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

Abstract

Workplace abuse against nurses remains a persistent issue within healthcare systems globally. Nurses face verbal, emotional, physical, and sexual abuse from patients, relatives, and colleagues, often with limited institutional protection. This study aims to (a) explore how general nurses in medical wards experience and respond to workplace abuse; (b) examine their coping responses to workplace abuse using Lazarus and Folkman’s Transactional Theory of Stress and Coping; and (c) address theoretical gaps in existing literature on nurse abuse. An ethnographic approach was employed in a district hospital in Ghana. Data was collected from 32 participants through participant observation, in-depth interviews, and informal conversations with general nurses working in medical wards. Thematic network analysis was used in the analysis. Verbal abuse was often normalized and underreported, while emotional, physical, and sexual abuse were appraised as harmful. In response to institutional inaction, nurses employed coping strategies such as emotional distancing, confrontation, avoidance, humor, and informal peer support. Many nurses experienced burnout, emotional detachment, job dissatisfaction, and a decline in professional commitment. Workplace abuse in general medical wards is pervasive and inadequately addressed. There is a need for institutional reforms, including transparent reporting mechanisms, protective policies, and accessible psychosocial support.

Plain Language Summary

“Sometimes Patients Abuse Us: Understanding Nurses’ Experiences Through Stress and Coping Theory”

Abuse against nurses in the workplace is a serious and ongoing problem within healthcare systems across the world. Nurses frequently face verbal insults, emotional mistreatment, physical threats, and even sexual harassment from patients, relatives, and colleagues. Unfortunately, many institutions provide little protection or support, leaving nurses vulnerable and often powerless in these situations. This study set out to understand how general nurses working in the medical wards of a district hospital in Ghana experience such abuse and how they respond to it. Using Lazarus and Folkman’s stress and coping theory, the research also aimed to shed light on the coping mechanisms nurses employ and to fill gaps in the existing literature on workplace abuse in nursing. An ethnographic approach was adopted, with data gathered from 32 nurses through participant observation, in-depth interviews, and informal conversations. The data were analyzed thematically, highlighting recurring patterns and meanings. The findings revealed that verbal abuse was so common that many nurses considered it a routine part of their work and therefore rarely reported it. In contrast, emotional, physical, and sexual abuse were regarded as more harmful and dehumanizing. Yet, despite the distress these forms of abuse caused, institutional authorities often failed to respond adequately. In the absence of strong institutional support, nurses turned to various coping strategies. These included emotionally distancing themselves from patients, directly confronting the abuser, avoiding situations that might escalate, using humor to diffuse tension, and seeking informal support from their peers. While these strategies provided temporary relief, they came at a cost. Many nurses reported experiencing burnout, emotional withdrawal from patients, dissatisfaction with their jobs, and a decline in their commitment to the profession.

Introduction

Workplace violence against nurses is a pervasive and complex challenge that undermines both individual well-being and the quality of healthcare delivery. The collective body of literature underscores that nurse abuse, encompassing verbal, physical, sexual harassment, and psychological abuse, is a widespread and critical issue across Africa, Ghana, and globally (Ekpor et al., 2024; Isara et al., 2024; Rossi et al., 2023; Tawiah et al., 2024). African contexts report prevalence rates similar to or slightly lower than global averages (Boafo & Hancock, 2017), but specific settings, such as psychiatric and emergency departments, often exhibit higher risks (Isara et al., 2024; Rossi et al., 2023).

In Korea, Cho et al. (2011) showed the high prevalence of verbal abuse of general nurses from patients, relatives, physicians and even co-workers. Results from a study in the USA also showed high rates of verbal and physical abuse against neurology nurses (Trahan & Bishop, 2016). Similarly, in Switzerland, psychiatry nurses were exposed to lifetime severe assaults, violence against property, verbal violence, verbal sexual violence, physical violence, and physical sexual violence (Schlup et al., 2021). Zhang et al. (2017) found that in China, nurses in senior ranks were less likely to experience workplace violence than those in junior ranks.

