Research DIMENSION
Lateral Hostilities Among Nurses Employed in Intensive Care Units, Emergency Departments, Operating Rooms, and Emergency Medical Services A National Survey in Italy Stefano Bambi, MSN, RN; Giovanni Becattini, MSN, RN; Gian Domenico Giusti, MSN, RN; Andrea Mezzetti, MSN, RN; Andrea Guazzini, Psych; Enrico Lumini, PhD, MSN, RN
Background: Lateral hostilities (LHs) are ‘‘nasty, unkind, aggressive behavior between colleagues working at comparable organizational levels.’’ When LHs occur ‘‘at least once a week for a period of not less than 6 months,’’ they become ‘‘bullying.’’ The frequency of lateral violence in health care literature varies from 5.7% to 65%. Objectives: The aim of this study was to explore the extent of LH and the effects on the quality of lives of Italian nurses working in prehospital emergency medical system, emergency department, intensive care unit, and operating rooms. Methods: A descriptive study was conducted through an online survey in the Web site of the National Italian Association of Critical Care Nurses (ANIARTI). Results: A total of 1504 nurses filled up the questionnaire, with 1202 valid data entries (79.9%). Of this group, 739 (61.5%) were women and 951 (79.1%) had experienced some form of LH at least once in the last 12 months, whereas 269 (22.4%) felt to be victims of bullying. The number of transfers to other departments/services due to LH was 43 cases
DOI: 10.1097/DCC.0000000000000077
November/December 2014
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
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(3.6%), and 829 (69%) experienced psychophysical disorders attributed to LH experienced in the span of the year. Discussion: Lateral hostility is a frequent occurrence that calls for implementation of management policies to achieving an overall improvement of the work environment climate. Keywords: bullying, horizontal, nursing [DIMENS CRIT CARE NURS. 2014;33(6):347/354]
Lateral hostility (LH) is a form of workplace violence defined as ‘‘nasty, unkind, aggressive behavior between colleagues working at comparable organizational levels.’’1 This behavior is characterized also by ‘‘lack of cooperation, criticism and scapegoating,’’ which may lead to damages to the working team.2 Sometimes, LH shows behavioral patterns aimed at controlling, deriding, or belittling a coworker or a group of coworkers.1 Whereas LH is made up mainly of verbal and emotional abuses, when physical aggressions are added to LH, it becomes ‘‘lateral violence’’ (LV).3 Table 1 shows the main features of LH. The Oppressed Groups Behavior Theory of Roberts, although not completely validated, gives an explanation of why LV develops inside nurses’ groups. Indeed, the model shows the interaction between nurses (oppressed group) and physicians/managers (dominating groups).4,5 Nurses, dominated by the values of physicians, develop lack of selfesteem, silence, and fear to react. The consequence is an emotive implosion that leads to aggressions within the nurses’ group.4,6,7 Alongside this theory, other biological, evolutionary, interpersonal, and intrapersonal models have been used to clarify LV.8 The main conditions leading to LV seem to be organizational procedures depriving workers of rights and privileges, generational and hierarchic abuses, low intraprofessional self-esteem, lack of support from nursing management, emergence of colleagues’ cliques, and finally, vicious circles of ‘‘aggression that generates aggression.’’5,6,9 The intensity and frequency of the aggressions provide an important distinction among these phenomena. Indeed, when the episodes of abuses featuring LV occur ‘‘at least once a week for a period of not less than 6 months,’’10 or, according to other authors, ‘‘at least twice a week,’’11 they are defined as ‘‘bullying.’’ The rate of LV reported in literature varies from 5.7% to 65%.12,13 Emotional abuses are particularly frequent in emergency departments (EDs) (62.4%), with a lower rate in intensive care units (ICUs) (28.8%).14 New graduate nurses reported LV between 33% and 58%.15,16 The wide variability of rates can be attributed to the features of the settings investigated. Consistently, LV has been associated with a large number of psychophysical complaints (Table 2). Talking about 348
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the events with a partner or friends is the most common reaction to the abuse.17 In clinical settings, nurses who have been victims of emotional abuse show the lowest work satisfaction levels when compared with those who experienced other types of violence.14 Furthermore, the rates for leaving the actual job is very high (78.5%), specifically in groups with length of service of less than 5 years.18 Many professional institutions struggle to find proper solutions. Moreover, there are lots of position statements against LH and LV, as well as guidelines to devise healthy work environments.3,19,20-24 A few positive reports about implementing internal zero-tolerance procedures have been published.25 Other prevention actions consider team-building programs.26 Finally, some university nursing faculties have focused some courses to help students build up adequate levels of self-esteem and self-confidence.27-29 The literature suggests that LH and LV are prevalent in nursing workplaces across the globe. However, there is a lack of information about the extent of LH and LV in Italy. The only available data are from Camerino et al, in 2008,12 reporting a rate of 5.6%. Thus, we performed a descriptive study with the aim to explore the extent of LH (defined as emotional and verbal abuse, without any physical aggression) and its consequences on the self-perceived professional and psychophysical quality of life among Italian nurses employed in prehospital emergency medical systems (EMSs), EDs, ICUs, and operating rooms (ORs).
