Introduction
Violence in the workplace is a growing concern in the healthcare profession. Non-physical violence or lateral violence is synonymous with intimidation, disruption, and unprofessional-like attitude of nurses toward fellow nurses. This should not have a place in the healthcare profession that must bear culture of safety and care for people. Lateral violence is experienced by new nursing graduates and even those with many years of experience.
Lateral violence is a violation of professional ethics in the healthcare profession and jeopardizes the welfare of nurses and the health and safety of patients. LV also compromises the entire health profession by putting it into a negative public image when it is supposed to uphold values and human dignity. (Fowler as cited in Brothers et al., 2011, p. 7)
Lateral violence is not just an ordinary workplace problem; it is a serious sociological problem that needs attention and immediate solution. It seems to be a new term but it has been around and identified in many studies for three decades now. It is however increasing and more studies should be afforded to address the problem.
Statistics showed that the healthcare profession has the highest prevalence of workplace violence. A survey by the American College of Physician Executives in 2008 showed that 97% of the participants, which included nurses and physicians, received degrading innuendos and comments, inappropriate remarks, cursing, and other statements not deserving for healthcare professionals. Degrading comments received the most common complaint (86%), while yelling was the second (73%). Physicians were mentioned as the most common offender when it came to verbal abuse (45%). It was noted that physicians received more favorable treatment than nurses. Pertaining to termination of employment as punishment, 61% said that nurses received a penalty of termination, while 22% said physicians received such penalty of termination. (Pontus & Ortner, 2012, p. 211)
The nursing profession has to recognize LV and its outcomes. About 60% of new graduates resign from their first employment within the first 6 months due to LV (Beecroft, Kunzman, & Krozek as cited in Embree & White, 2010, p. 166). This has to be a top priority for policymakers in the health profession to avoid demoralization among new nursing graduates.
Concepts and definition of lateral violence
Lateral violence is described as “disruptive, disparaging, or uncivil behavior” (Dimarino, 2011, p. 583). LV is a destructive behavior or violence committed by a nurse against another nurse, whose common forms are “non-verbal innuendo, verbal affront, undermining activities, withholding information, sabotage, infighting, scapegoating, backstabbing, failure to respect privacy, and broken confidences” (Griffin as cited in Sheridan Leos, 2008, p. 400).
However, it is not directed at the individual nurse but is a response to the health environment, particularly the practice setting which has been described as toxic and detrimental to the emotional, spiritual, and psychological well-being of a practicing nurse (Alpach as cited in Sheridan-Leos, 2008, p. 399). The toxic workplace is a result of downsizing, incorrect management styles, and growing competition in the health profession (Rowell as cited in Sheridan-Leos, 2008).
Verbal abuse that includes sexual harassment and discrimination is another type of lateral violence. Harassment is a common type of non-physical abuse, but it may involve unwanted behavior and unpleasant comments that can also end up in physical violence. On the other hand, sexual harassment involves sexual innuendos and sexual orientation. Another one is about racial discrimination and harassment which is linked to one’s color of skin, ethnic background and race. (Pontus & Ortner, 2012, p. 210)
Other common terms for lateral violence are horizontal violence or horizontal abuse, bullying, or aggression (Griffin as cited in Sheridan-Leos, 2008), and “nurse-to-nurse violence” (Johnson as sited in Dimarino, 2011, p. 583). Another term that makes it more uncivil, is “nurses eating they’re young”. Common examples of lateral nursing violence include silent behaviors, like rolling one’s eyes, raising eyebrows, showing a cold shoulder, sarcastic remarks and rude behavior.
Other abusive behaviors include humiliation, degrading a fellow nurse, or showing a lack of respect for others. Intimidating behavior includes foul language, impatience, refusal to request information, or some threatening actions. (Embree & White, 2010, p. 167)
Croft and Cash (2012) argued that violence in the healthcare profession is not only horizontal (nurse-to-nurse) but there is evidence from studies that it is also downward. There is no universal term for this subject or phenomenon that it has become difficult to integrate into research (Bartholomew as cited in Sheridan-Leos, 2008, p. 399).
The origins of LV have been attributed to role issues, thoughts of oppressing or bullying a fellow nurse, strict hierarchy, unfair work practices, anger, and so on. Organizations have to help eliminate the beginnings of LV by improving the work environment and nurse retention. Nurses should be provided with knowledge and skill to combat LV. (Embree & White, 2010, p. 172)
Theories and causes of lateral violence
One of the most common theories that describe the beginnings of lateral violence is the so-called oppressed-group model (Roberts as cited in Sheridan-Leos, 2009, p. 400). Nurses are an oppressed group and in their frustration, they tend to be violent with one another (Croft & Cash, 2012, p. 228). DeMarco and Roberts (as cited in Sheridan-Leos, 2009) also stated that nurses become powerless when dominated by others. However, seeing nurses as an oppressed group is to “articulate behaviors” and not to consider them as flawed. There is an unequal power balance in the workplace (Roberts, DeMarco, & Griffin as cited in Croft & Cash 2012, p. 228).
