Psychiatric nurses’ experiences of patient violence on acute psychiatric units in Turkey: a qualitative study

Abstract

Background

Previous research has found that nurses working in psychiatric clinics in an environment where patient violence is common due to patient-nurse interactions. Mental health nurses are often subjected to violent and aggressive behavior from patients. The experiences of assault have inflicted physical and psychological stress on mental health nurses, adversely impacting the quality of patient treatment. This study aims to explore psychiatric nurses’ experiences with patient-related violence.

Methods

A phenomenological descriptive design one of the qualitative methods guided this study that included 10 semi-structured interviews with a purposeful sample of 10 registered nurses who self-reported experiencing patient violence within acute care inpatient psychiatry in Turkey. The data was analyzed using inductive qualitative content analysis to create themes and categories within the research. The confirmability, transferability, credibility and consistency of the study were checked.

Results

Nurses reported experiencing physical, emotional and verbal violence. Thematic analysis of interview data found five themes as well as 14 subthemes: (i) Perceived Normalization of Violence; for many nurses violence was normal, because patients are mentally sick; (ii) Contributing factors to patient violence (iii) Impact of patient violence; (iv) Ways of coping with violence; (v) Strategies to Prevent Patient Violence.

Conclusion

This study provides comprehensive multidimensional insights into the causes, consequences and prevention of patient violence experienced by psychiatric nurses. The descriptions of nurses’ experiences of violence illustrate the severity of violence and its negative impact on nursing care. Patient violence can be minimized if psychiatric nurses receive psychological support to cope with the emotions caused by the violence, focus on and address the facility’s deficiencies and are trained in therapeutic interventions.

Background

According to the International Council of Nurses (ICN), workplace violence includes threats, physical violence, verbal abuse, sexual harassment, bullying (persistent bullying), discrimination and other types of negative behaviour. Workplace violence is a major threat to healthcare professionals worldwide [1]. Workplace violence has affected the physical and mental health of employees, reduced job satisfaction and negatively impacted the quality of healthcare. Registered nurses (RNs) are at higher risk of workplace violence, initiated by patients and their families, compared to other healthcare providers. Workplace violence, particularly against nurses, should disrupt effective communication between patients and nurses and jeopardize patient safety and the physical and mental well-being of nurses [1, 2].

Moreover, violence against nurses by patients is a serious and frequent problem in psychiatric clinics. It is known that nurses working in mental health facilities are 20 times more likely to be exposed to physical violence than nurses working in public health facilities [3]. The prevalence of workplace violence in psychiatric clinics is alarming, with studies indicating that a substantial percentage of psychiatric nurses experience various forms of violence, including verbal, physical, and sexual abuse [3, 4]. For instance, in a recent qualitative study of twelve nurses in a psychiatric ward in Brunei, the nurses indicated that the main types of violence they encountered at work were “emotional”, “physical” and “verbal” violence. Experiences of physical violence include pushing, slapping, kicking, hitting and throwing objects. Verbal and emotional violence included swearing, insults, verbal threats and emotional bullying. All nurses stated that this violent behaviour is “normal” or “part of the job” [4]. Psychiatric nurses are reported to be exposed to verbal and physical violence. The most common form of violence in outpatient psychiatry is verbal violence [3]. In Turkey, 82% of nurses who had been exposed to physical violence stated that they had been exposed to violence while working in psychiatric clinics [5]. Another study conducted in psychiatric wards in Turkey reported that 61% of nurses had been physically assaulted by patients [6]. However, it is seen that the studies conducted with psychiatric nurses in Turkey are limited and mainly focus on nurses working in general wards [7,8,9]. Research indicates that psychiatric nurses are at a significantly increased risk of experiencing violence from patients due to their close proximity and the nature of their work, which often involves managing patients with severe mental health issues who may exhibit aggressive behaviors [3, 10]. This heightened risk necessitates a deeper understanding of the specific experiences and coping mechanisms of psychiatric nurses, as existing literature suggests that their experiences are often overlooked or inadequately addressed [3].

Psychiatric clinics play an important role in the public health system as critical health centers where individuals with mental health problems are treated. Healthcare professionals working in these clinics are confronted with the situation of being in close contact with patients and managing their treatment and rehabilitation processes. Although this intensive interaction fosters an understanding of how to solve patients’ psychological problems, it sometimes also harbors the risk of patient violence [3, 11, 12]. The factors contributing to patient violence are multifaceted. Research indicates that workplace violence can disrupt effective communication between nurses and patients, thereby threatening both patient safety and the mental well-being of nursing staff [3, 13, 14]. Moreover, the stressful nature of psychiatric nursing, compounded by inadequate staffing levels and organizational support, exacerbates the risk of violence. For example, it has been shown that low staffing levels correlate with increased incidents of aggression, as nurses may be unable to adequately manage patient needs in high-stress situations [15]. Studies have shown that symptoms of illness, long-term hospitalization of patients, curfews and phone bans, dissatisfaction with medical care, inability to reach a physician, and institutional problems are factors that cause psychiatric nurses to be exposed to violence [3, 13, 14].

Cultural and contextual factors also play a role in the prevalence and nature of violence against psychiatric nurses. Variations in healthcare systems and societal attitudes towards mental health can influence how violence is perceived and managed. For instance, studies suggest that nurses in different countries may experience violence differently due to cultural norms surrounding mental health care [16, 17]. Furthermore, the lack of a universally accepted definition of patient violence complicates the development of effective policies and protective strategies [17].

