“Sometimes They Attack Us”: Transactional Theory Analysis of Nurse Abuse Experiences

Study Setting

Ghana is located in West Africa, has a population of approximately 30.3 million people and is organized into 16 regions across the northern, middle, and southern zones (Ghana Statistical Service, 2021). The country’s public healthcare system includes 10 regional hospitals that serve as secondary referral centers from primary care facilities, and five teaching hospitals that provide tertiary-level care (Sunkwa-Mills et al., 2023).

The research focused specifically on general nurses working in male and female medical wards, of a public district hospital in Ghana. Specialist nurses were excluded. This is because, according to the Ghana Health Service (2018), medical wards host the majority of hospital admissions, typically involving common conditions that do not require specialist care. The study site is made anonymous due to the sensitive nature of the study.

Study Design

This study adopted an ethnographic research design to explore the lived experiences of nurses facing abuse within the selected hospital. The ethnographic approach focuses on exploring how people relate to various aspects of their lives, including social, political, cultural, and historical contexts. Its primary aim in the social sciences is to understand how individuals interact with and are shaped by their social environments. A defining feature of this approach is the close connection between the researcher and the participants (Hallett & Barber, 2014).

Data Collection and Recruitment

Eligible participants included registered nurses and enrolled nurse assistants with at least 1 year of experience. The sample consisted of 31 general nurses and one key informant, the Deputy Director of Nursing Services (DDNS). Data were collected using semi-structured interviews, participant observations, and informal conversations. Participant observation is a key ethnographic method that involves researchers immersing themselves in participants’ daily lives to understand their experiences and behaviors. Often combined with informal interviews, it allows the ethnographer to capture what happens, where, when, how, and why social phenomena occur (Gobo, 2011).

A semi-structured interview guide, informed by the literature and field familiarity, was used, allowing flexibility. Twenty-six in-depth interviews, one key informant interview, and one focus group discussion (comprising five participants) were conducted. All in-depth interviews and focus group discussions were audio-recorded on a recording device with participants’ consent to ensure accurate capture of narratives. Informal conversations and participant observations were documented in a field diary.

Observational data were gathered using Spradley’s (2016) framework descriptive, focused, and selective observation. For instance, descriptive observation captured general details such as the time nurses reported for work, admissions and discharges, available equipment, notices posted on bulletin boards, and the number of ambulant and dependent patients. Focused observation targeted particular activities, such as identifying who performed specific tasks and analyzing how nurses engaged with patients, coworkers, and family members. Selective observation aligned directly with the broader research objectives, emphasizing nurses’ attitudes and behaviors toward patients and relatives, including their speech, tone, and physical expressions. These observations were conducted and documented concurrently daily. When specific narratives were needed, such as on the subject of verbal, the most illustrative examples from the observation notes were selected and cross-checked with relevant interview data for triangulation.

Data Analysis

Interviews were transcribed verbatim and, where necessary, translated from Twi language. To ensure accuracy, transcripts were cross-checked against audio files and field notes. The resulting transcripts in a written format constituted the primary dataset for analysis. The organization of narratives under sub-themes was achieved through a reflexive analytic process conducted by the author. Thematic network analysis, following Attride-Stirling’s (2001) model, guided the analytic process. Codes were clustered into basic and organizing themes, which were refined into global themes capturing systemic patterns of abuse. For instance, codes such as unsolicited touches, expressing sexual interests at work all grouped into an organizing theme called sexual harassment. Together with other organizing themes, including verbal abuse, physical abuse, and emotional abuse, a global theme of “Types of Abuse” was created. Quotations were incorporated, utilizing NVivo 12 Plus, for data management. Analysis and data collection occurred iteratively to refine emerging insights.

Rigor

Rigor was enhanced through multiple strategies to ensure the trustworthiness of the findings. Triangulation using interviews, participant observations, and focus group discussions enabled cross-verification of emerging themes and reduced the risk of single-method bias. Prolonged engagement in the field over 11 months strengthened credibility by enabling a deeper understanding of the setting and by establishing rapport with participants. Peer debriefing with research colleagues provided external checks on the analytic process, while member-checking with selected participants ensured that interpretations accurately reflected their perspectives. In addition, the interview guide was pilot-tested with three nurses from other facilities to refine the questions and enhance the dependability and reliability of the data collection process.

