Healthcare Violence: Why Peers Bully Peers

6 Contact Hours

Release Date: 8/24/2016 Expiration Date: 8/24/2019 Faculty Adrianne Avillion, D.Ed., RN and nursing . Dr. Avillion owns and is the Adrianne E. Avillion, D.Ed., RN, is an accomplished nursing CEO of Strategic Nursing Professional Development, a business professional development specialist and healthcare author. She earned that specializes in continuing for healthcare professionals her doctoral degree in adult education and her M.S. in nursing from and consulting services in nursing professional development. Her Penn State and a BSN from Bloomsburg University. Dr. most recent publications include The Path to Stress-Free Nursing Avillion has held a variety of nursing positions as a staff nurse in Professional Development: 50 No-Nonsense Solutions to Everyday critical care and physical medicine and rehabilitation settings with Challenges and Nursing Professional Development: A Practical Guide emphasis on neurological and mental health nursing as well as a for Evidence-Based Education. number of roles in nursing professional development. She Content reviewer has published extensively and is a frequent presenter at conferences Susan Reese, MSN, RN and conventions devoted to the specialty of

Audience The target audience for this education program is nurses who want to decrease the phenomenon of horizontal violence in healthcare .

Purpose statement and violence in the occur far too often. Whether This course presents an overview of horizontal violence as well as it is between professionals of a single discipline or among different characteristics of both abusers and victims. Causes of violence are disciplines, the consequences of bullying and violence are the same. presented as well as strategies to reduce . Learning objectives ŠŠ Describe the phenomenon of horizontal violence. ŠŠ Identify the characteristics of persons who commit horizontal ŠŠ Discuss the incidence and prevalence of horizontal violence. violence. ŠŠ Discuss how and why horizontal violence victims are chosen by ŠŠ Explain the causes of horizontal violence. their abusers. ŠŠ Analyze the impact of horizontal violence. ŠŠ Implement strategies to reduce and/or prevent horizontal violence. How to receive credit ●● Read the entire course online or in print which requires a 6-hour ○○ A mandatory test (a passing score of 70 percent is required). commitment of time. Test questions link content to learning objectives as a method ●● Depending on your state requirements you will asked to complete to enhance individualized learning and material retention. either: ●● Provide required personal information and payment information. ○○ An affirmation that you have completed the educational ●● Complete the MANDATORY Self-Assessment and Course activity. . ●● Print your Certificate of Completion. Accreditations and approvals Elite is accredited as a provider of continuing education by the American Nurses Credentialing Center’s Commission on Accreditation.

Individual state nursing approvals In addition to states that accept ANCC, Elite is an approved provider Nursing, Provider # 50-4007; Florida Board of Nursing, Provider # of continuing education in nursing by: Alabama, Provider #ABNP1418 50-4007; and Kentucky Board of Nursing, Provider # 7-0076 (valid (valid through April 30, 2017); California Board of Registered through December 31, 2017). Nursing, Provider # CEP15022; District of Columbia Board of Activity director June D. Thompson, DrPH, MSN, RN, FAEN, Lead Nurse Planner nursing.elitecme.com Page 39 Disclosure Resolution of Conflict of Interest Sponsorship/Commercial Support and Non-Endorsement In accordance with the ANCC Standards for Commercial Support It is the policy of Elite not to accept commercial support. Furthermore, for continuing education, Elite implemented mechanisms prior to the commercial interests are prohibited from distributing or providing planning and implementation of the continuing education activity, to access to this activity to learners. identify and resolve conflicts of interest for all individuals in a position to control content of the course activity.

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Introduction What first comes to mind when healthcare employees hear the word against peers and co-workers who are on the same hierarchical level “violence” in relation to their ? Many might respond that of an [3,5]. Horizontal violence has far-reaching and they think of an out-of-control emergency department patient under serious consequences. These consequences can affect the influence of drugs or alcohol who attempts to harm staff members. and retention, increase the risk of errors, negatively affect patient Others may remember a confused, frightened patient who tried to outcomes, and adversely affect the health and well-being of victims strike them. Still others may think about an angry visitor who verbally [3,4,5]. Some researchers believe that this type of violence has reached abused them. These ideas are not uncommon and are understandable. epidemic proportions [2]. In fact, according to the United States (U.S.) Bureau of Labor Statistics Census of Fatal Occupational Injuries (CFQI), of the 4,679 Nursing consideration: Horizontal violence is frequently fatal workplace injuries that occurred in the U.S. in 2014, 403 were underreported. Some reasons given for not reporting HV include a workplace homicides [1]. People who work in healthcare settings are lack of reporting policies and procedures, lack of faith in existing [2] at significant risk for workplace violence. According to information reporting systems, and fear of retaliation . If instances of HV provided by the Occupational Safety and Health Administration are to be reduced, there must be a means of not only reporting its (OSHA), from 2002 to 2013 the rate of serious workplace violence occurrence, but an organizational culture that has a zero tolerance incidents (i.e. those that required days off to recover from an injury) for such behavior. was more than four times greater in healthcare settings than in private HV is sometimes referred to as lateral violence or bullying. It causes industry [2]. Most of the violence in healthcare settings is committed by more harm than any other type of aggression in the workplace, patients. However, violence is also committed by students, co-workers, including bullying of nurses and other healthcare professionals by and visitors. physicians, , and subordinates [3,6]. Many instances of workplace violence in healthcare settings go unreported, even in facilities that have formal violence incident Nursing consideration: HV is defined as a consistent pattern of reporting systems. Results from a recent survey of 4,738 Minnesota behavior designed to control, diminish, or devalue a peer, which nurses showed that only 69% of physical assaults and 71% of non- gives rise to health and/or safety risks. As previously noted, it is also physical assaults were reported to a manager. One medical center aggression against peers who are on the same hierarchical level of reported that half of verbal and physical assaults by patients against an organization [3,5,6]. It is imperative that nurses at all hierarchical [2] nurses were never reported in writing . For instances of violence to levels in an organization work to fight the phenomenon of HV. be reduced, they must first be reported and acknowledged as a serious problem. EBP alert! Research shows that impaired communication among Nursing consideration: Workplace violence is a significant problem nurses and other members of the healthcare team is a major in healthcare settings. Nurses must advocate for ongoing education cause of errors. Bullying inevitably has a negative impact on of healthcare employees to increase awareness and provide tools to communication. Research also shows that experiencing bullying mitigate workplace violence. or even simply witnessing rude behavior negatively impacts the ability to perform cognitive tasks [4]. Thus, it is imperative that Another type of violence that occurs in healthcare settings is horizontal every effort be made to stop HV and other forms of bullying. violence. Horizontal violence, also known as HV, is aggression

The Phenomenon of Horizontal Violence Jackie is the nurse manager for two surgical units in a 500-bed patient outcomes, and to initiate and participate in nursing research. medical center. She has been a manager for nearly three years and Members of her nursing staff excel at their and have worked has been able to initiate unit-based councils on both of her units. with the medical center’s nurse researchers on studies that have Jackie is grooming her staff to become more autonomous, to assume strengthened evidence-based practice and led to improved patient more responsibility in identifying goals and objectives to improve outcomes. When vacancies are posted for Jackie’s units, she receives

Page 40 nursing.elitecme.com numerous applications from nurses already employed at the medical these kinds of comments; however, Christine walks away from her and center who want to transfer to her units. stops the nurse manager in the hallway. Rolling her eyes and laughing, However, Jackie has noticed that the more her nurses grow Christine comments, “I guess I am in trouble. Our new little nurse professionally and patient outcomes improve, the more she feels has hurt feelings!” Bernadette has had enough and quietly walks isolated from and ostracized by her fellow nurse managers. If she up to Christine and her manager. “I am willing to work hard and passes fellow managers in the hallway or in elevators, they do not learn. However, Christine’s actions are interfering with my ability to speak to her and avoid eye contact. During meetings, her learn and provide my best patient care. If these behaviors do not stop comments or ideas are either ignored or ridiculed. Jackie approaches immediately, I expect to be assigned another preceptor. If this does one of her colleagues who was once a good friend and asks why she not happen I will file a grievance.” Christine is astonished. No one is being treated in this fashion. The former friend replies, “How do has ever had the courage to confront her like this. The manager looks you expect us to act? All of your new ideas are showing us up and we embarrassed and says that perhaps assigning another preceptor would have been managers a lot longer than you have! You are either with be best. us or against us, and it seems to me that you are more concerned with The preceding scenarios illustrate some of the behaviors associated making yourself look good than being one of us! Plus, you are stealing with HV. Horizontal violence, as previously noted, is aggressive nurses from other units. You better stop this stuff or you are going to behavior directed toward one’s peers. Such behavior can involve be sorry you ever took a management !” , interfering with ability to work effectively, attempts Adam is a physical therapist. He works at a prestigious rehabilitation to embarrass a peer, derogatory facial expressions, and attempts to [3,5]. The following definitions help to clarify HV and hospital where he specializes in the therapy of patients who have undermine a peer just how destructive the phenomenon can be. Some of these behaviors suffered neurological impairment due to spinal cord injury, brain occur in other types of workplace violence, but for the purpose of this injury, and stroke. Adam is respected by his colleagues and his program, these definitions are written within the context of HV. Note manager as a hard worker who is progressive in his ideas and that some behaviors can overlap and may fall under more than one innovative in developing plans of patient care. He is very interested category: in clinical research and evidence-based practice. Because of his ●● Assigning unrealistic patient assignments: Assigning certain interest in research and his innovative clinical skills, Adam is asked to nurses to the most difficult patients on an ongoing basis or serve as the physical therapy representative on the interdisciplinary assigning an unfair and then refusing to help when neurologic research committee. Adam is eager to learn more about needed [5]. clinical research and participate in clinical research investigations. ●● Backstabbing: Occurs when someone complains about a peer At first, his co-workers share Adam’s enthusiasm. However, once a to others instead of speaking directly to that person about a month Adam attends a research committee meeting, during which time concern or problem. This type of behavior undermines trust and his patients are covered by another therapist. As part of his duties confidence[4]. as a member of the research committee, Adam must coordinate with ●● Bullying: A set of behaviors designed to make a victim feel his manager and co-workers to time to teach peers about threatened, humiliated, insulted, and/or helpless. These behaviors research and participate in research projects. His peers begin to resent can be verbal, suggest the threat of physical harm, and/or actually the time Adam is “given” for such projects, even though his new consist of physical actions designed to intimidate or cause physical responsibilities require significant work on Adam’s part. harm. Bullying is not an isolated event. It is usually persistent, Adam’s peers begin to complain about him, making comments that he ongoing, and systematic [3,4]. is not “pulling his weight” as a patient care provider. They start to ●● Covert behaviors: Actions that are not obviously aggressive or avoid Adam and often fail to include him in off-duty social activities. threatening [3]. Examples include being “too busy” to show a new Adam attempts to discuss these problems with his peers, but they only employee where supplies are kept, excluding a colleague from comment that they are tired of doing his work. One of them explains, social gatherings, and “forgetting” to tell a colleague about a “You are so into this research thing that you are forgetting that you schedule change. These kinds of behaviors can be especially hard are just a therapist like the rest of us. You think you are better than to pinpoint because they can often easily be explained as innocent we are.” Adam is shocked and asks his manager for guidance. The oversights. The victim of covert HV may have a hard time manager replies, “Just try not to take it personally. They will get convincing a manager that he or she (s/he) is experiencing HV if over it after some time has passed and they have more chances to the majority of the behaviors are covert [3]. participate in research. Try not to let it get to you.” Adam is upset, ●● Disruptive behaviors: Actions that are designed to interfere however, and begins to have trouble concentrating on his work. with a peer’s job performance, which can increase the risk for [4] Bernadette is a newly licensed RN. She is thrilled to have been hired error patient harm . Disruptive behaviors can include all types to work on a large inpatient pediatric unit. Bernadette is assigned of verbal and physical aggression and threaten the safety of both [7] to work with a preceptor named Christine, who is an RN with ten victims and patients . years of experience as a pediatric nurse. Christine is an excellent ●● Incivility: Involves disruptive behaviors (such as refusing to speak clinician and has the respect of her co-workers. The nurse manager to a colleague unless absolutely necessary) that often result in [3] of the unit often refers to Christine as, “my best nurse.” However, physical and psychological distress for the victims . as Bernadette’s orientation progresses, she finds that her co-workers ●● Overt behaviors: Actions that are obviously aggressive and respect Christine’s clinical knowledge, but are intimidated by her can be seen or heard. Overt behaviors include disgusted facial as well. Christine has a reputation for criticizing her peers and expressions, rolling of eyes, shouting, laughing at someone, [3,6,7] subordinates in front of others if she feels that they are “asking stupid criticism, fault-finding, gossiping, ridiculing, and arguing . questions” or “just do not know as much as they should.” Christine ●● : A behavior designed to deliberately undermine or [3,8] constantly criticizes Bernadette as well, making negative comments prevent someone else from succeeding . in front of patients and telling co-workers that, “I have my work cut ●● The : Characterized by refusing to speak to a out for me with this new nurse. They come out of with all these colleague, speaking abruptly, and withholding information are all [5] fancy ideas but cannot carry a full patient load for weeks.” One of behaviors that fall under the umbrella of the silent treatment . her colleagues tells Bernadette, “We are sorry you are going through ●● Taking the credit: Occurs when the perpetrator of HV takes credit [5] this, but that is just Christine. If we try to help you she will turn on us for someone else’s work . too.” Bernadette makes an effort to talk to Christine privately about nursing.elitecme.com Page 41 ●● Verbal abuse: Consists of spoken words that are meant to be peers, it is likely that patient outcomes and job performance may unkind, belittling, and/or humiliating. Verbal abuse is meant to be compromised. If she continues to fulfill her management role as cause distress, embarrassment, and/or suffering [3]. she believes best, her peers may make it difficult for her to continue ●● : Any repeated words, acts, or patterns working within the organization. of behaviors against a co-worker or group of workers that are Now evaluate the situation that Adam, the physical therapist interested unwelcome are considered to be harassment [3]. in clinical research, finds himself facing. At first, his colleagues are Nursing consideration: Be aware of how the aforementioned supportive and share his enthusiasm for the research process. Then, as behaviors can create a toxic work environment and how some of his workload increases related to research participation, his peers begin these behaviors are not especially overt, such as the silent treatment. to resent Adam, claiming that he now thinks he is better than the rest Nurses must be aware of all types of behaviors that fall into the of them. Adam’s manager seems to want to ignore the problem, telling category of HV. him, “Just try not to let it get to you.” This type of managerial response is one reason that HV exists and a reason that victims fail to report it. Consider how various behaviors are presented in the scenarios at the Because of the HV, Adam is starting to have trouble concentrating on beginning of this section. Jackie, the nurse manager, is an innovative his work, which increases the possibility of error. What began as an leader whose actions have helped to establish a work environment in exciting opportunity has turned into a frustrating barrier to job which her staff thrives and positive patient outcomes are achieved. satisfaction and the potential for compromised patient care. These accomplishments have angered her peers to the point that Finally, review the scenario that describes the problems that a newly they instigate a number of behaviors that qualify as HV. They avoid licensed nurse had to deal with during her orientation. HV committed speaking to her and avoid making eye contact. Such behaviors may by a preceptor and other, more experienced colleagues, is one of the be classified as covert since it can be difficult to prove that they are most common occurrences of HV. An experienced nurse, reported to deliberately not speaking to her and avoiding eye contact. However, be an excellent clinician, is acting as the preceptor for a new nurse. some of their other actions verge on verbal threats and . This preceptor intimidates her co-workers, and probably her nurse They ridicule her ideas, accuse her of stealing their staff nurses, manager as well. Bernadette, the new nurse, confronts the preceptor and come close to overtly threatening her with the statement, “You and the manager about the HV. Bernadette took action that all too few better stop this stuff or you are going to be sorry you ever took a victims of HV have the courage to do: he confronted the perpetrator management job!” and the manager who seemed to be willing to ignore the HV and the Some staff members may not realize that managers are also victims impact it had on her personally and professionally. of HV. They may assume that the phenomenon only exists at the The preceding examples show just a few of the many ways that HV is staff level. Unfortunately, HV occurs at all levels of the organization. committed. Note that persons who witness or know about HV and fail Jackie’s peers may be jealous, fearful that her success threatens their to do anything to stop it are just as responsible for the continuance of own jobs, or simply resentful of change. Whatever the reason or the problem as are those who directly commit HV. reasons, Jackie is dealing with HV at its worst. If she appeases her

