687372

research-article2017
JAPXXX10.1177/1078390316687372Journal of the American Psychiatric Nurses AssociationDrori et al.

Research Paper
Journal of the American Psychiatric

Patient Violence Toward Psychiatric

Nurses Association
2017, Vol. 23(2) 143­–148
© The Author(s) 2017
Health Care Workers in Israel as Reprints and permissions:
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Viewed Through Incident Reports: DOI: 10.1177/1078390316687372

https://doi.org/10.1177/1078390316687372
journals.sagepub.com/home/jap

A Retrospective Study

Tal Drori1, Hava Guetta2, Merav Ben Natan3,

and Yaakov Polakevich4

Abstract
BACKGROUND: Rates of violence perpetrated by patients toward health care workers are known to be higher
in psychiatry than in other fields. Objective standardized reports of violent incidents may clarify this phenomenon.
OBJECTIVE: The purpose of this study was to assess the characteristics of patient violence, as evident from
objective reports. STUDY DESIGN: In this retrospective chart review study, conducted at a large mental health
hospital in Israel between 2013 and 2015, reports of violent incidents perpetrated by people diagnosed with mental
health problems against health care workers of the hospital were reviewed. RESULTS: A total of 80 violent incidents
were recorded. The findings outline the characteristics of a typical assailant, a typical victim, and a typical incident,
and demonstrate associations between some of these characteristics. CONCLUSIONS: This information may be
beneficial for planning interventions for efficient coping with and prevention of violence at psychiatric inpatient facilities.

Keywords
patient violence, inpatients, reports, health care workers, risk factors

