Verbal abuse and psychological disorders among nursing student interns in KSA

Abstract

Objective

This study aimed to investigate the forms and frequency of verbal abuse (VA) among nursing student interns and determine the prevalence of psychological disorders (i.e. depression, stress, and anxiety) within this group.

Materials and methods

A cross-sectional study was conducted in an urban teaching hospital in KSA. Nursing student interns responded to the Verbal Abuse Questionnaire and Depression Anxiety Stress Scales.

Results

A total of 54 interns completed the questionnaires; 55% of them had been exposed to one type of VA at least once a year, and 5% of them had experienced VA several times a week. ‘Ignoring’ was the most frequently experienced form of VA (50.8%), and feeling overwhelmed was the most commonly experienced emotional reaction (51.1%) to VA. ‘Stop talking to the abusive person’ was the most frequently reported behavioural reaction to VA (57.9%). Most of them (59.3%) did not report a sign of depression, but 18.5% of them had severe to extremely severe depression. Most interns (70.4%) did not report a sign of anxiety, but approximately 11.1% of them had severe to extremely severe anxiety. A majority (70.4%) of the interns did not report a sign of stress, and only 5.6% of them reported experiencing severe stress.

Conclusion

VA is a major problem that is encountered in clinical settings, especially by future nurses. The present findings underscore the need to further examine the levels and forms of VA that are experienced by them and their reactions to such stress-inducing behaviours.

Introduction

Abuse is a worldwide problem that is detrimental to a person's physiological, psychological, and social status. Abuse can be of different types: verbal, physical, psychological, and sexual. All of them adversely affect the victim.¹

Verbal abuse (VA) is a devious type of occupational violence that is observed in health care settings.² Workplace abuse against nurses is defined as an offensive or threatening act directed towards nursing staff while they perform their duties.³ One of the common types of workplace abuse is VA, which is arguably the most disruptive act of aggression that is directed towards nurses.⁴ In recent times, the workplace abuse of nurses in hospitals and health institutions has been reaching an alarming level.⁵

In the existing literature, it is well documented that VA causes nurses to feel depressed and distressed. VA typically results in dramatic sequels such as low self-esteem and self-confidence, self-dissatisfaction, and disappointment.^6,7 In addition, VA also yields professional consequences such as absenteeism, turnover, poor quality of care, and even medical errors.^3,8,9

The prevalence of VA in several regions, including developed countries, has been examined earlier. A study conducted in the northern states of the United States of America found that approximately 90% of the participating nurses had experienced VA.¹⁰ In Ulrich's study, 65% of the participating nurses reported that they had experienced VA.¹¹ This misbehaviour has emerged as a worldwide phenomenon and is getting more and more ground. Recent findings suggest that this issue is becoming more prevalent in hospitals in Australia,¹² Turkey,⁶ Hong Kong,¹³ Italy,¹⁴ and Jordan.^15,16

Hospitals are challenging workplaces, and such environments can negatively impact personal relationships and are conducive to the perpetration of abuse.¹⁷ Interpersonal conflicts have been identified as one of the main sources of stress among nurses.¹⁸ As a result of excessive tasks and responsibilities, staff shortage, an increase in patient demands, reduced job satisfaction, and a high workload, nurses are likely to encounter many stressful situations.^19,20

Medical staff have been found to be verbally abusive towards nurses, and this is a source of stress among them.²¹ Jeong and Lee found that there is a positive correlation between VA and stress during clinical practice.²² VA has a negative impact on not only the quality of care that is provided to patients but also nurses' work; specifically, it affects their productivity, satisfaction, and mistakes on the job.²¹

Algwaiz and Alghanim conducted a study in KSA and found that more than 65% of the participating nurses had experienced workplace violence, including verbal and non-verbal abuse.²³ In particular, younger male nurses were more likely to have been abused and, remarkably, VA was the most common type of violence.²³ However, in his study, Mohamed found that more than 45% of the participating nurses had been exposed to VA and insulting language.²⁴