Incidence and Prevalence of Horizontal Violence Diana and her husband have recently relocated across the country so especially tough on new employees. Frank is one of the best IT that her husband can take advantage of a work-related promotion. She specialists Edward has ever worked with, but he has the reputation of is a social worker with several years of experience in acute hospital being a bully and more than one employee has resigned because of his settings. Diana interviews for a position in a large community hospital, intimidating manner. Edward discusses the issue with his wife, a nurse, hoping to continue working with intensive care unit (ICU) patients and who tells him that Frank is committing HV and needs to be stopped. their families. She has heard rumors that the social workers who work Edward admits that he never thought much about the effects of Frank’s in the ICU are a close-knit group who do not necessarily welcome behavior until now. He always thought it was just Frank’s personality, newcomers. During her interview with the director of the department, but now wonders if it is a lot more serious than that. Diana asks about the orientation process and the hospital’s policies HV is not a new phenomenon, and as the preceding examples show, relating to HV. The department director laughs and says, “That is a it can affect any and all healthcare . In fact, its occurrence problem pretty much confined to nursing. You do not see it in other and negative impact seems to be growing [6]. It is difficult to objectively departments.” Diana wonders if the director is naïve or just reluctant determine if this growth indicates an actual increase in occurrence or to address the issue. an increase in reporting by victims. Edward is an information technology (IT) specialist in a large urban medical center. He notices that one of his colleagues seems to be

Research Approximately a decade ago there were only about 200 research in nearly ten million articles and posts. Thanks to experts, such as articles pertaining to HV on PubMed [3]. Much of those articles were Kathleen Bartholomew, significant efforts are underway to study based on research conducted in the United Kingdom and Australia. HV and to identify strategies to reduce it and/or prevent it from Today, however, “horizontal violence” in a search engine results occurring[3,6].

Incidence and Prevalence Reports of HV incidence vary considerably, i.e. from 18% to as high reliable and valid measures. Investigators founds HV prevalences of as 76% of those surveyed [3]. This range is due, in part, to differences 27% and 31% in nurses who reported experiencing HV [3,9]. in the definition and measurement of HV by different investigators. According to Bartholomew, the most consistent information about prevalence comes from two extensive studies that used the same

Page 42 nursing.elitecme.com ●● In another survey, 30% of the 2,100 nurse participants reported EBP alert! HV is not a phenomenon that is unique to the U.S. that disruptive behavior occurred weekly, and 25% reported Internationally, one in three nurses reported that they plan to leave monthly occurrences [4]. their positions due to HV. A study of 4,500 nurses in the United ●● A study involving emergency room nurses found that about 27% Kingdom showed that one in six nurses reported experiencing had experienced within the previous six workplace mistreatment in the past year and 33 percent of them months [4]. [3] planned to leave their jobs because of verbal abuse . This shows ●● A study focusing on frequency of HV found that at least 20% of how important it is, even on an international level, for all nurses to respondents experienced incivility at least once a week [3]. take steps to curb this disturbing behavior.. ●● According to 2012 results from the Society for Human Resource Management and the Workplace Bullying Institute [3]: EBP alert! HV is also not unique to the nursing . For ●● Eighty percent of harassment cases filed were legal and “could example, two recent articles discuss bullying and lateral violence only be considered plain cruelty.” in the physical therapy discipline, including how to deal with it, ●● Seventy-three percent of reported instances of workplace violence and how to recognize if someone is committing it [10,11]. Thus, it is involved verbal abuse. imperative that there be an interdisciplinary collaboration when it ●● Sixty-two percent of respondents reported the existence of comes to decreasing HV. malicious gossiping or knew of rumors or spread about co- workers. ●● Fifty-one percent of participating organizations reported incidents According to the Workplace Bullying Institute (http://www. of bullying in the workplace. workplacebullying.org/) the workplaces most prone to bullying are ●● Fifteen percent of respondents witnessed emotional or healthcare, education and government [3]. The nursing literature of co-workers. contains numerous examples of HV. Results from some research studies indicate a startling prevalence [4]. The following information EBP alert! These statistics show the startling incidence and pertains to the incidence and prevalence of HV in nursing and prevalence of HV. This makes it absolutely imperative that every associated behaviors in the U.S.: effort be made to stop its progression and reduce its occurrence. ●● Verbal abuse contributes to 16 to 24% of staff and 25 to 42% of nurse administrator turnover [3]. ●● About 60% of newly licensed registered nurses leave their first Despite the growing incidence and prevalence of HV or lateral positions within six months because of some type of HV [3]. violence, some administrators, managers, and even staff members fail ●● Nurses who report the greatest degree of conflict with other nurses to recognize or acknowledge it as a serious problem. Amazingly, some also had the highest rates of burnout [3]. perpetrators do not even realize that their behaviors are actually a form ●● The 2011 staff of the professional journal Nursing conducted a of workplace violence. This lack of recognition makes it even more survey of 950 nurses, asking them to identify the “frequency with difficult to control HV. As Bartholomew, an expert in this field, points which nurses experience or witness HV.” Eighty-two per cent of out, “Bullying behaviors are like gangrene— when tolerated from respondents reported experiencing or witnessing at least one type a few physicians or nurses with strong personalities, the behaviors of HV on a weekly or daily basis [12]. spread and infect the entire team, and eventually, the patient.” [6] ●● One-third of the nurses who responded to a survey about HV reported experiencing emotional abuse during their last five shifts worked [4].

Choosing Victims How does someone become a victim of HV? How are victims chosen perceived as being unable to “pull their weight” on a particular by those who commit HV? Consciously or unconsciously, victims are unit or as “trouble-makers.” usually carefully selected by their perpetrators. ●● Someone who receives special attention or recognition from Victims are usually among the most vulnerable of staff members. They supervisors or physicians. Attention and recognition may cause may be newly licensed professionals or newly hired colleagues who resentment, jealously, or even fear that others will be passed over lack confidence and are without power or workplace friends who could for increases or promotions because someone else is getting help them adjust to their new environment and/or protect them from special attention. those who commit HV [5,13]. Researchers have identified certain factors ●● Someone who appears to lack confidence. People who are timid, that may make someone more vulnerable to HV. These include being shy, or appear to have low self-esteem are more prone to become [5,14]: victims of those who commit HV. ●● A new graduate or newly hired staff member. Persons new to a profession or to a workplace often do not have friends or an Nursing consideration: Education regarding HV should include established support network. Persons who are perceived to be what may make a nurse vulnerable to this particular kind of alone are sometimes targeted by those who commit HV. workplace violence. Helping nurses to behave assertively without ●● Someone who has received a promotion or honor that causes becoming aggressive may make them less likely to become a victim resentment or envy among co-workers. For example, consider and help to reduce the problem as well. the case of an RN who recently earned her Master’s degree in nursing and consequently was promoted to the position of nurse manager. Some of her new managerial colleagues are pursuing EBP alert! Severe or chronic understaffing contributes to the risk [5,13,14] their graduate degrees, but have not yet completed their studies. of HV . Therefore, it is important that those nurses who help Some of these colleagues may show their resentment by behaving to establish staff patterns and develop recruitment strategies realize in ways that are characteristic of HV. that staffing issues may increase the incidence of HV. ●● A person who has problems working well with others or who has trouble acquiring new skills. These kinds of persons may be nursing.elitecme.com Page 43 Characteristics of Persons Who Commit Horizontal Violence Roseanne is a pediatric nurse who has extensive knowledge and maintain them. Persons who aspire to have power and control may expertise in her specialty. She has a reputation for being “hard” on likewise use aggressive tactics to acquire them. her colleagues. She is quick to criticize her colleagues and the new ●● Belief that patients need protecting: Some persons believe nurses she helps to orient often resign before completing orientation. that they are the only ones who know how to take proper care of Roseanne does not see herself as intimidating. She sincerely believes patients. In their minds, their actions are justified since they are that she is acting in the best interest of the patients by “protecting” acting in what they see as the best interests of the patients. them from nurses who are not as “smart” as she is. When Roseanne ●● Fear: Persons who are fearful of being overshadowed by younger, arrives at work, the nurse manager asks to speak to her in private. less experienced colleagues may target these colleagues to secure He tells Roseanne that she has been named in a grievance filed by their own places within an organization. one of her colleagues who recently requested transfer to another unit. ●● Unhappiness at work or at home: Persons who are unhappy at Both the manager and Roseanne have been named in the grievance as work and/or at home may treat others badly. Without knowing it, committing HV. Roseanne was named for her HV behaviors, and the they may be trying to make others as unhappy as they are. manager was named for failing to stop the behaviors even after the ●● Inability to see the effects of their behaviors: Perpetrators of nurse brought them to his attention. Roseanne is outraged. “I am only HV often refuse to see that their behavior has a negative impact on doing my job! I have not done anything wrong!” coworkers, patient outcomes, and the work environment. ●● Feelings of increased pressures at work, including a lack Most people, especially victims of HV, assume that those who of managerial support: Some nurses who feel fearful or commit HV know exactly what they are doing when they bully and overwhelmed by work-related pressures may take out their intimidate others. However, many of those perpetrators of HV do not frustrations on others in the form of HV. acknowledge their behaviors as damaging nor do they see themselves as bullies [5]. In fact, many abusive, disruptive actions are committed The preceding characteristics are not all-inclusive. They do, however, without awareness of the damage such actions may cause. Persons offer some awareness of the types of persons who are likely to commit committing HV may frequently do so without awareness [11]. Consider HV. the many causes of HV discussed earlier in this program. These reasons give clues to the characteristics of those who commit HV. Nursing consideration: Continuing education for nurses should These characteristics include [3,6,10,11]: include techniques for self-evaluation. Some nurses may not be able ●● A need for power and control: Persons who have power and to acknowledge what motivates their behaviors and how to more control at work are often willing to behave disruptively in order to constructively deal with fears and concerns.

Possible Causes of Horizontal Violence There are numerous possible causes of HV. These vary, depending on several factors that contribute to the instigation of HV. The following the person committing the violence and the workplace environment. are examples of various triggers that may result in a person committing There may be more than one trigger of HV. In fact, it is usual to have HV.

Envy Lisa is a highly skilled critical care nurse. She is accustomed to being persons who seem to have developed professional friendships with seen as the expert by her colleagues. About two years ago Lisa helped managers or other administrative personnel; jealousy of persons to orient Sophie, a nurse who is now referred to as “one of the best who have received promotions or other career advancement nurses” by colleagues, the manager, and physicians alike. Lisa liked opportunities; and/or jealousy of persons who have the opportunity Sophie when she was a new nurse who was in awe of Lisa and her to pursue education opportunities such as graduate education. clinical skills. Now Lisa is afraid that Sophie is taking her place as the Envy does not have to be limited to jealously of work-related issues. clinical leader on the intensive care unit. The two women are assigned Perpetrators of HV may be jealous of a peer’s personal life. They to work on developing a research proposal. The day the proposal is may envy someone who has a loving spouse or significant other, or to be presented to the institutional review board (IRB), Sophie is sick. children, or a close circle of friends. This envy may cause them to Lisa presents the proposal as entirely her own work and implies that retaliate by committing HV against those whom they envy. Sophie did nothing to help with its development. ●● The preceding example illustrates one possible cause of HV: Envy Nursing consideration: Envy is a difficult emotion to acknowledge. or jealously is an attitude that is usually accompanied by bitterness Even more difficult to acknowledge is the fact that envy can lead and resentfulness [5]. Envy may be related, as in Lisa’s case, to to destructive behavior. Nurses need to work on supporting their jealously of a colleague’s clinical skills and the fear that the role colleagues, and examining their own feelings and behaviors. These of acknowledged clinical expert is going to be lost. Other work- are two ways to begin to halt the spread of HV. related reasons for envy that leads to HV may include: Jealously of

Control and power Jackson is the manager of a physical therapy department in a small his management style. Jason discourages change and innovation and rural hospital. He has been the manager for over 15 years and has most of the other managers would rather agree with him than “get on more managerial experience than most of the managers of other his bad side.” He believes that his way is best since his department has departments. Seniority and experience are greatly valued in this a record of achieving patient outcomes, the respect of the physicians, hospital, and the chief executive officer (CEO) supports Jason as one and a low incidence of adverse occurrences. Turnover is low and of the key decision-makers of the organization. Jason is confident in Jason knows it is likely to remain low since his hospital is the only one his ability and in the professional rapport he has established with the in the immediate geographic area. CEO. Jason gets a lot of satisfaction knowing that his experience is valued. He controls his department strictly and is rather autocratic in