Patient violence in inpatient psychiatric units has led to nurses finding themselves in unsafe situations that cause potential stress. It has also caused nurses to remain vigilant and at a higher risk of developing depressive symptoms [18]. It was also found that emotional distress was higher in nurses who were assaulted in mental health settings and quality of life was lower due to workplace violence [19]. Recent systematic reviews have also shown that violence in the workplace is associated with an increased rate of post-traumatic stress disorder [19] depressive symptoms, psychosocial problems and sleep disorders in psychiatric nurses [20]. As a result, the psychological impact of violence on nurses can lead to burnout, increased occupational stress, and even post-traumatic stress disorder (PTSD) [19, 20]. It is known that nurses who are victims of violence use positive coping methods such as talking to others, exercising, shopping, getting enough rest, praying, watching movies or TV series, approaching the problem positively and trying to solve it, as well as negative coping methods such as not reacting, engaging in avoidant behavior and crying [11].

Despite the increasing magnitude of the phenomenon and its recognition as an occupational hazard in hospitals around the world, the limited studies conducted in Turkey appear to focus on the epidemiology of workplace violence, its various risk factors, and its consequences across multiple settings [7,8,9]. International literature includes several qualitative studies that provide an in-depth exploration of psychiatric nurses’ experiences with patient violence. These studies have contributed significantly to understanding the emotional, psychological, and professional impact of workplace violence in mental health settings [4, 21,22,23]. However, despite these contributions, there remains a critical gap in exploring how these experiences unfold within different healthcare systems, particularly in Turkey [24]. The structural, cultural, and institutional factors shaping psychiatric care vary across countries, influencing both the nature of patient violence and the coping mechanisms employed by nurses.

In Turkey, research on psychiatric nurses’ experiences with patient violence is highly limited, neither of which employs a phenomenological approach to capture the lived experiences of nurses [24]. While these studies provide important insights, they do not fully explore how nurses interpret and internalize these experiences, how violence shapes their professional identities, and how institutional factors influence their coping mechanisms. By adopting a phenomenological approach, this study seeks to fill this gap by offering a contextually rich understanding of psychiatric nurses’ lived experiences within Turkish psychiatric settings.

Another underexplored area in Turkish research is the conceptual ambiguity surrounding patient violence. While international studies have examined different forms of violence—including verbal, emotional, and institutional aggression—Turkish literature has predominantly focused on physical violence [5,6,7]. This narrow focus fails to capture the full spectrum of challenges psychiatric nurses face in inpatient settings, where violence often manifests in more complex and subtle ways. By addressing these nuances, this study aims to refine the definition of patient violence and contribute to a more comprehensive framework for future research and policy development.

Additionally, there is limited research on how workplace violence affects psychiatric nursing care practices and patient management strategies within the Turkish context. Fear of patient aggression has been shown to contribute to increased reliance on coercive measures, which paradoxically may escalate aggression rather than reduce it [25]. However, no study has specifically examined how this phenomenon plays out within Turkey’s mental health system. By investigating psychiatric nurses’ experiences, this study aims to illuminate the interplay between patient violence, nursing care strategies, and the overall therapeutic environment, ultimately informing policies and interventions to enhance both staff safety and care quality. The findings of this study will not only complement existing international research but also provide a contextualized perspective specific to Turkey, addressing the unique challenges psychiatric nurses face within this healthcare system. By doing so, this research advocates for targeted institutional policies, improved training programs, and systemic changes that prioritize the safety and psychological well-being of mental health nursing staff.

In summary, the rationale for this qualitative study is multifaceted, encompassing the urgent need to address the high rates of violence experienced by psychiatric nurses, the importance of understanding their personal and professional coping strategies, and the potential for these insights to inform practice and policy improvements. By focusing on the lived experiences of psychiatric nurses, this research aims to address a significant deficiency in the literature and contribute to the ongoing efforts to create safer and more supportive work environments in psychiatric healthcare settings. In addition, it is believed that it will fill an important gap due to the limited number of studies addressing the violence experienced by psychiatric nurses in Turkey. Considering the prevalence and unique nature of violence against nurses in psychiatric clinics, this study phenomenologically investigates the patient violence experiences of psychiatric nurses in Turkey.

The research aims to: (1) What are psychiatric nurses’ experiences of patient violence? (2) What are psychiatric nurses’ views on the causes of patient violence? (3) What do psychiatric nurses experience as a result of violence? (4) What are psychiatric nurses’ views on preventing patient violence?

Methods

This study employs a qualitative design to explore the patient violence experiences of psychiatric nurses in Turkey. This approach allows for an in-depth understanding of the ways in which individuals make sense of their encounters, emphasizing their emotional, cognitive, and behavioral responses. Specifically, a phenomenological approach was adopted, guided by Colaizzi’s (1978) phenomenological analysis method [26]. This approach allowed for a deep understanding of participants’ personal experiences, perceptions, and meanings regarding their access to treatment. The study is grounded in a constructivist paradigm, which asserts that reality is socially constructed and shaped by individual experiences. Within this paradigm, the phenomenological approach was used to explore the lived experiences of participants [27, 28]. Colaizzi’s (1978) phenomenological analysis method was utilized to interpret the data, helping to identify both explicit and implicit meanings in participants’ narratives. Qualitative research methods are useful for understanding how participants perceive their experiences of patient violence. Additionally, in this study, we focused on identifying potential relationships and associations between a nurse’s exposure to patient violence and the resulting perceived impacts on their health, ability to provide care, or ability to empathically participate in the nurse-patient therapeutic alliance.

