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research-article2014
NSQXXX10.1177/0894318414558614Nursing Science QuarterlyClarke / Scholarly Dialogue
Scholarly Dialogue
Lateral Violence in Nursing: A Review of the Past Three Decades
Nursing Science Quarterly 2015, Vol. 28(1) 36–41 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0894318414558614 nsq.sagepub.com
Susan Jo Roberts, RN; DNSc; FAAN1
Abstract The author of this article reviews the literature on lateral violence in nursing. This concept was first discussed over three decades ago. Bullying and Incivility are concepts similar to lateral violence that have become increasingly utilized in nursing research and scholarly writing. The research on these concepts suggests that the behavior still exists in the nursing workplace, and that few interventions have been developed to change the behaviors or the power dynamics that cause them. Suggestions are included to change practice and scholarship in this area. Keywords bullying, lateral violence, nursing practice Lateral violence in nursing was first discussed over three decades ago. The initial hypothesis was that this behavior was prevalent in nursing and was related to a lack of power of nurses in the workplace (Roberts, 1983). Since that time research has documented the existence of the behaviors, sometimes called lateral violence, and at other times called bullying or incivility. An accumulating body of research documents the existence of such behaviors, and demonstrates their relevance to nursing practice. An understanding of the causation of the behaviors and their relationship to practice are not clear. An analysis of the literature demonstrated that these concepts are similar and overlapping, and are often used interchangeably. The behaviors have been linked to patient safety, psychological harm, and recruitment and retention of nurses (Joint Commission, 2008; Rosenstein & O’Daniels, 2008). The author here reviews the literature on lateral violence, bullying and incivility in nursing in order to: (a) differentiate the concepts, their meanings, inter-relatedness and theoretical basis, (b) explore the research that links these concepts to the nursing workplace, job satisfaction, and retention of nurses, (c) understand the reasons for these behaviors in nursing, and (d) analyze recommendations from the review for practice and research.
Method Literature for this review was retrieved from search of the databases, PubMed and CINAHL from 1990 through 2010, and from references in these articles that were repetitive and therefore deemed key earlier citations.
Lateral Violence Estimates of lateral violence in the nursing workplace range from 46-100% (Stanley, Martin, Michel, Welton & Nemeth,
2007). One analysis found that 85% of their sample had seen or experienced it, 90% had difficulty confronting the perpetrator and 40% percent of the nurses were considering leaving their job due to it (Wilson, Dietrich, Phelps & Choi, 2011). Lateral violence has frequently been related to absenteeism and thoughts about leaving nursing (Griffin, 2004; McKenna et al., 2003; Stanley et al., 2007), and has also been found to have an impact on patient safety, work satisfaction, and team nurse performance (Cox, 2003; Daiski, 2004). New graduates have been found to be particularly susceptible to lateral violence (Griffin, 2004; McKenna et al., 2003; Stanley et al., 2007; Thomas, 2009), and verbal abuse (Budin, Brewer, Chao & Kovner, 2013).
Definition of Lateral Violence Griffin (2004) defined lateral violence as “nurses covertly or overtly directing their dissatisfaction inward toward each other, toward themselves, and toward those less powerful than themselves” (p. 257). She noted that examples of behaviors included in lateral violence are: making faces or raising eyebrows in response to a colleague, making rude or demeaning comments, acting in ways that undermine the ability to help others, sabotaging another by withholding information, group infighting, scapegoating, passive aggressive communication, gossiping and failure to respect privacy or breaking confidences (Griffin, 2004). 1
Professor, Northeastern University
Contributing Editor: Pamela N. Clarke, RN, PhD, FAAN, Professor, University of Wyoming, School of Nursing, Dept. 3065, 1000 E. University Ave., Laramie, Wyoming 82079 Email: [email protected]
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Theory of Lateral Violence The most commonly cited theoretical explanation for lateral violence is based on the oppressed group behavior theory of Freire (1971), who theorized that members of powerless, oppressed groups develop distain for members of their own group, and have a belief in their own inferiority because they feel devalued in a culture where the power resides in another more dominant group. Such dynamics create low self-esteem and anxiety, as well as the use of submissive and passiveaggressive behaviors when confronted by the dominant group, because their fear makes them unable to express anger. Powerlessness and fear is the basis for a cycle in which aggression and anger toward the more powerful is turned inward toward one’s own group. The behaviors keep the group from organizing and developing the sense of unity and cohesiveness necessary to support each other and gain power in the culture (Freire, 1971).
Lateral Violence in Nursing Nursing has been noted to be an oppressed group because of lack of power and control in the workplace, since nurses are dominated by the medical profession in a long-standing hierarchy, that may have begun when healthcare moved from the home to the hospital (Roberts, 1983). Nurses developed these characteristics from working in a setting with this power imbalance are: (a) low self-esteem, (b) suppressed anger, and (c) passive-aggressive communication and silencing of their own needs (Bartholomew, 2006).
Measurement of Lateral Violence Tools have been developed to measure lateral violence (LV) in nursing. The Lateral Violence in Nursing Survey measured three constructs: (a) perceived effects of LV on an individual or group; (b) characteristics of the oppressors; (c) characteristics of coworker behaviors that act to mediate LV (Stanley et al., 2007). The Nurse Workplace Behavior Scale (NWS) has two components, which measures parts of the LV cycle: (a) internalized sexism and (b) minimization of the self (DeMarco, Roberts, Norris & McCurry, 2008). The testing of this tool found that these behaviors do exist in nurses and vary by age and practice setting.