Page 44 nursing.elitecme.com However, things start to change when the CEO retires and a new management staff and effectively slows progress on development of the administrator assumes responsibility for fulfilling a mandate from outpatient services. the board of directors: Expand outpatient services by establishing an The need for control often co-exists with envy. As in Jason’s case, outpatient therapy clinic. Several new managers are hired for various he may be envious of the new managers’ skills and ideas that are departments, including , nursing, and cardiac obviously valued by the new CEO. He is also determined not to rehabilitation. These managers are eager to initiate planned changes lose control over his work situation. He is equally determined not to to fulfill the board of directors’ mandate. They have skills and ideas lose the power he has had for many years thanks to his seniority and that are openly praised by the new CEO. Jason believes he is losing friendship with the former CEO. The need for power and control often control over the organization that he has helped to guide for many go hand-in-hand. Jason has lost sight of the goals of the organization. years. In an effort to maintain this control, Jason begins to target the He commits HV in order to try to maintain his sense of control and new managers by complaining about them behind their backs and power over others, which if left unchecked, may become the defining telling the new CEO that “these new people do not know what they are characteristic of his organization [3,6,14,15]. doing.” Jason’s behavior causes a great deal of dissention among the

Fear JoAnne is an RN who has an associate degree. She has been a colleagues and as nurses with BSN degrees are hired, JoAnne makes nurse for five years and consistently receives excellent performance sure to spread about their lack of knowledge and skill. evaluations. Recently, the healthcare system for which she works has Fear is a powerful motivator. Fear of change, fear of the loss of announced that beginning immediately, RN vacancies will be filled respect, and, as in JoAnne’s case, fear of job loss all contribute to fear only with nurses who have BSNs. Nurses who do not have BSNs will as a cause of HV [3,10,15]. Fear is closely aligned with envy and a need not be terminated but they will not be eligible for promotion to certain for control. Some perpetrators of HV commit aggressive acts in an levels of staff nurse, nor will they be eligible to apply for managerial effort to gain or maintain control over situations that they perceive to positions. The healthcare system offers tuition reimbursement and be threatening or harmful. Those who commit HV may do so in an some courses will be offered at the hospital in an effort to attempt to combat fear caused by what they perceive as threats to their facilitate nurses’ ability to obtain their BSN degrees. JoAnne is very jobs or status within an organization. angry. She does not want to go back to school and is afraid that her job will eventually be in jeopardy. As her resentment grows she starts Nursing consideration: Fear can be an especially powerful as well to encourage other nurses who do not have BSNs to avoid colleagues as a destructive emotion. Managers should be educated to recognize who do. She instigates a campaign of “silent treatment” toward these that fear can be triggered by change such as the constant need to update skills and knowledge. The need to belong Henry is an occupational therapist who works at a prestigious spinal The need to belong is powerful and, as in Henry’s situation, it is often cord injury center. He is a member of interdisciplinary team that has accompanied by fear. This can be fear of loss of friendship, fear of not a national reputation for excellence. The work is hard but rewarding, being “part of the team,” and/or fear of retaliation. If Henry would try and there are multiple applicants for every vacancy that is posted. to help his new colleague, would he once again become a victim of When Henry was hired almost two years ago, he had to struggle long HV? and hard to be accepted by the team. He experienced a variety of HV Some former victims of HV may become participants in an effort to actions committed by members from the occupational therapy, physical appease the person or persons who commit HV. Persons like Henry therapy, and nursing departments. He tries to convince himself that may ignore or go along with HV in an effort to avoid becoming his colleagues’ behaviors made him a better therapist since he had to victims again [3,5]. Those who witness HV are in excellent positions excel to prove himself to be a competent member of the team. Henry to help stop its ongoing perpetration. Having had to deal with the is relived that after nearly two years he is an accepted member of the effects of HV should (but often does not) make victims more willing team. Recently, a new occupational therapist joined the organization, to take steps to stop it. Unfortunately, fear of staying or becoming a and Henry observes that many of the colleagues who were hard on victim often makes people ignore, or even participate in, the act of him are bullying and intimidating the new therapist. Henry would like committing HV. to help his new colleague, but is afraid that if he does he will lose the acceptance he worked so hard to gain. He tells himself that his new Nursing consideration: The need to belong can be a powerful colleague will survive and that this is just something all new hires must motivator. People who ignore HV are just as guilty of such go through. But he feels guilty and a bit ashamed of his own failure to aggression as those who actually commit this type of violence. try to put a stop to the aggressive actions of others. Nurses must be willing to take a stand against these destructive behaviors if HV is ever to be controlled and eventually stopped.

Blaming the victim for the occurrence of horizontal violence Stephanie is critical care nurse who works in a large trauma center qualified nurses during the past 12 months. Stephanie responds by emergency room. The work is extremely challenging and only those rolling her eyes and saying “If they cannot stand the pressure and a nurses with excellent trauma skills and stamina survive the hectic pace little honest criticism then they do not belong here. They deserved what and demanding work schedule. Stephanie is assigned to participate they got. I am not here to babysit new nurses!” in the orientation of most newly hired nurses. She criticizes them in This scenario is a good example of blaming the victim, a justification public and ridicules them for asking “too many questions.” She also sometimes used by those who commit HV. In other words, it is the criticizes her experienced peers in this manner. The turnover rate is victim’s fault that s/e was subjected to HV [3,14]. Persons who commit quite high and many of those who resign mention that Stephanie’s HV may justify their behavior, with excuses such as: behavior was a major factor in their decision to leave. Stephanie’s manager asks to speak to her in private. The manger shows Stephanie documentation that links her behavior to the of ten highly nursing.elitecme.com Page 45 ●● “These people who are complaining that they are poorly treated ●● “These new nurses with fancy degrees just do not know what it is are just looking for ways to excuse the fact that they cannot do the like in the ‘real’ world.” jobs they were hired for.” ●● “New nurses should be seen and not heard! They deserve what ●● “Some people just cannot take criticism.” they get if they try to tell me how to take care of patients.” ●● “I was just kidding around. They cannot take a joke.” ●● In the minds of these perpetrators, their victims were “asking for ●● “If they cannot take the pressure of working here then they should it.” They truly believe that the victims are at fault. In other words, just leave. It is their fault if they cannot work up to my standards.” “they brought it on themselves.” ●● “This is nothing compared to the way I was treated when I first started working here!” Initiation or rite of passage Sarah is a new social worker. She works in an outpatient oncology Persons who use rite of passage or initiation as an excuse to commit clinic. After another hard day at work during which she was assigned HV have probably had to go through a similar initiation themselves. the most difficult patients, ignored by her co-workers, and asked to Therefore, in their minds, because they were once treated poorly, work on Saturday even though this should have been her weekend off, everyone who follows them must also be treated poorly [3,5,14]. Sarah thinks, “I feel as though I am back at college and going through ‘hazing week’ in order to be initiated into my sorority. I did not think Nursing consideration: Attempting to justify HV as a form of people acted like this in the real world.” initiation is sometimes tolerated and even encouraged by some nurse managers, especially in high pressure areas such as the emergency Initiation or rite of passage as an excuse for HV may seem, as Sarah department. It may be viewed as a test for new nurses or other new thinks, like going through the hazing process conducted by college employees to see if they can handle stress. It is actually just cruelty. fraternities and sororities. Viewed by some who commit HV as This tactic leads to an ongoing cycle of HV that is self-perpetuating. “paying your dues,” this concept justifies HV as something that Nurses must do everything they can to this vicious cycle of every employee must go through to prove they are “worthy” of the abuse. responsibilities assigned to them and that they “have what it takes” to work on a particular unit, in a certain department, or for a specific organization.

Opposition to change Louis is a respiratory therapist. He has worked at a large long-term busy preparing for new types of patients that they are neglecting their care facility for several years. Louis enjoys his job and likes having current job responsibilities. Louis’ fear of change is triggering HV. the chance to get to know patients and families as opposed to the The workplace literature is filled with references related to change and hectic pace of acute care. When he arrives at work one morning, how much opposition change triggers. Change often triggers his manager tells him that the owners of the facility have decided to and fear [3,6]. Examples of these types of worries and fears include [16]: build an addition to the building. This addition will be the location ●● Fear of failure: The need to continue to do what feels comfortable of a new program that will offer short-term stays for patients is often linked to nurses’ fears that they may not be able to learn needing rehabilitation after suffering a stroke and other debilitating new skills that change may require. conditions. Louis is told that he and the other therapists will need to ●● Fear of lack of support: Nurses may worry that they will not be rotate through this unit to provide respiratory care to these short-term supported by management as change is implemented. patients. Louis is annoyed and immediately begins to wonder if this ●● Fear of the unknown: Some nurses may fear change because change will lead to more change and more problems. He worries that it will cause changes in the way the organization functions and, his job responsibilities will change and that he may not be able to consequently, in how they will be expected to do their jobs. deal with acute patient rehabilitation needs. How will these changes ●● Fear of being embarrassed in front of colleagues: Change affect his work schedule? Will his job be in jeopardy? Several of Louis’ usually requires the acquisition of some type of new knowledge colleagues are enthusiastic about the new rehabilitation program or skill. Some nurses may be afraid that they may be slow to learn and talk about taking some continuing education courses to prepare and thereby be embarrassed in front of colleagues. for the new patient population. Now Louis begins to worry that these colleagues will outshine him when the new program is implemented. The preceding scenario shows that people like Louis react to change Louis begins to ridicule his colleagues’ enthusiasm. He opposes their (and their own fears and concerns) by lashing out at co-workers and ideas in staff meetings and complains to his manager that they are so committing HV.

Generational differences Emily is a nursing professional development specialist. She is as well. Baby Boomers entered a workplace in which employees preparing a series of continuing education programs regarding HV, e.g. saw themselves in terms of the organizations for which they worked. how to deal with it, and how to stop it. Some content must be devoted Succeeding generations, who saw their parents downsized, sometimes to potential generational differences as possible triggers for HV. Emily after years of working for one organization, developed a loyalty to does not want to stereotype members of each generation. How can she themselves, not to their places of . These generations address the issue without over-simplifying the issue of generational are usually accustomed to change and consider it the norm, not the differences? exception. Professionally, some generations see themselves in terms The term generation gap has been around for a very long time. of their professions, not in terms of their employers. The newest Conflicts among generations come from differences in upbringing, members of the workforce expect flexibility in work hours and a work education, and experiences of world events. For example, older environment that offers time for “fun” as well as time for serious adults remember a time when homes and cars could safely remain discussion. These members are accustomed to conducting life at unlocked while young colleagues cannot imagine a world in which breakneck speed thanks to the instant means of communication (e.g. not only homes and cars must be secured, but even school buildings Internet, texting, iPads, etc.) and learning opportunities that are now available [17].

Page 46 nursing.elitecme.com No matter what generation an employee represents, there are certain experiences usually enhance an adult’s ability to fulfill their role principles that apply to everyone when it comes to a healthy work responsibilities. environment and to the reduction of HV. Here are some guidelines to ●● All adults, no matter their age, background, or professional help bridge the generation gap [17]: experience, deserve to be treated with respect. ●● Remember not to generalize about a person because of their ●● HV is not limited to an older colleague victimizing a younger age, education, or work experience. For example, do not assume colleague. HV can be committed by a member of any generation that an older colleague is computer illiterate. S/he may thrive on against members of any other generation, including their own technology. Do not assume that younger colleagues automatically generational peers. adapt well to change. They may be significantly opposed to change. Nursing consideration: It should not be assumed that the cause ●● All adults, no matter their age or professional experience, bring an of HV is due solely to generational conflicts. There is seldom one abundance of life experiences with them to the work setting. These single cause of HV. Generally, several factors come together to trigger this phenomenon. Oppression theory David is a nursing student in his junior year at a large metropolitan own livings, but in order to be considered a respectable profession for university. As part of a major class project, David must prepare and women, nursing was advertised as a “calling” or a desire to do “God’s present a paper on the history of nursing. He decides to include work.” [2] Such beliefs led to the portrayal of nurses as [3]: information on oppression theory. His professor asks what oppression ●● Always caring and compassionate. theory has to do with the history of nursing. David replies that ●● Being “angels of mercy.” oppression theory is relevant since nurses, over the years, have been ●● Willing to work long hours without reward. part of this type of theoretical framework, especially when it comes to ●● Never complaining. HV. ●● Fulfilling a subordinate role. ●● Following orders. Oppression theory is based on the belief that whenever two or more ●● Remaining quiet. groups co-exist and one group has more power than another, a power ●● Deferring to others. imbalance exists. This imbalance leads to the development of a dominant group and a subordinate group. When the values of the As a result of advancements in nursing education and , these subordinate group are ignored, ridiculed, and/or repressed, oppression beliefs are beginning to fade. However, research shows that some occurs [3]. people, even healthcare colleagues in other disciplines, continue to Experts in the field of HV often apply oppression theory to HV uphold these beliefs. This prolongs what is sometimes referred to as [3]. in the nursing profession. Some believe that from its conception, the culture of oppression in nursing the members of the nursing profession were told to assume a Persons who believe that they are members of a subordinate group subordinate position, which almost automatically predisposed them to may feel that they are oppressed and powerless. According to oppression[3]. oppression theorists, these feelings lead to hostility, , and the Some experts believe that academic education may be ineffectual in desire for control. One way of gaining control is to oppress others, preparing nurses to deal with bullying. It is imperative, as part of basic whether it be out of frustration, anger, or simply the desire to education preparation, that nurses be taught to project confidence and subordinate others as a way of responding to subordination that HV [3]. deal with conflict effectively [5]. Without this preparation, nurses are in perpetrators are experiencing themselves danger of completing their entry level education feeling uncertain and It is wrong to assume that other disciplines (besides nursing) do not dependent. experience oppression. It is also wrong to assume that male nurses When nursing was initially established as a profession, all or nearly all do not experience oppression. This phenomenon can affect anyone of its practitioners were women at a time when women had few, if any, depending on the work environment and other factors that contribute legal rights. In most countries women could not vote, own property, or to the development of HV. It has been suggested that one reason for in some cases, inherit money or property. Women were not expected a lack of significant amounts of HV research regarding professions other than nursing is a failure to admit that HV exists. Sadly, some to work unless absolutely necessary and work opportunities were limited to domestic service, teaching, and other jobs that were deemed healthcare managers and staff members ignore the problem, try to “acceptable.” Nursing offered an opportunity for women to earn their hide its existence, or simply refuse to believe that HV behaviors are harmful.

