Research components

The focus of this week’s assignment is identifying research components. You will be responsible for reviewing two articles (listed below) and completing the following tasks for each one:

• Summarize each article utilizing the Week 2 research template. 

Identify and describe the problem, purpose, and hypothesis or research questions of each study.

• Analyze and discuss the significance of the research to nursing practice.
• Identify two details to support the research as qualitative or quantitative.
• NOTE: If a component is absent, student receives a zero for that component.

Cite all sources in APA format.

Students with the last name beginning with M-Z

Park, M., Cho, S., & Hong, H. (2015).

Prevalence and perpetrators of workplace violence by nursing unit and the relationship between violence and the perceived work environment.

Journal of Nursing Scholarship, 47(1), 87-95. doi: 10.1111/jnu.12112

Turk, M., Fapohunda, A., & Zoucha, R. (2015).

Using photovoice to explore Nigerian immigrants’ eating and physical activity in the United States.

Journal of Nursing Scholarship, 47(1), 16-24. doi: 10.1111/jnu.12105

HEALTH POLICY AND SYSTEMS

Prevalence and Perpetrators of Workplace Violence by Nursing
Unit and the Relationship Between Violence and the Perceived
Work Environment
Mihyun Park, PhD, RN1, Sung-Hyun Cho, PhD, RN2, & Hyun-Ja Hong, PhD, RN3

1 Assistant Professor, College of Nursing, The Catholic University of Korea, Seoul, South Korea
2 Associate Professor, College of Nursing, Research Institute of Nursing Science, Seoul National University, Seoul, South Korea
3 Vice President, Department of Nursing, The Catholic University of Korea, Seoul St. Mary Hospital, Seoul, South Korea

Key words
Nurse, violence, perpetrator, work demands,

trust, justice, Korea, Copenhagen Psychosocial

Questionnaire II

Correspondence
Sung-Hyun Cho, College of Nursing, Research

Institute of Nursing Science, Seoul National

University, 101 Daehak-ro, Jongno-gu, Seoul

110–799, South Korea.

E-mail: sunghcho@snu.ac.kr

Accepted: September 13, 2014

doi: 10.1111/jnu.12112

Abstract

Aims: To identify the prevalence and perpetrators of workplace violence
against nurses and to examine the relationship of work demands and trust
and justice in the workplace with the occurrence of violence.
Design: This study employed cross-sectional data from a 2013 nurse survey
conducted at a university hospital in Seoul, South Korea. The study sample
included 970 female nurses from 47 nursing units, including general, oncol-
ogy, intensive care units (ICUs), operating rooms, and outpatient departments.
Methods: The second version of the medium-sized Copenhagen Psychosocial
Questionnaire (COPSOQ II) was used to measure work demands (i.e., quan-
titative demands, work pace, and emotional demands), trust and justice, and
violence. Relationships among those variables were examined by conducting
multiple logistic regression analyses with multilevel modeling.
Findings: The 12-month prevalence of verbal abuse (63.8%) was highest, fol-
lowed by threats of violence (41.6%), physical violence (22.3%), and sexual
harassment (19.7%), but bullying had the lowest prevalence (9.7%). Physi-
cal violence, threats of violence, and verbal abuse occurred most frequently
in ICUs, whereas sexual harassment and bullying were highest in operat-
ing rooms. The main perpetrators were patients, followed by physicians and
patients’ families. Nurses perceiving greater work demands and less trust and
justice were more likely to have been exposed to violence.
Conclusions: The prevalence and perpetrators of violence varied considerably
among nursing units. Greater work demands and less trust and justice were
associated with nurses’ experiences of violence.
Clinical Relevance: Adequate work demands and a trusted and just work
environment may reduce violence against nurses. In return, reduction of vio-
lence will contribute to creating a better nursing work environment.

Workplace violence is a global problem affecting not only
people’s dignity but also their emotional and physical
well-being. While workplace violence affects all occupa-
tions, healthcare professionals, particularly nurses, are at
high risk because nurses work with people in distress and
are mostly female, both of which are risk factors for work-
place violence (Campbell et al., 2011). A recent integra-

tive review of workplace violence against nurses in the
Anglo, Asian, European, and the Middle Eastern regions
(Spector, Zhou, & Che, 2014) reported that, on aver-
age, 31.8% of nurses were exposed to physical violence,
62.8% to nonphysical violence, 47.6% to bullying, and
17.9% to sexual harassment during the prior year; there-
fore, workplace violence may affect a majority of nurses.

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In an international effort to promote workplace safety
in the healthcare sector, the International Council
of Nurses participated in a joint program with other
international organizations to develop the “framework
guidelines for addressing workplace violence in the
health sector” (International Labour Office, International
Council of Nurses, World Health Organization, & Public
Services International, 2002). In these guidelines, work-
place violence was defined as abusing, threatening, or
assaulting incidents experienced by staff, including phys-
ical or psychological violence (e.g., harassment, threats,
bullying, and verbal abuse). While physical violence
has been visibly recognized and reported, psychological
violence has not drawn enough attention despite its
cumulative adverse effects through repeated behavior.
Thus, more research on psychological workplace violence
is needed (International Labour Office et al., 2002; Lee,
Lee, & Bernstein, 2013; Robbins, Bender, & Finnis,
1997). In South Korea, employers are required by the
law to provide their employees with sexual harassment
prevention education. General guidelines for workplace
violence have also been published (Korea Occupational
Safety & Health Agency, 2009). However, best practice
guidelines and mandatory prevention programs specific
to health care that cover various types of workplace
violence have not been developed yet.

The source of violence is another concern because the
effect of violence varies among perpetrators (Grandey,
Kern, & Frone, 2007; Hershcovis & Barling, 2010). Crim-
inals, clients, and coworkers have generally been iden-
tified as the major perpetrators of workplace violence
(LeBlanc & Kelloway, 2002), with clients and cowork-
ers prominent in the health sector (Farrell, 1997; Lee &
Chung, 2007; Spector et al., 2014). According to Spector
and colleagues’ review study (2014), patients and their
relatives were perpetrators of most incidents of physical
violence (on average, 64.3% and 30.2%, respectively),
while the perpetrators of nonphysical violence varied,
but included nurse colleagues, superiors, physicians, and
other staff members. To understand the impact of vio-
lence, comparing the effects of violence from different
perpetrators might be meaningful. Furthermore, nurs-
ing studies reporting workplace violence have mainly
focused on the experiences of psychiatric, geriatric, or
emergency care nurses (Lawoko, Soares, & Nolan, 2004;
Mullan & Badger, 2007; Taylor & Rew, 2011) because
these areas have been identified as being at high risk for
workplace violence. However, this research may obscure
the fact that nurses may be exposed to violence anywhere
they work.

Assessing risk factors of workplace violence has
been suggested as the first step in preventing violence
(International Labour Office et al., 2002), including

individual characteristics, organizational factors, work
demands, and type of nursing unit. Individual factors are
age, gender, race, work experience, and education level
(Campbell et al., 2011; Rowe & Sherlock, 2005; Weaver,
2013). Organizational factors include culture and the
psychosocial work environment. Unfair treatment,
disrespect, and distrust among coworkers and superiors
have been identified as critical causes of conflict and
aggressive behaviors in organizations (Almost, 2006;
Daiski, 2004; Neuman & Baron, 1998). In addition,
heavy work demands under time pressure caused by
low staffing levels, high patient acuity, and high patient
turnover have been reported to create stressful situa-
tions for patients, families, and hospital staff members
(Carayon & Gurses, 2008; Di Martino, 2003); these
intense or continuous stressful situations increase the
risk for workplace violence by superiors, patients, and
patients’ families (Camerino, Estryn-Behar, Conway,
van Der Heijden, & Hasselhorn, 2008; Roche, Diers,
Duffield, & Catling-Paull, 2010). The type of nursing
unit or clinical area (e.g., intensive care, perioperative,
geriatric, psychiatric, and emergency) is also known to
influence the prevalence of violence against nurses due
to differences in their patient populations and the care
provided to patients (Camerino et al., 2008; Cook, Green,
& Topp, 2001; Park, Kang, Kim, & Kwon, 2011).

