Abstract
Background
Nursing students are particularly susceptible to workplace violence. However, there is limited research on the management competence of nursing students in responding to workplace violence.
Aim
This study aims to investigate the prevalence of workplace violence in hospitals and the management competence of workplace violence among nursing students, and explore the key factors related to their competence in managing violence.
Methods
A multi-center cross-sectional survey was conducted between September and December 2024, involving 455 nursing students from five tertiary hospitals in Sichuan and Guizhou provinces of China. The research employed several tools, including a general information questionnaire, the Workplace Violence Scale (WVS), the Management of Workplace Violence Competence Scale (MWVCS), the Organizational Climate Scale, and a Chinese version of the 10-item Connor-Davidson Resilience Scale (CD-RISC). Descriptive statistics, the Mann-Whitney U test, the Kruskal-Wallis test, and Spearman correlation analysis were performed using SPSS 26.0. Additionally, random forest models and LASSO regression were employed to identify key variables and to construct multiple linear regression models using RStudio.
Results
40.9% (n = 186) of nursing students experienced workplace violence. The average competence score (150.01 ± 19.65) exceeded the midpoint of the scale. Five key factors (organizational climate, psychological resilience, training experience, training willingness, and educational level) were identified as predictors and accounted for 47.9% of the variance in competence scores.
Conclusion
A positive organizational climate and psychological resilience are related to the high competence to manage workplace violence, and it is necessary to incorporate them into workplace violence prevention training.
Keywords: Workplace violence management competence, Workplace violence, Nursing students, Organizational climate, Psychological resilience
Background
Workplace violence (WPV) in hospitals is a serious occupational hazard. It includes verbal abuse, harassment, intimidation, and other forms of aggressive behavior that healthcare personnel encounter in their professional settings. These actions can threaten the safety, well-being, and health of these workers both directly and indirectly. According to World Health Organization (WHO) statistics, the prevalence of workplace violence in healthcare systems worldwide is as high as 62% [1]. Furthermore, nursing students are one of the most vulnerable populations to violence and aggression in healthcare settings. A meta-analysis covering 20 countries and regions discovered an overall incidence rate of 58.2% among nursing students during clinical practice [2]. In China, the prevalence of WPV among nursing students ranges from 68.51% to 91.90% [3], which is significantly higher than the results of the meta-analysis. According to Liu [4], the risk of violence in the nursing profession was four times higher than that faced by physicians and other healthcare practitioners. Moreover, a study [5] showed that nursing students are more likely than employed nurses to experience workplace violence and suffer from various forms of abuse. A UK study [6] indicated that the vast majority of students (81%) experienced non-physical aggression in the past year, followed by physical aggression (56%), and sexual harassment (40%). According to research in Turkey [7], more than half of students faced verbal violence (60.9%) or psychological violence (52.3%). Students in New Zealand reported experiencing several forms of bullying, including physical, verbal, psychological, and racial harassment [8].
Nursing students are a particularly vulnerable population to workplace violence because they are often younger, lack social experience, and have a limited understanding of nursing standards and procedures [9]. Furthermore, nursing students are powerless in the face of workplace violence because they lack the qualifications to practice nursing freely, have a lower hierarchical rank, and lack authority [8]. The consequences of workplace violence against nursing students in clinical settings are severe. It causes not only physical injuries, but also additional psychological and physical disorders. Fear and anxiety are direct psychological symptoms, sometimes accompanied by other emotions like humiliation, helplessness, and despair [2]. If these negative emotions are not controlled effectively, they can have a significant impact on nursing students’ physical health, leading to increased stress levels, fatigue, headaches, sleep disturbances, cognitive impairments, depression, and even suicide [10]. Furthermore, students’ exposure to violence in clinical settings can shape their perceptions and attitudes toward the profession. Exposure to workplace violence can leave nursing students feeling frustrated and uncertain about their careers, diminishing their self-efficacy and professional identity. This may cause students to leave the nursing profession, resulting in a loss of nursing skills and a shortage of nursing personnel [11]. Given the high prevalence and severe consequences of workplace violence in hospitals, it is critical to implement strategies that enhance nursing students’ competence to manage and respond to such incidents.
