Second-Level Nurses’ Experiences of Workplace Violence: A Scoping Review

the specifc experiences of second-level nurses. Conclusion . Te review contributes to new knowledge highlighting the second-level nurses’ workplace violence experiences worldwide. Te review indicated that there are gaps identifed and there is a need for greater understandings of workplace violence in second-level nurses to understand the scope of their problem and the nature of their experiences. Implications for Nursing Management . Nurse managers play a critical role to develop and implement efective policies and evidence-based interventions to improve the working conditions of the second-level nurses. Te results of this current review can be used to guide nurse managers and organisations in providing adequate support to reduce and prevent WPV and advocate for a positive workplace culture.


Background
Workplace violence (WPV) and harassment are defned as "a range of unacceptable behaviours and practices or threats thereof, whether a single occurrence or repeated, that aim at, result in, or are likely to result in physical, sexual, or economic harm and include gender-based violence and harassment" [1].WPV is not a new phenomenon.Accordingly, violence against the workforce is a serious problem in healthcare organisations, reportedly afecting up to 95% of healthcare professionals internationally [2].
WPV is a multifactorial and complex problem.It poses a signifcant threat to the health, safety, and wellbeing of healthcare professionals [3], having been linked with depression [4], anxiety symptoms [5], sleep problems [6], burnout, and mental fatigue [7], which is indicated to have negative consequences for the healthcare workers' productivity [8], retention [9], and the quality of care they provide to their patients [10].In 2014, estimated costs of WPV perpetrated by hospital patients or patient visitors in the US were $94,156 annually ($78,924 for treatment and $15,232 for indemnity) for a total of 106 (2.1%) of 5,016 hospital system nurses who reported WPV injuries [11].Te estimate does not capture the hidden costs of WPV-related incidents, including emotional pain, depression, isolation, and anxiety [12].
WPV in the healthcare industry is recognised as a signifcant workplace health and safety concern, with the nursing workforce identifed as the profession at most signifcant risk of being assaulted [13].It remains a persistent source of distress among nurses, irrespective of the contexts and settings in which they work [14].Furthermore, WPV is not limited to hospital settings but extends to all healthcare work environments and geographical locations, including rural, remote, metropolitan, international, community, mental health, and aged care, where nurses have more signifcant contact with patients and members of the community [15,16].
It is asserted that WPV against healthcare professionals remains an underreported and pervasive problem that has been tolerated and largely ignored [3].Subsequently, it also highlights challenges for researchers and highlights the pressing need for further research evidence to uncover universally applicable risk reduction methods [3].Te nursing profession is experiencing substantial nursing shortages due to economic pressures and the impact of an ageing population across the world, a crisis recognised before the COVID-19 pandemic [17].Consequently, this has prompted to a progression of healthcare workforce skill mix and adaptation to new roles to respond to changing needs [18].In many countries, there are two levels of nurse: the Registered Nurse (RN), or First-Level Nurse (FLN) and Second-Level Nurse (SLN).In Australia, RNs are educated in a three-year Bachelor of Nursing program, while SLNs are educated in the Vocational Education and Training (VET) sector in a two-year Diploma of Nursing pathway [19], and they have diferent education levels elsewhere.Across countries where these roles exist, second-level nursing roles and titles vary widely, including Nursing Associate (NA) in the United Kingdom (UK), Licensed Practical Nurse (LPN) and Licensed Vocational Nurse (LVN) in the USA, Registered Practical Nurse (RPN) and Licensed Practical Nurse (LPN) in Canada, and Enrolled Nurse (EN) in Australia, New Zealand (NZ) [20], Singapore [21], and Hong Kong [22].SLNs' roles and scope of practice difer among countries.In most cases, they work in various healthcare settings under the supervision of RNs, conducting patient observation, providing basic care, attending to patients' activities of daily living, such as hygiene care, and assisting support during rehabilitation [23].
A hierarchical healthcare workforce structure exists between frst level and second-level nurses, which potentially marginalises SLNs.Tey are situated low in the healthcare hierarchy while also at the coalface of patient interaction.RNs are perceived to provide critical thinking compared to SLNs' task-orientated, hands-on patient care [24].Furthermore, RNs are given higher ranking status, and contrastingly, SLNs are perceived as subordinated taskdoers, underpaid, undervalued, and low status [23].Roberts [25] identifed that nurses exhibit oppressed group behaviours (OGB).Te word "oppression" in nursing is characterised as powerlessness and submissiveness [26].Te model of OGB theory in nursing may help explain oppressed nurses' display of submissive behaviours in response to the domineering and powerful groups of physicians and hospital administrations [27].Roberts [25] explained that oppressed groups of nurses manifest collective lack of self-esteem.Furthermore, they develop submissive-aggressive behaviour syndrome.Subsequently, when nurses are not able to control self-hatred, low self-esteem, and dislike for other nursing staf, eventually these kinds of behaviours present negative consequences including horizontal violence and lateral violence [25].
Given the difcult circumstances around SLNs in the nursing workforce and limited research on SLNs in Australia [28][29][30], the UK [23], Canada [31], and Singapore [32], we sought to understand their experiences of WPV.To date, there has been a growing body of literature focusing on RNs' WPV experiences, yet that of SLNs has not been well explored.Hence, this scoping review sought to map and synthesise available international evidence on SLNs' unique experiences of WPV.
1.1.Scoping Review Objective.To synthesise and map available international evidence and what is currently known about SLNs' specifc WPV experiences.

