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Transition to Practice 2 – Group Assessment

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10 point plan to end violence and aggression

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10 point plan to end violence and aggression

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Article on Nurses' Workplace Bullying Experiences, Responses, and Ways of Coping

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Article on Nurses' Workplace Bullying Experiences, Responses, and Ways of Coping

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Abstract

Workplace bullying is a serious problem that hinders the provision of quality care services by seriously affecting their physical, psychological, and social health status. Workplace bullying experiences refer to verbal and nonverbal harassment, work-related harassment, and external threats. Workplace bullying responses are negative reactions that occur in individuals who have experienced workplace bullying, while coping is the process by which an individual copes with stress. This study aims to analyze the relationship between nurses' workplace bullying experiences, responses, and ways of coping. We studied 113 nurses working in hospitals, analyzed the data using SPSS 25.0. We found that the more positive use of the positive viewpoint, the lower the bullying reaction in the workplace (r = −0.268, p = 0.004). Workplace bullying responses were lower as more positive ways of coping were used (r = −0. 268, p = 0.004). In conclusion, nurses who experience bullying in the workplace should be supported by the hospital organization and within the nursing organization, and a receptive nursing culture should be established. There is also a need for an intervention plan that allows nurses to use positive ways of coping with workplace bullying experiences.

Keywords: workplace bullying experiences, workplace bullying response, ways of coping, bullying, nurse

1. Introduction

Among other types of violence at the workplace, bullying is an act of individuals or groups harming a certain individual by constantly trying to exclude him/her from a social context [ 1]. In Korea, in the 2000s, harassment of nurses in the workplace became an issue, and related research began in earnest. The social demand for prevention of bullying in the workplace, including the culture of "Taewoom," a word symbolizing bullying in the Korean nursing community, has increased. Therefore, from July 16th, 2019, the "Workplace Bullying Prohibition Act" was enforced, which prohibits employers or workers from using their position or relationship advantage at work to cause physical or mental pain to other workers [ 2]. Currently, Korean society is reforming the wrong nursing culture within nursing organizations through the enforcement of this law.

Workplace bullying experiences among nurses is defined as a negative act in a working situation characterized by a power imbalance, which can exert serious effects on the organization, as well as on individual nurses [ 3]. In hospitals, there are many types of bullying offenders, including patients, caregivers, doctors, and nurses. Of these, bullying most frequently occurs among nurses and is particularly committed by a colleague rather than by a manager [ 4].

Nursing, which is related to human life, is unpredictable, intensive work, and involves sundry emergencies. For this reason, nurses may work in a stressful situation and may be more likely to be bullied [ 5]. Nurses bullied at a workplace try to accept it instead of demanding the situation improve [ 6]. Since offenders are principally those in higher positions, such as senior nurses or managers, nurses in lower positions in the Korean society, based on the Confucian idea, tend to cope with the situation by bearing or evading it [ 7]. They cope with the situation passively by enduring and neglecting it and by regarding the attempt to face negative acts during work hours as a "part of nursing" [ 8].

Nurses bullied at the workplace may complain of mental symptoms, such as depression, anxiety, and fear, as well as physical symptoms, such as fatigue, headaches, and palpitations [ 9]. They are also more susceptible to burnout and turnover intention and have lower levels of organizational commitment and nursing productivity. This demonstrates that workplace bullying experiences can actually affect nurses' job attitudes and organizational performance [ 8]. These negative personal and organizational effects of workplace bullying experiences on nurses can result in socio-economic loss.

Individuals faced with a crisis like bullying attempt to find a solution to the problem, and such an attempt is called coping [ 10]. A literature review regarding nurses' experience of being bullied at the workplace shows that nurses bullied at the workplace can face the reality of being bullied and grow as nurses through several trials and errors, as well as through the formation of relationships with their colleagues; however, if they fail to get over the shock of being bullied, to make an unsuccessful effort to solve the problem, or unsuccessfully bear the frustrating result, they may give up their job altogether [ 5].

Problem-focused coping is the most desirable and effective coping ability. It involves thoughts and actions that accurately analyze the cause of a problem in a stressful situation and plan to actively solve it [ 11]. Based on this, the established hypothesis for this study was that there is a negative correlation between problem-focused coping, workplace bullying experiences, and workplace bullying response. Hypothesis verification can provide information on how to deal with nurses who should be first trained to solve problems related to bullying in the workplace. Moreover, to solve the workplace bullying experiences, the individual's specific ways of coping may control bullying responses and contribute to individual nurses' growth. It is necessary to analyze workplace bullying experiences, responses, and ways of coping.

However, little research has been conducted on the association between the ways of coping with bullying and bullying responses in nursing practice. This study aimed to examine nurses' experiences of workplace bullying, responses, and ways of coping; analyze the association among these factors; and provide basic data that could help control the negative effects of workplace bullying experiences and develop effective coping strategies.

