Nursing Clinical Teachers’ Knowledge, Attitudes, and Practices about Nursing Students Suffering from Workplace Violence in China: A Cross-Sectional Survey

WPV. Also, it should be incorporated into the preservice training system for nursing clinical teachers. Te content of training could focus on the sources, manifestations, infuencing factors, and prevention strategies of NSs sufering from WPV. Te method could be online theoretical teaching combined with ofine scenario simulation exercises. At the same time, strict admission criteria for nursing clinical teachers can be helpful in protecting the safety of NSs during the clinical rotation phase. For nursing managers, they should be kept abreast of organisational policies and adopt a zero-tolerance policy towards violence. It also can be recommended that nursing clinical teachers should be proactively involved in training to improve their own ability to protect NSs.


Introduction
Te COVID-19 emergency highlights the importance of nurses but also exacerbates the nursing workforce shortage.Nursing students (NSs) are the hope of the caring profession.Retention of them is a strategy to solve the problem [1].Workplace violence (WPV), a worldwide problem [2,3], has been shown to be one of the important factors afecting NSs' career choice satisfaction [4].Terefore, it is important to help them in preventing and managing WPV.Nursing clinical teachers are good individuals to achieve the aim.
In clinical rotation, nursing clinical teachers are the people who have the most contact with NSs.It is one of their responsibilities to help NSs manage WPV.However, there is little existing research about it.Tis study aims to assess nursing clinical teachers' knowledge, attitudes, and practices toward NSs sufering from WPV.

Background
WHO defned WPV in 2002 as "incidents where stafs are abused, threatened or assaulted in circumstances related to their work, involving an explicit or implicit challenge to their safety, well-being or health" [5].It includes physical assault, verbal abuse, threats, sexual harassment, and other forms [6].Compared to any other medical workers, nurses were vulnerable to sufering from WPV [7].However, the incidence of WPV experienced by NSs was also very high, ranging from 37.3% to 70% [8][9][10].For NSs, the source of WPV includes patients, nursing clinical teachers, and other health workers and peers [3].
NSs who have been exposed to WPV may experience physical morbidities or have psychological symptoms, such as headache, anxiety, fear, and low self-confdence [8,11,12].At the same time, WPV has the potential to afect their social life [13].Te more serious consequence is that WPV can lead to a signifcant decline in career choice satisfaction [4], creating further challenges for nursing, and exacerbating the workforce shortage [14].Terefore, how to help NSs manage WPV needs to be given full attention.
In clinical rotation, nursing teachers are the most needed groups for NSs.Tey are important in teaching NSs the necessary professional knowledge and skills, including managing WPV.Tey are the best protectors of NSs, because of their extensive work experience and expertise.Actually, many WPVs cannot be easily detected, and the majority of NSs in response to WPV is silent [14].Tus, nursing clinical teachers need to be aware of the emotional changes of NSs and to detect the development of negative emotions.At the same time, it is important to note that nursing clinical teachers can also be perpetrators of WPV to NSs [15].So, it is necessary for teachers to learn about WPV and regulate their behaviour.
At present, most of the research on managing NSs sufering from WPV is focused on how to improve NSs' awareness and enhance their ability to prevent and cope with it [16,17].Only a few suggestions about nursing clinical teachers can be found in the discussion or implication of articles.MacDonald et al. have mentioned that nursing clinical teachers should consistently respect NSs in all interactions, regularly refect on their own behaviour and communication, and establish facilitation skills to support and protect NSs as manage WPV [18].It is necessary to strengthen the education or training programs to teach communication skills to nurses and nursing clinical teachers who participate in the clinical practicum of NSs [19].At the same time, nursing clinical teachers by reviewing their past student experiences will also improve teaching methods and communication strategies [20].Tese ideas can serve as a reminder of inspiration for the administrators or nursing clinical teachers, but not systematic.Tere is a paucity of evidence surrounding the extent to which nursing clinical teachers are formally prepared to respond to NSs sufering from WPV.
Tis study is guided by the theory of knowledge, attitudes, and practices (KAP theory).It is one of the common theories used to investigate the state of behavioural implementation and to explore the impact factor, including three elements: knowledge, attitudes, and practices [21].Adequate knowledge helps to build positive attitudes, which are the basis for the emanation of practices.Attitudes are the driving force behind the development of practices [22].Finding out about the level of clinical teachers' knowledge, attitudes, and practices regarding NSs sufering from WPV can help identify defcits in their managing.Based on the situation, measures can be taken to improve the level of knowledge to help them change the attitudes and enhance the ability to manage NSs sufering from WPV.
Te aims of our study were to assess the knowledge, attitudes, and practices of nursing clinical teachers towards NSs sufering from WPV and to analyse the impact factors.We hope that this study can provide a foundation or a practical basis for developing a more comprehensive and scientifc strategy or policy for the protection of NSs.Te self-designed scale includes three sections.Section 1 named "knowledge" revolved around the concept, sources, manifestations, consequences, and prevention and coping measures of NSs sufering from WPV and contained 5 second-level indexes and 18 items.Section 2 named "attitudes" was set with the goal of exploring nursing clinical teachers' attitudes toward factors that infuence the NSs sufering from WPV and contained 3 second-level indexes and 7 items.Section 3 named "practices" shared 2 secondlevel indexes, prevention and coping, with 19 items.Each item was answered on a Likert 5-point scale ranging from strongly disagree (score 1) to strongly agree (score 5).Higher scores indicate higher levels of nursing clinical teachers' knowledge, attitudes, and practices about NSs sufering from WPV. Te scale was developed in 2022.Te frst draft was formed through a literature review, semistructured interviews, and the Delphi method.We administered the questionnaire to 302 nursing clinical teachers from three hospitals in Hubei province, China.Te collected data were subjected to item analysis, validity test, and reliability test.Te item content validity index (I-CVI) of the scale's content validity fuctuated from 0.90 to 1.00, and the scale content validity index using the averaging method (S-CVI/Ave) was 0.981.Te results of exploratory factor analysis (EFA) showed that there were 4 factors with eigenvalues greater than 1 in the knowledge index, with a cumulative variance contribution rate as high as 73.897%, and each item had a loading of >0.5 in only 1 of the factors.Tere were 2 factors for the attitudes index with a cumulative variance contribution of 75.388%, of which 1 item was deleted as its contribution to both factors was <0.5.Te EFA was again performed, with a cumulative variance contribution of 81.046%, and the remaining items met the retention requirement.Te number of factors for the practices index was 2, with a cumulative variance contribution of 82.052%, with each item loading >0.5 in only 1 factor.Te structural validity of the scale was good.In terms of reliability, the Cronbach's α of the scale was 0.961, the Cronbach's α of the knowledge index was 0.920, the Cronbach's α of the attitudes index was 0.904, and the Cronbach's α of the practices index was 0.977 (P < 0.001).Te intraclass correlation coefcient (ICC) of the scale was 0.650, and every index's ICCs were in the range of 0.740 to 0.881 (P < 0.001).Te content of the scale is shown in Attachment 1.