Failure to admit that HV exists Paula is an RN who has worked on various oncology units for the There are many reasons that HV is not recognized or acknowledged as last seven years. She recently relocated from a small city to a large well as excuses for its occurrence. Here are some managerial reasons urban area. She has interviews at several hospitals. Two questions and excuses for allowing the problem to continue [3,4,14]: Paula routinely asks the manager and staff members are: “How do ●● Managers may be reluctant to implement policies and procedures you deal with horizontal violence?”; and “What hospital policies pertaining to HV because they are afraid that their departments and procedures are in place to discourage workplace violence, may acquire a reputation for unpleasant working conditions which including HV?” If either a manger or his or her staff members deny may interfere with recruitment efforts. that HV exists, Paula knows that she does not want to work for their ●● Managers may ignore or downplay the problem of HV for fear organizations. She knows that HV exists to varying degrees in all of “offending” the perpetrators. Persons who commit HV may organizations. Paula expects an honest appraisal of the problem and be some of the most experienced clinicians. Some managers are information about hospital policies and procedures pertaining to HV. willing to put up with bullies who instigate HV if they are valued Having experienced HV in the past, Paula has learned to evaluate how by management for their clinical expertise or other job-related potential employers work to reduce and/or eliminate the problem. skills.

nursing.elitecme.com Page 47 ●● Managers may fail to acknowledge HV for fear that their of themselves, e.g. “Claiming that HV exists is just an excuse for supervisors and administrative staff will believe that they cannot weak or ineffectual staff members to make trouble.” deal with personnel problems. ●● Dealing with HV is just part of the job, e.g. “If people cannot deal ●● Managers may believe that a certain amount of bullying is with criticism then they do not belong here!” necessary to identify employees who lack confidence and ●● Some hold a belief that bullying is part of the initiation process . new employees must go through, e.g. “I had to go through it and ●● Managers may be unaware of the adverse effects of HV and so should everybody else.” assume that it is not a serious problem. ●● Fear is a powerful motivator for ignoring HV, e.g. “I feel bad when ●● Managers may actually believe that employees must go through a I see new people getting abused, but if I say something I am afraid rite of passage to work in their departments. they will go after me too.”

The preceding are a few examples of reasons management staff may Nursing consideration: One reason for ignoring the problem of give for failure to admit that HV exists. Here are some reasons staff HV or dismissing it as unimportant may be that mangers and staff members/peers may give for failing to admit that HV is a significant members alike do not realize the serious impact HV can have on its [3,4,5,14] problem : victims, patients, and the organization. Some managers may simply ●● As previously noted, persons most vulnerable to HV are those assume that the problem is insignificant or low on their priority who are new to the organization, lack confidence, or seem unsure of managerial concerns. Managers and administrators alike need education regarding the serious consequences of HV.

The Impact of Horizontal Violence Horizontal violence is toxic to its victims, patients, and the The most gripping reason for tackling the problem of HV and other organization in which it takes place [6]. HV takes a toll on the physical types of workplace violence is the fact that disruptive and intimidating and mental health of its victims, puts patients’ safety at risk by behaviors can lead to medical errors and patient harm. Other additional increasing the potential for error, and costs the organization thousands and compelling reasons to address HV include [18]: upon thousands of dollars [5,6]. Any plan to reduce and/or prevent the ●● Persons who have a history of disruptive behavior pose the greatest occurrence of HV must begin with an analysis of the impact of HV. risk for the filing of lawsuits against U.S. healthcare organizations. The Joint Commission has identified disruptive and intimidating ●● Disruptive behavior is contradictory to high professional standards. ●● Disruptive behavior contributes to poor teamwork, toxic work behaviors as ones that “undermine a culture of safety.” [18] In 2008 The Joint Commission emphasized its concern about these types of environments, increased patient complaints, and difficulty behaviors by issuing a Sentinel Event Alert on the topic. In this alert recruiting and retaining nursing staff. The Joint Commission describes disruptive and intimidating behavior Nursing consideration: A Sentinel Event is The Joint as including “overt actions such as verbal outbursts and physical Commission’s response to an unexpected occurrence “involving threats as well as passive activities such as refusing to perform death or serious physical or psychological injury or risk thereof.” assigned tasks or quietly exhibiting uncooperative attitudes during Risk thereof “includes any process variation for which a recurrence [18] routine activities.” would carry a significant chance of a serious adverse outcome.”[19] Nursing consideration: The 1999 Institute of Medicine (IOM) The Joint Commission’s 2008 Sentinel Event warned that “rude report “To Err is Human” recognized that “dangerous, reckless, language and hostile behavior among healthcare professionals goes or impaired” behavior can sometimes lead to patient harm [18]. beyond unpleasant and poses a serious threat to patient safety and [19] Healthcare leadership, including nurses Nurses should be familiar with leading healthcare associations’ and overall quality of care.” at all hierarchical levels, must acknowledge the seriousness of HV accrediting organizations’ published documents that address the and work to prevent it. issue of HV and other forms of workplace violence and support the implementation of their recommendations for reducing workplace violence. Impact on patients Veronica is a physical therapist with several years of experience Not knowing about the medication, Veronica continues to teach the in acute care settings. She has worked with orthopedic patients for patient how to transfer from wheelchair to toilet. The patient is unable several years, but has always been especially interested in the physical to concentrate and loses his balance. Veronica is able to stop him rehabilitation of stroke patients. She works in a large health system from falling and as she attempts to lower him back to his wheelchair that consists of an acute care hospital, several outpatient clinics, and she calls out for help. Her colleagues take their time coming to her a rehabilitation hospital. A vacancy in the rehabilitation hospital assistance, and when they arrive they find both Veronica and the would allow her the opportunity to work with stroke patients and patient on the floor. The patient has a laceration of the and expand her knowledge of neurologic physical therapy. She applies Veronica suffers muscle damage to her lower back. for and is hired to fill the position in the rehabilitation hospital. HV interferes with effective communication among colleagues. However, her new colleagues are less than welcoming. She receives Experts agree that inadequate communication interferes with the little orientation to her new duties and her co-workers are always exchange of information critical to the safety and well-being of too “busy” to help her adjust to her new job. She overhears them patients [2,4,12,21]. The potential for errors increases and if errors occur complaining about her. Apparently, they wanted another candidate to patients can be injured and desired outcomes compromised. The fill the vacancy for which Veronica was hired. She hears them conspire preceding scenario may seem extreme, but, unfortunately, similar to make things difficult for her so that she will “go back to orthopedics situations do occur. It is doubtful that Veronica’s colleagues wanted to where she belongs.” Part of making things difficult includes failing see either her or her patient suffer injury. However, sometimes those to communicate some essential patient information about one of who commit HV are so intent on intimidating their victims they fail to Veronica’s patients. This patient began a new medication that may consider just how serious the consequences of HV can be. cause him to have trouble concentrating until he adapts to its effects.

Page 48 nursing.elitecme.com Communication breakdown is not the only factor that can lead to EBP alert! Research also shows that poor communication has patient harm. If victims of HV are flustered, uncertain, and experience a significant negative impact on patient care and teamwork. a decrease in confidence, they are more likely to make mistakes. HV Medical errors are the third leading cause of death in the U.S. It is perpetrators may not want their victims to succeed at work. However, estimated that 80% of serious medical errors involve some type of what they often fail to understand is that setting up a peer for failure miscommunication, especially during the transfer of care from one can also set up a patient for serious harm. HV violence creates a provider to the next [20]! It is important that as part of continuing workplace environment that is dangerous to victims and patients alike. education, research evidence should be used to stress the impact of In fact, HV victims may experience damage to their physical and poor communication as it relates to HV. mental health and well-being [2,3,10].

Impact on physical health Leslie is an occupational therapist who works in a large medical him to see his physician. Tim reluctantly does so. After a thorough center. The occupational therapy (OT) department is divided into physical exam, his physician begins to suspect that Tim’s rapid heart units, and each unit is responsible for specific specialty areas. Leslie rate and minor arrhythmia are stress-related. was just promoted to the position of manager of OT for the spinal cord The preceding scenarios show that HV can have a physical impact on center. She is excited about this new career opportunity. However, her those who experience it. HV causes stress and anxiety. The healthcare managerial peers are less than welcoming, and she becomes a victim literature is filled with references to stress and its impact on the body. of HV. Leslie becomes anxious and stressed and, in her words, “I seem The stress triggered by HV can have detrimental effects on physical to catch every cold and virus that is going around.” One of her peers health [3,6]. A review of the literature shows that many victims of HV comments that, “Leslie sure takes a lot of sick time. And when she is at experience the following physical effects [3,14]: work she always seems to have a cold or a sore throat or something. I ●● Decrease in the effectiveness of the immune system: When the do not even like to be around someone who is sick all of the time!” immune system is compromised, the body’s resistance to infection Tim is a nurse on the pediatric unit. He has five years of experience is decreased, and the affected person is more vulnerable to illness. in the specialty and his performance evaluations are consistently ●● Increase likelihood of accidents and injury: Stress interferes excellent. However, one of his peers, Kathy, a nurse with 30 years with a person’s ability to concentrate and focus on tasks. Lack of experience as a pediatric nurse, dislikes Tim. She believes that it of focus and concentration makes a person more likely to make is unnatural for a man to want to work in pediatrics but is careful mistakes, have accidents, and suffer injury. not to say so at work. She rolls her eyes when he speaks during staff ●● Increase in the incidence of cardiac arrhythmias: Stress can meetings and goes out of her way to make sarcastic jokes about him have an adverse effect on the cardiovascular system, causing to their peers. Tim has attempted to discuss her behavior with her problems such as elevated blood pressure and heart rate as well as but she claims she is not doing anything wrong. Their nurse manager arrhythmias. tells Tim that unless Kathy does something that can be proven as HV, ●● Increase in sick days taken: The negative impact on the immune there is nothing that can be done. Tim begins to avoid Kathy as much system and the cardiovascular system as well as the increased as possible. He notices that he is experiencing a rapid heart rate likelihood of accidents and injury all contribute to an increase in and some heart palpitations that he attributes to caffeine intake even the number of sick days taken from work. though he rarely drinks caffeinated beverages. His wife encourages Impact on psychosocial health Jay is a neuropsychologist who works in a prestigious medical center every evening to “relax” after work. Lately his friends notice that in a large U.S. city. The work environment is quite competitive and instead of “a couple” of drinks Raymond has taken to drinking so the incidence of HV is high as Jay and his colleagues compete for much that he has to be driven home because he is too drunk to safely career advancement. Jay, the youngest member of the staff, is often drive. subjected to HV by his older colleagues who resent their younger and Bullying behaviors can cause psychological damage that can last a highly skilled colleague. Jay finds himself becoming quite irritable, lifetime. Researchers from Duke University interviewed 1,400 children and is increasingly short tempered with his wife and children. One between the ages of nine to sixteen about their social lives. Ten years evening Jay’s five-year old son forgets to put his toys away as he has later, the researchers interviewed the same children and found that been learning to do. Jay shouts at the boy and tells him that as a children who had been victims of bullying were [3]: he is going to give away the boy’s new tricycle. The boy ●● Four times more likely to have an anxiety disorder. bursts into tears and runs to his room. Jay’s wife is furious and tells ●● Four times more likely to have an antisocial disorder. him “I have had enough! It is the horrible people at work who are giving you trouble, not me or the kids! Either figure out a way to solve Researchers also found that the most troubled group affected the problem or you can find someplace else to live!” by bullying was children were had been both victims as well as perpetrators of bullying. These children were 14 times more likely Wendy is a nurse practitioner who works in a large outpatient clinic. to develop a panic disorder and almost five times more likely to be She excels at her job and has the respect of her supervisors and peers. depressed [3]. Five years ago Wendy was the victim of HV that was so severe that she filed a lawsuit against her former employer. Wendy still has nightmares HV can cause serious psychosocial problems as well as physical about the HV and sometimes finds herself suffering from periods of illness. These problems can range from anxiety to major depression, severe anxiety when she remembers the abuse she suffered. substance abuse, and damage to interpersonal relationships. The following psychosocial effects have been reported by some victims of Raymond is an RN working in a neurologic intensive care unit. HV [3,14,22]: The work environment is quite stressful. There is little trust among ●● Feelings of anger, irritability, and aggression: Victims of HV members of the nursing staff, who always seem ready to discredit a often find themselves experiencing and displaying anger and colleague in an attempt to gain the attention of the physicians and irritability to an unusual degree. Aggressive behaviors such as road nurse manager. Raymond usually has a couple of glasses of scotch rage and arguing with friends and family over trivialities to an nursing.elitecme.com Page 49 excessive degree may also occur. The first scenario in this section event such as HV. PTSD is characterized by ongoing anxiety, describes how Jay’s anger and frustration are being taken out on panic attacks, aggressive outbursts, nightmares about the traumatic his family at home. event, experiencing “flashbacks” during which the event is relived, ●● Damage to interpersonal relationships: The first scenario and avoidance of situations and activities that remind the person of also shows that Jay’s aggressive behaviors at home are having a the stressful event. To qualify as PTSD, these symptoms must last damaging impact on his relationships with his wife and children. for at least one month following the traumatic event [23]. This kind of damage does not have to be limited to spouse and children. All types of interpersonal relationships can suffer including those with a significant other, friends, parents, and EBP alert! A number of research studies support previous findings [3,23] siblings. regarding the psychosocial impact of HV : ●● Depression: Clinical depression may also occur as a result of HV. ●● A 2012 study of the psychological impact on psychological Depression can impact all facets of a person’s life. Depression can health conducted in Australia found that the impact differed become so severe that the person loses interest in work, leisure depending on the type of healthcare facility in which the nurses activities, and interpersonal relationships. Suicidal thoughts may worked. Full-time nurses who worked in aged care (long-term even occur. care) reported higher psychological distress than part time ●● Decreased self-esteem and self-worth: Feelings of worthlessness workers. Nurses who worked in the hospital setting reported may occur. The victim of HV may begin to believe that s/he is higher psychological distress. Nurses who worked in aged care unable to live a productive life. Confidence is destroyed. Self- also reported higher rates of depression. doubt is prevalent. These kinds of feelings are also symptomatic of ●● In Sweden, 4,238 workers from the Institute of Environmental depression. Medicine who witnessed workplace bullying were followed for ●● Feelings of loss of control over many aspects of life: These 18 months. At the conclusion of the evaluation period, women feelings may begin with a loss of control in the work environment who witnessed bullying showed a higher prevalence of clinical as the perpetrators of HV assume toxic control in the workplace. depression (about 33%) compared to male witnesses (about These feelings may spread into the victim’s personal life as well. 16%). Thus, just witnessing bullying was a significant risk ●● Decrease in motivation: The victim of HV may lose interest in factor for the development of depression. work. S/he believes that the workplace is so toxic that there is no ●● California researchers found that more than 50% of people point in trying to do a good job. This lack of motivation may also who experienced hostility at work reported that they spent affect the victim’s personal life. Family and friends may notice time worrying about the hostile incidents and its future that the affected individual has no interest in home and/or family, consequences. Additionally, experiencing hostility was found or in the pursuit of leisure activities. S/he may seem lethargic and to be harmful to job performance. Researchers found that even apathetic and have no interest in normal activities. These feelings a one-time experience can adversely affect cognitive function and behaviors can also be symptomatic of depression. and creativity. ●● Substance abuse: Raymond, in the preceding third scenario, ●● PTSD can continue to affect people for years after has begun to use alcohol to relax and forget about his problems experiencing the traumatic event that triggered the disorder. at work. There are a variety of substances that can be abused. In Some research shows that 50% of persons who experienced addition to alcohol, prescription drugs and illegal drugs may also HV suffer from stress and PTSD for as long as five years after be abused. Food is another substance that can be abused. Over- the event. eating may be a coping mechanism when trying to deal with the Research findings such as these should be part of the continuing effects of HV. education employees receive regarding HV. ●● Post-traumatic stress disorder (PTSD): PTSD is a mental health disorder that can develop as a result of experiencing a traumatic

