OUTCOME
The learner will identify at least one strategy you will implement to help decrease the incidence of lateral violence in nursing.

1.3 contact hours will be awarded for successful completion of this independent study.

This independent study was developed by: Barbara Brunt, MA, MN, RN-BC, NE-BC, FABC. The author and members of the planning committee have no conflict of interest.

DISCLAIMER

Information in this study is intended for educational purposes only. It is not intended to provide legal and/or medical advice.

The Ohio Nurses Association is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation (OBN-001-91).

Expires 11/2020
DIRECTIONS

1.   Please read carefully the below article “Combating Lateral Violence.”

2.   Complete and submit the post-test, evaluation form and the registration form.

The post-test will be reviewed. If a score of 70 percent or better is achieved, a certificate will be emailed to you. If a score of 70 percent is not achieved, a letter of notification of the final score and instructions on how to take second post-test will be sent to you. We recommend that this independent study be reviewed prior to taking the second post-test. If a score of 70 percent is achieved on the second post-test, a certificate will be issued.

If you have any questions, please contact the Ohio Nurses Association’s CE department at info@ce4nurses.org.

Combating Lateral Violence
By Barbara A. Brunt, MA, MN, RN-BC, NE-BC, FABC

Introduction

Lateral violence(LV) and bullying have been extensively reported and documented in the literature, yet this continues to be a problem in healthcare. This article will address current issues with the topic. The review of literature will focus on integrated reviews that highlight the extent of the problem and the impact on patient care. This is a problem that affects all types of nurses, and information on how this affects nursing students, newly graduated nurses, clinical nurses, change nurses, nurse educators, and nurse mangers will be shared. Current research studies on various aspects associated with LV will be reviewed, as well as instruments to measure LV. Finally, various strategies to combat LV will be shared.

There are many definitions relating to incivility, bullying, horizontal violence, and lateral violence. The definitions that will be used in this article are listed below:

Incivility is defined as “disrespectful, rude, or inconsiderate conduct” (Association for Perioperative Registered Nurses [AORN], 2015, p. 3).

Bullying is defined as “repeated, unwanted harmful actions intended to humiliate, offend, and cause distress in the recipient” (American Nurses Association [ANA], 2015, p. 3).

Horizontal Violence (HV) in nursing is defined as “hostile, aggressive, and harmful behavior by a nurse or a group of nurses toward a co-worker or group of nurses via attitudes, actions, words, and/or other behaviors” (Taylor, 2016, p. 1). This definition was chosen as it emphasizes it can initiated by or directed towards either a nurse or a group of nurses.

Lateral Violence (LV) describes behaviors intended to demean, undermine and/or belittle a targeted individual working at the same professional level (Sanner-Steihr & Ward-Smith, 2017). This article will use the term lateral violence to encompass the behaviors of incivility, bullying, and horizontal violence. However, the specific terms used by authors will be included with information about their findings.

Review of Literature
Lateral violence is a huge problem in nursing, and many authors have completed literature reviews that highlighted both the extent of the problem and common characteristics (Bambi et al., 2018; Pfeifer & Vessey, 2017; Roberts, 2015; Sidhu & Park, 2018; Wilson, 2016).

Bambi et al. (2018) reviewed 79 original papers to determine the prevalence and factors related to workplace incivility, lateral violence, and bullying among nurses. Some of the rates they found were very high – the overall percentage of workplace incivility ranged between 67.5 % and 90.4%, with workplace incivility among peers being higher than 75%. Workplace incivility had a high correlation with burnout, emotional exhaustion, absenteeism, cynicism, and poor job satisfaction. There was a much wider range in the reported prevalence of both lateral violence (from 1% to 87.45%) and the prevalence of bullying (from 2.4% to 82%). The authors concluded that workplace incivility, lateral violence, and bullying are widespread in the nursing profession, and that the consequences can be serious for the victims and the organization. Prevention must become a priority.

In a study specific to bullying and LV in Magnet™ organizations, Pfeifer and Vessey (2017) completed a review of 11 articles and found this problem continues to exist and remain a large issue even in Magnet™ settings. It has been postulated that because Magnet™ organizations promote a culture of collegiality and teamwork, they also reduce the occurrence of disruptive behaviors. Their review found prevalence rates of 27.3% to 84.8% for staff nurses. One study found that Magnet™ nurses reported significantly less nursing hostility than non-Magnet nurses, but 48.7 % of Magnet nurses still indicated that they experienced it either daily or weekly. They coded four overarching management themes from the articles, which focused on:
a. Policy development and implementation
b. Education and training
c. Surveillance and reporting
d. Accountability

Given the detrimental nature of LV, it is essential that nurses collaborate to create an organizational culture based upon shared respect and collegiality. By working together, leaders can help to establish a just culture – where nurses feel supported, psychologically safe, and are able to provide high-quality patient care.