METHODS We designed an online survey based on the Italian version30 of the LH questionnaire developed by Alspach,31 to investigate LH among critical care nurses in the United States. The tool, slightly modified and enhanced compared with the original version (not validated), begins with a brief introduction and definition of the issue and is composed of 16 close-ended and 1 open-ended questions. The first 7 items are related to demographic data (sex, age, length of service, health care unit of employment, and position in the institution). The next 9 items explore the experience of LHs in the last 12 months (form of LH experienced, which form of LH seems to be the most serious, frequency of LH
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Lateral Hostility Among Nurses in Different Departments
TABLE 1
Main Forms of Lateral Hostility1-3
‘‘Backbiting,’’ gossip, revealing secrets shared Aping and belittling, nonverbal allusions Verbal aggression Scapegoating, faultfinding Snobbishness and elitism regarding the work area, etc Humiliation Ignoring, isolating the others Bursts of anger, impatience Insults, ridicule; condescending language and gestures Intimidation, threats Sabotage, compromise Unjust evaluation of work Malice and jokes on race, ethnic group, religion, sex or sexual orientation
experienced, witnessing of LH toward colleagues, request to leave the actual unit of employment, change of unit during the last year, desire to stop to working as nurse, and the complaint experienced). Lastly, the open question asks for respondent comments about LHs. Data for the validation of the Italian version of the LH questionnaire were obtained from a sample of 22 nurses from the ED and ICU.30 Regarding face validity, the average values of the evaluations produced by experts indicated a good opinion about the neutrality and clarity features of the instrument.30 The concordance correlation coefficient pre-post was strong (>c = 0.8659; 95% confidence interval [CI], 0.6766-0.9479). Internal consistency performed on 329 questionnaires obtained after the pilot study was adequate (Cronbach ! with standardized variables = 0.7233; lower confidence limit, 0.6833).30 The Italian LH Questionnaire was transposed into an informatics version using the Limesurvey platform (http:// www.limesurvey.org; Boston, Massachusetts). Then it was entered in the Web site of ANIARTI (Associazione degli Infermieri di Area Critica), an Italian association of nurses employed in ICUs, EDs, emergency medical services, and ORs. The online survey could be freely accessed. It addressed staff nurses and head nurses working in EMSs, EDs, ORs, and ICUs. The survey was promoted through spots during the ANIARTI National Congress in 2011, a mailing list of association’s members, as well as invitations/announcements on the association’s official Web site. The timeframe for access to the Web platform to complete the questionnaire was from November 16, 2011 to March 4, 2012. The questionnaire was designed to ensure complete anonymity of respondents. Data were analyzed only in an
aggregate form. Moreover, the protection of subjects was safeguarded according to the recommendations of the Oviedo Convention and the Helsinki declaration. The survey protocol was approved by the ANIARTI Board of Directors. Results were analyzed through a Microsoft Excel 2007 spreadsheet (Microsoft Corporation, Chevy Chase, Maryland) and the software MedCalc (MedCalc Software, Version 12.3.0, Ostend, Belgium). Bivariate analyses was performed through Mann-Whitney test for independent samples related to continuous variables and # 2 test for discrete variables.
RESULTS Demographic Details of Respondents The number of nurses who participated in the survey was 1504. A total of 1202 (79.9%) completed and valid questionnaires were included in the analysis. The sociodemographic characteristics of the sample are reported in Table 3. A total of 739 (739, 61.5%) of the respondents were women. Seventy-three percent of the respondents ranged in age between 31 and 50 years. The Italian regions of South and Islands were the least represented (8.1%). Most respondents reported working in ICUs (605, 50.3%), followed by the emergency areas (ED and EMS), and lastly the OR. Nurses working night and day shift comprised majority of the sample (938, 78%).
