It Takes Two to Tango: Public Attitudes Toward Prevention of Workplace Violence Against Health Care Staff: A Mixed-Methods Study

Abstract

Workplace violence (WPV) directed toward health care staff by patients and their relatives has become one of the major problems faced by health care systems around the world. Incidences of WPV have increased over the past decade, crossing borders and cultures and creating a worrisome global phenomenon. To date, most of the research has examined health care workers’ perceptions of strategies that might prevent violence. Although the public, as prospective patients, has a central role in this state of affairs, little is known about public attitudes to prevention of violence in health care settings. In light of this, the current mixed-methods study aimed to explore public attitudes toward appropriate preventive and punitive measures that should be employed to diminish the occurrence of WPV incidents in health care settings. Five hundred sixty Jewish Israeli individuals participated in the study. Quantitative findings indicate the public’s overall agreement and positive attitudes toward preventive and punitive measures aimed at reducing WPV against health care staff. Qualitative findings revealed two main themes: “focusing on the staff” by improving their work conditions, training them to deal with violence, and providing a sense of security, as well as “focusing on the public” by teaching tolerance, raising awareness of zero tolerance to violence, and punitive measures. The Israeli public believes that to deal with the problem of violence in the health care system, it is necessary to act simultaneously on two levels: health staff and the health care system, and the general public. In view of these findings, we recommend that policy makers address this issue by adopting preventive measures, such as increasing the number of health care personnel, workshops for the staff on dealing with violence, campaigns against violence in health care settings, and enforcing appropriate punitive measures against attackers.

Keywords

workplace violence violence exposure bullying violent offenders

Background

Workplace violence (WPV) directed toward health staff by patients and their relatives has become one of the major problems faced by health care systems around the world. Incidents of WPV have increased over the past decade, crossing borders and cultures and creating a worrisome global phenomenon. Findings from the United States (The National Institute for Occupational Safety and Health, 2016; Occupational Safety and Health Administration, 2015b; Phillips, 2016), China (Lu et al., 2020; Wu et al., 2012), Iran (Najafi, Fallahi-Khoshknab, Ahmadi, Dalvandi, & Rahgozar, 2016), Europe, and South Africa (Gerberich et al., 2004) illustrate the scope of the phenomenon and, moreover, demonstrate its existence in all types of health care organizations: general hospitals, psychiatry, community, and nursing homes.

According to the World Health Organization (WHO; 2002), WPV is defined as “a behavior of an explicit or implicit challenge to the safety, well-being, or health of a person who is being abused, threatened, or attacked in their workplace. This includes verbal violence, assault, threat, physical violence, and sexual harassment” (p. 3).

It is estimated that between 8% and 38% of health care workers have experienced physical violence at some point in their careers. Many more are threatened or exposed to verbal aggression (WHO, 2017). In Israel, the Ministry of Health report on violence prevention (2017) indicates 3,500 reports a year, about 20% defined as physical violence and the rest as verbal violence. Only 11% of the cases are reported to the police, and even less are brought to court.

WPV in health care settings is a very destructive phenomenon, resulting in high costs to the organization and a negative impact on the physical and psychological status of the attacked, as well as decreased job motivation and productivity (Hahn et al., 2010; LanctÔt & Guay, 2014; Nau, Halfens, Needham, & Dassen, 2010; Zeng et al., 2013; Zerach & Shalev, 2015). Adverse psychological effects may include fear, anxiety, depression, and burnout (Chen, Lin, Ruan, Li, & Wu, 2016; LanctÔt & Guay, 2014; Zeng et al., 2013). Not only the organization and the worker are harmed by violence in the health care system. Findings suggest that violence toward a health care worker can also lead to a decrease in the quality of care provided to violent or violent suspects and in health outcomes (Hahn et al., 2010; LanctÔt & Guay, 2014; Phillips, 2016; Rosenthal, Byerly, Taylor, & Martinovich, 2018).