Roberts (2015) reviewed 30 years of research on LV in nursing. The most commonly cited theoretical explanation for LV was based on the oppressed group behavior theory described by Freire in 1971. Although there have been many recommendations to change the cycle of LV, Roberts only found two intervention studies in the literature. One focused on a team-building intervention and the other discussed an orientation program encouraging new nurses to use cognitive rehearsal (pre-scripted responses) to shield from LV. The literature verified that LV, bullying, and incivility exist within the nursing workforce. These problems are directly related to patient safety concerns, lack of job satisfaction, and decreased retention. Better clarification of these concepts and their etiology is needed for interventions to be planned, executed, and evaluated. Leadership and empowerment of nurses were necessary to decrease disruptive behaviors.

Nursing students’ curriculum was the focus on an integrated review by Sidhu & Park (2018). They reviewed 61 articles to examine the concept informing educational interventions, skills, and strategies that addressed the bullying of nursing students. Concepts identified included empowerment, socialization support, self-awareness, awareness about bullying, collaboration, communication, and self-efficacy, which all linked to empowerment. Active teaching methods that gave students opportunities to practice skills were the most effective. The authors identified seven specific strategies educators could use to empower nursing students and address bullying on an individual and organizational level.

Wilson (2016) completed a review of 28 articles in the literature on bullying. He concluded that an average of 20-25% of nurses in a range of countries report that they have experienced bullying behavior in their work setting. Common behaviors identified were being humiliated, having information withheld needed to perform their work, and being given unreasonable targets and deadlines to meet. The main impact was psychological distress, depression, and a negative impact on patient care. The authors concluded there needs to be a zero-tolerance attitude and prompt action for colleagues and managers to combat and eradicate bullying behaviors.

Several nursing organizations have developed position statements or toolkits to address this issue. ANA published a position statement on incivility, bullying, and workplace violence, outlining specific responsibilities for both registered nurses and employers (ANA, 2015). AORN published a position statement on a healthy perioperative practice environment, noting that disruptive behaviors such as incivility, bullying, and LV interfere with interprofessional and intraprofessional cooperation and partnerships (AORN, 2015). The American Organization of Nurse Executives and Emergency Nurses Association developed guiding principles and a toolkit to mitigate violence in the workplace (Chappell, 2015). The Joint Commission (TJC) issued a quick safety advisory titled “Bullying has no place in health care” (TJC, 2016) and a sentinel event alert on physical and verbal violence against health care workers (TJC, 2018).

Lachman (2014) noted that disruptive behaviors are a violation of the Code of Ethics for Nurses. The first three provisions explain the fundamental values and commitments of the nurse. Provision one requires that the nurse practices with compassion and respect for the inherent dignity, worth, and unique attributes of every person. Provision 1.5 deals with the relationships with colleagues and others. The principle of respect for persons extends to all individuals with whom the nurse interacts. The nurse maintains compassionate and caring relationships with colleagues and others with a commitment to fair treatment of individuals. Clearly this prohibits nurses from engaging in LV. Collaboration requires mutual trust, recognition and response among the health care team, shared decision making about patient care and open dialogue among all parties. The ANA Code of Ethics provides a guide for quality care and ethical obligations in professional nursing practice in today’s healthcare environment (Brunt, 2016).

Specific groups affected by LV
All groups are affected by LV and much has been written about specific groups. This next section will summarize findings relating to the various groups. General information on observers and enactors will be shared, followed by information related to nursing students, newly graduated nurses, clinical nurses, charge nurses, nurse educators, and managers.

MacCurtain and colleagues (2017) examined bystander responses to bullying and actions that influenced decisions to intervene. Their findings came from an analysis of 2,979 responses from nurses in Ireland. The most pervasive reaction to witnessing incidents of bullying was to discuss it with colleagues. They suggested psychological safety (feeling secure and safe to task risks within the team or organization) influenced bystanders’ perception of safety and influenced their response. Bystanders play a critical role in finding a solution to workplace bullying. Bystander action alerts the perpetrator to their action and others’ reaction to it, creating a potential social pressure (or formal sanctions) to change behaviors. They concluded peer, supervisory, and organizational safety and support are important factors in determining whether the bystander would stand back or step in.

Researchers have suggested that HV may be so integrated in the nursing culture that individual nurses do not recognize it when they witness or experience it. Taylor (2016) studied nurses’ perceptions of HV and identified five themes. These were:
1. Behaviors are minimized and not recognized
2. Fear inhibits all reporting
3. Avoidance and isolation are coping strategies
4. Lack of respect and support
5. Organizational chaos

The findings suggested that interventions must address a range of factors that perpetrate HV within the nursing work environment and consider the complexity of this phenomenon.

