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Kathleen Sellers PhD, RNLinda Millenbach PhD, RN

Kathy Ward MS, RN Melissa Scribani MS

New York Organization of Nurse ExecutivesFoundation of New York State NursesNew York State Nurses Association -NYSNAResearch Alliances of New York StateState University of New York Institute of Technology - SUNYIT

1. Define horizontal violence (HV)/ lateral violence.2. Examine the prevalence of horizontal violence (HV) amongst practicing New York State Registered Nurses.3. Provide strategies to address HV

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“Repeated, offensive, abusive, intimidating, orinsulting behavior, abuse of power, or unfair sanctions that makes recipients upset and feel humiliated, vulnerable, or threatened, creating stress and undermining their self-confidence”. (Vessey, DeMarco, and Budin 2007)

Oppressed Group BehaviorHuman Adaptability/ Acquisition TheoryBourdieu’s Theory of Practice

Oppressed Group Behavior◦ Farrell – Hydraulic Model

Want everyone to be the sameFishes swim together/anything different recognized as dangerous

◦ Frier (1963) – Brazilian, studied oppressed cultures in South America

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Human Adaptability/ Acquisition Theory◦ Gradually taking on more and more

becomes normal

Bourdieu’s Theory of Practice –◦ Relational, individuals situated within structured social fields◦Concepts – Field (practice unit), Capital (reward system), ◦Habitus (behavior) – “We’ve always done it this way.”

Nurses experience both physical and psychological consequences when they are the victims of HV. Physical symptoms include weight gain or loss, hypertension, cardiac palpitations, and irritable bowel syndrome (Rowell, 2005). Psychological disorders include depression, acute anxiety, and post traumatic stress disorder (Rowell, 2005).

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Human factors: humans can’t think straight when they are upset.Withholding information’s impact.Ruminating about an event takes cognitive resources away from other tasks (Bartholomew, 2009).Linked to medication errors, compromises in safety and quality, and patient mortality (Rosenstein & O’Daniel, 2008).Contributes to poor patient satisfaction.

Both direct and indirect HV behaviors can be harmful for effective task performance (Porath & Erez, 2007).HV leads to potentially preventable adverse events, errors, compromises in safety and quality, and patient mortality (Rosenstein & O’Daniel, 2008).The Joint Commission’s Sentinel Event Alert Issue 40 listed that disruptive or intimating behaviors undermine a culture of safety.

When organizations allow HV to continue without intervention, retention and recruitment are impacted. Nurses who feel the work environment has become unbearable often leave their institution creating higher rates of turnover. Some leave the profession permanently (Woelfle, 2007).

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There is much literature available that defines horizontal violence and the settings in which it occurs (Stevens, 2002).

There are also several studies that call for nursing management to take action against horizontal violence (Baltimore, 2006; Farrell, 2001; McKenna et. al., 2003; Woelfle, 2007).

Effective January 1, 2009 for all accreditation programs, The Joint Commission has a new Leadership standard (LD.03.01.01) that addresses disruptive and inappropriate behaviors in two of its elements of performance:◦ EP 4: The hospital/organization has a code of

conduct that defines acceptable and disruptive and inappropriate behaviors.◦ EP 5: Leaders create and implement a process for

managing disruptive and inappropriate behaviors.

There are several studies that call for nursing management to take action against horizontal violence (Baltimore, 2006; Farrell, 2001; McKenna et. al., 2003; Woelfle, 2007).The nursing profession has been writing about bullying cultures for at least 75 years (Stevens, 2002). Farrell (2001) argues that the way forward is to implement strategies that reduce the opportunities for bullying to occur. Often these strategies aren’t specific.

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Curtis, Bowen, and Reid (2007) suggest that students be taught conflict resolution skills and assertiveness training at the undergraduate level.

In the home health care setting, Thobaben (2007) suggests that administrators should monitor morale, and provide a climate where nurses feel safe to report horizontal violence without fear of reprisal.

Topic was raised by a graduate student at SUNYITPilot study conducted with members of NYONENYONE Board of Directors recommended that a larger study be conducted by a consortium of researchers -◦ New York Organization of Nurse Executives◦ Foundation of New York State Nurses◦ New York State Nurses Association - NYSNA◦ Research Alliances of New York State

Goal: heighten awareness of the HV so solutions could be developed

Transformational Leadership (Burns,1978) theory guided this study.Administrators as leaders motivate followers in new directions.In doing so the followers are transformed; becoming leaders.

