TRAUMA-INFORMED SECURITY IN VIOLENCE MITIGATION Mitigating Violence Against Nurses Through Trauma-Informed Security Brayden Oye J0383956 Bachelor of Law Enforcement Studies, School of Criminology, Justice Institute of British Columbia LAWS 4003: Research Project Melanie Chernoff July 28, 2023 1 TRAUMA-INFORMED SECURITY IN VIOLENCE MITIGATION Abstract The concerning surge in workplace violence against nurses indicates a significant threat to the safety of nurses. This study used a mixed-methods design and a pragmatic worldview to critically appraise secondary data on how trauma-informed security can reduce violence against nurses. The scope of this research study was limited to the healthcare security discipline and focused on the current threats of violence against nurses, its implications on healthcare safety and security, and the principles of trauma-informed security. The primary research question of this study aimed to determine “How might trauma-informed security reduce violence against nurses?” A correlation between trauma, hospitalization, and acts of violence and aggression was reported in this study. The themes explored in the literature suggested several factors related to workplace violence that impact the safety of nurses, the need for improved interprofessional relationships between nurses and security officers, and, importantly, the need for traumainformed hospital security practices and policies. This study advocates for hospital security practices and policies to be grounded on the principles of trauma-informed security and for further research on the benefits of transitioning towards a trauma-informed healthcare security model that improves the safety and security of security officers and nurses. Keywords: trauma-informed security, trauma, healthcare security officers, nurses, workplace violence, de-escalation, hospital security practices and policies 2 TRAUMA-INFORMED SECURITY IN VIOLENCE MITIGATION 3 Table of Contents Abstract ........................................................................................................................................... 2 Mitigating Violence Against Nurses Through Trauma-Informed Security ..................................... 5 Background ............................................................................................................................................... 5 Purpose Statement..................................................................................................................................... 5 Research Questions ................................................................................................................................... 6 Scope of the Study .................................................................................................................................... 6 Philosophical Worldview .......................................................................................................................... 7 Design and Methodology ................................................................................................................ 7 Research Design........................................................................................................................................ 7 Search Methodology ................................................................................................................................. 8 Inclusion and Exclusion Criteria .......................................................................................................................... 9 Article Selection...................................................................................................................................... 11 Literature Review .......................................................................................................................... 12 Description of Selected Articles.............................................................................................................. 13 Critical Analysis............................................................................................................................ 21 Challenges in Identifying Workplace Violence as a Symptom of the Problem ...................................... 21 Causes and Triggers of Workplace Violence Against Nurses ................................................................. 22 Challenges in Interprofessional Collaboration Between Nurses and Security Officers ......................... 23 The Need for Improved and Trauma-Informed Practices and Policies................................................... 25 Discussion ..................................................................................................................................... 27 TRAUMA-INFORMED SECURITY IN VIOLENCE MITIGATION 4 Enhancing the Concept of Safety............................................................................................................ 27 Building Trusting and Understanding Relationships .............................................................................. 28 Restoring a Sense of Empowerment, Resiliency, and Choice ................................................................ 30 Improving Collaboration Between Nurses and Security ........................................................................ 31 Limitations and Ethical Considerations ....................................................................................... 32 Recommendations ......................................................................................................................... 33 Conclusion .................................................................................................................................... 34 References ..................................................................................................................................... 36 TRAUMA-INFORMED SECURITY IN VIOLENCE MITIGATION 5 Mitigating Violence Against Nurses Through Trauma-Informed Security Background Workplace violence against nurses is at an all-time high. A 2022 report by the Canadian Federation of Nurses reported that 93% of nurses have faced violence in their workplace. Violence against nurses occurs at a higher rate than violence against police and correctional officers (Brophy et al., 2017). Violence against nurses includes physical acts of violence (i.e., assaults) and non-physical violence (i.e., threats, harassment, and verbal abuse) (Havaei et al., 2020). Despite these concerning rates of violence perpetuated against nurses, several studies have noted that “healthcare workplace violence is an underreported, ubiquitous, and persistent problem that has been tolerated and largely ignored” (Brophy et al., 2017, p. 2). To improve workplace safety, uniformed and trained healthcare security officers have been deployed on the frontlines to prevent and mitigate workplace violence against nurses (Bautista et al., 2021). Studies have noted that healthcare security officers play a vital role in responding to acts of violence and aggression through de-escalation, restraint application, and the use of force when necessary (Gillespie et al., 2010). However, several scholars have critiqued the effectiveness of current violence mitigation strategies and training used by healthcare security officers citing the minimal effect on de-escalating aggressive and violent situations and instead triggering traumatic and emotional responses that result in violence against nurses (Bautista et al., 2021). Purpose Statement This study aims to fill the gap in the existing literature on the relationship between trauma-informed security and workplace violence mitigation. As workplace violence against nurses continues to increase, there is a pressing need for effective and safe violence prevention TRAUMA-INFORMED SECURITY IN VIOLENCE MITIGATION 6 and mitigation strategies to be examined and implemented in current hospital security policies and practices. Findings from this study will aid in developing practical and effective violence prevention strategies that provide the groundwork for practices and policies for healthcare security professionals. Hence, this study places an overarching focus on trauma-informed security as an effective and safe solution to reducing violence against nurses. Research Questions The primary