The document outlines a research project that involves analyzing two articles related to growth mindset and its impact on student motivation and learning. It discusses the significant differences between fixed and growth mindsets and how these beliefs affect students' performance and reactions to challenges. The research demonstrates that fostering a growth mindset can enhance students' engagement and academic success in subjects like mathematics and science.

1. NSG3036 W2 Project
Research Template Name
Cite both articles reviewed in APA style:
***In the template, any direct quotes from the articles needs to
only include the page number.
Week 2 Template
Quantitative Article
Qualitative Article
Summarize the two assigned articles. In a paragraph, describe in
your own words what the study was about and what the
researchers found.
Identify and describe the problem for each article
Identified the purpose statement for each article
Identified hypothesis and/or research questions depending on
the methodology used in the articles.
After analyzing, discuss
each article’s significance to nursing practice.

2. Identify two details to support the study being quantitative or
qualitative
Name:
Growth Mindset
Task 1: Read the article Transforming Students’ Motivation to
Learn, by Carol S. Dweck, Winter 2008, (following
pages)before coming to class. Highlight the things you find
interesting as you read.
Task 2: Think about yourself and your own mindset about
mathematics and Engineering. Think about your personal
science history in light of what Carol S. Dweck and her
graduate students have discovered about mindsets and learning.
Write a draft of a paragraph or two about your reaction to this
article. You might include thoughts about the following.
· How did the article make you feel?
· Do you believe you have a fixed mindset or a growth mindset?
Explain why.
· How might the article influence how your approach to your
classes, particularly Engineering and Science classes, this
semester?
Bring a copy of this with you to class next time we meet. We
might / will use our responses to generate discussion and a list
of things we can do to help us move toward and maintain a
growth mindset.
Task 3: Review the draft of a paragraph or two you wrote

3. before the class discussion next week. Revise these paragraphs
if necessary and incorporate your thoughts on the mindset
article in your Draft. Be sure to address the specific questions
raised in Task 2.
Transforming Students’ Motivation to Learn Carol S.
DweckWinter 2008
This is an exciting time for our brains. More and more research
is showing that our brains change constantly with learning and
experience and that this takes place throughout our lives.
Does this have implications for students' motivation and
learning? It certainly does. In my research in collaboration with
my graduate students, we have shown that what students believe
about their brains — whether they see their intelligence as
something that's fixed or something that can grow and change
— has profound effects on their motivation, learning, and
school achievement (Dweck, 2006). These different beliefs, or
mindsets, create different psychological worlds: one in which
students are afraid of challenges and devastated by setbacks,
and one in which students relish challenges and are resilient in
the face of setbacks.
How do these mindsets work? How are the mindsets
communicated to students? And, most important, can they be
changed? As we answer these questions, you will understand
why so many students do not achieve to their potential, why so
many bright students stop working when school becomes
challenging, and why stereotypes have such profound effects on
students' achievement. You will also learn how praise can have
a negative effect on students' mindsets, harming their
motivation to learn.
Mindsets and Achievement
Many students believe that intelligence is fixed, that each

4. person has a certain amount and that's that. We call this a fixed
mindset, and, as you will see, students with this mindset worry
about how much of this fixed intelligence they possess. A fixed
mindset makes challenges threatening for students (because they
believe that their fixed ability may not be up to the task) and it
makes mistakes and failures demoralizing (because they believe
that such setbacks reflect badly on their level of fixed
intelligence).
Other students believe that intelligence is something that can be
cultivated through effort and education. They don't necessarily
believe that everyone has the same abilities or that anyone can
be as smart as Einstein, but they do believe that everyone can
improve their abilities. And they understand that even Einstein
wasn't Einstein until he put in years of focused hard work. In
short, students with this growth mindset believe that
intelligence is a potential that can be realized through learning.
As a result, confronting challenges, profiting from mistakes,
and persevering in the face of setbacks become ways of getting
smarter.
To understand the different worlds these mindsets create, we
followed several hundred students across a difficult school
transition — the transition to seventh grade. This is when the
academic work often gets much harder, the grading gets stricter,
and the school environment gets less personalized with students
moving from class to class. As the students entered seventh
grade, we measured their mindsets (along with a number of
other things) and then we monitored their grades over the next
two years.
The first thing we found was that students with different
mindsets cared about different things in school. Those with a
growth mindset were much more interested in learning than in
just looking smart in school. This was not the case for students
with a fixed mindset. In fact, in many of our studies with
students from preschool age to college age, we find that
students with a fixed mindset care so much about how smart
they will appear that they often reject learning opportunities —

5. even ones that are critical to their success (Cimpian, et al.,
2007; Hong, et al., 1999; Nussbaum and Dweck, 2008; Mangels,
et al., 2006).
Next, we found that students with the two mindsets had
radically different beliefs about effort. Those with a growth
mindset had a very straightforward (and correct) idea of effort
— the idea that the harder you work, the more your ability will
grow and that even geniuses have had to work hard for their
accomplishments. In contrast, the students with the fixed
mindset believed that if you worked hard it meant that you
didn't have ability, and that things would just come naturally to
you if you did. This means that every time something is hard for
them and requires effort, it's both a threat and a bind. If they
work hard at it that means that they aren't good at it, but if they
don't work hard they won't do well. Clearly, since just about
every worthwhile pursuit involves effort over a long period of
time, this is a potentially crippling belief, not only in school but
also in life.
Students with different mindsets also had very different
reactions to setbacks. Those with growth mindsets reported that,
after a setback in school, they would simply study more or
study differently the next time. But those with fixed mindsets
were more likely to say that they would feel dumb, study less
the next time, and seriously consider cheating. If you feel dumb
— permanently dumb — in an academic area, there is no good
way to bounce back and be successful in the future. In a growth
mindset, however, you can make a plan of positive action that
can remedy a deficiency. (Hong. et al., 1999; Nussbaum and
Dweck, 2008; Heyman, et al., 1992)
Finally, when we looked at the math grades they went on to
earn, we found that the students with a growth mindset had
pulled ahead. Although both groups had started seventh grade
with equivalent achievement test scores, a growth mindset
quickly propelled students ahead of their fixed-mindset peers,
and this gap only increased over the two years of the study.
In short, the belief that intelligence is fixed dampened students'

6. motivation to learn, made them afraid of effort, and made them
want to quit after a setback. This is why so many bright students
stop working when school becomes hard. Many bright students
find grade school easy and coast to success early on. But later
on, when they are challenged, they struggle. They don't want to
make mistakes and feel dumb — and, most of all, they don't
want to work hard and feel dumb. So they simply retire.
It is the belief that intelligence can be developed that opens
students to a love of learning, a belief in the power of effort and
constructive, determined reactions to setbacks.
How Do Students Learn These Mindsets?
In the 1990s, parents and schools decided that the most
important thing for kids to have was self-esteem. If children felt
good about themselves, people believed, they would be set for
life. In some quarters, self-esteem in math seemed to become
more important than knowing math, and self-esteem in English
seemed to become more important than reading and writing. But
the biggest mistake was the belief that you could simply hand
children self-esteem by telling them how smart and talented
they are. Even though this is such an intuitively appealing idea,
and even though it was exceedingly well-intentioned, I believe
it has had disastrous effects.
In the 1990s, we took a poll among parents and found that
almost 85 percent endorsed the notion that it was necessary to
praise their children's abilities to give them confidence and help
them achieve. Their children are now in the workforce and we
are told that young workers cannot last through the day without
being propped up by praise, rewards, and recognition. Coaches
are asking me where all the coachable athletes have gone.
Parents ask me why their children won't work hard in school.
Could all of this come from well-meant praise? Well, we were
suspicious of the praise movement at the time. We had already
seen in our research that it was the most vulnerable children
who were already obsessed with their intelligence and
chronically worried about how smart they were. What if
praising intelligence made all children concerned about their

7. intelligence? This kind of praise might tell them that having
high intelligence and talent is the most important thing and is
what makes you valuable. It might tell them that intelligence is
just something you have and not something you develop. It
might deny the role of effort and dedication in achievement. In
short, it might promote a fixed mindset with all of its
vulnerabilities.
The wonderful thing about research is that you can put
questions like this to the test — and we did (Kamins and
Dweck, 1999; Mueller and Dweck, 1998). We gave two groups
of children problems from an IQ test, and we praised them. We
praised the children in one group for their intelligence, telling
them, "Wow, that's a really good score. You must be smart at
this." We praised the children in another group for their effort:
"Wow, that's a really good score. You must have worked really
hard." That's all we did, but the results were dramatic. We did
studies like this with children of different ages and ethnicities
from around the country, and the results were the same.
Here is what happened with fifth graders. The children praised
for their intelligence did not want to learn. When we offered
them a challenging task that they could learn from, the majority
opted for an easier one, one on which they could avoid making
mistakes. The children praised for their effort wanted the task
they could learn from.
The children praised for their intelligence lost their confidence
as soon as the problems got more difficult. Now, as a group,
they thought they weren't smart. They also lost their enjoyment,
and, as a result, their performance plummeted. On the other
hand, those praised for effort maintained their confidence, their
motivation, and their performance. Actually, their performance
improved over time such that, by the end, they were performing
substantially better than the intelligence-praised children on
this IQ test.
Finally, the children who were praised for their intelligence lied
about their scores more often than the children who were
praised for their effort. We asked children to write something

8. (anonymously) about their experience to a child in another
school and we left a little space for them to report their scores.
Almost 40 percent of the intelligence-praised children elevated
their scores, whereas only 12 or 13 percent of children in the
other group did so. To me this suggests that, after students are
praised for their intelligence, it's too humiliating for them to
admit mistakes.
The results were so striking that we repeated the study five
times just to be sure, and each time roughly the same things
happened. Intelligence praise, compared to effort (or "process")
praise, puts children into a fixed mindset. Instead of giving
them confidence, it made them fragile, so much so that a brush
with difficulty erased their confidence, their enjoyment, and
their good performance, and made them ashamed of their work.
This can hardly be the self-esteem that parents and educators
have been aiming for.
Often, when children stop working in school, parents deal with
this by reassuring their children how smart they are. We can
now see that this simply fans the flames. It confirms the fixed
mindset and makes kids all the more certain that they don't want
to try something difficult — something that could lose them
their parents' high regard.
How should we praise our students? How should we reassure
them? By focusing them on the process they engaged in — their
effort, their strategies, their concentration, their perseverance,
or their improvement.
"You really stuck to that until you got it. That's wonderful!"
"It was a hard project, but you did it one step at a time and it
turned out great!"
"I like how you chose the tough problems to solve. You're really
going to stretch yourself and learn new things."
"I know that school used to be a snap for you. What a waste that
was. Now you really have an opportunity to develop your
abilities."
Brainology
Can a growth mindset be taught directly to kids? If it can be

9. taught, will it enhance their motivation and grades? We set out
to answer this question by creating a growth mindset workshop
(Blackwell, et al., 2007). We took seventh graders and divided
them into two groups. Both groups got an eight-session
workshop full of great study skills, but the "growth mindset
group" also got lessons in the growth mindset — what it was
and how to apply it to their schoolwork. Those lessons began
with an article called "You Can Grow Your Intelligence: New
Research Shows the Brain Can Be Developed Like a Muscle."
Students were mesmerized by this article and its message. They
loved the idea that the growth of their brains was in their hands.
This article and the lessons that followed changed the terms of
engagement for students. Many students had seen school as a
place where they performed and were judged, but now they
understood that they had an active role to play in the
development of their minds. They got to work, and by the end of
the semester the growth-mindset group showed a significant
increase in their math grades. The control group — the group
that had gotten eight sessions of study skills — showed no
improvement and continued to decline. Even though they had
learned many useful study skills, they did not have the
motivation to put them into practice.
The teachers, who didn't even know there were two different
groups, singled out students in the growth-mindset group as
showing clear changes in their motivation. They reported that
these students were now far more engaged with their
schoolwork and were putting considerably more effort into their
classroom learning, homework, and studying.
Joshua Aronson, Catherine Good, and their colleagues had
similar findings (Aronson, Fried, and Good, 2002; Good,
Aronson, and Inzlicht, 2003). Their studies and ours also found
that negatively stereotyped students (such as girls in math, or
African-American and Hispanic students in math and verbal
areas) showed substantial benefits from being in a growth-
mindset workshop. Stereotypes are typically fixed-mindset
labels. They imply that the trait or ability in question is fixed

