Nurse Education in Practice 14 (2014) 666e673

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Pre-registration nursing students' perceptions and experiences of violence in a nursing education institution in South Africa Tania de Villiers 1, Pat M. Mayers*, Doris Khalil Division of Nursing & Midwifery, Department of Health & Rehabilitation Sciences, Faculty of Health Sciences, University of Cape Town, Observatory, Cape Town, South Africa

a r t i c l e i n f o

a b s t r a c t

Article history: Accepted 29 August 2014

Violence is a growing problem worldwide in the field of health care and within the nursing profession. A study comprising a survey and focus groups with nursing students, and interviews with nurse educators was conducted to examine nursing students' perceptions and experiences of violence at a nursing education institution in the Western Cape, South Africa. A self-administered questionnaire was distributed to all nursing students. Two hundred and twenty three (n ¼ 223) respondents completed the questionnaire. Focus groups were conducted with purposively sampled student participants and semistructured interviews with nurse educators. The findings indicated that the nature of the violent incidents experienced by students on campus, especially in the residences, ranged from verbal abuse to violation of students' property and personal space, and could be attributed primarily to substance abuse. Violence among student nurses could negatively affect learning. In a profession in which nurses are exposed to violence in the workplace, it is important that violence in the learning environment is actively prevented and respect of individual rights, tolerance and co-operation are promoted. © 2014 Elsevier Ltd. All rights reserved.

Keywords: Nursing students Horizontal violence Nursing education Verbal abuse South Africa

Introduction and background The World Health Organisation (2002, p. 3) defines violence as “intentional use of physical force or power, threatened or actual … that either results in or has a high likelihood of resulting in injury, death, psychological harm, mal-development or deprivation”. In South Africa statistics on crime do not present an entirely accurate picture of what is happening, although a useful indicator. Since 1994, the birth of democracy, crimes reported to the police increased, peaking in 2003. Although serious crime, in particular contact crime, has reduced significantly over the last five years, it remains unacceptably high in comparison with global crime statistics. Of particular concern is the violent nature of social behaviour evident in the majority of serious crime categories, and the perceived link of crime and challenging socio-economic conditions (SAPS, 2013). Parallel to this is the growing number of violent incidents in the health care environment, which has become a global problem for nurses (Farrell, 2001; Blair and Wallace, 2002; Hiffe, 2002; Clark

* Corresponding author. Tel.: þ27 214066464. E-mail addresses: [email protected] (T. de Villiers), [email protected], [email protected] (P.M. Mayers), [email protected] (D. Khalil). 1 Tel.: þ27 848596055. 1471-5953/© 2014 Elsevier Ltd. All rights reserved.

and Springer, 2007; Woelfle and McCaffrey, 2007; Beech, 2008). The nursing profession has seen a steady increase in violence over the last decade (Chapman and Styles, 2006; Edwards and O'Connell, 2007; Taylor, 2013), with an increasing number of violent incidents perpetrated on nursing students (Calvert, 1996; Beech, 2001; Celik and Bayraktar, 2004). Nursing students have experiences of violence in the clinical setting (Çelebioglu et al., 2010; Ferns et al., 2005), but there is limited published research on violence amongst student nurses in nursing education institutions. In this study, violence has been broadly categorised into physical and psychological/emotional violence. Physical violence or abuse is the most visible form, characterized by infliction of injury. Physical abuse may include (but is not limited to) grabbing, striking, pinching, shoving, slapping, hitting, hair-pulling, biting, armtwisting, kicking, punching, hitting with objects, and/or use of harmful restraints or weapons. Emotional or psychological violence is defined as routinely making unreasonable demands or intentional infliction of anxiety, hurt, guilt or fear through verbal or nonverbal acts, which serve to degrade and undermine an individual's sense of self-worth and self-esteem while rejecting their opinions and needs. It includes, but is not limited to, attacking a person verbally by yelling, name-calling, constant criticism, insults, threats, intimidation, humiliation, criminally harassing or stalking, isolating the victim from family, friends or regular activities, and

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using ‘silent treatment’, denying the abuse ever happened and shifting responsibility (Newfoundland Violence Prevention Initiative, 2014). Sexual violence may be physical and/or emotional (Dartnall and Jewkes, 2013).