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Assess registered nurses practicing in New York State’s knowledge of, experience with and/or being a perpetrator HV.

Descriptive survey design.Approved by IRB.

Dunn’s (2003) validated tool based on Brile’s Sabotage Survey used.

Brile posed the questions in a “yes/no” format. This study is using a five point Likert Scale to enhance the analysis.Dunn (2003) established validity in a study of HV in operating room nurses.The instrument was reviewed by faculty of Seton Hall University for clarity, ease of use, and content validity. Cronbach’s alpha scores were .86 and .72 for parts one and two of the Sabotage Savvy Questionnaire respectively (Dunn, 2003).

1-None=no experiences with HV

2-Rare=experiences of HV once or twice a year3-Several=experiences of HV 3 or 4 times a

year4-Often= experiences every other month5-Frequent=experiences at least every month

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Feb and April 2009 – met with members of the consortium.Developed the study methodology, demographic data to collect and participant letter.Drafted letter to CNOs to seek participation.Identified point person from the Research Alliances and their role in the study.Obtain Bassett Healthcare’s support to house data and assist with data analysis.

Current sample consists of 2659 participants representing19 organizations.

Most (n-2415) are women, 34.6% are 50 years of age or older.Approximately 93.4 % of participants are White/non-Hispanic, 1.87% were Black, 1.79% were Asian, 1.02% were Latino and 1.90 % were of other races.

82.24 % of respondents worked in acute care.42.68 % of respondent’s facilities are unionized.33.98 % of respondents worked in a Magnet facility38.99 % respondents stated their facility had a policy on horizontal violence. Of these, 61.04 % stated the policy was enforced. 39.18 % of respondents did not believe that policy on HV was enforced if they had one.

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Position Frequency Percent

Administration 63 2.41

Manager 313 1.01

NP 73 .86

CNS 49 1.87

Staff Nurse 1900 72.88

Community Health/Public Health

19 0.72

CRNA 3 0.11

Nurse Educator/ Faculty

22 0.84

Nurse Educator/Staff 62 2.37

Other 64 2.45

More Than 1 Position 36 1.38

Percentage of respondents that reported knowledge of the following items occurring “often” and “frequent”:

o Not acknowledged for work (29.75%)o Expected to do other’s work (26.77%)o Nonsupport for your “issue” ( 23.44%)o Talking ceased upon arrival (22.61%)o Untrue information exchanged (22.14%)o Consistently criticized (21.08 %)o Reprimanded in front of others (19.24%)

Percentage of respondents that reported being victims of the following items “often” and “frequently”:o Not acknowledged for work (25.31%)o Expected to do other’s work (21.98%)o Not supported for your “issue”(19.76%)

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Male respondents were 6.75% of the respondentsFemale responders versus male respondents reported significantly more (p<.05)◦ knowledge of HV in 2 of the 20 items◦ incidents being a victim of HV in 3 of the 20 items◦ incidents of being a perpetrator in 5 of the 20 items

Chi Square analysis demonstrated that

Respondents working in a unionized organization had significantly more frequent (p < .05) knowledge of HV in 9 of the 20 questions surveyed and

Significantly (p<.05) more frequent experience in being a victim of HV in 6 of the 20 questions surveyed, and more experience in being a perpetrator of HV in 3 of 20 questions.

Responders in Magnet versus non-Magnet organizations had significantly less (p<.05) knowledge of HV and were perpetrators less often in a few areas.

Responders practicing in non-union facilities, the majority of Magnet organizations, versus union facilities, expressed significantly less knowledge (p< .05) of HV and significantly less experience with being a victim of HV.

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Chi square analysis demonstrates significant differences (p< .05) with years of experience for many questions.

The more years of experience in nursing, the more frequent knowledge of horizontal violence and the more frequent experience of being a victim of horizontal violence.

