Nurse-to-Nurse Hostility is a destructive yet common component of most nursing environments, having its roots in early adolescent experiences, hierarchical structures in healthcare settings and poor conflict resolution skills. This paper explores these issues, offering insight into the foundations of violence, and institutional and personal shifts that can create more compassionate, collaboratively- high- functioning, interdisciplinary teams. Building Bridges: An Inquiry into Horizontal Hostility in Nursing Culture and the use of Contemplative Practices to Facilitate Cultural Change Jan Jahner, RN-BC, CHPN February 1, 2011 0 Building Bridges: An Inquiry into Horizontal Hostility in Nursing Culture and the use of Contemplative Practices to Facilitate Cultural Change Table of Contents I Introduction 2 II An Overview of Lateral and Vertical Violence (Horizontal Hostility) 5 Origins 16 Drama Triangle 19 Recommendations from the Center for American Nurses 26 III Beyond the Recommendations: Getting at the Source 28 IV Developing Resiliency, Compassion, and Wisdom to Address Lateral and/or Vertical Violence 34 V Institutional Recommendations 42 VI A Personal Story 46 VI References 49 Appendices Introduction to Survey 51 Survey on Lateral and Vertical Experiences of Violence 52 Handouts for AAHPM 56 Outline of Workshop Given at AAHPM/HPNA assembly, Feb. 16, 11 60 Report of Building Bridges Workshop at the AAHPM/HPNA 2-16-11 61 1 Knowing others is intelligence, knowing yourself is true wisdom Mastering others is strength, mastering yourself is true power Lao-Tzu Introduction There is a “dirty little secret” inside nursing culture. When horizontal hostility is mentioned to nurses, they usually nod knowingly and may roll their eyes, yet most folks outside of nursing are shocked to hear the phrase “nurses eat their young and each other” coined by Kathleen Bartholomew (2006). Hostility is often exhibited as subtle forms of sabotage, and Roberts, (1983) states that the presence of sabotage occurring in a given healthcare setting is an indicator that horizontal violence and oppression exist in the workplace. “Nurses exhibit oppressed group behavior such as horizontal violence so commonly that it has become an accepted mode of behavior for many individual nurses, and indeed nursing in general’ (Girardin, 1995). Historically, nursing recruited young women who valued patient care, service, and self- sacrifice. Nurses were confronted with the common perception of being somehow less than (in maturity, critical thinking and skill capability) than their medical counterparts within a health care system composed primarily of (older) male physicians. These nurses, lacking power, autonomy, and self-esteem, at times took on the behaviors of the marginalized, looking to the powerful for approval and demeaning their own power. (Ferrell, 2001). Traditionally, nurses are valued by their ability to complete assigned tasks in a timely manner, promoting “Caring as an Economic Activity” (Hurley, 1999, p. 11). Nurses who spend too long on a task or with a patient find that they face consequences–-a missed meal, a reprimand or shunning, and because they disrupt nursing culture, they reap displeasure from peers. These same peers must be available as mentors or assistance in the workplace, 2 so maintenance of the (cultural) status quo is reinforced (Hurley, 2006). Research identifies (Bartholomew, 2006) nurse-to-nurse bullying in the workforce as a contributing factor in the current nursing shortage and a risk factor for medication errors. Studies (Stanley, 2007), indicate that both victims and witnesses of bullying often suffer silently and are unsure how to handle or integrate these hostile behaviors that are both subtle and embedded in nursing culture. My own socialization into nursing began in the emergency room and was filled with ambiguity along with a sharp learning curve. At times you were the angel in someone’s dark night; at times you barricaded your soul against terrifying responsibilities and a culture that appeared to have no time for humanity. One minute I were running a code 99 until the physician arrived, even though the aged blue body beneath my compressions seemed to be sustaining injuries, and the next I was dialing the police because of a suspected rape case. In neither situation was adequate time allowed for emotional support of the families, or debriefing for the nurse. As a new nurse there is a phenomenal amount one needs to learn after graduation. One needs mentors, ‘safe’ nurses to ask questions of and be vulnerable to--patient, skilled teachers who remember what it was like to be new in the profession. I started in the ER along with a nurse who had graduated a year before me, two older-than-average ‘newbies’ together. My experience of being mentored varied: some nurses listened and guided and others watched and waited for opportunities to humiliate, under the guise of ‘weeding out the weak’, possibly stemming from their own socialization into the nursing profession.. Power abuse was subtle but present; I lasted 10 years, the other nurse left within the year. 3 I’ve been an