Embree, J. L., & White, A. H. (2010, July). Concept Analysis: Nurse‐to‐Nurse Lateral Violence. In Nursing forum (Vol. 45, No. 3, pp. 166-173). Blackwell Publishing Inc.
The purpose of this paper is to examine the concept of nurse-to-nurse lateral violence (LV). Published literature-LV among nurses is significant and results in social, psychological, and physical consequences, negative patient and nursing outcomes, and damaged relationships. An extensive review of literature through Health Source, Cumulative Index to Nursing and Allied Health Literature (CINAHL), ProQuest health, and Medical Complete was used to determine agreement and disagreement across disciplines and emerging trends. This concept analysis demonstrates that nurse-to-nurse LV is nurse-to-nurse aggression with overtly or covertly directing dissatisfaction toward another. Origins include role issues, oppression, strict hierarchy, disenfranchising work practices, low self-esteem, powerlessness perception, anger, and circuits of power. The result of this analysis provides guidance for further conceptual and empirical research as well as for clinical practice. Organizations must learn how to eliminate antecedents and provide nurses with skills and techniques to eradicate LV to improve the nursing work environment, patient care outcomes, and nurse retention.
PURPOSE. The purpose of this paper is to examine the concept of nurse-to-nurse lateral violence (LV).
SOURCE. Published literature-LV among nurses is significant and results in social, psychological, and physical consequences, negative patient and nursing outcomes, and damaged relationships. An extensive review of literature through Health Source, Cumulative Index to Nursing and Allied Health Literature (CINAHL), ProQuest health, and Medical Complete was used to determine agreement and disagreement across disciplines and emerging trends.
CONCLUSION. This concept analysis demonstrates that nurse-to-nurse LV is nurse-to-nurse aggression with overtly or covertly directing dissatisfaction toward another. Origins include role issues, oppression, strict hierarchy, disenfranchising work practices, low self-esteem, powerlessness perception, anger, and circuits of power. The result of this analysis provides guidance for further conceptual and empirical research as well as for clinical practice. Organizations must learn how to eliminate antecedents and provide nurses with skills and techniques to eradicate LV to improve the nursing work environment, patient care outcomes, and nurse retention.
Search terms: Bullying, concept analysis, horizontal hostility, horizontal violence, lateral hostility, lateral violence, nurses eating their young
In order to stop lateral violence (LV), nurses must recognize LV and its consequences (Rowell, 2008). Approximately 60% of new nurses leave their first place of employment within the first 6 months because of LV that is perpetrated in the workplace (Beecroft, Kunzman, & Krozek, 2001; McKenna, Smith, Poole, & Coverdale, 2003; Winter-Collins & McDaniel, 2000).
Disruptive behaviors associated with LV continue to increase, are toxic to the nursing profession, and have a negative impact on retention of quality staff. These behaviors have been present in the literature for over 20 years (Bartholomew, 2006; Center for American Nurses, 2008; Needham et al., 2008; Farrell, 1997). Lack of a universal term and multiple closely related terms in the literature makes research integration regarding LV difficult (Bartholomew).
Nurse-to-nurse LV concept analysis clarifies the existing state of knowledge regarding this concept and identifies direction for further interventions (Griffin, 2004). Significant among nurses, LV results in social, psychological, and physical consequences, negative patient outcomes, and damaged relationships.
Understanding personal, interpersonal, and organizational factors impacting LV will lead to future interventional research and could positively impact retention and recruitment and lead to improvement of the disenfranchised nursing work environment (Leiper, 2005). Nurses will leave a workplace if LV is allowed to continue. Turnover is costly in terms of the stress of increased workload on remaining staff, and results in expense to the organization. Registered nurse (RN) turnover costs up to two times a nurse’s salary, and the cost of replacing one RN ranges from $22,000 to $145,000 depending on geographic location and specialty area (Jones & Gates, 2007).
The Method of Data Collection
Data collection for this concept analysis consisted of searching electronic databases. Key terms included concept analysis, LV, horizontal violence, lateral hostility, horizontal hostility, bullying, and nurses eating their young.
