovative and develop solutions that answer situations and still offer the most appropriate solutions. The reviewed articles have different levels of evidence but provide effective interventions and solutions to tackling the issue of workplace violence against healthcare workers. The articles show that while systematic reviews may offer the best level of evidence, other research approaches are still important.



Faghihi, M., Farshad, A., Abhari, M. B., Azadi, N., & Mansourian, M. (2021). The components

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d’Ettorre, G., Mazzotta, M., Pellicani, V., & Vullo, A. (2018). Preventing and managing

workplace violence against healthcare workers in Emergency Departments. Acta Bio Medica: Atenei Parmensis, 89(Suppl 4), 28. DOI: 10.23750/abm.v89i4-S.7113

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Kremic, M. B. F., Terzic-Supic, Z. J., Santric-Milicevic, M. M., & Trajkovic, G. Z. (2017).

Encouraging employees to report verbal violence in primary health care in Serbia: A cross-sectional study. Slovenian Journal of Public Health, 56(1): 11-17. 10.1515/sjph-2017-0002

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