The Health and Safety Executive (2025) defines work-related violence as any incident in which a person is abused, threatened or assaulted in circumstances relating to their work. Employers have a duty of care to protect staff from threats and violence in the workplace, with several pieces of legislation covering violence and aggression at work (Box 1).
Legislation covering violence and aggression at work
These laws are intended to identify hazards and assess and mitigate risk, via interventions such as training, reporting of incidents and support for workers. The Violence Prevention and Reduction Standard (NHS England, 2020a) and the NHS People Plan (NHS England, 2020b) were both introduced with an aim of supporting healthcare staff to work in a safe environment while safeguarding them from abuse, aggression and violence.
Despite these legislations and guidance, violence and aggression towards nursing students continues. Prevalence rates for unspecified types of violence or aggression sustained by nursing students range from 16.1% (n=101) (Garcia-Gamez et al, 2020) to 100% (n=126) (Hinchberger, 2009). Nursing students also commonly witness violence or aggression within their clinical placements (Hallett et al, 2021). This includes verbal (Celik and Bayraktar, 2004), physical (Hunter et al, 2022) and sexual (Hallett et al, 2021) violence and aggression.
Many incidents of violence and aggression sustained by nursing students go unreported (Almalki and Alfaki, 2022). They have had many psychological effects in nursing students including anxiety (Magnavita and Heponiemi, 2011); sadness (De Villiers et al, 2014); helplessness (Celebioglu et al, 2010); fear (Magnavita and Heponiemi, 2011); embarrassment (Nau et al, 2007); and lowered self-esteem (Üzar-Özçetin et al, 2021). Worryingly, during and following an act of violence and aggression, fewer than half of nursing students felt supported and received debriefing and emotional support (Hunter et al, 2022).
These factors, and the fact that violence and aggression sustained by nursing students is an under-researched topic, were the rationales for this research study.
Aims and objectives
The aim of the study was to identify the extent, type and impact ofviolence and aggression sustained by nursing and midwifery students. The objectives were:
Methods
Design
A cross-sectional questionnaire, designed to be used at one point in time only (CASP, 2025), was distributed at the end of the students' academic year.
Participants
Convenience sampling was used to recruit participants from one university in the UK. This sampling technique was used because a sample population was readily available, with ease of access, who met the inclusion criteria for the study (Golzar et al, 2022).
The inclusion criteria were students enrolled on preregistration nursing associate, BSc and MSc level nursing and midwifery programmes at a UK university.
Materials and procedures
The questionnaire was devised based upon a literature review of the topic area.
The survey was first distributed to nurse academic lecturers to test its validity, with only minor changes required. This was to ensure the accuracy of the questionnaire (face validity) and to ensure that it measured what it was supposed to measure (content validity) (Ranganathan et al, 2024). A small pilot study (n=5) was completed by nursing students, which resulted in minor grammatical corrections. These responses were not used in the survey.
The first part of the questionnaire collected demographic and background data. This included questions relating to the extent, type and impact of violence and aggression sustained by nursing and midwifery students. The questionnaire comprised 37 questions, with some questions inviting qualitative comments. To detect any signs ofpost-traumatic stress disorder, four slightly modified questions were asked, which were derived from the validated Primary Care PTSD Screen (US Department of Veteran Affairs, 2022).
The questionnaire was created using the Jisc (2025) online survey tool and distributed via generic email to 1681 preregistration nursing and midwifery students. The time span for the distribution and collection of the questionnaires was between June and September 2023. Reminders were made at fortnightly time intervals.
Ethical considerations
Participants were informed that taking part was entirely voluntary and that they had the right to withdraw from the study before the survey was completed and submitted to the researchers.
Students were informed that participation within the study or refusal to take part would have no bearing on their progress on their programme. There was no coercion or duress placed upon the participants in light ofthe lecturer—student relationship.
The information given to potential respondents stated that, owing to the delicate nature of the study, counselling or support from their university services or GP should be sought if they felt that they had been psychologically harmed by violence or aggression Because of the anonymous nature of survey, it was not possible to ensure this happened.
Responses were confidential and anonymous, and participants were informed that the survey was not a test of knowledge but that the researcher was interested in their honest views and opinions.
The study was approved by the ethics committee at the university (reference number: 3796).
Analysis
The completed questionnaires were distributed via the Jisc platform. The data were converted then analysed using software SPSS version 25 for Windows.