Workplace violence management refers to mitigating and preventing potential risks, hidden dangers, and uncertainties associated with violent conflicts. Workplace violence management competence refers to the knowledge, skills, and strategies required by nursing students in clinical practice for the prevention, identification, response, and post-incident handling of workplace violence incidents. The effective strategies for workplace violence management competence include four components: reduction of violence, readiness for violence, response to violence, and recovery from violence. According to Bandura’s Triadic Reciprocal Determinism model, individual behavior is shaped not only by the external environment but also through interactions with personal characteristics. Research showed that competence in managing workplace violence is connected to specific external factors such as the hospital setting and culture, team communication, and safety climate [12–14]. According to the findings [15, 16], positive organizational management, training, and a perceived supportive organizational climate all contribute to identifying violence risks, enhancing reaction capacities, and reducing workplace violence incidents. Previous studies have highlighted organizational climate as an important resource that positively affects work-related behaviors, attitudes, and skills [17]. Organizational climate refers to the collective perceptions and shared experiences of members regarding their work environment, encompassing emotions, beliefs, values, attitudes, behavioral patterns, and the practical expression of organizational culture. In cases of violence, a positive organizational climate and a highly supportive atmosphere may assist nursing students in better identifying violent episodes, implementing standardized responses, reducing psychological trauma, and improving their competence in managing workplace violence.
Besides environmental influences, personal psychological traits may play a crucial role in managing workplace violence. Studies [18–20] showed that factors like well-being, satisfaction, self-confidence, emotional intelligence, and psychological resilience together affect how individuals respond to violence. Notably, psychological resilience has been identified as a vital protective factor for nurses dealing with violence. Psychological resilience is defined as a person’s capacity to sustain a positive mindset and adapt to their surroundings when encountering stress, adversity, or challenges. Research focusing on nurses as secondary victims of workplace violence found that psychological resilience could help reduce their fear and anxiety, ease their pain and suffering, and support their recovery from violent incidents [21]. Furthermore, psychological resilience can influence how violence is perceived, lessen fear related to violence, and help individuals adopt targeted coping strategies, allowing them to manage violent situations comprehensively and sensibly. Psychological resilience, as a long-term psychological trait of individuals, may help nurse students relieve stress, maintain emotional stability, effectively settle violent conflicts, and enhance their competence to handle workplace violence.
Investigating nursing students’ experiences with workplace violence, their competence in managing such violence, and the factors that relate this competence is essential for developing effective prevention strategies. While existing studies have primarily focused on nurses and doctors, there is a scarcity of research specifically addressing nursing students. Therefore, further research is needed to assess nursing students’ competence to handle workplace violence, as well as the factors that relate to their competence, to improve their management and response competence, protect their mental health, enhance their professional skills, and advance the nursing field.
Based on Bandura’s Triadic Reciprocal Determinism, this study investigated the relationship among personal factors (operationalized as psychological resilience), environmental factors (operationalized as organizational climate), and behavior (operationalized as workplace violence management competence). The theory suggests that these three components mutually influence each other; accordingly, we hypothesize that psychological resilience and organizational climate relate to an individual’s competence to manage workplace violence. This study aims to: (1) examine the prevalence of workplace violence among nursing students in China and assess their competence in managing workplace violence; (2) investigate the correlates of violence management competence among nursing students, focusing on basic characteristics, psychological resilience, and organizational climate. and (3) determine the key factors that most significantly associated with their competence to manage workplace violence.
Method
We adhered to the STROBE guidelines for cross-sectional studies.
Study design and setting
This study used a multi-center cross-sectional survey design. Data were obtained from five tertiary institutions in China’s Sichuan and Guizhou provinces during September and December 2024.2.2 Participants and Sampling.
A convenience sampling method was employed. A total of 600 questionnaires were distributed to nursing interns. Of these, 519 commenced the survey. After excluding 51 invalid questionnaires and accounting for 13 participants who withdrew midway, 455 valid questionnaires were included for final analysis. The effective response rate is 87.67%. The inclusion criteria were: ① an internship period of at least one month; ② informed consent and voluntary participation in the study. The exclusion criteria included: ① interns who left their positions during the survey period due to personal reasons, sick leave, or academic leave; ② questionnaires with patterned responses or with extensive missing data (> 20% of items unanswered).
Variables and measurement tools
The study variables included demographic characteristics, workplace violence exposure, workplace violence management competence, organizational climate, and psychological resilience. Data were collected using anonymous, self-administered questionnaires comprising the following scales:
General information questionnaire
Developed by the researchers through literature review and expert consultation, it covered 14 items including gender, age, educational level, duration of internship, personality traits, recognition of the nursing profession, presence of medical professionals in the family, exposure to workplace violence during the internship, types of workplace violence encountered, attention to workplace violence, participation in workplace violence management training, willingness to attend such training, existence of a hospital reporting system for workplace violence, and the willingness to pursue a career in nursing after graduation.
Workplace violence scale (Wang, 2007) [22]
This scale assesses exposure to five types of violence: physical assault, emotional abuse, threats of assault, verbal sexual harassment, and physical sexual assault [23]. Responses were recorded as either ‘no’ or ‘yes’. The Cronbach’s α value was determined to be 0.92, and it was found to be 0.79 in this study.
