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

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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.

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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.

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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.

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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.

3. Vertical violence:

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Vertical violence (VV) can be defined as hostility occurring between individuals with

unequal power, such as a staff nurse and student, or manager and staff member,

which is disrespectful, humiliates or undermines self-confidence and growth. Often

the resultant feeling for the subordinate is one of fear and lack of safety. The term

vertical violence can be applied when a registered nurse (RN) abuses power and

longevity when orienting students and new graduates. While the nursing literature

has primarily focused on horizontal hostility (HH), in many ways the VV

experienced from the hierarchical structure of physician-nurse roles perpetuates

negative peer-to-peer behaviors.

4. Culture

Culture is defined as a set of shared basic assumptions about the organization’s

values (what is important), beliefs (how things work), and behaviors (the way we do

things) that have been reinforced in the workplace in an explicit or implicit ways

(Senge 1999). These assumptions have worked well enough to be considered valid

and, therefore, are taught to new members as the correct way to perceive, think, and

feel in relation to problems. Culture is deeply rooted in an organization’s history and

collective experience (Bartholomew, 2006).

5. Oppressed Group Behavior

Stanley (2007) reports that characteristics of oppressed groups include the indirect

expression of aggressive behavior, internalized hostility, and divisiveness. She goes

on to say that self-respect is diminished when individuals are not free to express

their feelings, thoughts, and desires. There is an indication that low self-esteem is

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related to the participations of nurses in a health care system that does not value

nursing and is based on the values of the medical model which rewards the

generators of income (Roberts, 1997).

Financial Costs: Nursing Retention

The economic impact of lateral violence is not only costly but directly impacts patient

safety. According to Griffin (2004), of the new graduates who leave their first nursing

positions, 60% do so because they have experienced some form of lateral violence. It is

estimated to cost $92,000 to recruit, hire, and orient a medical surgical nurse and the cost

rises to $145,000 to recruit, hire and orient a specialty nurse (Pendry, 2007). Current

research identifies the average voluntary nurse turnover rate in hospitals to be around

8.4%, this average increases to 27.1% for first year nurses (Stanley, 2007).

Patient Safety

Lateral violence behaviors interfere with effective health care communication and

therefore impacts patient safety. This is costly to health care organization as the rate of

medical errors increase with communication failures (Stanley, 2007). Other workplace

studies indicate that ruminating about an event takes your attention off task and leads to

increased errors and injuries (Stanley, 2007) Disruptive behavior is linked to 71% of

medical errors and 27% of patient mortality. Eighteen percent of those in a study by

Rosenstein witnessed at least one mistake as a result of disruptive behavior (ISMP, 2004).

The Silence Kills Website sites a study done by their group (www.silencekills.org )

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suggesting that 84% of MD’s have seen co-workers taking shortcuts that could be

dangerous to patients and 88% of MD’s say they work with people who show poor clinical

judgment. Fewer than 10% of MD’s, RN’s and clinical staff directly confront their

colleagues about their concerns.

Who is doing the bullying?

Stanley quotes the Vanderbilt University/Studer Group survey of healthcare professionals

found that nurses were the initiator of unprofessional behavior 85% of the time, physicians

79% of the time, managers 54%, and administrators 43 % of the time (Stanley, 2007).

According to Namie (2007) nearly three-quarters of all bullying occurs when the target is

not a protected-group member or when the harasser is a protected-group member. Namie

reviewed research related to bullying across numerous settings and states “woman-on-

woman harassment accounts for 50 % of all bullying” (Namie, 2007).

The Center for American Nurses Position Statement on Lateral Violence (2008) asserts that

hostile behaviors are toxic to the nursing profession and contribute to an organization’s

inability to retain quality staff members. This is of particular concern at a time when there

is a shortage of qualified nursing professionals. The Joint Commission (2007) is sited in the

Center’s Position Statement as acknowledging that unresolved conflict and disruptive

behavior can adversely affect safety and quality of care. Additionally, healthcare

organizations are grappling with a continuing nursing shortage today that is projected to

grow worse as nurses retire (American Association of Colleges of Nurses, 2007). Bullying

and lateral violence have a negative impact on the ability of the nursing profession to both

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retain and encourage recruitment. The Joint Commission’s (JC) 2007 survey revealed

results that 77% of respondents had witnessed disruptive behavior in physicians and 65%

had seen similar behavior in nurses. The JC summary indicates that lateral violence affects

nurses’ health and well-being and their ability to care for patients and takes its toll on

patient safety.

All too often, seasoned healthcare providers feel compelled to warn new staff members

about a particularly difficult physician, and perhaps even shield them from this person for

as long as possible. It's a telling sign of a culture that tolerates, even fosters, intimidation.

More than 2,000 (N=2,095) healthcare providers from hospitals (1,565 nurses, 354

pharmacists, 176 others) responded to an Institute for Safe Medical Practices (ISMP)

(2003), survey on this subject. Sadly, they clearly confirmed that intimidating behaviors

continue to be far from isolated events in healthcare. What's more, these behaviors are not

necessarily limited to a few difficult physicians, or for that matter, to physicians alone.

Regardless of the source of intimidation (physicians or others), respondents reported that

subtle yet effective forms of intimidation occurred with greater frequency than more

explicit forms. For example, during the past year, 88% of respondents of the ISMP 2003

survey encountered condescending language or voice intonation, 87% encountered

impatience with questions, and 79% encountered a reluctance or refusal to answer

questions or phone calls. Almost half of the respondents reported more explicit forms of

intimidation during the past year, such as being subjected to strong verbal abuse (48%) or

threatening body language (43%) (ISMP survey, 2003).

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So, what happens to the bully? A 2009 Workplace Bullying Institute (WBI) survey on

workplace bullying found that 28% of the bullies were promoted or rewarded or

experienced positive consequences for bullying behaviors. This same study found that

1.6% of the bullies lost their job, compared to 43.5% of the “targets” (of bullying) losing

their jobs by layoff, termination or quitting. Of these, 12.3% of the targets experienced

psychological injury while 54% reported most common employer tactic was “doing

nothing” to the bully. As I read through the narrative sections of our survey, two of the

stories described leaving nursing due to the hostility in the environment. Our 2010 survey

on lateral violence found one hospice nurse had only reentered the profession 2 years ago,

after nearly 30 years of working outside the field, needing significant retraining in order to

become part of a hospice team. Another nurse confided to me that he couldn’t actually

complete the survey; his memories of the last work environment were still far too painful,

stating “I’ve PTSD about this!”

Contributing factors: physician-nurse relationships.

One might well ask, what sets up nurses and other clinicians to tolerate intimidation and

other forms of hostility, either from peers or from physicians? What are the factors that

lead to disempowerment of nurses in particular? Gordon (2005) examined many of the

contributing factors. She discusses the risks nurses face that can be minimized but are

somewhat expected; injury related to assisting a patient that has fallen, being stuck with an

infected needle, being yelled at by upset family members or mentally unstable patients.

She states that mistreatment by physicians that fail to communicate about critical clinical

issues or deny the nurses access to needed information or resources create risks for nurses

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that they would not have anticipated. While physicians are not the sole source of nurse

disempowerment by any stretch; the historical relationship between physicians and nurses

plays a significant role. According to Gordon, during most of the years of training in which

residents are mentored by older, more experienced physicians, tribalism is encouraged.

Tribalism in this context can be understood as “an apprenticeship style of medical

education in which students learn to be doctors as part of tightly knit physician teams”

(Gordan, 2005, p. 28), a situation that might be seen as a counter social force of

interdisciplinary cooperation. There is a body of research that looks closely at the hazing

and aggression that occurs during these formative years, and recognizes that there is

virtually no training for medical students on how to interact with other medical

professionals. “The doctor-in-training quickly learns that he or she is constantly being

judged. He quickly learns never to put himself in a one-down position by admitting that he

is insecure about his knowledge or that he does not know something”(Gordon, 2005).

Gordon concludes that most of what nursing does is a complete mystery to most

physicians.

Often young residents are giving orders to frustrated nurses who know more about what is

going on with the patient than they do, resulting in tensions as experienced nurses learn to

be silent, reluctant to be labeled as “trouble-makers”. If the nurse is not treated as a

respected member of an interdisciplinary team, there may be simply no healthy outlet for

anger generated when observations, professional insight, and method of reporting are

devalued. Other responses to oppression may manifest as ineffective, nonproductive forms

of conflict resolution. Instead of dealing with a problem directly via rational discussion

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between or among members of an oppressed group, one or more of the parties involved

exhibits poor or even harmful communication techniques. A common outcome is acts of

sabotage by and toward members of the same oppressed group. Group members will talk

about each other behind each other's backs, lie, or in some way undermine each other.

Regardless of the method used, the purpose of this behavior is to control, humiliate,

denigrate, or injure the dignity of oppressed colleagues. The use of horizontal violence

demonstrates a lack of mutual respect and value for all involved (Dunn, 2003).

What follows may be a type of depersonalization of care: patients become dehumanized

and a diagnosis; ‘the leg” or “the chest pain”, not Mrs. Smith or Mr. Jones. What sometimes

is referred to as ‘office politics’ and task oriented work fosters “what has to be done”, in

“what’ amount of time, and the “who” and the personal relationship with the patient loses

value.