Interventions to Decrease Lateral Violence Bartholomew (2006) expressed her view that nurses and nurse managers need to find ways to “level the playing field” in order to decrease the behaviors. Her suggested process begins with an acknowledgment of what is going on in the workplace culture, followed by interventions to support, educate, and develop a trusting workplace. Daiski (2004) also suggested that staff members and administrators come together to explore the behaviors and their origins related to
powerlessness, and learn to praise and support each other. Others have agreed that these are helpful strategies, but noted that nurse managers may ignore the behaviors because of their inability to deal with negative coworkers and their inability to establish a supportive work environment (Stanley et al., 2007). This avoidance becomes critical as the situation continues (Bartholomew, 2006; Stanley et al., 2007).
Oppressed Group Behaviors and Marginalization Roberts (1983) argued that nurse managers, like other nurses, are influenced by their own oppressed group behaviors, and therefore are easily marginalized within the managerial system. Many managers align themselves with the power in the institution and inadvertently become part of the horizontal violence rather than providing the leadership needed to dispel the cycle of oppression. Several scholars suggested that if managers understand the origins of lateral violence they can utilize specific strategies to deal with the behaviors in their staff members. Strategies include: (a) assessing the units for lateral violence, (b) teaching nurses about the dynamics of oppression, (c) allowing time for reflection and celebration about the work, and (d) not tolerating bad behavior of individuals who are unwilling to change (Bartholomew, 2006).
Studies on Lateral Violence Although there have been many recommendations to change the cycle of lateral violence, only a few intervention studies exist. One study utilized a team-building intervention on units that had low job satisfaction scores; it focused on building trust, clarifying roles, and engaging staff members in decision-making and the intervention improved cohesion scores (Barrett et al., 2009). A second study used an orientation program for new graduate nurses that included an intensive educational program that consisted of identifying characteristics of lateral violence and utilizing an interactive intervention designed to “shield” against lateral violence through “cognitive rehearsal” with pre-scripted responses (Griffin, 2004). The education led to fewer experiences of lateral violence and an increase in retention of new graduates.
Bullying Bullying is a concept that is defined similarly to lateral violence and provokes similar outcomes, although the theoretical reasons for its existence within nursing is not clearly understood. Research on bullying in the healthcare workplace has increased over the last decade and is reported frequently in the nursing literature in the UK, Canada, Australia and New Zealand (Hutchinson, Jackson, Wilkes & Vickers, 2008; Hutchinson, Vickers, Jackson & Wilkes, 2006; Quine, 1999). One study of employees in the British National Health Service found that 38% of the employees had experienced
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Nursing Science Quarterly 28(1)
bullying in the previous year, while 42% had witnessed it (Quine, 1999). Of all employee groups, nurses reported being bullied most (44%), with almost half of the perpetrators reported to be managers, 34% were of the same level and 21% were less senior. Two-thirds of the victims tried to take action, but were dissatisfied with the results.
intimidation, and degradation, (b) erosion of professional competence and reputation, and (c) attack through work roles and tasks that included interference with getting the work done (Hutchinson et al., 2010).
The Effects of Bullying
The etiology of bullying is often thought to be a dynamic relationship between the victimization of individual workers and oppressive work regimes that create the workplace (Hutchinson, Jackson, Wilkes & Vickers. 2008). One person suggested that bullying fits the same cycle as battering, in as much as with bullying there is self-blame in the target, and escalation of the violence if the target resists or files a complaint (Felblinger, 2008). Based on in-depth, semi-structured interviews, Hutchinson and colleagues developed a model of bullying in the nursing workplace that incorporated three aspects of the organization that promote and sustain bullying. These are: (a) organizational tolerance and reward for bullying, (b) Informal work alliances, and (c) misuse of legitimate authority, processes, and procedures (Hutchinson, Jackson, Wilkes & Vickers, 2008). These organizational characteristics influence the likelihood of bullying, and they work together dynamically to enhance and sustain the bullying.
Sequelae of bullying were lower job satisfaction, increased stress, depression and anxiety, and intention to leave their job (Rodwell & Demir, 2013). A study from a Turkish hospital found that 21% of the nurses had experienced bullying, 42% from administrators with 22% from peers; depression and lowered work performance was noted as a consequence (Yildirim, 2009). One-third of new graduate nurses studied in Canada reported being bullied and the bullying experience was related to subsequent burn-out (Laschinger, Grau, Finegan & Wilk, 2010). A study with nurses in an Australian healthcare organization also found psychological distress and depression as the consequence of bullying (Rodwell & Demir, 2013) and a Canadian study reported post-traumatic stress disorder (PTSD) related to exposure to workplace bullying (Laschinger, & Nosko, 2013). Bullying has also been reported in the United States (US) nursing workforce, with a range of 27% to 31% in different studies (Johnson & Rea, 2009; Simon, 2008). The findings of one study reported a significant relationship between bullying and the intention to leave the organization (Simon, 2008). Another study report showed that nurses who worked in medical-surgical, critical care, operating room or recovery and obstetrical units, in this order had more frequent situations of bullying, with more senior staff members reported as the perpetrators (Vessey, DeMarco, Gaffney & Budin, 2009). Of those who reported being bullied, half lost interest in their job, or had a desire to resign, and 23% became increasingly absent or did resign.
Definitions of Bullying Numerous definitions of bullying exist. Simon defined bullying as “being humiliated or ridiculed, being ignored or excluded, being shouted at, receiving hints that you should quit your job, receiving persistent criticism, and excessive monitoring of your work” (Simon, 2008, p. 349). Another definition described it similarly, as being spoken to in a “belittling or demeaning manner” or “making you feel like your work is being controlled” (Yildirim, 2009, p. 507). Another definition suggested that it is “repetitive aggressive behavior from persons of higher position or power with the deliberate intent to cause psychological or physical harm” which adds an intentional aspect to it from someone in a position of higher power (Vessey, DeMarco, Gaffney & Budin, 2009, p. 302). Using data from interviews with 26 Australian nurses who had been bullied, a typology of bullying was developed: (a) personal attack, including isolation,
Etiology of Bullying
Measurement Tools for Bullying The Negative Acts Questionnaire, contains a list of bullying behaviors found in most definitions, and utilizes 22 questions to determine bullying overtime (Johnson & Rea, 2009; Simon, 2008; Laschinger et al., 2010). The Bullying Inventory for the Nursing Workplace extracted three factors from its 17 items: (a) attack on competence and reputation, (b) personal attack, and (c) attack through work tasks (Hutchinson, Wilkes, Vickers & Jackson. 2008). A review of measurement of workplace bullying showed that because of the complexity of the concept area, future measurement should include multiple methods of investigation (survey, diaries, interviews, and focus groups) to study both the inside perspective of the bullying experience and outside observation to gain a clearer understanding of the behavior (Cowie, Naylor, Rivers, Smith & Pereira, 2001).
