Determination of Nursing Students’ Resilience Levels, Care Behaviors, and Violence Management Competencies: A Descriptive, Cross-Sectional, and Relational Study

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Introduction
Individuals face many stressful situations and traumas throughout their lives [1,2].Tese stresses and traumas they encounter afect many areas of their lives, such as their private lives and school and work performance, and also disrupt their life balance.Traumatic experiences create intense negative emotions such as fear, helplessness, insecurity, anxiety, guilt, anger, timidity, and worthlessness in the individual.However, as a result of research studies, it has been stated that 5%-35% of people succumb to this negative situation in cases of stress and trauma [3,4].
Nursing students face many stress factors that afect their academic success and quality of life from the beginning of their educational experience [5][6][7].In the COVID-19 pandemic process, which has afected the whole world and our country, the limitations of the application areas in the education process, the uncertainties regarding graduation, the fear of losing due to COVID-19, and the long-term and uncontrollable stress experienced negatively afect their professional identities and health status.It is widely accepted that students lose their academic achievement by weakening of their thinking and decision-making skills [5,[8][9][10].
Nursing students' exposure to long-term and uncontrollable stress negatively afects their professional identities and health status [5,8].It has been shown in studies that it causes them to experience high-risk situations in terms of health [11].Tese efects are directly related to the adequacy of individual coping behaviors [12].Te effective use of coping strategies and high psychological resilience protect health [13].Students need to develop effective coping behaviors to cope with stress and to keep their psychological resilience high, as it will enable them to beneft from their education most appropriately, as well as to create a positive professional identity [5].
Individuals with high psychological resilience see the trauma they experience as an opportunity for their development, get rid of distress, and focus on positive change, relaxation, and psychological development [14,15].Te level of psychological resilience is a personal characteristic that protects individuals who are faced with negativities and stressors [16].Psychological resilience is seen as the process of adapting to important sources of stress such as serious health problems, trauma or familial and relational problems, and violence [17].If the person is psychologically resilient, he will continue to develop by the characteristics of his developmental period, fulfll the duties expected of him, maintain his relationships healthily, and be a successful individual both in his school life and in his private life.It is important for nursing students, who are an important part of the health team and future health professionals, to build, learn, and develop their psychological resilience, both for their health and the health of the group they care for [18].
Te concept of nursing and care are inseparable parts of a whole that has an academic and historical relationship [19].Te concept of care, which is defned by all nursing theorists, constitutes the essence of the nursing profession [20] and represents all the practices in health services that nurses provide to patients [21].It is internationally accepted that the concept of care is the basis of a good and efective nursepatient relationship [22].Te quality of care provided by nurses greatly contributes to the health care quality of the institution [23,24].
Violence is violence against a person or a group.It is the use of force that results in physical, sexual, or psychological harm.However, in recent years, it has been observed that workplace violence includes psychological violence as well as physical violence [25].Psychological violence is a constant attack on victims' self-confdence and self-esteem [26].It includes meanings that express behaviors such as all kinds of maltreatment, threats, violence, and humiliation systematically applied to individuals by their superiors, equal-level employees, or subordinates [27].Te violence that nurses encounter in the workplace originates from patients, relatives, physicians, and fellow nurses [28][29][30].Violence committed by nurses against nurses is quite common.While the violence seen between nurses at similar levels in a hierarchical system is called horizontal or lateral violence, the violence committed by nurses in higher positions against those in lower positions is called vertical violence [30].
Psychiatric nurses, as the healthcare professionals who are in most frequent contact with their clients, may be the most frequent victims of patients' aggression.Violent behaviors exhibited by psychiatric patients can include verbal abuse, physical threats or assault, and sexual harassment, all of which harm the victim both psychologically and physically [31].Although medications are efective in controlling psychiatric symptoms and therefore reducing aggression, it takes time for the medication to work.Terefore, aggression is common in the acute psychiatric healthcare setting.Liu et al. [32] reported in their study that 84.2% of the mental health nurses were attacked by their patients.Workplace violence has also been found to be a major cause of occupational stress among mental health nurses [33].Hasan and Tumah [34] reported in their study that there may be moderate to high levels of occupational stress among mental health nurses due to their job characteristics.
Violence in health, which has increased in recent years, reduces the motivation of nurses and negatively afects the quality of care [35].Violence in the feld of health is an important public health problem that negatively afects the physical and mental health of individuals [36][37][38].Among healthcare professionals, nursing students are more exposed to violence due to their young age, insufcient clinical experience, and difculty in communicating quickly with patients and nurses due to frequent rotations in clinics [38][39][40].When the studies conducted in Turkey were examined, it was found that nurse students were more exposed to verbal violence in the feld of practice [41,42].Clinical violence has negative efects on nursing students, and it is noteworthy that verbal abuse has more negative efects on clinical performance and emotions than physical violence.Violence against nursing students not only causes psychological harm but also afects their clinical performance and reduces the quality of patient care [39].However, the thought and behavior of leaving the profession may develop more in nursing students who are victims of violence, and as a result, leaving the profession may be the cause of nurse inadequacy in the future [43,44].
It was determined that the anxiety levels of nursing students who were exposed to violence increased, and in parallel, the duration of absenteeism increased in clinical practice processes [45].In addition to its physical and psychological negative efects on nursing students, violence also negatively afects students' perspectives, professional attitudes, and roles.Violence also reduces the job satisfaction of nursing students, negatively afects the quality of education and patient care standards, and impairs students' communication skills with patients and other health professionals [44,46].For this reason, it is important to determine the violence management competency status of nursing students.
In the literature, no study has been found that examines the psychological resilience level, care behaviors, and violence profciency status of nursing students together.In this context, this study is unique.Tis study aims to determine the psychological resilience levels, care behaviors, and violence management competencies of nursing students.

