Several years ago, during the peak of the recent nursing shortage, I attended a state nurses’ association conference. It was a working meeting dedicated to developing strategies to recruit and retain nurses.
In the work group I participated in, one reason given as to why novice nurses leave the workplace and the profession was how poorly they were treated by veteran nurses.
A dean from a local school of nursing shared how many of the senior, BSN students complained to their instructors nurses they worked with on their clinical assignments repeatedly told them:
“Get out of nursing now – while you still have a chance and a life.”
Of course, the veterans knew they had a captive audience so they told the students horror stories about what “real” nursing was.
The dean reported how angry, frustrated and confused these students were to have to endure these anti-nursing litanies during their clinical assignments. Students also lost trust in the dean and the faculty wondering if they had sold them a “bill of goods” for the past 3 years
Clearly the situation described above is an example of lateral, horizontal violence, bullying or aggression.
The 10 common behaviors of lateral violence in nurses, as described by lateral violence expert Martha Griffin, PhD, RN, CS, director of nursing education and research at Boston Medical Center, Boston, are: non-verbal innuendo, verbal affront, undermining actions, withholding information, sabotage, infighting, scapegoating, backstabbing, failure to respect privacy and broken confidences.1
If confronted the veteran nurses described would undoubtedly deny they were sabotaging future nurses. Instead their defense would probably be they just wanted the students to know what they were getting into.
It should be emphasized that lateral violence is not limited to new graduates. All nurses can be the victims of lateral violence or perpetrators.
Elephant in the Room
So what can be done to solve this problem?
Right now, nurses and experts agree the emphasis must be to recognize lateral violence will not go away if we ignore it. Also, it cannot be solved with a few education sessions about the scope and causes of the problem.
Let’s not leave it up to nursing associations and other regulatory agencies to develop more policies and mandate zero tolerance against harming each other.
Nursing leaders must serve as role models to help staff nurses and nurse managers develop the skills to know lateral violence when they see it and then confront the problem and behaviors directly, before the care provided for patients and families is further compromised.
In an article in Michigan Nurse, Michelle Fitzpatrick, MS, RN, CPNP, described the current state of lateral violence in nursing.
“Lateral violence continues in nursing because it can. Like the ‘elephant in the room’ nursing generally fails to acknowledge its existence,” she said. “Some experts on the topic of lateral violence in nursing have even referred to the phenomenon as ‘nursing’s dirty little secret,'” notes Fitzpatrick. “Too often there is tendency to blame the victim.”1
Culture of Safety
“Staff nurses and nurse managers have a responsibility to establish a culture in which there is zero tolerance for disruptive behaviors,” wrote Joy Longo, DNS, RNC-NIC, assistant professor, Christine E. Lynn College of Nursing, Florida Atlantic University, Boca Raton.
Currently Longo is developing a research instrument to measure horizontal violence.
Longo believes nurse managers are instrumental in decreasing disruptive environments by examining areas on their units where there is potential for hostility. One strategy she discusses is managers implement “rounding for outcomes” to assess nurses in their environment, to promote a healthy workplace.2
By rounding with nurses daily, the nurse manager can identify employee needs and concerns. She can recognize nurses for their contributions to quality care, establish a non-threatening way of addressing any deficits in care and finally the time to assess the potential or presence of any disruptive behaviors.2
It’s not easy for nurses to confront their peers about disruptive behaviors. Learning how to communicate in a group setting may be threatening for many nurses. Nurse managers must demonstrate their commitment to help nurses learn how to confront lateral violence.
Collaboration in healthcare today via interdisciplinary teams has become the norm in most healthcare organizations as a way to improve quality of care and cut costs. The longer a team works together – with stability of the crew and with some team members being experienced leaders – the team usually begins to trust each other. Teams then begin to feel comfortable to express thoughts and feelings to each other.
Interdisciplinary treatment planning meetings can be a great learning laboratory for nurses to practice direct communication. Of course, the longer a team exists, the more potential for conflict. If members trust each other, they are more likely to be amenable to learning and practicing conflict-resolution skills.
When team members become skilled in conflict management the incidence of disruptive behaviors decreases. This is well documented in the literature and by nurses’ anecdotes. When nurses, who are members of high-functioning interdisciplinary teams, are interviewed most report going through the pains of establishing team norms worth the effort. Almost all agree the quality of care is greatly improved in a collaborative environment.
Learning how to resolve conflicts is one thing, being effective in applying these skills is another. It takes time and practice for individuals to achieve proficiency in confronting disruptive behaviors – sometimes even years.
And it helps when staff nurses recognize when others are being victimized. Longo believes staff nurses can support other nurses who are victims. “Listening to stories of fellow workers will allow those who have experienced disruptive behaviors to express their emotions and possibly rethink the situation so they are prepared to confront it through conversation,” she explains.2
When a bully shows no signs of stopping, Namie and Namie report other nurses on the unit, who have seen the hostility, may call a ‘Code Bully.’ Usually done by word of mouth, the nurses stand behind the nurse who is the victim. Now the bully recognizes he is not facing one person but a group. Most of the time, the bully then realizes a power shift occurred and often this is enough to stop this episode of disruptive behavior.3
Namie and Namie offer an example in an operating room to illustrate how Code Bully can work. The situation is a disruptive surgeon. Before the surgery begins, the surgical team encircles the surgeon and tells him they will not assist him until an apology is given.3
The elephant is going to remain in the room until nurses become assertive in confronting lateral violence. This will not happen overnight and involves trial and error interventions. It must happen if the best and the brightest nurses are going to remain in the workplace to deliver quality care to patients.
References for this article can be accessed here.
Kay Bensing is a former psychiatric nurse and senior staff nurse consultant to ADVANCE.