Methods
A scoping review is defned as a "form of knowledge synthesis that addresses exploratory research aimed at mapping key concepts, types of evidence, and gaps in research related to a defned area or feld by systematically searching, selecting, and synthesising existing knowledge" [33].A scoping review is useful for examining emerging evidence, identifying knowledge gaps, and providing a rigorous and transparent method for identifying and mapping available evidence [34].Te current scoping review was conducted based on the methodological framework by Arksey and O'Malley [34] and included the fve stages of identifying the research question: identifying the research question, identifying the relevant studies, study selection, charting the data, and collating, summarising, and reporting the results [34].Levac et al. [35] further clarifed and enhanced Arksey and O'Malley's [34] framework and proposed recommendations for each stage of the scoping study framework, emphasising considerations for advancement, application, and relevance in maximising the usefulness and rigour of scoping study fndings within healthcare research and practice.

Relevant Studies.
A preliminary search of the literature was undertaken to identify relevant studies in investigating SLNs and WPV internationally (Table 1).To achieve rigour, several consultations from the research librarian were undertaken.Using the search terms, "Second Level Nurs * ,"

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Journal of Nursing Management "Enrolled Nurs * ," "Endorsed Enrolled Nurs * ," "Licensed Practical Nurs * ," "Licensed Vocational Nurs * "; (b) workplace violen * , "horizontal violen * ," "lateral violen * ," "vertical violen * ," "upwards violen," "nurse-to-nurse" confict', "mobbing," "incivility" and "nurses eating their young," six electronic databases were searched: ABI/INFORM Collection, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Directory of Open Access Journals (DOAJ), EBSCOhost Human Resources Abstracts, Medline ProQuest, and ProQuest Central.Keywords and subject headings were modifed to suit the requirements of the databases.Keywords using the truncation symbol ( * ) to broaden search terms within title and abstract felds were used in an initial search.In addition, Boolean operators or connecting words "OR" and "AND" were used to limit, broaden, or defne searches within and between categories.

Study Selection.
Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [36], inclusion criteria included primary research comprising qualitative, quantitative, and mixed methods studies, with full-text availability.Studies published between 1 January 2000 and 3 March 2022 in English language were included.Tis time frame was chosen based on when the need to advance EN education in Australia was recognised [37] up until the search date.Furthermore, in the UK, it was in 2002 when the Nursing and Midwifery Council (NMC) was established to ensure safe practices and professional standards were achieved [38].In addition, studies included participants working as SLNs who had experienced WPV within public hospitals, private hospitals, aged care, primary/community, and other healthcare settings.Te exclusion criteria included reviews of research, discussion papers, editorials, conference abstracts, and book reviews.Furthermore, studies with no data on SLNs, no available full text, or incorrect study design were excluded from the review.
A total of 1145 studies were identifed from an initial database search, and titles and abstracts were imported into EndNote then uploaded to Covidence [39] for screening.In addition, eight studies were added after hand-search in Google Scholar.A total of 134 duplicates were removed.In total, 1011 titles and abstracts were initially screened independently by three authors based on inclusion and exclusion criteria.
A total of 963 studies were excluded at this stage.Of the remaining 48 studies subjected to full-text review, 30 were excluded as no specifc data could be extracted on SLNs, they were wrong publication type, full text was not available, or the study design was incorrect.After rigorous examination, 18 studies were included in the fnal critical appraisal and data extraction review.A small number of conficts arising were resolved during team discussion (Figure 1).

Data Charting.
Quality appraisal was undertaken using the Joanna Briggs Institute (JBI) [40] critical appraisal tools.While not always included in scoping reviews, critical appraisal was conducted on all studies to assess overall quality [41].Criteria in judging the quality of the studies are described by evidence that is trustworthy, applicable to practical settings, consistent, and unbiased, irrespective of whether a qualitative or a quantitative method is employed [42].While some studies had low scores, the authors' intention was not to remove studies but to assess the overall quality of the existing knowledge base.Hence, no studies were removed based on quality appraisal.Te following data were extracted from the included studies based on JBI guidelines for scoping reviews [43].Data were extracted from the studies: author, year, country, aims, study design, data collection, data analysis, participants, research location, key fndings, results, and study limitations.

