Running head: LATERAL VIOLENCE 1

Lateral Violence Practiced by Nurses

Kelly McCarthy

Ferris State University

LATERAL VIOLENCE 2

Abstract

The concept of lateral violence is commonly practiced by nurses and has earned recognition as

the “nurse’s eating their young” phenomenon. This violence includes covert acts of bullying or

aggression such as gossiping, backstabbing, withholding information, nonverbal innuendo, and

sabotage, similar to preteen bullying seen in the education systems. This belittling and

downgrading of others through unkind words and cruel acts gradually affects ones confidence

and esteem. Therefore, threatening the health and well-being of nurses, and becoming a

significant patient safety issue. The purposed evidence based practice in hospitals to reduce

potential harm and distress to the patients and nurses involves a thorough examination of the

healthcare nursing environment, implementing a “zero- tolerance” program, and educating. With

help from healthcare organizations, accrediting bodies, and professional nursing organizations a

healthy work environment free from lateral violence will be achieved.

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Lateral Violence Practiced by Nurses

Lateral violence between nurses has been a subject of ongoing concerns for many years.

Its enduring impact is reflected throughout a variety of articles and statements in nursing

journals. But, why has the issue of nurse-to-nurse hostility become of vital concern now? The

violence issue has always been seen as a concern in the healthcare setting; however it is

becoming more emphasized and relevant due to the recent shortage of nurses and the heightened

awareness of work place violence and harassment. According to Embree (2010), disruptive

performances related with lateral violence continue to increase. Such behaviors have proven to

be hazardous in the nursing profession and have a negative effect on maintenance of quality and

staff. This effect is reinforced through the nursing theory of transpersonal caring by Jean Watson

and theory of the oppression group model. It is vital that the healthcare industry enforce

collaboration procedures to reduce potential harm and distress to the patients and nurses.

The purposed evidence based practice to diminish this issue involves a thorough

examination of the healthcare nursing environment. The first way to initiate a change in the

everlasting and enduring bullying cycle is to lead by example. “Registered nurses must role

model behavior that reinforces professionalism and negates intimidating and disruptive

behavior” (Norris, 2010, p. 10). Next, education of the issue within a workplace is critical. This

must include examples of lateral bullying, its physical and psychological impact on the staff, and

strategies to handle difficult behavior. Lastly, a Code of Conduct must be established. When a

code of conduct is set and victims feel safe to report maltreatment to authorities, the cycle will be

broken and ended. The adoption of the “zero tolerance” is becoming increasingly more common

throughout healthcare industry (Embree, 2010). This plan includes:

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“ educating nurses and staff to recognize and appropriately handle violent

conditions for new and experienced employees, holding open discussion forums

or focus groups to learn nurses’ perceptions of lateral violence, surveying to learn

the degree of intimidation in the workplace, and instituting conflict resolution

training” (Norris, 2010, p. 11).

With the practice of this tolerance plan, nurses will eventually have a safe and healthy

environment that will allow the performance of optimal care.

Lateral Violence within Nursing

Lateral Violence is a performance of violence and hostility that is towards one nurse from

another. It is a consistent pattern of behavior performed to control, diminish, or devalue an

individual or group (Embree, 2010). This demeaning and downgrading of others through unkind

words and cruel acts gradually affects the victim’s confidence and esteem, therefore, threatening

the health and well-being of nurses, and creating a patient safety issue. This practice has become

trademarked in the nursing community as the “Nurses eating their young” phenomenon (Norris,

2010). The common expressions of lateral violence include “nonverbal innuendo, verbal affront,

undermining activities, withholding information, sabotage, infighting, scapegoating,

backstabbing, failure to respect privacy, and broken confidences” (Sheridan-Leos, 2008, p.1).

Nurses who are a target or victim to this form of bullying may experience decreased job

satisfaction and an increased stress level (Embree, 2010). This toxic issue is practiced

continually through nursing and has enduring effects on all aspects of care.

Origin of Lateral Violence

Sensitivity and caring are a primary focus of the nursing profession. It seems ironic that

an act as hurtful and deteriorating as lateral violence is commonly performed. However, this

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repetition has occurred for years. The most accepted and understood theory to define the origin

of the bullying is known as the oppressed-group model. The model proposes that nurses are an

oppressed and powerless group dominated by others. Oppression occurs when an influential and

authoritative group controls and exploits a less powerful group (Sheridan-Leos, 2008). Nursing

is considered an oppressed group because the field tends to be dominated by mostly women, and

nurses have to report to physicians and administrations. Also, characteristics often found in

nurses such as caring and sympathy are viewed as less significant when compared to those of

medical practitioners, who often are seen as primary culture in healthcare (Sheridan-Leos, 2008).