Gordon poses “if a female nurse is bright and ambitious, she “should have become a doctor”,

and if she isn’t particularly bright or ambitious, why should doctors consult with her or

attend to her concerns?”(Gordon, 2005, p. 27). Nurses must call the doctor to “receive an

order” for minor therapies that they already know are the right thing to do. This

‘needing orders’, even for obvious interventions such as a catheter to relieve a distended

bladder is part of what sets a hierarchy in motion. In many situations, the nurse can’t tell

the doctor what she really thinks, or knows should be done; she must limit her report to

facts and making suggestions.

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Once I became a seasoned ER nurse and then later, a hospice nurse, I often knew exactly

what was needed, but also knew my communications with physicians needed to be shaped

as suggestions or questions. You quickly learned who couldn’t handle even suggestions,

and so just reported observations; “dumbing down” became part of the plan for patient

care. There are specialized units throughout the hospital where a nurse can earn a degree

of autonomy, but because of licensure, she walks a very thin line. Suggestions often are a

maneuvering of language to allow the physician the privilege of “giving orders’, so that the

nurse can do what she already knows is necessary. Usually this works smoothly and the

patient has excellent care, but the structured inequality has a disabling effect on nursing as

a profession. In order to preserve future interactions, the nurse inadvertently gives MD’s

power. According to Gordon (2005) nurses are expected to participate in training doctors

how to be their superiors.

Now that in-house physicians (hospitalists) are common, the hospital nurse often spends

less time trying to track down physicians to “receive orders”, however this time consuming

element still creates difficulties in most settings. Patients can do a great deal of waiting

while the nurse waits for a call back. Gordon (2005) cites physician-nurse relationships and

a culture of acquiescence to abuse as one of the reasons nurses want to leave the bedside

and either leave nursing, or further their studies to become advanced practice nurses.

It’s hard to describe what it feels like to be central to patient care and family support, yet

have to stand by silently while a physician botches delivering bad news, misses critical

components of a pain assessment, or by-passes opportunities to support a patient through

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critical decision making. I spoke to a nurse recently who described her moral distress

connected to “not being able to address end of life issues with the patients she was

providing chemotherapy for when it was clear that chemo no longer was providing any

benefit.” She feels the physicians who work at her cancer clinic are not comfortable

bringing up the subject of stopping therapy and seem unwilling to bring up end-of-life

issues or hospice care. The nurse then, feels like an accomplice in the provision of

inadequate care.

Nursing has become more specialized. Most nurses object to being floated to areas they are

unfamiliar with, yet are often perceived by administration as interchangeable ‘units’, able

to float into settings they’re inexperienced in. Putting trained professionals in unfamiliar

settings sets the nurse up for problems with co-workers and is profoundly disrespectful of

their specialized knowledge and experience, and yet this practice is common. Obviously,

this practice can be extremely unsafe for patient care. As one nurse put it “If you feel the

hospital thinks you’re just another shovel, then why not shovel yourself right out of the

institution—the profession—altogether”. Rose Ann De Moro, (Gordon, 2005) executive

director of the California Nurses Association argues that many of the new “innovations” in

cost cutting treat patients like “widgets on an assembly line and nursing as casual labor”.

Patricia Benner, a nursing researcher states that the “keep them down, keep them dumb,

keep them divided” approach to nursing by management is a logical extension of the

market model. Gordon, quotes Benner stating “There’s no vision of a community of

practice where people are assigned because of how well they work together, where they

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can learn from one another, it’s all like these interchangeable parts and you create an

institution that’s inhospitable, or alien to the complexity of the work”( 2005, p 283).

When my past manager, under pressure from administration, insisted that all the home

health nurses and hospice nurses provide both types of service and take call for both

populations, we all found ourselves instantly out of our depth; overwhelmed with new

expectations. The home health group that had poor interpersonal skills and were

uncomfortable with end of life discussions and the intricacies of pain management had an

even harder time than the hospice nurses who were suddenly learning very complex

procedures and home infusion techniques. Feeling disrespected, every single nurse fought

back—it took five years to turn the tide, and it turned because of patients’ complaints, not

because of nursing’s. All of these issues influence how nurses treat each other, the climate

of personal safety and mutual respect.

Administration cannot respond to the needs of a group characterized by silence and

invisibility, which are typical of an oppressed group that rarely has representation on the

hospital board and minimal representation in upper management (Weinberg, 2003).

Typically, administration has extremely little to do with nurses, does not seek them out to

hear their stories, and usually sees them as interchangeable commodities or opponents

across the bargaining table.

Origins

Horizontal hostility or LV behaviors appear at times to have roots that reach back to middle

school behaviors, when peer pressures and the establishment of social status begin to peak.

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The literature describes a phenomenon called relational aggression which can be defined as

any behavior that is intended to harm someone by damaging or manipulating relationships

with others (Simmons, 2003). The behaviors move across genders, but are predominant

among girls. Unlike other types of bullying, relational aggression is not as overt, or

noticeable as physical aggression. However, the effects can be damaging and long lasting!

Social scientists, educators and parents are becoming more aware of the long lasting effects

of relational aggression on all the players, identifying roles such as “the queen”, the “side-

kick”, the “gossip”, the “wannabe”, and the “target”. What is distressing is that all these roles

injure the adolescent’s capacity for self-awareness, and the development of relational

maturity. Looking at one of the roles; the “wannabe” (one who seeks popularity)”, we see

that she:

sees other girls’ opinions and wants as more important than hers

can’t tell the difference between what she wants and what the group wants

is desperate for the “right” look (clothes, hair, etc.).

feels better about herself when others come to her for help, advice

loves to gossip---phone and email are vital to her

may be dropped if she is seen as trying too hard to fit in.

hasn’t figured out who she is or what she values.

likely feels insecure about her relationships and has trouble setting

boundaries.

The usual motivation behind acts of relational aggression is to socially isolate the

victim while also increasing the social status of the bully. Perpetrators might be driven

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by jealousy, need for attention, anger, and fear of (or need for) competition. One reason

girls choose this type of bullying rather than more direct acts of harassment is that the

bully typically avoids being caught or held accountable. Girls who appear the most innocent

may indeed be the most hostile in their actions. These bullies are often popular, charismatic

girls who are already receiving positive attention from adults. Because of their positive

reputations, these girls may be the least likely suspects. Thus it can be very difficult to

identify the perpetrators of acts of relational aggression, and address the behaviors head

on.

Bartholomew, (2006) author of “Nurse to Nurse Hostility—Why Nurses Eat Their Young

and Each Other” poses the question--what is it within nursing that brings out behaviors

that appear so immature? It is possible that many nurses are attracted to the profession

because of a need to be needed, and further that they feel increased self-esteem once in a

helping role. Notice the characteristic of the “Wannabe” above that has been bolded.

Bartholomew (2006) suggests that nurses have felt like they are at the bottom of the food

chain because they are doers’: so absorbed in the tasks directly in front of them, there is not

time for reflective practices which would allow them to deal with their emotional state,

feeling the total weight of all the pressures from above. I know I was afraid of most

physicians when I started in the profession, and fearful of inciting the physicians

displeasure or wrath. Some of this discomfort was set in motion from the tales told by

nursing instructors, some from the mystic that had been present from childhood; doctors

were in the same category as priests or judges, clearly on pedestals. While younger

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physicians may adopt more of a collegial relationship with nurses, there remains a strong

hierarchical structure that supports nurse’s submissive posture.

Drama Triangles

Sensei Fleet Maul introduced the concept of the drama triangle during our core Upaya

Chaplaincy training in August of 2009. This rescuer, victim, perpetrator triangle also plays

a role in the perpetuation of horizontal hostility, and as the rescuer role is easily mistaken

for legitimate care-giving, nursing attracts many rescuer personalities. Briefly, the basic

concept underpinning the drama triangle is the connection between responsibility and

power, and their relationship to boundaries.

The Drama Triangle was originally conceived by Steven Karpman and was used to plot the

interplay and behavioral “moves” between two or more people. Karpman’s original

premise was based on the hypothesis that people form a “Script” which is essentially an

individual’s concept or belief about who they are, what the world is like; how they relate to

the world, and how the world relates to them, and how others treat them. Psychologists

theorize that an individual forms their Script by the time they are four or five years of age.

(Wikipedia, 2010) A Script is based on what an individual is told, what they experience, and

how they interpret these external stimuli from their own internal frame of reference.

The triangle often begins with someone, usually the victim, asking “will you help me?”, then

moves on to someone taking the rescuer role. Once The Game begins, a series of

complementary transactions continue as long as it suits both parties. These dynamics are

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unsustainable, as eventually the rescuer is resented for their patronizing, and the victim is

resented because of their continued neediness and some member of the duo shifts

positions and becomes the perpetrator. It can be observed that the Karpman Drama

Triangle works at both the social level, that is observable behavior, and at the internal

dynamic level, that is what a player feels inside. It is therefore quite possible to feel a Victim

and be seen by others as a Persecutor, or present as a Victim but in reality be a Persecutor.

A “Rescuer” is someone who often does not own their own vulnerability and seeks instead

to “rescue” those whom they see as vulnerable. The traits of a Rescuer is that they often do

more than 50% of the work, they may offer “help” unasked rather than find out if and how

the other person wants to be supported, and what the Rescuer agrees to do may in actual

fact not be what they really want to do. This means that the Rescuer may then often end up

feeling “hard done by” or resentful, used or unappreciated in some way. The Rescuer does

not take responsibility for themselves, but rather takes responsibility for the perceived

Victim whom they rescue. I have both been in this role, and witnessed these dynamics, and

it is true that the Rescuer will always end up feeling the Victim.

