Lateral Violence in the Perioperative Setting

Article Outline

• ABSTRACT
• Bullying and Lateral Violence in the OR
• The Effects of Lateral Violence on Victims
• The Role of Empowerment
  • Proven methods
  • Educational resources
• Recommendations
• Conclusion
• Examination
  • Lateral Violence in the Perioperative Setting
    • Purpose/Goal
    • Behavioral Objectives
    • Questions
• Answer Sheet
  • Lateral Violence in the Perioperative Setting
• Learner Evaluation
  • Lateral Violence in the Perioperative Setting
    • Purpose/Goal
    • Objectives
    • Content
    • Test Questions/Answers
    • Learner Input
• References
• Copyright

ABSTRACT 

Lateral violence is disruptive, bullying, intimidating, or unsettling behavior that occurs between nurses in the workplace.

The perioperative setting fosters lateral violence because of the inherent stress of performing surgery; high patient acuity; a shortage of experienced personnel; work demands; and the restriction and isolation of the OR, which allows negative behaviors to be concealed more easily.

Lateral violence affects nurses' health and well-being and their ability to care for patients. Interventions to reduce lateral violence include empowerment of staff members and zero tolerance for lateral violence. AORN J 89 (April 2009) 688–696. © AORN, Inc, 2009.

Key words:  lateral violence , nurse-to-nurse violence , workplace abuse , bullying , verbal abuse

Lateral violence, also known as nurse-to-nurse violence or bullying, is disruptive behavior that interferes with effective health care communication and thus threatens a culture of patient safety. Lateral violence is counterproductive to quality health care and has a negative effect on the health and well-being of health care professionals as well.

Bullying has been defined as an

offensive, abusive, intimidating, malicious or insulting behavior or abuse of power conducted by an individual or group against others, which makes the recipient feel upset, threatened, humiliated, or vulnerable [and] which undermines their self-confidence and may cause them to suffer stress.^1(p10)

Likewise, lateral violence in nursing includes physical, verbal, and emotional abuse by one nurse against another. Lateral violence can be manifested in verbal and nonverbal behaviors. Examples of common lateral violence behaviors include:

The Center for American Nurses position statement on lateral violence asserts that these behaviors are “toxic to the nursing profession”^3(p1) and contribute to an organization's inability to retain quality staff members. This is of particular concern at a time when there is a shortage of qualified nursing professionals. The Joint Commission revealed in a survey that 77% of respondents had witnessed disruptive behavior in physicians and 65% had seen similar behavior in nurses.⁴ The Joint Commission survey reported that nurses are primarily bullied by physicians; however, nurse-to-nurse hostility, was not an uncommon finding. Additionally, the Joint Commission reported that a survey conducted by the American College of Physician Executives revealed that 38.9% of respondents admitted that physicians who generate high amounts of revenue are treated leniently when they exhibit negative behavior.⁵, ⁶ This may contribute to the idea that lateral violence is an accepted part of the OR culture and must be tolerated. Although correction of physician issues is organizationally driven, nurses must take the lead in addressing the lateral violence or bullying behaviors that occur in their own profession.

Studies show that the primary reason lateral violence is widespread is that nurses do not recognize the issue as behavior that must be corrected; rather, they accept these behaviors as the “way things are.”⁶, ⁷, ⁸ Expressions such as “nurses eat their young” have long been a hallmark of the nursing profession, which is ironic in a profession that prides itself in being a community of caring and nurturing practitioners.

While this is not a new topic, having been referenced in the literature for the past 20 years, the frequency of lateral violence appears to be escalating.⁹ The unsettling and intimidating behaviors that constitute lateral violence among nurses not only threaten the health and well-being of the nurse, but also of the patients entrusted to the nurse's care.