Several factors have been reported in the literature as contributing to increased incidents of WPV in the health care system, including staff behavior, patient behavior, workplace circumstances, and long waiting times (Bakker, 2012; Shafran-Tikva, Chinitz, Stern, & Feder-Bubis, 2017). In addition, studies also pointed out that patients’ and their relatives’ lack of understanding of the hospital system and negative staff–patient/relative interactions can also lead to aggressive incidents (Baby, Gale, & Swain, 2018; Shafran-Tikva et al., 2017). In this context, it is also important to note the growing impact of the media on the spreading of WPV against health workers. Media reports influence public attitudes and interests and vice versa (Hoyle, Kyle, & Mahoney, 2017; Van Bekkum & Hilton, 2013). A study conducted recently in Scotland, exploring newspaper coverage of WPV against nurses, found an overall negative tone and reductionist approach accompanying reports on violent incidents in health facilities. Moreover, newspaper articles appeared to normalize the occurrence of WPV and nurses’ sense of helplessness (Hoyle, Smith, Mahoney, & Kyle, 2018). These may, in time, increase the frequency and severity of WPV against health care staff.

Prevention of WPV in Health Care Systems

In recent years, various programs have been developed and implemented internationally and in various professional organizations aimed at preventing WPV in health care systems. Among them are the “zero tolerance to violence” policy in the United Kingdom (Department of Health, 1999), the Road Map for Healthcare Facilities developed in the United Sates by OSHA (Occupational Safety and Health Administration, 2015a), The Workplace Violence Toolkit by the Emergency Nurses Association (2010), and the American Nurses Association’s (ANA) Position Statement (2015). In Mainland China, several criminal laws were passed to protect health care workers from WPV. These laws expressly state that any disruption to health care services or harm to health care workers is prohibited. The punishment for violence is a prison sentence of 3 to 7 years. However, because of the lack of reporting and lack of enforcement, these laws have almost no effect (Hall, Xiong, Chang, Yin, & Sui, 2018).

In Israel, beginning from 1999 several plans of action were formulated by the Ministry of Health, based on the work of special committees established to reduce WPV and increase the sense of security among health care staff. These committees provided recommendations for eliminating and dealing with the phenomenon of violence in the health care system. Most of the actions taken by health care organizations and approved laws have not proved sufficiently effective (Israeli Ministry of Health, 2017).

To date, worldwide, no intervention programs, including government interventions, have been shown to significantly reduce violent events in health care settings. In an attempt to understand this phenomenon, numerous studies have been conducted among health care professionals. The vast majority of these studies examined the prevalence of the phenomenon and its implications for the quality of care and the well-being of the workers. Several studies have also examined health care workers’ views regarding preventive and punitive measures that should be employed to diminish the occurrence of WPV in health care settings. Brophy, Keith, and Hurley (2018) found three levels of prevention strategies described by Canadian health care workers: Primary prevention includes increased staffing, redesigning the work environment to eliminate danger zones, better communication and identification strategies, increased security, and establishing and enforcing “zero tolerance” policies. Secondary prevention includes simplifying incident reporting, Code White teams, alarms, and training. Tertiary prevention strategies include a wide range of postincident supports and legislated measures, such as changes to the Criminal Code, charging perpetrators of violence, and enacting protection of “whistle-blowers.” Similar to these findings, Zhao et al. (2015) investigated Chinese health care workers’ perceived coping strategies with WPV. Participants described three levels of useful strategies that might prevent WPV, on the individual level, organizational level, and social level. On each of these levels, the strategies described were consistent with those described later by Brophy et al. (2018). Similar findings were also found by Maguire, O’Neill, O’Meara, Browne, and Dealy (2018), who investigated Australian emergency medical services personnel who had been violently assaulted in the past. Although they experienced a violent incident in the past, and their work environment was different from that of health care workers practicing in hospitals, the preventive and punitive measures they suggested were similar to the findings described earlier. Participants indicated four main groups of factors: (a) human factors, such as better training strategies aimed at de-escalation techniques and better situational awareness; (b) equipment factors, including chemical and physical restraint equipment; (c) operational and environmental factors, such as advanced warning systems and law enforcement by security officers on the scene; and (d) social/agency environmental factors focusing on improved public awareness.

Violent incidents develop as a result of a combination of several factors that occur simultaneously, including patients’ and relatives’ behavior. The human factor plays a central role in this complex situation and has the potential to control it and lead the situation to effective results (Lau, Magarey, & Wiechula, 2012). Thus, to fully understand this phenomenon, we must relate to all the human factors involved in this situation, including the public. The public are prospective patients and relatives in health care settings, and as such, their perceptions regarding preventive and punitive measures against violence are an important component for dealing with this phenomenon. It seems that the understanding of violence prevention from the public viewpoint could be helpful in implementing effective preventive measures against WPV. Our literature review found only a few studies examining patients’ and their relatives’ view of WPV in health care (Babaei et al., 2018; Landau, Bendalak, Amitay, & Marcus, 2018; Yaşar, Durukan, & Büken, 2017). Their findings indicate differences between the perception of health care staff and that of patients and relatives regarding factors that contribute to WPV. Health care staff perceived patients and their relatives as the cause of violence, whereas patients and their relatives perceived environmental and social factors as responsible for the development of violent incidents. The studies did not indicate public perceptions regarding preventive or punitive measures against WPV. Therefore, this study aimed to explore public attitudes toward prevention of WPV against health care staff, including punitive measures that should be employed to reduce the occurrence of violent incidents in health care facilities.

