Ethics^ Law,and Policy

Ethical Issues in the DisruptiveBehaviors of Incivility, Bullying, and

Horizontal/Lateral Violence

T he Joint Commission (2008) stated, "Intimidatingand disruptive behaviors can foster medical errors,contribute to poor patient satisfaction and to pre-

ventable adverse outcomes, increase the cost of care, andcause qualified clinicians, administrators and managersto seek new positions in more professional environ-ments" (p. 1). With the new Medicare reimbursementmechanisms for hospitals, these issues of cost, safety, andpatient satisfaction become even more crucial to address.Yet various kinds of disruptive behaviors - incivility, bul-lying, horizontal/lateral violence - still are tolerated inmany health care settings (Rosenstein & O'Daniel, 2005;Wilson, Diedrich, Phelps, & Choi, 2011).

The majority of clinicians enter their chosen disciplinewith a strong interest in caring for patients. Nurses' ideal-ism and professionalism can be undermined by theallowed presence of individuals who create an unhealthyor even hostile work environment. In this article, the eth-ical issues and ethical justifications for zero tolerance forthese dismpfive behaviors are described. After types ofdisruptive behaviors are defined and the prevalence dis-cussed, the focus will shift to the ethical issues and justi-fications for change for the individual nurse and for thehealth care organization. Four suggested practical changestrategies are provided.

Examples of disruptive behaviors are throwing objects,banging down the telephone receiver, intentionally dam-aging equipment, and exposing patients or staff to con-taminated fluids or equipment. In Figure 1 the types ofdisruptive behaviors are defined and other key behaviorsare outlined. The overlap of behaviors in the literaturemakes it difficult to separate the individual's actions intodifterent types, as overlap will be noticed (Read &Laschinger, 2013). However, bullying is beyond theambivalent disrespect of incivility because it is intention-al, intense mistreatment that targets particular individu-als or groups (e.g., nurses' aides, novice nurses). Someauthors consider these two disruptive behaviors as formsof horizontal/lateral violence (Purpora, Biegen, & Stotts,2012).

Vicki D. Lachman, PhD, APRN, MBE, FAAN, is President, V.L.Associates, a Consulting and Coaching Company, Philadelphia, PA.She serves on the American Nurses Association Ethics and HumanRights Advisory Board.

Prevalence of ProblemAlthough the prevalence of various types of disruptive

behaviors is unknown, some research suggests the wide-spread nature of this ethical issue. "A survey on intimida-tion conducted by the Insfitute for Safe MedicationPractices found that 40% of clinicians have kept quiet orremained passive during patient care events rather thanquestion a known intimidator" (Institute for SafeMedication Practices, 2003, p. 4). Recent reports show39% of graduates in their first year of practice witnessedbullying (Laschinger, 2011), and 31% experienced bully-ing (Laschinger & Grau, 2012). In a statewide survey ofSouth Carolina nurses on the issue of horizontal violence,more than 85% of respondents reported being victims,with experienced nurses often listed as perpetrators(Dulaney & Zager, 2010). Wilson and colleagues (2011)also found 85% of nurses had experienced horizontal/lat-eral violence.

Disruptive Behaviors are A Violation of theCode of Ethics for Nurses

The Code of Ethics for Nurses (American NursesAssociation [ANA], 2001) is the profession's nonnego-tiable ethical standard. Its first three provisions define themost essential values and commitments of the nurse,with four interpretative statements that are relevant toethical issues surrounding disruptive behaviors. Each willbe presented and ethical justification for change present-ed.

1.5 Relationships with Colleagues and OthersThe principle of respect for persons extends to all indi-viduals with whom the nurse interacts. The nursemaintains compassionate and caring relationshipswith colleagues and others with a commitment to fairtreatment of individuals, to integrity preserving com-promise, and to resolving conflict (ANA, 2001, p. 9).

This statement further emphasizes the standard ofconduct prohibits any form of harassment or intimidat-ing behavior and the expectation that nurses will valuethe unique contribution of all individuals. Clearly, state-ment 1.5 strictly prohibits nurses ftom engaging in inci-vility, bullying, or horizontal/lateral violence.