A “Victim, or target” is someone who usually feels overwhelmed by their own sense of

vulnerability, inadequacy or powerlessness, and does not take responsibility for

themselves or their own power, and therefore looks for a rescuer to take care of them. At

some point the victim may feel let down by their rescuer, or perhaps overwhelmed or even

persecuted by them. At this stage the victim will move to the persecutor position, and

persecute their erstwhile rescuer. They may even enlist another rescuer to persecute the

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previous rescuer. However, the victim will still experience them-selves internally as being

The Victim.

Berne, (2010) describes the position of “Persecutor” as synonymous with being unaware

of one’s own power and therefore discounting it. Either way the power used is negative and

often destructive. Any player in the “game” may at any time be experienced as the

persecutor by the other player/players. However their own internal perception may be

that they are being persecuted, and that they are the victim. There of course are instances

in which the persecutor is knowingly and maliciously persecuting the other person, as in

LV and VV; however a great deal of LV and VV is done unconsciously.

Each of the positions are taken up as a result of an issue being discounted or disowned. To

remedy this, the Rescuer needs to take responsibility for him/herself, connect with their

power and acknowledge their vulnerability. The Victim needs to own their vulnerability

and take responsibility for themselves and also recognize that they have power and are

able to use it appropriately. The Persecutor needs initially to own their power, rather than

be afraid of it or use it covertly (Berne, 2010).

These dynamics are seen over and over in healthcare institutions, and, unfortunately,

nursing has been in, or sees itself as in, a victim role far too long. Fortunately, we can move

towards an empowerment triangle, that of coach, challenger, and co-creator once this

option has been identified. In this model the acceptence of responsibility holds the highest

value, instead of being right, looking good, fixing or rescuing. The “Creator” is the central

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role in the “empowerment dynamic.” When this role is consciously chosen, one can claim

and tap into his or her capacity to choose their response to their life circumstances. They

also own their responsibility and contribution to their current circumstances. This role is

result-and-goal oriented, focused on desired outcomes. Along the way, a creator invariably

meets up with the “challenger;” either an individual or circumstance. True creators

welcome challengers. Creators are able to transform their perspectives about people,

conditions and/or circumstances into challenges to be met, understood, and (whenever

possible) overcome. The Challenger calls forth a Creator’s will and ability to create, often

spurring him or her to learn new skills, make difficult decisions, and do whatever is

necessary to achieve a dream or desire (Berne, 2010).

In order to more effectively move toward their dreams and desires, Berne finds that a

creator can benefit greatly by having a coach in their life, which is the antidote to the role of

the rescuer. A coach supports, assists, and facilitates a creator in clarifying and manifesting

the creator’s desired outcomes through the use of powerful questions. Coaches help

creators perceive new possibilities; coaches dare them to dream and find their power. A

coach acknowledges and helps leverage the power and capabilities of a creator and holds

them accountable for taking the steps necessary to move forward. Most importantly, a

coach sees the other as a creator that is creative and resourceful, even if they do not know

it themselves (Berne, 2010). Good mentors within the nursing profession are coaches at

heart, and often have been the recipient of coaching in their own development.

After our training with Sensei Fleet, I began observing drama triangles in action on a daily

basis at my hospital, and suggested we may want to consider training related to these

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dynamics and the relationship to the horizontal hostility that was evident as an issue that

was affecting retention and patient care. While the nursing leadership at my hospital was

reluctant to consider the drama triangle, they did invite Kathleen Bartholomew to provide

a half day workshop in 2008, which was transformative for me, but unfortunately didn’t

seem to get much traction at the time. Bartholomew’s work on horizontal hostility is now

internationally known as she has a strident voice for change. She points to additional

background difficulties that contribute to LV/VV. Many nurses have difficulty balancing

their lives: many are single parents, many do not belong to professional organizations, and

many do not belong to recreational organizations or clubs. As their own health slides, so

does their emotional health. Shifts often are 12 hours, adding exhaustion into the potential

for error, irritation, and poor teamwork. The nurse that works five 8-hour days can get to

know and bond with her patients and her team in ways that are not possible when working

2 or 3 days a week.

The average age of a nurse in 2006 was 48 yrs. old, again pointing to poor retention of the

new nurse. Bartholomew (2006) recounts story after story of nurses experiencing

humiliation, a sense of barely surviving in the pace, atmosphere, and inadequate mentoring

that often occurs due to lack of voice and the task oriented focus of an oppressed group.

In contemporary American society, young girls are socialized to internalize aggressive

feelings and use alternative methods such as relational aggression to deal with anger

(Simmons, 2002). It follows that in-fighting would become an attribute of this oppressed

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group. Bartholomew argues that attributes originally valued by the subordinate group are

devalued and that this devaluation manifests itself in low self-esteem causing displaced

aggression. These attributes include compassion, caring, sensitivity and vulnerability.

Three factors are described in Bartholomew’s 2006 work on nurse-to-nurse hostility that

increase psychological distress: the lack of an outlet for frustration, the lack of social

support systems, and unpredictability. Further, she summarizes the difficulties by stating

that from an organizational and professional context, we know that HH emerges due to (1)

a lack of voice or representation in the organizations’ hierarchical structure (2) a conflict of

primary interests with the dominant group (3) a constant power struggle for finite

resources (4) increasing pressure on hospitals to survive, and (5) a lack of solidarity within

the nursing profession (Bartholomew, 2006).

Bartholomew adds that many nurses are weak in conflict engagement skills, and use

avoidance and HH tactics rather than risk addressing the issues creating tension. My

experience and observations concur. Often subtle hostility is not addressed by the target

because of his/her awareness that the perpetrator lacks insight into their behavior, would

deny hostility and find new ways to isolating or causing injury to the target. Often this is

connected to difficulties with vulnerability and feelings of discomfort when confronted

with vulnerability.

An additional problem for nurses is the lack of time for debriefing, despite the complexity

of their work and the fact that they are working with human beings, suffering and death.

The subsequent isolation and anger can lead to depression, which then fosters a culture

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that is not attuned to others needs, or their own. A nurse may have a patient take a

significant turn for the worse, absorb all her time and attention as she initiates life-saving

measures, accompany the patient to ICU, and still be responsible for the four other patients

under her care—and thus have no time to process the hugely emotional experience of a

life-threatening event.

Impact on the individual

Nurses primarily report decreased job satisfaction and increased desire to leave, however

as I reviewed the literature and considered my own experiences, I found that there were

physical, behavioral, psychological and spiritual issues related to LV/VV:

Physical: Decreased immune response/resistance to infection, increase in stress

related disease, cardiac arrhythmias (increased risk of heart attack due to continuously

circulating catecholamine’s), fatigue, lethargy, hyperactivity, weight gain, weight loss,

headaches, impaired sleep, impaired mental processes such as poor concentration or

forgetfulness, GI distress, and loss of libido.

Emotional: anger, fear, guilt, resentment, sorrow, depression, cynicism , being grief-

stricken, anxiety, confusion, sarcasm, emotional outbursts, emotional shutdown, feeling

overwhelmed, hurt, frustration.

Behavioral: addictive behavior (alcohol, drugs, gambling, food, etc.), controlling

behaviors (the need to be “right”, inflexibility, rigidity), offender behavior (taking

aggression out on others who often have less authority), boundary violations,

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apathy, indifference, avoidance, erosion of relationships, agitation, shaming others, victim

behaviors (feeling powerless to change one’s situation), depersonalization (treating

patients as non-persons.

Spiritual: loss of meaning, crisis of faith, loss of control, loss of self-worth, disrupted

religious practices, disconnection with people, work, and community.

Additional Thoughts on Environment

Wherever choices exist, there is the potential for disagreement. Such differences, when

handled properly can be very enriching, and produce creative solutions and interactions.

When disagreements are poorly managed, contention often develops. People differ in their

ability to deal with strong emotions and conflicts as well as their sensitivity to comments or

actions of others and distress tolerance. People in conflict often enlist others to “hear them

out” or enlist their support. Since that person has only heard their side of the story,

providing support often comes easily. By finding someone who agrees with us, our self-

esteem is elevated. It is far wiser, however, to learn to deal directly with conflict, rather

than run from or side-step it; our self-esteem becomes much less vulnerable. Environments

that encourage open dialogue and allow adequate time for both patient care and

decompression are less likely to foster LV/VV.

Current Recommendations to address and correct horizontal hostility

The CENTER for American Nurses in their position paper of 2008 recommends numerous

strategies to eliminate disruptive behavior (lateral and vertical violence and bullying):

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Recommendations of Center’s frequently referenced Position Paper for Nurses:

Nurses and nurse leaders, managers and supervisors adopt and model professional

ethical behavior

Recognize and appropriately address bullying and disruptive behavior in the

workplace through enhanced conflict management and conflict resolution

Reflect on your own behavior and communicate respectfully with each other

For Employers/Healthcare Organizations

Implement zero tolerance policies that address disruptive behaviors (lateral

violence and bullying) and indicate such behaviors will not be tolerated. The

organizations should adopt zero tolerance policies that include appropriate

investigation and due process necessary to provide adequate safeguards to nurses

and others who are accused of lateral violence or bullying.

