Characteristics of workplace violence, responses and their relationship with the professional identity among nursing students in China: a multicenter cross-sectional study

Workplace violence (WPV) is defined as ‘Incidents where staff is abused, threatened or assaulted in circumstances related to their work, including commuting to and from work, involving an explicit or implicit challenge to their safety, well-being or health’, including physical and psychological violence [1]. WPV was reported occurring in 68.31% nursing staff, including 25.77% physical WPV and 63.65% non-physical WPV [2]. Meanwhile, nursing student is one of the most vulnerable and high-risk group suffering WPV, due to inadequate experience in clinical practice, frequent clinical placement shifts and challenges of building the relationships with patients and multidiscipline team in a short period [3]. Recent studies revealed that more than half of the nursing students experienced WPV during clinical practice [4‐6]. Wang [6] reported 66.2% Chinese nursing students suffered from WPV, including emotional abuse (77.6%), threat (55.9%), physical aggression (15.2%) and sex assault (10.3%). 84.8% of violence was identified by patients and patients’ family members, followed by nurses (78.6%) and physicians (57.9%) [7, 8]. Another study revealed most WPV came from patients and relatives (77.1%) [9]. Magnavita and Heponiemi [10] found that psychiatric and emergency departments were the highest risk work environments. However, the characteristics of violence and the responses of nursing students were unclear. Research found that midwifery students discussed the incident with acquaintance after a violence incident and few of them completed an incident report or received official debriefing [11]. Some students may worry about losing their job after the violence, while others do not trust the hospital staff.

WPV was considered causing long-term physical and psychological impact to the nursing students [12]. A survey in China indicated that 59.1% of the nursing students worried about WPV in the clinical practice [13] and the majority of the students experiencing WPV showed anxiety and depression [5]. Nursing students who witnessed or experienced WPV reported more psychological problems such as fear, anger and irritation than others [3]. WPV also impacts the students’ nursing performance. 12.3% of students announced that WPV experience influenced the quality of patient care [14]. Additionally, WPV deteriorated the professional acceptance of nursing students [1]. Budden et al. [5] found that 46.9% of the nursing students considered to change their careers after experiencing WPV. The students received inadequate WPV management training during the nursing education. It is necessary to clarify the impact of WPV to build up the professional identity among the nursing students, who are considered to be primary backup forces of the professional nurses.

Although many universities and hospitals tried to change the culture of clinical practice in China, the evidence of the change was still unclear. The objectives of this study are: (i) to analyse the violence incidence and experience among Chinese nursing students during clinical practice; (ii) to investigate the relationship with the development of students’ professional identity.

In this study, 42.98% of the 954 nursing students had experienced at least one case of violence in the past year during their internship. Among the various types of violence, the prevalence of nonphysical violence (verbal abuse 38.47% and bullying 14.78%) was much higher than those of physical violence (physical attack 2.73%, sexual harassment 1.99% and gathering disturbance 1.78%). Similar patterns were observed in regional and global statistics data. Spector et al. [21] indicated that non-physical violence (65.5%) was higher than physical violence (26.7%) globally. The gap between the finding of Spector et al. [21] and this study may relate to differences in health care environments, culture, and perception or definition of violence across different people and cultures. Considering the prevalence of global WPV reported by qualified staff, it is not surprising that such a significant number of nursing students experiencing similar events. The unacceptable circumstances should raise attention and awareness of WPV among nursing students. Adequate training in identifying, reporting and management of WPV should be introduced in the school and the clinical provider.

The second valuable finding of this study was to identify high-risk groups of nursing students. As mentioned before, senior degree nursing students encountered more violence than junior degree holders. Students who had changed their major and those who concerned more about violence encountered more violence. Consistent with previous literature, nurses with university degrees, higher workload or stress, worse adaption to the environment may get higher risk of experiencing any form of violence [22, 23]. This study found that the main responses of nursing students to the WPV were avoiding conflict and explaining with patience. Few students sought help from teachers, security guards, and police. In the future, more efforts should be placed on building students’ prevention and response-ability in the training programs.

Thirdly, the nursing students were main target of hospital violence. The emergency department was one of the high violence targets in the hospital. In the emergency department, high-risk patients, such as patients experiencing an episode of mental illness or inebriated patients, and longer waiting time, were determined to be precipitating factors of potential violent behaviour [24]. High patient expectations [25], and the negative propaganda in the media [26] lead to patients aggressive behaviour. Patients, for instance, took for granted that they deserve high-quality care and good clinical outcomes once they are admitted to the hospital, regardless of the severity of their disease [27]. However, these accusations are frequently one-sided presenting only the patient’s point of view and are inaccurate, thus creating public distrust and anger toward medical professionals [26]. Something always happens at the beginning of the violence, such as offensive behaviour, unsatisfied with nurses’ performance, rejected unreasonable requests, etc. It is important to develop the ability of early identification, assessment, reporting and management of WPV among the nursing students.

Fourthly, the impact of WPV on individuals, in terms of mental well-being, should not be underestimated, since students often need additional support to cope with and manage challenging situations. Perhaps the most alert finding in this study was that 86.34% of the nursing students didn’t report violence incidents. The reasons include: unaware of how to report (27.07%), indifference (20.49%), no response will happen (16.34%), etc. 11.22% of the nursing students considered WPV as part of their jobs. The culture which tolerates the violence incidents in clinical practice is unacceptable and should be abandoned. It was disclosed that students or novice nurses might come up against high rates of negative behaviour during their time in practice [28]. Laschinger [29] suggested negative work experiences may result in new graduates assimilating such behaviour and displaying the same toward others. It was found in this survey that more than half of the nursing students developed post-traumatic stress disorder after WPV, which suggested clinical nursing teachers should support the students in psychological adjustment and recovery after the occurrence of violence.

The adverse effects of violence on nursing students’ mental health and professional identity have been revealed. Students should start raising awareness when preparing for their clinical placements. The process should include information to help understand and identify WPV and get access to clear information on how to report incidents. Students should be confident that incidents have to be handled properly with post-incident support through counselling and debriefing. Schools and placement providers should also provide training to mentors to assess the learning environment through audit and post-placement evaluation and provide debriefing sessions to students to accumulate their experience. Cooperation between academics in situations and service providers is critical to create best learning environments for students and build capacity for tomorrow’s workforce [30]. Nurse education institutions and health service providers should work together to better protect the nursing students and develop shared policies and procedures which raise understanding and awareness of the consequences and management of bullying/harassment [31], build up a culture of zero tolerance toward such behaviour and set up a self-valued society.

Nursing educators and administrators should focus on the population of nursing students who are vulnerable to violence. Targeted violence prevention training sessions can be developed in conjunction with the violence occurrence characteristics and nursing student coping weaknesses identified in this study. In addition, hospitals could have some psychological counselors to help nursing students after they have experienced violence.

Clinical nursing teachers need to be aware of the impact of violence on the professional identity of nursing students. Close attention should be paid to psychological experience and changes in professional values of nursing students. Nursing educators could identify and adjust the negative mindset of nursing students early by establishing peer support system to guide them in a healthy and positive direction.

The results of this study demonstrated that nursing students were exposed to WPV during clinical practice, including physical and psychological behaviour. In addition, coping solutions and psychological adjustment of nursing students to violence were not satisfactory. The experience of violence significantly worsened the professional identity of nursing students, which harmed the quality of care and affect the long-term development of nursing. These results also highlighted the importance of violence prevention education during professional learning, especially training on risk assessment, how to cope with WPV, reporting WPV exposure and psychological recovery. More efforts are needed to reduce and prevent violence in the future.