Among those risk factors, this study focused on individ-
ual nurse characteristics, organizational factors of work-
place values (i.e., trust and justice), work demands, and
the type of nursing unit under the assumptions that the
prevalence of violence would differ by nursing unit and
that nurses’ greater work demands and lack of trust and
justice in the workplace would increase the occurrence
of violence. We also assumed that the influence of risk
factors on violence may vary by type of violence and per-
petrator rather than all risk factors leading to all types
of violence and the involvement of all types of perpetra-
tors. The aims of this study were to identify the preva-
lence of workplace violence perpetrated against nurses by
the type of violence and perpetrator and to examine the
relationship of work demands and trust and justice in the
workplace with the occurrence of violence.

Methods

We performed a cross-sectional study using nurse sur-
vey data collected in January and February of 2013.

Participants

The original nurse survey was conducted in a univer-
sity hospital in Seoul, South Korea. The survey targeted
all staff nurses working on all nursing units (48 units) of

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Park et al. Workplace Violence Against Nurses

the hospital, excluding the administration and emergency
departments, by convenience sampling. A total of 1,027
registered nurses (RNs) completed the original survey
(response rate = 95.2%). Detailed information on the
original sample has been provided elsewhere (Cho, Park,
Jeon, Chang, & Hong, 2014; Park, Jeon, Hong, & Cho,
2014). Of the total RNs surveyed, 13 nurses in the psy-
chiatric unit were excluded from our study population
because their work environment and patient characteris-
tics were assumed to be unique and different from other
nursing units. Male nurses (n = 38) were also excluded
to control for the effect of gender on violence. In ad-
dition, six nurses with incomplete responses preventing
the calculation of the prevalence of violence were further
excluded. The final study population included 970 female
RNs working on 47 nursing units.

Instruments

Nurse characteristics including age, marital status,
education, and years worked as an RN were included in
the survey questionnaire as potential factors associated
with violence. Violence, work demands, and trust and
justice in the workplace were measured using the sec-
ond version of the medium-sized Copenhagen Psychoso-
cial Questionnaire (COPSOQ II; Pejtersen, Kristensen,
Borg, & Bjorner, 2010). The COPSOQ II has been used
with various occupations, including health professions
and various countries, and its validity has been estab-
lished (Pejtersen et al., 2010). June and Choi (2013)
translated the COPSOQ II into Korean and examined the
validity and reliability of the Korean version using a sam-
ple of office workers. After reviewing the Korean version
developed by June and Choi (2013), we revised sev-
eral sections of the COPSOQ II and back-translated our
revised Korean version into English until the original and
Korean versions had equivalent meanings.

The COPSOQ II included four types of violence: phys-
ical violence, threats of violence, sexual harassment
(undesired sexual attention), and bullying (repeated un-
pleasant or degrading treatment). We also added ques-
tions about verbal abuse to the survey questionnaire to
identify verbal abuse that would not be directly related
to threats of violence, sexual harassment, or bullying.
Nurses were asked if they had been exposed to each type
of violence during the previous 12 months and answered
with one of five responses: “yes, daily”; “yes, weekly”;
“yes, monthly”; “yes, a few times”; or “no.” When nurses
replied with one of the four “yes” responses, they were
asked further about the perpetrators of the violence, and
multiple responses (data on more than one perpetrator)
were allowed. The COPSOQ II included four groups of
perpetrators (i.e., colleagues, managers or superiors, sub-

ordinates, and clients, customers, or patients). Based on
the literature, these original groups were revised into five
categories by our researchers: patients, patients’ families,
nurse colleagues, nurse managers, and physicians. The
first two groups comprised the “clients” and the others
were considered “insiders.”

Two domains, “demands at work” and “values at work-
place level,” included in the COPSOQ II were used
to measure nurses’ work demands and levels of trust
and justice in the workplace, respectively. The domain
“demands at work” consisted of three dimensions: quan-
titative demands (four items), work pace (three items),
and emotional demands (four items). The domain “val-
ues at workplace level” also consisted of three dimen-
sions: trust regarding management (four items), mutual
trust between employees (three items), and justice (four
items). Each item on the six dimensions was answered
with a 5-point scale (from “to a very small extent” to
“to a very large extent”; or from “never/hardly ever” to
“always”). Responses with the 5-point scale were then
converted to 0, 25, 50, 75, and 100, and a higher score
indicated a stronger feeling about each dimension (Pe-
jtersen et al., 2010). For example, a response of “always”
to a question about quantitative demand (e.g., “Is your
work unevenly distributed so it piles up?”) was converted
into 100 points; a response of “to a very small extent” to
a question about justice (e.g., “Are conflicts resolved in a
fair way?”) was converted into 0 points.

The Cronbach’s alpha of six dimensions ranged from
.61 to .82. Cronbach’s alpha of “mutual trust between
employees” and “emotional demands” was .61 and .66,
respectively, but the other dimensions had a Cronbach’s
alpha equal to .70 or higher.

Ethical Considerations

This study was approved by our institutional review
board. Nurses participated in the survey voluntarily and
were provided with an individual envelope to seal their
questionnaire immediately after completing it. Data used
in this study did not include any information that can be
used to identify individual nurses.

Data Analysis

The prevalence of the five types of violence was
computed as the proportion of nurses who had been
exposed to the violence (i.e., daily, weekly, monthly,
or a few times) out of the total number of nurses dur-
ing the previous 12 months. The overall prevalence was
also computed as the proportion of nurses who had been
exposed to at least one of five types of violence. The
12-month prevalence was compared by type of violence

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Workplace Violence Against Nurses Park et al.

and nursing unit. Nursing units were grouped into five
categories: general units, oncology units, intensive care
units (ICUs), operating rooms, and outpatient depart-
ments. The distribution of the five categories of perpetra-
tors (patients, patients’ families, nurse colleagues, nurse
managers, and physicians) was analyzed based on the
type of violence and nursing unit by presenting the per-
centage of nurses who experienced violence in each cat-
egory of perpetrator.

The relationships of work demands and trust and
justice in the workplace to violence were examined
using multiple logistic regression analyses with a sepa-
rate model for each type of violence with the outcome
as nurses who had experienced a specific violence ver-
sus nurses who had not experienced violence. The rela-
tionships of work demands and trust and justice in the
workplace with violence perpetrators were also examined
using multiple logistic regression analyses with a sepa-
rate model for each category of perpetrator. The outcome
of these models was nurses who had experienced vio-
lence by a specific perpetrator (e.g., patients) regardless
of the violence type versus nurses who had not experi-
enced violence by a perpetrator. Multilevel modeling was
employed in all regression analyses to take into account
the clustering of nurses within their units. Nurse charac-
teristics and the type of nursing unit were also included in
the regression models. Age was excluded from the regres-
sion models due to a high correlation with years worked
as an RN (r = .95, p < .001). SAS 9.3 (SAS Institute, Cary, NC, USA) was used to analyze the data.

Findings

Our study sample of 970 RNs had a mean age of 28.6
years. The majority were single (77.5%) and had a bac-
calaureate or higher academic degree (76.6%). The av-
erage years worked as an RN was 5.4 years; 33.7% had
worked less than 3 years as an RN, 31.6% for 3 to 5 years,
and the rest 6 years or longer.

Prevalence of Workplace Violence by Type of
Violence and Nursing Unit

The prevalence of violence is presented in Table 1.
Respondents could report experiencing violence “daily,”
“weekly,” “monthly,” or “a few times.” During the pre-
vious 12 months, 71% of nurses reported having been
exposed to at least one of five types of violence. The
12-month prevalence of verbal abuse (63.8%) was the
highest, followed by threats of violence (41.6%), phys-
ical violence (22.3%), and sexual harassment (19.7%);
bullying had the lowest prevalence (9.7%). The majority,
74.3% and 93.2% of those who had experienced verbal

abuse and sexual harassment, respectively, had been ex-
posed to the violence “a few times.”

The highest prevalence of violence overall (exposed
to at least one type of violence) was found in the ICUs
(82.8%), followed by outpatient departments (73.3%),
with the lowest prevalence (63.5%) in oncology units.
ICUs also had the highest prevalence of physical violence
(48.5%), threats of violence (61.4%), and verbal abuse
(75.8%) among the five groups of nursing units and the
second highest prevalence of sexual harassment (23.2%).
Sexual harassment (25.2%) and bullying (10.8%) oc-
curred most frequently in operating rooms. Outpatient
departments had the second highest prevalence of over-
all and physical violence, threats of violence, and verbal
abuse.

