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Frequency and Severity of Lateral and Vertical Violence in the Hospital Environment:A look at pre- and post- intervention research design

Karen DeFeo-Mattox RN MSNEileen Phillips RN MSN NE-BC

December 4, 2014

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Why do we care about lateral/vertical violence?

• Lateral Violence (LV) and Vertical Violence (VV) has been mentioned in the literature for two decades using synonymous terms such as bullying, incivility, and disruptive behavior and is linked to:– Increased absenteeism with negative effects on

health of employees– Nursing turnover– Decreased morale, poor communication and

collaboration – Decreased work productivity

Most importantly, in our Culture of Safety….

LV and VV contributes to poor or ineffective communication among caregivers and is strongly linked to:

• Patient safety• Increased errors• Adverse effects, insufficient quality of care,

and mortality due to decreased/avoidance of communication with bullies

(Felblinger, 2009; Purpora, 2012)

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Lateral/Vertical Violence Defined

• Lateral /Horizontal Violence – nurses overtly or covertly directing dissatisfaction inward towards each other, towards themselves, and towards those less powerful than themselves (Griffin, 2004).

• Vertical Violence -- VV occurs between RNs at different levels within nursing. It may be directed

downwards (abuse of legitimate authority, such as charge nurse to staff nurse) or upwards (abuse of informal power, such as staff nurse to nurse manager)

(Stanley, Martin, Michel, Welton, & Nemeth, 2007)

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Common forms of lateral violence

• Non-verbal innuendo• Verbal affront• Undermining activities• Withholding information• Sabotage• Infighting• Scape-goating• Backstabbing• Failure to respect privacy• Broken confidences (Griffin, 2004; Stagg, 2011)

Literature Review• Lateral violence is predicted to be witnessed by and affect between

65-80% of nurses surveyed in recently published papers (Becher, 2012)

• Lateral violence causes increased stress and can have many negative physical and psychological effects (Crabbs, 2011)

• Cognitive rehearsal as an intervention for newly licensed nurses increased retention from 40-60% to 91% (Griffin, 2004) and for experienced nurses increased awareness of lateral violence (Stagg, 2011)

• Negative effects on quality and safety of patient care. Sixty percent of actual or potential harm to patients can be linked to insufficient or ineffective communication (Purpora, 2012)

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Study Purpose

• To assess the frequency and severity of lateral violence in the acute care environment before and after an educational intervention.

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Research question in PICO(T) format

• Among interdisciplinary healthcare staff in one hospital in a 5 hospital system (P), how effective is a lateral violence CBT (I) compared to ________?, on improving the knowledge of and the perceived frequency and severity of LV and VV in the inpatient setting (O) as measured by a pre and post intervention survey?

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Methodology• Instruments-

– Lateral and Vertical Violence in Nursing Survey– https://www.surveymonkey.com/s/LW36J69

• Procedures- – Identification of staff inclusion criteria– Pre-intervention web-based survey distribution– Mandatory CBT intervention for all staff– Post-intervention redistribution of survey

• Data Analysis

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Research designWhy did we choose it?

• Pre and post intervention selection– Participants complete same survey before

and after educational intervention– Design aims to determine if the intervention

has a causal effect

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Instrument selection

• Difficulties finding the “perfect” research tool – Focus of many surveys did not align with our

question• Not able to see entire surveys in journals• Difficulties finding authors or getting

permission from authors

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Research Tools that did not make the cut

• Nurses Workplace Scale (NWS) (DeMarco & Roberts, 2004)

• Workplace Bullying Survey(Quine)

• NDNQI Adapted Index of Work Satisfaction(Taunton et al, 2004)

• The Nursing Incivility Scale(Guidroz et al, 2010)

• Impact of Events Scale- Revised (IES-R)• Organizational Civility Scale (OCS)

(Clark et al, 2013)

• Violence Climate Survey(Kessler et al, 2008)

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Validity and Reliability of Research Tools

Goal #1find a tool that will measure what you are askingGoal #2

Make sure the tool chosen is a validated one

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Lateral & Vertical Violence in Nursing Survey (LVNS+V)

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CBT selection

• Many educational interventions were available–Assessed for cost, ability to keep staff’s

attention, ease of distribution • Staff had flexibility to complete CBT• Minimal non-productive costs• Ability to distribute to large numbers of

staff

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Barriers to choosing an intervention

• Unable to embed video into Healthstream • Use of video was also cost prohibitive at

$12.95 per viewer• Teaching a class would have required

additional non-productive time plus replacement cost for staff

• Need help to teach several hundred people

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Additional Barriers Encountered

• Multiple system-wide surveys released at the same time– Limited to one hospital– With low numbers of staff, unable to have

control vs. experimental group• Nursing Research Fellowship timeline had

built in expectations for outcomes

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In a Research Utopia

• Able to hold a class for all staff who received the survey – non-productive time and replacement costs would not

be an issue• CBT video could be distributed and

monitored through Healthstream at no cost

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FINAL THOUGHTS• Lateral violence is a serious problem that is

often ignored.• Finding a solution to address the issue will have

a positive impact on the nursing environment and improve patient safety.

• We look forward to analyzing the data to see if the CBT education had a positive impact on the perceived frequency and severity of LV and VV in the hospital environment.

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References• Arthur, D. (1992). Measuring the professional self-concept of nurses: a critical review. Journal of Advanced

Nursing, 17, 712-719.• Becher, J., & Visovsky, C. (2012). Horizontal violence in nursing. MedSurg Nursing, 21(4), 210-213 & 232.• Crabbs, N.A. & Smith, C.K. (2011). From oppression to opportunity: eliminating lateral violence and bullying in

the workplace. MedSurg Matters!, 8-9.• DeMarco, R., Roberts, S.J., Norris, A., McCurry, M.K. (2008). The development of the nurse workplace scale:

self-advocating behaviors and beliefs in the professional workplace. Journal of Professional Nursing, 24(5), 296-301.

• Dong, D. & Temple, B. (2011). Oppression: a concept analysis and implications for nurses and nursing. Nursing Forum, 46 (3), 169-176.

• Felblinger, D.M. (2009). Bullying, incivility, and disruptive behaviors in the healthcare setting: identification, impact, and intervention. Frontiers of Health Services Management, 25(4), 13-23.

• Gaffney, D.A., DeMarco, R.F., Hofmeyer, A., Vessey, J.A., & Budin, W.C. (2012). Making things right: Nurses’ experiences with workplace bullying –a grounded theory. Nursing Research and Practice, 1-10.

• Griffin, M. (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.

• Purpora, C. & Blegen, M.A. (2012). Horizontal violence and the quality and safety of patient care: a conceptual model. Nursing Research and Practice, 2012, 1-5.

• Stagg, S.J., Sheridan, D., Jones, R.A., & Speroni, K.G. (2011). Evaluation of a workplace bullying cognitive rehearsal program in a hospital setting. The Journal of Continuing Education in Nursing, 42 (9),

395-401.• Stanley, K., Martin, M., Michel, Y., Welton, J., & Nemeth, L. (2007). Examining lateral violence in the nursing

workforce. Issues in Mental Health Nursing, 28, 1247-1265. doi:10.1080/01612840701651470

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