It is noteworthy that, similar to nurses, interns are also exposed to VA. They face mistreatment because they perform the same duties and have the same shift work hours. They also deal with the healthcare team, patients, and their families. More strikingly, Ferns and Meerabeau found that interns and fresh graduate nurses experience greater abuse than do registered nurses.²⁵ Relatedly, another study that was conducted among interns reported similar results.³

Despite the previous findings on VA, studying this phenomenon among nursing interns became an obvious need as they are on their first step of the nursing profession ladder. Even though VA has previously been investigated, there is an obvious need to examine this phenomenon among nursing interns because they are on the first rung of their nursing career ladder. To the best of our knowledge, no past study has focused on VA and psychological disorders among nursing student interns in KSA. Accordingly, the purposes of this study were to (a) examine the forms of VA that are experienced by nursing student interns, (b) determine the prevalence of stress, anxiety, and depression, and (c) to analyse the associations between the forms of VA and levels of psychological disorders.

Materials and Methods

Setting

This descriptive correlational study was conducted in a hospital in the eastern province of KSA across 6 months.

Sample and sampling criteria

The target population was nursing student interns who were working in the hospital during the study period. Data were collected from a convenience sample of interns who were practicing during their clinical internship year. Data were collected within the clinical setting during working hours.

Instruments

A description of each of these assessments is presented in the following sections:

• Socio-Demographic Form

Self-administered questionnaires were used in this study. A socio-demographic form was used to generate a general profile of the intern based on their socio-demographic characteristics (e.g. age, gender, Living arrangement).

• Verbal Abuse Questionnaire (VAQ)

An Arabic version of the VAQ, which is a structured questionnaire that was originally developed by Manderino and Berkey, was used. This questionnaire consists of 41 items and three subscales.²¹ Responses are recorded on a 7-point Likert scale that ranges from zero to six. Oweis developed the Arabic version of the VAQ.¹⁵ The VAQ consists of three sections. The first section assesses three dimensions: the form, frequency, and severity of VA. The second section assesses the emotional experiences of verbally abused participants. The third section assesses the actions and behaviours that abused interns have exhibited towards the abuser and themselves. The reliability of this instrument has been examined, and its Cronbach's alpha was found to be 0.81.¹⁵ Because of the limited number of respondents in the higher levels. Total scores can be classified into seven levels. However, only a few respondents obtained scores that could be classified into the higher levels. Therefore, the seven levels were collapsed into two: not exposed (no abuse) and exposed (abused once a year to daily).

• Depression Anxiety Stress Scales (DASS)

The DASS is a 42-item self-administered scale that measures negative emotional states. The scale consists of three subscales: depression, anxiety, and stress.²⁶ The respondents were required to indicate the extent to which they had experienced the symptom described in the item during the past week on a 4-point rating scale. Composite subscale scores can be computed by summing the individual scores of the items that are subsumed under a given subscale. The Arabic adaptation of this scale is available in the public domain. According to Lovibond and Lovibond, the DASS scores lie on a continuum that ranges from normal to extremely severe depression, anxiety, and stress. The severity of depression can be classified as follows: normal (0–9), mild (10–13), moderate (14–20), severe (21–27), and extremely severe (≥28). The severity of anxiety can be classified as follows: normal (0–7), mild (8–9), moderate (10–14), severe (15–19), and extremely severe (≥ 20). The severity of stress can be classified as follows: normal (0–14), mild (15–18), moderate (19–25), severe (26–33), and extremely severe (≥ 34).²⁷

Data analysis

Data analysis was carried out using version 20 of the Statistical Package for the Social Sciences. Descriptive statistics were computed and frequency distributions were generated to examine the baseline characteristics of the participants. We examined whether the continuous variables were distributed normally. Cross-tabulation analyses were undertaken to determine stress, anxiety, and depression levels among student interns who have and have not been exposed to VA. Results with a P-value ≤ 0.05 were considered to be statistically significant. Chi-squared test was used to examine the association between psychological disorders, different forms of VA, and demographic variables.

