Abstract
Background: Workplace violence (WPV), including verbal threats and physical assaults, toward healthcare professionals is an escalating threat to workforce safety, well-being, and retention. Although structured tools exist to assess aggression risk, most have been developed for psychiatric or emergency settings, and evidence supporting their validity or consistent use in general inpatient care remains limited. The Violence Risk Assessment (ViRA) is a proactive, nurse-administered, electronic health record (EHR) embedded tool designed to detect early behavioral and historical precursors of verbal or physical violence.
Purpose: To evaluate the reliability, internal consistency, and predictive validity of the 9-item ViRA across diverse inpatient and emergency care settings.
Methods: A multi-site, prospective cohort study was conducted across 20 pilot units within a large academic–community health system. Nurses completed ViRA assessments at admission, every 12 hours, and with any change in status or level of care. Analyses examined internal consistency (factor analysis), predictive validity (multivariable logistic regression with sensitivity and specificity), and interrater reliability (planned intraclass correlation). Training and testing models were developed using 14 months of data (369,865 assessments) and validated with an expanded 20-month dataset (551,349 assessments).
Results: Factor analysis supported a single-factor structure, confirming coherence among the nine items. Predictive modeling across adult and pediatric groupings showed that 9-item models performed best for adults, while reduced 6-item models were optimal for pediatrics. Final sensitivity/specificity were 80%/98% (Adult Emergency), 89.53%/33.15% (Adult Inpatient), and 91%/91% (Pediatric Emergency/Inpatient).
Implications for Nursing: The ViRA tool demonstrates adequate positive and negative predictive value to identify patients at risk for committing verbal or physical violence against healthcare workers. Early identification enables targeted assessment and timely risk communication, supporting workforce safety and prevention planning. Future research will examine the impact of specific interventions in reducing violence events after the risk is assessed.
Notes
Presenter notes available in attached slide deck.
Reference list included in attached slide deck.
Sigma Membership
Nu Beta at-Large
Type
Presentation
Format Type
Text-based Document
Study Design/Type
Cohort
Research Approach
Quantitative Research
Keywords:
Acute Care, Instrument and Tool Development, Workforce, Prevention of Violence in the Workplace, Work Environment, Risk Assessment
Recommended Citation
Watson, Heather Lynn; Thompson, Carol B.; Frangieh, Jihane; and Whalen, Medeleine, "Predicting the Unpredictable: Nursing Innovation for Early Identification of Violence Risk" (2026). International Nursing Research Congress (INRC). 26.
https://www.sigmarepository.org/inrc/2026/presentations_2026/26
Conference Name
37th International Nursing Research Congress
Conference Host
Sigma Theta Tau International
Conference Location
Toronto, Ontario, Canada
Conference Year
2026
Rights Holder
All rights reserved by the author(s) and/or publisher(s) listed in this item record unless relinquished in whole or part by a rights notation or a Creative Commons License present in this item record. All permission requests should be directed accordingly and not to the Sigma Repository. All submitting authors or publishers have affirmed that when using material in their work where they do not own copyright, they have obtained permission of the copyright holder prior to submission and the rights holder has been acknowledged as necessary.
Review Type
Abstract Review Only: Reviewed by Event Host
Acquisition
Proxy-submission
Date of Issue
2026-07-22
Funder
Johns Hopkins University School of Nursing
Predicting the Unpredictable: Nursing Innovation for Early Identification of Violence Risk
Toronto, Ontario, Canada
Background: Workplace violence (WPV), including verbal threats and physical assaults, toward healthcare professionals is an escalating threat to workforce safety, well-being, and retention. Although structured tools exist to assess aggression risk, most have been developed for psychiatric or emergency settings, and evidence supporting their validity or consistent use in general inpatient care remains limited. The Violence Risk Assessment (ViRA) is a proactive, nurse-administered, electronic health record (EHR) embedded tool designed to detect early behavioral and historical precursors of verbal or physical violence.
Purpose: To evaluate the reliability, internal consistency, and predictive validity of the 9-item ViRA across diverse inpatient and emergency care settings.
Methods: A multi-site, prospective cohort study was conducted across 20 pilot units within a large academic–community health system. Nurses completed ViRA assessments at admission, every 12 hours, and with any change in status or level of care. Analyses examined internal consistency (factor analysis), predictive validity (multivariable logistic regression with sensitivity and specificity), and interrater reliability (planned intraclass correlation). Training and testing models were developed using 14 months of data (369,865 assessments) and validated with an expanded 20-month dataset (551,349 assessments).
Results: Factor analysis supported a single-factor structure, confirming coherence among the nine items. Predictive modeling across adult and pediatric groupings showed that 9-item models performed best for adults, while reduced 6-item models were optimal for pediatrics. Final sensitivity/specificity were 80%/98% (Adult Emergency), 89.53%/33.15% (Adult Inpatient), and 91%/91% (Pediatric Emergency/Inpatient).
Implications for Nursing: The ViRA tool demonstrates adequate positive and negative predictive value to identify patients at risk for committing verbal or physical violence against healthcare workers. Early identification enables targeted assessment and timely risk communication, supporting workforce safety and prevention planning. Future research will examine the impact of specific interventions in reducing violence events after the risk is assessed.
Description
Focus: Clinical - Advancing Clinical Practice
Status: Completed Work/Project
This presentation reviews a successful research study designed to help protect healthcare staff by proactively identifying patients at high risk for committing verbal or physical violence. The nurse-led, EHR-embedded ViRA tool demonstrated validity and strong predictive performance, supporting early assessment to predict violence and enhance workforce safety.