Promote a Culture of Safety that encourages open and respectful communication

among all healthcare providers and staff.

Provide support to any individual impacted by lateral violence and/or bullying.

Provide education and counseling to victims and the perpetrators of horizontal

violence and bullying.

For Nursing Continuing Education and Academic Programs

Disseminate information to nurses and students that address conflict and provide

information about how to change disruptive behavior in the workplace.

Implement continuing education programs related to bullying and lateral violence

and interventions to address such behaviors.

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Develop educational programs regarding bullying and strategies on how to

recognize and address such disruptive behavior.

Develop and implement curricula that educate nursing students on the incidence of

disruptive behaviors including lateral violence and bullying, along with steps to take

to eradicate this behavior.

For Nursing Research

Continue to research the contributing factors and the process of lateral violence and

bullying behaviors and build on previous and current studies while seeking to

explore innovative interventions on how to eliminate manifestations of disruptive

behaviors, (Position Paper: Center for American Nurses Lateral Violence and

Bullying in the Workplace, 2008 p. 6 )

I would submit that unless we move the discussion up-stream, and involve

interdisciplinary teams, these measures will have only a marginal effect, since the problems

are far larger than the nursing field. Nurses do not work in bubbles, nursing is an

interdependent profession: unable, in most circumstances, to work without directing or

supporting clinicians. I also feel that the Center is missing some key understanding about

what actually creates lasting change.

Going beyond the recommendations: Getting at the source

Boundlessness is not other than form, Form is not other than Boundlessness (The Buddha)

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Over 2000 years ago, Gautama Siddhartha experienced an awakening, and, after careful

consideration, chose to share this awakening with others. He became known as the

awakened one; the Buddha. Two of the fundamental principles of what has come to be

understood as Buddhist philosophy are that we do not have a separate “self”, and that all

things are impermanent. Buddhism stands unique in the history of human thought in the

denying of the existence of “self” or soul, or Atman. “According to the teaching of the

Buddha, the idea of self is an imaginary, false belief which has no corresponding reality, and

it produces harmful thoughts of “me” and “mine”, selfish desire, craving, attachment,

hatred, ill-will, conceit, pride, egoism and other defilements, impurities and problems. Iit is

the source of all the troubles in the world from personal conflicts to wars between nations”

(Rahula, 1959, p 51). I will add that this fundamental error in thinking is certainly at the

root of lateral and horizontal hostility in nursing, and in section IV of this paper will

present practices that enhance our understanding and experience of the inter-connectivity

of all things; practices that take us into the heart of compassion and wisdom.

Two ideas are psychologically deep-rooted in man: self-protection and self-preservation.

Interestingly, early peoples created the idea of gods with the hope of protection and

security, and for self-preservation, man conceived the idea of an immortal Soul, or Atman,

which will live eternally. The Buddha saw through these mental projections and highly

developed theories, recognizing that everything is conditioned, relative and

interdependent, giving us these principles to build on:

When this is, that is

This arising, that arises

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When this is not, that is not

This ceasing, that ceases (Thich Nhat Hahn, 1974)

This foundation of the interdependent co-arising of all things points clearly in the direction

of things not possessing a separate self; nothing in itself contains an absolute identity. This

means a rejection of the principle of identity, which is the basis of formal logic. The

doctrine of no-self can be challenging, and in order to understand it the concept of

impermanence is essential. Most of us would agree that everything is in a perpetual state of

change. Science now can validate this with its microscopes and fine-tuned instruments, yet

the Buddha saw into his mind, his own experience and knew this to be true. “It is because

things transform themselves ceaselessly that they cannot maintain their identity, even

during two consecutive ksanas (the shortest imaginable periods of time). Not only are

physical phenomena impermanent and without a separate self, but the same is true of

physiologic al phenomena, for example our body, mental phenomena, and feelings” (Thich

Nhat Hanh, 1974, p. 38).

The Buddha taught that liberation, and freedom from suffering emanate from how we see,

understand and integrate our experience. While our concepts are fairly static, things and

experiences are dynamic and alive. Thich Nhat Hanh, (Thay) in his book Zen Keys talks

about how we label and conceive of a table, while nuclear physicists recognize it as a

multitude of atoms whose electrons are moving like a swarm of bees, and that if we could

put these atoms together, they might be smaller than one finger. The table is made of non-

table elements, just as the computer I am using to research and write this paper with is

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made of non-computer elements. We choose to label things: we give it a self. Thay, my first

Buddhist influence, encouraged me to look deeply at everything, and that if I did, I would

understand that nothing is separate. I have practiced and enjoyed this way of seeing, eating,

and listening since discovering Buddhist thinking. I can, for instance, be out skiing, gliding

along and experience the snow as the conditions that created it and I am no longer just

skiing. The snow is the lakes and rivers that have evaporated into the air, it is the clouds.

Trees shading the path are also sunshine, soil, oxygen and all the nutrients that brought

about its growth as well as the seed that started it, and the compost it would eventually

become.

The doctrine of no-self or ‘not-separate’ can be applied anywhere you look, bringing to light

the inter-being nature of things, and at the same time, demonstrates to us that the

concepts we have of things do not reflect and cannot convey reality. Language is a

construct, and thus, sadly, it is hopelessly inadequate to express the ultimate reality of our

interconnectivity, although poetry, art, and music can and do lift the veil. These core

understandings, when applied to human relationships, open new avenues for

consideration. The Buddha recognized that much of our suffering comes from ignorance

and misunderstanding, and as a healer, recognized that if we understand the source of our

suffering we can move towards the relief of suffering. He wisely created an eight fold path

to that end.

The ‘awakened one’ taught that the Nature of suffering (or dukkha) is as follows:

This is the noble truth of suffering: birth is suffering, aging is suffering, illness is suffering,

death is suffering; sorrow, lamentation, pain, grief and despair are suffering; union with

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what is displeasing is suffering; separation from what is pleasing is suffering; not to get

what one wants is suffering; in brief, the five aggregates are subject to clinging are suffering

(Rahula, 1959, p 66).

His ‘second noble truth’ was that the origins of suffering were imbedded in our craving and

attachments, and then disclosed that there could be an end to suffering, and finally that

there was a path that we could walk that reduced or ended our suffering. This Noble

Eightfold Path: right view, right intention, right speech, right action, right livelihood, right

effort, right mindfulness and right concentration, has been the backbone of Buddhist

thinking and practice since his awakening. From these teachings have come the 14

mindfulness practices taught by Thich Nhat Hahn and the 16 precepts taught by Zen

Buddhism. Hostility in nursing begins with an incorrect view of self and other and thus

right speech, right action and right intention often cannot occur as fear of vulnerability and

the need for power create separation and hierarchies.

Some African cultures do not speak in terms of ‘me’ and ‘my’; everything is couched in

terms of ‘our’ and ‘us’. Bishop Desmond Tutu says ‘in our African Language we say ‘a person

is a person through other persons’. I would not know how to be a human at all except I

learned this from other human beings. We are made for a delicate network of relationships of

interdependence. We are meant to complement each other. All kinds of things go horribly

wrong when we break that fundamental law of our being”. (Battle, 2009)

The amazing expanse of aspen trees up in the mountains above Santa Fe are an us; all

sharing a root system, and yet what we usually see is the individual tree. In order to come

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at the issues of workplace hostility and violence, we need to understand the

interdependent nature of the clinician relationships, and we need to understand the

interdependence that makes it quite impossible to injure or disrespect another without

injuring ourselves.

As I reflect on my many experiences as a nurse-witness of horizontal hostility and the

research I’ve explored, it seems clear that nurses, by and large, have a poor grasp on their

profound interconnectedness. Self-awareness and vulnerability coupled with courage and

respect are the byproducts of recognizing that self and other are non-dual in nature. Brene’

Brown, a researcher into human dynamics in a recent presentation for TED (Oct., 2010),

tells us that we cannot selectively choose our vulnerability. The depth of our human

connections love pretty much equal the depth of our pain and anguish. Her work looks at

the incredible courage involved in being vulnerable and recognizes numbing behaviors as a

barrier in the work of cultivating joy, compassion and vulnerability as part of our intrinsic

longing for connection.

Contempletive efforts train us in staying with our soft spot, and “to use our biases as

stepping-stones for connecting with the confusion of others” (Chodron, 2003). Pema

Chodron, a well-known Buddhist teacher, encourages us, no matter how bad it feels, to use

our vulnerability to extend kinship to others who suffer the same kind of aggression or

craving—who, just like us, get hooked by hope and fear (2003, p 79).

Along with a fundamentally flawed view of reality, one of the major hurdles in healthcare

is that physicians and nurses continue to be educated in silos with little understanding of

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different health professionals' roles and norms, thus creating an us versus them mentality

also known as identity conflicts. Gardner, (2010) states that members of groups with

identities that place a high priority on being treated with deference have difficulty making

compromises or respecting other groups. “Self-conceptions relating to ideas of authority

and legitimacy constitute barriers to successful conflict settlement. Physicians are taught to

be the leaders as they are responsible for the patients. They are taught they must know

how to handle all situations. Value-based disputes occur when people attempt to force one

set of values on others. As people are socialized, they learn to center their judgments on

values and procedures fundamental to their own common culture. One example of value

differences between physicians and nurses is the lack of shared norms regarding

communication (customary patterns and rules). What, how, and when information is

relayed are often key sources for miscommunication and conflict” (Gardner, 2010).