Participants

Registered nurses are trained within Turkey in broad-based, unspecialized programs. Nurses were purposively selected to participate in the study if they met the following inclusion criteria: (1) licensed as an RN in his/her province or territory; (2) currently or previously employed within the last three years as an RN in inpatient psychiatric unit; and (3) experienced any single type (or combination of types) of patient violence. Potential participants who were involved in any current legal proceedings regarding patient violence incidents were excluded because they were legally obligated to refrain from discussing their alleged experiences. There were no geographic restrictions and eligible nurses from any province or region in Turkey were eligible to participate. Patient violence is defined in this study as “any aggressive behavior exhibited by patients towards healthcare providers, particularly nurses, that can manifest in various forms, including verbal, physical, and psychological aggression”. This inclusive definition aligns itself with the World Health Organization (WHO) definition that violence in healthcare settings definition to provide consistency amongst existing definitions. To reach the participants, announcements were made on social media platforms. Nurses who contacted the researchers and agreed to participate were included in the study. The sample consisted of 10 psychiatric nurses in Turkey who had experienced violence by patients. The sample was determined by purposive sampling, and individual in-depth interviews collected data. In individual in-depth interviews, it is essential to reach data saturation to finalize the data collection process. Data saturation can be defined as the point at which new themes related to the phenomenon under investigation are not identified. The study noted data saturation in the 8th interview for participants and confirmed in the 9th interview. As the participants’ opinions started to repeat each other, it was concluded that data saturation was reached for the study and data collection ended with 10 participants.

Data collection

The data were collected via individual in-depth interviews between June and October 2023. Interviews were conducted by the first author, who has a doctoral degree in mental health nursing and training in qualitative research. The invitation letter explaining the purpose and method of the study was distributed via social media and psychiatric nursing associations. The study was conducted with nurses who agreed to participate in the study. Semi-structured in-depth interviews were performed using a tailored interview guide for this research. Semi-structured in-depth interviews were utilized to provide participants with opportunities for expressing their unique experiences while focusing on key themes relevant to the study aims. The interview guide completed pre-testing in a pilot study involving two individuals not included in the main study to enhance the clarity and organization of the questions. Minor modifications were implemented following the pilot research. Interviews were carried out either in person at a place selected by the participants or via telephone. Telephone interviews have been shown to save costs and travel time for participants, improve access to geographically separated individuals, and enhance the safety of interviewers [29, 30]. Before starting the interview, each participant was informed about using the voice recorder and their written and verbal consent was obtained. The interviews lasted between 45 and 60 min. Written notes and a voice recorder were used to document both verbal and non-verbal emotions. Transcripts of the interviews were sent to the nurses for approval, further comments and/or revisions.

Development of the semi-structured interview form

The semi-structured interview form was developed for this study. The first author organized an initial meeting with academic scholars in the psychiatric and mental health nursing and clinicians specializing in psychiatric nursing. This process facilitated the development of a semi-structured interview form consistent with the aims of the study. The form was finalized after receiving expert opinion. The interview guide was carefully designed to cover the following areas: (1) participants’ memories and interpretations of their experience of patient violence; (2) their views on the causes of violence; (3) the consequences of the violence they were subjected to; (4) individual experiences of patient violence and its perceived impact on their daily lives and quality of life; and (5) their views on preventing patient violence. The questions involved in the interviews are detailed in Appendix 1.

Ethical issues and reflexivity

Ethics approval was granted by the Ethics Committee for Non-Invasive Clinical Research in Van Yuzuncu Yil University (Protocol:2023/05–24 Date:12/05/2023). All participants gave written informed consent prior to participation in the study. This research was conducted ethically in accordance with the Declaration of Helsinki of the World Medical Association. The researchers did not know the participants beforehand. Interviews were conducted by one researcher. While researchers having expertise in psychiatric nursing has the potential to create bias, researchers can generate more reliable and nuanced findings that meaningfully contribute to the discourse on workplace violence in psychiatric settings by being aware of how their backgrounds impact the research process. Findings were reviewed by all researchers and reviewed by someone outside the research team and participants.

Data analyses

In the data analysis, qualitative content analysis was used to create themes and categories within the scope of the research. With this analysis method, the visible content obtained from the participants’ statements and the hidden content underlying the verbal expressions with the researcher’s interpretation were analyzed [31]. Colaizzi’s (1978) phenomenological analysis steps were used for data analysis [26]. (Authors’ work throughout the reporting is indicated by their initials).

While analyzing the data, the following steps were followed in order.

• 1. Transcription: The interviews on the voice recorder were transcribed into written text (E.K).

• 2. Familiarization with the Data: First, the transcripts were read repeatedly to understand the participants’ experiences, and short notes were taken (M.C.A.; C.H.A, E.K.).

• 3. Open Coding: The transcripts were processed line by line using relevant open coding and content labelling (M.C.A and E.K).

