HORIZONTAL HOSTILITY

Dealing with Difficult Situations in the Workplace

Presented to the Pre-Admission Clinic Staff, Victoria Hospital. LHSC December 16, 2009

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Definitions:

• Horizontal Hostility: :Sabotage directed at coworkers who are on the same level within an organization’s hierarchy (Dunn 2003)

• Verbal Abuse: “Communication perceived by a person to be a harsh, condemnatory attack, either professional or personal. Language intended to cause distress to a target”

(Buback 2004)

• Bullying: “The persistent, demeaning and downgrading of humans through vicious words and cruel acts that gradually undermine confidence and self –

esteem”

(Adams 1997)

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Observation….

• "When Mary retired, we realized she'd been hoarding equipment in her locker. We'd all wanted to be as organized as her but we hadn't realized all those years that she was preventing us from doing our jobs."

• "On my very first shift out of nursing school, I tried my very best and got great feedback from patients. All my supervisor could say at the end of the night was 'Pick up the pace tomorrow.' I was crushed!"

• "Physical violence, racism, swearing, making faces, gossiping, sabotaging work …

oh yes, I've seen it all

in my 35 years on the job. Every bullying behaviour you can think of."

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2003 Study revealed….

• A 2003 study in the Journal of Advanced Nursing found that half of newly qualified nurses report first-

hand experience with lateral violence. "Many senior nurses expect graduates to hit the ground running," says Judith Tompkins, chief of Nursing Practice and Professional Services and executive vice-president of Programs at the Centre for Addiction and Mental Health (camh) in Toronto. "When there is a lack of collegiality and mentoring from peers, young nurses are thrown into the workforce and are left feeling unsupported."

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Why are nurses especially vulnerable to lateral violence?• According to Dr. Barry Stein, a psychologist in Duncan, British Columbia, who specializes in workplace harassment and violence, "One of the real challenges is that most nurses are being worked off their feet. Lateral violence may be due to nurses displacing stress and aggression on one another."

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2002 Canadian Health Sciences Research Foundation Report..• "Workloads are reported to be at unsustainable levels,

particularly in light of the fact that the average age of nurses is increasing at the same time that the industry is anticipating a significant staffing shortage." Stein believes that despite attempts over the past few decades to raise the profile of nursing and attract more men, "nursing is still a pink ghetto, and often doesn't have enough support from human resources in the organization."

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Dr. Martha Griffin, activist and nurse educator…• reiterates the connection of lateral violence in nursing to the behaviours

of oppressed

groups, where inter-group conflict is seen in the context of being excluded from the power structure. "Nurses generally don't have sufficient control over their work environment and have a high degree of accountability coupled with a low degree of autonomy," says Griffin. "When nurses don't have control but must be accountable, you can see where they might not be happy with one another

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Few options….

• In such an entrenched culture, nurses who experience lateral violence may have few options. "Many decide to tough it out, go on stress leave or leave the profession," says Stein. Before preventive measures were taken at Brigham and Women's Hospital, where Griffin works, 60 per cent of nurses left within six months due to lateral violence. Other unhealthy coping strategies include taking up smoking, using alcohol excessively and abusing prescription medication. To the list, Rabyj

adds decreased

productivity and creativity, as well as increased orientation time and more sick leaves and use of benefits and short-term workers

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Results published by the American Association of Critical-Care Nurses

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Please note…

A silent witness to horizontal Hostility is an accomplice

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A silent witness to horizontal hostility is an accomplice

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Verbal Aggression: Overt and Covert

• Overt: name-calling, bickering, fault-finding, backstabbing, criticism, intimidation, gossip, shouting, blaming, using put-downs, raising eyebrows

• Covert:unfair assignments, sarcasm, eye-rolling, ignoring, making faces behind someone's back, refusing to help, sighing, whining, refusing to work with someone, sabotage, isolation, exclusion, fabrication

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Some Statistics to Note…..

