Workplace violence, work characteristics, and seniority levels among nurses: a cross-sectional study

This study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines for cross-sectional studies. In this cross-sectional survey study, a convenience sampling approach was employed to recruit 1,000 nurses (including 933 women and 67 men) from a medical center in New Taipei City, Taiwan, between February and May 2021. As the hospital on which this study focuses features a total nursing population of 1,000 nurses, we conducted a census survey of all nurses. The adequacy of the sample size was evaluated. This sample size was determined to be adequate in light of the guidelines for logistic regression sample size calculation proposed by Bujang [21], who recommended n = 100 + 50(i), where i is the number of independent variables. Since eight independent variables (i.e., sex, level of education, work shift, work hours, job control, psychological job demands, workplace justice, and seniority) were included in our study, the minimum required sample size was 500. Therefore, our sample of 1,000 nurses was more than sufficient for the planned analyses. The hospital has 977 beds, including general and specialized care units, covering various specialties and patient care settings. The inclusion criteria used in this research focused on full-time nurses aged > 20 years who provided direct patient care. The exclusion criteria pertained to (1) nurses who were on extended leave (e.g., maternity leave or sick leave); (2) nurses who worked part-time or were temporary nurses; (3) nurses who were unable to complete the questionnaire independently; and (4) nurses who did not provide direct patient care (e.g., head nurses). Additionally, incomplete questionnaires that featured missing responses were excluded from the analyses. The participants were categorized into senior nurses and novice nurses according to seniority. After the postgraduate year (PGY), nursing training programs in Taiwan—supported by the Ministry of Health and Welfare (MOHW)—last for two years [15]; thus, participants with ≤ 2 years of experience were classified as novice nurses, and those with > 2 years of experience were classified as senior nurses. The data were collected using paper-based questionnaires, which were distributed and completed at the hospital. The researchers personally visited the hospital to explain the study and recruit participants.

The demographic data, including marital status, age, level of education, and seniority, were self-reported. WPV experience was evaluated using one-item questions for each type of WPV, asking participants whether they had ever experienced any of the four types of WPV (physical violence, verbal violence, psychological violence, or sexual harassment) in the past 12 months; the response options were “yes” or “no.” Participants could select multiple types of WPV if they had experienced more than one type simultaneously. We classified participants who had experienced at least one type of WPV, regardless of the specific type(s), as having experienced “any WPV.” Previous studies have used an identical classification system for WPV types [12, 22].

Information on work characteristics, including rotation work shifts, the number of work hours, job control, psychological job demands, and workplace justice, was collected via a self-report questionnaire. The participants were asked whether their work involved fixed/day shifts or night/rotating shifts. Data concerning the average number of hours they had worked per week over the past month were also collected; on this basis, the nurses were divided into two categories (i.e., those who worked ≤ 48 h/week and those who worked > 48 h/week). The 48-hour threshold was selected on the basis of Taiwan’s Labor Standards Act (Article 36), which mandates at least one rest day every seven days [23]. For workers who work six days per week, the total number of standard maximum working hours is 48 (6 days × 8 h per day). This threshold is also in line with categorizations that have been used in previous studies [22, 24].

Job control and psychological job demands were measured via the Chinese version of the Job Content Questionnaire (C-JCQ), which is based on Karasek’s job strain model [25, 26]. Job control indicates the amount of autonomy and discretion that an employee has over their work tasks and processes. Psychological job demands are related to the mental requirements of the job, such as workload, intellectual demands, and time pressure [22, 26]. Job control is measured using nine items, including six for skill discretion and three for decision-making authority. Psychological job demands are measured on a nine-item scale. Both the job control and psychological job demand scales exhibited high reliability; namely, the corresponding Cronbach’s α coefficients were 0.80 and 0.82, respectively [27]. Analyzing job control and psychological job demands as independent constructs allows researchers to obtain a nuanced understanding of their individual and combined effects on WPV and job stress and is consistent with previous research methodologies [22, 27].