LH and Its Effects on Nurses A total of 951 (79.1%) participants had experienced at least some form of LH in the last 12 months. The reported forms of LH (median, 4; range, 1-23; interquartile range, 2-6) are listed in Table 4. In the same table, we report the forms of LH thought to be the most severe. We recorded a drastic drop in the rates of nurses who felt to have been victims of abuses at least once a week for a period of not less than 6 months (269, 22.4%). Moreover, a great percentage of nurses had witnessed at least an LH episode toward other nurses (985, 81,9%). Lastly, 361 nurses (30%) reported to be still victims of LH at the moment of completing the questionnaire. TABLE 2
Psychophysical Disorders Correlated to Lateral Hostility19
Chronic illnesses Absence from work Generally high stress levels Reduced self-confidence Psychological symptoms Psychosomatic symptoms Reduced work satisfaction Cardiovascular illnesses
November/December 2014
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TABLE 3
Sociodemographic Characteristics of Participants
Variable
n
TABLE 4
Forms of LHs Experienced by Respondents Over the Last 12 Months
%
The One Considered Most Experienced Severe
Age 20-30 y
207
17.2
31-40 y
452
37.6
41-50 y
425
35.4
51-60 y
117
9.7 0.08
960 y
1
Sex Male
463
38.5
Female
739
61.5
Geographical areas of Italya
Forms of LH
n
%
n
%
Complaints shared by others without first discussing it with you
415
34.5
50
4.2
Gossip, false information shared with others
354
29.5
38
3.2
Not acknowledged/credited for work done 327
27.2
69
5.7
Snobbish attitude regarding the quality of work, education, experience
325
27.0
44
3.7
Sarcastic comments
292
24.3
10
0.8
North
567
52.5
Conversations stop when you enter/arrive
265
22.0
9
0.7
Center
425
39.4
258
21.5
48
4
87
8.1
Important messages/information withheld or delayed Ignoring or discounting your input, ideas
241
20.0
25
2.1
Revealing confidential information to others
204
17.0
18
1.5
Frequent/habitual criticism attitude, belittling, patronizing attitudes
171
14.2
31
2.6
Indifference, discouragement and refusal to help
163
13.6
61
5.1
Restricted ability to express opinions or ideas
159
13.2
35
2.9
South and Isles Overall length of service G6 y
241
20.0
6-10 y
208
17.3
11-20 y
382
31.8
21-30 y
302
25.1
69
5.7
G6 y
347
28.9
Reneging on previous commitment
157
13.1
18
1.5
6-10 y
282
23.5
Mortifying attitudes
156
13.0
49
4.1
11-20 y
390
32.4
Isolating and segregating attitudes
127
10.6
66
5.5
161
13.4
Inequitable work/patient assignments
127
10.6
6
0.5
22
1.8
Reprimanded in front of others
117
9.7
25
2.1
Unwarranted criticism, scapegoating
116
9.7
28
2.3
Work judged in an unjust or offending manner 101
8.4
18
1.5
Humiliations, embarrassment
99
8.2
57
4.7
Professional or social segregation, exclusion from activities or conversations
79
6.6
113
9.4
Sabotage, undermining the work and/or personal field
61
5.1
158
13.1
Intimidation, threats
49
4.1
206
17.1
Others
24
2 20
1.6
930 y Length of service in EMS, ED, ICU, OR
21-30 y 930 y Type of service ED
264
22
OR
119
9.9
118 EMSs
214
17.8
General ICU
391
32.5
Specialty ICU
214
17.8
Night and day shift nurses
938
78
Day shift nurses
142
11.8
Head nurses
122
10.1
Total respondents
1202
Position
Missing/not valid answers given Total
4387 100
1202 100
Abbreviation: LH, lateral hostility. Abbreviations: ED, emergency department; EMS, emergency medical system; ICU, intensive care unit; OR, operating room.
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Lateral Hostility Among Nurses in Different Departments
The effect of LH on the quality of professional life was assessed through the number of requests for transfer to other departments/services due to LH over the last 12 months (136,11.3%). However, the actual change in departments/ services of assignation was only 43 (3.6%). Finally, 157 nurses (13.1%) considered leaving the nursing profession definitively during the last year. A total of 829 (829, 69%) reported psychophysical disorders, attributing them to LH experienced in the span of 1 year (median, 2; range, 1-11; interquartile range, 1-3) (Table 5).