Data Collection.
We distributed and collected the questionnaire using a professional online questionnaire survey, evaluation, and voting platform called Questionnaire Star in China.In July 2022, 869 valid questionnaires were returned with a valid return rate of 96.56%.

Ethical Considerations. Te study was approved by the Ethics Committee of Tongji Medical College of Huazhong
University of Science and Technology (No. S124), and appropriate permission was obtained from the director of nursing of the participating hospitals.Te questionnaire collection process is carried out on the premise that survey respondents participate in the survey voluntarily.
3.5.Data Analysis.SPSS 26.0 software was used for the analysis.Demographic information was described in the form of frequencies and percentages.As the data collected did not conform to a normal distribution, mean ± SD, the median (P 25 , P 75 ), and average score rate (the average score/ full score × 100%) were used to describe each index and item score.Te Shapiro-Wilk test was performed, and the results showed that the data did not conform to a normal distribution.Terefore, the impact factors were analysed using nonparametric tests (Mann-Whitney U test and Kruskal-Wallis H test), and P < 0.05 indicates statistical significance.For the correlation analysis of the three index scores, Spearman's correlation analysis has been used.6) teachers who had experienced WPV were signifcantly more knowledgeable than those who had not; (7) teachers who had witnessed WPV against NSs were signifcantly more knowledgeable than those who had not; (8) teachers whose NSs had sufered from WPV had signifcantly higher levels of knowledge than teachers who had no such experience.