After the initial research study, Taylor and Taylor (2017) postulated that nurses do not recognize HV when they witness or experience it and identified an alternative approach to address this issue as part of a qualitative research study on enactors of horizontal violence. Observation, document review, and semi-structured interviews in two inpatient hospital units were conducted in 2012, which identified three distinct types of enactors of HV. These were the pathological bully, the self-justified bully, and the unprofessional co-worker. They found that the unprofessional co-worker was the most frequent type and found those behaviors in every period of observation lasting more than a couple hours. Behaviors included eye-rolling, gossiping, face-making and shouting or using a condescending tone of voice. Nurses socialized to accept these behaviors as part of the job may not recognize them as aggressive. They indicated resources should be redirected towards addressing some of these lower-level behaviors and developing instruments to measure these enactor types.

Experiences with LV do not begin once an individual becomes a nurse but start in nursing education programs. Bowllan (2015) and Courtney-Pratt and colleagues (2017) described nursing students’ experiences with bullying. Bullying impacts students’ self-esteem, ability to learn, and capacity to positively socialize to the profession of nursing. Prevalence varied from 44% to over 95%. Perpetrators included clinicians, facilitators, academic educators and fellow students. This undermined students’ confidence and perception of competence and led them to question their career choice. Strategies identified by nursing students to cope with or manage the bullying included avoidance, trying to “just survive,” as well as seeking support from trusted academic staff, family and friends. Courtney-Pratt and colleagues (2017) concluded that reporting structures and support strategies need to be reexamined and resilience training is imperative. Additional interventions identified by Bowllan (2015) included assisting students with insight into the prevalence and nature of bullying behaviors, teaching coping skills to deal with these, providing opportunities for students to discuss the impact of bullying, and performing self-reflective exercises to enhance awareness about their personal and professional value systems. Furst (2018) explored nursing students’ experience with LV and its impact on career choice satisfaction and found a significant negative correlation between experiences of LV and career choice satisfaction.

Two authors described specific educational interventions to help nursing students deal with this problem. Gillespie et al. (2017) described the development of a multicomponent, multiyear educational program for nursing students. It included the following components:
1. A 25-slide web-based voiceover presentation intended to be viewed annually by all junior and senior nursing students as part of their annual mandatory training.
2. A 10-slide, classroom-based guided assessment for junior students during the fall semester.
3. A practicum-based debriefing guide to be used by faculty members teaching junior or senior level nursing clinical practice.
4. A classroom-based role play simulation developed for fall semester senior level nursing students.

Responses from students and faculty involved in the pilot program indicated the need to incorporate the program into additional nursing courses beginning during the sophomore year of the curriculum.

Palumbo (2018) studied incivility in nursing education and proposed using an e-learning module that was developed to help educate nursing students on how to recognize incivil behaviors within themselves, as well as others, and ways to combat it. Using a pretest/posttest model, results showed the nursing students obtained increased self-efficacy in their ability to define, direct, and combat actions. Incivility and ways to intervene were presented using voice-over slides, video scenarios, and embedded quizzes. Students were provided example of incivility in numerous formats including written, verbal and non-verbal forms and were provided with a code of conduct. This module could serve as a model and template for schools of nursing to help provide effective education and help in the eradication of academic incivility for future generations of nurses.

Numerous studies on LV with newly licensed nurses across the globe have been published. Studies from Iran, South Korea, Canada, and the United States addressed this problem. Ebrahimi et al. (2017) explored the Iranian nurses’ use of LV against newly graduated nurses through a qualitative study. They identified four categories of violence during their analysis: psychological violence, verbal violence, physical violence, and source of violence. In their study they interviewed experienced nurses who themselves committed workplace violence or witnessed it against newly graduated nurses. Recommendations included preparation of nurses for supporting newly graduated nurses, training newly graduated nurses how to deal with LV, holding sessions with nurses and newly graduate nurses, ensuring access to support and evaluation of behaviors of staff toward them by leaders, and identifying and resolving causes of violence such as staff shortages, and improper management.

Other authors (Rush, Adamack, Gordon, & Janke, 2014) focused on transition programs to support new graduates. They examined the relationships between access to support, workplace bullying and new graduate nurse transition within the context of new graduate transition programs. As part of a mixed-methods study, 245 new Canadian graduates completed an online survey approximately one year after starting employment as a registered nurse (RN). In this study 39% of the respondents indicated they experienced bullying or harassment and indicated the greatest need for support was at 1-3 months. The authors found that participation in a formal transition program improved access to support and transition for bullied graduate nurses and suggested these programs include bullying prevention strategies as well as education/training for preceptors, unit staff, and mentors to ensure they understood how to be a helpful resource for new graduate nurses.

