Improvement Story session at the 2013 Saskatchewan Health Care Quality Summit. For more information about the summit, visit www.qualitysummit.ca. Follow @QualitySummit on Twitter. The effects of lateral violence can be catastrophic for students in preceptored relationships. We wanted to promote healthy learning workplaces, and support teaching and learning environments for quality learning outcomes - we delivered in-services on lateral violence to increase awareness and to support positive interactions between nurses and students, while addressing negative communication behaviours and lateral violence. Better Teams Greg A. Riehl; Eli Ahlquist

1. Managing Lateral Violence and its Impact on
the Team: Nurses and Students
Elijah Ahlquist, Greg Riehl
This Session is sponsored by:

2. Health Quality Council
Managing Lateral Violence
and its Impact on the Team:
Nurses and Students
Eli Ahlquist RN MPA
Greg Riehl RN BScN MA

3. Outline
• What is lateral violence?
• What causes lateral violence?
• Who is doing it?
• Types.
• Effects.
• What can be done?
• Discussion.

4. 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

6. 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

7. 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

8. 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
first-hand experience with lateral
violence.
 Linda Rabyj, 2005

9. 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

10. 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

11. 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

12. 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.

13. 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

14. 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.

15. Workplace Violence & Harassment
Experts identify two primary
categories of lateral violence.
Overt(direct)
Covert (passive)

17. 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

18. 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

19. 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. Conflict
2. Aggressive acts
3. Management/Faculty Involvement
4. Branding as Difficult or Mentally ill
5. Expulsion

20. Who else is involved?
• Students/Patients
• Quality care
• Nurses
• Co-workers as bystanders
• Preceptors
• Systems
• Employers
• Faculty
• The ‘System’

21. 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?

22. 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. 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.

39. 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

40. Lateral Violence and Students
https://www.youtube.com/watch?v=fTmyym7_-zQ
http://www.xtranormal.com/watch/11704905/nursenurse-bully

41. Discussion, questions,
comments!!!
Thank you for your participation

42. Contact information
Eli Ahlquist RN, MPA
Program Head
Perioperative Nursing
SIAST, Wascana Campus
Email: ahlquist@siast.sk.ca
Phone: 306.775.7568
Greg Riehl RN BScN MA
Aboriginal Nursing Student
Advisor
Aboriginal Nursing Student
Achievement Program
SIAST, Wascana Campus
Email: greg.riehl@siast.sk.ca
Phone: 306.775.7383

43. References available on Request
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