Characteristics of the
In the attitudes index, the result of pairwise comparisons showed that (1) teachers younger than 50 scored much higher than those older than 50; (2) teachers with bachelor's and master degrees scored signifcantly higher than those with college degrees; (3) teachers with more than 15 years of work scored signifcantly lower than those with 6-10 and 11-15 years of work; (4) as the highest educational level of NSs that can be taught increased, the scores of teachers increased gradually; (5) teachers who had received training on prevention and coping with WPV scored signifcantly higher than those who had not received training.
In the practices index, the result of pairwise comparisons showed that (1) the practical abilities of teachers working in the operating room were signifcantly higher than those of teachers working in the department of obstetrics and surgery; (2) in terms of teachers' highest academic degree obtained and the highest educational level of NSs that they can be taught, there was no signifcant diference in pairwise comparisons; (3) the practical abilities of teachers who were deputy chief nurses or above were signifcantly lower than that of teachers who were senior nurses and supervisor nurses; (4) the practical abilities of teachers who had received training on prevention and coping with WPV were signifcantly higher than those of teachers who had not received training.

Correlation analysis of the Tree First-Level Indexes.
Tere was a signifcant positive correlation between nursing clinical teachers' knowledge, attitudes, and practices towards NSs sufering from WPV (P < 0.05) as shown in Table 4.

Discussion
Tis study was the frst to investigate WPV experienced by NSs from the perspective of nursing clinical teachers.Te study was guided by the KAP theory.Te fndings revealed a signifcant correlation between the 3 indexes, proving the KAP theory's viability as the theoretical foundation and research framework for the study.From the results, it appears that the nursing clinical teachers who participated in the survey had a moderate level of knowledge, attitudes, and practices regarding WPV against NSs.Because WPV against NSs is a negative event with serious consequences, the nursing clinical teachers' knowledge, attitudes, and practices average score rate should be as close to 100% as possible.However, the average score rates of all indexes are not up to 90%.Terefore, the level is medium.In the knowledge index, the second-level indexes with the highest average score rate were "defnition" and "consequences, prevention, and coping with WPV," and the item with the highest average score rate was "it is nursing clinical teachers" duty to help NSs prevent WPV, indicating that the participating nursing clinical teachers have a strong responsibility and can be more aware of their role in protecting NSs.Te second-level index with the lowest average score rate was "sources" of WPV for NSs.Further analysis of the contents of the three items with the lowest average score rate showed that they are not fully knowledgeable about the sources of WPV that NSs face.Tey were highly aware of external sources of WPV experienced by NSs (the perpetrators including patients and their families).But type III violence, which refers to violent acts by health worker to health worker, has not received enough attention and even lower awareness about the possibility of becoming perpetrators themselves.Terefore, nursing clinical teachers should be trained to increase their knowledge of WPV type III in NSs.In the attitudes index, the three lowest-scoring items all belong to the second-level index of "NSs and patients."It can be demonstrated that they did not pay sufcient attention to NS factors and patient factors that may lead to NSs sufering from WPV, which may be related to insufcient teaching experience, lack of WPV training, or teachers' belief that nurses are unable to intervene in patients' behaviours and perceptions.Regarding practices, the abilities to prevent WPV experienced by NSs are inadequate.Tis is especially apparent in whether clinical teachers had learned the knowledge and skills to prevent and cope with WPV and the timing of invasive nursing practices chosen.At the moment, hospitals and nursing management should take action to make up for the clinical teachers' lack of knowledge, attitudes, and practices.Only 48% of the clinical teachers had received training in managing WPV in the study.Also, the surveys have indicated that identifed challenges in managing WPV include inadequate training resources and inconsistent training models [24].As a result, it is essential that health organisations and institutions carry out training on the management of WPV in groups of clinical teachers, particularly about WPV that NSs may face.It can be included in the system of prejob training for them.In the theoretical education phase, web-based courses can be implemented to increase fexibility and participation in course scheduling.Also, according to the results of our study, whether a clinical nursing teacher has personally experienced WPV and whether one has witnessed and dealt with an NS being subjected to WPV will have an impact on the knowledge index scores.It can prove that the experience of WPV makes them more sensitive to the knowledge and more impressed with the content of education and training about it.Terefore, in behavioural training stages, scenario simulation rehearsal can also be added to the training to better help clinical nursing teachers achieve the transition from theory to practice.Khan et al. also have suggested that more realistic scenario-based interactions should be added to WPV management training for employees [25].Additionally, the WPV-trained teachers performed better on the attitudes and practices indexes.Tis underscores the importance of teachers' active engagement in the WPV management training.Tus, clinical teachers also should have a positive mindset and take the initiative to participate in training and learning in parallel to health organisations and institutions carrying out training on the management of WPV.After learning about NSs sufering from WPV, they should consciously regulate teaching behaviour.
Nursing clinical teachers' knowledge and attitudes scores are infuenced by their age and years of work.Tose who are younger with 6-10 years' work and 11-15 years' work in clinical are more able to learn new knowledge, more adaptable, and more experienced and have a systematic clinical mindset.Tese advantages can help them to better undertake the task of clinical teaching.Te highest academic degree obtained is also an infuencing factor.In China, undergraduate education focuses more on the development of systematic thinking than specialist education.Also, it also places a higher emphasis on students' mastery of theoretical professional knowledge.Terefore, teachers with bachelor's degrees scored signifcantly higher in all three areas than teachers with college degrees.In conclusion, when choosing clinical teachers, these aspects should be taken into consideration.It might make it possible to teach and protect NSs in clinical rotation using a more comprehensive and scientifc approach.
In the department, the management of NSs sufering WPV within the department is equally important.Leaders should manage NSs systematically and impartially.It is feasible to provide the necessary support to nursing clinical teachers and NSs, such as opening channels for reporting.At the same time, there should be a zero-tolerance attitude and management because it can efectively reduce the incidence of WPV [26].Also, leaders' attitudes and approaches to violence resolution are critical in the link between WPV and victims' depressive symptoms [27], so it will also increase NSs' sense of organisational security.