research question is, “How might trauma-informed security reduce violence against nurses? To better understand the research problem and question, the following subquestions will be addressed: “What factors contribute to violence against nurses in healthcare settings, and how do they impact the perception of workplace safety amongst nurses? and “What are the guiding principles and practices of trauma-informed security, and how can they mitigate violence against nurses?” Scope of the Study The scope of this study is limited to analyzing and collecting secondary data due to timeframe constraints. This study’s scope will focus on the threats of violence against nurses, their implications on hospital security and safety, and principles and practices of traumainformed healthcare security. Excluded from the scope of this study is the examination of current violence prevention strategies and discussion on trauma-informed practices and principles in other disciplines outside of healthcare security. TRAUMA-INFORMED SECURITY IN VIOLENCE MITIGATION 7 Philosophical Worldview A pragmatic worldview was selected for this research study. Through a pragmatic worldview, the focus of this study was on exploring and examining how trauma-informed security practices and policies can be effective solutions to reducing violence against nurses. Pragmatists are focused on finding the best solutions to problems that are not limited to one approach or solution (Creswell & Creswell, 2018). Therefore, a pragmatic worldview was most suitable for this study as pragmatism aims to better understand the research problem being explored (Creswell & Creswell, 2018). Design and Methodology Research Design A mixed-methods research design was used in this study. This research design allowed for quantitative and qualitative data to be analyzed to provide a more informed and comprehensive analysis and understanding of the information and research question (Creswell & Creswell, 2018). This, in turn, provided data validation, explanation, and support where quantitative and qualitative data was cross-referenced and integrated to provide a more in-depth understanding of the literature and mitigate the limitations of a single-method research design (Creswell & Creswell, 2018). The selected research technique for this study was a critical appraisal. A critical appraisal of existing literature on trauma-informed security in healthcare and violence against nurses assisted in answering the research question of how trauma-informed security can reduce violence against nurses. TRAUMA-INFORMED SECURITY IN VIOLENCE MITIGATION Search Methodology The search methodology for this study focused on searching for secondary data from an array of credible and reliable sources. Various search strategies, including the use of key search terms and inclusion and exclusion criteria, were used in this study to limit search results and provide the most valuable articles to answer the research question. This study’s search methodology used the Justice Institute of British Columbia library database (EBSCOhost) and Google Scholar as the primary search engines. Multiple search terms were used in the initial search, which resulted in several hits returned (See Table 1). Table 1 Results from the initial search. Search Database Search Terms # of Hits Returned JIBC Library (EBSCOhost) Workplace Violence AND JIBC Library: 6, 709 Google Scholar JIBC Library (EBSCOhost) Google Scholar JIBC Library (EBSCOhost) Healthcare Healthcare Security Officers AND Violence Trauma-Informed Security AND Hospitals Google Scholar: 236,000 JIBC Library: 208 Google Scholar: 117,000 JIBC Library: 94 8 TRAUMA-INFORMED SECURITY IN VIOLENCE MITIGATION Google Scholar JIBC Library (EBSCOhost) Google Scholar 9 Google Scholar: 17,000 Trauma-Informed Care AND Healthcare Violence JIBC Library: 1,102 Google Scholar: 35,300 Note. Table illustrating the search database used, search terms, and the number of hits returned from the initial literature search. Inclusion and Exclusion Criteria Inclusion and exclusion criteria were needed due to the extensive amount of hits returned from the initial search (See Table 2). This was to limit the number of hits returned and to ensure that only the most relevant and credible sources were selected for review. Inclusion criteria applied in the revised search included full-text, scholarly, English-written, peer-reviewed articles, reports, books, and journals from 2010 to 2023. The initial inclusion criteria were set only to yield Canadian-based literature; however, because of the lack of Canadian-based literature, available literature from outside Canada was included in this study. Future research would benefit from searching literature from and outside Canada from the start to understand the research problem and question better and allow for a more in-depth analysis. Exclusion criteria included sources that were not full-text, scholarly, English-written, peer-reviewed articles, reports, books, and journals from 2010 to 2023. Applying inclusion and exclusion criteria in this study was critical to ensure that the most relevant, credible, and peer-reviewed sources were selected to limit credibility concerns. TRAUMA-INFORMED SECURITY IN VIOLENCE MITIGATION 10 However, it is critical to note that it was impossible to apply all inclusion and exclusion criteria to the Google Scholar database. This meant that search results from Google Scholar could not be limited to full-text, scholarly, English-written, peer-reviewed sources. The only inclusion criteria that could be applied to the Google Scholar database were the key search terms and selected date range from 2010 to 2023. This explained why Google Scholar yielded significantly more search results than the JIBC library database (EBSCOhost), even though the same search terms were applied. Regardless, Google Scholar was still a valuable database for the literature search in this study as it yielded the most results and selected articles that were used in this study. Additionally, two grey literature sources were used in this study. The first source was the Canadian Federation of Nurses Union website, and the second was the Creswell text. These were considered grey literature as they were not from the JIBC library database or Google Scholar; therefore, inclusion and exclusion criteria were not applied. Despite this, these two sources were valuable in analyzing the scope of the research problem and providing information on the design of this research study. Table 2 Results from revised search. Revised search and number of hits with inclusion and exclusion criteria. TRAUMA-INFORMED SECURITY IN VIOLENCE MITIGATION Search Database Search Terms 11 # of Hits Returned (Inclusion/Exclusion Criteria) JIBC Library (EBSCOhost) Google Scholar JIBC Library (EBSCOhost) Google Scholar JIBC Library (EBSCOhost) Google Scholar JIBC Library (EBSCOhost) Google Scholar Workplace Violence AND Healthcare Healthcare Security Officers AND Violence Trauma-Informed Security AND Hospitals Trauma-Informed Care AND Healthcare Violence JIBC Library: 2, 218 Google Scholar: 22,900 JIBC Library: 26 Google Scholar: 17,600 JIBC Library: 6 Google Scholar: 15,800 JIBC Library: 131 Google Scholar: 17,600 Note. Table illustrating the search databased used, search terms, and number of hits returned with inclusion and exclusion criteria applied to the search. Article Selection A thorough evaluative approach was utilized to evaluate the returned literature from the refined literature search. The title of the sources was first examined for their relevance to the TRAUMA-INFORMED SECURITY IN VIOLENCE MITIGATION 12 scope of the research study and research questions. This involved analyzing the title for direct reference and usage of the key search terms. It should be noted that only the first search page was reviewed for search results that yielded a significant number of hits due to time restrictions for this study. Future research would benefit from having more time to explore the search results beyond the first search page to provide a more comprehensive review of the literature. A total of 20 articles were selected for an abstract review based on their initial relevance to the research question and scope. Next, the keywords and abstracts of these sources were evaluated. This required a review of the research problem, purpose and scope of the