chapter 5: healthcare violence: why peers bully peers · in clinical research and evidence-based...

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Chapter 5: Healthcare Violence: Why Peers Bully Peers

6 Contact Hours

Release Date: 8/24/2016 Expiration Date: 8/24/2019

FacultyAdrianne Avillion, D.Ed., RNAdrianne E. Avillion, D.Ed., RN, is an accomplished nursing professional development specialist and healthcare author. She earned her doctoral degree in adult education and her M.S. in nursing from Penn State University and a BSN from Bloomsburg University. Dr. Avillion has held a variety of nursing positions as a staff nurse in critical care and physical medicine and rehabilitation settings with emphasis on neurological and mental health nursing as well as a number of leadership roles in nursing professional development. She has published extensively and is a frequent presenter at conferences and conventions devoted to the specialty of continuing education

and nursing professional development. Dr. Avillion owns and is the CEO of Strategic Nursing Professional Development, a business that specializes in continuing education for healthcare professionals and consulting services in nursing professional development. Her most recent publications include The Path to Stress-Free Nursing Professional Development: 50 No-Nonsense Solutions to Everyday Challenges and Nursing Professional Development: A Practical Guide for Evidence-Based Education.Content ReviewerSusan Reese, MSN, RN

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

Purpose statementBullying and violence in the workplace occurs far too often. Whether it is between professionals of a single discipline or among different disciplines, the consequences of bullying and violence are the same.

This course presents an overview of horizontal violence as well as characteristics of both abusers and victims. Causes of violence are presented as well as strategies to reduce workplace violence.

Learning objectives � Describe the phenomenon of horizontal violence. � Discuss the incidence and prevalence of horizontal violence. � Discuss how and why horizontal violence victims are chosen by

their abusers.

� Identify the characteristics of persons who commit horizontal violence.

� Explain the causes of horizontal violence. � Analyze the impact of horizontal violence. � 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

commitment of time. ● Depending on your state requirements you will asked to complete

either: ○ An affirmation that you have completed the educational

activity.

○ A mandatory test (a passing score of 70 percent is required). Test questions link content to learning objectives as a method to enhance individualized learning and material retention.

● Provide required personal information and payment information. ● Complete the MANDATORY Self-Assessment and Course

Evaluation. ● Print your Certificate of Completion.

Accreditations and approvalsElite is accredited as a provider of continuing education by the American Nurses Credentialing Center’s Commission on Accreditation.

Individual state nursing approvalsIn addition to states that accept ANCC, Elite is an approved provider of continuing education in nursing by: Alabama, Provider #ABNP1418 (valid through April 30, 2017); California Board of Registered Nursing, Provider # CEP15022; District of Columbia Board of

Nursing, Provider # 50-4007; Florida Board of Nursing, Provider # 50-4007; and Kentucky Board of Nursing, Provider # 7-0076 (valid through December 31, 2017).

Activity directorJune D. Thompson, DrPH, MSN, RN, FAEN, Lead Nurse Planner

nursing.elitecme.com Page 52

DisclosureResolution of Conflict of InterestIn accordance with the ANCC Standards for Commercial Support for continuing education, Elite implemented mechanisms prior to the planning and implementation of the continuing education activity, to identify and resolve conflicts of interest for all individuals in a position to control content of the course activity.

Sponsorship/Commercial Support and Non-EndorsementIt is the policy of Elite not to accept commercial support. Furthermore, commercial interests are prohibited from distributing or providing access to this activity to learners.

DisclaimerThe information provided in this activity is for continuing education purposes only and is not meant to substitute for the independent

medical judgment of a healthcare provider relative to diagnostic and treatment options of a specific patient’s medical condition.

©2017: All Rights Reserved. Materials may not be reproduced without the expressed written permission or consent of Elite Professional Education, LLC. The materials presented in this course are meant to provide the consumer with general information on the topics covered. The information provided was prepared by professionals with practical knowledge of the areas covered. It is not meant to provide medical, legal, or professional advice. Elite Professional Education, LLC recommends that you consult a medical, legal, or professional services expert licensed in your state. Elite Professional Education, LLC has made all reasonable efforts to ensure that all content provided in this course is accurate and up to date at the time of printing, but does not represent or warrant that it will apply to your situation nor circumstances and assumes no liability from reliance on these materials. Quotes are collected from customer feedback surveys. The models are intended to be representative and not actual customers.

IntroductionWhat first comes to mind when healthcare employees hear the word “violence” in relation to their workplaces? Many might respond that they think of an out-of-control emergency department patient under the influence of drugs or alcohol who attempts to harm staff members. Others may remember a confused, frightened patient who tried to strike them. Still others may think about an angry visitor who verbally abused them. These ideas are not uncommon and are understandable. In fact, according to the United States (U.S.) Bureau of Labor Statistics Census of Fatal Occupational Injuries (CFQI), of the 4,679 fatal workplace injuries that occurred in the U.S. in 2014, 403 were workplace homicides [1]. People who work in healthcare settings are at significant risk for workplace violence. According to information provided by the Occupational Safety and Health Administration (OSHA), from 2002 to 2013 the rate of serious workplace violence incidents (i.e. those that required days off to recover from an injury) was more than four times greater in healthcare settings than in private industry [2]. Most of the violence in healthcare settings is committed by patients. However, violence is also committed by students, co-workers, and visitors.

Many instances of workplace violence in healthcare settings go unreported, even in facilities that have formal violence incident reporting systems. Results from a recent survey of 4,738 Minnesota nurses showed that only 69% of physical assaults and 71% of non-physical assaults were reported to a manager. One medical center reported that half of verbal and physical assaults by patients against nurses were never reported in writing [2]. For instances of violence to be reduced, they must first be reported and acknowledged as a serious problem.

Nursing consideration: Workplace violence is a significant problem in healthcare settings. Nurses must advocate for ongoing education of healthcare employees to increase awareness and provide tools to mitigate workplace violence.

Another type of violence that occurs in healthcare settings is horizontal violence. Horizontal violence, also known as HV, is aggression

against peers and co-workers who are on the same hierarchical level of an organization [3,5]. Horizontal violence has far-reaching and serious consequences. These consequences can affect recruitment and retention, increase the risk of errors, negatively affect patient outcomes, and adversely affect the health and well-being of victims [3,4,5]. Some researchers believe that this type of violence has reached epidemic proportions [2].

Nursing consideration: Horizontal violence is frequently underreported. Some reasons given for not reporting HV include a lack of reporting policies and procedures, lack of faith in existing reporting systems, and fear of retaliation [2]. If instances of HV are to be reduced, there must be a means of not only reporting its occurrence, but an organizational culture that has a zero tolerance for such behavior.

HV is sometimes referred to as lateral violence or bullying. It causes more harm than any other type of aggression in the workplace, including bullying of nurses and other healthcare professionals by physicians, supervisors, and subordinates [3,6].

Nursing consideration: HV is defined as a consistent pattern of behavior designed to control, diminish, or devalue a peer, which gives rise to health and/or safety risks. As previously noted, it is also aggression against peers who are on the same hierarchical level of an organization [3,5,6]. It is imperative that nurses at all hierarchical levels in an organization work to fight the phenomenon of HV.

EBP alert! Research shows that impaired communication among nurses and other members of the healthcare team is a major cause of errors. Bullying inevitably has a negative impact on communication. Research also shows that experiencing bullying or even simply witnessing rude behavior negatively impacts the ability to perform cognitive tasks [4]. Thus, it is imperative that every effort be made to stop HV and other forms of bullying.

THe PHenomenon oF HorIzonTAL VIoLenCeJackie is the nurse manager for two surgical units in a 500-bed medical center. She has been a manager for nearly three years and has been able to initiate unit-based councils on both of her units. Jackie is grooming her staff to become more autonomous, to assume more responsibility in identifying goals and objectives to improve

patient outcomes, and to initiate and participate in nursing research. Members of her nursing staff excel at their jobs and have worked with the medical center’s nurse researchers on studies that have strengthened evidence-based practice and led to improved patient outcomes. When vacancies are posted for Jackie’s units, she receives


numerous applications from nurses already employed at the medical center who want to transfer to her units.

However, Jackie has noticed that the more her nurses grow professionally and patient outcomes improve, the more she feels isolated from and ostracized by her fellow nurse managers. If she passes fellow managers in the hallway or in elevators, they do not speak to her and avoid eye contact. During management meetings, her comments or ideas are either ignored or ridiculed. Jackie approaches one of her colleagues who was once a good friend and asks why she is being treated in this fashion. The former friend replies, “How do you expect us to act? All of your new ideas are showing us up and we have been managers a lot longer than you have! You are either with us or against us, and it seems to me that you are more concerned with making yourself look good than being one of us! Plus, you are stealing nurses from other units. You better stop this stuff or you are going to be sorry you ever took a management job!”

Adam is a physical therapist. He works at a prestigious rehabilitation hospital where he specializes in the therapy of patients who have suffered neurological impairment due to spinal cord injury, brain injury, and stroke. Adam is respected by his colleagues and his manager as a hard worker who is progressive in his ideas and innovative in developing plans of patient care. He is very interested in clinical research and evidence-based practice. Because of his interest in research and his innovative clinical skills, Adam is asked to serve as the physical therapy representative on the interdisciplinary neurologic research committee. Adam is eager to learn more about clinical research and participate in clinical research investigations. At first, his co-workers share Adam’s enthusiasm. However, once a month Adam attends a research committee meeting, during which time his patients are covered by another therapist. As part of his duties as a member of the research committee, Adam must coordinate with his manager and co-workers to schedule time to teach peers about research and participate in research projects. His peers begin to resent the time Adam is “given” for such projects, even though his new responsibilities require significant work on Adam’s part.

Adam’s peers begin to complain about him, making comments that he is not “pulling his weight” as a patient care provider. They start to avoid Adam and often fail to include him in off-duty social activities. Adam attempts to discuss these problems with his peers, but they only comment that they are tired of doing his work. One of them explains, “You are so into this research thing that you are forgetting that you are just a therapist like the rest of us. You think you are better than we are.” Adam is shocked and asks his manager for guidance. The manager replies, “Just try not to take it personally. They will get over it after some time has passed and they have more chances to participate in research. Try not to let it get to you.” Adam is upset, however, and begins to have trouble concentrating on his work.

Bernadette is a newly licensed RN. She is thrilled to have been hired to work on a large inpatient pediatric unit. Bernadette is assigned to work with a preceptor named Christine, who is an RN with ten years of experience as a pediatric nurse. Christine is an excellent clinician and has the respect of her co-workers. The nurse manager of the unit often refers to Christine as, “my best nurse.” However, as Bernadette’s orientation progresses, she finds that her co-workers respect Christine’s clinical knowledge, but are intimidated by her as well. Christine has a reputation for criticizing her peers and subordinates in front of others if she feels that they are “asking stupid questions” or “just do not know as much as they should.” Christine constantly criticizes Bernadette as well, making negative comments in front of patients and telling co-workers that, “I have my work cut out for me with this new nurse. They come out of school with all these fancy ideas but cannot carry a full patient load for weeks.” One of her colleagues tells Bernadette, “We are sorry you are going through this, but that is just Christine. If we try to help you she will turn on us too.” Bernadette makes an effort to talk to Christine privately about

these kinds of comments; however, Christine walks away from her and stops the nurse manager in the hallway. Rolling her eyes and laughing, Christine comments, “I guess I am in trouble. Our new little nurse has hurt feelings!” Bernadette has had enough and quietly walks up to Christine and her manager. “I am willing to work hard and learn. However, Christine’s actions are interfering with my ability to learn and provide my best patient care. If these behaviors do not stop immediately, I expect to be assigned another preceptor. If this does not happen I will file a grievance.” Christine is astonished. No one has ever had the courage to confront her like this. The manager looks embarrassed and says that perhaps assigning another preceptor would be best.

The preceding scenarios illustrate some of the behaviors associated with HV. Horizontal violence, as previously noted, is aggressive behavior directed toward one’s peers. Such behavior can involve verbal abuse, interfering with ability to work effectively, attempts to embarrass a peer, derogatory facial expressions, and attempts to undermine a peer [3,5]. The following definitions help to clarify HV and just how destructive the phenomenon can be. Some of these behaviors occur in other types of workplace violence, but for the purpose of this program, these definitions are written within the context of HV. Note that some behaviors can overlap and may fall under more than one category:

● Assigning unrealistic patient assignments: Assigning certain nurses to the most difficult patients on an ongoing basis or assigning an unfair workload and then refusing to help when needed [5].

● Backstabbing: Occurs when someone complains about a peer to others instead of speaking directly to that person about a concern or problem. This type of behavior undermines trust and confidence[4].

● Bullying: A set of behaviors designed to make a victim feel threatened, humiliated, insulted, and/or helpless. These behaviors can be verbal, suggest the threat of physical harm, and/or actually consist of physical actions designed to intimidate or cause physical harm. Bullying is not an isolated event. It is usually persistent, ongoing, and systematic [3,4].

● Covert behaviors: Actions that are not obviously aggressive or threatening [3]. Examples include being “too busy” to show a new employee where supplies are kept, excluding a colleague from social gatherings, and “forgetting” to tell a colleague about a schedule change. These kinds of behaviors can be especially hard to pinpoint because they can often easily be explained as innocent oversights. The victim of covert HV may have a hard time convincing a manager that he or she (s/he) is experiencing HV if the majority of the behaviors are covert [3].

● Disruptive behaviors: Actions that are designed to interfere with a peer’s job performance, which can increase the risk for error patient harm [4]. Disruptive behaviors can include all types of verbal and physical aggression and threaten the safety of both victims and patients [7].

● Incivility: Involves disruptive behaviors (such as refusing to speak to a colleague unless absolutely necessary) that often result in physical and psychological distress for the victims [3].

● Overt behaviors: Actions that are obviously aggressive and can be seen or heard. Overt behaviors include disgusted facial expressions, rolling of eyes, shouting, laughing at someone, criticism, fault-finding, gossiping, ridiculing, and arguing [3,6,7].

● Sabotage: A behavior designed to deliberately undermine or prevent someone else from succeeding [3,8].

● The silent treatment: Characterized by refusing to speak to a colleague, speaking abruptly, and withholding information are all behaviors that fall under the umbrella of the silent treatment [5].

● Taking the credit: Occurs when the perpetrator of HV takes credit for someone else’s work [5].


● Verbal abuse: Consists of spoken words that are meant to be unkind, belittling, and/or humiliating. Verbal abuse is meant to cause distress, embarrassment, and/or suffering [3].

● Workplace harassment: Any repeated words, acts, or patterns of behaviors against a co-worker or group of workers that are unwelcome are considered to be harassment [3].

Nursing consideration: Be aware of how the aforementioned behaviors can create a toxic work environment and how some of these behaviors are not especially overt, such as the silent treatment. Nurses must be aware of all types of behaviors that fall into the category of HV.