“Nurses deal with their feelings of powerlessness and frustration by directing their dissatisfaction

toward each other in the form of oppressing behaviors” (Sheridan-Leos, 2008, p. 1). This model

provides an understanding as to how this vicious cycle perseveres.

Another major factor in the origin and continuation of lateral violence is a response to the

practice environment. The healthcare environment is seen as “emotionally, spiritually, and

physically toxic” (Sheridan-Leos, 2008, p.1). The work setting often experiences downsizing,

aggressive management styles, and increasing competition. Nurses who are practicing the act of

later violence see it as a safer display of stress. However, the receiver of the bullying behavior

becomes subject to a feeling of hurt and vulnerability, and is therefore reinforced of the

powerlessness (Embree, 2010). Lateral violence can become part of a health center’s culture, in

which discontinuing the behavior is seemingly impossible due to the “busy, high volume patient

areas, institutional polices and rules that are inflexible, and the lack of education programs and

policies to identify and reduce the incidence” (Norris, 2010, p.11). The result is a group of nurses

who fear asking for help from their coworkers, and consequently increasing the possibility of

errors.

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Similar acts of mentally and emotionally deteriorating behaviors are often portrayed by

girls, who are socialized to deal with their anger using forms of alternative aggression. Through

research studies that focus on preteen bullying in the education system, practices similar to that

of nurses are often found.

“Studies examining aggression amongst girls in the 10-12 age range demonstrate

that once girls reach the age of 9 and upwards, they realize the power they have

over the emotions and allegiances of others, and it is during this time that bullying

behavior may first manifest itself” (O’Neill, 2008, p. 699)

Girls are aggressive toward each other in concealed and indirect ways in order to gain control or

get even against another girl for reasons such as revenge, jealousy, and the proclamation of

social status and power. Research was reported that the five highest rated items that motivate

girls to bully are because the victim did not fit in, facial appearance, cried or was emotional,

overweight, or had good grades (O’Neill, 2008). It was also found that the conflicts presented

were often based on constructions of sexuality and popularity in the school-based relationships

of young women. However, with the help of parents, teachers, school administrators, community

leaders, and anti-bullying programs such as Olweus’ Intervention Model, the girl-on-girl

bullying can be prevented (O’Neill, 2008). Since nursing is predominantly dominated by

females, it is outwardly understandable how this indirect aggressive behavior is translated into

the healthcare field.

Effects of Lateral Violence

The effects of lateral violence in the workplace is extensive and over time can result in a

nurses decreased self-esteem, increased absences, clinical errors, and low productivity ( Norris,

2010). Research found by Marian Henderson (2009) stated that

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“ Nurses who are subjected to such hostility have been diagnosed with illnesses such as

depression, acute anxiety, post-traumatic stress disorder, weight loss, weight gain, hypertension,

cardiac palpations, and irritable bowel symptom resulting in increased staff turn-over rate and

more use of sick time. Also more nurses lack the initiative to do their job well” (p.2).

If the bullying practice continues at a workplace, nurses will leave. “Approximately sixty percent

of newly registered nurses leave their first position within six months because of some form of

(lateral violence)” (Embree, 2010, p.3). However, when a nurse chooses to leave the profession

instead of attempting to resolve the issue, the bully dose not cease but instead the spiteful series

continues, engulfing its next victim.

It is predicted that the United States will soon face a nursing shortage that far exceeds any

of those in the past.

“… research concluded that for each patient added to a nurse’s workload, the patient’s

risk of dying within thirty days of admission increased by seven percent. For example,

the risk of death increased to fourteen percent if a nurse’s assignment increased from four

to six patients. Fewer nurses means more deaths, and nurse-to-nurse mistreatment

contributes to reducing the numbers and effectiveness of nurses in healthcare”

(Henderson, 2009, p.2 ).

This poor treatment is affecting the healthcare industry greatly, and as nurses’ age increase and

their net income decreases, the industry is in a positioned of high risk for serious mistakes and an

overall decrease in quality of care.