study, and the study’s main findings to determine if the sources were credible and relevant to answering the research question and sub-questions of this study (Creswell & Creswell, 2018). From the abstract review, 15 articles were selected for final review and analysis. The selected articles were then analyzed in their full to verify their relevance and ability to assist in answering the research question. This final review process involved an extensive and thorough evaluation of the introduction, methodology, results, recommendations, and conclusions of the selected articles (Creswell & Creswell, 2018). Ultimately, all 15 articles were selected to be used in the research study, as they contributed or filled the gap in the literature by identifying critical themes that were directly related to the research question and scope of the study. Literature Review This research study is focused on 15 articles that were selected based on their relevancy to the research question. TRAUMA-INFORMED SECURITY IN VIOLENCE MITIGATION 13 Description of Selected Articles Havaei et al. (2020) conducted a cross-sectional descriptive, correlational research study to identify the different forms of workplace violence and the characteristics that influence workplace violence against nurses in British Columbia (BC). The researcher’s data was collected from 4462 nurses in BC through the administration of an electronic survey. The results indicated that emotional abuse, assault, and threats of physical harm were the most experienced forms of workplace violence amongst BC nurses and that the reported rates of workplace violence determined in this study were substantially higher than the discovered rates of other studies (Havaei et al., 2020). This is suggested to be because of increased reporting of workplace violence and increased awareness and proactiveness in recent years on preventing workplace violence against nurses (Havaei et al., 2020). One limitation of this study includes the relatively small sample size, which, as noted by Havaei et al. (2020), raises concerns about sampling bias. Despite this, this article provided critical information that aids in understanding the research problem and its current state of concern in healthcare safety and security. Havaei (2020) cross-sectional correlational survey design research study sought to examine the implications of workplace violence on the mental health of nurses. The researcher collected data from 5512 nurses from various health authorities across BC. Results from the survey indicated a correlation between workplace violence and negative mental health outcomes among nurses (Havaei, 2020). Importantly, the research findings suggested the need for nurses to be included in developing hospital security practices and policies targeting workplace violence prevention (Havaei, 2020). Shortcomings of this study include the small sample size, lack of representation of the most severe cases of workplace violence, lack of consideration of other factors that may influence the mental health of nurses, and the lack of cause-and-effect outcomes TRAUMA-INFORMED SECURITY IN VIOLENCE MITIGATION 14 because of the cross-sectional design of the research study (Havaei, 2020). Though the study has limitations, it effectively highlights the negative impact of workplace violence on the well-being of nurses and, importantly, notes the need for greater inclusion and collaboration with nurses in developing hospital security practices and policies (Havaei, 2020). Bautista et al. (2021) conducted a policy development research project to establish hospital security policies and practices based on trauma-informed approaches and principles. Through a collaborative effort, the researchers worked alongside healthcare security managers, hospital directors, and trauma-informed professionals to review and evaluate current hospital security policies and practices. Research findings indicated an absence of trauma-informed principles and approaches incorporated in hospital security policies and frontline practices used by security officers (Bautista et al., 2021). This study’s primary limitation was the exclusion of the experiences and perspectives of frontline security officers and their involvement in policy development (Bautista et al., 2021). Nonetheless, this article by Bautista et al. (2021) provided critical information on hospital security policies and practices and bridges a gap in the literature by identifying the absence and need for trauma-informed practices to be incorporated into hospital security. In their qualitative research study, Gillespie et al. (2010) sought to determine how frontline emergency department (ED) staff perceived the ability of security officers to deal with violent and aggressive situations. The researchers interviewed a sample of 31 ED workers from a hospital in the United States on their views on security officers and their ability to manage and de-escalate violent situations. Results from the research study indicated mixed views regarding the need for security officers during violent events. While most respondents favoured security involvement during violent events, others noted significant concern about the ability of security TRAUMA-INFORMED SECURITY IN VIOLENCE MITIGATION 15 to de-escalate situations rather than escalate them (Gillespie et al., 2010). Shortcomings of this study include the absence of security officers from the sample group and, as Gillespie et al. (2010) noted, their experiences in both responding to and experiencing violent and aggressive events. Notwithstanding, this article is relevant to answering the research question, as it provided insightful information on the views of clinical staff regarding the effectiveness of security officers in managing and mitigating workplace violence. Through a quantitative post-test research study, Asgraova and Sullivan (2012) sought to evaluate workplace violence practices and policies at St. Paul’s Hospital in Vancouver, BC, to provide critical recommendations on improving workplace violence prevention strategies. The researchers surveyed a sample of nurses, security officers, and social workers on their experiences managing violent and aggressive events. The results reported levels of physical and emotional strain amongst respondents associated with experiencing violence and aggression and lost sense of control in situations where de-escalation techniques were ineffective and force or control methods had to be utilized (Asgraova & Sullivan, 2012). Concerningly, the research findings indicated challenges in the relationship between nurses and security in managing violent events that have questioned the ability of security to effectively handle violent and aggressive situations (Asgraova & Sullivan, 2012). Weaknesses in this study include the small sample size and the self-administered survey design, which raise concerns about sampling bias and clarity regarding the survey questions (Asgraova & Sullivan, 2012). However, this study is highly relevant to the research question as it examined the effects of workplace violence on healthcare professionals and reinforced the need for a more informed and trauma-sensitive approach to deescalating violent and aggressive events effectively. TRAUMA-INFORMED SECURITY IN VIOLENCE MITIGATION 16 Brophy et al. (2017) analyzed the perceptions and experiences of workplace violence among healthcare workers in Ontario, Canada. Through an interview of 54 healthcare workers, the researchers determined clinical, environmental, organizational, social, and economic risk factors that perpetuate workplace violence in healthcare. It was well described by the research participants that organizational and social risk factors, such as the absence of effective and trained security personnel, poor communication between clinical staff and security, and the lack of patient-centred and trauma-centred practices and policies, are to blame for the increased rates of workplace violence in healthcare (Brophy et al., 2017). A limitation of this study, as Brophy et al. (2017) noted, is the lack of consideration and examination of whether racial factors and racial discrimination influence acts of violence against healthcare workers. However, this study is practical to the research study as it highlights the gaps in current healthcare security practices and policies and backs the need