Consider how various behaviors are presented in the scenarios at the beginning of this section. Jackie, the nurse manager, is an innovative leader whose actions have helped to establish a work environment in which her staff thrives and positive patient outcomes are achieved. These accomplishments have angered her peers to the point that they instigate a number of behaviors that qualify as HV. They avoid speaking to her and avoid making eye contact. Such behaviors may be classified as covert since it can be difficult to prove that they are deliberately not speaking to her and avoiding eye contact. However, some of their other actions verge on verbal threats and intimidation. They ridicule her ideas, accuse her of stealing their staff nurses, and come close to overtly threatening her with the statement, “You better stop this stuff or you are going to be sorry you ever took a management job!”

Some staff members may not realize that managers are also victims of HV. They may assume that the phenomenon only exists at the staff level. Unfortunately, HV occurs at all levels of the organization. Jackie’s peers may be jealous, fearful that her success threatens their own jobs, or simply resentful of change. Whatever the reason or reasons, Jackie is dealing with HV at its worst. If she appeases her

peers, it is likely that patient outcomes and job performance may be compromised. If she continues to fulfill her management role as she believes best, her peers may make it difficult for her to continue working within the organization.

Now evaluate the situation that Adam, the physical therapist interested in clinical research, finds himself facing. At first, his colleagues are supportive and share his enthusiasm for the research process. Then, as his workload increases related to research participation, his peers begin to resent Adam, claiming that he now thinks he is better than the rest of them. Adam’s manager seems to want to ignore the problem, telling 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. Because of the HV, Adam is starting to have trouble concentrating on his work, which increases the possibility of error. What began as an exciting career opportunity has turned into a frustrating barrier to job satisfaction and the potential for compromised patient care.

Finally, review the scenario that describes the problems that a newly licensed nurse had to deal with during her orientation. HV committed by a preceptor and other, more experienced colleagues, is one of the most common occurrences of HV. An experienced nurse, reported to be an excellent clinician, is acting as the preceptor for a new nurse. This preceptor intimidates her co-workers, and probably her nurse manager as well. Bernadette, the new nurse, confronts the preceptor and the manager about the HV. Bernadette took action that all too few victims of HV have the courage to do: he confronted the perpetrator and the manager who seemed to be willing to ignore the HV and the impact it had on her personally and professionally.

The preceding examples show just a few of the many ways that HV is committed. Note that persons who witness or know about HV and fail to do anything to stop it are just as responsible for the continuance of the problem as are those who directly commit HV.

InCIDenCe AnD PreVALenCe oF HorIzonTAL VIoLenCeDiana and her husband have recently relocated across the country so that her husband can take advantage of a work-related promotion. She is a social worker with several years of experience in acute hospital settings. Diana interviews for a position in a large community hospital, hoping to continue working with intensive care unit (ICU) patients and their families. She has heard rumors that the social workers who work in the ICU are a close-knit group who do not necessarily welcome newcomers. During her interview with the director of the department, Diana asks about the orientation process and the hospital’s policies relating to HV. The department director laughs and says, “That is a problem pretty much confined to nursing. You do not see it in other departments.” Diana wonders if the director is naïve or just reluctant to address the issue.

Edward is an information technology (IT) specialist in a large urban medical center. He notices that one of his colleagues seems to be

especially tough on new employees. Frank is one of the best IT specialists Edward has ever worked with, but he has the reputation of being a bully and more than one employee has resigned because of his intimidating manner. Edward discusses the issue with his wife, a nurse, who tells him that Frank is committing HV and needs to be stopped. Edward admits that he never thought much about the effects of Frank’s behavior until now. He always thought it was just Frank’s personality, but now wonders if it is a lot more serious than that.

HV is not a new phenomenon, and as the preceding examples show, it can affect any and all healthcare professions. In fact, its occurrence and negative impact seems to be growing [6]. It is difficult to objectively determine if this growth indicates an actual increase in occurrence or an increase in reporting by victims.

research Approximately a decade ago there were only about 200 research articles pertaining to HV on PubMed [3]. Much of those articles were based on research conducted in the United Kingdom and Australia. Today, however, “horizontal violence” in a search engine results

in nearly ten million articles and posts. Thanks to experts, such as Kathleen Bartholomew, significant efforts are underway to study HV and to identify strategies to reduce it and/or prevent it from occurring[3,6].

InCIDenCe AnD PreVALenCeReports of HV incidence vary considerably, i.e. from 18% to as high as 76% of those surveyed [3]. This range is due, in part, to differences 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

reliable and valid measures. Investigators founds HV prevalences of 27% and 31% in nurses who reported experiencing HV [3,9].

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EBP alert! HV is not a phenomenon that is unique to the U.S. Internationally, one in three nurses reported that they plan to leave their positions due to HV. A study of 4,500 nurses in the United Kingdom showed that one in six nurses reported experiencing workplace mistreatment in the past year and 33 percent of them planned to leave their jobs because of verbal abuse [3]. This shows how important it is, even on an international level, for all nurses to take steps to curb this disturbing behavior.

EBP alert! HV is also not unique to the nursing profession. For example, two recent articles discuss bullying and lateral violence in the physical therapy discipline, including how to deal with it, and how to recognize if someone is committing it [10,11]. Thus, it is imperative that there be an interdisciplinary collaboration when it comes to decreasing HV.

According to the Workplace Bullying Institute (http://www.workplacebullying.org/) the workplaces most prone to bullying are healthcare, education and government [3]. The nursing literature contains numerous examples of HV. Results from some research studies indicate a startling prevalence [4]. The following information pertains to the incidence and prevalence of HV in nursing and associated behaviors in the U.S.:

● Verbal abuse contributes to 16 to 24% of staff turnover and 25 to 42% of nurse administrator turnover [3].

● About 60% of newly licensed registered nurses leave their first positions within six months because of some type of HV [3].

● Nurses who report the greatest degree of conflict with other nurses also had the highest rates of burnout [3].

● The 2011 staff of the professional journal Nursing conducted a survey of 950 nurses, asking them to identify the “frequency with which nurses experience or witness HV.” Eighty-two per cent of respondents reported experiencing or witnessing at least one type of HV on a weekly or daily basis [12].

● One-third of the nurses who responded to a survey about HV reported experiencing emotional abuse during their last five shifts worked [4].

● In another survey, 30% of the 2,100 nurse participants reported that disruptive behavior occurred weekly, and 25% reported monthly occurrences [4].

● A study involving emergency room nurses found that about 27% had experienced workplace bullying within the previous six months [4].

● A study focusing on frequency of HV found that at least 20% of respondents experienced incivility at least once a week [3].

● According to 2012 results from the Society for Human Resource Management and the Workplace Bullying Institute [3]:

● Eighty percent of harassment cases filed were legal and “could only be considered plain cruelty.”

● Seventy-three percent of reported instances of workplace violence involved verbal abuse.

● Sixty-two percent of respondents reported the existence of malicious gossiping or knew of rumors or lies spread about co-workers.

● Fifty-one percent of participating organizations reported incidents of bullying in the workplace.

● Fifteen percent of respondents witnessed emotional or psychological abuse of co-workers.

EBP alert! These statistics show the startling incidence and prevalence of HV. This makes it absolutely imperative that every effort be made to stop its progression and reduce its occurrence.

Despite the growing incidence and prevalence of HV or lateral violence, some administrators, managers, and even staff members fail to recognize or acknowledge it as a serious problem. Amazingly, some perpetrators do not even realize that their behaviors are actually a form of workplace violence. This lack of recognition makes it even more difficult to control HV. As Bartholomew, an expert in this field, points out, “Bullying behaviors are like gangrene— when tolerated from a few physicians or nurses with strong personalities, the behaviors spread and infect the entire team, and eventually, the patient.” [6]

CHoosIng VICTImsHow does someone become a victim of HV? How are victims chosen by those who commit HV? Consciously or unconsciously, victims are usually carefully selected by their perpetrators.

Victims are usually among the most vulnerable of staff members. They may be newly licensed professionals or newly hired colleagues who lack confidence and are without power or workplace friends who could help them adjust to their new environment and/or protect them from those who commit HV [5,13]. Researchers have identified certain factors that may make someone more vulnerable to HV. These include being [5,14]:

● A new graduate or newly hired staff member. Persons new to a profession or to a workplace often do not have friends or an established support network. Persons who are perceived to be alone are sometimes targeted by those who commit HV.

● Someone who has received a promotion or honor that causes resentment or envy among co-workers. For example, consider 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 their graduate degrees, but have not yet completed their studies. Some of these colleagues may show their resentment by behaving in ways that are characteristic of HV.

● A person who has problems working well with others or who has trouble acquiring new skills. These kinds of persons may be

perceived as being unable to “pull their weight” on a particular unit or as “trouble-makers.”

● Someone who receives special attention or recognition from supervisors or physicians. Attention and recognition may cause resentment, jealously, or even fear that others will be passed over for salary increases or promotions because someone else is getting special attention.

● Someone who appears to lack confidence. People who are timid, shy, or appear to have low self-esteem are more prone to become victims of those who commit HV.

Nursing consideration: Education regarding HV should include what may make a nurse vulnerable to this particular kind of workplace violence. Helping nurses to behave assertively without becoming aggressive may make them less likely to become a victim and help to reduce the problem as well.

EBP alert! Severe or chronic understaffing contributes to the risk of HV [5,13,14]. Therefore, it is important that those nurses who help to establish staff patterns and develop recruitment strategies realize that staffing issues may increase the incidence of HV.


CHArACTerIsTICs oF Persons WHo CommIT HorIzonTAL VIoLenCeRoseanne is a pediatric nurse who has extensive knowledge and expertise in her specialty. She has a reputation for being “hard” on her colleagues. She is quick to criticize her colleagues and the new nurses she helps to orient often resign before completing orientation. Roseanne does not see herself as intimidating. She sincerely believes that she is acting in the best interest of the patients by “protecting” them from nurses who are not as “smart” as she is. When Roseanne arrives at work, the nurse manager asks to speak to her in private. He tells Roseanne that she has been named in a grievance filed by one of her colleagues who recently requested transfer to another unit. Both the manager and Roseanne have been named in the grievance as committing HV. Roseanne was named for her HV behaviors, and the manager was named for failing to stop the behaviors even after the nurse brought them to his attention. Roseanne is outraged. “I am only doing my job! I have not done anything wrong!”

Most people, especially victims of HV, assume that those who commit HV know exactly what they are doing when they bully and intimidate others. However, many of those perpetrators of HV do not acknowledge their behaviors as damaging nor do they see themselves as bullies [5]. In fact, many abusive, disruptive actions are committed without awareness of the damage such actions may cause. Persons committing HV may frequently do so without awareness [11]. Consider the many causes of HV discussed earlier in this program. These reasons give clues to the characteristics of those who commit HV. These characteristics include [3,6,10,11]:

● A need for power and control: Persons who have power and control at work are often willing to behave disruptively in order to

maintain them. Persons who aspire to have power and control may likewise use aggressive tactics to acquire them.

● Belief that patients need protecting: Some persons believe that they are the only ones who know how to take proper care of patients. In their minds, their actions are justified since they are acting in what they see as the best interests of the patients.

● Fear: Persons who are fearful of being overshadowed by younger, less experienced colleagues may target these colleagues to secure their own places within an organization.

● Unhappiness at work or at home: Persons who are unhappy at work and/or at home may treat others badly. Without knowing it, they may be trying to make others as unhappy as they are.

● Inability to see the effects of their behaviors: Perpetrators of HV often refuse to see that their behavior has a negative impact on coworkers, patient outcomes, and the work environment.

● Feelings of increased pressures at work, including a lack of managerial support: Some nurses who feel fearful or overwhelmed by work-related pressures may take out their frustrations on others in the form of HV.

The preceding characteristics are not all-inclusive. They do, however, offer some awareness of the types of persons who are likely to commit HV.

Nursing consideration: Continuing education for nurses should include techniques for self-evaluation. Some nurses may not be able to acknowledge what motivates their behaviors and how to more constructively deal with fears and concerns.

PossIBLe CAuses oF HorIzonTAL VIoLenCeThere are numerous possible causes of HV. These vary, depending on the person committing the violence and the workplace environment. There may be more than one trigger of HV. In fact, it is usual to have

several factors that contribute to the instigation of HV. The following are examples of various triggers that may result in a person committing HV.

envyLisa is a highly skilled critical care nurse. She is accustomed to being seen as the expert by her colleagues. About two years ago Lisa helped to orient Sophie, a nurse who is now referred to as “one of the best nurses” by colleagues, the manager, and physicians alike. Lisa liked Sophie when she was a new nurse who was in awe of Lisa and her clinical skills. Now Lisa is afraid that Sophie is taking her place as the clinical leader on the intensive care unit. The two women are assigned to work on developing a research proposal. The day the proposal is to be presented to the institutional review board (IRB), Sophie is sick. Lisa presents the proposal as entirely her own work and implies that Sophie did nothing to help with its development.

● The preceding example illustrates one possible cause of HV: Envy or jealously is an attitude that is usually accompanied by bitterness and resentfulness [5]. Envy may be related, as in Lisa’s case, to jealously of a colleague’s clinical skills and the fear that the role of acknowledged clinical expert is going to be lost. Other work-related reasons for envy that leads to HV may include: Jealously of

persons who seem to have developed professional friendships with managers or other administrative personnel; jealousy of persons who have received promotions or other career advancement opportunities; and/or jealousy of persons who have the opportunity to pursue education opportunities such as graduate education.

Envy does not have to be limited to jealously of work-related issues. Perpetrators of HV may be jealous of a peer’s personal life. They may envy someone who has a loving spouse or significant other, or children, or a close circle of friends. This envy may cause them to retaliate by committing HV against those whom they envy.

Nursing consideration: Envy is a difficult emotion to acknowledge. Even more difficult to acknowledge is the fact that envy can lead to destructive behavior. Nurses need to work on supporting their colleagues, and examining their own feelings and behaviors. These are two ways to begin to halt the spread of HV.

Control and powerJackson is the manager of a physical therapy department in a small rural hospital. He has been the manager for over 15 years and has more managerial experience than most of the managers of other departments. Seniority and experience are greatly valued in this hospital, and the chief executive officer (CEO) supports Jason as one of the key decision-makers of the organization. Jason is confident in his ability and in the professional rapport he has established with the CEO. Jason gets a lot of satisfaction knowing that his experience is valued. He controls his department strictly and is rather autocratic in

his management style. Jason discourages change and innovation and most of the other managers would rather agree with him than “get on his bad side.” He believes that his way is best since his department has a record of achieving patient outcomes, the respect of the physicians, and a low incidence of adverse occurrences. Turnover is low and Jason knows it is likely to remain low since his hospital is the only one in the immediate geographic area.