Ethical Approval and Considerations

Ethical approval for the study was granted by the Institutional Review Board of the College of Humanities, University of Ghana (protocol number: ECH 019/20-21) prior to data collection. Written informed consent was obtained from the DDNS and some participants, while a few remaining participants provided verbal consent. These participants explained that signing a written document felt unnecessarily formal and thus preferred to consent verbally to participate in the study. The study was conducted in accordance with the ethical principles of the Belmont Report, respect for persons, beneficence, and justice, and the American Psychological Association (APA) ethical guidelines for research involving human participants.

The study design was deliberately structured to minimize potential harm to participants. Participation was voluntary, and nurses could decline to answer any question or withdraw at any point without consequences. Pseudonyms were used, and identifying details were removed to protect confidentiality, particularly given the sensitive nature of workplace abuse. Interviews were conducted in private settings to reduce the risk of emotional distress or professional repercussions. The researcher adopted a non-interventionist role during observations to avoid influencing clinical care or exposing participants to additional risk.

The potential risks to participants were minimal and primarily related to emotional discomfort when recounting abusive experiences. These risks were outweighed by the potential benefits of the study, including raising awareness of workplace abuse and generating evidence to inform institutional policies that improve nurse safety and well-being. At a societal level, the findings contribute to strengthening health systems by highlighting systemic gaps that affect staff retention, morale, and quality of care.

Researcher Reflexivity

As a Ghanaian social scientist lacking a clinical nursing background, I entered the field as an outsider, unfamiliar with the technical and interpersonal dynamics of hospital care. I was introduced to participants as a researcher by the DDNS, and during the COVID-19 pandemic, I wore hospital scrubs as personal protective equipment, as recommended by the DDNS. While this was necessary, it raised ethical concerns about my presence. To mitigate this, I adopted a respectful observer role and avoided interfering in sensitive procedures.

Although some patients sometimes assumed I was a healthcare provider, I made sure to clarify my role as a researcher when appropriate. I contributed to non-clinical tasks like making beds and participated in staff workshops to foster rapport and trust. Initially, some nurses were cautious in their interactions with me, but after 11 months of engagement, participants became more open during interviews and informal discussions.

Participant Demographics

The study included 32 participants: 27 women and 5 men, with an average age of 32.6 years. Marital statuses included 23 married, 8 single, 1 divorced, and 1 separated. The participants represented a range of nursing ranks, from enrolled nurses to a principal nursing officer and one DDNS. Their years of service ranged from 1 to 21, with a median tenure of 5 years.

This study forms part of a broader research project. The methods described here were also applied in a related study that is currently under review for publication.

Primary Appraisal: Interpreting Abuse as Threatening or Harmful

Nurses in the study perceived various forms of abuse: physical, verbal, emotional, and sexual, as direct threats to their safety, personal dignity, and professional identity. These perceptions align with Lazarus and Folkman’s concept of threat or harm appraisals.

Secondary Appraisal: Assessing Coping Resources

The process of secondary appraisal, as outlined by Lazarus and Folkman’s (1984), involves evaluating available coping resources in response to a perceived stressor. For nurses experiencing abuse in the workplace, this stage entails assessing institutional support structures, peer support systems, and their capacities to respond to and manage the stress induced by violent encounters.

The data reveal that many nurses appraised their coping options as limited or ineffective. Most participants lamented the absence of formal institutional mechanisms for addressing abuse, particularly the lack of clearly defined reporting channels and administrative follow-up. This institutional vacuum contributed to a perception that reporting abuse would be futile. As Davida (female, 31 years, senior staff nurse) puts it, “They claimed it would not make any difference and so was considered a ‘useless’ effort.” This perception of futility is supported by studies such as Babiarczyk et al. (2020) and Orewa et al. (2025), which document that many nurses do not report workplace violence because they believe no meaningful action will result, or because they do not know whom to report to.