Workplace justice was assessed via a nine-item scale that measured employees’ perceptions of fairness in their work environment [22, 28‐30]. This scale evaluated four aspects of workplace justice: distributive justice (i.e., fairness in terms of the allocation of rewards and resources), procedural justice (i.e., fairness in terms of organizational processes and decisions), informational justice (i.e., the adequacy and truthfulness of information), and interpersonal justice (i.e., respect and dignity in treatment). Specifically, the nine items included in the scale assessed trust between supervisors and employees, the reliability of the information provided by supervisors, the transparency of communication, employees’ influence on management decisions, fairness in terms of work arrangements, fairness in terms of reward management, fairness in terms of performance evaluation, information provision during decision-making processes, and the respect provided by supervisors. Each item was scored on a 4-point Likert scale ranging from 1 (strongly disagree) to 4 (strongly agree). Items that were listed in the opposite format were reverse-scored, and the total score indicated the level of perceived workplace justice. The scale exhibited a high level of internal reliability, as indicated by a Cronbach’s α value of 0.87 [29]. The total scores were then ranked and divided into tertiles (i.e., low, medium, and high) on the basis of their distribution in our sample, which was in line with the approaches employed in previous research [22, 28, 30].

The demographic characteristics, work characteristics, and WPV experiences of all participants were analyzed. The demographic characteristics, prevalence of the four types of WPV, and work characteristics stratified by seniority were determined. Furthermore, multivariable logistic regression was used to analyze the associations between various demographic and work characteristics and the types of WPV. Age was not included in the multivariable logistic regression model to avoid potential bias, as age is highly correlated with clinical experience and seniority, potentially resulting in multicollinearity issues. Given that age and psychosocial work conditions (job control, psychological job demands, and workplace justice) have been revealed by previous studies to be correlated with WPV [31, 32], these variables were controlled for and included as confounding factors in the regression models. Since less than 50 participants reported experiencing sexual harassment, this parameter was excluded from the multivariable logistic regression model. All analyses were performed with SPSS 23.0 (IBM, Armonk, NY, USA).

The study was reviewed and approved by the Institutional Review Board of Taipei Medical University (IRB number: N202011044). The questionnaires were distributed by independent researchers to the nursing staff and collected after they were completed anonymously. The independent researchers briefly explained the study’s aims to the participants, and those who agreed to participate provided signed informed consent forms.

Regarding the types of WPV, nurses mainly experienced verbal violence rather than physical violence, psychological violence, or sexual harassment, which is consistent with the results of previous studies [10, 13, 33]. According to Kim, Mayer, and Jones (2021), verbal abuse is more common than physical violence. However, hospital notification systems often underestimate the former type of violence [33]. This trend highlights the need for increased awareness and improved reporting mechanisms that can capture the prevalence of verbal violence against nurses accurately. Effective workplace violence (WPV) notification systems are critical with regard to efforts to reduce violence against nurses. A strong reporting culture facilitates accurate data collection, which is essential with respect to the development of targeted interventions and policies that can address WPV. Additionally, when nurses feel supported during the process of reporting incidents and do not fear retaliation, this situation establishes a safer work environment, reduces burnout, and improves patient safety [36]. Therefore, healthcare institutions should prioritize the establishment and maintenance of comprehensive WPV reporting systems and improvements to violence notification systems and procedures with the goals of reducing notification burdens, protecting nurses, and improving the overall quality of care.

This review of previous studies highlights four major factors that may contribute to the high incidence of verbal violence observed in healthcare settings [2, 5]. First, an organizational culture that lacks robust policies and fails to prioritize workplace safety causes verbal violence to be tolerated and underreported. Second, systemic issues within healthcare environments, such as overcrowding, long wait times, and understaffing, exacerbate relevant tensions, thus leading to more verbal violence incidents. Third, insufficient training in conflict resolution and communication skills entails that healthcare workers are unprepared to manage aggressive behavior, thus increasing their vulnerability. Finally, patients and family members often experience heightened levels of stress and anxiety in the context of medical care, which can escalate into verbal aggression. Therefore, addressing these interconnected factors is essential with regard to efforts to establish a safer and more supportive healthcare environment for both staff and patients.

