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Violence experienced by Turkish nursing students in clinical settings: Their emotions and behaviors
Nurse Education Today 30 (2010) 687–691
Contents lists available at ScienceDirect
Nurse Education Today journal homepage: www.elsevier.com/nedt
Violence experienced by Turkish nursing students in clinical settings: Their emotions and behaviors Ayda Çelebiog˘lu a,*, Reva Balcı Akpinar b, Sibel Küçükog˘lu a, Raziye Engin a a b
Ataturk University, School of Nursing, Erzurum, Turkey Ataturk University, Erzurum School of Health, Erzurum, Turkey
a r t i c l e
i n f o
Article history: Accepted 8 January 2010
Keywords: Nursing student Violence Workplaces Emotions
s u m m a r y Aim: This descriptive study aimed to determine the violence experiences of nursing students’ in clinical settings, the types of violence, and the way their behaviors and emotions are affected after such an experience. Background: The risk of being subjected to violence among health staff is very high and the students who worked in the same kind of work environments also faced similar risks. Methods: The data of the study were obtained from the 380 nursing students who were studying at 2nd, 3rd, and 4th grades. Participation was voluntary. A questionnaire form was developed by the researchers and distributed to the students. Results: It was found that 50.3% of the students were subjected to violence, and 91.6% of these students were subjected to verbal violence. The students most frequently experienced anger, fury, and enmity (84.3%) after confronting violence. Conclusion: Findings of our study showed that similar to nurses, nursing students, who spent a significant proportion of their education in areas of practice, also experienced violence. Therefore, measures should be taken to prevent the violence inflicted upon nursing students in clinical settings, and nursing students should be provided with information related to communication and the coping methods with violence during their education. Ó 2010 Elsevier Ltd. All rights reserved.
Introduction Violence, which is currently prevalent in every sphere of social life, in all races and cultures, is defined as physical, emotional and sexual behavior that harms individuals physically and/or psychologically (Yurdakul, 1996; Erdem and Üstün, 1997). Workplace violence, on the other hand, is defined as ‘‘incidences where the worker is abused or assaulted by a person or people during situations related to their work” (Warshaw, 1996). Violence in health institutions is defined as ‘‘any incidence of threatening behavior, verbal threat, physical assault and sexual assault inflicted by the patient, the patient’s relatives or any other individual, which constitutes a risk for health staff’’ (Saines, 1999). Violence, which is frequently encountered in workplaces, is considered today as an issue of work security and health and is significantly focused on other areas of risk within the work environ-
* Corresponding author. Address: School of Nursing, Atatürk University, 25240 Erzurum, Turkey. Tel.: +90 442 2312747; fax: +90 442 2360984. E-mail addresses: [email protected], [email protected] (A. Çelebiog˘lu), [email protected] (R.B. Akpinar), [email protected] (S. Küçükog˘lu), [email protected] (R. Engin). 0260-6917/$ - see front matter Ó 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.nedt.2010.01.006
ment (Chanier, 1998; Uzun et al., 2001; Çelik and Bayraktar, 2004) and workplace violence in healthcare settings is increasing (Keely, 2002). The risk of being subjected to violence among health staff is 16 times higher than in other occupational groups in the service sector (Kingma, 2001). The literature notes that many nurses work in unsafe environments, and are three times more likely to experience violence than any other professional groups (Keely, 2002). The majority of nurses are women, and these women often work in unsafe environments (NIOSH, 2006). There may be a relationship between the risk of violence experienced by women in general and the violence risk of female nurses (Hinchberger, 2009). Studies on abuse against nurses have reported wide prevalence rates ranging from 37% to 72% (Fernandez et al., 1999; Stirling et al., 2001; Lin and Liu, 2005). Similarly in previous studies performed with Turkish nurses, it was observed that nurses were subjected to violence at high rates (Uzun, 2003; Alçelik et al., 2005; Ayrancı, 2005; Sßenuzun and Karadakovan, 2005; Çelik and Çelik, 2007; Çelik et al., 2007; Gökçe and Dündar, 2008; Kisa, 2008). Findings related to violence against staff nurses in the workplace is well documented. However, little is known about the student nurse population. It is found that in the limited numbers research performed with the students who worked in the same kind of work
688
A. Çelebiog˘lu et al. / Nurse Education Today 30 (2010) 687–691
environments also faced similar risks (Çelik and Bayraktar, 2004; Lash et al., 2006; Ferns and Meerabeau, 2007; Longo, 2007; Hinchberger, 2009). In the study by Finnis and Robbins (1994), Ferns and Meerabeau (2007) and Hinchberger (2009), it is reported that nursing students also confronted violence in various rates. In Turkey, in the study by Çelik and Bayraktar (2004), it was found that all of the nursing students experienced high rates of verbal violence, as well as academic, physical, and sexual violence. The study conducted by Lash and his colleagues (2006) revealed that students experienced verbal violence during clinical practices. Nursing students are often inflicted violence by patients, patients’ relatives, nurses, doctors and other staff (Çelik and Bayraktar, 2004; Lin and Liu, 2005; Lash et al., 2006; Ferns and Meerabeau, 2007). The difficulties experienced in the work environment have a negative impact on the members of the nursing profession, just as they affect the members of every professional group (Poster, 1993). Nurses’ confrontation with incidences that threaten security within the work environment can lead to negative impacts on both their own physical and psychological welfare and the quality of the service they provide. Violence has been shown to have biopsychological, emotional, cognitive, and social impacts on nurses (Lanza, 1983). It was found that the most frequently experienced emotions of the nurses who were subjected to violence were anger, fear, anxiety, post-traumatic stress syndrome, guiltiness, blaming oneself, and embarrassment (Needham et al., 2005). Similarly, nursing students have also demonstrated such emotions in the work environment from time to time (Kisa et al., 2002; Çelik and Bayraktar, 2004; Needham et al., 2005). Violence and assault in the work environment against the health staff, who seeks to help patients and the injured, are regarded as a surprising and an unacceptable occurrences (Scott, 2003). This study aimed to determine the violence experiences of nursing students’ in clinical settings, the types of violence, and the way their behaviors and emotions are affected after such an experience.