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Bullying and Lateral Violence in the OR 

Experts agree that the perioperative setting is an area in which nurses commonly become the victims of bullying and lateral violence. Whether perpetrated by physicians, administrators, or colleagues, bullying behaviors have been identified as a routine part of OR culture. This may be due to several factors including the inherent stress of performing surgery, high patient acuity, a shortage of experienced perioperative professionals, overtime and on-call demands, and a restricted department traditionally isolated from the rest of the facility, which allows negative behaviors to be concealed. Martha Griffin, RN, PhD, a nurse researcher, former perioperative nurse, and program coordinator for nursing professional development at Brigham and Women's Hospital in Boston, Massachusetts, states that “no other area in the hospital has a higher probability of lateral violence than the OR.”^2(p6) Dr Griffin adds that compared to other areas at her facility, she is contacted most frequently by OR personnel for assistance with behaviors that she refers to as “inhumane.” In a study published in the AORN Journal in December 2003, Dunn¹⁰ concluded that sabotage is one of the more frequent forms of lateral violence in the perioperative setting.

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The Effects of Lateral Violence on Victims 

Nurses themselves have been keenly aware of the deleterious effects lateral violence has on both their personal and professional lives. Cases of “burnout,” frustration, and disenchantment with the profession have caused nurses to abandon a career that many in the past considered a calling.¹¹ Nurses who are victims of bullying will experience more job stress, will have less job satisfaction, will exhibit increased absenteeism, and may provide substandard patient care, according to recent studies.⁶, ⁷, ⁸, ¹² The effects of lateral violence on nurses can manifest as both physical and psychological maladies. Nurses have reported such physical symptoms as

Psychologically, nurses have experienced anxiety; depression; substance abuse; feelings of isolation, insecurity, and low self-esteem; and in severe cases, post-traumatic stress disorder, including suicidal and homicidal thoughts. Studies have shown an increase in dysfunctional relationships for victimized nurses.¹³, ¹⁴

Lateral violence is an impediment to nurse collegiality and professional development. Lack of collegiality and professional development opportunties are well-known contributing factors to an organization's nurse vacancy rate. For example, a perioperative nurse who in the past has been berated and made to feel inadequate by a colleague may avoid new procedures and unfamiliar experiences, thus inhibiting his or her professional growth and development. Organizations experience increases in nursing turnover and an inability to retain qualified nursing personnel when lateral violence goes unchecked. Bland-Jones and Gates¹⁵ determined that costs associated with nursing turnover range from $22,000 to $64,000 per nurse, which would strain any facility's fiscal reserves.

Fear of reprisal and lack of organizational support have led perioperative nursing professionals and other nursing specialists to accept lateral violence behaviors as unavoidable. For example, how many fledgling perioperative nurses have been advised to develop a “thick skin” for survival during their orientation, which thereby conveys the expectation that abusive behavior is acceptable? Such a mind-set becomes enabling, so that bad behaviors are excused with the assumption that “that's the way things are” and that lateral violence must be tolerated, not changed. The cycle of abuse continues and in turn promotes an atmosphere of nurse-to-nurse hostility. Victims unconsciously mimic the behaviors that they endure and pass them on to the next wave of new nurses.

Although the personal implications created by lateral violence are quite apparent, nurses may not routinely make the connection to the negative effect bullying behaviors have on their ability to provide safe patient care. In addition, because this subject has not traditionally been broached in the curriculum of most nursing education programs, nurses often do not appreciate the effect that lateral violence has on them personally and professionally and on the delivery of quality health care.

Professional organizations such as the Joint Commission,⁶ the American Nurses Association (ANA),¹⁴ the Association of Critical Care Nurses (AACN),¹⁶ and the Council on Surgical and Perioperative Safety (CSPS)¹⁷ have issued statements condemning lateral violence in nursing as being in direct violation of a culture of patient safety. For example, lateral violence interferes with effective communication among health care providers which, in turn, undermines the safe delivery of patient care.

Professional communication is crucial when providing quality patient care. According to Johnson et al, verbal abuse is not only disrespectful, it also prevents effective communication in the workplace.¹⁸ They found that most verbal abuse occurs from physician to nurse, closely followed by nurse-to-nurse abuse.¹⁸ In 2002, the Joint Commission reported that the effect of abuse in the workplace can cause unfortunate consequences for patients, because nurses may be inhibited from communicating with intimidating physicians when seeking to clarify information that is directly important to patient care and safety.¹⁹ It is reasonable to assume that nurse-to-nurse communication is also negatively affected when one feels bullied by another, and this would also be detrimental to patient safety.

