NSQXXX10.1177/0894318415585625Nursing Science QuarterlyKarnick / Practice Applications

Practice Applications

Hostility Patterns: Implications for Nursing Practice

Nursing Science Quarterly 2015, Vol. 28(3) 202­–208 © The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0894318415585625 nsq.sagepub.com

Cynthia D. Sofhauser, RN; PhD1

Abstract In order to present the state of the science of hostility among and across disciplines, a review of the literature was completed. The knowledge gained may influence nursing practice. Scholarly works from nursing, medical and basic sciences, psychology, sociology, education, philosophy, business, communication, and criminology were reviewed. Similar patterns in the use of the concept were discovered. The patterns revealed five themes: hostility as a health-risk factor, hostility as a factor in family relationships, hostility as a factor in perceived challenge, hostility as a factor in criminal behavior, and hostility as a factor in the workplace. Based on the knowledge gained about hostility, implications for nursing practice related to changing the hostile working environment for nurses were suggested using modeling and role-modeling nursing theory. Keywords hostility, nursing, theory, working environment The world is seething with hostility. Hostility among and within nations and various cultural and religious groups that espouse different ideologies has become the norm rather than the exception. Hostility and related concepts are ubiquitous phenomena in everyday society. Whether referencing the hostile workplace environment in healthcare settings, the irate parent at children’s sporting events, the hostile commuter in traffic, the curt store clerk, politicians during a hotly contested race, or disagreeable neighbors across an imaginary property line, it appears that anyone can succumb. Adoption of hate crime legislation and legal literature that details the conduct that demonstrates hostility for such legislation, point to the violent extreme that can be generated by hostility. Hostility and its components were referred to by journalist Tom Wood (2012) in The Spectator. In his piece he wrote of the pervasiveness of an attitude in western society that he labeled, ostentatious anger, and in his description of this type of anger are all the components of hostility. Hostility is an experience known to most people in all walks of life. The purposes of this article are to present a review of hostility from the literature within and across disciplines to determine the state of the science and to offer implications for nursing practice based on knowledge of hostility. Scholarly works from nursing, medical and basic sciences, psychology, sociology, education, philosophy, business, communication, and criminology were reviewed. Hostility was searched in a number of databases from 2008-2014, both as a keyword and a subject heading.

Hostility in the Literature Myriad definitions and related concepts were identified in the literature and some are used interchangeably with hostility, for example, trait anger, anger, cynicism, animosity, and aggression, to name a few. Confusion was created by some authors who defined the construct, trait hostility, in the same manner that others defined hostility (Brondolo et al., 2009). The definition of hostility as a noun in the Oxford English Dictionary hints at the multi-dimensional nature of the concept; it is “opposition or antagonism in action, thought, or principle” (“hostility”, n.d.). Many authors viewed hostility as an enduring, negatively defined, personality characteristic, and a multi-dimensional phenomenon with three key aspects consistently identified: cognitive, affective, and behavioral ( Brondolo et al., 2009; Klabbers, Bosma, van den Akker, Kempen, & van Eijk, 2013). The definitions in the literature included at least one, if not all, of these aspects. Additionally, Smith and colleagues (Smith, Glazer, Ruiz, & Gallo, 2004) reported that although these three aspects were often subsumed under the label, hostility, the aspects could be more aptly labeled, cognitive hostility. Suls (2013) labeled the cognitive dimension hostility and defined it as a cynical 1

Associate Professor, Indiana University South Bend

Contributing Editor: Paula M. Karnick, RN, PhD, Director, Institute of Nursing Education, Emergency Nurses Association, Desplaines, IL. Email: [email protected]

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Karnick / Practice Applications attitude toward others. This is in line with the work of Klabbers and colleagues (Klabbers et al., 2013) who defined cognitive hostility as cynical distrust. Conceptual definitions were rarely given by biomedical researchers who investigated the health-risks of hostility. Rather, hostility was often defined by the instruments used to operationalize the concept. One of three scales was used to operationalize hostility: the Cook and Medley Hostility Scale (CMHS; Cook & Medley, 1954), or one of its subscales, that measures cynical distrust; the hostility subscale of the BussPerry Aggression Questionnaire (Buss & Perry, 1992); or the Buss-Durkee Hostility Inventory (Buss & Durkee, 1957). The CMHS has been used quite extensively, subjected to a number of factor analyses, and found to incorporate three sub-component beliefs: cynicism, mistrust or distrust, and denigration (Smith, et al., 2004). Regardless of the conceptual or operational definition, hostility was always seen as a personal matter. It is about self in relation to others. Individuals who exhibit hostile behavior are more likely to experience anger, disgust, and contempt, and exaggerate and distort threatening aspects of others. Personal ideas, attitudes, and emotions projected toward others can have deleterious interpersonal consequences. Similar patterns in the use of the concept, hostility, within and among disciplines were discovered and these arose as themes.

