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Lateral Violence in Nursing
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Lateral Violence in Nursing


This presentation was given in Brandon Manitoba, Prairie Mountain Health Region to the Operating Room Nurses.

This presentation was given in Brandon Manitoba, Prairie Mountain Health Region to the Operating Room Nurses.

Published in Health & Medicine , Career
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  • Tackling the nursing shortage and addressing retention and recruitment requires action. It is not enough to train RNs and LPNs with skills and competencies.We need to make it easier for them to stay and be a part of the team. Many senior nurses expect graduates to hit the ground running," says Judith Tompkins, chief of Nursing Practice and Professional Services and executive vice-president of Programs at the Centre for Addiction and Mental Health (CAMH) in Toronto. "When there is a lack of collegiality and mentoring from peers, young nurses are thrown into the workforce and are left feeling unsupported."
  • Women were more often the perpetrator – 65%Men target men and women equallyWomen target other women 70% of the time
  • Image http://www.homebirth.net.au/2010/03/bullying-culture-of-midwifery.html To effectively intervene in situations where toxic work environments lead nurses to exit the profession, understanding the dynamics of relational aggression (RA) can be helpful.Females and males express negative feelings differently across different ages and stages of development. This is relevant to female-dominated professions like nursing. http://nursing.advanceweb.com/Features/Articles/Why-Nurses-Bully-What-You-Can-Do-About-It.aspx
  • Persistent attitude of the role of Nurses being hand-maidens,Image http://nursing.advanceweb.com/Features/Articles/Why-Nurses-Bully-What-You-Can-Do-About-It.aspx
  • http://nursing.advanceweb.com/Features/Articles/Why-Nurses-Bully-What-You-Can-Do-About-It.aspx
  • Major characteristics of oppressedbehavior stem from the ability of dominantgroups to identify the “right” norms andvalues and from their power to enforceThem.Connection of lateral violence in nursing to the behaviors of oppressed groups, where inter-group conflict is seen in the context of being excluded from the power structure. Nurses generally don't have sufficient control over their work environment and have a high degree of accountability coupled with a low degree of autonomy.
  • http://www.mediate.com/articles/belak1.cfm
  • Emotional abuse committed directly or indirectly by a group.
  • Do our student witness bad behaviour, and do they learn bad behaviour?
  • PhysicalFatigue or insomniaStressGI distressHeadaches, depressionIncreased blood pressurePsychologicalShame or guiltProlonged duress stress disorder or post traumatic stress disorderSubstance abuse.Increased stress, anxiety, irritabilityPoor concentration, feeling overwhelmedInability to concentrateSocialIsolation Loss of libidoLoss of self confidence, decreased self esteemAvoidance and withdrawal behaviors, disconnection from othersIncreased use of tobacco, alcohol, and other substancesGriffin, m. Teaching cognitive rehearsal as a shield for lateral violence: an intervention for newly licensed nurses. Journal of continuing nursing. 2004; 35(6): 257-263.Cortina & Magley, 2003; Gilmour & Hamlin, 2003; Longo & Sherman, 2007; Normandale & Davies, 2002May also be PTSD and suicidal ideationIndividual factors:Type A personalityEmotional state – anger, burnoutInadequate conflict management skillsBeliefs and expectationsNo time for reflectionNo acknowledgement of the emotional work required
  • Pui Ling Fung The Open University of Hong Kong bplfung@ouhk.edu.hk
  • What to do?When nurses don't have control but must be accountable, you can see where they might not be happy with one another. Other unhealthy coping strategies include taking up smoking, using alcohol excessively and abusing prescription medication. Anti-harassment and diversity initiatives can make a big difference.
  • http://walrusmagazine.com/articles/2009.04-doctor-evil-miriam-schuchman/
  • Denial that behavior is a problemManager condones the behaviorManager exhibits the behaviorNegative behavior is accepted as the normInformationabout negative behaviors is suppressedManager protecting someone with good clinical skillsEmployee fear of retaliation causes ‘silencing of voice’Policies are in place but not enforcedManager lacks confrontation skillsTime pressure used as an excuse not to confront perpetratorsHuman resources department not consulted or not helpfulBlame is shifted to the victim
  • Cognitive Rehearsal TechniquesIntroduced by Dr. Martha Griffin in her study with new graduate nurses Taught nurses about the behaviorsProvided suggestions for what to say in response to each behaviorProvided laminated cards with the information that nurse could put behind her ID badgeGave nurses the opportunity to practice responding to lateral violence behaviorsImage http://nursing.advanceweb.com/features/articles/no-tolerance-for-bullying.aspx
  • A little off color, but effective for student groups.


  • 1. Brandon, Manitoba Decmebr11, 2013 Managing Lateral Violence and its Impact on the Team: Eli Ahlquist RN MPA
  • 2. Outline • What is lateral violence? • What causes lateral violence? • Who is doing it? • Types. • Effects. • What can be done? • Discussion.