for an improved and effective violence prevention strategy and model to be implemented. Beattie et al. (2018) conducted an explanatory study investigating the causes of workplace violence against nurses and the effects of workplace violence on the quality of patient care and the concept of safety in healthcare. The researchers gathered data through semistructured individual and group interviews with hospital directors, managers, and occupational health and safety members from hospitals in Australia. Research findings indicated that the comorbidity of psychiatric history, drug and substance usage, and traumatization triggers violent and aggressive behaviour (Beattie et al., 2018). This, in turn, as the researchers report, initiates fight or flight responses, which can be further escalated by triggers associated with the healthcare environment, such as unfamiliarity and the presence of authority (Beattie et al., 2018). Recommendations to mitigate violent and aggressive behavioural responses include using TRAUMA-INFORMED SECURITY IN VIOLENCE MITIGATION 17 trauma-informed approaches to identify and understand potential triggers to effectively mitigate the risk of violence and aggression (Beattie et al., 2018). A limitation of this study, however, is that the study is based on managerial perspectives rather than the perspectives of frontline healthcare workers that directly experience and manage violent and aggressive events, such as nurses and security officers (Beattie et al., 2018). Even so, this article supported the need for trauma-informed practices to be incorporated into violence prevention strategies in healthcare. In their research study, Butler et al. (2011) critically appraised trauma-informed care and how trauma-informed approaches provided a non-traumatizing approach to managing violent and aggressive situations. Findings from this study defined trauma-informed care as a patient-centred approach focused on understanding and appreciating the patient’s needs, experiences, and symptoms (Butler et al., 2011). Along with this, the researchers recognized how the healthcare setting and current violence prevention strategies, such as using seclusion rooms and restraints, can be traumatizing and triggering for patients, thus, causing violent or aggressive behaviour (Butler et al., 2011). This study directly connects workplace violence to underlying sources of trauma and mental illness, champions the need for sensitive and trauma-informed approaches, and discusses its applicability in hospital security policies and practices, which aligns with the overall purpose and scope of this study (Butler et al., 2011). Raja et al. (2015) study examined the application of trauma-informed care in healthcare. The researchers critically appraised the integration of trauma-informed principles into interactions with patients. Findings from the study supported the need for healthcare practitioners to understand the implications of trauma on behaviour and how a patient-centred approach to trauma is needed to increase patient cooperation and behavioural management of emotions triggered by seeking medical treatment (Raja et al., 2015). This study further advocated the TRAUMA-INFORMED SECURITY IN VIOLENCE MITIGATION 18 potential of trauma-informed security practices and policies to reduce workplace violence through a patient-centred approach focused on trust, communication, understanding, and problem-solving (Raja et al., 2015). Chaudhri et al. (2018) studied the implementation of trauma-informed care principles and practices to enhance the quality of patient care and experience. The study critically appraised existing literature on the principles of trauma-informed care and how they can be integrated into healthcare practices to understand the effects of trauma, recognize signs of trauma, respond effectively to trauma, and prevent re-traumatization (Chaudhri et al., 2018). It was suggested by the researchers that trauma-informed care, and security strengthens the patient-provider relationship (Chaudhri et al., 2018). This evidence solidifies the value of trauma-informed practice in enhancing patient care quality and experience, which can be presumed to reduce aversive emotions associated with poor patient care quality that can perpetuate violence and aggression toward nurses as a result (Chaudhri et al., 2018). Hales et al. (2017) examined the impact of trauma-informed practices on the workplace satisfaction of nurses. The researchers analyzed satisfaction surveys taken before and after implementing trauma-informed care practices and policies at a hospital in the United States. It was discovered that trauma-informed care practices and policies limited the usage of seclusion rooms and restraints and reduced the negative effects of using them on the physical and mental health of patients and nurses (Hales et al., 2017). Through their study, the researchers found critical evidence that implementing trauma-informed care practices and policies strengthens staff satisfaction and autonomy, which can be significantly threatened by the workplace violence nurses face (Hales et al., 2017). Though the article provides breakthrough evidence of the correlation between trauma-informed care and staff satisfaction, a primary limitation of the study TRAUMA-INFORMED SECURITY IN VIOLENCE MITIGATION 19 is that secondary data and not primary data were collected and analyzed (Hales et al., 2017). Yet, the study still provided critical information on how trauma-informed practices can mitigate the use of restrictive security measures while improving workplace satisfaction among nurses. Borckardt et al. (2011) randomized controlled study probed how trauma-informed practices in a psychiatric hospital in South Carolina reduced the rate of restrictive measures (seclusion and restraints) to deal with and manage aggressive and violent behaviour. Research findings determined that the implementation of trauma-informed interventions such as training, a therapeutic environment, trauma-informed policy and practice development, and increased patient involvement in treatment planning were impactful interventions in reducing the rates of restrictive responses to acts of violence and aggression (Borckardt et al., 2011). The generalizability of the findings from this study, however, is limited as the findings from this study were obtained from only a single hospital and population sample (Borckardt et al., 2011). Despite this limitation, this study advocates the potential of trauma-informed practices as a more effective, therapeutic, and less restrictive response to acts of violence and aggression (Borckardt et al., 2011). In their study, Galbert et al. (2023) investigated the attitudes and perceptions of nurses on the use of restrictive security measures such as restraints and seclusion rooms as a response to violent and aggressive behaviour through a cross-sectional research design. To evaluate the attitudes and perceptions of nurses, 149 staff members at a mental health facility were surveyed on their perceptions and attitudes toward using restrictive security measures (Galbert et al., 2023). The results indicated a low support rate for using restrictive security measures to respond to acts of violence and aggression (Galbert et al., 2023). It was also determined that the respondents reported a lack of training in alternative and non-restrictive interventions for violent TRAUMA-INFORMED SECURITY IN VIOLENCE MITIGATION 20 and aggressive behaviour (Galbert et al., 2023). A limitation of this study is the limited generalizability of the findings, as data was only collected from one sample group at one hospital (Galbert et al., 2023). Even so, the findings from this study bear the fact that using restrictive and coercive security interventions to violence and aggression is an unfavourable response among nurses, further alluding to the need and value of trauma-informed security practices and policies (Galbert et al., 2023). Groves et al. (2023) conducted a theory synthesis study to analyze how a patient’s sense of security in a hospital can be increased to reduce harmful acts to patients and nurses. This study examined symptoms of mistrust, vulnerability, fear, and anxiety that decrease a patient’s sense of security during hospitalization (Groves et al., 2023). The authors note that a decreased sense of security can trigger