It is critical that physicians and nurses have opportunities to hear one another, and also be

in shared learning environments such as Being With Dying training (Roshi Joan Halifax) or

Finding Meaning in Medicine and Nursing (Rachel Naomi Remen). While their training and

socialization is quite different, not only is there vast common ground, but these two

disciplines cannot function well in healthcare without each other.

Developing Resiliency, Compassion, and Wisdom to Address

Lateral and/or Vertical Violence

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They said to Him: Shall we then, being children, enter the Kingdom? Jesus said to them: When you make the two one, and when you make the inner as the outer and the outer as the inner and the above as the below and when you make the male and the female into a single one, then you shall enter the Kingdom. The Gospel of St. Thomas

An institution is made of people, and lasting change within the institution depends upon far

more than policies and strategies--leaders that are awake to possibility and grounded in

resiliency and ethical interpersonal behaviors need to emerge. Organizations and systems

can and do change from the middle, as noted in the systems work of Meg Wheatley (2006)

and Merle Lefkoff. When a person begins a mindfulness practice and expands their self-

awareness, change first occurs in the person and because of our interdependent nature,

ripples outward through their environment. Because of our inherent interconnectivity, we

cannot help but impact those with whom we live, work and rub up against. With

awareness, our thinking and actions begin to reflect choice and self-regulation. Research

about the brain’s plasticity is exploding: we can and do have the capacity to change our

brains, our thinking, and thus who we are and how we respond to the stimuli about us. The

Mind and Life Institute, initiated by Francisco Verela, His Holiness the Dalai Lama, David

Engle and Joan Halifax, has brought us a significant body of research that explores the

positive effects of contemplative practices. According to Duerr, (2008) contemplative

practice may be defined as practices that quiet the mind and help to cultivate a capacity for

deep concentration and insight, a stronger sense of connection to God or one’s higher

power (according to one’s personal definition), and an awareness of the

interconnectedness of all life. Mindfulness practice helps to develop critical (yet non-

judgmental) self-reflection, deep listening, and ability to engage in moment-to-moment

experience. (Duerr, 2008)

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Upaya chaplain coordinator Maia Duer’s review of the research literature points to five keys

to preventing and treating burnout and secondary trauma: 1) Compassion and self-

compassion, 2) resilience, 3) metacognition and attention, 4) self-awareness, and 5)

meaning. Thomas Merton stated that the whole idea of compassion is based on a keen

awareness of the interdependence of all these living beings, which are all part of one

another, and all involved in one another. According to Duerr, one definition of self-

compassion is “being kind and understanding toward oneself in instances of pain or failure;

perceiving one’s experiences as part of the larger human experience; holding painful

thoughts and feelings in balanced awareness rather than over-identifying with them”.

(Duerr, 2007)

Focusing largely on the impact of Mindfulness Based Stress Reduction courses developed

by Jon Kabat-Zin, Duerr describes outcomes from 30 empirical studies that looked at

medical professionals finding that there was a reduction in anxiety and depression,

reduction in other burnout symptoms, and increases in empathy, compassion, and self-

compassion. Further, she notes that there was a positive impact on other professional

skills. Numerous studies (Lutz, Brefczynski-Lewis, Johnstone, and Davidson, 2008) now

clearly demonstrate that regions of the brain involved with empathic responses are

impacted through the practice of meditation and mindfulness training. Further studies

have found that resilience training programs (including meditation and yoga) for health

care employees suffering from burnout have resulted in better coping styles and successful

reintegration (Duerr, 2007).

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Duerr points to studies by Shapiro, Coffey and Hartman (2008), showing that private

prayer was shown to be an effective mediator between caregiver burden and perceived

resiliency, and resilience was found to be associated with the ability to self-regulate one’s

emotions – another capacity strengthened by meditation practice. Research studies found

that efforts to suppress thoughts or reduce the frequency of certain thoughts can actually

increase the occurrence of those thoughts. Conversely, mindfulness practice was found to

be a useful tool for regulating emotions; that mindfulness practices encouraged acceptance

rather than avoidance of one’s experiences and that rumination about past and future

events decreased (Duerr, 2007)

In reviewing the studies done with care-providers, self-awareness, self-regulation (coping),

Duerr found that an ability to balance self and others’ interests were found to be critical to

managing stress, and of these, self-awareness was found to be fundamental to self-care.

The ability to attribute and reconstruct the meaning in caregiving was also found to be a

critical factor in moderating vicarious traumatization (Duerr, 2007).

One of the exciting findings from some of the studies is that the improvements in outlook,

emotional regulation and overall coping lasted long after the intervention of an eight week

mindfulness-based-stress reduction course (Duerr, 2007). I know from my own experience

that my daily meditation practice, coupled with efforts to bring mindfulness into work and

family life have had a noticeable impact on my emotional regulation and ability to let go of

rumination. I’m more self-aware of emotional fatigue, and more comfortable being in the

presence of extreme suffering. A large component of this regulation involves body

awareness: noticing what I am experiencing in the body in the moment-to-moment

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experience. This noticing can be helpful in slowing down reactivity and creating a sense of

spaciousness that allows the practitioner/clinician a larger sense of control and

equanimity. I’ve found my sense of humor has also grown as I watch myself in situations

that tend to be stressful; the noticing makes all the difference in coming back to

equilibrium.

There are some very simple techniques that, when added to general mindfulness, can

prevent a disagreement from escalating into a conflict: show respect, slow down the

interaction, adopt a non-judgmental stance, acknowledge the issues, understand their

effect on the other person, validate feelings, and use empathy. It’s also important that your

body speak of your sincerity, so maintaining an attentive posture or uncrossing arms to

indicate willingness to listen, along with using slow, thoughtful speech can be essential.

Distress tolerance is the ability to maintain social functions and relationships while

experiencing aversive emotion (e.g., anger, sadness, fear). Effective transformation of

conflict requires development of distress tolerance skills, as well as having the awareness

that one can pause and choose how to respond. Without models for tolerating frustration,

reactive individuals cannot learn to approach problems in useful ways. Daily meditation

practice is an excellent method of growing distress tolerance.

Donald Marks, a psychologist at Ohio State University, brought my attention to the work of

Kelly Wilson (2008), who encourages us to ask ourselves the following questions

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What are the biggest issues that I avoid in my encounters with members of my

team?

What are the issues I avoid in my encounters with colleagues from other teams?

What behavioral repertoires do I use to keep these hard things out of the way?

What have the consequences of these choices been for me and for my colleagues?

(Wilson, 2008)

Similar to some of Sharon Salzburg’s “loving-kindness” practices, Wilson suggests that we

need to cultivate a willingness to be present with and attuned to other’s distress across a

range of comfort zones: She asks us to

Imagine a frustrating and frightening interpersonal situation.

Now consider how you would feel toward each of the following people in that situation:

Someone very close to you (e.g., spouse, child, best friend).

A casual acquaintance (e.g., another physician or nurse you’ve just met)

Someone you would like to help but are, for some reason, unable to help (e.g., a

patient)

Next, we ask questions of ourselves in difficult encounters (or when preparing for them):

¢ What is it like to be this person right now?

¢ What is it like to be his or her employee, patient, co-worker?

¢ Where would compassionate attention focus?

¢ What would compassionate thinking reflect?

¢ What would compassionate behavior look like?

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¢ How could I increase my warmth for this person?

¢ How could I increase warmth toward myself as this person’s colleague?

(Wilson, 2008)

A thoughtful review of these questions can go a long way towards opening the heart.

Here are some common ways we avoid relating openly to others’ emotional experience

¢ Being in charge

¢ Being passive and nonthreatening

¢ Being “competent”

¢ Being an expert

¢ Being a scientist (lab coat and clipboard required)

¢ Being clever and insightful

¢ Being a “good listener”

¢ Providing consolation (e.g., “Relax, its ok.”)

¢ Choosing not to intervene

¢ Making light conversation

¢ Staying busy and problem-focused

Next, we are to ask ourselves the following questions (adapted from Wilson, 2008):

¢ What are the thoughts that occur to you when you lose contact (e.g., tune out,

shut down) with another person?

¢ What is the other person typically doing when these thoughts arise?

¢ How are these moments of lost contact likely to affect your relationship with

the other person?

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¢ How would it be different if you could remain connected to the other person

in the here and now?

Finally, Wilson encourages us to ask the following questions of ourselves each day:

¢ What really matters to me as a health care professional?

¢ What thoughts or feelings arise when I make this claim?

¢ What might it mean for me and my patients and colleagues if I could act to

further this value?

¢ When do I find myself turning away from this value?

¢ Can I gently return myself to what matters when I drift away?

(Wilson, 2008)

These practices can be cultivated on or off the cushion, and over time can introduce

compassionate wisdom into any institution. The more understanding we have about our

basic oneness the easier it is to improve our relationships, beginning with the relationship

with the self. Cognitive rehearsal as a method to assist nursing students to prepare for

potential LV behaviors has been studied by Griffin (2004) with optimistic results. Stanley,

(2007) quotes the findings of DE Marco, Roberts, and Chandler (2005) that examined group

writing as an intervention to decrease negative workplace behaviors. They found that

nurses who were provided a forum to talk and write about important topics developed

cohesive and supportive behaviors.