Using the following formula, the relative importance index (RII) was computed to calculate percentages for each item and ascertain the form and level of VA that had been experienced by the participants:

$$RII=\frac{7\left(\text{n}7\right)+6\left(\text{n}6\right)+5\left(\text{n}5\right)+4\left(\text{n}4\right)+3\left(\text{n}3\right)+2\left(\text{n}2\right)+1\left(\text{n}1\right)}{7\left(n7+n6+n5+n4+n3+n2+n1\right)}$$

where n1, n2, n3, . . . n7 represent the number of respondents in each category, and ‘1’ represents ‘never happens’, ‘2’ represents ‘happens one to six times per year’, . . . and ‘7’ represents ‘happens daily’.²⁸

Results

The internal consistencies of the VAQ (Cronbach's alpha = 0.95) and its subscales were high. Specifically, the internal consistencies of the forms of VA, emotional reaction, and behavioural response subscales were 0.89, 0.94, and 0.81, respectively. Moreover, the internal consistency of the DASS was also high (Cronbach's alpha = 0.96). With regard to the stress, anxiety, and depression subscales, their reliability coefficients were 0.91, 0.92, and 0.93, respectively.

Demographic characteristics

Table 1 presents the demographic characteristics of the participants. Most of them were women (64.8%), single (61.1%), non-smokers (85.1%), and living with their families (92.6%). Approximately 80% of the participants were 23 years of age or less, and most of them worked morning shifts only (87.0%). With regard to their income sources and expenditure patterns, 51.9% of the students were dependent on their internship allowance, and their monthly expenses were approximately 2400 Saudi riyals.

Table 1.

Demographic characteristics of the participants (N = 54).

Demographic Factors		n	%
Gender	Male	19	35.2
	Female	35	64.8
Marital status*	Single	33	61.1
	Married	20	37.0
Smoking*	Yes	7	13.0
	No	46	85.1
Living arrangement*	With family	50	92.6
	With friend	3	5.6
Shift	Morning	47	87.0
	Rotational	7	13.0
Income sources*	Allowance	28	51.9
	Allowance and family support	25	46.3
Age (in years)	≤ 23	43	79.6
	> 23	11	20.4
Expenditure*	≤ 2400 Saudi riyals	21	38.9
	> 2400 Saudi riyals	21	38.9

*Missing values.

Frequency and forms of VA

Approximately 55% of the students reported that they had experienced VA at least once a year. Amongst them, 27% had been verbally abused 1 to 6 times a year, and 68% had been exposed to VA 1 to 3 times per month. Further, 5% of them had been verbally abused several times per week or daily.

The RII was calculated to examine the forms and frequencies of VA and explore participants' emotional and behavioural reactions to VA (Table 2). Ignoring was the most frequently experienced form of VA (50.8%). Judging and criticising were the second most commonly experienced form of VA (41.8%), followed by discounting (38.9%) and blocking and diverting (37.7%). However, threatening was the least frequently experienced form of VA (14.6%).

Table 2.

The frequency of experience of different forms of VA and emotional and behavioural reactions to VA.

