Effective nursing leaders must develop and maintain a “zero-tolerance” work culture. This includes clear communication as to what is expected from someone who calls themselves a professional, and follow-through of consequences when one does exhibit negative behaviors. The proposal will include a questionnaire, role playing scenarios, and a six-month period of time that registered nurses will use conscious responses on cue cards to confront lateral violence when it occurs. Evaluation will include a follow-up questionnaire and video-taped interviews.
Nursing and healthcare leaders owe it to their staff and to themselves to learn and implement these methods to improve the work environment by immunization more effectively, having more satisfied employees, and improving patient safety. Problem The concept of lateral violence has been well-defined for about twenty years. Behaviors of lateral violence can be overt such as infighting and bickering with peers, or very covert such as eye-rolling and failure to respect confidences.
Studies show that nurses who are targets of lateral violence have less job satisfaction and have higher rates of burnout. (Wilson, Dietrich, Phelps, & Choc, 2011) It is estimated that it costs $92,000 to recruit, hire and orient a medical-surgical nurse. Multiply this by 51 nurses and the cost to the organization can be astronomical. Registered nurse turnover is also associated with higher nurse-patient ratios which can compromise patient care (Wilson et al. ). Bartholomew notes that a toxic work environment can be destructive to an organization.
Lateral violence creates feelings of inferiority, anger, and frustration. When working in a group, this can be counter- productive (Bartholomew, 2006). Although some nurses do not recognize the term lateral violence, they probably have experienced it at some point in their career. This is part of the problem identified. Many nurses have not been educated on lateral violence nor its effects on the perpetrators or the victims. There is usually no formal education given on the subject, in new hire orientation situations, or nursing school curriculums.
Solution The need for focused education and training of lateral violence has been identified. Development of a questionnaire to determine the prevalence of lateral violence will be completed and utilized at the beginning. Staff education including a Power Point Presentation and role-playing scenarios will be conducted. A group of nurses will then be asked to take part in a six onto trial of confronting lateral violence with conscious responses. Follow- up of this trial will include video-taped interviews and a second questionnaire.
A committee as yet to be formed will be responsible for long-term follow up and follow through. This will include incorporating the education into new hire orientation and student rotations. Incorporating Theory The solution this writer has proposed for the issue of lateral violence in the health care setting is focused education and training for all nurses. This would include the ability to recognize it for what it is, as well as methods of leaning with it appropriately.
Training would also include a set of behavioral standards that would be implemented hospital-wide. Lateral violence creates an unpleasant work environment and can have harmful effects on individual nurses, patient safety, and ultimately the entire organization (Tamarind, 201 1). Florence Nightingale discovered, while taking care Of soldiers in Crimea, that improving ones environment around them directly relates to a better well-being. This theory incorporates the restoration of usual health status of clients when their external environment is optimal.
It states that external factors associated with the patient’s surroundings affect life or biologic and physiologic processes and their development (2012). Nightingale’s theory relates to this writer’s process change plan in that victims of lateral violence often have difficulty concentrating on and performing their expected duties due to the stress they are put under with the distraction of an unstable work environment. If their work environment could be made more conducive to giving excellent, patient-centered care, everyone involved would benefit.
Dimmer discovered that in a hostile work environment, quality attain care and safety become compromised. New nurses will deliver care without answers they need because they received unprofessional answers or criticism from their preceptors (Dimmer, 2010). The Joint Commission said that lack of teamwork and ineffective communication is what attributes to 24% of sentinel events that result in death, injury, or permanent loss of function (Dimmer, 2010).
Nightingale’s Environmental Theory fits this writers proposed plan to educate and teach nurses that by recognizing and dealing with lateral violence early, they can improve both their own, and their co-workers’ environment. Behavior that is uncaring or unprofessional can result in an unsatisfying, uncivil work environment that often times results in burnout, lack of collegiality, and slowed professional development. One can usually tell how their day is going to go depending on which nurses are on that particular shift.
Perpetrators of lateral violence are often times the nurses with negative attitudes and responses. Nursing itself can be stressful depending on your work load, sickness of the patients, and dealing with families and their dynamics. Nurses should not have to have the added burden of co-workers bullying them. As a profession, nurses need to embrace this problem and ensure that nurse leaders and nurses are given the skills needed to effectively deal with lateral violence and foster a healthy work environment. Implementation Lateral violence has been an issue at Hospital EX. (H-EX.) for at least the last IS years.
Lateral violence is defined by the International Council of Nurses as “behavior that humiliates, degrades, or otherwise indicates a lack of respect for the dignity and worth of an individual” (Demount, Messenger, Whittaker, & Carbonic, 2012, p. 44). Nurses exhibiting negative behaviors to other nurses, cost often new graduates or newly hired, has become “acceptable” as some see it because of little or no intervention from management. Nurses who have been exhibiting these behaviors for many years feel it is their “rite of passage”.