56 lanuary-February 2014 • Vol. 23/No. 1 M E D S U R GISTTJHs IiSTG.

Ethical Issues in the Disruptive Behaviors of Incivility, Bullying, and Horizontal/Lateral Violence

FIGURE 1.Definition and Key Behaviors

Type

incivility

Bullying

iHorizontal/LateralViolence

Definition

Lack of respect for others• Psychoiogical in nature• Low-intensity, rude, or

inconsiderate conduct• Unclear intent to harm target

• Repetitive behavior thathappens a minimum of twicea week

' Long-term behavior thatcontinues for a minimum of6 months

• Targeted person finds self-defense difficult and cannotstop the abuse

"Unkind, discourteous.antagonistic interactionsbetween nurses who work atcomparable organizationallevels and commonlycharacterized as divisivebackbiting and infighting"(Alspach, 2008, p. 13).

Key Behaviors | Sources

• Rude comments• Offensive or condescending

language• Name calling• Public criticism• Ethnic or sexual jokes• Screaming• Attacking a person's integrity• Disregard for

interdisciplinary input aboutpatient care

• Persistent hostility• Regular verbal attacks• Repeated physical threats• Refusal to assist with duties• Write retaliatory comments

about the nurse to nursemanager

• Taunting the nurse in front ofothers

• Speaking negatively aboutthe nurse to administrators

• Complaints shared withothers without firstdiscussing with theindividual

• Sarcastic comments• Withholding support• Ignoring or discounting

individual's input• Insulting, condescending.

patronizing behaviors

Andersson, Pearson, &Wagner, 2001 ; Felblinger,2009; Read & Laschinger, 2013

Feiblinger, 2009; Lutgen-Sandvik, Tracy, & Alberts, =2007; McNamara, 2012; Read& Laschinger, 2013; Tuckey,Dollard, Hosking, & Winefield,2009

Alspach, 2008

2.3 CollahorationBecause of the complexity of the health care delivery

system, a multidisciplinary approach is needed. "By itsvery nature, collaboration requires mutual trust, recogni-tion, and respect among the health care team, shareddecision making about patient care, and open dialogueamong all parties..." (ANA, 2001, pp. 10-11). Disruptivebehaviors interfere significantly with nurses' intra-profes-sional cooperation and multidisciplinary partnership.

3.5 Acting on Questionable PracticeNurses are expected to recognize and take action con-

cerning any occurrences "of incompetent, unethical, ille-gal, or impaired practice by any member of the healthcare team..." (ANA, 2001, p. 14). Furthermore, nurses areexpected to express their concern to the persons observedwith the questionable practice and, if needed to resolvethe situation, direct their concern to an administrator. Asthe previous two interpretative statements indicate, inci-vility, bullying, and horizontal/lateral violence are con-sidered unethical practice. This interpretative statementalso indicates the organization's ethical responsibility to

have a well-publicized process to address practices thatviolate the expected code of conduct in the organization.

3.6 Addressing Impaired PracticeThis statement views impaired practice as not just sub-

stance abuse problems, but any colleagues "adverselyaffected by mental or physical illness or by personal cir-cumstances" (ANA, 2001, p. 15). This statement alsoidentifies the ethical responsibility of the organization tohave workplace polices that suppori the nurse in the con-frontation and the individual who clearly needs help inmanaging life in a more effective way. Incivility, bullying,and horizontal/lateral violence affect the work climate,job performance, and satisfaction of all who are impactedby such behaviors.

Practical Intervention StrategiesNo one solution exists for the complex problem of

negative human interaction within the organizationalculture. However, the literature suggests ways to preventand address disruptive behaviors. As an organizational

MEDSURGOSTTJIIS IIsTG. January-February 2014 • Vol. 23/No. 1 57

Ethics, Law, and Policy

consultant, I often am involved in helping individualsand leaders deal with disruptive behavior and have foundthese four strategies as crucial.