Introduction
Violence against health care workers is defined as “inci-
dents where staff are abused, threatened or assaulted in
circumstances related to their work . . . involving an
explicit or implicit challenge to their safety, well-being or
health” (International Labour Office, International
Council of Nurses, World Health Organization, & Public
Services International, 2002, p. 3). Violence in psychiat-
ric inpatient facilities is a significant problem worldwide
(Anderson & West, 2011; Bimenyimana, Poggenpoel,
Myburgh, & van Niekerk, 2009; Yarovitsky & Tabak,
2009). Violence rates in the field of psychiatry are known
to be higher than in other fields (Anderson & West, 2011;
Franz, Zeh, Schablon, Kuhnert, & Nienhaus, 2010). Such
violence has negative effects on the physical and mental
well-being of the caregiving staff, the quality of care pro-
vided, and the entire organization (Gates, Gillespie, &
Succop, 2011; Keski-Valkama et al., 2010; Roche, Diers,
Duffield, & Catling-Paull, 2010).
Several studies have attempted to characterize patients
who perpetrate acts of violence toward health care work-
ers. Patient characteristics, such as history of violence
(Rueve & Welton, 2008), psychiatric diagnosis (Anderson
& West, 2011; Cornaggia, Beghi, Pavone, & Barale,
2011), age (Anderson & West, 2011), sex (Anderson &
West, 2011; Keski-Valkama et al., 2010), duration of hos-
pitalization (Cornaggia et al., 2011; Sjöström, Eder,
Malm, & Beskow, 2001), and type of hospitalization
(involuntary vs. voluntary; Cornaggia et al., 2011) were
found to be related to violent behavior.
While there are studies that suggest that certain char-
acteristics are risk factors for violence, other studies pro-
vide inconclusive evidence. For example, while some
studies show that male patients are more likely to be vio-
lent than female patients (Iozzino, Ferrari, Large,
Nielssen, & de Girolamo, 2015), others demonstrate that
1
Tal Drori, MD, Tirat Carmel Mental Health Center, Tirat Carmel,
Israel
2
Hava Guetta, MA, RN, Tirat Carmel Mental Health Center, Tirat
Carmel, Israel
3
Merav Ben Natan, PhD, RN, Hillel Yaffe Medical Center, Hadera,
Israel
4
Yaakov Polakevich, MD, Tirat Carmel Mental Health Center, Tirat
Carmel, Israel
Corresponding Author:
Merav Ben Natan, Pat Matthews Academic School of Nursing, Hillel
Yaffe Medical Centre, PO Box 169, Hadera 38100, Israel.
Email: meraav@hy.health.gov.il
144 Journal of the American Psychiatric Nurses Association 23(2)
female patients are just as likely as male patients to be
violent (Anderson & West, 2011).
Several studies have found that patients who perpe-
trate violence are not a homogenous group and that their
behavior reflects a variety of biological, psychodynamic,
and social factors. These factors do not all necessarily
originate from the patient. Rather, there may also be
numerous contributing factors related to the health care
team, patients’ families and psychiatric facilities that may
influence violent behavior (Anderson & West, 2011).
There are different views with regard to the weight of
these factors as a cause of violent behavior (Rueve &
Welton, 2008). Some claim that there are several reasons
for violence carried out by people diagnosed with mental
health problems, including crowded departments, staff
shortages (Virtanen et al., 2011), or disharmony among
the staff (Cornaggia et al., 2011). Nonetheless, this vio-
lence often has no rational explanation (Anderson &
West, 2011).
Furthermore, several studies have tried to characterize
psychiatric health care workers who have a high risk of
being involved in violent incidents perpetrated by
patients. Daily care, including interpersonal contact with
patients, as in nursing (Anderson & West, 2011), limited
experience in psychiatry (Cashmore, Indig, Hampton,
Hegney, & Jalaludin, 2012; Rueve & Welton, 2008), and
same-sex victims and assailants (Cornaggia et al., 2011)
were found to increase the risk of violence.
Studies conducted to assess the extent of violence and
its various types at psychiatric inpatient facilities show
that the health care workers tend to report common and
prevalent encounters with violence (Cashmore et al.,
2012; Foster, Bowers, & Nijman, 2007; Jonker, Goossens,
Steenhuis, & Oud, 2008). It is hard, however, to assess
the incidence and extent of violence against health care
workers, as the concept of violence has many definitions,
as do the various methods of assessment, ranging from
self-reports to secondary analysis of worker requests for
compensation.
The inconclusive evidence regarding the phenomenon
of violence perpetrated by people diagnosed with mental
health problems toward health care workers requires fur-
ther investigation, using the most objective tools possi-
ble. This is especially relevant in light of underreporting
of incidents of violence. Very few studies have used
objective tools, such as mandatory standardized incident
reports, to investigate the phenomenon. However, such
reports may provide more objective information and help
clarify the phenomenon of patient violence in psychiatry.
Although this has been elaborated in several countries, to
date no study has examined violence of patients in psy-
chiatric settings toward health care workers in Israel.
Therefore, this study was undertaken to assess this phe-
nomenon in Israel by outlining incident, assailant, and
victim characteristics, as evident from mandatory objec-
tive staff reports. Its results will hopefully be able to pro-
vide additional knowledge that will inform practice in
similar countries as well.
Method
Study Design
This is a retrospective review study analyzing written
mandatory standardized incident reports.
Setting
The study was conducted at a large governmental mental
health hospital in Northern Israel. The hospital provides
treatment for a spectrum of mental disorders for adoles-
cents, adults, and older people. It provides inpatient ser-
vices at seven acute inpatient and chronic units, each with
approximately 40 patients. Acute units treat patients suf-
fering from acute psychotic illness, while chronic units
