Eliminating Lateral Violence inthe Ambulatory Setting: OneCenter’s Strategies

TINA J. DIMARINO, BSN, RN, CNOR

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ABSTRACT

Lateral violence (eg, disruptive, disparaging, or uncivil behavior inflictpeer on another) creates an unpleasant work environment that can haveffects on individual nurses, team members, patients, and the bottom lhealth care organization. Educating nurses about the most common formviolence and strategies for handling inappropriate behavior can be thetoward eliminating this behavior. Effective nursing leaders develop anda “zero-tolerance” culture that includes clear and concise behavioral exand consequences for employees who exhibit unprofessional behaviorcode of conduct, open communication, and quick resolution of issuesare strategies that one ambulatory surgery center has used to successfullateral violence in the workplace. AORN J 93 (May 2011) 583-588.Inc, 2011. doi: 10.1016/j.aorn.2010.10.019

Key words: lateral violence, horizontal violence, nurse-to-nurse violruptive behaviors, code of conduct, zero-tolerance culture, healthy wenvironment.

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Lateral violence, also called hviolence, nurse-to-nurse violity, and disruptive behavior,1

unpleasant work environment and heffects on individual nurses, patienthealth care organizations. Much hasten about the effects of lateral violeworkplace. When lateral violence isexist, it affects everyone at a facilitpatients. Lateral violence is definedoccurring “when oppressed groups/internalize feelings such as anger andmanifest their feelings through behav

gossip, jealousy, putdowns, and blaming.”

doi: 10.1016/j.aorn.2010.10.019

© AORN, Inc, 2011

ntalincivil-tes anrmfulty, andn writ-n thewed tocludinglly asiduals, anduch as

Lateral violence encompasses behaing from nonverbal acts such as eye-eyebrow raising to extremes of physiResearchers have found that the mosforms of lateral violence in nursing iverbal innuendo, verbal insults, gossimining, withholding information, sabfighting, scapegoating, backstabbing,respect privacy, and broken confiden

Vega and Comer emphasize the coof lateral violence by paraphrasing andren’s rhyme, “sticks and stones maybones, but words can break your spir

2 Nurses who are subjected to lateral violence in

May 2011 Vol 93 No 5 ● AORN Journal 583

nt.4,7-

verag.8 Inrganid witities amem

d teamsely a

easedtimidaors ay conmes.1

pe oftcomeerious

oftenrly.10

lenceth phess frr loseffe

deprer expembebehav

e neehe amas inolenc

enseRatheue, mal viomem

eral violences as negative.14 This rec-inating the

lateral vio-and singlesinates dif-lence is. Forther nurse’sa secondas lateralentify lateralrespectfulreduces con-sociated withprove workehavior.4

nurse withe when

organiza-romote aent.16 Effec-ntain a “zero-

bers of therofessionaloral expecta-ment of pro-tly, there is

ences forl behavior.11

icies andramount.9

e reportingof reprisalinappropriatenteredre vital.17

promote ature culti-

May 2011 Vol 93 No 5 DIMARINO

the workplace often leave employmeturnover can cost an institution, on atween $22,000 and $64,000 per nursetion to the financial burdens on the oremaining staff members are burdeneing to shoulder additional responsibiltrain replacements.10 Remaining staffmay have little trust in each other anmay suffer, which in turn may adverpatient safety and outcomes.10,11

In 2008, the Joint Commission reltinel Event Alert emphasizing that indisruptive, and unprofessional behavisuitable in a culture of safety and mato preventable negative patient outcoganizations that allow or ignore this tyior risk experiencing these negative ouLateral violence has been called a “sin the delivery of safe care.”10(p400)

Nurses affected by lateral violencethe enthusiasm to do their jobs propedition, nurses subjected to lateral vioence stress that can manifest itself boand emotionally.12 Physically, the streral violence can cause weight gain olessness, and illnesses, to name a fewEmotionally, the nurse may becomefeel anxious, have low self-esteem, olow morale.9,12,13 Over time, staff mcome to consider these unacceptableroutine.10,13

Education and strong leadership arhelp curtail inappropriate behavior. Ttory surgery center in which I work hseveral strategies to combat lateral viimprove the work environment.

