Reducing Lateral Violence: A humanistic educational approach (2013)
Submitted by Janet M. Reed, RN BSN, MSN
We’ve all witnessed it: the gossip, backbiting, and bullying that too often occurs in the nursing workplace.
Lateral violence (LV), also known as horizontal violence or workplace bullying, consists of behaviors including “bullying, intimidation, sarcasm, back-stabbing, criticism, exclusion, and various forms of unequal treatment” (Morris, 2012, p. 6). LV has been a topic of ongoing topic of concern in nursing for many years and is particularly prevalent in female dominated professions (Brothers, Condon, Cross, Ganske, & Lewis, 2010-2011; Griffin, 2004: Weinand, 2010). LV is often attributed to oppression theory, which states that nurses are an oppressed group because they are deemed less important than others (such as medical practitioners); therefore, nurses often lack autonomy and control over their profession which results in powerlessness and displaced aggression towards other nurses (Woelfe, 2007).
There has been a reported 1/3 increase in the rates of workplace physical violence from 2000 to 2006 (Serantes & Suarez, 2006). LV can be costly to organizations because of resulting decreased productivity, impaired patient care, as well as exacerbating the problem of the nursing shortage (Embree, 2010; McKenna et al., 2003; Sheridan-Leos, 2008). It has been reported in the literature that one in three nurses internationally leave a position due to LV in the workplace (McMillan, 1995). Consequences of LV include absenteeism from work, lower self-esteem, higher staff turnover, negative patient outcomes, and a toxic work environment (Embree, 2010).
New graduate nurses are especially susceptible. McKenna et al. (2003) studied the prevalence of LV for nurses in their first year using anonymous questionnaires for 551 new nurses and found that both overt and covert types of LV were widespread and commonly experienced by new nurses. Occurrences most often took the form of psychological harassment including intimidation, disinterest, discouragement, threats, verbal abuse, humiliation, excessive criticism, and denial of access to learning opportunities. Nurses experiencing LV reported higher absenteeism from work, many of them considered leaving nursing after only the first year, and they reported that there were no support systems available for them (McKenna et al., 2003).
Dyess and Sherman (2009) did a qualitative study on the learning needs of new graduates during the first year of employment. They found that lateral violence was common and that although hospital’s had an official “no tolerance policy,” many nurse managers tolerated this behavior on the units. They recommended that new nurses be taught about LV and scripted responses to deal with it, in an environment allowing for time to practice and role-play (Dyess & Sherman, 2009). Among new nurses surveyed by Vogelpohl (2011) in her dissertation, 77% reported never being educated on workplace violence, and almost 30% of nurses within their first three years in the profession reported that workplace bullying made them consider leaving the nursing profession (Vogelpohl, 2011).
The Center for American Nurses (CAN, 2008) issued a statement on LV that includes a list of recommendations for dealing with LV personally, organizationally, and in nursing education and research. Specifically, they have called for nurse educators to develop educational programs regarding workplace violence and strategies on how to recognize and address such disruptive behavior. Educating nurses on lateral violence, including how to recognize and deal with it professionally will help break the cycle for new generations. Providing opportunities for newer nurses to talk openly about their experiences in a safe group discussion is another helpful activity to reduce the negative effects of LV in the nursing workforce.
An appropriate learning theory that will support this emotionally charged topic is humanism. The humanistic theory evolved in education in the 1970’s from the human potential movement and emphasizes human freedom, choice, value, and dignity of each individual (Billings & Halstead, 2009). The learner is an active participant (as opposed to a passive respondent) in humanistic theory. Humanistic theory acknowledges that internal and external stimuli help influence human behavior, in conjunction with human free will and motivation; a positive change would be indicated by a change in learners’ perceptions (Byrnes, 1986). Bastable (2008) states that the purpose of humanistic learning is not mastering information, but rather “fostering curiosity, enthusiasm, initiative, and responsibility” (p.75).