Significance varied by question ◦ There was significantly greater (p< .05)experience

in knowledge of HV in those with a doctorate versus all other levels of preparation in answer to:

Credit taken for your workInformation withheldNonsupport for your issueReneged on commitmentAttempts to destroy credibility

There was significantly greater (p< .05) experience in being a victim of HV in those with an AD or BS versus all other levels of preparation in answer to:o Information withheld o Reneged on commitment o Not included in important meetings o Spoken up when someone else took credit for work they

did.Credit taken for your work – Significantly (p< .05) less for Masters compared with AD,BS and Doctorate.

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Reasons for not participating◦ Survey fatigue◦ Implemented action to prevent◦ Resistance from union representatives◦ Resistance from Human Resources

Limitations of the study◦ Upstate sample◦ Lack of diversity

There could be a miracle

◦ OR MORE LIKELY

ONE PERSON AT A TIME

Griffin, 2010

OrganizationFront line ManagerIndividual

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Organization◦ Top down, bottom up understanding of no

tolerance◦ But investigate the occurrences.◦ Participate in research to increase

awareness of the issue◦ Educate◦ Policy ◦ Code of Conduct◦ Need to change the culture

Management/faculty◦ Teaching Cognitive Rehearsal (Griffin, 2004) as a

shield for HVIndividual Professional Practice◦ Accept one’s fair share of the work load◦ Respect others privacy◦ Be co-operative◦ Be willing to help when requested◦ Keep confidences◦ Work cooperatively despite feelings of dislike

Crucial Conversations (Patterson,2002)

Management/faculty◦ Teaching Cognitive Rehearsal (Griffin, 2004) as a

shield for HV◦ Prompting cards -

15 universally accepted professional working behavior rulesLeader as the “culture gatekeeper” Identification of forms of “capital”

Behaviors rewarded? How?Behaviors sanctioned? How?Leader sets the tone

Active engagement vs. acts of omission (Farrell)

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Behavioral interventions (confrontation) resulted in the HV behavior stopping

It depersonalized the HV and made it a phenomenonConfrontation is difficult for all but is directly tied to the “holding yourself accountable for professional behavior in self and others”

Nonverbal innuendo (raising the eyebrow, face making ◦ I see from your facial expression that there may

something you wanted to address with me. It’s okay to speak with me directly.

Failure to respect privacy ◦ It bothers me to talk about that without their

permission. ◦ I only overheard that and it should not be repeated.

Language of respect starts with this statement of understandingMy colleague is:

IntelligentCompetentAnd wants the best for the patient (if this is not true then why are they here)

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Faxton-St. Luke’s Healthcare – Utica, NY

Highland Healthcare – Rochester, NY

Others from the audience

About FSLHC…

Location: Utica, N.Y.2 Campuses370 Inpatient Beds242 Skilled Nursing Beds8 Primary Care Offices12 Centers of ExcellenceRelationship Based Care3100 EmployeesUnionizedNon-Magnet

Cultural Initiatives◦ Relationship Based Care (RBC)◦ Commitment to My Co-Workers ◦ Reigniting the Spirit of Caring◦ Safety First

Getting to Nice TeamRole ClarificationPolicy ChangesEducation (including cognitive

rehearsal and practice scenarios)

Organization

Leadership

Individual

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Relationship Based Care

A patient care delivery model based on a philosophy of caring.Strengthens 3 relationships : Patient and Family, Self and Colleagues (Koloroutis, 2005).Care takes place in a Caring and Healing Environment with the Patient and Family at the center. 6 dimensions are critical for successful transformation (Koloroutis).

(Creative Health Care Management, 2011)

“…the foundation for every encounter in our organization. It helps us to honor the privilege we have as healers during some of the most sacred moments in the lives of those we touch. First and foremost, people will remember how we made them feel. Simply stated, it’s all about relationships.

-Patricia Roach, MS, RN, OCNSenior Vice President/Chief Nursing Officer

Faxton-St. Luke’s Health CareUtica, New York”

(Koloroutis, Felgen, Person and Wessel, 2007, p.32)

Both emphasize the development of collaborative relationships as a foundation to providing excellent patient care.Both emphasize that everyone has a valuable contribution to make.Both create a healthy, caring work environment.Both create and sustain an organizational culture that enables the delivery of safe, quality care to our patients and families.

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A three-day program that focuses on caring for self and others. A team experience that inspires employees to reconnect with the meaning, purpose and joy of their work, and how they contribute to our organization, patients, families and colleagues. Allows employees to get to know one another, respect one another and form a caring environment with a common vision.Part of FSLH’s Relationship-Based Care initiative.