Conclusions
In terms of managing WPV experienced by NSs, this study was the frst to investigate from the perspective of nursing clinical teachers.In China, nursing clinical teachers in the knowledge, attitudes, and practices indexes of NSs sufer

Table 1 :
Participants.A total of 869 nursing clinical teachers participated in this survey, of whom 848 (97.58%) were female and 21 (2.42%) were male; age ranges from 23 to 59 years, mean ± SD � 35.2 ± 5.9 years; 89.3% of the nursing clinical teachers had a maximum degree of bachelor's degree, and 61.91% had the title of supervising nurse practitioner.Te other sociodemographic characteristics are shown in Table1.4.2.Questionnaire Scores.Te average score rate of the knowledge, attitudes, and practices index was 77.24%, 83.17%, and 87.20%, respectively.In the knowledge index, the section on sources and forms of NSs sufering from WPV has a low average score rate of 62.25% and 74.05%; in the attitudes index, the nursing clinical teachers had lower Journal of Nursing Management Demographic details (N � 869).
(5)e signifcantly more knowledgeable than those with more than 15 years; (4) teachers with 1-5 years of clinical teaching experience were signifcantly more knowledgeable than those with more than 15 years;(5)in terms of the highest educational level of NSs that they can be taught, there was no signifcant diference in pairwise comparisons; (

Table 3 :
Single-factor analysis of general demographic information for each index.For two independent samples, the Mann-Whitney U test for nonparametric tests was used, with the indicator being the Z-value.For multiple independent samples, the Kruskal-Wallis H test was used, reporting the H value of the test.Q1: Have you received training on prevention and coping with WPV? Q2: Have you ever experienced WPV? Q3: Have you ever witnessed WPV against NSs? Q4: Have your NSs been subjected to WPV? Te bold values indicate P value less than 0.05.

Table 4 :
Correlation analysis of the three frst-level indexes.Journal of Nursing Management from WPV on medium.Tere are still defciencies in knowledge about the sources of violence, perceptions about infuencing factors, and behavioural practices for prevention.Terefore, due attention should be given to the training and education of clinical teachers in the management of NSs sufering from WPV.When selecting clinical teachers, the criteria of them need to be strictly controlled.NSs subjected to WPV should be given full attention.Before clinical nurses become teachers, it is necessary to develop targeted training around the management of WPV experienced by NSs, including the causes, sources, prevention, and coping with violence.Because of the busy work schedule, training can take the form of a combination of online theoretical teaching and ofine scenario simulation practices.Department managers should provide the necessary internal organisational support for NSs and clinical teachers.At the same time, the admission criteria for teachers should be strict.Teir age, experience of work, highest academic degree obtained, and professional competence should be considered whether being in the most suitable range for teaching work.Tese can help to improve the efectiveness of the management of NSs sufering from WPV.