The aim of this paper is to explore the administrative challenge of lateral violence in nursing. According to Koch (2012) the top ten forms of lateral violence in nursing include nonverbal innuendo, verbal affront, undermining activities, withholding information, sabotage, infighting, scapegoating, backstabbing, failure to respect privacy, and broken confidences. Furthermore, as described by Stokowski (2010) lateral violence is bullying. Additionally, Dimarino (2011) described lateral violence as horizontal violence, nurse to nurse violence, incivility, and disruptive behavior. Interestingly, even popular social media has picked up on the problem of lateral violence in nursing as highlighted by a newspaper editorial article (Hutchins, 2011) printed in Florida.
The author humorously touches on the well-known nursing statement “nurses eat their young” and encourages new graduate nurses to “be sure to choke them (mean nurses) on the way down”. However, all joking aside, lateral violence is a considerable trial to nursing as a profession and the prudent administrator will have a deep understanding of this topic. This paper will highlight the significance, background, and rational on the challenge of lateral violence. Additionally, this paper will note the importance to both the author’s current role (RN) and future role (NP) of lateral violence. An interprofessional focus on lateral violence will be examined from an educational and business perspective.
Legal and ethical considerations will be discussed. A look in to possible interventions, outcomes, and policy and regulations will conclude this paper. Additionally, there will be several instances of personal experiences and professional interviews throughout to help clarify the topic of lateral violence. The method of research for this paper is to search nursing and other professional databases using the keywords of lateral violence, bullying, horizontal hostility, and incivility. Significance
The significance of lateral violence on the nursing profession is almost
immeasurable. Interestingly, multiple articles have shown that around 60% of new graduate nurses will leave their employment as a direct result of lateral violence within six months (Beecroft, Kunzman, & Krozek, 2001; McKenna, Smith, Poole, & Coverdale, 2003; Winter-Collins & McDaniel, 2000; Embree & White 2010). The cost of turnover of one registered nurse varies. One article (Jones & Gates, 2007) suggested that the turnover cost of one registered nurse was up to two times the nurse’s salary. Furthermore, Jones and Gates estimated the typical cost per loss as $22,000-$64,000 depending on the specialty skill and experience of the nurse.
A personal interview of a director of nursing of a local home care and hospice organization highlighted that “losing a nurse is the most costly loss my organization faces”. The director further discussed that lateral violence is “the number one reason for loss of staff in my organization”. Of additional significance is the toll that lateral violence takes on each individual nurse. Embree and White (2010) stated that low self-esteem, depression, self-hatred, and feelings of powerlessness are all consequences of lateral violence. Furthermore, as a consequence to patients lateral violence produces negative patient outcomes as noted by Embree and White (2010). Background
Lateral violence and disruptive behaviors has appeared in nursing literature for over twenty years (Center for the American Nurses, 2008). Embree and White (2010) indicated that lateral violence originates from several factors including role issues, oppression, disenfranchising work practices, perceptions of powerlessness, strict hierarchy, anger, circuits of power, and low self-esteem. However, as noted by Stokowski (2010) bullying (lateral violence) exists in every workplace. Vessey, DeMarco, Gaffney, and Budin(2009) found that lateral violence most often occurs on medical-surgical units, followed by critical care units, then emergency departments, then perioperative units, and finally in obstetric units. Furthermore, founded by the same study was senior nurses, charge nurses, and nurse managers were most often cited as the individuals that most often publicly humiliated, isolated, excluded, and criticized other individuals.
Interestingly, when delving into the background of lateral violence, evidence implies that the bullying behaviors of nurse to nurse violence, starts in nursing schools (Sofield & Salmond, 2003). Furthermore, students reported feelings of being exploited, unwelcomed, and ignored but are unable to recognize these feelings as lateral violence (Hoel, Giga, & Davidson, 2007). Rationale
There are two underlying reasons for the pervasive nature of lateral violence in nursing according to Dellasega (2003). The first is the educational model of nursing. Dellasega (2003) stated that nurses are trained to be subservient and uncertain as compared to the medical students. One example of the subservient side of nursing is the nurse having to receive “orders” from the physician for virtually every action the nurse completes. The second factor is lack of freedom within the workplace. One example is when a nurse reaches her boiling point, she is fundamentally “stuck on her unit” and unable to walk away, let off steam and calm down.
