Disruptive Behavior and Nurse-to-Nurse Hostility

They eat their young.” This cannibalistic phrase aptly describes horizontal violence at its worst. “Horizontal” or “lateral” violence is the term used to describe disruptive behavior among and between nurses. In fact, this phrase is so well-known among nurses that Kathleen Bartholomew, RN, MN, wrote a book in 2006 titled Ending Nurse-To-Nurse Hostility: Why Nurses Eat Their Young and Each Other. In her book, she relays how one nurse describes horizontal violence: “Our communication is fraught with indirect aggression, bickering, and fault-finding. It is disheartening to experience the underhanded and devastating ways that nurses attack each other. These rifts divide us and lead us to injure one another.”(1)

This is just one example of the harmful impact of horizontal violence. Not only is horizontal violence injurious, but it also distracts nurses and others from fully focusing on their jobs, which often results in mistakes and errors. In turn, such mistakes and errors affect patient safety and the quality of care.

Can you afford to erode a culture of safety under your watch as a nurse or healthcare leader?

Prior to introducing a systematic process to prevent and eliminate horizontal violence among nurses and other caregivers, it is important to pause and focus upon some key definitions. In my work as an organizational psychologist, I [Martin] have too often run into situations when nursing and other health care leaders and managers cannot focus on the issue at hand—that is, preventing and addressing disruptive behavior—because they are battling over precise definitions.

Whether you refer to this behavior as horizontal violence,(2) lateral violence,(3) or horizontal hostility,(1) it boils down to physical, verbal, or emotional abuse,(4) or quite simply nurse-to-nurse aggression.(5) As stated earlier, this type of disruptive behavior has an impact on performance and outcomes. Skinner(5) describes it as “behavior that interferes with effective communication among health care providers and negatively impacts performance and outcomes. This type of behavior is not supportive of a culture of safety.”

Can you afford to erode a culture of safety under your watch as a nurse or healthcare leader? This behavior also impacts retention. Griffin reported that one in three nurses will leave an organization on account of horizontal violence.(6) Can you afford to have one in three of your nurses walk out the door because of disruptive behavior? Don’t rationalize by saying to yourself, “My nurses wouldn’t leave here because it is bad at other places too.”

Horizontal Violence: It’s Everywhere

Senior healthcare leaders must realize that the sources of horizontal violence among nurses and other caregivers come from many directions. If you focus on one source, you fail to fully capture the unfortunate ubiquity of the problem. One study(7) found that the most frequent sources of verbal abuse came from the following:

• Nurses (27%);

• Patients’ families (25%);

• Doctors (22%);

• Patients (17%);

• Residents (4%);

• Other (3%); and

• Interns (2%).

Too often, we assume that disruptive behavior only takes place in the relationship between a supervisor and a subordinate, or between a physician and a nurse. This is a false assumption. Unfortunately, another source of abuse that occurs is bullying among nursing students. This is of concern given that many academic medical centers and community hospitals train nursing students. Do you have a concrete plan in place to prevent and address horizontal violence for your nursing employees and aspiring nurses?

Drivers of Horizontal Violence

An important question to ask is the following, “Why do nurses engage in disruptive behavior and what can be done to stop it?” Griffin seeks to describe the underlying driver of lateral violence as overt or covert dissatisfaction with other nurses and even themselves.(6)

Griffin also mentions power differentials. Beyond dissatisfaction and power differences, Salin(8) proposed a three-factor model of the cause of workplace bullying, which is directly applicable to horizontal violence among nurses. According to Salin, the three factors are:

• Enabling structures;

• Motivating structures; and

• Precipitating processes.

Each one of these, as well as a way to decrease or eliminate these drivers, will be highlighted in the following sections.

Enabling Structures

Weeds do not grow unless there is sufficient sun and fertile soil. The same is true for horizontal violence. If the organizational soil is not fertile, horizontal violence will not bloom. What are the elements of organizational soil that enable horizontal violence to erupt in your organization?

1. Perceived power imbalances between the victim and the perpetrator;

2. Perceived low costs for the perpetrator;

3. Dissatisfaction in the work environment; and

4. Frustration in the work environment.

Imagine a charge nurse who routinely yells at other nurses and caregivers, or frequently loads up some nurses with difficult assignments while lightening the load of others. Imagine the nurse doing this without giving consideration to patient acuity and the competence level of the nurse or caregiver. Where is the manager of the charge nurse? What role does nursing leadership play in incidents such as this? Could it be that both the charge nurse and his or her immediate manager are benefiting in some way? Could it be that out of fear and intimidation the nurses are stepping up on the job (but falling apart on their journey home after each shift)? This vignette portrays the power imbalance between the charge nurse and the caregivers. This vignette also portrays how this type of behavior can continue and spread like a weed in this same unit over time and even onto other units and settings. To modify this situation, it is essential to work on three levels simultaneously: the individuals (charge nurse, nurse manager); the group (the unit); and the organization (the overall work environment).

Motivating Structures

The enabling structures are the organizational soil, and the motivating structures are the sun and the rain that really make horizontal violence bloom and blossom in your organization. On a more practical level, these motivating structures include the following:

• Fierce internal competition;

• Reward systems for engaging in horizontal violence; and

• Expected benefits for the perpetrator.