Interventions to Decrease Bullying No studies were found that utilized interventions to decrease bullying, but pressure has been brought on care institutions to decrease its existence. Regulatory bodies in several countries have mandated that hospitals have “zero tolerance” policies for bullying behavior (Hutchinson, Jackson, Wilkes & Vickers, 2008). The U. S. Joint Commission on Accreditation of Hospitals, based on reports of the extent of the problem and its impact on patient care and safety, issued a warning and requirement that hospitals develop policies to prohibit “disruptive behaviors” and guidelines for prevention
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Clarke / Scholarly Dialogue (Joint Commission, 2008). Several researchers question the effectiveness of these policies due to the increased rates despite the existence of policies (Hutchinson, Jackson, Wilkes & Vickers, 2008).
Responsibilities Involved with Bullying Johnson and Rea (2009) suggested that it is the responsibility of the nurse manager to assess and intervene when bullying occurs and to utilize individual education and change the factors that cause and sustain it because most victims do not report it due to fear and shame, or a belief that nothing will be done. Felblinger (2008) explained that the reaction of nurses to bullying makes them unique because they feel shame when they are bullied and take personal responsibility for the bullying, thus decreasing the chances of pushing back against it. Laschinger and colleagues (2010) found that new graduates reported less bullying when they had access to resources and alliances that promoted respect for expertise and fostered “respectful helping relationships.” One analysis recommended that all staff members need to take responsibility to confront bullying and support those bullied, and nurse managers need to create supportive and respectful work environments (Gaffney, DeMarco, Hofmeyer, Vessey & Budin, 2012).
Power and Autonomy with Bullying Staff members at the Agency for Healthcare Research and Quality raised the issue of the power differential and autonomy as the underlying organizational variable in bullying. They stated that autonomy in nursing practice is an essential attribute in decreasing bullying, and that care institutions must “ensure that nurses are empowered in deed as well as word; until they do, nurses may be considered second class citizens in these institutions to the detriment of their patients” (Hughes & Clancy, 2009, p.182). Hutchinson also noted that suggestions for interventions have focused on the education and support of the individual, but without work group and institutional change, the improvement cannot be sustained (Hutchinson et al., 2006). This recommendation is based on findings that bullying is utilized to maintain control of workers. Her research team developed a mixed intervention strategy that includes both individual and system change: (a) individual support and education/counseling and mediation between perpetrator and target, (b) corrective actions that enforce policies that discipline the bully, and training to deal with aggression, (c) policy change to discourage harassment and set up penalties, and (d) social interaction and “restorative” interventions that encourage collective responsibility to create a culture that is safe and supportive (Hutchinson & Jackson, 2013).
Incivility Another similar concept is incivility. Incivility is differentiated from bullying because there is no power differential
between the perpetrator and victim (Guidroz, BurnfieldGeimer, Clark, Schwaetschenau & Jex, 2010). Incivility appears to be less intense and less destructive than bullying or lateral violence, but is also related to burnout in the nursing workplace and lack of job satisfaction and retention (Laschinger, Letter, Day & Gilin, 2009). Read and Laschinger have found that authentic leadership and structural empowerment increased interpersonal collaboration and decreased “workplace maltreatment” in new graduate nurses. An “authentic leader” is defined as “confident, hopeful, resilient individual of high moral character who is self-aware and recognizes the strengths, weaknesses, values, and knowledge of themselves and others” (Read & Laschinger, 2013, p. 223).
Measurement Tools and Interventions for Incivility Two tools have been tested for use in measuring incivility, the Workplace Incivility Scale (Cortina, Magley, Williams & Langhout, 2001) and Nursing Incivility Scale (Guidroz, Burnfield-Geimer, Clark, Schwaetschenau & Jex, 2010). Only one study on interventions for incivility was found. The research utilized a CREW (civility, respect, and engagement at work) intervention and showed that nurses on units that experienced assessment and feedback on civility, education about incivility, and support from supervisors for 6 months reported greater civility, respect, job satisfaction and management trust than those on the units without the intervention (Leiter, Laschinger, Day & Oore, 2011).