The role of the educator using a humanistic approach will be that of facilitator, rather than acting as an authority figure (Bastable, 2008). Fundamental to humanism is the importance of positive interpersonal relationships, especially between educator and learner. Byrnes (1986) discusses the fact that humanistic learning happens best when the educator can create an environment which minimizes threats to harmonious relationships. The humanistic teacher assists learners towards achievement of human potential, or self-actualization (Maslow, 1954). According to Maslow’s hierarchy of needs, it is assumed that basic level needs must be met before humans can attain learning and self-actualization (Bastable, 2008). Learning happens best when threats to self are minimized (Byrnes, 1986). Humanists emphasize the importance of self-concept, self-esteem, and the affective domain (emotions, feelings) in the context of a learning situation (Bastable, 2008). Helping students become self-aware of feelings by providing time for student reflection is essential in humanism (Bastable, 2008). Traynor (2009) discusses that nursing practice itself has a humanistic basis and that this has led to humanism being prized in both practice and qualitative nursing research, although critics complain that humanism is too idealistic and superficial. Although humanism has its weaknesses, it provides an excellent basis for teaching on lateral violence due to its emphasis on the affective domain and involving learners as active participants in the learning process.
Using group discussion as a teaching strategy will prove to be effective in helping learners to discuss prior experiences involving lateral violence in the workplace. It will be important for the nurse educator to promote self-development by creating an informal and relaxed climate for group discussion. In order to minimize threats to self, the educator should facilitate a discussion that maintains confidentiality and respect. One technique that can be used is for the educator to have students write down their experiences and emotions and then act as a “filter” through which these experiences can be confidentially discussed in the group setting. The nurse educator can assist learners in recognizing and developing their potential by praising students’ comments, asking questions that enable students to contribute to the discussion, and elaborating on students’ responses. One advantage of group discussion as a teaching method is that it is effective in both the affective and cognitive domains (Bastable, 2008). Because group discussion encourages learners to share their own ideas and experiences, it makes learning more active and “learner-centered” which is consistent with the humanistic theory. Another reason why group discussion is the preferred teaching method for teaching about lateral violence is that it creates feelings of peer support, belonging, and accountability (Bastable, 2008).
Griffin (2004) acknowledges that the nursing profession has an obligation to reduce lateral violence by implementing new educational programs. Griffin (2004) did an exploratory descriptive study on 26 new registered nurses in their first position at a large hospital in Boston. They spent 2 hours learning about lateral violence and practicing cognitive-rehearsal techniques to deal with it. Griffin (2004) used lecture to provide information on LV and its consequences during the first hour, and then used interactive group discussions the second hour to practice the cognitive rehearsal responses. They were given small laminated “cueing cards” with written responses to common types of lateral violence. One year later focus groups were asked open ended questions to provide qualitative data on the intervention. Griffin (2004) found that after one year of employment, 96% of the nurses had witnessed LV on the units where they worked, and 46% said the violence was directed at them. An incredible 100% of the nurses responded that they had used the techniques they had learned to confront the responsible individual, although this was difficult for them. 4 of the 26 nurses were thinking of leaving their positions due to LV and were assisted to take other jobs within the hospital. The use of scripted responses and “cue cards” may assist new nurses in how to verbally respond to an attack of lateral violence.
Recent literature has discussed the need for new nurses to receive education on lateral violence in order to prevent them from leaving the nursing profession in light of the nursing shortage of qualified RN’s. Nursing employers need to recognize the epidemic that LV has become, and create an organization that understands it and knows how to deal with it (Weinand, 2010). As stated by Vogelpohl (2011), “nursing cannot afford to lose our new graduate nurses” (p. 151). It is essential to provide an educational forum to raise LV awareness especially to newly licensed nurses (Griffin, 2004). Humanism learning theory provides an appropriate framework for this topic due to its emphasis on the affective domain. Every nurse is responsible for “taming the beast” and reducing LV in the workplace, which both victims and perpetuators must accept responsibility for correcting the problem (Brothers et al., 2010-2012). The population of newly registered nurses is the best place to start because they represent the future of the profession (Griffin, 2004).
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