Picture a busy endoscopy center in which patient satisfaction, throughput, and revenue capture are consistently monitored by leadership, and managers are compared with one another based upon these three performance metrics. Not only are managers measured against these performance metrics, but their incentive compensation is based upon how they perform compared to their managerial peers. The nurses working in the endoscopy center feel pressure every day to perform, and they are rewarded for increasing these performance metrics even if it means chewing out a colleague or subordinate to do so.

To modify this situation, similar to enabling structures, you must work on all three levels—individual, group, and organization—but more so with regard to organizational factors, such as the selection of performance metrics and the incentive compensation design. What is curiously missing from both the performance dashboard and the incentive compensation is any measure related to caregiver satisfaction and an assessment of a culture of safety as well as quality.

Precipitating Processes

Precipitating processes are the catalysts that enable the right soil conditions (enabling structures) and right environment (motivating structures) to converge and then spark an incident of horizontal violence. Examples of precipitating processes include but are not limited to the following:

• Restructuring;

• Downsizing; and

• Other crises.

Reflect on what it would be like to work as a nurse, caregiver, or healthcare provider in a place where the board of trustees has signaled to senior leadership that costs must be cut to compensate for declining reimbursement by insurance companies. Add to this an increase in patients cancelling elective procedures due to difficult financial circumstances. There is a looming fear that layoffs will be recommended, that merit increases will be cut, and that vacant positions will not be filled, the latter resulting in caregivers having to do more work with fewer resources. These are the realities of health care today, but what is the impact on the work climate and how caregivers interact with each other? You might anticipate that nerves will be frayed, civility dampened, aggression increased, and the tone boil down to “every man and woman for him- or herself.”

Assessing Horizontal Violence in Your Organization

There are a growing number of assessment tools that you can use to gauge the degree of collegiality and collaboration among your nursing team. One such tool is the nurse–nurse collaboration (NNC) scale.(9) It is primarily designed to assess nurse interactions in ICU settings, but it could be used in other inpatient settings. Another tool is the nurse–physician collaboration scale, which is a 51-item instrument designed to measure collaboration.(10)

A simpler and more direct way to assess horizontal violence in your organization is to review records and incident reports from human resources, employee assistance programs, occupational health, risk management, and even security

A simpler and more direct way to assess horizontal violence in your organization is to review records and incident reports from human resources, employee assistance programs, occupational health, risk management, and even security. If you are a brave nurse or healthcare leader, you might carry out “rounding,” which has benefits beyond getting a sense of the work climate. It is also recommended that you conduct focus groups to determine if the workplace is psychologically and physically safe and free of horizontal violence. Before you begin to schedule rounds, focus groups, and meetings with key internal stakeholders, stop and ask the following three questions:

• How will I protect nurses and other caregivers who share information with me, particularly if the work climate is characterized by reprisal, retaliation, intimidation, vengeance, and even vigilante justice?

• What will I do with this information in a concrete way so that goals are established, accountability is preserved, and results take place?

• Will I continue to do this on a regular basis over a number of years, or will this be yet another “flavor of the month (or year)” activity?

Nipping Horizontal Violence in the Bud

Based on a study using interviews with 141 nurses and physicians,(11) it was found that certain organizational structures must be in place to prevent horizontal violence and promote a more collegial, collaborative relationship between physicians and nurses. These three organizational structures address: (1) the culture of the organization, which includes putting patients first; (2) programs, such as conflict resolution; and (3) patient rounding, essentially a walking-the-halls form of management.

Excerpted from Taming Disruptive Behavior , by William “Marty” Martin, MA, MS, MPH, PsyD, CHES and Dr. Philip Hemphill, PhD, LCSW.

References

1. Bartholomew K. Ending Nurse-to-Nurse Hostility: Why Nurses Eat Their Young and Each Other. Marblehead, MA: HCPro, 2006, p. 7.

2. Longo J, Sherman RO. Leveling horizontal violence. Nursing Management. 2007;38(3):34-37, 50-51.

3. Stanley KM, Martin MM, Nemeth LS, Michel Y, Welton JM. Examining lateral violence in the nursing workforce. Issues Ment Health Nurs. 2007;28:1247-1265.

4. Thomas SP. Horizontal hostility. Am J Nurs. 2003;103(10):87-101.

5. Skinner TC. Lateral violence in nursing. Nursing News & Views. 2011;13-14.

6. Griffin M. Teaching cognitive rehearsal as a shield for lateral violence: an intervention for newly licensed nurses. J Contin Educ Nurs. 2004;35:257-263.

7. Rowe MM, Sherlock H. Stress and verbal abuse in nursing: do burned out nurses eat their young? J Nurs Manag. 2005;13:242-248.

8. Salin D. Ways of explaining workplace bullying: a review of enabling, motivating, and precipitating structures and processes in the work environment. Human Relations. 2003;56:1213-1232.

9. Dougherty MB, Larson EL. The nurse-nurse collaboration scale. J Nurs Adm. 2010;40(1):17-25.

10. Ushiro R. Nurse-physician collaboration scale: development and psychometric testing. J Adv Nurs. 2009;65:1497-1508.

11. Mikuno BG, Smith NA, Poole SJ, Coverdale JH. Horizontal violence: Experience of registered nurses in their first year of practice. J Adv Nurs. 2003;42(1):90-96.