Impact on the organization Cheryl is a nurse manager who has been having trouble managing her staff members. It is estimated that Cheryl spends as much as 30% of unit’s budget. She is summoned to the Director of Nursing’s . The her time dealing with conflict and that this is costing many tens of director tells her that her unit is significantly over budget. Turnover thousands of dollars. is high and the unit is developing a reputation for conflict among

Finances The preceding scenario is not as uncommon as one may think. A study conducted by the American Management Association regarding EBP alert! The estimated cost of replacing a nurse is $27,000- the cost of conflict in the workplace estimates that managers spend $103,000. Since HV leads to an increase in turnover, it is possible about 20-50% of their time dealing with conflict in the work place. to correlate /transfers with HV (if the nurses report it) This translates to hundreds of thousands, to even millions of dollars with the costs of replacing and orienting a nurse [24]. HV can cost annually, depending on the work place and the extent of conflict[22] . tens of thousands of dollars as a result of turnover alone. How does the impact of workplace HV and other forms of bullying translate into measurable finances? According to The Joint There are financial ramifications associated with all facets of Commission, the impact of bullying on the organization includes [24]: HV’s impact on the organization. Here are some of the primary ●● Lower morale. factors closely associated with HV and its impact on organizational ●● Lower productivity. effectiveness and financial solvency: ●● Increased . ●● Rapid and increased turnover. ●● Compromised patient safety.

Page 50 nursing.elitecme.com Recruitment and retention Amanda is a newly licensed RN who is interviewing for her first job ●● It is estimated that about 60% of newly licensed nurses in the as a registered nurse. During the interview, she asks questions about U.S. resign from their first positions within the first six months of turnover and the policies and procedures that are in place to deal with employment because of some type of HV. HV. The director and nurse manager are surprised. ●● Job dissatisfaction contributes to both turnover and HV. A study They are not prepared to answer questions about these sensitive issues. of 43,329 nurses from Canada, England, Germany, Scotland, and Healthcare organizations can quickly acquire a reputation for having the U.S. showed that job dissatisfaction was high in all countries a dysfunctional work environment. Word of mouth and social represented except for Germany. networking sites all contribute to the ease with which information Research shows that newly graduated/licensed nurses are at the about an organization can spread. In this day and age, information greatest risk for experiencing HV. They often lack confidence and about HV and other forms of bullying are also easily communicated. support systems at work which makes them vulnerable to HV. Recent data relating to new nurse turnover rates include [3]: Nursing consideration: HV and other forms of bullying are ●● Turnover rates of 17.7% the first year. becoming increasingly common on Internet social media sites. ●● Turnover rates of 33.4% the second year. Nurses and other healthcare professionals may also choose to use ●● Turnover rates of 46.3% within the third year. social media to degrade and humiliate their colleagues as well as their workplaces. This has legal as well as ethical implications. Most HV is also a leading cause of experienced nurses leaving the organizations have established policies that address the nurse’s use profession. Disruptive behaviors are directly linked to job of social media outside of the workplace [25]. Thus, nurses must be dissatisfaction and intent to leave the job and the profession. Coworker aware of how and why they use social media to discuss work-related incivility seems to be the most damaging HV behavior and causes high [3] issues. levels of mental health symptoms . EBP alert! Experts anticipate a significant upcoming nursing Healthcare professionals are becoming more knowledgeable about shortage. By 2020, the number of employed nurses needed to serve asking questions concerning the work environment, including the the older adult population will increase by 26% (an increase of occurrence of workplace violence. If managers and human resources 712,000 nurses). An additional 495,000 replacements are needed to personnel deny the problem exists or are unable to explain the policies replace the current numbers of retiring nurses [3]. This means that and procedures that govern the problem, candidates may very well establishing positive work environments is essential to recruiting choose to work elsewhere. Administration, mangers, staff, and human and retaining nurses. A positive work environment is one that does resource personnel must first be willing to admit that HV exists. It NOT include HV. cannot be effectively combatted if it is not first acknowledged. Information regarding HV and recruiting and retention efforts is beginning to receive considerable attention in nursing literature. The preceding statistics indicate that turnover and nurses leaving The following are some statistics from the literature pertaining to the profession because of HV are significant problems. The costs recruitment and retention and HV [3,4,14]: associated with recruiting, orienting, and retaining healthcare ●● The turnover rate for clinical practicing nurses is between 33% and professionals can range from tens of thousands to hundreds of 37% in the U.S. thousands of dollars depending on the organization. Additional costs ●● The turnover rate for newly licensed RNs in the U.S. ranges from include paying staff members to ensure adequate staffing, 55% to 61%. advertising job openings, and interviewing and selecting candidates to fill vacancies. All of these factors add up to huge budgetary expenses that can force an organization to cut spending throughout the organization. Some of these cuts would likely involve eliminating jobs.

Sick time As previously noted, HV has an adverse effect on physical and mental 50 sick days per year [3]. Illness is not limited to physical signs and health. Deterioration of physical and/or mental health leads to illness symptoms: HV is linked directly to serious mental health problems. and an increased number of sick days. The organization must not only Both physical and mental health problems can last for years or even a pay sick time but also pay overtime for employees who must cover lifetime. The impact on HV victims’ health can be disastrous. shifts until the employee who is ill can return to work. Nursing consideration: The impact of HV on health is Sick days not only have an impact on the person who is ill but on the considerable. Nurses must be aware of how work conditions affect organization as well. Sick days cost the organization a considerable their health and the health of their colleagues. They must take steps amount of money, and research suggests that this amount could run to safeguard their health and work to establish a workplace that is into many thousands of dollars annually. Results from an Australian conducive to physical and mental health of not only patients about study show that 34% of nurses who experience HV take more than employees as well.

Quality and appropriateness of patient care Decreased productivity as a result of the effects of HV is a serious members and patients alike. Research also shows that in this type problem not only in healthcare, but throughout the work world. of environment there are increases in adverse occurrences such as Fortune-100 firm executives report spending as much as 13.5% of their medication errors and patient complaints as well as a decrease in total work time helping to restore interpersonal work relationships and desired patient outcomes [3,4]. [3] replacing employees who have resigned due to HV . Witnessing HV as well as being victims of HV drastically interferes In healthcare, research shows that the effects of HV interfere with with work productivity, costs organizations many thousands of dollars concentration and focus as well as communication among staff in recruitment and retention efforts, impairs morale, increases errors, members. These issues contribute to an unsafe environment for staff and distracts from the business of caring for patients and families. nursing.elitecme.com Page 51 A national survey that focused on work productivity showed that ●● Reports from 66% of the respondents said their job performance witnessing HV led to [3]: had declined because of witnessing HV. ●● A 47% intentional decrease in the amount of time spent at work (e.g. sick time). Nursing consideration: The preceding statistics further emphasize ●● A 38% intentional decrease in the quality of work. the need for witnesses and victims of HV to receive support and ●● An 80% amount of work time lost due to worrying about HV. help to deal with the aftermath of this destructive phenomenon. ●● A 63% amount of work time lost in efforts to avoid persons committing HV. Legal ramifications LEGAL WARNING: THIS EDUCATION PROGRAM IS NOT The preceding scenario shows that HV can have significant legal INTENDED TO SERVE AS LEGAL ADVICE OR COUNSEL. consequences. HV also makes an organization more vulnerable QUESTIONS CONCERING THE LEGAL RAMIFICATIONS to malpractice lawsuits. If there is an increase in errors, patient OF HV SHOULD BE DISCUSSED WITH QUALIFED LEGAL dissatisfaction, patient injury, or injury to the victim(s) of HV, COUNSELORS. there may also be a corresponding increase in malpractice lawsuits. Lawsuits, or the threat of lawsuits, increases employee stress and increases the financial burdens that face healthcare organizations. Phyllis is a registered nurse. After obtaining her nursing license she worked for three years on a medical-surgical unit. Phyllis wanted As of this writing, there are no specific laws that directly address some experience in this setting before pursing her goal to work in the problem of HV. Victims of HV and other forms of bullying who cardiac critical care. Over the past three years, Phyllis took every want to file a lawsuit do not have a clear-cut, direct pathway in court. opportunity to seek out continuing education pertaining to cardiac Victims and their legal advisors must look for components of laws that [26] critical care and recently began to take graduate level courses to may apply to acts of HV in their particular cases . pursue a Master’s degree in nursing. Highly recommended by her This does not mean, however, that lawsuits have not been filed; some nurse manager, Phyllis recently transferred to the hospital’s cardiac have even been successful. For example, in a recent review of lawsuits critical care unit. Phyllis is excited and enthusiastic and is prepared to and laws pertaining to HV, Rainford and colleagues presented several work hard to become an excellent critical care nurse. legal cases and one such case involved an emergency room nurse [26] However, her new co-workers are less than welcoming. The nurses identified as RS . A discharged employee returned to work with on the unit have a reputation for bullying new nurses and turnover a semiautomatic rifle and shot various staff members, one fatally. is high. Their rationale for their behavior is “you have to be tough RS spearheaded the efforts of the Alaska Nurses Association, which to work on this unit. Only the best survive.” Her preceptor Deborah passed a resolution in 2009 concerning workplace bullying, to organize makes a point of correcting and criticizing her in front of patients and colleagues, hoping to enhance workplace safety. RS was suspended spreads gossip about her, telling co-workers, “I am going to have to by his employing hospital and discharged without pay. He filed a get rid of this new nurse. She thinks she is better than everybody else. complaint under the National Labor Relations Act, which found in his Who does she think she is, telling me she is working on a Master’s favor. The hospital’s defense team surveyed the nursing staff prior to degree? So what? Some fancy degree will not help her here. I will see the decision, and found that 34% of the nurses who responded to the [26] to that.” survey reported bullying . Phyllis is understandably upset and has talked to Deborah on several There are a variety of ways that a victim of HV might try to establish occasions, telling her she is willing to learn from an experienced legal grounds for lawsuits. Employees who are victims of HV and critical care nurse, but that criticizing her in front of patients and commit errors that result in patient harm may try to establish a link discussing her with colleagues is disturbing and is compromising between their maltreatment and the committing of errors. For example, her ability to work efficiently. Deborah laughs and tells her to “get suppose organizational policies and procedures pertaining to HV exist used to it.” Phyllis approaches the nurse manager and asks for a new but are not followed. This failure to follow organizational mandates preceptor. The nurse manager replies by telling her, “Deborah is one may increase the risk for legal action against an organization, its of our best nurses. She is a little tough but you need to get used to it. It administrators, and its managers. Victims of HV may attempt to show is just her way of making sure you are good enough to work here.” that HV contributed directly to any errors that were made, and that the organization failed to follow its own mandates. Phyllis begins to suffer from severe headaches and a significant loss of appetite. She is losing weight and her asthma symptoms worsen As of this writing, few laws specific to bullying exist, although there significantly. Following the hospital’s policy concerning HV, Phyllis are laws against harassment. However, as the public becomes more consults with Human Resources personnel and decides to file a and more aware of the effects of HV, interest in legal protection grows. grievance regarding the HV behaviors she encountered. Management Some state legislators are proposing the passing of laws that would refuses to consider the grievance, citing Deborah’s excellent allow workers to sue for physical, psychological, or economic injury [5] performance evaluations as proof that the problem is Phyllis ’and not from abusive treatment at work . Deborah’s. Managers and administrators have a legal and ethical duty to their Shortly after the grievance compliant is dismissed, Phyllis is employees. An appropriate starting point is to differentiate between hospitalized following a severe asthma attack. She attributes the negligence and malpractice. Negligence is a broad term that refers to [27] decline in her health to the impact of HV and files a lawsuit against the conduct “lacking in due care.” Negligence is a deviation from the hospital, the cardiac care nurse manager, and Deborah. The hospital standard of care that a reasonable and prudent person would adhere to. settles out of court, and Phyllis receives a large monetary award. It also refers to something that a reasonable and prudent person would [27] Phyllis resigns and obtains employment at a competing hospital where NOT do . she is welcomed to the critical care setting with enthusiasm. Following Malpractice (also referred to as professional negligence) is a more Phyllis’ example, several other nurses file grievances against Deborah specific term that refers to not only a professional standard of care, and the nurse manager of the cardiac care unit. Ultimately both but to the professional status of the person providing care. In order Deborah and the nurse manager are terminated from their positions. to be liable for malpractice, the person who commits the wrong must be a professional such as a nurse, physician, therapist, or lawyer.