Search (S)
Search terms

Description of the Studies.
Numbers of participants identifed as SLNs in studies ranged signifcantly from two to 4076.Regarding research location, three studies were undertaken across multiple healthcare facilities and clinical areas; four in nursing homes and residential care facilities; multiple studies were drawn from state or national databases; and one from a college department.Four included studies were published within the last fve years (2018 to 2022), while the remaining 14 were published before 2017.Tree of the 18 studies focused explicitly on SLNs' experiences [50,52,53], while in the remaining 15, participants were a mix of RNs and SLNs [45-47, 49, 51, 54-62] or part of a diverse range of healthcare disciplines [48].
Five studies analysed written narratives of SLNs' lived experiences [46,48,49,55,56].Although the studies integrating qualitative data were pivotal to signifcant contributions by providing rich, thick, and nuanced data, issues were encountered, including dependability and confrmability.Tere were also challenges in unpacking and extracting specifc data for SLNs.For example, in the two Canadian studies, one focused on participants' ethnicities  for male staf were 254.4 for SLNs.Across all fscal years combined, standardised incidence rates for reported assaults among females were 2.3 times higher for SLNs For males, corresponding rates for SLNs were 1.5 times higher 10 Journal of Nursing Management and racial backgrounds but did not explicitly specify the number of SLNs [46], while the other did not mention the risks of WPV in a specifc healthcare profession [48].
Likewise, in research adopting quantitative methods, selfadministered surveys, issues of reliability and potential biases, and descriptions of participants' work locations were sometimes not disclosed.3).Two studies mentioned the types of physical violence injuries frequently reported as bruises, contusions, temporary discolouration, lacerations, and punctures [54,57].Te remaining studies reported physical violence according to broad defnitions of physical violence, without specifc details.Two studies confrmed that SLNs working in nursing homes or residential settings reportedly experienced physical violence greater than those working in other healthcare settings [45,47].For example, SLNs and other nursing staf (RNs, Nurses' Aides) working in Swedish nursing homes revealed signifcantly higher reported WPV incidents (P ≤ 0.01) compared to those working in other healthcare settings [45].Similarly, in Canada, SLNs and Health Care Assistants, working in dementia units reportedly experienced considerable aggressive acts compared with those working in Alzheimer's units (mean � 2.4 vs. mean � 0.9, p < 0.001) [47].Most physical violence incidents reported clients/patients [54,57,60] or co-workers [60] as perpetrators.
Tree studies discussed SLNs' bullying experiences in the workplace [50,51,53], with varying experiences.Participants self-identifed as being bullied, and the frequency of bullying behaviours reportedly ranged from at least one to 20 bullying behaviours and reported bullying acts ranged from never, now and then, monthly, weekly to daily [51] Te moral component of authentic leadership (AL) was a major determinant of overall workplace bullying (β � −0.59, p < 0.001), person-related bullying (β � −0.70, P < 0.001), and physical intimidation (β � −0.58, p < 0.001) [53].Unmanageable workloads, being ordered to work below the level of confdence, withholding information, having opinions and views ignored, and having responsibilities removed were cited as the most frequently reported negative acts of bullying [51,53].In contrast, the most reported perpetrators were peers, followed by supervisors [53].
A study from Swiss nursing homes was conducted examining the prevalence of workplace mobbing incidents, which was reported to be higher among SLNs and RNs compared to the unregulated healthcare workers (Nurse Aides) and other professionals (5%, 5.9%, and 2.6%, respectively) [61].Mobbing is defned as repeated, unwarranted behaviour aimed at an employee or group of employees evoking a threat to health and safety [65], occurring at least every week over six months or more [66].It is deliberate, systematic, and continuous harassment, similar to bullying, which involves physical violence or verbal harassment aimed at disturbing harm to the person being targeted [67].Mobbing is directly correlated to job satisfaction and intention to leave (p < 0.001) among hospital nurses (RNs, SLNS, Assistant Nurses, and Nurse Aides) [61].Overall, the prevalence of mobbing experiences for Swiss healthcare workers was relatively low [61].
Tree studies examined sexual harassment, two from Canada [46,47] and another from the USA [57], with SLNs reportedly experiencing this ranging from 7% to 22%.One study comprising a mixed nurses' population (FLNs and SLNs) did not explicitly specify the exact number of SLN participants; however, fndings revealed that fve ethnic minority nurses reported sexual harassment compared to one white Canadian nurse [46].Another study indicated that SLNs experienced higher incidence of forced sexual harassment compared to Health Care Assistants (22.2%, 5.5%, p � 0.046) [47].
Two Canadian studies examined racial discrimination by exploring FLNs and SLNs' experiences of work confict with patients and their family members, primarily focusing on ethnic minority nurses compared to white Canadian nurses [46], and another exploring cultural and racial diferences [48].Te visibly ethnic minority nurses, especially blacks, reported signifcant discrimination due to the colour of their skin, language barriers, accent, or perceived lack of competence [46].Two of seven qualitative narrative comments were discussed in that study, focusing on SLNs involving derogatory and disrespectful comments towards them.
One Australian study explored nurse-to-nurse or intraprofessional confict, and reportedly, many SLNs experienced bullying, stress, and harassment from RNs in the workplace [49], with common themes emerging as the scope of practice, teamwork, and team confict.SLNs reported that the terms "workloads" and "teamwork" were used interchangeably as perceived realities of unfair work distribution between SLNs and RNs, the "us and them" phenomenon.In the theme of the scope of practice,  (iv) Some RNs have lack of insight, the negative impact of their behaviour to their co-workers (i) Leaving the ward, manipulating the nursing staf roster to avoid working the same shifts with the other staf, or "shutting down to avoid further conficts" Filipova (2018) [    Journal of Nursing Management participants were critical of wage gaps between themselves and RNs.Te added responsibility of medication endorsement was initially perceived as a positive milestone for Endorsed SLNs, which would alleviate some traditional responsibilities and the SLNs' given extended responsibilities and scope of practice.Te SLN role traditionally focused on direct patient care activities and routine nursing tasks such as attending hygiene care and simple wound dressings [49].Furthermore, the study explored the sense of powerlessness of SLNs in maximising their skill sets around medication administration.SLNs identifed an inability to practise their skills depending on the ward and which RNs they worked with.Te researchers concluded that SLNs' scope of practice was heavily infuenced by whom they built alliances or partnerships, years of working experience, and sometimes understafng issues [49].

