Workplace violence, psychopathological symptoms, and deviant workplace behavior among nursing interns in China: a network analysis

Workplace violence (WPV) in healthcare has become a global concern, especially in developing and industrialized countries [1]. Statistically, healthcare workers are 16 times more likely to be reported as experiencing WPV than other industries. Of these, clinical nurses, a significant group of frontline healthcare workers, are at the highest risk of experiencing WPV, 4 times more likely than other healthcare professionals [2, 3]. China has also seen a significant increase in the incidence and number of workplace violence incidents against healthcare workers over the past decade [4, 5]. A study showed that 26.8 and 44.9% of healthcare workers experience physical and non-physical violence every year [6]. Nursing interns are not immune to workplace violence in clinical settings. Experiences of violence during clinical placements can directly affect the learning and performance of nurse interns, causing them to be less efficient and productive, to stop participating in nursing programs, or even to leave the profession altogether [7]. Internships are an essential way for nursing students to gain clinical nursing experience and become qualified nurses [8]. Given the harm and severity of workplace violence, there is an urgent need to comprehensively assess the situation of WPV among nurse interns and its consequences to provide more effective evidence for the development of targeted interventions.

It is well known that workplace violence not only exposes individuals to safety risks but also carries a significant mental health burden. A large number of studies have revealed the tremendous impact of workplace violence on the physical and mental health of nursing interns, including individuals’ worry, depression, helplessness, despair, anger, sleep disruption, lowered self-esteem, reduced work motivation, and impaired interpersonal relationships [9]. As nursing interns are new to clinical work, their psychological regulation is unstable, and they are unable to recognize precursor phenomena or early warning signs of violence [10]. In addition to the direct physical harm that WPV can inflict on them, frequent experiences may lead to somatic and psychiatric symptoms in nursing interns [11]. Fear and anger were identified as the most prevalent psychological symptoms among nurses after experiencing violence, accompanied by negative emotions such as unfairness, worry, and guilt. Alarmingly, these symptoms, if not effectively alleviated and treated, will lead to more severe depression, cognitive difficulties, psychoactive substance abuse, and even suicidal behavior [12‐14].

Workplace deviance behavior (WDB) is an important issue in healthcare management. WDB refers to employees’ intentional violations of organizational norms, such as interpersonal conflict, passivity, absenteeism, and insults to coworkers [15, 16]. Research has shown that WPV is associated with WDB and that nurses who are subjected to violence may retaliate through WDB [17]. Affective Events Theory (AET) states that negative emotions can lead directly to undesirable behaviors such as tardiness, absenteeism, or arguing with coworkers [18]. These emotions may also change work behaviors by influencing attitudes [19]. Employees may feel stressed and frustrated after being exposed to violence and, in turn, adopt deviant behaviors such as intra-organizational aggression or retaliation to release stress [20].

More importantly, there is evidence that there may be some bidirectional associations between workplace violence, psychopathological symptoms, and workplace deviant behavior. On the one hand, exposure to workplace violence may increase the risk of workplace deviant behavior and promote the development of psychopathological symptoms [21‐23]. On the other hand, workplace deviant behavior may exacerbate psychopathological symptoms and expose individuals to renewed distress from workplace violence [24]. WPV triggers high arousal of negative emotions and aggressive responses, leading employees to engage in harmful behaviors toward colleagues or the organization [25, 26]. Conversely, deviant behaviors can lead to interpersonal anomalies and even long-term relationship disintegration. This relationship breakdown can cause adverse emotional, cognitive, and health outcomes, further triggering aggressive reactions in employees and creating a vicious cycle [27, 28].

However, despite the growing interest in the work environments of nursing interns and its impact on their well-being, there is still a lack of empirical evidence of broad patterns of associations between WPV, psychopathological symptoms, and WDB. In particular, limited attention has been paid to the dynamic interactions between them. This study aimed to examine the dynamic relationship between nursing interns’ experiences of workplace violence, workplace deviant behaviors, and psychopathological symptoms (e.g., depression, anxiety, anger, and sleep disturbance) through a network analysis approach, which is of greater practical value for the identification of intervention centers and the development of targeted interventions.