Method

This study employed a mixed-methods research design aimed to increase the ability to validate and interpret people’s perceptions (Bryman, 2006). Discovering additional significance and further explanation of a phenomenon are made possible by the complementary mixed-methods design which combines quantitative and qualitative methods (Bryman, 2006), in this case, seeking to understand public perceptions regarding preventive and punitive measures that should be enforced to reduce the occurrence of WPV against health teams.

Procedure

Data were collected by 19 interviewers, registered nurses who were studying a research course as part of their master’s degree program in nursing at a central university in Israel. Interviewers participated in a weekly research seminar throughout one academic year. The course covered quantitative and qualitative research principles, including data gathering and analysis. Students were divided into three small work groups; each had a research seminar mentor from the research team. The research team trained and closely guided each work group through each step in the weekly meetings. Mentors were available to the students between meetings by email and telephone, to discuss and resolve any question that arose during the course. Each student recruited around 30 interviewees by means of the snowball sampling technique, including acquaintances and family members. Altogether, 570 questionnaires were distributed and 560 returned. The response rate was 98%.

Students differed in their gender, age, geographic area of residence, place of birth, years of experience, and work place. This sociodemographic diversity among the interviewers served to increase the sample’s diversity. In addition, mentors instructed students to try and include different social and family circles to increase and improve the sample’s diversity.

Each interviewee was interviewed based on a structured questionnaire written in Hebrew, consisting of three parts and including 28 multiple-choice questions.

Part 1: Sociodemographic data, including gender, age, religion, country of birth, marital status, level of education, and economic income (compared with the national average income)

Part 1 of the questionnaire also included two multiple-choice questions regarding the participant’s witnessing of verbal or physical violence against a member of a health care team. Participants could choose yes, no, or not to answer.

Part 2: Attitudes toward preventive measures of WPV against health care staff

This part was developed by the research team based on the findings by Zhao et al. (2015). The research team formulated 10 items and asked three health management and health systems experts to revise the questions for content validity and suitability for use in the Israeli culture. In addition, the 19 students who participated in this study as interviewers also revised the questions and were asked to give their suggestions and corrections. They were requested to indicate whether the questions represent the subject studied. The final version consisted of 10 items measuring respondents’ attitudes toward suggested strategies that might prevent WPV against health care staff. For example, “To what extent do you agree that a significant increase in the number of medical personnel might prevent WPV against health care staff?” Respondents were asked to rate their agreement/disagreement regarding each statement on a 4-point Likert-type scale ranging from 1 = “not at all” to 4 = “very much.” Scores ranged from 10 to 40. A higher score indicates a more positive view toward embracing the suggested preventive measures to prevent WPV against health care staff. Cronbach’s alpha was .78 (see the appendix).

Part 3: Attitudes toward recommended punitive measures against WPV

This part was developed by the research team based on the literature review (Brophy et al., 2018; Maguire et al., 2018) and in accordance with Israeli legislation and health care system. The research team formulated nine items and asked three health management and health systems experts to revise the questions for content validity and suitability for use in Israel. In addition, the 19 students who participated in this study as interviewers also revised the questions and were asked to give their suggestions and corrections. They were requested to indicate whether the questions represent the subject studied. The final version includes nine items describing various forms of punishment for dealing with WPV against health care staff. For example, “ To what extent do you agree with the removal of a person who has behaved violently against the health care staff from the facility for 6 months?” and “To what extent do you agree with a three-month prison sentence for a person who was verbally abusive toward the health care staff?” Respondents were asked to rate their agreement/disagreement regarding each statement on a 4-point Likert-type scale ranging from 1 = “not at all” to 4 = “very much.” Scores ranged from 9 to 36. A higher score indicates agreement with the suggested punitive measure against WPV in health care settings. Cronbach’s alpha was .80.