increased vigilance, agitation, and frustration (Groves et al., 2023). However, a limitation of this study is the minimal examination of the influence of systemic bias and marginalization on the sense of safety among patients and how culturally sensitive steps can be taken to increase the patient’s sense of safety (Groves et al., 2023). Nonetheless, this study champions the need for trauma-informed approaches focused on recognizing and understanding trauma, building trust and rapport, working together with the patient, and, importantly, preventing re-traumatization by increasing the sense of security and safety among patients (Groves et al., 2023). Markham (2022) appraised the shift in focus from procedural security to relational and therapeutic security in healthcare. The researcher noted that relational security prioritizes safe and positive interactions between clinical staff, healthcare security officers, and patients. Relational security approaches aggression and violence using interpersonal and therapeutic skills and recovery-oriented interventions instead of oppressive measures (Markham, 2022). Key TRAUMA-INFORMED SECURITY IN VIOLENCE MITIGATION 21 findings from this critical appraisal of existing literature on relational security emphasized the ability of relational security to facilitate discussion and communication between clinical staff, security, and patients where concerns can be addressed and understanding can be built (Markham, 2022). It was reported in this study that the incorporation of trauma-informed and relational security practices reduced rates of violence and aggression against nurses and invoked “…higher levels of motivation, treatment, engagement, and therapeutic alliance” (Markham, 2022, p. 3). The findings from this study champion the potential and positive impacts traumainformed practices and policies have on reducing workplace violence. Critical Analysis Challenges in Identifying Workplace Violence as a Symptom of the Problem A common theme in the literature reviewed suggested a need to better define and characterize workplace violence to fully grasp the scope of the problem (Asgraova & Sullivan, 2012; Havaei et al., 2020). Much of the available literature on workplace violence in healthcare has been limited to understanding and categorizing workplace violence based on two respective broad categories: physical and emotional violence (Havaei et al., 2020). However, this broad definition of workplace violence, as suggested respectively by both Asgraova and Sullivan (2012) and Havaei et al. (2020) in their studies, raises challenges in correctly identifying and reporting acts of violence and aggression. To bridge this limitation, the researchers broke down the definition of workplace violence to include physical assaults, threats, intimidation, harassment, sexual assault, and verbal abuse as acts of workplace violence (Havaei et al., 2020). In doing so, Havaei et al. (2020) discovered rates of reported workplace violence against nurses two to ten times more than the reported rates TRAUMA-INFORMED SECURITY IN VIOLENCE MITIGATION 22 of other research studies. This suggested that the broad definition of workplace violence used in other studies may cause challenges in accurately reporting acts of workplace violence, undermining the actual prevalence and scope of the problem. This, in turn, can cause the problem of workplace violence against nurses to persist and jeopardize their sense of safety and security while at work, which directly answers the sub-question of what factors threaten the safety and security of nurses. These pieces of literature provided critical evidence on the state of workplace violence that clarified the definition of workplace violence and provided contextual information on the scope of the research problem. Causes and Triggers of Workplace Violence Against Nurses Another emerging theme from the literature focused on determining the causes and triggers of violence against nurses (Beattie et al., 2018; Butler et al., 2011). This was primarily focused on understanding the triggers of violence and aggression that lead to workplace violence through the porges’ polyvagal theory (Beattie et al., 2018). The theory proposes that when our sense of safety is compromised or threatened, it triggers our fight-or-flight responses (Beattie et al., 2018). It is theorized that fight or flight responses are caused by aversive traumatic experiences and underlying mental health conditions that lead to violent and aggressive behaviours (Beattie et al., 2018). Thus, this theory attributes workplace violence to psychosocial and physiological factors (Beattie et al., 2018). Adding to this literature, Butler et al. (2011) noted that the healthcare environment can trigger behavioural outbursts. The researchers reported that factors associated with hospitalization, such as involuntary admission and medications, seclusion rooms, restraints, presence of authority, and restrictions, can cause aggressive and behavioural responses to such TRAUMA-INFORMED SECURITY IN VIOLENCE MITIGATION 23 conditions. These findings support the findings by Beattie et al. (2018) and Groves et al. (2023) that workplace violence is a symptom of underlying trauma and illnesses that are aggravated in the healthcare environment (Butler et al., 2011). Further, all three studies recognized the need for and importance of trauma-informed care and security as an approach to reducing potential triggers for violence and aggression and instead mitigating such risk through increasing the sense of safety and security among patients (Beattie et al., 2018; Butler et al., 2011; Grove et al., 2023). Although all three studies provide information relevant to the research question, the studies fail to consider the organizational and managerial causes of workplace violence. Havaei et al. (2020) note that organizational characteristics such as unprecedented emergency department wait times, staffing shortages, increased work demand, and, importantly, resource scarcity are influencing factors in the rise of aggressive and violent events in healthcare. Though organizational improvements to reduce workplace violence are beyond the scope of this research study, the issues mentioned by Havaei et al. (2020) are still relevant to the scope of this research study, as effective strategies are inevitably needed for de-escalating situations caused by the described organizational challenges. Challenges in Interprofessional Collaboration Between Nurses and Security Officers Challenges and barriers to effective interprofessional collaboration between nurses and security were a reoccurring theme reflected in the literature (Asgarova & Sullivan, 2012; Brophy et al., 2017; Gillespie et al., 2012). Although a majority of studies emphasized the essential role security officers hold in responding to violent and aggressive events through de-escalation, restraint application, and the use of force when necessary, the studies reported differences in TRAUMA-INFORMED SECURITY IN VIOLENCE MITIGATION 24 approaches and expectations between nurses and security in managing violent situations (Asgarova & Sullivan, 2012; Gillespie et al., 2012). Gillespie et al. (2012) noted trust and confidence challenges between nurses and security, particularly during violent and aggressive events. Here, the researchers identified a debate in the literature split between involving and not involving security in violent and aggressive situations. Reasons in favour of involving security included providing a presence of safety and security to de-escalate situations, while reasons against involving security were based on a significant concern that security was ill-equip and did not have the knowledge to manage and de-escalate violent situations (Asgarova & Sullivan, 2012; Gillespie et al., 2012). In a similar study at St. Paul’s Hospital in Vancouver, BC, Asgarova and Sullivan (2012) noted challenges to collaboration efforts between nurses and security. The results from this study reflected the findings found in Gillespie et al. (2012) study that indicated miscommunication and misunderstanding of the roles and responsibilities of security in violent circumstances often resulted in tension between nursing staff and security, thus, potentially jeopardizing patient and staff safety (Asgarova & Sullivan, 2012). Another common theme identified in the