Forms of VA	1	2	3	4	5	6	7	%
Ignoring	13	7	5	10	8	6	5	50.8
Judging and criticising	12	8	17	10	4	2	1	41.8
Discounting	19	8	7	11	4	1	4	38.9
Blocking and diverting	20	9	7	8	4	4	2	37.3
Accusing and blaming	19	7	16	7	3	2	0	34.1
Abuse disguised as jokes	28	9	8	2	3	3	1	27.0
Condescending	34	5	6	3	3	2	1	22.8
Abusive anger	30	10	8	5	1	0	0	21.4
Trivialising	34	9	5	3	1	0	2	20.1
Threatening	41	4	5	2	1	0	1	14.6
Types of emotional reactions to VA
Feeling overwhelmed	9	12	10	6	6	4	7	51.1
Anger	15	10	9	10	5	3	2	41.3
Frustration	21	9	8	6	3	3	4	36.8
Sadness/hurt	23	12	3	8	2	3	3	33.3
Confusion	27	10	4	6	3	3	1	28.6
Fear	31	8	9	2	3	0	1	22.5
Humiliation	37	6	3	3	1	3	1	19.8
Shame	38	5	5	2	0	4	0	18.3
Helplessness	37	7	6	2	0	0	2	17.5
Intimidated	37	7	5	3	1	0	1	17.2
Powerless	38	7	5	0	2	0	2	17.2
Defeated	40	5	6	1	0	0	2	15.3
Threatened	42	5	4	1	1	0	1	13.2
Types of behavioural reactions to VA
I stop talking to the abusive person.	8	10	6	10	4	3	13	57.9
I walk away from the situation.	9	11	5	13	7	2	7	52.1
I seek others for assistance and support.	18	10	7	6	4	5	4	41.0
I get busy with positive activities such as reading, writing, listening to music, etc. to alleviate my distress.	23	7	7	6	4	2	5	36.5
I withdraw.	22	11	7	6	2	2	4	34.1
I clarify any misunderstanding the person may have.	22	10	9	4	4	1	4	34.1
I discuss the situation directly with the abusive person.	24	10	9	5	3	2	1	29.9
I engage in negative activities such as smoking, overeating, etc. to alleviate my distress.	37	4	6	3	2	0	2	19.6
I blame myself for the abuse.	37	5	5	4	2	1	0	18.3
1: Never	2: 1–6 times/year	3: Once/month	4: 2–3 times/month	5: Once/week	6: Several times/week	7: Daily

VA, verbal abuse.

Emotional reactions to VA

The most commonly experienced emotional reactions to VA were feeling overwhelmed (51.1%) and angry (41.3%). On the other hand, feeling defeated (15.3%) and threatened (13.2%) were the least commonly experienced reactions to VA.

Behavioural reactions to VA

With regard to behavioural reactions, ‘stop talking to the abusive person’ was most frequently used by the interns (57.9%), followed by ‘walking away from the situation’ (52.1%). The least commonly used reactions were ‘blaming self’ (18.3%) and ‘engaging in negative acts such as smoking or overeating’ (19.6%).

Depression, anxiety, and stress

Most of the participants (59.3%) did not report a sign of depression; only 11.1% of them had mild depression, and 18.5% of them had severe to extremely severe depression. Most of the participants (70.4%) did not report a sign of anxiety; only 5.6% of them had mild anxiety, and 11% of them had severe to extremely severe anxiety. A majority (70.4%) of the participants did not report a sign of stress; only 5.6% of the students reported severe stress (Table 3).

Table 3.

Frequencies of student interns with varying severities of depression, anxiety, and stress.

Scale/Level		n (%)
Depression	Normal	32 (59.3)
	Mild	6 (11.1)
	Moderate	5 (9.3)
	Severe	6 (11.1)
	Extremely severe	4 (7.4)
Anxiety	Normal	38 (70.4)
	Mild	3 (5.6)
	Moderate	6 (11.1)
	Severe	4 (7.4)
	Extremely severe	2 (3.7)
Stress	Normal	38 (70.4)
	Mild	4 (7.4)
	Moderate	8 (14.8)
	Severe	3 (5.6)

Inter-correlations between the subscales of the DASS

Spearman’s rho was computed to examine the relationships between the subscales of the DASS. Strong positive correlations emerged between all the subscales: stress and depression (ρ = 0.819, P < 0.001), stress and anxiety (ρ = 0.754, P < 0.001), and depression and anxiety (ρ = 0.650, P < 0.001).