Standards and Code of ConductThe Joint Commission (2008) Sentinel Event Alert

"Behaviors that Undermine a Culture of Safety" address-es an organization's accountability to develop standards,a code of conduct, and suggestions to eliminate behaviorsthat undercut a culture of patient and staff safety.Standards to make a zero tolerance policy work weredeveloped by the American Association of Critical CareNurses (2004; 2005). The six standards are authentic lead-ership, skilled communication, true collaboration, eftec-tive decision making, appropriate stafflng that matchespatient needs and competencies, and meaningful recog-nition. Authentic leaders do not tolerate incivility andbullying, as they role-model respectful treatment and seethe need for trust between leaders and followers withinthe organization (Read & Laschinger, 2013). Abuse willcontinue unless programs for multidisciplinary skilldevelopment are established and actions are taken byadministrators to institute and enforce zero-tolerance pol-icy. Oftenders need to be disciplined and victims needsupport.

Skill DevelopmentMost participants in the study by Wilson and col-

leagues (2011) had at least a bachelor's degree in nursing,yet nearly 90% noted difflculty confronting someonewho was demonstrating horizontal/lateral violence. Thislack of skill reflects the importance of conflict resolutiontraining for all in the workplace. Many organizationshave developed their own training based on the bookCrucial Conversations: Tools for Talking When the Stakes areHigh (Patterson, Grenny, McMillan, & Switzler, 2012).Others have sent educators to the trainer certificationprovided by VitalSmarts® (2014), a well-known trainingmodel using this book. In my experience many clinicalnurses and nurse leaders lack the needed assertivenessand negotiation skills necessary to deal with disruptivebehaviors in the workplace.

EmpowermentStructural empowerment provides nurses with access

to four structures: information, opportunities, resources,and support (Laschinger, 2008). Empowerment is corre-lated inversely with workplace incivility and supervisorincivility in the general nursing population (Laschinger,Leiter, Day, & Gilin, 2009), as well as to bullying amongnew graduates (Laschinger, Grau, Finnegan, & Wilk,2010). Acts of incivility and bullying are attempts to takepower from others; therefore, structural empowerment isrelated to lower levels of incivility, bullying, and horizon-tal/lateral violence.

Addressing Practitioner ImpairmentHow often is substance abuse, ineftective management

of stress, or mental illness (speciñcally personality disor-ders) at the root of the disruptive behavior? In my 35

years of organizational consulting experience, the answeris "very often" (Lachman, 2012). Abusers habitually feelabove the workplace rules and policies (McNamara,2012). They see themselves as deserving special privilegeand entitled to behave in their chosen way because ofwhat they perceive as incompetent or inefñcient behav-ior of others. They are often excellent clinicians, but theylack insight into how they fail to work well with others.They often respond in a defensive and abusive manner toanyone who challenges their practice, especially whenthe challenge comes from someone they perceive asbeneath them in the organization.

The top-level administrator of this clinician (e.g., CNOor CMO) needs to be involved in resolution of the prob-lem, as abusers will not take seriously any intervention bya person of a lower status. Senior people in the organiza-tion need to be prepared for threats of getting them flred,taking the issue to the Board of Nursing or a local paper,or initiating a law suit. These are the tough cases, but thewillingness of senior administrators to deal or not dealwith these disruptive individuals defines the organiza-tional culture. An ethical culture requires leaders to havethe moral courage to address disruptive behavior, regard-less of who is violating the desired code of conduct.

ConclusionIncivility, bull)áng, and horizontal/lateral violence are

examples of workplace mistreatment that injure individ-ual nurses and the ethical climate of the organization.When these behaviors are allowed, nurse job satisfactionand even retention are aftected. The Code of Ethics forNurses (ANA, 2001) clearly identifles intimidating behav-iors as unethical and describes the individual nurse'sresponsibility to not engage in such behaviors. In addi-tion, this Code recognizes the responsibility of nurse lead-ers to implement and enforce policies, processes, educa-tion to correct the disruptive behaviors.