10. and that some groups have it and others don't. Much of the harm
that stereotypes do comes from the fixed-mindset message they
send. The growth mindset, while not denying that performance
differences might exist, portrays abilities as acquirable and
sends a particularly encouraging message to students who have
been negatively stereotyped — one that they respond to with
renewed motivation and engagement.
Inspired by these positive findings, we started to think about
how we could make a growth mindset workshop more widely
available. To do this, we have begun to develop a computer-
based program called "Brainology." In six computer modules,
students learn about the brain and how to make it work better.
They follow two hip teens through their school day, learn how
to confront and solve schoolwork problems, and create study
plans. They visit a state-of-the-art virtual brain lab, do brain
experiments, and find out such things as how the brain changes
with learning — how it grows new connections every time
students learn something new. They also learn how to use this
idea in their schoolwork by putting their study skills to work to
make themselves smarter.
We pilot-tested Brainology in 20 New York City schools.
Virtually all of the students loved it and reported
(anonymously) the ways in which they changed their ideas
about learning and changed their learning and study habits.
Here are some things they said in response to the question, "Did
you change your mind about anything?"
“I did change my mind about how the brain works…I will try
harder because I know that the more you try, the more your
brain works.”
“Yes... I imagine neurons making connections in my brain and I
feel like I am learning something.”
“My favorite thing from Brainology is the neurons part where
when u learn something, there are connections and they keep
growing. I always picture them when I'm in school.”
Teachers also reported changes in their students, saying that
they had become more active and eager learners: "They offer to

11. practice, study, take notes, or pay attention to ensure that
connections will be made."
What Do We Value?
In our society, we seem to worship talent — and we often
portray it as a gift. Now we can see that this is not motivating
to our students. Those who think they have this gift expect to sit
there with it and be successful. When they aren't successful,
they get defensive and demoralized, and often opt out. Those
who don't think they have the gift also become defensive and
demoralized, and often opt out as well.
We need to correct the harmful idea that people simply have
gifts that transport them to success, and to teach our students
that no matter how smart or talented someone is — be it
Einstein, Mozart, or Michael Jordan — no one succeeds in a big
way without enormous amounts of dedication and effort. It is
through effort that people build their abilities and realize their
potential. More and more research is showing there is one thing
that sets the great successes apart from their equally talented
peers — how hard they've worked (Ericsson, et al., 2006).
Next time you're tempted to praise your students' intelligence or
talent, restrain yourself. Instead, teach them how much fun a
challenging task is, how interesting and informative errors are,
and how great it is to struggle with something and make
progress. Most of all, teach them that by taking on challenges,
making mistakes, and putting forth effort, they are making
themselves smarter.
Carol S. Dweck is the Lewis and Virginia Eaton Professor of
Psychology at Stanford University and the author of Mindset:
The New Psychology of Success (Random House, 2006).
References
Aronson, J., Fried, C., & Good, C. (2002). Reducing the effects
of stereotype threat on African American college students by
shaping theories of intelligence.Journal of Experimental Social
Psychology, 38, 113–125.
Binet, A. (1909/1973). Les idées modernes sur les enfants

12. [Modern ideas on children]. Paris: Flamarion.
Blackwell, L., Trzesniewski, K., & Dweck, C.S. (2007). Implicit
Theories of Intelligence Predict Achievement Across an
Adolescent Transition: A Longitudinal Study and an
Intervention. Child Development, 78, 246–263.
Cimpian, A., Arce, H., Markman, E.M., & Dweck, C.S. (2007).
Subtle linguistic cues impact children's motivation.
Psychological Science, 18, 314-316.
Dweck, C.S. (2006). Mindset. New York: Random House.
Ericsson, K.A., Charness, N., Feltovich, P.J., & Hoffman, R.R.
(Eds.) (2006). The Cambridge Handbook of Expertise and
Expert Performance. New York: Cambridge University Press.
Good, C. Aronson, J., & Inzlicht, M. (2003). Improving
adolescents' standardized test performance: An Intervention to
reduce the effects of stereotype threat. Journal of Applied
Developmental Psychology, 24, 645-662.
Hong, Y.Y., Chiu, C., Dweck, C.S., Lin, D., & Wan, W. (1999)
Implicit theories, attributions, and coping: A meaning system
approach. Journal of Personality and Social Psychology, 77,
588–599.
Kamins, M., & Dweck, C.S. (1999). Person vs. process praise
and criticism: Implications for contingent self-worth and
coping. Developmental Psychology, 35,835–847.
Mangels, J. A., Butterfield, B., Lamb, J., Good, C.D., & Dweck,
C.S. (2006). Why do beliefs about intelligence influence
learning success? A social-cognitive-neuroscience model.
Social, Cognitive, and Affective Neuroscience, 1, 75–86.

13. Mueller, C. M., & Dweck, C. S. (1998). Intelligence praise can
undermine motivation and performance. Journal of Personality
and Social Psychology, 75, 33–52.
Nussbaum, A.D., & Dweck, C.S. (2007, in press).
Defensiveness vs. Remediation: Self-Theories and Modes of
Self-Esteem Maintenance. Personality and Social Psychology
Bulletin.
1
CLINICAL SCHOLARSHIP
Using Photovoice to Explore Nigerian Immigrants’ Eating and
Physical Activity in the United States
Melanie T. Turk, PhD, MSN, RN1, Abimbola Fapohunda, DrPH,
MPH, MS2, & Rick Zoucha, PhD, APRN-BC,
CTN-A3
1 Epsilon Phi, Assistant Professor, Duquesne University School
of Nursing, Pittsburgh, PA, USA
2 Consultant, FOB Group, LLC, Monroeville, PA, USA
3 Professor of Nursing, Duquesne University School of Nursing,
Pittsburgh, PA, USA
Key words
Immigrants, nutrition, physical activity,
Photovoice
Correspondence

14. Dr. Melanie T. Turk, Duquesne University School
of Nursing, 518 Fisher Hall, 600 Forbes Avenue,
Pittsburgh, PA 15282. E-mail: [email protected]
Accepted: July 19, 2014
doi: 10.1111/jnu.12105
Abstract
Purpose: African immigrants are one of the fastest growing
immigrant groups
to the United States; there is a crucial need to learn about
African immigrants’
beliefs and lifestyle behaviors that may impact health. The
purposes of this
study were to (a) explore the perceptions and practices of
Nigerian immigrants
regarding healthy eating and physical activity in the United
States; (b) assess
the influence of cultural beliefs of Nigerian immigrants on
eating and physical
activity; (c) describe the role that healthcare providers can play
in helping to
promote healthy eating and physical activity; and (d) evaluate
the feasibility
and efficacy of using Photovoice to collect data on the
perceptions and practices
of Nigerian immigrants regarding healthy eating and physical
activity.
Design: Qualitative visual ethnography using Photovoice.
Methods: Thirteen Nigerian immigrants were recruited. Data
were col-
lected using photography and focus group discussions at a
church. Photovoice

15. methodology and Leininger’s four phases of qualitative analysis
were used to
analyze photographs, field notes, and focus group transcripts.
Findings: Four overarching themes emerged from the data:
moderation is
healthy, Nigerian ways of living are healthy, acquiring
American ways is un-
healthy, and cultural context is important to promote healthy
behaviors.
Conclusions: Photovoice was a feasible, effective methodology
for collecting
data on the perceptions and practices of Nigerian immigrants.
Nigerian partic-
ipants believed that adherence to traditional dietary and activity
practices are
healthy. Nurses and other healthcare providers must make
concerted efforts
to communicate with and educate Nigerian immigrants about
healthful eating
and activity behaviors within their cultural context.
Clinical Relevance: The number of African immigrants to the
United States
has increased dramatically. Photovoice is a creative method to
learn about the
health beliefs and behaviors of the Nigerian immigrant
population.
Immigration plays a major role in the growth of the
population of the United States, and it is estimated that
82% of the population increase between 2005 and 2050
will be attributable to immigrants and their offspring
(Passel & Cohn, 2008). The African-born population in
the United States doubled in size from 881,300 in 2000
to 1.6 million in 2010, and one of the most common
countries of origin for African immigrants is Nigeria

16. (U.S. Census Bureau, 2010). Yet, to a large extent, the
health and wellness of the African immigrant population
remain unexplored (Venters & Gany, 2011). These de-
mographic trends indicate a crucial need to learn about
African immigrants’ beliefs and lifestyle behaviors that
may impact health.
While the African immigrant population has grown
exponentially, few studies have examined the health
16 Journal of Nursing Scholarship, 2015; 47:1, 16–24.
C© 2014 Sigma Theta Tau International
Turk et al. Using Photovoice With Nigerian Immigrants
of African-born residents in the United States (US),
including the impact of acculturation on diet and phys-
ical activity. The majority of immigrant health research
has focused on Hispanic and Asian populations and sug-
gests that, generally, these immigrant groups are health-
ier than native-born Americans (Barrington, Baquero, &
Borrell, 2010; Singh, Siahpush, & Hiatt, 2011). Limited
evidence also shows that African immigrants tend to be
healthier than US-born Whites and African Americans
(Read, Emerson, & Tarlov, 2005; Singh & Hiatt, 2006;
Singh & Miller, 2004). Studies on dietary patterns in
groups of immigrant populations show that traditional
diets are healthier than the nontraditional diets that
have evolved with acculturation (Delisle, 2010; Desilets,
Rivard, Shatenstein, & Delisle, 2007). Yet, immigrants
may face barriers in maintaining healthy native diets or
acquiring healthy physical activity habits in their new
countries. Among 5,230 immigrants to the US, 79% re-
ported being physically inactive (Koya & Egede, 2007),

17. and only 38% of a sample of African immigrants to the
Netherlands said they had engaged in physical activity
in the previous month (Beune, Haafkens, Agyemang, &
Bindels, 2010).
US national data systems used in monitoring health,
mortality, and disease patterns do not identify Africans
in the US as a separate ethnic group, and do not rou-
tinely report and analyze health data by immigrant sta-
tus (Singh & Hiatt, 2006; Singh & Miller, 2004; Singh,
Rodriguez-Lainz, & Kogan, 2013). Thus, data for African-
born immigrants are often entangled with data for
African Americans. An analysis of National Health Inter-
view Survey data showed that 58.4% of African adult im-
migrants were either overweight or obese in 2002 after
residing in the US for 15 or more years (Koya & Egede,
2007). Current statistics of Black US residents, including
persons born in the US or elsewhere, indicate that 54%
and 38% of Black female and male adults, respectively,
are either overweight or obese compared to 33% and
34% of White female and male adults (American Heart
Association Statistics Committee & Stroke Statistics Sub-
committee, 2014). While diet and activity are key deter-
minants of weight, an established contributor to health,
little is known about African immigrants’ perceptions and
practices around healthy eating and physical activity as
they relate to residing in the US.
Photovoice, in which participants use photographs to
describe their health and life experiences, is one method
that has been used as a health-promoting strategy (Wang
& Burris, 1997; Wang & Redwood-Jones, 2001). Initially
originated by Wang and Burris (1997) to document the
everyday lives of women in rural villages of China, Pho-
tovoice is a grassroots approach of community-engaged
research that assists people in identifying the strengths

18. and issues of their community through photography. The
Photovoice approach has been used previously with im-
migrant groups such as Latino, Chinese, Korean, and
Vietnamese immigrants to learn about topics such as hu-
man immunodeficiency virus prevention, family plan-
ning, mental and cardiovascular health, and the influence
of immigration (Fitzpatrick et al., 2009; Garcia & Saewye,
2007; Rhodes & Hergenrather, 2007; Schwartz, Sable,
Dannerbeck, & Campbell, 2007; Streng et al., 2004). Pho-
tovoice can provide Nigerian African immigrants the op-
portunity to express their ideas about eating habits and
physical activity within the context of their daily lives in
the US.
Purpose
The purposes of this study were to (a) explore the be-
liefs, perceptions, and practices of Nigerian immigrants
regarding healthy eating and physical activity behaviors
while living in the US; (b) assess the influence of cultural
beliefs of Nigerian immigrants on eating and physical ac-
tivity behaviors after migration to the US; (c) describe the
role that healthcare providers can play in helping to pro-
mote healthy eating and physical activity behaviors for
Nigerian immigrants; and (d) evaluate the acceptability,
feasibility, and efficacy of using Photovoice as a technique
to collect data on the perceptions and practices of Nige-
rian immigrants.
Methods
Design
A qualitative visual ethnography design using Pho-
tovoice was employed for this study, and two of the goals

