Lateral violence, a nursing epidemic?

By Sara Germann and Shannon Moore | 03/14/2017

There are tools available to prevent it.

Two women talking
The American Nurses Association (ANA) defines lateral violence as acts that occur between colleagues (distinguished from acts perpetrated by those in a position of authority). It includes withholding information, scapegoating, and gossiping. Despite attempts by ANA and state nursing organizations to address this issue and encourage workplaces to adopt a zero tolerance policy, lateral violence continues.

Sara GermannOne reason cited in the literature for the continuance of lateral violence among staff members is middle management’s lack of awareness of its prevalence. Another reason is overall unawareness by staff members of available resources to address it. Because of these deficiencies, we have created a lateral-violence education “toolbox” containing online resources that nurses can implement in a wide variety of settings.

Lateral violence takes many forms. It can be overt or subtle, which makes it difficult at times to recognize and challenging to address. It is often assumed that in nursing, novice nurses are always the focus of lateral violence—that the direction of the violence is from more experienced nurses toward less experienced—but this is not what we have observed in more than 18 years of practice. (We have experienced it personally.) Lateral violence also occurs outside the hospital in the academic setting, which is disturbing since educators set the example for nursing students.

Shannon MooreNovice against seasoned
For example, in the emergency department of a community hospital, nurses with two decades of experience worked side by side with nurses in their first years of employment. The nurses with less experience formed a clique and began ganging up on the seasoned nurses, complaining to management that the seasoned nurses were slow and their practice outdated. Both assertions were unfounded. After their complaints were investigated and dismissed, the novice nurses commenced subtle acts of lateral violence. In addition to eye rolling and gossiping, they ridiculed the appearance and personal beliefs of other nurses. At one point, coverage of work breaks was suspended and patient care undermined.

Seasoned against novice
As mentioned above, lateral violence also occurs in the other direction. For decades, there have been complaints that nurses “eat their young” and commit violence against novice nurses. An example of this occurred on the medical-surgical unit of a large urban hospital. Cindy, a novice nurse, was assigned four patients, a typical load for that unit. Because of her patients’ medical conditions, associated treatments, and inability to perform daily living activities, Cindy’s patients were considered high-acuity. Mary, an experienced nurse assigned to the same area of the unit, thought Cindy needed to be taught a lesson about the difficulties of nursing because she came from a well-known family with a history of making endowments to the hospital. To teach Cindy, Mary refused to respond to any of her requests for help, telling her instead that she would have “to get her hands dirty” and figure out how to manage on her own. Mary also convinced other nurses to do the same. Because of lack of assistance from Mary and the other nurses, Cindy stayed on duty for hours past her scheduled shift and received poor performance reviews. She eventually left the nursing profession.

Academic-preparation related
At times, differences in academic preparation instigate lateral violence. In response to a report by the Institute of Medicine, the American Association of Colleges of Nursing (AACN) developed a white paper advocating baccalaureate-level education for nurses. After the paper was distributed, divisions occurred between those with associate degrees and those with bachelor’s degrees.

Katie, who had an Associate Degree in Nursing, experienced the negative effect of this division when she began working in an intensive care setting. She had six years of nursing experience and had received awards for nursing excellence during her time at a community hospital, so she felt ready for a new challenge and accepted a position at a large academic hospital center. Katie began her orientation on a unit with Susan, a bachelor’s-prepared nurse with two years of experience.

Susan repeatedly made comments to Katie about her academic preparation, lack of a “real” education, and previous work experience that she said wasn’t “real” nursing. When Katie asked questions about unit policy, Susan would roll her eyes and comment that if Katie had a degree from a “better” school, she would know where to look for that information. Despite the excellent care she provided patients and her positive performance evaluations, Katie always felt looked down on because of her associate-degree preparation. She left the unit after one year to complete her bachelor’s degree and then a master’s degree.

In academic settings
Finally, lateral violence also occurs in academic settings. Judy and Sally taught different sections of the same nursing course. Sally preferred the “flipped classroom” approach. Her students also preferred it and commented positively on the technique in their course evaluations. Judy used the traditional approach, and when students commented in their course evaluations that they preferred the flipped-classroom method, her course evaluations were negatively impacted.

When the course started again the following year, Judy barred Sally from using the flipped method, stating that it impacted her negatively and would prevent her from achieving tenure. Although Sally offered to teach both sections using the flipped-classroom approach, Judy declined and threatened to involve the supervisor, a personal friend of hers. The intimidation discouraged Sally from pursuing it further, and she subsequently left the institution.

An epidemic?
Lateral violence is so prevalent in the nursing profession that it may be appropriate to call it an epidemic. It can jeopardize patient care and substantially contribute to loss of bedside nurses and nurses working in other roles. We must address this issue as if it were an infectious disease because it has infiltrated our profession at every level and threatens the health of our colleagues.

Given the variety of expression that lateral violence exhibits, nurses must have appropriate resources to prevent and address this behavior. To combat lateral violence, nursing organizations have begun to create toolboxes containing resources to implement at the unit level. As mentioned above, we have created a toolbox with resources that we feel are universally appropriate for the profession. These resources provide nurses in hospitals and academic settings with the tools they need to become informed on lateral violence and how to reduce it.

*Names have been changed.

 Editor’s note: Sara Germann and Shannon Moore will be presenting a poster at the Creating Healthy Work Environments conference, slated for 17-19 March 2017 at the JW Marriott in Indianapolis, Indiana, USA. The theme of the conference is “Building a Healthy Workplace: Best Practices in Clinical and Academic Settings,” and the poster presentation by Germann and Moore is titled “A toolbox to diminish lateral violence in the workplace.”

Sara Germann, MSN, RN, ANP, is assistant professor, School of Nursing, University of Indianapolis, Indianapolis, Indiana, USA, is working toward her DNP at Purdue University. Shannon Moore, MSN, RN, is assistant professor, School of Nursing, also at the University of Indianapolis. 

 

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