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Electronic (e-mail) abuse was also explored in one study, with 7.1% of SLNs reported being the least victims of e-mail abuse compared to other nursing professions [60].Electronic abuse is defned as "a statement of behaviour that is reasonable for a worker to interpret as a threat or abuse via email" [60].Examples include bullying, defaming, harassing, interrogating, accusing, and blaming [60].Signifcant relationships were found between electronic abuse and education (0.001) and electronic abuse and years of experience (<0.001) [60].In this study, nurses with diplomas were reported to be the least electronically abused compared to other nursing professionals who had achieved academic attainments (bachelor's or master's degrees and "other") [60].

Long-Term Impacts and Outcomes.
Long-term impacts and outcomes of WPV for SLNs, patients, and organisations can be classifed into attitudinal, behavioural, health, fnancial, and patient care impacts.
Tree studies also explored the fnancial impacts of WPV, including reduced productivity and lost employee work hours [54,62], increased turnover, decreased retention, and nursing shortage [54,56], salary replacement dollars for overtime and agency staf [62], counselling cost [54], potential organisational ramifcations from lawsuits, and negative publicity with potential negative impact on staf recruitment and retention [62].
Patient care impacts included that delivery of patient care could lead to increased documentation and medication errors, staf focus being shifted from work activities to discussion of incidents, and consequently, decreased attention to patient care needs [56,62] and failure to implement protection through adequate stafng, programs, engineering controls, and environmental design [48].

Actions and Coping Strategies.
A range of actions and coping strategies were identifed in the included studies, which participants ofered based on their own experiences (Table 3).Tey can be categorised according to primary, secondary, and tertiary prevention strategies [48].
Primary prevention strategies are aimed at preventing WPV from occurring.Multiple studies explored primary prevention strategies [46-49, 53, 55, 58, 59].Such strategies include enhanced hospital security [46,48], "switching" with other nurses who had better work relationships with patients or working in pairs for patients who had been fagged as uncivil [46], seeking advice from colleagues, family members or friends, or talking to patients' family members [46,49,55], adopting zero-tolerance policies, increasing stafng, and using personal alarms [48].Other primary prevention strategies included WPV training programs [48,58] and supportive organisational environments [53].
Secondary prevention or early prevention strategies are actions to prevent violence at early signs of violence.Several studies investigated secondary prevention, including encouraging and simplifying incident reporting processes and using the criminal justice system [48] and repressive or sanctioning interventions [47].
Tertiary prevention strategies are actions taken when violence is occurring or after it has occurred to prevent or reduce the potential for physical and psychological harm to parties involved and to inform subsequent primary and secondary prevention strategies.Tertiary prevention strategies were mentioned in multiple studies and included teamwork, open communication [53], and policy-based strategies and support [46,47].One study suggested adopting a "radical" mechanism of leaving the ward, manipulating nursing staf rosters, or "shutting down" to avoid further conficts [49].