19. of Photovoice identified by Wang and Burris (1997) were
highlighted: (a) encouragement of individuals to record
their community’s strengths and concerns and (b) fa-
cilitation of critical dialogue through group discussions
about photos taken by the participants. The Photovoice
method includes a four-step process of discovery and en-
gagement. The first step is community training regarding
the process. Three additional steps include (a) selecting
the photos that most accurately reflect the community
and culture; (b) contextualizing the data, which is telling
stories about what the photos mean; and (c) summariz-
ing the data by identifying themes or emerging theories
(Wang & Burris, 1997). Photos taken by the participants
are the principal medium by which viewpoints, percep-
tions, and recommendations develop. Using the photos
as the impetus for discussion via focus groups, this
methodology allows for the collection of rich, in-depth
Journal of Nursing Scholarship, 2015; 47:1, 16–24. 17
C© 2014 Sigma Theta Tau International
Using Photovoice With Nigerian Immigrants Turk et al.
data, possibly not attainable through observations or in-
terview alone.
Setting
Two focus group meetings were held in October and
November of 2013 at a Christian church attended pri-
marily by Nigerian immigrants in an urban area of
Western Pennsylvania. The focus groups were held im-
mediately following the religious service in a private
room in the church hall. A preliminary study conducted

20. with a community advisory committee from the church
to learn about the community’s health issues, needs, and
concerns revealed a concern about obesity among the im-
migrant group (unpublished data). Thus, we continued
working with this community to learn about their views
on healthy eating and activity in the US.
Participants
Individuals were eligible to participate if they were im-
migrants to the US from Nigeria, at least 18 years old, and
able to read and write in English. Participants also needed
to be able to use the digital camera we provided to take
photos of what they perceived as unhealthy and healthy
eating and activity. Recruitment was facilitated by a re-
search team member of Nigerian descent who had estab-
lished connections with community gatekeepers. We also
utilized the snowball method, in which word of mouth is
utilized, and participants referred to the study other in-
dividuals who might be interested (Munhall, 2011). We
recruited 13 participants.
Procedures
Prior to any study activities, institutional review board
approval was obtained from the university where the
principal investigator is employed. During our first re-
cruitment meeting at the church, the study was explained
to interested individuals, and written informed consent
was obtained. We returned to the church in 2 weeks to
distribute the digital cameras, demonstrate how to use
the cameras, and explain to the participants what they
needed to photograph for the study. We also discussed
potential issues related to using cameras, such as respect-
ing privacy and asking for permission to take someone’s
picture. We instructed participants to take photos for the

21. next 2 weeks of what they perceived as unhealthy eating
and physical activity. In order to explore the total per-
spective of what was seen as healthy, we also gathered
data about perceptions of what is unhealthy to provide
contrasting ideas. Participants were told they could take
as many photos as they liked, but they would need to
select the top four photos that most accurately reflected
their perceptions of what is unhealthy eating and activity.
In order to facilitate the discussion of each participant’s
pictures at the focus group meetings, it was necessary that
they only select their top four pictures to discuss. A brief
demographic questionnaire was completed by all partici-
pants at this time.
Held 2 weeks later, the next meeting was a focus group
to discuss the photos of unhealthy eating and activity.
Participants were informed that the meeting would be
audiotaped but that their responses would remain con-
fidential. Each participant’s four photos were projected
onto the wall for everyone to view, and each person dis-
cussed their photos with the group. At the end of the first
focus group, which lasted approximately 80 min, partici-
pants were told to take photos of healthy eating and ac-
tivity, and select their top four pictures to discuss when
they returned for another group meeting in 2 weeks.
The second focus group was focused on a discussion
of what the participants perceived as healthy eating and
physical activity and was facilitated as described in the
preceding paragraph. This second focus group lasted ap-
proximately 90 min. Both focus group sessions were au-
diotaped and transcribed verbatim. Healthy snacks were
provided at all meetings, and participants were permitted
to keep the digital camera to compensate them for their
time.

22. Data Collection
The day before each scheduled focus group meeting,
participants selected four photos that most accurately re-
flected their perceptions of what is unhealthy and what
is healthy, and emailed these photos to the principal in-
vestigator. The research assistant then compiled all the
photos in a PowerPoint (Microsoft Corp., Redmond, WA,
USA) presentation with a slide for each participant’s pho-
tos for display at the meeting. The discussion during
each focus group was facilitated by the authors using a
semistructured interview guide following the pneumonic
SHOWeD to encourage description about the photos, as
is consistent with the Photovoice methodology (Wang
& Burris, 1997). The interview guide included the fol-
lowing questions: (a) What do you See here? (b) What
is really Happening here? (c) How does this relate to
Our lives? (d) Why does this situation exist? (e) What
can we Do about it? We also explored with the partici-
pants what made a food or activity healthy or unhealthy,
whether there were ways to improve the healthiness of
the food, and what healthcare providers might do to pro-
mote healthy eating and activity for Nigerian immigrants.
At least two researchers and a research assistant were
present for each meeting. Two members of the research
18 Journal of Nursing Scholarship, 2015; 47:1, 16–24.
C© 2014 Sigma Theta Tau International
Turk et al. Using Photovoice With Nigerian Immigrants
team who were of Nigerian descent were present for all

23. meetings. In order to capture the dynamics of the set-
ting, group, and discussion, the research assistant took
observational field notes. The participants all discussed
their photos individually, and additional input and de-
scription were provided by other group members for each
person’s photos. The photos were all of high quality,
and only one male participant’s photos were not view-
able by the other participants at the focus group that fo-
cused on healthy eating and activity. He did, however,
remember his photos and described them for the group.
Open-ended questions and probes were also used to help
participants express their ideas, attitudes, feelings, and
perceptions about healthy and unhealthy eating and ac-
tivity in the US.
Data Analysis
Transcribed interviews and photos were uploaded to
the NVivo 10 qualitative data software management
system (QSR International, 2013). Transcripts and field
notes were read and re-read by two researchers, and
the analysis followed Leininger’s four phases of quali-
tative data analysis (Leininger, 1991): (a) collecting and
documenting raw data, (b) identifying descriptors and
categories, (c) identifying patterns and initiating contex-
tual analysis, and (d) identifying themes and theoreti-
cal formulations. Phase one consisted of collecting the
data, field notes, observations, and initial analysis. Phase
two focused on the identification of categories; data were
coded according to the domains of inquiry and specific
aims, and 18 categories emerged. In the third phase, the
researchers searched for common patterns via contextual
analysis; data were scrutinized to discover saturation of
ideas, and seven patterns emerged from the categories.
During the final phase, the researchers looked for ma-
jor themes and recommendations from the data, and four

24. themes emerged. See Table 1 for the categories, patterns,
and themes. Two investigators analyzed transcripts, field
notes, and photos individually and then together, dis-
cussing their analysis and coding choices until consensus
was reached. Analytic memos were maintained as an au-
dit trail for data collection and analysis decisions.
Results
Thirteen Nigerian immigrants agreed to participate,
and 11 participants were present at each focus group
meeting. Participants ranged in age from 27 to 57 years,
were mostly female (92%), and were employed outside
of the home (62%). Everyone had some college educa-
tion. The range of time participants had lived in the US
was between 9 months and 30 years. Most participants
considered English to be their primary language (77%);
one participant each stated Yoruba, Igbo, or Kanuri was
his or her primary language. Participants reported being
part of the Yoruba, Bini, Igbo, or Kanuri ethnic groups.
See Table 2 for the participant characteristics.
Eating and Activity Themes
Four overarching themes emerged from the data: Mod-
eration is healthy, Nigerian ways of living are healthy, ac-
quiring American ways is unhealthy, and cultural context
is important to promote healthy behaviors. These themes
captured the perceptions that the participants had about
healthy and unhealthy eating habits and physical activ-
ity in the context of their daily lives within the US. Al-
though we asked participants to photograph and discuss
both eating behaviors and physical activity, the bulk of
their photos and comments focused on eating habits and
cooking practices.

25. Moderation is healthy is the first theme that
emerged. This theme encompasses the idea that eating
and activity behaviors should not be done to excess in or-
der to remain healthy. Several participants spoke about
the importance of controlling portion sizes. One woman
stated, “I mean, it’s all about portion. I remember my
mom, when she was alive, she was a nurse, and in the
house we could have a small bowl, and no matter what
you want to eat, it has to fit into that bowl.” Another
woman conveyed that while portion size is important,
the taste of foods is important as well; she stated, “Pro-
portion is everything. I’m not going to finish a whole
bowl [of rice]. I’m just going to take a bit. But at the
same time, I’m not going to not eat doughnuts if I feel like
eating doughnuts.” For her, eating foods like doughnuts
could still be seen as healthy if the food was consumed in
moderation. An excessive amount of watching television
and sitting was identified as unhealthy by the statements,
“. . . for unhealthy activity, TV, too much TV,” and “sitting
and studying is unhealthy activity . . . I’m sitting down.”
Another aspect of the moderation is healthy theme re-
ferred to the timing of meals. Eating too late at night
or eating foods that were considered “heavy” late in
the evening was considered unhealthy. This notion was
demonstrated by one woman’s statement, “I know with
our own food too, the time of the day, you can’t eat
pounded yam at 9:00 p.m., and go to bed . . . you’re not
doing anything. It’s just going to sit in there.” Another
woman reinforced this idea with the comment, “We eat
the solid food in the afternoon; we don’t eat solid food at
night.” Eating heavier foods during the day and not eat-
ing at night was consistent with healthier eating habits.
Nigerian ways of living are healthy theme referred

26. to the participants’ perceptions that their traditional foods
Journal of Nursing Scholarship, 2015; 47:1, 16–24. 19
C© 2014 Sigma Theta Tau International
Using Photovoice With Nigerian Immigrants Turk et al.
Table 1. Categories, Patterns, and Subsequent Themes That
Emerged From the Data Analysis
Categories Patterns Themes
Children’s preferences Generational differences in food choices
Moderation is healthy
Choices Becoming unhealthy in the United States Nigerian ways
of living are healthy
Cooking it healthy Preference for Nigerian food as healthy
Acquiring American ways is unhealthy
Cultural influence Seeing overweight/obesity as economic
Cultural context is important to promote healthy behaviors
Family eating Role for health care in promoting health
Fast food/convenience food Viewing American food as
unhealthy
Food staples
Good for children
Healthcare provider input

27. Healthy activity
Healthy eating
Moderation
Nigerian food
Substitutions for traditional ingredients
Taste is important
Timing of meals
Unhealthy activity
Unhealthy cooking
and activities were healthy. The majority of the photos
of healthy foods we received were Nigerian dishes, al-
though some photos were of items such as fresh fruits,
steamed vegetables, and water. In describing a Nigerian
food, pounded yam, one woman stated, “It gives us car-
bohydrate because that gives us energy for our body
building.” One woman’s photo of a bean dish was in-
cluded in the healthy foods, and she stated, “That is
actually cooked beans . . . what I do is I cut the plan-
tains and I cook it with the beans so, I don’t have to fry
these. . . .” Everyday physical activity common in their
native country was seen as healthy, for example, “In
Nigeria, we get our activities mostly by walking. It’s not
like people have cabs like here.” Although three partici-
pants discussed engaging in scheduled exercise, most par-
ticipants described incorporating everyday activities as a
means of getting enough physical activity; one woman

28. noted,
If I go to the mall, I don’t park close to the store. I like
parking far away to get exercise. I don’t go to the gym,
but I like to get my exercise, so I don’t park too close.
Another woman indicated that her household chores
were her physical activity. “I have the leaves and the tools
to blow the leaves, and this is the only kind of exercise
that I do.”
While Nigerian ways of living were mainly seen as
healthy, many participants still recognized that some
Nigerian dishes were not as healthy as they could be
and described healthier cooking adaptations. For ex-
ample, plantains are commonly deep fried, and it was
noted,
Table 2. Participant Characteristics (N = 13)
Demographic characteristic M (SD)
Age (years) 34 (8.9)
Number of children 1.7 (1.7)
Number of people living in household 3.6 (1.6)
Years lived in the United States 10.1 (7.8)
n (%)
Gender (women) 12 (93%)
Employed outside the home 8 (62%)