Page 52 nursing.elitecme.com Courts of law define malpractice as “any professional misconduct, policies and procedures regarding HV. However, her concerns or unreasonable lack of skill or fidelity, in professional or judiciary were dismissed with the given excuse that the HV perpetrator held duties.” [27] Additionally, this wrong must result in injury, unnecessary clinical expertise. suffering, or death to the injured party due to ignorance, carelessness, ●● Foreseeability: Foreseeability involves the notion that certain lack of professional skill, disregard of established rules, policies, events may reasonably be expected to have a certain impact procedures, and/or principles, neglect, or a malicious or criminal intent [27]. Thanks to research studies that describe the impact of HV, [27]. organizational leadership should know that HV has numerous negative consequences. In Phyllis’ case, the nurse manager should Nursing consideration: Nurses and other professionals are have been aware of the impact of HV. In fact, the organization, judged by the standards of care that guide their practice. Thus, it is which had established policies and procedures concerning HV, absolutely essential that nurses be aware of the nursing standards of should have made every effort to adhere to its own standards. practice that guide their professional actions! ●● Causation: Causation can be difficult to prove since causation requires that an injury must have occurred directly as a result of Consider how the elements of malpractice might be applied to a the breach of duty. Therefore, it means that the injury would not situation in which HV exists. In the clinical setting, healthcare have occurred had duty not been breached. This means that Phyllis [27] professionals’ elements of malpractice include : had to show convincing evidence that her physical health problems ●● Duty owed to the patient. were directly caused by the HV she experienced, and that they ●● Breach of duty owed to the patient. would not have occurred if she had not been subjected to HV. ●● Foreseeability. ●● Injury: The fifth element of malpractice requires that there ●● Causation. is evidence of an actual injury or harm. The plaintiff (such as ●● Injury. Phyllis in the case study) must demonstrate some sort of physical, ●● Damages. emotional, or financial injury occurred because of the breach of Consider how these elements may apply to administrators, managers, duty. The burden of proof was on Phyllis and her legal counsel to and co-workers in relation to victims of HV using the scenario that show that her deteriorating health was directly due to HV. introduced this section as the foundation for discussion. The following ●● Damages: The fundamental purpose of awarding damages is definitions have been adapted from definitions relating to malpractice compensation. The law is attempting to restore the injured party as it pertains to patient lawsuits [27]. This adaptation is an attempt to to his or her “original position so far as is financially possible. show what might be possible. There is, however, no guarantee that The goal of awarding damages is not to punish the defendants persons who file grievances or lawsuits because of HV will win these (the organization or persons being sued), but to assist the injured initiatives. party.” [27] In the hypothetical scenario, Phyllis was awarded ●● Duty to the employee: An organization, via its administrators financial compensation. and managers, assumes a duty and responsibility for employees. If employees can show that co-workers have committed HV and Part of this duty and responsibility is an obligation to provide management fails to adhere to policies and procedures relating to HV, a workplace environment that is safe and appropriate. Once a there may be grounds for filing a grievance according to the mandates duty is established, the employee has a right to expect that the of those policies and procedures. Additionally, if HV victims can organization will act in the best interests of their employees. prove that harm or injury occurred as a result of HV, there may also be Phyllis, for example, had a right to expect that as part of acting grounds for legal action. Thus, the very existence of unopposed HV in her best interests, the organization would provide a reasonable can make organizations more vulnerable to legal consequences. orientation to her new role as a critical care nurse. A reasonable and prudent person would NOT be expected to inflict HV on the Nursing consideration: Continuing education regarding the impact person being oriented. of HV must include potential legal ramifications. Leadership and ●● Breach of duty to the employee: A breach of duty might exist management in particular should be aware that their failure to if an employer fails to provide a safe and appropriate work intervene when HV occurs can leave not only the organization, but environment. An example of such a failure might be a failure to also management, vulnerable to legal action. follow policies and procedures related to HV. Phyllis followed

Strategies to Reduce or Prevent Horizontal Violence There are a number of strategies important to the reduction and/or which is garnering increasing attention as a strategy to help healthcare prevention of HV. Before discussing the actual practical recommended workers effectively heal themselves without resorting to HV. actions, it is important to review the “theory of the wounded healer,”

Theory of the wounded healer The concept of the wounded healer suggests that a healer’s (e.g. nurse, Nursing consideration: It is important to be able to differentiate physician) own wounds and sufferings can carry healing powers for the wounded healer from the impaired professional. An impaired their patients. Carl Jung, psychiatrist and founder of the school of professional is one whose personal distress leads to a negative analytic psychology, proposed that a healer’s own experiences of impact on their job performance. A wounded healer is a professional trauma and pain (both physical and emotional) can be used to better whose own “woundedness” (i.e. experiences of pain and suffering, [28,29] help patients to complete the healing process . and recovery) helps him/her to understand and assist others to heal [29]. The concept of the wounded healer was first documented over 2,500 years ago. It has its origins in Greek mythology and shamanistic traditions [28,29]. Shamanism itself is an ancient healing tradition and way of life. It emphasizes a connectedness with nature and all of creation [30]. Some experts point out that wounded healers are familiar nursing.elitecme.com Page 53 with the problems that patients face, having experienced similar ●● If the pain of the traumatic event is unresolved, it can lead to difficulties and worked through them. Wounded healers use their own anger, emotional problems, substance abuse, job dissatisfaction, experiences to help patients in the healing process [29]. and a negative work environment.

According to wounded healer theory, if trauma is handled effectively, Nursing consideration: According to Conti-O-Hare the wounded the pain of the trauma (whether it be physical or emotional) is healer represents the highest level of using self therapeutically [28]. consciously recognized, transformed, and transcended into healing. Resolving trauma can have a positive impact on both professional Marion Conti-O’Hare developed the theory of the nurse as wounded and personal lives. healer. She based this theory on an exploration of a nurse’s ability to transcend personal pain and suffering for the purpose of building Christie and Jones adapted the theory of nurse as wounded healer to better therapeutic relationships with others [28]. Several important terms dealing with lateral violence in nursing [28]. The three steps for a nurse related to the wounded healer theory include [28]: experiencing HV to become a wounded healer are: ●● Recognition: The awareness that something is negatively affecting ●● Upon experiencing HV, nurses need to recognize the traumatic someone, either via his/her own thought processes and self- event and closely examine and dissect the components of the evaluation, or with the assistance of other people in his/her life. event. Nurses must answer these questions: ●● Transformation: Involves seeking affirmation and control over ○○ What happened? feelings of pain and/or fear through counseling and/or sharing. The ○○ What could be changed? person may use energy from the past to increase understanding of ○○ How should it have been handled? the present and future. ●● The next step, transformation, involves transforming the pain into ●● Transcendence: A higher level of understanding that can be an acceptable and manageable understanding by answering these spiritual and/or higher thinking. It allows the person to use this questions: understanding to increase their therapeutic relationship with others. ○○ What can be learned from the trauma? ●● Walking wounded: People who have experienced either physical ○○ Has this changed me or the people I care about? or verbal trauma that they have not dealt with. Not dealing with ○○ How can this be used to make things better? the trauma causes changes in their ability to cope with current ●● The final step is transcendence, which occurs only if the previous stressors, which leads to negative consequences. two steps (recognition and transformation) have been completed ●● Wounded healer: Persons who achieve expanded consciousness successfully. Transcending the pain allows the nurse to acquire through self-reflection and spiritual growth. This allows them to insight and knowledge, which can be used to help others deal with process, convert and heal trauma. The scar from the trauma remains, their own pain and suffering. Transcendence allows the nurse to giving these people greater ability to understand the pain of others. say: Marion Conti-O’Hare developed her “nurse as wounded healer” theory ○○ I understand your pain. based on the belief that nursing is a profession in need of this healing ○○ How can I make things better for you? process. She explained that everyone experiences trauma in their Only after completing all three steps can the nurse become a wounded personal or professional lives or both. The pain and fear caused by healer. these traumas can affect people for the rest of their lives. The effects The nurse as wounded healer theory provides a possible framework of trauma do not resolve without interventions. The ability to deal with for dealing with pain and suffering related to trauma such as HV. But trauma can significantly impact someone’s ability to care for others. it is also necessary to have practical strategies that can (and should) be But if the trauma is transformed and transcended, the experience of implemented to stop the vicious cycle of this phenomenon. healing can be used to help others [28]. A holistic approach must be used when dealing with the issue of HV According to Conti-O’Hare the nurse as wounded healer framework and other forms of bullying in healthcare organizations. Research consists of [28]: shows that strategies aimed at changing organizational culture are ●● The nurse experiences a traumatic event. more successful than those that attempt to change the behavior only ●● The physical pain and/or psychological distress leads to becoming of specific individuals. Efforts focused on individual behavior may a member of the walking wounded. be dismissed as an over-reaction. Perpetrators may justify their ●● In order to embark on the pathway to healing, the pain must be behaviors by blaming the victim, rationalize behavior as a difference in recognized, transformed, and transcended. This helps the nurse to personality, or even simply claim that they are just having a little joke move from being a member of the walking wounded to becoming at another person’s expense. a wounded healer. ●● The wounded healer, having resolved the pain of the trauma, is It is essential that steps be taken not only to deal with HV as it able to implement a therapeutic use of self, develop increased happens, but to stop it from occurring as well. The following empathy with patients, and facilitate a positive work environment. paragraphs offer practical suggestions for dealing with HV.

Communication tips Ellen is just completing her first year of employment as an RN. She is as an “easy target.” She enrolls in an assertiveness training course. a rather shy person who lacks confidence, and she has been subjected Instead of quietly trying to ignore the behaviors of her peers Ellen to HV throughout this first year. HV behaviors consisted mostly of now confronts them. She stands erect and maintains eye contact. criticism in front of co-workers and gossip behind her back. Ellen’s She speaks clearly in a firm tone of voice. Ellen tells colleagues who nurse manager sympathizes with Ellen but comments, “you need to are criticizing her that she is as willing to learn as anyone but will stand up for yourself. People have a tendency to pick on those who not tolerate being embarrassed in front of others. When she learns make themselves easy targets.” This inappropriate comment makes of the gossip being spread about her, she confronts those who are Ellen realize that her nurse manager is going to be of no help to her. responsible. Her peers are surprised at her newfound confidence and Ellen believes that filing a grievance is not an option because she is the HV gradually begins to stop. afraid of retaliation. She lives in a rather isolated rural area and this Unfortunately, Ellen’s situation is not uncommon. Lack of managerial is the only hospital within commuting distance. Relocating is not an support and the need to remain in a particular workplace can make the option because of family obligations. Ellen realizes that there is one trauma of HV even worse. However, there are things Ellen, and those thing she can do to help herself: Make it more difficult to be viewed

Page 54 nursing.elitecme.com like her, can do to stop the violence. Effective communication is one else as well as how closely others stand next to nurses. Invading such strategy. someone’s personal space can be perceived as argumentative and Earlier in this education program information about who are the most possibly threatening. When communicating during what could be a likely targets of HV was offered. It is important to project an air of tense situation (e.g. confronting someone who is committing HV) confidence. How one communicates with others has a lot to do with be aware of personal space parameters. stopping or preventing HV. Communicating assertively is not the only ●● Active listening: In addition to maintaining eye contact, respond means of communication designed to stop HV. Active listening is also to what someone else is saying. Nodding the head, asking for an important part of reducing this type of workplace violence. Here clarification, and making comments such as, “I understand that are some suggestions for projecting both an attitude of confidence and you are concerned about the work schedule,” or “I am interested in willingness to listen to what others have to say [3,14,31,32]: your ideas about purchasing new IV pumps” show that the nurse ●● Posture: Stand or sit erect with arms at sides. Avoid crossing the is really listening to the concerns and/or ideas of others. Never arms and/or clenching fists. These actions give the impression of appear to be bored or in a hurry. Do not tap a foot, glance at a anger and/or not being open to the ideas of others. Do not fidget or watch or stand with one hand on the doorknob when talking to make nervous gestures (e.g. swing legs, tap desk with a pen, wring someone else. hands). Such gestures give the impression of nervousness and lack ●● Willingness to learn: Nurses should always be willing to learn. of confidence. No one knows all there is to know about a particular profession. ●● Eye contact: Maintain eye contact as culturally appropriate. The fact that the nurse is willing to learn (and voice willingness For most U.S. citizens, eye contact indicates an interest in what to learn) will go a long way to enhancing professional rapport the other person is saying. Eye contact gives the impression of with colleagues. However, do not make self-demeaning comments confidence as well as interest in what the other person is saying such as, “I know I do not know much about nursing yet,” or “I without appearing intimidated. really did not do a good job with that procedure.” Self-demeaning ●● Tone of voice: Speak clearly. Speak loudly and slowly enough to comments can exacerbate HV and give the impression of an easy be understood easily. Do not allow the voice to become shrill. Do target for workplace bullying. not shout. Do not mumble. ●● Willingness to help: Help colleagues whenever possible. In ●● Facial expressions: Do not frown or roll eyes. Maintain a calm general, peers will remember who “came to their rescue” on a bad expression. Avoid showing amusement unless the person with day and will reciprocate when needed. whom the nurse is communicating is genuinely trying to be funny. Nursing consideration: It may be helpful to practice Laughing at someone is never appropriate. Facial expressions communication techniques in front of a mirror. Using a mirror should indicate an interest in the communication process without as a teaching tool allows the nurse to evaluate her/his non- giving the impression of anger or fear. verbal communication (e.g. posture, facial expressions). Practice ●● Self-analysis: Be aware of personal communication style. Do communicating in a private setting. Record such practice situations you cross your arms without being aware of doing so? Are you so that the tone and quality of one’s speech can be evaluated. maintaining eye contact? What about tone of voice? Record yourself speaking. Do you speak too quickly? Too softly? Too The preceding tips are good suggestions for projecting confidence loudly? Be as objective as possible. Ask a trusted friend or family as well as a desire to listen to what others have to say. Good member to help “rehearse” communication techniques. communication helps to reduce the incidence of HV. However, ●● Personal space: Personal space varies among countries and there are always colleagues, for whatever reason, who seem to be cultures. In the U.S., personal space is usually about three feet. the primary instigators of HV. It is important to be prepared to deal Be aware of how closely a nurse sits or stands next to someone directly with those who commit HV.