In Africa, factors like prolonged patient waiting times and nurses’ lack of awareness about institutional policies and reporting procedures for workplace violence were found to be significantly linked to the occurrence of nurse abuse (Ekpor et al., 2024). A study from Southern Ethiopia revealed how nurses who frequently care for patients in units have a higher likelihood of experiencing workplace violence by these patients and on an evening shift (Fute et al., 2015). Another study from Northwest Ethiopia found that the number of staff members on a shift influenced the likelihood of workplace violence, showing that it was more likely when five or fewer staff were on duty (Tiruneh et al., 2016). Usman et al. (2025) also found out in Northern Nigeria that the contributing factors to workplace violence were insufficient training on workplace violence, poor awareness of reporting procedures, and challenges linked to career choice, underscoring the pressing need for targeted strategies to safeguard healthcare workers and enhance their work environment.

Ghanaian studies particularly highlight sexual harassment and obstetric violence as significant concerns, with nuanced gender dynamics and cultural factors influencing both the frequency and normalization of abuse (Boafo, 2016; Mohammed et al., 2024). A study in Ghana by Lartey et al. (2020) showed how nurses and midwives endure an emotional abuse of bullying behavior from patients and relatives, yet these nurses endured because they believed it was part of the job, and for job security. In many low- and middle-income countries, including Ghana, the situation is exacerbated by structural inefficiencies, resource limitations, and cultural attitudes that often normalize or trivialize mistreatment of frontline healthcare workers (Boafo, 2016).

Among the forms of abuse, verbal abuse is identified as the most prevalent, often dismissed as a routine part of nursing work (Ekpor et al., 2024; Orewa et al., 2025). This normalization contributes to underreporting and hinders the accurate assessment of its true extent (Babiarczyk et al., 2020; Mohammed et al., 2024). Although physical violence occurs less frequently than verbal abuse, it remains a serious concern, especially in high-risk areas such as psychiatric and emergency departments (Mnif et al., 2022; Schlup et al., 2021). Sexual harassment, while less common, persistently affects a significant minority of nurses, predominantly women, and is primarily perpetrated by male patients, though physicians are occasionally involved (Boafo & Hancock, 2017; Edward et al., 2016; Mohammed et al., 2024). There is broad agreement that patients and their families are the main instigators of violence (Orewa et al., 2025; Park et al., 2023), though colleagues and supervisors also play a key role, particularly in cases of verbal and psychological abuse (Evans et al., 2023).

Despite nurses being central to patient care, their experiences of abuse remain underreported and poorly addressed by institutional mechanisms. This study identifies and fills three gaps in literature. First, many studies have focused on psychiatric and emergency units (Hiebert et al., 2022; Schlup et al., 2021; Varcoe, 2001), which is understandable given the heightened vulnerability of mental health patients and the high-stress nature of emergency care. However, limited attention has been given to abuse of nurses in medical wards, where the intensity of pressure may differ. This points to a significant gap in the literature regarding nurses’ experiences in these settings. The second is context. Existing literature is focused on prevalence and types of abuse (Edward et al., 2016; Orewa et al., 2025), perpetrators and contributing factors (Evans et al., 2023; Yosep et al., 2022), and the consequences of abuse and psychological impact (Alhalal, 2025; Gedik et al., 2023), but little is known about the coping strategies of nurses who experience abuse. Third, the theoretical underpinnings. Many studies apply sociological theories focusing on power relations and organizational culture such as Foucault’s power dynamics and structural violence concepts (Berquist et al., 2018), psychological theories including personality traits influencing vulnerabilities to bullying (Halim et al., 2018), and cognitive adaptation and psychological hardness models (Chapman et al., 2010). This study adopts the Transactional Theory of Stress and Coping, a theory that addresses both the psychological and sociological coping ways of nurses who have been abused. The theory offers a process-based understanding of how nurses cognitively and emotionally interpret abusive encounters, and how these interpretations influence their coping behaviors. Also, while this theory has been widely used to explore how individuals respond to personal stressors, few studies have applied this framework to understand workplace violence within healthcare settings in sub-Saharan Africa.

Hence, this study contributes to filling these gaps by contextualizing coping responses within the medical wards of a district hospital using the Transactional Theory of Stress and Coping as its theoretical lens. Thus, offering new insights into nurses’ experiences of abuse from patients and relatives, how it influences nurses’ behavior and how it interacts with systemic limitations in shaping behavioral outcomes.