Explorative Statistics We did not find any statistically significant differences in the experience of LH based on sex, age groups, length of service, or geographical areas, even though the South and Isles seem to be the most affected, with 88.5% (# 2 = 5.887, P = 0.0527) reporting experiences of LH. Moreover, respondents from the South and the Isles report the highest incidence in nurse-to-nurse bullying (31%; # 2 = 6.188, P G 0.05). Nurses who experienced LH witnessed LH perpetrated against other colleagues more frequently than did respondents who did not experience LH (84.7% vs 53.4%; # 2 = 103.664, P G 0.01). Furthermore, they reported a higher median of LH forms (3 and 1, respectively; Mann-Whitney test = 57,162.00; P G 0.01). There were no statistically significant differences based on sex, geographical areas, age groups, and length of service in regard to nurses who had requested to change unit/ service because of the LH experienced. However, nurses from ORs reported the highest percentages of formal request TABLE 5
Frequency of Disorders Attributed to Lateral Hostility and Experienced by Participants Over the Last 12 Months
Forms of Psychophysical Disorders
n
%
Low morale
465
38.7
Anxiety
277
23.0
Sleep disorders
256
21.3
Frequent flashbacks of the lateral violence experienced
249
20.7
Reduced self-esteem
248
20.6
Gastrointestinal disorders
166
13.8
Headaches
147
12.2
Apathy
119
9.9
Depression
73
6.1
Sensation of remoteness/alienation
64
5.3
Intentional absence from work
35
2.9
Total
2099
100
to leave their units (16.8%; # 2 = 13.428, P G 0.01). Similarly, the proportion of victims of nurse-to-nurse bullying who requested to leave their units was higher than respondents who did not experience bullying (29.3% and 6.1%, respectively; # 2 = 110.262, P G 0.01). The number of nurses who did indeed change their departments/services of assignation over the last 12 months was highest among those with shorter lengths of service (G6 years, 5.7%; # 2 = 13.328, P G 0.01), followed by the group between 21 and 30 years (5.5%). Head nurses changed unit of assignation more than did nurses in any other nursing positions (7.3%; # 2 = 6.233, P G 0.05). The same results emerged also among the victims of bullying, as compared with those who were not (8.5% and 2.1%, respectively; # 2 = 23.022, P G 0.01). There was a wide gap between the median rates of LH typologies among nurses who changed unit of assignation within the year, compared with those who did not (7 and 3, respectively; Mann-Whitney test = 12,345.00; P G 0.01). The desire of definitively leaving the nursing profession because of the LH experienced over the last year affects a far greater number of women than men (15.5% and 9%, respectively; # 2 = 9.996, P G 0.01). Similar results were reported with nurse victims of bullying, as compared with the others (31.2% and 7.8%, respectively; # 2 = 98.654, P G 0.01). There was also a statistical significance difference in median rates of LH forms between those who thought of leaving the job and those who did not (6 and 2, respectively; Mann-Whitney test = 33734.50; P G 0.01). The effects of LH on the quality of psychophysical life is a major finding from this study, as 82.5% of the LH victims claimed to have experienced at least 1 symptom or disorder attributed to this phenomenon within the past 12 months. Most affected by symptoms and disorders were OR nurses (85.7%; # 2 = 26.822, P G 0.01). Moreover, the percentage of victims of nurse-to-nurse bullying who reported related disturbances was very high (95.1%; # 2 = 109.573, P G 0.01). Individuals who had experienced symptoms and disorders were more likely to request a change in unit of assignation more than did nurses without any kind of symptoms and disorders (15.5% vs 1.8%; # 2 = 46.654, P G 0.01). In addition, they obtained the change in unit of assignation within the year (4.8% vs 0.8%; # 2 = 10.920, P = 0.01), and they expressed the desire to leave the nursing profession more frequently (18.5% and 0.8%, respectively; # 2 = 69.998, P G 0.01).
DISCUSSION A higher percentage of nurses in this study (79.1%) reported being LH victims than previously reported in the international literature. This rate is substantial when compared with 65% reported by a study performed in the November/December 2014
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United States on 1850 nurses covering all nursing positions and in various clinical settings.13 Our results are also much higher than the 5.6% incidence of ‘‘horizontal harassment’’ in Italy that emerged from the longitudinal European Nurses’ Early Exit study.12 Some of this variation may be attributed to the presence of different kinds of psychometric tools and questionnaires used in the literature to measure LH and LV.12,15,17 Another cause of this wide variation can be the singular features of the settings explored by the international studies.12,15,17 We found that 3 typologies of LH considered the most severe (‘‘intimidation, threats,’’ ‘‘sabotage,’’ and ‘‘professional and/or social isolation’’) were the least frequently reported by nurses (Table 4). These results could suggest that the level of damage aimed by perpetrators is, at least first glance, relatively low. Only 30% of the participants (37.9% of the victims of LH) were still affected by LH at the time of completing the questionnaire. These data may explain the 22.4% of respondents (28.2% of LH victims) who experienced a more intense and frequent pattern of LH falling within the definition of bullying by peers. Presently, there is not a single definition of bullying in literature. As a result, we arbitrarily chose ‘‘the occurrence of harassment at least once a week for a period of not less than 6 months’’10 instead of ‘‘at least