Violence in South Africa presents has taken on “new and complex forms, and is not a transitional phenomenon but is deeply rooted in the society” (Centre for the Study of Violence and Reconciliation (CSVR), 2007; 5). Violence in South Africa has a long history. Apartheid not only established racialized inequality, but had a destructive psychological impact on self-worth and traditional family structures and values. High levels of violence were manifested in the urban and peri-urban townships in the 1950s prior to escalation of political violence in the 1970s and 1980s (Dissel, 2007). From the 1970s to the 1990s extreme levels of political violence, including widespread use of torture, had a brutalizing impact on individuals and society. The longstanding and well-established system of migrant labour (mass movement of people from their permanent home, usually rural, to a place of work in a city) instituted by the apartheid regime undermined the socialising role of families and other social institutions (Phillips, 2003). There is a strong link between violence, gender and crime in South Africa (CSVR, 2007). Perpetrators are mostly young men, yet roughly 85% of murder victims are also young men (SAPS, 2013). The age of men at initiation of perpetration of sexual violence (17e25 years old) is a factor in identifying this group for targeting (The 2nd South African National Youth Risk Behaviour Survey (SANYRBS), 2008; Jewkes et al., 2010a, 2010b).

within the nursing student community in USA, Europe, Australia and Turkey (Calvert, 1996; Celik and Bayraktar, 2004; Chapman and Styles, 2006; Edwards & O'Connell, 2007) have been reported. The prevalence of violent experiences among nursing students in higher education institutions in South Africa is unclear; however there is a high incidence of sexual violence in South African youth (Jewkes et al., 2010a). The impact of violence on nursing students has physical and mental health consequences (Campbell, 2002; Jewkes et al., 2010b; Taylor, 2013). These include unwanted pregnancy, HIV infection, mental illness such as post-traumatic stress disorder and depression, and stigma. Attrition and throughput rates may also be affected (Hutchinson, 2009). There is a lack of agreement on the definition of what constitutes aggression and violence, together with no uniform, standard instrument for measuring this (Rippon, 2000). This may exacerbate the challenges of managing this phenomenon. Lashley and De Meneses (2001) recommended that clear definition of ‘uncivil behaviours’ should be developed for nursing students and nurse educators. The inclusion of violence education, including management thereof, in undergraduate nursing curricula has been recommended (Blair and Wallace, 2002; Johnson and Stevens, 2002; Beech, 2008). The primary purpose of nursing care is to provide for the patient's physical, emotional and spiritual needs, and violence among nursing students is the antithesis of the caring ethos of the profession. Nurses are unlikely to perform at their best when tensions are high (Woelfle and McCaffrey, 2007). Impaired interpersonal relationships among student nurses can cause poor work performance, errors and accidents (Kolanko et al., 2006).

Violence in schools

Problem statement

Violence in South African education settings outside of nursing education institutions, e.g. among high school youth (SANYRBS, 2008; Jewkes et al., 2010a) is a source of concern, providing strong evidence that such experiences commence early. Schools are considered to be especially dangerous. In the 2008 report on public hearings on school based violence, pupils and teachers were found to be perpetrators of violence; both groups suffered the impact of bullying, gender-based violence, accidental violence, sexual assault or harassment, physical and psychological violence (SAHRC, 2008). The high levels of violence in South African schools reflect a complicated combination of past history and recent stresses at individual, school and community levels (Vally et al., 1999; Zulu et al., 2004). Despite the end of apartheid, race and ethnic tensions remain at the centre of much of the violence (Vally et al., 1999). Present-day violence in education in South Africa must be understood with reference to this history and to contemporary political and economic disadvantage and inequality. Flisher et al. (2006) reported on injuryrelated behaviour among high school learners in six South African sites, in which high rates of adolescent injury-related behaviour in male and female learners in urban and rural settings were found.

In the year prior to the study a number of violent incidents among nursing students were reported to the Education institution management, and subsequently to the police. A female nursing student was allegedly raped by a male student; however the case was later withdrawn due to alleged fears of victimisation. In another incident two male students allegedly assaulted a fellow male nursing student. This was reported to the police and the two alleged perpetrators were arrested, but the case was later withdrawn. This study emerged to investigate nursing students' perceptions of violence and their experiences of violence, either observed, or personally experienced (interpersonal, by educators, administrative staff, fellow nurse learners, nurse managers).

Nursing education and violence

This study comprised a survey of nursing students' perceptions and experiences of violence at their nursing education campus, followed by focus groups that explored at greater depth the nursing students' experiences of violence. Semi structured interviews were conducted with nurse educators to explore their perceptions of the violence experienced by nursing students.