However, things start to change when the CEO retires and a new administrator assumes responsibility for fulfilling a mandate from the board of directors: Expand outpatient services by establishing an outpatient therapy clinic. Several new managers are hired for various departments, including occupational therapy, nursing, and cardiac rehabilitation. These managers are eager to initiate planned changes to fulfill the board of directors’ mandate. They have skills and ideas that are openly praised by the new CEO. Jason believes he is losing control over the organization that he has helped to guide for many years. In an effort to maintain this control, Jason begins to target the new managers by complaining about them behind their backs and telling the new CEO that “these new people do not know what they are doing.” Jason’s behavior causes a great deal of dissention among the

management staff and effectively slows progress on development of the outpatient services.

The need for control often co-exists with envy. As in Jason’s case, he may be envious of the new managers’ skills and ideas that are obviously valued by the new CEO. He is also determined not to lose control over his work situation. He is equally determined not to lose the power he has had for many years thanks to his seniority and friendship with the former CEO. The need for power and control often go hand-in-hand. Jason has lost sight of the goals of the organization. He commits HV in order to try to maintain his sense of control and power over others, which if left unchecked, may become the defining characteristic of his organization [3,6,14,15].

FearJoAnne is an RN who has an associate degree. She has been a nurse for five years and consistently receives excellent performance evaluations. Recently, the healthcare system for which she works has announced that beginning immediately, RN vacancies will be filled only with nurses who have BSNs. Nurses who do not have BSNs will not be terminated but they will not be eligible for promotion to certain levels of staff nurse, nor will they be eligible to apply for managerial positions. The healthcare system offers tuition reimbursement and some college courses will be offered at the hospital in an effort to facilitate nurses’ ability to obtain their BSN degrees. JoAnne is very 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 to encourage other nurses who do not have BSNs to avoid colleagues who do. She instigates a campaign of “silent treatment” toward these

colleagues and as nurses with BSN degrees are hired, JoAnne makes sure to spread gossip about their lack of knowledge and skill.

Fear is a powerful motivator. Fear of change, fear of the loss of respect, and, as in JoAnne’s case, fear of job loss all contribute to fear as a cause of HV [3,10,15]. Fear is closely aligned with envy and a need for control. Some perpetrators of HV commit aggressive acts in an effort to gain or maintain control over situations that they perceive to be threatening or harmful. Those who commit HV may do so in an attempt to combat fear caused by what they perceive as threats to their jobs or status within an organization.

Nursing consideration: Fear can be an especially powerful as well as a destructive emotion. Managers should be educated to recognize that fear can be triggered by change such as the constant need to update skills and knowledge.

The need to belongHenry is an occupational therapist who works at a prestigious spinal cord injury center. He is a member of interdisciplinary team that has a national reputation for excellence. The work is hard but rewarding, and there are multiple applicants for every vacancy that is posted. When Henry was hired almost two years ago, he had to struggle long and hard to be accepted by the team. He experienced a variety of HV actions committed by members from the occupational therapy, physical therapy, and nursing departments. He tries to convince himself that his colleagues’ behaviors made him a better therapist since he had to excel to prove himself to be a competent member of the team. Henry is relived that after nearly two years he is an accepted member of the team. Recently, a new occupational therapist joined the organization, and Henry observes that many of the colleagues who were hard on him are bullying and intimidating the new therapist. Henry would like 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 colleague will survive and that this is just something all new hires must go through. But he feels guilty and a bit ashamed of his own failure to try to put a stop to the aggressive actions of others.

The need to belong is powerful and, as in Henry’s situation, it is often accompanied by fear. This can be fear of loss of friendship, fear of not being “part of the team,” and/or fear of retaliation. If Henry would try to help his new colleague, would he once again become a victim of HV?

Some former victims of HV may become participants in an effort to appease the person or persons who commit HV. Persons like Henry may ignore or go along with HV in an effort to avoid becoming victims again [3,5]. Those who witness HV are in excellent positions to help stop its ongoing perpetration. Having had to deal with the effects of HV should (but often does not) make victims more willing to take steps to stop it. Unfortunately, fear of staying or becoming a victim often makes people ignore, or even participate in, the act of committing HV.

Nursing consideration: The need to belong can be a powerful motivator. People who ignore HV are just as guilty of such aggression as those who actually commit this type of violence. 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 violenceStephanie is critical care nurse who works in a large trauma center emergency room. The work is extremely challenging and only those nurses with excellent trauma skills and stamina survive the hectic pace and demanding work schedule. Stephanie is assigned to participate in the orientation of most newly hired nurses. She criticizes them in public and ridicules them for asking “too many questions.” She also criticizes her experienced peers in this manner. The turnover rate is quite high and many of those who resign mention that Stephanie’s 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 resignation of ten highly

qualified nurses during the past 12 months. Stephanie responds by rolling her eyes and saying “If they cannot stand the pressure and a little honest criticism then they do not belong here. They deserved what they got. I am not here to babysit new nurses!”

This scenario is a good example of blaming the victim, a justification sometimes used by those who commit HV. In other words, it is the victim’s fault that s/e was subjected to HV [3,14]. Persons who commit HV may justify their behavior, with excuses such as:


● “These people who are complaining that they are poorly treated are just looking for ways to excuse the fact that they cannot do the jobs they were hired for.”

● “Some people just cannot take criticism.” ● “I was just kidding around. They cannot take a joke.” ● “If they cannot take the pressure of working here then they should

just leave. It is their fault if they cannot work up to my standards.” ● “This is nothing compared to the way I was treated when I first

started working here!”

● “These new nurses with fancy degrees just do not know what it is like in the ‘real’ world.”

● “New nurses should be seen and not heard! They deserve what they get if they try to tell me how to take care of patients.”

● In the minds of these perpetrators, their victims were “asking for it.” They truly believe that the victims are at fault. In other words, “they brought it on themselves.”

Initiation or rite of passageSarah is a new social worker. She works in an outpatient oncology clinic. After another hard day at work during which she was assigned the most difficult patients, ignored by her co-workers, and asked to work on Saturday even though this should have been her weekend off, 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 people acted like this in the real world.”

Initiation or rite of passage as an excuse for HV may seem, as Sarah thinks, like going through the hazing process conducted by college fraternities and sororities. Viewed by some who commit HV as “paying your dues,” this concept justifies HV as something that every employee must go through to prove they are “worthy” of the 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.

Persons who use rite of passage or initiation as an excuse to commit HV have probably had to go through a similar initiation themselves. Therefore, in their minds, because they were once treated poorly, everyone who follows them must also be treated poorly [3,5,14].

Nursing consideration: Attempting to justify HV as a form of initiation is sometimes tolerated and even encouraged by some nurse managers, especially in high pressure areas such as the emergency department. It may be viewed as a test for new nurses or other new employees to see if they can handle stress. It is actually just cruelty. This tactic leads to an ongoing cycle of HV that is self-perpetuating. Nurses must do everything they can to break this vicious cycle of abuse.

opposition to changeLouis is a respiratory therapist. He has worked at a large long-term care facility for several years. Louis enjoys his job and likes having the chance to get to know patients and families as opposed to the hectic pace of acute care. When he arrives at work one morning, his manager tells him that the owners of the facility have decided to build an addition to the building. This addition will be the location of a new program that will offer short-term stays for patients needing rehabilitation after suffering a stroke and other debilitating conditions. Louis is told that he and the other therapists will need to rotate through this unit to provide respiratory care to these short-term patients. Louis is annoyed and immediately begins to wonder if this change will lead to more change and more problems. He worries that his job responsibilities will change and that he may not be able to deal with acute patient rehabilitation needs. How will these changes affect his work schedule? Will his job be in jeopardy? Several of Louis’ colleagues are enthusiastic about the new rehabilitation program and talk about taking some continuing education courses to prepare for the new patient population. Now Louis begins to worry that these colleagues will outshine him when the new program is implemented. Louis begins to ridicule his colleagues’ enthusiasm. He opposes their ideas in staff meetings and complains to his manager that they are so

busy preparing for new types of patients that they are neglecting their current job responsibilities. Louis’ fear of change is triggering HV.

The workplace literature is filled with references related to change and how much opposition change triggers. Change often triggers worry and fear [3,6]. Examples of these types of worries and fears include [16]:

● Fear of failure: The need to continue to do what feels comfortable is often linked to nurses’ fears that they may not be able to learn new skills that change may require.

● Fear of lack of support: Nurses may worry that they will not be supported by management as change is implemented.

● Fear of the unknown: Some nurses may fear change because it will cause changes in the way the organization functions and, consequently, in how they will be expected to do their jobs.

● Fear of being embarrassed in front of colleagues: Change usually requires the acquisition of some type of new knowledge or skill. Some nurses may be afraid that they may be slow to learn and thereby be embarrassed in front of colleagues.

The preceding scenario shows that people like Louis react to change (and their own fears and concerns) by lashing out at co-workers and committing HV.

generational differencesEmily is a nursing professional development specialist. She is preparing a series of continuing education programs regarding HV, e.g. how to deal with it, and how to stop it. Some content must be devoted to potential generational differences as possible triggers for HV. Emily does not want to stereotype members of each generation. How can she address the issue without over-simplifying the issue of generational differences?

The term generation gap has been around for a very long time. Conflicts among generations come from differences in upbringing, education, and experiences of world events. For example, older adults remember a time when homes and cars could safely remain unlocked while young colleagues cannot imagine a world in which not only homes and cars must be secured, but even school buildings

as well. Baby Boomers entered a workplace in which employees saw themselves in terms of the organizations for which they worked. Succeeding generations, who saw their parents downsized, sometimes after years of working for one organization, developed a loyalty to themselves, not to their places of employment. These generations are usually accustomed to change and consider it the norm, not the exception. Professionally, some generations see themselves in terms of their professions, not in terms of their employers. The newest members of the workforce expect flexibility in work hours and a work environment that offers time for “fun” as well as time for serious discussion. These members are accustomed to conducting life at breakneck speed thanks to the instant means of communication (e.g. Internet, texting, iPads, etc.) and learning opportunities that are now available [17].


No matter what generation an employee represents, there are certain principles that apply to everyone when it comes to a healthy work environment and to the reduction of HV. Here are some guidelines to help bridge the generation gap [17]:

● Remember not to generalize about a person because of their age, education, or work experience. For example, do not assume that an older colleague is computer illiterate. S/he may thrive on technology. Do not assume that younger colleagues automatically adapt well to change. They may be significantly opposed to change.

● All adults, no matter their age or professional experience, bring an abundance of life experiences with them to the work setting. These

experiences usually enhance an adult’s ability to fulfill their role responsibilities.

● All adults, no matter their age, background, or professional experience, deserve to be treated with respect.

● HV is not limited to an older colleague victimizing a younger colleague. HV can be committed by a member of any generation against members of any other generation, including their own generational peers.

Nursing consideration: It should not be assumed that the cause of HV is due solely to generational conflicts. There is seldom one single cause of HV. Generally, several factors come together to trigger this phenomenon.

oppression theoryDavid is a nursing student in his junior year at a large metropolitan university. As part of a major class project, David must prepare and present a paper on the history of nursing. He decides to include information on oppression theory. His professor asks what oppression theory has to do with the history of nursing. David replies that oppression theory is relevant since nurses, over the years, have been part of this type of theoretical framework, especially when it comes to HV.

Oppression theory is based on the belief that whenever two or more groups co-exist and one group has more power than another, a power imbalance exists. This imbalance leads to the development of a dominant group and a subordinate group. When the values of the subordinate group are ignored, ridiculed, and/or repressed, oppression occurs [3].

Experts in the field of HV often apply oppression theory to HV in the nursing profession. Some believe that from its conception, the members of the nursing profession were told to assume a subordinate position, which almost automatically predisposed them to oppression[3].

Some experts believe that academic education may be ineffectual in preparing nurses to deal with bullying. It is imperative, as part of basic education preparation, that nurses be taught to project confidence and deal with conflict effectively [5]. Without this preparation, nurses are in danger of completing their entry level education feeling uncertain and dependent.

When nursing was initially established as a profession, all or nearly all of its practitioners were women at a time when women had few, if any, legal rights. In most countries women could not vote, own property, or in some cases, inherit money or property. Women were not expected to work unless absolutely necessary and work opportunities were limited to domestic service, teaching, and other jobs that were deemed “acceptable.” Nursing offered an opportunity for women to earn their

own livings, but in order to be considered a respectable profession for women, nursing was advertised as a “calling” or a desire to do “God’s work.” [2] Such beliefs led to the portrayal of nurses as [3]:

● Always caring and compassionate. ● Being “angels of mercy.” ● Willing to work long hours without reward. ● Never complaining. ● Fulfilling a subordinate role. ● Following orders. ● Remaining quiet. ● Deferring to others.

As a result of advancements in nursing education and training, these beliefs are beginning to fade. However, research shows that some people, even healthcare colleagues in other disciplines, continue to uphold these beliefs. This prolongs what is sometimes referred to as the culture of oppression in nursing [3].

Persons who believe that they are members of a subordinate group may feel that they are oppressed and powerless. According to oppression theorists, these feelings lead to hostility, anger, and the desire for control. One way of gaining control is to oppress others, whether it be out of frustration, anger, or simply the desire to subordinate others as a way of responding to subordination that HV perpetrators are experiencing themselves [3].

It is wrong to assume that other disciplines (besides nursing) do not experience oppression. It is also wrong to assume that male nurses do not experience oppression. This phenomenon can affect anyone depending on the work environment and other factors that contribute to the development of HV. It has been suggested that one reason for a lack of significant amounts of HV research regarding professions other than nursing is a failure to admit that HV exists. Sadly, some healthcare managers and staff members ignore the problem, try to hide its existence, or simply refuse to believe that HV behaviors are harmful.

Failure to admit that HV existsPaula is an RN who has worked on various oncology units for the last seven years. She recently relocated from a small city to a large urban area. She has interviews at several hospitals. Two questions Paula routinely asks the manager and staff members are: “How do you deal with horizontal violence?”; and “What hospital policies and procedures are in place to discourage workplace violence, including HV?” If either a manger or his or her staff members deny that HV exists, Paula knows that she does not want to work for their organizations. She knows that HV exists to varying degrees in all organizations. Paula expects an honest appraisal of the problem and information about hospital policies and procedures pertaining to HV. Having experienced HV in the past, Paula has learned to evaluate how potential employers work to reduce and/or eliminate the problem.

There are many reasons that HV is not recognized or acknowledged as well as excuses for its occurrence. Here are some managerial reasons and excuses for allowing the problem to continue [3,4,14]:

● Managers may be reluctant to implement policies and procedures pertaining to HV because they are afraid that their departments may acquire a reputation for unpleasant working conditions which may interfere with recruitment efforts.

● Managers may ignore or downplay the problem of HV for fear of “offending” the perpetrators. Persons who commit HV may be some of the most experienced clinicians. Some managers are willing to put up with bullies who instigate HV if they are valued by management for their clinical expertise or other job-related skills.


● Managers may fail to acknowledge HV for fear that their supervisors and administrative staff will believe that they cannot deal with personnel problems.

● Managers may believe that a certain amount of bullying is necessary to identify employees who lack confidence and assertiveness.

● Managers may be unaware of the adverse effects of HV and assume that it is not a serious problem.