This belief manifests from many years of negative behaviors going on, without management or nurse leader resolution. Management many times dismisses the behavior by making the comment, ‘that’s just the way he/ she is” (Tamarind, 2011). Education and focused training on recognizing the most common forms of lateral violence, and approaches for dealing with inappropriate behaviors can help with eliminating this issue. There are certain behaviors that are expected from a person who refers to themselves as a professional (Griffin, RUN, CSS, PhD, 2004), (Appendix A).
These behaviors include accepting one’s share of work, respecting privacy, cooperating with peers with regard to shared work conditions, help willingly when requested, keep confidences, work cooperatively, don’t denigrate to superiors, address coworkers by first name and ask advice when necessary, make eye contact, don’t be too inquisitive about each other’s lives, repay debts and favors, don’t elk about a coworker, stand up for the absent member when he/she is not present, and don’t publicly criticize.
Unless effective nurse leaders and managers develop and enforce a zero-tolerance culture that includes these behavioral expectations and consequences for those who do not follow them, lateral violence can shape an unpleasant environment at work. This has the potential to cause harm to individual nurse, members of their team, patients, and the overall financial viability of the health care organization. Florence Nightingale discovered that improving ones environment around them, directly relates to a better well-being. This theory incorporates the restoration of usual health Status of clients.
When their external environment is optimal it states that external factors associated with the patients surroundings affect life or biologic and physiologic processes and their development (2012). Although the patient is the focus of Nightingale’s Environmental Theory, this writer believes this theory can also relate to the proposed process change. Victims of lateral violence often have difficulty concentrating on and performing their expected duties due to the stress they are put under with the distraction of an unstable or even hostile work environment.
New hires and new graduate nurses already are under pressure to fit-in. Lateral violence stops them from asking questions, seeking validation of known knowledge, and stops them from acquiring the knowledge-build they need in clinical practice. If their work environment could be made more conducive to giving excellent, patient-centered care, everyone involved would benefit. Dimmer discovered that in a hostile work environment, quality patient care and safety became compromised. New nurses will deliver care without answers they need because they received unprofessional answers or criticism from their preceptors (Dimmer, 2010).
Berry, et al conducted research involving only novice nurses (nurses who have been in practice less than two years), and discovered that 72. 6% reported an incident of work place bullying within the previous month (Berry, Gillespie, Gates, & Schafer, 2012). Furthermore, 63% of the acts were perpetrated by their more experienced nursing colleagues. The Joint Commission said that (Dimmer, 2010). At H-EX. a major concern is nurse retention. Orienting new nurses can be costly to an organization. When a nurse leaves their position after weeks, or even months of orientation because of lateral violence, it can e very frustrating to the organization.
Johnson & Area found in their study that work place bullying was significantly associated with the intent to leave one’s current job and nursing as a profession (Johnson & Area, 2009). Permission has been granted from H-EX. Chief Clinical Officer and the Executive Management Committee to this author to implement a process change where lateral violence is concerned. Currently the process involves reporting unprofessional or disruptive behavior to the unit manager who has the responsibility of disciplining appropriately. Anonymity is not always kept which creates even more animosity.
Often times these reports go unchecked which can empower the perpetrator and/or discourage the victims and/or witnesses. The first part of the process change will involve education of the most common forms of lateral violence (Appendix B) to the nursing staff, including nurse managers, nurse leaders, house supervisors, registered nurses, licensed practical nurses and unit technicians. Many people don’t recognize lateral violence when it occurs because it can be very covert. Eye- rolling raising of eyebrows, sarcasm, giving the silent treatment, and refusing o work with someone are all common covert forms Of lateral violence.
More obvious are the overt behaviors such as verbal affront, infighting, cooperating, intimidation and back-stabbing. The education will involve a non-optional staff meeting that will begin with a Power Point Presentation outlining these forms of lateral violence, some of which go unchecked every day as “just something he/she does”. There will be three or four different opportunities for staff to attend to attempt to accommodate everyone. Notices in the form of email will be sent out far in advance so staff can prepare. The second part of the meeting will involve a question and answer time.
Also a few staff, chosen ahead of time and agreeable to participate, will engage in some role-playing scenarios. These scenarios will range in severity from very covert forms of lateral violence such as eye-rolling, or talking behind one’s back; to overtly criticizing or yelling at another, (Appendix C); these scenarios involve a “bull)/’ and a “target”, and were designed to give instruction on conscious responses to common negative behaviors. Staff members will also be given cue cards that are designed to attach on to their identification badges.
These cards (Appendix E) have each of the ten most common forms of lateral violence aligned with an appropriate response. These will be the same responses that will be taught in the staff meeting setting. Limitations will include those staff who refuse to use the conscious responses, and those who deny that any of this information relates to them. The staff will be asked to use these cards for the next six months at which time a video-taped interview will be requested by this author to gather data regarding the experiment. The goal would be for about 25% of staff agreeing o the video-taped interview follow-up.
