Lateral Violence in Nursing

Chapter I: Introduction

It is true with every industry and profession. Most newly hired employees experience some form of hostility from seniors in the workplace.  Such hostility may be in the form of overt antagonism, or the more subtle but no less damaging cold treatment, where the newbie is ignored as if he or she does not exist or matter at all.  It is a very common occurrence, so much so that most people consider it as a rite of passage that every new worker must suffer and overcome.

This form of hostility in the workplace is called Lateral Violence or what is also known as Horizontal Hostility.  This form of antagonism comes in a myriad of forms; it can be a nonverbal condescending gesture like a ‘raised eyebrow’, an unflattering facial expression, or a verbal, sarcastic quip.  Basically any act that is meant to discourage or make a person feel bad in the workplace may be considered as lateral violence.  Some people may be intentional in inflicting this type of hostility while others may be unconsciously mean.

In the nursing profession, newly hired nurses may be subject to the same form of violence in the workplace.  Most, if not all newly licensed nurses face lateral violence from their superiors.  If you have just entered the nursing profession, then you will have to contend with enmity from your peers apart from the actual responsibilities that you have to your patients.  Some deliberate and serious examples of lateral violence in the nursing profession are the attempts to sabotage the neophyte’s progress or ‘testing’ his/her mettle by putting them in charge of a ‘difficult to deal with’ patient (Griffin, 2006, p. 260).  Indeed it can really be disheartening, especially because the people you have been expecting to support and encourage you are the very people who are bringing you down and making things hard for you.

Our lives are governed and works around a balanced cycle between the old and the new.  As the saying goes, the old makes way for the new.  In the natural world the latest marks the end of the former.  This is very true in the world of technology as new gadgets are turned out every few weeks, making the latest obsolete in a very short time.  It is all a part of nature’s perfect plan.  In the law of evolution, new species emerge that are better able to adapt to the ever-changing conditions of the world.  As such, the new come better equipped to make it through the struggle for existence than the old do.

But such does not always hold true in the working world. The emergence or arrival of new employees does not necessarily signal the extinction of the old.  Every vocation has space enough to accommodate both the experienced and the inexperienced.  It is intended to be a symbiotic relationship, with one benefiting from the strengths of the other.  Every profession regards the veterans with reverence and appreciation for all that has been accomplished, and the beginners with anticipation for the possibilities that lie ahead.  But then again, the struggle for survival is as old as time and has been ingrained in our system for far too long.  We are territorial in so far our own niches are concerned; and the slightest possibility of threat can bring out that protective instinct in all of us.  And in the professional world, that defense mechanism comes in the form of lateral violence.  In the mistaken notion of a struggle for survival, every old bird’s stomach flutters every time a greenhorn comes around. In his/her desperation he wages a silent war on the poor beginners and makes them as miserable as humanly possible. And then at nighttime before sleep comes they pat themselves on the back and celebrate their win. (Sen, 2001, p. 67)

Background of the Study

In varying degrees, every newcomer in every field deals with latent violence from their senior colleagues.  This is the culture and there is no getting away from it.  In the nursing profession the occurrence of lateral violence is alarming, especially given the sensitive nature of a nurse’s vocation.  Imagine the hundreds of nurses required in any given hospital and the fewer opportunities available for career growth. There is latent hostility because of the fierce competition.  Furthermore, nurses are what Dr. Martha Griffin rightly calls an “oppressed population” (2006, p. 258).  The nurses put in hours and hours of work into caring for their patients, thus they feel they deserve some acknowledgement. This acknowledgement, however, never comes. What comes instead is resentment; deep, intense resentment towards the power structure from which the nurses are categorically, if not intentionally excluded.