This study explored the network structure between workplace violence, psychopathology symptoms, and workplace deviant behaviors among Chinese nursing interns using network analysis. Findings suggest that workplace violence, workplace deviant behavior, and psychopathology represent interrelated domains with spatially continuous and interconnected nodes. While some studies have explored the relationships between these constructs using regression and structural equation modeling, network analysis allowed for analyzing the complex relationships inherent in these constructs. This study further demonstrates the effectiveness of the network perspective in elucidating the complex relationships between and interconnections of different symptoms. The findings may provide broader insights into preventing workplace deviant behaviors in caregivers and developing targeted interventions for psychopathological symptoms.

Regarding the strongest edges across clusters, the strongest correlations were demonstrated between VSH and the more severe PSH in the workplace violence cluster, Anger-Anxiety in the psychopathological symptoms cluster, and IBD-OBD in the workplace deviant behavior cluster. This finding appears to provide a fragmented picture of only a limited range of existing studies. This is despite the high prevalence (roughly between 37 and 72%) of sexual harassment (including verbal, physical, mental, and visual forms) and the harm it poses to nursing interns as a significant form of interpersonal violence reported in a large number of previous nursing studies [35, 36]. However, these studies did not consider associations between subsets of individual factors. The present study found that more severe types of PSH tended to be highly correlated with less severe VSH. Those repetitive and unwelcome intimacy issues or sexual remarks that occur at work may deteriorate into more severe physical harm or rape (PSH) [37]. Within the psychopathological symptoms cluster, Anger showed the strongest correlation with Anxiety. In general, Anger and Anxiety are the most prevalent psychological symptoms, and they are linked through a common physiological response to stress. Because irritability is characterized by a lowered anger threshold, it is a typical symptom of anxiety disorders [38, 39]. More severe expressions of anger (e.g., trait anger, internalized anger expressions), as well as prolonged experiences of anger, are associated with anxiety disorders independently of co-associations with other psychiatric disorders. Anger may be an essential emotion related to anxiety disorders [40]. Therefore, we can understand the strongest relationship between anger and anxiety. At the same time, symptoms such as depression, somatic, memory, mania, and sleep are more likely to accompany it. In addition, we found the strongest relationship between IBD-OBD within workplace deviant behavior. In previous studies, it is unclear whether employees tend toward organizational deviant behaviors, interpersonal deviant behaviors, or possibly both. However, in Chinese organizations with high power distance, committing deviant behaviors against the organization tends to be dangerous, and retaliation to superiors becomes difficult, making them more prone to deviant behaviors against colleagues around them [41]. When violence against nurses occurs in the workplace, one way in which predominantly female nurses show psychological resistance is by engaging in interpersonal transgressions [42], and transgressions may vary with severity, from minor transgressions (interpersonal) to more severe (organizational) transgressions [43].

Notably, the computation of nodal relationships revealed pairwise interactions between workplace violence, psychopathological symptoms, and workplace deviant behaviors that have been obscured in prior research. We identified some of the most highly correlated cross-cluster nodes as VA-Depression, VA-ABSR, Repetitive thoughts-ABOM, Anxiety-ABSR, and Personality functioning-LDV. This broad pattern of associations provides evidence of specificity between experiences of violence in the workplace and specific psychopathological symptoms and deviant behaviors. First, the strongest relationship was found between the VA and Depression nodes. This is consistent with previous findings that violence experienced by nurses often leads to depression [44, 45]. Regardless of the form of violence, it is a precursor to depression [46]. The most common form of workplace violence experienced by students during clinical training is verbal violence [47, 48]. Verbal violence is a form of emotional abuse designed to inflict intense humiliation, defamation, and fear on the exposed person, and in some ways, verbal violence can cause more harm than physical violence [49]. Because it is often difficult to recognize or define as a violent experience, verbal violence is often overlooked compared to physical violence. As practicing nursing interns are new to clinical work, their psychological regulation is unstable, and they are unable to recognize violence precursor phenomena or warning signs [3]. Most nursing interns show strong emotional reactions after experiencing verbal violence, which is a major factor in developing depression [46]. In addition, the relationship between VA and ABSR in the cluster of workplace deviant behaviors is also stronger. On the one hand, frequent exposure to VA is believed to reduce nursing interns' professional commitment and professional identity and create negative attitudes toward nursing, prompting them to reconsider whether or not to consider nursing as their intended career; on the other hand, VA-induced occupational stress and emotional exhaustion that leads to low level of quality of care for patients and nursing outcomes [50, 51].