Patients become inadvertent victims when the attention of nurses is misdirected as a result of lateral violence. Consequently, patient satisfaction scores may be lowered, which could expose the facility to a decrease in market share and an increased susceptibility to liability.

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The Role of Empowerment 

Empowerment continues to be a long-sought-after goal of the nursing profession. Roberts in 2000²⁰ and DeMarco and Roberts in 2003²¹ declared that nurses are an oppressed population, and as a result, nurses act out toward each other in an attempt to gain power and self-esteem. The oppressed group theory contends that the resultant feelings of powerlessness and frustration felt by nurses, who have traditionally been dominated by physicians and administrators within a health care hierarchy, translate into acts of aggression within the group. Providing nurses with the tools to address, confront, and move beyond lateral violence can be empowering. Likewise, raising awareness of lateral violence and educating staff members to recognize its manifestations is a primary step in prevention. As nurses begin to identify bullying behaviors, it becomes difficult for the patterns to continue.²²

In 2008, Simpson²³ identified interventions for nurses to prevent hostility in the workplace. Simpson suggests that nurses speak up and mediate when they witness hostile behavior, refuse to participate in gossip, encourage questions from colleagues, and mentor and support new nurses. Nurses also must work with facility leaders to develop and enforce a zero-tolerance policy and initiate behavior change with positive actions and role-modeling.²³

In 2007, Johnson et al¹⁸ identified additional techniques for decreasing verbal abuse. They recommended that nurses react immediately at the moment of the abuse, redirect behavior to focus on the patient, immediately report the incident, and insist on a resolution to the incident.¹⁸

A 2004 study by Buback²⁴ concluded that assertiveness training is essential and that providing OR staff members with training that focused on conflict resolution and communication skills was effective when dealing with verbal abuse.²⁴ Educating nursing students as part of their curriculum will prepare new graduates to address and confront lateral violence in their future practice. Newly licensed nurses benefited from lateral violence awareness focus groups that also taught confrontation skills.² The empowerment brought by these skills positively affected retention rates.² Ongoing lateral violence education is imperative for the practicing nurse as well.

Hospital administrations should provide didactic and role-playing workshops to teach staff members how to address these behaviors in their environments. Workshops should offer behavioral techniques and communication tools to prevent and address lateral violence. It is not just nursing students and staff nurses who require empowerment; mid-level and senior executives are in need as well. Managers benefit from leadership training workshops as they learn and practice skills that address and diminish lateral violence in their workplaces.²⁵ As managers perceive the support of their senior administrators they are able to function more effectively and offer more support to their staff members. Managers' empowerment could also be derived from the administrators' enforcement of a zero-tolerance policy toward lateral violence. As examples are set and supported by hospital administrators, empowerment for both managers and staff members increases.

Another route to empowerment is recognition of nursing accomplishments. Empowerment also comes from support of nurses by nurses.²⁵ Including nursing staff members in the decision-making process serves to empower and highlight nursing contributions. Woelfle and McCaffrey²⁶ highlighted an earlier study by Daiski²⁷ in their discussion of lateral violence. Daiski's study of the views of hospital nurses concluded that nurses want recognition and inclusion in decision-making and that mutual support is cultivated in the nursing profession. The ultimate outcome of nurse empowerment would be to improve patient outcomes and help staff members to achieve self-validation and pride in their work.