closed-ended questions regarding the descriptive characteristics, and the second section included closed-ended questions that aimed to reveal incidences of nursing students’ confrontation with violence, the types of violence they confronted, by whom the violence was inflicted, their opinions on why they confronted violence. In addition students’ behaviors and emotions after confrontation with violence also were asked. The items were evaluated by two experienced nurse educators for content and clarity. The questionnaire was tested in a pilot study with 12 students. There were minör revisions in the questionnaire. The data from the pilot study were not included in this study. Data analysis The statistical analyses of the data were made by means of SPSS statistical package program. For statistical analyses, percentage and frequency were calculated to show the characteristics, violence types, sources, students’ behaviors and emotions. The chisquare test was used to compare of the students’ confrontation situations according to their grades. Significance level was set at p < 0.05. Ethical consideration Before the research was initiated, legal permission was obtained from the administrations of both schools. The students were informed about the aim and method of the study, and their written informed consents were received. Participation was voluntary. Results The descriptive characteristics of the students within the scope of the study can be seen in Table 1. The age range of the 380 stuTable 1 Students’ descriptive characteristics.
Methods
Descriptive characteristics
Number
%
Design and settings
Age 19–23
380
21.16 ± 1.57
Year at school 2nd year 3rd year 4th year Total
153 135 92 380
40.3 35.5 24.2 100
Confrontation with violence Yes No Total
191 189 380
50.3 49.7 100
Type of violence Verbal violence Physical violence Sexual violencea Total
175 8 8 191b
91.6 4.2 4.2 100
Persons inflicting violence Patients and their relatives Nurses Doctors Other staff Total
102 41 38 10 191b
53.4 21.5 19.9 5.2 100
Frequency of confrontation with violence Once Twice Three times Four times or more Total
73 34 13 71 191b
38.2 17.8 6.8 37.2 100
The design of the study was descriptive survey and data were collected in 2007. The data of the study were obtained from the students of School of Nursing and School of Health, Atatürk University. It was Midwifery and Nursing Departments in School of Health. The sampling included only nursing students, who were studying at 2nd, 3rd, and 4th grades. First graders were not included in the scope of the study as they had not started working in the area of practice yet. At the time when the research was carried out in the classes mentioned above, a total of 450 students were registered in the schools mentioned above: 270 in School of Nursing and 180 in School of Health. Because the students in both of the vocational schools were educated in the same clinical settings they were regarded as homogenous groups and were evaluated as a single group. On the day when the questionnaire was administered, all the students who were present at school (432 students) were informed about the aim and the method of the study, and the questionnaire forms were distributed. Of 432 questionnaire forms, 380 (88.0%) were returned. Data collection The questionnaire was developed by the researchers on the basis the literature (Uzun et al., 2001; Uzun, 2003; Çelik and Bayraktar, 2004; Ferns and Meerabeau, 2007). The questionnaire consisted of two sections. The first section included open- and
a Attitudes such as talks and jokes with sexual content, and attempts of physical contact. b Calculations were made for students who confrontated with violence.
A. Çelebiog˘lu et al. / Nurse Education Today 30 (2010) 687–691
dents constituting the sample of the study was 19–23 years (mean age: 21.16 ± 1.57 years), and a great majority (40.3%) were 2nd year students. Evaluation of the results indicated that half of the students (50.3%) were subjected to violence, and 91.6% of these students were subjected to verbal violence. It was found that of the 191 reported incidences of violence, 102 involved encounters with patients and the relatives of patients (53.4%) and of these 102, verbal abuse accounted for 92 cases and 7 situations of physical abuse were reported (Tables 1 and 2). According to the students, among the reasons for being subjected to violence, the anxiety and fears felt by the patient and/ or his/her relatives was the highest (70.2%), followed the lack of confidence in the nursing student by the patient, his/her relatives, and the clinical staff (63.9%), and the student being a female (53.9%) (Table 3). After the students confronted with violence, the majority did not react to the patient (66.0%), while the lowest rate was found for the attitude of being unwilling to take care of their patients (4.2%) (Table 4). The students most frequently experienced anger, fury, and enmity (84.3%) after confronting violence, while the least frequently experienced feelings were embarrassment and shame (20.9%). In addition, it was observed that 81.2% of the students felt anxiety, and 30.9% were unwilling to provide care (Table 5). When the data regarding whether nursing students confronted violence, the frequency of their confrontation with violence, and the distribution of the violence types were analyzed according to the grades of the students, no statistically significant difference were found among the groups (p > 0.05). Discussion The aim of our study was to determine the number and situations in which nursing students confronted violence during their practical training, the type of violence they confronted and the way their behaviors and feelings were influenced following this
689
Table 4 Students’ behaviors subsequent to being subjected to violence.
a
Behaviorsa
Number
%
I I I I I
126 32 29 18 8
66.0 16.8 15.2 9.4 4.2
did not react to the patient and continued providing care transferred my patient to another colleague thought of dropping out of school did not go to the practice did not take care of my patient
More than one answer was provided.