Furthermore, physical violence is usually the most severe form of violence and should be reported to superiors or other administrative departments compared to other forms of violence. However, previous studies have reported that physical violence may be underreported [37]. This is attributable to the fact that the nurses will account for a patient’s condition (cognitive impairment, nervous damage, and psychiatric disease), and they will not hold the patient responsible or feel the need to report the incident, as the effects on the nurses are minor. Some nurses who reported being harassed also worried that the offender would harass them, become violent toward them, threaten them and their family members, or even affect their work [2, 37]. Furthermore, several nurses mistakenly believe that WPV is part of their job and that they have unfortunately been in the wrong place at the wrong time [2]. In clinical practice, verbal warnings or a lack of additional action are common among offenders [9]. According to several studies, nurses may underestimate the frequency of WPV reports [7, 9, 37].

These results indicate that nurses must have appropriate awareness of WPV to decrease its adverse effects. To decrease the prevalence or harm of WPV, nurses’ awareness of, attitudes toward, and ability to cope with WPV should be strengthened [13], and training content and methods should be designed for different types of WPV. This will increase nurses’ motivation and proactive behavior to ensure that all nurses are well protected and work in a safe working environment.

The nature of nursing work, higher levels of psychological job demands, and lower levels of workplace justice were revealed to be correlated with all types of WPV; these results are similar to those that have been reported in previous studies [38]. The psychological job demands faced by nurses have been reported to be associated with self-rated health (SRH) [30], job control-related stress, job control, job satisfaction, and fatigue [39, 40]. Nursing inherently involves a high-pressure environment that is associated with significant psychological job demands, including heavy workloads, role conflicts, and time constraints. Nurses are required to maintain high levels of motivation and task performance, thereby achieving quality outcomes with minimal errors, which can lead to various challenges to their physical and mental health. Thus, the implementation of policies that can effectively manage psychological job demands is critical with regard to efforts to improve nurses’ overall well-being.

Workplace justice may be a protective factor against turnover, and lower workplace justice may have adverse psychosocial effects on nursing staff. Therefore, establishing a fair system and increasing work autonomy can decrease turnover intentions among nurses [11]. Moreover, WPV reporting systems remain a critical area for improvement. As noted by Huang et al. (2022), many healthcare institutions worldwide lack effective policies to support WPV reporting [7]. Complex and underdeveloped reporting systems have often been identified as barriers to WPV reporting; this limitation hinders the proper documentation and resolution of such incidents. The findings of a cross-sectional study of nurses in five European countries highlighted the importance of improving WPV reporting systems [41]. The study in question revealed substantial underreporting of WPV events; in particular, nurses identified a fear of retaliation, a lack of institutional support, and burdensome reporting procedures as significant barriers to filing reports. That study also indicated that although nurses experienced high rates of WPV, many chose not to report such incidents due to their belief that reporting these events would not lead to meaningful changes or interventions. These results are indicative of global trends in WPV reporting and highlight the need for institutions to simplify reporting procedures and establish more supportive environments that can encourage nurses to come forward without fearing repercussions.

The non-significant association between job control and WPV observed in this study is consistent with the findings reported by Yeh et al. (2020) [19] and Magnavita et al. (2020) [18]. High-stress, dynamic environments such as those associated with nursing and job control alone may be insufficient to mitigate WPV risks due to the unpredictable nature of patient interactions and workplace demands. In tiered care settings that feature strict protocols and limited autonomy, the protective effect of job control may be limited. Yeh et al. (2020) revealed that WPV reduces employees’ sense of job control and increases their turnover intentions by reducing their job satisfaction and perceived control over the work environment [19]. Although job control can reduce stress and reduce turnover, its mitigating effect may be limited in structured healthcare settings that feature minimal autonomy. On the other hand, Magnavitta et al. (2020) emphasized the fact that job control and workplace justice may indirectly influence the impact of WPV by reducing stress and enhancing coping mechanisms [18]. These findings suggest that while job control is essential with respect to efforts to mitigate workplace stress, the limited relevance of this factor in this context highlights the importance of other factors, such as psychological job demands, social support, and workplace justice, in efforts to address WPV. Future researchers should investigate how job control interacts with these factors as well as its role in the complex dynamics underlying WPV in the context of healthcare. Such investigations could inform the development of tailored interventions that can address the multifaceted challenges associated with WPV in caregiving environments.