Participants and Setting.
Te population of the research consisted of 71,538 nursing students who received undergraduate education in Turkey.Te sample size of the study was determined as at least 382 nursing students with the known universe sample calculation formula [19].Te research was carried out with 454 nursing students in Turkey in August 2022.Nursing students who accepted to participate in the study and flled out the forms formed the sample of the study.Te purpose and nature of this study were explained to the participants, they were invited to participate in the research, and then the forms were applied.Te data of the research were collected via WhatsApp and prepared in Google Forms.

Data Collection.
To collect the data for the study, the personal information form, the Psychological Resilience Scale for Adults, the Care Behaviors Scale-24, and the Violence Management Competency Scale for nursing students were used in the study.Te personal information form was prepared by the researchers in line with the current literature.Te Adult Resilience Scale, Caring Behaviors Scale-24, and Violence Profciency Scale are reliable measurement tools that have been validated and are reliable in the Turkish society.By applying the aim of the article, the measurement of nursing students has safely measured the targeted parameters, and its use and intelligibility are at a good level.Tis study was reported following the STROBE recommendations.

Personal Information
Form.Te personal information form was prepared by the researchers on the literature [47][48][49], and this form consists of a total of ten questions including questions about the age, gender, class, marital status, economic level, place of residence, and situations of experiencing violence of students.(RSAs).RSA, which was developed by Friborg et al. [50], was translated into Turkish by Basim and Cetin [17] and its validity and reliability were established.Te evaluation of scale items was released as in the original study.To get rid of the acquaintance bias, the fve boxes opposite the answers are evaluated in a fve-point Likert format and the desired evaluation is made.If it is desired to increase psychological resilience as the scores increase, the answer boxes should be evaluated as 1, 2, 3, 4, and 5 from left to right.If this opinion is taken into account, in the scale, questions 1, 3,4,8,11,12,13,14,15,16,23,24,25,27,31, and 33 are reverse questions.Te total Cronbach alpha coefcient of the original scale is 0.86.Caring Behaviors Scale-42 (CBS-42) was developed by Wolf et al. [51].It was designed by the patient and the nurse in 1994 to evaluate the nursing care process bilaterally.In 2006, Wu et al. transformed it into the Caring Behaviors Scale-24 (CBS-24) as the short form of BDS 42 [52].Te Turkish validity and reliability study of the Caring Behaviors Scale-24 (CBS-24) form was conducted by Kursun and Kanan [53] in 2010, and the Cronbach alpha value was found to be 0.97 in patients and 0.96 in nurses.Te scale consists of the following 4 subgroups: assurance, knowledge skills, respect, and commitment.8 items (16, 17, 18, 20, 21, 22, 23, and 24) for the assurance subdimension, 5 items for the knowledge-skills subdimension (9, 10, 11, 12, and 15.), a total of 24 items for the respect subdimension, 6 of which are for the subdimension of beingness (1, 3, 5, 6, 13, and 19), and 5 for the subdimension of commitment (items 2, 4, 7, 8, and 14).A 6point Likert-type scale (1: never, 2: rarely, 3: sometimes, 4: usually, 5: often, and 6: always) is used for each item of the scale.Scoring of the scale is done by summing the scores corresponding to the answers given and calculating the arithmetic mean.In this way, in addition to obtaining a single score from the scale, subdimension scores are also obtained.Te increase in the total score of the scale and the scores obtained from the subdimensions indicates that the level of perception of the quality of care of the patients or nurses increases.