Table 5 Students’ emotions subsequent to confrontation with violence.
a
Students’ emotionsa
Number
%
Anger/fury/enmity Anxiety Disappointment Powerlessness/hopelessness/defenselessness Unwillingness in caregiving Fear Embarrassment/shame
161 155 114 76 59 41 40
84.3 81.2 59.7 39.8 30.9 21.5 20.9
More than one answer was given.
experience. The evaluation of the results showed that the rate of the students subjected to violence in the clinical settings was 50.3%. Verbal violence (91.6%) was the most frequently encountered type of violence, followed by physical violence (4.2%) and sexual violence (4.2%). In previous studies involving nurses, it was observed that nurses were subjected to violence at high rates (Fernandez et al., 1999; Stirling et al., 2001; Uzun, 2003; Lin and Liu, 2005; Alçelik et al., 2005; Ayrancı, 2005; Sßenuzun and Karadakovan, 2005; Çelik and Çelik 2007; Çelik et al., 2007; Gökçe and Dündar, 2008; Kisa, 2008).
Table 2 The distribution of the people inflicting violence upon students and types of violence. Persons inflicting violence
Patients and their relatives Nurses Doctors Other staff
Physical violence
Sexual violence
n
Verbal violence %
n
%
n
%
n
Total (191) %
92 41 35 7
90.2 100.0 92.1 70.0
7 0 0 1
6.9 0 0 10.0
3 0 3 2
3.0 0 7.9 20.0
102 41 38 10
100.0 100.0 100.0 100.0
Table 3 The reasons for being subjected to violence according to students’ perceptions (n = 191).
a
Reasons for being subjected to violencea
Number
%
The anxiety and fears of patients and/or relatives of patients The patient, the patient’s family and the clinical staff’s lack of confidence in the nursing student Being a female The patient and/or his/her family’s low level of education Lack of security measures The fact that the patient is feeling pain Insufficient number of health staff The mental health problems of patients and/or their relatives Lack of tolerance and patience of patients and their families Students’ lack of effective communication skills with furious patients and their families Being in close contact with patients and/or their families The consumption of alcohol by the patient and/or his/her relatives Nursing students’ lack knowledge and skills in caregiving Being negatively affected by the media Lack of sufficient time allocated to the patient
134 122 103 81 72 70 57 50 46 45 44 43 42 33 26
70.2 63.9 53.9 42.4 37.7 36.6 29.8 26.2 24.1 23.6 23.1 22.5 22.0 17.3 13.6
More than one answer was provided.
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It was found in our study that the students confronted with verbal violence were inflicted most frequently by patients and their relatives, followed by nurses, doctors, and other staff respectively. Physical violence was also found to be inflicted at a high rate by patients and their relatives. In a study performed by Çelik and Bayraktar (2004) the students confronted with verbal violence most frequently by their classmates (41.3%), patients (34.2%), nurses (33.8%) and doctors (31.6%). In the Uzun’s study (2003) patient relatives were greatest source of verbal abuse (59.8%). The study by Çelik et al. (2007) revealed that nurses were subjected to physical violence in their work environment by patients relatives. Although nursing students are often inflicted violence by patients and their relatives as are nurses, there are also incidences of violence by nurses inflicted on student nurses (21.5%). This indicates a problem in terms of professional awareness of nurses because nursing students are expected to be supported in the area of practice by nurses, who will be their colleagues in the future. However, the findings of our study may be an indication of the fact that nurses working in the clinics do not support the nursing students and do not regard them as a member of the profession. As a reason for being subjected to violence, the majority of the students reported external reasons, and a few of them indicated the reason for being subjected to violence as not being able to communicate with furious patients and/or their families. However, it is known that having sufficient knowledge and skill in preventing and protecting oneself from violence can largely prevent incidences of violence (Keely, 2002). Being unaware of their inadequacies is considered a condition that can hinder the development of the students in this regard. Some students also reported that neither the patients and their relatives nor doctors and nurses had confidence in them, and thus, they were inflicted violence by patients, their relatives, doctors and nurses. This may suggest that students lack the skills to communicate well with their social environment and do not have self-esteem. Therefore, further and detailed studies on this issue are warranted. None of the students informed an authority of the individual who inflicted violence, which may be an indication of their lack of knowledge on the issue. The evaluation of the students’ attitudes after being subjected to violence towards patients showed that most of the students did not show any reaction but just continued taking care of the patient; the number of the students who stopped taking care of their patients was low. This is important since it shows that priority is given to ‘‘caring the patient professionally” and carrying out basic nursing responsibilities and that a professional point of view is instilled in students. Such an attitude may be an indication of the fact that carrying out two of the responsibilities, ‘‘Relieving pain” and ‘‘Promoting Health, the reason for existence”, within the ‘‘Codes of Ethics in Nursing”, prepared by the International Nursing Coun_ cil, are the most important priorities of students (Inanç