Horizontal Violence Experienced By Student Nurses at a community college
This post shares information regarding a community college in NJ where I percepted this summer. I was to review their public data and determine a "problem" and come up with a "solution." I determined that Horizontal Violence was quite evident at their clinical facilities. I recommended to develop a seminar for the nursing staff at these facilities to increase awareness of HV and hopefully change the behavior. This seminar will also be beneficial for the nursing students to attend.
The data collected from the community college's Clinical Facilities Evaluations demonstrate the apparent existence of what is termed horizontal violence, or Nurse-to-Nurse Hostility. One particular comment that is a prime example of this hostility is number 2, “One RN on 2E was impolite and criticized students in front of other students and staff re: administration of Digoxin. I felt like she was a drill sergeant and not a good role model. My answers were right, but she kept criticizing me all day.”
After meeting with the Chairperson of the Nursing Program and discussing the data reviewed, it was agreed that the one of the most prevalent issue that the Nursing Program is facing currently is that of Nurse-to-Nurse Hostility at their four main clinical facilities. Before seeing the data this author collected, she mentioned a community hospital in New Jersey as the site that she felt demonstrated this behavior most predominately.
Nurse-to-nurse hostility is most commonly termed as horizontal violence, but it is also referred to as horizontal hostility, horizontal aggression, lateral hostility, bullying and interpersonal conflict. It is aggressive behavior by an individual or several individuals that is directed towards another member or members of the same group. It is an inter-group conflict (Hastie, 2002). Matthew-Blanton (2002) as cited by Conti-O’Hare (2002) provides a more descriptive definition of horizontal violence:
"Horizontal violence is a harmful behavior, via attitudes, actions
words and other behavior, that is directed towards us by colleagues.
It controls, humiliates, denigrates, and injures the dignity of another.
It indicates a lack of mutual respect and value for the worth of the
individual and denies another’s fundamental human rights. It is a
self-serving, nonproductive response that perpetuates an escalating
cycle of resentment and retaliation. When practiced by healthcare
professionals, horizontal violence can be deleterious to patient care." (¶ 10)
Horizontal violence is often manifested as behaviors such as sarcastic remarks, intentional rolling of ones eyes, ignoring, gossiping, exclusion from activities and/or conversations, lack of support, unfair assignments, fault finding, intimidation, controlling behaviors, and rudeness (Hastie, 2002).
In a study conducted in Tasmania, the results indicated that nurses who experienced horizontal violence named it as the greatest reason for their work distress. This type of aggression ranked higher than aggression from patient’s family members, doctors, and patients themselves. The type of horizontal violence or hostility experienced most was rudeness, abusive language, and humiliation (Farrell, 1999). Other studies have shown that nurses who experience workplace bullying exhibit symptoms of Post Traumatic Stress Disorder (Tehrani, 2004) and other physical stress reactions such as stomach and back pain, heart palpitations and dizziness. Many experience feelings of helplessness, hopelessness and powerlessness. Bullied employees reported greater levels of mental fatigue and burnout, and also have a higher incidence of sick leave (Agervold, 2004). Horizontal violence can also result in sleeping disorders, anxiety, depression, lack of motivation, lack of emotional control, hypertension, apathy, low morale, poor concentration, eating disorders, disconnectedness, low self-esteem, self-doubt, indecisiveness, impaired personal relationships and even suicide (Hastie, 2002). As reported by Taylor (2004), 153 nurses and midwives killed themselves between the years 1990 and 1992 in the United Kingdom. This demonstrates “that nursing is one of the most stressful occupations, with nurse suicide the highest rate for female suicide” (p. 118).
Student nurses also experience and are affected by horizontal violence. In a study conducted in the United Kingdom, it was concluded that the students had started their studies with normal self-esteem. When their nursing studies were complete, results showed a below average self-esteem and 95% of the participants rated themselves as anxious, depressed and unhappy. The study concluded that “the process of becoming a nurse has a dramatic, negative effect on some aspects of student’s self-esteem” (Randle, 2003a, p. 143). Interviews from the students “illustrate dramatically the distressing experience that students reported from their clinical placements” (Randle, 2003a, p. 143). The author concluded that this decrease in self-esteem and unhappy feelings were largely due to horizontal violence (2003a).