Violence within the South African context

Clark and Springer (2007) found that uncivil behaviour had a negative effect on the academic setting and disrupted the teachinglearning environment. Disruptive behaviour such as cheating in examinations and assignments, absenteeism and distractions in class have consistently been reported by nurse educators (Clark and Springer, 2007), but problematic student behaviour such as verbal abuse, yelling at educators and physical contact has been reported as a rising concern (Lashley and De Meneses, 2001). The prevalence of violence among nursing students is not clear. Studies on violence

Aim The aim of the study was to explore the perceptions and experiences of violence among pre-registration nursing students in the Western Cape, South Africa. Method

Research setting The study was conducted at a nursing education institution campus in the Western Cape Province, which offers pre-and-post


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registration nursing programmes at Diploma level. Pre-registration/ undergraduate nursing education in South Africa is a four-year comprehensive programme offered at diploma or degree level, which leads to registration as a Nurse (General, Psychiatric and Community) and Midwife with the South African Nursing Council. The nursing education institution offers the four-year diploma programme and admits approximately 300 students per year.

questions, based on a questionnaire developed for a larger study (Khalil, 2009): Section A obtained socio-demographic data, Section B provided a pre-determined list of options regarding nursing students' experiences of violence, from which participants had to select and Section C related to students' perceptions of violence. Some open-ended questions were included to allow for descriptions of experiences or perceptions of violence.

Study population

Ethical considerations

The study population comprised 580 pre-registration nursing students (Table 1). All students from first to fourth year, including those repeating courses, irrespective of age, race, sex or creed were included. Racial categories are still utilised in South African settings where it is necessary to redress the consequences of apartheid. The categories for racial classification are based on those of the previous regime: White; Coloured [mixed race]; Asian and Black [of African origin]. At the time of the study, the majority of the students were in their first and second year of study, as there had been a year in which there were no new admissions due to restructuring of the nursing education in the Western Cape, and the fourth year students were those who remained from the final intake of the programme prior to the restructuring. Convenience sampling was employed for the focus groups and the nurse educator interviews and participation was voluntary.

Ethical approval was obtained from the Human Research Ethics Committee, Faculty of Health Sciences, University of Cape Town. The Head and Management Committee of the Nursing Education institution approved the study and access to the student body was obtained from the Students' Representative Council. Ethical principles and codes of the Declaration of Helsinki (Seoul version) were adhered to World Medical Association October (2008). Information sessions were held with each class of nursing students. Prior to commencing data collection, all potential respondents were informed about the objectives of the study, that participation was voluntary and that all responses would be rendered anonymous. Return of the questionnaire was taken as consent to participate. Written informed consent was obtained from participants in the focus groups, who were assured of privacy, confidentiality and anonymity with respect to reporting. The researcher enlisted the assistance of the education institution counsellor prior to data collection to be on standby for emotional support and counselling if required. All nurse educators were informed about the study, verbally and via email (from education institution managers). Interested persons were invited to contact the researcher for further information, and were assured of confidentiality and voluntary participation with all attendant rights.

Sampling Sampling was carried out using the following three steps: (i) Survey: Non-probability convenience sampling was used to obtain the nursing student sample (n ¼ 223). Of the 580 nursing students, 289 (49.83%) were in first year, 183 (31.55%) in second year, 88 (15.17%) in third year and 20 (3.45%) in their fourth year of study. At the time of the study most students were in their first and second year of study, as there had been no admissions to the nursing school for one year due to restructuring of the nursing education system in the Western Cape. Fourth year students were those who remained from the final intake prior to restructuring. (ii) Focus groups: Nine nursing students volunteered to participate in focus groups. The researcher handed out information letters to all nursing students when she addressed them in their classrooms on the research study, and asked if any would like to participate in the focus groups. Students' questions pertaining to the study were answered. The voluntary and confidential nature of the focus groups was emphasised. (iii) Interviews with nurse educators: Convenience purposive selection was used for the semi-structured interviews with nurse educators. Instrument A self-administered questionnaire was used in the first phase. The questionnaire comprised three sections with a total of 25 Table 1 Nursing student population. African Mixed Indian White Total % Of total Male Female race population First year 197 Second year 73 Third year 29 Fourth year 5 Total 304