Distributions of Perpetrators by Type of
Violence and Nursing Unit

The distributions of perpetrators by type of violence
and nursing unit are presented in Table 1. Overall, the
majority (64.4%; 444/689) of violent incidents were per-
petrated by patients, followed by physicians (49.3%), and
patients’ families (48%). Patients, followed by families,
were the most frequent perpetrators of physical violence
and threats of violence; patients, followed by physicians,
were the major perpetrators of sexual harassment and
verbal abuse. In the operating rooms, however, physi-
cians were the most frequent perpetrators of all types
of violence except for bullying. Bullying was perpetrated
mostly by nurse colleagues (68.1%) across all nursing
units.

Relationships of Work Demands and Trust and
Justice in the Workplace With the Occurrence of
Violence

The relationships of nurse characteristics, work
demands, and trust and justice in the workplace with the
occurrence of violence are presented in Table 2. After the
relationship of the type of nursing unit with violence was
controlled for, nurses with 3 years or more experience as
an RN were more likely to experience threats of violence
than those with less than 3 years. When nurses perceived
a higher work pace, they were more likely to have been
exposed to physical violence, threats of violence, and ver-
bal abuse with an odds ratio (OR) of 1.02, which indi-
cates a 2% increase in the odds of violence when the
work pace increases by 1 point out of 100 points. To make
this OR of 1.02 using the 0–100 point scoring compara-
ble with that in other studies using 1–5 point scoring, a
25-point increase in work pace, which is equivalent to
an increase by 1 out of 5 points (e.g., responses change

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Park et al. Workplace Violence Against Nurses

Table 1. Prevalence of Workplace Violence and Distribution of Perpetrators (N = 970)

Prevalence Perpetrator, n (%)a

Prevalence Patients’ Nurse Nurse

n Exposed (%) Patients family colleagues managers Physicians

Any type of violence

Overall 970 689 71.0 444 (64.4) 331 (48.0) 112 (16.3) 61 (8.9) 340 (49.3)

General unit 302 214 70.9 145 (67.8) 130 (60.7) 34 (15.9) 18 (8.4) 108 (50.5)

Oncology unit 241 153 63.5 102 (66.7) 93 (60.8) 28 (18.3) 16 (10.5) 74 (48.4)

Intensive care unit 198 164 82.8 133 (81.1) 66 (40.2) 27 (16.5) 11 (6.7) 76 (46.3)

Operating room 139 92 66.2 8 (8.7) 4 (4.3) 17 (18.5) 9 (9.8) 73 (79.3)

Outpatient department 90 66 73.3 56 (84.8) 38 (57.6) 6 (9.1) 7 (10.6) 9 (13.6)

Physical violence

Overall 969 216 22.3 177 (81.9) 66 (30.6) 6 (2.8) 2 (0.9) 11 (5.1)

General unit 302 56 18.5 46 (82.1) 24 (42.9) 1 (1.8) 1 (1.8)

Oncology unit 241 31 12.9 20 (64.5) 16 (51.6) 2 (6.5) 2 (6.5) 1 (3.2)

Intensive care unit 198 96 48.5 91 (94.8) 18 (18.8) 1 (1.0)

Operating room 139 14 10.1 4 (28.6) 2 (14.3) 8 (57.1)

Outpatient department 89 19 21.3 16 (84.2) 8 (42.1) 1 (5.3)

Threats of violence

Overall 967 402 41.6 298 (74.1) 184 (45.8) 11 (2.7) 12 (3.0) 82 (20.4)

General unit 300 124 41.3 90 (72.6) 69 (55.6) 2 (1.6) 28 (22.6)

Oncology unit 241 81 33.6 53 (65.4) 50 (61.7) 4 (4.9) 5 (6.2) 17 (21.0)

Intensive care unit 197 121 61.4 110 (90.9) 38 (31.4) 4 (3.3) 3 (2.5) 10 (8.3)

Operating room 139 33 23.7 5 (15.2) 2 (6.1) 2 (6.1) 25 (75.8)

Outpatient department 90 43 47.8 40 (93.0) 25 (58.1) 1 (2.3) 2 (4.7) 2 (4.7)

Sexual harassment

Overall 970 191 19.7 106 (55.5) 29 (15.2) 5 (2.6) 3 (1.6) 66 (34.6)

General unit 302 61 20.2 45 (73.8) 14 (23.0) 2 (3.3) 1 (1.6) 10 (16.4)

Oncology unit 241 35 14.5 24 (68.6) 9 (25.7) 1 (2.9) 6 (17.1)

Intensive care unit 198 46 23.2 27 (58.7) 2 (4.3) 1 (2.2) 2 (4.3) 17 (37.0)

Operating room 139 35 25.2 2 (5.7) 1 (2.9) 1 (2.9) 30 (85.7)

Outpatient department 90 14 15.6 8 (57.1) 3 (21.4) 3 (21.4)

Verbal abuse

Overall 970 619 63.8 370 (59.8) 287 (46.4) 64 (10.3) 46 (7.4) 303 (48.9)

General unit 302 191 63.2 119 (62.3) 115 (60.2) 20 (10.5) 14 (7.3) 96 (50.3)

Oncology unit 241 136 56.4 85 (62.5) 81 (59.6) 20 (14.7) 10 (7.4) 70 (51.5)

Intensive care unit 198 150 75.8 111 (74.0) 54 (36.0) 15(10.0) 11 (7.3) 67 (44.7)

Operating room 139 80 57.6 5 (6.3) 3 (3.8) 8 (10.0) 8 (10.0) 63 (78.8)

Outpatient department 90 62 68.9 50 (80.6) 34 (54.8) 1 (1.6) 3 (4.8) 7 (11.3)

Bullying

Overall 970 94 9.7 2 (2.1) 6 (6.4) 64 (68.1) 15 (16.0) 7 (7.4)

General unit 302 29 9.6 1 (3.4) 3 (10.3) 19 (65.5) 5 (17.2) 1 (3.4)

Oncology unit 241 25 10.4 2 (8.0) 15 (60.0) 4 (16.0) 4 (16.0)

Intensive care unit 198 18 9.1 1 (5.6) 1 (5.6) 13 (72.2) 1 (5.6) 1 (5.6)

Operating room 139 15 10.8 12 (80.0) 1 (6.7) 1 (6.7)

Outpatient department 90 7 7.8 5 (71.4) 4 (57.1)

Note. Empty cells indicate no case. aThe sum of percentages may be over 100% due to multiple responses.

from “to a large extent” to “to a very large extent”), corre-
sponded to a 64% increase in the odds of violence (OR =
1.64 = (1.02)25). Perceiving greater emotional demands
was also associated with a greater likelihood of experi-
encing threats of violence, sexual harassment, and verbal
abuse. Higher mutual trust between employees was asso-
ciated with a greater occurrence of threats of violence, but
with a lower occurrence of bullying. Justice was inversely

related with verbal abuse (OR = 0.98) and bullying
(OR = 0.98).

Table 3 presents the relationships of nurse charac-
teristics, work demands, and workplace values to the
type of perpetrator. When the type of nursing unit was
controlled for, nurses holding a baccalaureate or higher
degree were more likely to experience violence by physi-
cians than were those with a diploma in nursing. Those

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Workplace Violence Against Nurses Park et al.

Table 2. Relationships of Work Demands and Workplace Values to Violence by Type of Violence: Odds Ratio [95% Confidence Interval]

Physical violence Threats of violence Sexual harassment Verbal abuse Bullying

Single (vs. married) 0.84 [0.49, 1.43] 0.92 [0.59, 1.45] 1.28 [0.77, 2.13] 1.09 [0.71, 1.67] 0.69 [0.37, 1.29]

Diploma (vs. BSN or higher) 0.93 [0.60, 1.44] 0.75 [0.52, 1.09] 0.96 [0.63, 1.44] 0.74 [0.52, 1.05] 0.71 [0.39, 1.29]

Years worked as an RN (vs. <3)

3–5 1.37 [0.87, 2.16] 1.82 [1.23, 2.70]∗∗ 1.19 [0.77, 1.85] 0.93 [0.63, 1.36] 0.79 [0.43, 1.46]
�6 1.53 [0.88, 2.67] 2.03 [1.27, 3.26]∗∗ 1.60 [0.96, 2.68] 1.01 [0.65, 1.58] 1.32 [0.68, 2.56]

Work demands

Quantitative demands 1.01 [0.99, 1.02] 1.00 [0.99, 1.01] 1.00 [0.99, 1.01] 1.00 [0.99, 1.01] 1.02 [0.998, 1.04]

Work pace 1.02 [1.01, 1.04]∗∗ 1.02 [1.01, 1.03]∗∗ 1.01 [0.99, 1.02] 1.02 [1.01, 1.03]∗∗ 1.00 [0.98, 1.02]
Emotional demands 1.01 [0.99, 1.03] 1.02 [1.00, 1.03]∗ 1.02 [1.01, 1.04]∗∗ 1.03 [1.01, 1.04]∗∗∗ 1.01 [0.99, 1.03]

Workplace values

Trust regarding management 1.02 [0.995, 1.04] 0.99 [0.97, 1.01] 1.02 [0.997, 1.04] 1.00 [0.98, 1.01] 1.01 [0.99, 1.04]

Mutual trust between employees 0.99 [0.98, 1.01] 1.02 [1.00, 1.03]∗ 0.99 [0.97, 1.00] 1.01 [0.999, 1.02] 0.96 [0.94, 0.98]∗∗∗

Justice 0.99 [0.97, 1.00] 0.99 [0.97, 1.00] 0.99 [0.98, 1.01] 0.98 [0.97, 0.99]∗∗ 0.98 [0.96, 0.99]∗

Note. ∗p < .05, ∗∗p < .01, ∗∗∗p < .001. Effects of the type of nursing unit were controlled for in the multiple regression analyses.