Many of these students related stories when they felt “bullied” by other nurses, both at the clinical sites and by their instructors. These actions made them feel powerless and, in order to cope, they began to exhibit behaviors that would allow them to fit in with and become more like their aggressor. By the end of their coursework, the behaviors of horizontal violence that they initially experienced by other nurses, where now the same behaviors they exhibited to others. They identified the bullying behaviors as part of becoming a nurse (Randle, 2003a). Their attitude towards bullying behaviors changed during their course work, and they “seemed to be blind to the conflicts and anxieties they had first experienced, and not speaking about their anxieties become part of their repertoire” (Randle, 2003b, p. 397). One student stated, “You just have to fit in and get on with the work really.” Another student said, “I make myself do what basically everybody else does. I do what they do” (Randle, 2003b, p. 397).
One common theory regarding horizontal violence is that nurses, just as women, are an oppressed group and are acting out as such. An oppressed group is “people who share with others low status, absence of power, low autonomy, reduced mobility, limited access to resources, and other disadvantages” (Lee, 2001). As cited by Lee (2001), Paulo Freire (1968) described horizontal violence as a behavior that oppressed people exhibit. In order to deal with feelings of powerlessness, the oppressed group would displace negative emotions and aggressiveness onto each other instead of their oppressor, or dominant group. Oppressed groups exhibit behaviors of self-hatred such as lashing out at each other, remaining silent due to shame and embarrassment of their status, and attempting to act and/or befriend their oppressor. Over time, oppressed groups begin to believe and support their oppressor’s beliefs and behavior towards them. They help to fulfill their oppressor’s prophecies about them, and act and behave as their oppressor would expect. They internalize their oppression and believe that they are deficient and deserve this treatment. They develop self and group hatred, low self-esteem, powerlessness, low self-confidence and hopelessness (Lee, 2001). The culture of nursing has many of the attributes stated for oppressed groups, and is portrayed by not only the females, but their male counterparts (Bartholomew, 2006).
Currently, this community hospital is striving for Magnet Status. Two of the 14 forces of magnetism as identified by the American Nurse Credentialing Center (ANCC) that relate to the interaction and relationship between staff nurses and student nurses are numbers 11 and 13. Number 11 states, “Nurses as teachers: Nurses are permitted and expected to incorporate teaching in all aspects of their practice.” Number 13 states, “Interdisciplinary relationships: Interdisciplinary relationships are positive and show mutual respect across all disciplines.” (American Nurses Credentialing Center, n.d., p. 4) The Chairperson stated that the ANCC organization questions them regarding how the nursing staff at a particular clinical site behaves towards and regards the students and the faculty. ANCC takes this interaction into consideration when granting or renewing its Magnet designation.
Nurse-to-Nurse hostility affects the goals of the Nursing Program because it affects the student’s learning experience and learning abilities. The studies mentioned above have shown that nurses exposed to horizontal violence exhibit symptoms such as indecisiveness, poor concentration, self doubt, depression and the inability to handle stressful situations. The studies have also demonstrated that it can lower the self esteem of the student nurse. It also may contribute to the attrition rate seen in the first two semesters at this community college.
Professional nurses can empower themselves by joining nursing organizations, becoming involved in committees at work, changing their “put down” language, continuing their education, motivating other nurses, breaking the silence regarding horizontal violence, engaging in self-caring activities such as exercise and good nutrition, becoming politically involved, and engaging in reflective practice, such as journaling, to promote personal growth and emotional competence. Most important, nurses can empower themselves by acknowledging their participation in and then no longer engaging in horizontal violence (Hastie, 2002).
Many agree that the key to overcoming disempowerment within nursing is empowerment. Nursing students and novice nurses can be empowered by other nurses through positive or active mentoring. The role of the mentor is that of a supporter, an assessor, and a role model. Mentorship has shown to lead to empowerment and “is one of the most effective methods to promote excellence within the nursing professional…In light of the current volatile state of healthcare, mentoring can empower inexperienced nurses to experience more self-confidence in environments which oftentimes impede growth and development” (White, 2001, ¶ 9-10).
A seminar for staff nurses at the community hospital can be developed to help raise the awareness of the issue of Nurse-to-Nurse Hostility and prepare them to become positive mentors to student nurses, new graduate nurses, and nurses with less experience. Many hospitals today pair new nurses with an experienced nurse. The nurses work the same shifts and this is often referred to as preceptorship. Precepting is limited in its scope. It has defined learning goals and is expected to occur for an allotted period of time. Mentoring is quite different from precepting. It has no time limit and there are no set learning goals. Mentors are described as an “expert in their chosen area of practice, are well respected by all members of the treatment team for their knowledge, caring and compassion towards patients and their families, and have intense commitment to the discipline of nursing.” (Thomka, 2006, p. 53) Mentoring is complex and dynamic and their influence continues to affect and guide the mentee positively for a long time, perhaps the rest of their lives. Another positive outcome of mentorship is that the mentee will eventually become the mentor to a new nurse, hopefully leading to the end of the cycle of horizontal violence.