● Managers may actually believe that employees must go through a rite of passage to work in their departments.

The preceding are a few examples of reasons management staff may give for failure to admit that HV exists. Here are some reasons staff members/peers may give for failing to admit that HV is a significant problem [3,4,5,14]:

● As previously noted, persons most vulnerable to HV are those who are new to the organization, lack confidence, or seem unsure

of themselves, e.g. “Claiming that HV exists is just an excuse for weak or ineffectual staff members to make trouble.”

● Dealing with HV is just part of the job, e.g. “If people cannot deal with criticism then they do not belong here!”

● 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 so should everybody else.”

● Fear is a powerful motivator for ignoring HV, e.g. “I feel bad when I see new people getting abused, but if I say something I am afraid they will go after me too.”

Nursing consideration: One reason for ignoring the problem of HV or dismissing it as unimportant may be that mangers and staff members alike do not realize the serious impact HV can have on its victims, patients, and the organization. Some managers may simply assume that the problem is insignificant or low on their priority of managerial concerns. Managers and administrators alike need education regarding the serious consequences of HV.

THe ImPACT oF HorIzonTAL VIoLenCeHorizontal violence is toxic to its victims, patients, and the organization in which it takes place [6]. HV takes a toll on the physical and mental health of its victims, puts patients’ safety at risk by increasing the potential for error, and costs the organization thousands upon thousands of dollars [5,6]. Any plan to reduce and/or prevent the occurrence of HV must begin with an analysis of the impact of HV.

The Joint Commission has identified disruptive and intimidating behaviors as ones that “undermine a culture of safety.” [18] In 2008 The Joint Commission emphasized its concern about these types of behaviors by issuing a Sentinel Event Alert on the topic. In this alert The Joint Commission describes disruptive and intimidating behavior as including “overt actions such as verbal outbursts and physical threats as well as passive activities such as refusing to perform assigned tasks or quietly exhibiting uncooperative attitudes during routine activities.” [18]

Nursing consideration: The 1999 Institute of Medicine (IOM) report “To Err is Human” recognized that “dangerous, reckless, or impaired” behavior can sometimes lead to patient harm [18]. Nurses should be familiar with leading healthcare associations’ and accrediting organizations’ published documents that address the issue of HV and other forms of workplace violence and support the implementation of their recommendations for reducing workplace violence.

The most gripping reason for tackling the problem of HV and other types of workplace violence is the fact that disruptive and intimidating behaviors can lead to medical errors and patient harm. Other additional and compelling reasons to address HV include [18]:

● Persons who have a history of disruptive behavior pose the greatest risk for the filing of lawsuits against U.S. healthcare organizations.

● Disruptive behavior is contradictory to high professional standards. ● Disruptive behavior contributes to poor teamwork, toxic work

environments, increased patient complaints, and difficulty recruiting and retaining nursing staff.

Nursing consideration: A Sentinel Event is The Joint Commission’s response to an unexpected occurrence “involving death or serious physical or psychological injury or risk thereof.” Risk thereof “includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome.” [19] The Joint Commission’s 2008 Sentinel Event warned that “rude language and hostile behavior among healthcare professionals goes beyond unpleasant and poses a serious threat to patient safety and overall quality of care.” [19] Healthcare leadership, including nurses at all hierarchical levels, must acknowledge the seriousness of HV and work to prevent it.

Impact on patientsVeronica is a physical therapist with several years of experience in acute care settings. She has worked with orthopedic patients for several years, but has always been especially interested in the physical rehabilitation of stroke patients. She works in a large health system that consists of an acute care hospital, several outpatient clinics, and a rehabilitation hospital. A vacancy in the rehabilitation hospital would allow her the opportunity to work with stroke patients and expand her knowledge of neurologic physical therapy. She applies for and is hired to fill the position in the rehabilitation hospital. However, her new colleagues are less than welcoming. She receives little orientation to her new duties and her co-workers are always too “busy” to help her adjust to her new job. She overhears them complaining about her. Apparently, they wanted another candidate to fill the vacancy for which Veronica was hired. She hears them conspire to make things difficult for her so that she will “go back to orthopedics where she belongs.” Part of making things difficult includes failing to communicate some essential patient information about one of Veronica’s patients. This patient began a new medication that may cause him to have trouble concentrating until he adapts to its effects. Not knowing about the medication, Veronica continues to teach the

patient how to transfer from wheelchair to toilet. The patient is unable to concentrate and loses his balance. Veronica is able to stop him from falling and as she attempts to lower him back to his wheelchair she calls out for help. Her colleagues take their time coming to her assistance, and when they arrive they find both Veronica and the patient on the floor. The patient has a laceration of the forehead and Veronica suffers muscle damage to her lower back.

HV interferes with effective communication among colleagues. Experts agree that inadequate communication interferes with the exchange of information critical to the safety and well-being of patients [2,4,12,21]. The potential for errors increases and if errors occur patients can be injured and desired outcomes compromised. The preceding scenario may seem extreme, but, unfortunately, similar situations do occur. It is doubtful that Veronica’s colleagues wanted to see either her or her patient suffer injury. However, sometimes those who commit HV are so intent on intimidating their victims they fail to consider just how serious the consequences of HV can be.


EBP alert! Research also shows that poor communication has a significant negative impact on patient care and teamwork. Medical errors are the third leading cause of death in the U.S. It is estimated that 80% of serious medical errors involve some type of miscommunication, especially during the transfer of care from one provider to the next [20]! It is important that as part of continuing education, research evidence should be used to stress the impact of poor communication as it relates to HV.

Communication breakdown is not the only factor that can lead to patient harm. If victims of HV are flustered, uncertain, and experience a decrease in confidence, they are more likely to make mistakes. HV perpetrators may not want their victims to succeed at work. However, what they often fail to understand is that setting up a peer for failure can also set up a patient for serious harm. HV violence creates a workplace environment that is dangerous to victims and patients alike. In fact, HV victims may experience damage to their physical and mental health and well-being [2,3,10].

Impact on physical health Leslie is an occupational therapist who works in a large medical center. The occupational therapy (OT) department is divided into units, and each unit is responsible for specific specialty areas. Leslie was just promoted to the position of manager of OT for the spinal cord center. She is excited about this new career opportunity. However, her managerial peers are less than welcoming, and she becomes a victim of HV. Leslie becomes anxious and stressed and, in her words, “I seem to catch every cold and virus that is going around.” One of her peers comments that, “Leslie sure takes a lot of sick time. And when she is at work she always seems to have a cold or a sore throat or something. I do not even like to be around someone who is sick all of the time!”

Tim is a nurse on the pediatric unit. He has five years of experience in the specialty and his performance evaluations are consistently excellent. However, one of his peers, Kathy, a nurse with 30 years of experience as a pediatric nurse, dislikes Tim. She believes that it is unnatural for a man to want to work in pediatrics but is careful not to say so at work. She rolls her eyes when he speaks during staff meetings and goes out of her way to make sarcastic jokes about him to their peers. Tim has attempted to discuss her behavior with her but she claims she is not doing anything wrong. Their nurse manager tells Tim that unless Kathy does something that can be proven as HV, there is nothing that can be done. Tim begins to avoid Kathy as much as possible. He notices that he is experiencing a rapid heart rate and some heart palpitations that he attributes to caffeine intake even though he rarely drinks caffeinated beverages. His wife encourages

him to see his physician. Tim reluctantly does so. After a thorough physical exam, his physician begins to suspect that Tim’s rapid heart rate and minor arrhythmia are stress-related.

The preceding scenarios show that HV can have a physical impact on those who experience it. HV causes stress and anxiety. The healthcare literature is filled with references to stress and its impact on the body. The stress triggered by HV can have detrimental effects on physical health [3,6]. A review of the literature shows that many victims of HV experience the following physical effects [3,14]:

● Decrease in the effectiveness of the immune system: When the immune system is compromised, the body’s resistance to infection is decreased, and the affected person is more vulnerable to illness.

● Increase likelihood of accidents and injury: Stress interferes with a person’s ability to concentrate and focus on tasks. Lack of focus and concentration makes a person more likely to make mistakes, have accidents, and suffer injury.

● Increase in the incidence of cardiac arrhythmias: Stress can have an adverse effect on the cardiovascular system, causing problems such as elevated blood pressure and heart rate as well as arrhythmias.

● Increase in sick days taken: The negative impact on the immune system and the cardiovascular system as well as the increased likelihood of accidents and injury all contribute to an increase in the number of sick days taken from work.

Impact on psychosocial healthJay is a neuropsychologist who works in a prestigious medical center in a large U.S. city. The work environment is quite competitive and the incidence of HV is high as Jay and his colleagues compete for career advancement. Jay, the youngest member of the staff, is often subjected to HV by his older colleagues who resent their younger and highly skilled colleague. Jay finds himself becoming quite irritable, and is increasingly short tempered with his wife and children. One evening Jay’s five-year old son forgets to put his toys away as he has been learning to do. Jay shouts at the boy and tells him that as a punishment he is going to give away the boy’s new tricycle. The boy bursts into tears and runs to his room. Jay’s wife is furious and tells 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 the problem or you can find someplace else to live!”

Wendy is a nurse practitioner who works in a large outpatient clinic. She excels at her job and has the respect of her supervisors and peers. 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 about the HV and sometimes finds herself suffering from periods of severe anxiety when she remembers the abuse she suffered.

Raymond is an RN working in a neurologic intensive care unit. The work environment is quite stressful. There is little trust among members of the nursing staff, who always seem ready to discredit a colleague in an attempt to gain the attention of the physicians and nurse manager. Raymond usually has a couple of glasses of scotch

every evening to “relax” after work. Lately his friends notice that instead of “a couple” of drinks Raymond has taken to drinking so much that he has to be driven home because he is too drunk to safely drive.

Bullying behaviors can cause psychological damage that can last a lifetime. Researchers from Duke University interviewed 1,400 children between the ages of nine to sixteen about their social lives. Ten years later, the researchers interviewed the same children and found that children who had been victims of bullying were [3]:

● Four times more likely to have an anxiety disorder. ● Four times more likely to have an antisocial disorder.

Researchers also found that the most troubled group affected by bullying was children were had been both victims as well as perpetrators of bullying. These children were 14 times more likely to develop a panic disorder and almost five times more likely to be depressed [3].

HV can cause serious psychosocial problems as well as physical illness. These problems can range from anxiety to major depression, substance abuse, and damage to interpersonal relationships. The following psychosocial effects have been reported by some victims of HV [3,14,22]:

● Feelings of anger, irritability, and aggression: Victims of HV often find themselves experiencing and displaying anger and irritability to an unusual degree. Aggressive behaviors such as road rage and arguing with friends and family over trivialities to an


excessive degree may also occur. The first scenario in this section describes how Jay’s anger and frustration are being taken out on his family at home.

● Damage to interpersonal relationships: The first scenario also shows that Jay’s aggressive behaviors at home are having a damaging impact on his relationships with his wife and children. 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 siblings.

● Depression: Clinical depression may also occur as a result of HV. Depression can impact all facets of a person’s life. Depression can become so severe that the person loses interest in work, leisure activities, and interpersonal relationships. Suicidal thoughts may even occur.

● Decreased self-esteem and self-worth: Feelings of worthlessness may occur. The victim of HV may begin to believe that s/he is unable to live a productive life. Confidence is destroyed. Self-doubt is prevalent. These kinds of feelings are also symptomatic of depression.

● Feelings of loss of control over many aspects of life: These feelings may begin with a loss of control in the work environment as the perpetrators of HV assume toxic control in the workplace. These feelings may spread into the victim’s personal life as well.

● Decrease in motivation: The victim of HV may lose interest in work. S/he believes that the workplace is so toxic that there is no point in trying to do a good job. This lack of motivation may also affect the victim’s personal life. Family and friends may notice that the affected individual has no interest in home and/or family, or in the pursuit of leisure activities. S/he may seem lethargic and apathetic and have no interest in normal activities. These feelings and behaviors can also be symptomatic of depression.

● Substance abuse: Raymond, in the preceding third scenario, has begun to use alcohol to relax and forget about his problems at work. There are a variety of substances that can be abused. In addition to alcohol, prescription drugs and illegal drugs may also be abused. Food is another substance that can be abused. Over-eating may be a coping mechanism when trying to deal with the effects of HV.

● Post-traumatic stress disorder (PTSD): PTSD is a mental health disorder that can develop as a result of experiencing a traumatic

event such as HV. PTSD is characterized by ongoing anxiety, panic attacks, aggressive outbursts, nightmares about the traumatic event, experiencing “flashbacks” during which the event is relived, and avoidance of situations and activities that remind the person of the stressful event. To qualify as PTSD, these symptoms must last for at least one month following the traumatic event [23].

EBP alert! A number of research studies support previous findings regarding the psychosocial impact of HV [3,23]:

● A 2012 study of the psychological impact on psychological health conducted in Australia found that the impact differed depending on the type of healthcare facility in which the nurses worked. Full-time nurses who worked in aged care (long-term care) reported higher psychological distress than part time workers. Nurses who worked in the hospital setting reported higher psychological distress. Nurses who worked in aged care also reported higher rates of depression.

● In Sweden, 4,238 workers from the Institute of Environmental Medicine who witnessed workplace bullying were followed for 18 months. At the conclusion of the evaluation period, women who witnessed bullying showed a higher prevalence of clinical depression (about 33%) compared to male witnesses (about 16%). Thus, just witnessing bullying was a significant risk factor for the development of depression.

● California researchers found that more than 50% of people who experienced hostility at work reported that they spent time worrying about the hostile incidents and its future consequences. Additionally, experiencing hostility was found to be harmful to job performance. Researchers found that even a one-time experience can adversely affect cognitive function and creativity.

● PTSD can continue to affect people for years after experiencing the traumatic event that triggered the disorder. Some research shows that 50% of persons who experienced HV suffer from stress and PTSD for as long as five years after the event.

Research findings such as these should be part of the continuing education employees receive regarding HV.

Impact on the organizationCheryl is a nurse manager who has been having trouble managing her unit’s budget. She is summoned to the Director of Nursing’s office. The director tells her that her unit is significantly over budget. Turnover is high and the unit is developing a reputation for conflict among

staff members. It is estimated that Cheryl spends as much as 30% of her time dealing with conflict and that this is costing many tens of thousands of dollars.

FinancesThe preceding scenario is not as uncommon as one may think. A study conducted by the American Management Association regarding the cost of conflict in the workplace estimates that managers spend about 20-50% of their time dealing with conflict in the work place. This translates to hundreds of thousands, to even millions of dollars annually, depending on the work place and the extent of conflict [22].

How does the impact of workplace HV and other forms of bullying translate into measurable finances? According to The Joint Commission, the impact of bullying on the organization includes [24]:

● Lower morale. ● Lower productivity. ● Increased absenteeism. ● Rapid and increased turnover. ● Compromised patient safety.

