Lateral Violence & Incivility in Nursing Amy Noonan Pamela Dusseau

Objectives Define lateral violence Identify lateral violence behavior Recognize the effect on nurses and patient care Define incivility Identify uncivil behaviors Recognize effect of uncivil behavior on peers and patients Discuss options to eradicate lateral violence and uncivil behavior directed at and coming from nurses

Lateral Violence may also be called: Bullying Horizontal violence Workplace Incivility Workplace violence Interpersonal conflict Psychological violence Lateral or Horizontal Violence tends to be covert and hard to identify. This means that the victim has a hard time seeking assistance. Many times if it isn’t a severe case of violence the victim may second guess the seriousness of the event and will not seek help.

Lateral Violence (LV) in Nursing Aggressive and destructive behavior or psychological harassment of nurses against each other, or another healthcare worker (Yoder-Wise, 2015,p. 583). LV is characterized by the presence of a series of undermining incidents over time (Becher & Visovksy, 2012) Is often unrecognized and unreported Nurses are victimized 3 times more than other health workers (Ovayolu, Ovayolu, & Karadag, 2014). May start as early as nursing school LV is aggressive and destructive behavior or psychological harassment of nurses against each other, or another healthcare worker (Yoder-Wise, 2015). LV is characterized by the presence of a series of undermining incidents over time, as opposed to on isolated conflict in the work place. “A survey on intimidation conducted by the Institute for Safe Medication Practices found that 40% of clinicians have kept quiet or remained passive during patient care events rather than question a known intimidator” (TJC, 2008). Many nurses do not seek help because there is the fear they will be further alienated from their peers because they are a “whiner” Nurses are exposed to abuse & violence from co-workers as well as violent acts of patients and their families (Ovayolu, 2014). A study of student nurses reported that 53% had been put down by a staff nurse (ANA, 2013).

Forms of Lateral Violence (LV) Verbal abuse: name calling, blaming, humiliation, arguing Physical abuse: giving unreasonable assignments Threats or threatening behavior: intimidation Cyber harassment (bullying on internet) Criticizing Psychological abuse: using silence, ignoring, isolation Violence in the health sector has a negative impact not only on the professional and personal lives of the health care workers, but also on the quality of care provided to patients (Ovayolu, Ovayolu, & Karadag, 2014) “Bullying at work can include all types of mistreatment such as: Verbal abuse- name calling Humiliation being told you are not good enough to perform a task Physical abuse- can be slapping, hitting, elbowing, pushing etc., but also assigning unreasonable patient assignments that are physically taxing. Threats may include someone saying: if this happens, you will experience this from me” (if you tell the supervisor I will tell everyone you had a nose job) Intimidation could include things like being scolded in front of team members Criticizing : sarcastic comments, “teasing” Psychological abuse: using silence- not speaking to someone, isolating someone from a group.

Lateral Violence Statistics: 43% of nurses, pharmacists, and others experienced threatening body language while working (ANA, 2013) 56.9% of nurses reported having been threatened or have experienced verbal abuse at work (ANA, 2013) 61.1% of nurses studied reported seeing LV between co-workers on their unit (Becher & Visovsky, 2012) LV has been known to extend from nurse leaders to the staff they supervise. In a recent study 43% of nurses, pharmacists and other health care workers reported having experienced threatening body language while working. 56.9% of nurses reported having been threatened or have experienced verbal abuse at work (ANA, 2013) 61.1% of the nurses studied reported seeing lateral violence between co-workers on their unit (Becher & Visovsky, 2012) Lateral violence has also been known to extend from nurse leaders to the staff they supervise

Results of Lateral Violence Damages the dignity of the individual Increased medical errors Decrease patient satisfaction Increase number of adverse outcomes Increase cost of care Staff turnover Retaliation The victim of LV may experience low self-esteem, anxiety, depression, and sleeping disorders. Powerlessness, anger, and work absences occur. Many consider leaving their positions and some actually leave the profession (Becher & Visovsky, 2012). “TJC indicates that poor communication is the leading factor in sentinel events affection healthcare teams and compromising patient saftey. When essential information related to patient care is omitted as an act of LV, the victimized nurse is in a poor position to care for patients and patient safety is compromised” (Becher & Visovsky, 2012). Intimidating and disruptive behaviors can foster medical errors, contribute to poor patient satisfaction and adverse outcomes, increase the cost of care, and employee turnover (TJC, 2008).

The report defined medical occupations as: physicians, nurses, technicians, and other medical professionals. While media attention tends to focus on reports of workplace homicides, the vast majority of workplace violence incidents result in non-fatal, yet serious injuries. Statistics based on the Bureau of Labor Statistics (BLS) and National Crime Victimization Survey (NCVS)2 data both reveal that workplace violence is a threat to those in the healthcare and social service settings (OSHA, 2015).