REFERENCESAlspach, G. (2008). Lateral hostility between critical care nurses. Critieal

Care Nurse, 28(2), 13-19,American Association of Critioal Care Nurses. (2004), Zero tolerance for

abuse position statement Retrieved from http://www,aacn.org/wd/practice/doos/publicpolicy/zero-tolerance-for-abuse,pdf

American Associafion of Critioal Care Nurses, (2005), Standards forestablishing and sustaining healthy work environments: A journeyto exœWenœ. American Journal of Critical Care, 14(3), 187-197,

American Nurses Association (ANA), (2001), Code of ethics for nurseswith interpretive statements. Silver Spring, MD: Author.

Andersson, L,M,, Pearson, CM,, & Wagner, C,W. (2001). When work-ers flout convention: A study of workplace incivility. HumanRelations, 54, 1387-1419,

Dulaney, P, & Zager, L, (2010). Lateral violence: It's time to stop thisblight on our profession. South Carolina Nurse, 77(1), 1.

Felblinger, D.M, (2009), Bullying, incivility, and disruptive behaviors in thehealthcare setting: Identification, impact, and intervention. Frontiersof Health Services Management, 25(4), 13-23.

Institute for Safe Medication Practices, (2003). Results from ISMP sur-vey on workplace intimidation. Retrieved from https://ismp.org/Survey/surveyresults/SurveyO311 .asp

continued on page 60

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Nurses as Educators

Generation X (1965-1980)Because of scheduling demands, learners within

Generation X prefer distance learning that does notrequire classroom interaction. They are comfortable withtechnology and change (Burmss & Popkess, 2012).Therefore, convenience is key to learning in an environ-ment that is enjoyable. This group prefers hands-on activ-ities, role playing, and availability of visual methods(tables, graphics) for learning (Avillion, 2009; Kitchie,2008).

Generation Y (1981-2001)Similar to Generation X, individuals of Generafion Y

prefer a convenient, flexible, and creative environment.Learners are able to multitask and focus more on doinginstead of knowing. Learning is expected to be fun, withimmediate feedback expected. Blended learning andgroup interaction in a structured environment are charac-teristic of this group. In addition, learners are very knowl-edgeable about technology because they have grown upwith it. However, comfort with technology may hindertheir critical thinking skills and ability to prioritize rolesand responsibilities (Burruss & Popkess, 2012).

ConclusionIn developing educational programs and training for

nurses, educators must understand the principles of adultlearning, learning styles, and generational influences onlearning. The learning process is improved when educa-tion is presented with teaching methods that are coordi-nated with nurses' preferred learning styles. When learn-ing needs are met, education is enhanced to promoteunderstanding and retention of information that ulti-mately impacts patient care (Avillion, 2009). CECI

REFERENCESAvillion, A.E. (2009). Learning styles in nursing education: Integrating

teaching strategies into staff development Marblehead, MA:HCPro.

Burruss, N., & Popkess, A. (2012). The diverse learning needs of stu-dents. In D.M. Billings, & J.A. Halstead (Eds.), Teaching in nursing:A guide for faculty (4tU ed.) (pp. 15-33). St. Louis, MO: Elsevier.

Herman, J.W. (2008). Creative teaching strategies for the nurse educa-tor Philadelphia, PA: F.A. Davis.

Kitchie, S. (2008). Determinants of learning. In S.B. Bastable (Ed.),Nurse as educator: Principles of teaching and learning for nursingpractice (3rd ed.) (pp. 93-145). Boston, MA: Jones and Bartlett.

Knowles, M.S., Holton, E.P., & Swanson, R.A. (2012). The adult learner:The definitive classic in adult education and human resourcedevelopment (7th ed.). New York, NY: Routledge.

Ethics, Law, and Policycontinued from page 58

Lachman, V.D. (2012, November 15). Beyond difficult people: Dealingwith personality disorders in the workplace. Paper presented at theShippensburg Chamber of Commerce, Shippensburg, PA.

