Horizontal Violence and Nursing Staff Turnover
As part of my continuing study of the issue of nursing staff turnover, I recently read a new article describing “horizontal violence” and its impact on intentions to leave. The authors define horizontal violence thusly.
“…inter-group conflict that is manifested in overt and covert non-physical hostility such as sabotaging, infighting, scapegoating, and bickering.”
The authors studied a random sample of 300 staff nurses selected from a pool of 1,500 nurses employed full or part-time for at least a year at a single U. S. medical facility. They mailed a validated questionnaire of twenty questions asking if they had experienced or observed various behaviors on the job. The receive 104 useable responses (36%), the overwhelming majority from Caucasian (93%) women, (96%). 67% had a bachelor’s degree, and 89% were full time nurses, they had a mean age of 40 and had worked at the hospital for a man of 14 years. The nurses reported a mean of 8.1 violent behaviors with seven items being reported by more than half the respondents. “Feeling responsible for a co-worker’s duties,” (81%); “reprimanded or confronted in presence of others” (69%); “reneged on a commitment to you,” (63%); “untrue information about you passed on or exchanged” (60%); and “failure to acknowledge you or confronted in front of others,” (60%). They found nurses who reported higher numbers of observed violent behaviors were more likely to planning to leave, particularly among the younger nurses. The authors conclude:
“An evolving paradigm shift to intentional intolerance for horizontal violence on the part of new/younger nurses entering the nursing practice world will challenge administrators to develop and implement standards for protection.”
While laudable, it is difficult to see how administrative regulations are likely to influence this sort of inter-personal behavior. I am reminded of the time one of my nursing leaders told me “Nurses will eat their young.” Of course this sort of violent behavior was once institutionalized. When I was a young doctor there were well known examples of instrument throwing surgeons and attending physicians who specialized in belittling and berating those around them. All of this was justified in the name of teaching, which I am not sure I really believed. With age and experience, I have come to the conclusion these were often men, and they were almost always men, who felt they had to be perfect and knew they weren’t, and tried to deal with that discomfort by lashing out. It was, I think, behavior based on a fundamentally weak ego structure. In more recent times I know of a very gifted physician who was raised in that older era who could not adapt with the times and ended up being terminated despite his manifest talents.
I think the young folks have it right—we should not be creating hostile, negative environments. The work we expect physicians and nurses to do has plenty of negative aspects including fear, death, disease, dismemberment, and disability, to name a few. To deal with these things effectively requires the caregiver to be operating from a base of reasonable calm and well-being. Osler famously claimed that equanimity was a physician’s greatest asset, and I suspect he was and still is right. On the other hand, I am not sure this is a management task—I think it is a leadership task.
Is it possible that making progress on this issue is one of those places where clinical leadership by physicians is crucial for organizational effectiveness? Certainly there is a place for clinical nursing leadership. The Chief Nursing Officer at Vanderbilt University was recently quoted as saying one of her top priorities was:
“Leadership development is one. I can’t overstate how important it is to invest in nursing leadership to meet the many challenges we face in the delivery of value-based care. We also have to look for new ways to extend the skills and experience of nurses into leadership positions.”
In the same issue, McConville reported the experience at Moses Cone Hospital in North Carolina.
“Leadership is critical for promoting engagement among physicians and employees. Highly visible leaders who are enthusiastic champions for drawing on the skills and knowledge of health care professionals are essential antecedents to engaging physicians and employees. Leaders who involve physicians and nurses in organizational decision-making and in key improvement initiatives understand that doing so promotes a culture of teamwork and heightens these professionals’ perception of their value to the organization—both of which are critical for obtaining the necessary buy-in and support for sustainable improvement efforts.”
Does senior management think of their clinical staff by name or does it think of them as “full-time equivalents.” Maybe words reflect fundamental values. Maybe the notion of “FTE” directly contributes to a culture of horizontal violence. Something to think about.
14 November 2015
 Armmer F, Ball C. Perceptions of Horizontal Violence in Staff Nurses and Intent to Leave. Work 2015;51:91-97. doi: 10.3233/WOR-152015.
 “Embracing the New Normal.” Partners, a Press Ganey Publication, #35, August/September 2015, p. 11.
 McConville E. Leading the Way to a Culture of Engagement. Partners, a Press Ganey Publication, #35, August/September 2015, p. 20.
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