Lazarus and Folkman’s (1984) Transactional Theory of Stress and Coping emphasizes that individuals continually evaluate the demands of their environment. Stress is not merely a function of external stimuli but rather how these stimuli are appraised. Primary appraisal involves evaluating whether an encounter is irrelevant, benign, or stressful. If deemed stressful, it is further appraised as a threat, harm/loss, or a challenge. Secondary appraisal assesses what can be done about the situation by evaluating available coping resources such as personal efficacy, social support, and institutional safeguards (Folkman, 2008; Lazarus & Folkman, 1984).

The stressor, which is perceived as threatening or challenging (primary appraisal), prompts the individual to engage in coping strategies aimed either at managing emotional responses (emotion-focused coping) or addressing the stressor directly (problem-focused coping). These coping efforts lead to outcomes that alter the person-environment relationship, which are then reappraised. If the outcome is seen as positive, it elicits positive emotions; if it is negative or unresolved, it leads to ongoing distress, prompting the individual to consider additional coping strategies to manage or resolve the stressor.

The Transactional Theory of Stress and Coping is appropriate for this study because it views workplace abuse as both an external and subjective experience shaped by individual appraisals of threat and coping ability. Distinguishing between problem-focused and emotion-focused coping helps explain how nurses in Ghana respond to abuse through strategies like confrontation, withdrawal, or emotional detachment. The theory also connects personal coping processes to broader institutional and cultural constraints, aligning with the study’s aim to examine how nurses experience and manage workplace abuse in hierarchical, resource-limited healthcare settings.

By grounding the analysis in this model, the paper not only highlights the subjective meaning-making processes that shape nurses’ reactions but also underscores the systemic gaps that perpetuate a culture of impunity and how nurses cope with this stress. Using an ethnography in a medical ward and applying the Transactional theory of Stress and Coping, this paper addresses two research questions: (1) What workplace abuse do general nurses in medical wards face? (2) How do general nurses in medical wards cope with the stress of workplace abuse?

Methods

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.

Physical Abuse

Physical abuse emerged as one of the most direct and traumatic forms of workplace violence experienced by nurses in the medical wards. Participants recounted various acts of aggression perpetrated by both patients and their relatives, often during routine care activities or moments of perceived dissatisfaction. These incidents included slapping, pushing, and other forms of bodily assault, which were not only physically harmful but also emotionally degrading and professionally disempowering.

Franklina (female, 33 years, senior enrolled nurse), a participant in the focus group discussion, vividly recalled: “Sometimes they attack us. I have been slapped before.” Her statement reflects the unpredictable nature of such encounters and the emotional toll they take. Similarly, Moro (male, 27 years, staff nurse) shared: “Some of them don’t comply. A patient slapped me because I reported him to the ward in-charge for refusing to take his medications.” This illustrates how professional accountability, such as reporting non-compliant patients, can expose nurses to retaliation. Francis (male, 32 years, senior enrolled nurse) also recounted a disturbing experience with patient relatives:

Some relatives visited a patient, but they were many, so I asked them to come in twos. One of the guys just came out from the group and pushed me. I fell. I fell flat on my back… When I got up, I asked him why he did that, and he waved me off rudely shouting, fior…fior! (get away…get away)!

These confrontations align with findings by Ekpor et al. (2024), Isara et al. (2024) and, Trahan and Bishop (2016) who underscore that physical abuse, though less frequent than verbal abuse, is a significant source of workplace violence in healthcare settings. According to Lazarus and Folkman’s (1984) Transactional Theory of Stress and Coping, such incidents as Francis, Moro and Franklina encountered are more likely to be appraised by the nurses as highly threatening, triggering primary appraisals of harm and loss. Such appraisals may not only be reactions to physical injury, but also to the broader implications for professional dignity and emotional stability.

Verbal Abuse

Verbal abuse was often initiated through insults. Some patients and relatives exhibited rude and confrontational behavior, which nurses attributed to anxiety, frustration, or individual temperaments of such patients/relatives. On one occasion, I witnessed a patient insult Betty (female, 39 years), the in-charge (IC) nurse for the male ward. The patient called the IC “stupid” because the IC found out he had absconded before discharge (to avoid financial obligation) during an earlier admission to the ward, and the IC had queried him about it. The IC also ignored him, thereafter, avoiding any further interaction, including providing him with healthcare. In this incident, according to the theory, the insult may reflect a primary appraisal moment for the IC, and it is likely perceived as a personal affront and a threat to professional identity, especially given the hierarchical role of the IC within the ward. Another participant also reported a similar instance from a patient’s relative. Bernice (female, 33 years, senior staff nurse) intimated:

A patient’s husband was speaking with us, and a man who accompanied him kept interrupting the conversation. At some point, my in-charge said, “Ah, brother… this is her husband; allow him to talk.” He retorted, “Go away with your foolishness! You don’t respect… eh?” We also told him our piece of mind! Sorry to say this, but sometimes you need to put some sense into them when it gets to this point!