Anxiety has the highest strength and expected influence on the whole network structure. This result suggests that Anxiety is the most central symptom in the entire network. Nursing administrators must pay close attention to Anxiety in practicum students and follow the development of the severity of mood-related symptoms. On the one hand, the internship stage is one of the most anxious periods for nursing students [52, 53]. Undergraduate nursing education in China requires students to complete a clinical internship lasting at least ten months [54]. The internship phase requires nursing students to face multiple pressures, such as academic research, employment, graduation, certification examinations, and the demands of clinical practice. At the same time, they worry about work-related errors due to inadequate preparation for internships [55]. On the other hand, nurses often describe WPV as a constant source of anxiety [56]. Anxiety serves as a normal physiological or psychological response to an external event, and this response can cause intense emotional states (tension, obsession, panic, and irritability) in individuals [57]. Most nurse practitioners tend to feel higher levels of anxiety after experiencing WPV, affecting nurses’ self-confidence in their work, which in turn can lead to an inability to respond effectively to workplace violence [58, 59].

In addition, closeness to centrality is an important indicator of the node’s characteristics, which affects other symptoms faster and is at the center of the whole network [34]. Based on the results of centrality analysis, the present study identified “Depression” as having the highest closeness to centrality, being at the center of the network, and being the most strongly associated with other symptoms. Depression is the most common mental health disorder today. The prevalence of depressive symptoms among nurses in China is 57.2%, and reducing the prevalence of depressive symptoms among nurses has become an urgent task for hospital administrators [46]. Therefore, the role of “Depression” in the symptom network should be emphasized to identify nursing interns who are in a depressed mood promptly. Professional training should focus more on how to effectively recognize depression in various stressful scenarios faced by nursing interns to block the pathway of other symptoms in the network preemptively.

Finally, the mediator centrality index (betweenness) suggests that anxiety symptoms are the central psychopathological node. This is consistent with the idea that anxiety plays an important role in the initiation of workplace violence as well as in the onset and course of workplace deviant behavior [60]. Anxiety is both a consequence of physical and non-physical violence and is the strongest predictor of workplace deviant behavior, especially aggressive behavior towards organizational members [61]. Based on the findings of this paper, effective interventions are necessary for nursing interns. Psychological interventions can positively influence an individual’s self-control and emotional regulation and negatively influence destructive deviance and promote work, task performance, and constructive behavior [62‐64]. For example, mindfulness-based cognitive therapy (MBCT), with the advantages of high compliance and significant efficacy, is widely used in the treatment of anxiety as well as depression [65]. It can hinder the potential adverse situational influences on an individual, positively affecting work, task, and safety performance and reducing destructive bias tendencies [66]. Nursing educators should enhance the psychological training of nurses by integrating positive thinking training into the teaching and learning process to encourage them to better cope with the complex challenges of their future work and life. Policymakers should establish a series of care and monitoring mechanisms to ensure that measures to promote the mental health of nurses are better implemented.

This study is the first to document the network structure of workplace violence, psychopathological symptoms, and workplace deviant behaviors in Chinese nursing interns. The results confirm some of the well-established findings in the field, with the top ten strongest borderline distributions observed in the model distributed across the scale structures, with the strongest preponderance between VSH-PSH. The present study identified “Depression” as being centrally located and most strongly associated with the other symptoms and “Anxiety” as being the most central symptom in the network and the most critical bridging symptom. These findings provide a more precise target for preventing and intervening in nursing interns -related symptoms.

Some limitations of this study deserve attention. First, because this was a cross-sectional study, it was not possible to determine causal relationships between the elements. Ongoing research should use longitudinal data over time to examine the relationship between workplace violence, psychopathic symptoms, and workplace deviant behavior. Second, participants may be at risk for recall bias, leading to inaccurate responses. Prospective cohort studies may reduce recall bias. Also, the incidence of workplace violence against nursing interns may be underestimated and underreported. Underreporting may be due to the acceptance of workplace violence as part of a nurse’s job, their fear of blame or retaliation, and fear of trouble for themselves if they report it. Third, the different identities of the perpetrators may have other impacts on the emotional and behavioral responses of nursing interns. Differences in outcomes between different perpetrators of violence (supervisors, colleagues, or patients) were not further analyzed in this study. Fourth, the study did not investigate variables, such as supervisors’ management styles of workplace violence and nurses’ strategies for coping with WPV, which may have implications for both workplace deviant behaviors and physical and mental health. Therefore, based on the above research limitations, we will consider them in further studies.