New nurse retention was the focus of two articles. Chang and Cho (2016) examined the relationship between workplace violence and job outcomes and Weaver (2013) studied the effects of HV and bullying on new nurse retention. Chang and Cho defined workplace violence to include physical, verbal, sexual and emotional abuse. They reported on the first phase on a longitudinal study tracking RNs for 3 years. Almost 60% of the 312 respondents indicated experiences with verbal abuse and over 25% of the respondents had experienced bullying behaviors. Job satisfaction, burnout, commitment to the workplace, and intent to leave were the job outcomes measured. Verbal abuse and bullying were found to have a strong negative association with job outcomes. Their study suggested that improving workplace safety by managing workplace violence could significantly affect the job outcomes of newly licensed nurses.

Weaver (2013) examined the effects of HV and bullying on newly graduated nurses and described potential strategies to break the chain of violence. The consequences of interpersonal violence included financial loss for hospitals and negative psychosocial effect and poor retention of new graduate nurses. To combat this problem individual nurses and healthcare organizations need to develop appropriate interventions. Education and mentoring may help but ultimately it is the responsibility of the individual to police his or her actions and refrain from participating in interpersonal conflict. For issues of HV to be eliminated, individuals must be willing to report incidences, so they can be addressed. Zero-tolerance policies can prevent bullying and HV but must be enforced to be effective.

As noted in the literature, LV is pervasive among all nurses, and numerous authors have studied this among clinical nurses. Zhang et al. (2017) studied 3,865 nurses from 28 hospitals in China and found that verbal abuse was the most prevalent form of violence at 61.25%. They found that nurse who have less experience, work a rotating roster, work in emergency or pediatric departments, have low empathy levels, and who work in poor nursing environments have greater odds of experiencing violence. They suggested that nurse leaders provide or enhance support for clinical nurses.

Myers et al. (2016) explored 126 clinical nurses’ experiences with HV in three diverse non-affiliated organizations within the United States. Respondents identified HV at all organizational levels, including individual, group/unit, supervisory/administrative, and institutional. The authors identified solutions to HV, including education/training, having/showing respect, being accountable, communicating appropriate behaviors, and intervening as necessary. Nurse managers need to continue to address HV by using a variety of known tactics, as well as adopting new evidence-based interventions as they are identified. In addition, they concluded that professional nursing organizations should continue to disseminate antibullying messages.

Predictors of nurses’ experience of verbal abuse was studied by Keller, Krainovich-Miller, Budin, and Djukic (2018). They examined individual, workplace, dispositional, contextual, and interpersonal predictors of RNs’ reported experiences of verbal abuse from RN colleagues in a secondary analysis of a larger research study. Their sample of 1,208 nurses in this study found significant predictors of RNs’ experience of verbal abuse by RN colleagues in all categories. One individual (marital status), three workplace characteristics (setting, schedule, and role), as well as one dispositional (negative affectivity), one contextual (organizational constraint) and two interpersonal factors (distributive justice and workgroup cohesion) were significant predictors of RN’s experience of verbal abuse by RN colleagues. They concluded that leaders, in collaboration with clinical nurses, might consider practice approaches to remove organizational constraints and increase group cohesiveness.

One multi-intervention strategy to minimize HV in the acute care setting for clinical nurses was described by Parker et al. (2016). Evidence-based interventions to create a nurse-led culture to address HV included policies, behavioral performance reviews, and staff/manager educational programs. They implemented organizational, leadership, and individual interventions, beginning with an educational program involving unit and departmental council leaders to share knowledge and raise awareness of the dynamics and prevalence of HV among staff and to develop a plan to minimize HV at the unit level. The Force of Excellence Day Away retreat was attended by unit-based Magnet™ champions, leaders of unit councils (staff nurses, unit managers and nursing directors), nursing professional development practitioners, and the Chief Nursing Officer. Individuals who attended the retreat were expected to take the information back to their home unit. To sustain the initiative, the nursing shared governance structure allowed for ongoing discussion and incorporation of tips, adjustments and best practices. At the organization level, there was top-down, bottom-up commitment to zero tolerance of HV and clear performance expectations to ensure sustainability. Individuals were encouraged to use the phrase “Remember the Promise” as universal messaging to hold peers accountable and curtail negative behavior.

