Sie sind auf Seite 1von 50

(Title)

(Subtitle, if any)

(Name)

(Subject)

(Name of Professor)

(Date)
Chapter II: Literature Review

Chapter Roadmap

This study will take a look at a perennial problem new nurses cannot seem to

avoid, horizontal violence. Also, in an effort to better understand nurse-on-nurse

horizontal violence, a literature review has been conducted to gather the major themes

encompassing horizontal violence. A review on literature that expounds on the concept

of horizontal violence and its historical aspects will first be presented. Then, a broad

overview of articles that single out nurse-on-nurse horizontal violence will be

incorporated to further strengthen its existence as researched and documented by various

experts. These written works will also establish the culture of horizontal violence in the

nursing profession.

Following the overview on horizontal violence is a focus on literature that

presents studies that made use of the same methodology used in this paper. The next set

of literature to be presented will serve as support to this study’s theoretical framework as

well as those that serve as scholarly answers to the research. Then, a review of the most

current articles dealing with horizontal violence will be reviewed. Finally, a discussion

about the all the literature presented will follow to serve as the chapter’s summary.

History and Concept of Horizontal Violence

Horizontal violence, otherwise known as lateral violence or bullying in the

nursing profession, has been in literature for over 25 year now. Nursing was founded in a
society that is basically patriarchal in nature which up to the present composed mainly of

females. Even at the onset, the profession calls for a position that has a subordinate role.

At the beginning, women are yet to be given many rights as men and the nursing

profession is a way for them to “stand on their own” (Johnston, 2010, p.38). However,

the profession can only be acceptable, basically because the women nurses are going to

be caring for, among others, male strangers, the profession is depicted to be "God's work"

and a "calling. Consequently, the nurses are the angels of mercy. As angels, they are not

expected to get mad. This gave nurses during those times the image that they are always

caring, are willing to work long hours, will reject their own needs in favor of others, do

not complain, speak only when spoken to and are always subordinate (Bartholomew,

2006). This situation made it easy for horizontal violence to proliferate in no time.

The term "horizontal violence" was first used by theorist Paulo Freire in 1972. It

was used to explain the ongoing conflict among the African population at the time. Freire

observed that power imbalance results into two groups where one is dominant and the

other subordinate. He therefore theorized that in such situations, where one group is more

powerful than the other, oppression occurs when values of the subordinate group are

repressed by the dominant one. Freire believed that since the subordinate group was

pushed to have their own ideas and values rejected in favor of the values and ideas of the

dominant group, they developed a feeling of inferiority. When the inferior group started

acting out their self-hatred, internal conflict ensues and will spread. This is how

Bartholomew (2006) explained the beginnings of horizontal violence in the nursing

profession. To get a clearer understanding of the concept of horizontal violence, the next

set of literature defining it will be reviewed.


Horizontal violence (Dunn, 2003; Farrell, 1997; Hastie, 2002; Longo and

Sherman, 2007), lateral violence (Griffin, 2004; Stanley, et al., 2007; Rowell, 2007) and

horizontal hostility (Bartholomew, 2006; Thomas, 2003) are terms commonly used to

describe the verbal, physical or emotional abuse of an employee. When applied to the

nursing profession, horizontal violence is defined as a nurse to nurse aggression. The

violence involved may be both in verbal or nonverbal behaviors. The ten most common

forms of lateral violence in nursing are undermining activities, verbal and non-verbal

innuendos, withholding information, scapegoating, infighting, backstabbing, etc. (Griffin,

2004, p.257).

The definition of horizontal violence among nurses is any act or behavior of

hostility or aggression, which could be oral, emotional, or physical, carried out by a

coworker towards another coworker. This act or behavior can either be blatant or subtle

and takes place because of power imbalance, the carrying on of learned behaviors, and

oppression (McCall, 1996; Roberts, 1983; Skillings, 1992).

Lateral violence is also referred to as aggression, bullying, or horizontal violence

(Griffin, 2004). Other literature terminologies relevant to lateral violence are “nurses

eating their young”, verbal abuse, and horizontal hostility. The occurrence of lateral

violence has been expressed in nursing literature for over 25 years (Farrell, 1997;

Roberts, 1983). Lateral violence is defined in literature as explicitly or vaguely

expressing their displeasure inward toward: (1) themselves, (2) those lower than them

with regards to authority, and (3) each other (Griffin). Incorporating studies on lateral

violence is a challenge because of the absence of a universal term to include all the said

actions (Bartholomew, 2006). Lateral violence reveals itself in a range of mean, hostile
relations that take place among nurses at the same organizational chain of command

(Alspach, 2007); these relations may be expressed either overtly or covertly

(Bartholomew; Griffin). Since majority of the interactions among nurses are nonverbal,

the form of lateral violence that has the most impact are those expressed covertly

(Bartholomew). Lateral violence is an action or behavior of hostility expressed by a nurse

against another nurse. The usual expressions of lateral violence have been described by

Griffin (2004) as verbal insult, nonverbal insinuation, undermining tasks and activities,

backstabbing, infighting, sabotaging, refusal to give information, broken confidentialities,

and failure to give privacy. Generally, lateral violence is emotional or verbal abuse, but

there are times when it is expressed as physical mistreatment (Longo and Sherman,

2007). Lateral violence is an issue prevalent in nursing (Stanley, Dulaney, & Martin,

2007; Woelfle & McCaffrey, 2007).

The aforementioned definitions given by various experts on the field are one in

saying that violence in the field of nursing exists. The history cited attributes the

beginnings of the said violence in the structure of the profession itself wherein nurses are

commonly female and the job description entails them to be submissive. For a deeper

understanding of the problem, the next set of literature to be reviewed will be an

overview of nurse-to-nurse horizontal violence.

Overview

Horizontal violence among nurses is basically similar with how bullies act in

other settings; they intentionally speak and behave the way they do to discredit or

intimidate the victim. They have the tendency to be cunning and falsehearted, which is

why they are usually called “two-faced”. More frequently, they bully the victim verbally
or by isolating him or her.

The bully will get in the way of the victim’s work activities and present consistent

sarcasm, hostility, criticism, and invention of complaints, to set up the victim for

disappointment with the intent of humiliating the victim and breaking down his or her

self-confidence. Such deeds are damaging and are usually done gradually. They

frequently happen in settings where there can be no witnesses. The one bullying is

continually aware that he or she is inflicting damage and will keep on belittling the victim

to become more dominant. There are varying time intervals for bullying behavior,

ranging from a number of months to a number of years (Lewis, 2006)

It is interesting to note that in most of the studies made about all types of bullying

and horizontal violence which are in existence, e.g., nurse-to-visitor, physician-to-nurse,

patient-to-nurse and nurse-to-nurse, most nurses who experienced horizontal violence

reported that it is the latter type that is most distressing to handle. It is ironic that nurse to

nurse aggression is quite prevalent and that nurse themselves, who are supposed to

-understand the other nurses more, are the ones that will show aggression to their

colleagues. In a study made, 50% of all the bullies are female and those bullied are 84%

women (Johnston, 2010, p. 38).

Characteristics of Nurse-to-Nurse Horizontal Violence

• “Criticism, sabotage, undermining, infighting, scapegoating, and bickering” (Duffy,

1995, p. 9)

• “Intimidation, humiliation, excessive criticism, exclusion, innuendo, denial of access to

opportunity, disinterest, discouragement, and the withholding of information;” (as quoted

in McKenna, Smith, Poole, & Coverdale, 2003, p. 91)


• “Learning opportunities blocked, felt neglected, were given too much responsibility

without appropriate support… rude[ness]” (McKenna et al., p. 93)

• “Raising of eyebrows… abrupt responses… not being available… withholding

information about practice or about patients… sabotage… in-fighting… failure to respect

privacy … broken confidences” (Dunbar, 2005, p.1)

• “Dismissing, belittling, undermining, humorous ‘put downs’… gossiping… sarcastic

comments… nitpicking… minimizing another’s concerns… slurs and jokes based on

race, ethnicity, religion, gender, or sexual orientation… withholding support… limiting

right to free speech and right to have an opinion… “better than” attitude… chronic

understaffing” (Hastie, 2002, pp. 2-3).

The power of horizontal violence in nursing is now being countered by awareness,

education, and on-the-job zero tolerance for abuse. “We’ve always cared for others. Now

let’s care for each other” (Leiper, 2005, p. 45).