The DASS and demographic characteristics

Chi-squared analysis was carried out to examine group differences in depression levels. and the only significant difference was found in the expenditure of the interns on their stuff. A significant difference was found only between interns who differed in their monthly expenditure: ≤ 2400 and > 2400 Saudi riyals, χ² (1, N = 42) = 4.84, P = .028. Differences in depression levels between groups that differed in other demographic characteristics (i.e. gender, marital and smoking status, living arrangement, shift, age, and source of income) were not significant (Table 4).

Table 4.

Differences in the proportion of participants with normal and mild to extreme depression and anxiety between participants with different levels of monthly expenditure.

Variable		Depression
		Normal	Mild to extreme	P
Expenditure (Saudi riyal)	≤ 2400	9 (42.9%)	12 (57.1%)	0.028
	> 2400	16 (76.2%)	5 (23.8%)
		Anxiety
		Normal	Mild to extreme	P
Expenditure (Saudi riyal)	≤ 2400	12 (57.1%)	9 (42.9%)	0.040
	> 2400	18 (85.7%)	3 (14.3%)

Chi-squared analysis was carried out to examine group differences in anxiety levels. A significant difference was found only between interns who differed in their monthly expenditure: ≤ 2400 and > 2400 Saudi riyals, χ² (1, N = 42) = 4.20, P = .040. Differences in anxiety levels between groups that differed in other demographic characteristics (i.e. gender, marital and smoking status, living arrangement, shift, age, and source of income) were not significant (Table 4). Chi-squared analysis was carried out to examine group differences in stress levels, but none of the group differences was significant.

Forms of VA and psychological disorders

The result of the chi-squared analysis showed that there was a significant relationship between condescending (i.e. a form of VA) and anxiety, χ² (1, N = 54) = 4.46, P = 0.0035. Anxiety was more prevalent among interns who had been exposed to condescending forms of VA than among their counterparts who had not been exposed to them (37.8%–11.8%). Additionally, blocking and diverting (i.e. a form of VA) was found to be significantly related to anxiety, χ² (1, N = 54) = 3.80, P = 0.05. Anxiety was more prevalent among interns who had been exposed to blocking and diverting than among those who had not been exposed to such forms of VA (45.5%–18.8%). All other results were non-significant (Table 5).

Table 5.

Relationship between psychological disorders and different forms of verbal abuse.