Violence Management Profciency Scale in Application
Areas for Nursing Students.It was developed by Lu et al. [54] and consists of 28 items.Turkish validity and reliability of the scale was performed by Karabey et al. [55]; the Cronbach α value was found to be 0.96.Te scale items are 5-point Likert-type, i.e., (1) strongly disagree, (2) disagree, (3) undecided, (4) agree, and (5) strongly agree.Te total score of the scale consists of the sum of the items scored according to the answers given by the nursing students in line with the abovementioned scoring.Te minimum score that can be obtained from the scale is 28, and the maximum score is 140.

Data Analysis.
Te data obtained from the study were evaluated using SPSS.25 statistical package program.Frequency and percentage were used in the analysis of sociodemographic data.Te normality of the data was checked using the Kolmogorov-Smirnov test.When comparing data that ft normally distributed, the independent sample t-test for two independent groups and the F-test (ANOVA) for more than two groups were analyzed.He used Spearman correlation analysis to examine the relationship between variables.Te signifcance level was taken as p < 0.05.

Ethical Considerations. Written permission was obtained from the noninterventional clinical research Ethics
Committee (2022/10-35) before starting the study.Te students participating in the study were informed about the purpose of the study and their consent was obtained.Te study was conducted by the principles of the Declaration of Helsinki.

Research Questions
(1) What are the resilience levels of nursing students?(2) What is the violence management competence of nursing students?
Perspectives in Psychiatric Care

Results
Te distribution of nursing students according to some introductory characteristics is given in Table 1.It was determined that 74.4% of the students participating in the study were women, 95.8% were between the ages of 18-23, 54.4% had an income equal to their expenses, and 67.8% stayed in the dormitory.Again, it was found that 11.46% of the students were exposed to violence, 86.5% of the students who were exposed to violence were exposed to sexual violence, and 42.3% of the students were found to stay away from the violence to cope with it.
Table 2 shows the distribution of nursing students' total score averages and subdimension mean scores of the Resilience Scale, Caring Behaviors Scale, and Violence Management Profciency Scale.It was determined that the mean score of the students on the psychological Resilience Scale was 100.18 ± 13.04, the total mean score on the Caring Behaviors Scale was 5.15 ± 0.67, and the total mean score on the Violence Management Efciency Scale was 108.83 ± 16.31.
In Table 3, some introductory characteristics of the students included in the study and the total and subdimension mean scores of the Resilience Scale are presented.Te self-perception subdimension of the students aged 18-23 who participated in the study was 19.25 ± 3.35 (p � 0.001), the family reconciliation subdimension score average was 18.52 ± 4.50 (p � 0.001), and the social resources subdimension average was 19.16 ± 4.54 (p � 0.002).Te mean score of the structural style subdimension of the students whose income is more than their expenses was found to be 10.19 ± 3.27 (p � 0.005), and the mean score of the social profciency subdimension was 20.42 ± 2.54 (p � 0.002).Te future perception subdimension mean score of the students living with their friends at home was 15.12 ± 1.88 (p � 0.003), and the structural style subdimension mean score was 10.05 ± 3.91 (p � 0.004).
Table 4 shows some introductory characteristics of nursing students and the total score and subdimension mean scores of the Caring Behaviors Scale.Tere was no statistically signifcant correlation between students' descriptive characteristics and their Caring Behaviors Scale scores.
According to the descriptive characteristics of the students participating in the study in Table 5, the Violence Management Adequacy Scale's total score and subdimension mean score are given.Te mean postevent recovery subdimension score of male nursing students was found to be 40.44 ± 6.98 (p � 0.003).Te violence response and interaction subdimension mean score of the students living with their friends at home was 12.43 ± 2.03 (p � 0.004), and the Violence Management Profciency Scale mean score was 115.56 ± 6.33 (p � 0.002).
Table 6 presents the relationship between the psychological resilience care behaviors and violence management profciency of the students included in the study.Tere was a positive and moderate relationship (r � 0.399, p � 0.001) between the students' Resilience Scale and the Violence Management Adequacy Scale and a positive and weak relationship between the Caring Behaviors Scale and the Resilience Scale (r � 0.255, p < 0.05).When the relationship between violence management profciency and care behaviors is examined, it can be said that there is a positive, moderate, and signifcant relationship (r � 0.514, p < 0.05).

