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Students’ experiences of violence in clinical settings: what senior nurses can do

Healthcare workers are often the target of aggression, but nursing students on placements are vulnerable too

Healthcare workers are often the target of aggression, but nursing students on placements are vulnerable too


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Violence and aggression cause significant problems for healthcare staff working in a range of settings. Findings from a meta-analysis suggest that 44% of nurses have experienced violence in the previous six months (Spector et al 2014). 

Verbal abuse is the most commonly experienced type of aggression across all healthcare settings (Edward et al 2014) while physical aggression is most prevalent in mental health settings (Shiao et al 2010), although emergency department staff also experience high levels of physical assault (Gates et al 2011). Patients are most likely to be the perpetrators of aggression and nursing staff experience high levels of aggression (Campbell et al 2011).

Effects on students

There is a large body of evidence describing staff experiences of aggression but the extent of violence and aggression towards nursing students in clinical placements is less well researched. 

However, the findings of a recent systematic review and meta-analysis (Hallett 2018) on this subject present a similar picture to that seen among nursing staff. 

'Victims of bullying can experience psychological and physiological effects, but bullying may be difficult to spot in students'

The review focused on pre-registration nursing students and included only studies that examined rates of violence and aggression in clinical settings. Data for the review came from 26 studies in 11 different countries, reporting results from 8,805 nursing students. Information was extracted about the types of violence that nursing students experience and the sources of this violence.

Bullying was most common, with three out of five nursing students reporting that they had experienced it. This was followed by non-physical aggression, the use of inappropriate words or behaviour that causes distress, reported by more than half of the nursing students surveyed. Almost one in five nursing students had experienced sexual harassment, with a similar number reporting racism, and, although fewer reported experiencing physical aggression, this was still reported by almost one in six. 

Sources of aggression

As with qualified staff, patients were the most likely perpetrators of aggression overall, accounting for almost half of all incidents. Others, in descending order, were nurses, visitors, doctors and other nursing students. 

Patients were the most likely source of both physical and non-physical aggression, accounting for around half of all incidents; these were followed by nurses, accounting for about one in six incidents of physical and non-physical aggression.

Bullying, perhaps unsurprisingly, was most likely to come from nurses, with more than half of incidents involving qualified staff and one in ten other nursing students. More than half of all incidents of sexual harassment were perpetrated by patients, while almost one quarter were by doctors.

Some of the studies in the review also identified whether students report the aggression they experience, but findings are inconsistent. One study found that one in five students reported non-physical aggression, but twice this number reported physical aggression (Magnavita and Heponiemi 2011). 

However, other studies have found that three out of five students reported non-physical aggression (Ferns and Meerabeau 2009) and that three quarters reported physical aggression (Grenade and Macdonald 1995). The only study to identify reporting rates of bullying found that a little over one in ten incidents were reported (Unal et al 2012).

Power imbalance

The findings of this review have implications for senior nurses. The level of bullying experienced by nursing students supports the argument that nurses ‘eat their young’, despite the many organisational and cultural changes that have occurred in the 30 years since this accusation was first made (Meissner 1986). 

Victims of bullying can experience psychological and physiological effects, but bullying may be difficult to spot in students, whose placements are relatively short. A noticeable change in attitude towards a placement could be related to a student experiencing bullying or another type of aggression, and this should be explored. 

'One of the reasons given by nurses for not reporting incidents is that they do not see any changes made and so believe that reporting is not worthwhile'

Educational establishments should prepare students to prevent and manage violence in all its manifestations, but they may not provide training on how to deal with bullying. The power imbalance between students and staff means it can be difficult for students to report bullying. 
 
The imbalance can be even more difficult to manage when the perpetrator is a doctor; with a quarter of all incidents of sexual harassment involving doctors, this could be a significant problem. 

Clear reporting processes

Senior nurses should help to create environments in which students feel supported, with clear processes for reporting all types of aggression. 

Furthermore, it is important for students to know the outcome of their reporting. One of the reasons given by nurses for not reporting incidents is that they do not see any changes made and so believe that reporting is not worthwhile (Hogarth et al 2016). Students may not remain in a placement area long enough to see any changes that are made, but they can still be informed of the outcome. 

Senior nurses should also work with educational establishments to ensure that students who experience aggression receive support to manage possible after-affects. 

Finally, it is important to remember that students may have little or no real experience in dealing with angry people. Nurses, particularly in some areas, experience violence and aggression from patients so frequently it becomes ‘part of the job’. However, this notion should be refuted; nursing students should be taught, not to learn to live with it, but to prevent it where possible and report it when it happens.

References

Campbell JC, Messing JT, Kub J et al (2011) Workplace violence: prevalence and risk factors in the safe at work study. Journal of Occupational and Environmental Medicine. 53, 1, 82-89.

Edward K-l, Ousey K, Warelow P et al (2014) Nursing and aggression in the workplace: a systematic review. British Journal of Nursing. 23, 12, 653-659.

Ferns T, Meerabeau E (2009) Reporting behaviours of nursing students who have experienced verbal abuse. Journal of Advanced Nursing. 65, 12, 2678-2688.

Gates DM, Gillespie GL, Succop P (2011) Violence against nurses and its impact on stress and productivity. Nursing Economics. 29, 2, 59.

Grenade G, Macdonald E (1995) Risk of physical assaults among student nurses. Occupational Medicine. 45, 5, 256-258.

Hallett N (2018) Student experienced violence: systematic review and meta-analysis. RCN International Nursing Research Conference 2018. Birmingham, 16-18 April. 

Hogarth KM, Beattie J, Morphet J (2016) Nurses’ attitudes towards the reporting of violence in the emergency department. Australasian Emergency Nursing Journal. 19, 2, 75-81.

Magnavita NMD, Heponiemi TP (2011) Workplace violence against nursing students and nurses: an Italian experience. Journal of Nursing Scholarship. 43, 2, 203-10.

Meissner J (1986) Do nurses eat their young? Nursing. 16, 3, 52-53.

Shiao JS-C, Tseng Y, Hsieh Y-T et al (2010) Assaults against nurses of general and psychiatric hospitals in Taiwan. International Archives of Occupational and Environmental Health. 83, 7, 823-832.

Spector PE, Zhou ZE, Che XX (2014) Nurse exposure to physical and nonphysical violence, bullying, and sexual harassment: a quantitative review. International Journal of Nursing Studies. 51, 1, 72-84.

Unal S, Hisar F, Gorgulu U (2012) Assertiveness levels of nursing students who experience verbal violence during practical training. Contemporary Nurse. 42, 1, 11-19.

 


Nutmeg Hallett is a lecturer in mental health nursing at the University of Birmingham

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