Incivility Incivility includes a wide range of behaviors from ignoring others, to rolling one’s eyes, to yelling, and eventually to personal attacks (Yoder-Wise, 2015, p. 465). As opposed to LV incivility can be an isolated event or a series of events. Incivility can start with a single episode and graduate into LV Rudeness, disrespect, and general disdain for colleagues are further examples of incivility Incivility includes a wide range of behaviors from ignoring others, to rolling one’s eyes, to yelling, and eventually to personal attacks (Yoder-Wise, 2015, p. 465). Although incivility is considered professional misconduct, a breech of etiquette, and representative of moral decay, the question of intent to harm distinguishes incivility from bullying or other forms of aggressive behavior (Feblinger, 2008).

Suggestions for Meaningful Conversations Fully prepare yourself before engaging in a critical conversation, Ask, “If I do not respond” or “If I do respond”, Consider the potential barriers to effective communication, Agree on a mutually beneficial time and place for your interaction, Bear in mind "the interest-based approach to principled negotiation," developed by Fisher and Ury (1991) Concentrate on interests (instead of focusing on being right), Prevention of lateral violence in the workplace starts long before an employee walks through the door. We believe that civility in health care organizations begins with teaching and modeling civility for nursing students in both the classroom and clinical settings (Clark & Ahten, 2012).

The Economic Cost of Incivility 48% intentionally decreased their work effort. 47% intentionally decreased time spent at work. 38% intentionally decreased the quality of their work. 80% lost work time worrying about the incident. 63% lost work time avoiding the offender. 66% said that their performance declined. 78% said that their commitment to the organization declined. 12% said that they left their job because of the uncivil treatment. 25% admitted to taking their frustration out on customers. Workplace incivility can not only be costly in terms of the physical and emotional pressure on employees; incivility can also severely undermine the financial stability of companies and organizations through low productively, missed work time, poor employee retention and loss of revenue from dissatisfied customers. A poll of 800 managers and employees in 17 industries reflects on the negative impact of workplace incivility (Porath & Pearson, 2013).

Solutions to LV & Incivility The American Associated of Critical Care Nurses (AACN) Standards of Zero Tolerance. Skilled Communication True Collaboration Effective Decision Making Appropriate Staffing Meaningful Recognition Authentic Leadership Dianne M. Felblinger, associate professor, College of Nursing, University of Cincinnati, OH, recommends adopting the American Association of Critical Care Nurses (AACN) Standards of Zero Tolerance for Establishing and Sustaining Healthy Work Environments which include; skilled communication, true collaboration, effective decision making, appropriate staffing, meaningful recognition, and authentic leadership (Felblinger, 2008).

Solutions to LV & Incivility “Once the boundaries of appropriate interpersonal behaviors are identified and internalized, nurses and administrators can begin to create a respectful work environment.” (Felblinger, 2008) Felblinder further notes, Education is needed at the individual and the unit level in an effort to raise the awareness of everyone involved (Felblinger, 2008).

Conclusion Identifying and addressing instances of LV & Incivility is essential to fostering a healthy work environment that promotes safe patient care and “directs valuable human energy toward attainment of organizational goals and contributes to increased productivity (Felblinger, 2008).”

References American Nurse Association. (2013). Lateral violence and bullying in nursing. Retrieved from http://www.nursingworld.org/Mobile/Nursing- Factsheets/lateral-violence-and-bullying-in-nursing.html Becher, J., & Visovsky, C. (2012). Horizontal violence in nursing. Medsurg Nursing, 21(4), 210-213. Retrieved from https://www.amsn.org/sites/default/files/documents/practice- resources/health-work-environment/resources/MSNJ-Becher- Visovsky-21-04.pdf Ovayolu, O., Ovayolu, N., & Karadag, G. (2014). Workplace bullying in Nursing. American Association of Occupational Heatlh Nurses. 62(9) The Joint Commision (2008). Behaviors that undermine a culture of saftey. Retrieved from http://www.jointcommission.org/assets/1/18/SEA_40.PDF Yoder-Wise, P. (2105). Leading and managing in nursing (6th ed.). St.Louis, MO: Elsevier.

References (cont.) C. M., & Ahten, S. (2012). Beginning the Conversation: The Nurse Educator's Role in Preventing Incivility in the Workplace. Georgia Nursing, 72(3), 16-17 Felblinger, D. (2008). Incivility and bullying in the workplace and nurses’ shame responses. Journal of Obstetric. , Gynecologic, & Neonatal Nursing. 37 (234-242). DOI: 10.1111/j.1552-6909.2008.00227.x Porath, C. & Pearson, C. (2013). The price of incivility. Harvard Business Review. Retrieved from https://hbr.org/2013/01/the-price-of-incivility/