et al., 1999). On the other hand, the students did not react to the patients and/or their relatives who inflicted violence, which suggests that students’ communication skills with the furious/aggressive patients and their family are not well-developed. The failure to give an appropriate reaction can lead to not only an increase in the fury felt by the patient and his/her family but also the emergence of feelings of anger, fury, and enmity as a result of not being able to express her feelings. Moreover, although the number of the students who transferred the care of her own patient to another colleague, who thought of dropping out of school, and who did not go to school the following day was low, it indicates the negative impacts of violence on nursing students’ educational life. It was reported that feelings of anger, fury, enmity, anxiety, disappointment, weakness, helplessness, defenselessness, fear and embarrassment were the emotions that nursing students experienced most frequently after they confronted violence. This shows that students have poor stress management skills, and difficulty
in communicating and expressing their feelings. Feelings of fear and shame may have an impact on student’s inability in expressing their feelings. Moreover, experiencing the feeling of embarrassment can be explained as the student’s blaming herself for being subjected to violence. In previous studies conducted on nurses and students, similar findings were found (Sheehan et al., 1990; Poster, 1993; Finnis and Robbins, 1994; Uzun et al., 2001; Kisa et al., 2002; Çelik and Bayraktar, 2004; Needham et al., 2005). These negative feelings show that students are highly affected by the violence they are confronted with. Thus, with exposure to violence while the education of nursing students is in progress, both their psychological status and the quality of the service they provide and their adaptation to the work environment may be affected negatively, which in turn may have negative effects on their education and their adaptation to the profession. The findings in our study are important as they indicate how important the problem of violence in the workplace is, not only for the staff but also for the students who spend a significant amount of their time in the field. Conclusion Findings of our study show that violence was a important problem for nursing students in clinical settings. We suggest that measures should be taken to prevent the abuse inflicted upon nursing students in areas of practice, and nursing students should be provided with information related to communication and the methods of health care during their education. Students also should be encouraged to learn strategies and to practice how to respond to violent situations in the workplace. References _ Alçelik, A., Deniz, F., Yesßildal, N., Mayda, A.S., Sßerifi, B.A., 2005. AIBÜ Tıp Fakültesi Hastanesi’nde görev yapan hemsßirelerin sag˘lık sorunları ve yasßam alısßkanlıklarının deg˘erlendirilmesi. TSK Koruyucu Hekimlik Bülteni 4 (2), 55– 65 (in Turkish). Ayrancı, Ü., 2005. Violence toward health care workers in emergency departments in west Turkey. The Journal of Emergency Medicine 28 (3), 361–365. Çelik, S.Sß., Bayraktar, N., 2004. A study of nursing student abuse in Turkey. Journal of Nursing Education 43 (7), 330–336. Çelik, Y., Çelik, S.S ß ., 2007. Sexual harassment against nurses in Turkey. Journal of Nursing Scholarship 39 (2), 200–206. _ Ug˘urluog˘lu, Ö., 2007. Verbal and physical abuse Çelik, S.S ß ., Çelik, Y., Ag˘ırbasß, I., against nurses in Turkey. International Nursing Review 54, 359–366. Chanier, E., 1998. The workplace: a battle ground for violence. Public Personnel Management 27 (4), 557–569. Erdem, Y., Üstün, B., 1997. Hemsßirelerin çalısßma ortamında karsßılasßtıkları ßsiddet durumları: gözden geçirme. Hacettepe Üniversitesi Hemsßirelik Yüksek Okulu Dergisi 4 (2), 99–109 (in Turkish). Fernandez, C.M., Bouthillette, F., Rabound, J.M., et al., 1999. Violence in the emergency department: a survey of health care workers. Canadian Medical Association Journal 161 (10), 1245–1248. Ferns, T., Meerabeau, L., 2007. Verbal abuse experienced by nursing students. Journal of Advanced Nursing 61 (4), 436–444. Finnis, S., Robbins, I., 1994. Sexual harassment of nurses: an occupational hazard? Journal of Clinical Nursing 3 (2), 87–95. Gökçe, T., Dündar, C., 2008. Samsun ruh ve sinir hastalıkları hastanesi’nde çalısßan hekim ve hemsßirelerde ßsiddete maruziyet sıklıg˘ı ve kaygı düzeylerine etkisi. _ Inönü Üniversitesi Tıp Fakültesi Dergisi 15 (1), 25–28 (in Turkish). Hinchberger, P.A., 2009. Violence against female student nurses in the workplace. Nursing Forum 44 (1), 37–56. _ Inanç, N., Hatipog˘lu, S., Yurt, V., Avcı, E., Akbayrak, N., Öztürk E., 1999. Hemsßirelik Esasları. Damla Matbaacılık, Ankara, 25–26 (in Turkish). Keely, B.R., 2002. Recognition and prevention of hospital violence. Dimensions of Critical Care Nursing 21 (6), 236–241. Kingma, M., 2001. Workplace violence in the health sector: a problem of epidemic proportion. International Nursing Review 48, 129–130. Kisa, S., 2008. Turkish nurses’ experiences of verbal abuse at work. Archives of Psychiatric Nursing 22 (4), 200–207. Kisa, A., Dziegielewski, S.F., Atesß, M., 2002. Sexual harassment and its consequences: a study within Turkish hospitals. Journal of Health Social Policy 15 (1), 77–94. Lanza, M.L., 1983. The reactions of nursing staff to physical assolt by patient. Hospital Community Psychiatry 34, 44–47. Lash, A.A., Kulakac, O., Buldukoglu, K., Kukulu, K., 2006. Verbal abuse of nursing and midwifery students in clinical settings in Turkey. Journal of Nursing Education 45 (10), 396–403.