• 4. Code Categorization: The codes were grouped into categories and subcategories based on conceptual similarities and differences (M.C.A.; C.H.A. E.K.). For example, the codes ‘acceptance of violence as a part of life’ and ‘exposure to violence leads to desensitization’ were categorized under ‘Normalization of Violent Behavior,’ which was then integrated into the overarching theme ‘Perceived Normalization of Violence.’ Similarly, the codes ‘deep breathing’ and ‘talking with friends and family members’ were grouped under ‘Positive Coping,’ which formed part of the broader theme ‘Ways of Coping with Violence.

• 5. Theme Development: Categories were synthesized into broader themes by identifying underlying patterns across participants’ narratives. The initial themes were reviewed by a psychiatrist to ensure coherence with clinical findings.

• 6. Consensus and Refinement: The themes were discussed among researchers until a consensus was reached, ensuring alignment with the research objectives (M.C.A.; C.H.A.). The conceptual structure of the themes was further refined through iterative discussions.

• 7. Member Checking: Participants were contacted via phone and provided with a summary of the findings. Their feedback was incorporated into the final analysis where necessary (C.H.A.). Participants were provided with a summary of the findings through phone, and their feedback was incorporated into the final analysis where necessary. To ensure the trustworthiness of the data analysis, the following strategies were applied:

Researcher triangulation

Multiple researchers (M.C.A. and C.H.A.) independently coded the data. The initial coding results were compared, and discrepancies were discussed until a consensus was reached. This approach minimized individual biases and enhanced the credibility of the findings.

Reflexivity

To minimize researcher bias, a reflexive journal was maintained, where researchers noted their assumptions and reflections throughout the analysis process.

Peer debriefing

To ensure the credibility of the findings, peer debriefing sessions were conducted with an independent qualitative researcher, who reviewed the themes and provided feedback on their accuracy.

Results

Characteristics of nurses

The age of the participants ranged from 25 to 50 (M = 33.7). Two participants were male, and eight participants were female. All individuals were employed in a regular hospital’s acute inpatient psychiatry units rather than in specialized Psychiatry Hospitals in four cities: Van (n = 6), Adana (n = 2), Istanbul and Konya (n = 1). All had worked as staff nurse within a period of data collection. The mean year of length of worked on inpatients psychiatry units was 9.2 years (min: 3-max:21). The socio-demographic characteristics of the sample can be found in Table 1.

Table 1 Characteristics of participants

Types of violence

Within the context of interviews, nurses described a total of 13 incidents of physical violence initiated and directed towards them by a patient. Types of physical violence included being punched, kicked, having cola poured on the face, being slapped, being pushed, having a necklace ripped off by the collar, being beaten. Five incidents included a combination of these (e.g. being slapped and kicked at the same time). These experiences were not limited to physical violence alone, and many incidents included simultaneous verbal violence (n = 3) in the form of threats, curses, or imprecations. Verbal violence experiences, which included emotional and psychological violence, were somewhat more difficult for most RNs to describe. These events ranged from profanity, threats, intimidation, and gestures, to curses and abusive, aggressive, or degrading events. The most frequently described experience was curses and swearing at family (n = 8).

In this study, the psychiatric nurses’ experiences of patient violence were categorized into five main themes: perceived normalization of violence, contributing factors to patient violence, impact of patient violence, ways of coping with violence, strategies to prevent patient violence. These themes provide key insights into the frequency of violence experienced by nurses and its impact on their professional ability to deliver care (See in Table 2).

Table 2 Themes emerged from participants’ expressions

Theme 1: Perceived normalization of violence

This theme consists of two sub-themes: Normalization of Violent Behavior and Cultural Influence. Participants’ perceptions of violence were mixed. For most participants, violence was part of their job and a normal occurrence (n:8). Participants reported that while they feared physical violence, they were more affected by verbal violence. For example, many participants initially stated that verbal violence was a very common occurrence, but they still felt sad, especially when their families were cursed. The participants’ statements are as follows:

…. I have been subjected to verbal violence many times. During treatment, there was a female patient who swore at me while looking at my face, I will never forget her. I have been subjected to so much verbal violence that I do not even remember it, it has become ordinary now. After all, she is “sick” (H3)

For participants, when violence was accepted as unintentional, it was legitimized as part of their illness and as such the level of perceived threat and harm was reduced.

Additionally, psychiatric nurses expressed that perceived patient violence are influenced by socio-cultural norms. The normalization of violence in society, tolerance toward authority figures, gender roles, and the perception that violence against healthcare workers is “part of the job” shape how nurses make sense of their experiences. Some nurses describe patient violence as an “uncontrollable symptom of illness,” leading to its dismissal, while others emphasize that violent tendencies among patients are shaped by broader socio-cultural dynamics. The participants’ statements are as follows:

Violence is seen as normal here. When a patient yells at me or threatens me, people think, ‘Well, this is a psychiatric ward, it’s expected.’ But we are human too, and being exposed to violence all the time is emotionally exhausting. (H7)

Theme 2: Affecting factors of violence

According to the participants’ statements, the factors influencing patient violence in psychiatric settings can be categorized into five sub-themes: “loss of control,” “type of diagnosis,” “nursing interventions,” “impact of the Past”, and “restriction practices” Each of these sub-themes highlights different aspects of patient behavior that contribute to violent incidents in psychiatric wards. For participants, patient violence incidents were often caused by illness.