EDUCATIONEducation serves as a first line of deftering a healthy work environment.4

allowing negative behaviors to continers and directors educated about laterand conflict resolution can help staff

achieve positive outcomes. Educating nurs

584 AORN Journal

9 Thise, be-addi-

zation,h hav-ndberswork

ffect

a Sen-ting,

re un-tribute

1 Or-behav-s.11

barrier

lackIn ad-experi-ysicallyom lat-s, sleep-cts.12

ssed,eriencers mayiors as

ded tobula-

stitutede and

for fos-r thananag-lence

bers

about the most common forms of lathelps them to recognize the behaviorrather than accepting them as normalognition is often the first step in elimbehavior.15

Knowledge about what constituteslence calls attention to the behaviorsthem out as unacceptable. It also elimfering opinions about what lateral vioexample, one nurse may attribute anoincivility to being stressed out, whilenurse may define that same behaviorviolence.14 Helping staff members idviolence (ie, chronic disruptive or disbehavior versus a one-time reaction)fusion. Educational intervention is asincreasing nurses’ commitment to imrelationships and eradicate negative bFurthermore, education provides thethe tools to cope or confront someonnecessary.4

LEADERSHIPLeaders have a responsibility to theirtion, staff members, and patients to pprofessional, positive work environmtive nursing leaders develop and maitolerance” culture by holding all memhealth care team accountable for unpbehavior.11 Clear and concise behavitions are paramount in the encouragefessional behavior.11 Just as importana need for clear and concise consequemployees who exhibit unprofessiona

In addition to having written polconsequences, communication is paStaff members who feel comfortablproblems to managers without fearwill not remain silent witnesses tobehavior.4,10 Work relationships cearound mutual respect and caring aRespectful and caring relationshipspositive culture.14,15 A positive cul

es vates professional behavior.17

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other orgafor lave wors an

a heaOur eting thy theorkaddi

onduct fo-nication,r codexpectationsy furtherptable be-tified bydisruptive

of conduct,tarting pointding policy.n and pro-

f memberss, or talkese discus-sure stafft have work-aff member. Over time,managers

oicing their

iolence to allce programs.everyonets on the em-ization. Wenual basis sois accept-

ASC. As afind andterials into

clearly iden-deviationses need tozation byen employ-ur expecta-of conductrds. We ac-

LATERAL VIOLENCE www.aornjournal.org

The nurse manager is instrumentalpositive culture in an organization.14

can Organization of Nurse Executive“collaboration and communication arhealthy workplace.”6(p88) Leaders whteamwork, autonomy, and freedom frsive behaviors also aid in creating suronment.9,17 Effective nurse managerclear expectations for behavior, modeior consistently, hold all staff membeaccountable for their behavior, and focommunication for staff members whaddress problems. All nurses deservewith respect and to practice in an envconducive to the safe care of patients

OUR CENTER’S STRATEGYI experienced lateral violence duringa perioperative nurse. Backstabbing,nonverbal innuendo, and infighting bwere rampant at the ambulatory surg(ASC) where I worked. I was on theend of this behavior and, at other timobserver or witness to its infliction oremember thinking, “How is this peget away with such behaviors?” Viccluding me, reported the behaviorswith little or no resolution. Many tiers dismissed the behavior by comm“Oh, that’s just the way he is.” I nowork at that ASC.

I now serve as administrator for anMy experience with incivility and oution’s commitment to zero toleranceviolence has helped to create a positivironment at our center. Administratoagers at this facility want to providework atmosphere for staff members.have resulted in staff members repormorale is at an all-time high. They sacoming to work and that the ASC’s wronment is pleasant and enjoyable. In

have not experienced any turnover related

eating aAmeri-es thatded in aterppres-envi-

videbehav-

uallyopennt to

treatedent

nure asl andorsnter

vingwas aners. Iable to

, in-anagersmanag-

ng,er

r ASC.niza-

teralrk en-d man-lthyffortsat theiry enjoyenvi-tion, we

eral violence incidents. Our code of ccuses on the values of caring, commurespect, and teamwork (Figure 1). Ouclearly and succinctly describes our eof acceptable behavior, and our policidentifies the consequences of unaccehavior (Figure 2). The resources idenLongo,4 such as the steps to combatbehaviors and tips for drafting a codewere helpful in providing us with a sto create this code and the correspon

Managers encourage communicatiomote an open-door policy where stafcan express concerns, vent frustrationabout whatever is on their minds. Thsions are confidential. Managers reasmembers that the discussions will norelated repercussions, even when a stis voicing concerns about a coworkerstaff members have come to trust theand learned to be more open about vconcerns.

We provide education on lateral vstaff members through annual inserviThese sessions serve as reminders toabout negative behavior and its effecployees, patient safety, and the organreview our code of conduct on an anthat there is no confusion about whatable or unacceptable behavior in ourresult of this yearly review, we oftenincorporate additional educational maour policies.