29. Level of education
Some college or associate’s degree 6 (46.2%)
Baccalaureate degree 3 (23.1%)
Master’s or doctoral degree 4 (30.7%)
Marital status
Married 12 (93%)
Widowed 1 (7%)
Annual household incomea
<$20,000/year 2 (15.3%)
$20,001–$50,000/year 4 (30.7%)
>$50,000/year 5 (38.4%)
aTwo participants did not report income.
There was one of the questions about plantains and
how they’re not exactly healthy to fry, so I put in an
example of how I bake them . . . and it tastes very close
to the fried ones, so that’s nice.
A male participant discussed preparing foods with little
to no oil, such as, “I’ve learned to completely stay away
from oil. I use a bottle of oil a year.” Others discussed how
Nigerian meat dishes are cooked and served in a broth
but that care needed to be taken to remove additional fat,
for example,

30. 20 Journal of Nursing Scholarship, 2015; 47:1, 16–24.
C© 2014 Sigma Theta Tau International
Turk et al. Using Photovoice With Nigerian Immigrants
I was talking about the broth that is overnight in the
fridge . . . a portion of this exposed will have fat on top
of the broth. You just have to skim the broth. Some of
this fat has to come off.
Yet, some participants were reluctant to choose healthier
options for cooking, and one woman commented about a
traditional vegetable stew, “You have to use a little bit of
palm oil for taste. If you take out all the fat, what else do
you have for taste?”
Acquiring American ways was the third theme that
emerged from the data and incorporates perceptions that
many foods, activities, and behaviors common in the
US are unhealthy. Related to fast food, several photos
were described, including, “This one is the pizza picture.
We can see it dripping in oil.” Another woman said, “I
count everything fast food as unhealthy. I don’t allow my
children to eat it.” Several participants stated that their
children preferred unhealthy American food, but that
they tried to balance what they served their children, for
example, “I try to give them salad to eat. . . . So I make
sure I give them a lot, so then for their main meal, they’ll
just eat less of the unhealthy meal.” When asked about
whether there were individuals in their Nigerian commu-
nity in the US who were obese, most participants said that
there were, and one woman noted, “When you go into
a different country you throw your culture away. . . .”
Another commented on the hectic lifestyle in the US:

31. “When you’re going to work and you can’t cook, and you
don’t have time, it’s a problem.” One male participant
described the Nigerian immigrant’s lifestyle in the US by
saying, “I realize that we work a lot, and it’s a killer. I just
feel that for Africans here in this country, they are work-
ing two jobs, three jobs, going to school, stress is killing
people. . . .” Because of this busy lifestyle, participants
talked of quiet time, meditation, and prayer as healthy
activities in the context of their lives in the US. “I can
see that physical activity can be something different, just
keeping still for some cultures. . . .” “Quiet time is usually
like the time that you meditate. . . . When I’m driving, I
use that particular time to take a quick word of prayer. . . .
So I think that helps with my sanity.” Conscious efforts
were needed to cope with the demands of their fast-paced
lifestyle in the US.
Cultural context is important to promote healthy
behaviors, the final theme, referred to what healthcare
providers can do to encourage Nigerian immigrants to
eat healthier and engage in healthy physical activity. Par-
ticipants emphasized the importance of providers taking
time to ask about and learn the foods that Nigerians eat.
One woman stated,
If I’m seeing a doctor here, the doctor doesn’t under-
stand what I’m eating in terms of the African dishes
. . . if I come with what I eat, then you can advise me
on portion control or maybe substitutions for some of
the things.
This need for education from healthcare providers was
expressed by others.
Like teaching Africans how to make healthy meals
. . . people are afraid to step out of their comfort zone

32. . . . training that would not only teach how to make
meals, but also teach how to get it healthy.
Participants talked about wanting educational activities
within their community setting. “If you can suggest ac-
tivities that we can do, and if you could give us some sug-
gestions of healthy activities we can use for our [women’s
group] meetings. . . .” Others wanted to explore the pos-
sibility of including a gym in the church hall. “What I
was thinking, was like if you can get like a gym here that
would be a way of encouraging people to do the physical
activity. For us, we can’t go to the gym for free.” Par-
ticipants also thought that nurses and other healthcare
providers “should encourage people to do more cooking
at home instead of going to the restaurants.”
Discussion
Never before utilized with Nigerian immigrants, Pho-
tovoice was a valuable method to explore the beliefs,
perceptions, and practices of these participants regard-
ing healthy eating and physical activity behaviors while
living in the US. This methodology was well received
and easily used by the Nigerians in this study. At the
conclusion of the study, we talked with the participants
about their experiences using the digital camera to cap-
ture their perceptions of unhealthy and healthy lifestyle
behaviors since immigration to the US. All participants
expressed that the camera was easy to use, and that they
enjoyed taking photos and discussing their ideas. The
photo-elicited discussions were rich with descriptions of
healthy and unhealthy Nigerian and American foods and
adaptations that could be applied to improve the health-
iness of certain foods. The facilitated group dialogue cov-
ering each participant’s photos ensured that everyone’s
voice was heard, and a diverse range of perspectives

33. was put forth and considered. Ideas about healthy eating
and activity within the context of their busy lives were
revealed through the interactive dialogue fostered by
the photos.
Little has been published about the health and lifestyle
behaviors of African immigrants to the US. Evidence
supports the idea that African immigrants are healthier,
Journal of Nursing Scholarship, 2015; 47:1, 16–24. 21
C© 2014 Sigma Theta Tau International
Using Photovoice With Nigerian Immigrants Turk et al.
overall, than African Americans of a similar age (Ven-
ters & Gany, 2011), but acculturation, or adoption of
the new country’s lifestyle habits, may put African immi-
grants at risk for chronic conditions such as obesity (Ka-
plan, Huguet, Newsom, & McFarland, 2004). Traditional,
native diets are often healthier than the dietary patterns
that evolve with acculturation (Delisle, 2010; Desilets
et al., 2007). However, immigrants may experience bar-
riers in maintaining their native diet or learning about
healthy cooking habits in the new country of residence.
The participants in our study spoke of some of these bar-
riers in their descriptions of their hectic lives in the US
and difficulty finding time to cook proper meals. The fact
that most Nigerian foods were seen as healthier than the
food choices in the US was one of the major themes of
our findings.
Although no previous evidence was found document-
ing Nigerian immigrants’ perceptions of healthy eat-
ing and activity in the US, research with African and

34. Asian immigrants to Norway (Garnweidner, Terragni,
Pettersen, & Mosdol, 2012) and with Somali and Su-
danese immigrants to the US (Wieland et al., 2013) is
complementary to some of our findings. Female immi-
grants to Norway, asked about how they perceived Nor-
wegian cuisine in relation to their native foods, reported
that they had limited time to prepare their native foods
when they were working, so they resorted to cooking
the more readily prepared Norwegian food. These women
also emphasized that maintaining their native cuisine was
very important, as did the participants in our study. This
finding is in line with previous literature documenting
that native foods are an essential component of identity
and ethnic belonging among immigrant groups (Linden &
Nyberg, 2009; Tuomainen, 2009). While the partici-
pants in our study favored Nigerian food as healthy,
they also saw a need to modify some dishes because
of inherent unhealthiness when prepared according to
Nigerian customs. Although most of the participants’
photos and comments focused on eating and cook-
ing practices, their talk of physical activity highlighted
that household chores and normal daily activities, such
as parking farther away from the store, encompassed
healthy activity. They also described limited time and ex-
tended work hours as barriers to being physically active.
Similarly, Wieland and colleagues (2013) reported that
Somali and Sudanese immigrants to the US viewed ac-
tivities like household work and walking to school as ex-
ercise; long work schedules and lack of time were also
identified as barriers to physical activity among these two
African immigrant groups.
Participants discussed the potential role that health-
care providers could play in helping to promote healthy
eating and physical activity for Nigerian immigrants to

35. the US. They described how providers are unaware of
the African dishes they eat and suggested that Nigerian
patients take this information with them to a sched-
uled healthcare visit. In a Norwegian study, Pakistani
immigrants also voiced concerns about physicians’ and
healthcare workers’ lack of understanding about cul-
tural dietary practices and foods (Fagerli, Lien, &
Wandel, 2005). The participants in our study were in-
terested in having providers make recommendations on
portion sizes and healthier methods for preparing their
native foods. Nurses and other healthcare providers must
take time to inquire about traditional meal preparation,
and learn about immigrant patients’ cultural foods. Once
insight into these cultural dishes and cooking methods
is obtained, providers could suggest more healthful sub-
stitute ingredients or cooking techniques that are con-
sistent with cultural preferences in terms of taste and
flavor. Effective communication about healthy eating
during the patient encounter needs to incorporate cultur-
ally sensitive advice and messages that not only promote
healthier alternatives, but are considerate of the person’s
culture.
Limitations and Lessons Learned
Because of the qualitative nature of this research, the
findings cannot be generalized beyond the participants in
this study. Our investigation helped to illuminate what
healthy eating and activity in the US are for this group
of fairly highly educated, mostly female, Nigerian immi-
grants. We also encountered some challenges in collect-
ing the data. For the convenience of the participants, the
focus group meetings took place immediately after the
church service. As a result, some participants needed to
bring their small children, who were occasionally dis-
ruptive, making it difficult to hear the discussion, and

36. we would have been wise to offer child care during
the meetings.
Conclusions
Photovoice was a feasible and effective methodology
for collecting data on the perceptions and practices of
Nigerian immigrants as they relate to eating and activ-
ity behaviors in the US. Our analysis of findings indicated
four overarching themes: Moderation is healthy, Nigerian
ways of living are healthy, acquiring American ways is
unhealthy, and cultural context is important to promote
healthy behaviors. Nurses and other healthcare providers
must make concerted efforts to communicate with
and educate Nigerian immigrants about healthful eat-
ing and activity behaviors within their cultural context.
22 Journal of Nursing Scholarship, 2015; 47:1, 16–24.
C© 2014 Sigma Theta Tau International
Turk et al. Using Photovoice With Nigerian Immigrants
Additional research is needed to develop interventions
for supporting healthy eating and physical activity among
African immigrant groups. Photovoice may be an appro-
priate method to consider for use in intervention devel-
opment with Nigerian immigrants.
Acknowledgments
We would like to thank the participants who gave their
time to this study and the Redeemed Christian Church
of God for the use of their facility. Thank you to Nosa
Osagiede for her assistance with data collection. We also

37. acknowledge the Duquesne University Faculty Develop-
ment Fund, which provided funding for the study. The
first author was a participant in the 2014 National League
for Nursing (NLN) Scholarly Writing Retreat, sponsored
by the NLN Foundation and Pocket Nurse.
Clinical Resources
� Center for Disease Control and Prevention Im-
migrant and Refugee Health: http://www.cdc.
gov/immigrantrefugeehealth/
� U.S. Department of Agriculture National Agri-
cultural Library. Ethnic/cultural food pyramids:
http://fnic.nal.usda.gov/dietary-guidance/past-
food-pyramid-materials/ethniccultural-food-
pyramids
� World Health Organization. Global recommenda-
tions on physical activity for health: http://www.
who.int/dietphysicalactivity/factsheet˙recomme-
ndations/en/
References
American Heart Association Statistics Committee & Stroke
Statistics Subcommittee. (2014). Executive summary: Heart
disease and stroke statistics—2014 update. Circulation, 129,
399–410. doi:10.1161/01.cir.0000442015.53336.12
Barrington, D. S., Baquero, M. C., & Borrell, L. N. (2010).
Racial/ethnic disparities in obesity among US-born and

38. foreign-born adults by sex and education. Obesity, 18(2),
422–424.
Beune, E., Haafkens, J. A., Agyemang, C., & Bindels, P.
(2010). Inhibitors and enablers of physical activity in
multiethnic hypertensive patients: Qualitative study.
Journal of Human Hypertension, 24, 280–290.
Delisle, H. (2010). Findings on dietary patterns in different
groups of African origin undergoing nutrition transition.
Applied Physiology, Nutrition, and Metabolism, 35(2), 224–
228.
Desilets, M. C., Rivard, M., Shatenstein, B., & Delisle, H.
(2007). Dietary transition stages based on eating patterns
and diet quality among Haitians of Montreal, Canada.
Public Health Nutrition, 10(5), 454–463.
Fagerli, R. A., Lien, M. E., & Wandel, M. (2005). Experience
of dietary advice among Pakistani-born persons with type 2
diabetes in Oslo. Appetite, 45(3), 295–304.
Fitzpatrick, A. I., Steinman, L. E., Tu, S. P., Ly, K. A., Ton, T.