The purpose of this study was to examine nurses' workplace bullying experiences, workplace bullying responses, and ways of coping; analyze the correlation among these factors; provide basic data necessary to reduce the negative effects of workplace bullying experiences; and develop strategies to improve the quality of nursing. Its specific objectives were as follows:

To examine the participants' workplace bullying experiences, workplace bullying responses, and ways of coping;

To determine ways of coping based on the participants' general characteristics;

To determine the correlation among the participants' workplace bullying experiences, workplace bullying responses, and ways of coping.

2. Materials and Methods

2.1. Research Design

This study involved descriptive research aimed at examining nurses' workplace bullying experiences, workplace bullying responses, and ways of coping and at determining correlation among these factors.

2.2. Research Participants

This study targeted nurses with more than six months of clinical experience working at university hospitals in D city and C province. According to the definition [ 12] of workplace bullying experiences as repetitive bullying that lasts for more than six months, nurses that had been employed for less than six months were excluded. The number of subjects for the correlation analysis between workplace bullying experiences, workplace bullying response, and response methods of nurses was based on previous studies [ 13]. When the significance level of 0.05, the effect size of 0.02, and power of 0.8 predictor was 11, the minimum sample size using the GPower sample size estimator v.3.1.9.2. program (Universität Kiel, Kiel, Germany) was 95. The questionnaire was distributed to a total of 120 people in consideration of the 20% dropout rate, but (due to the lack of content in the responses), seven inappropriate questionnaires were excluded. A total of 113 questionnaires were used for data analysis.

2.3. Research Instrument

2.4. Data Collection

The data collection period for this study was from August 1st to September 30th, 2019. For data collection, the chief of the nursing department in the institution was given an explanation of the purpose of the study and was asked to permit data collection.

We visited each ward of the three university hospitals that allowed the survey, and explained to the nurses the purpose and method of the study. We guaranteed anonymity and autonomy for participation in the study, advised of the possible benefits and disadvantages, and the possibility of abandoning the survey. Subjects who wished to participate in the survey were asked to sign a research consent form to collect data, and a questionnaire was distributed to nurses who signed the consent to participate in the study. The questionnaire was provided in individual opaque envelopes with double-sided tape attached.

Immediately after the subject responded to the questionnaire, the questionnaire was placed in an opaque individual envelope, sealed with double-sided tape, and collected by the researcher. Immediately after the researcher personally collects the questionnaire, a predetermined gift was provided as a token of gratitude to the subjects who completed the survey.

2.5. Ethical Considerations

This study was approved by the institutional review board (EU19-55) of Eulji University. The questionnaire was distributed only to the subjects who agreed to participate in the study. The collected questionnaires were kept safely in the place where the locker was located. Participants were informed that the collected surveys would be kept for three years, after which they would be destroyed using a document shredder.

2.6. Data Analysis

The collected data were analyzed using the SPSS 25.0 program (IBM, Armonk, NY, USA). The general characteristics of the subject were gender, marital status, education, type of duty, age (years), religion, working unit, and the total length of career (years). Data were analyzed by frequency and percentage according to each general characteristic.

Descriptive statistical methods of frequency, mean, and standard deviation were used to determine the subject's workplace bullying experiences, response, and way of coping. The response method, according to the general characteristics of the subjects, was analyzed by t-test and ANOVA.

Finally, The correlation among the participants' workplace bullying experiences and sub-factors (verbal attacks and alienation, improper work instructions, physical threats), workplace bullying response and sub-factors (physical and psychological withdrawal, poor quality of patient care, increasing distrust), and the six ways of coping (problem-focused, wishful thinking, detachment, seeking social support, focusing on the positive, tension reduction) was analyzed. The correlation between variables was analyzed using Pearson's correlation coefficient.

3. Results

3.1. Participants' General Characteristics

Of the 113 participants, 106 (93.8%) were female, and 7 (6.2%) were male. Ninety-two (81.4%) were unmarried, and 21 (18.6%) were married. Fifty-one (45.1%) were three-year nursing school graduates, 57 (50.4%) were four-year nursing school graduates, and 5 (4.4%) were graduate school graduates or at higher education levels.

One hundred and six (93.8%) were on shift work, and 7 (6.2%) were on full-time work. Eighty-one (71.7%) were in their twenties, 29 (25.7%) in their thirties, and 3 (2.7%) in their forties or older. Forty (35.4%) had a religion, and 73 (64.6%) had no religion.

Forty-five (39.8%) worked in the medicine ward, 21 (18.6%) in the surgery ward, 38 (33.6%) in special departments (e.g., intensive care units, operation rooms, and emergency rooms), and 30 (8.0%) in other departments (e.g., newborn unit, nursing department, artificial kidney unit, and physician assistant). Fifteen (13.3%) had nursing careers lasting less than 1 year, 54 (47.8%) had careers lasting 1 to <5 years, 31 (27.4%) had careers lasting 5 to <10 years, and 13 (11.5%) had careers lasting at least 10 years ().