Nurses stated that the patient’s forced hospitalization and lack of insight caused violence. Many patients are admitted to psychiatric hospitals involuntarily, which can lead to feelings of frustration, helplessness, and resistance. This lack of autonomy often manifests as aggression toward healthcare providers, including nurses who are perceived as enforcers of hospitalization. The participants’ statements are as follows:

……2 months ago, I was subjected to violence by a female patient who was brought by force and did not accept admission. Our female patient first attacked the clinic, the surroundings, the nurse’s desk, the walls, and the door. (H1)

All participants stated that the type of diagnosis influenced their violent behaviour. Certain psychiatric diagnoses are associated with a higher risk of violent behavior. Conditions such as schizophrenia with paranoid delusions, bipolar disorder during manic episodes may increase the likelihood of aggression toward nurses. Nurses often experienced violence from patients with schizophrenia or bipolar patients. While bipolar patients mostly engaged in verbal violence, they stated that they often experienced physical violence from patients diagnosed with schizophrenia. The participants’ statements are as follows:

He was a patient I had just admitted to. He came with a diagnosis of psychosis. He was also a patient with paranoid thoughts. While giving me his medication, you want to kill me. I know you came to kill me. Come on, let’s see if you can, let’s see, he said and started kicking me in the knee. I left the room immediately. (H7)

Some nursing practices, such as administering injections, setting physical restraints, or enforcing medication adherence, can provoke aggressive reactions from patients. These interventions, while necessary, may be perceived as intrusive or punitive. Participants stated that hurting the patient while performing interventions such as bloodletting caused violent behavior. The participants’ statements are as follows:

It was my third year in this clinic (psychiatry clinic). I went to get blood. I hurt him because I drew blood unintentionally. He swore and cursed my family and children so badly that I froze. This was an experience of violence that I can never forget. (H4)

Transference refers to patients projecting past experiences or emotions onto healthcare providers. Some patients may associate nurses with figures from their past, such as authority figures, abusive individuals, or caregivers, which can lead to aggression. Participants stated that patients’ transference situations towards themselves caused violent behavior. The participants’ statements are as follows:

She was tall, approximately 178–180 cm tall. She did not want me to enter the room during doctor visit with our professors and assistants. She never showed such behavior to my other colleagues. When I entered the room, she reacted by saying, “I don’t want to see this woman leave.” One day, she came to the nurse’s office and walked up to me saying, “You are too loud, I am disturbed by your voice, I am disturbed by you.” I warned her to leave the room, and she left immediately. Then I explained the situation to our assistant doctor in charge. Our doctor said that in the past the patient was with hijab and that maybe when she sees you, you remind her of the traumas she experienced while she was with hijab. (H7)

Patients often make requests that cannot be fulfilled due to hospital regulations. Denying these requests, such as refusing to give extra medication or preventing unauthorized leave, can trigger violent reactions. Participants stated that rejecting patients’ demands and requests due to service rules caused violent behavior. The participants’ statements are as follows:

When I told a patient he couldn’t leave the ward without a doctor’s approval, he got extremely angry and threw a chair at me. (H9)

Theme 3: Impact of patient violence

The theme, “Impact of patient violence”, explores the psychological and emotional challenges faced by psychiatric nurses when encountering patient-related violence. This theme reflects the multifaceted effects of violence not only on nurses’ professional roles but also on their personal emotional well-being.

Patient violence has a profound impact on nurses, causing not only a physical threat but also significant emotional distress. The immediate emotional reactions, such as fear, anxiety, and stress, are easily observed, but over time, these feelings can evolve into deeper psychological issues like burnout, anger, sadness, and doubt. These emotional struggles can undermine nurses’ job performance and professional commitment, while also testing their emotional resilience.

While nurses focused on the personal consequences of being subjected to verbal or physical violence, one participant also mentioned the professional consequences. They explained that the emotional and physical consequences of being subjected to violence affected their ability to fulfill their professional nursing role. Nurses expressed a wide range of emotions such as fear, anger, sadness, doubtfulness, burnout and anxiety following incidents of physical and verbal violence. Fear was described as most intense when nurses felt they were unlikely to be able to manage the situation or in situations of physical violence that were perceived as extremely dangerous. Anger toward patients was expressed after both verbal and physical incidents of patient violence. Participants reported experiencing fear, anger and shock more often, especially after physical violence. One RN, explained:

At first, I was very surprised and then these feelings turned into fear. Then I got angry and then I calmed down. Because the violence was done by a patient I never expected. I was surprised and scared. Since there was nowhere to escape at the end of the corridor, I was forced to be beaten. At that moment I was full of anger, but I couldn’t do anything because he was a patient and my hands were tied. Frankly, these were very mixed feelings for me. It was like this in my other experiences of violence. First, I was scared, then the fear turned into anger and then I had to calm down. (H2)

After the physical violence occurred, and lasting from several days to months, participants reported feeling hypervigilance and anxiety. One participant stated that she had difficulty fulfilling her professional roles after the violence. The participants’ statements are as follows:

I felt very bad. Very bad. I felt incredibly bad. I was feeling sad but I was trying hard not to reflect it on work. I can say that after a while, anger started to form. I had no desire to treat the patient. He didn’t even want to come to work until I learned the reason. I waited to see how he would react when he met that patient. (H6)

Nurses described their feelings because of feeling vulnerable, not being prepared to manage violence effectively, and fearing how violence might escalate. Nurses reported feeling angry and hurt when verbal violence was perceived as a personal attack on them or their families as a person or a personal insult to their role/competence.