literature was the lack of awareness and ability to respond to violent and aggressive events through deescalation strategies by security rather than resorting to the use of force prematurely (Asgarova & Sullivan, 2012; Gillespie et al., 2012). This was reflected in the perceptions of nursing staff, that reported that “…staff did not call security unless they perceived a personal threat to themselves for fear security would make the situation worse” (Asgarova & Sullivan, 2012, p. 36). These findings are evidence of the need for improved training for security officers and improved working relationships between nursing staff and security that prioritizes a focus on deescalation to reduce workplace violence (Asgarova & Sullivan, 2012). TRAUMA-INFORMED SECURITY IN VIOLENCE MITIGATION 25 While these works of literature are critical in recognizing and understanding the challenges and concerns in the interprofessional relationship between nursing staff and security, it is exclusive to the experiences and opinions of nursing staff. Although nursing staff are the primary caregivers and take the lead during violent situations, security officers also play a critical role, as noted in the literature (Asgarova & Sullivan, 2012; Gillespie et al., 2012). Future research would benefit from examining the perspectives of security and their perceived effectiveness during violent situations while investigating their views on their collaboration efforts with the nursing staff (Bautista et al., 2021). This, in turn, would allow for an examination of both primary stakeholders’ opinions and perspectives to better recognize and respond to challenges in interprofessional efforts related to the safe management and de-escalation of violent situations. Nonetheless, these findings provided essential information in answering the research question by identifying a critical gap in current healthcare security practices and policies that hinder the relationship between security and nurses, which, in turn, hinders violence mitigation efforts and the perception of safety amongst nurses. The Need for Improved and Trauma-Informed Practices and Policies The most common theme identified in the literature advocated for better violence prevention and mitigation strategies to reduce workplace violence against nurses (Asgarova & Sullivan, 2012; Beattie et al., 2018; Butler et al., 2011; Gillespie et al., 2010; Havaei et al., 2020). Beattie et al. (2018) recognized the need for and importance of trauma-informed care in reducing violence against nurses. Several findings from other studies further backed this claim by indicating that oppressive interventions to aggression and violence, such as the use of restraints and seclusion rooms, are ineffective responses to mitigating workplace violence in healthcare (Borckardt et al., 2011; Hales et al., 2017; Markham, 2022). It was also noted in the TRAUMA-INFORMED SECURITY IN VIOLENCE MITIGATION 26 literature that the usage of oppressive intervention strategies imposes negative physical and emotional implications on nurses, security officers, and patients and is perceived to be an unfavourable intervention to violence and aggression (Galbert et al., 2023; Hales et al., 2017). These common findings in the literature reviewed directly advocate the need for a traumainformed security model. Through a trauma-informed care and security approach, careful consideration is taken to understand an individual and identify potential triggers for violent and aggressive behaviour (Beattie et al., 2018; Chaudhri et al., 2018; Raja et al., 2018). Focus is placed on communication and understanding to regulate and control behavioural responses to possibly unfavourable and traumatizing situations that aim to strengthen a sense of safety rather than threaten it (Beattie et al., 2018; Chaudhri et al., 2018; Raja et al., 2018). This directly correlates to the research findings of Hales et al. (2017) and Chaudhri et al. (2018), who not only suggested that traumainformed care and security can improve patient care quality and experience but also improve the workplace satisfaction of nurses through effective violence prevention. Similarly, Butler et al. (2011) found similar support for trauma-informed care as an important and effective workplace violence reduction strategy. It is noted in the literature that the quality of patient care, patient safety, and workplace safety is negatively impacted when a lack of effort and awareness is taken “…to understand fully the presenting issues and their context” (Butler et al., 2011, p. 180). Likewise, Markham (2022) found that trauma-informed and relational security effectively reduces violence and aggression against nurses through therapeutic intervention and effective interpersonal skills. Both studies described the importance of a traumainformed security model and how it can reduce violence against nurses through four essential principles: (1) enhancing the concept of safety, (2) building and maintaining trusting and TRAUMA-INFORMED SECURITY IN VIOLENCE MITIGATION 27 understanding relationships, (3) restoring a sense of empowerment, resiliency, and choice, and (4) prioritizing collaboration to achieve mutual goals safely and effectively (Butler et al., 2011; Markham, 2022). Discussion It was well established in the literature that there is an urgent need to improve workplace safety for nurses. Importantly, the literature described significant gaps in current hospital security practices and policies, citing poor interprofessional relationships between healthcare security officers and clinical staff and an absence of trauma-informed security practices used by security officers to de-escalate violent situations safely (Asgarova & Sullivan, 2012; Bautista et al., 2021). Given these gaps in current hospital security practices and policies, a shift of focus towards trauma-informed security practices and policies is best supported by the literature reviewed as an effective, safe, and sensitive approach to reducing violence against nurses. That being said, trauma-informed security is defined as an approach to violence and aggression focused on understanding and responding to the underlying symptoms of trauma that lead to acts of violence and aggression (Butler et al., 2011). Trauma-informed security is grounded on the principles of safety, trust, empowerment, and collaboration (Butler et al., 2011). Enhancing the Concept of Safety A trauma-informed security approach to mitigating violence against nurses recognizes the connection between the concept of safety and behavioural reactions (Beattie et al., 2018). It is well established in the literature that oppressive interventions to violence and aggression negatively influence behaviour and can severely diminish one’s perception of safety (Beattie et al., 2018; Groves et al., 2023). Given that hospitalization already has the potential to trigger TRAUMA-INFORMED SECURITY IN VIOLENCE MITIGATION 28 emotions of unfamiliarity, fear, and anxiety, reliance on oppressive intervention efforts to deescalate situations may only exacerbate it (Beattie et al., 2018; Butler et al., 2011; Markham, 2022). A specific focus on less oppressive de-escalation and violence prevention efforts should be the utmost priority of healthcare security organizations. Through trauma-informed security, enhancing the concept of safety is achieved through a less threatening and confrontational approach to workplace violence that recognizes the existence of trauma and its impact on behaviour, which can be worsened by hospitalization (Beattie et al., 2018; Butler et al., 2011; Markham, 2022). Understanding the concept of safety and its impact on behaviour when the perception of safety is threatened is a critical recognition that needs to be implemented into hospital security practices and policies. This includes implementing hospital security practices and policies that respect patient privacy, provide safe and comfortable spaces for patients to have a cool-down period, and de-escalation strategies that are focused on rapport and trust building as opposed to disciplinary and restrictive measures (Butler et al., 2011; Markham, 2022). By understanding the impacts of trauma and recognizing the sensitive needs that arise as a result, the appropriate shift in approach can be made to restore a mutual sense of physical and emotional safety between the