EBP alert! The estimated cost of replacing a nurse is $27,000-$103,000. Since HV leads to an increase in turnover, it is possible to correlate resignations/transfers with HV (if the nurses report it) with the costs of replacing and orienting a nurse [24]. HV can cost tens of thousands of dollars as a result of turnover alone.

There are financial ramifications associated with all facets of HV’s impact on the organization. Here are some of the primary factors closely associated with HV and its impact on organizational effectiveness and financial solvency.


recruitment and retentionAmanda is a newly licensed RN who is interviewing for her first job as a registered nurse. During the interview, she asks questions about turnover and the policies and procedures that are in place to deal with HV. The human resources director and nurse manager are surprised. They are not prepared to answer questions about these sensitive issues.

Healthcare organizations can quickly acquire a reputation for having a dysfunctional work environment. Word of mouth and social networking sites all contribute to the ease with which information about an organization can spread. In this day and age, information about HV and other forms of bullying are also easily communicated.

Nursing consideration: HV and other forms of bullying are becoming increasingly common on Internet social media sites. Nurses and other healthcare professionals may also choose to use social media to degrade and humiliate their colleagues as well as their workplaces. This has legal as well as ethical implications. Most organizations have established policies that address the nurse’s use of social media outside of the workplace [25]. Thus, nurses must be aware of how and why they use social media to discuss work-related issues.

Healthcare professionals are becoming more knowledgeable about asking questions concerning the work environment, including the occurrence of workplace violence. If managers and human resources personnel deny the problem exists or are unable to explain the policies and procedures that govern the problem, candidates may very well choose to work elsewhere. Administration, mangers, staff, and human resource personnel must first be willing to admit that HV exists. It 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 following are some statistics from the literature pertaining to recruitment and retention and HV [3,4,14]:

● The turnover rate for clinical practicing nurses is between 33% and 37% in the U.S.

● The turnover rate for newly licensed RNs in the U.S. ranges from 55% to 61%.

● It is estimated that about 60% of newly licensed nurses in the U.S. resign from their first positions within the first six months of employment because of some type of HV.

● Job dissatisfaction contributes to both turnover and HV. A study of 43,329 nurses from Canada, England, Germany, Scotland, and the U.S. showed that job dissatisfaction was high in all countries represented except for Germany.

Research shows that newly graduated/licensed nurses are at the greatest risk for experiencing HV. They often lack confidence and support systems at work which makes them vulnerable to HV. Recent data relating to new nurse turnover rates include [3]:

● Turnover rates of 17.7% the first year. ● Turnover rates of 33.4% the second year. ● Turnover rates of 46.3% within the third year.

HV is also a leading cause of experienced nurses leaving the profession. Disruptive behaviors are directly linked to job dissatisfaction and intent to leave the job and the profession. Coworker incivility seems to be the most damaging HV behavior and causes high levels of mental health symptoms [3].

EBP alert! Experts anticipate a significant upcoming nursing shortage. By 2020, the number of employed nurses needed to serve the older adult population will increase by 26% (an increase of 712,000 nurses). An additional 495,000 replacements are needed to replace the current numbers of retiring nurses [3]. This means that establishing positive work environments is essential to recruiting and retaining nurses. A positive work environment is one that does NOT include HV.

The preceding statistics indicate that turnover and nurses leaving the profession because of HV are significant problems. The costs associated with recruiting, orienting, and retaining healthcare professionals can range from tens of thousands to hundreds of thousands of dollars depending on the organization. Additional costs include paying staff members overtime to ensure adequate staffing, 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 timeAs previously noted, HV has an adverse effect on physical and mental health. Deterioration of physical and/or mental health leads to illness and an increased number of sick days. The organization must not only pay sick time but also pay overtime for employees who must cover shifts until the employee who is ill can return to work.

Sick days not only have an impact on the person who is ill but on the organization as well. Sick days cost the organization a considerable amount of money, and research suggests that this amount could run into many thousands of dollars annually. Results from an Australian study show that 34% of nurses who experience HV take more than

50 sick days per year [3]. Illness is not limited to physical signs and symptoms: HV is linked directly to serious mental health problems. Both physical and mental health problems can last for years or even a lifetime. The impact on HV victims’ health can be disastrous.

Nursing consideration: The impact of HV on health is considerable. Nurses must be aware of how work conditions affect their health and the health of their colleagues. They must take steps to safeguard their health and work to establish a workplace that is conducive to physical and mental health of not only patients about employees as well.

Quality and appropriateness of patient care Decreased productivity as a result of the effects of HV is a serious problem not only in healthcare, but throughout the work world. Fortune-100 firm executives report spending as much as 13.5% of their total work time helping to restore interpersonal work relationships and replacing employees who have resigned due to HV [3].

In healthcare, research shows that the effects of HV interfere with concentration and focus as well as communication among staff members. These issues contribute to an unsafe environment for staff

members and patients alike. Research also shows that in this type of environment there are increases in adverse occurrences such as medication errors and patient complaints as well as a decrease in desired patient outcomes [3,4].

Witnessing HV as well as being victims of HV drastically interferes with work productivity, costs organizations many thousands of dollars in recruitment and retention efforts, impairs morale, increases errors, and distracts from the business of caring for patients and families.


A national survey that focused on work productivity showed that witnessing HV led to [3]:

● A 47% intentional decrease in the amount of time spent at work (e.g. sick time).

● A 38% intentional decrease in the quality of work. ● An 80% amount of work time lost due to worrying about HV. ● A 63% amount of work time lost in efforts to avoid persons

committing HV.

● Reports from 66% of the respondents said their job performance had declined because of witnessing HV.

Nursing consideration: The preceding statistics further emphasize the need for witnesses and victims of HV to receive support and help to deal with the aftermath of this destructive phenomenon.

Legal ramificationsLEGAL WARNING: THIS EDUCATION PROGRAM IS NOT INTENDED TO SERVE AS LEGAL ADVICE OR COUNSEL. QUESTIONS CONCERING THE LEGAL RAMIFICATIONS OF HV SHOULD BE DISCUSSED WITH QUALIFED LEGAL COUNSELORS.

Phyllis is a registered nurse. After obtaining her nursing license she worked for three years on a medical-surgical unit. Phyllis wanted some experience in this setting before pursing her goal to work in cardiac critical care. Over the past three years, Phyllis took every opportunity to seek out continuing education pertaining to cardiac critical care and recently began to take graduate level courses to pursue a Master’s degree in nursing. Highly recommended by her nurse manager, Phyllis recently transferred to the hospital’s cardiac critical care unit. Phyllis is excited and enthusiastic and is prepared to work hard to become an excellent critical care nurse.

However, her new co-workers are less than welcoming. The nurses on the unit have a reputation for bullying new nurses and turnover is high. Their rationale for their behavior is “you have to be tough to work on this unit. Only the best survive.” Her preceptor Deborah makes a point of correcting and criticizing her in front of patients and spreads gossip about her, telling co-workers, “I am going to have to get rid of this new nurse. She thinks she is better than everybody else. Who does she think she is, telling me she is working on a Master’s degree? So what? Some fancy degree will not help her here. I will see to that.”

Phyllis is understandably upset and has talked to Deborah on several occasions, telling her she is willing to learn from an experienced critical care nurse, but that criticizing her in front of patients and discussing her with colleagues is disturbing and is compromising her ability to work efficiently. Deborah laughs and tells her to “get used to it.” Phyllis approaches the nurse manager and asks for a new preceptor. The nurse manager replies by telling her, “Deborah is one of our best nurses. She is a little tough but you need to get used to it. It is just her way of making sure you are good enough to work here.”

Phyllis begins to suffer from severe headaches and a significant loss of appetite. She is losing weight and her asthma symptoms worsen significantly. Following the hospital’s policy concerning HV, Phyllis consults with Human Resources personnel and decides to file a grievance regarding the HV behaviors she encountered. Management refuses to consider the grievance, citing Deborah’s excellent performance evaluations as proof that the problem is Phyllis ’and not Deborah’s.

Shortly after the grievance compliant is dismissed, Phyllis is hospitalized following a severe asthma attack. She attributes the decline in her health to the impact of HV and files a lawsuit against the hospital, the cardiac care nurse manager, and Deborah. The hospital settles out of court, and Phyllis receives a large monetary award. Phyllis resigns and obtains employment at a competing hospital where she is welcomed to the critical care setting with enthusiasm. Following Phyllis’ example, several other nurses file grievances against Deborah and the nurse manager of the cardiac care unit. Ultimately both Deborah and the nurse manager are terminated from their positions.

The preceding scenario shows that HV can have significant legal consequences. HV also makes an organization more vulnerable to malpractice lawsuits. If there is an increase in errors, patient dissatisfaction, patient injury, or injury to the victim(s) of HV, 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.

As of this writing, there are no specific laws that directly address the problem of HV. Victims of HV and other forms of bullying who want to file a lawsuit do not have a clear-cut, direct pathway in court. Victims and their legal advisors must look for components of laws that may apply to acts of HV in their particular cases [26].

This does not mean, however, that lawsuits have not been filed; some have even been successful. For example, in a recent review of lawsuits and laws pertaining to HV, Rainford and colleagues presented several legal cases and one such case involved an emergency room nurse identified as RS [26]. A discharged employee returned to work with a semiautomatic rifle and shot various staff members, one fatally. RS spearheaded the efforts of the Alaska Nurses Association, which passed a resolution in 2009 concerning workplace bullying, to organize colleagues, hoping to enhance workplace safety. RS was suspended by his employing hospital and discharged without pay. He filed a complaint under the National Labor Relations Act, which found in his favor. The hospital’s defense team surveyed the nursing staff prior to the decision, and found that 34% of the nurses who responded to the survey reported bullying [26].

There are a variety of ways that a victim of HV might try to establish legal grounds for lawsuits. Employees who are victims of HV and commit errors that result in patient harm may try to establish a link between their maltreatment and the committing of errors. For example, suppose organizational policies and procedures pertaining to HV exist but are not followed. This failure to follow organizational mandates may increase the risk for legal action against an organization, its administrators, and its managers. Victims of HV may attempt to show that HV contributed directly to any errors that were made, and that the organization failed to follow its own mandates.

As of this writing, few laws specific to bullying exist, although there are laws against harassment. However, as the public becomes more and more aware of the effects of HV, interest in legal protection grows. Some state legislators are proposing the passing of laws that would allow workers to sue for physical, psychological, or economic injury from abusive treatment at work [5].

Managers and administrators have a legal and ethical duty to their employees. An appropriate starting point is to differentiate between negligence and malpractice. Negligence is a broad term that refers to conduct “lacking in due care.” [27] Negligence is a deviation from the standard of care that a reasonable and prudent person would adhere to. It also refers to something that a reasonable and prudent person would NOT do [27].

Malpractice (also referred to as professional negligence) is a more specific term that refers to not only a professional standard of care, but to the professional status of the person providing care. In order to be liable for malpractice, the person who commits the wrong must be a professional such as a nurse, physician, therapist, or lawyer.


Courts of law define malpractice as “any professional misconduct, or unreasonable lack of skill or fidelity, in professional or judiciary duties.” [27] Additionally, this wrong must result in injury, unnecessary suffering, or death to the injured party due to ignorance, carelessness, lack of professional skill, disregard of established rules, policies, procedures, and/or principles, neglect, or a malicious or criminal intent [27].

Nursing consideration: Nurses and other professionals are judged by the standards of care that guide their practice. Thus, it is absolutely essential that nurses be aware of the nursing standards of practice that guide their professional actions!

Consider how the elements of malpractice might be applied to a situation in which HV exists. In the clinical setting, healthcare professionals’ elements of malpractice include [27]:

● Duty owed to the patient. ● Breach of duty owed to the patient. ● Foreseeability. ● Causation. ● Injury. ● Damages.

Consider how these elements may apply to administrators, managers, and co-workers in relation to victims of HV using the scenario that introduced this section as the foundation for discussion. The following definitions have been adapted from definitions relating to malpractice as it pertains to patient lawsuits [27]. This adaptation is an attempt to show what might be possible. There is, however, no guarantee that persons who file grievances or lawsuits because of HV will win these initiatives.

● Duty to the employee: An organization, via its administrators and managers, assumes a duty and responsibility for employees. Part of this duty and responsibility is an obligation to provide a workplace environment that is safe and appropriate. Once a duty is established, the employee has a right to expect that the organization will act in the best interests of their employees. Phyllis, for example, had a right to expect that as part of acting in her best interests, the organization would provide a reasonable orientation to her new role as a critical care nurse. A reasonable and prudent person would NOT be expected to inflict HV on the person being oriented.

● Breach of duty to the employee: A breach of duty might exist if an employer fails to provide a safe and appropriate work environment. An example of such a failure might be a failure to follow policies and procedures related to HV. Phyllis followed

policies and procedures regarding HV. However, her concerns were dismissed with the given excuse that the HV perpetrator held clinical expertise.

● Foreseeability: Foreseeability involves the notion that certain events may reasonably be expected to have a certain impact [27]. Thanks to research studies that describe the impact of HV, organizational leadership should know that HV has numerous negative consequences. In Phyllis’ case, the nurse manager should have been aware of the impact of HV. In fact, the organization, which had established policies and procedures concerning HV, should have made every effort to adhere to its own standards.

● Causation: Causation can be difficult to prove since causation requires that an injury must have occurred directly as a result of the breach of duty. Therefore, it means that the injury would not have occurred had duty not been breached. This means that Phyllis had to show convincing evidence that her physical health problems were directly caused by the HV she experienced, and that they would not have occurred if she had not been subjected to HV.

● Injury: The fifth element of malpractice requires that there is evidence of an actual injury or harm. The plaintiff (such as Phyllis in the case study) must demonstrate some sort of physical, emotional, or financial injury occurred because of the breach of duty. The burden of proof was on Phyllis and her legal counsel to show that her deteriorating health was directly due to HV.

● Damages: The fundamental purpose of awarding damages is compensation. The law is attempting to restore the injured party to his or her “original position so far as is financially possible. The goal of awarding damages is not to punish the defendants (the organization or persons being sued), but to assist the injured party.” [27] In the hypothetical scenario, Phyllis was awarded financial compensation.

If employees can show that co-workers have committed HV and management fails to adhere to policies and procedures relating to HV, there may be grounds for filing a grievance according to the mandates of those policies and procedures. Additionally, if HV victims can prove that harm or injury occurred as a result of HV, there may also be grounds for legal action. Thus, the very existence of unopposed HV can make organizations more vulnerable to legal consequences.

Nursing consideration: Continuing education regarding the impact of HV must include potential legal ramifications. Leadership and management in particular should be aware that their failure to intervene when HV occurs can leave not only the organization, but also management, vulnerable to legal action.

sTrATegIes To reDuCe or PreVenT HorIzonTAL VIoLenCeThere are a number of strategies important to the reduction and/or prevention of HV. Before discussing the actual practical recommended actions, it is important to review the “theory of the wounded healer,”

which is garnering increasing attention as a strategy to help healthcare workers effectively heal themselves without resorting to HV.