Horizontal Violence: An Issue of Oppression

Dr. Martha Griffin, an educator in nursing and an activist, supposes that oppressed

group behavior is the reason behind the occurrence of lateral violence. Oppressed group

actions and behavior happen when one group has developed the belief that it has been

eliminated from the authority structure (Ratner, 10). According to Griffin, nurses hardly

have control over their work environment yet they still are held responsible when

problems arise, causing personal trauma and anxiety. The oppressed group member acts

impertinently and nastily towards colleagues and peers of lower status or authority

because he or she is afraid to address the source of the distress that affects him or her. As
a result, the oppressed group member strikes out at colleagues, unlicensed assistance

staff, students, patients, etc.

Horizontal Violence: An Issue of Gender

Horizontal violence may also be understood as a gender issue since according to

the National Sample Survey of Registered Nurses (RNs) conducted in 2000, only 5.4% of

registered nurses are males (DHHS/HRSA/BHP/DON, 2000 p.8). The gender theory

states that horizontal violence in nursing takes place because females did not grow up

appreciating themselves socially or the roles they perform. Often, females are socialized

to think of themselves as less smart and weaker than males and that their duty in life is to

serve and submit to males.

Horizontal Violence: A Role Issue

During the first year of nursing education, the nurses are already being trained to

work in teams. Physicians, on the other hand, have traditionally been taught and trained

to think of themselves as the ones with authority. These traditional professional principles

contradict each other and provide the basis for conflicts between physicians and nurses. It

is the expectation of nurses that they would be working with physicians as colleagues.

The physicians, however, are not very enthusiastic with that idea.

Nurse-to-nurse horizontal violence and horizontal violence among nurses take

place for a variety of reasons. Because in a nursing workplace, a lot of roles and duties

are involved, role issues can crop up between and among nurses; between advanced
practice registered nurses (APRNs) and managers; between managers and staff nurses;

and APRNs and staff nurses.

Horizontal Violence: An Issue of Self-Esteem

The theory of self-esteem is quite complicated. Self-esteem is a foremost factor in

the aforementioned approaches to the issue of horizontal violence.

The main themes of self-esteem are that: (1) it is a key element in predicting

behavior; (2) it takes place along a continuum and not a polarizing entity; (3) and that it

includes different ‘selves’, in that a person can think of himself differently as a nurse,

than he does as a parent.

One’s self-esteem can either be boosted or degraded in social interaction, as he or

she receives opinions about how other people see him or her and judge his or her actions

and activities (Randle, 395). Self-esteem is subjective and created at the same time in the

sense that a person’s self-esteem is partially what he or she thinks of himself or herself

based on how other people act in response to him or her, and partially based on his or her

own experiences in life.

A nurse develops his or her professional self-esteem largely by his or her

communications and dealings with mentors, instructors, superintendent nurses, and

student colleagues. As students of nursing watch those higher than them, they cultivate a

starting idea of how a professional should act and behave towards colleagues, students,

and patients.

The aforementioned literature establishes the existence of horizontal violence and

proves that it abounds. Yet, what has been included is only a small fraction of what is
available. In the succeeding topics, more instances of horizontal violence will be presented,

this time even made concrete with evidences produced by methodologies and in depth

analysis of the problem.

Methodology

Violence in the workplace is damaging to healthcare dynamics and is now an issue that

cannot be disregarded. The form of violence in the workplace that is becoming

increasingly practiced is horizontal violence among nurses. Nurse bullying is bringing

about upshots that are unsafe to patient care, for the nursing profession itself, and to

healthcare establishments.

Having been in existence for many decades already, many studies and researches

on the subject of horizontal violence have been done worldwide. One of those who

conducted such study was Cheryl Dellasega (2009, p. 52). She has completed a literature

review on horizontal violence with female nurses. Her work showed that indeed, the

problem is being experienced by most nurses that are new in the profession. The

examples she gave of this violence are sabotaging of a nurse to effect failure, name-

calling, gossiping and eye-rolling.

Still another work on measuring mobbing experiences of academic nurses was

done in 2008. This study was prepared not only to learn of such experiences but also to

develop a mobbing scale that can be used for further studies (Ozturk, H., Sokmen, S.,

Yilmaz, F., Cilinger, D., 2008, p.235). This study used Leymann, one of the founders in

the research of horizontal violence, later violence and mobbing behaviors, to define what
mobbing behaviors are. According to him, “mobbing or psychological terror is hostile

and unethical communications directed in a systematic manner towards a person”

(Ozturk, H., &al., 2008, Yilidirim, D., & al., 2007, p.451). This study was prepared to be

able to develop a mobbing scale for academic nurses and to determine whether academic

nurses experience mobbing and to what extent mobbing existed at the university nursing

schools in Turkey.

The findings of the study noted that one hundred and sixty-two academic nurses

with an average age of 33 years and had an average of 11 of experience sixty-one percent

had stated that they were victims of a mobbing experience. After the questionnaire had

been evaluated 34% of the 61% of academic nurses who participated stated that they

were mobbing victims scored to have been mobbing victims. Of those surveyed, 49%

were still experiencing mobbing while 67% were exposed to mobbing for three years or

more (Ozturk, H., & al., 2008, p.438). The study also showed that the participants had

suffered psychological effects from mobbing behaviors “this means that the participants

suffered psychological effects that resulted in fatigue” (Ozturk, H., & al., 2008, p.438).

With all of the data, it shows that nurses of an academic status regardless of age are

falling victim to mobbing behaviors in the Turkish Universities.

An older study that was done in New Zealand by Mckenna, B. G., Smith, N. A.,

Poole, S. J., & Coverdale, J.H., (2003) Horizontal Violence: experiences of registered

nurses in their first year of practice has been referenced in several of the studies that were

mentioned before. This study conducted by McKenna, et. al., was to get a picture of
what the novice nurse was experiencing in relation to horizontal violence in the first year

of practice.

The study was conducted in New Zealand. They decided to mail out

questionnaires to 1,169 individuals who registered as new nurses that year. The

researchers had a forty-seven percent of their surveys returned and the results of what

those surveys stated were astounding. The descriptive study was conducted with open

ended questions pertaining to the type of horizontal violence that the graduate nurse had

experienced. The researchers also wanted to know the reaction of the graduate nurse to

the horizontal violence that was experienced. Ninety-four percent of the respondents

were female and six percent were male. Forty-six percent of the populations of graduate

nurses were under the age of thirty.

The study revealed horizontal violence is present and very real to graduate nurses

coming into the work force with seasoned nurses. The experiences that were described

were backstabbing, bullying, humiliation, and withholding opportunities for learning.

Some of the highest types of horizontal violence experienced were learning being

blocked; in the surgical units this would include intensive care units. The surgical units

were also high with emotional neglect, and lack of supervision. Through this study they

found that the type of horizontal violence that was experienced was covert in nature. The

new graduates also reported that they had been absent to work due to horizontal violence.

The graduate nurses had also reported that constructive criticism was not perceived as

such, they felt they were being talked down to. The worst and most disturbing result was
the graduate nurses had thought about or already had left the nursing profession due to

the horizontal violence experienced. Twelve percent of the graduate nurses had stated

that they had to have counseling due to the distressing events that was experienced.

Another study made on the subject that is of the same type of methodology as I

used in my dissertation is one made by Kathleen Sellers, PhD, RN, wherein she made a

descriptive study to examine the prevalence of horizontal violence in RNs who are

members of NYONE (New York Organization of Nurse Executives). Knowing the nurse

administrators' knowledge on the subject and the degree of encounter they had is the aim

of the study. The theoretical framework made use of was the transformational leadership

theory. The methodology made use of a convenient number of RNs as sample, all of

which are members of NYONE. They completed a Briles' Sabotage Savvy questionnaire

that included their demographic information among others. Likert model was also used

in this study. The study established the existence of horizontal violence in the profession

of nursing in consistence with what was already written about it. The study even showed

that the problem is already deeply rooted that it has already become a culture and is not

easily recognized. This makes the problem even harder to solve since it is not even

known to be a problem anymore.

Another research made on the nurse on nurse horizontal violence written by Cheryl

Woelfle and Ruth McCaffery (2007). They wanted to know if horizontal violence really

existed among nurses in the workplace and if it did what were the consequences of

horizontal violence among nurses in relation to patient care. They reviewed specifically

four different research articles the first article used was a “descriptive correlation design
that was used to examine the possible relationship between the perceived acts of

horizontal violence and the different levels of job satisfaction as reported by preoperative

nurses” (Woelfle, C., McCaffery, R. 2007, p.124). Participants are 145 preoperative

nurses from the preoperative nurses association for registered nurses (AORN) and their

ages ranged from 31 to 68, and ninety-eight of these nurses were female. They were

given a questionnaire to fill out containing forty questions to find out if the surveyed

nurse had ever been a victim of horizontal violence or bullying in the work place.