  • 3. Objectives 1. Identify terms used to describe negative coworker behavior 2. Describe an experience with negative coworker behavior 3. Discuss strategies to manage negative coworker behavior
  • 4. Lateral Violence “Exists on a spectrum, from seemingly ordinary behaviour such as gossiping or criticism, to intimidation, racism and outright physical intimidation or harm.” Linda Rabyj, 2005
  • 5. Definition Lateral Violence (LV), also called Horizontal violence, Nurse-to-Nurse violence, incivility, and disruptive behaviours, creates an unpleasant work environment and has harmful effects on individual nurses, patient safety, and health care organizations. Johnson, 2009 & Dimarino, 2011
  • 6. Building a culture of respect combats lateral violence A 2003 study in the Journal of Advanced Nursing found that half of newly qualified nurses report firsthand experience with lateral violence. Linda Rabyj, 2005
  • 7. Who gets targeted? Anyone who is different from the group norm on any major characteristic • • • • Experience Education Race/ethnicity Gender Targeted person’s gender • 79% Female • 21% Male
  • 8. Who is Doing the Bullying? 2009 survey by Workplace Bullying Institute: - Main perpetrator’s gender • 65% Female • 35% Male 2009 WBI survey sited in New York Times: - Men target men and women equally - Women target women 70% of the time
  • 9. Why does this happen in the Workplace? • Isolated from the public and other staff • High-stress environment • Limited autonomy in practice • High-paced environment • Lack of experienced staff • Cliques or closely bonded groups • Hierarchical climate • Gender imbalance • Attitudes to training • Non acceptance of difference
  • 10. Why? Nurses practice in a historically patriarchal environment. • Oppression leads to low-self esteem. • Nurse exert power over one another through lateral violence. Lateral violence is perpetuated through the culture of nursing (new nurses, curriculum, etc). • “Nurses eat their own” • “See one do one teach one” We now work with four different generations in the workforce, adding to the complexities of effective communication.
  • 11. Who is doing it? Coworker-on-coworker aggression • Directed toward individuals at same power level • Intended to cause psychological pain • Does not include physical aggression Intergroup conflict • Shift to shift/class to class/group to group… • Cliques within a workgroup • Department to department
  • 12. Three types of BULLIES Sydney based clinical psychologist and workplace bullying specialist Keryl Egan has formulated three workplace bully profiles: 1.Accidental bully 2.Narcissistic bully 3.Serial bully
  • 13. Accidental bully This person is task orientated and just wants to get things done, tends to panic when things are not getting done, and goes into a rage about it. This person is basically decent, they don’t really think about the impact of what’s happening or what they have done. They are responding to stress and it is believed that they can be coached out of this behavior.
  • 14. Narcissistic Bully They are grandiose and have dreams of breath taking achievement. They feel they deserve power and position. They can fly into a rage when reality confronts them. This person is very destructive and manipulative, they don’t set out in a callous way to annihilate any person – it is purely an expression of their superiority.
  • 15. Serial Bully Has a sociopathic and psychopathic personality. This type of bully is intentional, systematic and organized and is often relentless. They usually get things done in terms of self-interest. They employ subtle techniques that are difficult to detect or prove. Coaching is often ineffective. They exhibit the following: • Grandiose, but charming • Authoritative, aggressive and dominating • Fearless and shameless • Devoid of empathy or remorse • Manipulative and deceptive • Impulsive, chaotic or stimulus seeking • Master of imitation or mimicry
  • 16. Conflict It’s not all Bad Functional Conflict is considered positive, as it can increase performance, support change, and identify weaknesses or areas that need to be supported. Dysfunctional Conflict is harmful to people and the organization. This type of confrontation does nothing to support goals or objectives.
  • 17. Workplace Violence & Harassment Experts identify two primary categories of lateral violence. Overt(direct) Covert (passive)
  • 18. 10 Most Common Forms of Lateral Violence in Nursing 1. Non-verbal innuendo, 2. Verbal affront, 3. Undermining activities, 4. Withholding information, 5. Sabotage, Griffin. 2004
  • 19. 10 Most Common Forms of Lateral Violence in Nursing 6. Infighting, 7. Scapegoating, 8. Backstabbing, 9. Failure to respect privacy, and 10.Broken confidences. Griffin. 2004
  • 20. Mobbing A group of coworkers gang up on another • often with the intent to force them to leave the work group Five phases of Mobbing 1. 2. 3. 4. 5. Conflict Aggressive acts Management/Faculty Involvement Branding as Difficult or Mentally ill Expulsion
  • 21. Who else is involved? • Students/Patients • Quality care • Nurses • Co-workers as bystanders • Preceptors • Systems • Employers • Faculty • The ‘System’
  • 22. Do Nurses eat their young – and each other… This old adage should not be the price the next generation has to pay to join the nursing profession. What stories do you want your students to talk about with their peers, co-workers, or at their 5 or 10 year reunion?