Theory of the wounded healerThe concept of the wounded healer suggests that a healer’s (e.g. nurse, physician) own wounds and sufferings can carry healing powers for their patients. Carl Jung, psychiatrist and founder of the school of analytic psychology, proposed that a healer’s own experiences of trauma and pain (both physical and emotional) can be used to better help patients to complete the healing process [28,29].

Nursing consideration: It is important to be able to differentiate the wounded healer from the impaired professional. An impaired professional is one whose personal distress leads to a negative impact on their job performance. A wounded healer is a professional whose own “woundedness” (i.e. experiences of pain and suffering, 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


with the problems that patients face, having experienced similar difficulties and worked through them. Wounded healers use their own experiences to help patients in the healing process [29].

According to wounded healer theory, if trauma is handled effectively, the pain of the trauma (whether it be physical or emotional) is consciously recognized, transformed, and transcended into healing. Marion Conti-O’Hare developed the theory of the nurse as wounded healer. She based this theory on an exploration of a nurse’s ability to transcend personal pain and suffering for the purpose of building better therapeutic relationships with others [28]. Several important terms related to the wounded healer theory include [28]:

● Recognition: The awareness that something is negatively affecting someone, either via his/her own thought processes and self-evaluation, or with the assistance of other people in his/her life.

● Transformation: Involves seeking affirmation and control over feelings of pain and/or fear through counseling and/or sharing. The person may use energy from the past to increase understanding of the present and future.

● Transcendence: A higher level of understanding that can be spiritual and/or higher thinking. It allows the person to use this understanding to increase their therapeutic relationship with others.

● Walking wounded: People who have experienced either physical or verbal trauma that they have not dealt with. Not dealing with the trauma causes changes in their ability to cope with current stressors, which leads to negative consequences.

● Wounded healer: Persons who achieve expanded consciousness through self-reflection and spiritual growth. This allows them to process, convert and heal trauma. The scar from the trauma remains, giving these people greater ability to understand the pain of others.

Marion Conti-O’Hare developed her “nurse as wounded healer” theory based on the belief that nursing is a profession in need of this healing process. She explained that everyone experiences trauma in their personal or professional lives or both. The pain and fear caused by these traumas can affect people for the rest of their lives. The effects of trauma do not resolve without interventions. The ability to deal with trauma can significantly impact someone’s ability to care for others. But if the trauma is transformed and transcended, the experience of healing can be used to help others [28].

According to Conti-O’Hare the nurse as wounded healer framework consists of [28]:

● The nurse experiences a traumatic event. ● The physical pain and/or psychological distress leads to becoming

a member of the walking wounded. ● In order to embark on the pathway to healing, the pain must be

recognized, transformed, and transcended. This helps the nurse to move from being a member of the walking wounded to becoming a wounded healer.

● The wounded healer, having resolved the pain of the trauma, is able to implement a therapeutic use of self, develop increased empathy with patients, and facilitate a positive work environment.

● If the pain of the traumatic event is unresolved, it can lead to anger, emotional problems, substance abuse, job dissatisfaction, and a negative work environment.

Nursing consideration: According to Conti-O-Hare the wounded healer represents the highest level of using self therapeutically [28]. Resolving trauma can have a positive impact on both professional and personal lives.

Christie and Jones adapted the theory of nurse as wounded healer to dealing with lateral violence in nursing [28]. The three steps for a nurse experiencing HV to become a wounded healer are:

● Upon experiencing HV, nurses need to recognize the traumatic event and closely examine and dissect the components of the event. Nurses must answer these questions:

○ What happened? ○ What could be changed? ○ How should it have been handled?

● The next step, transformation, involves transforming the pain into an acceptable and manageable understanding by answering these questions:

○ What can be learned from the trauma? ○ Has this changed me or the people I care about? ○ How can this be used to make things better?

● The final step is transcendence, which occurs only if the previous two steps (recognition and transformation) have been completed successfully. Transcending the pain allows the nurse to acquire insight and knowledge, which can be used to help others deal with their own pain and suffering. Transcendence allows the nurse to say:

○ I understand your pain. ○ How can I make things better for you?

Only after completing all three steps can the nurse become a wounded healer.

The nurse as wounded healer theory provides a possible framework for dealing with pain and suffering related to trauma such as HV. But it is also necessary to have practical strategies that can (and should) be implemented to stop the vicious cycle of this phenomenon.

A holistic approach must be used when dealing with the issue of HV and other forms of bullying in healthcare organizations. Research shows that strategies aimed at changing organizational culture are more successful than those that attempt to change the behavior only of specific individuals. Efforts focused on individual behavior may be dismissed as an over-reaction. Perpetrators may justify their behaviors by blaming the victim, rationalize behavior as a difference in personality, or even simply claim that they are just having a little joke at another person’s expense.

It is essential that steps be taken not only to deal with HV as it happens, but to stop it from occurring as well. The following paragraphs offer practical suggestions for dealing with HV.

Communication tipsEllen is just completing her first year of employment as an RN. She is a rather shy person who lacks confidence, and she has been subjected to HV throughout this first year. HV behaviors consisted mostly of criticism in front of co-workers and gossip behind her back. Ellen’s nurse manager sympathizes with Ellen but comments, “you need to stand up for yourself. People have a tendency to pick on those who make themselves easy targets.” This inappropriate comment makes Ellen realize that her nurse manager is going to be of no help to her. Ellen believes that filing a grievance is not an option because she is afraid of retaliation. She lives in a rather isolated rural area and this is the only hospital within commuting distance. Relocating is not an option because of family obligations. Ellen realizes that there is one thing she can do to help herself: Make it more difficult to be viewed

as an “easy target.” She enrolls in an assertiveness training course. Instead of quietly trying to ignore the behaviors of her peers Ellen now confronts them. She stands erect and maintains eye contact. She speaks clearly in a firm tone of voice. Ellen tells colleagues who are criticizing her that she is as willing to learn as anyone but will not tolerate being embarrassed in front of others. When she learns of the gossip being spread about her, she confronts those who are responsible. Her peers are surprised at her newfound confidence and the HV gradually begins to stop.

Unfortunately, Ellen’s situation is not uncommon. Lack of managerial support and the need to remain in a particular workplace can make the trauma of HV even worse. However, there are things Ellen, and those


like her, can do to stop the violence. Effective communication is one such strategy.

Earlier in this education program information about who are the most likely targets of HV was offered. It is important to project an air of confidence. How one communicates with others has a lot to do with stopping or preventing HV. Communicating assertively is not the only means of communication designed to stop HV. Active listening is also an important part of reducing this type of workplace violence. Here are some suggestions for projecting both an attitude of confidence and willingness to listen to what others have to say [3,14,31,32]:

● Posture: Stand or sit erect with arms at sides. Avoid crossing the arms and/or clenching fists. These actions give the impression of anger and/or not being open to the ideas of others. Do not fidget or make nervous gestures (e.g. swing legs, tap desk with a pen, wring hands). Such gestures give the impression of nervousness and lack of confidence.

● Eye contact: Maintain eye contact as culturally appropriate. For most U.S. citizens, eye contact indicates an interest in what the other person is saying. Eye contact gives the impression of confidence as well as interest in what the other person is saying without appearing intimidated.

● Tone of voice: Speak clearly. Speak loudly and slowly enough to be understood easily. Do not allow the voice to become shrill. Do not shout. Do not mumble.

● Facial expressions: Do not frown or roll eyes. Maintain a calm expression. Avoid showing amusement unless the person with whom the nurse is communicating is genuinely trying to be funny. Laughing at someone is never appropriate. Facial expressions should indicate an interest in the communication process without giving the impression of anger or fear.

● Self-analysis: Be aware of personal communication style. Do you cross your arms without being aware of doing so? Are you maintaining eye contact? What about tone of voice? Record yourself speaking. Do you speak too quickly? Too softly? Too loudly? Be as objective as possible. Ask a trusted friend or family member to help “rehearse” communication techniques.

● Personal space: Personal space varies among countries and cultures. In the U.S., personal space is usually about three feet. Be aware of how closely a nurse sits or stands next to someone

else as well as how closely others stand next to nurses. Invading someone’s personal space can be perceived as argumentative and possibly threatening. When communicating during what could be a tense situation (e.g. confronting someone who is committing HV) be aware of personal space parameters.

● Active listening: In addition to maintaining eye contact, respond to what someone else is saying. Nodding the head, asking for clarification, and making comments such as, “I understand that you are concerned about the work schedule,” or “I am interested in your ideas about purchasing new IV pumps” show that the nurse is really listening to the concerns and/or ideas of others. Never appear to be bored or in a hurry. Do not tap a foot, glance at a watch or stand with one hand on the doorknob when talking to someone else.

● Willingness to learn: Nurses should always be willing to learn. No one knows all there is to know about a particular profession. The fact that the nurse is willing to learn (and voice willingness to learn) will go a long way to enhancing professional rapport with colleagues. However, do not make self-demeaning comments such as, “I know I do not know much about nursing yet,” or “I really did not do a good job with that procedure.” Self-demeaning comments can exacerbate HV and give the impression of an easy target for workplace bullying.

● Willingness to help: Help colleagues whenever possible. In general, peers will remember who “came to their rescue” on a bad day and will reciprocate when needed.

Nursing consideration: It may be helpful to practice communication techniques in front of a mirror. Using a mirror as a teaching tool allows the nurse to evaluate her/his non-verbal communication (e.g. posture, facial expressions). Practice communicating in a private setting. Record such practice situations so that the tone and quality of one’s speech can be evaluated.

The preceding tips are good suggestions for projecting confidence as well as a desire to listen to what others have to say. Good communication helps to reduce the incidence of HV. However, there are always colleagues, for whatever reason, who seem to be the primary instigators of HV. It is important to be prepared to deal directly with those who commit HV.

Dealing directly with persons who commit HVSarah is an RN who works on one of several medical/surgical units in a large community hospital. This morning she is asked to “float” 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 patients she will be caring for. An older, more experienced colleague, Norma, rolls her eyes and complains that, “If Sarah doesn’t know what she is doing she might as well go back to her own unit.” The nurse manager intervenes and tells Norma to provide Sarah with the information she needs. Norma does so, but reluctantly. She tells a patient that Sarah “Does not usually work on this unit but I guess she will know how to take care of you.” Norma walks out of the room and Sarah overhears her tell other nurses that, “This nurse they sent us is really a pain. She expects to be treated like royalty.” Sarah finishes providing care to the patient and leaves the room. She asks to speak to Norma privately. Norma rolls her eyes and steps into the nurses’ lounge, “Hurry up I do not have all day.” Sarah responds by saying, “I am more than willing to help take care of patients since you are short staffed. However, I will not tolerate the comments you are making about me in front of patients and to other nurses. This must stop now.”

It is not easy to talk to the person who is committing HV. The encounter will be difficult and, most likely, emotional. It is important that the victim of HV remain calm and address the problem without

shouting or crying. It may be helpful to practice what you will say and how you will say it.

Nursing consideration: Nurses should always adhere to the principles of good communication techniques when dealing with HV. Shouting, crying, or other displays of a loss of control will only make the situation worse.

The most important strategy concerning HV is to deal with the problem the first time it occurs. Do not ignore it. Ignoring the problem will only make the perpetrator believe that s/he can get away with it, and the problem will most likely escalate. It is critically important that the victim of HV makes it clear that this behavior will not be tolerated. In the preceding scenario, Sarah confronts Norma as soon as possible. Here are some suggestions when confronting persons who commit HV [7,10,15,21,22,31,32,33,34]:

● Stay calm. If a nurse becomes angry, defensive, or cry, the persons committing HV will assume that s/he cannot defend themselves. The HV will more than likely continue or even become worse. It is not easy to remain calm in these types of situations. However, remaining calm is a skill that is essential for all forms of communication. HV is not the only challenging situation nurses face. Calmness nearly always helps to defuse tense situations. Calmness also helps victims of HV to gain some control over the situation.


● Confront the perpetrator in private. Do not address the issue in front of an audience. If the person committing HV refuses to speak in a private location, the nurse may need to speak to him or her in a more public setting, but NEVER in front of patients. Refusing to speak in a private setting may be a bully’s way of avoiding having to deal with the problem or of continuing the HV in a public forum to gain support for her/his actions. If forced to confront the person in a hallway, do so as quietly as possible.

● Deal with the situation as soon as possible. Obviously, patients cannot be left unattended in order to confront a bully. But do not allow an entire shift or longer to go by. The longer the perpetrator “gets away with it” the longer and more virulent the HV will become. HV often continues because its instigators are so seldom confronted about it. Those who commit HV are getting some sort of satisfaction from their behaviors. By dealing with them calmly and swiftly some of the satisfaction is decreased.

● Set boundaries. Sarah, in the preceding scenario, calmly explains what will not be tolerated. Notice that it is best to start by indicating an appropriate action. As in Sarah’s case, she starts by 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 to learn. The next sentence should be a calm, definite statement that the HV will not be tolerated. Be specific. For instance, Sarah states that she will not tolerate the negative statements being made in front of patients. In some circumstances it may be necessary to communicate what steps will be taken if the behaviors do not stop. For instance, a new employee may say that if behaviors do not stop s/he will request a new preceptor. Do not threaten. Start by saying what behaviors have occurred and that they will not be tolerated. If

they continue, another confrontation will be necessary and at that time indicate to the perpetrator what the next step will be (e.g. ask for a new preceptor, file a grievance, etc.). Find out what policies and procedures are in place for dealing with HV and adhere to them. Know how to file a grievance in accordance with hospital policy and procedures and follow them meticulously.

● Focus on behaviors, not personalities. When setting boundaries, talk about the behaviors that are not acceptable. Avoid “you” statements such as “you are making fun of me” or “you are criticizing me in front of other nurses.” Instead give examples such as “comments that I do not know what I am doing in front of patients upset the patients and embarrass me. I will not tolerate these comments.” This avoids accusatory statements that might escalate into a shouting match. Make it clear that the behaviors are unacceptable, not the person committing them. This is difficult since it is hard to separate behaviors from the person committing HV. However, when confronting unacceptable behaviors, it is best to avoid focusing on personalities even though it may seem that the personality is the problem!

Nursing consideration: It is never easy to have confrontational types of conversations. But the person instigating the HV must be confronted as soon as possible after it occurs. The more time that goes by after experiencing HV the more difficult it will be to confront the perpetrator. Additionally, memories of the event may fade, even if only a day has gone by. A lapse in time also makes it easier for the perpetrator to deny the event occurred or at least to diminish its significance.

DocumentationThe grievance committee is preparing to interview a nurse who has filed a grievance against a colleague and her nurse manager, citing HV as the reason for the complaint. The colleague, a nurse who has worked at the hospital for many years, is a close personal friend of the manager. The committee asks the nurse to explain why she has filed the grievance and what exactly occurred to trigger this complaint. To the surprise of the committee, the nurse distributes copies of meticulous documentation regarding numerous instances of HV, including dates, times, details, and witnesses to the events. She has also cited how these disruptive behaviors violate the organization’s policies regarding HV and other forms of workplace violence. The nurse also has documentation detailing what steps she took to stop the violence, including discussing the situation with the perpetrator and reporting the situation to her nurse manager. She also has specific dates, times, and locations of the events that took place when she attempted to defuse the situation. All documentation is dated and timed and written objectively.