Strengthens relationships between caregivers and their colleagues.

Reinforces and strengthens behaviors such as functional trust, respectful communication and responsibility acceptance (Creative Health Care Management, 2011).

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Developed when specific issues came to the attention of Human Resources regarding inappropriate behavior.Number of departments (nursing administration, HR, Education) involved in addressing the concern of HV however needed a unified or strategic approach. Found that behavior not always uniformly addressed on the unit due to a lack of clarity about roles and responsibilities of Nursing Unit Leadership (Nurse Managers, Hospital Supervisors, Clinicians, Charge Nurses)

Develop Role Clarification for Nursing Unit Leadership: Who is responsible for what in addressing HV or other inappropriate behaviors?Provide skill development for Charge Nurses to be prepared to address HV or other inappropriate behaviors and how to report back to Nurse Managers.Roll out education for employees to understand their roles and responsibilities in preventing and reporting HV or other inappropriate behaviors.Develop a HV Policy with Zero Tolerance

Focus groups held with each nursing leadership group to get their perceptions on what each group felt their roles and responsibilities were as well as what they perceived the other leadership groups roles and responsibilities to be.

Role Clarification for Nurse Manager, Hospital Supervisor, Nurse Clinician and Charge Nurses defined and distributed.

Whatever your role is, we ALL have a responsibility for our work environment

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Does Your Institution Have a Policy Regarding Horizontal Violence

YesNo

Unknown

10.48%

61.90%

27.62%

FSLH Data from HV Study

If Yes is HV Policy Enforced?

Yes

No

66.18%

33.82%

FSLH Data from HV Study

What does this tell us?

Our Horizontal Violence Policy: ADMINISTRATIVE DIRECTIVE

5.0 PROCEDURE / DIRECTIVE

5.1. Defining Horizontal Violence

5.2. Effects of Horizontal Violence 5.3. Employees Who Are Victims: 5.4. Leadership Strategies for Addressing Horizontal Violence 5.5. Zero-tolerance Policy

It is the goal of FSLH to eliminate all acts of HV from the workplace. In support of this goal, all employees found to be perpetrators of horizontal violence will be subject to FSLH’s disciplinary action procedures. The level of discipline issued will depend on the severity of the behavior and the impact it has on the employee/victim. FSLH reserves the right to accelerate the disciplinary action process, up to and including termination of employment, if the behavior is found to be severely harmful and egregious in nature or if it results in a negative impact in any way on patient care.

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Increase awareness and knowledge of HV.Mandatory Education.Educational video.Group discussion.Cognitive rehearsal techniques.Practice responding to HV scenarios.Campaign for Quality – October 14, 2011

Other ideas??

The Highland Hospital Experience

On Magnet JourneyPractice Excellence requires:◦ Professional interpersonal communication◦ Accountability for professional behaviorsGap IdentifiedCouncil structure utilized to plan intervention

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Shared Governance Structure

Direct Care RN’s on Magnet Core Team ◦ identified nursing image as a barrier to achieving

excellence◦ Suggested engaging council leadership to develop

interventionRetreat planned and presented by the team April 2008

Examination of nursing image at Highland:perceived vs. real

Determination of desired stateCreation of education for all nursing staff: “Lighting the Way” Education delivered by council leadershipAlignment with Nurse ManagersUniversal messaging: “Remember the Promise”

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2009 NYONE HV Survey◦ Highland nurses experience significantly

(p<.05) less prevalent horizontal violence than was reported by the average of other nurses throughout the state.

Some survey highlights:Acknowledgement of being a victim of HV frequently or often (three separate measures):◦ Highland 13-19%◦ All others >30%Acknowledgement of knowing HV exists in the workplace (three separate measures):◦ Highland 17-22%◦ All others > 30%

Being a perpetrator of HV frequently or often (three separate examples):◦ Highland 6-10%◦ All others > 15%Highland Nurses were more likely to say that the hospital had a policy against horizontal violence and that it was enforced than the average of the survey.

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RN engagement:◦ Creating and executing the plan◦ Creating and using the tools to address HV◦ Peer accountability◦ Belief in the value of the exercise

Seems to exist only in……Organizational cultures that permit it! (Farrell, 2009)

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