3.2. Participants' Workplace Bullying Experiences, Responses, and Ways of Coping

Participants scored an average of 29.39 (±7.33) out of 64 for workplace bullying experiences. As for its sub-factors, they scored an average of 18.58 (±5.08) out of 40 for verbal abuse and alienation, an average of 8.17 (±2.32) out of 16 for inappropriate task assignment, and an average of 2.64 (±0.92) out of 8 for physical threat. They scored an average of 30.98 (±6.09) out of 52 for workplace bullying responses.

As for sub-factors, they scored an average of 19.75 (±4.10) out of 32 for physical and psychological withdrawals, an average of 4.57 (±1.26) out of 8 for lower quality of nursing, and an average of 6.66 (±1.99) out of 12 for increased distrust. As for their ways of coping, they scored an average of 22.19 (±2.51) out of 32, 12.6 (±1.76) out of 20 for wishful thinking, 13.99 (±2.14) out of 24 for detachment, 18.21 (±2.28) out of 28 for seeking social support, 10.59 (±1.74) out of 16 for focusing on the positive, and 7.42 (±1.57) out of 12 for tension reduction ().

3.3. Participants' Workplace Bullying Experiences, Responses, and Ways of Coping by Their General Characteristics

As for variation in the participants' ways of coping based on their general characteristics, wishful thinking showed statistically significant variation by gender (t= −2.31, p = 0.023) and religious status (t= −2.63, p = 0.010); that is, females scored higher for their way of coping based on wishful thinking than males. Religious participants scored higher for their way of coping based on wishful thinking compared to the non-religious.

Among the sub-areas of ways of coping, tension reduction showed statistically significant variation by marital status (t= −2.99, p = 0.003) and working type (t= −2.26, p = 0.026); that is, the unmarried scored higher for their way of coping based on tension reduction than the married; whereas, the participants on shift work scored higher for their way of coping based on tension reduction than those on full-time work ().

3.4. Correlation among Workplace Bullying Experiences, Responses, and Ways of Coping

Workplace bullying experiences were significantly positively correlated with workplace bullying responses (r = 0.52, p < 0.001) and was positively correlated with physical and psychological withdrawal (r = 0.29, p = 0.002), lower quality of nursing (r = 0.60, p < 0.001), and increased distrust (r = 0.59, p < 0.001) among its sub-factors.

Workplace bullying experiences were significantly negatively correlated with problem-focused ways of coping (r = −0.23, p = 0.013) and ways of coping from a focusing on the positive (r = −0.23, p = 0.016).

Workplace bullying response was significantly negatively correlated with the way of coping from a focusing on the positive (r = −0.27, p = 0.004), which was significantly negatively correlated with physical and psychological withdrawal (r = −0.20, p = 0.031), lower quality of nursing (r = −0.25, p = 0.008), and increased distrust (r = −0.24, p = 0.009) among its sub-factors.

Of the sub-factors for workplace bullying response, lower quality of nursing was significantly negatively correlated with problem-focused ways of coping (r = −0.187, p = 0.047), and increased distrust was significantly positively correlated with detachment (r = −0.234, p = 0.013) ().

4. Discussion

This study aimed to examine nurses' workplace bullying experiences, responses, and ways of coping and to determine the association among these factors. The nurse practitioners in this study complained of helplessness, depression, stress, insomnia, and physical discomfort after being bullied at the workplace. This result is consistent with the finding of a literature review that nurses exposed to horizontal violence may experience such psychological problems as distress, anger, fear, and anxiety, as well as some physical symptoms, such as headaches, sleep disorder, and indigestion [ 16]. In addition, in this study, it was found that nurses who experienced bullying in the workplace made a lot of mistakes in their work and had a desire to change jobs, similar to the results of previous studies [ 17]. This result demonstrates that the experience of being bullied at a workplace can have physically and mentally negative effects on individual nurses, lower the quality of the nursing service, and increase turnover intention. Therefore, hospital organizations need to give support to nurses with the aim of identifying individual nurses' negative responses to the experience of being bullied at the workplace and coping with them. Nursing organizations need to establish a receptive nursing culture that permits nurses to reveal their experiences of being bullied at the workplace or resultant negative responses or distress and to create a site for communication among them.

Workplace bullying responses were negatively correlated with ways of coping from focusing on the positive; that is, the more likely nurses were to apply ways of coping from focusing on the positive, the less likely they were to show workplace bullying responses. Nurses who tried to see the positive side of an event and regarded the present issue as a driving force of growth were less likely to show negative responses to workplace bullying. This result is supported by the finding of a literature review that nurses experiencing the last phase of relief during the process of coping with workplace bullying accepted their seniors' bullying as a kind of training for their own growth [ 18].