Persons who experience HV should keep a documentation record of the events. These are personal records and HV should not be documented in a patient’s medical record. Note the date, time, and location of the event. Document what was said or done and who was responsible for the HV behaviors. It is important to be objective. For example, do not document that: “On July 1, 2015 at 10AM, my preceptor embarrassed me in front of a patient.” Instead document

that: “On July 1, 2015 at 10AM, in Room 228, I was changing a sterile dressing under the supervision of my preceptor, Karen Saunders, on a patient who had undergone an abdominal hysterectomy. During the procedure Ms. Saunders rolled her eyes and commented, ‘I guess we will be here all day since you are so slow.’ She then addressed the patient directly and stated, ‘You have to understand that these new nurses just do not know as much as they should.”

Nursing consideration: Be careful to observe HIPAA and other confidentiality mandates. When presenting information in front of a grievance committee, for example, patients’ names should be avoided and should not be part of any documentation distributed to committee members.

By being objective and specific an accurate account is recorded. This type of personal record may be needed if it becomes necessary to approach a nurse manager or to file a grievance in accordance with organizational policies and procedures.

Nursing consideration: When recording documentation as it relates to HV, remember the principles of proper documentation in the medical record. It needs to be objective, without bias, concise, and include dates and times of occurrence and any actions taken to stop the HV. Always avoid becoming embroiled in emotional outbursts, 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 nursing. Although a knowledgeable and experienced clinician, Marie has a widely acknowledged reputation as a bully. Over the years, numerous nurses have resigned or requested transfer to other units because of Marie’s behavior. Unfortunately, Marie had the vocal support of her nurse manager and the VP of Nursing, both of whom were her close personal friends. Both of these persons have recently retired and Marie has been promoted to manager of her unit. She looks

forward to assuming managerial duties and comments that, “now things will really be done right. Only the best nurses are going to survive on my unit.”

Upon returning from a two-week vacation, Marie learns that the newly hired VP for Nursing has called for a meeting of all nurse managers. One of the topics for discussion is HV. Marie also learns that the VP has been meeting with groups of staff nurses on their units. Staff nurses are impressed that the VP approached them. “She did not


expect us to come to her, and she really seems to be listening.” Many of the staff nurses have friends who work at a nearby medical center where the VP was Associate Director of Nursing. She has a reputation for facilitating a work environment that enhances patient outcomes and professional growth and development of members of the nursing department. She also has a reputation for having a zero tolerance for HV and other forms of bullying and workplace violence.

As Marie enters the meeting room she comments to another manager, “I am not worried. I have been here a long time and will be here after she is gone. I am not here to pamper nurses. I am here to get the job done and if that takes getting rid of some crybabies, so be it.”

The VP for Nursing is waiting for everyone to arrive. She greets each nurse manager by name and introduces herself as Nicole Adams. Nicole provides a brief history of her professional life and ends by saying that her goal is to improve patient outcomes and increase opportunities for professional growth. She continues by explaining that HV is a major concern of hers and of this hospital’s administration. She distributes handouts that give a brief overview of the impact of HV and links its existence to turnover and medical errors, particularly in this organization.

Nicole looks each of the managers in the eye and says, “I will not tolerate HV under any circumstances. One of the first actions we are going to take is to revise the existing policies and procedures concerning this destructive phenomenon. Each of you is responsible for eliminating HV and how you contribute to establishing a violence-free organization will be reflected in your performance evaluations. Having been a victim of HV when I was a young nurse, I know how devastating it is. As I recovered from its effects, I made myself a promise that throughout my career I would do everything I could to prevent other nurses from going through what I went through.”

As she finished speaking Nicole looks directly at Marie. Marie begins to feel very nervous. She looks closely at Nicole and realizes that she once subjected Nicole to extreme bullying when Nicole was a newly licensed nurse on the oncology unit.

The preceding scenario shows that sometimes committing HV can ultimately have a serious impact on those who commit it. It also supports the need for all employees at all levels of the organization to adopt a zero tolerance policy regarding HV and other forms of workplace violence.

In order to reduce/eliminate HV, it is important that all employees, including managers and administrators, be aware of policies and procedures that deal with HV and other types of workplace violence and strictly adhere to them. If someone is a victim of HV, and confronting the abusers directly fails to stop the abuse, it is important that s/he follow policies and procedures related to such abuse. In many cases, the next step is for the victim to meet with his or her immediate

supervisor. When doing so, it is probably helpful to bring the written record of the HV to the meeting. This helps to keep the meeting objective and prevents displays of emotion such as anger or tears that may interfere with reaching a satisfactory solution to stop the problem.

The Joint Commission has published guidelines for the prevention of disruptive workplace behaviors. These guidelines include recommendations that written policies and procedures guarantee zero tolerance for disruptive or intimidating behaviors. All employees, including administrators and managers, of an organization should receive education about disruptive behaviors and how to initiate behaviors that enhance respect and professionalism throughout the workplace. The guidelines also note that employees who report disruptive behaviors must not be reprimanded or experience any retaliation for such reporting. A system to deal with, monitor, and stop/prevent disruptive behaviors must be established, and all actions taken to stop disruptive behaviors must be documented [5].

The Joint Commission Leadership Standard (LD.03.01.01) addresses disruptive and inappropriate behaviors. It recommends some specific steps to prevent bullying including [19,24]:

● Educate all healthcare team members about professional behavior including such basic issues as being courteous during telephone interactions, business etiquette, and general people skills.

● Hold all team members accountable for modeling behaviors that are disruptive.

● Establish a code of professional conduct and behavior that promotes a civil, professional work environment with a zero tolerance for workplace bullying.

● Enforce the code of professional conduct consistently and equitably.

● Establish a comprehensive approach that addresses intimidating and disruptive behaviors including a zero tolerance policy. Strong involvement and support from physician leadership is encouraged.

● Reduce fears of retribution against persons who report intimidating and disruptive behaviors.

● Empathize with and apologize to patients and families who are involved in, or witnesses of, intimidating or disruptive behaviors.

● Determine how and when disciplinary actions should begin. ● Develop a system to detect and receive reports of unprofessional

behavior. ● Use non-confrontational interaction strategies to address

intimidating and disruptive behaviors. These strategies are to be implemented within the context of an organizational commitment to the health and well-being of all staff and patients.

Nursing consideration: Zero tolerance means that HV and other forms of workplace bullying is not to be tolerated, ever, under any circumstances. All nurses must take an active role in developing and implementing zero tolerance policies and procedures.

Conflict management stylesIt is important that all employees be helped to recognize the various conflict management styles and what styles are appropriate under what conditions. Here are examples of some of the most common conflict management styles [32,33]:

Thomas is a member of an interdisciplinary research committee. He is one of the committee’s newest members. The group is discussing sample selection for a research project. Thomas respectfully questions the proposal for sample selection currently under review. He believes that it lacks objectivity and may have an adverse impact on the reliability of the results of the research. However, the person who proposed the selection is a colleague who has served on the committee for many years and has the respect of the group. There is significant support for the proposal as it is currently written. Thomas apologizes and agrees to go along with the group’s recommendations even though he believes the proposal as written will hamper effective research.

This is an example of accommodation. Accommodation exists when one person or group gives in to the demands of another person or group. This action may compromise patient care, organizational standards, or other important factors. Accommodation is appropriate only if the person who “gives in” realizes that s/he has made an error. “Giving in” to avoid conflict may be seen as weak and ineffective by others.

Nursing consideration: Persons may “give in” to avoid becoming a victim of HV or to attempt to stop being a victim of HV.

Stella and Maureen are senior physical therapists. They have a friendly rivalry for the respect and attention of their less experienced colleagues. During a staff meeting, they take opposite sides of a discussion pertaining to a new scheduling format. Neither is willing to discuss or listen to the other’s viewpoint. Such open disagreement


compromises staffing patterns and may also eventually impact patient care.

This is an example of competition. This is a negative approach to resolving conflict. With competition, neither involved party is concerned with achieving the best possible outcome. The only concern is winning. In a competition there is always a winner and always a loser. There are also peripheral winners and losers. Supporters of the winner may also feel that they have won. Supporters of the loser may feel as though they belong to a losing team. Ultimately, the most significant losers are the patients, whose well-being may be compromised as a result of competition.

Arlene is the nurse manager of several medical units. She knows that there is conflict among the units regarding staffing and the budgetary allotment for unit resources. Staff members have asked for a multi-unit staff meeting to resolve the issues. Arlene is reluctant to schedule a meeting that she fears will further disrupt professional rapport. She hopes that eventually each unit will determine a way to deal with the resources they have.

This is an example of avoidance. Avoidance means that the conflict is being completely ignored in the hope that it will eventually resolve itself or even disappear entirely. But ignoring conflict seldom, if ever, results in a positive outcome. Avoiding conflict usually prolongs the conflict and often causes it to escalate. It may lead to competition, accommodation, and other forms of negative conflict resolution tactics.

Linda and Victor are social workers whose patient population consists primarily of elderly persons who have experienced strokes or have other debilitating conditions. Linda believes that Mrs. Burns, a stroke patient, should be taken in by one of her many children after discharge. Victor believes that her care is so extensive that she should be discharged to a long-term care facility. They cannot come to an agreement and family members are arguing among themselves as to

what to do. Linda and Victor decide to present the option that each of the children take turns having Mrs. Burns in their homes on a trial basis. If none of them are able to care for her she will then go to a long-term care facility. Neither social worker is happy with this option.

This scenario is an example of compromise, which means that all parties involved in the conflict give up something in order to resolve it. Since neither party is comfortable with the outcome, compromise is usually only a temporary resolution of the problem and some conflict still exists. Linda and Victor also seem to be allowing their personal beliefs and values to impact their actions. Their role is not to present options that they think are best but to present all options and facilitate family discussion. Compromise is seldom effective.

The nurses who work on a busy surgical unit are forming a unit-based council. One of their first projects is to initiate self-scheduling. It is a difficult process but all agree that the first consideration must be adequate staffing. After discussing, sometimes forcibly, a variety of options, the group comes up with a way of scheduling that allows nurses to work only one weekend a month as well as a system that has each nurse taking her turn to work overtime or additional shifts when needed without scrambling at the last minute to find coverage.

This scenario is an example of collaboration. It is also referred to as negotiation and results in a win-win situation. Collaboration means that a solution that is satisfactory to everyone involved is found. Collaboration generally helps to advance the achievement of goals and objectives, and ultimately, desired patient care outcomes.

When working with diverse groups of colleagues it is helpful to identify one’s personal conflict management style. Once a personal conflict management style is identified, one can aim towards implementing a collaboration style of management rather than other styles that can potentially escalate conflict.

educationAngela is the manager of the nursing professional development (NPD) department in a large medical center. She and her staff have been asked to prepare a series of education offerings pertaining to HV and other forms of workplace bullying. Because of their educational expertise, Angela and her staff have been asked to provide education for the entire medical center, not just the department of nursing. This is a huge task. Angela decides to begin with a review of policies and procedures relating to HV and workplace bullying and a definition of terms. She rightly believes that many employees may not know what HV and bullying actually are.

Some of Angela’s staff members are reluctant to address the issue of HV and bullying. Some of them have been bullied, and some have even willingly committed HV. Others are wary of bringing up a topic that may cause anger and frustration among staff who do not understand the seriousness or the problem. There may even be some concern that the organization’s bullies may turn their vengeance on persons attempting to stop the harassment via education and training. No one wants to admit they may have been behaving in ways that cause actual physical and/or psychological harm.

Angela decides that even before beginning to plan education programs she must address the topic of HV with her staff. They cannot teach about the topic unless they are familiar with how it occurs, its impact, and effective strategies to stop it. Self-analysis will begin with Angela and her staff. Self-analysis is sometimes a painful process, but by performing self-analysis, Angela and the educators in her department will be better able to guide learners through the process. Educators will also need support from administration, management, and leadership since this sensitive topic will most likely trigger a variety of emotions from those who have experienced HV and those who have committed it.

Education cannot be provided unless a system is in place to assess its effectiveness. Part of Angela’s job is to determine if education has helped to decrease HV and enhance the organizational culture. She and her staff must establish an evaluation process to measure the impact of their education endeavors.

Angela has chosen a basic starting foundation for education. Definition of terms and explanations existing policies and procedures are important. Many effective techniques can be used to educate staff members about HV, some of which include role play, case studies, and sharing of personal experiences.

Education is essential to the reduction and elimination of HV. ALL employees, including administrators and managers, must participate in education and training related to HV. However, participation is not enough. What is learned during the education process MUST be translated into the culture of the organization and consistently implemented.

Nursing consideration: The essential outcome to education is the consistent implementation of strategies to reduce or prevent HV. A critical component of the education process is to measure the impact of education. In this case, measurement should include assessing if HV and other forms of bullying actually decrease in the workplace following education [17].

Remember that HV occurs in all departments, not just those whose staff members are direct patient care providers as well as at every level in the hierarchy. Education specialists need to take the lead in the planning, implementation, and evaluation of education pertaining to HV and other types of bullying.

Before education can take place, effective policies and procedures must be written with a clear, specific statement so that there is


zero tolerance for disruptive behaviors, including HV. See the recommendations for these policies and procedures in the section under strategies to reduce or prevent HV. Additionally, policies and procedures should explicitly state the consequences for committing and/or tolerating HV. Every employee should be required to read these documents, agree to uphold their standards, and sign a documentation record that they have done so.

Nursing consideration: Employees should be evaluated on their contributions to establishing and maintaining a culture of safety and optimal work environments. How employees facilitate or hinder these goals should be reflected in their performance evaluations. ALL employees, including administration and management, should be evaluated on how they personally impact the culture of the organization.

Education on HV is of critical importance and attendance for education should be facilitated and mandatory. It is difficult to incorporate time for an educational meeting outside of an employee’s department; therefore, such education and training does not have to be done entirely in a classroom. Computer-based learning, staff meeting presentations, role play, and distribution of case studies can all be utilized so that the actual time in the classroom is limited to manageable amounts. Information to be presented should include [3,7,11,14,17]:

● An explanation of what HV is and what it is not: Role play, case studies, and actual examples (preferably from situations that have been witnessed within the organization), are good ways of making the HV relatable and not just a theory. Be sure that scenarios used as examples do not include names, specific units, or other items that would specifically identify the victims or those who commit it. This will embarrass and anger some people and escalate the problem. As discussed earlier in this education program, some perpetrators of HV may deny or even fail to recognize that they are committing acts of violence that have serious, long-term impacts on all employees, patients, and families.

● An overview of the organization’s policies and procedures that deal with disruptive behaviors: This overview should include asking employees how they see themselves as responsible for policy and procedure implementation.