Themes From an exploration of the hostility literature, five themes were identified: hostility as a health-risk factor, hostility as a factor in family relationships, hostility as a factor in perceived challenge, hostility as a factor in criminal behavior, and hostility as a factor in the workplace. Hostility as a relational phenomenon plays out in various contexts as identified in the themes.

Hostility as a Health-Risk Factor Hostility as a health-risk factor was predominant in the biomedical, nursing, and basic science literature. As a healthrisk factor hostility was identified in coronary heart disease (CHD) and linked to other diseases as well. Hostility as a health-risk factor first appeared in the bio- behavioral medical literature as a precursor to CHD. After various studies on Type-A behavior, attention turned to hostility as a cardiotoxic factor of the Type-A behavior pattern (Shekelle, Gale, Ostfeld, & Paul, 1983). Since that time, a great deal of research has focused on hostility as a risk factor for CHD and various diseases and conditions. The cognitive aspect of hostility has been linked consistently to cardiac disease risk. In a meta-analysis of 38 prospective studies involving almost 80,000 subjects investigating the psychosocial correlates of coronary heart disease (CHD), Chida and Steptoe (2009) found that hostility and anger, as measured by the Cook and Medley Hostility

Scale, were associated with CHD outcomes in both CHD and healthy populations. Cognitive hostility has also been linked to all-cause mortality independent of health behaviors (Klabbers et al., 2013). Links have been established with stroke and transient ischemic attacks (Everson-Rose et al., 2014); altered metabolic activity found in metabolic syndrome (D’Antono, Moskowitz, & Nigam, 2013); diabetes and somatic symptoms irrespective of disease effects (Hyphantis, Goulia, & Carvalho, 2013); inflammatory markers for coronary disease, stroke, and all-cause mortality (Smith, Uchino, Bosch, & Kent, 2014). Given its deleterious health effects, hostility in the nursing literature was examined as both a precursor and consequence of disease. Descriptive and interventional studies have involved various patient populations, for example, psychiatric patients in seclusion (Lai, Su, Lin, Yu, & Lin, 2010), patients post-coronary artery bypass grafting (Elliott et al., 2010), breast cancer patients undergoing chemotherapy (Hongli, Li, & Haiping, 2013), patients with nausea postchemotherapy (Ingersoll et al., 2010), and elderly cardiac patients (Moser et al., 2010). Although hostility as a healthrisk factor was pervasive in the healthcare disciplines, mechanisms for linking the concept and health outcomes were unclear. Focusing on physiologic mechanisms underlying the link between hostility and disease, researchers have discovered that the serotonin system and genetic pathways are predictive of hostility and adult anger (Hakulinen et al., 2013). Links have been found between cynical hostility and two known markers of cellular aging, leukocyte telomere length and leukocyte telomerase activity (Brydon et al., 2012). Bio-behavioral mechanisms, most notably inactivity and smoking, were found to influence the effect of hostility on future cardiac events in a sample of over 1,000 outpatients with stable coronary heart disease (Wong, Na, Regan, & Whooley, 2013). A link between hostility and known physiologic risk factors for disease was established when hostility was found to be a predictor of increased risk for metabolic syndrome and higher levels of C-reactive protein (CRP; a marker of inflammation) in Finnish women (Elovainio et al., 2011). Pointing to a link between hostility in an interpersonal relationship and CRP, Smith and colleagues (Smith et al., 2014) found an association between CRP and hostility in 94 couples, both individually and between couples. Study findings revealed a correlation between high hostility in a spouse and an elevated CPR level in their partner, independent of partner hostility levels and irrespective of gender (Smith et al.).

Hostility as a Factor in Family Relationships Hostility as a factor in family relationships was predominant in the sociological and education literature. Two main areas of focus were identified: parental hostility and the dysfunctional, abusive family. A hurtful, parenting environment can have harmful effects on the developing personality of a child.