Management of workplace violence competence scale (Lu et al., 2021) (MWVCS) [24]
It includes seven dimensions: violence cognition, nurse-patient interaction, utilization of protective facilities, risk assessment, knowledge renewal, response to violence, and after-the-event recovery, comprising a total of 40 items. Each item is rated on a 5-point Likert scale, ranging from “strongly disagree” to “strongly agree,” and scored 1 to 5 points, respectively. Total scores range from 40 to 200, with higher scores indicating greater competence in managing workplace violence. The Cronbach’s α value was determined to be 0.88, whereas in this study, the Cronbach’s α value was determined to be 0.97.
Organizational climate scale (Wang et al., 2013) [25]
It consists of four dimensions: trust, communication, emotional, and fairness, with 12 items in total. Responses use a 5-point Likert scale from “strongly disagree” to “strongly agree,” scored 1 to 5. Total scores range from 12 to 60, where higher scores reflect a more positive organizational climate. The Cronbach’s alpha for this scale was 0.88, and in this study was 0.95.
The Chinese version of the 10-item Connor-Davidson Resilience Scale (CD-RISC) (Ye et al., 2017) [26]
It was employed to evaluate nursing students’ psychological resilience. The scale contains 10 items rated on a 5-point Likert scale from 0 (“never”) to 4 (“always”), with total scores ranging from 0 to 40. Higher scores indicate greater psychological resilience. The Cronbach’s alpha for this scale was 0.85, and in this study was 0.92.
Sample size determination
The study involved 27 primary variables. Based on Kendall’s method, the required sample size was 10–15 times the number of variables. Accounting for a 20% potential dropout rate, the minimum sample size was calculated to be 338 participants. The final sample of this study was 455.
Bias control
To minimize potential biases, all data collectors received unified training to ensure consistent procedures. The anonymous nature of the survey was emphasized to participants to reduce social desirability bias and encourage honest responses.
Statistical analysis
This study employed a two-stage analytical strategy combining Random Forest and LASSO regression.
We employed the Random Forest algorithm, an ensemble machine learning method based on decision trees, using the randomForest package in RStudio. It could effectively capture nonlinear relationships and interaction effects among variables. The model operates by constructing multiple decision trees; for each tree, a bootstrap sample is drawn, and at each split, a random subset of predictors is considered. This randomness reduces correlation among trees, enhancing the ensemble’s robustness. Data not included in a tree’s bootstrap sample—known as Out-Of-Bag (OOB) data—serves as an internal validation set to estimate prediction error and assess variable importance. In this study, variable importance was measured by the % Increase in Mean Squared Error (%IncMSE), which quantifies the average increase in the model’s prediction error when a variable’s values are randomly permuted among OOB samples. A higher %IncMSE indicates a stronger contribution to predictive accuracy. This study developed a Random Forest model to predict workplace violence management competence as the dependent variable, incorporating 12 feature variables including demographic and sociological factors, psychological resilience, and organizational climate. The weight values of these variables were calculated and ranked to determine their relative importance. This method helps identify key variables and enhances the predictive performance of the model.
Following the Random Forest screening, we applied Least Absolute Shrinkage and Selection Operator (LASSO) regression for refined variable selection and linear model construction. To avoid overfitting due to potential covariance among predictors, LASSO adds an L1 penalty (the sum of the absolute values of the coefficients) to ordinary least squares estimation, which shrinks the coefficients of variables with weak predictive power toward zero, effectively performing variable selection and dimensionality reduction. The optimal penalty parameter, lambda (λ), was determined via 10‑fold cross‑validation using the cv.glmnet() function, selecting the value at “lambda.1se”—the largest λ within one standard error of the minimum mean cross‑validated error—to ensure model simplicity and stability. After retraining the LASSO model with this optimal λ, coefficients were extracted using the coef () function. Variables retaining non‑zero coefficients were identified as the key predictors for workplace violence management competence.
The rationale for combining these two methods lies in the following: First, Random Forest first conducts a comprehensive and assumption-free exploration of variable importance, preventing the omission of key predictors. It could also capture potential nonlinearities and interactions that standard multiple linear regression would miss. Building on this, LASSO performs secondary refinement and linear model construction on the screened variables, mitigating multicollinearity and overfitting risks and resulting in a stable and interpretable predictive model. When a variable exhibits a high %Inc MSE value in Random Forest and retains a non-zero coefficient in LASSO, its credibility as a key influencing factor is enhanced through methodological triangulation, significantly improving the reliability of the study’s conclusions. Finally, the variables selected through the above sequential process were used to fit a standard multiple linear regression model. This final step provides estimates of regression coefficients (β) and the proportion of variance explained (R²) for workplace violence management competence. This convergence of evidence from distinct analytical methods significantly enhances the reliability and interpretability of the final multiple linear regression model and the study’s conclusions.
