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Horizontal Violence Amongst Nurses

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York University

on 15 March 2013

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Transcript of Horizontal Violence Amongst Nurses

Nurses What is Horizontal Violence? Jessica Skinner
Gavin Russell
Kristen MacDonald
Colleen Macdougall-Howe
Nicole Lorenz
Jacetine Bayno
Jessica Elliott
Kajal Patel After this presentation students will be able to:

1. Describe multiple forms/levels of horizontal violence that exist amongst nurses.

2. Explain why horizontal violence amongst nurses is a problem.

3. List the change theories/strategies that would be most effective in creating lasting change for this issue.

4. Identify organizational changes that must occur in order to maintain change.

5. Differentiate between how the "unfreezing", "moving", and "refreezing" stages look in relation to changing this issue.

6. List the qualities of a transformational leader.

7. Discuss recommendations (in terms of communication and conflict resolution) that would be useful in reducing horizontal violence amongst nurses These days are the most trying of my life
I did this to help, to comfort, to heal
But those who surround me dumbfound me
They want me to fail at it all
I’m new to this crew and an outcast
They have years, I merely have months
They talk to me as one would to a child
And some days a dog

Every word, every action of mine is met with scrutiny
They question if I have any education
Or if I’ve ever had a job
And I know that no explanation will be correct
I hear whispers behind my back
And wagers on how long I will last
If this continues, it will not be long

I want to stand up and I want to fight
But I need help, and I need it from them
“Ask and ye shall receive”
Cold stares, and shrugging shoulders
I lie awake at night, my focus is out
And in to myself I withdraw
Working friendships and hazing
Or dignity and socio-professional suicide

I am the new and the novice
You were me at one time
Why do you do this to your former self?
Do you not remember?
I look to you for guidance
And all you offer is ridicule
Can I work like this forever? Do I want to?
Will I become you?

Eat your young to ensure they never grow
And do so in darkness so that no one will know Effects of Horizontal Violence Physical Effects Psychological Effects Social Effects How Do You Create Change? Normative-Reeducative Approach Kurt Lewin's Change Theory Horizontal violence is defined as: "'hostile, aggressive, and harmful behaviour by a nurse or group of nurses towards a co-worker or group of nurses via attitudes, actions, words, and/or behaviours'"

(Thobaben as cited in Becher & Visovsky, 2012) Horizontal violence is an inter-group conflict with overt and covert elements of hostility.

Overt: obvious for others to see (usually physical or psychological)

Covert: hidden from others, especially authority figures Bullying Behaviours can be: Criticizing
Refusal to assist/support
Undermining behaviours
Threatening/Intimidating/Offensive body language or comments
Assigning unreasonable tasks/assignments Studies show: Why is Horizontal Violence so Prevalent in Nursing? Why is Horizontal Violence an Issue? weight loss
fatigue/ exhaustion
hypertension ( McKenna, Smith, Poole, & Coverdale, 2003) fear
symptoms of depression
sleep interruption/disorder
post-traumatic stress disorder
suicidal behaviours (McKenna et al., 2003; Becher & Visovsky, 2012) lack of confidence/self-esteem
lack of control
lack of support
avoidance of professional relationships
lowered work performance ( Broome, 2008; Becher & Visovsky, 2012) Podcast: http://podcast.cbc.ca/mp3/podcasts/whitecoat_20110917_46304.mp3 Recommendations 30% dealt with aggression from co-workers daily
34% reported co-workers/preceptors had been rude, verbally abusive, humiliating, and unjustly critical
87% were expected to do the work of others
73% were not acknowledged for the work they had completed
51% 'frequently' or 'almost always' felt conflict with their preceptor
40% of new nurses change/leave their position within the first three years of practice due to unfriendly work environment