Proven methods 

Based on the current literature, several strategies have been explored and evaluated with proven results in decreasing lateral violence among nurses. Martin et al²⁸ noted in 2008 that educational interventions that increase awareness of lateral violence are extremely effective. According to Stanley et al,²² a useful strategy is to use short presentations during staff meetings to raise awareness and educate staff members about lateral violence. This article also indicated that nurse managers often requested half-day workshops that focused on the major causes or factors behind lateral violence: intergenerational conflict and age and gender differences, and how they related to the 10 most common forms of lateral violence.²² Participant evaluations of educational offerings proved to be helpful in determining what was beneficial for staff members. Self-awareness exercises were rated as the most effective tool by workshop participants. Workshop participants verbally complained that they disliked role-playing activities; however, participant evaluations revealed this method to be a valuable experiential learning technique.²²

Griffin used interviewing and focus groups to evaluate the teaching of cognitive rehearsal techniques to new graduate nurses when attempting to empower nurses to confront workplace conflicts.² These techniques equipped new nurses with prerehearsed responses to negative remarks made by experienced colleagues. Armed with scripted cue cards of objective, nonemotional responses (eg, when noticing another nurse raising his or her eyebrows or making a face during a conversation, the cue card instructed the nurse to say, “I sense you may have something to say to me. It is okay to speak directly to me.”), nurses using this proactive method decreased and in some cases eliminated bullying behaviors. After the graduate nurses were educated about lateral violence and its causes, these new nurses felt more in tune with and better understood their co-workers, especially the ones who frequently exhibited these actions in the workplace.² These nurses also indicated that the use of the cognitive rehearsal techniques was an empowering tool.

Psychiatric nurse liaisons have been a recent addition to the arsenal of interventions aimed at reducing the occurrence of nurse-to-nurse aggression. According to Martin et al,²⁸ the psychiatric consultation liaison nurse (PCLN) has been described as an objective, specially-trained agent who can equip nurses with the skills necessary to identify negative behaviors and empower nurses with methods of conflict resolution.

Interventions found to be effective in conflict resolution and prevention of lateral violence include raising awareness of its existence and naming it. Recognition makes perpetration more difficult. A zero-tolerance policy must be established, and exit interviews must allow honest feedback about work relationships. Management support for zero-tolerance policies and inclusion of training are important to alleviate abusive behaviors.

Prevention may be accomplished through the development and enforcement of professional standards that staff members have helped to create. Additionally, preceptors, faculty members, and clinical educators must empower new graduates with knowledge about lateral violence, teach them behavioral techniques to confront it, coach nurses in the use of these techniques, and provide workshops that use didactic and experiential learning activities.², ²² Through educational workshops, the PCLN can help nurses and their organizations develop and implement strategies that reduce and prevent episodes of bullying. For example, a PCLN has been credited with the development and successful implementation of behavior standards at the Medical University of South Carolina, Charleston, in 2007.

Awareness of lateral violence has been further highlighted through efforts of nurse consultants who educate staff and faculty members with proactive strategies to cope with abusive behavior. The South Carolina Area Health Education Consortium provides workplace violence workshops. Participants' personal experiences, outlined in a survey, revealed that to date, 200 of 210 respondents had been victims of lateral violence at some point in their careers.²²

Educational resources 

To become familiar with Internet-accessible education pertaining to lateral violence in nursing, perioperative professionals can avail themselves of various sites. The ANA has a web page that expressly addresses workplace violence (http://www.nursingworld.org/MainMenuCategories/ANAPoliticalPower/State/StateLegislativeAgenda/Workplaceviolence.aspx). The ANA Workplace Violence page directs the visitor to such links as the 2008 Joint Commission Sentinel Event Alert, a report by the Bureau of Justice (1993-1999) on workplace violence, and the Occupational Health and Safety Administration (OSHA) web site. The ANA offers an educational module for nurses interested in expanding their knowledge base regarding lateral violence. This offering is free for members, with a nominal fee for non-members, at http://www.nursingworld.org/mods/mod440/lateralfull.htm.

Several state nurses' associations have provided anti-bullying information on their web sites in an effort to increase awareness among professionals; these are available to all nurses with Internet access. The Michigan Nurses' Association is one such organization that provides a comprehensive resource relating to lateral violence at http://www.minurses.org/lateralviolence. Other states have presented position statements and educational offerings via newsletters, conferences, on-line programs, and continuing education modules for members of their respective nursing associations.