It is necessary to improve the systematic organizational culture and environment with the objective of solving the fundamental problems of workplace bullying [ 18, 19]. However, since this takes a long time to change, and problem-solving needs to focus on the position of the bullied, priority should be given to the development of a plan to maintain well-being for individuals. On the basis of the finding of a literature review that education for positive coping with a problem situation could reduce the negative effects of being bullied [ 20], it is necessary to develop an intervention for nurses to apply ways of coping with workplace bullying from a positive perspective.

Among the sub-areas of workplace bullying responses, lower quality of nursing was negatively correlated with problem-based ways of coping; that is, nurses making a plan to analyze and settle a problem situation were less likely to make a mistake related to work or were less willing to resign, due to the offender after being bullied at the workplace. This result implies that while they regarded themselves as victims of bullying, they controlled the negative responses to bullying through their own strong belief and efforts to solve the problem, instead of avoiding the situation they faced. Many researchers have been worried about nurses' strong turnover intention due to workplace bullying [ 8, 21, 22]. On the basis of these results, therefore, it is necessary to add education and training related to problem-based ways of coping with the plan for intervention to reduce turnover intention caused by workplace bullying.

Among the sub-areas of workplace bullying responses, increased distrust was positively correlated with detachment-based ways of coping; that is, nurses trying to endure in overcoming a problem situation, believing that time will solve, can have a negative idea of nursing, as well as a loss of belief in the hospital or the manager after being bullied at the workplace. Many nurses have tried to forget the problem caused by the experience of being bullied at the workplace and avoided it [ 8]. The failure to cope well with bullying responses can form distrust in the organization and a negative idea of nurses, which is deeply associated with the turnover intention [ 9, 13]. Even those nurses forming a negative image of the hospital and nurses after being bullied at the workplace need to work; thus, they seem to try to neglect the present problem, and the repetition of this situation can cause them to stop their work. Therefore, managers in each unit of the hospital need to identify cases of bullying through an in-depth and steady interview with nurses and help them cope well with their situation.

5. Conclusions

This study involved descriptive research aimed at examining nurse practitioners' workplace bullying experiences, responses, and ways of coping; analyzing the association among these factors; and providing the basic data necessary to develop a strategy for reducing negative results from workplace bullying experiences and improving the quality of nursing. Nurses applying ways of coping from a positive perspective were less likely to show workplace bullying responses. Those applying problem-based ways of coping were less likely to make a mistake related to work or were less willing to resign. Those applying neglect-based ways of coping were more likely to have distrust in the organization and a negative idea of nurses after being bullied at the workplace. It is, therefore, necessary to create an intervention program for nurses to cope with workplace bullying experiences from a positive perspective and give education and training to them so that they can analyze and settle the problem situation. Nurses in each unit of the hospital need to identify the cases of bullying and help victims cope well with the situation through in-depth interviews.

Based on these results, it can be seen that the consideration of individual coping methods should be included when planning an interventional program for preventing bullying in the workplace or organizational policy for nurses. In addition, a more in-depth, repeated study is suggested on the relationship between workplace bullying experiences and workplace bullying responses according to individual countermeasures to workplace bullying.

Author Contributions

Conceptualization, S.Y.Y. and H.Y.A.; methodology, H.Y.A.; software, S.Y.Y.; formal analysis, S.Y.Y.; investigation, S.Y.Y.; data curation, S.Y.Y. and H.Y.A.; writing-original draft preparation, S.Y.Y.; writing-review and editing, H.Y.A.; supervision, H.Y.A.; All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Conflicts of Interest

The authors declare no conflict of interest.

References

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Nurses' Workplace Bullying Experiences, Responses, and Ways of Coping

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Workplace bullying is a serious problem that hinders the provision of quality care services by seriously affecting their physical, psychological, and social health status. Workplace bullying experiences refer to verbal and nonverbal harassment, work-related harassment, and external threats.

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-Kahoot
-Talking for 2 mins each during the presentation
-Im going to get all the references checked by a librarian so that they're perfect
-I will post the powerpoint here for feedback and u guys can just write on the comments box so that I can change it

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https://journals.sagepub.com/doi/full/10.1177/0894318414558614

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The author of this article reviews the literature on lateral violence in nursing. This concept was first discussed over three decades ago. Bullying and Incivility are concepts similar to lateral violence that have become increasingly utilized in nursing research and scholarly writing. The research on these concepts suggests that the behavior still exists in the nursing workplace, and that few interventions have been developed to change the behaviors or the power dynamics that cause them. Suggestions are included to change practice and scholarship in this area.

References

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Lateral Violence in Nursing: A Review of the Past Three Decades - Susan Jo Roberts, 2015

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The author of this article reviews the literature on lateral violence in nursing. This concept was first discussed over three decades ago. Bullying and Incivility are concepts similar to lateral violence that have become increasingly utilized in nursing research and scholarly writing.