References
Agervold, M. & Mikkelsen, E.G (2004). Relationships between bullying, psychosocial work environment and individual stress reactions. Work & Stress, 18(4), 336-351.
American Nurses Credentialing Center. (n.d.). Introduction to the Magnet Recognition Program
for Students of Nursing. Silver Spring, MD: Author. Retrieved on August 8, 2006 from
http://www.nursingworld/.org/ancc/magnet/forms/studentmanual.pdf.
Bartholomew, K. (2006). Ending Nurse-to-Nurse Hostility: Why Nurses Eat Their Young and Each Other. Marblehead, MA: HCPro, Inc.
Conti-O’Hare, M. & O’Hare, J.L. (2002). Don’t Perpetuate Horizontal Violence [Electronic Version]. Nursing Spectrum. Retrieved from http://community/. Nursingspectrum.com/
Magazinearticles/article.cfm?AID=5708
Farrell, G.A (1999). Aggression in clinical settings: nurses’ views – a follow-up study. Journal of Advanced Nursing, 29(3), 532-541.
Hastie, C. (2002, August). Horizontal violence in the workplace. Birth International. Retrieved from http://www.birthinternational.com/articles/hastie02.html
Lee, M.B., & Saeed, I. (2001). Oppression and Horizontal Violence: The Case of Nurses in Pakistan. Nursing Forum, 36(1), 15-23.
Randle, J. (2003a). Changes in self-esteem during a 3-year pre-registration Diploma in Higher
Education (Nursing) programme. Journal of Clinical Nursing, 12, 142-143.
Randle, J. (2003b). Bulling in the nursing profession. Journal of Advanced Nursing, 43(4), 395-
401.
Taylor, B. & Barling, J. (2004). Identifying sources and effects of career fatigue and burnout for mental health nurses: a qualitative approach. International Journal of Mental Health Nursing, 13, 117-125.
Tehrani, N. (2004). Bullying: a source of chronic post traumatic stress? British Journal of Guidance & Counselling, 32(3), 357-366.
Thomka, L. (2006, February). Are we there yet? The long and winding journey of mentoring.
MODRN Nurse Magazine, 2(1), 49-55).
White, M.A. (2001). Is “Eating Our Young” contributing to the nursing shortage? [Electronic Version]. Nursing Spectrum. Retrieved from http://community/. Nursingspectrum.com/
Magazinearticles/article.cfm?AID=3364
The data collected from the community college's Clinical Facilities Evaluations demonstrate the apparent existence of what is termed horizontal violence, or Nurse-to-Nurse Hostility. One particular comment that is a prime example of this hostility is number 2, “One RN on 2E was impolite and criticized students in front of other students and staff re: administration of Digoxin. I felt like she was a drill sergeant and not a good role model. My answers were right, but she kept criticizing me all day.”
After meeting with the Chairperson of the Nursing Program and discussing the data reviewed, it was agreed that the one of the most prevalent issue that the Nursing Program is facing currently is that of Nurse-to-Nurse Hostility at their four main clinical facilities. Before seeing the data this author collected, she mentioned a community hospital in New Jersey as the site that she felt demonstrated this behavior most predominately.
Nurse-to-nurse hostility is most commonly termed as horizontal violence, but it is also referred to as horizontal hostility, horizontal aggression, lateral hostility, bullying and interpersonal conflict. It is aggressive behavior by an individual or several individuals that is directed towards another member or members of the same group. It is an inter-group conflict (Hastie, 2002). Matthew-Blanton (2002) as cited by Conti-O’Hare (2002) provides a more descriptive definition of horizontal violence:
"Horizontal violence is a harmful behavior, via attitudes, actions
words and other behavior, that is directed towards us by colleagues.
It controls, humiliates, denigrates, and injures the dignity of another.
It indicates a lack of mutual respect and value for the worth of the
individual and denies another’s fundamental human rights. It is a
self-serving, nonproductive response that perpetuates an escalating
cycle of resentment and retaliation. When practiced by healthcare
professionals, horizontal violence can be deleterious to patient care." (¶ 10)
Horizontal violence is often manifested as behaviors such as sarcastic remarks, intentional rolling of ones eyes, ignoring, gossiping, exclusion from activities and/or conversations, lack of support, unfair assignments, fault finding, intimidation, controlling behaviors, and rudeness (Hastie, 2002).