twice a week.’’11 This choice may have affected the discrepancies in the percentage of nurses who complained about bullying by peers. Despite the fact that the South and the Isles are the geographic areas least represented within the survey (8.1%), the proportion of nurses who were victims of bullying in these areas significantly exceeds that of the Center and North of Italy, suggesting the need for further investigations. Younger age and shorter lengths of service have been identified as risk factors for LH and LV in the published literature32-34; however, similar results did not emerge in our study. This may be a result of cultural issues typical of Italy or simply to the specific workplace settings (ie, emergency, OR, and critical care areas). In our study, the OR seemed to be the ‘‘most toxic’’ workplace. Operating room nurses experience most LH and its psychophysical effects. Conversely, in international literature, EDs seem to be the workplaces most affected by violence and emotional abuse.14,17 Currently, we have no elements to explain these differences, as this issue needs more research. In this study, witnessing of LH toward other colleagues resulted in the greatest response, with 81.9% of all the participants reporting that they had witnessed LH , whereas other authors reported percentages not higher than 77%.35 One of the most feared effects of bullying and LH is the damage to institutions due to high rate of workplace turnovers. This survey instead shows that the requests of changing unit during the last year were forwarded by 11.3% 352
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of respondents (14.3% of LH victims). Moreover, the percentage of those who effectively were assigned to another unit dropped to just 3.6%. Actually, the more important issue related to LV and LH is the risk of nurses leaving the nursing profession. In the literature, the percentage of nurses who decide to quit their current job or to leave the nursing profession altogether varies from 14% to 34%.13,36,37 Our survey found that 13.1% of nurses (16.5% of LH victims) had thought about leaving the profession during the previous year. On this point, we acknowledge that there are cultural and lifestyle differences between the United States and Italy. Whereas in our country, there is a widely held notion that one should have a permanent job for the rest of one’s life, in the United States, there is much more job mobility. Furthermore, this ‘‘low’’ percentage could be a result also of the current economic crisis, increasing the fear of leaving a ‘‘stable’’ job. The presence of symptoms and disorders related to LH accounts for the 69% of respondents of this survey (87.1% of LH victims). We have highlighted that psychosocial complaints are significantly related to the presence of bullying and changing of unit/service, as well as to the thought of leaving the profession. Although our survey has a notably high participation rate, there are still several limitations. First, the validation study of the Italian version of LH questionnaire was performed on a small sample (22 nurses from ED and ICU) and was limited to face validity, test-retest validity, and internal consistency.30 Second, online surveys may be affected by selection bias. In fact, despite the fact that this approach strongly attracts response from users because of the ease and speed in filling the questionnaire, it completely ‘‘cuts out’’ those who do not have an Internet access.38 Moreover, we cannot exclude the presence of self-selection bias, which could overestimate the proportion of victims of LH respondents.39 Finally, the lack of a password or other protection system for access to the online questionnaire could have exposed the data to the risk of deliberate manipulations through repeated (and potentially unlimited compilations) responses from anybody who accessed it. When the collected data were closely examined, some incongruences were evident in the compilation of the questionnaires. They were presumably attributable to errors in interpretation of the questions rather than to mistakes made in filling out the form itself. In particular, whereas 251 (20.9%) respondents affirmed that they had not experienced any form of LH, there were only 241 (20%) nurses who did not select any form of LH in the questionnaire items. A similar discrepancy emerged between participants who stated they did not experience any disorder related to LH over the last 12 months (373, 31%) and those who did not tick off any kind of disorder in the same question (395, 32.8%).
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Lateral Hostility Among Nurses in Different Departments
This Italian national survey showed that LH among nurses is mostly diffused in emergency, critical care, and OR settings. Nonetheless, LH seems to be quite tolerated in terms of consequences on the job, even though it appears to markedly affect psychophysical quality of life. This is especially true when it is perpetrated with noteworthy intensity and frequency (nurse-to-nurse bullying). Lateral hostility affects all workplace settings and suggests for policies designed to at achieve an overall improvement of the workplace climate. In Italy, there is still a lack of acknowledgement about the spread and relevance of this issue, especially by nurse managers and the nursing academic area. At this moment, there is no hospital or university education program about the prevention of LH or bullying in nursing. This study can be a starting point to talk about LH and their consequences in our country and think about solutions. The ANIARTI took note of these results and is working on a specific position statement.
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35. 36. 37.