Compensation has been approved for staff that comes in on their day off. At the end of this meeting, staff Will be given a questionnaire. This questionnaire will use a 6-point Liker scale, and consist of ascertaining how often a person has been witness to, or experienced different forms of lateral violence. It will also garner information from the perspective of how the employee has personally been affected at this particular organization. The third question pertains to the categories of employees who are exhibiting negative behaviors, (Appendix D).
This questionnaire can also be accessed via the hospital’s website for those that would rather complete it online. This writer felt that in addition to the meeting a questionnaire was needed because of the prevalence of victims or witnesses who suffer in silence. Martin found that 50% to 80% of events go unreported, (Martin, 2008). New graduates or newly hired nurses often do not report events simply because they fear retaliation and they want to fit in. Seasoned nurses often do not report incidents because of the frustration with management’s lack of intervention in the past.
The video-taped interview will sake place approximately six months after the education and training of the conscious responses. The interviews will hope to garner information regarding: Prevalence of lateral violence since receiving the formal education and training, whether or not the interviewee responded to the lateral violence, if the interviewee used the cue cards to help with a response, and if any of the lateral violence prohibited the interviewee from learning what they need to know, or make them think about leaving their position at the hospital A final question will simply ask if they have any recommendations.
In Griffin’s search, many of the newly registered nurses studied said that the experienced nurses had no knowledge of lateral violence and felt they had “made-up” the term (Griffin, 2004). That has also been the experience of this author. When told lateral violence is the topic of the Capstone Project, an explanation of what it is, is always required. When dealing with lateral violence, all nurses, nurse managers, and nurse leaders need to help create an environment with core values that include promoting staff empowerment, communication, collaboration and lifelong learning.
Nightingale believed that healthy surroundings are necessary for proper nursing care” (2012, p. 1 Simply explained, Nightingale’s Environmental Theory says that the nurse, patient (victim of lateral violence in the case of this writing) and environment interact with each other. Nurse-nurse relationships focus on collaboration and cooperation. In lateral violence environments there are dangers, but in non-hostile environments there are benefits, (2012). Nurse Leaders and managers must strive to maintain a “zero-tolerance” culture when it comes to lateral violence.
Steps to take to get to that level are education, identifying, ND eventually consequences for the perpetrator if and when it does happen. Evaluation Outcomes are defined as final results of an intervention and evaluation is assessment Of both processes and outcomes Of a program or implementation, (Benefit-overshot & Johnston, 2007). Evaluation has many facets such as evaluating data that is generated internally, evaluating outcomes, and evaluating the implementation of evidence?all aimed at accomplishing the goal?quality patient outcomes.
Evaluation of the proposed process involving education and training regarding lateral violence will be accomplished in three steps. The first step will include a questionnaire being sent via email to the audience members, (Appendix F). This questionnaire will be similar to the first questionnaire given. It will ask members of the target audience to rate their answers based on a five-point Liker scale. The following questions will be asked: How helpful do you feel the education and training regarding lateral violence was?
How prepared do you feel should you be confronted with lateral violence? Do you personally feel your work environment has improved, either by improvement of your behavior, or improvement of your coworkers’ behavior? There will also be free-text space available on this questionnaire for members to give feedback and suggestions on how to improve the education and training. The second part of the evaluation will involve the formation of a committee that will include nurses, house supervisors, and one or two members of the Executive Management Committee (EMCEE).
The role of this committee will be to continue to evaluate the education and training for staff members regarding the prevalence of lateral violence, and how to deal with it constructively. The committee will also be responsible for incorporating this education and training into new employee orientation, as many times new hires are the intended targets of lateral violence. Due to time constraints, a compressed version of the education and training proposal will be developed to present to nursing students who rotate through the facility.
Young believes that the destructive mind-set of “nurses eat their young” may begin in nursing school, (Young, 201 1). The belief is that the seed of hostility is sown that early due to the shortage of nursing educators and the direct competition with peers to even get into a nursing program; yet there is not raining or education available to students regarding lateral violence in their curriculum. Many of the students who rotate through the facility come back to seek employment. It is hoped that this education and training given to them as a student will give them tools to use in their future profession.
The committee will also have “drop-boxes” located throughout the hospital. The employees will be notified via email and the monthly newsletter, Vital Signs, that these boxes are available for them to provide feedback to committee members. It is hoped that feedback will be constructive; however t is known that in any work environment, variables exist. There will be the employees who feel none of this education and training pertains to them and that it all is a waste of their time; and they may express their dissatisfaction by way of the drop box.