Table 3. Relationships of Work Demands and Workplace Values to Violence by Type of Perpetrator: Odds Ratio [95% Confidence Interval]

Patients Patients’ family Nurse colleagues Nurse managers Physicians

Single (vs. married) 0.77 [0.46, 1.27] 0.95 [0.60, 1.52] 0.77 [0.39, 1.51] 0.81 [0.35, 1.84] 0.96 [0.60, 1.53]

Diploma (vs. BSN or higher) 0.98 [0.66, 1.46] 1.01 [0.70, 1.46] 0.62 [0.36, 1.07] 0.77 [0.37, 1.61] 0.62 [0.43, 0.91]∗

Years worked as an RN (vs. <3)

3–5 1.36 [0.89, 2.07] 1.15 [0.78, 1.70] 0.57 [0.34, 0.96]∗ 0.78 [0.37, 1.66] 1.64 [1.11, 2.44]∗

�6 1.19 [0.71, 1.98] 1.44 [0.90, 2.31] 0.41 [0.21, 0.81]∗ 0.80 [0.33, 1.93] 1.65 [1.02, 2.66]∗

Work demands

Quantitative demands 1.00 [0.99, 1.02] 1.01 [0.99, 1.02] 1.01 [0.99, 1.03] 1.03 [1.00, 1.05]∗ 1.01 [0.99, 1.02]
Work pace 1.02 [1.00, 1.03]∗ 1.01 [0.99, 1.02] 0.99 [0.98, 1.01] 0.98 [0.96, 1.01] 1.01 [0.99, 1.02]
Emotional demands 1.02 [1.00, 1.03]∗ 1.03 [1.01, 1.04]∗∗∗ 1.03 [1.01, 1.04]∗∗ 1.01 [0.99, 1.04] 1.03 [1.01, 1.04]∗∗∗

Workplace values

Trust regarding management 1.01 [0.99, 1.02] 0.99 [0.98, 1.01] 1.02 [0.997, 1.04] 0.97 [0.94, 1.00] 0.99 [0.98, 1.01]

Mutual trust between employees 1.01 [0.99, 1.02] 1.01 [0.99, 1.03] 0.98 [0.96, 0.99]∗ 0.99 [0.96, 1.01] 1.01 [0.99, 1.02]
Justice 0.98 [0.97, 0.99]∗ 0.99 [0.98, 1.01] 0.97 [0.95, 0.99]∗∗ 0.98 [0.95, 1.01] 0.98 [0.97, 0.99]∗

Note. ∗p < .05, ∗∗p < .01, ∗∗∗p < .001. Effects of the type of nursing unit were controlled for in the multiple regression analyses.

with 3 or more years of experience as an RN were less
likely to experience violence by nurse colleagues, but
more likely to by physicians than were nurses with less
than 3 years of experience. Higher quantitative demands
were associated with an increased occurrence of vio-
lence by nurse managers, whereas higher work pace was
associated with violence by patients. Emotional demands
were positively related with violence by all perpetra-
tors except for nurse managers. Higher mutual trust be-
tween employees was associated with a lower occurrence
of violence by nurse colleagues. Justice was inversely
related with violence by patients, nurse colleagues, and
physicians.

Discussion

This study reports the high prevalence of workplace
violence against nurses in a university hospital, suggest-
ing the need for attention to workplace violence. The

overall prevalence (71%) of workplace violence in this
study was high compared to the prevalence range
(mean = 57.3%; range = 24.7%–88.9%) that was re-
ported in a recent review of 136 articles related to vio-
lence against nurses (Spector et al., 2014). The prevalence
of nonphysical violence (e.g., verbal abuse and threats
of violence) was higher than that of physical violence in
both studies. Compared with emergency, geriatric, and
psychiatric nurses who had a high prevalence of phys-
ical violence in the review, the nursing units in this
study (general, oncology, intensive care, operating room,
and outpatient) had a relatively low prevalence of phys-
ical violence. The prevalence of bullying (9.7%) in this
study was also lower than those reported in the review
(mean = 47.6%; range = 26.4%–86.5%) and among Ko-
rean nurses in another study (23%; Lee et al., 2013).

Overall, the main sources of workplace violence in this
study were patients, which were consistent with previous
studies (Spector et al., 2014). Violence in general hospital

92 Journal of Nursing Scholarship, 2015; 47:1, 87–95.
C© 2014 Sigma Theta Tau International

Park et al. Workplace Violence Against Nurses

settings is likely to be perpetrated by clients (i.e., patients
or patients’ relatives). However, unlike previous stud-
ies, this study found physicians, not patients’ relatives, to
be the second most frequent perpetrators, based on the
high prevalence of sexual harassment and verbal abuse
by physicians. Verbal abuse and sexual harassment from
physicians have been frequently reported in the nurs-
ing literature (Cook et al., 2001; Robbins et al., 1997). A
Korean study indicated that verbal abuse from physicians
reflects a hierarchical rather than collegial, mutual re-
lationship between nursing and medicine in Korea (Lee
& Chung, 2007). Nurse colleagues were major perpetra-
tors of bullying, which is frequently mentioned in the
nursing literature (Lee et al., 2013; Weaver, 2013). The
prevalence of violence also varied considerably among
nursing units. ICUs had the highest prevalence of phys-
ical violence, threats of violence, and verbal abuse. Vio-
lence in ICUs was mainly perpetrated by patients, which
may stem from intentional or unintentional aggression of
patients in a confused or irritable mental status or severe
pain (Park et al., 2011). While violence from patients or
patients’ families was rare for nurses in operating rooms,
the nurses were more likely to be exposed to violence
from physicians.

This study found that high work demands were signif-
icantly associated with workplace violence, as reported
in previous studies (Camerino et al., 2008; Roche et al.,
2010). Although these relationships cannot be consid-
ered causal, this finding suggests that excessive workloads
may increase the prevalence of violence against nurses.
Inverse relationships were also found between workplace
values (trust and justice) and bullying. These relation-
ships can be interpreted as reciprocal associations. For
example, when nurses work in an environment with low
trust and justice, they may be more likely to experience
bullying, or nurses may perceive low trust among col-
leagues and unfair treatment as a result of experienc-
ing bullying. Therefore, increasing trust and justice in the
workplace may reduce bullying, and in return, reduction
of bullying can create a trusted and just work environ-
ment. We also found an unexpected positive relationship
between mutual trust among employees and threats of
violence. Because threats of violence were perpetrated
mainly by outsiders (patients and their relatives) or physi-
cians rather than by nursing colleagues, further investiga-
tions are needed to identify other factors that may explain
this relationship.

This study also reported that nurses with less nursing
experience were more likely to experience violence from
nurse colleagues. Prompting the expression “nurses eat
their young,” new nurses have been recognized to be
at high risk for horizontal violence (Rowe & Sherlock,
2005; Weaver, 2013). Nursing scholars have emphasized

the importance of maintaining workplace values such as
mutual support, respect, and trust among nurses to limit
horizontal violence (Daiski, 2004; Farrell, 1997).