Positive Impacts of Diminishing Workplace Violence

If hospitals enforce efforts to cease lateral violence in the workplace, the delivery of safe,

quality care will be positively affected. This concept is reinforced and provides a strong

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foundation through Jean Watson’s philosophy of transpersonal caring. The theory defines the

outcome of nursing activity in regard to the humanistic aspects of life and is focused on the

caring process to promoting, restoring health, and preventing disease or illness (Vance, 2004).

The caring process requires the nurse to be knowledgeable about human actions, reactions,

individual needs, strength and limitations of clients and family, as well as those of the nurse.

Caring represents all factors the nurse uses to safely and adequately deliver care to a client, with

a focus on caring for oneself as well as the patient. Watson suggests that caring, as a moral ideal,

provides the stance from which one intervenes as a nurse (Vance, 2004). This stance is critical

for ensuring that nurses practice ethical standards for good conduct, character, and motives. With

correct use of resources and informative systems in ending lateral violence, such as the internet,

medical journals, and employing a “zero tolerance” plan , a nurse’s ethics of care will increase

and a well-established way of controlling and breaking the lateral bullying cycle can be

implemented successfully. When lateral violence is present in the workplace a variety of aspects

of care are being negatively impacted, therefore focus is distracted from initial task. Since our

own personal care can influence how we perform care for our patients, it is crucial that a

procedure is in place to eliminate bullying, aide the nurse-client relations, promotes healing and

wholeness, and overall have a lasting positive impact within the healthcare industry.

When there is less distraction in the work place from issues irrelevant to the patients,

many aspects of nursing will benefit. Nurses will have more time to increase their client- nurse

relationship, therefore understanding individual diversity needs, and necessary accommodations

to promote health and lifespan considerations. With cooperation between staff, nurses will be

seen as better and stronger leaders and role models that society can safely trust with healthcare

needs.

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Since the United States is currently in the middle of a nursing shortage, the loss of nurses

due to lateral violence is unacceptable. This issue has engaged many healthcare organizations,

accrediting bodies, and professional nursing organizations to examine the nursing work

environment. With the help from a variety of resources available, hospitals can achieve a healthy

work environment for the nursing staff, free from lateral violence.

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Appendix A

Appendix B

INITIALS PROOFREAD FOR: APA ISSUES

X 1. Page Numbers: Did you number your pages using the automatic functions of your Word program? [p. 230 and example on p. 40)]

X 2. Running head: Does the Running head: have a small “h”? Is it on every page? Is it less than 50 spaces total? Is the title of the Running head in all caps? Is it 1/2” from the top of your title page? (Should be a few words from the title of your paper). [p. 229 and example on p. 40]

X 3. Abstract: Make sure your abstract begins on a new page. Is there a label of Abstract and it is centered at the top of the page? Is it a single paragraph? Is the paragraph flush with the margin without an indentation? Is your abstract a summary of your entire paper? Remember it is not an introduction to your paper. Someone should be able to read the abstract and know what to find in your paper. [p. 25 and example on p. 41]

X 4. Introduction: Did you repeat the title of your paper on your first page of content? Do not use ‘Introduction’ as a heading following the title. The first paragraph clearly implies the introduction and no heading is needed. [p. 27 and example on p. 42]

X 5. Margins: Did you leave 1” on all sides? [p. 229]

X 6. Double-spacing: Did you double-space throughout? No triple or extra spaces between sections or paragraphs except in special circumstances. This includes the reference page. [p. 229 and example on p. 40-59]

X 7. Line Length and Alignment: Did you use the flush-left style, and leave the right margin uneven, or ragged? [p. 229]

X 8. Paragraphs and Indentation: Did you indent the first line of every paragraph? See P. 229 for exceptions.

X 9. Spacing After Punctuation Marks: Did you space once at the end of separate parts of a reference and initials in a person’s name? Do not space after periods in abbreviations. Space twice after punctuation marks at the end of a sentence. [p. 87-88]

X 10. Typeface: Did you use Times Roman 12-point font? [p. 228]

X 11. Abbreviation: Did you explain each abbreviation the first time you used it? [p. 106-111]

X 12. Plagiarism: Cite all sources! If you say something that is not your original idea, it must be cited. You may be citing many times…this is what you are supposed to be doing! [p. 170]

X 13. Direct Quote: A direct quote is exact words taken from another. An example with citation

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would look like this:

“The variables that impact the etiology and the human response to various disease states will be explored” (Bell-Scriber, 2007, p. 1).