treat those suffering from long term but milder psychiat-
ric illness. Additionally, one chronic unit treats psychoge-
riatric patients, including those with severe dementia.
The hospital employs approximately 133 nurses, 45 phy-
sicians, and 32 nurse aides.
Investigative Methods
According to the guidelines of the Israeli Ministry of
Health (2008), it is mandatory that health care workers
fill out an incident report form regarding any violence
perpetrated against them. These mandatory forms must
then be submitted to the facility’s administrative depart-
ment. Incident reports cover multiple forms of violence,
including verbal, physical, and sexual violence, includ-
ing sexual harassment, and indecent assault with or
without physical contact. Each psychiatric facility uses
a nationally standardized incident report form. The pur-
pose of reporting is to promote the ability of mental
health service management and mental health facilities
to manage risks as part of mental health care, to super-
vise the quality of care and to maintain the personal
safety of health care workers. The data were significant
both for the process of patient care and to enable the
mental health system to identify potential problems and
address them. These data were gathered and transmitted
to the head office of mental health services at the
Ministry of Health, which reaches the necessary sys-
temic conclusions for the benefit of both patients and
health care workers. Health care workers are trained in
the use of these forms and are aware of the legal and
professional mandate to use them to report all incidents
of violence.
Drori et al. 145
The study instrument was the standardized structured
form used to report violent incidents. The form records
the following data concerning a violent incident: Name,
sex, year of birth, and date of hospitalization of the assail-
ant; department, time, shift, place, type of hospitalization
(voluntary vs. involuntary); type of violence (verbal,
physical, and sexual violence, including sexual harass-
ment and indecent assault with or without physical con-
tact), mental and physical state of the assailant during and
after the incident; severity of harm to the victim; name,
sex, and position of the health care worker involved in the
incident; and a short description of the incident (filled in
by hand by a health care worker not necessarily involved
in the incident). All items in the form are closed ques-
tions, that is, the person who fills in the form must mark
an answer from the provided alternatives, in exception of
the item where there is a requirement to provide a short
written description of the incident.
Procedure
The inclusion criteria were all violent incidents reported
using the nationally standardized incident report form
over the previous 2 years dating back from the onset of
the study (between April 2013 and April 2015). The
reports were collected using a convenience sample. Of
these, only reports of violence perpetrated by people
diagnosed with mental health problems against health
care workers of the hospital were extracted, for a total of
80 cases.
Ethical Considerations
Anonymity of the patients and the health care workers
involved in violent incidents has been maintained, as
names have been deleted from the forms. This study was
conducted with the approval of the institutional review
board of the mental health hospital in Israel at which the
research was conducted.
Data Analysis
Descriptive statistics were used to describe and summa-
rize the data. Also, to determine differences between
groups, the data were analyzed with chi-square tests and t
tests. All the statistical analyses were carried out with
SPSS software (Version 19 for Windows). The level of
significance was set at p < .05.
Findings
During the 2-year period examined in this study, a total of 80
violent incidents were perpetrated by patients against staff.
This is equivalent to an average of one incident every 9 days.
Incident Characteristics
Most of the violent incidents occurred during the morn-
ing or evening shift, with an almost equal distribution
(47.5%, n = 38, and 46.3%, n = 37, respectively), but the
most common time was 11:00 a.m. About half the inci-
dents occurred in a public place (52.5%, n = 42). Other
common sites of violent incidents were in quiet rooms
(23.8%, n = 19) or the vicinity of the nurses’ station
(22.5%, n = 18).
In the majority of cases the type of violence reported
was physical violence (70%, n = 56), in 32.5% (n = 26) of
the cases threats, and in 28.8% (n = 23) of the cases ver-
bal violence. In some of the cases a combination of differ-
ent types of violence was reported, for example, violence
involving threats as well as verbal violence.
Most of the violent incidents aimed at a single health
care worker (56.3%, n = 45), involved physical violence
(χ2 = 14.6, degrees of freedom [df] = 1, p < .01), while
most cases of violence involving threats, 55% (n = 44)
were aimed at a group of health care workers (χ2 = 6.7, df
= 1, p < .01). Furthermore, most of the violent incidents
(55%, n = 44) were found to occur during the evening
shift (χ2 = 10.2, df = 2, p < .01). Following the violent
incident, 42.5% (n = 34) of the victims required medical
care.
Assailant Characteristics
The majority of the assailants were men (68%, n = 55),
the mean age of assailants was 33.8 years (SD = 18.8,
range 9-66), about half the assailants had been hospital-
ized voluntarily (56%, n = 45) and 44% (n = 35) were
under an involuntary hospitalization order. Most of the
assailants were from the acute adult department or the
acute youth department (89%, n = 71). The rest were
from the psychogeriatric department and chronic depart-
ments. All the assailants were fully conscious. Most were
reported as being agitated (89%, n = 71), 32.5% (n = 26)
as having hallucinations, and 2.5% (n = 2) as suffering
from depression. Men were found to be more inclined to
assault nursing aides, and women to assault nurses (χ2 =
16, df = 6, p < .05).
Victim Characteristics