39. G., Yip, M. P., & Sin, M. K. (2009). Communicating with
pictures: Perceptions of cardiovascular health among Asian
immigrants. American Journal of Public Health, 99(12),
2147–2149.
Garcia, C. M., & Saewyc, E. M. (2007). Perceptions of mental
health among recently immigrated Mexican adolescents.
Issues in Mental Health Nursing, 28(1), 37–54.
Garnweidner, L. M., Terragni, L., Pettersen, K. S., & Mosdol,
A. (2012). Perceptions of the host country’s food culture
among female immigrants from Africa and Asia: Aspects
relevant for cultural sensitivity in nutrition
communication. Journal of Nutrition Education and Behavior,
44(4), 335–342. doi:10.1016/j.jneb.2011.08.005
Kaplan, M. S., Huguet, N., Newsom, J. T., & McFarland, B. H.
(2004). The association between length of residence and
obesity among Hispanic immigrants. American Journal of
Preventive Medicine, 27(4), 323–326.
Koya, D., & Egede, L. (2007). Association between length of

40. residence and cardiovascular disease risk factors among an
ethnically diverse group of United States immigrants.
Journal of General Internal Medicine, 22(6), 841–846.
Leininger, M. M. (1991). The theory of Culture Care Diversity
and
Universality. NLN Publication No. 15–2402. New York, NY:
National League for Nursing.
Linden, A. L., & Nyberg, M. (2009). The workplace lunch
room: An arena for multicultural eating. International
Journal of Consumer Studies, 33(1), 42–48.
Munhall, P. L. (2011). Nursing research: A qualitative
perspective
(5th ed.). Sudbury, MA: Jones and Bartlett.
Passel, J. S., & Cohn, D. (2008). U.S. population projections:
2005–2050. Washington, DC: Pew Research Center.
Retrieved from
http://pewhistoric.org/files/reports/2085.pdf
QSR International. (2013). NVivo 10 research software.
Retrieved from http://www.qsrinternational.com/nv2010-

41. 2064-bit-download
Read, J., Emerson, M., & Tarlov, A. (2005). Implications of
black immigrant health for U.S. racial disparities in health.
Journal of Immigrant and Minority Health, 7(3), 205–212.
Rhodes, S. D., & Hergenrather, K. C. (2007). Recently arrived
immigrant Latino men identify community approaches to
promote HIV prevention. American Journal of Public Health,
97(6), 984–985. doi:10.2105/AJPH.2006.107474
Schwartz, L. R., Sable, M. R., Dannerbeck, A., & Campbell, J.
D. (2007). Using Photovoice to improve family planning
services for immigrant Hispanics. Journal of Health Care for
the Poor and Underserved, 18(4), 757–766.
Singh, G. K., & Hiatt, R. A. (2006). Trends and disparities in
socioeconomic and behavioural characteristics, life
Journal of Nursing Scholarship, 2015; 47:1, 16–24. 23
C© 2014 Sigma Theta Tau International
Using Photovoice With Nigerian Immigrants Turk et al.
expectancy, and cause-specific mortality of native-born and

42. foreign-born populations in the United States, 1979–2003.
International Journal of Epidemiology, 35(4), 903–919.
Singh, G. K., & Miller, B. A. (2004). Health, life, expectancy,
and mortality patterns among immigrant populations in
the United States. Canadian Journal of Public Health, 95(3),
114–121.
Singh, G. K., Rodriguez-Lainz, A., & Kogan, M. D. (2013).
Immigrant health inequalities in the United States: Use of
eight major national data systems. Scientific World Journal,
Article No. 512313, 1–21. doi:10.1155/2013/512313
Singh, G. K., Siahpush, M., & Hiatt, R. A. (2011). Dramatic
increases in obesity and overweight prevalence and body
mass index among ethnic-immigrant and social class
groups in the United States, 1976–2008. Journal of
Community Health, 36(1), 94–110.
Streng, J. M., Rhodes, S. D., Ayala, G. X., Eng, E., Arceo, R.,
&
Phipps, S. (2004). Realidad Latina: Latino adolescents, their

43. school, and a university use Photovoice to examine and
address the influence of immigration. Journal of
Interprofessional Care, 18(4), 403–415.
Tuomainen, H. M. (2009). Ethnic identity, (post) colonialism
and foodways: Ghanians in London. Food, Culture, and
Society, 12(4), 525–554. doi:10.2752/175174409X456773
U.S. Census Bureau. (2010). American community survey.
Retrieved from http://www.census.gov/
acs/www/data˙documentation/2010˙release/
Venters, H., & Gany, F. (2011). African immigrant health.
Journal of Immigrant and Minority Health, 13(2), 333–344.
doi:10.1007/s10903-009-9243-x
Wang, C., & Burris, M. A. (1997). Photovoice: Concept,
methodology, and use for participatory needs assessment.
Health Education & Behavior, 24(3), 369–387.
Wang, C. C., & Redwood-Jones, Y. A. (2001). Photovoice
ethics: Perspectives from flint Photovoice. Health Education
& Behavior, 28(5), 560–572.

44. Wieland, M. L., Tiedje, K., Meiers, S. J., Mohamed, A. A.,
Formea, C. M., Ridgeway, J. L., . . . Sia, I. G. (2013).
Perspectives on physical activity among immigrants and
refugees to a small urban community in Minnesota. Journal
of Immigrant and Minority Health Advance online
publication. doi:10.1007/s10903-013-9917-2
24 Journal of Nursing Scholarship, 2015; 47:1, 16–24.
C© 2014 Sigma Theta Tau International
Reproduced with permission of the copyright owner. Further
reproduction prohibited without
permission.
HEALTH POLICY AND SYSTEMS
Prevalence and Perpetrators of Workplace Violence by Nursing
Unit and the Relationship Between Violence and the Perceived
Work Environment
Mihyun Park, PhD, RN1, Sung-Hyun Cho, PhD, RN2, & Hyun-
Ja Hong, PhD, RN3
1 Assistant Professor, College of Nursing, The Catholic
University of Korea, Seoul, South Korea
2 Associate Professor, College of Nursing, Research Institute of
Nursing Science, Seoul National University, Seoul, South Korea

45. 3 Vice President, Department of Nursing, The Catholic
University of Korea, Seoul St. Mary Hospital, Seoul, South
Korea
Key words
Nurse, violence, perpetrator, work demands,
trust, justice, Korea, Copenhagen Psychosocial
Questionnaire II
Correspondence
Sung-Hyun Cho, College of Nursing, Research
Institute of Nursing Science, Seoul National
University, 101 Daehak-ro, Jongno-gu, Seoul
110–799, South Korea.
E-mail: [email protected]
Accepted: September 13, 2014
doi: 10.1111/jnu.12112
Abstract
Aims: To identify the prevalence and perpetrators of workplace
violence
against nurses and to examine the relationship of work demands
and trust
and justice in the workplace with the occurrence of violence.
Design: This study employed cross-sectional data from a 2013
nurse survey
conducted at a university hospital in Seoul, South Korea. The
study sample

46. included 970 female nurses from 47 nursing units, including
general, oncol-
ogy, intensive care units (ICUs), operating rooms, and
outpatient departments.
Methods: The second version of the medium-sized Copenhagen
Psychosocial
Questionnaire (COPSOQ II) was used to measure work demands
(i.e., quan-
titative demands, work pace, and emotional demands), trust and
justice, and
violence. Relationships among those variables were examined
by conducting
multiple logistic regression analyses with multilevel modeling.
Findings: The 12-month prevalence of verbal abuse (63.8%) was
highest, fol-
lowed by threats of violence (41.6%), physical violence
(22.3%), and sexual
harassment (19.7%), but bullying had the lowest prevalence
(9.7%). Physi-
cal violence, threats of violence, and verbal abuse occurred
most frequently
in ICUs, whereas sexual harassment and bullying were highest
in operat-
ing rooms. The main perpetrators were patients, followed by
physicians and
patients’ families. Nurses perceiving greater work demands and
less trust and
justice were more likely to have been exposed to violence.
Conclusions: The prevalence and perpetrators of violence varied
considerably
among nursing units. Greater work demands and less trust and
justice were
associated with nurses’ experiences of violence.
Clinical Relevance: Adequate work demands and a trusted and
just work
environment may reduce violence against nurses. In return,

47. reduction of vio-
lence will contribute to creating a better nursing work
environment.
Workplace violence is a global problem affecting not only
people’s dignity but also their emotional and physical
well-being. While workplace violence affects all occupa-
tions, healthcare professionals, particularly nurses, are at
high risk because nurses work with people in distress and
are mostly female, both of which are risk factors for work-
place violence (Campbell et al., 2011). A recent integra-
tive review of workplace violence against nurses in the
Anglo, Asian, European, and the Middle Eastern regions
(Spector, Zhou, & Che, 2014) reported that, on aver-
age, 31.8% of nurses were exposed to physical violence,
62.8% to nonphysical violence, 47.6% to bullying, and
17.9% to sexual harassment during the prior year; there-
fore, workplace violence may affect a majority of nurses.
Journal of Nursing Scholarship, 2015; 47:1, 87–95. 87
C© 2014 Sigma Theta Tau International
Workplace Violence Against Nurses Park et al.
In an international effort to promote workplace safety
in the healthcare sector, the International Council
of Nurses participated in a joint program with other
international organizations to develop the “framework
guidelines for addressing workplace violence in the
health sector” (International Labour Office, International
Council of Nurses, World Health Organization, & Public
Services International, 2002). In these guidelines, work-
place violence was defined as abusing, threatening, or

48. assaulting incidents experienced by staff, including phys-
ical or psychological violence (e.g., harassment, threats,
bullying, and verbal abuse). While physical violence
has been visibly recognized and reported, psychological
violence has not drawn enough attention despite its
cumulative adverse effects through repeated behavior.
Thus, more research on psychological workplace violence
is needed (International Labour Office et al., 2002; Lee,
Lee, & Bernstein, 2013; Robbins, Bender, & Finnis,
1997). In South Korea, employers are required by the
law to provide their employees with sexual harassment
prevention education. General guidelines for workplace
violence have also been published (Korea Occupational
Safety & Health Agency, 2009). However, best practice
guidelines and mandatory prevention programs specific
to health care that cover various types of workplace
violence have not been developed yet.
The source of violence is another concern because the
effect of violence varies among perpetrators (Grandey,
Kern, & Frone, 2007; Hershcovis & Barling, 2010). Crim-
inals, clients, and coworkers have generally been iden-
tified as the major perpetrators of workplace violence
(LeBlanc & Kelloway, 2002), with clients and cowork-
ers prominent in the health sector (Farrell, 1997; Lee &
Chung, 2007; Spector et al., 2014). According to Spector
and colleagues’ review study (2014), patients and their
relatives were perpetrators of most incidents of physical
violence (on average, 64.3% and 30.2%, respectively),
while the perpetrators of nonphysical violence varied,
but included nurse colleagues, superiors, physicians, and
other staff members. To understand the impact of vio-
lence, comparing the effects of violence from different
perpetrators might be meaningful. Furthermore, nurs-
ing studies reporting workplace violence have mainly
focused on the experiences of psychiatric, geriatric, or