92 110 55 15 272

0 0 1 0 1

0 0 3 0 3

289 183 88 20 580

49.83 31.55 15.17 3.45 100

37 33 32 0 102

252 150 56 20 478

Data collection Phase 1: survey A pilot study was conducted on 20 students from another education institution who did not participate in this study, to test reliability and validity of the questionnaire. No major changes were required. The questionnaire was distributed to all nursing students over a 12-week period in order to allow for as many students as possible to have the opportunity to participate. The questionnaire was distributed to all student nurses at the campus. Completed questionnaires were placed in sealed boxes in designated areas in the campus buildings and collected by the researcher. Nursing students were allowed to complete the questionnaires in their own time, but reminders were sent midway during the data collection period. Questionnaires were stored in a safe box for exclusive management by the researcher, thus ensuring confidentiality. Phase 2: focus groups Convenience sampling was employed for the focus groups and participation was voluntary. Information letters with the researchers' contact details were given to all nursing students during a general information session. Nine first-and second-year nursing students volunteered to participate in focus group interviews (no senior students volunteered); however, they refused to participate in mixed racial groups, but agreed to participate if groups were segregated. Groups were thus conducted as follows: three mixed race female nursing students; three African male nursing students; and three African female nursing students. Focus groups were audio-recorded. Field notes were made immediately after each

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focus group, which were used for clarification in the transcribing of the recordings.

(Table 3). Sabotage of personal items was also reported as a problem, particularly in the student residence.

Phase 3: interviews with nurse educators Semi-structured interviews were conducted at a convenient time and place with nurse educators. Individual appointments were made with each participant. The audio-recorded interviews lasted approximately 40 min. The researcher made field notes immediately after each interview (Creswell, 2007), which facilitated transcribing of the interviews but were not included in the data analysis.

Psychological violence

Data analysis

Most students (62.3%; n ¼ 139) reported having had an experience of violence; 103 (46.2%) had experienced verbal abuse from fellow nursing students on campus, 35.87% (n ¼ 80) threatening behaviour and 26% (n ¼ 58) physical assaults within the student residence. Of the 153 responses to this question, 41.2% (n ¼ 63) indicated that at least one fellow student had spoken to them about an experience of violence. Four students (9%) indicated that at least 10 nursing students had spoken to them about such experiences. Nursing students identified effects of violence in the classroom as intolerance of others, conflict and loss of interest in attending lectures. Effects of violence among nursing students during clinical placement were withdrawal behaviour, poor interpersonal relations and intolerance. Nursing students also reported experiencing increased anxiety as a result of their experience and observations of violence.

The survey data were entered into Microsoft Excel. Continuous data were summarised and analysed using frequency distributions and proportions. Open-ended question responses were analysed using content analysis and categorised into groups. Focus group and interview recordings were transcribed verbatim, read and reread and thematically analysed following guidelines by Creswell (2007). To enhance validity, the co-researchers verified the emergent themes. Results Survey results 580 questionnaires were distributed and 223 were returned, a response rate of 38.45%. Respondents ranged in age from 18 to 49 years, with 50% (n ¼ 112) aged between 18 and 22 years. This latter group had entered the nursing programme directly after completing their secondary education. Of the respondents, the largest groups were in the first (n ¼ 118 53%) and second year of study (n ¼ 79 36%). This reflects the easier access to students who were for the most part attending lectures during the data collection period. 22 third year students (10%) and four final year students (1%) returned completed questionnaires. Experiences of all types of violence 104 students reported experiences of violence perpetrated by other nursing students (Table 2). Verbal violence (verbal abuse, threats, shouting and name calling) was most commonly reported (65%) by respondents. Physical assault was reported by 6%. Students reported different reactions to their experiences of violence these ranged from being left speechless (16%), to sadness and disappointment (32%), humiliation (14%), wanting to retaliate (14%), helplessness (13%) and fear (11%).

Gossipping was the most common type of psychological abuse (n ¼ 99). Most of the abuse was experienced from classmates and students from other years. Discrimination, intimidation and labelling were reported as mainly nurse educator behaviour (Table 4). Experiences of violence among nursing students

Perceptions of reasons for violence Open-ended questions allowed for comment. Nursing students generally felt that violence was an on going problem at the institution. Reasons for their perceptions of violence were grouped into ten categories: theft and burglary, vandalism, physical fights, robbery, alcohol and drug abuse, racial tension, discrimination, no management supervision, feeling unsafe, and rudeness. There was a difference of opinion as to whether violence was targeted at specific groups. Racial tension and division between mixed race (Coloured) and African nursing students was evident in the responses. There were 150 (67.3%) students who reported that violence was not directed against nursing students from specific ethnic, cultural or religious groups, while 26.9% (n ¼ 60) felt that there was specific targeting: 10.3% (n ¼ 23) against specific ethnic groups, 21% (n ¼ 21) against cultural groups and 3.1% (n ¼ 7) against religious groups. Findings from the focus groups Three focus group themes emerged: it's not a safe place; racial tension; and abusive behaviour.