The surveys reported that the most common type of sabotage or bullying was one

expecting another to do their work. The “saboteurs reported that their most frequent form

of victimizing was to stop talking when others entered into the room, and they

complained about others without discussing it first with that person” (Woelfle, C.,

McCaffery, R., 2007, p.124). With the survey, they did not find a direct correlation with

satisfaction of nurses in the preoperative area and dissatisfaction with their current jobs.

They did find that preoperative nurses did act inappropriately and unprofessionally

amongst each other in the preoperative environment, “the study represents a significant

positive correlation between the IWS scores and reported sabotage” (Woelfle, C.,

McCaffery, R., 2007, p. 126). The weakness in this study was noted that maybe the

preoperative nurse was not being completely honest on the survey that was taken in

relation to the job satisfaction and significant sabotage in the working environment.

Theoretical Framework

As sensitivity and caring (Bartholomew, 2006) are the focus of the nursing

profession, LV occurring at all is ironic (McKenna, Smith, Poole, & Coverdale, 2003;

Woelfle & McCaffrey, 2007). Although other theories describe why LV occurs, the most
cited theory to describe the origins of LV can be found in the oppressed-group model

(Roberts, 1983). The model suggests that nurses are an oppressed and powerless group

dominated by others (DeMarco & Roberts, 2003). Oppression exists when a powerful and

dominant group controls and exploits a less powerful group. Nursing has been described

as an oppressed group because the profession is mostly women, and nurses report to

mostly male physicians and administrators (Farrell, 1997). Cherished nursing

characteristics, such as sensitivity and caring, are viewed as less important or even

negative when compared to those of medical practitioners, who often are seen as the

central culture in health care (Woelfle & McCaffrey).

The literature supports this view, stating that nurses lack autonomy, control over

their work, and self-esteem and subscribe to submissive-aggressive syndrome to affect

change (Freshwater, 2000). Submissive-aggressive syndrome is a term that describes

when nurses feel they have lost their power (submissiveness), and react by overpowering

others through aggressiveness (Bartholomew, 2006). Roberts (1983, 2000) has described

the application of Freire's (1971) oppression theory to nursing. The theory explains that

members of an oppressed group display common behavioral characteristics, such as low

self-esteem and self-hatred (Roberts, 1983; Woelfle & McCaffrey, 2007). LV among

nurses evolves from feelings of low self-esteem and lack of respect from others in the

work environment (Longo & Sherman, 2007). Oppression theory proposes that nurses

perceive themselves as powerless and oppressed in the healthcare setting. As an

oppressed group, nurses feel alienated and have little control of their practice. This leads

to a cycle of low self-esteem and feelings of powerlessness (DeMarco & Roberts, 2003).

Rather than confronting the issue (and risking retaliation by leadership in the healthcare
system), the oppressed group manifests their frustration on other nurses lateral to them.

One explanation of why lateral violence is so prevalent in nursing focuses on the

profession as an oppressed group. Nurses have often been considered an oppressed group

as historically the profession is primarily female and has long been subordinate to male

physicians, administrators and marginalized nurse managers (Longo & Sherman, 2007,

p.35). Symptomatic of an oppressed group mentality, feelings of low self esteem and

powerlessness develop when members feel alienated and removed from autonomy and

lack control over their working environment (Longo & Sherman, 2007, p.35). From

oppression, emerge nurses who are socialized into relationships of unbalanced power

further internalizing their feelings of inferiority; resultantly stifling their ability to assert

control over their own future and turning against colleagues (Hutchinson, Vickers,

Jackson, & Wilkes, 2006, p.120).

One explanation of why lateral violence is so prevalent in nursing focuses on the

profession as an oppressed group. Nurses have often been considered an oppressed group

as historically the profession is primarily female and has long been subordinate to male

physicians, administrators and marginalized nurse managers (Longo & Sherman, 2007,

p.35). Symptomatic of an oppressed group mentality, feelings of low self esteem and

powerlessness develop when members feel alienated and removed from autonomy and

lack control over their working environment (Longo & Sherman, 2007, p.35). From

oppression, emerge nurses who are socialized into relationships of unbalanced power

further internalizing their feelings of inferiority; resultantly stifling their ability to assert

control over their own future and turning against colleagues (Hutchinson, Vickers,

Jackson, & Wilkes, 2006, p.120).


Sandra Roberts, PhD, RN, FAAN noted in 1983 that nurses generally display the traits of

that of an oppressed group. They show self-hatred, low self-confidence and

powerlessness. Roberts was the first to apply Freire's oppression theory to nursing. She

cited Bartholomew's idea that the concept of nursing being an oppressed profession is

traceable to the issue on gender and that this fact is evidenced by significant literature

(Roberts, 2009, p.388). She added that according to Bartholomew, since medicine is

male dominated (referring to the physicians), the female nurses are naturally the ones

who experienced oppression. Roberts stressed that with the modern times where more

are expected of the nurses, the discipline becomes more stressful and pressuring for them.

More are expected out of their profession and this is where the hostility may arise and the

nurses take it out on each other. That basically is the beginning of horizontal violence, at

least the documented part of it.

Origin Theories

• Oppressed-group model theory (Roberts 1983)

– Nurses are an oppressed and powerless group dominated by others

– Nursing profession mostly women and have to report to male physicians

and administrators

– Sensitivity and caring view as less important or even negative when

compared to those of medical practitioners

– Nurses lack autonomy, control over their work, and self-esteem and

subscribe submissive-aggressive syndrome

• Submissive-aggressive syndrome

– When nurses feel they lost power and react by overpowering others
– through aggressiveness

• Oppression theory

– Members of an oppressed group display common behavioral

characteristics low self esteem and self-hatred

– LV evolves from feelings of low self-esteem and lack of respect from

others in the work environment

– Nurse perceive themselves as powerless and oppressed in the health care

setting

• Leads to feelings of alienation and lack of control over practice

– Leads to cycle of low self-esteem and powerlessness

– Nurses manifest frustrations to other nurses lateral to them rather than

confronting the issue because of risk of retaliation by leadership in the

healthcare system.

Horizontal Violence Updates

Workplace violence is a central human rights issue and a source of inequality,

discrimination, stigmatization and conflict in the workplace.

The consequences of workplace violence in health care include the deterioration of the

quality of care provided and the decision of workers to leave the profession which can

result in the loss of health services to the general public and an increase in healthcare cost

(Longo and Lynn, 2010).


Reversing the bullying culture in nursing

By Lynda Olender-Russo, PhD(c), MA, NEA-BC, RN 2009

Leaders within healthcare organizations are struggling to manage disruptive behavior

and bullying in the workplace.

A serious situation is emerging in the health care system of the United States.

The country is bracing for a projected unprecedented shortage of more than 500,000 RNs

by 2025, due in part to baby boomer nurses retiring at the same time as the demand for

healthcare is rising. Moreover, despite the 3.3% increase in student enrollment and a

stable RN vacancy rate of 8.1%, RN turnover rates range from 8.4% to 13.9%; and the

demand for registered nurses still is expected to increase 2% to 3% annually (AACN,

2009).
dissatisfaction and related intent to leave the work environment are believed to be key

factors contributing to the shortage. Moreover, exposure to incivility, including

workplace bullying, is one of the primary factors influencing RN dissatisfaction and

turnover rates, (Simmons, 2008, p. 48) and can be a reason why some leave the

profession altogether (Duffield et al, 2004, p. 664).

Discussion

Impact of Lateral Violence: Emotional, Physical and Financial

The economic impact of lateral violence is not only costly but directly impacts patient

safety. According to Griffin (2004), of the new graduates who leave their first nursing

positions, 60% leave because they have experienced some form of lateral violence. It is

estimated to cost $92,000 to recruit, hire, and orient a medical surgical nurse and the cost

rises to $145,000 to recruit, hire and orient a specialty nurse (Pendry, 2007). Current

research identifies the average voluntary nurse turnover rate in hospitals to be around

8.4%, this average increases to 27.1% for first year nurses (Price, Waterhouse, Coopers,

2007). The impact of this turnover not only erodes an organizations budget, but it impacts

the organization’s ability to recruit and hire new staff once they develop a reputation for

tolerating lateral violence (Bartholomew, 2006). Additional costs come from the

emotional and physical symptoms that result from lateral violence. This can cause an

increased use of sick leave which impacts staffing patterns and places a strain on the unit.

(Rowell, 2007).

Lateral violence behaviors interfere with effective health care communication and

therefore impact patient safety. This is costly to health care organization as the rate of

medical errors increase with communication failures (Wolf & McCaffrey, 2007).
The current healthcare environment, with nursing shortages looming and the uncertainty

of national healthcare reform, demands that leadership in the organization must do

everything possible stop the loss of nurses because of lateral violence. The answer is

obvious… we must implement strategies that support a healthy work environment. If

lateral violence is not addressed, for all involved it is “all pain and no gain”.