Members of the committee will be accountable for collecting the responses from the drop box and presenting them at the meetings to be addressed. The committee will follow-up on the issue of lateral violence by way of tracking complaints from employees and hopefully seeing a decreasing trend in occurrences. They will also develop, within six to sight months, an annual competency exam that employees will be responsible to complete via the Entraining program. Committee meetings will be held monthly to address any new limitations to the process change that have been identified.
They will also discuss any changes that are necessary related to process change and to discuss continued validity of the tools used to collect data. This will help to establish a standardized process for educating and training employees about lateral violence. The final step to the evaluation process will take place about six months after education and training of conscious responses is done, at which time died-taped interview follow-up will take place with as many nurses that will agree to participate.
They will have spent the past six months using the cue cards, (Appendix E) with conscious responses on them when confronted with lateral violence. The interviews will hope to garner information regarding: Prevalence of lateral violence since receiving the formal education and training. Did interviewee respond to the lateral violence? Were the cue cards used to help with a response? Did any of the lateral violence prohibit the interviewee from learning what they need to know, or make them think about leaving their position at the capital? The last question will simply ask if they have any recommendations.
Many of the newly registered nurses studied in Griffin’s research said that the “made-up” the term, (Griffin, 2004). Dissemination The success and ultimate impression of a process change depends on the effectiveness of the dissemination strategy and how it is presented to the key stakeholders, (Walsh, 2010). To bring awareness to the forefront about lateral violence and the effect it has on nurses, patient care, and the well- being of an organization, the intent is to complete the dissemination strategy within two months of gathering the data. This time frame would allow the scheduling of presentations to all of the audiences.
The intended audiences will include the Executive Management Committee (EMCEE), the department managers and house supervisors, and the nursing staff. These are the same audiences the education and training was provided to. The physicians would also be invited to attend. The goal of the dissemination process will be for all members of each audience to have access to the information gathered related to lateral violence. As an objective, each group will acknowledge an understanding of what lateral violence is, and how to recognize it early; and mom conscious responses to common forms of lateral violence.
Research data from the questionnaires will be available to all audience members to detail the prevalence and impact lateral violence has on patient care, the overall care of staff members, and the financial well-being of the organization. This information will be done via oral presentation. Handouts will include a copy of the questionnaire with the results graphed, and copies of the conscious responses that were taught to the participating registered nurses, (Appendix E). Results of the video-taped follow-up interviews will be made available to all audiences after they are gathered.
The time-frame for the video-taped interviews is six months after the education and training is presented. The objective of all of the audiences is to become more aware of lateral violence, and to improve practice in this area. Although this research project will be conducted on registered nurses, all members of the audience are people who have the possibility of being both the perpetrator and/or the target of lateral violence. Monitoring will continue after implementation of the education and training, and continued follow-up with the nurses, especially he participants in the conscious response exercise.
The ultimate goal will be for the incidents of lateral violence to diminish significantly following the implementation. Evaluation of the process will also be done by way of a survey, and a committee as yet to be formed, made up of nurses, house supervisors, and a member of EMCEE to receive anonymous feedback in the form Of complaints of ongoing lateral violence, Or praise regarding a decrease in the negative behaviors, and a return to an environment where the main focus is giving excellent patient care.
Conclusion Lateral violence is disruptive behavior directed at coworkers who are on the name level within an organization, and an issue with nurses in almost every health care facility. Nurse Managers and nurse leaders must be able to recognize the problem, no matter how small, communicate the problem, and respond to the problem with a “zero-tolerance” culture. Until this occurs, lateral violence will continue to eat away at our profession which has the potential to create an even worse nursing shortage than the one being predicted.
The fundamental roots of the nursing profession is caring, therefore it is difficult to even admit that nurses could be hurting each other. If our profession is to survive, it needs an intervention which starts by creating a process change in health care organizations. Review of Literature Berry, p. , Gillespie, G. , Gates, D, & Schafer, J. (2012). Novice nurse productivity following workplace bullying. Journal of Nursing Scholarship, 80-87. This article determines the prevalence and effects of workplace bullying (WEB) on novice nurses and their work productivity.
The method used was defined as an internet-based descriptive cross-sectional survey. The researchers had 197 participants who completed the study fully. The artisans were all nurses with less than two years of practice. The outcomes of this study showed that novice nurse productivity was negatively impacted by WEB, and is purposeful to this author’s plan to provide education and training to deal with WEB appropriately. Tamarind, T. J. , (2011). Eliminating lateral violence in the ambulatory setting: One center’s strategies.
Academy of Operating Room Nurses, 93(5), 583-588. This article gives a brief overview of lateral violence and how it affects everyone involved from nurses, team members, patients, and the financial well-being of a facility. It encourages education for nurses regarding the common forms of lateral violence, which goes along with this author’s proposed plan. The article also has a sample Code of Conduct that employees can sign that they have read and will abide by. Dimmer, D. , (2010).