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Within the psychological and educational literature that focused on children and their psychosocial development, the parent-child relationship was central to studies that focused on the effects of hostility within the home. Parent-child hostility was a construct explored in the literature and was found to be predictive of child depression with variations due to parent and child gender (Lewis, Collishaw, Thapar, & Harold, 2014). Families that displayed higher non-adaptive functioning consisted of parents who were characterized by high emotional involvement, hostility, or criticism (Delvecchio et al., 2014). Parenting hostility was uniquely associated with children’s well-being and outcomes such as, overall psychosocial impairment, externalizing problems, and inability to focus (Febres et al., 2014; Rijlaarsdam et al., 2014). Parental hostility was the only significant predictor for children’s bullying in 52 parent/caregivers studied in an evaluation of a program to reduce early childhood bullying (Burkhart, Knox, & Brockmyer, 2013). Paternal hostility, in particular, significantly predicted relative increases in youth delinquent behaviors (Wu et al., 2014). Also, maternal hostility has been found to predict disruptive behavior in children and is defined as “maternal anger, criticism, negativity and disapproval directed towards the child” (Sellers et al., 2014, p. 112). Hostility in the abusive, dysfunctional family has been studied and reported in sociological literature. Living in an abusive, dysfunctional family can have lasting effects on parents as well as their children; hostility begets hostility. Buchanan and colleagues (Buchanan, Power, & Verity, 2014) found that sustained hostility created an environment of domestic violence that affected the attachment between mother and infant. A history of maternal maltreatment, by subsequent maternal and paternal hostility and harsh discipline was found to be associated with children’s externalizing problems such as, aggressive, delinquent, and antisocial problems (Rijlaarsdam et al., 2014). In a study by McFarlane and colleagues (McFarlane, Symes, Binder, Maddoux, & Paulson, 2014) with 300 women who had experienced intimate partner abuse, mothers with borderline clinical external problems such as hostility and aggression were 4.5 times more likely to have children with those same problems. In another study, Francis and Wolfe (2008) found that abusive fathers, when compared to non-abusive fathers, scored higher in hostility. These abusive fathers, when faced with child-related stimuli could form quick negative attributions and engage in abusive behavior.

Hostility as a Factor in Perceived Challenge Hostility as a factor in perceived challenge was found in philosophical and sociological literature. Fundamental to this theme is the perception of an overt or covert challenge to a belief or behavior. Four key areas were identified: philosophical discourse, internet and media violence, driving behaviors, and disenfranchised groups.

The presentation of new ideas can threaten the status quo and create fear of change, especially when those ideas challenge cemented worldviews. In philosophical discourse, expressing a dissident opinion is often met with hostile rebuttal from invested parties in differing philosophical camps. Hostility as a factor in perceived challenge was found in the educational psychology literature. Perceived challenge can be experienced in the surreal, virtual world and may influence behavior with real beings. It was significant to gauge the effects of engaging with media violence on children. Exposure to aggressive media scenarios has been shown to increase hostile attribution bias in children, such that after viewing aggressive scenarios, children infer hostile intent with subsequent exposure to benign scenarios (Martins, 2013). In a study of adolescents, Ko and colleagues (2014) found hostility to be predictive for addiction to violent internet games, which caused increased hostility. Hostility as a factor in perceived challenge surfaced in studies dealing with the psychosocial risk factors associated with dangerous driving and traffic accidents. This was not surprising, since “traffic is interaction” (Kovácsová, Rošková, & Lajunen, 2014, p. 303). The hostility investigated in these studies (Gidron, Gaygısız, & Lajunen, 2014; Kovácsová et al., 2014; Nesbit & Conger, 2012) was defined with all three aspects of the concept, cognitive, affective, and behavioral whereby, hostile drivers are challenged by the driving behaviors of others. Gidron and colleagues (Gidron et al.) found a positive correlation between hostility and dangerous driving behaviors. Furthermore, dangerous drivers showed a preference for left-hemispheric activation during driving, and this was mediated by hostility (Gidron et al.). A study of college student drivers who reported problematic or aggressive driving behaviors showed that they had a tendency to harbor hostile thoughts (measured as hostile cognitions) and dysfunctional attitudes about others while driving and in their day-to-day lives (Nesbit & Conger, 2012). Other researchers also found that hostility was a unique predictor of aggressive driving behaviors (Kovácsová et al., 2014). It would appear that hostile cognitions fuel negative driving outcomes. Gidron and colleagues (Gidron et al., 2014) noted that what they termed externally manifested hostility by a driver may provoke other drivers and create a cycle of hostile responding. References to a climate of hostility, suspicion, and intolerance were found in the sociological, philosophical, and nursing literature dealing with the plight of disenfranchised groups. For example, Bruce (2013), in his report of a qualitative study done after a Pride parade in a southern city, described what he labeled, the damaging cultural cycle of hostility and invisibility toward gay, lesbian, bisexual, and transgender individuals. Those he interviewed defined the “face of hostility” that they experienced as ranging from disapproving looks to anti-gay violence (Bruce).