However, being dependant on it none of them can attack the power structure itself. So instead, the senior embattled nurses take the easy way out and attack the defenseless newcomers who are left to their guidance.  Of this problem with lateral violence, Dr. Griffin explains, Nurses generally don’t have sufficient control over their work environment and have a high degree of accountability coupled with a low degree of autonomy. When nurses don’t have control but must be accountable, you can see where they might not be happy with one another. (2006, p. 262)

Significance of the Study

Contrary to what some people may believe, nursing is a very challenging and important profession.  Nurses are an intrinsic part of the medical fraternity.  Without their care and compassion, thousands of patients would die unattended all over the world, every single day.  With the advent of modern medical technology, health care is becoming more complex as more and more people avail of health services due to improvement in medical treatment protocols. Modern hospitals are being built, and consequently, the demand for nurses will increase all the more. To spend a great deal of resources for the recruitment and retention of nurses and only to lose them to lateral violence is indeed a big waste. Thus it is important that people; future nurses, future senior nurses and people unattached to the medical community come to know about this issue.

For those who are part of the nursing profession, knowing about lateral violence is the best way to prepare for it and know how to deal with it should it happen.  For senior nurses, knowing about lateral violence is beneficial because some may be committing this form of hostility without meaning to.  Upon realizing how such hostility affects younger nurses, and adversely affect the nursing profession as a whole, hopefully the senior nurses will be more mindful of their actions and regard lateral violence as counter-productive to everyone concerned.

For the fresh graduate, being informed about lateral violence empowers you to make the appropriate reaction. Remember, you need not suffer the insults and hostility in silence. Lateral violence maybe a common phenomenon, but there is absolutely no reason to think that it is ‘natural’, or something that you deserve. If you have been offended or think someone meant to offend you with lateral violence, it is well within your rights to directly confront the person who has done you wrong. Let the authorities know and make sure that the appropriate administrative or legal actions are taken. Lateral violence perpetuates itself if you do not stop it in its tracks. If you see a colleague who is a victim of lateral violence, you have the moral obligation to intervene. Remember that when it comes to violence, passivity is almost as bad as committing the crime yourself.

For administrators, knowledge about latent violence will help in policy-making. Programs can be instituted to provide sanctions that will discourage latent violence among nurses. The problem with latent violence in the nursing profession is made even more acute because of the shortage in nurses across the country.  The work in itself is difficult because everyday you are responsible for human lives. And the presence of latent violence makes it all the more difficult, even tragic for both the nurses and their patients.  Every year 60% of new entrants in the nursing profession leave a facility; 20% bid a goodbye to the profession altogether. The reasons are varied but they are mostly due to the high stress level of the job. Every act of lateral violence is one more nurse second-guessing his or her decision to enter the profession, and not a few leave entirely because of it.

This is not to indicate that all of these dropouts decide to change their career interest due to latent violence alone. But even if one newcomer drops out of the profession merely due to being victimized then it’s truly a loss for the nursing community as a whole. Since lateral violence can leave people feeling helpless and confused and thoroughly victimized, it is as much a form of violence as any other. (Fletcher, 2003) The problem of latent violence exacts a high price in terms of costs to the hospital.  The costs to hire, retain, and train new nurses can drain the resources of any hospital. Moreover, the instability brought about by the constant turnover of nurses can disrupt the efficient and seamless operations of the hospital because the constant influx of new nurses requires orientation, training and some grounding time.

If we are to solve the problem with the critical shortage of nurses, then we must take a closer look at lateral violence and see how it affects the rate of nurses transferring or leaving the profession to pursue a different career. We have to keep the nurses that we have now in order to survive the following critical years. Consider these numbers from Health Affairs: 47.2% of nurses will retire in the next 10 years; by 2010 henceforth, 40% of all nurses will be older than age 50; 90% of Intensive Care Unit nurses report symptoms of Post-Traumatic Stress Disorder. (Buerhaus & Staiger, 2004)  Certainly if we want to keep our nurses, and encourage more to enter the profession, then we must endeavor to make their working conditions as pleasant as possible, and the issues of lateral violence is among the most important that has to be addressed.

