A comprehensive systematic review on lateral/horizontal violence in the profession of nursing

Review Questions/Objective The overall aim of this comprehensive systematic review is to synthesise the best available evidence on the experience of lateral/horizontal violence in the profession of nursing and the effectiveness of programs/strategies meant to decrease its prevalence or mitigate its negative effects. Specifically, this review will seek to answer the following questions: What is the experience of being a licensed nurse who is a victim of lateral/horizontal violence? What is the experience of being a student nurse who is a victim of lateral/horizontal violence? What is the impact of experiencing lateral/horizontal violence on job retention and job satisfaction? What are the most effective interventions/strategies for decreasing the prevalence or mitigating the negative effects of lateral/horizontal violence on licensed nurses? Background Lateral/Horizontal (L/H) violence is a widely reported phenomenon in the nursing literature. There are a myriad of definitions but broadly it is defined as nurse-on- nurse aggression, resulting in destructive behavior of nurses against each other. 1,2 L/H violence is the demeaning and downgrading of others with unkind words and cruel acts that often result in a lack of confidence and self esteem in the victims. 3 The American Nurses Association describes L/H violence as any inappropriate behavior, confrontation, or conflict ranging from verbal abuse to sexual and physical harassment between co-workers. 4. L/H violence and the subsequent effects have been reported in the nursing literature for more than 20 years. Attempts to explain this phenomenon has often been influenced by theories of oppression and feminism.Oppression is the use of authority or power by a dominant group to exploit the less powerful or influential.5 Lee and Saeed contend that the foundation of oppression in nursing lies in the political, historical, cultural and economic structures of a particular country. They describe oppression in terms of a system of related constraints, limitations and restrictions, meant to demean others. 6 Other explanations for L/H violence identify the potentiating factors of generational differences leading to variations in value systems and work ethic, and the inherently stressful work of bedside nursing. 7,8, 9 Griffin has identified the following as the 10 most frequent forms of L/H violence in nursing practice: nonverbal innuendo; verbal affront; undermining activities; withholding information; sabotage; infighting; scapegoating; backstabbing; failure to respect privacy; and, broken confidences.10 Hutchinson et al created a topology of bullying behavior: personal attacks meant to attack one's identity and self-esteem; erosion of professional competence; meant to damage another's professional identity; limit career opportunities; and, attack through work roles and tasks meant to obstruct work or make work more difficult. 11 It has long been acknowledged that nurses as a group and a predominantly female populated profession have been oppressed by others perceived as more dominant and powerful, but it appears nurses are likewise capable of oppressing their own. In a study by McKenna et al it was found that new graduates seem to be particularly vulnerable to experiencing L/H violence.12 Reports of covert interpersonal conflict were common. Over half of the participants reported feeling undervalued, over a third reported that they had learning opportunities blocked and were given too much responsibility without support. Overt forms of conflict in the form of direct verbal statements that were rude, abusive, humiliating or involved unjust criticism were also reported.12 In another study by Johnson and Rea (N=249) 27.3% of the participants had experienced bullying in the previous 6 months. Most of the respondents who had been bullied identified their managers or charge nurses as the perpetrators.13 In another study, Kahil reports that the highest prevalence of violence in nursing is at the psychological level and that professional nurses and senior nurse managers were the main category of nurses who mistreated other nurses.14 A study by Randle suggests that student nurses are also vulnerable to experiencing the phenomenon of L/H violence. 15 Students in this study (N=39) described incidents in which their own self-esteem was battered by experienced nurses but equally concerning was they also reported observing some of these nurses bullying patients and felt pressured to follow suit. As a consequence of observing this behavior the students began to question their long held belief that caring was an important value in nursing.15 Some have contended that L/H violence might start as early as nursing school, with students reporting bullying behaviors by classmates.16 Students often report feeling exploited, ignored and unwelcomed in nursing practice environment.17 In a study examining experiences of bullying behavior in nursing education Cooper explored students perceptions of the types, sources and frequency of bullying behaviors, the coping strategies used by student nurses to survive the experience and the ways in which nursing programs prepare students to cope. Using a investigator-developed tool 696 participants responded to the research questions. The data indicated that 95.6 % reported experiencing at least one bullying behavior during classroom or clinical work. Cursing, swearing and other belittling behaviors were the most frequently reported. The most usual coping mechanism was to do nothing. Most of the respondents were not aware of any policies or procedures that were in place to discourage this behavior. 18 Stevenson et al believes that enculturation is the primary reason for bullying among nurses and that the patterns are learned in nursing education and the earlier years of practice. The authors further assert that bullying behaviors are often accepted as normal behavior in nursing and can fail to be identified as a problem at all.20 Baltimore agrees with this assertion believing that bullying is a learned behavior and accepted as part of the professional ethos.8 There is little doubt that L/H violence is a prevalent problem in the profession of nursing and strategies for addressing it vary. Griffin reports the successful use of cognitive rehearsal strategies. 10 Roberts and Freshwater believe that the negative side-effects of L/H violence can be decreased through education. 21, 22 Some institutions have developed zero-tolerance strategies but find them hard to enforce and several authors have suggested zero-tolerance in combination with other interventions. 15,23–24 Hutchinson suggests that programs based on the premise of restorative justice can be a strategy that might hold some promise for addressing this problem. She posits that this approach would encourage active responsibility for confronting bullying by building pro-social workplace environments. 