Observations of physical violence perpetrated by nursing students Not a safe place The most common types of violence observed by nursing students were shouting, fighting, swearing and discrimination Table 2 Personal experiences of violence. Personal experiences of violence


Verbal abuse Discrimination Shouting Physical assault Name Calling Being ignored Threats

22 14 19 6 15 15 9

The education institution has a student residence on the campus. First and second year students, except for those who are married, are strongly advised to live in the residence. Residence life Table 3 Observed physical violence perpetrated by nursing students on fellow students. Violent incidents

Percentage (%)

Pushing Sabotage of personal items Assault, no injuries Fist fights (no injuries) Fist fights (with injuries) Fights or attacked by a group of students

26 22 21 11 10 10


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Table 4 Psychological violence perpetrated by nursing students. Categories of psychological violence

Incidents (%)

Gossipping Verbal abuse Being ignored Humiliation Labelling Shouting Discrimination Insinuations Intimidation Swearing Bullying Innuendos Isolation Marginalization

14 9 8 8 8 8 7 7 7 6 5 5 4 4

provides structure and routine. The student residence presents many challenges for students related to violence: “… I'm a second-year student … that was middle of the night … she was there arguing with a guy. So I asked her why you arguing with the guy, because he actually wanted to slap her. So she told me that he actually wants to rape this girlie in her room and what he did was … he put something into the lock … so when she was inside she couldn't lock the door from the inside … then he knew that was gonna happen obviously because he came back and he actually wanted to rape her in the room. He was a student. She was a first year and he was a second-year guy”. “I mean it starts with breaking in … you a girl, you alone in that room. Tomorrow it ends up in rape and that's why I also prefer not to sleep alone in my room. I prefer to sleep with somebody else because I'm kinda very scared”. “This is not a safe place. We're afraid of being raped, assaulted or killed”. “The residence is an unsafe place. Your door is locked, but your things are still stolen”.

Racial tension There was increased racial tension among students and profiling of the ‘other’. According to the African (black) participants, the mixed-race (Coloured) nursing students were the worst perpetrators of violence, while the respondents felt that African students (‘the Blacks’) were the worst. The African females felt that mixedrace females were vulgar and rude and had a superior attitude towards them. The mixed-race females felt that the African females were aggressive and boisterous, and “pushed them around in the passages and in the food queue”. The comments reflect a lack of acceptance, a sense of being different and mistrust of the ‘other’. For example, the mixed race students felt that: “… as Coloureds have different views than the Blacks, then they intimidate us so that we can also have the same view as them” “According to my knowledge, break-ins only in the Coloureds' rooms” “… the funniest thing with all those break-ins, they broke in through the ceilings but they skipped every black girl's room and they only broke into the coloureds' … so I am reading something out of that …” The black nursing students in turn, felt that “At school, violence by Coloured students is directed at Blacks and vice versa”. Both coloured and back student were aware of perceived preference and discrimination:

“There is still some kind of colour division. Instead in hospitals our nurse educators take Black students as if they don't know anything … at the moment there are racial and gender issues amongst students”.