Discussion
In this study, which was carried out to determine the resilience levels, care behaviors, and violence management competencies of nursing students, a signifcant relationship was found among the psychological resilience levels, care behaviors, and violence management competencies of the students, and our fndings were discussed with the relevant literature.
Resilience refers to the ability to adapt successfully to difculties, traumas, or other major stressors [56].Nursing students are faced with an intensely stressful physical and psychological environment, the difculties of acute patient care, and the fear of making mistakes [57,58].Again, nursing students experience some difculties in balancing their academically competitive and stressful learning environments and social lives [59][60][61][62].In this study, it was determined that the psychological resilience levels of nursing students were moderate (Table 2).When the literature was examined, Rios-Risquez et al. [63] reported that the psychological resilience levels of nursing students were moderate in their study to determine the relationship between resilience, academic burnout, and psychological health in nursing students.Again, Smith and Yang [64] found that the psychological resilience levels of nursing students were moderate in their study to determine the stress, resilience, and psychological wellbeing of Chinese undergraduate nursing students.Ozsaban et al., (2017) conducted a study to evaluate nurses' psychological resilience, academic stress and current social support levels and found that students' individual characteristics afected their psychological resilience.Pinar et al. [66] conducted a study to examine the resilience, self-confdence, and problemsolving skills of midwife candidates, and it was found that students between the ages of 17-21 had higher levels of psychological resilience than students between the ages of 22-26.Again, in our study, it was found that students whose income level is higher than their expenditure level had higher scores on the structural style and social profciency subdimensions of the psychological resilience scale (Table 3).When the literature was examined, Guo et al. [67] reported that the psychological resilience levels of nurses with high-income levels were also high in their study to determine the psychological resilience levels of Chinese nurses.Again, Ozsaban et al. [65] reported that social resource subdimension score averages were lower in those with less income than their expenses compared to other groups.In this study, it was determined that nursing students living at home with their friends had statistically higher scores on the future perception and structural style subdimensions of the Resilience Scale (Table 3).It is thought that living together with their friends creates social support for students and nursing students are strengthened psychologically, and they increase their psychological resilience levels by noticing their defciencies and strengths.Awareness should be raised and appropriate initiatives should be taken to increase psychological resilience in nursing students, which is a personal trait that can be learned and developed.
Te concept of care, which is at the core of the nursing profession and is indispensable for the profession, is among the basic functions of the nurse to increase the health and wellbeing of individuals and improve health [68,69].It is possible to develop the care behaviors that form the heart and soul of the nursing profession through education and training processes [70].When the literature was examined, Karabey et al. [55] determined that nursing students' care behaviors were at a high level in their study conducted to refect the violent tendencies of nursing students in their care behaviors.Türk et al. [71] reported that students' care behavior scores were high in their study conducted to determine the reasons for choosing a profession and the perception of care behaviors of nursing students.Again, Gul and Arslan [72], in their study to determine nursing students' care behaviors, found that students' care behaviors were at a high level.Te high level of care behaviors that constitute the cornerstone of nursing in nursing students is thought to be pleasing in terms of the development of the nursing profession.
Nursing students are more exposed to workplace violence due to their younger age, insufcient clinical experience, frequent rotations in clinical practice, and difculty in communicating with patients and nurses compared to healthcare professionals [39,40].At this point, nursing students need to gain and develop their violence management competencies in healthcare settings.It was determined Perspectives in Psychiatric Care Perspectives in Psychiatric Care that the violence management competencies of the nursing students included in our study were at a high level (Table 2).Hopkins et al. [73] of Western Australian nursing students' clinical practice during their aggression and violence in the work they have done to determine the extent and characteristics of nursing students in the clinical setting at a serious risk of aggression and violence faced and have determined what they feel.It was determined that male students in this study had higher mean scores in the postevent recovery subdimension of the Violence Management Adequacy Scale than female students (Table 5).Yang et al. [74], in their study to determine the incidence, type, related factors, and efects of workplace violence on mental health nurses, determined that male nurses had a signifcantly higher incidence of verbal aggression, sexual harassment, and physical assault than female nurses.It has also been reported that male  nurses tend to feel more protective towards female nurses and, therefore, have a higher risk of exposure to aggressive patients [75,76].In our study, it was determined that the violence management adequacy scores of the nursing students living with their friends at home were statistically signifcantly higher than the other groups (Table 5).When the literature is examined, studies in which the violence tendencies of nursing students are determined [77,78] have been found, but there has been no study examining the violence management competencies of nursing students.Te comparison of this aspect of our study with the literature remained limited.
In this study, a statistically signifcant positive correlation was found among nursing students' levels of resilience, care behaviors, and violence management competencies (Table 6).When the literature is examined, Jeong and Lee [79] reported a positive relationship between verbal abuse experience and emotional coping style in their study to determine the efect of verbal abuse experience, coping style, and resilience on emotional response and stress in nursing students during clinical practice.Karabey et al. [55], in their study to determine the refection of nursing students' violence tendencies on care behaviors, found that there was a statistically negative relationship between students' violence tendencies and care behaviors.Again, Labrague and Los Santos [80] and Tabakakis [81] reported that a high level of psychological resilience leads to positive results in the feld of health by increasing the job satisfaction and performance of nurses.He et al. [82] and Rios-Risquez et al. [63] have also reported that psychological resilience has a signifcant relationship with positive psychological wellbeing.Lee and Kim [83], in their study to determine the efects of emotional intelligence and resilience on the relationship between type D personality and caring ability in nursing students, found that nursing students had a signifcant efect on having type D personality and psychological resilience.