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Contents lists available at ScienceDirect
Nurse Education Today journal homepage: www.elsevier.com/nedt
Violence experienced by Turkish nursing students in clinical settings: Their emotions and behaviors Ayda Çelebiog˘lu a,*, Reva Balcı Akpinar b, Sibel Küçükog˘lu a, Raziye Engin a a b
Ataturk University, School of Nursing, Erzurum, Turkey Ataturk University, Erzurum School of Health, Erzurum, Turkey
a r t i c l e
i n f o
Article history: Accepted 8 January 2010
Keywords: Nursing student Violence Workplaces Emotions
s u m m a r y Aim: This descriptive study aimed to determine the violence experiences of nursing students’ in clinical settings, the types of violence, and the way their behaviors and emotions are affected after such an experience. Background: The risk of being subjected to violence among health staff is very high and the students who worked in the same kind of work environments also faced similar risks. Methods: The data of the study were obtained from the 380 nursing students who were studying at 2nd, 3rd, and 4th grades. Participation was voluntary. A questionnaire form was developed by the researchers and distributed to the students. Results: It was found that 50.3% of the students were subjected to violence, and 91.6% of these students were subjected to verbal violence. The students most frequently experienced anger, fury, and enmity (84.3%) after confronting violence. Conclusion: Findings of our study showed that similar to nurses, nursing students, who spent a significant proportion of their education in areas of practice, also experienced violence. Therefore, measures should be taken to prevent the violence inflicted upon nursing students in clinical settings, and nursing students should be provided with information related to communication and the coping methods with violence during their education. Ó 2010 Elsevier Ltd. All rights reserved.
Introduction Violence, which is currently prevalent in every sphere of social life, in all races and cultures, is defined as physical, emotional and sexual behavior that harms individuals physically and/or psychologically (Yurdakul, 1996; Erdem and Üstün, 1997). Workplace violence, on the other hand, is defined as ‘‘incidences where the worker is abused or assaulted by a person or people during situations related to their work” (Warshaw, 1996). Violence in health institutions is defined as ‘‘any incidence of threatening behavior, verbal threat, physical assault and sexual assault inflicted by the patient, the patient’s relatives or any other individual, which constitutes a risk for health staff’’ (Saines, 1999). Violence, which is frequently encountered in workplaces, is considered today as an issue of work security and health and is significantly focused on other areas of risk within the work environ-
* Corresponding author. Address: School of Nursing, Atatürk University, 25240 Erzurum, Turkey. Tel.: +90 442 2312747; fax: +90 442 2360984. E-mail addresses: [email protected], [email protected] (A. Çelebiog˘lu), [email protected] (R.B. Akpinar), [email protected] (S. Küçükog˘lu), [email protected] (R. Engin). 0260-6917/$ - see front matter Ó 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.nedt.2010.01.006
ment (Chanier, 1998; Uzun et al., 2001; Çelik and Bayraktar, 2004) and workplace violence in healthcare settings is increasing (Keely, 2002). The risk of being subjected to violence among health staff is 16 times higher than in other occupational groups in the service sector (Kingma, 2001). The literature notes that many nurses work in unsafe environments, and are three times more likely to experience violence than any other professional groups (Keely, 2002). The majority of nurses are women, and these women often work in unsafe environments (NIOSH, 2006). There may be a relationship between the risk of violence experienced by women in general and the violence risk of female nurses (Hinchberger, 2009). Studies on abuse against nurses have reported wide prevalence rates ranging from 37% to 72% (Fernandez et al., 1999; Stirling et al., 2001; Lin and Liu, 2005). Similarly in previous studies performed with Turkish nurses, it was observed that nurses were subjected to violence at high rates (Uzun, 2003; Alçelik et al., 2005; Ayrancı, 2005; Sßenuzun and Karadakovan, 2005; Çelik and Çelik, 2007; Çelik et al., 2007; Gökçe and Dündar, 2008; Kisa, 2008). Findings related to violence against staff nurses in the workplace is well documented. However, little is known about the student nurse population. It is found that in the limited numbers research performed with the students who worked in the same kind of work
688
A. Çelebiog˘lu et al. / Nurse Education Today 30 (2010) 687–691
environments also faced similar risks (Çelik and Bayraktar, 2004; Lash et al., 2006; Ferns and Meerabeau, 2007; Longo, 2007; Hinchberger, 2009). In the study by Finnis and Robbins (1994), Ferns and Meerabeau (2007) and Hinchberger (2009), it is reported that nursing students also confronted violence in various rates. In Turkey, in the study by Çelik and Bayraktar (2004), it was found that all of the nursing students experienced high rates of verbal violence, as well as academic, physical, and sexual violence. The study conducted by Lash and his colleagues (2006) revealed that students experienced verbal violence during clinical practices. Nursing students are often inflicted violence by patients, patients’ relatives, nurses, doctors and other staff (Çelik and Bayraktar, 2004; Lin and Liu, 2005; Lash et al., 2006; Ferns and Meerabeau, 2007). The difficulties experienced in the work environment have a negative impact on the members of the nursing profession, just as they affect the members of every professional group (Poster, 1993). Nurses’ confrontation with incidences that threaten security within the work environment can lead to negative impacts on both their own physical and psychological welfare and the quality of the service they provide. Violence has been shown to have biopsychological, emotional, cognitive, and social impacts on nurses (Lanza, 1983). It was found that the most frequently experienced emotions of the nurses who were subjected to violence were anger, fear, anxiety, post-traumatic stress syndrome, guiltiness, blaming oneself, and embarrassment (Needham et al., 2005). Similarly, nursing students have also demonstrated such emotions in the work environment from time to time (Kisa et al., 2002; Çelik and Bayraktar, 2004; Needham et al., 2005). Violence and assault in the work environment against the health staff, who seeks to help patients and the injured, are regarded as a surprising and an unacceptable occurrences (Scott, 2003). This study aimed to determine the violence experiences of nursing students’ in clinical settings, the types of violence, and the way their behaviors and emotions are affected after such an experience.