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Institutional Recommendations

“This above all: to thine own self be true, And it must follow, as the night the day, Thou canst not then be false to any man” William Shakespeare, Hamlet I:III

Because we develop our interpersonal skills and styles early in life, and in our careers,

there is no easy fix to the issues of bullying in the workplace. Increasing our capacity for

compassion and understanding of the “other” is essential, as is growing our own resiliency.

The following recommendations to facilitate institutional change have been gleaned from

the numerous sources of this article, particularly from the ISMP article about intimidation

in health care settings (ISMP, 2004).

1. Establish a steering committee of chaplains, social work, senior leaders, middle

managers, physicians, pharmacists, nurses, and other staff from diverse areas of the

workplace.

2. Define workplace intimidation, vertical and horizontal violence and list

examples of the many forms it can take. This will be no easy task, since people have varying

tolerances to certain behaviors, but consider this simple definition: not being treated with

respect, or any behavior, no matter how small, that causes another to doubt their self-

worth and professionalism.

3. Develop a mission statement that defines the organization's cultural ethic. The

committee should establish an action plan and share it with the workforce, gain full

administrative support, and educate providers about the damaging effects of vertical and

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lateral violence on patient safety and staff morale. A few physician leaders must be on

board from the beginning of the change process.

4. A code of conduct should flow logically from an organization's mission statement.

While no code can list every possible violation, naming the blatantly unacceptable

behaviors as well as behaviors that can subtly undermine team cohesion, staff morale, self-

worth, and safety. Openly discuss, among diverse staff, positive and negative behaviors

related to interpersonal interactions. Have all existing and new staff sign a copy of the

code of conduct and values statements upon hire/appointment and annually. Also include

the code of conduct and values statements in all job descriptions, medical staff bylaws, and

performance appraisals.

5. Survey staff attitudes about horizontal hostility- LV/VV, the kinds of behaviors

they find intimidating, and the levels of violence/intimidation occurring in your

organization from all healthcare providers. The survey can also be used for self-reflection

to garner information about whether staff feel valued in the organization, how they handle

stress and intimidation, how they treat others at work, and secret rules they share with

new staff about how to interact with (or avoid) certain staff.

6. Open the dialogue about workplace intimidation. Hold frank discussions using

objective moderators to keep the conversation productive. The survey results will likely

trigger a process of questioning the way healthcare providers interact with each other.

However uncomfortable, opening the dialogue on this issue is crucial to the development of

more effective and respectful ways of interacting with each other.

7. Establish a standard, assertive communication process for use among

healthcare providers who must convey important information. For example, consider

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asking staff to use the first names of colleagues, even doctors, to get their attention when

important information must be communicated. Using a colleague's first name can help

break down artificial barriers that may impede effective communication. To enhance

awareness of intimidating behaviors, consider establishing a code, such as "red light," that

can be used to halt or identify the behavior immediately. Stating the problem along with its

rationale and a potential solution can also improve assertive communication. If the

response from a colleague is not mutually acceptable, follow a conflict resolution process.

8. Offer Mindfulness Based Stress Reduction classes, as well as workshops for

leadership and staff that allow clinicians to be introduced to some of the concepts and

practices described in this paper. Consider providing a quiet place for meditation or

writing practice, or establishing a regular meditation group.

9. Establish a conflict resolution process to communicate effectively and protect

patients, not to punish, embarrass, or coerce involved staff. Be sure the process provides

an avenue for resolution outside the typical chain of command if the conflict involves a

subordinate and his supervisor.

10. Encourage confidential reporting of behaviors that involve lateral and vertical

hostility. Provide periodic updates to complainants on how the issue is being addressed.

11. Enforce zero tolerance for intimidating behaviors, regardless of the offender's

standing in the organization. Expect intimidating behaviors to reemerge and establish a

process for dealing with each reported event. Confront offenders with data, authority, and

compassion; punitive responses will not foster interpersonal skills or the desired culture

changes. Always hear both sides of the story. Provide courses, both on-line and in groups

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to offenders as a way of continuing to call VV and LV by its true name and offer

opportunities for change.

12. Provide ongoing education that reinforces your organization's commitment to a

caring and respectful culture. Use role-playing and vignettes to strengthen skills

associated with assertive communication, conflict resolution, and interpersonal

interactions. Offer embodiment practices such as yoga, Tai-Chi, and meditation. Uphold

the acceptance of responsibility over being right or looking good when errors occur or

problems arise. Provide managers with customer service and conflict resolution training,

as well as other non-clinical skills necessary to facilitate the desired culture.

13. Reward outstanding examples of collaborative teamwork, respectful

communication, and positive interpersonal skills. For example, several times a year, allow

staff to select and recognize colleagues, including physicians, who demonstrate superior

interpersonal skills, thus establishing role models for the organization.

14. Whenever possible, provide education across disciplines, promoting dialogue

and collegiality. Allow and encourage nurses teaching physicians early in their residencies,

as well as physicians teaching nursing in their formative education. Continue

opportunities for exchange of perspectives in formal and informal settings.

A Personal Story

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Jesus, De Chardin, Shakespeare and the Buddha had it right, yet said it differently: loving

the self includes loving and respecting others; these are not separate possibilities. It has

been a pleasure to explore the issues of lateral and vertical violence, in a way, the research

has facilitated both healing and professional life review, so I will end with a brief personal

story. In 1991 my brother died of colon cancer, and during the months prior to his death

and following, my grief and mourning was deep and distracting. As my sleep suffered, and

as the long-distance phone-caring grew, my work-pace in the emergency room suffered,

right along with my experience of the world as something that made sense. He was 41, and

other than phone-calls, his wife kept his family mostly at bay till the very end. Every death I

had been connected to through my work in the ER took on a different shade. The team I

worked with picked up and moved on after dying had occurred, just as I had. I wasn’t

picking up and moving on, but I was showing up, and I was aware that I needed support,

listening and a little slack. Having three teenagers no doubt added to the recipe for

exhaustion in all dimensions. I felt (and no doubt acted) like a victim in need of rescue.

What followed, within a team that had held me in very high regard for a very long time, felt

like a snowball. Mistakes that were minor or average in the fast paced setting became

major events; emotions became the subject of gossip and innuendo. As attention on my

performance increased, so did anxiety, a sense of being overwhelmed, and a sense of dread.

I didn’t realize that my vulnerability made most of my comrades uncomfortable, or that the

subtle attacks and sabotage were a form of self-protection. I knew that walking around the

corner to nurses in a cluster that were suddenly silent meant I was a topic, just I had seen

happen to other nurses or EMT’s that were being edged out of the team. I felt observed,

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watched. I asked for a month off to regain my balance. My physician insisted on at least 6

weeks. When I returned I felt physically and emotionally much more stable, ready for work.

The team was not ready to let me back in. A myriad of subtle, overt and covert attacks and

cold shoulders made it very clear I should seek a position in another department, although

I tried hard not to have that occur: my identity rested deeply in that of being a standout ER

nurse. A setting in which I had thrived had become hostile, and I learned that “my story”,

what-ever that now was, was all over the hospital. I ran in to it in the strangest places. It

felt like some of the nurses in my smallish hospital were actually feeding off of my former

distress, trying to keep their version of my crisis alive. It felt like vultures, looking for

something juicy to suck on, were lurking in the vicinity of my efforts to normalize my work-

life.

Eventually, it was a natural step to move across the street to the hospice house, where I

found safety and invisibility. The maturity of the interdisciplinary team and their

recognition of normal grief was a surprise and a relief. The shame of having gone from a

respected part of an “in” group, i.e. protected-member, to “a target” was difficult to shake, it

cut deep into my sense of self-worth, so much so that being in the hospital to pick up

medications or interview patients involved a kind of inner bracing that lasted for more

than three years. Somehow, these colleagues had gotten to something very central and

deeply sensitive during a time of profound vulnerability and challenge. A sense of safety

and normalcy upon entering the emergency room took years to rebuild. Of course I faked it,

a brisk soldier, going where I was needed, feeling like I was wearing armor.

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My experience of loss and humiliation has become transformed. My desire to take a deep

look back, from the position of a softer, more comfortably vulnerable clinician has taught

me a great deal. While the move into end-of-life care 18 years ago was a blessing and a joy,

one of the hidden gifts is the hospice benefits’ reliance on an interdisciplinary team. The

dynamics shift, creating a more level field, and the interdisciplinary team meetings become

an opportunity to build trust.

The experience of horizontal hostility remained a teacher waiting for my curiosity and

strength to encourage her out of the back closet, and up to the podium.

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References

Bartholomew, K (2006). Ending Nurse-to-Nurse Hostility: Why nurses eat their young and each other. Marblehead, MA: HCPro, Inc

Battle, Michael, (2009), Ubuntu: I in You and You in Me, abstract, retrieved from http://hubpages.com/hub/ubuntu-theology

Berne, Eric, (2010) Karpman Drama Triangles , retrieved from Wikipedia, at http://en.wikipedia.org/wiki/Karpman_drama_triangle

Center for American Nurses Position Statement on Lateral Violence and Bullying in the Workplace, February 2008, page 1 retrieved from

Chodron, Pema, (2003) The Wisdom of Uncertainty

Dunn, H. (2003) Horizontal Violence in Operating Room Nurses, American Operating Room Nurses Journal retrieved from http://findarticles.com/p/articles/mi_m0FSL/is_6_78/ai_111895683/

Gardner, D.(2010) Expanding Scope of Practice: Inter-Professional Collaboration or Conflict, Nursing Economics, July-August, 2010, Vol. 28/ No. 4 retrieved from http://www.nursingeconomics.net/necfiles/CrucialConversations/cc_JA10.pdf

Girardin, L (1995) "Feminism at work: Stories from feminist nurses" (Honors thesis, Southern Cross University, Lismore, New South Wales, Australia, 1995, p 27.