Although not exclusive to nursing, http://www.worktrauma.org is web site that calls itself the leading educational self-help site for managers as well as victims of abuse in the workplace. This web site, with origins in South Africa, acknowledges workplace violence as a serious threat, and provides a plethora of free resources including research articles; surveys, including one from the US Department of Labor; victim support group access; and intervention strategies with suggestions that advocate for the integrated health and wellness of victims. The section with emphasis on workplace violence in the health care sector is of particular interest to nurses. The informational links provided by this web site are comprehensive and furnish sound practical advice with solid educational offerings.

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Recommendations 

Countries such as Canada,²⁹ Australia,³⁰ and the United Kingdom³¹ have laws protecting employees from workplace aggression, including lateral violence. Local, state, and federal legislation with provisions specific to lateral violence would provide US workers, including nurses, with safeguards and legal recourse.

Privately, emphasis should be directed toward initiatives that promote an organizational culture of collegiality with the development of policies and procedures that include zero tolerance for offenders. The Joint Commission,⁶ the ANA,¹⁴ AACN,¹⁶ and CSPS¹⁷ support education to increase awareness and implementation of zero tolerance policies by health care organizations. These will promote healthy and safe workplaces for nurses and provide patients with safe care. Comprehensive education with organizational zero tolerance could effectively stem the tide of lateral violence so that all health care professionals would be able to practice in an atmosphere of mutual respect and collegiality. The Joint Commission has a standard effective January 2009 that “addresses disruptive and inappropriate behaviors in two of its elements of performance.”⁶ Additionally, organizations should implement the following initiatives with medical staff, management, and staff member education to combat the occurrence of nurse-to-nurse hostility:

Guidance can be drawn from the lateral violence position statements of the Joint Commission,⁶ the Center for American Nurses,³ the Institute for Safe Medication Practices,³² the AACN,¹⁶ and the CSPS.¹⁷

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Conclusion 

Nursing colleagues must begin to address lateral violence in the perioperative setting. A multidisciplinary buy-in with support from the administration, however, is imperative for success. Continuing education with the aim of increasing awareness, together with a zero tolerance policy, should be the standard for all health care organizations. While lateral violence is at the very least unprofessional, in its more common expression, it threatens the health and well-being of nurses and becomes a patient safety issue. Perioperative professionals must realize that all workplace bullying, regardless of the source, creates an unproductive, dangerous work environment at a time when safety in health care is a crucial mandate.

At present, members of AORN's Perioperative Environment of Care Committee have proposed a position statement that champions a healthy work environment that will be voted on in the House of Delegates at AORN's March 2009 Congress.³³ The expectation is that as more evidence validates the dire consequences of bullying, and the nursing shortage becomes increasingly acute, professional organizations will become more vocal in this regard.

Likewise, the perioperative nursing community must band together and do its part to recognize its individual and collective role in lateral violence and commit to professional, collegial behaviors. When nurses set the tone with an attitude of mutual respect and solidarity, nursing practice improves with patients and caregivers reaping the benefits. In working to eradicate lateral violence in the perioperative setting, nurses not only champion the cause of patient safety, but advocate for their fellow professionals and the nursing community at large. It is time for nurses to give and receive the respect that the profession so justly deserves, and perioperative nurses should accept nothing less from one another or their professional colleagues.

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Examination 

Lateral Violence in the Perioperative Setting 

Purpose/Goal 

To educate perioperative nurses about lateral violence in the perioperative setting.

Behavioral Objectives 

After reading the article on lateral violence in the perioperative setting, nurses will be able to

Questions 

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Answer Sheet 

Lateral Violence in the Perioperative Setting 

Event #09103

Session #1077

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Learner Evaluation 

Lateral Violence in the Perioperative Setting 

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This evaluation is used to determine the extent to which this continuing education program met your learning needs. Rate these items on a scale of 1 to 5.

Purpose/Goal 

To educate perioperative nurses about lateral violence in the perioperative setting.

Objectives 

To what extent were the following objectives of this continuing education program achieved?

Content 

To what extent

Test Questions/Answers 

To what extent

Learner Input 

What other topics would you like to see addressed in a future continuing education article? Would you be interested or do you know someone who would be interested in writing an article on this topic?

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References 

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