Forms of verbal abuse		Depression		Anxiety		Stress
		Absent	Present	Absent	Present	Absent	Present
Judging and criticising	Not exposed	6 (18.8)	6 (27.3)	8 (21.1)	4 (25.0)	8 (21.1)	4 (25.0)
	Exposed	26 (81.3)	16 (72.7)	30 (78.9)	12 (75.0)	30 (78.9)	12 (75.0)
	P	0.52a		0.73a		0.73a
Accusing and blaming	Not exposed	9 (28.1)	9 (40.9)	13 (34.2)	5 (31.3)	11 (28.9)	7 (43.8)
	Exposed	23 (71.9)	13 (59.1)	25 (65.8)	11 (68.8)	27 (71.1)	9 (56.3)
	P	0.33		0.83		0.29
Abusive anger	Not exposed	18 (56.3)	11 (50.0)	21 (55.3)	8 (50.0)	21 (55.3)	8 (50.0)
	Exposed	14 (43.8)	11 (50.0)	17 (44.7)	8 (50.0)	17 (44.7)	8 (50.0)
	P	0.65		0.72		0.72
Discounting	Not exposed	10 (31.3)	6 (27.3)	11 (28.9)	5 (31.3)	10 (26.3)	6 (37.5)
	Exposed	22 (68.8)	16 (72.7)	27 (71.1)	11 (68.8)	28 (73.7)	10 (62.5)
	P	0.75		1.00a		0.52a
Condescending	Not exposed	22 (68.8)	10 (45.5)	26 (68.4)	6 (37.5)	25 (65.8)	7 (43.8)
	Exposed	10 (31.3)	12 (54.5)	12 (31.6)	10 (62.5)	13 (34.2)	9 (56.3)
	P	0.08		0.03 *		0.13
Ignoring	Not exposed	8 (25.0)	5 (22.7)	11 (28.9)	2 (12.5)	9 (23.7)	4 (25.0)
	Exposed	24 (75.0)	17 (77.3)	27 (71.1)	14 (87.5)	29 (76.3)	12 (75.0)
	P	0.85		0.30a		1.00a
Trivialising	Not exposed	17 (53.1)	13 (59.1)	22 (57.9)	8 (50.0)	20 (52.6)	10 (62.5)
	Exposed	15 (46.9)	9 (40.9)	16 (42.1)	8 (50.0)	18 (47.4)	6 (37.5)
	P	0.67		0.60		0.51
Blocking and diverting	Not exposed	12 (37.5)	5 (22.7)	15 (39.5)	2 (12.5)	13 (34.2)	4 (25.0)
	Exposed	20 (62.5)	17 (77.3)	23 (60.5)	14 (87.5)	25 (65.8)	12 (75.0)
	P	0.25		0.05*		0.51
Threatening	Not exposed	23 (71.9)	17 (77.3)	30 (78.9)	10 (62.5)	28 (73.7)	12 (75.0)
	Exposed	9 (28.1)	5 (22.7)	8 (21.1)	6 (37.5)	10 (26.3)	4 (25.0)
	P	0.66		0.31a		1.0a
Abuse disguised as jokes	Not exposed	17 (53.1)	9 (40.9)	20 (52.6)	6 (37.5)	18 (47.4)	8 (50.0)
	Exposed	15 (46.9)	13 (59.1)	18 (47.4)	10 (62.5)	20 (52.6)	8 (50.0)
	P	0.38		0.31		0.86

*P ≤ .05.

^aFisher's exact test.

Discussion

The purpose of this study was to (a) explore the forms of VA that are experienced by nursing student interns, (b) determine the prevalence of stress, anxiety, and depression within this group, and (c) examine the associations between different forms of VA and levels of psychological disorders.

In this study, more than half of the participants had been exposed to at least one type of VA once a year. Many studies have reported similar results, and the figures range from 40% to 92%.^2,7,25,29, 30, 31, 32, 33 However, other studies have reported lower prevalence rates. Ahmed found that the prevalence of VA was 37%.³⁴ Similarly, in our study, only 5% of the participants had been exposed to daily or weekly abuse; this finding is consistent with Budin, Brewer, Chao, and Kovner's findings.⁸ In contrast, Shoghi, Sanjari, Shirazi, Heidari, Salemi, and Mirzabeigi reported prevalence rates (19.5%) of VA.³⁵ Celik and Bayraktar reported that 100% of the nurses who participated in their study had been subjected to VA.¹ Other researchers have conducted studies to identify the underlying causes of this misconduct. According to Park, Cho, and Hong,⁵ excessive workload and low-trust relationships within medical teams increase the prevalence of abuse among nurses. Moreover, Budin, Brewer, Chao, and Kovner found that negative work conditions are a risk factor for VA.⁷

In this study, ignoring was the most commonly experienced form of VA among students, followed by judging and criticising. They were least commonly exposed to threatening behaviours. This finding is consistent with the results of Kisa's study in which the most frequently experienced form of VA was found to be judging and criticising, abusive anger, and accusing and blaming.³⁰ Moreover, Budin, Brewer, Chao, and Kovner found that speaking in a condescending manner and ignoring were the most frequently experienced forms of VA.⁷ Similar to the findings of the studies that have been conducted by Oweis and Diabat¹⁵ and Abdou², anger, judging and criticising, accusing and blaming, and abusive anger were found to be the most recurrently experienced types of VA. Other studies have found that the most frequently experienced forms of VA are shouting, swearing, yelling, and rude language.^1,34 Oweis and Diabat have contended that challenging working conditions and a shortage of nurses can engender a negative response to VA.¹⁵