Discussion
Te scoping review sought to explore WPV among SLNs.Tis was found to be present worldwide, and settings included hospitals, communities, nursing homes and residential settings, metropolitan and non-metropolitan areas, and diverse nursing specialty areas.To the authors' knowledge, the current review is the frst comprehensive review that has attempted to explore WPV specifc to this group.Eighteen studies were included, and more than half Journal of Nursing Management were conducted in North America, indicating that this has been a research focus in that country but not necessarily in others globally.Overall, included studies were dominated by research in high-income countries, including North America, the USA (38.8%) and Canada (27.7%).Conversely, there was much less in European countries, including Sweden, Norway, and Switzerland (5.55% respectively), followed by Australia (11.11%) and Africa (5.55%).Tere were no included studies from Asian, African, or South American countries.Hence, further research is needed from such countries.
Te scoping review highlights scant international evidence around SLNs' specifc WPV experiences.Across the studies reviewed, evidence of reported prevalence rates is unclear.Reporting prevalence rates experienced by SLNs revealed signifcant variations of WPV, physical violence (10.6% to 76%) and non-physical violence (12% to 87.9%).Due to diferences in study methods and populations studied, it is difcult to compare studies.
One possible explanation for the broad range of prevalence rates is the lack of consensus on defnitions of WPV.Despite eforts to document international data on WPV, studies have indicated a lack of consistency in defning WPV across countries, and appeals have been made to standardise defnitions [3,68,69].In the current review, most included studies used a broad defnition of violence.Considering that experiences of WPV are primarily distinctive, it is possible that researchers' goals in conducting studies is to capture the overall picture of all violent incidents, relying on an individual's interpretation of violence, thus using a broad defnition of violence [45].Furthermore, in the current review, the diference behind a wide range of prevalence rates was the defnition of bullying/mobbing: "never, now and then, monthly, weekly, or daily" [51] or "occurring at least every week, over six months, or more" [66].Terefore, more research is needed to understand better explanations of prevalence estimates and how to support this group of nursing professionals efectively.
Regardless of the limited comparability of research studies that have examined SLNs' WPV experiences, some fndings share similarities with prevalence rates with other categories of nurses.For example, there is a reported wide variation in prevalence rates of horizontal violence reportedly experienced by RN graduates (working in their frst year of practice) [70].Horizontal violence, also known as lateral violence, bullying, or incivility, comprises a group of negative and harmful behaviours among peers [71].RN graduates reportedly experienced a wide variation of horizontal violence at diferent times working in their frst year of practice in countries such as Iran (n � 278, 46%) [72], Canada (n � 242, 98%) [73], China (n � 357, 77%) [74], and South Korea (n � 312, 47%) [75].
Te fndings suggest that SLNs share commonalities with graduate RNs and nursing students experiencing this phenomenon.It is possible that SLNs, like graduate RNs and nursing students, are vulnerable and are at higher risk to WPV.Jafree [77] stipulates that nurses have greater chances of experiencing WPV and this may be due to low-ranked status, working long hours in the hospital, exposure to patients, less experience, and less likely to report WPV.Previous studies confrm that graduate RNs [73,75] and nursing students [76][77][78][79] are particularly vulnerable and prone to WPV.Graduate RNs are considered lower-ranked nursing category and prone to WPV exposure due to their relatively limited work experience, less confdence in their new role, and lack of awareness of the implicit rules of the work environment [69].Researchers have also suggested from a retrospective survey on an Italian experience that nursing students were exposed to WPV during their clinical placements due to their lack of experience, changes of wards, and new environment and patient interaction; thus, they were vulnerable to patient-to-nurse violence [76].Based on this current review, there is a need for more research exploring SLNs' specifc issues and reporting of prevalence experienced by SLNs which is currently insufcient on which to draw conclusions.
Te results of this current review presented limited published studies of SLNs and WPV, revealing small sample sizes of SLNs and unclear numbers of SLNs in many of the studies.Te key fndings from SLNs were often found to be mixed with those of FLNs; therefore, it was challenging to capture their specifc WPV experiences.Undoubtedly, this review underscores the existence of WPV.It is possible that SLNs experienced more physical violence and non-physical violence in their workplace.Healthcare professionals, specifcally nurses, are among the most exposed to WPV [81].Te nursing workforce comprises frontline workers, and patients spend more time with nurses than other healthcare professionals, thus increasing the potential for violence [82].Findings from a previous quantitative review revealed that most physical and non-physical violence is committed by patients and their families/friends, and non-physical violence is often committed by staf members such as other nurses [83].Based on this current scoping review, despite signifcant research on WPV in nursing, the research mainly focuses on FLNs or mixed nursing populations.SLNs are an essential nursing workforce in the healthcare industry; therefore, it is crucial to explore more about their unique WPV experiences.