Nurses as an oppressed group are only one perspective. The organizational structure in the health profession can also be a factor. Oppression and organizational context are two theories that can be found in the literature about the causes of lateral violence.
Another theory is based on self-hatred and low self-esteem felt by an oppressed group in the nursing profession. Lack of respect for others is also another reason, but there can be environmental factors that are not addressed during practice settings. Organizational culture is linked to lateral violence. Organizational culture is defined as the values, beliefs and practices of an organization that has a positive or negative influence on the members of the organization. (Brothers et al., 2011, p. 7)
Established processes in the workplace have to support positive and correct behaviors in order to avoid a culture of tolerance for lateral violence. Practice environments for nurses have been considered not conducive to young grads “psychologically, emotionally, and spiritually”, and these are beyond the nurses’ control. These environments are related to “economics, competition and management” (Alspach as cited in Brothers et al., 2011, p. 7). This supports and builds lateral violence in later life and as nurses find jobs in other clinics or hospitals.
Nurses and health workers face various types of personalities and one of them is the toxic personality, also called bully. This personality discourages effective communication. The toxic personality or bully pushes their own agenda and does not want to listen or communicate with the group or team. Their style is demanding – they tell people what to do instead of working with and for the group. They are not cooperative and do not think about what’s good for the organization. Conceptualizing for the needs of others is not their style. They don’t accept mistakes or – as they say – they don’t commit mistakes. (Pontus & Ortner, 2012, p. 216)
Other causes of lateral violence have been attributed to post-traumatic stress disorder (PTSD can be cause or effect), financial problems, low self-esteem, physical stress and musculoskeletal problems, fears of various kinds, sleep disturbance, depression that is getting more severe, and digestive problems. (Brothers et al. 2010, p. 8)
Consequences of lateral violence
Victims of lateral violence tend to be isolated and do not know where to ask for help or assistance. The nurses are in a toxic situation where negative feelings abound, aggravated by the indifference of others. (Pontus & Ortner, 2012, p. 217)
LV contributes to stress and tension in the workplace. It affects individuals, co-workers, health institutions, families of health workers and the organization as a whole. This is one reason why organizations are deeply concerned about the impact and the seriousness of the problem. The affected nurse feels anger as a natural reaction. This is followed by anxiety and depression, disbelief, low job performance, low self-esteem and low satisfaction in life. The victim nurse may experience physical and psychological pain and symptoms like headaches, sleeplessness, trauma and helplessness, and even Post Traumatic Stress Disorder (PTSD) (Ryan & Poster as cited in Brothers et al., 2011, p. 7).
Consequences range from social to psychological factors including negative outcomes, even broken relationships of nurses with their husbands and families (Acton, 2012). A serious consequence is when a nurse resigns or “leaves employment” which may cost about $22,000 to $64,000 per nurse in turnover expenses (Dimarino, 2010, p. 584). Those who remain in the clinic or hospital have to bear the additional burden and responsibilities. They would have to train new nurses, while quality service is affected.
Other noted outcomes of lateral violence are low morale among nurses, high nurse turnover, reported illness of the nurses themselves, continuous absences, and eventually low productivity and errors in administering health to patients. (Pontus & Ortner, 2012, p. 210)
Discussion
A study was conducted by the British Columbia Nurses Union and Union of Psychiatric Nurses on the subject of bullying and lateral violence in the nursing profession. The findings in this study concluded that there were significant factors and causes that led to the existence of bullying and lateral violence experienced by the nurses in British Columbia. The Unions acquired a number of participants in the studies who were registered nurses, registered psychiatric nurses, and licensed practical nurses. The study further said that the work environment for the nurses was not ordinary, meaning there were stressors some of which involved life-and-death decisions, and too much workload. Nurses worked under doctors’ orders and were considered “oppressed and less powerful” (Sheridan-Leos as cited in Croft & Cash, 2012, p. 227).
Leaders should be role models and the first ones to deal with lateral violence. They have a responsibility to their fellow nurses and to the institution they serve. This responsibility includes promoting a professional and positive work ethic and avoiding even the slightest, distasteful comments committed by nurses against their own. Leaders must maintain a “zero tolerance” to a culture of unprofessionalism, and develop clear and concise behavior to encourage professionalism in the health environment. Communication is very important in the health workplace and policies should be geared toward effective communication. With good communication between leaders and nurses, subordinate nurses are encouraged to report problems without fear of reprisal. Work relationships should also be built in an atmosphere of mutual respect and positive attitude and work ethic. A positive culture encourages professionalism in the health sector. (Dimarino, 2010, p. 584)
The British Columbia studies further examined the organizational context where the nurses worked, focusing on the “organizational rules, norms, and power structures” (Hutchinson et al. as cited in Cash & Croft, 2012). They found that organizations that are authoritarian run the risk of having smaller communities with informal leaders. These organizations also provide a reward system through patronage and have members which resist change.