ExpectationsProfessional behavior is required andtified. We do not overlook or acceptfrom professional behavior. Employebecome team members of our organiadhering to our code of conduct. Whees are hired, we review with them otions and ask them to sign our codeand pledge adherence to these standa

to lat- tively discourage gossiping and disruptive or rude

AORN Journal 585

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s clarify mis-

and discuss

on ground.

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ior. If the

s to discuss

erbal or writ-

esolving the

nship with

nd may

r experience,

ether and

fill the va-

nagers main-

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and all

policies that

May 2011 Vol 93 No 5 DIMARINO

behaviors by reinforcing and adherin

code of conduct. Teamwork is of the

importance.

ActionsManagers, nurse leaders, and staff m

held accountable for their behaviors.

problems as quickly as possible, as lo

so does not negatively affect patient

experience, matters that go unresolve

to escalate create a negative environm

fects team performance. Employees a

aged to report code of conduct violat

as possible. Managers counsel emplo

not acting in a respectful, caring, pro

manner by providing guidance in the

propriate communication skills. If the

conflict between employees, the man

the employees in discovering the roo

problem. In our experience, most con

result of miscommunication or differ

Figure 1. Code of conduct. Reprinted with p

586 AORN Journal

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st

rs are

ddress

s doing

In our

are left

hat af-

cour-

s soon

who are

nal

f ap-

ter is a

ssists

e of the

are a

rcep-

tions. Without resorting to placing bl

ing fault, managers use a proactive a

help ensure that employees are follow

of conduct. Managers help employee

communications and misperceptions

these with both parties to reach comm

We encourage employees to identi

complish appropriate resolutions. Eac

held accountable for his or her behav

manager makes at least three attempt

the problem or gives the employee v

ten warnings and is unsuccessful in r

conflict, we dissolve the work relatio

the employee. This is often difficult a

leave us short-staffed. It has been ou

however, that team members pull tog

work harder while steps are taken to

cant position. It is imperative that ma

tain proper documentation of all inte

volving the counseling of employees

verbal and written warnings. Written

ermission from Mid-Atlantic Surgery Pavilion, Aberdeen, MD.

s theers li

the pbod

havioseledior whysicrs of

over, andateral vio-we continueends for hir-n. Staffour commit-Patients re-SC’s atmo-eel safe in

rgery

LATERAL VIOLENCE www.aornjournal.org

managers consistently follow serve aline of defense if an employee considafter being discharged.

In addition to employees, we holdcian owners (ie, the ASC’s governingmanagers to the same standards of bePhysicians who act out also are counsimilarly to employees, if their behavit or resolution is not achieved, the pprivileges are revoked by the membe

Figure 2. Code of conduct policy and pPavilion, Aberdeen, MD.

governing body.

firsttigation

hysi-y) andr.and,arrantsian’sthe

ResultsIn 2010, we experienced no staff turnthere were no reported instances of llence in the organization. In fact, asto grow, staff members refer their friing consideration when positions opemembers report feeling satisfied withment to a healthy work environment.port in satisfaction surveys that the Asphere is pleasant. Patients say they f

ure. Reprinted with permission from Mid-Atlantic Su

roced

our care and that the staff members appear happy.

AORN Journal 587

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1-109.benefits ofrse retention.d.org/MainPeriodicals/o3Sept07/er 18, 2010.al violence.

violence in:399-403.atient safety.ointcommissiona_40.htm. Ac-

raw CA, Pagacerioperative

s: nurse-to-0;45(3):166-

Michel Y, Wel-e nursing07;28(11):1247-

risk? Tenn

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on M. Dealingzero tolerance.09;47(12):

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strator ofAberdeen,affiliationpotentialof this

May 2011 Vol 93 No 5 DIMARINO

Research has helped us discover addtional resources and strengthen our p

CONCLUSIONAs nursing professionals strive to erafessional behaviors from the work enignoring lateral violence is no longerResponsibility for eliminating lateralstarts with the owners, leaders, and mthe health care organization and endsstaff members, who must consistentlyand deal with these behaviors when tWith commitment, clearly identifiedand consistent actions, we have shapof caring and respect at our ASC. Thhas improved our organization, fosterdelivery of care to our patients, and cenvironment that allows our nurses toto practice excellent nursing.

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Tina J. DiMarino, BSN, RN, CNOnurse consultant for Custom Surgicatants, LLC, Street, MD, and adminithe Mid-Atlantic Surgery Pavilion,MD. Ms DiMarino has no declaredthat could be perceived as posing aconflict of interest in the publication

article.