Limitations

There were limitations to this study. First, this study
employed a cross-sectional design; thus, the significant
associations of work demands, trust, and justice with the
occurrence of violence cannot be considered causal rela-
tionships. Second, we added verbal abuse questions to the
survey to identify verbal abuse that would not be directly
related to threats of violence, sexual harassment, or bul-
lying. However, verbal abuse might not be exclusive of
other types of psychological violence. The low prevalence
of bullying reported in this study would be attributed to
the lack of mutual exclusiveness between verbal abuse
and bullying. Third, one of our aims was to examine dif-
ferences in the prevalence and perpetrators of violence by
nursing unit within the same hospital; therefore, our sur-
vey was conducted in a large university hospital. Collect-
ing data in one hospital had an advantage of controlling
for some factors (e.g., hospital characteristics) that could
influence violence. However, these results may not be
generalized to other hospitals (e.g., nonteaching or small
hospitals) or care settings that could have different age
distributions of RNs, work demands, and environments.
Fourth, we relied on the nurses’ ability to recall violent
experiences during the previous 12 months, and this may
have influenced our data on the prevalence of violence.
However, previous studies commonly use a 12-month
recall to estimate prevalence. Asking nurses about vi-
olence experienced within a shorter period (e.g., 6
months) may have minimized the recall bias.

Conclusions

This study provided comprehensive information
related to the prevalence, perpetrators, and risk factors of
workplace violence against nurses in a general hospital
setting in South Korea. In particular, we reported con-
siderable differences in the prevalence and perpetrators
of violence among nursing units. Hospital and nurse
managers should be familiar with the common types of
violence and main perpetrators in each unit. Strategies
for violence prevention should be tailored to specific
nursing units based on the prevalence and main perpetra-
tors of violence. In addition, we found that greater work
demands and less trust and justice in the workplace were
associated with nurses’ experiences of violence. These
associations suggest that adequate work demands and
a trusted and just work environment may reduce

Journal of Nursing Scholarship, 2015; 47:1, 87–95. 93
C© 2014 Sigma Theta Tau International

Workplace Violence Against Nurses Park et al.

violence against nurses. In return, reduction of vio-
lence will contribute to creating a better nursing work
environment.

Acknowledgments

This work was supported by the Research Settlement
Fund for new faculty of Seoul National University.

Clinical Resources
� International Council of Nurses. Workplace

violence in the health sector. http://www.icn.ch/
pillarsprograms/workplace-violence-in-the-health-
sector/

� Centers for Disease Control and Prevention. Work-
place safety & health topics: Occupational violence.
http://www.cdc.gov/niosh/topics/violence/

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permission.

CLINICAL SCHOLARSHIP

Using Photovoice to Explore Nigerian Immigrants’ Eating and
Physical Activity in the United States
Melanie T. Turk, PhD, MSN, RN1, Abimbola Fapohunda, DrPH, MPH, MS2, & Rick Zoucha, PhD, APRN-BC,
CTN-A3

1 Epsilon Phi, Assistant Professor, Duquesne University School of Nursing, Pittsburgh, PA, USA
2 Consultant, FOB Group, LLC, Monroeville, PA, USA
3 Professor of Nursing, Duquesne University School of Nursing, Pittsburgh, PA, USA

Key words
Immigrants, nutrition, physical activity,

Photovoice

Correspondence
Dr. Melanie T. Turk, Duquesne University School

of Nursing, 518 Fisher Hall, 600 Forbes Avenue,

Pittsburgh, PA 15282. E-mail: turkm@duq.edu

Accepted: July 19, 2014

doi: 10.1111/jnu.12105

Abstract

Purpose: African immigrants are one of the fastest growing immigrant groups
to the United States; there is a crucial need to learn about African immigrants’
beliefs and lifestyle behaviors that may impact health. The purposes of this
study were to (a) explore the perceptions and practices of Nigerian immigrants
regarding healthy eating and physical activity in the United States; (b) assess
the influence of cultural beliefs of Nigerian immigrants on eating and physical
activity; (c) describe the role that healthcare providers can play in helping to
promote healthy eating and physical activity; and (d) evaluate the feasibility
and efficacy of using Photovoice to collect data on the perceptions and practices
of Nigerian immigrants regarding healthy eating and physical activity.
Design: Qualitative visual ethnography using Photovoice.
Methods: Thirteen Nigerian immigrants were recruited. Data were col-
lected using photography and focus group discussions at a church. Photovoice
methodology and Leininger’s four phases of qualitative analysis were used to
analyze photographs, field notes, and focus group transcripts.
Findings: Four overarching themes emerged from the data: moderation is
healthy, Nigerian ways of living are healthy, acquiring American ways is un-
healthy, and cultural context is important to promote healthy behaviors.
Conclusions: Photovoice was a feasible, effective methodology for collecting
data on the perceptions and practices of Nigerian immigrants. Nigerian partic-
ipants believed that adherence to traditional dietary and activity practices are
healthy. Nurses and other healthcare providers must make concerted efforts
to communicate with and educate Nigerian immigrants about healthful eating
and activity behaviors within their cultural context.
Clinical Relevance: The number of African immigrants to the United States
has increased dramatically. Photovoice is a creative method to learn about the
health beliefs and behaviors of the Nigerian immigrant population.

Immigration plays a major role in the growth of the
population of the United States, and it is estimated that
82% of the population increase between 2005 and 2050
will be attributable to immigrants and their offspring
(Passel & Cohn, 2008). The African-born population in
the United States doubled in size from 881,300 in 2000
to 1.6 million in 2010, and one of the most common
countries of origin for African immigrants is Nigeria

(U.S. Census Bureau, 2010). Yet, to a large extent, the
health and wellness of the African immigrant population
remain unexplored (Venters & Gany, 2011). These de-
mographic trends indicate a crucial need to learn about
African immigrants’ beliefs and lifestyle behaviors that
may impact health.

While the African immigrant population has grown
exponentially, few studies have examined the health

16 Journal of Nursing Scholarship, 2015; 47:1, 16–24.
C© 2014 Sigma Theta Tau International

Turk et al. Using Photovoice With Nigerian Immigrants

of African-born residents in the United States (US),
including the impact of acculturation on diet and phys-
ical activity. The majority of immigrant health research
has focused on Hispanic and Asian populations and sug-
gests that, generally, these immigrant groups are health-
ier than native-born Americans (Barrington, Baquero, &
Borrell, 2010; Singh, Siahpush, & Hiatt, 2011). Limited
evidence also shows that African immigrants tend to be
healthier than US-born Whites and African Americans
(Read, Emerson, & Tarlov, 2005; Singh & Hiatt, 2006;
Singh & Miller, 2004). Studies on dietary patterns in
groups of immigrant populations show that traditional
diets are healthier than the nontraditional diets that
have evolved with acculturation (Delisle, 2010; Desilets,
Rivard, Shatenstein, & Delisle, 2007). Yet, immigrants
may face barriers in maintaining healthy native diets or
acquiring healthy physical activity habits in their new
countries. Among 5,230 immigrants to the US, 79% re-
ported being physically inactive (Koya & Egede, 2007),
and only 38% of a sample of African immigrants to the
Netherlands said they had engaged in physical activity
in the previous month (Beune, Haafkens, Agyemang, &
Bindels, 2010).

US national data systems used in monitoring health,
mortality, and disease patterns do not identify Africans
in the US as a separate ethnic group, and do not rou-
tinely report and analyze health data by immigrant sta-
tus (Singh & Hiatt, 2006; Singh & Miller, 2004; Singh,
Rodriguez-Lainz, & Kogan, 2013). Thus, data for African-
born immigrants are often entangled with data for
African Americans. An analysis of National Health Inter-
view Survey data showed that 58.4% of African adult im-
migrants were either overweight or obese in 2002 after
residing in the US for 15 or more years (Koya & Egede,
2007). Current statistics of Black US residents, including
persons born in the US or elsewhere, indicate that 54%
and 38% of Black female and male adults, respectively,
are either overweight or obese compared to 33% and
34% of White female and male adults (American Heart
Association Statistics Committee & Stroke Statistics Sub-
committee, 2014). While diet and activity are key deter-
minants of weight, an established contributor to health,
little is known about African immigrants’ perceptions and
practices around healthy eating and physical activity as
they relate to residing in the US.