Griffin, M (2004). Teaching cognitive rehearsal as a shield for lateral violence: an intervention for newly licensed nurses. Journal of Continuing Education in Nursing. 35(6), 1-7.

Gordon, S (2005) Nursing Against the Odds, How Health Care Cost Cutting, Media Stereotypes, and Medical Hubris Undermine Nurses and Patient Care, Cornell University Press, Ithica NY, 2005, p. 29

Gordon, S (2005) Nursing Against the Odds, How Health Care Cost Cutting, Media Stereotypes, and Medical Hubris Undermine Nurses and Patient Care, Cornell University Press, Ithica NY, 2005, p. 282

Hurley, J. (2006) Nurse-to-Nurse Hostility; Recognizing it and Preventing It, National Student Nurses Association Journal, Sept/Oct 2006.

Institute for Safe Medication Practices On-Line Journal, “Mapping a Plan for Cultural Change in Healthcare, 3- 11, 2004 Retrieved from on-line journal of the Institute for Safe Medication Practices at http://www.ismp.org/newsletters/acutecare/articles/20040325.asp and http://www.ismp.org/Newsletters/acutecare/articles/20040311_2.asp

Maull, Fleet (2009) August Core Training, Upaya Chaplain Training, Upaya Zen Center, See also Karpman Drama Triangle on Wikipedia http://en.wikipedia.org/wiki/Karpman_drama_triangle

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Namie, G (2009). (Still) bullying with impunity Labor Day survey, September 2009. Workplace Bullying Institute. Accessed 2/4/2011 from: http://workplacebullying.org/research.html

Namie G. (2007) The Challenge of Workplace Bullying retrieved from http://onlinelibrary.wiley.com/doi/10.1002/ert.20151/abstract

Rahula, W (1959) What the Buddha Taught, Walpola Rahula, Grove Press, NY, NY, p 51

Roberts, S J, (1983) Oppressed group behavior: Implications for nursing, Advances in Nursing Science 5 (July 1983) p 21-30.

Silence Kills, (2007) key findings, Lack of Communication Cause Medical Errors retrieved from http://www.silencekills.com

Simmons, Rachel, (2003) Odd Girl Out: The Hidden Culture of Aggression in Girls. Harcourt Press

Simons S (2008). Workplace bullying experienced by Massachusetts registered nurses and the relationship to intention to leave organization, Advances in Nursing Science, 31(2), E48-E59.

Stanley, K, Martin, M, Michel, Y, Milton, J, Nemeth, L (2007) Examining Lateral Violence in the Nursing Workforce, Issues in Mental Health Nursing, Vol 28: page 1248

Hanh, T N (1974) Zen Keys Doubleday, NY, New York, P38

Weinberg, DB, (2003) Code Green: Money Driven Hospitals and the Dismantling of Nursing, IRL Press, Cornell University

Wilson (2008), referenced by Marks, D slide set: Contempletive Medicine: Mindfulness as an antidote for Institutional Hostility in Healthcare Settings. February 16, AAHPM/HPNA.

Wiseman, Rosalind, (2002) Queen Bees & Wannabees: Helping Your Daughter Survive Cliques, Gossip, Boyfriends, and Other Realities of Adolescence, referenced in Mean Girls: realities of relational aggression, retrieved from http://www.spsk12.net/departments/specialed/Relational%20Aggression.htm

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January 10, 2011

Dear Colleague

We request your involvement in an inquiry into horizontal hostility in healthcare settings. Nursing research has looked at this issue extensively. We hope to build on that research with a broader understanding of the conflicts and issues between disciplines.

The short survey was designed to gather data from health care providers from multiple disciplines that work together providing patient care. We hope to learn more about the origins, manifestations, and resolution of conflict in the interdisciplinary team, as well as within specific disciplines. Our team of researchers is preparing a groundbreaking workshop that will address the issues of bullying, hostility, healing, and resilience titled, “Building Bridges, Breaking Barriers, Respecting Boundaries: Transforming Conflict in the Interdisciplinary Team and Your Medical Institution” for an international conference scheduled in February 2011.

Enclosed is a survey that will take approximately 15 minutes to complete, along with a pre-paid envelope for you to return the survey. We have allowed additional space for narratives, and will pay particular attention to trends that emerge. The survey is anonymous, will be reported in the aggregate, and is being administered in a variety of settings across the country.

This survey allows us to be better prepared to address this disabling phenomenon that is prevalent in the healthcare field. Completion of the anonymous survey is voluntary and will be understood as your agreement to be surveyed. There are no foreseeable risks, discomforts, nor cost to you for participation; in fact, the survey may begin a process of awareness and healing. Non-participation involves no penalties. The information obtained from this survey will be aggregated and no individual data will be reported. We ask you not to use names in your narratives, to ensure anonymity, privacy and respect. We ensure confidentially, and ask that you do not sign your survey.

We received IRB approval from Johns Hopkins University Hospital in Maryland for this survey. We plan to publish our results in 2011. You may send in your survey to [email protected]. Our deep thanks for your interest and attention.

Sincerely, Patrick Clary, MD Donald Marks, Psy.D New Hampshire Palliative Care Service Center for Palliative Care, The Ohio St. University Hospital 550 Lincoln Avenue 453, W. 10th Ave, 246 Atwell Hall Portsmouth, NH 03801 Columbus, Ohio, 43210 603 969 0815 614 293 8052

Jan Jahner, RN-BC, CHPN Lynn Billing, RN, CHPN, BC Ambercare Hospice Duffey Pain and Palliative Care Service 550-D Galesteo St. Weinberg-Suite 1210, 401 N Broadway Santa Fe, NM 87505 Baltimore, MD 2131 505 699 0996 410 614 4461

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“Building Bridges, Breaking Barriers, Respecting Boundaries” 2010-2011

An inquiry into lateral violence and bullying in the workplace Date Site:

We will be collecting information about you from your responses to this survey. Your taking part in this survey is completely voluntary. Your information will only be seen by the research team described in the introductory letter. We will try to make sure that the information we collect from you is kept private and used only for this research study. If you do not participate in this study your job will not be affected. Completing this questionnaire will serve as your consent to take part in this research study.

The culture of service in the world of healthcare is being subjected to growing pressures and progressively more rapid change. This unprecedented rate of change along with ingrained socialization patterns has deeply challenged our healthcare community’s capacity to cope and support one another. Despite the pressures, a sense of safety is imperative to enable clinicians to stay connected to their patients and each other.

Safety and quality of patient care is dependent on teamwork, communication, and a collaborative work environment. Intimidating and disruptive behaviors include overt actions such as verbal outbursts and physical threats, as well as passive activities such as refusing to perform assigned tasks or quietly exhibiting uncooperative attitudes during routine activities. Intimidating and disruptive behaviors are often manifested by health care professionals in positions of power. Such behaviors include reluctance or refusal to answer questions, return phone calls or pages; condescending language or voice intonation; and impatience with questions. The following terms will be used in this survey:

Bullying – “persistent harassment, both physical and primarily psychological in its nature, which demeans, devalues, and humiliates individuals” (Victims, 2004, p. 14). Bullying is associated with a perpetrator at a higher level or authority gradient, for example, nursing supervisor to staff nurse, attending physician to resident, etc (CENTER for American Nurses, 2007).

Horizontal hostility or lateral violence- any inappropriate behavior, confrontation, or conflict – ranging from verbal abuse to physical and sexual harassment between coworkers, usually at the same organizational level. (Examples: sabotage, scapegoating, infighting, backstabbing, being humiliated in front of others, unreasonable assignments.)

This Survey is designed as an inquiry into occasions that you’ve witnessed or experienced in the workplace, but before you begin, please take a moment to reflect back to the time when you first entered the health care field, and just spend a minute getting in touch with that initial picture of yourself as a clinician, your feelings and aspirations. There are several opportunities for a short narrative. If you choose a longer answer, please know we will pay close attention to your reflections.

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Profession Years in practice_ Type of Setting Leadership Staff

Number of times you’ve changed work settings since you began working

Times the change was connected, at least 50% or more, to bullying/lateral violence in the workplace

Are you currently experiencing horizontal hostility or bullying from colleagues? Yes_ No

Please use the following scale to answer the next several questions: Please circle your answer

Daily Frequently Occasionally Rarely Never

5 4 3 2 1

Frequency that you contemplate leaving your current position due to, bullying or hostility?

5 4 3 2 1 Explain (optional)

Frequency that you witness clinicians demonstrating horizontal hostility or bullying others through non- verbal intimidation, including facial to expressions such as eye-rolling, staring, looks of disgust

5 4 3 2 1 Explain (optional)

How often do you go out of your way to avoid conflict at work? 5 4 3 2 1

Frequency you find yourself engaging in aggressive or demeaning behaviors with colleagues that you later regret.