All data were analyzed using SPSS 26.0 and RStudio. Descriptive statistics (frequencies, means, standard deviations, medians, interquartile ranges) were used. The Kolmogorov-Smirnov test confirmed the non-normal distribution of the data; therefore, non-parametric tests (Mann-Whitney U, Kruskal-Wallis H) were employed for group comparisons. Spearman correlation analyzed bivariate relationships. To identify the most important predictors of management competence, variables with p < 0.05 in univariate analyses and correlation were entered into a Random Forest model in RStudio to rank variable importance. Subsequently, LASSO regression was applied to compress coefficients and filter key variables, which were finally included in a multiple linear regression model for multivariate analysis. Missing data were handled using Multiple Imputation. The significance level was set at α = 0.05.
Results
Common method bias test
Common method bias was examined using Harman’s single-factor test. The results indicated that nine factors had eigenvalues greater than 1. Among these, the first factor accounted for 35.7% of the variance, which is below the critical threshold of 40%, suggesting that common method bias was not a significant concern in this study.
Characteristics of the participants
This study involved 455 nursing students from two provinces, with an average age of 21.31 ± 1.89 years and an average internship period of 6.67 ± 2.96 years. 82.41% (375) of the students were female, and 60.9% (277) held a bachelor’s degree. 44.4% (202) were willing to continue working in nursing after graduation, 52.5% (238) had a moderate level of recognition of the nursing profession, and 16.9% (77) had a high level of recognition of the nursing profession. Additionally, 63.1% (287) had medical professionals in their family. Regarding workplace violence, 50.3% (229) received training, 46.2% (210) showed moderate willingness to participate in such training, and 31.2% (142) had a high willingness to participate. Furthermore, 56.7% (258) were unclear whether their hospital has a workplace violence reporting system, and only 13.6% (62) would choose to report incidents of workplace violence if they occur.
Workplace violence exposure to nursing students
Out of the 455 nursing students surveyed, 40.9% (n = 186) reported encountering workplace violence during clinical practice. Emotional abuse (34.1%) was the most common type, followed by threats of assault (12.1%) (Table 1). Among the 186 incidents reported, 55.9% (n = 104) involved a single type of violence, 26.3% (n = 49) involved two types, and 17.7% (n = 33) experienced three or more types.
Table 1.
Percentage of nurse students who suffered workplace violence (n = 455)
| Types of WPV | Not suffered | Suffered | Percentage |
|---|---|---|---|
| Physical Assault | 418 | 31 | 8.1% |
| Emotional Abuse | 300 | 155 | 34.1% |
| Threats of Assault | 400 | 55 | 12.1% |
| Verbal Sexual Harassment | 410 | 45 | 9.9% |
| Physical Sexual Assault | 424 | 31 | 6.8% |
Current status of the management of workplace violence competence scale
The overall average score on the MWVCS was 150.01 ± 19.65. Among the subscales, the highest score was for after-the-event recovery, while risk assessment received the lowest score (Table 2).
Table 2.
Total score and subscale mean scores on the nursing students’ workplace violence management competence scale
| Violence management competence scale/ subscale | Item | Median (Q1-Q3) | Mean ± SD |
|---|---|---|---|
| Violence Cognition | 5 | 18(15–20) | 17.12 ± 3.58 |
| Nurse-Patient Interaction | 6 | 24(23–27) | 24.36 ± 3.83 |
| Utilization of protective facilities | 4 | 14(12–16) | 13.79 ± 3.12 |
| Risk Assessment | 3 | 11(10–12) | 11.06 ± 2.05 |
| Knowledge Renewal | 3 | 12(11–13) | 11.80 ± 1.70 |
| Response to violence | 8 | 30(27–32) | 29.65 ± 4.61 |
| After-the-event recovery | 11 | 43(39–45) | 42.24 ± 5.88 |
| Total score(min:40-max:200) | 40 | 153(140–161) | 150.01 ± 19.65 |
SD: Standard Deviation Q1-Q3: First and third quartiles
Univariate analysis of the management of workplace violence competence scale
Univariate analysis, using the MWVCS score as the dependent variable, identified significant associations with several factors: educational level, recognition of nursing professions, attention to WPV, willingness to participate in WPV response training, WPV training experience, WPV experience, whether self-report after experiencing WPV, presence of WPV incident reporting system in the hospital, whether pursue a career in nursing after graduation, and types of violence experienced (all p < 0.05; Table 3).
Table 3.