Photovoice, in which participants use photographs to
describe their health and life experiences, is one method
that has been used as a health-promoting strategy (Wang
& Burris, 1997; Wang & Redwood-Jones, 2001). Initially
originated by Wang and Burris (1997) to document the
everyday lives of women in rural villages of China, Pho-
tovoice is a grassroots approach of community-engaged
research that assists people in identifying the strengths

and issues of their community through photography. The
Photovoice approach has been used previously with im-
migrant groups such as Latino, Chinese, Korean, and
Vietnamese immigrants to learn about topics such as hu-
man immunodeficiency virus prevention, family plan-
ning, mental and cardiovascular health, and the influence
of immigration (Fitzpatrick et al., 2009; Garcia & Saewye,
2007; Rhodes & Hergenrather, 2007; Schwartz, Sable,
Dannerbeck, & Campbell, 2007; Streng et al., 2004). Pho-
tovoice can provide Nigerian African immigrants the op-
portunity to express their ideas about eating habits and
physical activity within the context of their daily lives in
the US.

Purpose

The purposes of this study were to (a) explore the be-
liefs, perceptions, and practices of Nigerian immigrants
regarding healthy eating and physical activity behaviors
while living in the US; (b) assess the influence of cultural
beliefs of Nigerian immigrants on eating and physical ac-
tivity behaviors after migration to the US; (c) describe the
role that healthcare providers can play in helping to pro-
mote healthy eating and physical activity behaviors for
Nigerian immigrants; and (d) evaluate the acceptability,
feasibility, and efficacy of using Photovoice as a technique
to collect data on the perceptions and practices of Nige-
rian immigrants.

Methods

Design

A qualitative visual ethnography design using Pho-
tovoice was employed for this study, and two of the goals
of Photovoice identified by Wang and Burris (1997) were
highlighted: (a) encouragement of individuals to record
their community’s strengths and concerns and (b) fa-
cilitation of critical dialogue through group discussions
about photos taken by the participants. The Photovoice
method includes a four-step process of discovery and en-
gagement. The first step is community training regarding
the process. Three additional steps include (a) selecting
the photos that most accurately reflect the community
and culture; (b) contextualizing the data, which is telling
stories about what the photos mean; and (c) summariz-
ing the data by identifying themes or emerging theories
(Wang & Burris, 1997). Photos taken by the participants
are the principal medium by which viewpoints, percep-
tions, and recommendations develop. Using the photos
as the impetus for discussion via focus groups, this
methodology allows for the collection of rich, in-depth

Journal of Nursing Scholarship, 2015; 47:1, 16–24. 17
C© 2014 Sigma Theta Tau International

Using Photovoice With Nigerian Immigrants Turk et al.

data, possibly not attainable through observations or in-
terview alone.

Setting

Two focus group meetings were held in October and
November of 2013 at a Christian church attended pri-
marily by Nigerian immigrants in an urban area of
Western Pennsylvania. The focus groups were held im-
mediately following the religious service in a private
room in the church hall. A preliminary study conducted
with a community advisory committee from the church
to learn about the community’s health issues, needs, and
concerns revealed a concern about obesity among the im-
migrant group (unpublished data). Thus, we continued
working with this community to learn about their views
on healthy eating and activity in the US.

Participants

Individuals were eligible to participate if they were im-
migrants to the US from Nigeria, at least 18 years old, and
able to read and write in English. Participants also needed
to be able to use the digital camera we provided to take
photos of what they perceived as unhealthy and healthy
eating and activity. Recruitment was facilitated by a re-
search team member of Nigerian descent who had estab-
lished connections with community gatekeepers. We also
utilized the snowball method, in which word of mouth is
utilized, and participants referred to the study other in-
dividuals who might be interested (Munhall, 2011). We
recruited 13 participants.

Procedures

Prior to any study activities, institutional review board
approval was obtained from the university where the
principal investigator is employed. During our first re-
cruitment meeting at the church, the study was explained
to interested individuals, and written informed consent
was obtained. We returned to the church in 2 weeks to
distribute the digital cameras, demonstrate how to use
the cameras, and explain to the participants what they
needed to photograph for the study. We also discussed
potential issues related to using cameras, such as respect-
ing privacy and asking for permission to take someone’s
picture. We instructed participants to take photos for the
next 2 weeks of what they perceived as unhealthy eating
and physical activity. In order to explore the total per-
spective of what was seen as healthy, we also gathered
data about perceptions of what is unhealthy to provide
contrasting ideas. Participants were told they could take
as many photos as they liked, but they would need to

select the top four photos that most accurately reflected
their perceptions of what is unhealthy eating and activity.
In order to facilitate the discussion of each participant’s
pictures at the focus group meetings, it was necessary that
they only select their top four pictures to discuss. A brief
demographic questionnaire was completed by all partici-
pants at this time.

Held 2 weeks later, the next meeting was a focus group
to discuss the photos of unhealthy eating and activity.
Participants were informed that the meeting would be
audiotaped but that their responses would remain con-
fidential. Each participant’s four photos were projected
onto the wall for everyone to view, and each person dis-
cussed their photos with the group. At the end of the first
focus group, which lasted approximately 80 min, partici-
pants were told to take photos of healthy eating and ac-
tivity, and select their top four pictures to discuss when
they returned for another group meeting in 2 weeks.

The second focus group was focused on a discussion
of what the participants perceived as healthy eating and
physical activity and was facilitated as described in the
preceding paragraph. This second focus group lasted ap-
proximately 90 min. Both focus group sessions were au-
diotaped and transcribed verbatim. Healthy snacks were
provided at all meetings, and participants were permitted
to keep the digital camera to compensate them for their
time.

Data Collection

The day before each scheduled focus group meeting,
participants selected four photos that most accurately re-
flected their perceptions of what is unhealthy and what
is healthy, and emailed these photos to the principal in-
vestigator. The research assistant then compiled all the
photos in a PowerPoint (Microsoft Corp., Redmond, WA,
USA) presentation with a slide for each participant’s pho-
tos for display at the meeting. The discussion during
each focus group was facilitated by the authors using a
semistructured interview guide following the pneumonic
SHOWeD to encourage description about the photos, as
is consistent with the Photovoice methodology (Wang
& Burris, 1997). The interview guide included the fol-
lowing questions: (a) What do you See here? (b) What
is really Happening here? (c) How does this relate to
Our lives? (d) Why does this situation exist? (e) What
can we Do about it? We also explored with the partici-
pants what made a food or activity healthy or unhealthy,
whether there were ways to improve the healthiness of
the food, and what healthcare providers might do to pro-
mote healthy eating and activity for Nigerian immigrants.

At least two researchers and a research assistant were
present for each meeting. Two members of the research

18 Journal of Nursing Scholarship, 2015; 47:1, 16–24.
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Turk et al. Using Photovoice With Nigerian Immigrants

team who were of Nigerian descent were present for all
meetings. In order to capture the dynamics of the set-
ting, group, and discussion, the research assistant took
observational field notes. The participants all discussed
their photos individually, and additional input and de-
scription were provided by other group members for each
person’s photos. The photos were all of high quality,
and only one male participant’s photos were not view-
able by the other participants at the focus group that fo-
cused on healthy eating and activity. He did, however,
remember his photos and described them for the group.
Open-ended questions and probes were also used to help
participants express their ideas, attitudes, feelings, and
perceptions about healthy and unhealthy eating and ac-
tivity in the US.

Data Analysis

Transcribed interviews and photos were uploaded to
the NVivo 10 qualitative data software management
system (QSR International, 2013). Transcripts and field
notes were read and re-read by two researchers, and
the analysis followed Leininger’s four phases of quali-
tative data analysis (Leininger, 1991): (a) collecting and
documenting raw data, (b) identifying descriptors and
categories, (c) identifying patterns and initiating contex-
tual analysis, and (d) identifying themes and theoreti-
cal formulations. Phase one consisted of collecting the
data, field notes, observations, and initial analysis. Phase
two focused on the identification of categories; data were
coded according to the domains of inquiry and specific
aims, and 18 categories emerged. In the third phase, the
researchers searched for common patterns via contextual
analysis; data were scrutinized to discover saturation of
ideas, and seven patterns emerged from the categories.
During the final phase, the researchers looked for ma-
jor themes and recommendations from the data, and four
themes emerged. See Table 1 for the categories, patterns,
and themes. Two investigators analyzed transcripts, field
notes, and photos individually and then together, dis-
cussing their analysis and coding choices until consensus
was reached. Analytic memos were maintained as an au-
dit trail for data collection and analysis decisions.

