Nurses working in hospitals and other healthcare facilities are at disproportionally high risk for physical violence because of the very nature of their job. To maintain personal safety and an environment free from the potential of physical violence, nurses must be alert to signs of trouble. Not all healthcare workplace violence is of a physical nature initiated by patients or their families; like any other business, it is also subject to horizontal violence or interdisciplinary incivility. Horizontal violence comes in the form of intimidating or derisive behavior between and among staff, managers, or physicians; it interferes with optimal job performance and has negative effects on the delivery of high-quality patient care. No organization can completely prevent or eliminate workplace violence, but with proper planning and effective programs, the chances of such violent occurrences can be dramatically reduced.
Horizontal violence or lateral aggression are terms used to describe aggressive and destructive behavior of co-workers against each other. Other terms associated with this type of violence include bullying and interpersonal conflict. These behaviors exist in what has been termed toxic workplaces.
Another term often used is incivility, which includes a wide range of behaviors from ignoring, to rolling one’s eyes, to yelling, and eventually to personal attacks, both physical and psychological.
Safety and quality of patient care depend on teamwork, communication, and a collaborative work environment. To ensure quality and to promote a culture of safety, healthcare organizations must address the problem of behaviors that threaten the performance of the healthcare team.
Intimidating and disruptive behaviors can cause accidents with preventable adverse outcomes. The psychological stress of incivility in its many forms can lower work performance, foster medical errors, and contribute to poor patient satisfaction. All of these issues related to incivility increase the cost of care. They also cause qualified clinicians, administrators, and managers to seek new positions in more professional environments. Workplace bullying is often reported to result in enough psychological distress to nurses to cause them to leave the profession. These concerns underscore the urgent need for prevention of both patient-to-nurse and nurse-to-nurse violence.
In a toxic workplace, dysfunctional attitudes and emotions seem to permeate the atmosphere. This phenomenon harms both the company and the other employees. Over time, positively motivated employees drift away from the workplace and only employees comfortable in the negatively charged atmosphere remain on staff. Organizations who articulate a strong set of cultural values regarding communication, respect, and professionalism as well as an evaluation system that ranks both technical performance and the professional treatment of fellow employees are felt to be less likely to develop a toxic environment.
In 2008, the Center for American Nurses published a position paper stating there is no place in a professional practice environment for lateral violence and bullying among nurses or between healthcare professionals. These disruptive behaviors are toxic to the nursing profession and have a negative impact on retention of quality staff. Horizontal violence and bullying should never be considered normally related to socialization in nursing nor be accepted in professional relationships. The statement goes on to assert that all healthcare organizations should implement a zero tolerance policy related to disruptive behavior, including a professional code of conduct and educational and behavioral interventions to assist nurses in addressing disruptive behavior.
In 2008, the Joint Commission revised its standards for disruptive behavior calling for identification of manifestations of abuse and violence in healthcare organizations. One of the recommended policies is “zero tolerance” for intimidating and/or disruptive behaviors, especially the most egregious instances of disruptive behavior such as assault and other criminal acts. Organizations are encouraged to have interprofessional dialogue across a variety of forums as a proactive way of addressing ongoing conflicts, overcoming them, and moving forward through improved collaboration and communication.
In 2008, the Joint Commission revised its standards for disruptive behavior calling for identification of manifestations of abuse and violence in healthcare organizations. One of the recommended policies is “zero tolerance” for intimidating and/or disruptive behaviors, especially the most egregious instances of disruptive behavior such as assault and other criminal acts. Organizations are encouraged to have interprofessional dialogue across a variety of forums as a proactive way of addressing ongoing conflicts, overcoming them, and moving forward through improved collaboration and communication.
There are two approaches to dealing with incivility and the toxic workplaces they create. One is from an organizational level. This includes primarily establishing specific behavioral values that address professional, courteous, and respectful interactions among all staff. Mangers, supervisors, and administrators should model professional ethical behavior and foster an environment of mutual respect.
Bullying or disruptive behavior must be addressed and closely tied to performance evaluation with clear descriptions of the consequences of nonadherence. This implementation must be a ground-up strategy that brings the front line and administration together. Team strategies can be used to identify and take on incivility wherever it is. Training in recognizing bullying behavior and conflict management can help individuals create a “zero tolerance” environment for bullying behavior.
Individual assessment related to how you as an individual deal with incivility or bullying is also important. Do you ignore bullying when it happens to others? Do you participate in incivility without recognizing the results of your actions? Do you gossip about other staff members? Do you have feelings of superiority over other staff? Do you communicate with respect?
Being part of a organizational team that works to establish a cultural norm f civility can be an eye-opening experience. Such a team works to keep civil behavior reinforced as part of everyday functioning. Being a member of this team can also teach skills in how to manage acts of incivility and provide the base to build stronger work teams.