The Denial Mode

Like every other community, the nursing profession is a fraternity that has strong self-preservation instincts. This keeps the nurses from openly recognizing pr acknowledging that horizontal hostility exists among nurses.  However, despite these denials, the fact still remains that more than 60% of new RN’s drop out within the first 6 months in the job due to pressures and enmity from their co-workers.  According to Kar, a recent study in the U.S revealed that turnover rates due to hostile behavior by co-workers or superiors ranges between 33% – 37% for practicing nurses, and 55% – 61% for neophytes.

That veteran nurses still resign from their jobs because of lateral violence is already saying something. Furthermore, a growing number of nurses are getting hooked to various prescription drugs just to be able to deal with the pressures in the work place. (2006)  Aside from the social and emotional ordeal, health issues such as hypertension, migraine, irritable bowel syndrome are just some of the medical conditions that nurses suffer from regularly because of the high stress of the profession. Indeed if the nursing profession wants to protect itself, then it must acknowledge that lateral violence does exists among nurses and that it is one of the greatest problems besetting their profession as of late.

Null and Research Hypotheses

A properly designed research can help determine the factors that contribute to the occurrence of lateral violence. One of the most significant causes could well be stress and burnout, along with other factors such as the ‘corporate’ or business approach to healthcare, lack of respect for nurses, lack of control, inherent subordination in the profession, and competition. Stress and burnout – It is an accepted fact that there are fewer nurses out there to meet the demand for them. As a result, the current crop of professional nurses must contend with long hours and overflowing of patients. There is hardly any time for rest and very little room to complain.  As a result, most nurses ‘burnout’ quick and easy and large numbers of these battle-weary nurses drop out of the profession every year adding to the already critical shortage in nurses.

The ‘corporate’ approach to healthcare – Most people join the nursing profession out of a sincere desire to help people.  They enter the profession with noble intentions and lofty ideals. However once within the system, they end up disillusioned with the business approach that most health care facilities have adopted.  The ideals are swallowed and crushed by a system that operates on profit and loss, instead of genuine service. Due to this corporate stance, a lot of nurses get thoroughly disenchanted early on in their careers. And the bitterness, many think, seeps into their relationship with coworkers in the form of lateral violence.

Lack of respect, lack of control, inherent subordination in the profession – Much has been said about the fact that nursing is a thankless job is. Despite the long hours and the back-breaking work that it requires, the nursing profession grants very few concessions to make up for these difficulties. Nurses receive very little respect for the amount of work that they do. They remain invisible, confined to the background where they hand out scissors and scalpels while surgeons perform life-saving surgeries, and they are hardly appreciated for their contribution to well-being of the patient. Moreover, nursing, from its very inception, has been labeled as a ‘woman’s job’.

By linking the profession to women, the medical world has inadvertently stereotyped the profession as well. As with historical stereotypes of women, meekness and passivity has become associated with nursing as well. Nurses are ‘angels’, and they cannot, as an implicit rule, express anger or resentment. As a result, nurses are forced to repress their emotions, with all the frustration and resentment seething beneath the surface, ready to explode with the slightest of provocation.  All of these repressed negative emotions may find release as lateral violence.

Competition – Since the number of nurses is limited, many aging nurses tend to keep working far longer than they should. These senior nurses have the tendency to be insecure about their job, and as a result, they are highly territorial and protective of their turf.  And their anxiety is well-founded; age is generally regarded as a handicap to the nursing profession.  Nurses need to stay on their feet all through their long shifts. They need to have boundless supplies of energy and vigor to keep up with their jobs. In this regard, the newer nurses have an advantage because of their youth.  For the older nurses, every new nurse that is hired is a threat to their position. The arrival of nurses who are younger, faster, and better-trained thus brings out the instinct to fiercely compete with each other. They exercise lateral violence as a means to prove their power over the young ones, but it is actually a feeble attempt at masking their fears of becoming obsolete and being replaced.