References

Alspach, G. (2008). Lateral hostility between critical care nurses a survey report.
Critical Care Nurse, 28(2), 13-19.

Baltimore, J. J. (2006). Nurse collegiality: fact or fiction? Nursing management, 28-36.

Bartholomew, K. (2006). Ending nurse-to nurse hostility. Marblehead, MA 01945: HCPRO,


Inc. Center for American Nurses. (2007). Bullying in the workplace: Reversing a
culture. Silver Spring, MD: Center for American Nurses.

Broome, B.A., (2008). Dealing with sharks and bullies in the workplace. The ABNF
Journal, 28-30.

Center for American Nurses. (2007). Bullying in the workplace: Reversing a culture.
Silver Spring, MD: Center for American Nurses.

Chaboyer, W., Najman, J., Dunn, S. (2001). Cohesion among nurses: a comparison of
bedside vs. charge nurses' perceptions in Australian hospitals. Journal of
Advanced Nursing, 35(4), 526-532.

Christmas K. Workplace abuse: finding solutions. Nurs Econ. 2007;25(6):365-367.

Dellasega, C.A. (2009). Bullying among nurses. American Journal of Nursing, 109(1)
52-58. doi: 10.1097/01.NAJ.00003440389.11651.08

Dunn, H. (2003). Horizontal violence among nurses in the operating room. AORN
Journal, 78(6), 977-980, 982, 984-988.
Farrell, G. A. (1997). Aggression in clinical settings: nurses' views. Journal of Advanced
Nursing, 25(3), 501-508.

Freire, P. (1970). Pedagogy of the Oppressed. New York, NY: Continuum Books.

Fudge, L. (2006). Horizontal violence and vertical violence in the workplace. Canadian
operating room nursing journal, 13-16.

Griffin, D. (2004). Teaching cognitive rehearsal as a shield for lateral violence: an


intervention for newly licensed nurses. The Journal of Continuing Education in
Nursing, 35(6), 257-263.

Grossman, S., (2009). Peering the essence of collaborative mentoring in critical care.
Dimensions of Critical Care Nursing, 28(2), 73-75.

Hader R. Workplace Violence Survey 2008: unsettling findings: employees safety isn't
the norm in our healthcare settings. Nurs Manage. 2008;39(7):13-19.

Hastie, C. (2002). Horizontal violence in the workplace. Retrieved July 11, 2010, from
http://www.acegraphics.com.au/articles/hastie02.html.

Institute for Safe Medication Practices. (2004a). Intimidation: Practitioners speak up


about this unresolved problem (Part I). March 11. Retrieved July 10, 2010, from
http://www.ismp.org/Newsletters/acutecare/articles/20040311_2.asp.

Johnston, M., et. al. (2010). "The Bullying Aspect of Workplace Violence in Nursing".
JONA’S Healthcare Law, Ethics, and Regulation, Volume 12, Number 2, pp. 36-
42.

Kehler, J. (2005). Graduate nurses eat them or season them? Arkansas State Board of
Nursing Update, 16-17.

Longo, J., & Sherman, R. O. (2007). Leveling horizontal violence. Nursing Management,
38(3), 34-37, 50, 51.

Longo, J., Sherman, R.O., (2007). Leveling horizontal violence. Nursing Management,
34-51.

McKenna, B. G., Smith, N. A., Poole, S. J., Coverdale, J. H. (2002). Horizontal violence:
experiences of registered nurses in their first year of practice. Journal of
advanced Nursing, 42(1), 90-96.

Ozturk, H., S. Sokmen, F. Yilmaz, and D. Cilinger, (2008). Measuring Mobbing


Experiences of Academic Nurses: Development of a Mobbing Scale. Journal of
the American Academy of Nurse Practitioners." J Am Acad Nurse Pract., 20(9):
435-42.

Prouix, D. M., Boucier, B. J. (2008). Graduate nurses in the intensive care unit: an
orientation model. Critical Care Nurse, 28(4), 44-52.

Roberts, Susan, et. al., (2009)."The effect of oppressed group behaviours on the culture of
the nursing workplace: a review of the evidence and interventions for change".
Blackwell Publishing Limited. Journal of Nursing Management, Volume
17, Issue 3, pp 288-293.

Roche, M., Diers, D., Duffield, C., Castling-Paull, C. (2009). Violence toward nurses,
the work place environment, and patient outcomes. Journal of Nursing
Scholarship, 42(1) 13-21.

Rowell, P. A. (2007). Lateral Violence: Nurse against nurse. Retrieved July 11, 2010,
from http://nursingworld.org/mods/mod440/lateralfull.htm.

Sofield, L., & Salmond, S. W. (2003). Workplace violence: a focus on verbal abuse and
intent to leave the organization. Orthopaedic Nursing, 22(4), 274-283.

Stanley, Karen M; Dulaney, Peggy; Martin, Mary M. "Nurses 'Eating Our Young'-It Has
a Name: Lateral Violence." The South Carolina Nurse. South Carolina Nurses'
Association. 2007. Retrieved July, 10, 2010 from HighBeam Research:
HYPERLINK "http://www.highbeam.com/doc/1P3-
1293382161.html"http://www.highbeam.com/doc/1P3-1293382161.html.

Task Force on the Prevention of Workplace Bullying. (2001). Report of the task force on
the prevention of workplace bullying: Dignity at work-the challenge of workplace
bullying. Dublin: Health and Safety Authority. Retrieved July 12, 2010, from
http://publications.hsa.ie/index.asp?docID=111.

Thomas, S. P. (2003). Professional development. 'Horizontal hostility': Nurses against


themselves: How to resolve this threat to retention. American Journal of Nursing,
103(10), 87-88, 101.

Ulrich, B. T., Lavandero, R., Hart, K.A., Woods, D., Leggett, J., Taylor, D. (2006).
Critical care nurses' work environments: a baseline status report. Critical Care
Nurse, 26(5) 46-57.

Vessey, J.A., Demarco, R.F., Gaffney, D.A., Budin, W. C., (2009). Bullying of staff
registered nurses in the workplace: a preliminary study for developing personal
and organization strategies for the transformation of hostile to healthy workplace
environments. Journal of Professional Nursing, 25(5) 299-306.

Vollers, D., Hill, E., Robert, C., Dambaugh, L., Brenner, Z., (2009). AACN's healthy
work environment standards and an empowering nurse advancement system.
Critical Care Nurse, 29(6) 20-26.

Woelfle, C.Y. and McCaffery, R. (2007). Nurse on Nurse. Nursing Forum, 42(3), 123-
131.

Yildirim, D., Yildirim, A., Timucin, A. (2007). Mobbing behaviors encountered by nurse
teaching staff. Nurse Ethics, 14(4), 447-463.

McCall, E. (1996, April). Horizontal violence in nursing: The continuing silence. The
Lamp, 28-31.

Hastie, C. (2002, August 6). Horizontal violence in the workplace. Birth International:
Specialists in Birth and Midwifery. Retrieved July 19, 2010, from
http://www.acegraphics.com.au/articles/hastie02.html.
Leiper, J. (2005). Nurse against nurse: How to stop horizontal violence. Nursing 2005, 35
(3), 44-45.

Roberts, S.J. (1983) Oppressed Group Behavior: Implications for Nursing. Advances in
Nursing Science, 5, 21-30.

Skillings, L.N. (1992). Perceptions and feelings of nurses about horizontal violence as an
expression of oppressed group behavior. In J.L. Thompson, D.G. Allen, & L
Rodrigues-Fisher (Eds.), Critique, resistance, and action: Working papers in the
politics of nursing(pp. 167-185). New York: National League for Nursing Press.

Namie R and Namie G. (2008). Workplace Bullying Institute. http://


www.bullyinginstitute.org. Published 2008. Accessed July 19, 2010.

American Association of Colleges of Nursing. Fact Sheet. Nursing Shortage (2009).


http://www.aacn.nche.edu/Media/FactSheets/NursingShortage.htm|
~http://www.aacn.nche.edu/Media/FactSheets/NursingShortage.htm. Updated
June 2009. Accessed July 19, 2010.

Simmons, S. (2008). Workplace bullying experienced by Massachusetts registered nurses


and the relationship to intention to leave the organization. ANS Adv Nurs Sci:31
(2): E 48-59.

Duffield, C, Pallas, LO, Aitken, LM (2004). Nurses who work outside nursing. J Adv
Nurs.;47(6):664-671.