Discussion This review verifies that lateral violence, bullying and incivility exist within the nursing workplace. Their existence is important to nursing because they are related to patient safety concerns, lack of job satisfaction, and decreased retention of nurses. A review of the work in this area suggested that better clarification of these concepts and their etiology is needed in order for interventions to be planned, executed, and evaluated. The relationship of leadership and power within the workplace also needs to continue to be studied related to the existence of lateral violence. More interventions will be useful in exploring change in the dynamics in the workplace that create the behaviors and transformations that can change the workplace. Also clarification of these concepts is needed when used in studies with nurses. Key elements of bullying include a persistent attack by managers or co-workers that cause intimidation, isolation, damage to professional identity, and obstruction of work. Lateral violence also includes demeaning behaviors and actions that inhibit work, but also include passive-aggressive communication and inter-group rivalry related to powerless groups. The research in this area is complex, but a careful and clear definition of the concepts and their measurement could improve the research. An understanding of where the behaviors come from is important as well. Some have suggested that there is an interaction between the reasons for lateral violence (poor
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Nursing Science Quarterly 28(1)
self-esteem, powerlessness, and violence within the group) and bullying that makes the negative behaviors more pervasive and powerful in nursing (Roberts, 1983). Several researchers have argued however that workplace bullying is rather a function of the character of the workplace and the need by administrators to keep employees regulated than the characteristics of worker (Hutchinson, Jackson, Wilkes & Vickers, 2008; Hutchinson et al., 2006; Johnson & Rea, 2009; Lewis, 2006). Hutchison and colleagues (2006) have argued that the idea that bullying is related to oppressed group behavior is “flawed” because the oppression theory assigns “risks apportioning blame solely to nurses and obscures the role of power relations within the organization” (p. 123). They have expressed concern that oppression theory as an explanation for bullying can “normalize” the behavior in nursing and may decrease chance of changes in the larger organization that contribute to bullying. Johnson (2009) acknowledged that bullying appears in other groups, but noteed that higher rates found in nurses may be at least partially explained by the effects of oppression and powerlessness in nursing. This explanation suggested that nurses, due to low self-esteem, blame themselves for the bullying and therefore do not report it or try to change it (Felblinger, 2008).
Leadership, Empowerment, and the Concepts There appears to be agreement that the basic etiology of lateral violence, bullying, and incivility is related to the way in which power and control is distributed in the workplace (Hughes & Clancy, 2009; Hutchinson, 2006). Read and Laschinger (2013) have demonstrated a powerful connection between the characteristics of certain leaders (confident, self-aware, and cognizant of abilities and strengths of nurses) and a workplace culture that is collegial and fosters teamwork. Empowered leaders create a culture that provides positive relationships with colleagues and more autonomy for nurses. They have also found that a culture that does not have workplace bullying or incivility is one that empowers nurses by providing access to resources and allows for them to have control over their work.
Decreasing Lateral Violence, Bullying, and Incivility New graduates have been found to be the most commonly affected by lateral violence, bullying, and incivility. They often experience the behaviors as a personal attack and view them as an indication of their lack of ability rather than a system problem. An intervention found to be helpful in retaining new staff was teaching “cognitive rehearsal” in their first orientation (Griffin, 2004). Teaching new nurses the necessary skills to deal with negative behaviors and
preparing them for the experience helps to prevent negative reactions. Inclusion of this education in orientations is relatively simple and should be further tested. Many scholars have suggested that understanding lateral violence will decrease the behaviors because nurses will understand the etiology and change their behavior (Bartholomew, 2006; Stanley et al., 2007). Hutchinson and colleagues (2008) have argued that these educational interventions would only change the understanding of nurses but not eradicate the behavior because there is a primary need to change the workplace that surrounds them. They argued that interventions should involve individual support and education, counseling and mediation, enforcement of policies against bullying, and efforts to create a culture that is safe and supportive for nurses and for patients (Hutchinson & Jackson, 2013; Hutchinson, Jackson, Wilkes & Vickers, 2008; Hutchinson, Vickers, Jackson & Wilkes, 2006).
Conclusion The concepts of lateral violence, bullying and incivility have been cited internationally as important disruptive behaviors in the healthcare workplace and especially in nursing. Definitions vary and have overlapping components. Similarly, the etiology of the concepts is often not considered, or not clarified as to its relationship to the behaviors. Future research is indicated. Leadership and empowerment of nurses are two essentials for decreasing disruptive behaviors. Strong, consistent and supportive leaders appear to be the important variables in keeping nurses from disruptive behaviors. Organizations with empowered leaders Most of the literature reviewed for this column on the underlying etiology and continuation of both lateral violence and bullying in the nursing workplace suggested that it is a learned behavior in individuals related to workplace power dynamics. Many researchers have argued that policies that require reporting as a strategy to decrease these behaviors do not work because there is fear and lack of belief that any change will occur due to the workplace dynamics. Development and implementation of interventions require alteration in the power dynamics within the workplace with priority given to resource allocation for creation of a different nursing workplace culture. This would enhance recruitment, retention, and job satisfaction of nurses and ensure safety of patients. Declaration of Conflicting Interests The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this editorial.
Funding The author received no financial support for the research, authorship, and/or publication of this editorial.