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Karnick / Practice Applications Others in society deemed to be different from the mainstream were also often met with hostility. In the philosophical literature Hirschman (2013) wrote of the hostility toward those in the out-groups deemed different by those in the ingroup, and he said this prevents the interpersonal connections necessary for a benevolent society. Intergroup hostilities are said to have occurred along the lines of politics, religion, race, sexual orientation, culture, abilities, and geographical boundaries. The dynamics involved in the development of in-group hostility that often leads to violence toward outgroups is the subject of much research. Those with disabilities also experience hostility. Sin and colleagues (Sin, Hedges, Cook, & Comber, 2009) wrote that the environment in which those with mental disabilities live was often one of violence and hostility.

Hostility as a Factor in Criminal Behavior Hostility as a factor in criminal behavior was found in the educational and criminology literature. Two primary areas of focus included children and their propensity for violence and offenders in sexually-based crimes. Hostility was linked to criminal behavior in children. Adolescents whose fathers abused drugs felt victimized and discriminated against as a result of parental drug use. This was associated with adolescent maladjustment and substance abuse and had a direct link to adolescent risky, sexual behavior (Brook, Brook, Rubenstone, Zhang, & Finch, 2010). Betancourt and colleagues (Betancourt, Borisova, de la Soudière, & Williamson, 2011) examined the effects on 273 children who were forced to serve as soldiers in the Sierra Leone wars and found high levels of hostility especially in those children who perpetrated injury and killing. Hostility as a factor in criminal behavior was found in the criminology literature that focused predominantly on offenders in sexually-based crimes. In a framework developed to classify male-on-male assaults, 42% of male-on-male sexual assaulters displayed hostility as a dominant theme in the attack (Almond, McManus, & Ward, 2014). Crime scene analysis in cases of stranger-rape recidivism revealed hostility as a behavioral theme (Lehmann, Goodwill, GallaschNemitz, Biedermann, & Dahle, 2013).

Hostility as a Factor in the Workplace Hostility as a factor in the workplace was central in the business, communication, labor, and nursing literature. It dealt with interpersonal disagreement and discord that occurred among co-workers. Two major areas of focus included the business and healthcare settings. Within business settings, hostile criticism was found in the workplace from superiors; workplace hostility was found among workers; and worker hostility to customers and customers to workers was also found. Workplace hostility as a construct received much attention, with clarification of the