Additionally, as noted by Simmons (2002) contemporary American culture teaches young girls to suppress aggressive feelings and use alternative methods for dealing with anger. This directly affects nursing as reported by Bureau of Health Professions (2004) 94% of registered nurses are women. Current Role Effects
Currently, the author of this paper is facing a challenging endeavor related to lateral violence. Due to down-sizing and budget cuts, the unit which the author had previously work has been closed. This has resulted in registered nurses, emergency department techs, and unit secretaries bargaining for new positions within the hospital. Unfortunately, lateral violence has been swirling around these changes, adding to the stress of an ugly situation and creating a highly toxic work environment. Behaviors currently being exhibited by the staff include undermining activities, withholding information, sabotage, infighting, scapegoating, backstabbing, and broken confidences. These behaviors are seven of the ten most common behaviors of lateral violence listed above according to Koch (2012). As an additional personal experience in lateral violence in the current role as a registered nurse is the role of preceptor and orientee. As an experienced registered nurse, the expectation is to train new nurses in a respectful and professional manner.
Recently, the additional pay for the hard work of training new nurses has been discontinued. The first response of many experienced registered nurses (myself included) was simple, “I will no longer take on orientees”. However, now that the shoe is on the other foot and additional training to excel in a new position is needed by the author, the hostility of the former preceptors is tangible, creating a very uncomfortable and stressful work environment. Role of Nurse Practitioner
The future role which will be investigated with respects to lateral violence will be the role of the Nurse Practitioner. There is little literature directly linking lateral violence to the role of a nurse practitioner. However, Stokowski (2010) implicated that most often the managers of care are the persons perpetrating lateral violence. Additionally, physicians are notorious for disruptive behavior towards nurses. Considering the fact that nurse practitioners are going to be in charge of patient care and replace physicians for some patient’s routine medical care it is imperative that Nurse Practitioner’s do not display characteristics of lateral violence or disruptive behaviors that managers and physicians have been cited doing. General Inter-professional Implications
Impact on the inter-professional team of lateral violence included disruption in relationships, poor cooperation, grievances, and diversions of management’s time (Forte, 1997; Cortina, 2008). As the patient care team is made up of nursing assistants, secretaries, physical therapy, occupational therapy, speech therapy, imaging associates, laboratory personnel, and dietary personal the cost of poor cooperation and communication can be costly to the patient. One study (Hutton & Gates, 2008) indicated that lateral violence (incivility) from direct supervisors and patients directly correlated to loss of productivity. As registered nurses often lead the inter-professional team, the cost of loss of productivity on staff and to patients is significant. Two specific inter-professional focuses (education and business/financial) will be further examined. Education
As previously highlighted lateral violence often begins in nursing school (Sofield & Salmond, 2003). Therefore, it is imperative to examine lateral violence through the eyes of educators on an inter-professional team. Although research on practice education and lateral violence is limited,
according to Hunt and Marini (2012), indirect (lateral violence) incivility is the most prevalent reported behavior from clinical practice teachers. This is often the first experience that young women have within the nursing profession and shape their future careers. Highlighted by multiple sources is the negative impact that lateral violence has on future performance and student learning aof student nurses (Clark, 2008; Cleary, Hunt, & Horsfall, 2010; Anthony & Yastik, 2011). Business / Financial
The repercussions on business finance related to lateral violence are costly. Turnover is commonly cited as the most expensive consequence of lateral violence. Accordingly, Cortina, Magley, Williams, and Langhout (2001) and Pearson, Anderson, and Wegner (2001) have reported an increase in the attention given to lateral violence (workplace incivility) in both general management and workplace stress literature. Additionally, linked by Cortina et al (2001) was lateral violence to decreased job performance and overall job dissatisfaction. Intentional reduction in work effort and quality of work was highlighted by the work of Pearson and Porath (2005). Supervisor incivility was cited as an important factor in the prediction of retention outcomes of organizations (Spence-Lashinger, Leiter, Day, & Gilin, 2009). In light of the above mentioned factors, the prudent business owner and/or administrator would be served well by having a high level of knowledge about lateral violence. Legal
According to Matt (2012) there are laws that nurses violate when they engage in lateral violence. When nurses participate and engage in acts of lateral violence they may be violating laws against harassment of coworkers (Matt, 2012).Harassment of coworkers can be considered a criminal offense in some states. Civil laws such as defamation may also be applied to cases of lateral violence when rumors damage the person’s reputation (Matt, 2012). Additionally, it should be noted that as of May 2011, there were 14 bills addressing the issue of lateral violence in 10 different states (The healthy workplace campaign, 2011). Unfortunately, Michigan does not have any legislation pending. Additionally, noted by Matt (2012) are federal laws under the Occupational Safety and Health Act of 1970. The act mandates employers to “furnish to each of his employees employment and a place of