closed-ended questions regarding the descriptive characteristics, and the second section included closed-ended questions that aimed to reveal incidences of nursing students’ confrontation with violence, the types of violence they confronted, by whom the violence was inflicted, their opinions on why they confronted violence. In addition students’ behaviors and emotions after confrontation with violence also were asked. The items were evaluated by two experienced nurse educators for content and clarity. The questionnaire was tested in a pilot study with 12 students. There were minör revisions in the questionnaire. The data from the pilot study were not included in this study. Data analysis The statistical analyses of the data were made by means of SPSS statistical package program. For statistical analyses, percentage and frequency were calculated to show the characteristics, violence types, sources, students’ behaviors and emotions. The chisquare test was used to compare of the students’ confrontation situations according to their grades. Significance level was set at p < 0.05. Ethical consideration Before the research was initiated, legal permission was obtained from the administrations of both schools. The students were informed about the aim and method of the study, and their written informed consents were received. Participation was voluntary. Results The descriptive characteristics of the students within the scope of the study can be seen in Table 1. The age range of the 380 stuTable 1 Students’ descriptive characteristics.
Methods
Descriptive characteristics
Number
%
Design and settings
Age 19–23
380
21.16 ± 1.57
Year at school 2nd year 3rd year 4th year Total
153 135 92 380
40.3 35.5 24.2 100
Confrontation with violence Yes No Total
191 189 380
50.3 49.7 100
Type of violence Verbal violence Physical violence Sexual violencea Total
175 8 8 191b
91.6 4.2 4.2 100
Persons inflicting violence Patients and their relatives Nurses Doctors Other staff Total
102 41 38 10 191b
53.4 21.5 19.9 5.2 100
Frequency of confrontation with violence Once Twice Three times Four times or more Total
73 34 13 71 191b
38.2 17.8 6.8 37.2 100
The design of the study was descriptive survey and data were collected in 2007. The data of the study were obtained from the students of School of Nursing and School of Health, Atatürk University. It was Midwifery and Nursing Departments in School of Health. The sampling included only nursing students, who were studying at 2nd, 3rd, and 4th grades. First graders were not included in the scope of the study as they had not started working in the area of practice yet. At the time when the research was carried out in the classes mentioned above, a total of 450 students were registered in the schools mentioned above: 270 in School of Nursing and 180 in School of Health. Because the students in both of the vocational schools were educated in the same clinical settings they were regarded as homogenous groups and were evaluated as a single group. On the day when the questionnaire was administered, all the students who were present at school (432 students) were informed about the aim and the method of the study, and the questionnaire forms were distributed. Of 432 questionnaire forms, 380 (88.0%) were returned. Data collection The questionnaire was developed by the researchers on the basis the literature (Uzun et al., 2001; Uzun, 2003; Çelik and Bayraktar, 2004; Ferns and Meerabeau, 2007). The questionnaire consisted of two sections. The first section included open- and
a Attitudes such as talks and jokes with sexual content, and attempts of physical contact. b Calculations were made for students who confrontated with violence.
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dents constituting the sample of the study was 19–23 years (mean age: 21.16 ± 1.57 years), and a great majority (40.3%) were 2nd year students. Evaluation of the results indicated that half of the students (50.3%) were subjected to violence, and 91.6% of these students were subjected to verbal violence. It was found that of the 191 reported incidences of violence, 102 involved encounters with patients and the relatives of patients (53.4%) and of these 102, verbal abuse accounted for 92 cases and 7 situations of physical abuse were reported (Tables 1 and 2). According to the students, among the reasons for being subjected to violence, the anxiety and fears felt by the patient and/ or his/her relatives was the highest (70.2%), followed the lack of confidence in the nursing student by the patient, his/her relatives, and the clinical staff (63.9%), and the student being a female (53.9%) (Table 3). After the students confronted with violence, the majority did not react to the patient (66.0%), while the lowest rate was found for the attitude of being unwilling to take care of their patients (4.2%) (Table 4). The students most frequently experienced anger, fury, and enmity (84.3%) after confronting violence, while the least frequently experienced feelings were embarrassment and shame (20.9%). In addition, it was observed that 81.2% of the students felt anxiety, and 30.9% were unwilling to provide care (Table 5). When the data regarding whether nursing students confronted violence, the frequency of their confrontation with violence, and the distribution of the violence types were analyzed according to the grades of the students, no statistically significant difference were found among the groups (p > 0.05). Discussion The aim of our study was to determine the number and situations in which nursing students confronted violence during their practical training, the type of violence they confronted and the way their behaviors and feelings were influenced following this
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Table 4 Students’ behaviors subsequent to being subjected to violence.
a
Behaviorsa
Number
%
I I I I I
126 32 29 18 8
66.0 16.8 15.2 9.4 4.2
did not react to the patient and continued providing care transferred my patient to another colleague thought of dropping out of school did not go to the practice did not take care of my patient
More than one answer was provided.