Other studies found that nurses felt more distressed through verbal violence by fellow nurses than by patients or others (Farrell; Farrell, Bobrowski, & Bobrowski as cited in Stanley et al., 2007, p. 1249). Farrell held the same view that the problem of lateral violence should be viewed in the contexts of “organizational structure, workplace practices, and the nature of interpersonal conflict” (Stanley et al., 2007). In Stanley et al.’s study, the respondent nurses felt hopeless and powerless in bringing about change, but they provided suggestions to control LV and they wanted to be a part of the solution. The respondents were young professionals who wanted to improve in their job and were reported as loyal to their job.
The British Columbia studies also recommended that nurses should critically examine the organization and the environment they are working with, what factors constrain them from examining that environment and question what leads to patronage and bullying in the workplace. (Croft & Cash, 2012, p. 239)
A nurse manager should act as a leader and maintain a culture of positive outlook in the organization. The leader should encourage “collaboration and communication” in the workplace, promote teamwork and cooperation, independence and freedom from disruptive behaviors. Proficient nurse managers should develop positive expectations for behavior among subordinate nurses. (Dimarino, 2011, p. 585)
In a study using “cognitive rehearsal” to address lateral violence, researchers theorized that using behavioral intervention, like immediate action or confrontation, changed the attitude of aggressive nurses. This knowledge allowed them to deal with LV. The newly registered nurses were made to understand how nurses used lateral violence in the workplace. The outcome was a positive outlook – the nurses successfully used this knowledge in their integration and retention processes. (Griffin, 2004, p. 262)
Professional nurses should help control the growing tide of LV in the workplace by making an effort to help each other and acknowledge their role in the commission of this unwanted phenomenon in the health environment. Doing this will help control nurses’ behavior and the growth of LV. Nurses should help in changing the cycle of negative attitudes to enhance professional and personal reflection. Two methods can be used in this process: cognitive rehearsal and what professionals call “carefronting”. Carefronting is an activity that uses reflection on biblical passages about respect, forgiveness, and the ability to confront hostility and interpersonal relationship in the workplace. Moreover, nurses can integrate their personal needs and wants. Caring for one another becomes a cycle and lateral violence will be healed and forgotten. (Sheridan-Leos, 2008, p. 402)
A study on professional reflection used the services of 26 licensed nurses wherein the nurses attended two-hour special education programs about LV and were taught to practice methods to confront the LV behavior. The study concluded that knowledge of the phenomenon allowed the participants to depersonalize LV. The participants learned in the process and their retention rate improved. (Griffin as cited in Sheridan-Leon, 2008, p. 402)
Conclusion
Health administrators work hard to recruit and maintain nurses and provide the resources for a healthy work environment. Lateral violence undermines the diligent efforts of health institutions. LV is a phenomenon common between nurses and “inter-group conflict” (Duffy, Farrell as cited in Stanley et al., 2007, p. 1248). LV is not only confined to the nursing profession but is common throughout the healthcare profession; it is most common within peers where a group is “without power within the system” (Stanley et al. 2007, p. 1259).
Lateral violence diminishes the quality of healthcare. Effects of lateral violence are as harmful as physical violence. A nurse must not allow herself/himself to be a part of lateral violence. Fellow nurses, especially those involved in committing lateral violence, may not be happy about it but it is one effective way to stop it (Middelton-Moz, 1999, p. 131).
An effective approach is by educating nurses about common strategies and behaviors of LV. Small groups can help reduce the effects of LV. They can reduce anger and bad thoughts through relaxation techniques or meditation, or resolve to be friendly and hold on to feelings. Victims of LV have to control their feelings since those who internalize anger tend to be powerless, and also those who externalize their anger also feel the same since they cannot bring about desired outcomes (Thomas as cited in Stanley et al., 2007, p. 1249). They can also consult experts when LV is becoming worse in the workplace. Consultation is an effective way, and nurses, especially in the lower ranks, should consult and report the slightest incidence of lateral violence.
Organizations and the health profession have a big role to play in the effort to totally eradicate lateral violence in the workplace. This phenomenon is not only directed at nurses but also at the system. The methods to address the problem have to be designed by all sectors involved in the system. It is not clear whether education about lateral violence is a part of the university curriculum, nor is it a part of the nursing curriculum. This should be addressed squarely as lateral violence hinders licensed nurses from asking information or asking questions. (Griffin, 2004, p. 258)
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