nurses’ experiences of bullying and burnout in hospital settings. J Adv Nurs. 2010;66:2732-2742. Griffin M. Teaching cognitive rehearsal as a shield for lateral violence: an intervention for newly licensed nurses. J Contin Educ Nurs. 2004;35:257-263. Kwok RP, Law YK, Li KE, et al. Prevalence of workplace violence against nurses in Hong Kong. Hong Kong Med J. 2006; 12:6-9. Vessey JA, Demarco RF, Gaffney DA, Budin WC. Bullying of staff registered nurses in the workplace: a preliminary study for developing personal and organizational strategies for the transformation of hostile to healthy workplace environments. J Prof Nurs. 2009;25:299-306. Moayed FA, Daraiseh N, Shell R, Salem S. Workplace bullying: a systematic review of risk factors and outcomes. Theor Issues Ergon. 2006;7:311-327. The Joint Commission. Behaviors that undermine a culture of safety. Sentinel Event Alert. Issue 40. July 9, 2008. http://www.jointcommission .org/assets/1/18/SEA_40.PDF. Accessed September 18, 2011. American Association of Critical Nurses. AACN public policy. Position StatementVZero Tolerance for Abuse. 2004. http://www .aacn.org/WD/Practice/Docs/PublicPolicy/Zero_Tolerance_for_ Abuse.pdf. Accessed September 18, 2011. American Association of Critical Nurses. AACN Public Policy. Position statementVworkplace violence prevention. 2004. http:// www.aacn.org/WD/Practice/Docs/PublicPolicy/Workplace_Violence .pdf. Accessed October 5, 2011. American Association of Critical Nurses. Standards for establishing and sustaining healthy work environments. A journey to excellence. Executive Summary. AACN 2005. http://www.aacn.org/ WD/HWE/Docs/ExecSum.pdf. Accessed September 18, 2011. Registered Nurses Association Ontario. Healthy Work Environment Best Practice Guideline. Professionalism in Nursing. March 2007. http://www.rnao.org/Storage/28/2303_BPG_Professionalism .pdf. Accessed September 18, 2011. Dimarino TJ. Eliminating lateral violence in the ambulatory setting: one center’s strategies. AORN J. 2011;93:583-588. Barrett A, Piatek C, Korber S, Padula C. Lessons learned from a lateral violence and team-building intervention. Nurs Adm Q. 2009;33:342-351. Begley CM, White P. Irish nursing students’ changing selfesteem and fear of negative evaluation during their preregistration programme. J Adv Nurs. 2003;42:390-401. Deltsidou A. Undergraduate nursing students’ level of assertiveness in Greece: a questionnaire survey. Nurse Educ Pract. 2009; 9:322-330. Begley CM, Glacken M. Irish nursing students’ changing levels of assertiveness during their pre-registration programme. Nurse Educ Today. 2004;24:501-510. Bambi S, Becattini G, Lumini E. A questionnaire about lateral hostility between critical care nurses: validation study. Scenario. 2012;29:36-42. Alspach G. Lateral hostility between critical care nurses: a survey report. Crit Care Nurse. 2008;28:13-19. Yildirim D. Bullying among nurses and its effects. Int Nurs Rev. 2009;56:504-511. Pai HC, Lee S. Risk factors for workplace violence in clinical registered nurses in Taiwan. J Clin Nurs. 2011;20:1405-1412. Chen WC, Sun YH, Lan TH, Chiu HJ. Incidence and risk factors of workplace violence on nursing staffs caring for chronic psychiatric patients in Taiwan. Int J Environ Res Public Health. 2009;6:2812-2821. Simons S. Workplace bullying experienced by Massachusetts registered nurses and the relationship to intention to leave the organization. ANS Adv Nurs Sci. 2008;31:E48-E59. McKenna BG, Smith NA, Poole SJ, Coverdale JH. Horizontal violence: experiences of Registered Nurses in their first year of practice. J Adv Nurs. 2003;42:90-96. Johnson SL, Rea RE. Workplace bullying: concerns for nurse leaders. J Nurs Adm. 2009;39:84-90.
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38. Sax LJ, Gilmartin SK, Bryant AN. Assessing response rates and nonresponse bias in Web and paper surveys. Res High Educ. 2003;44:409-432. 39. Bethlehem J. How accurate are self-selection web surveys? Discussion paper (08014 Statistics Netherlands, The Hague/Heerlen. 2008. http://www.cbs.nl/NR/rdonlyres/EEC0E15B-76B0-4698-9B268FA04D2B3270/0/200814x10pub.pdf. Accessed September 30, 2012.
ABOUT THE AUTHORS Stefano Bambi, MSN, RN, is a PhD candidate in nursing science at the University of Florence and is from the Emergency and Trauma Intensive Care Unit of Azienda Ospedaliero Universitaria Careggi, Florence, Italy. He is a staff nurse in the Emergency and Trauma Intensive Care Unit. He was formerly a lecturer in emergency and critical care nursing at University of Florence (Italy). Giovanni Becattini, MSN, RN, is from the Nursing Executive Floor, USL 7, Siena, Italy. He is a nurse manager, and he was formerly a lecturer in emergency and critical care nursing at University of Florence (Italy). Gian Domenico Giusti, MSN, RN, is from the Intensive Care Unit at Perugia Hospital, Perugia, Italy. He is a staff nurse in Intensive Care
Unit, and he is currently a lecturer in emergency and critical care nursing at University of Perugia (Italy). Andrea Mezzetti, MSN, RN, is from the Prehospital Emergency Service at Ospedale San Giuseppe, Empoli, Italy. Andrea Guazzini, Psych, is an associate researcher at the Centre for the Study Of Complex Dynamics (CSDC), Department of Science of Education and Psychology, at the University of Florence, Italy. He also collaborates to nursing studies designs and statistical analysis. Enrico Lumini, PhD, MSN, RN, is from University-Hospital Integrated Department at Azienda Ospedaliero Universitaria Careggi, Florence, Italy. He is currently a lecturer in emergency and critical care nursing at University of Florence (Italy). The authors have disclosed that they have no significant relationship with, or financial interest in, any commercial companies pertaining to this article. Address correspondence and reprint requests to: Stefano Bambi, MSN, RN, University of Florence, Emergency and Trauma Intensive Care Unit, DAI-DEA, Azienda Ospedaliero Universitaria Careggi, Largo Brambilla 3, 50134 Florence, Italy ([email protected]; [email protected]).