49. emergency care nurses (Lawoko, Soares, & Nolan, 2004;
Mullan & Badger, 2007; Taylor & Rew, 2011) because
these areas have been identified as being at high risk for
workplace violence. However, this research may obscure
the fact that nurses may be exposed to violence anywhere
they work.
Assessing risk factors of workplace violence has
been suggested as the first step in preventing violence
(International Labour Office et al., 2002), including
individual characteristics, organizational factors, work
demands, and type of nursing unit. Individual factors are
age, gender, race, work experience, and education level
(Campbell et al., 2011; Rowe & Sherlock, 2005; Weaver,
2013). Organizational factors include culture and the
psychosocial work environment. Unfair treatment,
disrespect, and distrust among coworkers and superiors
have been identified as critical causes of conflict and
aggressive behaviors in organizations (Almost, 2006;
Daiski, 2004; Neuman & Baron, 1998). In addition,
heavy work demands under time pressure caused by
low staffing levels, high patient acuity, and high patient
turnover have been reported to create stressful situa-
tions for patients, families, and hospital staff members
(Carayon & Gurses, 2008; Di Martino, 2003); these
intense or continuous stressful situations increase the
risk for workplace violence by superiors, patients, and
patients’ families (Camerino, Estryn-Behar, Conway,
van Der Heijden, & Hasselhorn, 2008; Roche, Diers,
Duffield, & Catling-Paull, 2010). The type of nursing
unit or clinical area (e.g., intensive care, perioperative,
geriatric, psychiatric, and emergency) is also known to
influence the prevalence of violence against nurses due
to differences in their patient populations and the care
provided to patients (Camerino et al., 2008; Cook, Green,

50. & Topp, 2001; Park, Kang, Kim, & Kwon, 2011).
Among those risk factors, this study focused on individ-
ual nurse characteristics, organizational factors of work-
place values (i.e., trust and justice), work demands, and
the type of nursing unit under the assumptions that the
prevalence of violence would differ by nursing unit and
that nurses’ greater work demands and lack of trust and
justice in the workplace would increase the occurrence
of violence. We also assumed that the influence of risk
factors on violence may vary by type of violence and per-
petrator rather than all risk factors leading to all types
of violence and the involvement of all types of perpetra-
tors. The aims of this study were to identify the preva-
lence of workplace violence perpetrated against nurses by
the type of violence and perpetrator and to examine the
relationship of work demands and trust and justice in the
workplace with the occurrence of violence.
Methods
We performed a cross-sectional study using nurse sur-
vey data collected in January and February of 2013.
Participants
The original nurse survey was conducted in a univer-
sity hospital in Seoul, South Korea. The survey targeted
all staff nurses working on all nursing units (48 units) of
88 Journal of Nursing Scholarship, 2015; 47:1, 87–95.
C© 2014 Sigma Theta Tau International
Park et al. Workplace Violence Against Nurses

51. the hospital, excluding the administration and emergency
departments, by convenience sampling. A total of 1,027
registered nurses (RNs) completed the original survey
(response rate = 95.2%). Detailed information on the
original sample has been provided elsewhere (Cho, Park,
Jeon, Chang, & Hong, 2014; Park, Jeon, Hong, & Cho,
2014). Of the total RNs surveyed, 13 nurses in the psy-
chiatric unit were excluded from our study population
because their work environment and patient characteris-
tics were assumed to be unique and different from other
nursing units. Male nurses (n = 38) were also excluded
to control for the effect of gender on violence. In ad-
dition, six nurses with incomplete responses preventing
the calculation of the prevalence of violence were further
excluded. The final study population included 970 female
RNs working on 47 nursing units.
Instruments
Nurse characteristics including age, marital status,
education, and years worked as an RN were included in
the survey questionnaire as potential factors associated
with violence. Violence, work demands, and trust and
justice in the workplace were measured using the sec-
ond version of the medium-sized Copenhagen Psychoso-
cial Questionnaire (COPSOQ II; Pejtersen, Kristensen,
Borg, & Bjorner, 2010). The COPSOQ II has been used
with various occupations, including health professions
and various countries, and its validity has been estab-
lished (Pejtersen et al., 2010). June and Choi (2013)
translated the COPSOQ II into Korean and examined the
validity and reliability of the Korean version using a sam-
ple of office workers. After reviewing the Korean version
developed by June and Choi (2013), we revised sev-
eral sections of the COPSOQ II and back-translated our

52. revised Korean version into English until the original and
Korean versions had equivalent meanings.
The COPSOQ II included four types of violence: phys-
ical violence, threats of violence, sexual harassment
(undesired sexual attention), and bullying (repeated un-
pleasant or degrading treatment). We also added ques-
tions about verbal abuse to the survey questionnaire to
identify verbal abuse that would not be directly related
to threats of violence, sexual harassment, or bullying.
Nurses were asked if they had been exposed to each type
of violence during the previous 12 months and answered
with one of five responses: “yes, daily”; “yes, weekly”;
“yes, monthly”; “yes, a few times”; or “no.” When nurses
replied with one of the four “yes” responses, they were
asked further about the perpetrators of the violence, and
multiple responses (data on more than one perpetrator)
were allowed. The COPSOQ II included four groups of
perpetrators (i.e., colleagues, managers or superiors, sub-
ordinates, and clients, customers, or patients). Based on
the literature, these original groups were revised into five
categories by our researchers: patients, patients’ families,
nurse colleagues, nurse managers, and physicians. The
first two groups comprised the “clients” and the others
were considered “insiders.”
Two domains, “demands at work” and “values at work-
place level,” included in the COPSOQ II were used
to measure nurses’ work demands and levels of trust
and justice in the workplace, respectively. The domain
“demands at work” consisted of three dimensions: quan-
titative demands (four items), work pace (three items),
and emotional demands (four items). The domain “val-
ues at workplace level” also consisted of three dimen-
sions: trust regarding management (four items), mutual

53. trust between employees (three items), and justice (four
items). Each item on the six dimensions was answered
with a 5-point scale (from “to a very small extent” to
“to a very large extent”; or from “never/hardly ever” to
“always”). Responses with the 5-point scale were then
converted to 0, 25, 50, 75, and 100, and a higher score
indicated a stronger feeling about each dimension (Pe-
jtersen et al., 2010). For example, a response of “always”
to a question about quantitative demand (e.g., “Is your
work unevenly distributed so it piles up?”) was converted
into 100 points; a response of “to a very small extent” to
a question about justice (e.g., “Are conflicts resolved in a
fair way?”) was converted into 0 points.
The Cronbach’s alpha of six dimensions ranged from
.61 to .82. Cronbach’s alpha of “mutual trust between
employees” and “emotional demands” was .61 and .66,
respectively, but the other dimensions had a Cronbach’s
alpha equal to .70 or higher.
Ethical Considerations
This study was approved by our institutional review
board. Nurses participated in the survey voluntarily and
were provided with an individual envelope to seal their
questionnaire immediately after completing it. Data used
in this study did not include any information that can be
used to identify individual nurses.
Data Analysis
The prevalence of the five types of violence was
computed as the proportion of nurses who had been
exposed to the violence (i.e., daily, weekly, monthly,
or a few times) out of the total number of nurses dur-
ing the previous 12 months. The overall prevalence was

54. also computed as the proportion of nurses who had been
exposed to at least one of five types of violence. The
12-month prevalence was compared by type of violence
Journal of Nursing Scholarship, 2015; 47:1, 87–95. 89
C© 2014 Sigma Theta Tau International
Workplace Violence Against Nurses Park et al.
and nursing unit. Nursing units were grouped into five
categories: general units, oncology units, intensive care
units (ICUs), operating rooms, and outpatient depart-
ments. The distribution of the five categories of perpetra-
tors (patients, patients’ families, nurse colleagues, nurse
managers, and physicians) was analyzed based on the
type of violence and nursing unit by presenting the per-
centage of nurses who experienced violence in each cat-
egory of perpetrator.
The relationships of work demands and trust and
justice in the workplace to violence were examined
using multiple logistic regression analyses with a sepa-
rate model for each type of violence with the outcome
as nurses who had experienced a specific violence ver-
sus nurses who had not experienced violence. The rela-
tionships of work demands and trust and justice in the
workplace with violence perpetrators were also examined
using multiple logistic regression analyses with a sepa-
rate model for each category of perpetrator. The outcome
of these models was nurses who had experienced vio-
lence by a specific perpetrator (e.g., patients) regardless
of the violence type versus nurses who had not experi-
enced violence by a perpetrator. Multilevel modeling was
employed in all regression analyses to take into account

55. the clustering of nurses within their units. Nurse charac-
teristics and the type of nursing unit were also included in
the regression models. Age was excluded from the regres-
sion models due to a high correlation with years worked
as an RN (r = .95, p < .001). SAS 9.3 (SAS Institute, Cary,
NC, USA) was used to analyze the data.
Findings
Our study sample of 970 RNs had a mean age of 28.6
years. The majority were single (77.5%) and had a bac-
calaureate or higher academic degree (76.6%). The av-
erage years worked as an RN was 5.4 years; 33.7% had
worked less than 3 years as an RN, 31.6% for 3 to 5 years,
and the rest 6 years or longer.
Prevalence of Workplace Violence by Type of
Violence and Nursing Unit
The prevalence of violence is presented in Table 1.
Respondents could report experiencing violence “daily,”
“weekly,” “monthly,” or “a few times.” During the pre-
vious 12 months, 71% of nurses reported having been
exposed to at least one of five types of violence. The
12-month prevalence of verbal abuse (63.8%) was the
highest, followed by threats of violence (41.6%), phys-
ical violence (22.3%), and sexual harassment (19.7%);
bullying had the lowest prevalence (9.7%). The majority,
74.3% and 93.2% of those who had experienced verbal
abuse and sexual harassment, respectively, had been ex-
posed to the violence “a few times.”
The highest prevalence of violence overall (exposed
to at least one type of violence) was found in the ICUs
(82.8%), followed by outpatient departments (73.3%),

56. with the lowest prevalence (63.5%) in oncology units.
ICUs also had the highest prevalence of physical violence
(48.5%), threats of violence (61.4%), and verbal abuse
(75.8%) among the five groups of nursing units and the
second highest prevalence of sexual harassment (23.2%).
Sexual harassment (25.2%) and bullying (10.8%) oc-
curred most frequently in operating rooms. Outpatient
departments had the second highest prevalence of over-
all and physical violence, threats of violence, and verbal
abuse.
Distributions of Perpetrators by Type of
Violence and Nursing Unit
The distributions of perpetrators by type of violence
and nursing unit are presented in Table 1. Overall, the
majority (64.4%; 444/689) of violent incidents were per-
petrated by patients, followed by physicians (49.3%), and
patients’ families (48%). Patients, followed by families,
were the most frequent perpetrators of physical violence
and threats of violence; patients, followed by physicians,
were the major perpetrators of sexual harassment and
verbal abuse. In the operating rooms, however, physi-
cians were the most frequent perpetrators of all types
of violence except for bullying. Bullying was perpetrated
mostly by nurse colleagues (68.1%) across all nursing
units.
Relationships of Work Demands and Trust and
Justice in the Workplace With the Occurrence of
Violence
The relationships of nurse characteristics, work
demands, and trust and justice in the workplace with the
occurrence of violence are presented in Table 2. After the
relationship of the type of nursing unit with violence was

57. controlled for, nurses with 3 years or more experience as
an RN were more likely to experience threats of violence
than those with less than 3 years. When nurses perceived
a higher work pace, they were more likely to have been
exposed to physical violence, threats of violence, and ver-
bal abuse with an odds ratio (OR) of 1.02, which indi-
cates a 2% increase in the odds of violence when the
work pace increases by 1 point out of 100 points. To make
this OR of 1.02 using the 0–100 point scoring compara-
ble with that in other studies using 1–5 point scoring, a
25-point increase in work pace, which is equivalent to
an increase by 1 out of 5 points (e.g., responses change
90 Journal of Nursing Scholarship, 2015; 47:1, 87–95.
C© 2014 Sigma Theta Tau International
Park et al. Workplace Violence Against Nurses
Table 1. Prevalence of Workplace Violence and Distribution of
Perpetrators (N = 970)
Prevalence Perpetrator, n (%)a
Prevalence Patients’ Nurse Nurse
n Exposed (%) Patients family colleagues managers Physicians
Any type of violence
Overall 970 689 71.0 444 (64.4) 331 (48.0) 112 (16.3) 61 (8.9)
340 (49.3)
General unit 302 214 70.9 145 (67.8) 130 (60.7) 34 (15.9) 18
(8.4) 108 (50.5)

