Vol. 4 Issue 13
Odd Nurse Out
Nurse-to-nurse hostility hurts more than just feelings
Professional Partnership Series PART I
Editor's note: This article is Part 1 of a three-part series on the professional partnerships that impact the role of nurses. Part 2, focusing on nurse/physician relationships, will appear in the July 2 issue.
"You wouldn't think it would happen to a director, but they ran her out. They sabotaged her and ignored her until she quit. That one only lasted a year. I could see how they distanced themselves from her. She always sat alone."1
That's how one nurse, along with many others recounted her experience with horizontal hostility in the workplace in the recently published book, Ending Nurse-to-Nurse Hostility: Why Nurses Eat Their Young and Each Other by Kathleen Bartholomew, MN, RN. Horizontal hostility is the term experts are using to describe aggressive behavior between individuals on the same power level such as nurse to nurse or manager to manager, intended to intimidate, sabotage and/or undermine the confidence and self-esteem of another.
These acts of aggression can be overt such as criticism, name-calling, fault-finding and shouting. Covert examples include unfair assignments, ignoring someone and isolation tactics through clique formation. No matter how they're viewed, every act of horizontal hostility, whether conscious or unconscious, is an act of violence that injures far more than a nurse's feelings. They divide teams, create unstable staffing issues for hospitals, threaten to erode patient safety and discredit the standing of nurses as healthcare professionals. With so much at stake, why then would those who work in a profession rooted in caring for others be so malicious to each other?
From the Top Down
Whether it be the pressures of the nursing shortage, meeting patient ratios or strained physician relations, everyone agrees there's plenty of stress factors in nursing. While nurses may be biting to each other because of these reasons, experts believe the real source of horizontal hostility trickles down vertically from the new corporate structure of managed healthcare that changed the very function of nursing nearly 30 years ago.
"Our virtues are killing us. The facts that we adapt incredibly, work so hard and never complain are no longer compatible with the healthcare system," Bartholomew stressed. "The values have changed. Healthcare now is a business. We're the only country in the world that uses the word 'industry' in conjunction with taking care of people. The implications of that are profit, loss, productivity, business and technology; all the things that, at their core, have nothing to do with nursing."
Bartholomew believes the subordination of nurses began even before the first HMO committee convened in a boardroom. Nursing itself was founded in a patriarchal society where women who had no rights seized an opportunity to stand on their own. To make the idea of these professional women acceptable to the larger public, they were labeled "angels" with a "calling" doing "God's work." Everyone knows angels don't express their feelings, least of all anger.
With no voice of their own, nurses acquiesced into a position of powerlessness and subordination. Being disregarded by health systems and disrespected by physicians rendered their pivotal role in healthcare invisible. In some institutions, nursing is included on the same bill as room charges and a plastic water pitcher.
Bartholomew said it's nurses' residual anger from their own powerlessness that's at the root cause of horizontal hostility. That invisible, insignificant identity is so engrained in nursing culture, however, that most nurses don't even recognize it. Worse yet, many act out subconsciously to preserve it because it's the only identity they've known. Even in society at large, invisible nurses can't seem to get the respect they deserve.
"There are 2.9 million nurses in America," Bartholomew stated. "How many people can name just one? During the Terry Schiavo case in Florida, where were the expert nurses in the media, making statements about the care they provided her for years? Who wanted to hear from them?"
Of all the types of aggression nurses experience in the workplace, the majority report the most distressing form to deal with is nurse-to-nurse hostility.2 In the U.S., turnover rates for peer or supervisor verbal abuse fluctuates between 33 and 37 percent for clinical practicing nurses and 55 to 61 percent for new nurses. Nearly 60 percent of new RNs will leave their first position within 6 months because of some form of horizontal hostility.3
In addition to the costs of re-recruitment and overtime coverage, an Australian study first published in 1999 in the Journal of Advanced Nursing showed that of the nurses who didn't leave because of lateral violence, 34 percent took more than 50 sick days per year.2
The toll of horizontal hostility goes far beyond just financial. Nurses experiencing these attacks may even experience the onset or exacerbation of irritable bowel syndrome, migraines, hypertension, asthma, arthritis and fibromyalgia, among other conditions. Bartholomew pointed out that in her interviews, post-traumatic stress disorder was clearly an issue for many nurses, even years after the inciting incident.
Speak Your Truth
When it comes to taking back their power, Bartholomew believes nurses need to reclaim the voice taken from them and speak their truth. It's a nurse's most powerful tool. In a hostile environment, it wouldn't seem like confrontation would be the key to better nurse relations. Bartholomew sees it as breaking the code of silence.