Slightly more than half the victims were men (55%, n =
44). This figure is notable as men make up 35% of the
nursing staff of the facility. In most cases, the violence
was aimed at a single health care worker (65%, n = 52)
versus violence aimed at a group of health care workers.
Most of the assault incidents against a single health care
worker were aimed at nurses (68.8%, n = 55). Nurse aides
were the second most often assaulted professional group,
146 Journal of the American Psychiatric Nurses Association 23(2)
although they experienced far fewer assaults (13.8%, n =
11). The rest of those assaulted were physicians and
housekeeping staff. The position of health care workers
who were the target of violence involving threats differed
significantly, with physicians and nurse aides being tar-
geted by this type of violence more than other health care
workers (χ2 = 17.2, df = 6, p < .01).
Discussion
The purpose of this study was to assess the extent of vio-
lent incidents committed by people diagnosed with men-
tal health problems against health care workers at a
psychiatric inpatient facility in Israel and to explore the
characteristics of these assaults based on mandatory stan-
dardized violent incident reports. The research findings
show that, on average, every week one of the hospital’s
health care workers—a nurse, physician, nurse aide, or
housekeeping employee—was the target of violence by
patients. These findings are consistent with previous
studies that indicate a high frequency of violent incidents
(Jonker et al., 2008; Keski-Valkama et al., 2010; Moylan
& Cullinan, 2011). The research findings show that more
than a third of the victims required medical care follow-
ing the incident. This is in addition to the psychological
consequences that were not a structured part of the
reports, but have been indicated by previous studies
(Cashmore et al., 2012; Keski-Valkama et al., 2010).
The incident reports reviewed in this study reveal that
the majority of the assailants were men, but still, women
constituted significant percentage (more than 30%) of the
assailants. This finding is consistent with previous stud-
ies, which found that in psychiatry women may be as vio-
lent as men (Anderson & West, 2011; Sturup, Monahan,
& Kristiansson, 2013). The variation in proportion of
men versus women may be related to other factors, and
these are worthy of further research.
In addition, in the present study, the typical assailant
appears to be hospitalized in an acute department, a find-
ing consistent with previous studies. It has been sug-
gested that acute units often have the most symptomatic
patients, in comparison to longer term units (Daffern,
Mayer, & Martin, 2003). However, Bader, Evans, and
Welsh (2014) did not find a significant difference in vio-
lent incident rates between long term and acute psychiat-
ric units.
Notably, in the current study, the type of hospitaliza-
tion (voluntary or involuntary) did not prove to be signifi-
cant, as nearly half the assailants had been hospitalized
voluntarily. This is in contrast to previous studies which
found that involuntary hospitalization was associated
with higher rates of inpatient violence (Cornaggia et al.,
2011; Iozzino et al., 2015). This discrepancy may have to
do with the fact that the hospital at which the study was
conducted has strict instructions on the care and protec-
tion of patients hospitalized involuntarily, contributing to
a reduced number of violent incidents among this group.
Iozzino et al. (2015) also suggested that the association
between involuntary admission and violence is likely to
be complex, reflecting other factors.
According to the reports, the large majority of assail-
ants were in a state of agitation during the incident. It was
not always clear, based on the reports, whether this agita-
tion preceded the incident and constituted a type of cata-
lyst for the violent incident, or whether it emerged
following staff’s handling of the violent incident. In a
review by Papadopoulos et al. (2012), patient behavioral
cues were attributed to 38% of all violent incidents.
Therefore, in the present study, cases where it was not
clear whether agitation preceded or not a violent incident
raise a concern whether the staff knows how to read and
interpret the behavioral cues.
Notably, according to the data recorded on the stan-
dardized structured forms, health care workers present at
the incident estimated that most of the assailants did not
experience hallucinations during the incident, possibly
indicating that most of the assailants acted with a certain
degree of control. These findings are consistent with the
literature, which states that there is often no rational
explanation for patient assaults against health care work-
ers (Anderson & West, 2011; Papadopoulos et al., 2012).
The reports also indicated the characteristics of a typi-
cal violent incident. In most cases, the incidents involved
physical violence, in contrast to previous studies where
nurses mainly reported encountering verbal violence
(Cashmore et al., 2012; Foster et al., 2007; Jonker et al.,
2008). This may indicate that mandatory reporting may
lead to sorting of incidents, in which health care workers
are more likely to report physical violence than they are
to report verbal violence. As shown in previous studies,
verbal violence is often perceived by health care workers
as part of the routine of psychiatric care (Stewart &
Bowers, 2013). This implies that mandatory reporting is
not enough for proper monitoring of violence perpetrated
by people diagnosed with mental health problems against
health care workers, and that other measures may be
required as well.
Most of the violent incidents, particularly those
involving physical violence, were aimed at a single health
care worker. About half the incidents occurred in a public
place, that is, one accessible to all patients. Physical vio-
lence and threats occurred at a similar frequency in the
morning and evening shifts. This finding may indicate
that a violent incident might indeed occur at any moment