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Clarke / Scholarly Dialogue References Barrett, A., Piatek, C., Korber, S., & Padula, C. (2009). Nursing Administration Quarterly, 33(4), 342-351. Bartholomew, K. (2006). Ending Nurse to Nurse Hostility: Why Nurses eat their young and each other. Marblehead, MA: CiHCPro, Inc. Budin, W.C., Brewer, C.S., Chao, Y., & Kovner, C. (2013). Verbal abuse from nurse colleagues and work environment of early career registered nurses. Journal of Nursing Scholarship, 45(3), 308-316. Cortina, L. M., Magley, V. J., Williams, J.H., & Langhout, R. D. (2001). Incivility in the workplace: Incidence and impact. Journal of Occupational Health Psychology, 6(1), 64-80. Cowie, H., Naylor, P., Rivers, I., Smith, P. K., & Pereira, B. (2001). Measuring workplace bullying. Aggression and Violent Behavior 7(1), 33-51. Cox, K. (2003). The effects of intrapersonal, intragroup, and intergroup conflict on team performance effectiveness and work satisfaction. Nursing Administration Quarterly 27(2), 153-163. Daiski, I. (2004). Changing nurses’ dis-empowering relationship patterns. Journal of Advanced Nursing, 48(1), 43-50. DeMarco, R., Roberts, S. J., Norris, A. E., & McCurry, M. (2008). The development of the Nurse Workplace Scale (NWS): Selfadvocating behaviors and beliefs in the professional workplace. Journal of Professional Nursing, 24(5), 296-301. Felblinger, D. (2008). Incivility and bullying in the workplace and nurses’ shame responses. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 37(2), 234-242. Freire, P. (1971). Pedagogy of the Oppressed. New York, NY: Herder and Herder. Gaffney, D. A., DeMarco, R. F., Hofmeyer, A., Vessey, J. A., & Budin, W. C. (2012). Making things right: Nurses’ experience with Workplace Bullying–A grounded theory. Nursing Research and Practice, 1, 1-10, doi:10.1155/2012/243210. Griffin, M. (2004). Teaching cognitive rehearsal as a shield for lateral violence: An Intervention for newly licensed nurses. Journal of Continuing Education in Nursing, 35(6), 257262.ed Guidroz, A. M., Burnfield-Geimer, J. L., Clark., O., Schwetschenau, H. M., & Jex, S. M. (2010). The Nursing Incivility Scale: Development and validation of an occupation-specific measure. Journal of Nursing Measurement, 18(3), 176-200. Hughes, R. G., & Clancy, C. C. (2009). Complexity, bullying and stress. Journal of Nursing Care and Quality, 24(3), 180-183. Hutchinson, M., & Jackson, D. (2013). Hostile clinician behaviours in the nursing work environment and implications for patient care: A mixed-methods systematic review. BioMed Central Nursing 12(25), 1-12. Hutchinson, M., Jackson, D., Wilkes, L., & Vickers, M. (2008). A new model of bullying in the nursing workplace. Advances in Nursing Science, 31(2), E60-E71. Hutchinson, M, Vickers, M., Jackson, D., & Wilkes, L. (2006). Workplace bullying in nursing: Toward a more critical organizational perspective. Nursing Inquiry, 13(2), 118-126. Hutchinson, M, Vickers, M., Wilkes, L., & Jackson, D. (2010). A typology of bullying behaviours: the experience of Australian nurses. Journal of Clinical Nursing, 19(16), 2319-2328.
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research-article2014
NSQXXX10.1177/0894318414558614Nursing Science QuarterlyClarke / Scholarly Dialogue
Scholarly Dialogue
Lateral Violence in Nursing: A Review of the Past Three Decades
Nursing Science Quarterly 2015, Vol. 28(1) 36–41 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0894318414558614 nsq.sagepub.com
Susan Jo Roberts, RN; DNSc; FAAN1
Abstract The author of this article reviews the literature on lateral violence in nursing. This concept was first discussed over three decades ago. Bullying and Incivility are concepts similar to lateral violence that have become increasingly utilized in nursing research and scholarly writing. The research on these concepts suggests that the behavior still exists in the nursing workplace, and that few interventions have been developed to change the behaviors or the power dynamics that cause them. Suggestions are included to change practice and scholarship in this area. Keywords bullying, lateral violence, nursing practice Lateral violence in nursing was first discussed over three decades ago. The initial hypothesis was that this behavior was prevalent in nursing and was related to a lack of power of nurses in the workplace (Roberts, 1983). Since that time research has documented the existence of the behaviors, sometimes called lateral violence, and at other times called bullying or incivility. An accumulating body of research documents the existence of such behaviors, and demonstrates their relevance to nursing practice. An understanding of the causation of the behaviors and their relationship to practice are not clear. An analysis of the literature demonstrated that these concepts are similar and overlapping, and are often used interchangeably. The behaviors have been linked to patient safety, psychological harm, and recruitment and retention of nurses (Joint Commission, 2008; Rosenstein & O’Daniels, 2008). The author here reviews the literature on lateral violence, bullying and incivility in nursing in order to: (a) differentiate the concepts, their meanings, inter-relatedness and theoretical basis, (b) explore the research that links these concepts to the nursing workplace, job satisfaction, and retention of nurses, (c) understand the reasons for these behaviors in nursing, and (d) analyze recommendations from the review for practice and research.
Method Literature for this review was retrieved from search of the databases, PubMed and CINAHL from 1990 through 2010, and from references in these articles that were repetitive and therefore deemed key earlier citations.
Lateral Violence Estimates of lateral violence in the nursing workplace range from 46-100% (Stanley, Martin, Michel, Welton & Nemeth,
2007). One analysis found that 85% of their sample had seen or experienced it, 90% had difficulty confronting the perpetrator and 40% percent of the nurses were considering leaving their job due to it (Wilson, Dietrich, Phelps & Choi, 2011). Lateral violence has frequently been related to absenteeism and thoughts about leaving nursing (Griffin, 2004; McKenna et al., 2003; Stanley et al., 2007), and has also been found to have an impact on patient safety, work satisfaction, and team nurse performance (Cox, 2003; Daiski, 2004). New graduates have been found to be particularly susceptible to lateral violence (Griffin, 2004; McKenna et al., 2003; Stanley et al., 2007; Thomas, 2009), and verbal abuse (Budin, Brewer, Chao & Kovner, 2013).
Definition of Lateral Violence Griffin (2004) defined lateral violence as “nurses covertly or overtly directing their dissatisfaction inward toward each other, toward themselves, and toward those less powerful than themselves” (p. 257). She noted that examples of behaviors included in lateral violence are: making faces or raising eyebrows in response to a colleague, making rude or demeaning comments, acting in ways that undermine the ability to help others, sabotaging another by withholding information, group infighting, scapegoating, passive aggressive communication, gossiping and failure to respect privacy or breaking confidences (Griffin, 2004). 1
Professor, Northeastern University
Contributing Editor: Pamela N. Clarke, RN, PhD, FAAN, Professor, University of Wyoming, School of Nursing, Dept. 3065, 1000 E. University Ave., Laramie, Wyoming 82079 Email: [email protected]
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Theory of Lateral Violence The most commonly cited theoretical explanation for lateral violence is based on the oppressed group behavior theory of Freire (1971), who theorized that members of powerless, oppressed groups develop distain for members of their own group, and have a belief in their own inferiority because they feel devalued in a culture where the power resides in another more dominant group. Such dynamics create low self-esteem and anxiety, as well as the use of submissive and passiveaggressive behaviors when confronted by the dominant group, because their fear makes them unable to express anger. Powerlessness and fear is the basis for a cycle in which aggression and anger toward the more powerful is turned inward toward one’s own group. The behaviors keep the group from organizing and developing the sense of unity and cohesiveness necessary to support each other and gain power in the culture (Freire, 1971).