Basic characteristics of nursing students and their univariate analysis of workplace violence management competency scores (n = 455)
| Variable | N | Median (Q1-Q3) | U/H | p |
|---|---|---|---|---|
| Educational level | ||||
| Diploma/Certificate | 178 | 157(144–166) | -4.292 | 0.000 |
| Bachelor degree | 277 | 150(135–159) | ||
| Recognition of nursing professions | ||||
| Low | 140 | 144(126.5–157) | 47.598 | 0.000 |
| Median | 238 | 154(143–162) | ||
| High | 77 | 160(151–174) | ||
| Attention to workplace violence | ||||
| Low | 144 | 150(126.5–159) | 14.666 | 0.001 |
| Median | 215 | 153(142–161) | ||
| High | 96 | 158(145.5–166) | ||
| Willingness to attend workplace violence response training | ||||
| Low | 103 | 138(121–152) | 63.277 | 0.000 |
| Median | 210 | 155(146–162) | ||
| High | 142 | 157.5(144–166) | ||
| Variable | Variable | Variable | Variable | Variable |
|---|---|---|---|---|
| Have you attended workplace violence response training? | ||||
| Yes | 229 | 157(148–165) | -6.524 | 0.000 |
| No | 226 | 147(130–158) | ||
| Have you exposed to workplace violence? | ||||
| Yes | 186 | 147(135–156) | -5.876 | 0.000 |
| No | 269 | 157(145–165) | ||
| Would you self-report after experiencing workplace violence? | ||||
| Yes | 393 | 154(142–162) | -4.442 | 0.000 |
| No | 62 | 140(121–155) | ||
| Does the hospital have a workplace violence reporting system? | ||||
| Yes | 148 | 159.5(151–168) | ||
| No | 49 | 144(127–155) | 14.666 | 0.001 |
| Unclear | 258 | 148.5(134–158) | ||
| Will you pursue a career in nursing after graduation? | ||||
| Yes | 202 | 156(146–166) | 25.314 | 0.000 |
| No | 63 | 146(127.5–158) | ||
| Unclear | 190 | 150(137–159) | ||
| Types of workplace violence experienced | ||||
| None | 269 | 157(145–165) | 35.279 | 0.000 |
| One | 104 | 147.5(137-156.5) | ||
| Two | 49 | 144(135–157) | ||
| Three and above | 33 | 145(127–154) | ||
Q1-Q3: First and third quartiles. U: Mann-Whitney U test. H: Kruskal Wallis test
Random forest model and LASSO regression to identify key factors related to workplace violence management competence
Variable importance ordering
All variables with p < 0.05 from univariate and correlation analyses were included in the Random Forest model to obtain a data-driven, assumption-free ranking of their relative importance for predicting management competence. Two key parameters in the Random Forest model were optimized: the number of predictors randomly sampled at each split (mtry) and the number of trees (ntree). The mtry, typically set to the square root of the total number of predictors, was optimized to 3 based on the lowest OOB error. The Random Forest model achieved an Out-of-Bag Root Mean Squared Error (RMSE) of 14.06. The ntree was set to 500, as the OOB error stabilized at this number of trees, ensuring model convergence. Twelve variables found significant in the univariate analysis were included in a Random Forest model. The % Increase in Mean Squared Error indicates the average reduction in accuracy when a variable is excluded; a higher % Inc MSE denotes greater importance [27]. Results revealed that organizational climate and psychological resilience were the most important variables, as illustrated in Fig. 1.
Fig. 1.
The importance order of variables related to nursing students’ management of workplace violence competence
Variable selection
We conducted the LASSO analysis in accordance with the variable importance order results. The optimal parameter λ was set up by 10-fold cross-validation. As illustrated in Fig. 2, the interval between lambda. min (left dashed line) and lambda.1se (right dashed line) indicates the region where the model’s bias and variance are most stable [18]. The optimal penalty parameter (λ = 0.214) was chosen at the lambda.1se point, achieving a balance between model simplicity and accuracy. At this λ value, the 10‑fold cross‑validated root mean squared error was 1.44. The LASSO regression narrowed down the original 12 variables to 5 key factors: organizational climate, psychological resilience, workplace violence training experience, training willingness, and educational level. This concise result captures the most critical elements related to workplace violence management competence. These five variables were then included in a multiple linear regression model, which together accounted for 47.9% of the variance in students’ workplace violence management competence scores (Table 4).
Fig. 2.
Screening of feature variables based on LASSO analysis
Table 4.