An extensive review of literature through Health Sources, Cumulative Index to Nursing and Allied Health Literature (CINAHL), ProQuest health, and Medical Complete was used to determine agreement and disagreement across disciplines and emerging information. An analysis based on Walker and Avant (2005) was completed to determine common themes, uses of the concept, defining attributes, exemplar cases, borderline cases, contrary cases, antecedents, consequences, and empirical referents.
Findings Related to Nurse-to-Nurse LV
After review of the literature, surrogate terms and attributes were identified. The definition of nurse-to-nurse LV was identified by different authors, and a working definition of the concept was suggested as nurse-to-nurse LV (Figure 1). The antecedents and consequences of nurse-to-nurse LV are discussed, and the concept map and hypotheses are addressed.
Steps used in analysis included concept selection, common theme determination, identification of the aim of the analysis, uses of the concept, and defining attributes (Walker & Avant, 2005).
Surrogate Terms and Related Concepts
Within nursing, LV has been defined as nurse-to-nurse aggression. The 10 most common forms of LV in nursing are “non-verbal innuendo, verbal affront, undermining activities, withholding information, sabotage, infighting, scape-goating, backstabbing, failure to respect privacy, and broken confidences” (Griffin, 2004, p. 258).
LV occurs when oppressed groups /individuals internalize feelings such as anger and rage and then manifest these feelings through behaviors such as gossip, jealousy, putdowns, and blaming (Legal Definition, 2008). LV has also been identified as “Sabotage directed at coworkers who are on the same level within an organization’s hierarchy” (Dunn, 2003, p. 977).
Abusive behavior is that which humiliates, degrades, or indicates a lack of respect for the dignity and worth of an individual (Rowell, 2008). Intimidating behavior includes condescending language, impatience, angry outbursts, reluctance or refusal to answer questions, threatening body language, and physical contact (Alspach, 2007).
Farrell (2005) defines horizontal hostility /LV as a consistent pattern of behavior designed to control, diminish, or devalue a peer or group. This verbal or physical behavior creates a risk to health and /or safety. Verbal behavior is more common and includes any form of personal or professional mistreatment.
Covert and overt behaviors are attributes of LV and covert behaviors are the most damaging (Griffin, 2004). Covert behaviors include unfair assignments, sarcasm, eye-rolling, ignoring, making faces behind someone’s back, refusing to help, sighing, whining, refusing to work with someone, sabotaging others, isolation, exclusion, or fabrication. Thomas (2003) identified that literature supports the commonality of stories of horizontal hostility and that negative emotions have seriously undermined institutional attempts to create a satisfied nursing workforce. Bullying is abusive, intimidating, or insulting behavior, is persistent, and undermines self-confidence (Shewchuk, 2005; Taskforce on Workplace Bullying Issues Report, 2001).
Cox (1991) described verbal abuse as disruptive and any communication that a nurse perceives to be a harsh, condemnatory attack professionally or personally (Buback, 2004). Verbal abuse can be blatant or subtle and consists of communication through words, tone, or manner that disparages, intimidates, patronizes, threatens, accuses, or disrespects another person (Ulrich et al., 2006).
Critical attributes of nurse-to-nurse LV are the 10 most frequently reported attributes in the literature. These are listed under surrogate terms and related concepts (Griffin, 2004).
A literature search revealed both qualitative and quantitative methods for defining the concept of LV, and examples of these are cited in Table 1. The Sabotage Savvy Questionnaire asked study participants to recognize the presence of or absence of acts of sabotage, as a victim and as a saboteur (Woelfle & McCaffrey, 2007). The Index of Work Satisfaction questionnaire was used to describe current work situation to determine the hierarchy of importance of workplace concerns. An attitude questionnaire looked at how satisfied nurses were with their current nursing position (Woelfle & McCaffrey).
McKenna et al. (2003) analyzed characteristics of the most disturbing incidents experienced by nurses in their first year of practice. The Impact of Event Scale measured the level of distress over 7 days. Results were similar to symptoms of posttraumatic stress disorder.
Unstructured qualitative interviews were provided at the beginning and end of nursing students’ 3-year prenursing course in the United Kingdom. Bullying was found to be a common experience in the transition to becoming a nurse while Daiski (2004) performed a descriptive and exploratory study in Canada to examine views of hospital staff nurses’ beliefs about relationships (Randle, 2003).