Please note where the quotation marks are placed, where the final period is placed, no first name of author, and inclusion of page number, etc. Do all direct quotes look like this? [p. 170-172]

X 14. Quotes Over 40 Words: Did you make block quotes out of any direct quotes that are 40 words or longer? [p. 170-172]

X 15. Paraphrase: A paraphrase citation would look like this:

Patients respond to illnesses in various ways depending on a number of factors that will be explored (Bell-Scriber, 2007).

It may also look like this: Bell-Scriber (2007) found that……

[p. 171 and multiple examples in text on p. 40-59]

For multiple references within the same paragraph see page 174.

X 16. Headings: Did you check your headings for proper levels? [p. 62-63].

X 17. General Guidelines for References:

A. Did you start the References on a new page? [p. 37]

B. Did you cut and paste references on your reference page? If so, check to make sure they are in correct APA format. Often they are not and must be adapted. Make sure all fonts are the same.

C. Is your reference list double spaced with hanging indents? [p. 37]

INITIALS PROOFREAD FOR GRAMMAR, SPELLING, PUNCTUATION, & STRUCTURE

X 18. Did you follow the assignment rubric? Did you make headings that address each major section? (Required to point out where you addressed each section.)

X 19. Watch for run-on or long, cumbersome sentences. Read it out loud without pausing unless punctuation is present. If you become breathless or it doesn’t make sense, you need to rephrase or break the sentence into 2 or more smaller sentences. Did you do this?

X 20. Wordiness: check for the words “that”, and “the”. If not necessary, did you omit?

X 21. Conversational tone: Don’t write as if you are talking to someone in a casual way. For example, “Well so I couldn’t believe nurses did such things!” or “I was in total shock over

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that.” Did you stay in a formal/professional tone?

X 22. Avoid contractions. i.e. don’t, can’t, won’t, etc. Did you spell these out?

X 23. Did you check to make sure there are no hyphens and broken words in the right margin?

X 24. Do not use “etc.” or "i.e." in formal writing unless in parenthesis. Did you check for improper use of etc. & i.e.?

X 25. Stay in subject agreement. When referring to 1 nurse, don’t refer to the nurse as “they” or “them”. Also, in referring to a human, don’t refer to the person as “that”, but rather “who”. For example: The nurse that gave the injection….” Should be “The nurse who gave the injection…” Did you check for subject agreement?

X 26. Don’t refer to “us”, “we”, “our”, within the paper…this is not about you and me. Be clear in identifying. For example don’t say “Our profession uses empirical data to support ….” . Instead say “The nursing profession uses empirical data…..

X 27. Did you check your sentences to make sure you did not end them with a preposition? For example, “I witnessed activities that I was not happy with.” Instead, “I witnessed activities with which I was not happy.”

X 28. Did you run a Spellcheck? Did you proofread in addition to running the Spellcheck?

X 29. Did you have other people read your paper? Did they find any areas confusing?

X 30. Did you include a summary or conclusion heading and section to wrap up your paper?

X 31. Does your paper have sentence fragments? Do you have complete sentences?

X 32. Did you check apostrophes for correct possessive use. Don’t use apostrophes unless it is showing possession and then be sure it is in the correct location. The exception is with the word it. It’s = it is. Its= is possessive.

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References

Embree, J., & White, A. (2010). Concept analysis: nurse-to-nurse lateral violence. Nursing

Forum, 45(3), 166-173. doi:10.1111/j.1744-6198.2010.00185.x

Henderson, M. (2009, September 16). Hostility and violence in the nursing profession. Retrieved

from http://marian-henderson.suite101.com/hostility-and-violence-in-the-nursing-

profession-a149150

Norris, T. (2010). Lateral violence: is nursing at risk?. Tennessee Nurse, 73(2), 1.

O’Neill, S. (2008). Bullying by tween and teen girls. American Education Research Journal,

3(37), 699-725. Retrieved from http://www.sacsc.ca/Literature Review_finalSON.pdf

Sheridan-Leos, N. (2008, June). Understanding lateral violence in nursing. Clinical Journal of

South Carolina Nurse, 17(3), 11.

Vance, T. (2004). Caring and the professional practice of nursing. RN Journal, Retrieved from

http://www.rnjournal.com/journal_of_nursing/caring.htm