Table 5 Students’ emotions subsequent to confrontation with violence.
a
Students’ emotionsa
Number
%
Anger/fury/enmity Anxiety Disappointment Powerlessness/hopelessness/defenselessness Unwillingness in caregiving Fear Embarrassment/shame
161 155 114 76 59 41 40
84.3 81.2 59.7 39.8 30.9 21.5 20.9
More than one answer was given.
experience. The evaluation of the results showed that the rate of the students subjected to violence in the clinical settings was 50.3%. Verbal violence (91.6%) was the most frequently encountered type of violence, followed by physical violence (4.2%) and sexual violence (4.2%). In previous studies involving nurses, it was observed that nurses were subjected to violence at high rates (Fernandez et al., 1999; Stirling et al., 2001; Uzun, 2003; Lin and Liu, 2005; Alçelik et al., 2005; Ayrancı, 2005; Sßenuzun and Karadakovan, 2005; Çelik and Çelik 2007; Çelik et al., 2007; Gökçe and Dündar, 2008; Kisa, 2008).
Table 2 The distribution of the people inflicting violence upon students and types of violence. Persons inflicting violence
Patients and their relatives Nurses Doctors Other staff
Physical violence
Sexual violence
n
Verbal violence %
n
%
n
%
n
Total (191) %
92 41 35 7
90.2 100.0 92.1 70.0
7 0 0 1
6.9 0 0 10.0
3 0 3 2
3.0 0 7.9 20.0
102 41 38 10
100.0 100.0 100.0 100.0
Table 3 The reasons for being subjected to violence according to students’ perceptions (n = 191).
a
Reasons for being subjected to violencea
Number
%
The anxiety and fears of patients and/or relatives of patients The patient, the patient’s family and the clinical staff’s lack of confidence in the nursing student Being a female The patient and/or his/her family’s low level of education Lack of security measures The fact that the patient is feeling pain Insufficient number of health staff The mental health problems of patients and/or their relatives Lack of tolerance and patience of patients and their families Students’ lack of effective communication skills with furious patients and their families Being in close contact with patients and/or their families The consumption of alcohol by the patient and/or his/her relatives Nursing students’ lack knowledge and skills in caregiving Being negatively affected by the media Lack of sufficient time allocated to the patient
134 122 103 81 72 70 57 50 46 45 44 43 42 33 26
70.2 63.9 53.9 42.4 37.7 36.6 29.8 26.2 24.1 23.6 23.1 22.5 22.0 17.3 13.6
More than one answer was provided.
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It was found in our study that the students confronted with verbal violence were inflicted most frequently by patients and their relatives, followed by nurses, doctors, and other staff respectively. Physical violence was also found to be inflicted at a high rate by patients and their relatives. In a study performed by Çelik and Bayraktar (2004) the students confronted with verbal violence most frequently by their classmates (41.3%), patients (34.2%), nurses (33.8%) and doctors (31.6%). In the Uzun’s study (2003) patient relatives were greatest source of verbal abuse (59.8%). The study by Çelik et al. (2007) revealed that nurses were subjected to physical violence in their work environment by patients relatives. Although nursing students are often inflicted violence by patients and their relatives as are nurses, there are also incidences of violence by nurses inflicted on student nurses (21.5%). This indicates a problem in terms of professional awareness of nurses because nursing students are expected to be supported in the area of practice by nurses, who will be their colleagues in the future. However, the findings of our study may be an indication of the fact that nurses working in the clinics do not support the nursing students and do not regard them as a member of the profession. As a reason for being subjected to violence, the majority of the students reported external reasons, and a few of them indicated the reason for being subjected to violence as not being able to communicate with furious patients and/or their families. However, it is known that having sufficient knowledge and skill in preventing and protecting oneself from violence can largely prevent incidences of violence (Keely, 2002). Being unaware of their inadequacies is considered a condition that can hinder the development of the students in this regard. Some students also reported that neither the patients and their relatives nor doctors and nurses had confidence in them, and thus, they were inflicted violence by patients, their relatives, doctors and nurses. This may suggest that students lack the skills to communicate well with their social environment and do not have self-esteem. Therefore, further and detailed studies on this issue are warranted. None of the students informed an authority of the individual who inflicted violence, which may be an indication of their lack of knowledge on the issue. The evaluation of the students’ attitudes after being subjected to violence towards patients showed that most of the students did not show any reaction but just continued taking care of the patient; the number of the students who stopped taking care of their patients was low. This is important since it shows that priority is given to ‘‘caring the patient professionally” and carrying out basic nursing responsibilities and that a professional point of view is instilled in students. Such an attitude may be an indication of the fact that carrying out two of the responsibilities, ‘‘Relieving pain” and ‘‘Promoting Health, the reason for existence”, within the ‘‘Codes of Ethics in Nursing”, prepared by the International Nursing Coun_ cil, are the most important priorities of students (Inanç et al., 1999). On the other