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 that of physical violence (body 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(24) indicated that non-physical violence (65.5%) was higher than physical violence (26.7%) globally. The gap between the finding of Spector et al(24) 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 those with junior degree students. Students who had changed their college major and those who concerned more about violence encountered more violence. Consistent with previous literates, nurses with university degrees, higher workload or stress, worse adaption to the environment may get higher risk of experiencing any form of violence(25, 26). This study found that the main responses of nursing students to the WPV were avoiding conflict and explaining with patience, while fewer students sought help from teachers, security guards, and police. In the future, training programs offered by nursing educators should focus on raising students’ prevention and response-ability in combination with building up characteristics of nursing students.
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(27). High patient expectations(28), and the negative propaganda in the media(29) lead to patients aggressive behavior. Patients, for instance, tend to believe that they deserve high-quality care and good clinical outcomes once they are admitted to the hospital, regardless of the severity of their disease(30). 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(29). Something always happens at the beginning of the violence, such as offensive behavior, 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%), irrelevant to me (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(31). Laschinger(32) suggested negative work experiences may result in new graduates assimilating such behavior 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. It is urgent to provide relevant violence prevention education and training for nursing students to meet the need. 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 counseling 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(33). 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(34), build up a culture of zero tolerance toward such behavior and set up a self-valued society.
Limitations of the study
Firstly, this study was conducted in five cities in China, and the results may not apply to other regions. Secondly, due to the limitation of human resources, this study did not investigate nursing students at different practice time points. Whether the occurrence of WPV, coping style, and professional identity of nursing students have changed before and after clinical practice needs longitudinal research. Thirdly, the cross-sectional study cannot fully reflect the thoughts of nursing students. In the future, it will be necessary to deeply explore nursing students' understanding and experience of violence through qualitative research, especially before and during the relevant violence prevention training conducted by nursing educators.