In this study, the emotional reactions that were most frequently experienced by the participants were feeling overwhelmed and angry, and the least frequently experienced reactions were feeling defeated and threatened. Kisa found that the most common emotional reaction to VA is anger, followed by shock/surprise and sadness and hurt.³⁰ Similar findings have also been reported by Öztunç³⁶ and Uzun.³⁷ These results are consistent with the results of Oweis and Diabat's¹⁵ study in which the most common emotional reaction to VA among nurses was found to be anger, followed by shame, humiliation, and frustration. Anger has been identified as the strongest and most frequent emotional response to VA, and it is often associated with thoughts of transgression.^10,37 Relatedly, Çelebioğlu, Akpinar, Küçükoğlu, and Engin found that feelings of anger, fury, enmity, anxiety, disappointment, weakness, helplessness, defencelessness, fear, and embarrassment were the emotions that were most frequently experienced by their participating nurses.³³ In Rowe and Sherlock’s study, anger and judging and criticising emerged as the most commonly experienced forms of VA.³⁸ Further, Abdou found that VA has pernicious effects and can result in confusion, frustration, and indifference among nurses.² Subsequently, Oweis and Diabat found that undesirable responses are related to negative working conditions and a high workload.¹⁵

In the present study, the most commonly reported behavioural reaction among nursing student interns was ‘stop talking to the abusive person’, followed by ‘walking away from the situation’, ‘blaming self’, and ‘engaging in negative acts such as smoking or overeating’. Similarly, Oweis and Diabat found that nurses most frequently used the following strategies to cope with VA: engaging in maladaptive activities, refraining from talking to the abusive person, walking away from the situation, blaming oneself for the abuse, and withdrawing.¹⁵ On the other hand, Kisa found that discussing the situation with the abusive person, staying calm, and walking away from the situation were the most frequently exhibited behavioural reactions among nurses.³⁰ Moreover, Rowe and Sherlock found that anger, sadness, hurt, and frustration were the most common emotional responses to VA.³⁸ According to Budin, Brewer, Chao, and Kovner, junior nurses may be afraid to confront other nurses or lack the necessary effective communication skills and, consequently, experience negative reactions in stressful situations.⁷

A majority of the interns did not report a sign of depression, anxiety, or stress; only a small percentage of the participants had severe to extremely severe depression, anxiety, and stress. Similar results have been reported by Rathnayake and Ekanayaka; they found that approximately half of the nurses who participated in their study did not have a sign of depression and that only 15.2% of them had extremely severe depression.³⁹ Moreover, 40.2% of the participants reported no sign of anxiety, and 16.3% of them reported extremely severe depression. Only 17.5% of the nurses did not report a sign of stress; 21.7% of them reported extremely severe stress. Bayram and Bilgel conducted a study in Turkey and found that 51.8% of the participants did not have a sign of depression, and that 8% of them had severe to extremely severe depression.⁴⁰ Approximately 40% of them did not have a sign of anxiety, and 21% of them had severe to extremely severe anxiety. Approximately half of the participants did not have a sign of stress, and only 7% of them had severe to extremely severe stress. Examining medical students, Wahed and Hassan conducted a study among medical students and reported the following prevalence rates: no depression = 39.8% and severe to extremely severe depression = 23.1%; no anxiety = 35.7% and severe to extremely severe anxiety = 29.9%; no stress = 37.6% and severe to extremely severe stress = 30.8%.⁴¹ According to Cheung and Yip, new nursing recruits may experience anxiety, stress, or psychological conflicts because they are not fully equipped to perform their tasks and their professional personalities have still not fully matured.⁴² In addition, they do not receive adequate support from colleagues and supervisors.

