Dr. (assistant professor of nursing for Anne Arundel Community College, MD)
Submitted by Lena Choudhary
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Hurray for the Millennial Nurses!
Horizontal violence is present at epidemic levels in the field of nursing. The pervasive culture of healthcare attempting to meet the needs of an overwhelming number of extremely ill patients with limited resources has caused individuals to fight amongst themselves. A root cause analysis would focus on various systems level dysfunctions that exist in acute care settings. Staffing reductions, the economy, and the lack of power at administrative levels should and can be dissected. There are circumstances at the interpersonal level that can and should be inspected as well. Intergenerational notions of the work ethic between experienced nurses, aged on average 48 years, and new graduates often from the millennial generation breed conflict. Understanding these differences and embracing the benefits will lead to a more cohesive work and school environment. As nursing educators we can integrate the tools and coping skills in our teaching to provide new graduates with the ability to create a more civil work environment.
“Horizontal or lateral violence,” “bullying” or “nurses eating their own” is any physical or verbal attack by a colleague that makes the person feel devalued or humiliated (Farrell, 2005). Horizontal violence has many root causes. Historically nursing has held a position of subordination to other professions in the healthcare field. This oppression breeds infighting, (Bartholomew, 2006). Budget cuts in the 1990’s left nurses without a voice at the administrative level of hospitals. No nursing administrators were left to weigh in on how and where funding should be allocated. Staff were cut leaving nurses with large patient workloads along with patients at very high acuity levels. Nurses desire to provide holistic nurturing and care to their clients. When they are blocked from achieving this purpose because of limited resources and the lack of power or control to change the system they are working in the natural result is hostility, (Bartholomew, 2006).
As a nursing professor I see lateral violence from many perspectives. My clinical students witness experienced nurses bullying the new graduates. In the hospital environment 60% of new nurses leave their first position within the first 6 months of graduating due to “lateral violence,” (Griffin, 2004). If the students also work as techs they may have felt the brunt of the harassment themselves from nurses delegating duties down to them. When my students graduate they often feel pressure from the senior nurses in comments such as “What, you don’t know how to put in a Foley? What did you learn in nursing school?” They also feel isolated from their previous tech colleagues who now view them as the enemy. Our faculty comes from that same pool of nurses who have witnessed, been the victim of or joined in the bullying just to survive the nursing environment. They bring these expectations into the classroom and clinical environment. The students are acculturated into the hostile nursing environment during their academic years. When the students begin to feel frustrated, overwhelmed and powerless they then begin to harass each other.
As educators and experienced nurses, the average age being 48 years old, we have been molded by our environment and work ethics to look at the new nurses with a negative expectation. There are cultural barriers that keep novice nurses separated from the veterans. Baby boomers have a cultural expectation that one must give everything to their careers. Women can do it all if they just work hard enough and multitask well enough. Millennials are not willing to give 200% to their jobs. They expect to have balance in their lives. They want to be able to pursue a career but not at the expense of family and their own health. Experienced nurses may read this as not "caring." This discrepancy can breed resentment between both parties.
The cultural divide that breeds resentment is the notion that nurses are the most caring of individuals. I often hear experienced nurses complain that the new nurses do not care. This new generation of nurses comes to nursing for the money. Educators and managers intimate that this will make them inferior as professional nurses if money is their inspiration for taking up the "calling" of nursing. Historically nurses, all female, where allowed to care in intimate ways for male patients by defining their work as “Gods work," (Bartholomew, 2006). So the idea of nurses being angels caring for others without concern for their own safety and health was created. The culture of nursing expects nurses to give of themselves without concern for their own physical, emotional and psychological health.
People peruse their careers for many reasons. They may have known their whole lives that they wanted to be a nurse. They may be from a family of several generations of nurses. They may be paramedics who watch nurses and are intrigued, or feel it will boost their income, or allow them more autonomy in the job. They may be foreign physicians who are not permitted to work in their original capacity in the states. They may be returning moms or retired servicemen or women, or workers from other disciplines recently laid off, or liberal arts graduates with no job prospects. Do any of these factors indicate a lack of "caring?" Do we want to differentiate and "test" for caring? After reading 180 applications for nursing school do you really still believe that essay that discusses how they witnessed nurses caring for their grandmother and were inspired again? Do we believe that caring cannot be learned?