RN for 26 years now, and have come to realize that I was socialized into a role, a culture, and a hierarchy, and that vertical and lateral violence (VLV) and bullying played a significant part of that socialization. While I experienced, witnessed, and sadly participated on the edge of LV, it is only in the last 4-5 years that I’ve began to inquire about its origins, impact on the profession, patient outcomes, teamwork and on myself personally. As I have become healthier and stable emotionally, the unhealthy manner in which health care clinicians often treat each other has become more glaring, particularly in light of the fact that we uphold caring as the hallmark of our profession. This paper and the workshop associated with the project will document this inquiry, looking at current research, delving into personal experience, and describing possible steps to mitigate the very human tendency to turn anger inward, vertically and laterally, when structures deeply disempower a group. The Upaya chaplain program and the work of Roshi Joan Hallifax has had a profound influence on my research and conclusions related to the need to address and transform horizontal and vertical hostility in healthcare. Buddhist teaching, current brain research and the findings of contemplative researchers such as Jon Kabat-Zin have filled me with hope for our profession, as we learn that engrained behaviors and perceptions can and do change. Outcomes such as building resiliency and compassion are very compelling to me, given healthcare settings’ deeply entrenched structures. Since I am currently working as part of an interdisciplinary hospice team interacting with healthcare clinicians in a broad range of settings, my observations and discussions will be incorporated. 4 The American Academy of Hospice and Palliative Medicine/Hospice and Palliative Nurses Association accepted an abstract I submitted exploring VLV that introduces mindfulness practices to build resiliency, insight and compassion. Methods and results of the workshop will be described later in this paper. In light of the inadequate research that is available about lateral/vertical violence in interdisciplinary teams, our interdisciplinary team designed a survey that is being administered in more than 4 sites in the United States. Although there is a moderate amount of research regarding nurse-to-nurse hostility, the survey investigates a more diverse population and was administered primarily to persons working in hospice and palliative care. The team I assembled in the summer of 2010 have been collaborating on the research as well as shaping the four hour workshop which occurs February 16, 2011 in Vancouver, BC. I am deeply indebted to this wonderful group, whose members all that have been touched in some way by Upaya, as well as by the issues of this inquiry. We hope to publish our results sometime in 2011. An overview of Lateral and Vertical Violence (Horizontal Hostility) We are one; after all, you and I. Together we suffer, together exist, and forever will recreate each other. Pierre Teilhard de Chardin Definitions 1. Bartholomew (2006) defines horizontal or lateral violence, also known as nurse-to- nurse hostility, as “a consistent (hidden) pattern of behavior designed to control, diminish, or devalue another peer (or group) that creates a risk to health and/or safety. ” LV can be understood as disruptive behavior that interferes with effective health care communication and thus threatens a culture of patient safety. 5 The terms horizontal hostility (HH) and lateral violence (LV) will be used interchangeably in the paper. LV occurs when people who are victims of a situation of dominance turn on each other rather than confront the system that oppresses them both. Frequently, LV occurs when oppressed groups/individuals internalize feelings such as anger and rage, and manifest their feelings through overt or covert behavior. Our preliminary research findings suggest a strong correlation between poor conflict management/engagement skills and the experience of lateral violence, and thus we can wonder about how “care-ers” create and manage boundaries and vulnerability. LV includes overt and covert physical, verbal, and emotional abuse by one nurse against another and can manifest in verbal and nonverbal behaviors. Griffin identified the ten most common forms of LV behaviors described in the international nursing literature (Duffy, 1995; Farrell, 1997, 1999; McCall, 1996) as non-verbal innuendo (eg, behavior that may disregard or minimize another nurse such as eye-rolling or eyebrow raising), verbal affronts, undermining activities, withholding of information, sabotage, infighting, scapegoating, backstabbing, failure to respect privacy, and broken confidences” (2004). 2. Bullying has been defined by the Workforce Bullying Institute as an offensive, abusive, intimidating, malicious or insulting behavior or abuse of power conducted by an individual or group against others, which makes the recipient feel upset, threatened, humiliated, or vulnerable [and] which undermines their self-confidence and may cause them to suffer stress.