Lateral Violence in Nursing Nursing has been noted to be an oppressed group because of lack of power and control in the workplace, since nurses are dominated by the medical profession in a long-standing hierarchy, that may have begun when healthcare moved from the home to the hospital (Roberts, 1983). Nurses developed these characteristics from working in a setting with this power imbalance are: (a) low self-esteem, (b) suppressed anger, and (c) passive-aggressive communication and silencing of their own needs (Bartholomew, 2006).
Measurement of Lateral Violence Tools have been developed to measure lateral violence (LV) in nursing. The Lateral Violence in Nursing Survey measured three constructs: (a) perceived effects of LV on an individual or group; (b) characteristics of the oppressors; (c) characteristics of coworker behaviors that act to mediate LV (Stanley et al., 2007). The Nurse Workplace Behavior Scale (NWS) has two components, which measures parts of the LV cycle: (a) internalized sexism and (b) minimization of the self (DeMarco, Roberts, Norris & McCurry, 2008). The testing of this tool found that these behaviors do exist in nurses and vary by age and practice setting.
Interventions to Decrease Lateral Violence Bartholomew (2006) expressed her view that nurses and nurse managers need to find ways to “level the playing field” in order to decrease the behaviors. Her suggested process begins with an acknowledgment of what is going on in the workplace culture, followed by interventions to support, educate, and develop a trusting workplace. Daiski (2004) also suggested that staff members and administrators come together to explore the behaviors and their origins related to
powerlessness, and learn to praise and support each other. Others have agreed that these are helpful strategies, but noted that nurse managers may ignore the behaviors because of their inability to deal with negative coworkers and their inability to establish a supportive work environment (Stanley et al., 2007). This avoidance becomes critical as the situation continues (Bartholomew, 2006; Stanley et al., 2007).
Oppressed Group Behaviors and Marginalization Roberts (1983) argued that nurse managers, like other nurses, are influenced by their own oppressed group behaviors, and therefore are easily marginalized within the managerial system. Many managers align themselves with the power in the institution and inadvertently become part of the horizontal violence rather than providing the leadership needed to dispel the cycle of oppression. Several scholars suggested that if managers understand the origins of lateral violence they can utilize specific strategies to deal with the behaviors in their staff members. Strategies include: (a) assessing the units for lateral violence, (b) teaching nurses about the dynamics of oppression, (c) allowing time for reflection and celebration about the work, and (d) not tolerating bad behavior of individuals who are unwilling to change (Bartholomew, 2006).
Studies on Lateral Violence Although there have been many recommendations to change the cycle of lateral violence, only a few intervention studies exist. One study utilized a team-building intervention on units that had low job satisfaction scores; it focused on building trust, clarifying roles, and engaging staff members in decision-making and the intervention improved cohesion scores (Barrett et al., 2009). A second study used an orientation program for new graduate nurses that included an intensive educational program that consisted of identifying characteristics of lateral violence and utilizing an interactive intervention designed to “shield” against lateral violence through “cognitive rehearsal” with pre-scripted responses (Griffin, 2004). The education led to fewer experiences of lateral violence and an increase in retention of new graduates.
Bullying Bullying is a concept that is defined similarly to lateral violence and provokes similar outcomes, although the theoretical reasons for its existence within nursing is not clearly understood. Research on bullying in the healthcare workplace has increased over the last decade and is reported frequently in the nursing literature in the UK, Canada, Australia and New Zealand (Hutchinson, Jackson, Wilkes & Vickers, 2008; Hutchinson, Vickers, Jackson & Wilkes, 2006; Quine, 1999). One study of employees in the British National Health Service found that 38% of the employees had experienced
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bullying in the previous year, while 42% had witnessed it (Quine, 1999). Of all employee groups, nurses reported being bullied most (44%), with almost half of the perpetrators reported to be managers, 34% were of the same level and 21% were less senior. Two-thirds of the victims tried to take action, but were dissatisfied with the results.
intimidation, and degradation, (b) erosion of professional competence and reputation, and (c) attack through work roles and tasks that included interference with getting the work done (Hutchinson et al., 2010).
The Effects of Bullying
The etiology of bullying is often thought to be a dynamic relationship between the victimization of individual workers and oppressive work regimes that create the workplace (Hutchinson, Jackson, Wilkes & Vickers. 2008). One person suggested that bullying fits the same cycle as battering, in as much as with bullying there is self-blame in the target, and escalation of the violence if the target resists or files a complaint (Felblinger, 2008). Based on in-depth, semi-structured interviews, Hutchinson and colleagues developed a model of bullying in the nursing workplace that incorporated three aspects of the organization that promote and sustain bullying. These are: (a) organizational tolerance and reward for bullying, (b) Informal work alliances, and (c) misuse of legitimate authority, processes, and procedures (Hutchinson, Jackson, Wilkes & Vickers, 2008). These organizational characteristics influence the likelihood of bullying, and they work together dynamically to enhance and sustain the bullying.