patient, nursing staff, and security which reduces the potential for workplace violence and further traumatization (Butler et al., 2011; Markham, 2022). Building Trusting and Understanding Relationships Relationships of trust and understanding are paramount to trauma-informed practice (Beattie et al., 2018). For some, the healthcare environment and personnel symbolize systems and bodies of mistrust and misunderstanding (Beattie et al., 2018; Groves et al., 2023). This can TRAUMA-INFORMED SECURITY IN VIOLENCE MITIGATION 29 trigger behavioural and emotional responses unique to the individual’s experience with trauma, which increases the risk of workplace violence (Beattie et al., 2018; Groves et al., 2023). For this reason, it is dire for hospital security officers to build relationships of trust and understanding with individuals who may feel hopeless, neglected, and misunderstood (Beattie et al., 2018; Butler et al., 2011; Markham, 2022). As Beattie et al. (2018) state, trauma-informed security “…seeks to identify ‘what has happened to [the individual]’ rather than ‘what is wrong with [the individual]’” (p. 119). In other words, trauma-informed security offers a change in approach to addressing acts of violence and aggression where enforcement is no longer the primary approach and instead, an emphatic and understanding approach is taken to de-escalate the situation safely (Beattie et al., 2018; Butler et al., 2011). It should be noted that the intention of trauma-informed security is to reduce the use of enforcement and forceful tactics to gain compliance and cooperation in violent situations (Beattie et al., 2018; Butler et al., 2011). That being said, enforcement and forceful tactics may be necessary for life-or-death situations or when all deescalation strategies have been exhausted; however, less oppressive intervention and effective de-escalation are the utmost priority of trauma-informed security. A trauma-informed security approach to workplace violence recognizes the importance of relationship and trust-building to effectively de-escalating situations (Beattie et al., 2018). Markham (2022) emphasizes that “establishing trusting relationships with patients can act as a less restrictive means of managing behaviour” (p. 10). Healthcare security officers can build trusting and understanding relationships by recognizing the individual needs of the patient, communicating clearly, clarifying ambiguities, and, importantly, respecting the emotional boundaries of the individual or patient (Beattie et al., 2018; Butler et al., 2011). With a focus on trauma-informed security, healthcare security officers be better equipped to de-escalate situations TRAUMA-INFORMED SECURITY IN VIOLENCE MITIGATION 30 through non-enforcement strategies and de-escalation techniques that restore a sense of safety, care, and hope rather than dimmish those perceptions (Beattie et al., 2018; Butler et al., 2011; Markham, 2022). Restoring a Sense of Empowerment, Resiliency, and Choice Trauma-informed security recognizes the subjective context of trauma and how individualized approaches are needed to respond to the effects of trauma effectively and safely (Butler et al., 2011; Chaudhri et al., 2018; Raja et al., 2015). The effects of trauma can diminish one’s sense of efficacy, dignity, and personal control of their life which can be further exacerbated in a healthcare environment where individual choice may be limited given the circumstances surrounding the individual (Beattie et al., 2018; Butler et al., 2011; Markham, 2022). Trauma-informed security emphasizes restoring an individual’s feeling of choice where possible (Beattie et al., 2018; Butler et al., 2011). Providing opportunities for individuals to restore their sense of control over their lives, emotions of hopelessness, fear, and frustration can be minimized as one’s sense of dignity is re-established (Beattie et al., 2018; Butler et al., 2011). It is recommended that healthcare security practices and policies aim to empower the resilience and dignity of individuals by providing the opportunity for choice wherever possible and recognizing the potential of individuals to effectively regulate their emotions (Beattie et al., 2018; Butler et al., 2011; Markham, 2022). Doing so serves as an effective preventive and deescalation strategy for workplace violence which is imperative to addressing the surging rate of workplace violence perpetuated against nurses (Beattie et al., 2018; Butler et al., 2011; Markham, 2022). TRAUMA-INFORMED SECURITY IN VIOLENCE MITIGATION 31 Improving Collaboration Between Nurses and Security The challenges in the interprofessional relationship between security and nurses during violent and aggressive events were well reported in this study. Several studies highlighted the cynical opinion among nurses of the ability of security to be effective in de-escalating situations and preventing further violence and traumatization (Asgraova & Sullivan, 2012; Gillespie et al., 2010). It was further suggested that nurses and healthcare security collaborate to develop a standard of practice grounded on trauma-informed care and security (Asgraova & Sullivan, 2012; Markham, 2022). A developed standard of practice for managing violent and aggressive events would provide consistency in approaches to responding to violence and aggression, clarify roles and responsibilities, support communication between nurses and security, and provide guidance on the use of trauma-informed practice to reduce risk and reliance on oppressive responses (Markham, 2022). Establishing a trauma-informed standard of care and security would fill the gap in the interprofessional relationship between nurses and security. Through the collaboration principle of trauma-informed care and security, nurses and security work together to effectively manage and prevent violent and aggressive acts from occurring and have confidence in each other’s abilities to do so (Asgraova & Sullivan, 2012; Markham, 2022). This collaborative partnership would also allow for nurses and security to train together in responding to violence and aggression through a trauma-informed approach that would also mitigate any ambiguities and barriers between the two professions during such situations (Asgraova & Sullivan, 2012; Hales et al., 2017; Markham, 2022). Hales et al. (2017) noted that improving and supporting collaboration efforts and communication between nurses and security can increase the perception of safety and workplace satisfaction amongst nurses, “which is plausible considering trauma-informed TRAUMA-INFORMED SECURITY IN VIOLENCE MITIGATION 32 approaches prioritize the experiences of [nurses] by ensuring their physical and emotional safety” (p. 307). Limitations and Ethical Considerations Limitations and potential ethical issues did exist for this study. This study was limited to collecting and analyzing only secondary data due to time constraints, which limited the ability to gather and analyze primary data through collection techniques that could have directly answered the research question. The study was also limited in that it did not evaluate the effectiveness of current violence prevention strategies and models, nor did it compare current violence prevention strategies to trauma-informed security practices. Lastly, the study was limited to discussing and analyzing trauma-informed security practices within the discipline of healthcare and healthcare security and not trauma-informed practices in other disciplines and whether there is a difference in the effectiveness of trauma-informed practice to reduce workplace violence among different disciplines. Potential ethical issues for this study included biases, the appropriate citation of the sources, and the potential for further concern regarding workplace safety in healthcare settings among nurses (Creswell & Creswell, 2018). The potential for biases in this study was mitigated by focusing on and including objective information and excluding subjective facts and opinions (Creswell & Creswell, 2018). The appropriate citation of the sources used in this study was based on the American Psychological Association (APA) citation guidelines to ensure full credit was given to the original authors of the sources (Creswell & Creswell, 2018). TRAUMA-INFORMED SECURITY IN VIOLENCE MITIGATION 33 Recommendations Improving the safety of healthcare