Abusive behaviour Respondents related abusive behaviour (such as physical fighting among students) to drug and alcohol abuse. Abusive behaviour occurred between male and female students in the residence. In one incident a male student physically abused his girlfriend, also a student: “Me and my friends were cooking in her room. … our block mate's boyfriend … he was a second year last year. He came drunk into her room and he asked her what am I doing there, because I was the only Coloured. They were all black. And then he started calling me names, but in their language. … my friend started to defend me … and then he started to slap her. … And then he threw the juice in her face and threw the hairpiece on the floor and she spat in his face and then he spat back. He locked the door and he started kicking her and slapping her all in her face and then my friend came up and she unlocked the door, but I was just sitting there. … he wanted to hit me with the broomstick … we laid a charge …” The violence affected the nursing students in a number of ways: increased conflict, loss of interest in attending lectures, as well as withdrawal, poor interpersonal relations, intolerance (during clinical placements) and increased anxiety (when studying). Findings from interviews with nurse educators Five nurse educators were interviewed. Six themes emerged: substance abuse, violation of others' property, abusive behaviour, clashes with the law, fearfulness and anxiety, and nursing students as victims of gender-based violence. Substance abuse The residence seems to be where most of the violent incidents related to drug and alcohol abuse occur. Nurse educators reported that drug and alcohol abuse among nursing students had increased over the last two to three years, and was an important contributing factor to violence among nursing students on campus. A nurse educator, asked whether violent incidents stemmed from drug and alcohol abuse responded: “To a large extent ja, to a large extent, with the big plate glass windows at the back we’re continually being broken into … because people climb over the wall and sell it through the plate glass to our students …” There is a strong sense that certain violent incidents are covered up, because nursing students are afraid of intimidation or further violence. Although the nurse educators had not personally been victims, they had witnessed violent incidents or violence had been reported to them. There was also the perception that the increase of violence in the institution and residences was linked to the increasing numbers of male students being admitted to the nursing programme. High risk periods for violence was perceived as being linked to the availability of money to spend: “When there's money in the pocket” “… but certainly there are times that are more high risk than others, for example the end of exams, when the bursary money gets paid … or it used to be when the salaries were paid out”

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Vandalism and violation of others' property The vandalism reported was destruction of nursing students' personal belongings and of the campus environment, e.g. abuse of fire extinguishers, breaking of windows, and damage to property. One educator stated: “… but breaking windows and doors, everything … Another thing that they are fond of doing is using the fire extinguishers, just emptying the fire extinguishers out in the passages …” Abusive behaviour Physical abuse among nursing students was an issue of real concern for the nurse educators. Fighting in the residence has been reported when nursing students were drunk: “… a lot of drunkenness and breaking of furniture and things like that; I don't want to make generalizations … but certainly I've noticed a trend that the perception … that as the number of males increases, so does the number of disciplinary inquiries that were held and that was specifically substance abuse, alcohol abuse, assault, vandalism, damage to property, examples are fire hydrants used in the corridors, broken windows, physical assault. … for at least four or five cases I've been taking students to casualty for stitches [sutures]. … they've been stabbed …” Drugs and alcohol were believed to contribute to the problem behaviour. Although the educators tried to assist where possible, they were not usually on campus over the weekend, when substance abuse was more likely to occur: “Sometimes they do talk to a lecturer and then they get referred. Then, I've just only heard about people who on the weekend getting … you know on drugs, doing things like breaking the windows, and all the other students locking themselves in their rooms, too scared to come out … you hear that they were unsupervised residents there at ‘institution X’ … apparently somebody got raped there.” Educators were concerned that some cases of sexual harassment and sexual assault among nursing students went unreported. Students were often reluctant to confide in nurse educators: “A lot of students don't speak to the lecturers …” “Yes, I know of one case that the student was convicted of rape, eventually. But until such time as he was convicted of raping another student on the premises … he attended lectures with that very student that he had raped.” Educators were not aware of any incidents of violence towards patients. They were of the opinion that violence in society was often mirrored in the student behaviour on campus: “… for many the education institution is a microcosm really of what is happening out there. So what happens out there, it's happening here.”

Clashes with the law The educators spoke of the difficulties that they had observed that with respect to police contact. As victims, nursing students reported incidents of assault, burglary and theft of personal possessions, allegedly by other nursing students. Students who were perpetrators had been arrested for theft, assault or sexual harassment. Police were


called to the campus if there was suspicion of drinking or abuse of drugs on the premises. The educators were aware of a male nursing student who was serving a sentence for assault. Fearfulness and anxiety Nursing students were perceived by the educators to be afraid of intimidation or further violence perpetrated against them if they reported an incident. They expressed their concern, that, despite the confidentiality of the focus groups which the researcher had conducted, students might not have been able to ‘open up’ about the real situation. They were concerned that the study might not reflect the true experiences of violence at the institution because nursing students might feel intimidated about revealing the true extent of the violence and intimidation: “… there are cover-ups going on. I'm not sure who's covering up for who, but we only find things out months later, you know” “… maybe the learners are experiencing more things that they don't even want to talk about … sometimes, you know, they might be afraid as well”