Two of the 19 students, who chose to gather qualitative data as well, asked 60 interviewees an open-ended question (each student asked 30 interviewees the open question) before referring to the multiple-choice questions. As recommended by Lincoln and Guba (1985), to ensure credibility, confirmability, and dependability of the study, the open question had an interview guide. The interview guide was based on the literature on prevention of WPV against health care staff and included topics that appeared in parentheses, the contents of which were not presented to the interviewees as they served as a reminder for the interviewers regarding why it is recommended to ask the interviewees more detailed or more specific questions. The open-ended question was, “How do you think violence against medical staff in hospitals and clinics can be prevented?” The topics in the parentheses included security, education, preparing staff to deal with the phenomenon, raising public awareness of the phenomenon, punishment, deterrence, media advertising, and others. Each interview lasted approximately 1 hr, and it took 3 months for the two interviewers to interview 30 respondents each. The interviews were conducted in Hebrew. Answers to the open-ended question were audio-recorded and later transcribed verbatim. To guarantee a consistent and reliable approach to interviewing, during weekly meetings one of the researchers and the students reviewed the interview transcripts together to provide the students with feedback.

Inclusion criteria were Jews over the age of 18, with no restriction of communication abilities and not a health care worker. Although a convenience sample was used, sample diversity was ensured by approaching participants from different Jewish religious subgroups, gender, age, and different geographical areas of the country.

Data Analysis

The quantitative data analysis was performed using SPSS (IBM^® SPSS^® English version 25.0) software (SPSS Inc., Chicago, IL, USA). Means and frequencies were used as descriptive statistics for sociodemographic characteristics and for the main research variables. Pearson’s correlation coefficients were calculated to measure the associations between being witness to verbal/physical violence, attitudes toward strategies that could prevent WPV against health care staff, and attitudes toward recommended punishment strategies for those who use violence against health care staff. An analysis of covariance (ANCOVA) test was performed to explore differences in attitudes toward preventive and punishment measures by sociodemographic variables and in witnessing verbal/physical violence. To control a possible bias regarding our “snowball” sample, we coded each of the 19 interviewers. This variable was inserted to the ANCOVA test as a covariate variable. The result revealed p> .05, suggesting there were no differences between the sub-sample of each student. Statistical significance was set at p < .05 for all analyses.

Constant comparative analysis was applied to the qualitative analysis of the open-ended question (Glaser & Strauss, 1967). The constant comparative analysis method is a process of Grounded theory, in which data are collected, repeated data are labeled, and comparable codes are categorized through constant comparisons. In the current study, we used the constant comparative analysis method for naturalistic inquiry by maintaining an emic perspective (participant’s view as insider), and conceptual frameworks maintained the etic perspective (outsider/distant concepts), as recommended by Fram (2013). The two interviewing students and one of the research authors read each interview, and recurring content was identified and divided into themes and subthemes. Validation of the findings was carried out using the peer debriefing procedure (Lincoln & Guba, 1985), by presenting the findings and the literature explaining the findings, to the students who participated in the seminar course, at two meetings. Each meeting lasted 90 min. The findings were presented and discussed until agreement regarding analysis and distribution of the themes and subthemes was reached.

Ethical Considerations

The study was approved by the Tel-Aviv University’s ethics committee (no. 02012018). Participants were given an explanation about the study before answering the questionnaire, and their informed consent was obtained. Given that interviewers were all registered nurses, mentors emphasized to the students during data collection that they should not, under any circumstances, refer to patients who are under their care. Such action would be contrary to the Ethics Committee’s approval and to the purpose of the research.

Findings

A total of 570 individuals participated in the study; 60 of them were also interviewed using an open-ended question. Most of the participants were young (37.6 ± 13.4 years), women (52.9%), Israeli born (71.6%), and in a relationship (71.6%). Their degree of religiosity represented various Jewish groups, with most of the sample reporting being secular (54.5%). The level of education and economic income varied, with the majority of the sample reporting an academic education (44.8%) and a below-average income (47.9%). Regarding witnessing a verbal/physical violence incident against health care staff, the majority of the sample (57.7%) reported being witness to verbal violence and not being witness to physical violence (80.7%). Table 1 presents the sociodemographics of the sample.

Table 1.

Sociodemographic Characteristics of the Sample (N = 560).