Rau-Foster, M. (2004). Workplace civility and staff retention. Nephrol Nurs J.;31(6):702.

The Joint Commission, (2008). Behaviors that undermine a culture of safety. Sentinel
Event Alert, Issue 40.
http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_40.htm|
~http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_40.htm.
Published July 9, 2008. Accessed July 19, 2010.

Lipley, N., (2005). ( Bullying at work on increase, RCN survey finds. Nurse Mgmt.:
12(10):5.

Beyea SC., (2004). Intimidation in healthcare settings and patient safety, AORN J.
2004;80(1):115-117.

Jackson D, Clare J, Mannix J., (2002). Who would want to be a nurse? Violence in the
workplace—a factor in recruitment and retention. J Nurse Manag.;10(1):13-20.

Hoel H, Giga SI, Davidson MJ, (2006). Expectations and realities of student nurses'
experiences of negative behaviour and bullying in clinical placement and the
influences of socialization processes. Health Serv Manage Res. 2007;20(4):270-
278.

Hutchinson, M, Vickers, M, Jackson, D & Wilkes L. (2006). Workplace bullying in


nursing: towards a more critical organizational perspective. Nurs Inq.
2006:13(2):118-126.

Duffy, E. (1995). Horizontal violence: A conundrum for nursing. The Collegian, 2 (2), 5-
17.

Dunbar, C. (2005). Managers can prevent incidents of horizontal violence. AORN


Management Connections, 1 (5), 1, 4.

McKenna, B. G., Smith N. A., Pool, S. J., & Coverdale, J. H. (2003) Horizontal violence:
Experiences of registered nurses in their first year of practice. Journal of
Advanced Nursing, 42 (1), 90-96.

Lewis MA. Nurse bullying: organizational considerations in the maintenance and


perpetration of health care bullying cultures. J Nurs Manag. 2006;14:52-58.

Randle, J., (2003). Bullying in the nursing profession. J Adv Nurse: 43(4):395-401.

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), 257-263.

Pendry, P.S., (2007). Nursing Economics, 25(4):217-221.

Price Waterhouse Coopers Health Institute (2007). What works: Healing healthcare
staffing shortage: Retrieved October 26, 2009 from http://pwchealth.com/cgi-
localhregister.cgi?link=reg/pub-whatworkss.pdf.
Roberts, S.J., (1983). Oppressed group behavior: Implications for nursing. Advances in
Nursing Science, 54(4), 21-30.

Rowell, P.A., (2007). Lateral violence: Nurse against nurse. Retrieved October 26, 2009,
from Woelfle, C.Y. & McCaffrey, R., (2007). Nurse on nurse. Nursing Forum,
42(3), 123-132.

Joy Longo DNS, RNC-NIC Christine E. Lynn College of Nursing Florida Atlantic
University, 2010)
JONA’S Healthcare Law, Ethics, and Regulation / Volume 12, Number 2 / April–June 2010

III. Horizontal Violence Manifestations in Nursing

Horizontal violence and bullying exists and have been extensively reported,

studied and documented among medical professionals. This fact poses serious negative

outcomes for all concerned especially registered nurses, their patients and even the

employers. Such disruptive and unacceptable behaviors are toxic to the medical and

nursing profession and give a negative impact on quality staff retention. This kind of

violence in the workplace is something that should not be accepted in any professional

relationships and could never be taken as a normal act of socialization. The problem is in

existence and more literature on the subject will be included in this paper to prove the
point.

Bullying is taken to be a malicious, offensive, abusive, insulting and intimidating

behavior. It is taken to be an abuse of power done by a person or a group of people

against others to make the offended party feel upset, humiliated, upset or vulnerable.

These actions undermine the self-esteem of an individual and causes then stress. Such a

behavior is taken to be systematic, persistence and ongoing (Task Force on the

Prevention of Workplace Bullying, 2001, p. 10). Bullying and horizontal violence are

basically the same. In the nursing profession, the Bully is the one with a higher

authority or level, for instance, a nursing supervisor against a staff nurse (CENTER for

American Nurses, 2007).

Another article that reviewed was mobbing behaviors encountered by nurse

teaching staff. Dilek Yildirim, Aytolan Yildirim, and Arzu Timucin conducted this.

“The term mobbing behaviors is defined as antagonistic behaviors with unethical

communication directed systematically at one individual by one or more individuals in

the workplace” (Yilidirim, D., Yildirim, A., Timucin, A., 2007, p.447). This study was

taken from nursing mobbing behaviors as encountered by nursing school teaching staff in

Turkey.

This study was a cross sectional study conducted to realize the mobbing behaviors

that were encountered by ninety-one percent of nursing educators in the Turkish

University education system. The study sample included thirty-three professors, forty-

three associate professors, 59 assistant professors, thirty-five instructors, and thirty-five

research assistants. A questionnaire was prepared for the study and was then sent to the
participants. In Turkey, only women can perform as nurses in this country so the

sampling was purely women only. The data was then collected from April through June

of 2006. Two hundred and ten individuals answered the questionnaire and returned it

giving the percentage of returned sixty-nine percent. The questionnaire had four sections

to it. The first part was a list of mobbing behaviors and the participant had to answer

whether they had experienced any of these behaviors. The second part was to answer

what the reaction to these behaviors were. They had to rate from a six point Likert scale

to answer all of these questions. The third section was to try to understand what they had

done to escape the mobbing behavior. The fourth was the demographic criteria of the

individual taking the questionnaire.

The results of the study was the “most common behaviors included attacks on

personal status eighty-five percent and attacks on personality was eighty-two percent; the

most frequently encountered behavior was using nonverbal behavior to belittle you in

from others, and the most common sources of this behavior towards sixty-eight percent of

the participants was from their managers, twenty-seven percent was from their co-

workers and five percent from the hierarchal positions” (Yilidirim, D., & al., 2007,

p.451). They also found that employees had the second most common mobbing behavior

towards demeaning others and dishonoring coworkers in some way. The third most

common was the blaming of others for things that were not their responsibility from

either managers or other co-workers. After establishing that the mobbing behavior does

exist, the questions that follow were, what was the response to the mobbing behavior and

what did you do to escape the mobbing behavior? The most common response to what
was the response to the mobbing behavior was they “felt tired and stressed by seventy

five percent, had headaches by sixty-nine percent, replayed or relived the behavior over

and over sixty-nine percent, and negatively affected their lives outside of work sixty-

seven percent” (Yilidirim, D., & al., 2007, p.453). The response to the how did you

respond to the mobbing behaviors? The most frequently used answer was “I just try to

work harder and harder, seventy-eight percent, I am being a lot more careful to avoid

criticism at work, seventy-eight percent, talk face to face with the person involved,

seventy-one percent and other thought seriously about resigning from their job, fifty

percent “(Yilidirim, D., & al., 2007, p.453). Overall it is evident that most of the nursing

educators had experienced some kind of mobbing behavior in their career.

Unfortunately for the nurses, organizations are basically hierarchical and have no

culture of professional collegiality. They also failed to make any move in advancing the

role of nursing. It is often the case that nurses simply accept the situation and have a

victim mentality, making them powerless. Many of these nurses have already expressed

concern about their supervisors' lack of action when it comes to addressing horizontal

violence in the workplace (Farrell, 1997; Stanley et al., 2007).

While the above study had nurses feeling other nurses' aggression that hardest to

handle, Sofield and Salmond (2003, p. 274) in their own researches, found that the foremost

abusers of nurses are physicians, then patients and patients’ families. One-third of the

participants consider resignation as their answer to the verbal abuse. They find from the

subjects that they lacked the skills needed in dealing with the abuse they are receiving and
see themselves to be powerless in changing the situation (Sofield & Salmond, 2003, p. 283).

The Institute for Safe Medication Practices published a survey in 2004

regarding workplace intimidation. Of the 2,095 respondents that included pharmacists, nurses

and other providers, about half remembers being abused verbally when inquiring from

physicians about prescription and medication specifications (Institute for Safe Medication

Practices, 2004a).

IV. Evidences of Existence of Horizontal Violence from Previous Studies

Having been in existence for many decades already, many studies and researches

on the subject of horizontal violence have been done worldwide. One of those who

conducted such study was Cheryl Dellasega (2009, p. 52). She has completed a literature

review on horizontal violence with female nurses. Her work showed that indeed, the

problem is being experienced by most nurses that are new in the profession. The

examples she gave of this violence are sabotaging of a nurse to effect failure, name-

calling, gossiping and eye-rolling.