Theme 4: Ways of coping with violence

The statements of the participants were divided into two sub-themes: “positive coping”, and “negative coping”. Each sub-themes were divided into its own categories. Immediately after experiencing verbal or physical patient violence, individual coping strategies were used. These included positive strategies such as deep breathing, relaxation, taking precautions, and distancing, as well as negative strategies such as blaming self, desensitization, crying, running away and remain unresponsive. One RN, explained:

I was scared, yes. I moved away from that area, or rather they moved the patient away from me. I sat and thought. Did he pull my hair because I left it open? Maybe I shouldn’t have left it open. I sat in the nurse’s office for a few minutes. (H1)

A significant factor contributing to the reliance on negative coping strategies is the lack of adequate institutional support and resources. When faced with violence, nurses have reported resorting to avoidance tactics, such as desensitization, running away and remain unresponsive, as a way to protect themselves from the immediate psychological impact of the violence they experience. Furthermore, the normalization of violence in psychiatric settings has led to a culture in which maladaptive coping has become a common response among nurses. In general, participants were relieved to see violence as part of their job and the disease. One RN, explained:

As I mentioned, they have no criminal liability. I chose this profession with love. I do it with love. There have been many times when I sat down and cried. I just said it was the irony of our profession and moved on. (H9)

All or most RNs sought support from informal systems. Participants more consistently reported seeking informal support from colleagues, family, and friends, regardless of the type of violence. It was seen that nurses shared more with their colleagues. One RN, explained:

I talked to my more experienced friends. I was relieved to receive information about what I should do, how I should behave, and which patient I should approach with what potential. (H10)

Theme 5: Strategies to prevent patient violence

Four sub-themes were created from nurses’ views on preventing patient-related violence they were exposed to: “improvement therapeutic environment”, “improvement institutional conditions”, “nurses focused approaches”, and “patient focused approach”. Each sub-themes were divided into its own categories. Nurses believed that enhancing the therapeutic environment could be achieved by improving the conditions of the isolation room, clinical settings, and recreational activities, which may help prevent patient violence. The participants’ statements are as follows:

We are very poor in terms of security. This is obvious. Our rooms are not like the rooms in the psychiatric ward they should be. There are many security problems in the rooms. Patients may harm themselves. We are very limited in terms of activities. There are very limited areas where patients can do different activities. There is no way even to the garden. If such opportunities are provided, patients will focus on activities they will enjoy more instead of reflecting their energy on us, as I think patient based. (H4)

Most participants also reported that enhancing institutional conditions, such as increasing the number of nurses and security staff, would alleviate the workload and foster a safer working environment, thereby preventing the violence they faced. The participants’ statements are as follows:

One nurse is on duty at night. We really need it in every little problem. This is our biggest deficit. The number of nurses should be increased. (H6)

The number of security guard can be increased. Because this is our biggest problem in general. If this is taken care of, the problems will be greatly reduced. (H5)

Moreover, nurses reported that having effective communication skills and knowledge about psychiatric diseases and therapeutic approaches can prevent violence by contributing to understanding patients. The participants’ statements are as follows:

First of all, I think it is very important for both us and the patient that we should not personalize the patients’ behavior towards us. In this case, the issue ends with the psychiatric nurse. Therefore, the psychiatric nurse must know the patient, know the patient’s diagnosis, and the nurse must have harmony within the clinic, that is, harmony with the patient, the service, and the colleague. We must have eyes everywhere in the service. It is necessary to ensure the trust in the service and to ensure harmony both in the service and within the group. I think it is important how much we can trust the patient and communicate. (H8)

………. Psychological support should definitely be given to all healthcare personnel. This strengthens us to cope with the violence we experience. (H6)

Two nurses stated that providing psychoeducation to patients and their relatives would reduce violent behavior. The participants’ statements are as follows:

I think that patients and their relatives should be given psychoeducation on topics such as illness management, precursor symptoms, and anger management. (H7)

Discussion

In the current study, the findings obtained from the violence experiences of nurses working in psychiatric clinics are based on the type of violence they were exposed to; “Perceived Normalization of Violence”, “Contributing factors to patient violence”, “Impact of patient violence”, “Ways of coping with violence” and “Strategies to Prevent Patient Violence”.

The findings of this study highlight the significant exposure of psychiatric nurses to patient-initiated violence, encompassing both physical and verbal aggression. Participants reported a total of 13 incidents of physical violence, which included being punched, kicked, having a beverage poured on their face, being slapped, pushed, having a necklace forcefully removed, and being beaten. In five cases, multiple forms of physical violence occurred simultaneously, indicating the severity and unpredictability of these encounters. Furthermore, physical violence was often accompanied by verbal aggression, such as threats, insults, and profanities. These findings underscore the multifaceted nature of workplace violence in psychiatric settings, emphasizing the need for comprehensive preventive measures, institutional support, and targeted interventions to enhance the safety and well-being of psychiatric nurses.

In Turkey, research indicates that psychiatric nurses are frequently subjected to various forms of violence. Öztürk et al. (2023) identified that verbal abuse, including threats and insults, is the most common form of workplace violence, followed by physical assaults [24]. This aligns with findings from Alanazi et al. (2023), who reported that nurses experience a range of aggressive behaviors from patients, including scratching, spitting, and being struck with hands or elbows [32]. Another study, the prevalence of physical violence is significant, with studies indicating that up to 82% of psychiatric nurses have encountered either physical or verbal assaults in the past year [33].