Cognitive rehearsal as an intervention was used for a study on LV in newly hired registered nurses in their first position at a tertiary acute hospital. This strategy conceptually uses cognition and automatic thoughts. Gaining knowledge of LV with a behavioral intervention to stop the behavior served to empower this group of nurses and encouraged them to effectively confront laterally violent nurses. Use of cognitive rehearsal as a response to LV in this study may have helped raise consciousness about LV in the general nursing population (Griffin, 2004).
A theoretical model of social consciousness with constructs of stereotyping and mainstream violence was also developed in response to cross-cultural issues. This model included transcultural nursing, cultural safety, and a feminist scholar’s critique of oppression and power in nursing, and healthcare systems (Giddings, 2005).
Randle (2003) used the Professional Self-Concept Nursing Inventory and the Tennessee Self-Concept Scale and found that both general and professional self-esteem deterioration occurred, and Taylor (2001) performed a qualitative study to identify and transform dysfunctional nurse-nurse relationships through reflective practice and action research.
Antecedents are events or incidents that must occur prior to the occurrence of the concept (Walker & Avant, 1995). Antecedents to the concept nurse-to-nurse LV are lack of empowerment, authoritarian leadership, oppression, learned helplessness, negative nursing unit culture, toxic work environment, suppressed anger, low self-esteem, shrinking resources, conflict avoiding culture, personal behaviors, managers broader span of control, relationships, professionally uncooperative, imbalance of power, poor coping skills, strict hierarchy, and previous abuse.
Theoretically defining a concept supplies meaning in terms of context and assists in validating the concept’s definition (McEwen & Willis, 2007). LV may be seen as arising from several origins but is most frequently identified as arising from oppressed group behavior (Duffy, 1995; Friere, 1972; Griffin, 2004; Hutchinson, Vickers, Jackson, & Wilkes, 2006; Ratner, 2006; Roberts, 1983).
LV may also result from learned behavior within a given workplace (Lewis, 2006). In reality, the individual versus organizational contributions to this problem may be deeply interwoven and nearly impossible to distinguish (Ratner, 2006). Self-esteem has also been cited as the root of LV for nurses (Longo & Sherman; 2007; Nazarko, 2001; Rowell, 2008). Gender issues have also been rooted to LV because women have not been socialized to appreciate themselves or the roles that they play (Rowell). Anger has also been cited as a precursor to LV in nursing. Withholding anger until it seeps out as either passive and /or aggressive behavior is expressed as LV (Thomas, 2003).
In an attempt to empirically examine the extent of LV in nurses’ work settings, Farrell (1997) undertook a grounded theory study and identified three forms of aggression in nursing practice: nurse/patient (or patient/nurse), nurse/family (or family /nurse), and nurse/nurse. Overall findings suggest that most personally troubling for nurses was nurse-to-nurse aggression, or professional LV (Farrell, 1997).
Nurses in the least organizationally powerful position typically manifest LV on their unit and toward those with the least power, who tend to be new hires or new RNs (Farrell, 1997; Freshwater, 2000; Hamlin, 2000). Tolerance for some forms of nursing LV is seen historically in the context of a rite of passage or expressed in the thought – this is how it was as a new nurse (Bartholomew, 2006). General and hierarchical abuse is another theoretical belief regarding the origin of LV, and this occurs because of the importance of the status (Leiper, 2005). Hutchinson et al. (2006) posit that this behavior can become so normalized within an organizational culture that it is almost invisible. Another model is Foucault and the circuits of power model. This was proposed by Clegg to provide an alternative understanding of the theory behind LV (Hutchinson et al.).
Consequences of Nurse-to-Nurse LV
Consequences of nurse-to-nurse LV include low self-esteem, depression, self-hatred, negative patient outcomes, and feelings of power lessness. Other results of LV include the inability to recruit, increased turnover, damaged relationships, lack of retention, lack of cooperation, toxic work environment, and personal, emotional, social, psychological, and physical consequences (Namie & Namie, 2000).