This may be interpreted as threatening through the lens of the theory, the encounter described above reflects an evaluation of the interaction as a direct psychological threat to the nurse’s sense of respect, authority, and professional identity. The verbal abuse, marked by confrontational interruptions and insults, triggered a stress response in the nurse. This gentleman’s hostile behavior would be perceived as harmful and potentially escalating, thereby threatening the nurse’s emotional safety and control.

Georgina (female, 29 years, senior enrolled nurse) also reported:

The other time, one relative said to me, “I”m sure it was this nurse who killed my kin because she never smiles. I even mentioned that when he’s left in her charge, she’ll kill him and yes, she has!

According to the transactional theory, such an accusation would likely be appraised as a personal and professional threat. It challenges Georgina’s ethical standing, competence, and moral character. This verbal abuse may evoke intense emotional responses such as shock, fear, anger, guilt, or helplessness, particularly because it touches on the most sensitive aspect of caregiving, life and death responsibility.

The narrative on verbal abuse was not only limited to nurse-patients/relatives but also colleague-colleague. Mabel (female, 27 years, enrolled nurse) reported bullying behavior by a senior nurse.

During my clinical, we were all afraid of a particular nurse. The way she would speak to you and look down upon you was enough to get you discouraged and depressed at once! “Once, she asked my colleague amidst patients, ‘What use are you as a nurse? Who asked you to be a nurse?’” My colleague cried all day. Since then, we noticed she lost confidence in the work and became timid, which affected her delivery.

Rita (female, 45 years, female ward in-charge) also narrated how a junior colleague also insulted her over a car parking space.

Some people choose to misbehave in the hospital because of their possessions. One bitterly insulted me because I parked my then-old car in the car park. In her view, since she drove a new car, she needed a better spot than I did, so I should rather park under the trees (untarred). This lady is only an enrolled nurse (Junior Nurse) at another ward, and I was not only a Principal Nursing Officer (Senior Nurse) but also an IC!

These narratives reveal intra-professional abuse, which is often overlooked in discussions of workplace violence just as other studies found (Cho et al., 2011; Orewa et al., 2025). In Mabel’s account, the demeaning remarks and public humiliation directed at her colleague likely triggered a perception of personal inadequacy, public shame, and professional invalidation. In Rita’s narrative, the insult from a junior colleague challenged not only her personal dignity but also her professional authority and hierarchical position as an in-charge nurse and senior officer. The fact that the insult was framed around material possessions added another layer of symbolic disrespect, undermining status and professional respect.

Emotional Abuse

Beyond physical and verbal assaults, participants also reported emotional abuse. One of these is the preconceived notion that nurses have poor behavior. Participants argued that many patients arrive at the hospital with preconceived notions about how disrespectful nurses are. As a result, at the slightest provocation from a nurse, they often vent their anger, having already been prepared for the nurses’ poor behavior before arrival. Nurses also explained that these patients’ behaviors may typically stem from having experienced poor behavior from nurses in this or other facilities, or from hearing about others’ experiences from friends and family who attended other hospitals. Hence, this notion becomes the standard for interacting with all nurses. Josephine (female, 33 years, senior staff nurse) elaborated:

Sometimes patients and relatives come in with preconceived ideas about us. They have heard that nurses are not good, so they are ready for you even when you ask the most straightforward question, which only demands a yes or no. If you have not met someone but are already prepared for them, we will also be ready to meet you. When you come along with trouble, I will also meet you with trouble, simple!

