Chinese nursing students’ experiences of workplace violence in the clinical setting: a qualitative study

Technical Summary: Chinese Nursing Students' Experiences of Workplace Violence in the Clinical Setting

Problem Statement
Workplace violence (WPV), encompassing abuse, threats, and assault, is a pervasive issue in healthcare, with nurses constituting the majority of victims. Nursing students, positioned at the bottom of the clinical hierarchy and possessing limited experience, are particularly vulnerable. While quantitative studies in China have established high incidence rates of WPV among nursing students (ranging from 33.97% to 87.80%), there is a lack of comprehensive qualitative understanding regarding the specific nature of these experiences, the underlying rationales, and the students' coping mechanisms. Existing literature often treats WPV narrowly; this study addresses the need for a broader definition that includes bullying, incivility, and verbal, physical, and sexual violence to fully capture the student experience in Chinese clinical settings.

Methodology
The study employed a descriptive phenomenological design to explore the lived experiences of nursing students.

• Setting and Sample: Purposive sampling was used to recruit 16 fourth-year undergraduate nursing students from Henan University of Chinese Medicine. These students were practicing in four third-tier teaching hospitals in Zhengzhou City, China.
• Inclusion Criteria: Participants were required to be undergraduate nursing students in clinical practice (minimum 6 months), have experienced WPV, and provide voluntary informed consent.
• Data Collection: Data were gathered through in-depth, semi-structured, face-to-face interviews conducted between March and June 2025. Interviews lasted 21–57 minutes and were conducted by two researchers. The interview guide focused on types of violence encountered, handling strategies, and the impact of these experiences. Nonverbal cues were noted, and all sessions were video-recorded and verbatim transcribed.
• Data Analysis: Conventional content analysis was utilized. Researchers engaged in iterative line-by-line reading to identify primary codes, which were then categorized through comparison. Rigor was ensured through consensus discussions among three researchers, memo writing, and the maintenance of an audit trail. Data saturation was reached after 16 interviews.

Key Contributions and Results
The analysis yielded four overarching categories describing the phenomenon of WPV among Chinese nursing students:

1. Instances of Workplace Violence:

   • Perpetrators: Violence originated primarily from patients and their relatives, but also frequently from nursing staff, specifically clinical instructors.
   • Forms: Patient-related violence manifested mainly as verbal abuse, reprimands, and occasional physical intimidation (e.g., threats of slapping). Instructor-related violence was characterized by psychological aggression, including intentional ignoring, denial of learning opportunities, lack of respect, and failure to provide safety warnings (e.g., regarding infectious diseases).

2. Rationale for Workplace Violence:

   • Student Factors: Participants attributed much of the violence to their own lack of clinical experience and the gap between theoretical knowledge and complex clinical realities.
   • Systemic and Instructor Factors: Unprofessional competence among instructors, uneven literacy levels, and the dual burden of instructors (serving as both clinical nurses and supervisors without adequate incentives) were cited as contributors.
   • Cultural Context: Some students viewed bullying as a "rite of passage," while others noted that high-stress units and patient frustration with unmet expectations often led to students becoming scapegoats.

3. Responses to Workplace Violence:

   • Avoidance and Stoicism: The predominant reaction was to ignore the aggressor or "grin and bear it" to avoid escalating the situation or jeopardizing their practicum.
   • Active Coping: Some students engaged in peer support (sharing experiences with classmates), self-adjustment through empathy (understanding patient instability), and introspection to improve their skills.
   • Communication: A subset of participants believed that improved communication could mitigate incidents.

4. Impact on Nursing Students:

   • Psychological Toll: Experiences of WPV led to feelings of sadness, loss, nervousness, and a significant decline in confidence.
   • Professional Identity: The trauma contributed to a perception of nursing as an overwhelming and burnout-prone profession, causing some students to question their future career commitment.

Significance and Claims
The paper claims that nursing students in China face a multifaceted environment of violence that extends beyond patient aggression to include significant mistreatment by clinical instructors. The study highlights that when clinical instructors are perpetrators, the psychological harm is often more severe because students view instructors as a primary support system.

The authors conclude that addressing this issue requires a multi-level approach:

• Institutional Reform: Health institutions should establish evaluation and incentive mechanisms to motivate clinical instructors and alleviate their dual-role stress.
• Educational Intervention: Nursing educators must provide rigorous training on violence prevention, communication, and resilience.
• Policy Development: There is a need for policies that create a safe practice environment and foster a "zero tolerance" culture toward violence, moving beyond the normalization of abuse as a standard part of clinical training.

The study emphasizes that while enhancing student resilience is promising, it must be paired with structural changes to the clinical learning environment to effectively protect nursing students.