24 Failure of institutions to address L/H violence places the institution and staff at risk for increased turnover, decreased job satisfaction and compromised patient care.15. In two studiesby Buerhaus et al a total of 5, 805 licensed nursing in the US were surveyed to explore their level of satisfaction with the profession. The authors concluded that job satisfaction is a strong indicator as to whether to stay or leave a position.25, 26 The findings from these studies hold relevance for job retention. The goal of this review is to synthesise the best available evidence on the meaning of L/H violence, the effect it has on victims, and the effectiveness of programs in decreasing its negative effects. Prior to commencement of this systematic review, the Cochrane Library, Joanna Briggs Institute (JBI) database and CINAHL database were searched and no previous systematic reviews on the specific topic were located. Inclusion Criteria Types of Participants This review will consider studies with a focus on licensed nurses and student nurses. For purposes of this review ‘licensed nurse’ refers to a nurse who holds a license to practice nursing at any level. Due to the ambiguity of nomenclature, different titles for licensed nurse will be considered, including but not limited to registered nurse, practical nurse, vocational nurse.) Types of Interventions/Phenomena of Interest The qualitative component of this review will consider as phenomena of interest the actual experience of horizontal/lateral violence by licensed nurses and student nurses. The quantitative component of this review will examine interventions/strategies meant to decrease the prevalence or mitigate the effects of lateral/horizontal violence on licensed or student nurses. Some examples of programs or strategies reported in the literature are intense education programs, cognitive rehearsal strategies, zero tolerance policies and workshops. Context This review will consider research on the experience of lateral/horizontal violence in the profession of nursing and the efficacy/effectiveness of programs/strategies that are designed to decrease its prevalence or mitigate its negative effects in any setting where licensed or student nurses practise. Types of Outcomes The qualitative component of this review will include experiential accounts of being a nurse or student nurse who has experienced lateral/horizontal violence. The quantitative component of this review will consider studies that report outcomes such as but not limited to: types and intensity/severity of effects of lateral/horizontal violence on licensed or student nurses number of lateral/horizontal violence episodes/ prevalence of lateral/horizontal violence. job satisfaction job retention. Types of studies The qualitative component of this review will consider studies that focus on qualitative data including, but not limited to, designs such as phenomenology, grounded theory, ethnography, and action research. Descriptive qualitative studies that describe the experience or describe the effects of the experience will also be considered. The quantitative component of this review will consider randomized controlled trials (RCT's); in the absence of RCT's, other research designs such as non-randomized controlled trials, quasi-experimental study designs including before and after studies, and observational studies will be considered. Search Strategy The search strategy aims to find both published and unpublished English language primary research studies. There is no restriction of dates because it is unclear when the earliest research on this topic was available. Assessment for inclusion of foreign language publications will be based on the English language abstract, and if considered appropriate and feasible, an English language translation will be sought. A three-step search strategy will be utilized in each component of this review. An initial limited search of MEDLINE and CINAHL will be undertaken followed by analysis of the text words contained in the title and abstract, and of the index terms used to describe article. A second search using all identified keywords and index terms will then be undertaken across all included databases. Thirdly, the reference list of all identified reports and articles will be hand searched for additional studies. Databases to be searched include: BioMed Central CENTRAL (The Cochrane Library) CINAHL Conference Proceedings Current Contents EBSCOHost Health Source: Nursing/Academic Edition Elsevier Science Direct EMBASE Institute for Health & Social Care Research (IHSCR) New York Academy of Medicine Grey Literature Report Nursescribe ProQuest Digital Dissertations Psych ARTICLES PsychINFO PubMed (MEDLINE) Reference lists of identified studies and review papers Science Direct SCOPUS Sociological Abstracts TRIP The following keywords will be used in the search strategy. Nurs* and (“lateral violence” or ‘horizontal violence” or “vertical violence” or bully* N3 nurs* or mobbing or hostil* or eating N3 young or “workplace bullying”) Assessment of Methodological Quality For the qualitative component of the review, qualitative research papers selected for appraisal will be assessed by two independent reviewers for methodological quality prior to inclusion in the review. The two reviewers will use the standardised critical appraisal instruments from the Joanna Briggs Institute, specifically the Qualitative Assessment and Review Instrument (QARI) (Appendix I). Any disagreements between the reviewers will be resolved through discussion with a third reviewer. For the quantitative component of the review papers to be included in the review will be obtained and independently reviewed by two independent reviewers for methodological quality prior to inclusion in the review. The two reviewers will use the standardised critical appraisal instruments from the Joanna Briggs Institute, specifically the JBI-MAStARI (Meta Analysis of Statistics Assessment and Review Instrument) (Appendix I). Any disagreements between the reviewers will be resolved through discussion with a third reviewer. Data Extraction For the qualitative component of the review data will be extracted from papers included in the review using the standardised data extraction tool from the Joanna Briggs Institute Qualitative Assessment and Review Instrument (JBI-QARI) (Appendix II) For the quantitative component of the review data will be extracted from papers included in the review using the standardised extraction too from the Joanna Briggs Institute Meta Analysis of Statistics Assessment and Review Instrument (MAStARI) (Appendix II) Data Synthesis Qualitative research findings will, where possible, be pooled using the Qualitative Assessment and Review Instrument (JBI-QARI). This will involve the aggregation or synthesis of findings to generate a set of statements that represent that aggregation, through assembling the findings (Level 1 findings) rated according to their quality, and categorizing these findings on the basis of similarity in meaning (Level 2 findings). These categories are then subjected to a meta-synthesis in order to produce a single comprehensive set of synthesized findings (Level 3 findings) that can be used as a basis for evidence-based practice. Where textual pooling is not possible the findings will be presented in narrative form. Quantitative papers will, where possible, be pooled in statistical meta-analysis using the Joanna Briggs Institute Meta Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI). All results will be subject to double data entry. Odds ratio (for categorical data) and weighted mean differences (for continuous data) and their 95% confidence intervals will be calculated for analysis. Heterogeneity will be assessed using the standard Chi-square. Where statistical pooling is not possible, the findings will be presented in narrative form. Conflict of Interest There are no conflicts of interest.