construct and the development of an instrument for measuring its occurrence (Selden & Downey, 2012). Interpersonal disagreements were often fueled by hostility at the organizational level. Those workers at the grassroots level of a hostile organization were often demoralized and harbored hostility themselves. Falk and Blaylock (2012), in reference to leadership styles during the great recession of 2007-2009, listed hostility as one of the negative characteristics. Falk and Blaylock stated that hostility in an organizational leader played a key role in altering judgment that enabled poor business decisions. Medler-Liraz and Kark (2012) supported this notion and discovered that the quality of leader-follower relations was related to the display of employee hostility to customers . The less hostile the employee, the greater was their ability to provide solutions to customer problems (Medler-Liraz & Kark). Nurse-to-nurse hostility in the workplace was found to be developing rapidly; it encompassed everything from bullying to incivility to lateral (horizontal) violence within the working environment of the nurse in all areas and all levels (Jackson, Hutchinson, Luck, & Wilkes, 2013; Reynolds, Kelly, & Singh-Carlson, 2014). To underscore the importance of workplace hostility in nursing, delegates of the 2010 American Nurses Association House of Delegates drafted a resolution against hostility, abuse, and bullying in the workplace (American Nurses Association, 2010). The 2010 resolution strengthened the 2006 document in stating that nurses were responsible for taking appropriate action against workplace hostility propagated by all healthcare team members, patients, or their families. Horizontal hostility in nursing has become a ubiquitous phenomenon in care settings in the United States and abroad (Wilson, Diedrich, Phelps, & Choi, 2011). For example, in a descriptive study of over 1,200 Italian intensive care, emergency room, and operating room nurses, 79% reported being a victim of lateral hostility within the past year, with 69 % experiencing psychophysical ailments as a result (Bambi et al., 2014). That which creates a hurtful environment for the nurse can also pose a threat to patients. Horizontal hostility is seen as predicting a number of adverse outcomes for practicing nurses including intent to leave (Wilson et al., 2011), dissatisfaction, lack of empowerment, and poor morale (Hickson, 2013). Most notably, workplace hostility posed a threat to patient safety (Wilson & Phelps, 2013) by fostering an environment that promoted a lack of professional obligation and commitment to patient care (Hickson, 2013). Workplace hostility for the nurse was also found to be propagated by patients and their significant others, putting the nurse and other caregivers at risk. The focus was on ameliorating hostility by understanding, predicting, and intervening with those patients whose pathology included aggressive behaviors. Hostility experienced by the practicing nurse from their psychiatric patients was a particular concern evidenced in the literature (Tema, Poggenpoel, & Myburgh, 2011).

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Nursing Implications for the Workplace Implications for nursing practice based on the state of the science of hostility can be drawn from all five themes, since nurses interact with patients, families, patients with health risks, and with workplace hostility in all healthcare settings and in day-to-day life. However, for this article the focus is on hostility toward nurses in the workplace. The importance of this theme is not only underscored by significant current nursing literature on the topic, but echoed by the 2010 ANA House of Delegates resolution against hostility, bullying, and abuse in the workplace (American Nurses Association, 2010) and by the formation of a new Professional Issues Panel on Workplace Violence and Incivility. The purpose of the panel is to develop a position statement to guide nurses and their employers regarding violent and hostile actions (American Nurses Association, 2014). Current nursing literature points to the working nurse’s world that is filled with hostility, primarily from colleagues and superiors. Hostility in the nurse workplace can be examined through the lens of the modeling and role-modeling (MRM) nursing theory (Erickson, Tomlin, & Swain, 1983). From a MRM theoretical perspective, with the major concepts of basic needs, attachment, adaptation, and loss, the root of nurse-workplace hostility may be seen as the result of unresolved loss which negatively affects the ability to cope with daily stressors and meet basic needs, ultimately resulting in morbid grief and chronic needs deficit (Erickson et al.). The working nurse experiences some form of loss on a daily basis in dealing the complexities of patient care in an ever-changing healthcare environment. Losses result from the fact that patients, to whom nurses are often attached, do not always get well, and control exercised by those involved in the business of healthcare threatens to erode caring nursing practices. Furthermore, nurses have a need to feel valued and respected by those with whom they work in order to adapt to the complexities of the healthcare environment (Erickson et al.). Nurses in supervisory positions are most able to assist their colleagues by first recognizing the impact of loss on the practicing nurse and its possible role in the development of horizontal hostility. Recognizing that the hostile nurse may be experiencing loss provides a unique perspective. Three recommendations for practice are suggested based on principles of MRM theory. First, promote unconditional acceptance of all staff members, even those engaging in hostile behaviors, which is a key nursing role identified by MRM theory. Second, affirm the strengths of each team member and announce how individual contributions enable the unit to function in a manner that promotes caring and healing. Third, promote a positive orientation of the unit environment where all staff members work together and value each other’s contributions.

Summary Hostility was the topic of this article, which reported nursing, medical and basic sciences, psychology, sociology, education,

philosophy, business, communication, and criminology literature. Five themes were identified arising from the literature: hostility as a health-risk factor, hostility as a factor in family relationships, hostility as a factor in perceived challenge, hostility as a factor in criminal behavior, and hostility as a factor in the workplace. Application of principles from modeling role-modeling nursing theory was used to suggest nursing implications for practice changes in the hostile working environment of the nurse. Declaration of Conflicting Interests The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding The author received no financial support for the research, authorship, and/or publication of this article.

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Nursing Science Quarterly 28(3)

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Hostility Patterns: Implications for Nursing Practice.

In order to present the state of the science of hostility among and across disciplines, a review of the literature was completed. The knowledge gained...
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