Variable	N (%)
Gender
Male	264 (47.1)
Female	296 (52.9)
Place of birth
Israel	401 (71.6)
Non-Israeli born	159 (28.4)
Marital status
In a relationship	401 (71.6)
No relationship	159 (28.4)
Religiosity
Secular	305 (54.5)
Traditional	186 (33.2)
Religious	69 (12.3)
Education
High school	195 (34.8)
Diploma	114 (20.4)
Academic degree	251(44.8)
Income
Below average	268 (47.9)
Average	153 (27.3)
Above average	130 (23.2)
Witnessed verbal violence
Yes	323 (57.7)
No	236 (41.1)
No answer	1 (0.2)
Witnessed physical violence
Yes	107 (19.1)
No	452 (80.7)
No answer	1 (0.2)
Age	M (SD)	Range	Median
	37.6 (13.4)	18-82	34.0

Attitudes Toward Strategies That Could Prevent WPV Against Health Care Staff

The mean score was 3.13 ± 0.53 (range = 1-4), indicating respondents’ agreement that embracing the suggested strategies, such as significantly increasing the number of medical personnel or stationing policemen on the wards/clinics, might prevent WPV.

Attitudes Toward Recommended Punitive Measures for Those Who Use Violence Against Health Care Staff

The mean score was 2.82 ± 0.69 (range = 1-4), indicating overall agreement with punitive measures, such as a 3-month prison sentence for a person who was verbally abusive toward the health care staff.

Associations Between Witnessing Verbal/Physical Violence and Attitudes Toward Preventive and Punitive Measures

To examine the associations between these variables, Pearson’s correlations were performed. Table 2 presents the correlation matrix between the research variables. As shown, witnessing a verbal violence incident was positively correlated with witnessing a physical violence incident (r = 0.37; p < .01). Attitudes toward preventive strategies were positively correlated with attitudes toward punitive measures for those who use violence against health care staff (r = .45; p < .01).

Table 2.

Correlation Matrix of the Research Variables.

	Witnessed Verbal Violence	Witnessed Physical Violence	Attitudes Toward Preventive Strategies	Attitudes Toward Punitive Measures
Witnessed verbal violence	1
Witnessed physical violence	.37**	1
Attitudes toward preventive strategies			1
Attitudes toward punitive measures			.455**	1

p < .01.

Differences in Attitudes Toward Preventive and Punitive Measures by Sociodemographic Characteristics and Witnessing a Verbal/Physical Violence Incident

An ANCOVA test revealed significant gender, economic income, and social differences in attitudes toward preventive strategies for WPV against health care staff (Table 3). Women and those who reported being in a relationship tended to have a more positive attitude toward the preventive strategies suggested for WPV in health care (3.17 vs. 3.07, p < .05; 3.15 vs. 3.04, p < .05; 3.15 vs., 3.05, p < .05, respectively, Table 3). Also, participants who reported being in a relationship scored higher for suggested punitive measures than participants who reported no relationship (2.86 vs. 2.70, p < .01, Table 3). No significant differences were found by educational level, religiosity, or witnessing verbal/physical violence.

Table 3.

ANCOVA Test—Differences in Attitudes Toward Preventive and Punishment Strategies by Gender, Income, Education, and Marital Status (N = 560).

Variable	Attitudes Toward Punitive MeasuresM (SD)	Attitudes Toward Preventive StrategiesM (SD)
Gender
Male	2.77 (0.67)	3.07 (0.51)
Female	2.85 (0.69)	3.17 (0.54)
p =	0.16	0. 03
t =	−1.42	−2.19
Economic income
Below average	2.81 (0.69)	3.15 (0.53)
Average or above	2.79 (0.65)	3.04 (0.53)
p =	0.82	0.03
t =	0.21	2.13
Education
Below academic	2.79 (0.71)	3.16 (0.52)
Academic	2.84 (0.66)	3.08 (0.53)
p =	0.47	0.09
t =	−0.72	1.67
Marital status
In a relationship	2.86 (0.67)	3.15 (0.50)
No relationship	2.70 (0.70)	3.05 (0.59)
p =	0.01	0.04
t =	2.38	2.14

Qualitative analysis of the public’s thoughts regarding prevention of WPV against medical teams identified two main themes: “focusing on the staff” and “focusing on the public.” Three subthemes emerged from the theme “focusing on the staff”: “improving working conditions,” “training to deal with violence,” and “security as deterrence.” Three subthemes emerged from the theme “focusing on the public”: “teaching tolerance,” “raising awareness of zero tolerance to violence,” and “punishment.”