Compared to other categories of nurses and healthcare workers included in studies, fve reported that SLNs were most likely to be physically assaulted [48,49,52,55,58].One study in the current review indicated that SLNs were more likely than RNs to experience physical violence [57].Incidents of physical violence against nurses are widespread in hospital environments [83] and reportedly exacerbated in 18 Journal of Nursing Management aged care facilities [84].Consistent with other research fndings, nurses were subjected to signifcant WPV and aggression.According to the World Health Organisation (WHO) [85], up to 38% of nurses worldwide experienced physical violence throughout their nursing careers.In a systematic review and meta-analysis conducted in the Southeast Asian and Western Pacifc Regions, nurses working in private and public hospital environments, specifcally those working in psychiatric and emergency departments, are reportedly exposed to higher levels of WPV [86].In a descriptive, quantitative study conducted in a teaching public hospital in Brazil, emergency nurses reportedly experienced verbal abuse (n � 21, 38%), mobbing (n � 14, 25.4%), and physical violence (n � 6, 11%) [87].A meta-analysis study conducted to assess the incidence of violence against Chinese nurses indicated that the 12-month incidence of WPV was 71% (95% CI: 67%-75%), and the incidence of verbal violence (63%) (95% CI: was the most common type of violence [88].
Based on the fndings of the current review, there are potential reasons why SLNs might encounter higher rates of physical violence than RNs.Butcher and MacKinnon [20] contend that contextual factors, such as the ambiguous scope of practice for SLNs and RNs in the workplace and the nursing profession's hierarchical relationships, played a critical role in fostering tension and SLN-to-RN confict.International studies have indicated an ambiguous scope of practice between SLN and RN roles [23,[89][90][91][92][93].Furthermore, SLNs are perceived to be of lesser status in the nursing hierarchy [23,[89][90][91]93], which tend to separate SLNs and RNs.Additionally, SLNs are perceived as undervalued, unless they transitioned to becoming RNs [30].Consequently, the lack of clear distinction of roles between SLNs and RNs, expanded scopes of practice, role confusion, perceived inequity in workload distribution, and lack of respect could potentially contribute to SLNs being exposed to intra-professional confict [49].Based on this discussion, there is insufcient research exploring SLNs' typically unique WPV experiences.Hence, further research is needed to understand the nuances of SLNs' specifc workplace issues and the short-and long-term efects of exposure to WPV, particularly in the healthcare settings where it is an important concern.
Te current review indicated that SLNs reportedly were more prone to experiencing WPV in various workplace settings, including emergency, medical, surgical, acute care, mental health, nursing homes, and residential care facilities.Te fndings are comparable to other studies highlighting locations where WPV towards nurses occurs.For example, in a cross-sectional study conducted in Italy, emergency nurses reportedly experienced widespread verbal abuse and physical assault [94].In a cross-sectional study conducted in psychiatric hospitals in China, nurses reportedly experienced a high prevalence of verbal and physical violence [95].In Australia, according to the New South Wales Nurses and Midwives Association Survey, it was found that more than 90% of 282 nurses working in aged care facilities had experienced at least one incident of WPV (physical and nonphysical) during the previous 12 months from residents, relatives, and visitors [96].In a systematic review and metaanalysis study, the global prevalence and predictors of WPV committed by patients or visitors towards healthcare workers are high, with disparities in geographical locations, workplace settings, work schedule, and occupations [64].Tis comprehensive study's key fndings reported that the prevalence of any type of WPV against healthcare workers is high, specifcally in psychiatric and emergency settings in Asia, North America, and Australasian countries.Among occupations, nurses (n � 138,857, 44.9%) reportedly experienced the highest of any type of WPV, physical and nonphysical violence, compared to doctors (n � 44,537, 40.1%) and other healthcare professionals (n � 18,824, 41%) [64].Based on these fndings, initiatives and efective approaches are needed to mitigate WPV incidents.
Te current review indicated that SLNs, like FLNs of ethnic minority backgrounds, reportedly experienced racial discrimination.Despite relatively small data and the challenges of extracting data for SLNs, this review fags that visible minorities experienced racial inequality where patient and patient family members reportedly prefer white nurses.Tis is indicative of a racial hierarchy where white nurses are perceived as competent and superior, and ethnic minority nurses as inferior [46].Similar fndings indicated that the experiences of racial discrimination were common among minority and ethnic nurses compared to white nurses.In a cross-sectional study conducted from a survey of 528 UK nurses, black, Asian, and minority ethnic (BAME) nurses reportedly experienced three times more discrimination than white nurses and midwives [97].Te study's key fnding indicated that bullying and discrimination were substantially associated with higher burnout and higher burnout was linked with poorer perceptions of patient safety on the individual and ward level [97].An anonymous online questionnaire survey conducted to explore the experiences of NZ RNs of Chinese ethnicity during the COVID-19 pandemic indicated that 47.06% of the 51 nurses reportedly experienced racial discrimination, workplace bullying, and judgement [98].A study from the National Commission to Address Racism in Nursing [99] demonstrated that racism in nursing was problematic, with approximately 56% of 5,623 nurses reporting that racism afected their wellbeing.Turman et al. [100] stipulate that contributing factors linked with nurses' deteriorating mental wellbeing include chronic staf shortages, increasing workload, poor renumeration, bullying, harassment, discrimination, and racism in the workplace.Based on the current review fndings, it is therefore crucial that nurse managers and organisations must invest in the SLNs' overall wellbeing by promoting an inclusive nursing culture and culture of change.Creating a culture that values inclusion requires a critical review of the culture of an organisation.Nurse managers need to practise efective leadership by ensuring inclusive cultures within organisations, manifested by no tolerance for negative or toxic cultural norms, such as bullying and WPV, which can profoundly impact workplace behaviour [101].An inclusive culture is also achieved when cultural diversity is valued and all staf experience a sense of inclusion, featuring equality and non-discrimination [102].