Still another work on measuring mobbing experiences of academic nurses was

done in 2008. This study was prepared not only to learn of such experiences but also to

develop a mobbing scale that can be used for further studies (Ozturk, H., Sokmen, S.,

Yilmaz, F., Cilinger, D., 2008, p.235). This study used Leymann, one of the founders in

the research of horizontal violence, later violence and mobbing behaviors, to define what
mobbing behaviors are. According to him, “mobbing or psychological terror is hostile

and unethical communications directed in a systematic manner towards a person”

(Ozturk, H., &al., 2008, Yilidirim, D., & al., 2007, p.451). This study was prepared to be

able to develop a mobbing scale for academic nurses and to determine whether academic

nurses experience mobbing and to what extent mobbing existed at the university nursing

schools in Turkey.

The findings of the study noted that one hundred and sixty-two academic nurses

with an average age of 33 years and had an average of 11 of experience sixty-one percent

had stated that they were victims of a mobbing experience. After the questionnaire had

been evaluated 34% of the 61% of academic nurses who participated stated that they

were mobbing victims scored to have been mobbing victims. Of those surveyed, 49%

were still experiencing mobbing while 67% were exposed to mobbing for three years or

more (Ozturk, H., & al., 2008, p.438). The study also showed that the participants had

suffered psychological effects from mobbing behaviors “this means that the participants

suffered psychological effects that resulted in fatigue” (Ozturk, H., & al., 2008, p.438).

With all of the data, it shows that nurses of an academic status regardless of age are

falling victim to mobbing behaviors in the Turkish Universities.

An older study that was done in New Zealand by Mckenna, B. G., Smith, N. A.,

Poole, S. J., & Coverdale, J.H., (2003) Horizontal Violence: experiences of registered

nurses in their first year of practice has been referenced in several of the studies that were

mentioned before. This study conducted by McKenna, et. al., was to get a picture of
what the novice nurse was experiencing in relation to horizontal violence in the first year

of practice.

The study was conducted in New Zealand. They decided to mail out

questionnaires to 1,169 individuals who registered as new nurses that year. The

researchers had a forty-seven percent of their surveys returned and the results of what

those surveys stated were astounding. The descriptive study was conducted with open

ended questions pertaining to the type of horizontal violence that the graduate nurse had

experienced. The researchers also wanted to know the reaction of the graduate nurse to

the horizontal violence that was experienced. Ninety-four percent of the respondents

were female and six percent were male. Forty-six percent of the populations of graduate

nurses were under the age of thirty.

The study revealed horizontal violence is present and very real to graduate nurses

coming into the work force with seasoned nurses. The experiences that were described

were backstabbing, bullying, humiliation, and withholding opportunities for learning.

Some of the highest types of horizontal violence experienced were learning being

blocked; in the surgical units this would include intensive care units. The surgical units

were also high with emotional neglect, and lack of supervision. Through this study they

found that the type of horizontal violence that was experienced was covert in nature. The

new graduates also reported that they had been absent to work due to horizontal violence.

The graduate nurses had also reported that constructive criticism was not perceived as

such, they felt they were being talked down to. The worst and most disturbing result was
the graduate nurses had thought about or already had left the nursing profession due to

the horizontal violence experienced. Twelve percent of the graduate nurses had stated

that they had to have counseling due to the distressing events that was experienced.

Another study made on the subject that is of the same type of methodology as I

used in my dissertation is one made by Kathleen Sellers, PhD, RN, wherein she made a

descriptive study to examine the prevalence of horizontal violence in RNs who are

members of NYONE (New York Organization of Nurse Executives). Knowing the nurse

administrators' knowledge on the subject and the degree of encounter they had is the aim

of the study. The theoretical framework made use of was the transformational leadership

theory. The methodology made use of a convenient number of RNs as sample, all of

which are members of NYONE. They completed a Briles' Sabotage Savvy questionnaire

that included their demographic information among others. Likert model was also used

in this study. The study established the existence of horizontal violence in the profession

of nursing in consistence with what was already written about it. The study even showed

that the problem is already deeply rooted that it has already become a culture and is not

easily recognized. This makes the problem even harder to solve since it is not even

known to be a problem anymore.

Another research made on the nurse on nurse horizontal violence written by Cheryl

Woelfle and Ruth McCaffery (2007). They wanted to know if horizontal violence really

existed among nurses in the workplace and if it did what were the consequences of

horizontal violence among nurses in relation to patient care. They reviewed specifically

four different research articles the first article used was a “descriptive correlation design
that was used to examine the possible relationship between the perceived acts of

horizontal violence and the different levels of job satisfaction as reported by preoperative

nurses” (Woelfle, C., McCaffery, R. 2007, p.124). Participants are 145 preoperative

nurses from the preoperative nurses association for registered nurses (AORN) and their

ages ranged from 31 to 68, and ninety-eight of these nurses were female. They were

given a questionnaire to fill out containing forty questions to find out if the surveyed

nurse had ever been a victim of horizontal violence or bullying in the work place.

The surveys reported that the most common type of sabotage or bullying was one

expecting another to do their work. The “saboteurs reported that their most frequent form

of victimizing was to stop talking when others entered into the room, and they

complained about others without discussing it first with that person” (Woelfle, C.,

McCaffery, R., 2007, p.124). With the survey, they did not find a direct correlation with

satisfaction of nurses in the preoperative area and dissatisfaction with their current jobs.

They did find that preoperative nurses did act inappropriately and unprofessionally

amongst each other in the preoperative environment, “the study represents a significant

positive correlation between the IWS scores and reported sabotage” (Woelfle, C.,

McCaffery, R., 2007, p. 126). The weakness in this study was noted that maybe the

preoperative nurse was not being completely honest on the survey that was taken in

relation to the job satisfaction and significant sabotage in the working environment.

V. Updates on Horizontal Violence

Even in the present times where women are known to have become more
independent and modern, instances of horizontal violence is still prevalent. An

international qualitative study was done in 2008 with the use of surveys. This study

showed that most of the victims of violence in the workplace are women. This count

accounts for almost 93% of the national average. On the other hand, it is the nurses

which are the victims of such kind of abuse in a healthcare setting. Those who have

received such abuse were subjected to bullying, verbal abuse, harassment and worse,

cases of physical contact. 80% of those who have taken the survey are nurse leaders who

have experienced some form of horizontal violence in the workplace. Of the said figure,

83% are more than 36 years old and 80% works in a hospital that big enough to

accommodate 101 to 500 beds (Hader, 2008, p. 15).

A disturbing 48% of non-fatal injuries received by nurses and their assistants

came from assaults that happened in their workplace. This is a finding from the study

done by the Bureau of Labor Statistics. Further studies reveal that nurses, compared to

other healthcare professionals, are 16 times more likely to experience abuse (Christmas,

2007, p. 365). In the same 2008 international survey, 22 out of 1000 nurses are found to

have fallen victim to horizontal violence in the hospital setting. The more common form

is that of verbal more than physical violence.

Bullying in the medical setting is said to happen most of the time in the top three

areas, i.e., medical or surgical units, intensive care units (ICU) and the emergency

department (ER). The occurrences of horizontal violence are lesser in the areas such as

child health and maternal health areas, psychiatry and operating rooms. This information
shows that horizontal violence is more prevalent in the areas with high stress and where

the action is fast paced. On the other hand, where the action is slower, the probability of

having violence is lesser. In any instance, the fact remains that violence is happening in

the healthcare setting and will remain to affect nurses in many nations unless something

is done about it. This makes the reality more apparent that safety does not really exist in

healthcare anymore.

Another study about violence towards nurses and the effect on patients was made

in 2009. The goal was to find out if there if violence was really a part of the workplace

atmosphere (Roche, et al, 2009, p.13). The study showed that more than 80.3 % of the

participants has really encountered during the last 5 work shifts they had perceived

emotional abuse. The result of the study also pinpointed certain situations which

antagonized such violence. Outcome showed unanticipated changes in the patient mix

during shifts.

Even the World Health Organization has been showing concern with the

horizontal violence happening in healthcare settings. It is aware of the problem

becoming an epidemic already and has started to think of solutions by first producing

guidelines in dealing with the violence when it happens. WHO touched on the patient to

nurse type of violence as well and the effects it has on the emotions of the nurses. The

results of the survey made by WHO also made a significant finding, that the highest

rating for workplace violence was in the areas of highest acuity like the intensive care

units.
Horizontal violence, has finally received the spot light in the United States as a

problem and a topic to be researched. Vessey, J. A., Demarco, R. F., Gaffney, D. A.,

Budin, W. C., (2009) thought it was time to shed light on the topic in the United States.