Others, especially nurse managers who were verbally abused, in the case of Betty (female, 39 years, IC), who was called “stupid,” felt ashamed to report such incidents because it would tarnish her image which corroborates with Mohammed et al.’s (2024) study. Nevertheless, Zhang et al. (2017) on the contrary, established that when a nurse’s social status is high, there is a likelihood of receiving tremendous respect and a lower chance of being prone to violence. A few who did not report claimed they had no information about whom to report to.

Some participants also expressed their displeasure at how nursing care has been institutionalized to be “overly” centered on the rights and protection of the patient, but not the nurse. Samuela (female, 33 years, senior nursing officer) complained: “I know there is literature on nursing safety, but we don’t hammer more on that; everything is all about the client.” This indicates a perception of institutional imbalance. While she acknowledges the existence of literature on nursing safety, her secondary appraisal suggests a belief that this knowledge may not be actively translated into policy or practice. In her view, the institutional environment offers insufficient protection or advocacy for nurses, thereby diminishing her perceived ability to cope with incidents of abuse. This lack of structural reinforcement likely contributes to emotional exhaustion and disengagement, signaling low institutional efficacy as a coping resource. Kate (female, 30 years, enrolled nurse) also lamented:

If a patient slaps me, I am not supposed to slap the patient back. I have to just watch the person go. If I slap the patient too, I am the one at fault and I’m unprofessional.

She recognizes that although she is a victim, professional ethics and institutional policy constrain her response options. This may lead to a perceived lack of agency, with the only permissible coping mechanism being passive endurance.

The Deputy Director of Nursing Service, in response to these comments, rejected the assertion that nursing management is not instrumental in addressing nursing safety issues. She explained: “I do my best. A nurse had a problem with a patient who threw something at her, we deliberated on the issue, queried the security man and reported to the administrator.” According to the transactional theory, this demonstrates her own secondary appraisal of institutional capacity and effort. She frames herself as responsive and action-oriented, however, this may be viewed by nurses as symbolic or reactive rather than preventive. If management assesses that these isolated interventions are sufficient, it may not align with the nurses’ experiences of repeated, unresolved threats, reinforcing their sense of inadequate systemic support.

While some nurses found solace in peer support, such assistance was often limited to informal conversations and emotional venting rather than structured mechanisms for resolution. The lack of formal peer advocacy or debriefing systems meant that emotional burdens were not meaningfully alleviated, and collective action was rarely mobilized. Additionally, many nurses internalized the abuse, perceiving themselves as powerless within a broader system that failed to protect or empower them. Such an evaluation diminishes self-efficacy and contributes to long-term consequences including disengagement, burnout, and avoidance of specific patient interactions (Alhalal, 2025; Isara et al., 2024).

Thus, secondary appraisal within this context underscores how institutional neglect and the absence of protective mechanisms constrain coping capacities, magnify emotional strain, and perpetuate a climate in which abuse is normalized or silently endured.

Problem-Focused and Emotion-Focused Coping Strategies

The coping strategies adopted by nurses in response to workplace abuse can be broadly classified into problem-focused coping and emotion-focused coping, as conceptualized in the transactional theory (Lazarus & Folkman, 1984). These strategies reflect individuals’ dynamic attempts to manage the demands placed on them by stressful encounters.

Problem-focused coping involves actions aimed at directly addressing or mitigating the source of stress. Nurses in this study described several such responses employed in retaliatory confrontation, challenging rude or aggressive patients and relatives in an effort to assert control over the situation. For instance, Josephine’s (female, 33 years, senior staff nurse) response, “When you come along with trouble, I will also meet you with trouble, simple!” suggests a reactive coping strategy, in which emotional defensiveness and reciprocal aggression are employed to protect herself from perceived or actual disrespect.

Stella’s (female, 29 years, staff nurse) response, “I come in, blast them…,” when a relative purported that nurses are incompetent, demonstrates an effort to restore dignity and assert control through confrontation. This strategy likely arises from a felt need to counteract the emotional injury and power imbalance introduced by the accusation.