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Hi Guys,
Found this article has some good points welcome to use as well

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In this article, I describe a study exploring horizontal violence and nurses' perceptions of the phenomenon within the context of two 28-bed inpatient hospital units. The purpose of the study was to develop a clearer understanding of horizontal violence, incorporating observation and inquiry to identify the language nurses use to describe their experiences and factors in the nursing work environment that may perpetuate the phenomenon. Observation, review and analysis of policies, and interviews with staff were completed between June and November 2012. Thematic analysis resulted in five themes: (a) behaviors are minimized and not recognized, (b) fear inhibits all reporting, (c) avoidance and isolation are coping strategies, (d) lack of respect and support, and (e) organizational chaos. The findings suggest future interventions must address a range of factors that perpetuate horizontal violence within the nursing work environment with consideration for the embeddedness and complexity of the phenomenon.

Keywords: nursing, workplace, violence, observation

Approach and Perspective

Qualitative inquiry is recognized as a valid approach to gaining an understanding of a multifaceted phenomenon within a context-bound setting ( Patton, 2002). As the purpose of this study was to develop a clearer understanding of the complex phenomenon of horizontal violence in the context of two hospital units, a descriptive exploratory approach was used. Data collection methods included nonparticipant overt observation, document review, and nonstructured and semistructured interviews. Nonstructured interviews with staff were impromptu conversations about the events of the day and occurrences on the units. Semistructured interviews with nurse participants focused on their experience and sense making of horizontal violence.

This study was conducted from a constructivist perspective, where meaning and sense making are studied because meaning and sense making shape action ( Guba & Lincoln, 2008). I was interested in the nurses' understanding of the phenomenon of horizontal violence and actions taken in response to their experiences. A constructivist perspective allows for multiple interpretations of realities and alternative interpretations of data ( Fetterman, 1989). In using this approach, I did not seek to uncover a single truth but to develop an understanding of the multiple, situational realities experienced by individuals in their day-to-day work lives.

Site Selection and Access

Although horizontal violence is recognized as a problem within all health care professional groups, nurses are understood to be at the greatest risk for intraprofessional aggression ( Vessey et al., 2010). Nurses in some settings are at greater risk than others ( Hawkins & Kratsch, 2004). Based on the responses of 303 nurses to an Internet survey advertised in print and on the website for the publication Nursing Spectrum, horizontal violence in the form of bullying occurred most frequently in medical/surgical (23%), critical care (18%), emergency (12%), operating room/post anesthesia care unit (9%), and obstetrical (7%) areas of care ( Vessey, DeMarco, Gaffney, & Budin, 2009). Although I did not have control over which units would volunteer to participate in the study, I hoped the participating units would be units where horizontal violence was suspected.

A number of potential research sites were identified through my professional network. When an associate chief nursing officer at the first facility approached expressed interest, I forwarded a letter of introduction and summary of the study to her. After a formal presentation to the nursing executive committee and representatives of the nurses' union, participation by this 400+-bed not-for-profit urban health care facility in the Northeastern United States was approved. Three nurse managers who believed their staff morale was adversely affected by horizontal violence granted me permission to observe day-to-day activities on their units. Unfortunately, one of the three managers was laid off and the unit's participation was withdrawn when its management was merged with that of another unit. The two units remaining were each 28-bed inpatient units: one general medical/surgical unit (Unit A) and one specialty surgical unit (Unit B).

Participants and Consent

A summary of the planned study and a copy of the consent form were posted in the break rooms on both units. The 120 hospital staff (80 nurses, 22 patient care assistants, 14 unit secretaries, two nurse educators, and two nurse managers) on the payrolls of the participating units and any hospital staff coming to the units to provide care were eligible to participate. I reviewed both documents with each staff member and explained how they could participate or opt out of participation. Although I was granted general permission to observe on both units staff members could opt out of further participation by declining opportunities to interact or speak with me. Only one nurse declined participation. Patients and their visitors were not included in the study, and observations did not take place in patient rooms to maintain privacy and confidentiality.

Protection of Human Participants

Initial approval for the study was obtained from my academic institution. The participating facility's Institutional Review Board (IRB) determined that because I was not a member of staff or working with a researcher at the facility, my study would not require their review. Letters outlining this decision and verifying permission to conduct research in the hospital were submitted to my academic institution's IRB and final approval was granted.

All study participants were verbally consented to assure confidentiality. Names and other identifiers were removed from field notes and pseudonyms were used in transcripts. I was aware that exploring and recounting experiences of the phenomenon of horizontal violence might be distressing for some participants. Resources for counseling were identified in advance of participation and provided during the consent process.

Data Collection

Data collection took place over the period of 5 months between June and November 2012.