For each questionnaire, question descriptive statistics were performed. Descriptive statistics are a collection of methods used to summarise the key features of a data set when analysing quantitative data (Bell, 2010). In this study, percentages and means were measured and presented.
Findings
Response rate
The survey was distributed to 1681 students and 369 responded, giving a response rate of 22%. Most (92.4%) ofthe respondents were female and 44.41% were aged 26-40 years. The majority of the respondents (n=199; 53.9%) were studying adult nursing. The respondents were fairly equally distributed over the first three years of the programme. The demographic data of the respondents can be seen in Table 1.
| Characteristic | n (%) |
|---|---|
| Gender | |
| Female | 341 (92.4) |
| Male | 26 (7.1) |
| Prefer not to say | 2 (0.5) |
| Total | 369 (100) |
| Age (years) | |
| 18-25 | 144 (39.2) |
| 26-40 | 163 (44.4) |
| 41-60 | 60 (16.4) |
| Total * | 367 (100) |
| Programme of study | |
| Adult health nursing | 199 (53.9) |
| Mental health nursing | 89 (24.1) |
| Midwifery | 39 (10.6) |
| Child health nursing | 27 (7.3) |
| Nursing associate | 15 (4.1) |
| Total | 369 (100) |
| Year of study ** | |
| First year | 121 (32.9) |
| Second year | 125 (34.0) |
| Third year | 116 (31.5) |
| Fourth year | 6 (1.6) |
| Total | 368 (100) |
Violence or aggression experienced in the current academic year
In total, 54.7% (n=202) of students reported sustaining violence or aggression in their current academic year. Of these, 94.1% (n=190) had experienced verbal violence and aggression, of which 32.1% (n=61) had sustained verbal violence or aggression more than five times during this period. Of the students who had experienced violence and aggression, 47.5% (n=96) had experienced physical violence in their current academic year.
In total, 38 students sustained physical violence or aggression once, 27 twice and 13 on more than five occasions. Of those who had experienced violence or aggression, 11.9% (n=24) had sustained sexual violence. For 11 students, this occurred once and, for five students, it happened more than five times.
Perpetrators
Where students reported multiple acts of verbal violence or aggression overall, perpetrators were most commonly patients (n=171; 54.81), followed by carers/relatives (n=35; 11.2%) then nurses (n=35; 11.2%). Perpetrators came from 11 groups, including healthcare assistants, members of the public, doctors, nursing students, allied health professionals, midwives and ancillary personnel, plus one unknown person.
Most of the perpetrators of the verbal violence or aggression were male (n=144; 53.8%). Of the 102 reported episodes of physical violence or aggression, 89.2% (n=91) involved the patient, while 8.8% (n=9) involved fellow healthcare personnel, and a majority (n=45; 52.9%) were instigated by a man. Some students reported more than one episode of verbal violence.
Of most instances ofsexual violence (n=24), the perpetrator was the patient (n=21; 87.5%), followed by a healthcare assistant (n=2; 8.3%) then a carer/relative (n=1; 4.1%). Most perpetrators were male (n=21; 87.5%). There were variable response rates to questions on physical and sexual violence.
Potential causes or contributing factors
Students were able to report potential causes or contributing factors for the violence or aggression. There were 436 responses and 16 causes and contributing factors identified. Common causes were the effect of a person's mental health condition (n=156; 35.8%), a lack of staffing (n=73; 16.7%) and the effect of a person's physical condition (n=61; 14.0%). The potential causes or contributing factors can be seen in Table 2.
| Potential causes or contributing factors | n (%) |
|---|---|
| Effect of a person's mental health condition | 156 (35.8) |
| Lack of staffing | 73 (16.7) |
| Effect of a person's physical condition | 61 (14.0) |
| Poor communication | 45 (10.3) |
| Patient was in pain | 42 (9.6) |
| Lack of security measures | 24 (5.5) |
| Effects of alcohol | 18 (4.1) |
| Perceived healthcare personnel dislike of students | 4 (1.0) |
| Patient frustration at waiting | 6 (1.4) |
| Because they were a student | 1 (0.2) |
| Effects of drugs | 1 (0.2) |
| Unwilling to teach student nurses | 1 (0.2) |
| End-of-life patient | 1 (0.2) |
| Perceived due to student's dark skin colour | 1 (0.2) |
| Patient had severe autism | 1 (0.2) |
| Not warned that patient had been previously aggressive | 1 (0.2) |
Locations
Violence or aggression occurred in 11 locations. The most reported were the hospital ward environment (n=141; 38.7%) and the patient's bedside (n=79; 1.7%) (Table 3).