58. Oncology unit 241 153 63.5 102 (66.7) 93 (60.8) 28 (18.3) 16
(10.5) 74 (48.4)
Intensive care unit 198 164 82.8 133 (81.1) 66 (40.2) 27 (16.5)
11 (6.7) 76 (46.3)
Operating room 139 92 66.2 8 (8.7) 4 (4.3) 17 (18.5) 9 (9.8) 73
(79.3)
Outpatient department 90 66 73.3 56 (84.8) 38 (57.6) 6 (9.1) 7
(10.6) 9 (13.6)
Physical violence
Overall 969 216 22.3 177 (81.9) 66 (30.6) 6 (2.8) 2 (0.9) 11
(5.1)
General unit 302 56 18.5 46 (82.1) 24 (42.9) 1 (1.8) 1 (1.8)
Oncology unit 241 31 12.9 20 (64.5) 16 (51.6) 2 (6.5) 2 (6.5) 1
(3.2)
Intensive care unit 198 96 48.5 91 (94.8) 18 (18.8) 1 (1.0)
Operating room 139 14 10.1 4 (28.6) 2 (14.3) 8 (57.1)
Outpatient department 89 19 21.3 16 (84.2) 8 (42.1) 1 (5.3)
Threats of violence
Overall 967 402 41.6 298 (74.1) 184 (45.8) 11 (2.7) 12 (3.0) 82
(20.4)
General unit 300 124 41.3 90 (72.6) 69 (55.6) 2 (1.6) 28 (22.6)

59. Oncology unit 241 81 33.6 53 (65.4) 50 (61.7) 4 (4.9) 5 (6.2) 17
(21.0)
Intensive care unit 197 121 61.4 110 (90.9) 38 (31.4) 4 (3.3) 3
(2.5) 10 (8.3)
Operating room 139 33 23.7 5 (15.2) 2 (6.1) 2 (6.1) 25 (75.8)
Outpatient department 90 43 47.8 40 (93.0) 25 (58.1) 1 (2.3) 2
(4.7) 2 (4.7)
Sexual harassment
Overall 970 191 19.7 106 (55.5) 29 (15.2) 5 (2.6) 3 (1.6) 66
(34.6)
General unit 302 61 20.2 45 (73.8) 14 (23.0) 2 (3.3) 1 (1.6) 10
(16.4)
Oncology unit 241 35 14.5 24 (68.6) 9 (25.7) 1 (2.9) 6 (17.1)
Intensive care unit 198 46 23.2 27 (58.7) 2 (4.3) 1 (2.2) 2 (4.3)
17 (37.0)
Operating room 139 35 25.2 2 (5.7) 1 (2.9) 1 (2.9) 30 (85.7)
Outpatient department 90 14 15.6 8 (57.1) 3 (21.4) 3 (21.4)
Verbal abuse
Overall 970 619 63.8 370 (59.8) 287 (46.4) 64 (10.3) 46 (7.4)
303 (48.9)
General unit 302 191 63.2 119 (62.3) 115 (60.2) 20 (10.5) 14
(7.3) 96 (50.3)

60. Oncology unit 241 136 56.4 85 (62.5) 81 (59.6) 20 (14.7) 10
(7.4) 70 (51.5)
Intensive care unit 198 150 75.8 111 (74.0) 54 (36.0) 15(10.0)
11 (7.3) 67 (44.7)
Operating room 139 80 57.6 5 (6.3) 3 (3.8) 8 (10.0) 8 (10.0) 63
(78.8)
Outpatient department 90 62 68.9 50 (80.6) 34 (54.8) 1 (1.6) 3
(4.8) 7 (11.3)
Bullying
Overall 970 94 9.7 2 (2.1) 6 (6.4) 64 (68.1) 15 (16.0) 7 (7.4)
General unit 302 29 9.6 1 (3.4) 3 (10.3) 19 (65.5) 5 (17.2) 1
(3.4)
Oncology unit 241 25 10.4 2 (8.0) 15 (60.0) 4 (16.0) 4 (16.0)
Intensive care unit 198 18 9.1 1 (5.6) 1 (5.6) 13 (72.2) 1 (5.6) 1
(5.6)
Operating room 139 15 10.8 12 (80.0) 1 (6.7) 1 (6.7)
Outpatient department 90 7 7.8 5 (71.4) 4 (57.1)
Note. Empty cells indicate no case. aThe sum of percentages
may be over 100% due to multiple responses.
from “to a large extent” to “to a very large extent”), corre-
sponded to a 64% increase in the odds of violence (OR =
1.64 = (1.02)25). Perceiving greater emotional demands
was also associated with a greater likelihood of experi-
encing threats of violence, sexual harassment, and verbal

61. abuse. Higher mutual trust between employees was asso-
ciated with a greater occurrence of threats of violence, but
with a lower occurrence of bullying. Justice was inversely
related with verbal abuse (OR = 0.98) and bullying
(OR = 0.98).
Table 3 presents the relationships of nurse charac-
teristics, work demands, and workplace values to the
type of perpetrator. When the type of nursing unit was
controlled for, nurses holding a baccalaureate or higher
degree were more likely to experience violence by physi-
cians than were those with a diploma in nursing. Those
Journal of Nursing Scholarship, 2015; 47:1, 87–95. 91
C© 2014 Sigma Theta Tau International
Workplace Violence Against Nurses Park et al.
Table 2. Relationships of Work Demands and Workplace Values
to Violence by Type of Violence: Odds Ratio [95% Confidence
Interval]
Physical violence Threats of violence Sexual harassment Verbal
abuse Bullying
Single (vs. married) 0.84 [0.49, 1.43] 0.92 [0.59, 1.45] 1.28
[0.77, 2.13] 1.09 [0.71, 1.67] 0.69 [0.37, 1.29]
Diploma (vs. BSN or higher) 0.93 [0.60, 1.44] 0.75 [0.52, 1.09]
0.96 [0.63, 1.44] 0.74 [0.52, 1.05] 0.71 [0.39, 1.29]
Years worked as an RN (vs. <3)

62. 3–5 1.37 [0.87, 2.16] 1.82 [1.23, 2.70]∗ ∗ 1.19 [0.77, 1.85] 0.93
[0.63, 1.36] 0.79 [0.43, 1.46]
�6 1.53 [0.88, 2.67] 2.03 [1.27, 3.26]∗ ∗ 1.60 [0.96, 2.68] 1.01
[0.65, 1.58] 1.32 [0.68, 2.56]
Work demands
Quantitative demands 1.01 [0.99, 1.02] 1.00 [0.99, 1.01] 1.00
[0.99, 1.01] 1.00 [0.99, 1.01] 1.02 [0.998, 1.04]
Work pace 1.02 [1.01, 1.04]∗ ∗ 1.02 [1.01, 1.03]∗ ∗ 1.01 [0.99,
1.02] 1.02 [1.01, 1.03]∗ ∗ 1.00 [0.98, 1.02]
Emotional demands 1.01 [0.99, 1.03] 1.02 [1.00, 1.03]∗ 1.02
[1.01, 1.04]∗ ∗ 1.03 [1.01, 1.04]∗ ∗ ∗ 1.01 [0.99, 1.03]
Workplace values
Trust regarding management 1.02 [0.995, 1.04] 0.99 [0.97, 1.01]
1.02 [0.997, 1.04] 1.00 [0.98, 1.01] 1.01 [0.99, 1.04]
Mutual trust between employees 0.99 [0.98, 1.01] 1.02 [1.00,
1.03]∗ 0.99 [0.97, 1.00] 1.01 [0.999, 1.02] 0.96 [0.94,
0.98]∗ ∗ ∗
Justice 0.99 [0.97, 1.00] 0.99 [0.97, 1.00] 0.99 [0.98, 1.01] 0.98
[0.97, 0.99]∗ ∗ 0.98 [0.96, 0.99]∗
Note. ∗ p < .05, ∗ ∗ p < .01, ∗ ∗ ∗ p < .001. Effects of the type
of nursing unit were controlled for in the multiple regression
analyses.
Table 3. Relationships of Work Demands and Workplace Values
to Violence by Type of Perpetrator: Odds Ratio [95%
Confidence Interval]
Patients Patients’ family Nurse colleagues Nurse managers

63. Physicians
Single (vs. married) 0.77 [0.46, 1.27] 0.95 [0.60, 1.52] 0.77
[0.39, 1.51] 0.81 [0.35, 1.84] 0.96 [0.60, 1.53]
Diploma (vs. BSN or higher) 0.98 [0.66, 1.46] 1.01 [0.70, 1.46]
0.62 [0.36, 1.07] 0.77 [0.37, 1.61] 0.62 [0.43, 0.91]∗
Years worked as an RN (vs. <3)
3–5 1.36 [0.89, 2.07] 1.15 [0.78, 1.70] 0.57 [0.34, 0.96]∗ 0.78
[0.37, 1.66] 1.64 [1.11, 2.44]∗
�6 1.19 [0.71, 1.98] 1.44 [0.90, 2.31] 0.41 [0.21, 0.81]∗ 0.80
[0.33, 1.93] 1.65 [1.02, 2.66]∗
Work demands
Quantitative demands 1.00 [0.99, 1.02] 1.01 [0.99, 1.02] 1.01
[0.99, 1.03] 1.03 [1.00, 1.05]∗ 1.01 [0.99, 1.02]
Work pace 1.02 [1.00, 1.03]∗ 1.01 [0.99, 1.02] 0.99 [0.98,
1.01] 0.98 [0.96, 1.01] 1.01 [0.99, 1.02]
Emotional demands 1.02 [1.00, 1.03]∗ 1.03 [1.01, 1.04]∗ ∗ ∗
1.03 [1.01, 1.04]∗ ∗ 1.01 [0.99, 1.04] 1.03 [1.01, 1.04]∗ ∗ ∗
Workplace values
Trust regarding management 1.01 [0.99, 1.02] 0.99 [0.98, 1.01]
1.02 [0.997, 1.04] 0.97 [0.94, 1.00] 0.99 [0.98, 1.01]
Mutual trust between employees 1.01 [0.99, 1.02] 1.01 [0.99,
1.03] 0.98 [0.96, 0.99]∗ 0.99 [0.96, 1.01] 1.01 [0.99, 1.02]
Justice 0.98 [0.97, 0.99]∗ 0.99 [0.98, 1.01] 0.97 [0.95, 0.99]∗ ∗
0.98 [0.95, 1.01] 0.98 [0.97, 0.99]∗
Note. ∗ p < .05, ∗ ∗ p < .01, ∗ ∗ ∗ p < .001. Effects of the type

64. of nursing unit were controlled for in the multiple regression
analyses.
with 3 or more years of experience as an RN were less
likely to experience violence by nurse colleagues, but
more likely to by physicians than were nurses with less
than 3 years of experience. Higher quantitative demands
were associated with an increased occurrence of vio-
lence by nurse managers, whereas higher work pace was
associated with violence by patients. Emotional demands
were positively related with violence by all perpetra-
tors except for nurse managers. Higher mutual trust be-
tween employees was associated with a lower occurrence
of violence by nurse colleagues. Justice was inversely
related with violence by patients, nurse colleagues, and
physicians.
Discussion
This study reports the high prevalence of workplace
violence against nurses in a university hospital, suggest-
ing the need for attention to workplace violence. The
overall prevalence (71%) of workplace violence in this
study was high compared to the prevalence range
(mean = 57.3%; range = 24.7%–88.9%) that was re-
ported in a recent review of 136 articles related to vio-
lence against nurses (Spector et al., 2014). The prevalence
of nonphysical violence (e.g., verbal abuse and threats
of violence) was higher than that of physical violence in
both studies. Compared with emergency, geriatric, and
psychiatric nurses who had a high prevalence of phys-
ical violence in the review, the nursing units in this
study (general, oncology, intensive care, operating room,
and outpatient) had a relatively low prevalence of phys-
ical violence. The prevalence of bullying (9.7%) in this