Document review

Document review focused on policies related to behavioral expectations, specifically the facility's workplace violence policy and codes of conduct. My intent in reviewing and analyzing these documents before spending time on the units was to understand the facility's policies related to behavioral expectations and become familiar with the language used to describe reportable behaviors in these policies. I continued to review distributed educational materials, posters, assignment rosters, and hospital forms throughout the study to develop a better understanding of the workplace and unit culture. Analysis of these materials was outlined and documented using a worksheet adapted from worksheets for document analysis developed by the Education Staff at the National Archives and Records Administration in Washington, D.C. ( National Archives, n.d.).

Observation

I was a nonparticipant observer on both units, dressed in solid-colored trousers and a plain shirt with a hospital id badge. Observation occurred across all shifts with approximately half of the hours occurring on day shifts and half of the remaining hours split between evening and night shifts. The majority of my observations took place at the unit secretaries' desk, a public space at the center of each unit. Additional observations occurred in the hallways, break rooms, and in the shared medication room. Observation was overt and participants were aware of the study aims and its focus on "any noncaring, nonsupportive behavior between nurse colleagues." Although I took note of helping behaviors on both units, my focus was on the nonhelping behaviors outlined and described in the first three columns in .

Table 1.

Behavior

Overt or Covert

Possible Manifestations

Observed and/or Reported

Examples From Study Data/Frequency

Documentation included field notes detailing observed events and interactions, and records of informal conversations with staff. Initial periods of observation were scheduled during times when staff was likely to interact; handover, rounds, medication administration times, and during scheduled meetings and learning opportunities. There were 75 periods of observation lasting from 1 hour to 9 hours, with the average period of observation lasting 5 hours. Three hundred seventy hours of observation of the day-to-day activities and staff interaction on both units were completed over a period of 5 months.

Interviews

Members of staff participated in nonstructured and semistructured interviews. Nonstructured interviews, essentially informal conversations, with nurses, managers, doctors, unit secretaries, patient care assistants, transporters, housekeepers, and others, took place during every period of observation. In these conversations, participants recounted events of the day, informed me of occurrences I had missed, shared details about their lives outside of work, and asked questions about the study. Thirty-one staff members participated in semistructured interviews; 22 nurses (21 women/one man), two nurse managers (both women), two nurse educators (both women), and five administrators from Human Resources, Quality and Safety, Patient Experience, and Risk Management (all women).

Interviews with managers, educators, and administrators focused on their understanding of current policies and procedures to address the phenomenon, as well as their role in managing behavior within their unit or within the hospital facility. Some also shared their experiences of horizontal violence. Semistructured interviews with nurse participants focused on their experiences and sense making of the phenomenon. Although the term horizontal violence was listed in the title of the study in the study summary and consent forms, the phenomenon was otherwise not named to allow participants to use their own language to describe their perceptions and experiences but was broadly defined as "any physical or emotional, noncaring or nonsupportive behavior between nurse colleagues."

The nurses participating in semistructured interviews were self-selecting. There was no incentive offered for participation. Twelve Unit A nurses were interviewed, and 10 Unit B nurses were interviewed. The majority of these nurses were women ( n = 21) and White ( n = 21), ranging in age from mid-20s to mid-50s. The majority held associate degrees in nursing ( n = 16). Six nurses held bachelor's degrees. One nurse interviewed was a new grad. The remaining nurses had from 2 to 14 years of experience on the units. This sample reflected the nurse demographics of the two units.

The semistructured interview questions with nurses included the following:

Why did you become a nurse?

Is nursing different than you thought it would be before you went to nursing school or before you started working as a nurse? How?

Tell me about a good day at work

Tell me about a bad day at work.

In sharing stories about a bad day at work when nurse participants recounted behaviors identified as related to horizontal violence in the literature, they were asked to elaborate.

The majority of the interviews were digitally recorded with consent and transcribed verbatim. I took notes (with consent) during these interviews to capture participants' reaction to questions and summarize responses in case of recording failure. I also took notes (with consent) during interviews in cases where the participant did not wish to be digitally recorded. I created transcripts summarizing those interviews from these notes. Interviews ranged in length from 15 minutes to 2 hours.

Data Analysis

The document analysis worksheets, field notes, and interview transcripts were converted into Microsoft Word documents. I coded and analyzed the data thematically using applied thematic analysis as outlined by Guest, MacQueen, and Namey (2012). The majority of coding was completed by reading and rereading materials, systematically examining the data to identify common elements, highlighting these elements in printed copies of the data, and creating index cards of potential themes. These themes were further reduced and merged into five overarching themes.