Laschinger, H.K.S. (2008). Effects of empowerment on professionalpractice environments, work satisfaction, and patient care quality:Further testing the nursing worklife model. Journal of Nursing CareOuality, 23(A), 322-330.

Laschinger, H.K.S. (2011). Job and career satisfaction and turnoverintentions in newly graduated nurses. Journal of NursingManagement, 20(4), 472-484.

Laschinger, H.K.S., & Grau, A.L. (2012). The influence of personal dis-positional factors and organizational resources on workplace vio-lence, burnout, and health outcomes in new graduate nurses:Cross-sectional study. International Journal of Nursing Studies,49(3), 282-291.

Laschinger, H.K.S., Grau, A.L, Finnegan, J., & Wilk, P (2010). Newgraduate nurses' experiences of bullying and burnout in hospitalsettings. Journal of Advanced Nursing, 66(12), 2732-2742.

Laschinger, H.K.S., Leiter, M., Day, A., & Gilin, D. (2009). Workplaceempowerment, incivility, and bumout: Impact on staff nurse recruit-ment and retention outcomes. Joumal of Nursing Management,78(8), 302-311.

Lutgen-Sandvik, P.S., Tracy, J., & Alberts, K. (2007). Burned by bullyingin the American workplace: Prevalence, perception, degree, andimpact. Journal of Management Studies, 44, 837-862.

McNamara, S.A. (2012). Incivility in nursing: Unsafe nurse, unsafepatients. AORN Journal, 95(4). doi:10.1016/j.aorn.2012.01.020

Patterson, K., Grenny, J., McMillan, R., & Switzler, A. (2012). Crucialconversations: Tools for talking when stakes are high (2nd ed.).New York, NY: McGraw-Hill.

Purpora, C, Biegen, M.A., & Stotts, N.A. (2012). Horizontal violenceamong hospital staff nurses related to oppressed self or oppressedgroup. Journal of Professional Nursing, 28, 306-314.

Read, E., & Laschinger, H.K.S. (2013). Correlates of new graduate nurs-es' experiences of workplace mistreatment. Journal of NursingAdministration, 43(4), 221-228.

Rosenstein, A.H., & O'Daniel, M. (2005). Disruptive behavior and clinicaloutcomes: Perceptions of nurses and physicians. AmericanJournal of Nursing, iO5(1), 54-64.

The Joint Commission. (2008). Behaviors that undermine a culture ofsafety. Sentinel event alert, issue 40. Retrieved from http://www.jointcommission.org/assets/1 /18/SEA_40.pdf

Tuckey, M.D., Dollard, M.E., Hosking, P.J., & Winefield, A.H. (2009).Workplace bullying: The role of the psychological workplace envi-ronment factors. International Journal of Stress Management,16(3), 2^ 5-232.

VitalSmarts. (2014). Cnjcial conversation training. Retrieved from http7/www.vitalsmarts.com/products-solutions/crucial-conversations/

Wilson, B.L., Diedrich, A., Phelps, C.L, & Choi, M. (2011). Bullies atwork: The impact of horizontal hostility in the hospital setting andintentto leave. The Journal of Nursing Administration, 47(11), 453-458.

MinutesQuality of Care Is Similar for Safety-Net and Non Safety-Net Hospitals

Safety-net hospitals tend to struggle financiallycompared to their non safety-net counterpartslocated in more affluent areas. Yet findings ftom anew study suggest, despite their financial struggles,safety-net hospitals can achieve equal or even bet-ter outcomes compared to non safety-net hospi-tals. Researchers found similar hospital outcomesfor mortality and re-admission rates amongMedicare patients hospitalized for three conditionsat safety-net and non safety-net hospitals. Themargin of performance, on average, was less thanone percentage point between safety-net and nonsafety-net hospitals.

For more info, see Ross, J.S. (2012). Based on keymeasures, care quality for Medicare enroUees atsafety-net and non-safety-net hospitals was almost

1. Health Affairs, 31(8), 1739-1748.1313

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