1. TERRY CLIFFORD, MSN, RN, CPAN PORTLAND, MAINE, USA ASPAN IMMEDIATE PAST PRESIDENT “MANAGING HORIZONTAL VIOLENCE”

2. Objectives  Review definition and behaviors associated with ‘Horizontal Violence’ (HV)  Review theoretical causes of HV  Review consequences of HV  Review strategies for managing HV

3. What is Horizontal Violence? Horizontal violence or lateral violence can be described as overt or covert aggressive and destructive behavior of nurses against each other. It’s more than ‘Nurses eat their young’….

4. Alternative terms Mobbing Bullying Lateral Violence Nurse Hazing Horizontal Violence Verbal Abuse Workplace Violence Workplace Aggression

5. Types of Behaviors

7. Backstabbing Scapegoating Infighting Disrespectful behaviors Failure to respect privacy Broken confidences Withholding information Verbal affronts Belittling remarks Persistant criticism Humiliation Intitmidation False accusations Social isolation Unreasonable workloads

8. Incidence Scandinavian Countries – 1 to 5 % UK and US – 10 to 38 % Austrailia – 50 to 57% Turkey – 86.5%

9. Causes Apathy towards ‘bad’ behaviors  Desensitized  “It is what it is.” Enabling  “That’s just the way she/he is”  “She/he is just having a bad day” Complacency  “I don’t have time to deal with it”  “I don’t want to get involved”  “A silent witness” Fear of retaliation  “If I say something, I’ll be the next target”

10. Causes Subservient role to MDs (oppressed-group model = perceived lack of power)  Nursing, under Florence Nightingale, developed as a very hierarchical system where submission was ‘expected, encouraged, indeed, demanded’. Low self esteem Leadership too authoritarian/too ‘laissez-faire’ Stressful work environment – volatility  Shrinking resources  Downsizing  Restructuring Demanding work

12. Consequences at work Adverse affects on teamwork Adverse effect on patient care/safety  Nurses stressed by the effects of a hostile environment are more likely to make errors. Unreported errors/near misses Nurse retention issues  60% of nurses new to practice leave their first positions within six months because of some form of lateral violence being perpetrated against them Excessive sick time Lack of trust Lack of respect

13. Consequences to the nurse Stress related illnesses:  PHYSICAL  Weight loss  Weight gain  Hypertension  Cardiac palpitations  Irritable bowel syndrome  EMOTIONAL  Depression and/or anxiety  Humiliation  Feeling alienation Job dissatisfaction

14. Management tips Integration of TEAM BUILDING Educate all healthcare team members on appropriate professional behavior/code of conduct Train leaders in conflict management – giving feedback, assessing unit culture Reduce fear of intimidation and retribution for those who report disruptive behaviors (“Just” Culture) Develop a “ZERO” Tolerance policy

15. SAMPLE

16. Is this happening to you??? Gain control.  Realize that the aggressor is at fault, not you. Get help from your employer. Make a plan for action.  Talk with family, friends, and co-workers  Get info from books and Websites  Seek advice and support from others who’ve had similar experiences  Talk with a counselor or call an advice line. Take action.  Keep a detailed log of all incidents, with names of witnesses.  Keep written records so you’ll have substantive and quantifiable evidence. If these incidents are affecting your health, see your health care provider.  If an illness is diagnosed, make sure the cause is recorded; for example, stress in the workplace.

17. Is this happening to you??? Confront the aggressor.  Make it clear that this behavior is offensive and must stop. Make a formal written complaint.  By taking this step, you transfer the onus of taking action to the organization.  Follow the grievance procedures provided by your organization or union. Take legal action.  As a last resort, consider consulting an experienced lawyer about your legal options.

18. Tips to change this pattern… Lead by example  For instance, if a colleague lashes out at you regarding your opinion on a unit issue, you should hear the person out, think about what and why it was said, then respond to your colleague in a non-judgmental and non- argumentative tone. Learn to identify and deal with your own triggers and emotions at work  Changing the cycle of negative behavior requires personal and professional self-reflection Find BALANCE  Don’t work when you are home – rest, play, eat well….

19. Culture of Caring Initiate and participate in workplace celebrations Compliment your colleagues Encourage respect for each other’s ideas Think before you respond Support colleagues who are struggling with personal or workplace issues

20. Thank you! “Take care of yourself, always take the high road, assume that a workable relationship can be established, and reach out to experts for advice.” C Kerfoot, 2008

21. Questions? tclifford@aspan.org