• 1 in 3 nurses plans o leave his or her position because of horizontal hostility (Macmillan 1995)

• 1996 survey England, 30% of respondents stated that they were subjected to aggression on a daily or near daily basis (Farrell 1999)

• Studies in the US indicate that 90 –

97% of nurses experience verbal abuse from physicians (

• & Berkey 1997)• Nurses who report the greatest degree of conflict with

other nurses also report the highest rate of burnout

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Known effects of Verbal Abuse

• Emotional:• Anger, irritability

• Decreased self-esteem, self-doubt

• Lack of motivation and feelings of failure from being able to meet personal expectations

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Social Effects:

• Strained relationships with partner and friends

• Low interpersonal support

• Absence of emotional support

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Psychological Effects:

• Depression

• PTSD –

50% continue to suffer stress 5 years after the incident

• Burnout – depersonization, lack of

control

• Maladaptive responses – substance abuse,

overeating

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Physical Effect:

• Decreased immune response or resistance to infection

• Cardiac arrhythmias (increased risk of heart attack due to continuously circulating catecholamines)

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“The effects of nursing stress have potentially enormous financial

and human costs”

-Hillhouse and Alder (1997)

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The Bottom Line…….

• Key is to:

• Hold staff accountable for hostile behaviors

• Insist upon a crucial conversation between both parties when any nurse experiences hostility

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Root Causes of Hostility

• Intrinsic Factors:

• Emotional state –

anger, burnout• Personality style• Beliefs and expectations• Inadequate communication and conflict management skills

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“Burnout”

• “40% of hospital nurses have burnout levels that exceed the norms for healthcare workers, and job dissatisfaction among hospital nurses is 4 times greater than the average for all U.S. workers”

-(Aiken et al. 2002)

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Personality Style

• In a 1990 study of Type A and B personalities in female RNs, 82% of nurses classified themselves as having a Type A personality which is characterized by hard-

driving behavior patterns• Individuals are typically

very driven, somewhat impatient and aggressive

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Belief Systems

• I must have approval from others• I must be perfect and consider myself worthless if I make a mistake

• People should be blamed and punished when they do wrong

• It is a catastrophe when things are not as you want them to be

• Unhappiness is caused by external circumstances beyond your control

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Belief Systems Continued….

• You should worry over possible negative events constantly

• The influence of past events can never be changed or removed

• For every problem, there is a perfect solution that must be found

• Compliments are self aggrandizing• A good nurse should be able to function on her or his own, without any help

• There is nothing I can do about the situation –

that’s just the way it is around here

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Extrinsic Factors

• Violent Work place-

verbal abuse from patients, families and physicians

• Poor nurse –

physician relationships

• Task and time imperatives

• Demands for efficiency/productivity

• Culture

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Stats again….

• In the US 429,100 violent crimes against nurses on duty from 1993-1999 was recorded

• In 2002, 88% of hospitalized nurses reported verbal assault

• 74% reported being physically assaulted while at work by patients, family members or visitors in one year

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“Nurses experienced workplace crime at a rate72% higher than medical technicians

and at twice the rate of other healthcareworkers” (Thomas 2004)

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Nurse -

Physician Relationships

• 1997 survey showed that 90% of nurses had witnessed 6 to 12 unpleasant incidents between physicians and nurses within 1 year. (Manderino and Berkey 1997)

• The most common feeling a nurse experiences after an incident of verbal abuse is anger

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Task and Time Imperatives

• Results in depersonalization of care

• “patients are seen as tasks, not people

• Nurses have become experts at work arounds, thereby increasing the probability of error

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Increased efficiency

• Leads to decreased reflective practice

• No time to debrief which may lead to frustration and isolation

• No opportunity for story telling and connection

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Culture

• “Why would I want to go to college {and become a nurse so that someone else can tell me what to do all the time?”

• -

A nurse’s daughter

• Military model in which nurses lack autonomy to make independent decisions

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Interventions to Combat Horizontal Hostility…• Leveling the playing field• Empowering staff by increasing voice and agency

• Raising awareness• Increasing self esteem• Creating an open communication network• Providing opportunities for reflection• Increasing social support networks• Illuminating the problem by bringing the consequences into the open

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How do we achieve this at LHSC?

• Zero tolerance policy for Code of Conduct

• Staff educational in- services regarding

conflict and resolution strategies

• Unit council development

• Mentorship and preceptorships for new staff and students

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Everyday,In every interaction

We either approve of the old scriptOr write a new way

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It starts with me…..

• Familiarize myself with the code of conduct

• Treat all persons in the workplace with dignity and respect and avoid any conduct which might constitute harassment or discriminatory behavior

• Report incidents of harassment or discriminating that has been experienced or witnessed to management

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Resolving Issues or Dealing with Difficult Situations……

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How do I deal with Issues of Inappropriate behavior?• Assess the situation• What is the severity of the incident?• Is it something you feel comfortable responding to on your own?