Moreover, Hilton et al. (2023) noted that two-thirds of psychiatric professionals have experienced direct workplace violence, which includes being attacked or threatened while managing patients [19]. This alarming statistic underscores the high-risk environment in which psychiatric nurses operate. Similarly, Al-Kalbani et al. (2024) reported that a significant majority of psychiatric nurses in Oman experienced workplace violence prevalence was high (90.6%), with verbal (86.8%) and physical violence (57.5%) being the most common types, further corroborating the widespread nature of violence in psychiatric settings [34]. This body of evidence suggests that psychiatric nurses face considerable risks in their professional environments, necessitating the implementation of robust workplace policies, de-escalation training, and support mechanisms to mitigate the impact of violence and safeguard healthcare professionals.

In this study, psychiatric nurses tend to perceive the frequent incidents of violence in their work environment as the nature of the job. This situation is normalized by continuous exposure, inadequacy of institutional support mechanisms, and the fact that violent incidents are usually inconclusive. Due to their professional identity, trying to understand patient behaviors and thoughts such as “after all, he/she is the patient” may cause them to minimize violence. This perception is further reinforced by the fact that violence becomes invisible not only physically but also in forms such as verbal harassment and threats. Studies have reported that psychiatric nurses normalize patient violence because they see it as a part of their job [4, 21, 24]. These findings draw attention to strengthening institutional support mechanisms, raising awareness through training programs and activating reporting processes to prevent patient violence in psychiatric wards.

In the study, according to the nurses’ statements, it was observed that the diagnosis of the disease had a significant effect on violent behaviors. Violent behaviors of patients with diagnoses such as schizophrenia and bipolar disorder were associated with the nature of these diseases. The fact that bipolar patients mostly use verbal violence and patients with schizophrenia tend to use physical violence reflects the behavioral consequences of diagnostic characteristics. This situation provides important information about which diagnosed patients nurses should be more careful with and how they should approach in psychiatric treatment settings. Forced hospitalization of patients and lack of insight into their illness emerges as an important cause of violent behavior. Forced hospitalizations can lead patients to lose their sense of control and express it violently. Lack of insight can lead to patients not accepting their illness and resisting the treatment process, which increases the potential for violence against nurses. Literature suggest that all nurses working in psychiatric clinics reported that situations such as psychosis, prolonged hospitalization or the desire to talk to doctors when they are not available, not being discharged, not being able to take daily leave, not meeting patients’ needs such as access to the garden or use of the telephone triggered exposure to violence by patients [4, 21, 23]. Situations where nurses need to intervene in patient care, especially situations such as giving medication or enforcing rules, can be triggers of violence. Studies have shown that violence against nurses working in psychiatric hospitals is affected by factors such as the timing, source of violence, patient dissatisfaction with medical care and lack of institutional support for nurses, as well as factors such as the fact that nurses working in psychiatric clinics are predominantly women, the young age of staff and the length of time they have worked in psychiatric clinics [3, 13]. These findings emphasize that interventions towards patients should be made in a softer, explanatory and empathic manner. Nurses’ communication skills and patient management strategies play a critical role in the process of rejecting patients’ requests or implementing rules. Based on these findings, in order to protect nurses against patient violence and reduce patient violence, nurses can be provided with trainings to reduce the risk of violence, information about the behavioral characteristics of diagnostic groups, measures to increase physical and emotional safety in psychiatric clinics, safe escape routes and emergency protocols for nurses. In addition, nurses’ adoption of an empathic and understanding approach in their communication with patients can increase patients’ compliance with treatment and reduce the incidents of violence, and more humane and respectful regulations can be made regarding the compulsory hospitalization processes of patients.

In the current study, nurses working in psychiatric clinics experience emotions such as fear, anger, sadness, suspicion, burnout and anxiety when exposed to violence, and these experiences negatively affect their ability to perform their profession, their work motivation and their desire to stay in the profession in the long term. In addition, physical violence can cause direct physical harm and lead to nurses being absent from work, while the psychological effects on nurses can turn into serious psychiatric problems such as post-traumatic stress disorder (PTSD) over time. In a study conducted with psychiatric nurses, participants reported experiencing negative emotions such as sleep disturbances, sadness, fear, anxiety and stress in the face of patient-related violence [4]. According to a study conducted in Japan, psychiatric nurses exposed to violence by patients were psychologically negatively affected and tended to have a higher risk of burnout [35]. In another study, it was reported that the most common negative emotion experienced by healthcare personnel exposed to violence was anger [23]. This situation affects nurses’ ability to fulfill their nursing roles, job satisfaction and general mental health, and indirectly affects the quality of healthcare and human resources negatively.