Dealing directly with persons who commit HV Sarah is an RN who works on one of several medical/surgical units shouting or . It may be helpful to practice what you will say and in a large community hospital. This morning she is asked to “float” how you will say it. to another medical/surgical unit that is short-staffed. As soon as she arrives, she asks for a brief orientation to the unit and a report on the Nursing consideration: Nurses should always adhere to the patients she will be caring for. An older, more experienced colleague, principles of good communication techniques when dealing with Norma, rolls her eyes and complains that, “If Sarah doesn’t know HV. Shouting, crying, or other displays of a loss of control will only what she is doing she might as well go back to her own unit.” The make the situation worse. nurse manager intervenes and tells Norma to provide Sarah with The most important strategy concerning HV is to deal with the the information she needs. Norma does so, but reluctantly. She tells problem the first time it occurs. Do not ignore it. Ignoring the problem a patient that Sarah “Does not usually work on this unit but I guess will only make the perpetrator believe that s/he can get away with it, she will know how to take care of you.” Norma walks out of the room and the problem will most likely escalate. It is critically important that and Sarah overhears her tell other nurses that, “This nurse they the victim of HV makes it clear that this behavior will not be tolerated. sent us is really a pain. She expects to be treated like royalty.” Sarah In the preceding scenario, Sarah confronts Norma as soon as possible. finishes providing care to the patient and leaves the room. She asks Here are some suggestions when confronting persons who commit HV to speak to Norma privately. Norma rolls her eyes and steps into the [7,10,15,21,22,31,32,33,34]: nurses’ lounge, “Hurry up I do not have all day.” Sarah responds by ●● Stay calm. If a nurse becomes angry, defensive, or cry, the persons saying, “I am more than willing to help take care of patients since you committing HV will assume that s/he cannot defend themselves. are short staffed. However, I will not tolerate the comments you are The HV will more than likely continue or even become worse. It making about me in front of patients and to other nurses. This must is not easy to remain calm in these types of situations. However, stop now.” remaining calm is a skill that is essential for all forms of It is not easy to talk to the person who is committing HV. The communication. HV is not the only challenging situation nurses encounter will be difficult and, most likely, emotional. It is important face. Calmness nearly always helps to defuse tense situations. that the victim of HV remain calm and address the problem without Calmness also helps victims of HV to gain some control over the situation. nursing.elitecme.com Page 55 ●● Confront the perpetrator in private. Do not address the issue in they continue, another confrontation will be necessary and at that front of an audience. If the person committing HV refuses to speak time indicate to the perpetrator what the next step will be (e.g. ask in a private location, the nurse may need to speak to him or her in for a new preceptor, file a grievance, etc.). Find out what policies a more public setting, but NEVER in front of patients. Refusing to and procedures are in place for dealing with HV and adhere to speak in a private setting may be a bully’s way of avoiding having them. Know how to file a grievance in accordance with hospital to deal with the problem or of continuing the HV in a public forum policy and procedures and follow them meticulously. to gain support for her/his actions. If forced to confront the person ●● Focus on behaviors, not personalities. When setting boundaries, in a hallway, do so as quietly as possible. talk about the behaviors that are not acceptable. Avoid “you” ●● Deal with the situation as soon as possible. Obviously, patients statements such as “you are making fun of me” or “you are cannot be left unattended in order to confront a bully. But do not criticizing me in front of other nurses.” Instead give examples allow an entire shift or longer to go by. The longer the perpetrator such as “comments that I do not know what I am doing in front “gets away with it” the longer and more virulent the HV will of patients upset the patients and embarrass me. I will not tolerate become. HV often continues because its instigators are so seldom these comments.” This avoids accusatory statements that might confronted about it. Those who commit HV are getting some sort escalate into a shouting match. Make it clear that the behaviors of satisfaction from their behaviors. By dealing with them calmly are unacceptable, not the person committing them. This is difficult and swiftly some of the satisfaction is decreased. since it is hard to separate behaviors from the person committing ●● Set boundaries. Sarah, in the preceding scenario, calmly explains HV. However, when confronting unacceptable behaviors, it is best what will not be tolerated. Notice that it is best to start by to avoid focusing on personalities even though it may seem that indicating an appropriate action. As in Sarah’s case, she starts by the personality is the problem! saying she is willing to help during a period of short staffing.A new orientee might start by saying that s/he is willing and eager Nursing consideration: It is never easy to have confrontational to learn. The next sentence should be a calm, definite statement types of conversations. But the person instigating the HV must that the HV will not be tolerated. Be specific. For instance, Sarah be confronted as soon as possible after it occurs. The more time states that she will not tolerate the negative statements being made that goes by after experiencing HV the more difficult it will be to in front of patients. In some circumstances it may be necessary to confront the perpetrator. Additionally, memories of the event may communicate what steps will be taken if the behaviors do not stop. fade, even if only a day has gone by. A lapse in time also makes it For instance, a new employee may say that if behaviors do not stop easier for the perpetrator to deny the event occurred or at least to s/he will request a new preceptor. Do not threaten. Start by saying diminish its significance. what behaviors have occurred and that they will not be tolerated. If Documentation The grievance committee is preparing to interview a nurse who has that: “On July 1, 2015 at 10AM, in Room 228, I was changing a sterile filed a grievance against a colleague and her nurse manager, citing dressing under the supervision of my preceptor, Karen Saunders, on HV as the reason for the complaint. The colleague, a nurse who has a patient who had undergone an abdominal hysterectomy. During the worked at the hospital for many years, is a close personal friend of the procedure Ms. Saunders rolled her eyes and commented, ‘I guess we manager. The committee asks the nurse to explain why she has filed will be here all day since you are so slow.’ She then addressed the the grievance and what exactly occurred to trigger this complaint. patient directly and stated, ‘You have to understand that these new To the surprise of the committee, the nurse distributes copies of nurses just do not know as much as they should.” meticulous documentation regarding numerous instances of HV, including dates, times, details, and witnesses to the events. She has Nursing consideration: Be careful to observe HIPAA and other also cited how these disruptive behaviors violate the organization’s confidentiality mandates. When presenting information in front policies regarding HV and other forms of workplace violence. The of a grievance committee, for example, patients’ names should be nurse also has documentation detailing what steps she took to stop avoided and should not be part of any documentation distributed to the violence, including discussing the situation with the perpetrator committee members. and reporting the situation to her nurse manager. She also has specific By being objective and specific an accurate account is recorded.This dates, times, and locations of the events that took place when she type of personal record may be needed if it becomes necessary to attempted to defuse the situation. All documentation is dated and timed approach a nurse manager or to file a grievance in accordance with and written objectively. organizational policies and procedures. Persons who experience HV should keep a documentation record of the events. These are personal records and HV should not be Nursing consideration: When recording documentation as it relates documented in a patient’s medical record. Note the date, time, and to HV, remember the principles of proper documentation in the location of the event. Document what was said or done and who was medical record. It needs to be objective, without bias, concise, and responsible for the HV behaviors. It is important to be objective. include dates and times of occurrence and any actions taken to stop For example, do not document that: “On July 1, 2015 at 10AM, my the HV. Always avoid becoming embroiled in emotional outbursts, preceptor embarrassed me in front of a patient.” Instead document whether in person or in written documentation.

Zero tolerance HV policies and procedures Marie is a registered nurse with 20 years of experience in oncology forward to assuming managerial duties and comments that, “now nursing. Although a knowledgeable and experienced clinician, Marie things will really be done right. Only the best nurses are going to has a widely acknowledged reputation as a bully. Over the years, survive on my unit.” numerous nurses have resigned or requested transfer to other units Upon returning from a two-week vacation, Marie learns that the newly because of Marie’s behavior. Unfortunately, Marie had the vocal hired VP for Nursing has called for a meeting of all nurse managers. support of her nurse manager and the VP of Nursing, both of whom One of the topics for discussion is HV. Marie also learns that the were her close personal friends. Both of these persons have recently VP has been meeting with groups of staff nurses on their units. Staff retired and Marie has been promoted to manager of her unit. She looks nurses are impressed that the VP approached them. “She did not

Page 56 nursing.elitecme.com expect us to come to her, and she really seems to be listening.” Many . When doing so, it is probably helpful to bring the written of the staff nurses have friends who work at a nearby medical center record of the HV to the meeting. This helps to keep the meeting where the VP was Associate Director of Nursing. She has a reputation objective and prevents displays of emotion such as anger or tears that for facilitating a work environment that enhances patient outcomes may interfere with reaching a satisfactory solution to stop the problem. and professional growth and development of members of the nursing The Joint Commission has published guidelines for the prevention department. She also has a reputation for having a zero tolerance for of disruptive workplace behaviors. These guidelines include HV and other forms of bullying and workplace violence. recommendations that written policies and procedures guarantee zero As Marie enters the meeting room she comments to another manager, tolerance for disruptive or intimidating behaviors. All employees, “I am not worried. I have been here a long time and will be here after including administrators and managers, of an organization should she is gone. I am not here to pamper nurses. I am here to get the job receive education about disruptive behaviors and how to initiate done and if that takes getting rid of some crybabies, so be it.” behaviors that enhance respect and professionalism throughout the workplace. The guidelines also note that employees who report The VP for Nursing is waiting for everyone to arrive. She greets each disruptive behaviors must not be reprimanded or experience any nurse manager by name and introduces herself as Nicole Adams. retaliation for such reporting. A system to deal with, monitor, and stop/ Nicole provides a brief history of her professional life and ends by prevent disruptive behaviors must be established, and all actions taken saying that her goal is to improve patient outcomes and increase to stop disruptive behaviors must be documented [5]. opportunities for professional growth. She continues by explaining that HV is a major concern of hers and of this hospital’s administration. The Joint Commission Leadership Standard (LD.03.01.01) addresses She distributes handouts that give a brief overview of the impact of HV disruptive and inappropriate behaviors. It recommends some specific and links its existence to turnover and medical errors, particularly in steps to prevent bullying including [19,24]: this organization. ●● Educate all healthcare team members about professional behavior including such basic issues as being courteous during telephone Nicole looks each of the managers in the eye and says, “I will not interactions, business etiquette, and general people skills. tolerate HV under any circumstances. One of the first actions we ●● Hold all team members accountable for modeling behaviors that are going to take is to revise the existing policies and procedures are disruptive. concerning this destructive phenomenon. Each of you is responsible ●● Establish a code of professional conduct and behavior that for eliminating HV and how you contribute to establishing a violence- promotes a civil, professional work environment with a zero free organization will be reflected in your performance evaluations. tolerance for workplace bullying. Having been a victim of HV when I was a young nurse, I know how ●● Enforce the code of professional conduct consistently and devastating it is. As I recovered from its effects, I made myself a equitably. promise that throughout my career I would do everything I could to ●● Establish a comprehensive approach that addresses intimidating prevent other nurses from going through what I went through.” and disruptive behaviors including a zero tolerance policy. Strong As she finished speaking Nicole looks directly at Marie. Marie begins involvement and support from physician leadership is encouraged. to feel very nervous. She looks closely at Nicole and realizes that she ●● Reduce fears of retribution against persons who report intimidating once subjected Nicole to extreme bullying when Nicole was a newly and disruptive behaviors. licensed nurse on the oncology unit. ●● Empathize with and apologize to patients and families who are The preceding scenario shows that sometimes committing HV can involved in, or witnesses of, intimidating or disruptive behaviors. ultimately have a serious impact on those who commit it. It also ●● Determine how and when disciplinary actions should begin. supports the need for all employees at all levels of the organization ●● Develop a system to detect and receive reports of unprofessional to adopt a zero tolerance policy regarding HV and other forms of behavior. workplace violence. ●● Use non-confrontational interaction strategies to address intimidating and disruptive behaviors. These strategies are to be In order to reduce/eliminate HV, it is important that all employees, implemented within the context of an organizational commitment including managers and administrators, be aware of policies and to the health and well-being of all staff and patients. procedures that deal with HV and other types of workplace violence and strictly adhere to them. If someone is a victim of HV, and Nursing consideration: Zero tolerance means that HV and other confronting the abusers directly fails to stop the abuse, it is important forms of workplace bullying is not to be tolerated, ever, under any that s/he follow policies and procedures related to such abuse. In many circumstances. All nurses must take an active role in developing and cases, the next step is for the victim to meet with his or her immediate implementing zero tolerance policies and procedures. Conflict management styles It is important that all employees be helped to recognize the various This is an example of accommodation. Accommodation exists when conflict management styles and what styles are appropriate under what one person or group gives in to the demands of another person or conditions. Here are examples of some of the most common conflict group. This action may compromise patient care, organizational management styles [32,33]: standards, or other important factors. Accommodation is appropriate Thomas is a member of an interdisciplinary research committee. He only if the person who “gives in” realizes that s/he has made an error. is one of the committee’s newest members. The group is discussing “Giving in” to avoid conflict may be seen as weak and ineffective by sample selection for a research project. Thomas respectfully questions others. the proposal for sample selection currently under review. He believes Nursing consideration: Persons may “give in” to avoid becoming a that it lacks objectivity and may have an adverse impact on the victim of HV or to attempt to stop being a victim of HV. reliability of the results of the research. However, the person who proposed the selection is a colleague who has served on the committee Stella and Maureen are senior physical therapists. They have a for many years and has the respect of the group. There is significant friendly rivalry for the respect and attention of their less experienced support for the proposal as it is currently written. Thomas apologizes colleagues. During a staff meeting, they take opposite sides of a and agrees to go along with the group’s recommendations even though discussion pertaining to a new scheduling format. Neither is willing he believes the proposal as written will hamper effective research. nursing.elitecme.com Page 57 to discuss or listen to the other’s viewpoint. Such open disagreement agreement and family members are arguing among themselves as to compromises staffing patterns and may also eventually impact patient what to do. Linda and Victor decide to present the option that each care. of the children take turns having Mrs. Burns in their homes on a trial This is an example of competition. This is a negative approach basis. If none of them are able to care for her she will then go to a to resolving conflict. With competition, neither involved party is long-term care facility. Neither social worker is happy with this option. concerned with achieving the best possible outcome. The only concern This scenario is an example of compromise, which means that all is winning. In a competition there is always a winner and always a parties involved in the conflict give up something in order to resolve loser. There are also peripheral winners and losers. Supporters of it. Since neither party is comfortable with the outcome, compromise is the winner may also feel that they have won. Supporters of the loser usually only a temporary resolution of the problem and some conflict may feel as though they belong to a losing team. Ultimately, the still exists. Linda and Victor also seem to be allowing their personal most significant losers are the patients, whose well-being may be beliefs and values to impact their actions. Their role is not to present compromised as a result of competition. options that they think are best but to present all options and facilitate Arlene is the nurse manager of several medical units. She knows that family discussion. Compromise is seldom effective. there is conflict among the units regarding staffing and the budgetary The nurses who work on a busy surgical unit are forming a unit-based allotment for unit resources. Staff members have asked for a multi-unit council. One of their first projects is to initiate self-scheduling. It is staff meeting to resolve the issues. Arlene is reluctant to schedule a a difficult process but all agree that the first consideration must be meeting that she fears will further disrupt professional rapport. She adequate staffing. After discussing, sometimes forcibly, a variety of hopes that eventually each unit will determine a way to deal with the options, the group comes up with a way of scheduling that allows resources they have. nurses to work only one weekend a month as well as a system that has This is an example of avoidance. Avoidance means that the conflict each nurse taking her turn to work overtime or additional shifts when is being completely ignored in the hope that it will eventually resolve needed without scrambling at the last minute to find coverage. itself or even disappear entirely. But ignoring conflict seldom, if ever, This scenario is an example of collaboration. It is also referred to as results in a positive outcome. Avoiding conflict usually prolongs the negotiation and results in a win-win situation. Collaboration means conflict and often causes it to escalate. It may lead to competition, that a solution that is satisfactory to everyone involved is found. accommodation, and other forms of negative conflict resolution tactics. Collaboration generally helps to advance the achievement of goals and Linda and Victor are social workers whose patient population consists objectives, and ultimately, desired patient care outcomes. primarily of elderly persons who have experienced strokes or have When working with diverse groups of colleagues it is helpful to other debilitating conditions. Linda believes that Mrs. Burns, a identify one’s personal conflict management style. Once a personal stroke patient, should be taken in by one of her many children after conflict management style is identified, one can aim towards discharge. Victor believes that her care is so extensive that she should implementing a collaboration style of management rather than other be discharged to a long-term care facility. They cannot come to an styles that can potentially escalate conflict.