65. study was also lower than those reported in the review
(mean = 47.6%; range = 26.4%–86.5%) and among Ko-
rean nurses in another study (23%; Lee et al., 2013).
Overall, the main sources of workplace violence in this
study were patients, which were consistent with previous
studies (Spector et al., 2014). Violence in general hospital
92 Journal of Nursing Scholarship, 2015; 47:1, 87–95.
C© 2014 Sigma Theta Tau International
Park et al. Workplace Violence Against Nurses
settings is likely to be perpetrated by clients (i.e., patients
or patients’ relatives). However, unlike previous stud-
ies, this study found physicians, not patients’ relatives, to
be the second most frequent perpetrators, based on the
high prevalence of sexual harassment and verbal abuse
by physicians. Verbal abuse and sexual harassment from
physicians have been frequently reported in the nurs-
ing literature (Cook et al., 2001; Robbins et al., 1997). A
Korean study indicated that verbal abuse from physicians
reflects a hierarchical rather than collegial, mutual re-
lationship between nursing and medicine in Korea (Lee
& Chung, 2007). Nurse colleagues were major perpetra-
tors of bullying, which is frequently mentioned in the
nursing literature (Lee et al., 2013; Weaver, 2013). The
prevalence of violence also varied considerably among
nursing units. ICUs had the highest prevalence of phys-
ical violence, threats of violence, and verbal abuse. Vio-
lence in ICUs was mainly perpetrated by patients, which
may stem from intentional or unintentional aggression of
patients in a confused or irritable mental status or severe
pain (Park et al., 2011). While violence from patients or

66. patients’ families was rare for nurses in operating rooms,
the nurses were more likely to be exposed to violence
from physicians.
This study found that high work demands were signif-
icantly associated with workplace violence, as reported
in previous studies (Camerino et al., 2008; Roche et al.,
2010). Although these relationships cannot be consid-
ered causal, this finding suggests that excessive workloads
may increase the prevalence of violence against nurses.
Inverse relationships were also found between workplace
values (trust and justice) and bullying. These relation-
ships can be interpreted as reciprocal associations. For
example, when nurses work in an environment with low
trust and justice, they may be more likely to experience
bullying, or nurses may perceive low trust among col-
leagues and unfair treatment as a result of experienc-
ing bullying. Therefore, increasing trust and justice in the
workplace may reduce bullying, and in return, reduction
of bullying can create a trusted and just work environ-
ment. We also found an unexpected positive relationship
between mutual trust among employees and threats of
violence. Because threats of violence were perpetrated
mainly by outsiders (patients and their relatives) or physi-
cians rather than by nursing colleagues, further investiga-
tions are needed to identify other factors that may explain
this relationship.
This study also reported that nurses with less nursing
experience were more likely to experience violence from
nurse colleagues. Prompting the expression “nurses eat
their young,” new nurses have been recognized to be
at high risk for horizontal violence (Rowe & Sherlock,
2005; Weaver, 2013). Nursing scholars have emphasized
the importance of maintaining workplace values such as

67. mutual support, respect, and trust among nurses to limit
horizontal violence (Daiski, 2004; Farrell, 1997).
Limitations
There were limitations to this study. First, this study
employed a cross-sectional design; thus, the significant
associations of work demands, trust, and justice with the
occurrence of violence cannot be considered causal rela-
tionships. Second, we added verbal abuse questions to the
survey to identify verbal abuse that would not be directly
related to threats of violence, sexual harassment, or bul-
lying. However, verbal abuse might not be exclusive of
other types of psychological violence. The low prevalence
of bullying reported in this study would be attributed to
the lack of mutual exclusiveness between verbal abuse
and bullying. Third, one of our aims was to examine dif-
ferences in the prevalence and perpetrators of violence by
nursing unit within the same hospital; therefore, our sur-
vey was conducted in a large university hospital. Collect-
ing data in one hospital had an advantage of controlling
for some factors (e.g., hospital characteristics) that could
influence violence. However, these results may not be
generalized to other hospitals (e.g., nonteaching or small
hospitals) or care settings that could have different age
distributions of RNs, work demands, and environments.
Fourth, we relied on the nurses’ ability to recall violent
experiences during the previous 12 months, and this may
have influenced our data on the prevalence of violence.
However, previous studies commonly use a 12-month
recall to estimate prevalence. Asking nurses about vi-
olence experienced within a shorter period (e.g., 6
months) may have minimized the recall bias.
Conclusions

68. This study provided comprehensive information
related to the prevalence, perpetrators, and risk factors of
workplace violence against nurses in a general hospital
setting in South Korea. In particular, we reported con-
siderable differences in the prevalence and perpetrators
of violence among nursing units. Hospital and nurse
managers should be familiar with the common types of
violence and main perpetrators in each unit. Strategies
for violence prevention should be tailored to specific
nursing units based on the prevalence and main perpetra-
tors of violence. In addition, we found that greater work
demands and less trust and justice in the workplace were
associated with nurses’ experiences of violence. These
associations suggest that adequate work demands and
a trusted and just work environment may reduce
Journal of Nursing Scholarship, 2015; 47:1, 87–95. 93
C© 2014 Sigma Theta Tau International
Workplace Violence Against Nurses Park et al.
violence against nurses. In return, reduction of vio-
lence will contribute to creating a better nursing work
environment.
Acknowledgments
This work was supported by the Research Settlement
Fund for new faculty of Seoul National University.
Clinical Resources
� International Council of Nurses. Workplace
violence in the health sector. http://www.icn.ch/

69. pillarsprograms/workplace-violence-in-the-health-
sector/
� Centers for Disease Control and Prevention. Work-
place safety & health topics: Occupational violence.
http://www.cdc.gov/niosh/topics/violence/
References
Almost, J. (2006). Conflict within nursing work
environments: Concept analysis. Journal of Advanced
Nursing, 53, 444–453.
doi:10.1111/j.1365-2648.2006.03738.x
Camerino, D., Estryn-Behar, M., Conway, P. M., van Der
Heijden, B. I. J. M., & Hasselhorn, H.-M. (2008).
Work-related factors and violence among nursing staff in
the European NEXT study: A longitudinal cohort study.
International Journal of Nursing Studies, 45, 35–50.
doi:10.1016/j.ijnurstu.2007.01.013
Campbell, J. C., Messing, J. T., Kub, J., Agnew, J., Fitzgerald,
S., Fowler, B., . . . Bolyard, R. (2011). Workplace violence
prevalence and risk factors in the safe at work study.
Journal of Occupational and Environmental Medicine, 53(1),

70. 82–89. doi:10.1097/Jom.0b013e3182028d55
Carayon, P., & Gurses, A. P. (2008). Nursing workload and
patient safety—A human factors engineering perspective.
In R. Hughes (Ed.) Patient safety and quality: An
evidence–based handbook for nurses. Rockville, MD: Agency
for Healthcare Research and Quality.
Cho, S., Park, M., Jeon, S., Chang, H., & Hong, H. (2014).
Average hospital length of stay, nurses’ work demands,
and their health and job outcomes. Journal of Nursing
Scholarship, 46(3), 199–206. doi:10.1111/jnu.12066
Cook, J. K., Green, M., & Topp, R. V. (2001). Exploring the
impact of physician verbal abuse on perioperative nurses.
AORN Journal, 74, 317–331.
doi:10.1016/S0001-2092(06)61787-0
Daiski, I. (2004). Changing nurses’ dis-empowering
relationship patterns. Journal of Advanced Nursing, 48,
43–50. doi:10.1111/j.1365-2648.2004.03167.x
Di Martino, V. (2003). Relationship of work stress and

71. workplace violence in the health sector. In World Health
Organization (Ed.), Joint programme on workplace violence in
the health sector. Geneva, Switzerland: International Labor
Office, International Council of Nurses, World Health
Organization, and Public Services International.
Farrell, G. A. (1997). Aggression in clinical settings: Nurses’
views. Journal of Advanced Nursing, 25, 501–508.
doi:10.1046/j.1365-2648.1997.1997025501.x
Grandey, A. A., Kern, J. H., & Frone, M. R. (2007). Verbal
abuse from outsiders versus insiders: Comparing
frequency, impact on emotional exhaustion, and the role
of emotional labor. Journal of Occupational Health Psychology,
12, 63–79. doi:10.1037/1076-8998.12.1.63
Hershcovis, M. S., & Barling, J. (2010). Towards a multi-foci
approach to workplace aggression: A meta-analytic review
of outcomes from different perpetrators. Journal of
Organizational Behavior, 31, 24–44. doi:10.1002/job.621
International Labour Office, International Council of Nurses,

72. World Health Organization, & Public Services
International. (2002). Framework guidelines for addressing
workplace violence in the health sector. Geneva, Switzerland:
International Labour Office.
June, K. J., & Choi, E. S. (2013). Reliability and validity of the
Korean version of the Copenhagen Psycho-social
Questionnaire Scale. Korean Journal of Occupational Health
Nursing, 22, 1–12. doi:10.5807/kjohn.2013.22.1.1
Korea Occupational Safety & Health Agency. (2009).
Workplace violence prevention guide. Incheon, Korea: Author.
Lawoko, S., Soares, J. J. F., & Nolan, P. (2004). Violence
towards psychiatric staff: A comparison of gender, job and
environmental characteristics in England and Sweden.
Work & Stress, 18, 39–55.
doi:10.1080/02678370410001710337
LeBlanc, M. M., & Kelloway, E. K. (2002). Predictors and
outcomes of workplace violence and aggression. Journal of
Applied Psychology, 87, 444–453.

73. doi:10.1037/0021-9010.87.3.444
Lee, S. H., & Chung, S. E. (2007). Nurses’ experience of verbal
abuse in hospital setting. Journal of Korean Academy of
Nursing Administration, 13, 526–536.
Lee, Y. J., Lee, M. H., & Bernstein, K. (2013). Effect of
workplace bullying and job stress on turnover intention in
hospital nurses. Journal of Korean Academy of Psychiatric and
Mental Health Nursing, 22, 77–87.
doi:10.12934/jkpmhn.2013.22.2.77
Mullan, B., & Badger, F. (2007). Aggression and violence
towards staff working with older patients. Nursing Standard,
21(27), 35–38.
Neuman, J. H., & Baron, R. A. (1998). Workplace violence
and workplace aggression: Evidence concerning specific
forms, potential causes, and preferred targets. Journal of
Management, 24, 391–419.
doi:10.1177/014920639802400305
Park, H., Kang, H., Kim, K., & Kwon, H. (2011). Exposure to

74. workplace violence and coping in intensive care unit
94 Journal of Nursing Scholarship, 2015; 47:1, 87–95.
C© 2014 Sigma Theta Tau International
Park et al. Workplace Violence Against Nurses
nurses. Journal of Korean Academy of Psychiatric and Mental
Health Nursing, 20(3), 291–301.
Park, M., Jeon, S., Hong, H., & Cho, S. (2014). A comparison
of ethical issues in nursing practice across nursing units.
Nursing Ethics. doi:10.1177/0969733013513212
Pejtersen, J. H., Kristensen, T. S., Borg, V., & Bjorner, J. B.
(2010). The second version of the Copenhagen
Psychosocial Questionnaire. Scandinavian Journal of Public
Health, 38(3 Suppl.), 8–24.
doi:10.1177/1403494809349858
Robbins, I., Bender, M. P., & Finnis, S. J. (1997). Sexual
harassment in nursing. Journal of Advanced Nursing, 25,
163–169. doi:10.1046/j.1365-2648.1997.1997025163.x

75. Roche, M., Diers, D., Duffield, C., & Catling-Paull, C. (2010).
Violence toward nurses, the work environment, and
patient outcomes. Journal of Nursing Scholarship, 42, 13–22.
doi:10.1111/j.1547-5069.2009.01321.x
Rowe, M. M., & Sherlock, H. (2005). Stress and verbal abuse
in nursing: Do burned out nurses eat their young? Journal
of Nursing Management, 13, 242–248. doi:10.1111/j.1365-
2834.2004.00533.x
Spector, P. E., Zhou, Z. E., & Che, X. X. (2014). Nurse
exposure to physical and nonphysical violence, bullying,
and sexual harassment: A quantitative review. International
Journal of Nursing Studies, 51, 72–84.
doi:10.1016/j.ijnurstu.2013.01.010
Taylor, J. L., & Rew, L. (2011). A systematic review of the
literature: Workplace violence in the emergency
department. Journal of Clinical Nursing, 20, 1072–1085.
doi:10.1111/j.1365-2702.2010.03342.x
Weaver, K. B. (2013). The effects of horizontal violence and

76. bullying on new nurse retention. Journal for Nurses in
Professional Development, 29, 138–142. doi:10.1097/NND.
0b013e318291c453
Journal of Nursing Scholarship, 2015; 47:1, 87–95. 95
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