Another group affected by HV is charge nurses. Longo, Cassidy, and Sherman (2016) collected data from a convenience sample of 366 charge nurses and found they also regularly experienced HV. As nurse manager administrative responsibilities have expanded, they depend on charge nurses to assume responsibility for quality outcomes and to help meet the increasing number of organizational performance measures. As a result, the charge nurse has a strong influence on the health of the work environment and the quality of care provided in patient care areas. The most frequent type of HV experienced by charge nurses was inappropriate emotional and verbal behaviors from other nurses. To properly address HV, charge nurses need to be empowered. Education and administrative support are essential elements needed by the charge nurse. Longo et al. (2016) concluded a shared organizational vision for a healthier work environment would contribute to the quality and safety of patient care.

Nurse educators can help combat LV in both the educational and clinical setting. Sanner-Steir and Ward-Smith (2017) conducted a review of the literature to determine the potential for nursing faculty to change the cycle of lateral violence. From their review, they recommended three main strategies for nursing faculty to use to reduce incidence of LV and help students manage this phenomenon. First, curricular content should address integrating LV content into simulation experiences and facilitating that knowledge into clinical experiences. Second, codes of conduct should guide behavior for both students and faculty. Finally, as role models, faculty should be aware of their own behaviors, role modeling respectful communication, facilitating a courteous academic environment, and developing nurses capable of identifying and appropriately responding to LV. These same strategies can be used by nursing professional development (NPD) practitioners in the clinical setting.

In another study, Sanner-Steihr (2018) explored the impact of a cognitive rehearsal intervention of nursing students’ self-efficacy to respond effectively to disruptive behaviors. A total of 129 nursing students enrolled in their final academic year participated in this study. Data were collected immediately prior to and following the education, and again at three months. Measures of self-efficacy and knowledge remained significantly increased three months after the intervention compared to pre-test. She concluded cognitive rehearsal interventions can increase self-efficacy to respond to disruptive behaviors with sustained effects up to three months later. Her findings confirm the need for educators to provide response strategy education in curricula.

Managers play an important role in holding staff accountable for LV behaviors and several authors examined various factors related to leadership style, as well as specific interventions. Kaiser (2017) examined the impact of leadership styles on the reported rates of nurse-to-nurse incivility.
There were 237 participants defined as “staff nurses” who participated in this study. Transformational leadership style had the strongest correlation with low levels of incivility. Staff input and leaders/staff teamwork also influenced staff incivility. Although their data found an association between leader behaviors and the levels of incivility among nurses, there is no clear indication that leadership style directly relates to the levels of incivility among nurses. Rather, data indicate that leadership behaviors such as staff empowerment and relational factors can be a vehicle to positively impact nurse-to-nurse relationships.

Olender (2017) looked at the relationship between, and factors influencing, staff nurse perceptions of nurse manager caring (NMC). She assessed 156 staff nurses self-report of NMC and their exposure to negative acts. As staff nurses’ perceptions of NMC increased, their perception of exposure to bullying significantly decreased. Her study highlighted the importance of caring leadership to reduce exposure to bullying behaviors. The data lend support to the idea of educating nurse managers relating the application of caring behaviors to support staff at the point of care.

Instead of looking at manager characteristics, Skarbek and colleagues (2015) examined which manager interventions were deemed to be effective and what environmental characteristics cultivated a healthy, caring work environment. This qualitative study identified four themes: (a) awareness, (b) scope of the problem, (c) quality of performance, and (d) healthy, caring environment. Findings indicated mandated antibullying programs were not as effective as individual manager interventions. Systems must be in place to hold individuals accountable for their behavior. Communication, collective support, and teamwork are essential to create environments that lead to the delivery of safe optimum patient care.

Research Studies on Factors Associated with LV
This next section will outline some research studies on various results associated with HV, such as intent to help, intent to leave, psychological distress, teamwork, job satisfaction, med errors, and impact on nurses’ health.

Baez-Leon and colleagues (2016) explored factors influencing intention to help and helping behavior in witnesses of bullying in nursing settings. Three hundred and thirty-seven witnesses completed self-report measures of variables predicting intention to help and helping behavior. There was a large amount of evidence from research on bullying that suggested that witnesses can greatly influence both the onset and development of bullying. Five measures were developed to examine several variables that might function as predictors of intention to help and helping behavior. These were guilt, tension, identification with the work group, support to peers’ initiative to intervene, and absence of fear retaliation. Participants reported intention to help was propelled by feelings of tension, group identify, support to peer’s initiative and absence of fear or retaliation. Helping behavior, however, was only driven by the absence of fear of retaliation. Fear of retaliation seems to be a factor preventing witnesses from acting to help victims, and this should be taken into consideration when designing and implementing policies against bullying.