Multiple linear regression analysis of variables related to nursing students’ violence management competence
| variables | β | SE | β’ | t | p |
|---|---|---|---|---|---|
| Constant | 75.609 | 5.305 | 14.252 | 0.000 | |
| Educational level | -2.834 | 1.411 | -0.070 | -2.008 | 0.045 |
| WPV training experience | 5.523 | 1.368 | 0.141 | 3.984 | 0.000 |
| WPV training willingness | 3.987 | 0.958 | 0.148 | 4.162 | 0.000 |
| Organization climate | 0.892 | 0.104 | 0.341 | 8.564 | 0.000 |
| Psychological resilience | 1.102 | 0.129 | 0.331 | 8.537 | 0.000 |
F:84.435, p < 0.000; ΔR2:0.479
Discussion
Our findings revealed that 40.9% of nursing interns reported experiencing workplace violence. This confirms that WPV is a prevalent issue. However, the fact is that our prevalence is lower than that reported in a meta-analysis [2]. This discrepancy could arise from several methodological and contextual factors. First, variations in measurement techniques, operational definitions of WPV, and recall periods across studies can lead to substantial differences in reported rates. The Workplace Violence Scale used in this study categorizes violence into five specific types. This structured, binary (yes/no) approach might fail to capture subtler, more frequent forms of psychological aggression or micro-aggressions that nursing students may not immediately identify as “violence” but are included in broader definitions used in other studies. If prior studies employed tools with broader items or asked about “any aggressive behavior,” they would naturally yield higher prevalence. Furthermore, our questionnaire asked about experiences “during clinical practice” without specifying a tightly bounded recall period (e.g., “the past month”). This indefinite frame, combined with the potentially traumatic nature of the events, might lead to recall decay or intentional suppression of memories, especially for less severe but more common incidents. Second, prevailing sociocultural norms in China, characterized by collectivism and the concept of ‘saving face,’ may significantly inhibit students’ willingness to report incidents, particularly for subtle forms of aggression such as emotional abuse. These norms can encourage tolerance of conflict and prioritize maintaining group cohesion over individual reporting. It is also plausible that the lower prevalence stems from a lack of awareness of violence recognition among nursing students. Workplace violence encompasses a broad spectrum of behaviors, including verbal signals (such as loud talking, shouting, cursing, threats), nonverbal signals (such as aggressive postures, throwing objects, clenching fists, staring), and emotional expressions (such as anxiety, stress, fear, and tearfulness). These different behavioral clues are often difficult to identify as warning signs of violence [28]. Inexperienced students, lacking formal training and explicit criteria for what constitutes unacceptable aggression, may fail to identify these earlier or less physical manifestations as forms of WPV. Despite this lower prevalence, our finding that students’ exposure is higher than that reported for some registered nurse populations [7] aligns with the understanding that their younger age, transitional period, and lower hierarchical position may render them particularly vulnerable. In terms of the distribution of violence types, emotional abuse (34.1%) and threats of assault (12.1%) were the predominant forms of violence experienced by nursing students. Moreover, a phenomenon that warrants attention is that nearly half (44%) of the reported incidents involved two or more different types of violence (26.3% two types, and 17.7% three or more types). This indicates that nursing students are frequently exposed to complex, multiple forms of violence. These findings align with previous research involving Chinese nurses [14] and Turkish nursing students [29]. The prevalence of emotional abuse and threats of assault among nursing students may be linked to patients’ dissatisfaction with medical outcomes, as well as the fact that perpetrators face lower consequences for non-physical violence compared to physical violence. Multiple types of workplace violence incidents can lead to significant emotional distress, including psychological strain, anger, detachment, and emotional numbness. Some nursing interns even perceive workplace violence as an inherent part of their profession [30]. Exposure to multiple types of workplace violence increases the risk of psychological issues such as post-traumatic stress disorder, depression, and burnout [31], and can diminish nursing students’ professional identity and job satisfaction, increasing their likelihood of considering career changes [2]. It is necessary to improve the competence to manage WPV.
While the overall mean competence score was high (150.01 ± 19.65), we noted that levels varied significantly across dimensions. The highest score was obtained in after-the-event recovery, while the lowest score was recorded in risk assessment. This finding indicates that students are better at handling and recovering from violent incidents after they occur, but are inadequately prepared for identifying risks and preventing violence before it happens. This result is consistent with findings from a Turkish two-center study [7]. Random forest and Lasso regression analyses revealed that organizational climate and psychological resilience were important factors in improving nursing students’ competence in dealing with workplace violence. This supports the Triadic Reciprocal Determinism hypothesis, which emphasizes the role of interactions between the environment and the individual in shaping behavior. The most significant predictor of workplace violence management competence was the organizational climate. According to research from Vietnam [14], organizational risk factors are the primary contributors to workplace violence, and fostering a positive hospital organizational culture and improving the overall hospital environment are effective strategies for reducing workplace violence and protecting healthcare workers. Additionally, Derscheid’s study found that employees who perceive a strong organizational safety climate are less likely to have experienced workplace violence [12]. Similarly, Peng’s [32] study demonstrated that a positive organizational climate can greatly reduce workplace bullying. The strong link between organizational climate and workplace violence underlines the crucial role of organizational climate in providing psychological and emotional support to nursing students, improving their emotional regulation and response skills, managing conflicts, and enhancing their competence to handle violence.