Their study entitled, “Bullying of staff registered nurses in the workplace: a preliminary

study for developing personal and organization strategies for the transformation of hostile

to healthy workplace environments”, validated the perceptions of horizontal violence

occurring in the registered nurses workplace. They had responses from three hundred

and three nurses with the mean age of forty-nine to compile data from. The top two

perpetrating units in the hospital setting were the medical surgical floor and the intensive

care units. Fifty seven percent of the participants of this study were employed for less

than five years.

With supporting evidence showing that damaging effects on the psychological

aspect of the novice nurses while in the work place environment by creating an

atmosphere that is less than encouraging we are also increasing the numbers for the

nursing shortage. Due to the less than encouraging environments that novice nurses are in

“new nurses are at significant risk, with resignation rates reaching sixty percent in their

first year of practice” (Vessey, & al., 2009, p.300). Over the last two decades we have

seen an increase in the data acquired pertaining to the nursing shortage. There has been

much commercializing and marketing of the nursing profession to promote an increase in

the enrollment for the profession. Yet when the novice nurse finally gets to participate

fully in her profession she/he finds themselves an active reciprocate of horizontal


violence. Therefore, the seasoned nurse has created a decrease in confidence in ability

and skill of the novice nurse while caring for the acutely ill patient and causing

psychological distress due to lack of support during the novice nurses shift. “When

individual’s contributions are ridiculed, their sense of professional mastery is threatened

and their self esteem is eroded. The results personal disenfranchisement and poorer job

satisfaction” (Vessey, & al., 2009, p.301) this would than encourage less effective leaders

in the nursing unit to seek jobs elsewhere.

In helping the nurses, particularly the novice ones, to overcome such violence or

to completely eradicate the problem of lateral violence in the medical profession, the

following literature which speaks of solutions are indicated hereunder.

In the literature by Vollers, et. al. (2009) entitles AACN'S Healthy Work

Environment Standards and An Empowering Nurse Advancement System, it is indicated

that nurses should be empowered in order for them to create a healthy working

environment. The advancement systems that hospitals should have are used as example

of how nurses would feel such empowerment if clinical advancement is indeed utilized

(Vollers, et al, 2009, p. 20). Through the said clinical advancement system, new nurses

will have goals that they would want to achieve and they would feel what it is really

meant to be have their profession. Through this advancement system where they have a

ladder they can go up to, these novice nurses can perform their professional roles easier

with the feeling of support from their coworkers. This results into a healthier and more

supportive working environment.


Nurses may be allowed to practice skilled communications by participating in the

grand rounds. This will give the nurses the opportunity to ask questions and more

importantly, to practice the skilled communication. Having true collaboration within the

teams belonging in the interdisciplinary healthcare as well as all levels of management

will result in a cohesive team that works together for the same goal. The new nurses

should be able to witness such good collaboration. Failure to find such a good teamwork

within all levels can create hierarchical oppression among them. This will be like setting

up the healthcare facility for lateral violence.

Having an effective decision making within the healthcare organization’s

infrastructure is vital in order to have true collaboration as well as a positive working

environment. Such a decision making process must be quick and done in a shared

governance atmosphere. This means that all parties involves should be given a hand in

the decision making process with each ones input taken into consideration before

decision is reached. This also makes the nurses feel that the decision made is their own

and thus make then take ownership of patient satisfaction, nurse satisfaction and

retention.

Another way to make the nurses feel empowered is by correct staffing. This

means that there should be a proper ratio of nurse to patient. Nurses should not feel that

management is cutting cost by having to take care of a number of patients that is already

more than they can handle, then they would feel some aggression. Feeling such an

aggression can have them taking out their frustration or anger on other employees which
in turn is the start of horizontal violence in the healthcare setting. Having appropriate

staffing eliminates the feeling that nurses are undervalued and disconnected.

Being cognizant of the value of each nurse at work as well as their skills, talents

and intellect helps them see and feel that they are indeed valued. The result of such an

action would be for these nurses to feel empowered in doing a better work and provide

their patients the best care they can give. They would also feel like they are a part of the

facility where they are working for. When all the above steps are taken, the nurse will

surely become a provider of true leadership that will be very useful in all levels of the

medical system.

VI. Application of Theoretical Framework

The literature review made in this paper is chosen particularly in response to the

thesis questions I previously made. To reiterate, these questions are the following: (1)

While in orientation, do novice nurses experience horizontal violence in the ICU's in a

Midwestern magnet status hospital?; (2) Is bullying present during the orientation process

in the cardiovascular ICU?; (3) Do the novice nurses experience sabotage while in

orientation?; and (4) Has the novice nurses experienced feeling like an outcast or have

they experienced name-calling during their orientation in the cardiovascular ICU?

Answers to these questions are already very apparent with the literature included in the

paper. Horizontal violence is indeed existing in the nursing discipline, not only the ICU

department during orientation. Many incidents of horizontal violence were already


presented and I intend to prove that this also happens in the ICU, based on my own study

and methodology, further into my dissertation.

One theory that stands out when discussions on the theoretical framework with

regard to horizontal violence is Paulo Freire’s oppression theory. Under this theory,

Freire puts forward a pedagogy wherein a person learns to develop his own life via the

situations he goes through in his daily life which serves as his learning experience. What

his theory speaks of is the pedagogy of the oppressed more than the pedagogy for the

oppressed. He is saying a fact as it is, not suggesting something to solve a problem.

In Freire's proposed method, there are two implied moments, one that involves the

subject knowing his circumstances and being conscious of being oppressed and subjected

to decisions imposed by his oppressors and one that refers to the action of the oppressed

wherein he fights to free himself from his oppressors. Freire believes that the individual

involves does not take such an oppressive reality with just simple awareness but a need to

fight against status quo is inbred. The oppressed becomes concrete and focused with his

efforts. When they have a relationship, it is the oppressed that seems to be the instigators

of the violence that exists in the relationship though such condition will have them trying

to change their status.

Moreover, the oppressors blame those who are in opposition of their being

irresponsible, depraved, disobliging and at fault for being in such a situation. This is

despite the fact that even if those descriptions are at times apt. Those are actually the

response of one that is oppressed and is actually the outcome of the exploitation that
these oppressed individuals are subjected to. What makes the situation worse is when the

oppressed will just accept such a reality and simply adapt to it without a question or a

fight. This will generate in the oppressed an irrevocable emotional dependence. To be

able to fight such a situation, it is vital that a person get to know himself and start fighting

for their own emancipation.

Such is the idea of Freire as shown in the oppression theory that he

conceptualized. What Freire suggests is that the problem of horizontal violence is

already in existence, and may not even be as noticeable due to it being already deep-

rooted. However, he also is cognizant of the fact that such situation is a problem that

should not just be accepted. Instead, nurses who may be experiencing such kind of

problem should start knowing herself more and from there start having focus and fight for

what is right for her. This is how the problem of horizontal violence should be handled.

This is also the main reason for this study.

The need to establish and realize the existence of a problem is the foremost idea.

When this is done, things should not stop there. Instead, the study that will establish the

existence of horizontal violence in the workplace should be the starting point of its

solution.

VII. Final Remarks

The written literatures indicated in the preceding topics are clear indication that
horizontal violence has been in existence for a long time already and still persists to exist

in this modern world. While it is not only limited to the nursing profession, the focus has

been on the violence applied to nurses by nurses themselves. The phenomenon happens

not only in the ICU during orientation of these nurses by also in the other sections of the

medical world. The literature on the matter abounds and those included in this paper

more than sufficed to prove it.

Evidence suggests workplace bullying and related disruptive behavior are

commonplace, and on the rise. The combination of a busy healthcare setting, difficult

patient situations, and the requirement for interdependent relationships can serve as a

breeding ground for incivility and bullying behaviors (Rau-Foster, 2004, 702). In

response to a survey by the Joint Commission, more than 50% of nurses reported having

been a victim of bullying and/or disruptive behavior at work, and more than 90% stated

that they witnessed the abusive behavior of others (The Joint Commission, 2008). Despite

the subsequent Joint Commission Sentinel Alert requiring healthcare facilities to design

and implement a system wide approach to ensure employee awareness of disruptive

and/or bullying behaviors, bullying continues and still is perceived to be steadily on the

rise (Lipley, 2005, p. 5). The implications for nurses' work environments are noteworthy,

since the health and availability of nurses are vital for the provision of a safe environment

for our most vulnerable population—the patients we serve (Beyea, 2004, p. 115; Jackson,

2002, p. 13 and Simmons, 2008, p. 48).