In a study conducted in Tasmania, the results indicated that nurses who experienced horizontal violence named it as the greatest reason for their work distress. This type of aggression ranked higher than aggression from patient’s family members, doctors, and patients themselves. The type of horizontal violence or hostility experienced most was rudeness, abusive language, and humiliation (Farrell, 1999). Other studies have shown that nurses who experience workplace bullying exhibit symptoms of Post Traumatic Stress Disorder (Tehrani, 2004) and other physical stress reactions such as stomach and back pain, heart palpitations and dizziness. Many experience feelings of helplessness, hopelessness and powerlessness. Bullied employees reported greater levels of mental fatigue and burnout, and also have a higher incidence of sick leave (Agervold, 2004). Horizontal violence can also result in sleeping disorders, anxiety, depression, lack of motivation, lack of emotional control, hypertension, apathy, low morale, poor concentration, eating disorders, disconnectedness, low self-esteem, self-doubt, indecisiveness, impaired personal relationships and even suicide (Hastie, 2002). As reported by Taylor (2004), 153 nurses and midwives killed themselves between the years 1990 and 1992 in the United Kingdom. This demonstrates “that nursing is one of the most stressful occupations, with nurse suicide the highest rate for female suicide” (p. 118).
Student nurses also experience and are affected by horizontal violence. In a study conducted in the United Kingdom, it was concluded that the students had started their studies with normal self-esteem. When their nursing studies were complete, results showed a below average self-esteem and 95% of the participants rated themselves as anxious, depressed and unhappy. The study concluded that “the process of becoming a nurse has a dramatic, negative effect on some aspects of student’s self-esteem” (Randle, 2003a, p. 143). Interviews from the students “illustrate dramatically the distressing experience that students reported from their clinical placements” (Randle, 2003a, p. 143). The author concluded that this decrease in self-esteem and unhappy feelings were largely due to horizontal violence (2003a).
Many of these students related stories when they felt “bullied” by other nurses, both at the clinical sites and by their instructors. These actions made them feel powerless and, in order to cope, they began to exhibit behaviors that would allow them to fit in with and become more like their aggressor. By the end of their coursework, the behaviors of horizontal violence that they initially experienced by other nurses, where now the same behaviors they exhibited to others. They identified the bullying behaviors as part of becoming a nurse (Randle, 2003a). Their attitude towards bullying behaviors changed during their course work, and they “seemed to be blind to the conflicts and anxieties they had first experienced, and not speaking about their anxieties become part of their repertoire” (Randle, 2003b, p. 397). One student stated, “You just have to fit in and get on with the work really.” Another student said, “I make myself do what basically everybody else does. I do what they do” (Randle, 2003b, p. 397).
One common theory regarding horizontal violence is that nurses, just as women, are an oppressed group and are acting out as such. An oppressed group is “people who share with others low status, absence of power, low autonomy, reduced mobility, limited access to resources, and other disadvantages” (Lee, 2001). As cited by Lee (2001), Paulo Freire (1968) described horizontal violence as a behavior that oppressed people exhibit. In order to deal with feelings of powerlessness, the oppressed group would displace negative emotions and aggressiveness onto each other instead of their oppressor, or dominant group. Oppressed groups exhibit behaviors of self-hatred such as lashing out at each other, remaining silent due to shame and embarrassment of their status, and attempting to act and/or befriend their oppressor. Over time, oppressed groups begin to believe and support their oppressor’s beliefs and behavior towards them. They help to fulfill their oppressor’s prophecies about them, and act and behave as their oppressor would expect. They internalize their oppression and believe that they are deficient and deserve this treatment. They develop self and group hatred, low self-esteem, powerlessness, low self-confidence and hopelessness (Lee, 2001). The culture of nursing has many of the attributes stated for oppressed groups, and is portrayed by not only the females, but their male counterparts (Bartholomew, 2006).
Currently, this community hospital is striving for Magnet Status. Two of the 14 forces of magnetism as identified by the American Nurse Credentialing Center (ANCC) that relate to the interaction and relationship between staff nurses and student nurses are numbers 11 and 13. Number 11 states, “Nurses as teachers: Nurses are permitted and expected to incorporate teaching in all aspects of their practice.” Number 13 states, “Interdisciplinary relationships: Interdisciplinary relationships are positive and show mutual respect across all disciplines.” (American Nurses Credentialing Center, n.d., p. 4) The Chairperson stated that the ANCC organization questions them regarding how the nursing staff at a particular clinical site behaves towards and regards the students and the faculty. ANCC takes this interaction into consideration when granting or renewing its Magnet designation.