  • 23. Clinical Settings - Impacts on Patients Disruptive behavior linked to: • 71%: medical errors • 27%: patient mortality • 18%: witnessed at least one mistake as a result of disruptive behavior Rosenstein & O’Daniel, 2008 Ruminating about an event takes your attention off task and leads to increased errors and injuries Porath & Erez, 2007
  • 24. Impacts on Nurses • Physical • Psychological • Social
  • 25. Impact on Nurses/Students
  • 26. Impacts on Health Systems • Dwindling workforce - 1 in 3 nurses will leave the profession (2003) • Reduced professional status • Corrosion of recruitment and retention
  • 27. Impacts on Health Systems Negative Impact on the work environment: • Communication and decision making • Collaboration and teamwork Leading to: ⇑ ⇓ ⇑ ⇑ employee disengagement job satisfaction and performance risk for physical and psychological health problems absenteeism and turnover
  • 28. Impacts on Health Systems cont. Cost of Lateral Violence: • “Turnover costs up to two times a nurses salary, and the cost of replacing one RN ranges from $22,000 to $145,000 depending on geographic location and specialty area.” Jones, C & Gates, M. (2007). • The lag in time for a new nurse to become proficient is a significant consideration.
  • 29. Impacts on Student and Grad Nurses • Students and grad nurses are extremely susceptible to Lateral Violence and experience more negative impacts than experienced nurses. Prevention Strategies are needed • Top down and bottom up approaches • Mentoring and investigation systems • Role Models • Education • Empowerment
  • 30. We All need to ask ourselves: • “Did I participate in bullying?” • “Did I support this kind of behavior in others?” • “Did I intervene if and when I observed it?” “We must work to uncover and reverse atrocities, one person, one company, and one law at a time” Bullyproof Yourself at Work, G & R Namie
  • 31. What to do? • Awareness • Education • Dialogue • Zero tolerance policy • Be confident • Develop effective coping mechanisms • Confront the situation • Rehearsal • Enact policy and procedure • Code of conduct • Don’t accept it!
  • 32. OMG a student Witnesses a Code Pink • When there is an event that needs handling in the OR a “Code Pink” is called. • A group of available individuals from other theaters will come to the perpetrators theater and stand silently staring at them. • As an example, the surgeon is shouting, being verbally abusive or throwing equipment. Mehallow, C. Verbal Abuse in Healthcare. http://healthcare.monster.com/nursing/articles/verbalabuse/
  • 33. Zero Tolerance Policies The Joint Commission and the American Association of Critical Care Nurses (AACN). • 2008: mandate the development and implementation of processes to offset LV that enforce a code of conduct, teach employees communication skills, and supporting staff. • 2009: advocates that communication skills should be as proficient as clinical skills.
  • 34. Culture of Silence • “Because we set ourselves up to be healers, this kind of behaviour is in the shadows. We don’t know what to do about it, so we try to disown it.” • In practice, this means nurses can’t stay silent when another nurse’s actions “makes them cringe”. • Having the conversation is what matters . . . it shows that both professionals share responsibility for behaviour affecting staff and patients. Monica Branigan, 2009
  • 35. Nursing Culture needs to change • “New nurses personalize their experiences and assume they are unique to themselves” • "Our program empowered nurses to advocate for themselves. As it liberated them, retention rates improved. We attribute this to recognition of lateral violence. Newer nurses can learn from those who've gone before.“ Dr. Martha Griffin, 2005
  • 36. Why Don’t We Stop Lateral Violence? “It’s not a problem in our work area” “Everybody does it – just get used to it” “If I say anything, I’ll be the next target” “We have policies but they aren’t enforced” “She sets herself up for getting picked on”
  • 37. What can you do? • Dialogue is ultimately far more effective than pointing fingers • Cognitive Rehearsal Techniques • Health care professionals across the spectrum working together more effectively, and patients receiving better care.
  • 38. DESC model • Describe - the behavior. • Explain – the effect the behavior has on you, co-workers, patient care, etc. • State – the desired outcome. • Consequences – What will happen if the behavior continues.
  • 39. Rehearsal Research has demonstrated the benefit of rehearsal for new employees. I.e. When a staff member makes a facial gesture (raising an eyebrow) the participant was instructed to say “I see from your facial expression that there may be something you wanted to say to me. It’s ok to speak directly to me”. Griffin, 2004
  • 40. Teamwork and Communication • Involve everyone in solving problems related to these issues. • Develop a set of “RIGHTS” for everyone. • Effective anti-bullying practices must include a statement of exactly what constitutes bullying. • Communication needs to be a part of culture.
  • 41. Tackling a Culture of Intimidation • Open communication and increased communication to nursing senior management. • Providing accessible professional development opportunities for all staff. • Developing a policy on bullying/lateral violence in the work-place and conflict resolution mechanisms. • Self-reflection and active feedback from our peers to develop insight into our own b behaviour
  • 42. https://www.youtube.com/watch?v=fTmyym7_-zQ http://www.xtranormal.com/watch/11704905/nursenurse-bully Lateral Violence and Students
  • 43. Discussion, questions, comments!!! Thank you for your participation
  • 44. Contact information Eli Ahlquist RN, MPA Greg Riehl RN BScN MA Program Head Aboriginal Nursing Student Advisor Perioperative Nursing Aboriginal Nursing Student Achievement Program SIAST, Wascana Campus SIAST, Wascana Campus Email: ahlquist@siast.sk.ca Email: greg.riehl@siast.sk.ca Phone: 306.775.7568 Phone: 306.775.7383
  • 45. References available on request Find our Presentation on slideshare