Incivility is described as "rude or disrespectful behavior that demonstrates a lack

of regard for others" (Rau-Foster, 2004, p. 702). If left unabated, more aggressive

behaviors, such as workplace bullying, can flourish and acculturate within a unit,

department, and even the organization at large. The definition of workplace bullying has

evolved over the years, from behavior that included open physical assault or violence, to

more subtle, even masked behaviors such as backbiting, blaming, disparaging, and

exclusionary treatment meant to do harm to another (Hoel, 2002, p. 270 and Randle,

2003, p. 395). While a few researchers believe bullying only occurs horizontally among

coworkers, the majority feel that a real or imagined imbalance of power between the

bully and the victim is a necessary element of bullying behavior (Hutchinson, et al, 2006,

p.118) and what makes the phenomenon of workplace bullying separate and distinct from

other disruptive behaviors, such as incivility or workplace violence, is that these

behaviors are not random acts. They are intentional, occurring over a prolonged period of

time, and targeted at an individual who is unable to defend himself. Although bullying

may seem harmless to an untrained eye, a deliberate, ongoing pattern of negative

behaviors can have a cumulative effect, leading to serious harm to the intended victim in

the long run (Hutchinson, et al, 2006, p.118 and Woelfle & McCaffrey, 2007, p. 123).

Characteristics of Nurse-to-Nurse Horizontal Violence

• “Criticism, sabotage, undermining, infighting, scapegoating, and bickering” (Duffy,

1995, p. 9)

• “Intimidation, humiliation, excessive criticism, exclusion, innuendo, denial of access to

opportunity, disinterest, discouragement, and the withholding of information;” (as quoted

in McKenna, Smith, Poole, & Coverdale, 2003, p. 91)


• “Learning opportunities blocked, felt neglected, were given too much responsibility

without appropriate support… rude[ness]” (McKenna et al., p. 93)

• “Raising of eyebrows… abrupt responses… not being available… withholding

information about practice or about patients… sabotage… in-fighting… failure to respect

privacy … broken confidences” (Dunbar, 2005, p.1)

• “Dismissing, belittling, undermining, humorous ‘put downs’… gossiping… sarcastic

comments… nitpicking… minimizing another’s concerns… slurs and jokes based on

race, ethnicity, religion, gender, or sexual orientation… withholding support… limiting

right to free speech and right to have an opinion… “better than” attitude… chronic

understaffing” (Hastie, 2002, pp. 2-3).

The power of horizontal violence in nursing is now being countered by awareness,

education, and on-the-job zero tolerance for abuse. “We’ve always cared for others. Now

let’s care for each other” (Leiper, 2005, p. 45).

Lateral Violence as a Role Issue

As nurses we are familiar with role issues with physicians. Nurses are educated from the

first year of the educational process to work in teams; however, physicians have

traditionally been educated to believe they are the “captain of the ship”. These conflicting

professional cultural beliefs are a basis for stress between physicians and nurses. Nurses

expect to work as colleagues with physicians; however, physicians often do not see that

as desirable. Such differing cultural expectations breed conditions that are ripe for lateral

violence.
Lateral violence between and among nurses can occur for various reasons. Since there are

a number of roles within nursing, role issues can arise between staff nurses; between staff

nurses and managers; managers and advanced practice registered nurses (APRN), and

staff nurses and APRNs. For nurses who embrace the nursing culture of “eating its

young”, it might be demonstrated through abusive and demeaning behaviors towards

students and new graduates. The same types of behaviors can occur toward other nurses

if they vary from the “group norm”. Regardless of the nurse’s status, undercutting

behaviors and words which demean hurt all nurses and establish a toxic workplace.

Lateral Violence as an Oppressed Group Issue

Dr. Martha Griffin, RN, an activist and nurse educator, believes lateral violence is the

result of oppressed group behavior. Oppressed group behavior occurs when one group

believes it has been excluded from the power structure. (Ratner, 10). Griffin believes that

nurses have little control over their work environment and yet are held accountable

resulting in personal stress. The member of the oppressed group is abusive to peers and

those individuals with lesser status because she/he fears addressing the source of the

stress affecting her/him. Therefore, the nurse strikes out at peers, students, unlicensed

assistive personnel, patients, etc.

Lateral Violence as a Gender Issue.

This gender theory is applicable because as of the 2000 National Sample Survey of RNs,

only 5.4% of RN are men (DHHS/HRSA/BHP/DON, 2000 p.8). This theory states that

lateral violence occurs because women have not been socialized to appreciate themselves

or the roles they play. Women are often socialized to believe they are not as strong or

smart as men and their role in life is to serve men. In addition, nurses often are not
empowered during the educational and enculturation processes to value themselves as

people and as health care providers. To be able to engage a physician in a discussion over

differences in approaches to patient care, the nurse must feel equal in power, professional

stature, and professional knowledge. If nurses do not have such feelings and are

frustrated, angry, or fearful, they often will vent their feelings laterally or downward.

Lateral Violence as a Self-Esteem Issue

Self esteem is a major consideration in all of the above approaches to the problem of

lateral violence. Self-esteem theory is very complex.

The major threads of self-esteem “are that it is a major predictor of behavior; that

it is not a polarizing entity but rather occurs along a continuum; and that it consists of

different ‘selves’, in that an individual can feel differently about themselves as a nurse,

than they do as a parent. Self-esteem is built up or damaged in social interaction, as

people receive feedback about how others view them and judge their behavior.” (Randle,

395) “Self esteem-refers to self- evaluative attitudes that are integral to the individual or,

in a simpler form, it refers to the individual’s perception of themselves.” (Randle, 395-6)

Self-esteem is both subjective and constructed. This means that your self-esteem is

partially what you think of yourself based on how others react to you and partially based

on your own life experiences.

Healthy self-esteem is characterized by use of the authentic self, empathy, the

development of relationships, and the ability to face adversity (Randle, 396.) In nursing

practice, healthy self-esteem allows for empathetic behavior; the delivery of personalized,

holistic care, and the development of interpersonal relationships with patients, their

significant others, and their health care providers.


Professional self-esteem is largely developed by the nursing student’s interactions with

instructors, supervising nurses during clinical times, and student peers. As nursing

students observe those in power, they develop a beginning concept of how a professional

acts toward patients, students, and colleagues.

Research has demonstrated that the interactions that occur during the student’s education

will shape her/his professional image. One study demonstrated empirically that nursing

student clinical experiences were negative because the students were bullied. Much

negative damage was done to the students’ psychology, not only in their image of

themselves as nurses, but also as people. (Randle, 397) The lateral violence/bullying

behavior undermined their self-esteem, making them feel powerless; angry, anxious, and

stressed. Such an atmosphere can endanger patients. (Mc Kenna, et al., 2003)

Nurses “professionalized” in such abusive environments carry their bullying behaviors

into their patient care. They may choose to control patients by delaying their response to

the patient's needs – pain medications, toileting, etc. These disgruntled RNs can also

strike out at a patient’s family by refusing to keep them informed of the patient’s

condition or not providing support in other ways to them or the patient. This type of

behavior causes fear of retribution in both the family and patient. (Dunn, 2003).

The aforementioned literature establishes the existence of horizontal violence and

proves that it abounds. Yet, what has been included is only a small fraction of what is

available. In the succeeding topics, more instances of horizontal violence will be presented,

this time even made concrete with evidences produced by methodologies and in depth

analysis of the problem.


Nurse bullying is bringing about upshots that are unsafe to patient care, for the

nursing profession itself, and to healthcare establishments.

Workplace bullying is defined as repeated, health-harming mistreatment of one or more

persons by one or more perpetrators that takes one or more of the following forms: verbal

abuse; offensive conduct/behaviors (including nonverbal) which are threatening,

humiliating or intimidating; and work interference—sabotage—which prevents work

from getting done (Namie and Namie, 2008).

Discussion
Reversing the bullying culture in nursing

By Lynda Olender-Russo, PhD(c), MA, NEA-BC, RN 2009

Leaders within healthcare organizations are struggling to manage disruptive behavior

and bullying in the workplace.

A DIRE SITUATION IS LOOMING in the US healthcare system. The country is

bracing for a projected unprecedented shortage of more than 500,000 RNs by 2025,

due in part to baby boomer nurses retiring at the same time as the demand for healthcare

is rising. Moreover, despite the 3.3% increase in student enrollment and a stable

RN vacancy rate of 8.1%, RN turnover rates range from 8.4% to 13.9%; and the demand

for registered nurses still is expected to increase 2% to 3% annually (AACN, 2009).


dissatisfaction and related intent to leave the work environment are believed to be key

factors contributing to the shortage. Moreover, exposure to incivility, including

workplace bullying, is one of the primary factors influencing RN dissatisfaction and

turnover rates, (Simmons, 2008, p. 48) and can be a reason why some leave the

profession altogether (Duffield et al, 2004, p. 664).

Das könnte Ihnen auch gefallen