* Often unrecognized and under-reported
* Over half of the events of horizontal violence are not reported (Becher & Visovsky, 2012; Leiper, 2005; King-Jones, 2011; MacKusick & Minick, 2010) Bullying behaviour is seen as the 'norm'
Indifference and lack of support foster a culture of hostility
Contributes to increased stress levels, decreased job satisfaction, and high turnover rates
A qualitative study done by Farrell (1997) showed that all "respondents reported that interstaff aggression was more upsetting and problematic to deal with than aggression from patients or other disciplines"
New graduate nurses who experience horizontal violence report higher levels of absenteeism
Cost of horizontal violence is approximately $30,000 - $100,000/year for each individual (costs are incurred from absenteeism, treatment for depression and anxiety, decreased performance and increased job turnover)
Lack of morale and positive attitudes lead to a loss of trust and a decrease in communication which has a negative impact on patient care Increased patient acuity, poor staffing, and reduced resources lead to an increase in stress and conflict

Nurses struggle with oppression in the healthcare environment and begin to internalize negative stereotypes and displace these negative emotions/feelings onto peers (Becher & Visovsky, 2012; King-Jones, 2011) (Fudge, 2006; Becher & Visovsky, 2012; King-Jones, 2011; MacKusick & Minick, 2010) This strategy is a long-term plan focused on improved communication and collaboration to resolve conflicts more effectively and create a positive, supportive work environment that is conducive to abuse-free work and healthy interpersonal relationships. (Sullivan, 2013) Transformational Leaders Trustworthy leaders who support and empower staff, take a stand on issues and focus on merging the values, beliefs, and goals of the staff in order to move towards a positive environment. Qualities of a Transformational Leader: Inspire
Motivate Environmental Change By changing the attitudes, beliefs, and culture of the staff through integrated transformational leadership, education/training, and implementation/enforcement of a zero-tolerance bullying policy you can begin to change the environment as a whole. (Sullivan, 2013) Lewin proposed that: In order for change to be maintained there must be a change to the environment as a whole
Individual behaviour is influenced by the group environment or 'field'
To change the group environment there must be changes in the behavioural norms and social processes (Burnes, 2004) STAGE 1: 'Unfreezing' STAGE 2: 'Moving' STAGE 3: 'Refreezing' Reassure staff and students that they are in a safe environment to voice feelings and/or concerns
Nurse managers, nursing mentors, clinical mentors, and peer leaders must ensure that zero-tolerance bullying policies are being enforced
Fear of consequences induces survival anxiety in those who exhibited bullying behaviours Bullies must be fearful of the consequences of negative, harmful behaviour. The bullied individuals must feel safe from potential retaliation It is imperative to create motivation in all to move in the direction of positive change. It is important for nurse leaders to determine all factors contributing to conflict within/between staff and students.

Small group discussions/focus groups
Anonymous workplace satisfaction surveys
Open door policies
Human resources
Changes to clinical workplace and curriculum development "Stabilize the group at a new quasi-stationary equilibrium in order to ensure that the new behaviours are relatively safe from regression." (Burnes, 2004, p. 986) Ensure organizational policies and procedures are outlined, upheld, and enforced
Formal education (define horizontal violence, outline direct approaches to modifying behaviours, review of consequences)
Informal education (posters and fliers)
Continuously assess to see if the current solutions are effective and/or continue to be effective