Focusing on the Staff

Improving working conditions

According to the interviewees, improved conditions include a pleasant and spacious working environment, giving the staff enough time for food breaks and rest, a personal panic button, and increasing manpower. These aspects enable the staff to provide optimal care and treatment, as a 29-year-old woman stated: Increasing manpower is necessary because once the patient receives an immediate response, it will save the family and the patient frustration. A 32-year-old man also said,

When the workplace is pleasant and safe, the staff is calmer and nicer. The option of giving the patient a bed in a hospital room and not in the hallway, personal panic buttons, and food breaks are factors that contribute to a tolerant and nonviolent environment.

Training to deal with violence

The need to train health teams to cope with violence was raised by the majority of participants, who said that the staff should be taught interpersonal strategies aimed at calming and reducing violence. Workshops for the staff were mentioned as necessary to practice mediation with patients and guidance on how to deal with a patient who expresses violence. The following quotes reflect these perceptions: You have to send the teams to practice self-defense, it really gets scary (34-year-old woman); The staff should know how to calm, treat, moderate, and not fan the flames. They must know what to answer and what to do in diverse situations (30-year-old man).

Security as deterrence

Security as deterrence was described as providing a sense of security for the staff. Security personnel in wards and clinics, uniformed and armed policemen, and the installation of security cameras were mentioned. As a 26-year-old man said, The staff deserves increased security, armed police, and security cameras in every corner. This way patients will think twice and act with moderation and discretion. It’s just like a traffic policeman on the road deters and prevents violence.

Focusing on the Public

Teaching tolerance

Prevention of violence against the medical staff was mentioned in the participants’ interviews as an aspect that should be addressed in their education from childhood: Kindergartens, schools, and home education must teach tolerance of others, as a 50-year-old man stated: Unfortunately, violence stems from home, continues to school and to life itself. Everyone thinks he deserves special treatment and that is something that should be changed.

Raising awareness of zero tolerance to violence

Raising public awareness of zero tolerance to violence through media ads was described as an approach that leads to prevention of violence toward medical personnel. Campaigns about the danger of violence against staff, publicizing the name of people who demonstrate violence toward the staff, exposure of security photographs in which violent behavior is seen, and TV/Internet commercials against violence in hospitals and clinics were all mentioned: People who demonstrate violence toward nurses or doctors should be ashamed, their names should be publicized, their faces should be seen in the media (29-year-old man); A campaign to eradicate violence in hospitals and clinics should emphasize that the patient’s life is in the hands of the staff, the staff shouldn’t be blamed for delaying treatment because there are priorities and system constraints (40-year-old woman).

Punishment

Most of the interviewees expressed their desire for strict enforcement and imposing heavy punishments on the violent person. Punitive measures included prevention of treatment from the violent individual, financial fine, criminal record, imprisonment, and community service, as a 38-year-old man said: You have to take a strict attitude against anyone who curses or raises a hand against medical staff. They need to be punished. Something like a fine, imprisonment, sanctions, so it will deter.

Discussion

This study aimed to explore public attitudes toward prevention of WPV against health care staff, including punitive measures that should be employed to reduce the violent incidences at health care facilities.

More than half of our sample (57.7%) had witnessed a verbal violence incidence against a health care staff member. Physical violence incidents were rated second in prevalence (19%). These findings are similar to those reported by health care staff in Israel (Ministry of Health, 2017) and around the world (Hills & Joyce, 2013; LanctÔt & Guay, 2014; Pompeii et al., 2013; Spector, Zhou, & Che, 2014; WHO, 2017). Patients and relatives in hospital reported similar experiences (Babaei et al., 2018). These data indicate the high frequency of WPV events and the severity of the phenomenon worldwide. Still, our research findings show that overall public attitudes support the need to prevent WPV against health care staff and to punish those who act violently against health care staff. These findings are very encouraging. We assume that the positive public attitudes toward preventive and punishment measures in this study may be related to recent violent incidents against nurses and an increased awareness of this serious phenomenon in Israeli society. Recently, the Israeli media publicized two severe cases of attacks against nurses in a clinic and in a hospital. One case ended with the death of the nurse and the other with a serious injury. Both cases aroused wide awareness of the issue, including demonstrations and strikes by health care staff. According to news reports in Israel, in both cases indictments were filed against the offenders. In light of these cases, the interviewees may have developed more positive attitudes.