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Evidence from this current review indicated insufcient research on SLNs, particularly qualitative, the nature and impact on this group of nurses, and extensive understandings of SLNs.Te review also indicates patients and co-workers as perpetrators of WPV towards SLNs.However, it is challenging to ascertain if perpetrators are the same or diferent compared to the RN group.Tis scoping review suggests that SLNs' experiences are less understood than RNs, although evidence from one study [57] indicates that SLNs reportedly encounter more physical violence than RNs.Hence, there is insufcient knowledge to draw conclusions.Clearly, more empirical research is needed to provide sufcient information on the experiences of this group of nurses and their support needs.
Regarding educational preparation to combat WPV, two studies explored educational projects on antiviolence programs [51] and WPV safety training programs [58] in the US context.Te study by Ridenour et al. [58] reported that RNs (n = 203, 78.7%) received a higher proportion of any of the components of WPV training than SLNs (n = 97, 56.2%, p = 0.0022).Furthermore, the authors found that RNs who attended required training components reported feeling more secure at work, suggesting that training is a critical tool to address WPV [58].One way to mitigate the magnitude and prevalence of WPV is to include structured educational intervention programs, fostering efective communication skills and using de-escalation techniques in recognising potentially violent patients [103].For example, Ceravolo et al. [104] proposed a train-the-trainers approach program.Essentially, the aim was to train clinical champions in the workplace to promote expansion of specialist skills and knowledge in reducing WPV by reinforcing nurses' communication skills as an efective and cost-saving approach [104].Results of the study after employing train-the-trainer workshops series over three years indicated that nurses who reportedly experienced verbal abuse at work reduced from 90% (n = 634) to 76% (n = 370).In addition, the number of nurses who consider that verbal abuse would infuence their overall nursing care delivery reportedly increased from 42% (n = 276) to 63% (n = 204), indicating strengthened level of awareness [104].It is imperative that nurse managers and organisations need to prioritise WPV training programs for the nursing workforce, particularly SLNs, so they are well equipped with the knowledge and training they need as frontliners.
Lastly, regarding rates of WPV, the review suggests wide reports of prevalence across the studies, and thus the actual prevalence for this group remains unclear.Similar disparities were recently identifed in a systematic review of horizontal violence in novice nurses [105].Hence, understanding the full scope of WPV for diferent nursing groups is difcult.Te review fndings indicated SLNs were less likely to experience electronic abuse compared to FLNs.However, more research is needed to understand the unique WPV experiences of SLNs.