As new/different conflicts and issues arise the cycle must begin again. (Burnes, 2004; Sullivan, 2013) Case Study Questions? Stacey is a new grad nurse who was recently employed on a surgical unit. Stacey has been there for about three months now. In this time frame, a couple of the staff members have decided to pick on Stacey by often using statements such as “I can’t believe you don’t know that! Didn’t you go to school?” and “You are so stupid!” These two senior nurses have also been subtle about humiliating Stacey and hiding equipment so Stacey falls behind in her work. Stacey does not know how to handle this situation anymore and is feeling overwhelmed and stressed. She is having difficulties sleeping and dreads going to work, which leads her to taking more sick days. At this point Stacey does not feel that she is able to go talk to her nurse manager for fear that the horizontal violence would only get worse. If you were Stacey in this situation how would you deal with the two senior nurses? What are some techniques that you could use to successfully with this situation? Has anyone ever had a situation like this? If so, how did you deal with it? When you are confronted with intimidation or a power play such as from a senior nurse, intimidation can be neutralized by the person increasing self confidence and their own self of power. This can be generated by using the other person’s name frequently, avoid statements such as “I’m sorry, but..”, and do not do fillers such as ‘ah’, or ‘um’. Again the person should speak clearly and forcefully, listen for what is not being said, stand when you talk, and maintain eye contact when you are talking to another person (Sullivan 2013). Nurses should exhibit empowering, mentoring, and nurturing behaviours in all aspects of the workplace; patient care and working with co-workers and students. (King-Jones, 2011) Nurse leaders must hold themselves and their peers accountable for demonstrating positive, professional behaviour in the workplace. (Becher & Visovsky, 2012) Preceptors should receive formal training/education the detrimental effects of horizontal violence in the workplace and conflict resolution techniques so that they can model positive professional behaviour while mentoring, guiding, and supporting students. (Becher & Visovsky, 2012) Documentation, such as journaling, can help to maintain a timeline of the occurrences of horizontal violence and provide an emotional/psychological outlet. Documentation should include a list of witnesses, times, dates, as well as any texts, notes, or e-mails from the aggressor. (Becher & Visovsky, 2012) If nurse managers are the perpetrators of horizontal violence staff in the human resources department can serve as a useful resource for staff. (Becher & Visovsky, 2012) Nurses must:
Acknowledge the existence of horizontal violence in the workplace
Confront horizontal violence
Take appropriate actions to mitigate/stop it ( Becher & Visovsky, 2012) Zero tolerance bullying policies in all healthcare workplaces. (Broome, 2008; Becher & Visovsky, 2012) 'First year of practice' orientation programs to support new graduates. (McKenna et al., 2003) Consult with a lawyer about legal action to be taken in severe instances of horizontal violence. There are laws in place to ensure that staff can report incidents without losing their job or suffering other consequences.

The National Labor Relations Act and Occupational Safety and Health Administration (OSHA) have regulations demanding that organizations fulfill their responsibility to ensure a safe and secure work environment. (Leiper, 2005) Mandatory staff training programs on how to effectively use:

Change processes
Conflict management
Decision-making skills
Stress management techniques (Fudge, 2006) Becher, J., & Visovsky, C. (2012). Horizontal violence in nursing. MedSurg Nursing, 21(4), 210-232.

Broome, B.A. (2008). Dealing with sharks and bullies in the workplace. The ABNF Journal.

Burnes, B. (2004). Kurt Lewin and the planned approach to change: A reappraisal. Journal of Management Studies, 41(6) 977-1002

Fudge, L. (2006). Why, when we are deemed to be carers, are we so mean to our colleagues? Horizontal and vertical violence in the workplace. Canadian Operating Room Nursing Journal, 13-16.

Jackson, D. et al. (2010). Trial and retribution: A qualitative study of whistleblowing and workplace relationships in nursing. Contemporary Nursing, 36(1-2), 34-44.

King-Jones, M. (2011). Horizontal violence and the socialization of new nurses. Creative Nursing, 17(2), 80-86.

Leiper, J. (2005). Nurse against nurse: How to stop horizontal violence. Nursing2005, 35(3), 44-45.

MacKusick, C.I., & Minick, P. (2010). Why are nurses leaving? Findings from an initial qualitative study on nursing attrition. MedSurg Nursing, 19(6), 335-340.

McKenna, B.G., Smith, N.A., Poole, S.J., & Coverdale, J.H. (2003). Horizontal violence: Experiences of registered nurses in their first year of practice. Journal of Advanced Nursing, 42(1), 90-96.

Sullivan, E. (2013). Development of self as nurse: Nurse as leader and agent of change. Boston, MA: Pearson Learning Solutions. References: (Broome, 2008; Fudge, 2006) (Fudge, 2006; Leiper, 2005) (Burnes, 2004; Becher & Visovsky, 2012) (Burnes, 2004; King-Jones, 2011) (Sullivan, 2013)
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