A significant positive correlation was found between participants’ witnessing of verbal violence and their witnessing of physical violence. This finding is consistent with those reported in an Australian qualitative study conducted among emergency department nurses, patients, and their relatives: The majority of physical violence happens concurrently with verbal violence. This association between verbal and physical violence may indicate that verbal violence can sometimes act as a precursor of impending physical violence (Lau et al., 2012). Similar findings were also found in a recent study conducted among patients and their relatives in emergency departments in Israel (Landau et al., 2018). Researchers found both verbal and physical violence increased among respondents reporting negative feelings while in the emergency department. Moreover, within this group there was an increase in incidents of verbal and physical violence, as patients and relatives witnessed or even acted violently against team members.

Attitudes toward preventive strategies were positively correlated with attitudes toward punitive measures. A possible explanation for this finding may be the conceptual connection between prevention and punishment. Prevention of violence and punitive measures against violence are interrelated, and when people are asked about them together their thoughts and attitudes may be similar.

Women and respondents reporting being in a relationship tended to have a more positive attitude toward the preventive strategies suggested against WPV in health care. A possible explanation may be related to a different perception of violence by gender. Dagirmanjian et al. (2017) found that men explain and justify violent behavior through social contexts of the male role in society. In certain situations, violent behavior was perceived as essential when there is a sense of threat to one’s social status or self-image. It may be that as a result men found it more difficult than women to support the preventive measures proposed in this study.

Being in a relationship usually requires the couple to develop interpersonal skills, tolerance, flexibility, and sometimes give things up for the other. It is to be assumed that individuals who have acquired these skills in the course of their shared life with a spouse may also use them in other incidents where there is resistance or conflict between individuals, such as a violent event, and so be more supportive of preventive measures against WPV.

The qualitative findings indicated two main courses of action for the prevention of WPV in health care according to the public view: The first is focusing on the health care staff’s behavior and the second is focusing on public behavior, meaning that to deal with this phenomenon, the public thinks that action should be taken on two levels in combination. The first includes strategies that focus on the health care staff’s behaviors and environmental factors which contribute to the development of violent incidents, and the second focuses on preventive and punitive measures directed at the public. The interviewees referred in the first theme to uncomfortable physical conditions in the work environment, such as a crowding and overloaded work environment for staff and patients, the lack of a place for breaks, the lack of security means (personal panic button, security cameras, armed policemen), and a severe shortage of manpower. These were associated directly with low perceived quality of medical care provided to patients and grasped as a precursor to violent incidents. In other words, the public is aware of the objective difficulties faced by the staff on a daily basis, but at the same time it is difficult to prevent the violence. This finding is consistent with earlier studies in Israel among patients and accompanying persons while in hospital. WPV occurs as a consequence of interacting factors, among them being the workplace environment and manpower shortages (Landau et al., 2018; Shafran-Tikva et al., 2017). The interviewees also pointed out the need to train health care staff to cope with violence. The training includes dealing with physical violence, as well as the emotional and psychological aspects of care. The public expects teams to be competent professionals with regard to communication and interpersonal skills with patients and their families. The staff is expected to identify situations that might deteriorate into violence, manage them professionally, and ensure optimal patient care. The interviewees describe trust in the staff and an expectation that staff members will be able to act and lead in times of distress. These expectations are well documented in the literature (Baby et al., 2018; Landau et al., 2018; Landau & Bendalak, 2010; Shafran-Tikva et al., 2017). Interestingly, these preventive measures indicated by the public to prevent WPV are almost identical to those suggested by health care workers (Brophy et al., 2018; Maguire et al., 2018; Zhao et al., 2015) and are consistent with the Israeli Ministry of Health recommendations regarding health staff’s specific training to prevent WPV (Israeli Ministry of Health, 2017). Meaning, the two sides of the phenomenon think alike but still find it difficult to implement effective ways of preventing it.

The second theme, “focusing on the public,” dealt with strategies aimed at the public. The public perceives that violence against medical staff can be prevented by educating the population, raising awareness of “zero tolerance to violence,” and promoting punitive measures for violent behavior. Education, according to the interviewees, should begin at an early age, as violence in health care has become a norm. Two possible explanations may be related to this behavior: The first is the change in patients’ role in health care systems around the world, that is, patient empowerment. Patients and their families are no longer passive participants in their health care: They expect sharing of information and decision making, as well as respecting their wishes (Timmermans & Oh, 2010). Situations that threaten or impair their perceived role may provoke resistance from patients/relatives, who consequently express themselves violently. The second explanation is related to the Israeli cultural context. A recent Israeli study among oncologists indicated cultural characteristics (open interpersonal boundaries, a family-oriented society, a multicultural society with varied cultural norms) that affect physician–patient interactions, including anger and violence directed against physicians (Granek, Ben-David, Bar-Sela, Shapira, & Ariad, 2019). A possible solution could be health staff members who work as mediators between all parties. By providing orderly information, appropriate explanations, and sharing, they may assuage the situation and prevent violence (Shafran-Tikva et al., 2017). This solution should take into account the cultural diversity of patients, caregivers, and the health care system.