Results

Thirteen Nigerian immigrants agreed to participate,
and 11 participants were present at each focus group
meeting. Participants ranged in age from 27 to 57 years,
were mostly female (92%), and were employed outside
of the home (62%). Everyone had some college educa-
tion. The range of time participants had lived in the US
was between 9 months and 30 years. Most participants

considered English to be their primary language (77%);
one participant each stated Yoruba, Igbo, or Kanuri was
his or her primary language. Participants reported being
part of the Yoruba, Bini, Igbo, or Kanuri ethnic groups.
See Table 2 for the participant characteristics.

Eating and Activity Themes

Four overarching themes emerged from the data: Mod-
eration is healthy, Nigerian ways of living are healthy, ac-
quiring American ways is unhealthy, and cultural context
is important to promote healthy behaviors. These themes
captured the perceptions that the participants had about
healthy and unhealthy eating habits and physical activ-
ity in the context of their daily lives within the US. Al-
though we asked participants to photograph and discuss
both eating behaviors and physical activity, the bulk of
their photos and comments focused on eating habits and
cooking practices.

Moderation is healthy is the first theme that
emerged. This theme encompasses the idea that eating
and activity behaviors should not be done to excess in or-
der to remain healthy. Several participants spoke about
the importance of controlling portion sizes. One woman
stated, “I mean, it’s all about portion. I remember my
mom, when she was alive, she was a nurse, and in the
house we could have a small bowl, and no matter what
you want to eat, it has to fit into that bowl.” Another
woman conveyed that while portion size is important,
the taste of foods is important as well; she stated, “Pro-
portion is everything. I’m not going to finish a whole
bowl [of rice]. I’m just going to take a bit. But at the
same time, I’m not going to not eat doughnuts if I feel like
eating doughnuts.” For her, eating foods like doughnuts
could still be seen as healthy if the food was consumed in
moderation. An excessive amount of watching television
and sitting was identified as unhealthy by the statements,
“. . . for unhealthy activity, TV, too much TV,” and “sitting
and studying is unhealthy activity . . . I’m sitting down.”

Another aspect of the moderation is healthy theme re-
ferred to the timing of meals. Eating too late at night
or eating foods that were considered “heavy” late in
the evening was considered unhealthy. This notion was
demonstrated by one woman’s statement, “I know with
our own food too, the time of the day, you can’t eat
pounded yam at 9:00 p.m., and go to bed . . . you’re not
doing anything. It’s just going to sit in there.” Another
woman reinforced this idea with the comment, “We eat
the solid food in the afternoon; we don’t eat solid food at
night.” Eating heavier foods during the day and not eat-
ing at night was consistent with healthier eating habits.

Nigerian ways of living are healthy theme referred
to the participants’ perceptions that their traditional foods

Journal of Nursing Scholarship, 2015; 47:1, 16–24. 19
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Using Photovoice With Nigerian Immigrants Turk et al.

Table 1. Categories, Patterns, and Subsequent Themes That Emerged From the Data Analysis

Categories Patterns Themes

Children’s preferences Generational differences in food choices Moderation is healthy

Choices Becoming unhealthy in the United States Nigerian ways of living are healthy

Cooking it healthy Preference for Nigerian food as healthy Acquiring American ways is unhealthy

Cultural influence Seeing overweight/obesity as economic Cultural context is important to promote healthy behaviors

Family eating Role for health care in promoting health

Fast food/convenience food Viewing American food as unhealthy

Food staples

Good for children

Healthcare provider input

Healthy activity

Healthy eating

Moderation

Nigerian food

Substitutions for traditional ingredients

Taste is important

Timing of meals

Unhealthy activity

Unhealthy cooking

and activities were healthy. The majority of the photos
of healthy foods we received were Nigerian dishes, al-
though some photos were of items such as fresh fruits,
steamed vegetables, and water. In describing a Nigerian
food, pounded yam, one woman stated, “It gives us car-
bohydrate because that gives us energy for our body
building.” One woman’s photo of a bean dish was in-
cluded in the healthy foods, and she stated, “That is
actually cooked beans . . . what I do is I cut the plan-
tains and I cook it with the beans so, I don’t have to fry
these. . . .” Everyday physical activity common in their
native country was seen as healthy, for example, “In
Nigeria, we get our activities mostly by walking. It’s not
like people have cabs like here.” Although three partici-
pants discussed engaging in scheduled exercise, most par-
ticipants described incorporating everyday activities as a
means of getting enough physical activity; one woman
noted,

If I go to the mall, I don’t park close to the store. I like
parking far away to get exercise. I don’t go to the gym,
but I like to get my exercise, so I don’t park too close.

Another woman indicated that her household chores
were her physical activity. “I have the leaves and the tools
to blow the leaves, and this is the only kind of exercise
that I do.”

While Nigerian ways of living were mainly seen as
healthy, many participants still recognized that some
Nigerian dishes were not as healthy as they could be
and described healthier cooking adaptations. For ex-
ample, plantains are commonly deep fried, and it was
noted,

Table 2. Participant Characteristics (N = 13)

Demographic characteristic M (SD)

Age (years) 34 (8.9)

Number of children 1.7 (1.7)

Number of people living in household 3.6 (1.6)

Years lived in the United States 10.1 (7.8)

n (%)

Gender (women) 12 (93%)

Employed outside the home 8 (62%)

Level of education

Some college or associate’s degree 6 (46.2%)

Baccalaureate degree 3 (23.1%)

Master’s or doctoral degree 4 (30.7%)

Marital status

Married 12 (93%)

Widowed 1 (7%)

Annual household incomea

<$20,000/year 2 (15.3%)

$20,001–$50,000/year 4 (30.7%)

>$50,000/year 5 (38.4%)

aTwo participants did not report income.

There was one of the questions about plantains and
how they’re not exactly healthy to fry, so I put in an
example of how I bake them . . . and it tastes very close
to the fried ones, so that’s nice.

A male participant discussed preparing foods with little
to no oil, such as, “I’ve learned to completely stay away
from oil. I use a bottle of oil a year.” Others discussed how
Nigerian meat dishes are cooked and served in a broth
but that care needed to be taken to remove additional fat,
for example,

20 Journal of Nursing Scholarship, 2015; 47:1, 16–24.
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Turk et al. Using Photovoice With Nigerian Immigrants

I was talking about the broth that is overnight in the
fridge . . . a portion of this exposed will have fat on top
of the broth. You just have to skim the broth. Some of
this fat has to come off.

Yet, some participants were reluctant to choose healthier
options for cooking, and one woman commented about a
traditional vegetable stew, “You have to use a little bit of
palm oil for taste. If you take out all the fat, what else do
you have for taste?”

Acquiring American ways was the third theme that
emerged from the data and incorporates perceptions that
many foods, activities, and behaviors common in the
US are unhealthy. Related to fast food, several photos
were described, including, “This one is the pizza picture.
We can see it dripping in oil.” Another woman said, “I
count everything fast food as unhealthy. I don’t allow my
children to eat it.” Several participants stated that their
children preferred unhealthy American food, but that
they tried to balance what they served their children, for
example, “I try to give them salad to eat. . . . So I make
sure I give them a lot, so then for their main meal, they’ll
just eat less of the unhealthy meal.” When asked about
whether there were individuals in their Nigerian commu-
nity in the US who were obese, most participants said that
there were, and one woman noted, “When you go into
a different country you throw your culture away. . . .”
Another commented on the hectic lifestyle in the US:
“When you’re going to work and you can’t cook, and you
don’t have time, it’s a problem.” One male participant
described the Nigerian immigrant’s lifestyle in the US by
saying, “I realize that we work a lot, and it’s a killer. I just
feel that for Africans here in this country, they are work-
ing two jobs, three jobs, going to school, stress is killing
people. . . .” Because of this busy lifestyle, participants
talked of quiet time, meditation, and prayer as healthy
activities in the context of their lives in the US. “I can
see that physical activity can be something different, just
keeping still for some cultures. . . .” “Quiet time is usually
like the time that you meditate. . . . When I’m driving, I
use that particular time to take a quick word of prayer. . . .
So I think that helps with my sanity.” Conscious efforts
were needed to cope with the demands of their fast-paced
lifestyle in the US.

Cultural context is important to promote healthy
behaviors, the final theme, referred to what healthcare
providers can do to encourage Nigerian immigrants to
eat healthier and engage in healthy physical activity. Par-
ticipants emphasized the importance of providers taking
time to ask about and learn the foods that Nigerians eat.
One woman stated,

If I’m seeing a doctor here, the doctor doesn’t under-
stand what I’m eating in terms of the African dishes
. . . if I come with what I eat, then you can advise me
on portion control or maybe substitutions for some of
the things.