| Location | n (%) |
|---|---|
| Hospital ward environment | 141 (38.7) |
| Patient's bedside | 79 (1.7) |
| Hospital corridor | 35 (9.6) |
| Nurses' station | 35 (9.6) |
| Community setting | 28 (7.7) |
| Hospital grounds | 27 (7.4) |
| Treatment room | 7 (1.9) |
| Delivery room | 4 (1.1) |
| Patient's own home | 4 (1.1) |
| University environment | 2 (0.6) |
| Waiting room | 2 (0.6) |
Specialty
There were 22 specialties where violence and aggression was reported. The most common specialty was the medical environment (n=78), followed by mental health inpatient (n=60) (Table 4).
| Specialty | n (%) |
|---|---|
| Medical environment | 78 (32.5) |
| Mental health inpatient | 60 (25.0) |
| Community hospital | 20 (8.3) |
| Emergency department | 20 (8.3) |
| Midwifery inpatient | 12 (5.0) |
| Paediatric inpatient | 12 (5.0) |
| Mental health outpatient/community | 11 (4.68) |
| General practice surgery | 4 (1.7) |
| Nursing home | 4 (1.7) |
| District nurses | 3 (1.3) |
| Intensive care unit | 3 (1.3) |
| Midwifery outpatient/community | 3 (1.3) |
| Paediatric outpatient/community | 1 (0.4) |
| Theatres (including anaesthetics and recovery) | 1 (0.4) |
| Hospice | 1 (0.4) |
| Healthcare of the elderly | 1 (0.4) |
| Surgical | 1 (0.4) |
| Forensic medium-secure unit | 1 (0.4) |
| Renal | 1 (0.4) |
| Respiratory | 1 (0.4) |
| School for excluded children | 1 (0.4) |
| Other | 1 (0.4) |
Physical injuries sustained
There were 11 types of physical injury sustained following the violence and aggression. The most common were a bruise (n=41; 30.6%); a scratch (n=34; 25.4%); being spat on (n=31; 23.1%); being slapped (n=15; 11.2%); and being bitten (n=5; 3.7%).
Feelings or emotions following the episode of violence or aggression
Twenty emotions were expressed following the violence or aggression episode. The most commonly mentioned feelings or emotions were anxiety/stress (n=98; 11.2%), loss ofconfidence (n=83; 9.5%) and feeling overwhelmed (n=67; 7.5%). Some students (n=58; 6.6%) stated that they wanted to leave their placement. The emotions are shown in Table 5.
| Feelings or emotion | n (%) |
|---|---|
| Anxiety/stress | 98 (11.2) |
| Loss of confidence | 83 (9.5) |
| Overwhelmed | 67 (7.6) |
| Embarrassment | 61 (7.0) |
| Frustration | 59 (6.7) |
| Wanted to leave placement | 58 (6.6) |
| Fear | 57 (6.5) |
| Humiliation | 55 (6.3) |
| Helplessness | 51 (5.8) |
| Unsafe | 50 (5.7) |
| Low job satisfaction | 47 (5.4) |
| Powerless | 47 (5.4) |
| Incompetence | 44 (5.0) |
| Anger | 41 (4.7) |
| None | 32 (3.7) |
| Depression | 21 (2.4) |
| Sad | 2 (0.2) |
| Apathy to the patient | 1 (0.1) |
| Felt sorry for those patients | 1 (0.1) |
| Felt happy that I was supported by my colleagues | 1 (0.1) |
| Upset | 1 (0.1) |
Post-traumatic stress disorder incidence
The survey asked four questions that tested for the incidence of post-traumatic stress disorder (PTSD) following violence or aggression. In total, 111 of the 202 students who has sustained violence or aggression answered yes to at least one question relating to PTSD. Therefore, 55.0% of students who had sustained violence or aggression has at least one characteristic of PTSD. In total, 30/202 students who had sustained violence or aggression answered yes to three or four of the questions relating to PTSD, suggesting that 14.9% of students showed signs of PTSD (3-4 affirmative answers are required to confirm signs of PTSD).