In contexts where nurses are socially undervalued, for instance in the scenario, where a relative tells a nurse, “Go away with your foolishness!” the nurse’s response (“We also told him our piece of mind… sometimes, you need to put sense in them”) indicates the use of a defensive coping strategy to reassert control and mitigate emotional distress. The threatening nature of the interaction lies not only in the verbal aggression itself but also in the perceived disrespect and loss of authority, which challenges the nurse’s role and dignity within the clinical setting.

Georgina’s (female, 29 years, senior enrolled nurse) narrative expands the threat by pointing to both explicit advances (e.g., kissing attempts) and persistent, unsettling behaviors (e.g., lustful gazes, touching, or sexual hallucinations). The fact that these incidents are more likely to occur during night shifts increases the perception of vulnerability, reinforcing chronic anticipatory stress and the need for hypervigilance as a coping strategy. Her response, inviting a patient’s wife into the ward, is a strategic, problem-focused coping mechanism that re-establishes boundaries and diverts risk.

The absence of organizational safeguards and formal avenues for conflict resolution has led these nurses to formulate coping strategies in isolation, often shaped more by necessity than by structured support. These patterns reflect a reactive stance in which personal protection becomes paramount in the absence of institutional accountability. The findings resonate with those of Babiarczyk et al. (2020), who observed that when organizational support is weak, nurses resort to self-directed coping strategies, which may not be sustainable over time.

Emotion-focused coping, by contrast, is directed toward managing the emotional consequences of stress rather than the stressor itself (Folkman, 2008). Nurses often engage in emotional suppression or distancing, ignoring abusive patients or withholding engagement as a form of self-preservation. For instance, Samuela’s (female, 33 years, senior nursing officer) initial reaction, pretending nothing happened, when a patient touched her buttocks, illustrates primary appraisal and a moment of emotional regulation, possibly driven by uncertainty or the desire to maintain professionalism. However, when the behavior recurred, it was clearly appraised as a deliberate violation, prompting a coping response through confrontation and, eventually, withdrawal of care. This withdrawal was motivated by fear and the knowledge of a prior nurse rape case. Boafo and Hancock (2017) also reported that nurses who were abused became super alert and vigilant which was also the case for participants in this study who were sexually harassed.

Rita’s (female, 45 years, female ward IC) experience of personal sacrifice, feeding a patient from her own resources, followed by ingratitude and insult, is appraised as a betrayal of prosocial intent, generating emotional pain and disillusionment. As she declared, “We have stopped assisting patients financially,” demonstrates withholding engagement. This suggests a threat to emotional well-being and moral expectations within the caregiving relationship.

Concerning the observation of Betty (female, 39 years, IC), who was insulted by a patient as “stupid,” her withdrawal strategy, choosing to ignore the patient and avoid further interaction, aligns with emotion-focused coping, where the individual attempts to regulate internal emotional responses rather than confront or change the external stressor. Such avoidance may serve to preserve emotional stability and prevent escalation. While this may prevent further stress in the short term, repeated reliance on such strategies may contribute to emotional fatigue or diminished patient care in the long run.

Regarding the verbal abuse from colleagues, Mabel’s colleague, who was insulted by a senior nurse (What use are you as a nurse?), internalized the abuse, leading to emotional withdrawal and impaired professional performance. This passive coping mechanism, while protective in the short term, may result in long-term psychological harm and reduced professional engagement. On the other hand, Rita (female, 45 years, female ward IC), who was told to park her old car under the trees, despite being in a position of authority, was verbally and emotionally abused. Her emphasis on hierarchy (“I was not only a Principal Nursing Officer but also an IC”) suggests an injured sense of professional pride and possibly suppressed anger or frustration, and she adopted a posture of silent endurance rather than confronting or formally addressing the junior nurse’s misconduct.

Additionally, humor and sarcasm emerged as subtle but significant tools for deflecting humiliation and restoring emotional equilibrium. As one nurse remarked, “Some insult us, so you retaliate and tell them your piece of mind, ‘it cools your soul’” emphasizes the therapeutic value of emotional release in the face of betrayal or aggression.