● How to deal with HV: A variety of strategies should be used to show how to deal with HV. Learners do not want to simply listen to a lecture or read a policy. Role play and case studies should show effective and non-effective ways of dealing with the problem. This type of contrast can show what works and what does not. It can also lead to a frank discussion of HV. It should also be emphasized is that those who witness HV and other types of bullying and fail to try to stop it are as guilty as those who are committing it.

● Presentation of organizational data related to HV: This could include statistics about turnover, the effects of HV, and the cost of the problem to the organization. On a departmental level, actual data showing how HV has impacted patient care, recruitment, and retention could be presented. Evidence of HV must be provided to the employees to prove its existence to those who may be skeptical. Employees need to be made aware that HV has long-term consequences for physical and emotional health.

● How to recognize HV when it is seen or when it is committed: Remember that earlier in this program it was mentioned that some people do not even realize that their behaviors constitute workplace violence. Every employee should have to perform a self-analysis of his/her own behavior. Part of this self-analysis should include how personal behaviors impact colleagues, managers, subordinates, patients, and families.

The preceding suggestions are some ideas to instigate an educational campaign to stop HV. A one-time education session is not sufficient to

alleviate HV. On-going education should occur during various points in employees’ careers such as:

● Orientation: The topic of HV should be addressed during orientation of all new staff members and include information as described above. Some may argue that this will intimidate new employees and create a negative impression of the organization. On the contrary, awareness of HV and tools to combat it effectively, empowers a new employee. It also shows that the organization has a commitment to put a stop to disruptive behaviors.

● Preceptor training: Every person who precepts new employees should be educated and aware of HV in terms of how to recognize it and how to stop it. Education must also emphasize that HV is NEVER appropriate and that there is a zero tolerance for its occurrence.

● Mandatory training: All healthcare organizations must have annual mandatory training which should be inclusive of how to recognize and stop HV as well as any pertinent updated information.

● Continuing education: Ongoing information about HV and other types of workplace violence should be part of every organization’s continuing education endeavors. Education could include updates from the literature, information based on analysis of the organization’s own efforts to stop HV and other forms of workplace violence, and how successful the organization has been in stopping HV. Education should include the impact of HV within the organization, a frank discussion of the impact on quality of care, patient outcomes, and job satisfaction. Employees need to learn how to cope with HV in a professional and non-violent manner.

Nursing consideration: Employees should be asked for feedback as to the kind of education they would like regarding HV. For example, they may want more opportunities for role play and discussion or they may have interest in conducting research about HV. Suggestions from employees should be solicited on what should be done to help stop HV as well as how to deal with it when it occurs.

Another facet of education should include directly addressing each employee, making them know they are responsible for breaking the bullying cycle, enhancing patient outcomes, and developing and maintaining a culture of safety. For example, nursing employees could be asked [17,35]:

● Do you remember what it was like to be a new nurse? Have you been treating new nurses as you would want to be treated?

● Have you made an effort to welcome new nurses? Have you tried to make them feel that they are part of the group?

● Have you ever been bullied? If so, what occurred during the bullying? Who committed the bullying? Do not ask for specific names but ask for generalities. For example, was the bullying committed by a manager, preceptor, peer, subordinate, etc.?

● If you were bullied, what did you do? Did you take steps to stop the bullying? Did anyone help you to deal with the bullying? What made the bullying worse? What made it better?

● Do you think that the bullies you have encountered knew what they were doing? Do you think they deliberately set out to intimidate and/or harm you?

● Do you know what the impact of bullying might be? What is the impact of bullying in your department?

● What conflict management styles are you familiar with? How do you think you should handle it when confronted by a bully?

● Do you think your organization opposes bullying? Why or why not?

● Do you see yourself as a role model for professional behavior? Why or why not?

● Do you know of examples of professional behavior on your unit?


● Do you think you are responsible for helping to stop bulling? Why or why not?

● Are you afraid of retaliation if you report bullying? Why or why not?

● Do you ever think that there is a justifiable reason to bully someone? Why or why not?

● Do you feel comfortable dealing with a bully? What may help you to deal with a bully? Do you know how to deal with bullying in a professional manner?

● What do you think would help stop bullying in the workplace? ● Do you think bullying is a problem in your organization? Why or

why not?

Nursing consideration: Administration, management, and leaders have important roles in breaking the cycle of HV. They should emphasize that HV is not tolerated and they should encourage those who experience and/or witness HV to report it without fear of retaliation.

Organizations should offer counseling for the victims of HV. Its impact can be extremely devastating to physical and mental health. The organization has an obligation not only to take steps to stop HV but to help its victims to recover from its impact.

ConclusionHV is not a new phenomenon but it is one that is becoming more well-known and more openly acknowledged by accrediting bodies. All persons who work within the healthcare field must take responsibility for putting a stop to HV. In order to provide a safe work environment for employees and an environment that is conducive to the best possible patient care, HV must be recognized and a zero tolerance for its occurrence be upheld by administration, management, and staff. Education is a critical part of developing and maintaining an

environment free from HV and must be mandatory for everyone who works in healthcare. It is essential that organizational leadership serve as role models for appropriate behavior and that those who commit HV, no matter what their role in the organization, be held accountable for their actions. A holistic approach involving the entire organization is the best way to stop the cycle of HV and bullying. Creation of a culture of safety not only involves looking at patient outcomes but at the health and well-being of employees as well.


references1. United States Department of Labor. (2015). Workplace violence. Retrieved July 8, 2016 from https://

www.osha.gov/SLTC/workplaceviolence/. 2. United States Department of Labor/OSHA. (2015). Worker violence in healthcare: Understanding

the challenge. Retrieved July 8, 2016 from https://www.osha.gov/Publications/OSHA3826.pdf. 3. Bartholomew, K. (2014). Ending nurse-to-nurse hostility (2nd ed.). Danvers, MASS: HCPro.4. Skinner, T. C. (2011). Lateral violence in nursing. Nursing News & Views, 6(1), 13-14.5. Stokowski, L. A. (2010). A matter of respect and dignity: Bullying in the nursing profession.

Retrieved July 8, 2016 http://www.medscape.com/viewarticle/729474.6. Bartholomew, K. (2013). Break the spell and end lateral violence in nursing. Retrieved July 8, 2016

from http://www.nursetogether.com/Career/Career-Article/itemid/2621.aspx. 7. Patient Safety Network (PSNet). (2014). Disruptive and unprofessional behavior. Retrieved July8,

2016 from https://psnet.ahrq.gov/primers/primer/15/disruptive-and-unprofessional-behavior. 8. Scott, V. (2015). Workplace conflict resolution essentials for dummies. Hoboken, NJ: Wiley.9. Purpora, C., Blegen, M., & Stotts, N. (2012). Horizontal violence among hospital staff nurses related

to oppressed self or oppressed group. Journal of Professional Nursing, 28(5), 306-314. 10. Fuimano-Donley, J. (2012). How to deal with a bully: Before you do anything, you must manage

yourself. Advance for Physical Therapy and Rehab Medicine. Retrieved March 28, 2012 from http://physical-therapy.advanceweb.com/Editorial/Content/PrintFriendly.aspx?CC=233986.

11. Fuimano-Donley, J. (2012). Are you committing lateral violence? Advance for Physical Therapy & Rehab Medicine. Retrieved March 28, 2012 from http://physical-therapy.advanceweb.com/Editorial/Content/PrintFriendly.aspx?CC=245681.

12. Dumont, C., et al. (2012). Horizontal violence survey report. Nursing2012, 44-49. 13. Harris, H. (2014). Workplace bullying in nursing: The causes, effects, and possible solutions for the

ongoing problem of lateral violence in nurses. Advance for Nurses. Retrieved July 10, 2016 from http://nursing.advanceweb.com/Features/Articles/Workplace-Bullying-in-Nursing.aspx.

14. Dellasega, C. (2011). When nurses hurt nurses: Recognizing and overcoming the cycle of bullying. Indianapolis, IN: Sigma Theta Tau International.

15. Clark, C. M., & Ahten, S. M. (2011). Nurses: Resetting the civility conversation. Retrieved August 27, 2011 from http://www.medscape.com/viewarticle/748104_print.

16. Peter Barron Stark Companies. (2014). Why employees resist change. Retrieved July 11, 2016 from https://www.peterstark.com/why-employees-resist-change/.

17. Avillion, A. E. (2015). Nursing professional development: A practical guide for evidence-based education. Danvers, MASS: HCPro.

18. The Joint Commission. (2013). Revisiting disruptive and inappropriate behavior. Retrieved July 11, 2016 from https://www.jointcommission.org/jc_physician_blog/revisiting_disruptive_and_inappropriate_behavior/.

19. The Joint Commission. (2011). Joint Commission, nurses and bullying. Retrieved July 12, 2016 from https://bullyinworkplace.com/2011/07/04/joint-commission-nurses-and-bullying/.

20. Underwood, T. (2013). Improved “handoff” communication curbs medical errors. Retrieved May 11, 2016 from http://vector.childrenshospital.org/2013/12/improved-handoff-communication-curbs-medical-errors/.

21. Human, J. (2012). 5 nuggets of wisdom for workplace bullying: The best defense against a bully is a good offense. Advance for Physical Medicine and Rehab Medicine. Retrieved July 13, 2016 from http://physical-therapy.advanceweb.com/Editorial/Content/PrintFriendly.aspx?CC=243942.

22. Garner, C., & Broyles, P. (2011). Nursing strategies: Understanding the sources & costs of conflict. Part 1. Retrieved July 12, 2016 from http://www.americansentinel.edu/blog/2011/07/20/nursing-strategies-understanding-the-sources-costs-of-conflict/.

23. Kovach, P. (Clinical Ed.). (2013). Professional guide to diseases (10th ed.). Wolters Kluwer Health/Lippincott Williams & Wilkins.

24. The Joint Commission. (2016). Bullying has no place in health care. Retrieved July 13, 2016 from https://www.jointcommission.org/assets/1/23/Quick_Safety_Issue_24_June_2016.pdf.

25. The National Council of State Boards of Nursing. (2011). White paper: A nurse’s guide to the use of social media. Retrieved July 13, 2016 from https://www.ncsbn.org/Social_Media.pdf.

26. Rainford, W. C., et al. (2015). The disruptive force of lateral violence in the healthcare setting. Retrieved July 14, 2016 from http://www.medscape.com/viewarticle/840331_5.

27. Guido, G. W. (2014). Legal and ethical issues in nursing (6th ed.). Boston, MASS: Pearson.28. Christie, W., & Jones, S. (2013). Lateral violence in nursing and the theory of the nurse as wounded

healer. The Online Journal of Issues in Nursing. Retrieved July 15, 2016 from http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol-19-2014/No1-Jan-2014/Articles-Previous-Topics/Lateral-Violence-and-Theory-of-Wounded-Healer.html.

29. Zerubavel, N., & Wright, M. O. (2012). The dilemma of the wounded healer. Psychology, 49(4), 482-491.

30. Dance of the Deer Foundation. (2016). What is Shamanism? Retrieved July 16, 2016 from https://www.shamanism.com/what-is-shamanism.

31. Garner, C., & Broyles, P. (2011). Nursing strategies: Interaction guidelines for painless conflict resolution. Part 3. Retrieved July 16, 2016 from http://www.americansentinel.edu/blog/2011/08/03/nursing-strategies-interaction-guidelines-for-painless-conflict-resolution/.

32. Garner, C., & Broyles, P. (2011). Nursing strategies: Countering workplace conflict with positive communication strategies. Part 4. Retrieved July 16, 2016 from http://www.americansentinel.edu/blog/2011/08/10/nursing-strategies-countering-workplace-conflict-with-positive-communication-strategies/.

33. Garner, C., & Broyles, P. (2011). Nursing strategies: Common tactics for managing conflict. Part 2. Retrieved July 16, 2016 from http://www.americansentinel.edu/blog/2011/07/27/nursing-strategies-common-tactics-for-managing-conflict/#

34. Kelley, J. (2012). Time for a difficult conversation? Facilitate stressful dialog with grace and tact. Advance for Physical Medicine and Rehab Medicine. Retrieved July 16, 2016 from http://physical-therapy.advanceweb.com/Editorial/Content/PrintFriendly.aspx?CC=237469.

35. Townsend, T. (2012). Breaking the bullying cycle. Retrieved July 10, 2016 from https://americannursetoday.com/break-the-bullying-cycle/.


1. HV behaviors that are not obviously aggressive or threatening are referred to as:a. Incivility.b. Overt.c. Covert.d. Sabotage.

2. When discussing the incidence and prevalence of horizontal violence nurses should know that:a. HV is a phenomenon that occurs only in the United States.b. The workplaces most prone to bullying are healthcare,

education, and government. c. A study focusing on the frequency of HV found that at least

50 percent of respondents experienced incivility at least once a week.

d. About 25 percent of newly licensed registered nurses leave their first positions within six months because of HV.

3. Which of the following persons is most likely to become a victim of HV?a. Someone who receives special attention or recognition from

supervisors or physicians. b. A nurse who works on a unit that has no RN vacancies.c. A nurse with 10 years of experience.d. Someone who has high self-esteem.

4. All of the following issues may trigger someone to commit HV EXCEPT:a. A need for power and control.b. Belief that patients need protecting.c. Lack of managerial support.d. The desire to see new employees secure their own places

within an organization.

5. A nurse who commits HV justifies her behavior by saying new nurses “have to pay their dues like everyone else.” This is referred to as:a. Initiation or rite of passage.b. Fear of failure.c. Blaming the victim.d. Generational differences.

6. Oppression Theory is based on the belief that:a. Conflicts among generations create tension.b. When one group has more power than another a power

imbalance exists. c. Bullies are unable to acknowledge that horizontal violence

exists.d. Opposition to change leads to oppression.

7. Which of the following statements about the impact of horizontal violence is accurate?a. HV leads to miscommunication, which is involved in 80

percent of serious medical errors.b. PTSD affects about 10 percent of victims of HV.c. Antisocial disorders seldom affect HV victims.d. Victims of HV are so downtrodden that they seldom display

anger or aggression.

8. Horizontal violence can have legal implications. The notion that certain events may reasonably be expected to have a certain impact is referred to as:a. Causation.b. Foreseeability.c. Damages.d. Injury.

9. As part of the Wounded Healer theory the achievement of a higher level of understanding that can be spiritual and/or higher thinking is referred to as:a. Recognition.b. Transformation.c. Transcendence. d. Resonance.

10. Communication is an important strategy to stop horizontal violence. Good communication techniques include all of the following EXCEPT:a. Stand or sit erect with arms at your sides.b. Maintain a calm expression.c. Avoid eye contact.d. Realize that personal space is usually about three feet.

HeALTHCAre VIoLenCe: WHy Peers BuLLy PeersFinal examination Questions

Select the best answer for questions 1 through 10 and mark you answers online at nursing.elitecme.com.

ANCCFL06PBE17B

chapter 5: healthcare violence: why peers bully peers · in clinical research and evidence-based...

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