In addition, psychiatric nurses tried to calm themselves by using methods such as deep breathing, relaxation techniques, precautions and distancing. These strategies can be individually health-protective and increase resilience to stress. For example, one nurse preferred to keep her distance and collect her mind for a while after the violence. Reactions such as self-blame, desensitization, crying, running away and remaining unresponsive may have negative effects on the mental health of nurses in the long term. Such strategies can reduce nurses’ job satisfaction and motivation to work. An example of such negative emotional reactions is when a nurse blames herself for leaving her hair uncovered. Apart from these, it is very important for nurses to receive support from colleagues, family and friends in the process of coping with workplace stress. Sharing experiences with colleagues provides nurses with both practical knowledge and emotional support. Receiving information from more experienced colleagues can help nurses to be better prepared for similar situations in the future. Moreover, nurses’ perception of violence as a natural part of their work can increase professional resilience, but it can also lead to the normalization of violence. It has been reported that the preferred coping method of nurses working in psychiatric clinics after being exposed to workplace violence is to talk to their colleagues [4]. On the other hand, psychiatric nurses seek solace from their spouses after being exposed to workplace violence. Other coping methods include exercising, shopping, getting enough rest, praying and watching movies or TV series [4, 11, 36]. Problem-oriented coping strategies such as positive reappraisal, positive approach, problem solving and seeking social support have been reported to be frequently used by nurses working in psychiatric clinics [36]. These findings reveal that the methods of coping with violence used by nurses working in psychiatric clinics may be both health protective and potentially harmful. In order to develop healthier coping mechanisms for nurses and to strengthen their support systems, more workplace education, psychological support programs and protective policies at the institutional level are necessary. Awareness and cultural change are also important so that violence is not seen as a normal part of work.

In addition, the opinions of nurses working in psychiatric clinics on strategies to prevent patient-induced violence were evaluated through improving the therapeutic environment, improving institutional conditions, and nurse- and patient-oriented approaches. Nurses stated that improving the conditions of isolation rooms, clinical environments and recreational activities to improve the therapeutic environment can prevent violence. In order to improve institutional conditions, it was emphasized that increasing the number of nurses and security personnel would reduce the workload and provide a safer working environment. In nurse-oriented approaches, it was stated that effective communication skills and knowledge about psychiatric diseases would help to better understand patients and prevent violence. In the literature, it is reported that creating a structured safe space close to home, effective design of the clinical environment, appropriate physical conditions and areas where patients can participate in activities improve patient compliance with the clinic [3, 15, 23, 37]. These findings reveal the needs of nurses to improve both their personal competencies and their working environment.

Strengths and limitations

The strength of the research is the content of the in-depth interviews, which were conducted with individual in-depth interviews. Each participant had sufficient time to share their experiences and was able to express their opinions freely. This aim of this study was to explore the experiences of psychiatric nurses in dealing with patient-related violence in acute care inpatient psychiatric settings through qualitative approach. Whilst the study provides valuable insights, it is important to recognise its limitations to ensure a comprehensive understanding of the research findings. The study may have limited generalisability as it focuses specifically on acute care inpatient psychiatric settings. The nature and prevalence of patient violence may vary in different mental health settings, such as outpatient facilities or community-based settings. Therefore, the results of the study may not be generalisable to psychiatric nursing practise in different psychiatric settings. Also, not including participants with less than 3 years of experience might limit insights from newer professionals. In addition, the fact that the study is based on self-reported experiences of patient violence among psychiatric nurses may lead to social desirability bias. The responses of the participants in the qualitative study may have been influenced by their personal perceptions and emotional well-being, which could potentially affect the accuracy of the reported experiences. Another limitation to consider is the possible influence of organisational factors on experiences of patient violence among psychiatric nurses. Workplace dynamics, staffing, and institutional policies could significantly influence nurses’ experiences of patient violence. However, the qualitative study may not have fully explored the organisational context in which the violence occurred, limiting the comprehensive understanding of contributing factors. In addition, the sample size and geographical scope of the study may have limitations. Future longitudinal studies will be more useful in understanding the effects of patient violence. In addition, cross-cultural studies will fill an important gap in the literature in terms of revealing psychiatric nurses’ experiences of violence and their coping with violence.

Conclusion

With this study, we were able to gain sufficient knowledge about the experiences of patient violence of nurses working in psychiatric clinics. In conclusion, this study contributes to the literature to better understand the experiences of patient violence of nurses working in psychiatric clinics in Turkey and the impact of these experiences. The findings should be used to improve safety in the work environment, protect nurses’ health and prevent violence. Precautionary measures such as prevention strategies, training of nurses and strengthening of policies and protocols should be taken. At the same time, it is important that nurses have access to support services to deal with violence and that the facility provides appropriate conditions in the work environment. The findings of this study highlight the importance of understanding psychiatric nurses’ personal experiences of patient violence in order to provide a more holistic and richer description of the phenomenon that can inform future clinical practice and intervention programmes. The study contributes to a deeper understanding of the specific challenges faced by psychiatric nurses in Turkey, thereby informing the development of tailored clinical practices and intervention programmes to address these challenges. To address these challenges, it is imperative that healthcare administrators implement comprehensive training programs focused on violence prevention and management strategies. Such training should encompass de-escalation techniques and risk assessment protocols, as nurses have expressed a strong desire for ongoing education in these areas. Additionally, creating a supportive work environment that fosters open communication and provides psychological support can mitigate the adverse effects of violence on nurses. Moreover, institutional policies must be established to ensure a zero-tolerance approach to violence, which includes clear reporting mechanisms and protective measures for nursing staff. By prioritizing the safety of psychiatric nurses, healthcare systems can enhance the quality of care provided to patients, ultimately leading to better health outcomes and a more positive work environment.