In this study, there was a strong positive correlation between depression, anxiety, and stress. Similar results have been reported by Rathnayake and Ekanayaka.³⁹ Interestingly, the proportion of participants with different levels of depression and anxiety varied between interns whose monthly expenditures were ≤ 2400 and > 2400 Saudi riyals. Other demographic differences (i.e. gender, marital and smoking status, living arrangement, shift, age, and income sources) in the proportion of participants with different levels of depression and anxiety were not significant. In contrast, demographic differences (i.e. gender, marital and smoking status, living arrangement, shift, age, and income sources) in the proportion of participants with different levels of stress were not significant. In this regard, Cheung and Yip found that depression, stress, and anxiety were correlated with household income.⁴² Similarly, Cheung, Wong, Wong, Law, Ng, Tong, Wong, Ng, and Yip found that financial difficulty was correlated with anxiety, depression, and stress.⁴³ Wahed and Hassan found that depression and stress were significantly associated with a lower socioeconomic level.⁴¹ In contrast, Abdallah and Gabr found that depression and stress were significantly associated with socioeconomic status but not with living arrangement.⁴⁴ This difference is attributable to the fact that their participants received financial support from their families. Cheung, Wong, Wong, Law, Ng, Tong, Wong, Ng, and Yip have emphasised that students who earn high incomes can fulfil their own needs.⁴³

In this study, anxiety was more likely to be reported by interns who had been exposed to condescending and blocking and diverting forms of VA than their counterparts who had never been abused. Concordantly, Uzun³⁷ has observed that anxiety is a consequence of VA among nurses, and Ahmed³⁴ found that a majority of the nurses who participated in his study had been exposed to verbal and physical abuse and experienced anxiety. In Malliarou and Karathanasi's study,⁴⁵ approximately 34.8% of abused nurses reported a significant level of anxiety. In another study, 28% of abused women reported experiencing anxiety and fear,⁴⁶ thereby indicating that interns may lack effective coping skills to cope with VA and reduce their stress levels. Therefore, in order to better understand the association between anxiety and VA, future studies should examine this relationship in greater detail.

Finally, it is noteworthy that the present study has some limitations, which should be addressed in future investigations. First, because a cross-sectional design was adopted in this study, causal relationships between variables could not be examined. Second, all the participating students worked in the same hospital. In addition, recall bias may have adversely impacted their ability to provide accurate responses to the assessments. These limitations limit the generalisability of the present findings.

Conclusion

VA is a major concern to students because it threatens their well-being and prevents them from performing their tasks optimally. It is important to ascertain the level and form of VA and emotional and behavioural reactions of students, especially those who will become nurse practitioners following their training. Undoubtedly, their psychological status will affect their professional behaviour and adversely impact the quality of care that they provide to patients.

The present results are consistent with past findings regarding the frequency with which nursing student interns experience VA and their psychological status. Further, more than half of the interns had been exposed to one type of VA, especially ignoring. Interns typically reacted to VA by feeling overwhelmed and refraining from talking to the abuser. Most of the interns did not report a sign of depression, anxiety, or stress. A significant association emerged only between monthly expenditure and depression and anxiety. In future studies, the sources of VA should be examined, and nurses who experience high levels of VA and have psychological disorders should be identified.

Source of funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Conflict of interest

There is no conflict of interest.

Ethical approval

The study protocol and questionnaires were approved by the ethics committee of the university to which the research team was affiliated. Students were provided with an information sheet, which they were required to read, and the purpose and significance of the study and the benefits of participation were verbally described. The students were assured of the voluntariness of their participation.

Authors contributions

EAS and MMA planned the study. AAJ collected, analysed, and synthesised the data and wrote the first draft of the article. EAS and MMA assisted with data analysis and synthesis and contributed to the writing of the article. All the authors have read and approved the final manuscript. All authors have critically reviewed and approved the final draft and are responsible for the content and similarity index of the manuscript.