These coping strategies, whether problem or emotion-focused, illuminate the psychological burden borne by nurses in environments where abuse is prevalent and institutional responses are lacking. As supported by Isara et al. (2024) and Schablon et al. (2018) such stressors, if unresolved, can erode professional commitment and well-being. While these responses may offer short-term relief or protection, they underscore the urgent need for comprehensive organizational reform that empowers healthcare workers with effective, supportive, and formalized coping mechanisms.

Outcomes and Reappraisal

The outcomes of coping efforts, particularly when they fail to mitigate or eliminate stressors, are essential to understanding the broader implications of workplace violence on nurses. Within the framework of the Transactional Theory of Stress and Coping, outcomes are influenced by how effectively an individual appraises and responds to stressors, and whether coping efforts lead to resolution or persistent strain.

In this study, very few participants reported positive outcomes and reappraisal. Moro (male, 27 years, staff nurse) explained, “A patient can abuse you, but if you love nursing, you forgo those things and perceive the patient as not normal. Forget them and carry on.” Moro’s experience reflects a rare instance of positive outcome and cognitive reappraisal. The outcome suggests emotional detachment and psychological resilience, enabling him to uphold his professional role without internalizing the offense. Moro’s comment, “you forgo those things and perceive the patient as not normal,” is a clear example of cognitive reappraisal. After his initial emotional response, Moro reinterprets the patient’s behavior as stemming from mental instability or illness rather than personal malice. This reframing enables him to reduce the perceived threat and justify continuing care without feeling resentful.

Many nurses, however, reported unfavorable reappraisals, whereby stress likely remained unresolved despite attempts at coping. These likely unresolved stressors manifested in several detrimental outcomes. Burnout was frequently cited, characterized by emotional exhaustion, depersonalization, and a reduced sense of personal accomplishment. For instance, Awurama (female, 33 years, staff nurse) confessed, “Sometimes I’m so depressed, I am not motivated to work.” Some nurses also began to withdraw emotionally or physically from their work as a means of protecting themselves. This included absenteeism, deliberate avoidance of certain patients, or the erosion of compassionate care resulting from prolonged exposure to stressors such as emotional abuse and burnout while others expressed their desire to withdraw from the profession. Offeibea (female 36 years, senior nursing officer) said, “I have resigned from this job in my heart already. I’m only trying to gather some capital to start a business.” Princess (female, 27 years, staff nurse) also lamented, “I regret choosing nursing as a profession; I had no idea it would be like this.” In a study by Usman et al. (2025) in Nigeria, some of the nurses also expressed regret about choosing the profession and were unwilling to encourage their children to pursue nursing. These suggest negative cognitive reappraisal. This form of reappraisal may deepen the sense of helplessness and dissatisfaction, suggesting that they see little room for improvement or positive change. Edward et al. (2016) also support that unresolved abuse leads to job dissatisfaction, burnout, absenteeism, and intentions to leave the profession.

These experiences suggest the cumulative impact of repeated exposure to workplace violence, particularly when paired with institutional inaction. Chronic strain from unaddressed abuse leads to disengagement, and in some cases, nurses contemplate leaving the profession altogether. Thus, reappraisal in this context reflects not the resolution of stress, but rather its persistence and intensification, with long-term implications for both individual well-being and health system stability.

Limitations

Despite its contributions, this study is subject to limitations. While the interviews were triangulated with observations, participants may have withheld or underreported sensitive experiences, particularly those involving sexual harassment or perceived institutional betrayal, due to fear of stigma or professional repercussions. Again, this study, like all qualitative researches, relied partly on retrospective, self-reported accounts, which may be subject to recall bias and personal interpretations. In addition, as with all ethnographic research, the researcher’s presence and positionality may have influenced data generation and interpretation, and a researcher’s halo effect cannot be entirely excluded.

Future research should incorporate more confidential and diverse data collection methods. For instance, anonymous surveys, diary methods, or digital ethnography could be used to encourage more open disclosure of experiences without fear of identification or reprisal.