We must ameliorate our cultural expectations that people come to nursing to “only” care for others. Nurses are not caring enough for themselves. Geiger-Brown, Trinkoff and Rogers (2011) found that 55% of the nurses they sampled fell into the category of obese. These rates of obesity, much higher than the general population, addiction and divorce in nursing is the strongest data to support that nurses need to care for themselves before they can care for anyone else.
I am hopeful that this new generation will make some great changes needed in the healthcare environment. Many new nurses indoctrinated into the holistic model of nursing get frustrated when they come to the hospital and find they have no time to provide holistic care. Nurses spend the majority of time pushing pills and documenting. They leave the profession completely disillusioned. If the Millennials demand better working conditions, it will make the environment better for all of us. They will be able to make demands due to the imminent nursing shortage in years to come. More reasonable work hours and nurse patient ratios will allow nurses to love their work again and practice the way we were trained. Rather than fighting this new crop of nurses, we Baby Boomer nurses should embrace a change that our new colleagues may be able to help bring about.
So what can we do as nursing educators? Start by discussing the topic with your colleagues. Educating ourselves about the causes and misunderstandings that lead to horizontal violence is the first step. Then discussing the topic with other faculty allows us to work together to address the bullying that occurs in academia between academics. Lastly by addressing horizontal violence across the curriculum awareness will spread throughout this new generation of nurses and provide them the tools they will need to make significant change in the culture of nursing.
As educators we must encourage our students to take on leadership roles, to actively pursue the power to make systems level changes, to have a voice in how resources are dispersed from the top of the organization down. This is daunting to our students when they are just beginning their careers and need and desire to focus first and foremost on mastering the skills and knowledge to be a competent nurse. The good news is that there are many actions that the individual can take to change the hostile environment they find themselves in right away. Students need to be provided with a realistic picture of the nursing environment they will be joining. At the same time we must provide them with the tools to effectively and constructively make the changes necessary to enjoy their work and to support each other in their healthcare roles.
I have incorporated the topic of horizontal violence in the final course our 4th semester nursing students are required to take. The course is entitled “Nursing trends.” Conflict management in the workplace is a trend that must be addressed to prepare our new graduates. I have them read and present on Kathleen Bartholomew’s book entitled Ending Nurse- to Nurse Hostility, (2006). We do role playing activities asking students to brainstorm and to practice what to say and how to respond to the irate physician you are calling for a verbal order, or the colleague that rolls their eyes when you ask for help in hanging your first piggy back IV. Just discussing in clinicals what the students have witnessed, how they have handled bullying in the past, and how we could handle it differently in the future is tremendously valuable. Our students have to be told they do not have to put up with hostile behavior, and then they have to be provided with resources to deal with it when it occurs.
I am hopeful that this hostile culture of nursing will change. New nurses are ready to stand up for what they believe is civil behavior. They are not willing to put up with the “old boys network.” Our responsibility as the veterans is to teach them the practical skills necessary to manage this change in a positive, constructive and professional manner. And at times to just stay out of their way!
Bartholomew, K. (2006). Ending nurse-to-nurse hostility: Why nurses eat their young and each other. Danvers: HCPros, inc.
Farrell, G. (2005). From tall poppies to squashed weeds: why don’t nurses pull together more? Journal of Advanced Nursing 35 (1): 26-33.
Griffin, D. (2004). Teaching cognitive rehearsal as a shield for lateral violence: an intervention for newly licensed nurses. The Journal of Continuing Education in Nursing, 35(6), 257-263.
Hollis, L. (2012). Bully in the Ivory Tower. Patricia Berkly, LCC
MacDonald, C. & Roberts-Pittman, B. (2010). Cyberbullying among college students: Prevalence and demographic differences. Procedia Social and Behavioral Sciences 9, 2003-2009.
Geiger-Brown, J., Trinkoff, A., Rogers, V.E. (2011). The impact of work schedules, home, and work demands on self reported sleep in registered nurses. Journal of Occupational and Environmental Medicine, 53(3), 303-7.