Nurse-to-Nurse hostility affects the goals of the Nursing Program because it affects the student’s learning experience and learning abilities. The studies mentioned above have shown that nurses exposed to horizontal violence exhibit symptoms such as indecisiveness, poor concentration, self doubt, depression and the inability to handle stressful situations. The studies have also demonstrated that it can lower the self esteem of the student nurse. It also may contribute to the attrition rate seen in the first two semesters at this community college.
Professional nurses can empower themselves by joining nursing organizations, becoming involved in committees at work, changing their “put down” language, continuing their education, motivating other nurses, breaking the silence regarding horizontal violence, engaging in self-caring activities such as exercise and good nutrition, becoming politically involved, and engaging in reflective practice, such as journaling, to promote personal growth and emotional competence. Most important, nurses can empower themselves by acknowledging their participation in and then no longer engaging in horizontal violence (Hastie, 2002).
Many agree that the key to overcoming disempowerment within nursing is empowerment. Nursing students and novice nurses can be empowered by other nurses through positive or active mentoring. The role of the mentor is that of a supporter, an assessor, and a role model. Mentorship has shown to lead to empowerment and “is one of the most effective methods to promote excellence within the nursing professional…In light of the current volatile state of healthcare, mentoring can empower inexperienced nurses to experience more self-confidence in environments which oftentimes impede growth and development” (White, 2001, ¶ 9-10).
A seminar for staff nurses at the community hospital can be developed to help raise the awareness of the issue of Nurse-to-Nurse Hostility and prepare them to become positive mentors to student nurses, new graduate nurses, and nurses with less experience. Many hospitals today pair new nurses with an experienced nurse. The nurses work the same shifts and this is often referred to as preceptorship. Precepting is limited in its scope. It has defined learning goals and is expected to occur for an allotted period of time. Mentoring is quite different from precepting. It has no time limit and there are no set learning goals. Mentors are described as an “expert in their chosen area of practice, are well respected by all members of the treatment team for their knowledge, caring and compassion towards patients and their families, and have intense commitment to the discipline of nursing.” (Thomka, 2006, p. 53) Mentoring is complex and dynamic and their influence continues to affect and guide the mentee positively for a long time, perhaps the rest of their lives. Another positive outcome of mentorship is that the mentee will eventually become the mentor to a new nurse, hopefully leading to the end of the cycle of horizontal violence.
References
Agervold, M. & Mikkelsen, E.G (2004). Relationships between bullying, psychosocial work environment and individual stress reactions. Work & Stress, 18(4), 336-351.
American Nurses Credentialing Center. (n.d.). Introduction to the Magnet Recognition Program
for Students of Nursing. Silver Spring, MD: Author. Retrieved on August 8, 2006 from
http://www.nursingworld/.org/ancc/magnet/forms/studentmanual.pdf.
Bartholomew, K. (2006). Ending Nurse-to-Nurse Hostility: Why Nurses Eat Their Young and Each Other. Marblehead, MA: HCPro, Inc.
Conti-O’Hare, M. & O’Hare, J.L. (2002). Don’t Perpetuate Horizontal Violence [Electronic Version]. Nursing Spectrum. Retrieved from http://community/. Nursingspectrum.com/
Magazinearticles/article.cfm?AID=5708
Farrell, G.A (1999). Aggression in clinical settings: nurses’ views – a follow-up study. Journal of Advanced Nursing, 29(3), 532-541.
Hastie, C. (2002, August). Horizontal violence in the workplace. Birth International. Retrieved from http://www.birthinternational.com/articles/hastie02.html
Lee, M.B., & Saeed, I. (2001). Oppression and Horizontal Violence: The Case of Nurses in Pakistan. Nursing Forum, 36(1), 15-23.
Randle, J. (2003a). Changes in self-esteem during a 3-year pre-registration Diploma in Higher
Education (Nursing) programme. Journal of Clinical Nursing, 12, 142-143.
Randle, J. (2003b). Bulling in the nursing profession. Journal of Advanced Nursing, 43(4), 395-
401.
Taylor, B. & Barling, J. (2004). Identifying sources and effects of career fatigue and burnout for mental health nurses: a qualitative approach. International Journal of Mental Health Nursing, 13, 117-125.
Tehrani, N. (2004). Bullying: a source of chronic post traumatic stress? British Journal of Guidance & Counselling, 32(3), 357-366.
Thomka, L. (2006, February). Are we there yet? The long and winding journey of mentoring.
MODRN Nurse Magazine, 2(1), 49-55).
White, M.A. (2001). Is “Eating Our Young” contributing to the nursing shortage? [Electronic Version]. Nursing Spectrum. Retrieved from http://community/. Nursingspectrum.com/
Magazinearticles/article.cfm?AID=3364
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