facilities is a top priority and concern for healthcare security organizations and health authorities. The rise in violence against nurses demands immediate and effective action to mitigate workplace violence. Through the findings and suggestions examined in this study, healthcare security organizations are in a unique position to shift towards a trauma-informed security model that is better suited to deal with complex challenges and situations healthcare security officers deal with daily. It is recommended that healthcare security organizations adopt trauma-informed security practices and policies that focus on the core principles of safety, choice, empowerment, trustworthiness, and collaboration, as a constructive approach to preventing workplace violence against nurses (Butler et al., 2011). Further, it is highly recommended that healthcare security organizations prioritize traumainformed training for all frontline healthcare security officers so that officers can skillfully intervene and de-escalate violent and aggressive situations (Asgraova & Sullivan, 2012; Beattie et al., 2018; Gillespie et al., 2010; Markham, 2022). Furthermore, recommendations are made to bridge the gap in the literature further. First, future research would benefit from examining the experiences and perspectives of frontline healthcare security officers on workplace violence to provide a more rounded understanding of the problem (Bautista et al., 2021). Secondly, given the lack of Canadian-based literature on the impact of trauma-informed security and workplace violence prevention in healthcare, future Canadian-based studies would be beneficial, considering that workplace violence against nurses is a significant issue among nurses in Canadian healthcare facilities (Canadian Federation of Nurses, 2022). Lastly, more research into how trauma-informed security practices and policies can be translated into helping healthcare security officers and nurses cope and manage the effects TRAUMA-INFORMED SECURITY IN VIOLENCE MITIGATION 34 of workplace violence they experience would be highly beneficial to promoting the health and resiliency of nurses and healthcare security officers. Conclusion This research study has the potential to bring significant improvements to healthcare security and safety. Through a critical appraisal of the literature, factors influencing the rise of violence against nurses included challenges identifying and reporting workplace violence, factors associated with trauma and hospitalization that trigger aggressive and violent responses, and obstacles to effective and safe workplace violent mitigation due to interprofessional challenges between security officers and nurses (Asgraova and Sullivan, 2012; Beattie et al., 2018; Havaei et al., 2020). The most consistent solution to reducing violence against nurses across the literature advocated the need to incorporate the four principles of trauma-informed security (safety, trust, empowerment, and collaboration) into hospital security practices and policies as the foundation for workplace violence intervention and prevention (Butler et al., 2011). A significant gap in the literature still exists in examining the perceptions and attitudes of healthcare security officers on how they believe trauma-informed security can reduce workplace violence against nurses (Bautista et al., 2021). Further research should aim to analyze these perceptions and attitudes among healthcare security officers to better examine how traumainformed security can be a valuable practice and policy for healthcare security. Additionally, further research would benefit from directly comparing current violence prevention strategies to trauma-informed security practices to further determine how trauma-informed security is a much safer and more effective approach to addressing the rising problem of workplace violence against nurses. Ultimately, workplace violence against nurses is a critical issue that places a TRAUMA-INFORMED SECURITY IN VIOLENCE MITIGATION responsibility on healthcare security organizations to take immediate and effective action to protect and improve the safety and security of nurses working tirelessly across the globe to provide quality patient care. 35 TRAUMA-INFORMED SECURITY IN VIOLENCE MITIGATION 36 References Asgarova, S., & Sullivan, R. (2012). Evaluation of the code white program to reduce workplace violence at St. Paul’s hospital. School of Social Work, University of British Columbia. https://www.jibc.ca/sites/default/files/research/pdf/Code-White_Report.pdf Bautista, A. V., Obsenschain, K. C., Potterton, J. T., & Murray, A. L. (2021). Trauma-informed hospital security: A policy for intimate partner violence in a pediatric healthcare setting. Journal of Hospital Management and Health Policy, 5(39), 1-10. http://dx.doi.org/10.21037/jhmhp-20-15 Beattie, J., Griffiths, D., Innes, K., & Morphet, J. (2018). Workplace violence perpetrated by clients of health care: A need for safety and trauma-informed care. Journal of Clinical Nursing, 28(1-2), 116-124. https://doi.org/10.1111/jocn.14683 Borckardt, J. J., Madan, A., Grubaugh, A. L., Danielson, C. K., Pelic, C. G., Hardesty, S. j., Hanson, R., Herbert, J., Cooney, H., Benson, A., & Frueh, C. (2011). Systematic investigation of initiatives to reduce seclusion and restraint in a state psychiatric hospital. Psychiatric Services, 62(5), 477-483. https://doi.org /10.1176/ps.62.5.pss6205_0477 Brophy, J. T., Keith, M. M., & Hurley, M. (2017). Assaulted and unheard: Violence against healthcare staff. NEW SOULTIONS: A Journal of Environmental and Occupational Health Policy, 0(0), 1-26. https://doi.org /10.1177/1048291117732301 Butler, L. D., Critelli, F. M., & Rinfrette, E. S. (2011). Trauma-informed care and mental health. Directions in Psychiatry, 31(3), 197-210. https://www.researchgate.net/profile/LisaButler-5/publication/234155324_Trauma- TRAUMA-INFORMED SECURITY IN VIOLENCE MITIGATION 37 Informed_Care_and_Mental_Health/links/02bfe50f9b4cbb8051000000/TraumaInformed-Care-and-Mental-Health.pdf Canadian Federation of Nurses Union. (2022). Canadian Federation of Nurses Union Member Survey Summary Report. https://nursesunions.ca/wpcontent/uploads/2022/02/Viewpoints_Survey_Results_2022_January_EN_FINAL-1.pdf Chaudhri, S., Zweig, K. C., Hebbar, P., Angell, S., & Vasan, A. (2019). Trauma-informed care: A strategy to improve primary healthcare engagement for persons with criminal justice system involvement. Journal of General Internal Medicine, 34, 1048-1052. https://doi.org/10.1007/s11606-018-4783-1 Creswell, J. W. & Creswell, J.D. (2018). Research design: Qualitative, Quantitative and mixed methods approaches (5th ed.) Thousand Oaks, CA: Sage Galbert, I., Azab, A. N., Kaplan, Z., & Nusbaum, L. (2023). Staff attitudes and perceptions towards the use of coercive measures in psychiatric patients. International Journal of Mental Health Nursing, 32, 106-116. https://doi.org/10.1111/inm.13064 Gillespie, G. L., Gates, D. M., Miller, M., & Howard, P. K. (2012). Emergency department workers’ perceptions of security officers effectiveness during violent events. Work, 42(1), 21-27. http://dx.doi.org/10.3233/WOR-2012-1327 Groves, P. S., Bunch, J. L., & Kuehnle, F. (2023). Increasing a patient’s sense of security in the hospital: A theory of trust and nursing action. Nursing Inquiry, 1-11. https://doi.org/10.1111/nin.12569 TRAUMA-INFORMED SECURITY IN VIOLENCE MITIGATION 38 Hales, T. W., Nochajski, T. H., Green, S. A., Hitzel, H. K., & Woike-Ganga, E. (2017). An association between implementing trauma-informed care and staff satisfaction. Advances in Social Work, 18(1), 300-312. https://doi.org/10.18060/21299 Havaei, F. (2020). Does the type of exposure to workplace violence matter to nurses’ mental health? Healthcare, 9(41), 1-11. https://doi.org/10.3390/healthcare9010041 Havaei, F., MacPhee, M., & Ma, A. (2020). Workplace violence among British Columbia nurses across different roles and contexts. Healthcare, 8(1), 1-14. https://doi.org/10.3390/healthcare8020098 Markham, S. (2022). See think act: The need to rethink and refocus relational security. The Journal of Forensic Psychiatry & Psychology, 33(2), 1-31. https://doi.org/10.1080/14789949.2022.2044068 Raja, S., Hasnain, M., Hoersch, M., Gove-Yin, S., & Rajagopalan, C. (2015). Fam Community Health, 38(3), 216-226. https://doi.org/10.1097/FCH.0000000000000071