Lateral violence is a manifestation of deeper, more complex issues that involve the individual and the entire system as well. As such, lateral violence may be impossible to pin to just one factor alone. It is perhaps a combination of all these factors that pushes senior nurses into committing lateral violence against their own. Of course, the nature of people must also be considered. Some individuals are just naturally rude or mean.  In such a case he/she will inflict agony on others naturally and unreasonably, without care or concern for the above-mentioned factors. Hopefully such occurrences will be extremely rare if not completely impossible. (Roy, 2005)

A number of people also insist that the new nurses contribute to the issue of lateral violence.  Most senior nurses think that fresh graduates come into the work place believing the ‘nurses eat their young’ concept to be gospel truth.  As a result they do not use the requisite conflict management techniques or adaptive methods that need to be exercised by new recruits in every profession.  Instead, these new nurses become highly sensitive and easy to dismiss an act as lateral violence. They are quick to spot and criticize stray cases of hostility from their seniors, and in the process, miss out on truly cooperative coworkers. People are quick to complain about hostility but slow to praise good treatment. Such is human nature; we tend to focus and amplify the negative things and overlook the positive ones. As such, some cases of latent violence may be an issue of perception as well, and this research must take that into consideration.

Delimitations of the study

The scope of this study is limited only to the nursing professionals of a certain medical facility. Only two medical departments will be observed, but it will involve all the nurses working different shifts, regardless of their tenure or length of stay in the hospital.  The research is intended to be highly reproducible in other hospitals because of the simple and straightforward nature of the study.

Chapter II: Review of Related Literature

The study of lateral violence requires some discussion of the theory of oppressed group behavior.  In fact the term lateral violence was first used by Fanon in the early 1960’s to describe the hostilities that occur among people within the same oppressed group. (Chiarella, 2002, p. 80)  Oppressed group behavior has been used to explain the persistence and prevalence of hostility among nurses. According to this theory, the cycle of oppression is perpetuated by the unshakable belief of the oppressed that they are inferior. (Friere, 1971)  The oppressed begin to detest their own characteristics, and begin to assume the character of the dominating group in the hopes of improving their lot.  (Roberts, 2006, p. 23) The view that nurses are an oppressed group is based on the observation that they are still marginalized in the health care industry, an industry which the public stubbornly perceives as is still dominated by medicine and doctors. (Roberts, 1999, p. 132) The medical profession, being the dominating group, insinuates its norms and values to the nursing profession, and oppresses them in the process. (Fay, 1992, p. 42)

This oppressed group behavior in the profession translates to a self-deprecating behavior within and among nurses. This self-deprecating attitude is the one factor that has been primarily implicated in the “tensions within nursing practices which cause horizontal classicism and racism within the discipline.” (Kollak, 2006, p. 84) The sense of oppression translates to lateral violence because the oppressed, in this case the nurses, are unable to lash out at their superiors, and vent their anger on their colleagues or equals in the profession. (Clark, 2003, p. 168) This oppressed group mentality is made even worse by the “negative effects of gendered socialization”, which involves the perception of nurses as a female occupation. Along with this perception are the stereotyping that labels women as passive and weak, and this stereotyping of women affects the nursing profession by extension. (Oermann, 2005, p. 367)

Definition of Terms

Lateral violence – defined as hostility that is present within the cross section of a specific group of population whether or not it is evident on the surface. Lateral violence may be in the form of verbal abuse such as insults and other defamatory statements, cold treatments, and other work-related hostilities.
Horizontal Hostility – defined in the same manner as lateral violence.
Null Hypotheses – defined as an assumption that is subjected to proof or verification.
Research Hypotheses – defined as an assumption that is going through the process of attestation through a series of applied tests.
Organizational hostility – defined as violence within the parameters of an institution or organization.
Quantitative method – defined as methods applied or subjected to the quantitative data gathering and analysis.

Chapter III: Methodology

One of the primary ways in which social science is defined is in terms of its difference from the so-called ‘pure sciences’ such as physics, chemistry, biology etc. Its use of theory and methodology is, therefore, closely related to this distinction. Social scientists often emphasize that there is no certainty in the study of social sciences. This is because social science deals with human beings, which are inherently mutable. Taking this element of transience into consideration, social scientists have had to use qualitative methods in most of their researches.