Defining characteristics of LV were validated or demonstrated in the literature as overtly or covertly directed dissatisfaction inward, toward those less powerful than themselves, or nurse-to-nurse aggression (Griffin, 2004). Oppression and low self-esteem have been theorized as precursors to LV (Rändle, 2003) and have been issues throughout nursing and practice settings (Hutchinson et al., 2006; Stanley, Dulaney & Martin, 2007; Woelfle & McCaffrey, 2007).
An exemplar for nurse-to-nurse LV is a seasoned nurse who works night shift. Upon graduation from nursing school the now seasoned nurse was assigned a preceptor who was a strict disciplinarian, demeaning her when mistakes were made, shifting work off, and belittling her in front of physicians, peers, and supervisors. To survive in this workplace the now seasoned nurse began exhibiting laterally violent behaviors to peers and to new nurses in order to fit in on her nursing unit.
The now seasoned nurse comes into work on a Friday evening. Her coworkers are busy caring for patients, while she surfs the net and knits a blanket for a friend. She ignores call lights that are not her patients. The nurses on the unit ask for assistance and she rolls her eyes at them (nonverbal innuendo) and tells them that she is not going to perform their work (verbal affront) because she is so much more efficient than they are and they just need to get over it and do the work. She then ignores the staff the rest of the night, turning away from them when they speak to her, and giving them the “silent treatment” (nonverbal affront). Some of the staff ignore the behavior and continue to do the seasoned nurse’s work. Other staff suffer in silence, pray for shift end, and wonder how soon they can get transferred to another shift or off of this nursing unit.
This exemplar demonstrates attributes, antecedents, and consequences of nurse-to-nurse LV identified in the concept analysis. The attributes are nonverbal innuendo, verbal, and nonverbal affront. The antecedents are exhibiting demeaning and belittling behavior as well as shifting duties from the seasoned nurse to other nurses. The consequences evident in this exemplar are ignoring the behavior, suffering in silence, continuing to do extra work, and reinforcing the laterally violent nurse’s behavior.
Clarifying LV terminology will assist in research and could lead to further study to develop effective interventions to combat nurse-to-nurse LV. Most definitions agree that LV is overtly or covertly directing dissatisfaction toward another. Antecedents to LV from individual characteristics are oppression, learned helplessness, previous abuse, and low-self-esteem. From interpersonal factors, antecedents include personal behaviors and relationships precede LV. Organizational factors resulting in LV include authoritarian leadership, increased span of control, toxic work environment, shrinking resources, imbalance of power, and strict hierarchy (Giddings, 2005; Namie & Namie, 2000).
LV arises from several origins, including role issues, oppression, strict hierarchy, disenfranchising work practices, low self-esteem, perception of powerlessness, anger, and circuits of power. Critical attributes add clarity to analysis as these are applied to an exemplar.
Limitations of this concept analysis include that the analysis may not adequately address LV because of numerous antecedents. The term LV has not been consistently defined, and this may provide opportunity for error in analysis.
Organizations must learn how to eliminate antecedents and provide nurses with skills and techniques to eradicate LV to improve the nursing work environment, patient care outcomes, and nurse retention. Use of cognitive rehearsal to provide nurses with skills to combat LV may be an effective method to assist in halting the consequences of nurse-to-nurse LV.
Disruptive behaviors associated with LV continue to increase, are toxic to the nursing profession, and have a negative impact on retention of quality staff.
Consequences of nurse-to-nurse LV include low self-esteem, depression, self-hatred, negative patient outcomes, and feelings of powerlessness.
LV arises from several origins, including role issues, oppression, strict hierarchy, disenfranchising work practices, low self-esteem, perception of powerlessness, anger, and circuits of power.
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Jennifer L. Embree, RN, MSN, CCNS, NE-BC, and Ann H. White, RN, PhD, NE-BC
Jennifer L. Embree, RN, MSN, CCNS, NE-BC, is a University of Southern Indiana DNP Student, Indiana University School of Nursing Adjunct Faculty, Campbellsburg, IN. Ann H. White, RN, PhD, NE-BC, is Assistant Dean for Nursing, University of Southern Indiana, Evansville, IN.
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