• Would you feel more comfortable having a leader or an HR representative respond to the issue?

• Is it in violation of the harassment, abuse or privacy policies?

• Does it involve a patient?

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Is it something you feel comfortable responding to on your own? • Give feedback directly

• Firmly tell the person that his/her behavior is not acceptable and ask them to stop

• Do not retaliate

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How should I structure the conversation?• Opening statement:

Clearly name the issue,Select specific examplesDescribe your emotions about the issueClarify what is at stake if the behavior or situation does not changeIdentify your contribution to this problem Indicate your wish to resolve the issue togetherInvite your colleague to respond

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Then….

• Inquire into your colleague’s point of view and perspective on the issue

• Use paraphrasing and a perception check• Dig for full understanding• Make sure that your colleague feels as though they have been heard and that you fully understand and acknowledge his/her position and interests

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You then should collaboratively seek resolution of the issue by:• Summarizing what you have learned in the discussion and where you are now

• Determining if anything has been left unsaid that needs saying

• Clarifying what is needed to resolve the issue and determining how you can move forward from here given your new understanding of the issue

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Finally, make an agreement to move forward andresolve the issue ensuring that it is clearlydetermined how you will hold each other

responsible for keeping the agreement and how youfollow-up and follow-through with one another.

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What if they are not receptive to my feedback?

• Interrupt the conversation firmly but politely

• Tell the person that you:Do not like the tone of

the conversationWill not tolerate being spoken to in that wayWill end the conversation if necessaryAsk the person to leave or leave yourself

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If the behavior continues or escalates, you should….

• Report the matter to one of the following as soon as possible following the incident:Your immediate managerThe immediate manager of the individual whose behavior is in questionA Human Resource ConsultantA union representative

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Is it in violation of the harassment, abuse or privacy policies?• You will need to report the incident to one of the following as soon as possible:Your immediate managerThe immediate manager of the individual whose behavior is in questionA Human Resources ConsultantA union representative

Depending on the severity you may be asked to describe the complaint in writing

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Tips

• Keep a factual journal or diary of daily events

• Record: date, time, what happened in as much detail as possible, the names of the witnesses and the outcome of the event

• Keep copies of any letters, memos, e-mails etc from the person

• Do not retaliate

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Will the information be kept confidential?• To protect the interests and reputation of the parties, confidentiality will be maintained throughout the investigatory process to the extent practical and appropriate under the circumstances

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What is the leader’s responsibility?

• Acts as an advisor to the complainant by:Providing a copy of the Code of Conduct and supporting policies to the complainantAddressing any concerns regarding personal safety and assuring that the hospital will not tolerate retaliation for complaintsOffering supportDocumenting the allegations and the evidenceReviewing the hospital’s obligations to investigate potential incidents of harassment that it is aware of

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Continued…..

Informing the complainant of the right to file a complaint with the Ontario Human Rights Commission or any other applicable governing body or college and where appropriate, to pursue the matter with the policeAsking the employee what she or he prefers as a remedy for the situation

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If further action is required;

• The person initiating the complaint may request that the hospital resolve the matter informally

• The complainant must be prepared to be identified to the respondent and for the complainant to be discussed with the respondent

• The HRC or another appropriate member will initiate an investigation in conjunction with the Officer Responsible and the following actions will be taken

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Actions Taken…

Meet with the respondent or representative to discuss the allegations and obtain response

Mediate a mutually acceptable resolution between parties

Provide the respondent with a copy of the policy

Take appropriate corrective, interim and/or disciplinary measures, if warranted

Meet with any witnesses

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In addition…

• The complainant may not wish to proceed with further action under the policy. (This does not obviate the hospital from its obligations to proceed)

• The Advisor may feel that further action under the policy is not appropriate because the matter is not within the scope of the policy, or it has been addressed appropriately or the complaint has been determined as frivolous, malicious or in bad faith, or unreasonably delayed in being reported

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Does it involve a patient?

• Refer to the following policies:

• Adult Patient Abuse Procedures

• Abuse involving a Child

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“I remain convinced that a transformationmust take place in nursing, a transformationin the hearts and minds of individual nursesthat ultimately creates peace and harmony

in our relationships with one another. Ifwe do not link arms to face today’s

formidable challenges, nursing’s futurecould be in jeopardy”

- S. Thomas