Because lateral violence is more of a study on human behavior, a qualitative approach will then employed. Non-quantitative data such as verbal and non-verbal behavior will be the primary object for observation of the nurses. Since human beings tend to operate in terms of emotions and behavior which are difficult to quantify, the qualitative approach is more viable in this case. As such, it is important to remember that the theories guiding this research may not necessarily be applicable in all situations. As the subject of this research is mutable, so are the theories that form the construct of this research.

Data Collection Procedure

Data collection is the actual process of gathering evidence to support a hypothesis. For this specific study, several methods of data collection will be employed. Aside from questionnaires and observation logs, this research will also base its analysis on the historical records of the chosen hospitals. The historical data is simply the information that the hospitals have regarding the report of incidences of lateral violence for the past five years. These will be analyzed, and hopefully from there, be able to generate some baseline profile on the incidences of lateral violence from the two subject hospitals. The historical data is limited by what the hospital has and what they are willing to disclose. Hopefully the hospitals will be willing to participate because any findings will help improve their existing system in so far as retention of nurses is concerned, which it turn benefits the hospital and the patients as well.

As part of the data collection procedures, observation will be used both in the preliminary, actual, and end stages of the research. Observation is a very effective tool to perform an initial exploration of an area, or to establish a framework. This can then be further studied using more focused methods. It is also useful in the end stages of a study as a means of checking information collected in a different way (Sapsford,  2006, p. 58) Observations can provide information on the behavior of nurses as they go about their daily tasks inside the hospital. For the questionnaire, a simple design intended to determine whether they have experienced lateral violence or have done it themselves. The survey will also attempt to uncover how nurses perceive lateral violence and how they feel when they are the object of it. Suggestions will also be asked regarding how lateral violence can be decreased or altogether eliminated in the nursing profession. These questionnaires will be handed out to nurses at random, without regard for their age, years at work, and place of work.

For the observation part of this study, the nurses will be informed that there will be a research conducted and they may be observed. In order to keep the results as candid as possible, the actual observation will be performed at random, without any discernible pattern as to time and place. Observation by nature is deceptive (Musante, 2002, p. 198) because if it were known beforehand, then the data will be “faked” or unnatural, and this defeats the purpose of the observation. However this is not to say that observation must be unethical. The subjects must have informed consent. All the participants in this research will be informed of observations, but the exact nature and specific details will not be given to them.

Instruments

The main instrument will be observation logs, questionnaires and surveys that will elicit a discernible pattern of the occurrence of lateral violence among nurses, both as victims and perpetrators. To address the limitations of the questionnaire and survey method, observations will be performed to validate the results of the questionnaires and surveys. Observation will take place in a natural setting, and the subjects are unaware that their behavior is being monitored.

Sampling

The premise of a sampling is anchored on the fact that it researchers cannot be conducted on everyone in the population. Sampling aims to extract a representational portion of the research subject and be able to extrapolate the results as predictive of the rest of population.  The data sampling would be randomly managed utilizing stratified means with thirty-seven questionnaires completed by both male and female nurses. The choice to use nurses alone in this research was made for two reasons. First, because they are the subject of the research; and second, because the study aims to compare how nurses react to lateral violence based on several.

Reliability and Validity

Reliability and validity are the two benchmarks of research integrity. These two characteristics legitimize the data and make the findings credible and authentic. Validity refers to construct or content; whether the test measures what it aims to measure. (Campbell, 1993, p.1) Reliability on the other hand, refers to the extent to which the test being used is consistent and dependable. Between the two, validity is more important because a test is worthless if it does not aim at the right target.