Intent to leave due to perceptions of HV in staff nurses was studied by Armmer and Ball (2015). A random sample of 104 registered nurses from a Midwestern hospital completed a demographic information form, the Briles’ Sabotage Savvy Questionnaire (BSSQ) and the Michigan Organizational Assessment Questionnaire (MAOQ). Correlations indicated a significant positive relationship between perceptions of HV and intent to leave. Results also indicated the longer nurses were employed the more likely they were to perceive themselves as victims of HV. Younger nurses indicated more willingness to leave a position due to perceived HV than older nurses. Strategies to address to impact of HV are needed. Workplace strategies could include mentoring, ongoing assessment of organizational climate, and zero tolerance for HV.

Berry et al. (2016) reported phase one study results examining the relationship of psychological distress and workplace bullying (WPB). The study was designed to determine the differences in perceived stress, anxiety state, and posttraumatic stress symptoms using workplace bullying exposure levels and select nurse characteristics. Participants completed the Negative Acts Questionnaire (NAQ), a Perceived Stress Scale, a state anxiety scale, a Posttraumatic Stress Disorder Checklist (PCL-C), and a demographic questionnaire. Almost one-third of the respondents in this study reported WPB behaviors at least twice weekly, with almost 60% feeling targeted and unable to defend themselves. WPB was linked to stress, anxiety, and posttraumatic stress symptoms unrelated to the demographic characteristics. Nurse leaders need to coach nurses on professional expectations to address WPB behaviors.

The impact of teamwork on WPB was studied by Logan and Malone (2017). In this study 128 nurses in two hospitals completed three surveys: attitude about team work survey, team characteristics survey, and negative intention questionnaire. Nearly all respondents agreed or strongly agreed that a team approach is an effective method for providing patient care, that the team approach results in better care, that communication is essential, and that each member needs to spend time and energy to make the team work. Thirty-one percent of the respondents reported experiencing WPB in the 6 months preceding the survey. They found the presence of team characteristics such as leadership, communication, cooperation, balanced participation, and conflict resolution related to low levels of bullying. Nurse managers can promote effective teams and reduce bullying by designing and implementing relevant policy and training.

The mediating role of peer relationships between HV and job satisfaction was described by Purpora and Blegen (2015), in addition to the association between nurse and work characteristics and job satisfaction. An anonymous four-part survey of a random sample of 175 RNs in California provided the data. A statistically significant negative relationship was found between HV and peer relationships and job satisfaction and a statistically significant positive relationship was found between peer relationships and job satisfaction. Data suggest that peer relationship can attenuate the negative relationship between HV and job satisfaction. The authors concluded that leaders should consider peer relationships as an important factor when considering effective interventions that foster hospital nurses’ job satisfaction in the presence of HV.

The impact of LV and bullying on patient care has been a topic of numerous studies. Wright and Khatri (2015) looked at the relationship with psychological/behavioral responses of nurses and medical errors in relation to bullying behaviors. They compared three types of bullying (person-related, work-related, and physically intimidating) with the outcomes of psychological/behavioral responses and medical errors. Health care organizations need to reduce negative components that impact nurses’ job performance and their mental and physical health. The sample included 241 participants who completed the Negative Act Questionnaire-Revised, and outcomes were measured with a modified version of Rosentein and O’Daniel’s job performance scale. Person-related bullying showed a significant positive relationship with both psychological/behavioral responses and medical errors, while work-related bullying showed a significant positive relationship with only psychological/behavioral responses. Physically intimidating bullying did not show a significant relationship to either outcome. Health care organizations should identify bullying behaviors and implement bullying prevention strategies to reduce these behaviors and the adverse effects they have on outcomes.

Sauer and McCoy (2017) examined the impact of bullying on nurses’ health. Their sample of 345 nurses licensed in one state completed questionnaires on demographics, bullying, physical and mental health, stress, and resilience. In this sample 40 % of nurses were bullied, and a higher incidence of bullying was associated with lower physical health scores and lower mental health scores. Nurses who were bullied had significantly higher stress scores and significantly lower resilience scores. This can decrease the nurses’ quality of life and impede their ability to deliver safe, effective patient care.

The effect on patient care and patient safety was furthered described in an integrative review by Houck and Colbert (2017). They examined 11 studies that made an association between perceived WPB and patient safety. Seven themes were identified that harmed patients or posed a risk to patients, which were: 1) patient falls, 2) errors in treatment or medication, 3) delayed care, 4), adverse event or patient mortality, 5) altered thinking or concentration, 6) silence or inhibits communication, and 7) patient satisfaction or patient complaints. The results of these studies indicated that WPB in the work environment jeopardized patient safety. Participants perceived WPB as a threat to safety in 9 of the 11 studies. It is crucial to understand the association between WPB and patient safety so that effective policies and interventions can be developed that support a change in the culture of healthcare to one that is respectful of all individuals.