Sequelae of bullying were lower job satisfaction, increased stress, depression and anxiety, and intention to leave their job (Rodwell & Demir, 2013). A study from a Turkish hospital found that 21% of the nurses had experienced bullying, 42% from administrators with 22% from peers; depression and lowered work performance was noted as a consequence (Yildirim, 2009). One-third of new graduate nurses studied in Canada reported being bullied and the bullying experience was related to subsequent burn-out (Laschinger, Grau, Finegan & Wilk, 2010). A study with nurses in an Australian healthcare organization also found psychological distress and depression as the consequence of bullying (Rodwell & Demir, 2013) and a Canadian study reported post-traumatic stress disorder (PTSD) related to exposure to workplace bullying (Laschinger, & Nosko, 2013). Bullying has also been reported in the United States (US) nursing workforce, with a range of 27% to 31% in different studies (Johnson & Rea, 2009; Simon, 2008). The findings of one study reported a significant relationship between bullying and the intention to leave the organization (Simon, 2008). Another study report showed that nurses who worked in medical-surgical, critical care, operating room or recovery and obstetrical units, in this order had more frequent situations of bullying, with more senior staff members reported as the perpetrators (Vessey, DeMarco, Gaffney & Budin, 2009). Of those who reported being bullied, half lost interest in their job, or had a desire to resign, and 23% became increasingly absent or did resign.
Definitions of Bullying Numerous definitions of bullying exist. Simon defined bullying as “being humiliated or ridiculed, being ignored or excluded, being shouted at, receiving hints that you should quit your job, receiving persistent criticism, and excessive monitoring of your work” (Simon, 2008, p. 349). Another definition described it similarly, as being spoken to in a “belittling or demeaning manner” or “making you feel like your work is being controlled” (Yildirim, 2009, p. 507). Another definition suggested that it is “repetitive aggressive behavior from persons of higher position or power with the deliberate intent to cause psychological or physical harm” which adds an intentional aspect to it from someone in a position of higher power (Vessey, DeMarco, Gaffney & Budin, 2009, p. 302). Using data from interviews with 26 Australian nurses who had been bullied, a typology of bullying was developed: (a) personal attack, including isolation,
Etiology of Bullying
Measurement Tools for Bullying The Negative Acts Questionnaire, contains a list of bullying behaviors found in most definitions, and utilizes 22 questions to determine bullying overtime (Johnson & Rea, 2009; Simon, 2008; Laschinger et al., 2010). The Bullying Inventory for the Nursing Workplace extracted three factors from its 17 items: (a) attack on competence and reputation, (b) personal attack, and (c) attack through work tasks (Hutchinson, Wilkes, Vickers & Jackson. 2008). A review of measurement of workplace bullying showed that because of the complexity of the concept area, future measurement should include multiple methods of investigation (survey, diaries, interviews, and focus groups) to study both the inside perspective of the bullying experience and outside observation to gain a clearer understanding of the behavior (Cowie, Naylor, Rivers, Smith & Pereira, 2001).
Interventions to Decrease Bullying No studies were found that utilized interventions to decrease bullying, but pressure has been brought on care institutions to decrease its existence. Regulatory bodies in several countries have mandated that hospitals have “zero tolerance” policies for bullying behavior (Hutchinson, Jackson, Wilkes & Vickers, 2008). The U. S. Joint Commission on Accreditation of Hospitals, based on reports of the extent of the problem and its impact on patient care and safety, issued a warning and requirement that hospitals develop policies to prohibit “disruptive behaviors” and guidelines for prevention
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Clarke / Scholarly Dialogue (Joint Commission, 2008). Several researchers question the effectiveness of these policies due to the increased rates despite the existence of policies (Hutchinson, Jackson, Wilkes & Vickers, 2008).
Responsibilities Involved with Bullying Johnson and Rea (2009) suggested that it is the responsibility of the nurse manager to assess and intervene when bullying occurs and to utilize individual education and change the factors that cause and sustain it because most victims do not report it due to fear and shame, or a belief that nothing will be done. Felblinger (2008) explained that the reaction of nurses to bullying makes them unique because they feel shame when they are bullied and take personal responsibility for the bullying, thus decreasing the chances of pushing back against it. Laschinger and colleagues (2010) found that new graduates reported less bullying when they had access to resources and alliances that promoted respect for expertise and fostered “respectful helping relationships.” One analysis recommended that all staff members need to take responsibility to confront bullying and support those bullied, and nurse managers need to create supportive and respectful work environments (Gaffney, DeMarco, Hofmeyer, Vessey & Budin, 2012).
Power and Autonomy with Bullying Staff members at the Agency for Healthcare Research and Quality raised the issue of the power differential and autonomy as the underlying organizational variable in bullying. They stated that autonomy in nursing practice is an essential attribute in decreasing bullying, and that care institutions must “ensure that nurses are empowered in deed as well as word; until they do, nurses may be considered second class citizens in these institutions to the detriment of their patients” (Hughes & Clancy, 2009, p.182). Hutchinson also noted that suggestions for interventions have focused on the education and support of the individual, but without work group and institutional change, the improvement cannot be sustained (Hutchinson et al., 2006). This recommendation is based on findings that bullying is utilized to maintain control of workers. Her research team developed a mixed intervention strategy that includes both individual and system change: (a) individual support and education/counseling and mediation between perpetrator and target, (b) corrective actions that enforce policies that discipline the bully, and training to deal with aggression, (c) policy change to discourage harassment and set up penalties, and (d) social interaction and “restorative” interventions that encourage collective responsibility to create a culture that is safe and supportive (Hutchinson & Jackson, 2013).
Incivility Another similar concept is incivility. Incivility is differentiated from bullying because there is no power differential
between the perpetrator and victim (Guidroz, BurnfieldGeimer, Clark, Schwaetschenau & Jex, 2010). Incivility appears to be less intense and less destructive than bullying or lateral violence, but is also related to burnout in the nursing workplace and lack of job satisfaction and retention (Laschinger, Letter, Day & Gilin, 2009). Read and Laschinger have found that authentic leadership and structural empowerment increased interpersonal collaboration and decreased “workplace maltreatment” in new graduate nurses. An “authentic leader” is defined as “confident, hopeful, resilient individual of high moral character who is self-aware and recognizes the strengths, weaknesses, values, and knowledge of themselves and others” (Read & Laschinger, 2013, p. 223).