A valid test is always reliable, but not all reliable tests are valid. Therefore it is important to establish validity because it is the anchor that will keep the data focused and on target. Some tests are reliable in the sense that they consistently measure the wrong things, producing dependable results but testing the wrong target. (Campbell, 1993) There are several measures to test for validity. Content validity is established by showing that the test items are a sample of a universe in which the investigator is interested. Content validity is determined through the deductive method; establishing the goals and narrowing the goals to find a suitable test.

Construct validity refers to the scope of the test; whether it measures all the conceptual aspects or domain of the thing that it wants to measure, taking into account other factors and elements. (Aneshensel, 2004, p. 15) Criterion validity is the ability of the test to predict other areas or aspects which are related to the subject. Because validity involves construct, which are intangible, its measurement involves some level of subjectivity. As such, it cannot be accurately measured and quantified. In this case, the instruments must be focused on nurses and lateral violence and nothing else so that validity of the study is secured.

Reliability is independent of construct and is purely a matter of reproducibility; whether the same tests would yield the same results when done repeatedly. Reliability can only be established by administering the same test in the same subject. Because the subject does not change, then the same test should yield the same results. (Aneshensel, 2004) Variances in the results are indicative of error. The measure of reliability can be expressed as the ratio between the total scores minus the error or deviation.

A score of 1 means perfect reliability; where the test yields the exact same results every time. A value of .50 means that the error variance and the true variance are equal. Normally .60 is the set cut-off value; a higher score means greater reliability and lower than .60 is acceptable in research. Perfect reliability does not exist because a test would always yield some level of variances because human beings are mutable.

Descriptions of statistical methods that will be used

The objective in this study was to see how lateral violence affects nurses and to see how prior knowledge about lateral violence and its management is beneficial or detrimental toward nurses. The variables involved would include age groups, level of education, and understanding of one’s rights and responsibilities. Other variables may include the economic standings of the nurses and the cultural background of the nurses. The data for this work was managed through a sheet of questionnaire handed out to nurses attending a variety of institutions near the researcher’s location. The questions are answered in various ways. The process to deliver and collect these questionnaires spanned approximately two weeks.

To measure correlation between the data, Pearson’s correlation will be used to analyze the relationships between data. The correlation will then be compared using several benchmarks like age, years in service, and ethnical background. Measures of central tendencies such as the mean, mode, median, and standard deviation will be used to check how the data in every area is dispersed or highly different from each other or if they are tightly clustered around the average or the mean. To determine the relationship of the averages between and among data, the t-test or the ANOVA may be used. If only two means from two groups are to be compared, then the t-test should suffice. Finally, once the data has been analyzed using statistical methods, the causality between factors and the incidence of lateral violence can be determined.

Ethical Consideration

This research will treat all data with utmost confidentiality and respect. And data gathered will only be used for the specific purpose of the research and the researches will not disclose any information that is not pertinent to the subject at hand. The research will be conducted with express permission of the participants, and the researcher will provide all the necessary information that the target subject needs to decide whether to participate in the study or not.

Actions to be taken against Lateral violence

Lateral violence experts advise action at two different levels. The first is Individual Level and the second is Organizational Level.

Action at an Individual Level

If you are facing horizontal hostility on a regular basis here are 3 things you ought to do; Have a talk with the offendor, Approach the authorities and Strive towards creating shared values.

Have a talk with the offendor – Don’t clench your teeth and silently bear a hostile comment or gesture; be polite and ask your tormentor what the problem is. Explain how his/her bad attitude is affecting your work. Most offenders stop after being confronted with their misdeed.

Approach the authorities – If matters get too difficult to handle, it is time to approach the authorities. Make your supervisor or any other authority hear about your grievances. But remember to not stretch facts in order to suit your needs. Speak your truth and leave the rest to the person in charge. File a complaint in paper and then monitor to see if actions are taken. In case no action is taken, follow it up. Continue complaining until the authorities take notice and do something about it.

Strive towards creating shared values – Work with your coworkers, whether new or old. Try and take them into your confidence and learn to be cooperative. It might not work with everyone but it will work with some people. Establish sincere friendships. Also, make sure that you do not participate or encourage incidents of latent violence.