This need for education from healthcare providers was
expressed by others.

Like teaching Africans how to make healthy meals
. . . people are afraid to step out of their comfort zone
. . . training that would not only teach how to make
meals, but also teach how to get it healthy.

Participants talked about wanting educational activities
within their community setting. “If you can suggest ac-
tivities that we can do, and if you could give us some sug-
gestions of healthy activities we can use for our [women’s
group] meetings. . . .” Others wanted to explore the pos-
sibility of including a gym in the church hall. “What I
was thinking, was like if you can get like a gym here that
would be a way of encouraging people to do the physical
activity. For us, we can’t go to the gym for free.” Par-
ticipants also thought that nurses and other healthcare
providers “should encourage people to do more cooking
at home instead of going to the restaurants.”

Discussion

Never before utilized with Nigerian immigrants, Pho-
tovoice was a valuable method to explore the beliefs,
perceptions, and practices of these participants regard-
ing healthy eating and physical activity behaviors while
living in the US. This methodology was well received
and easily used by the Nigerians in this study. At the
conclusion of the study, we talked with the participants
about their experiences using the digital camera to cap-
ture their perceptions of unhealthy and healthy lifestyle
behaviors since immigration to the US. All participants
expressed that the camera was easy to use, and that they
enjoyed taking photos and discussing their ideas. The
photo-elicited discussions were rich with descriptions of
healthy and unhealthy Nigerian and American foods and
adaptations that could be applied to improve the health-
iness of certain foods. The facilitated group dialogue cov-
ering each participant’s photos ensured that everyone’s
voice was heard, and a diverse range of perspectives
was put forth and considered. Ideas about healthy eating
and activity within the context of their busy lives were
revealed through the interactive dialogue fostered by
the photos.

Little has been published about the health and lifestyle
behaviors of African immigrants to the US. Evidence
supports the idea that African immigrants are healthier,

Journal of Nursing Scholarship, 2015; 47:1, 16–24. 21
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Using Photovoice With Nigerian Immigrants Turk et al.

overall, than African Americans of a similar age (Ven-
ters & Gany, 2011), but acculturation, or adoption of
the new country’s lifestyle habits, may put African immi-
grants at risk for chronic conditions such as obesity (Ka-
plan, Huguet, Newsom, & McFarland, 2004). Traditional,
native diets are often healthier than the dietary patterns
that evolve with acculturation (Delisle, 2010; Desilets
et al., 2007). However, immigrants may experience bar-
riers in maintaining their native diet or learning about
healthy cooking habits in the new country of residence.
The participants in our study spoke of some of these bar-
riers in their descriptions of their hectic lives in the US
and difficulty finding time to cook proper meals. The fact
that most Nigerian foods were seen as healthier than the
food choices in the US was one of the major themes of
our findings.

Although no previous evidence was found document-
ing Nigerian immigrants’ perceptions of healthy eat-
ing and activity in the US, research with African and
Asian immigrants to Norway (Garnweidner, Terragni,
Pettersen, & Mosdol, 2012) and with Somali and Su-
danese immigrants to the US (Wieland et al., 2013) is
complementary to some of our findings. Female immi-
grants to Norway, asked about how they perceived Nor-
wegian cuisine in relation to their native foods, reported
that they had limited time to prepare their native foods
when they were working, so they resorted to cooking
the more readily prepared Norwegian food. These women
also emphasized that maintaining their native cuisine was
very important, as did the participants in our study. This
finding is in line with previous literature documenting
that native foods are an essential component of identity
and ethnic belonging among immigrant groups (Linden &
Nyberg, 2009; Tuomainen, 2009). While the partici-
pants in our study favored Nigerian food as healthy,
they also saw a need to modify some dishes because
of inherent unhealthiness when prepared according to
Nigerian customs. Although most of the participants’
photos and comments focused on eating and cook-
ing practices, their talk of physical activity highlighted
that household chores and normal daily activities, such
as parking farther away from the store, encompassed
healthy activity. They also described limited time and ex-
tended work hours as barriers to being physically active.
Similarly, Wieland and colleagues (2013) reported that
Somali and Sudanese immigrants to the US viewed ac-
tivities like household work and walking to school as ex-
ercise; long work schedules and lack of time were also
identified as barriers to physical activity among these two
African immigrant groups.

Participants discussed the potential role that health-
care providers could play in helping to promote healthy
eating and physical activity for Nigerian immigrants to

the US. They described how providers are unaware of
the African dishes they eat and suggested that Nigerian
patients take this information with them to a sched-
uled healthcare visit. In a Norwegian study, Pakistani
immigrants also voiced concerns about physicians’ and
healthcare workers’ lack of understanding about cul-
tural dietary practices and foods (Fagerli, Lien, &
Wandel, 2005). The participants in our study were in-
terested in having providers make recommendations on
portion sizes and healthier methods for preparing their
native foods. Nurses and other healthcare providers must
take time to inquire about traditional meal preparation,
and learn about immigrant patients’ cultural foods. Once
insight into these cultural dishes and cooking methods
is obtained, providers could suggest more healthful sub-
stitute ingredients or cooking techniques that are con-
sistent with cultural preferences in terms of taste and
flavor. Effective communication about healthy eating
during the patient encounter needs to incorporate cultur-
ally sensitive advice and messages that not only promote
healthier alternatives, but are considerate of the person’s
culture.

Limitations and Lessons Learned

Because of the qualitative nature of this research, the
findings cannot be generalized beyond the participants in
this study. Our investigation helped to illuminate what
healthy eating and activity in the US are for this group
of fairly highly educated, mostly female, Nigerian immi-
grants. We also encountered some challenges in collect-
ing the data. For the convenience of the participants, the
focus group meetings took place immediately after the
church service. As a result, some participants needed to
bring their small children, who were occasionally dis-
ruptive, making it difficult to hear the discussion, and
we would have been wise to offer child care during
the meetings.

Conclusions

Photovoice was a feasible and effective methodology
for collecting data on the perceptions and practices of
Nigerian immigrants as they relate to eating and activ-
ity behaviors in the US. Our analysis of findings indicated
four overarching themes: Moderation is healthy, Nigerian
ways of living are healthy, acquiring American ways is
unhealthy, and cultural context is important to promote
healthy behaviors. Nurses and other healthcare providers
must make concerted efforts to communicate with
and educate Nigerian immigrants about healthful eat-
ing and activity behaviors within their cultural context.

22 Journal of Nursing Scholarship, 2015; 47:1, 16–24.
C© 2014 Sigma Theta Tau International

Turk et al. Using Photovoice With Nigerian Immigrants

Additional research is needed to develop interventions
for supporting healthy eating and physical activity among
African immigrant groups. Photovoice may be an appro-
priate method to consider for use in intervention devel-
opment with Nigerian immigrants.

Acknowledgments

We would like to thank the participants who gave their
time to this study and the Redeemed Christian Church
of God for the use of their facility. Thank you to Nosa
Osagiede for her assistance with data collection. We also
acknowledge the Duquesne University Faculty Develop-
ment Fund, which provided funding for the study. The
first author was a participant in the 2014 National League
for Nursing (NLN) Scholarly Writing Retreat, sponsored
by the NLN Foundation and Pocket Nurse.

Clinical Resources
� Center for Disease Control and Prevention Im-

migrant and Refugee Health: http://www.cdc.
gov/immigrantrefugeehealth/

� U.S. Department of Agriculture National Agri-
cultural Library. Ethnic/cultural food pyramids:
http://fnic.nal.usda.gov/dietary-guidance/past-
food-pyramid-materials/ethniccultural-food-
pyramids

� World Health Organization. Global recommenda-
tions on physical activity for health: http://www.
who.int/dietphysicalactivity/factsheet˙recomme-
ndations/en/

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NSG3036 W2 Project

Research Template Name

Cite both articles reviewed in APA style:

***In the template, any direct quotes from the articles needs to only include the page number.

Week 2 Template

Quantitative Article

Qualitative Article

Summarize the two assigned articles. In a paragraph, describe in your own words what the study was about and what the researchers found.

Identify and describe the problem for each article

Identified the purpose statement for each article

Identified hypothesis and/or research questions depending on the methodology used in the articles.

After analyzing, discuss
each article’s significance to nursing practice.

Identify two details to support the study being quantitative or qualitative