Onward reporting
In total 62.9% (n=127) respondents reported the violence or aggression. The nurse/midwife in charge (n=110; 86.6%) and the practice assessor/supervisor (n=49; 38.6%) were the most common people it was reported to. Worryingly, the personal tutor was informed only on a small number of occasions (n=14; 11.0%).
Reasons for not reporting
There were 15 reasons why violence and aggression was not reported. The most common reasons given were because it was the normal representation of the patient (n=36; 27.7%); because the student did not believe anything would be done about it (n=24; 18.5%) and because the student was worried reporting would affect their assessment of competence (n—13; 10.0%). Reasons for non-reporting can be seen in Table 6.
| Reason(s) why you did not report the episode | n (%) |
|---|---|
| It was the normal representation of the patient | 36 (27.7) |
| Did not believe anything would be done about it | 24 (18.5) |
| Worried reporting would affect your assessment of competence | 13 (10.0) |
| You were too shy to report the incident | 9 (7.0) |
| It was a minor injury/incident | 8 (6.2) |
| You were afraid to report the incident | 8 (6.2) |
| You were embarrassed to report the incident | 8 (6.2) |
| Did not know how to report the incident | 6 (4.65) |
| Due to patient's condition eg end of life; delirium | 4 (3.1) |
| Lack of time to report | 4 (3.1) |
| You were worried about confidentiality | 4 (3.1) |
| Supervisor took over | 3 (2.3) |
| Didn't think it was worthy of reporting due to staffing levels and frustrations high among patients | 1 (0.8) |
| It was a complicated reporting procedure | 1 (0.8) |
| I didn't feel it warranted a report | 1 (0.8) |
Outcome of reporting
Following the episode of violence and aggression, the most common outcome was that there was a debrief (n—38; 30.2%) followed by nothing happening (n—35; 27.8%) and the matter being dealt with satisfactorily (n—33; 26.2%).
Support following the violence or aggression
The most common support mechanism following the incident was speaking to family/friends (n—83; 31.9%), followed by having a debrief within the team (n—75; 28.9%). Worryingly, 25.4% (n—66) of respondents did not seek or receive any support and only 8.9% (n—23) spoke to their personal tutor at the university.
University education on de-escalation or prevention and management of violence or aggression
In total, 35.8% (n—132) felt that they had had enough training and education within the university programme regarding de-escalation or the prevention and management of violence or aggression. This meant that almost two-thirds did not.
Discussion
This survey showed that perpetrators of violence were more commonly male. The prevalence rate of male violence was in the range of 52.9%—88.9%, depending upon the type of violence. This is a similar finding to the limited published evidence on this topic. Available data shows that men account for between 66.7% (n=120) (Aghajanloo et al, 2011) and 90.5% (n=19) (Almalki and Alfaki, 2022) of aggression and violence towards nursing students.
The survey showed verbal violence as the most common type, with a prevalence rate of 94.1%. This is within the range shown in the limited literature. Recorded rates of verbal assaults are between 15.9% (n=189) (Őzcan et al, 2014) and 100% (n=225) (Qelik and Bayraktar, 2004). This includes swearing, shouting and insults (Hunter et al, 2022). There are almost equal rates of men and women involved in verbal violence. This is supported in the literature, which shows perpetrators of verbal assault being almost equally male and female (Aghajanloo et al, 2011). Perpetrators of verbal violence in the survey were predominantly patients (54.8%), which is less than the 91.4% (n=96) identified by Hallett et al (2021). Other perpetrators included a patient's relative/carer, nursing staff, nursing students and other healthcare personnel, as previously reported (Aghajanloo et al, 2011; deVilliers et al, 2014; Hallett et al, 2021).
The survey showed 47.5% (n=96) ofstudents had experienced physical violence or aggression. This is within the range of between 4.2% (n=8) (Qelebioglu et al, 2010) and 69.6% (Hunter et al, 2022) reported in the literature. This included slapping or hitting, scratching, punching, pushing, kicking, grabbing, spitting and having an object thrown. This is consistent with the types ofphysical violence reported in the literature (Hallett et al, 2021; Almalki and Alfaki, 2022; Hunter et al, 2022). The perpetrators of physical violence directed towards nursing students in the survey were commonly men (n=45; 52.9%) and predominantly patients (n=91; 89.2%). This mirrors the rate of 97.2% (n=70) identified by Hallett et al (2021).