Conclusion
It was determined that the psychological resilience of the nursing students included in the study was at a medium level and their caring behaviors and violence management skills were at a high level.It has also been determined that the students' age, gender, and residence status are efective variables for psychological resilience, while gender and residence status are efective variables on violence management competence.In the study, a statistically signifcant positive relationship was found among nursing students' psychological resilience levels, caring behaviors, and violence management competencies.
It is thought that the quality of the care provided will increase by increasing the endurance levels of mental health nurse students and improving their violence management skills.It is also very important that theoretical and practical training on violence management and psychological resilience for nursing students is included in the curriculum during the education and training processes of nurse academicians.Nursing students should be supported to recognize and manage signs of violence in mental health environments and increase their individual resilience levels.

Implications for Nursing Practice
Nursing considers humans as a whole, biologically, psychologically, and socially, and sees the need for spiritual care as an undeniable fact.Nursing students who are young in the healthcare system and have insufcient clinical experience are exposed to violence in the workplace, have problems in violence management, and feel inadequate.It is an undeniable fact that violence in the workplace has a physical dimension as well as a psychological dimension, and it leaves permanent problems on the person.Workplace violence also reduces nursing students' job satisfaction, negatively afects the quality of education and patient care standards, and impairs students' communication skills with patients and other healthcare professionals.Especially challenging patient profles and working conditions of mental health nurses challenge mental health nurses and mental health nurse students.It is important for nursing students, who are an important part of the healthcare team and future healthcare professionals, especially nursing students practicing in mental health practice areas, to build, learn, and develop their psychological resilience for the health of both themselves and the group they care for.In this context, nursing students need to be supported by nurse academicians and clinical nurses in recognizing and managing signs of violence in mental health environments and increasing their individual resilience levels.It is thought that the quality of nursing care will increase by determining the psychological resilience levels, caring behaviors, and violence management competencies of nursing students, who are the professionals of the future, during their education and training processes and by increasing their awareness.

Table 1 :
Distribution of nursing students by some descriptive characteristics.

Table 2 :
Distribution of the mean scores of the Resilience Scale, the Caring Behaviors Scale, and the Violence Management Efciency Scale.

Table 3 :
Resilience scores of nursing students according to some descriptive characteristics.
Statistically signifcant p values are indicated as * .

Table 4 :
Nursing students' Caring Behaviors Scale scores according to some descriptive characteristics.

Table 5 :
Violence Management Profciency Scale scores of nursing students according to some descriptive characteristics.Violence Management Profciency Scale in application areas

Table 6 :
Correlation of resilience care behaviors and violence management profciency.
*Perspectives in Psychiatric Care