In summary, an approach that involves addressing both psychological job demands and workplace justice while simultaneously improving WPV reporting systems is essential with regard to efforts to mitigate the impact of WPV on nursing staff. The development of supportive institutional frameworks can enhance not only nurse retention but also the quality of the care delivered to patients.

Novice nurses face unique challenges during their transition from education to clinical practice, thus requiring them to engage in substantial learning and adaptation [14, 42]. The process of adjusting to new work environments, hospital systems, and professional roles, alongside the need to manage complex interpersonal dynamics, often imposes significant psychological strain. Limited experience, underdeveloped coping strategies, and workplace stress further exacerbate the difficulty of this transition [43]. These challenges, which are exacerbated by understaffing, frequently result in feelings of inadequacy and fear, thus increasing these nurses’ susceptibility to workplace violence (WPV) [43].

Research has consistently reported that novice nurses experience higher rates of WPV than do their senior counterparts, particularly with respect to psychological violence [8, 10]. Poorer social support, weaker communication skills, and reduced ability to respond to WPV contribute to the heightened vulnerability exhibited by these nurses [42]. Their limited awareness of WPV and lack of confidence in their ability to address incidents often lead them to adopt negative attitudes toward violence management [43]. These factors, alongside the high prevalence of burnout and turnover in this context, highlight the critical need for targeted interventions during this transitional period [16, 42].

To address these issues, nursing managers and healthcare organizations must implement tailored education and training programs to enhance novice nurses’ confidence and skills pertaining to the management of WPV [43]. Hospitals should prioritize the unique needs of novice nurses, particularly by offering training and support systems that address risks related to WPV. The establishment of a supportive environment, complemented by comprehensive prevention and management strategies, can promote positive attitudes toward violence management and improve nurses’ overall safety and well-being. These measures can not only help novice nurses navigate this critical phase but also contribute to the formation of a resilient nursing workforce [16, 42].

Education should focus on equipping novice nurses with strategies that can enable them to manage workplace stress and address violence effectively while reinforcing management principles and procedures pertaining to WPV. The establishment of robust support systems can improve nurses’ attitudes and institutional awareness, as research has highlighted the significant role played by confidence in shaping individuals’ responses to WPV [13, 43]. Moreover, the need to develop the clinical and professional skills necessary to promote independent practice within a team exacerbates psychological strain, thus increasing the difficulty of the adjustment process [14, 42, 43]. Mentorship by senior nurses is another key approach to the task of supporting novice nurses. Professional guidance and mental health support during the transitional phase can mitigate the impact of psychological violence, strengthen coping strategies, and foster positive working relationships [42, 44]. Alongside ongoing WPV education, mentorship represents an essential buffer against stress and promotes resilience. Therefore, future researchers should explore the specific factors that influence WPV among novice nurses and develop more effective prevention and intervention strategies with the goal of nurses’ awareness of and confidence in their ability to manage WPV, which are essential components of efforts to mitigate these risks and establish a supportive environment for their professional growth.

Interestingly, this study did not reveal any significant differences in the rates of verbal and physical violence rates between novice and senior nurses, which may be due to the “healthy worker effect” [4]. Novice nurses who cannot tolerate violence may choose to resign during their probation period. However, the higher vulnerability to psychological violence exhibited by novice nurses, as indicated by the findings of this research, suggests that resignation within the three-month timeframe may be more closely linked to psychological violence rather than to verbal or physical violence. Future researchers should investigate why novice nurses resign within this timeframe and examine whether verbal or physical violence contributes to their decisions in this regard. Correlation surveys could also provide valuable insights into the relationship between WPV exposure and turnover among novice nurses.

Our findings highlight the persistence of workplace violence among nurses, thus indicating a need to promote healthier work environments. These results offer insights that nurse leaders and policymakers can use to improve workplace characteristics by promoting work autonomy, establishing a safe culture, and ensuring effective violence management, thereby potentially mitigating nurses’ exposure to workplace violence and reducing their turnover intentions.