Raising public awareness of zero tolerance to violence can be seen as a continuation of the above strategy regarding the education of the younger generations. Interviewees suggested that advertising in all media and exposure of violent events may raise awareness of the consequences of this behavior and its serious consequences among all parties involved. These actions have been taking place more and more in Israel in recent years. The media reveals security videos from hospitals, documenting in real time what happened. And yet, there are still violent incidents in the health care system.

The last subtheme concerned the public’s view of punitive measures that could prevent WPV against health care staff. Interestingly, the public supports the enforcement of strict and uncompromising measures against people who act violently against health care staff. The measures include prevention of treatment from the violent individual, a financial fine, dismissal from the health facility, and even imprisonment. These measures are consistent with the prevention programs discussed earlier (Hall et al., 2018; Israeli Ministry of Health, 2017; Department of Health, 1999; OSHA “Road Map for Healthcare Facilities,” 2015a). Although strategies for education and training have been proposed in the past, we are also witnessing the realization that in some cases only punishment will reduce the incidence of violence.

Practical Implications

The current study is one of the few focusing on public attitudes toward WPV in health care, and specifically preventive and punitive measures against WPV. It is unique in its mixed-methods research design, using both quantitative and qualitative methods to explore public’s attitudes toward violence prevention directed at health care staffs. The findings indicate that most of the Israeli public is aware of the violence displayed toward health care staff and believes that it can be prevented and that punitive measures can and should reduce violence in the health care system. In light of these encouraging findings, policy makers and health administrators should promote violence prevention as part of their annual work plans and monitor its implementation. Dealing with violence requires investing in staff training, adding manpower, improving environmental conditions, investing in ways of reducing the potential for violence, and dealing with violence once it breaks out. Adding safety measures and placing more security guards in health care settings may promote the staff’s sense of security.

The enforcement and punishment systems must also join to prevent the violence by means of rapid enforcement and appropriate punishment in a relatively short period of time subsequent to the violent incident. All the described activities must be carried out as a whole and be integrated in a campaign of continuous publicity and media across the country, in various social networks and at medical facilities, to raise awareness among the public.

Study Limitations

This study used a convenience sample, yet the sample was large (N= 560) and represented a diverse population in its sociodemographic characteristics, such as age, gender, income, education, and religiosity. In addition, participants lived in different geographical areas of Israel. The sample included only the Jewish population; in future it is recommended to add more cultural/religious/ethnic groups to represent all the social groups in the population studied. The qualitative section included only one open-ended question. In future studies it is recommended that this part be expanded to include several open-ended questions, so interviewees are asked in depth about their feelings regarding prevention of WPV against health care staff.

Footnotes

Appendix

To what extent do you think each of the following may prevent violence against health care staff?

Please rate your agreement/disagreement regarding each statement on a 4-point scale ranging from 1 = “not at all” to 4 = “very much.”

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Sigalit Warshawski

Authors Biographies

Sigalit Warshawski, RN, PhD, is a lecturer and head of the Baccalaureate Nursing program in the Nursing Department at Tel Aviv University, Israel. Her research combines mixed-methods studies on nurse education, nursing informatics, and interprofessional collaboration in health teams. She is also interested in studying workplace violence against health care staff and innovative strategies that could help eliminate this phenomenon.

Anat Amit Aharon, RN, MHA, PhD, is a teacher in the Nursing Department at Tel Aviv University, Israel. Her research focuses on nurses’ workplace, quality and safety, patients’ health outcomes, and the impact of poverty on health promotion and health outcomes,

Michal Itzhaki, RN, PhD, is senior lecturer and the chair of the Nursing Department at Tel Aviv University, Israel. Her research combines mixed-methods studies on emotions of health care workers, patients, and family members in complex care situations that evoke emotions such as stress, guilt, embarrassment, fear, anger, tolerance, and empathy. She is interested in studying perceptions and knowledge of the general public, health care workers, and patients, about terminal illnesses and unexpected situations.

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