Psychological resilience is the second most significant factor related to competence in managing workplace violence. It serves as a vital internal resource for individuals, playing a key role in alleviating and reducing psychological stress. It has been identified as a protective factor against negative outcomes such as emotional labor, occupational burnout, and post-traumatic stress disorder. Research indicated that nurses with higher resilience are less impacted by workplace violence and experience lower levels of depression, anxiety, and other emotional issues [33]. These results are supported by Amin et al., who found that psychological resilience directly influences nursing students’ competence in managing workplace violence. It acts as a safeguard in high-pressure situations, helping nursing students stay calm during violent incidents and quickly remove themselves from dangerous environments [20].
The association between organizational climate and psychological resilience, and nursing students’ competence to manage workplace violence, aligns with Bandura’s triadic reciprocal determinism theory, which highlights the interaction among environment (organizational climate), individual (psychological resilience), and behavior (workplace violence management competence). Our findings suggest that a positive organizational climate and higher psychological resilience are associated with greater competence in managing workplace violence, which may guide future training and support programs.
The study also found that experience with workplace violence training, willingness to attend training, and educational level were related to nursing students’ competence in managing workplace violence. Those who have received training, show a strong willingness to participate in training, and hold vocational diplomas or certificates demonstrate higher levels of violence management competence. Previous research has shown that workplace violence prevention training effectively enhances nursing students’ problem-focused and emotion-focused coping skills [34]. Additionally, students who have attended such training are better at recognizing violence risks and are more likely to consciously and actively avoid violent situations [35]. Moreover, students with a high willingness to engage in training tend to pay more attention to violence prevention knowledge, grasp violence situations more quickly, update their knowledge more rapidly, and exhibit stronger violence management skills. However, only 50.3% of the nursing students in this study had participated in violence prevention training. Furthermore, 56.7% of students were unsure whether their hospital has a WPV reporting system, and only 13.6% planned to report incidents if they occurred. This reveals the inadequacy of training coverage and the reporting system’s lack of awareness and reliability. Consequently, healthcare institutions and nursing schools must prioritize increasing training participation rates and fostering a climate that encourages incident reporting to translate these predictive factors into higher competence levels. A noteworthy finding is that vocational diploma students reported higher perceived competence in managing workplace violence than bachelor’s-degree students—a result that differs from a prior study [35]. Rather than indicating the inherent superiority of one educational pathway, this discrepancy may be explained by two complementary assumptions. First, differences in curriculum focus and clinical socialization may play a role: vocational programs typically emphasize hands-on skill acquisition and early immersion in clinical contexts, which could enhance students’ confidence in executing protocol-based responses to ward conflicts [36]. Second, the self-reported nature of the outcome measure introduces the possibility of assessment bias: bachelor’s students, trained in reflective and critical thinking, might apply more stringent self-evaluation standards when rating their competence, whereas diploma students may report greater confidence in well-defined procedural skills. Thus, the observed difference likely reflects variations in educational emphasis and self-perception rather than objective performance gaps. Accordingly, violence prevention training should be tailored to address the distinct learning experiences and self-assessment tendencies of students across different educational tracks. The varied forms of workplace violence, combined with the multidimensional nature of violence management competence, present complex challenges for managing violence effectively. This study confirms the significant association of psychological resilience and organizational climate with violence management competence. However, the cross-sectional nature of the design does not permit causal inferences to be drawn. We hope this article offers valuable insights for nursing education and practice management. This article suggests the need to simultaneously enhance individual psychological resilience and improve organizational environments within clinical training systems. Firstly, the identified significance of psychological resilience calls for the integration of resilience-building programs—such as self-efficacy training, role-playing, and scenario simulations—into both academic and clinical training. These programs can equip students with the internal resources necessary to mitigate the psychological impact of WPV [37]. Secondly, for clinical institutions, the vital role of organizational climate demands actionable strategies. Hospital administrators should prioritize the development of a transparent, non-punitive reporting system for interns, and encourage training clinical teachers to foster a supportive and safe learning environment. This is crucial for building trust and ensuring that students feel secure in reporting incidents without fear of negative consequence of internship. Thirdly, this study found that nursing students scored higher in after-the-event recovery and response to violence, but lower in risk assessment and knowledge renewal. This indicates that current nursing education and clinical training focus more on immediate response skills rather than preventive measures and risk identification. It implies that it is imperative to integrate targeted training modules to develop students’ skills in identifying early warning signs of violence, thereby shifting the focus from reactive recovery to proactive prevention. Finally, given the positive correlation between training participation/willingness and competence, we strongly advocate for making standardized, evidence-based WPV management training a mandatory component of nursing internships. And these programs should be tailored to meet the specific needs of students from different educational backgrounds.