Josephine’s narrative highlights the stress-inducing effects of negative societal narratives about nurses and how these perceptions, when internalized by patients, may become relational threats under the transactional theory. As some studies have reported, if a profession is deemed essential, it is because society accords it prestige. Therefore, the positive attitude of patients toward the nursing profession may not only be due to the quality of nurse-patient relationships but also to a positive nursing image. In the same vein, the negative attitude toward the profession may result from the negative nursing image (Akgün & Kardas, 2014; Midilli et al., 2017). Therefore, it was not surprising that nurses reported patients disrespected them due to preconceived notions about the nursing profession.

Perceiving nurses as incompetent is another form of emotional abuse that the nurses complained about, resulting in unprofessional conduct between themselves and patients/relatives. Some clients considered the nursing profession inferior or think nurses do not know their jobs. They rank doctors higher than nurses, just as Zhang et al. (2017) also found that the nursing profession in China has a relatively lower social ranking than doctors because nursing is deemed less prestigious than a doctor’s job. Hence, even if patients/relatives object to a particular treatment (whether they understand it or not), they are more likely to vent their frustrations on nurses rather than on doctors; nurses then become victims of abuse. Stella (female, 29 years, staff nurse) purported:

Sometimes, we encounter patients or relatives who claim that you are not competent enough to care for their kin. That is when I come in, blast them, and make them understand that that is not how you talk to people!

As seen in Stella’s feedback, such statements are likely to be interpreted as personally offensive and professionally damaging, particularly within a context where respect and recognition are integral to a caregiver’s identity.

Another common form of emotional abuse expressed by participants was described as “patient’s payback.” In the Ghanaian context, it is not unusual for nurses to support financially struggling patients with expenses such as medication or food. One such situation involved a nurse who phoned a patient’s relative about the need to purchase a medication of GH¢100 (approximately US$13 at an exchange rate of 7.9 as at the time of data collection). The relative, unable to pay at the time, pleaded that the nurse cover the cost and promised reimbursement when he next visited. Acting out of urgency, the nurse complied and informed a colleague on the next shift. However, the patient was discharged the next day, but none of her colleagues on that shift were aware of this arrangement, and the informed colleague was not on duty that day. The man did not pay and said nothing about this debt upon discharge. The nurse felt deeply betrayed. In response, she chose not to assist similar cases again. Though not part of their official duties, previous hospital ethnographies by Van der Geest and Sarkodie (1998) and Dapaah (2016) similarly highlight instances where nurses extended financial help to patients.

Several nurses also shared accounts of personal sacrifices, ranging from paying for treatment to providing food, only to feel unappreciated or misled by patients. These experiences were likely interpreted as acts of betrayal, prompting some nurses to vow never to offer such support again. Consequently, when nurses later decline similar requests, patients sometimes perceive them as unkind or inhumane, despite financial support being outside their professional remit. Rita (female, 45 years, female ward IC) observed thus:

Sometimes, it is painful to sacrifice for patients. It hurts when the patient you fed from your own pocket does not acknowledge your effort. Some insult us, so you retaliate and tell them your piece of mind. It cools your soul. We have now stopped financially assisting patients. They are taking advantage of us.

According to the theory, this perceived ingratitude and verbal abuse may be interpreted as threats to her sense of moral worth, empathy, and professional identity. The physical and emotional abuse of nurses is consistent with that of other researchers on workplace violence (Ekpor et al., 2024; Isara et al., 2024). In Babiarczyk et al.’s (2020) report on workplace violence against nurses in five countries, including Poland, the Czech Republic, the Slovak Republic, Turkey, and Spain, more than half of the participants (nurses) in each of these countries had experienced emotional violence, while a few had experienced physical attacks in the last 12 months before the study. Nevertheless, one-third of the participants had experienced both types of violence/abuse.

Sexual Harassment

Sexual harassment was commonly reported in two forms: verbal advances and unwanted physical contact, primarily from male patients expressing sexual interest toward female nurses in inappropriate clinical settings. While consensual interactions between adults may be acceptable in general contexts, the professional environment of a hospital makes such expressions ethically unacceptable. Rita (female, 45 years, female ward in-charge) remarked that it would be more appropriate to express such interest outside work hours.

What nurses found most disturbing were instances in which male patients attempted to touch them inappropriately during care routines. In response, some nurses took measures such as issuing warnings or withdrawing care responsibilities for fear of further escalation, referencing previous cases of assault. Samuela (female, 33 years, senior nursing officer) confessed:

I was setting his line when he touched my buttocks. At first, I pretended nothing had happened, just to give him the benefit of the doubt. Then, when it happened again, I gave him a stern warning. Since then, I did not nurse him again because I heard of a situation where a nurse was raped.

