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.
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 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 t ...
NSG3036 W2 ProjectResearch Template NameCite both articles r.docx
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
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
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.
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
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,
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
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
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/
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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,
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,
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
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
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
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