Action at an Organizational level

Here are some suggestions as to what administrators one can do to prevent incidents of horizontal hostility in the organization.

Try assertiveness training for the new recruits – Make a sincere effort to make your staff assertive by putting them through a well-designed assertiveness training program. Let them be trained right before they step into the job so that their confidence remains high and they can tackle all cases of latent violence effectively.

Try an awareness training program for all employees – All your employees need to know about lateral violence and how to deal with it properly. Awareness empowers nurses to make informed choices.

Become responsible – Let your nurses know that you will not tolerate any horizontal hostility and that people engaging in it will face consequences. Also, make sure to check up on regular absentees to find out if they are victims of latent violence. Adopt a strict zero-tolerance policy.

Give your nurses the respect they deserve – Let your nurses introduce themselves as an ‘RN’ when meeting the patient for the first time. Have doctors address nurses by their names.

Address anger management issues in the work place – Step up your initiatives to deal with anger management. Contact your in-house counselor or psychiatrist regarding the needs of your employees. Remember, addressing anger can help remove almost every trace of latent violence in your hospital once and for all. (Mukherjee, 2004)

References:

• Aneshenshel, C. (2004). Measurement: Reliability, Validity, and Association. 15-16.
• Buerhaus, P. & Staiger, D, et al (2004). New Signs Of A Strengthening U.S. Nurse Labor Market? Project HOPE. Retrieved on July 18, 2007 from http://content.healthaffairs.org/cgi/content/abstract/hlthaff.w4.526v1
• Campbell, K. (1993). Establishing Consistency Reliability of Measurement Data of a New Instrument, the Information Preference Questionnaire. 1-4
• Chiarella, M. (2002). The Legal and Professional Status of Nursing.  Elsevier Health Sciences. p.80
• Clark, C. (2003) Holistic Assertiveness Skills for Nurses: Empower Yourself and Others. Springer Publishing Company. p. 168
• Dollard, John, Doob, Leonard W., Miller, Neal E., Mowrer, O. H. and Sears, Robert R. (2005) Frustration and Aggression: the Inner Story of Public Service. New Haven and London: Yale University Press.
• Fay, A. (1992). Inside Nursing: A Critical Ethnography of Clinical Nursing Practice. SUNY Press. p. 42
• Fletcher, R; (2003). Beliefs and Knowledge: Believing and Knowing. Howard & Price
• Friere, P. (1971) Pedagogy of the Oppressed. New York: Herder and Herder
• Griffin, M. (2004).Teaching cognitive rehearsal as a shield for lateral violence: an intervention for newly licensed nurses. Journal of Continuing Education in Nursing, 35 (6): 257-63
• Heinrich, K & Oermann, M. (2005) Annual Review of Nursing Education. Springer Publishing Company. P. 367
• Kar, P; (2006). History of Nursing and related application of Psychology. Dasgupta & Chatterjee
• Kollak, I & Kim, S. (2006). Nursing Theories: Conceptual & Philosophical Foundations. Springer Publishing Company. p.84
• Medical Collage Handout- Year 2006. (2006); Kolkata Medical Collage
• Mukherjee, Sachin D. (2004). Thought Strategies. IBL & Alliance Ltd
• Musante! DeWalt, Kathleen, & DeWalt Billie. (2002) Participant Observation: A Guide for Fieldworkers. Rowman Altamira. 198
• Roberts, S (2006). Oppressed Group Behavior and Nursing. Eds. Andrist, L & Nicholas, P.  A History of Nursing Ideas. Jones & Bartlett. p. 23-31
• Roberts, S. Nurse Executives in the 1990’s: Executive or Oppressed. Ed. Turner, S.  Essential Readings in Nursing Managed Care. Aspen Reference Group. p. 130
• Sapsford, R. & Jupp, V. (2006). Data Collection and Analysis. Sage Publications, 58.
• Sen, S; (2001). Thinking and Acting against Corporate Vices; ABP Ltd