Rigor

As the sole researcher, I attempted to maintain rigor and minimize bias in a number of ways. Throughout the study, I shared findings with another researcher experienced in qualitative methods. We met every 2 weeks during initial data collection and reviewed the development of the codebook and finalization of themes. I kept a reflective journal throughout the research process to assist in maintaining objectivity. I felt that my extended time in the field allowed me to establish a rapport and develop trust with the participants. Over time, the staff appeared willing to share experiences and perceptions openly, contributing to a more accurate picture of the unit culture. The use of multiple data collection methods also contributed to a more accurate depiction of the unit, staff, and their experiences. I reviewed interview transcripts or summaries with individual participants whenever possible. Moreover, a 14-page booklet summarizing the study findings was shared with all staff on both units via email and copies of the summary document were also left in the break room for their review. The seven nurse participants who provided feedback described that the findings resonated with their experiences and were an accurate picture of life on their units.

Intimidating and disruptive behaviors are unprofessional and not tolerated. Behaviors that are considered intimidating and disruptive can be verbal or physical. They include verbal outbursts and foul language; sexual harassment in any form; physical roughness; threats; refusing to perform assigned tasks; quietly exhibiting uncooperative attitudes during routine activities; reluctance or refusal to answer questions, return phone calls or pages; condescending language or voice intonation; and impatience with questions.

Themes

Behaviors are minimized and not recognized

The lack of clearly defined behavioral expectations and lack of knowledge of and enforcement of the Code of Conduct contributed to a lack of recognition of behaviors as problematic and reportable. Even the nurse managers and educators, the unit staff most familiar with policies, were not sure about the policies or reportable behaviors. One nurse educator shared, "I am not sure if there is a policy that covers bullying here. There is no clear-cut definition of bullying to work with. It's so unclear." When asked about expected behaviors, a manager reported, "I don't think we have defined it. We are revising our policies. The Code of Conduct might have a better understanding of what is expected in behaviors, what is acceptable."

As the behaviors associated with horizontal violence were tolerated, nurses and other staff members appeared to accept them as part of the job and minimized the long-term impact on communication, teamwork, and safety. Addressing conflicts with colleagues was not a priority for the nurses with some even stating that they did not care about getting along with their coworkers. These nurses described that taking care of their assigned patients was the priority above all else:

At the end of the day, it doesn't matter how my peers treat me, I am here for my patients and I can go to sleep at night. I am here to make sure that the patient got the assistance they needed.

Nurses described a focus on their own patient assignment and having little time or concern for conflict resolution.

Fear inhibits all reporting

Horizontally violent behaviors, when recognized, were generally not reported. Approximately half of the nurses interviewed identified barriers to reporting; among those fears was the fear of reprisal. "If I complain, no one will help me." "If you say anything, then it is going to be worse." Nurses also described a fear of being labeled. "If I report, then I'll be a snitch." "If I file an incident report, I'll be labeled a complainer."

This fear of reporting extended beyond horizontal violence into reporting of medication errors on one unit and unsafe staffing on the other. Two or three nurses on each unit believed they would be labeled incompetent if they made a mistake or couldn't manage their patient load on their own. Even concerns about missing medications and supplies were suppressed, as these nurses knew their colleagues and managers often labeled nurses who verbalized frustrations as complainers. A few nurses shared their belief that reporting did not result in change. They described that nothing happened when reports were made and reporting was not worthwhile.

Avoidance and isolation are coping strategies

Twenty-one of the 22 nurses interviewed described themselves as conflict avoidant. A few shared that they knew what kind of day they would have as soon as they looked at the schedule. If they were on shift with staff they were in conflict with or felt they could not rely on, they described working alone and not asking for help because they believed they would not receive it.

It hasn't been a unit well known for teamwork. People work singularly. "I just want to work by myself. If you need me call me, but I'm not reaching out to you." Staff see themselves as team players but if you look closer they may not necessarily be. (Manager)

I don't ask unless I really need help. And that's why, because no one will help me. You know, some of our nurses don't even go to a code. They just keep going on with their day. So you know what, don't expect me to help you. That's how I feel. (Nurse)

Two nurses (one from each unit) independently shared purposefully positioning themselves at far ends of the unit hallways to avoid interaction and being asked to help nurses who would not help them.

Another finding, perhaps rooted in conflict avoidance, was a lack of bystander intervention. When a member of staff was subject to verbal abuse by a colleague, bystanders did not intervene, potentially further isolating the target and in their silence condoning the behavior. During the 370 hours of observation, I never witnessed any bystander intervention.

Lack of respect and support

The nurses described a lack of respect for their role and feeling unsupported, having no control over workflow or resources. Despite posters hanging on the walls of both units promoting teamwork, many members of staff did not feel included as part of the patient care team. Patient care assistants described not being included in the plan of care by the nurses. Nurses described having to track down physicians who had described the plan to the patient and not included them in the conversation.

Nurses and other staff described a disconnect with administration. They felt the hospital administration had no idea about what was happening on the units. One nurse shared, "I've never seen admin come to the floor, do rounds, talk to nurses, or make their face known. Makes you think admin doesn't have an idea about what the front line does."