The rate of sexual violence was 11.9% (n=24), which lies at the lower end of the previously reported rate of between 4.2% (n=8) (Qelebioglu et al, 2010) and 39.5% (n=51) (Hallett et al, 2021). Men accounted for 88.9% of episodes, and the commonest perpetrators being patients (87.5%; n=21) is consistent with the reported rate of 100% (n=51) by Hallett et al (2021).
The majority (n=127; 62.9%) of respondents reported the violence or aggression. This lies within the rates reported in the literature. Non-reporting has been found to be between 14.3% (Almalki and Alfaki, 2022) and 70% (Hinchberger, 2009). Reasons for non-reporting in the survey are also similar to those within the literature, namely: it being the normal representation of the patient; the perception that nothing could be done about it; embarrassment; and not wanting to cause trouble (Hunter et al, 2022). A common reason in this survey was the student felt that reporting the incident may affect their assessment of competence.
This survey has identified that only a small number of episodes of violence or aggression are reported to students' personal tutors. Hence, reporting mechanisms between the student's practice placement and higher education institutions need to be improved by making it simple to do and to increase the number of episodes that are dealt with (Hallett et al, 2021).
The major reasons why students felt the violence or aggression occurred in the survey were the effects of patients' physical and mental health conditions. However, the primary ones reported in the literature include: a lack of confidence in the nursing student (©elebioglu et al, 2010); staff thoughtlessness (Nau et al, 2007); and students being inexperienced and young (Üzar-Özçetin et al, 2021).
The most common emotions expressed following violence or aggression within the survey were anxiety/stress and a loss of confidence. These were also reported within a systematic review completed by Dafny et al (2023) and within other studies (©elebioglu et al, 2010; Magnavita and Heponiemi, 2011; Üzar-Özçetin et al, 2021).
Signs of PTSD were identified in 14.6% of the students who had experienced violence or aggression. Extensive investigation of the literature has not found this psychological effect, so this may be the first research paper to specifically identify PTSD in nursing and midwifery students following violence or aggression.
Many students who had experienced violence or aggression did not seek support or contact their personal tutor at their higher education institute (HEI). This feeling of being unsupported echoes the work of Hunter et al (2022). Hence there is a requirement for more wellbeing support to be freely available for students while on practice placement and within their HEI following an episode of violence or aggression (Aghajanloo et al, 2011; Hunter et al, 2022). This needs to be provided in the short and long term, depending on the severity of the effects of the episode, to help nursing and midwifery students cope with negative experiences (Hopkins et al, 2018).
Approximately one in three students felt that they had sufficient training and education within their HEI regarding de-escalation or the prevention and management of violence or aggression. This is mirrored in previous work by Hunter et al (2022). Therefore, better training and education before placement and at subsequent intervals during the programme need to be implemented within HEIs (Bilgin et al, 2016; Hopkins et al, 2018).
Education and training should encompass: essential communication skills training at the HEI (©elebioglu et al, 2010; Aghajanloo et al, 2011); interpersonal skills and conflict management training (deVilliers et al, 2014); and de-escalation techniques (Hunter et al, 2022). Through this, students could gain self-confidence to deal with violence and aggression (Nau et al, 2007).
A climate of non-tolerance to violence and aggression within healthcare organisations needs to become the norm to protect healthcare staff and students. Hence, healthcare providers should ensure that they adhere to safety policies, guidelines and procedures (Nau et al, 2007) such as the Violence Prevention and Reduction Standard (NHS England, 2020a) and the People Plan (NHS England, 2020b) to achieve continuous improvement in violence prevention and reduction. This may include the provision of panic alarms, mobile phones, pagers and the maintenance of adequate staffing levels (Hinchberger, 2009).
Limitations
The survey was conducted in one rural, coastal university in the UK and therefore may not be representatives of universities nationwide. The response rate was only 22% so there may be an issue with non-response bias.
Conclusion
Limited research has been conducted within the UK on the issue of violence experienced by nursing students. This study has identified the rates of verbal, physical and sexual violence and aggression sustained by nursing and midwifery students in the UK. The main perpetrator, the potential causes and the location of the violence and aggression have also been identified.
Violence and aggression have physical and psychological effects and are not reported for several reasons. Very few students informed their university personal tutor of such incidents.
Future research should examine: underexplored areas such as whether violence or aggression affects student nursing and midwifery attrition rates; whether violence or aggression affects career choices; and whether the prospect of violence or aggression prevents recruitment onto nursing and midwifery programmes.