Conclusion
To our knowledge, this is the first study to investigate the relationship between nursing students’ psychological resilience and organizational climate in relation to workplace violence management competence. The findings highlight the importance of both psychological resilience and organizational climate in effectively handling workplace violence, as well as the necessity for specialized training focused on violence prevention. Nonetheless, variations in violence management competence exist across different populations, regions, countries, and cultural contexts. Further research can be conducted in the future to expand on these findings. Given the widespread occurrence of workplace violence globally, enhancing nursing students’ competence to manage such situations is crucial for minimizing occupational hazards and ensuring stability within the nursing profession.
Strengths and limitations
Strengths
This study offers a dual perspective on nursing students’ violence management competence by examining both psychological resilience and organizational climate. The combination of Random Forest and LASSO regression enabled effective identification of key predictors. The substantial sample size (n = 455) contributes to the broader applicability of the findings.
Limitations
First, the cross-sectional design prevents the determination of causal directions. We cannot determine whether an organizational climate enhances competence or if competent students perceive the climate more positively. Similarly, the resilience-competence relationship may be bidirectional. Second, the geographic concentration in the less developed Central-Western region (Sichuan and Guizhou) suggests that the prevalence of violence and the weight of influencing factors may not accurately reflect the realities in more developed Eastern Chinese healthcare settings. Third, the study relies on self-reported data, meaning the measures are susceptible to recall bias and social desirability bias. That is to say, the prevalence of WPV, especially for more subtle forms like emotional abuse, might be underestimated due to recall issues, and the high self-assessed competence scores may partially reflect the participants might overestimate their abilities due to social desirability bias or lack of awareness of their own skill gaps. More fundamentally, self-assessed competence may not fully equate to objectively demonstrated performance in real-world violent situations. Our high mean competence score likely reflects nursing students’ confidence or perceived preparedness rather than a validated, objective capability. Consequently, future research should aim to triangulate findings by incorporating multi-method assessments, such as objective structured clinical examinations, simulations with expert ratings, or observational studies in clinical settings, to obtain a more reliable and behaviorally anchored measure of workplace violence management competence. Finally, the gender imbalance (82.4% female) means that our model of association factors is predominantly informed by the experiences of females. The experiences and coping mechanisms of male nursing students are underrepresented in the literature. Therefore, the key factors we identified may be different for male students.
Based on these limitations, future research should pursue several directions: (a) employing longitudinal designs to trace temporal developments and establish causal relationships between organizational climate, psychological resilience, and management competence; (b) conducting multi-regional or international comparative studies to enhance the generalizability of findings, particularly by including regions with varying socioeconomic and healthcare contexts; (c) incorporating mixed-methods approaches—combining quantitative surveys with qualitative interviews—to mitigate self-report biases and gain deeper insight into actual experiences and competencies; and (d) purposefully sampling gender-balanced cohorts to enable meaningful gender-based comparisons and better represent the experiences of male nursing students. Finally, the insights from this study can inform the development of targeted interventions aimed at fostering supportive organizational climates and strengthening psychological resilience.
Acknowledgements
We Acknowledge all the students participating in this study, and the investigators collect the data.
Author contributions
LFY (First Author): Conceptualization, Data Curation, Formal Analysis, Investigation, Methodology, Software, Visualization, Writing-Original Draft, Writing-Review & Editing; WD: Methodology, Investigation, Data Curation, Writing-Original Draft; WJL (Corresponding Author): Conceptualization, Funding Acquisition, Resources, Supervision, Validation, Writing-Original Draft, Writing-Review & Editing; RQQ: Investigation, Methodology, Supervision; Software; LT: Supervision, Validation; DLM: Data Curation, Investigation. All authors reviewed the manuscript.
Funding
This research was approved by the Humanities and Social Sciences Research and Planning Fund project of the Ministry of Education (no. 22YJA630087).
Data availability
Data supporting the findings of this study are available from the corresponding author upon reasonable request.
Declarations
Ethics approval and consent to participate
This study was conducted in accordance with the Declaration of Helsinki. This study was approved by the Medical Ethics Committee of Affiliated Hospital of Chengdu University of Traditional Chinese Medicine (NO. 2023KL-098). Participation in the study was entirely voluntary, and informed consent was obtained from all participants.
Consent for publication
All authors approved the final manuscript and the submission to this journal.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
Data supporting the findings of this study are available from the corresponding author upon reasonable request.