Call for Manuscripts If you are a critical care nurse, nurse educator, nurse manager, nurse practitioner, clinical nurse specialist, researcher, other healthcare professional, or knowledgeable about topics of interest to critical care nurses, Dimensions of Critical Care Nursing would like to hear from you. We are seeking manuscripts on innovative critical care topics with direct application to clinical practice, leadership, education, or research. We are also interested in any topic related to quality, safety, and healthcare redesign. Specifically, we are interested in manuscripts on the latest critical care technology, drugs, research, procedures, leadership strategies, ethical issues, career development, and patient/family education. Do not submit articles that have been previously published elsewhere or are under consideration for publication in other journals or books. Send your query letter, outline or manuscript to: Dimensions of Critical Care Nursing Kathleen Ahern Gould, PhD, RN Editor-in-Chief Dimensions of Critical Care Nursing [email protected] For more specific author guidelines, visit our Web site: www.dccnjournal.com Thank you for your interest in DCCN. We will make every effort to be sure you are satisfied with the service you receive from us! DOI: 10.1097/DCC.0b013e318299816b
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Lateral Hostilities Among Nurses Employed in Intensive Care Units, Emergency Departments, Operating Rooms, and Emergency Medical Services A National Survey in Italy Stefano Bambi, MSN, RN; Giovanni Becattini, MSN, RN; Gian Domenico Giusti, MSN, RN; Andrea Mezzetti, MSN, RN; Andrea Guazzini, Psych; Enrico Lumini, PhD, MSN, RN
Background: Lateral hostilities (LHs) are ‘‘nasty, unkind, aggressive behavior between colleagues working at comparable organizational levels.’’ When LHs occur ‘‘at least once a week for a period of not less than 6 months,’’ they become ‘‘bullying.’’ The frequency of lateral violence in health care literature varies from 5.7% to 65%. Objectives: The aim of this study was to explore the extent of LH and the effects on the quality of lives of Italian nurses working in prehospital emergency medical system, emergency department, intensive care unit, and operating rooms. Methods: A descriptive study was conducted through an online survey in the Web site of the National Italian Association of Critical Care Nurses (ANIARTI). Results: A total of 1504 nurses filled up the questionnaire, with 1202 valid data entries (79.9%). Of this group, 739 (61.5%) were women and 951 (79.1%) had experienced some form of LH at least once in the last 12 months, whereas 269 (22.4%) felt to be victims of bullying. The number of transfers to other departments/services due to LH was 43 cases
DOI: 10.1097/DCC.0000000000000077
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(3.6%), and 829 (69%) experienced psychophysical disorders attributed to LH experienced in the span of the year. Discussion: Lateral hostility is a frequent occurrence that calls for implementation of management policies to achieving an overall improvement of the work environment climate. Keywords: bullying, horizontal, nursing [DIMENS CRIT CARE NURS. 2014;33(6):347/354]
Lateral hostility (LH) is a form of workplace violence defined as ‘‘nasty, unkind, aggressive behavior between colleagues working at comparable organizational levels.’’1 This behavior is characterized also by ‘‘lack of cooperation, criticism and scapegoating,’’ which may lead to damages to the working team.2 Sometimes, LH shows behavioral patterns aimed at controlling, deriding, or belittling a coworker or a group of coworkers.1 Whereas LH is made up mainly of verbal and emotional abuses, when physical aggressions are added to LH, it becomes ‘‘lateral violence’’ (LV).3 Table 1 shows the main features of LH. The Oppressed Groups Behavior Theory of Roberts, although not completely validated, gives an explanation of why LV develops inside nurses’ groups. Indeed, the model shows the interaction between nurses (oppressed group) and physicians/managers (dominating groups).4,5 Nurses, dominated by the values of physicians, develop lack of selfesteem, silence, and fear to react. The consequence is an emotive implosion that leads to aggressions within the nurses’ group.4,6,7 Alongside this theory, other biological, evolutionary, interpersonal, and intrapersonal models have been used to clarify LV.8 The main conditions leading to LV seem to be organizational procedures depriving workers of rights and privileges, generational and hierarchic abuses, low intraprofessional self-esteem, lack of support from nursing management, emergence of colleagues’ cliques, and finally, vicious circles of ‘‘aggression that generates aggression.’’5,6,9 The intensity and frequency of the aggressions provide an important distinction among these phenomena. Indeed, when the episodes of abuses featuring LV occur ‘‘at least once a week for a period of not less than 6 months,’’10 or, according to other authors, ‘‘at least twice a week,’’11 they are defined as ‘‘bullying.’’ The rate of LV reported in literature varies from 5.7% to 65%.12,13 Emotional abuses are particularly frequent in emergency departments (EDs) (62.4%), with a lower rate in intensive care units (ICUs) (28.8%).14 New graduate nurses reported LV between 33% and 58%.15,16 The wide variability of rates can be attributed to the features of the settings investigated. Consistently, LV has been associated with a large number of psychophysical complaints (Table 2). Talking about 348
