An Exploration of the Nature, Contributing Factors, and Consequences of Violence against Nurses by Patients and Visitors in the Emergency Department of the Shanxi Provincial Capital City in Northern China

Violence against emergency department (ED) nurses by patients and visitors poses a significant threat to nurses’ well-being, undermines motivation, and compromises patient care quality. However, limited research has explored its nature, contributing factors, and consequences in China. This thesis addressed this gap by examining what constitutes the nature, contributing factors, and consequences of violence against nurses by patients and visitors in the ED of the Shanxi provincial capital city, mainland China, and how these aspects are understood and experienced by ED nurses. By integrating a conceptual framework, an integrative literature review, and a robust mixed-methods design, this thesis provides a comprehensive examination of the phenomenon. A sequential priority model, integrating a quantitative cross-sectional survey with a qualitative descriptive follow-up phase, was employed. The survey, conducted in ten tertiary public hospitals, included 336 ED nurses meeting strict inclusion criteria. Using an adapted Questionnaire on Violence Against Emergency Department Nurses by Patients/Visitors, the study found an overall prevalence of violence at 74.40% (n=250), with visitor-perpetrated violence (66.67%) surpassing patient-perpetrated incidents (51.19%). Key contributing factors, including dissatisfaction with non-ED medical staff, delayed security responses, and inadequate security measures, were identified as moderately relevant across all types of violence. Policies addressing workplace violence showed a significant protective association, with their absence or uncertainty linked to a twofold increase in violence risk (p=0.038, OR = 2.226). Regarding consequences, colleague support was the most frequently reported resource, while short-term impacts, particularly on work motivation, were more pronounced in visitor-perpetrated violence. The qualitative phase involved interviews with 13 purposively selected ED nurses who had experienced violence within the past year. Latent content analysis revealed two central themes: Theme 1: Nurses as Healers or Targets: Confronting Misplaced Anger, encompassing escalation and contributing factors of violence; and Theme 2: Healing in Shackles: Maintaining Professional Composure and Emotional Desensitization, which addressed emotional tolls and professional responses to violence. By integrating quantitative and qualitative findings, the study identified a distinct trajectory of violence, where psychological and physical aggression frequently overlaps and escalate gradually, while isolated physical violence occurs unpredictably. Factors contributing to violence extended beyond patients to visitors, including a particularly vulnerable “normal but unaccompanied” group. The consequences reflected a dual burden for ED nurses: insufficient institutional support and enduring personal and professional impacts. These findings offer theoretical insight into the cumulative and systemic nature of violence in EDs, providing a nuanced framework for future research and guiding urgently needed reforms toward safer, more equitable emergency care environments globally.