Purpora and Blegen (2012) developed a conceptual model to illustrate how the quality and safety of patient care could be affected by HV. In their model peer communication is hypothesized as one of many important contributions to protecting patients from harm and is positively related to the quality and safety of patient care. Safety needs and psychological noise provide the link between HV and peer communication. Using safety needs and psychological noise to link them, the proposition is that HV is negatively related to peer communication; that is, as HV increases, peer communication decreases. This model was supported in a study conducted by Purpora, Blegen, and Stotts (2015). HV was inversely related to peer relations and quality of care, and positively related to errors and adverse events. Including peer relations in the analyses altered the relationship between HV and quality of care but not between HV, errors, and adverse effects. Supportive peer relationships were important to mitigate the impact of HV on quality of care.

Instruments
The most common instruments used to measure LV in nursing are the Negative Acts Questionnaire-Revised developed by Einarsen, Hoel, and Notelaers (2009), the Horizontal Violence Scale (Longo & Newman, 2014) and Lateral Violence in Nursing Survey (Nemeth et al., 2017).

The NAQ-R is an instrument designed to measure nurses’ perceptions about the prevalence of HV in their workplace. This 22-item scale asked nurses how frequently they had experienced negative behaviors such as “being exposed to an unmanageable workload” or “being humiliated or ridiculed in connection with your work” within the six months prior to survey completion. Response choices ranged from 1 (never) to 5 (daily). Overall scores were summed with a total possible score ranging from 22 to 110. The higher the score, the more often nurses experienced negative acts in their workplace.

The Horizontal Violence Scale (HVS) is a 23-item 4-point Likert scale used to determine the existence and extent of HV in practice settings. It can be used to augment the study of the work environment, especially in relation to healthy work environments. Longo and Newman (2014) described the development and psychometric testing of this scale, including content validity, construct validity, and results of the testing of the instrument.

Nemeth et al. (2017) described the development and validation of the Lateral Violence in Nursing Survey (LVNS). The LVNS is a 23-item survey focusing on the prevalence and seriousness of LV, causes and other aspects of LV within the workplace. This could provide leaders with an evidence-based tool to assist with retention and developing a positive unit tone. The LVNS can be used to validate the prevalence and seriousness of LV on a nursing unit or within an entire nursing service.

Strategies to Combat Lateral Violence
The next section will review specific strategies identified to deal with LV. There has been a plethora of literature addressing ways to deal with this issue.

Castronovo, Pullizzi and Evans (2016) proposed a unique solution to deal with nurse bullying behaviors in the workplace. They believe to resolve the problem of nurse bullying the solution must include an incentive for institutions to implement the necessary interventions and to ensure they are effective. Currently the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) has a survey which measures patients’ perceptions of hospital care. The authors proposed a national standardized measurement tool be developed and implemented pertaining to the level of nurse bullying and that it be factored into the calculation of the value-based incentive payment in the Hospital Value-Based Purchasing program. A survey like the HCAHPS could be developed to measure nurses’ perspectives of workplace bullying. They further proposed that the outcome of the surveys be made available to the public as an added feature on the Hospital Compare website, which is currently used with respect to HCAHPS.

One of the strategies proposed by Egues and Leinung (2013) included education. Workshops, evaluated through pretests/posttests and written evaluation, revealed increased knowledge about concepts of LV and their application to the workplace, recognition of LV, and methods of dealing with LV in nursing. Other strategies included conscientiously and consistently role modeling exemplary behaviors, engaging in personal self-reflection, drafting policies for prevention and reporting, working as a team, and taking care of oneself. Changes to address and strategize against LV must be supported.

Cognitive rehearsal as an intervention against incivility and LV has been discussed by several authors. Dr Griffin first described it as an intervention in 2004 and updated the literature and reviewed the use of cognitive rehearsal as an evidence-based strategy ten years later (Griffin & Cark, 2014). She defined cognitive rehearsal as a behavioral technique consisting of three parts:
 Participating in didactic instruction about incivility and LV
 Identifying and rehearsing specific phrases to address incivility and LV
 Practicing the phrases to become adept at using them

The use of this strategy has been replicated in subsequent studies and found to be an effective way to prepare nurses to identify and address incidents of LV. Cognitive rehearsal can take on various forms. For example, the TaemSTEPPS approach (Agency for Healthcare Research and Quality, 2014) is a communication tool designed for healthcare professionals which provides an evidence-based framework to improve patient safety within healthcare organizations. CUS, an acronym for Concerned, Uncomfortable, and Safety is one communication structure provided by Team STEPPS. This can be adapted for cognitive rehearsal by the following response: “I am Concerned about the tone of this interaction. I am Uncomfortable and beginning to feel stressed. I’m worried that my discomfort and stress may impact the Safety of our patients. Please address me in a respectful way.” (Griffin & Clark, 2014, p. 7).