(while the patient is awake). However, the study findings
show that certain situations seem to be more prone to the
risk of violence, for example, a health care worker iso-
lated from other health care workers in a public place.
Drori et al. 147
Therefore, violence must be anticipated in such situations
and appropriate measures to prevent it should be
undertaken.
Although the frequency of violent incidents was simi-
lar between morning and evening shifts, 11:00 a.m. was
found to be a particularly “sensitive” time, exhibiting a
peak of violent incidents. This finding may allude to the
studied departments’ routine, which might trigger these
violent outbursts, an issue that requires further investiga-
tion. This is the time when patients await the medical
decision whether they are to be released or not. Previous
studies have found that environmental factors such as
space, overcrowding, shift patterns, limited privacy, and
raised temperature trigger violent behavior (Cornaggia
et al., 2011; Dickens, Piccirillo, & Alderman, 2013;
Virtanen et al., 2011). In a study by Bader et al. (2014) of
an inpatient forensic psychiatric facility, there were nota-
ble increases in violence rates during busy meal, medica-
tion, and shift change times. The reports also describe a
typical victim. Reports on violent incidents toward a sin-
gle health care worker show that the victim was usually a
nurse, corroborating the literature (Anderson & West,
2011; Franz et al., 2010). Nursing professionals are on the
front line of care, maintain constant contact with patients,
and are also the largest professional group.
According to the current findings, male and female
health care workers were assaulted in similar propor-
tions. Cornaggia et al. (2011) found that same-sex vic-
tims and assailants increase the risk of violence.
Therefore, this finding may reflect the proportion of
male versus female patients, as well as male versus
female health care team members of the facility where
the study has been conducted.
Examination of the associations between assailant,
victim, and incident characteristics provides more infor-
mation about the violence phenomenon. In most types of
violence, no association was found between the profes-
sional role of the victim and the type of violence experi-
enced, showing that a person holding any position can be
the target of any type of violence. Nonetheless, physi-
cians and nurse aides were found to receive more threats
than other health care workers. In this case, there may be
an association with the role and conduct of the specific
profession, which may arouse the frustration of the
patient and lead to violence. In a review by Papadopoulos
et al. (2012), staff–patient interaction was the most fre-
quent type of antecedent overall, precipitating an esti-
mated 39% of all violent incidents.
The strength of the current study is that it was based on
mandatory incident reports that health care workers are
obligated to file for all violent incidents. Hence, it is pos-
sible to reach more reliable conclusions about patient vio-
lence toward mental health professionals and other
workers than, for instance, when examining self-reports.
Thus, no recall bias is involved, as health care workers
report incidents close to their time of occurrence.
Additionally, the study examined all incidents of violence
toward a variety of health care workers rather than a sin-
gle professional group, enabling a wider view of the
phenomenon.
Limitations
Several limitations must be considered when interpreting
study results. The research methodology leaves room for
the possibility, which may be minimal but cannot be
rejected out of hand, that the decision whether and what
to report is at the discretion of the health care worker.
Some violent incidents, in particular verbal violence,
might have been perceived as routine and not worthy of
report. Hence, it is possible that the research conclusions
tend to refer to more serious violent incidents. Another
limitation of the current study is that the reports come
from a single facility, limiting generalizability of the find-
ings. Additionally, the standardized form for reporting
may limit the depth and detail of the description of each
incident.
Conclusions
The research findings indicate that violence toward men-
tal health workers is a common and serious problem. The
research findings make it possible to outline the character-
istics of the typical assailant, victim, and violent incident,
and some of these show associations, although it seems
that the interaction between various factors is complex.
Although this study was conducted in Israel, findings
may help form worldwide recommendations with regard
to steps to help reduce violence perpetrated by people
diagnosed with mental health problems against health
care workers. First, health care workers must be aware of
the characteristics of patients who may be likely to exhibit
violent behavior. Second, health care workers, supported
by facility administration, should minimize situations
prone to risk, for example, by avoiding situations in
which health care workers find themselves isolated and
exposed to patients. For example, this can include design-
ing and managing patients’ physical environment to
reduce factors like crowding that have been shown to
increase the likelihood of patient violence. Third, it is
necessary to examine the departments’ routines and to
determine how they may trigger patient violence. Finally,
we recommend conducting further research to explore
which factors affect health care workers’ reporting of vio-
lent incidents. We also suggest further research to deter-
mine how both the assailant and health care worker victim
interpret the causative factors behind incidents of
violence.
148 Journal of the American Psychiatric Nurses Association 23(2)
Author Roles
All the authors participated in the research proposal, collection
of the data, data analysis, and preparation of the article.
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.
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