5 4 3 2 1 Explain (optional)

Please use the following scale to answer the next several questions: Please circle your answer

Excellent Good Variable Poor Very bad

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5 4 3 2 1

How would you rate your sense of safety or ability to be vulnerable with your truth/feelings around your colleagues in your current workplace setting? 5 4 3 2 1 Explain (optional) _

How would rate your comfort with “conflict engagement” skills? 5 4 3 2 1

How would rate your ability to feel your feelings and identify them as they arise? 5 4 3 2 1

How would you rate your ability to let go of ruminations or strong feelings related to difficult interactions with colleagues and/or supervisors? 5 4 3 2 1

If you feel you’ve been a victim of hostility, what is your comfort level in talking openly about your experiences with other colleagues? 5 4 3 2 1

Rate your comfort level with going to your department head with concerns about lateral hostility

5 4 3 2 1

How open would your manager/supervisor be to opportunities to look deeply into the workplace cultural trends and help create change, if the culture is not one that promotes harmony and open communication?

(extremely receptive ) 5 4 3 2 1 (not at all)

Please list activities you use to in your efforts to cope with work related stressors (healthy or unhealthy). (i.e. eating, drinking alcohol, meditation, prayer, humor, exercising, hobbies, etc.)

Take a moment to reflect on an interaction with a colleague that was satisfying and uplifting. What word (words) would you use to describe that feeling

Optional Narrative Opportunity. We’d be very pleased if you could write about a difficult experience that haunts you, or one that you were able to resolve related to bullying or horizontal hostility. (or you may want to write further about the previous question).

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Are you interested in being contacted related to survey results?

Would you like more information about Bullying and Horizontal Hostility? Yes__ No

e-mail address_

Would participating in a workshop that taught resiliency skills, conflict engagement and enhanced your understanding of this topic and how to address it your setting be of interest to you? Yes No

Prior to the survey, you spent a moment recalling our original intentions. Taking another moment to notice how that felt, you man notice a tangible shift. These memories and aspirations are useful in navigating the workplace terrain, and have great potential to facilitate change. Currently methods such as mindfulness based stress reduction, yoga, meditation and reflective writing practices are assisting clinicians bring renewed enjoyment and equanimity into their workplace settings. If interested in research findings related to these and other practices in the healthcare field, Please write to the address on the cover letter.

Thank you for your participation. Survey results of the aggregate will be shared at the Hospice and Palliative Medicine/Hospice and Palliative Nurses Association annual Assembly Feb. of 2011 during a 4 hour workshop titled:

Building Bridges, Breaking Barriers, Respecting Boundaries: Transforming Conflict In The Interdisciplinary Team And Your Medical Institution.

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Building Bridges – Reflective Writing exercise

INTERNED

When the year began, I thought I'd write a record, late at night, after the scut-work and the basic business had been numbered in needle-sticks. I would heal my patients and fill a hundred notebooks before I'd rest, and I would tell stories of how each drop of blood hit my coat,

about my fame for diagnosing horrors I would sugar-coat for the patient, my graceful prose in the medical record filling the interns and the Attending with awe. But that was before fire burned me the first day: twenty new admissions, the business office calling with names of patients with insurance, the rest stranded on gurneys, as if lying in the corridor could heal

a tumor or the heart that had failed too long. "Heal the patients?" the Attending would shout, his starched white coat a reminder I was just a peon. Clean-shaven, he had time to rest, and he scorched every word I wrote in the record, pimped me when I presented a case, because the business of Academic Medicine is to learn your place in the pecking order "Fire

me!" I thought, "let him stay awake all night in the fire- storm of the wards. Ask him to find a way to heal the alcoholics and malingerers whose only business is to stay warm through the winter without a coat." Who cared anymore about progress notes in the record? All I wanted was a night without my beeper, to rest

for twelve solid hours without seeing blood, while the rest of the interns worked up admissions and turfed each fire to consultants, every slave so tired they'd forget to record anything they did. And groggy me the next morning, working to heal the moaning, puking, screaming patients who bled on my coat-- I wished they would die, wished I'd gone into my father's business,

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managed his factory where no one would give me the business if I nodded off during a mid-day meeting of tried to rest, even in the bathroom, because the pager in my coat pocket blasted when I peed, screwed up my aim, the fire in my bloodshot eyes to ferocious I wondered if I could heal anyone, anyone at all. A single cure would have been a record.

My business that year was to walk through fire without sleep or rest, to hope, "Someday I will heal." The blood on my coat holds the clearest record.

- Richard Berlin (used with permission)

2:30 Beginning to create our community / our container / our context

2:35 Check In

2:45 Writing together. Choose one of these options and let it take you anywhere it takes you.

(a) Write freely to: “they gave me the business” “learning your place in the pecking order”

(b) Alternate " I walk through fire" "I am burning" as refrains to elicit words. 56

(c) Do you have a story that wants to be / needs to be told to clear the way for this experience?

(d) Write any story, recent or not, which is asking for telling in this context.

3:00 Read-Around / Readbacks/ Conversation about what we heard

3:10 Closing with Intention/ distribution of “soul cards” write on the card your impression, something unsaid, appreciation, aspiration, to be collected by the group leader.

Glossary of Terms:

Fastwrite: Writing fast enough to stay a step ahead of the inner critic or editor.*

Read-around: Sharing a piece of writing in the large circle. Each person has a portion of time in which to read. Passing is an honorable option. Confidentiality is expected.

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Readbacks: during read-arounds listeners write words and phrases which moved them in some way. Space in the Circle is opened at the end of Read-around, and these words are read aloud in no special order (like polyphonic music, interweaving of words).

*

1.Keep your hand moving. Don’t allow what stalls and tries to get control of what you are saying.

2Don’t cross out. Even if you write something you didn’t mean to say, leave it

3.Don’t worry about spelling, punctuation, grammar. Don’t even care about staying in the lines.

4.Lose control.

5.Don’t think. Don’t get logical

from Goldberg, Natalie, Writing Down the Bones Freeing the Writer Within, Shambala. 1984.

Note: for guidance in leading such groups please see Mary Pierce Brosmer’s Women Writing for (a) Change (Sorin

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Examples of Bullying Behaviors, Overt & Covert Lateral and/or Vertical Violence

Overt: Covert:

Name calling, Sarcasm, Bickering Refusal to help, Sighing, Whining

Fault Finding, Back Stabbing Refusal to work with someone

Criticism, Intimidation, Gossip Sarcasm, Sabotage, Isolation

Shouting, Unfair Assignments Fabrication, Body Language Eye rolling, facial expressions

Signs of Suffering

Physical: Fatigue, Exhaustion, Lethargy, Hyperactivity, Weight Gain, Weight Loss, Susceptibility to illness, Persistent physical ailments, Headaches, Gastrointestinal disturbances, Impaired sleep, Impaired mental processes such as poor concentration or forgetfulness

Emotional: Anger, Fear, Guilt, Resentment, Sorrow, Depressed, Cynical, Grief- stricken, Anxiety, Confused, Sarcastic, Emotional outbursts, Emotional shutdown, Feeling overwhelmed, Hurt, Frustration

Behavioral: Addictive behavior (alcohol, drugs, gambling, food, etc.) Controlling behaviors (the need to be “right”, inflexibility, rigidity) Offender behavior: (Taking aggression out on others who often have less authority) Boundary Violations: Apathy, Indifference, Avoidance, Erosion of relationships, Agitation, Shaming others, Victim behaviors: (feeling powerless to change one’s situation) Depersonalization: (Treating patients as non-persons)

Spiritual: Loss of meaning, Crisis of faith, Loss of Control, Loss of self-worth, Disrupted religious practices, Disconnection with people, work, community

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Updated (1/27/11) Outline

The four hour workshop scheduled as a Pre-conference event is on Feb. 16, 1-5pm. We meet for 2.5 hours in the am at the Hyatt, (not sure which room) as a dry run, in particular related to council process, expressive writing exercise, and the role play

1. Initial didactic section that covers the issues of horizontal hostility in healthcare environments and its consequences, our preliminary research, personal stories (Lynn, Jan) 50 min Jan and Lynn segway into a short role play that pulls in Patrick and Don.

2. After a brief introduction to council process and expressive writing (Patrick) we will break into 6 smaller groups or “councils” (still anticipating about 40-44 persons in workshop)

each of us facilitating a Council process/reflective writing process (Council process has been posted as a handout on AAHPM site)

A. Reflective writing as per Patrick’s notes: please review: we’ve a good start-off poem, but still open to other possibilities Allow 45 min for exercise

Break (10 min)

3. We come back to larger group; Don leads second didactic session related to empathy and communication, more research into the neuroscience connected to mindfulness practice and related compassion and resiliency building techniques. This is followed by brief q and a. 45 min.

4. Jan leads experience of guided meditation (using Dan Siegel’s techniques related to wheel of awareness and providing an experience of grounding, tracking, resourcing (elements of Trauma Resiliency) 10 min

then we ask people to become triads, with opportunity to share about the meditation experience

10 min.

5. Patrick: Reflection on the role of physicians in lateral and vertical violence. 15 min. Final short didactic session: Jan: Recommendations for healthcare settings 15 min. (see hand out # 2) panel of all up front for final Q & A, Final discussion 40 min

Ritual, with Burning of notebooks, and a poem concludes the workshop, on back patio of conference

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