Nursing students as victims of gender-based violence Violence has not only been observed and/or reported within the education setting; participants reported violence experienced within intimate partner relationships. Partners who abuse drugs and alcohol are another source of concern for the educators: “… sexually harassed or … beaten up or their partners using TIK [crystal meth] and are abusing them …” “One student in the clinical area when I was doing accompaniment told me that her boyfriend had beaten her up …” The education institution is situated in an area where gangsterism is rife. Nursing students have fallen victim to robbery and abuse outside the campus, en route to and from class: “I don't think a day goes by where there isn't some form of violence reported by the students, but it's not violence within the campus, it's violence perpetrated on the students outside of the institution” “We’ve also had reports … where the students were attacked outside, when they’re going to the shops, they walk to the station, their cell phones are being stolen”

Discussion Violence at the nursing education campus within the classroom setting, recreational spaces and residence was perceived and experienced by nursing students as a threat to their safety and security. The student residence, located on the campus, was the primary setting in which incidents of violence occurred and was therefore perceived as unsafe. Lack of protection was a cause of anxiety and concern for the student residents. Violent incidents were attributed to alcohol and drug abuse, racial tension, lack of supervision by the residence management, robbery and general rudeness. Gossipping and verbal abuse, the primary types of psychological violence, is reported in other studies (Edwards and O'Connell, 2007; Woelfle and McCaffrey, 2007). Verbal violence in nursing workplace settings has been associated with high levels of psychological problems, high job strain, low social support and low organisational justice (Magnavita and Heponiemi, 2011).


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Racial discrimination and intolerance were perceived to be a particular issue for students. Racism is a very sensitive issue which engenders anxiety, and has long been ignored in nursing education (Cortis and Law, 2005; Nairn et al., 2004; Narayanasamy and White, 2005). Despite limited evidence as to how it can be addressed (Curtis et al., 2007; Nairn et al., 2004), cross-cultural nursing and antidiscrimination should be emphasised in nursing curricula (Allen et al., 2013). Markey and Tilki (2007) argue that organisational factors perpetuate institutional racism and lecturers are limited in their ability to recognise and address this in the learning context. For South Africans in particular, the legacy of apartheid has presented on-going challenges for interracial relationships (Durrheim et al., 2011). This study demonstrated this challenge, where students of different races and genders had difficulty integrating with each other. None of the participants reported having been exposed to sexual abuse, but they were aware of previous incidents at the nursing education institution. Sexual harassment of nursing students in the clinical setting has been documented by a number of authors (Bronner et al., 2003; Kisa and Dziegielewski, 1996; Ryan and Maguire, 2006) but this phenomenon on a nursing campus has not been found in the literature. South Africa has high levels of interpersonal violence and in particular sexual assault of women, and young female nursing students may be at increased risk. Although violence experienced by nurses in the workplace is well documented, the experiences of violence among nursing students within the nursing education environment, causes and effects of such violence, need further investigation, as well as the perceived link between substance abuse and occurrences of violent behaviour within the nursing student population. Violation of property and personal space, as evidenced in this study, has not been widely reported, and this may be a local phenomenon in which further research is necessary. Recommendations The problem of violence among nursing students is clearly rooted in a complex web of social factors, including substance abuse (drugs & alcohol), racial tension and discrimination, which mirror the societal environment. This study demonstrates that violence among nursing students is cause for concern in nursing education, nursing practice and the broader health care profession. There are a number of implications for education, research and practice which emanate from this study. Nursing curricula should include interpersonal skills and conflict management training as well as a specific module on the management of aggression in the workplace. It is also essential that the impact on health of violent and aggressive behaviour is included in the curriculum. Highquality intervention programmes aimed at combating violence should be implemented. It is therefore important that diversity and trans-cultural nursing skills are taught by promoting intercultural communication and cooperative learning, e.g. inclusion of appropriate learning activities. Nursing students should be realistically challenged and encouraged to develop skills to manage frustration and irritation, recognise manifestations of fear which may precede aggressive and violent behaviour. Modelling of appropriate behaviour, particularly with respect to management of anger and conflict, is important. Nurse educators have an important role to play in facilitating acquisition of skills to enable nursing students to develop a sense of self-efficacy and self-worth and the ability to reflect on their practice in order to recognise their own behaviour and facilitate change. Racial discrimination and intolerance in South Africa is still problematic, as evident in this study. It is important that diversity