"She must speak her truth at all times, particularly to the person she's experiencing the hostility from," Bartholomew advised. "It helps to describe what she's experiencing, explain why it offends her, state what she wants to change and make clear what the consequences are if it doesn't.
"I know it's hard to believe, but once a nurse understands the emotional damage she's doing, the behavior almost always stops. In my years as manager of a 57-bed unit, I can tell you from firsthand experience that it works," she continued. "When nurses speak their truth and go to the source of the problem, the backbiting stops. Assertiveness helps nurses be more professional and that's what we are, professionals."
EQ, or emotional quotient, has been an emerging concept in anger management in the last decade. George Anderson, MSW, BCD, CAMF, of LA-based Anderson & Anderson offers anger management training for nurses and physicians and says EQ, unlike IQ, is not fixed and can be vastly improved over time.
"EQ is a fairly new and exciting concept. It's key in eliminating anger in the workplace because it determines the extent to which you are able to empathize or sense the feelings and needs of others as well as your own and respond in a way that leads to a positive outcome," Anderson advised.
Bartholomew also insists that even though the pain of a verbal assault is real, the anger of the perpetrator is based in something far deeper than even she realizes. Keep a cool head and know that it's not all about you.
Rebuilding an Image
Bartholomew suggests assertiveness training for all nurses. She warns managers to be aware of cliques, incident reports constantly filled out by the same nurse and absenteeism as symptoms of department hostility. Adopting a zero tolerance policy is essential and verbally standing up for absent co-workers is imperative because a silent witness to horizontal hostility is an accomplice.
She recommends nurses use "RN" when introducing themselves as an important step in rebuilding the professional nursing image. Educate patients about the nurse's specific role in their plan of care. Not apologizing when calling a physician and expecting doctors you interact with regularly to know your name are all ways the role of nursing can be elevated to its rightful place. These are all ways nurses can empower themselves to begin to feel appreciated instead of angry.
"Nurses need to start demanding the respect they deserve, beginning with other nurses," Bartholomew stated. "It's time to stand up and say, 'No, I'm not coming to work and being treated like this. The work I do is too important.'"
"It doesn't really matter where anger comes from, whether it's personal or professional," Anderson added. "It's all dealt with in the same way. I was seeing a physician for road rage issues. Once he started dealing with his anger, his bedside manner scores at work went way up. When you deal with your anger constructively, it improves all areas of your life."
1. Bartholomew, K. (2006). Ending nurse-to-nurse hostility: Why nurses eat their young and each other. Marblehead, MA: HCPro, Inc.
2. Farrell, G. (1999). Aggression in clinical settings: Nurses' views–a follow-up study. Journal of Advanced Nursing 29(3), 532-541.
3. Griffin, M. (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.
Luke Cowles is regional editor at ADVANCE.
In Your Own Hands
When it comes to eliminating a horizontal hostility issue, most of the tools are at your disposal. Here is what a few human resource and recruitment managers recommend to put the power back in your own hands.
"Don't wait for things to escalate. Address the issue with the staff member as it happens," advised Paula Willems, BSN, RN, nursing recruitment programs manager for Queen of the Valley Medical Center in Napa. "We train our nurses to take it to the source and not to a friend or manager. That only triangulates the issue and helps it build momentum."
"Customer service skills are part of our new employee orientation," added Vicky McGavack, BSN, RN, COHN-S, director of employee health services with Hoag Memorial Hospital Presbyterian in Newport Beach. "The training provides them with the skills they need to deal with any difficult situation, whether it involves a patient, co-worker or physician."
Use Internal Programs
"We offer ongoing seminars in effective communication," Willems explained. "Nurses, especially managers, are strongly encouraged to attend. Everyone should investigate similar opportunities at their facility."
"Every person in our facility attends customer service modules as part of our service excellence training," said Diane Griffiths, RN, employment director at Hoag. "It teaches us not just how to create a patient experience, but an employee experience."
"The hospital also offers a hotline where complaints are referred to the appropriate vice president as well as an anonymous e-mail service," McGavack added.
Participate in Shared Governance
"Shared governance is the path by which nurses will eventually regain the autonomy they deserve and reclaim the voice that's been silenced for years," Willems stated.
Use Open Door Policies
"Every 2 weeks our CEO, VP of human resources and VP of a particular area pick a department in which to have breakfast or lunch," McGavack shared. "Food is delivered and anyone can walk in and speak to the administrators."
"If you're experiencing hostility from a co-worker, you're probably not the only one," Griffiths said. "Having a body of evidence will help if you need to take it to the next level."