employment which are free from recognized hazards that are causing or are likely to cause death or serious physical harm to his employees” (OSHA, 1970). Thereby, placing responsibility on the employer for ensuring that lateral violence is not perpetrated in their organization. Ethical
Nursing is frequently considered the most ethical and moral profession (Matt, 2012). However, lateral violence exists within this profession despite a stringent code of ethics meant to build high moral character. There are several ethical principles and codes that are significant when thinking about lateral violence. The principles of nonmaleficence, beneficence, and justice are cited by Matt (2012) as the key principles violated when nurses engage in lateral violence. Furthermore, when examining the moral character of nurses Beauchamp and Childress (2009) listed six virtues of moral character for all health care professionals. Compassion, discernment, trustworthiness, integrity, conscientiousness, and conscience are the virtues listed and defiled when nurses participate in lateral violence. Additionally, the American Nurses Association (ANA) addresses the workplace in provision six “the nurse participates in establishing, maintaining, and improving healthcare environments and conditions of employment conducive to the provision of quality health care and consistent with the values of the profession through individual and collective action.”(Fowler, 2008). Clearly when nurses participate in actions of lateral violence the expectation of the provision is undermined. Intervention
Four key interventions for successfully implementing a lateral violence policy were identified by Coursey, Rodriguez, Dieckmann, and Austin (2013) and included changing behavior to support and encourage a culture that supports a lateral violence policy, frequent and consistent involvement of nursing administration with the nursing personnel, intentionally changing policy and the environment, and implementing numerous interventions simultaneously when one intervention may not be effective alone. Dimarino (2011) noted that education specifically related to the most common forms of lateral violence and strategies to deal with each form as a specific and effective first line intervention. As highlighted by a personal interview
with a manager of a medical unit when she stated “the first time I had to deal with lateral violence, I did nothing because I did not know what to do. After this happened to me for a while, I practiced in the mirror what I would I say when this particular bully was rude to me. It was very difficult the first time, but effectively stop her in her tracks” (personal interview, 2013). Therefore, arming staff with tools to use when they are subject to lateral violence would be an effective intervention. Code of conduct policies are further interventions which will be discussed under policies and regulations.
Joint Commission’s (2009) guideline recommendations are vague and take into account physician’s disruptive behavior. Key highlights of the recommendations include education of staff about behaviors, hold individuals account able, zero tolerance policies that are enforced, leadership training, surveillance and reporting systems, and document all attempts at addressing bad behaviors. Outcomes
Results of successfully deterring lateral violence include no to low staff turnover, increase in employee referrals, increased employee satisfaction, increased patient satisfaction as reported by Dimarino (2011). Another way to measure the outcome of interventions against lateral violence would be use of “The Lateral Violence in Nursing Survey” (Coursey, et al., 2013). Additionally, the outcome of unregulated lateral violence is nurses leaving the nursing profession (Leiper, 2005). Policy and Regulation
One possible policy to implement for a reduction in lateral violence is a code of conduct. One example of a code of conduct provided by Dimarino (2013) highlighted five bullet points the nurse must agree to work by. The following are the highlighted bullet points; 1)Treat colleagues with upmost respect, courtesy, and civility 2)Always act in a professional manner toward fellow employees, patients and family members 3)Work as a member of the team to achieve the common goals of the center 4)Negative behaviors will not be tolerated in the workplace and will be subject to disciplinary action 5)Employees are expected to recognize and report misconduct to administrators and may do so without fear of reprisal. Nurses
sign this contract as a condition of employment. Disciplinary action up to an including termination is highlighted for failure to comply with the rules of the conduct. Dimarino (2011) concluded his research stating that this intervention has improved his organization by fostering safe care to the patient, allowing nurses to flourish and practice excellence in nursing care. Conclusion
In a world where bullying is becoming an increasingly higher profile topic, nursing must react to accusation of rampant lateral violence. As nursing is often considered the most moral, caring, and ethical profession there is no room for lateral violence. As highlighted above patient’s have poorer outcome when being cared for by nurses that are suffering silently with lateral violence. In order to stay true to our caring profession, it is imperative for administrators to face this challenge with an open mind and begin interventions based on evidence in their organizations.
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