and transcultural nursing skills are taught by promoting intercultural communication and cooperative learning through appropriate activities. Within nursing student residences, structures to optimise the safety and wellbeing of students must be in place, including adequate and appropriately skilled staff, clear residence rules and codes of conduct, explicit and fair disciplinary practice, clear consequences for non-adherence and effective grievance procedures. Ownership and involvement of nursing students in residence activities and management will assist in creating a culture of tolerance and acceptance. Creation of safe learning and recreational spaces, and facilities which promote healthy interaction are essential to promote balanced work and recreation. Resident and student committees are a vital component of institutional life, and effective student participation can facilitate creation and maintenance of a non-violent environment. Exposure to violence in the nursing education institution and residence increases stress and may indeed engender maladaptive responses. Nurse educators and residence staff play an important role in supporting nursing students, who need to feel that there are people other than their families who are interested in them and their progress. In a profession in which nurses are exposed to violence in the workplace, it is important that violence in the learning environment is actively prevented and respect of individual rights, tolerance and co-operation are promoted. References Allen, J., Brown, L., Duff, C., Nesbitt, P., Hepner, A., 2013. Development and evaluation of a teaching and learning approach in cross-cultural care and antidiscrimination in university nursing students. Nurse Educ. Today 33 (12), 1592e1598. Beech, B., 2001. Sign of the times or the shape of things to come? A 3-day unit of instruction on ‘aggression and violence in health settings’ for all students during pre-registration nurse training. Accid. Emerg. Nurs. 9 (3), 204e211. Beech, B., 2008. Aggression prevention training for student nurses: differential responses to training and the interaction between theory and practice. Nurse Educ. Pract. 8 (2), 94e102. Blair, M., Wallace, C., 2002. Violence in society: nursing faculty respond to a health care epidemic. J. Nurs. Educ. 41 (8), 360e362. Bronner, G., Peretz, C., Ehrenfeld, M., 2003. Sexual harassment of nurses and nursing students. J. Adv. Nurs. 42 (6), 637e644. Calvert, W.J., 1996. The effects of violence in society upon nursing curriculum imperatives. ABNF J. 7, 124e128. Campbell, J.C., 2002. Health consequences of intimate partner violence. The Lancet 359, 1331e1336. Çelebioglu, A., Akpinar, R.B., Küçükoglu, S., Engin, R., 2010. Violence experienced by Turkish nursing students in clinical settings: their emotions and behaviors. Nurse Educ. Today 30 (7), 687e691. Celik, S.S., Bayraktar, N., 2004. A study of nursing student abuse in Turkey. J. Nurs. Educ. 43 (7), 330e336. Chapman, R., Styles, I., 2006. An epidemic of abuse and violence: nurse on the front line. Accid. Emerg. Nurs. 14 (4), 245e249. Clark, C.M., Springer, P.J., 2007. Thoughts on incivility: student and faculty perceptions of uncivil behavior in nursing education. Nurs. Educ. Perspect. 28 (2), 93e97. Cortis, J., Law, I., 2005. Anti-racist innovation and nurse education. Nurse Educ. Today 25, 176e180. Creswell, J.W., 2007. Qualitative Inquiry & Research Design. Choosing Among Five Approaches. Sage Publications, Thousand Oaks. Centre for the Study of Violence and Reconciliation (CSVR), 2007. Annual Report 2007. Available from: Curtis, J., Bowen, I., Reid, A., 2007. You have no credibility: nursing students' experiences of horizontal violence. Nurse Educ. Pract. 7 (3), 156e163. Dartnall, E., Jewkes, R., 2013. Sexual violence against women: the scope of the problem. Best practice & research. Clin. Obstet. Gynaecol. 27 (1), 3e13. Dissel, A., 2007. Causes of violence in South-Africa. In: Presentation to the South-African Human Rights Commission Conference on Crime and Human Rights. Available from: pdf2007.pdf. Durrheim, K., Tredoux, C., Foster, D., Dixon, J., 2011. Historical trends in South African race attitudes. South Afr. J. Psychol. 41 (3), 263e278. Edwards, S.L., O'Connell, C.F., 2007. Exploring bullying: implications for nurse educators. Nurse Educ. Pract. 7 (1), 26e35. Farrell, G.A., 2001. From tall poppies to squashed weeds: why don't nurses pull together more? J. Adv. Nurs. 35 (1), 26e33.

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Pre-registration nursing students' perceptions and experiences of violence in a nursing education institution in South Africa.

Violence is a growing problem worldwide in the field of health care and within the nursing profession. A study comprising a survey and focus groups wi...
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