Koh (2016) also addressed the use of cognitive rehearsal as a strategy to manage WPB. He completed a literature review of 9 articles published from 2005 to 2015 and suggested that cognitive rehearsal scripted responses empowered nurses with knowledge and confidence to manage workplace violence. He found it to be an effective individual tool for enabling individuals to protect themselves against workplace violence.
Effective policies are required to deal with bullying behaviors. Johnson (2015) focused on policy development based on suggestions from research and practice to craft effective anti-bullying policies. She suggested including representatives from the various groups who will be affected by the policies, to allow them an opportunity to comment to provide buy-in. Successful policies are clear and concise, and contain the following elements: an introduction, an outline of the roles and responsibilities of organizational members in workplace bullying management, and the actions that employees and managers can take in response to workplace bullying. Policies are only effective if members of the organization are aware of them and utilize them. Support for policies needs to come from all levels of administration, and education needs to recur frequently.

Keller, Budin, & Allie (2016) described how a task force to address bullying was used to implement an antibullying program. Nursing leadership at a Magnet™-designated academic medical center identified bullying as a priority that needed to be addressed, since the current policy and anonymous hotline for reporting behaviors were not effective. Twenty staff nurses and nurse leaders across the organization volunteered to join the group. They surveyed nurses with the NAQ-R to assess the current state. Results were consistent with findings from other studies. Results were shared with staff and an educational module was developed to put on the hospital’s online learning platform. They developed a “BE NICE” Champion Program. This acronym stood for:
 Bullying
 Elimination
 Nursing
 In a
 Caring
 Environment

The purpose of the program was to provide participants with the tools needed to identify signs of bullying, support peers, and ultimately eliminate bullying in the workplace. This 3 to 4-hour, face-to-face program, led by task force members, included presentation, demonstrations, role-playing, and opportunity for practice. The bullying intervention strategy used was called the 4Ss: stand by, support, speak up, sequester. Two one-hour follow-up sessions were held six months after the initial program to allow champions to discuss their experiences and to assist the task force in prioritizing future directions. The author concluded that although adoption of positions statements and standards of practice has helped health care organizations better address bullying in the workplace, a bullying task force can further foster a healthy and caring work environment.

Using simulation to teach responses to LV was outlined by Sanner-Stiehr (2017). Simulation provided an effective platform for delivering education. Objectives reflected restoring respectful communication and ensuring delivery of safe patient care, which are ultimately compromised when LV occurs. Simulations designed to teach LV response strategies can be presented as stand-alone scenarios or integrated into existing patient care simulations. Debriefing, which allows time for the participants to reflect on their experience, remained the most important step in the process. This allowed participants to apply response strategies learned in the simulation to similar situations. This is a strategy that can be used in nursing education programs, as well as programs for clinical staff.

Taylor and Taylor (2018) indicated that efforts to address HV have not proven effective to date. Context is recognized as a contributing factor, and they suggested moving the focus away from the individual and investigating systems contributions to use existing quality improvement (QI) frameworks. Framing HV as a quality improvement concern meant treating all instances of HV and related behaviors as QI incidents. This requires that all staff have the following:
1. Awareness of HV and the ability to identify interpersonal interactions that have negative personal and/or organizational consequences as potential QI incidents.
2. The analytic tools and skills to conduct root cause analysis of these incidents, and
3. The ability to act based on the root cause analysis including development of interpersonal and intrapersonal skills to address perpetrator, victim/target, and audience/bystander roles, and the ability to identify systems failures contributing to unnecessary workarounds and stress.

They concluded framing HV and related behaviors as a QI concern would allow institutions to use existing QI framework and work within an existing QI culture.

Bartholomew (2014) outlined several best practices to eliminate HV. These included nurturing our young, awareness and prevention, managerial response, organizational opportunities, and individual responses. Education should start in nursing schools and continue with nurse residency programs. Awareness is the key to prevention for all staff members. Managers need to hold staff accountable, being persistence and consistent with their responses. Organizations need a coordinated approach to this issue. Enacting a twofold model (i.e. increasing a healthy environment while simultaneously decreasing hostility) is the most effective approach that managers can take to enact change at the organizational level. Individual nurses need to assess the role they play in ending or perpetuating HV and take an active role in addressing instances of HV.

All of us as nurses need to be aware of the problems related to LV and implement strategies as individuals and in our practice settings to combat this problem. The incidence is not decreasing, despite numerous studies and strategies to combat it. Lateral violence is detrimental to patient safety and should not be allows to continue. This is a serious problem and it is imperative that the profession addresses this problem. Nurses, individually and collectively, must enhance their knowledge and skills in managing conflicts and promote workplace policies to eliminate LV.

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