Georgina (female, 29 years, senior enrolled nurse) also elaborated:

Sometimes male patients want to kiss or hold you, so if you are on night duty with such a patient, you always have to be alert. A patient said he wanted to kiss me. His wife was outside the ward, so I asked her to come in and do her wifely duty [both laugh]. Some will look at you lustfully; some will be hallucinating and will even go to the extent of touching your hair.

Samuela and Georgina’s accounts reflect direct sexual harassment in the clinical setting, which, according to the transactional theory, is perceived as a serious threat to personal safety, bodily autonomy, and emotional well-being. These encounters are not merely uncomfortable, they are evaluated as physically and psychologically threatening, especially within the hierarchical nurse-patient relationship where professional boundaries are expected. These experiences prompted some female nurses to distance themselves from male patients or to avoid specific care assignments entirely. Maintaining a composed demeanor after experiencing such violations was emotionally taxing.

Male nurses interviewed had not experienced any form of sexual harassment from patients, their relatives, or co-workers, although they acknowledged physical and verbal abuse. This disparity underscores gendered dimensions of workplace abuse, revealing that female nurses face additional risks of sexual vulnerability, whereas male nurses encounter non-sexual forms of violence, denoting a power play and the sexual vulnerability of women as compared to men.

Similar studies in Ghana that reported sexual abuse also found that the main offenders of workplace sexual harassment against the nurses were male physicians, male nurses, male relatives of patients and male patients (Mohammed et al., 2024). Mohammed et al. (2024) also report that gender, years of work experience, type of healthcare facility (by ownership), and marital status were significant predictors of nurses’ likelihood of experiencing sexual harassment. Boafo et al. (2016) also revealed that the experience of sexual harassment emerged as the strongest predictor of nurses’ intention to emigrate.

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.

Conclusion

This study has illuminated the multifaceted nature of workplace abuse experienced by nurses in a Ghanaian public district hospital and analyzed their coping mechanisms through the lens of Lazarus and Folkman’s Transactional Theory of Stress and Coping. The findings reveal that nurses face a spectrum of abuse, physical, emotional, sexual, and verbal, primarily from patients, their relatives, and sometimes colleagues, which they appraise as threats to their safety, dignity, and professional identity. The narratives suggest that intra-professional verbal abuse, just like patient-perpetrated violence, may trigger complex psychological appraisals and nurses, regardless of rank, evaluate these experiences as deeply threatening to their personal and professional identity.

The coping responses adopted, whether emotion-focused or problem-focused, are shaped by personal resilience, peer support, and, crucially, institutional constraints. While some nurses demonstrated adaptive coping through emotional detachment or cognitive reframing, many reported adverse outcomes such as burnout, emotional withdrawal, absenteeism, and even regret over their career choice. These outcomes were compounded by inadequate institutional responses, a lack of formal support systems, and an overemphasis on patient rights at the expense of staff safety. Secondary appraisal processes suggest that nurses often perceive themselves as unsupported and powerless, leading to disengagement and a decline in morale.

This research makes three significant contributions to literature. First, by focusing on general medical wards, a relatively understudied space, it challenges the prevailing emphasis on psychiatric and emergency units. Second, it shifts attention beyond prevalence to explore how abuse is coped with and internalized. Third, by applying the Transactional Theory of Stress and Coping, it introduces a theoretically grounded framework that captures both the psychological and structural facets of nurse abuse. The study also extends the theory to low-resource healthcare settings, showing that stress is not just an individual reaction but a socially, culturally and structurally embedded process.

Practically, the findings show that these patterns may reflect weak institutional support and silence around abuse, which may push nurses toward emotion-focused coping, such as withdrawal or detachment, rather than problem-solving. The study calls for interventions that strengthen coping resources, like providing psychosocial support such as counseling, effective reporting systems, and introducing training for all hospital staff on managing workplace abuse. A more balanced rights-based framework is also needed to ensure nurses’ protection alongside patient rights. Additionally, public education campaigns should be launched to improve societal perceptions of the nursing profession, reduce stigma, and foster mutual respect. Together, these measures can help create a safer, more supportive work environment and strengthen nurse retention and professional morale.

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.