Measurement Tools and Interventions for Incivility Two tools have been tested for use in measuring incivility, the Workplace Incivility Scale (Cortina, Magley, Williams & Langhout, 2001) and Nursing Incivility Scale (Guidroz, Burnfield-Geimer, Clark, Schwaetschenau & Jex, 2010). Only one study on interventions for incivility was found. The research utilized a CREW (civility, respect, and engagement at work) intervention and showed that nurses on units that experienced assessment and feedback on civility, education about incivility, and support from supervisors for 6 months reported greater civility, respect, job satisfaction and management trust than those on the units without the intervention (Leiter, Laschinger, Day & Oore, 2011).
Discussion This review verifies that lateral violence, bullying and incivility exist within the nursing workplace. Their existence is important to nursing because they are related to patient safety concerns, lack of job satisfaction, and decreased retention of nurses. A review of the work in this area suggested that better clarification of these concepts and their etiology is needed in order for interventions to be planned, executed, and evaluated. The relationship of leadership and power within the workplace also needs to continue to be studied related to the existence of lateral violence. More interventions will be useful in exploring change in the dynamics in the workplace that create the behaviors and transformations that can change the workplace. Also clarification of these concepts is needed when used in studies with nurses. Key elements of bullying include a persistent attack by managers or co-workers that cause intimidation, isolation, damage to professional identity, and obstruction of work. Lateral violence also includes demeaning behaviors and actions that inhibit work, but also include passive-aggressive communication and inter-group rivalry related to powerless groups. The research in this area is complex, but a careful and clear definition of the concepts and their measurement could improve the research. An understanding of where the behaviors come from is important as well. Some have suggested that there is an interaction between the reasons for lateral violence (poor
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self-esteem, powerlessness, and violence within the group) and bullying that makes the negative behaviors more pervasive and powerful in nursing (Roberts, 1983). Several researchers have argued however that workplace bullying is rather a function of the character of the workplace and the need by administrators to keep employees regulated than the characteristics of worker (Hutchinson, Jackson, Wilkes & Vickers, 2008; Hutchinson et al., 2006; Johnson & Rea, 2009; Lewis, 2006). Hutchison and colleagues (2006) have argued that the idea that bullying is related to oppressed group behavior is “flawed” because the oppression theory assigns “risks apportioning blame solely to nurses and obscures the role of power relations within the organization” (p. 123). They have expressed concern that oppression theory as an explanation for bullying can “normalize” the behavior in nursing and may decrease chance of changes in the larger organization that contribute to bullying. Johnson (2009) acknowledged that bullying appears in other groups, but noteed that higher rates found in nurses may be at least partially explained by the effects of oppression and powerlessness in nursing. This explanation suggested that nurses, due to low self-esteem, blame themselves for the bullying and therefore do not report it or try to change it (Felblinger, 2008).
Leadership, Empowerment, and the Concepts There appears to be agreement that the basic etiology of lateral violence, bullying, and incivility is related to the way in which power and control is distributed in the workplace (Hughes & Clancy, 2009; Hutchinson, 2006). Read and Laschinger (2013) have demonstrated a powerful connection between the characteristics of certain leaders (confident, self-aware, and cognizant of abilities and strengths of nurses) and a workplace culture that is collegial and fosters teamwork. Empowered leaders create a culture that provides positive relationships with colleagues and more autonomy for nurses. They have also found that a culture that does not have workplace bullying or incivility is one that empowers nurses by providing access to resources and allows for them to have control over their work.
Decreasing Lateral Violence, Bullying, and Incivility New graduates have been found to be the most commonly affected by lateral violence, bullying, and incivility. They often experience the behaviors as a personal attack and view them as an indication of their lack of ability rather than a system problem. An intervention found to be helpful in retaining new staff was teaching “cognitive rehearsal” in their first orientation (Griffin, 2004). Teaching new nurses the necessary skills to deal with negative behaviors and
preparing them for the experience helps to prevent negative reactions. Inclusion of this education in orientations is relatively simple and should be further tested. Many scholars have suggested that understanding lateral violence will decrease the behaviors because nurses will understand the etiology and change their behavior (Bartholomew, 2006; Stanley et al., 2007). Hutchinson and colleagues (2008) have argued that these educational interventions would only change the understanding of nurses but not eradicate the behavior because there is a primary need to change the workplace that surrounds them. They argued that interventions should involve individual support and education, counseling and mediation, enforcement of policies against bullying, and efforts to create a culture that is safe and supportive for nurses and for patients (Hutchinson & Jackson, 2013; Hutchinson, Jackson, Wilkes & Vickers, 2008; Hutchinson, Vickers, Jackson & Wilkes, 2006).
Conclusion The concepts of lateral violence, bullying and incivility have been cited internationally as important disruptive behaviors in the healthcare workplace and especially in nursing. Definitions vary and have overlapping components. Similarly, the etiology of the concepts is often not considered, or not clarified as to its relationship to the behaviors. Future research is indicated. Leadership and empowerment of nurses are two essentials for decreasing disruptive behaviors. Strong, consistent and supportive leaders appear to be the important variables in keeping nurses from disruptive behaviors. Organizations with empowered leaders Most of the literature reviewed for this column on the underlying etiology and continuation of both lateral violence and bullying in the nursing workplace suggested that it is a learned behavior in individuals related to workplace power dynamics. Many researchers have argued that policies that require reporting as a strategy to decrease these behaviors do not work because there is fear and lack of belief that any change will occur due to the workplace dynamics. Development and implementation of interventions require alteration in the power dynamics within the workplace with priority given to resource allocation for creation of a different nursing workplace culture. This would enhance recruitment, retention, and job satisfaction of nurses and ensure safety of patients. Declaration of Conflicting Interests The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this editorial.
Funding The author received no financial support for the research, authorship, and/or publication of this editorial.
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