The main strength of the present study lies in its comprehensive investigation of WPV types and workplace characteristics within health systems, particularly among nursing staff at different seniority levels. While previous research has predominantly focused on WPV prevalence, types, and sources among nursing staff in different units, limited research has investigated the relationship between seniority levels and violent behaviors. Our study revealed that nurses with different seniority levels experience distinct types of WPV, necessitating tailored WPV policies. These findings can help nurse leaders and policymakers enhance workplace conditions by promoting autonomy, fostering a safe culture, and implementing effective violence management, which may mitigate nurses’ exposure to WPV and reduce turnover intention. Another notable strength is the identification of WPV risk factors and the recognition that psychological job demands and workplace justice may be protective factors against WPV. Therefore, developing effective policies to manage psychological job demands and enhance workplace justice can empower nurses and nurture proactive mindsets, contributing to the mitigation of WPV.

Nonetheless, this study has some notable limitations. First, a convenience sampling approach was used, and the participants were recruited exclusively from a medical center in northern Taiwan, which may limit the external validity of the findings of this research. One important limitation of this study is that we did not collect data concerning the sources of workplace violence, thus rendering us unable to differentiate between internal violence from colleagues and external violence from patients/families. Recent research has reported that these two sources of violence have different impacts on nurses’ health outcomes, such that internal workplace violence is more strongly associated with poor health outcomes than is violence from patients and families [45]. Additionally, different types of workplace violence are associated with distinct antecedent factors that require targeted prevention strategies [46]. Furthermore, we did not account for the participants’ specific workplace care settings. Research has reported that in certain settings, such as emergency departments and mental health units, workplace violence (WPV) events are more frequent. This unaddressed variable could have served as a potential confounder, and future researchers should incorporate a clear way of distinguishing among different workplace settings to capture the variability in WPV incidence across healthcare environments more effectively. Moreover, Future surveys may cover more diverse levels of care, including by incorporating region- or hospital-specific differences to capture various nuances of WPV between novice and senior nursing staff more effectively, thus allowing such research to validate the findings of this study. Second, we assessed the occurrence of WPV only on the basis of a binary “Yes/No” question, which limited the depth of the data collected as part of this research. A more nuanced approach, such as utilizing a Likert scale to measure the frequency of WPV events (e.g., weekly, monthly, rarely, or never), would have provided richer and more informative data. This approach would facilitate a more comprehensive understanding of the frequency and severity of WPV incidents among novice and senior nurses.

Additionally, the exclusion of nurses who left the profession during their probationary period—often as a result of their inability to cope with WPV—may have caused the full impact of WPV on nursing staff to be underestimated. The inclusion of these individuals in future studies would offer a more holistic understanding of the consequences of WPV with respect to nurse retention. The COVID-19 pandemic likely altered workplace conditions and patient interactions, thereby potentially influencing the prevalence of WPV during the study period. This contextual factor adds a layer of complexity to the task of interpreting the findings of this research, as the pandemic may have temporarily increased the frequency or reporting of WPV. Although our study offers a timely depiction of WPV during this period, the findings of this research should thus be interpreted cautiously. Another limitation pertains to our division of nurses into different seniority group, i.e., novice nurses (i.e., those with ≤ 2 years of experience) and senior nurses (i.e., those with > 2 years of experience). While this categorization is in line with the postgraduate year (PGY) nursing training program used in Taiwan, we acknowledge that the senior group spans multiple career stages, thereby potentially obscuring trends in nurses’ levels of WPV exposure. Future research featuring larger sample sizes should consider more detailed seniority categories, such as 0–1 years, 1–5 years, and > 5 years, as suggested by Pien [47], to obtain a better understanding of how workplace violence risks evolve across career stages.

Finally, the study featured a cross-sectional design, which limited its ability to establish causal relationships among the predictor variables. The incorporation of nurses’ clinical experience as a variable in future research could provide a more nuanced understanding of the effects of WPV on nurses at various stages of their careers. Future researchers should also differentiate between internal violence from colleagues and external violence from patients/families, as these different sources of workplace violence may require distinct intervention strategies. Understanding the characteristics and impacts of different types of violence could facilitate the development of more targeted and effective prevention measures, particularly since internal workplace violence has been reported to have stronger negative effects on nurses’ health outcomes [45, 46]. In conclusion, addressing these limitations in future studies—by broadening the scope of participant recruitment, refining the measurement of WPV frequency, clarifying the identity of WPV perpetrators, and accounting for clinical experience—would enhance the generalizability and depth of findings pertaining to WPV among healthcare professionals.