Limitations.
Several limitations need to be acknowledged in this current review.Concerning the included literature, the studies were written in English language.It is possible that there may be salient literature written in other languages that may provide more diverse perspectives on the topic.Another limitation is that SLNs are not of particular interest to FLNs.SLNs as a group are poorly researched in comparison to FLNs.Additionally, the included studies are peer-reviewed literature only; the authors did not consult the grey literature during the development of this review; hence, there is a possibility that relevant data might be overlooked that should have been included in the current review.Lastly, despite consultations from the research librarian and trying to capture all names that describe second-level nursing roles in the search strategy, there is a potential that there were missing second-level nursing titles and names that the authors did not identify.Terefore, it could be suggested that the current review is inaccurately delineated and does not accurately represent the SLNs' WPV experience.Regardless of these limitations, this study provided valuable information that can be used to develop further studies on the specifc WPV experiences of SLNs.

Conclusion
Tis review reports signifcant insights into the WPV phenomenon experienced by SLNs.As far as the authors are concerned, this is the frst review to integrate the published research studies on the SLNs' WPV experiences.Te current review provides a comprehensive overview that contributes to new knowledge highlighting the SLNs' WPV experiences worldwide.Tere are a growing number of studies which are being published and the common themes in the review experienced by SLNs include physical and non-physical violence.However, there is compelling evidence from this review that there are gaps identifed and there is a need for greater understandings of WPV in SLNs to understand the scope of their problem and the nature of their experiences.Considering that in the current review, only two studies focused on WPV education programs [51,58] illuminates the challenges for nurse managers in fostering an inclusive nursing culture.Tis can be demonstrated by creating a supportive environment and prioritising SLNs' wellbeing, empowering them through valuing ongoing professional development on WPV safety and training program, and improve nurse retention rate by cultivating a respectful, inclusive culture where open communication is encouraged, and recognising and appreciating the nurses' hard work and contributions promote a collaborative team and inclusive culture and establishing a zero-tolerance approach to WPV. working environment where nurses are valued, supported, and provided with utmost protection and security from physical and non-physical violence.Furthermore, this review elucidates the prevalent culture of racial discrimination and sexual harassment.It is crucial that nurse managers are role models where they are proactively committed in creating a diverse and inclusive nursing workforce by strengthening the organisational structure from the top levels of the nursing hierarchy down to the lower levels.Te results of this current review can be used to guide nurse managers and hospital organisations in providing adequate support to reduce and prevent WPV, specifcally for SLNs.

( i )
Scope of practice (ii) Teamwork (iii) Team confict (i) Continued disunity and confict among RNs and ENs "Healthy" coping mechanisms (ii) Territorial conficts afect staf and quality of patient care (i) Consulting colleagues, humour, and seeking advice from their managers (iii) Division of labour and responsibilities leads to miscommunication, bullying, and harassment Radical mechanisms (less satisfactory or long-term solutions): Felt comfortable reporting WPV incidents to supervisor, manager, or someone else (ii) Verbal abuse (iii) Electronic abuse Tong et al. (2017) [61] (i) Mobbing (i) Attitudinal: job satisfaction, intention to leave (i) Efective leadership (ii) Behavioural: absenteeism, presenteeism (ii) Stafng and resource adequacy (iii) Health issues: neck and back pains-fatigue, tiredness, lack of energy; problems with falling asleep or staying asleep; headaches, feelings of pressure in the head, or facial pains; aching limbs or joints (iii) Teamwork and safety climate Journal of Nursing Management

5. 1 .
Implications for the Nurse Manager.Tis review highlights issues of critical importance for nurse managers and organisations on the urgent need to develop and implement efective policies and interventions to improve the working conditions of the SLNs.SLNs are the neglected and understudied group within the nursing profession.Regarding WPV safety training, nurse managers must provide sufcient evidence-based safety training programs to combat WPV.Tis review also illuminates the need to create an inclusive nursing culture, a culture conducive to a positive 20 Journal of Nursing Management
30scriptive qualitative design using focus groups Data analysed using constant comparison method30RNs and SLNs (enrolled nurses (ENs)) in three Sydney metropolitan hospitals (medical/or surgical wards) in New Cross-sectional using online survey with validated tools Psychological capital questionnaire (PCQ) Negative acts questionnaire-revised (NAQ-R) 206 SLNs (practical licensed nurses (PLNs)) from the College of Practical Licensed Nurses of Alberta (CPLNA), Quasi-experimental pre-and post-survey using: Nurse workplace behaviour scale (NWS) and silencing the self-work scale (STTS-W) Focus group 135 critical access hospitals (CAHs, or hospitals with 25 or fewer inpatient beds) Pre-survey: 48 (35%) of 135 CAH nurses participated Post-survey: 35 (24%) of the 143 nurses participated were focus group participants for the pre-survey (n � 8) Educational preparation Pre-survey (n � 44); 9% SLNs (LPNs) Post-survey (n � 33); 3% SLNs, Focus group (n � 8), 24% SLNs Ericksen et al. (2006) Norway [52] To identify physical, psychological, social, and organisational work factors that predict level of psychological distress in nurses' aides Prospective cohort study using questionnaire based on validated tools Symptom checklist-25 (SCL-5) that measures psychological distress and general Nordic questionnaire for psychological and social factors at work (QPSNordic)-measure of working conditions, and measures of mastery and commitment 5076 members of Norwegian's union of health and social workers, the Union's, of whom 4076 were SLNs (nurses' aides (NAs)) who completed second questionnaire and answered at least three questions about psychological distress 15 months later