Education Angela is the manager of the nursing professional development (NPD) Education cannot be provided unless a system is in place to assess department in a large medical center. She and her staff have been its effectiveness. Part of Angela’s job is to determine if education has asked to prepare a series of education offerings pertaining to HV helped to decrease HV and enhance the organizational culture. She and other forms of workplace bullying. Because of their educational and her staff must establish an evaluation process to measure the expertise, Angela and her staff have been asked to provide education impact of their education endeavors. for the entire medical center, not just the department of nursing. This Angela has chosen a basic starting foundation for education. is a huge task. Angela decides to begin with a review of policies and Definition of terms and explanations existing policies and procedures procedures relating to HV and workplace bullying and a definition of are important. Many effective techniques can be used to educate staff terms. She rightly believes that many employees may not know what members about HV, some of which include role play, case studies, and HV and bullying actually are. sharing of personal experiences. Some of Angela’s staff members are reluctant to address the issue of Education is essential to the reduction and elimination of HV. ALL HV and bullying. Some of them have been bullied, and some have even employees, including administrators and managers, must participate willingly committed HV. Others are wary of bringing up a topic that in education and training related to HV. However, participation is may cause anger and frustration among staff who do not understand not enough. What is learned during the education process MUST the seriousness or the problem. There may even be some concern be translated into the culture of the organization and consistently that the organization’s bullies may turn their vengeance on persons implemented. attempting to stop the harassment via education and training. No one wants to admit they may have been behaving in ways that cause actual Nursing consideration: The essential outcome to education is the physical and/or psychological harm. consistent implementation of strategies to reduce or prevent HV. A Angela decides that even before beginning to plan education programs critical component of the education process is to measure the impact she must address the topic of HV with her staff. They cannot teach of education. In this case, measurement should include assessing if about the topic unless they are familiar with how it occurs, its impact, HV and other forms of bullying actually decrease in the workplace [17] and effective strategies to stop it. Self-analysis will begin with Angela following education . and her staff. Self-analysis is sometimes a painful process, but by Remember that HV occurs in all departments, not just those whose performing self-analysis, Angela and the educators in her department staff members are direct patient care providers as well as at every will be better able to guide learners through the process. Educators level in the hierarchy. Education specialists need to take the lead in the will also need support from administration, management, and planning, implementation, and evaluation of education pertaining to leadership since this sensitive topic will most likely trigger a variety HV and other types of bullying. of emotions from those who have experienced HV and those who have committed it. Before education can take place, effective policies and procedures must be written with a clear, specific statement so that there is

Page 58 nursing.elitecme.com zero tolerance for disruptive behaviors, including HV. See the alleviate HV. On-going education should occur during various points recommendations for these policies and procedures in the section in employees’ such as: under strategies to reduce or prevent HV. Additionally, policies and ●● Orientation: The topic of HV should be addressed during procedures should explicitly state the consequences for committing orientation of all new staff members and include information as and/or tolerating HV. Every employee should be required to read these described above. Some may argue that this will intimidate new documents, agree to uphold their standards, and sign a documentation employees and create a negative impression of the organization. record that they have done so. On the contrary, awareness of HV and tools to combat it effectively, empowers a new employee. It also shows that Nursing consideration: Employees should be evaluated on their the organization has a commitment to put a stop to disruptive contributions to establishing and maintaining a culture of safety and behaviors. optimal work environments. How employees facilitate or hinder ●● Preceptor training: Every person who precepts new employees these goals should be reflected in their performance evaluations. should be educated and aware of HV in terms of how to recognize ALL employees, including administration and management, should it and how to stop it. Education must also emphasize that HV be evaluated on how they personally impact the culture of the is NEVER appropriate and that there is a zero tolerance for its organization. occurrence. ●● Mandatory training: All healthcare organizations must have Education on HV is of critical importance and attendance for annual mandatory training which should be inclusive of how education should be facilitated and mandatory. It is difficult to to recognize and stop HV as well as any pertinent updated incorporate time for an educational meeting outside of an employee’s information. department; therefore, such education and training does not have ●● Continuing education: Ongoing information about HV and to be done entirely in a classroom. Computer-based learning, staff other types of workplace violence should be part of every meeting presentations, role play, and distribution of case studies can organization’s continuing education endeavors. Education could all be utilized so that the actual time in the classroom is limited to include updates from the literature, information based on analysis manageable amounts. Information to be presented should include of the organization’s own efforts to stop HV and other forms of [3,7,11,14,17]: workplace violence, and how successful the organization has ●● An explanation of what HV is and what it is not: Role play, case been in stopping HV. Education should include the impact of HV studies, and actual examples (preferably from situations that have within the organization, a frank discussion of the impact on quality been witnessed within the organization), are good ways of making of care, patient outcomes, and . Employees need the HV relatable and not just a theory. Be sure that scenarios used to learn how to cope with HV in a professional and non-violent as examples do not include names, specific units, or other items manner. that would specifically identify the victims or those who commit it. This will embarrass and anger some people and escalate the Nursing consideration: Employees should be asked for feedback as problem. As discussed earlier in this education program, some to the kind of education they would like regarding HV. For example, perpetrators of HV may deny or even fail to recognize that they are they may want more opportunities for role play and discussion committing acts of violence that have serious, long-term impacts or they may have interest in conducting research about HV. on all employees, patients, and families. Suggestions from employees should be solicited on what should be ●● An overview of the organization’s policies and procedures that done to help stop HV as well as how to deal with it when it occurs. deal with disruptive behaviors: This overview should include asking employees how they see themselves as responsible for Another facet of education should include directly addressing each policy and procedure implementation. employee, making them know they are responsible for breaking the ●● How to deal with HV: A variety of strategies should be used bullying cycle, enhancing patient outcomes, and developing and to show how to deal with HV. Learners do not want to simply maintaining a culture of safety. For example, nursing employees could listen to a lecture or read a policy. Role play and case studies be asked [17,35]: should show effective and non-effective ways of dealing with the ●● Do you remember what it was like to be a new nurse? Have you problem. This type of contrast can show what works and what been treating new nurses as you would want to be treated? does not. It can also lead to a frank discussion of HV. It should ●● Have you made an effort to welcome new nurses? Have you tried also be emphasized is that those who witness HV and other types to make them feel that they are part of the group? of bullying and fail to try to stop it are as guilty as those who are ●● Have you ever been bullied? If so, what occurred during the committing it. bullying? Who committed the bullying? Do not ask for specific ●● Presentation of organizational data related to HV: This could names but ask for generalities. For example, was the bullying include statistics about turnover, the effects of HV, and the cost of committed by a manager, preceptor, peer, subordinate, etc.? the problem to the organization. On a departmental level, actual ●● If you were bullied, what did you do? Did you take steps to stop data showing how HV has impacted patient care, recruitment, and the bullying? Did anyone help you to deal with the bullying? What retention could be presented. Evidence of HV must be provided made the bullying worse? What made it better? to the employees to prove its existence to those who may be ●● Do you think that the bullies you have encountered knew what skeptical. Employees need to be made aware that HV has long- they were doing? Do you think they deliberately set out to term consequences for physical and emotional health. intimidate and/or harm you? ●● How to recognize HV when it is seen or when it is committed: ●● Do you know what the impact of bullying might be? What is the Remember that earlier in this program it was mentioned that impact of bullying in your department? some people do not even realize that their behaviors constitute ●● What conflict management styles are you familiar with? How do workplace violence. Every employee should have to perform a you think you should handle it when confronted by a bully? self-analysis of his/her own behavior. Part of this self-analysis ●● Do you think your organization opposes bullying? Why or why should include how personal behaviors impact colleagues, not? managers, subordinates, patients, and families. ●● Do you see yourself as a role model for professional behavior? Why or why not? The preceding suggestions are some ideas to instigate an educational ●● Do you know of examples of professional behavior on your unit? campaign to stop HV. A one-time education session is not sufficient to nursing.elitecme.com Page 59 ●● Do you think you are responsible for helping to stop bulling? Why Nursing consideration: Administration, management, and leaders or why not? have important roles in breaking the cycle of HV. They should ●● Are you afraid of retaliation if you report bullying? Why or why emphasize that HV is not tolerated and they should encourage not? those who experience and/or witness HV to report it without fear of ●● Do you ever think that there is a justifiable reason to bully retaliation. someone? Why or why not? ●● Do you feel comfortable dealing with a bully? What may help you Organizations should offer counseling for the victims of HV. Its impact to deal with a bully? Do you know how to deal with bullying in a can be extremely devastating to physical and mental health. The professional manner? organization has an obligation not only to take steps to stop HV but to ●● What do you think would help stop bullying in the workplace? help its victims to recover from its impact. ●● Do you think bullying is a problem in your organization? Why or why not?

Conclusion HV is not a new phenomenon but it is one that is becoming more environment free from HV and must be mandatory for everyone who well-known and more openly acknowledged by accrediting bodies. All works in healthcare. It is essential that organizational leadership serve persons who work within the healthcare field must take responsibility as role models for appropriate behavior and that those who commit for putting a stop to HV. In order to provide a safe work environment HV, no matter what their role in the organization, be held accountable for employees and an environment that is conducive to the best for their actions. A holistic approach involving the entire organization possible patient care, HV must be recognized and a zero tolerance is the best way to stop the cycle of HV and bullying. Creation of a for its occurrence be upheld by administration, management, and culture of safety not only involves looking at patient outcomes but at staff. Education is a critical part of developing and maintaining an the health and well-being of employees as well.

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Page 60 nursing.elitecme.com Healthcare Violence: Why Peers Bully Peers Self-Evaluation Exercises Select the best answer for each question and check your answers at the bottom of the page. You do not need to submit this self-evaluation exercise with your participant sheet. 1. HV creates a toxic work environment. An HV behavior that 7. A review of the literature shows that HV can lead to: involves someone complaining about a peer to others instead of a. Increased efficiency of the immune system. speaking directly to that person about a concern or problem is b. Increase in the incidence of cardiac arrhythmias. known as: c. A decreased need for emotional support. a. Bullying. d. A decrease in the incidence of medical errors. b. Backstabbing. c. Covert behavior. 8. Which of the following statements regarding the impact of d. Verbal abuse. horizontal violence is true? a. HV primarily impacts mental health. 2. Which of the following questions pertaining to incidence and b. HV may lead to clinical depression. prevalence of HV is correct? c. In Sweden, workplace bullying seldom impacts mental health. a. HV is unique to the nursing profession. d. Research shows that victims of HV seldom think about the b. Verbal abuse contributes to about 50 percent of staff turnover. incident after it occurs. c. In the United States about 60 percent of newly licensed nurses leave their first positions within six months because of HV. 9. When discussing the theory of the wounded healer it is important d. A study involving emergency room nurses found that less than to know that: one percent of them experienced workplace bullying. a. A wounded healer is a professional whose own woundedness helps him/her to understand and assist others to heal. 3. A nurse who ______is more vulnerable to HV. b. Recognition is the achievement of a higher level of a. Has an established network of work friends. understanding that can be spiritual and/or higher thinking. b. Has received a promotion or honor. c. Walking wounded have successfully dealt with their trauma. c. Is self-confident. d. The nurse as wounded healer theory is based on the belief that d. Is expected to acquire new skills. nurses do not need healing, but need to heal others.

4. Characteristics of people who commit HV include all of the 10. When dealing with horizontal violence it is important that: following EXCEPT: a. Victims include their feelings, emotions, and opinions as part a. A need for power. of their documentation. b. Unhappiness at work or at home. b. Victims know that HIPAA mandates do not apply when c. Fear of being overshadowed by younger colleagues. dealing with horizontal violence. d. Accepting that their behaviors have a negative impact on c. All employees of an organization receive education about coworkers. disruptive behaviors. d. All employees realize that competition is an effective strategy 5. A preceptor who is bullying a new employee justifies her behavior for dealing with HV. by saying: “I was just kidding around. She can’t take a joke.” This is an example of: a. Blaming the victim. b. Generational conflict. c. Fear. a. Oppression theory.

6. The image of nurses as being always caring and compassionate and fulfilling a subordinate role is part of: a. Generational differences. b. Opposition to change. c. Oppression theory. d. Failure to admit.

Answers: 10.c 9.a 8.b 7.b 6.c 5.a 4.d 3.b 2.c 1.b nursing.elitecme.com Page 61