Another nurse described lack of recognition of the role of the nurse: "Top down, the people don't recognize the people at the bedside enough. I don't think they do. It's disappointing, and the nurses know that and feel that."

Despite one senior administrator insisting that staff had to know how much workers' hard work was appreciated, staff told me they did not feel valued. A few of the nurses felt that even their patients didn't recognize or respect their role. "I feel like we're Dunkin Donuts here . . . You're customer service. We're a hospital. I am not your waitress. I am not your bed companion. I'm not any of that." In addition, when patients and families were verbally abusive and threatening, nurses felt they had no recourse. Nurses from both units shared that when a patient or family member was abusive, even their nurse managers failed to support them.

Nurses identified another major stressor and potential patient safety risk: batched admissions and discharges. Physicians often told patients they would be discharged in the morning but would not return to the units to complete the required paperwork until the afternoon, when patients were discharged en masse. This created a chaotic environment where nurses managed multiple discharges as new admissions arrived. One manager identified discharges as a serious issue adversely affecting nurse/doctor relationships on her unit.

Discharge is a source for nurse/doctor frustration. It has elevated to violence. The doctor tells the patient they are going home in the morning. The nurse has to front the doctor as delays happen late in the day. Not a way to start the evening shift. It's not fair to the evening nurses. They are blasted by the patient and by the family. (Manager)

Nurses had no power in controlling the flow of admissions to their own units. One evening when one nurse asked whether there could be a 15-minute delay in a transfer while she settled her first admission, the nurse on the transferring unit called bed management, who then called the receiving nurse telling her that her patient would be sent immediately. A nurse involved in the exchange shared, "Bed control is the bully now."

Even nurse managers could not close beds or control patient flow. When one manager closed a bed on her unit because one patient in the shared room was extremely physically and verbally aggressive, the bed was unblocked from above and another patient was put into that shared room despite concerns for staff and patient safety. During the 5-month period of data collection, educational resources for nurses were cut and the majority of the associate chief nursing officer positions were eliminated. As part of one patient care initiative on one of the units, nurses had been given control over resources to improve their patients' experience. That funding was also eliminated. In a conversation in the hall, a nurse who had been part of the committee to improve the patient experience described, "That [initiative] was about caring. Now that we don't have it, we obviously don't give a shit."

Organizational chaos

All staff interviewed described system problems that adversely affected their ability to provide care. Nurses and Patient Care Assistants described not having access to equipment and tracking down medications and supplies that should have been readily available. Treatments were delayed when patients were not ready for transport when transport arrived and when transport did not arrive on time or was not available.

No equipment. Not restocked. No more flushes. No one answers your page in facilities. No one has taken the dirty linen and it's overflowing. All of these factors are creating an environment that is more stressful than it has to be. It sets the tone. These increase the risk for violence. I'm not saying it's directly related, but it does contribute to it happening. (Nurse Educator)

System failures also contributed to a sense that other people in the institution were not doing their jobs while the individual making that attribution felt they were hard working. Relationships between units and between shifts within units were also affected when the perception was that staff members on these other units and other shifts were intentionally passing on work they should have done. A nurse manager described ongoing conflict between her unit and the emergency department (ED).

There is a mutual lack of understanding and disrespect between the ED and the floors. The floors don't understand the role of the ED and the ED doesn't respect the floor nurses. Is the ED slammed or are they just dumping? That's a huge risk factor for nurse-to-nurse violence. (Manager)

Every nurse interviewed believed a lack of accountability allowed people who had bad personalities or poor work ethics to stay on.

Despite the implementation of initiatives designed to improve patient flow at this facility, there was a lack of follow-up when transportation did not arrive, when medications were delayed, and when supplies ran short. There appeared to be no recourse other than to work around the problem or, as often happened, call and yell at someone in the department perceived to be behind the problem (often transport, pharmacy, or central supply).

I extend my sincerest gratitude to the participants in this study and thank Dr. Neenah Estrella-Luna and Dr. Susan Jo Roberts for their support.

Rosemary Taylor, PhD, RN, is an assistant professor at the University of New Hampshire Department of Nursing in Durham, New Hampshire, USA.

Declaration of Conflicting Interests: The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding: The author disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was supported in part by a research grant from the Gamma Epsilon Chapter of Sigma Theta Tau International.

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# data[].attributes.attachment_link.title
Nurses' Perceptions of Horizontal Violence

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In this article, I describe a study exploring horizontal violence and nurses' perceptions of the phenomenon within the context of two 28-bed inpatient hospital units. The purpose of the study was to develop a clearer understanding of horizontal violence, incorporating observation and inquiry to identify the language nurses use to describe their experiences and factors in the nursing work environment that may perpetuate the phenomenon.

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Assessment 2 Group Presentation Details S221

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Assessment 1 Group Governance Plan  Details S221 (1)