hand, the students did not react to the patients and/or their relatives who inflicted violence, which suggests that students’ communication skills with the furious/aggressive patients and their family are not well-developed. The failure to give an appropriate reaction can lead to not only an increase in the fury felt by the patient and his/her family but also the emergence of feelings of anger, fury, and enmity as a result of not being able to express her feelings. Moreover, although the number of the students who transferred the care of her own patient to another colleague, who thought of dropping out of school, and who did not go to school the following day was low, it indicates the negative impacts of violence on nursing students’ educational life. It was reported that feelings of anger, fury, enmity, anxiety, disappointment, weakness, helplessness, defenselessness, fear and embarrassment were the emotions that nursing students experienced most frequently after they confronted violence. This shows that students have poor stress management skills, and difficulty
in communicating and expressing their feelings. Feelings of fear and shame may have an impact on student’s inability in expressing their feelings. Moreover, experiencing the feeling of embarrassment can be explained as the student’s blaming herself for being subjected to violence. In previous studies conducted on nurses and students, similar findings were found (Sheehan et al., 1990; Poster, 1993; Finnis and Robbins, 1994; Uzun et al., 2001; Kisa et al., 2002; Çelik and Bayraktar, 2004; Needham et al., 2005). These negative feelings show that students are highly affected by the violence they are confronted with. Thus, with exposure to violence while the education of nursing students is in progress, both their psychological status and the quality of the service they provide and their adaptation to the work environment may be affected negatively, which in turn may have negative effects on their education and their adaptation to the profession. The findings in our study are important as they indicate how important the problem of violence in the workplace is, not only for the staff but also for the students who spend a significant amount of their time in the field. Conclusion Findings of our study show that violence was a important problem for nursing students in clinical settings. We suggest that measures should be taken to prevent the abuse inflicted upon nursing students in areas of practice, and nursing students should be provided with information related to communication and the methods of health care during their education. Students also should be encouraged to learn strategies and to practice how to respond to violent situations in the workplace. References _ Alçelik, A., Deniz, F., Yesßildal, N., Mayda, A.S., Sßerifi, B.A., 2005. AIBÜ Tıp Fakültesi Hastanesi’nde görev yapan hemsßirelerin sag˘lık sorunları ve yasßam alısßkanlıklarının deg˘erlendirilmesi. TSK Koruyucu Hekimlik Bülteni 4 (2), 55– 65 (in Turkish). Ayrancı, Ü., 2005. Violence toward health care workers in emergency departments in west Turkey. The Journal of Emergency Medicine 28 (3), 361–365. Çelik, S.Sß., Bayraktar, N., 2004. A study of nursing student abuse in Turkey. Journal of Nursing Education 43 (7), 330–336. Çelik, Y., Çelik, S.S ß ., 2007. Sexual harassment against nurses in Turkey. Journal of Nursing Scholarship 39 (2), 200–206. _ Ug˘urluog˘lu, Ö., 2007. Verbal and physical abuse Çelik, S.S ß ., Çelik, Y., Ag˘ırbasß, I., against nurses in Turkey. International Nursing Review 54, 359–366. Chanier, E., 1998. The workplace: a battle ground for violence. Public Personnel Management 27 (4), 557–569. Erdem, Y., Üstün, B., 1997. Hemsßirelerin çalısßma ortamında karsßılasßtıkları ßsiddet durumları: gözden geçirme. Hacettepe Üniversitesi Hemsßirelik Yüksek Okulu Dergisi 4 (2), 99–109 (in Turkish). Fernandez, C.M., Bouthillette, F., Rabound, J.M., et al., 1999. Violence in the emergency department: a survey of health care workers. Canadian Medical Association Journal 161 (10), 1245–1248. Ferns, T., Meerabeau, L., 2007. Verbal abuse experienced by nursing students. Journal of Advanced Nursing 61 (4), 436–444. Finnis, S., Robbins, I., 1994. Sexual harassment of nurses: an occupational hazard? Journal of Clinical Nursing 3 (2), 87–95. Gökçe, T., Dündar, C., 2008. Samsun ruh ve sinir hastalıkları hastanesi’nde çalısßan hekim ve hemsßirelerde ßsiddete maruziyet sıklıg˘ı ve kaygı düzeylerine etkisi. _ Inönü Üniversitesi Tıp Fakültesi Dergisi 15 (1), 25–28 (in Turkish). Hinchberger, P.A., 2009. Violence against female student nurses in the workplace. Nursing Forum 44 (1), 37–56. _ Inanç, N., Hatipog˘lu, S., Yurt, V., Avcı, E., Akbayrak, N., Öztürk E., 1999. Hemsßirelik Esasları. Damla Matbaacılık, Ankara, 25–26 (in Turkish). Keely, B.R., 2002. Recognition and prevention of hospital violence. Dimensions of Critical Care Nursing 21 (6), 236–241. Kingma, M., 2001. Workplace violence in the health sector: a problem of epidemic proportion. International Nursing Review 48, 129–130. Kisa, S., 2008. Turkish nurses’ experiences of verbal abuse at work. Archives of Psychiatric Nursing 22 (4), 200–207. Kisa, A., Dziegielewski, S.F., Atesß, M., 2002. Sexual harassment and its consequences: a study within Turkish hospitals. Journal of Health Social Policy 15 (1), 77–94. Lanza, M.L., 1983. The reactions of nursing staff to physical assolt by patient. Hospital Community Psychiatry 34, 44–47. Lash, A.A., Kulakac, O., Buldukoglu, K., Kukulu, K., 2006. Verbal abuse of nursing and midwifery students in clinical settings in Turkey. Journal of Nursing Education 45 (10), 396–403.
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