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the events with a partner or friends is the most common reaction to the abuse.17 In clinical settings, nurses who have been victims of emotional abuse show the lowest work satisfaction levels when compared with those who experienced other types of violence.14 Furthermore, the rates for leaving the actual job is very high (78.5%), specifically in groups with length of service of less than 5 years.18 Many professional institutions struggle to find proper solutions. Moreover, there are lots of position statements against LH and LV, as well as guidelines to devise healthy work environments.3,19,20-24 A few positive reports about implementing internal zero-tolerance procedures have been published.25 Other prevention actions consider team-building programs.26 Finally, some university nursing faculties have focused some courses to help students build up adequate levels of self-esteem and self-confidence.27-29 The literature suggests that LH and LV are prevalent in nursing workplaces across the globe. However, there is a lack of information about the extent of LH and LV in Italy. The only available data are from Camerino et al, in 2008,12 reporting a rate of 5.6%. Thus, we performed a descriptive study with the aim to explore the extent of LH (defined as emotional and verbal abuse, without any physical aggression) and its consequences on the self-perceived professional and psychophysical quality of life among Italian nurses employed in prehospital emergency medical systems (EMSs), EDs, ICUs, and operating rooms (ORs).
METHODS We designed an online survey based on the Italian version30 of the LH questionnaire developed by Alspach,31 to investigate LH among critical care nurses in the United States. The tool, slightly modified and enhanced compared with the original version (not validated), begins with a brief introduction and definition of the issue and is composed of 16 close-ended and 1 open-ended questions. The first 7 items are related to demographic data (sex, age, length of service, health care unit of employment, and position in the institution). The next 9 items explore the experience of LHs in the last 12 months (form of LH experienced, which form of LH seems to be the most serious, frequency of LH
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Lateral Hostility Among Nurses in Different Departments
TABLE 1
Main Forms of Lateral Hostility1-3
‘‘Backbiting,’’ gossip, revealing secrets shared Aping and belittling, nonverbal allusions Verbal aggression Scapegoating, faultfinding Snobbishness and elitism regarding the work area, etc Humiliation Ignoring, isolating the others Bursts of anger, impatience Insults, ridicule; condescending language and gestures Intimidation, threats Sabotage, compromise Unjust evaluation of work Malice and jokes on race, ethnic group, religion, sex or sexual orientation
experienced, witnessing of LH toward colleagues, request to leave the actual unit of employment, change of unit during the last year, desire to stop to working as nurse, and the complaint experienced). Lastly, the open question asks for respondent comments about LHs. Data for the validation of the Italian version of the LH questionnaire were obtained from a sample of 22 nurses from the ED and ICU.30 Regarding face validity, the average values of the evaluations produced by experts indicated a good opinion about the neutrality and clarity features of the instrument.30 The concordance correlation coefficient pre-post was strong (>c = 0.8659; 95% confidence interval [CI], 0.6766-0.9479). Internal consistency performed on 329 questionnaires obtained after the pilot study was adequate (Cronbach ! with standardized variables = 0.7233; lower confidence limit, 0.6833).30 The Italian LH Questionnaire was transposed into an informatics version using the Limesurvey platform (http:// www.limesurvey.org; Boston, Massachusetts). Then it was entered in the Web site of ANIARTI (Associazione degli Infermieri di Area Critica), an Italian association of nurses employed in ICUs, EDs, emergency medical services, and ORs. The online survey could be freely accessed. It addressed staff nurses and head nurses working in EMSs, EDs, ORs, and ICUs. The survey was promoted through spots during the ANIARTI National Congress in 2011, a mailing list of association’s members, as well as invitations/announcements on the association’s official Web site. The timeframe for access to the Web platform to complete the questionnaire was from November 16, 2011 to March 4, 2012. The questionnaire was designed to ensure complete anonymity of respondents. Data were analyzed only in an
aggregate form. Moreover, the protection of subjects was safeguarded according to the recommendations of the Oviedo Convention and the Helsinki declaration. The survey protocol was approved by the ANIARTI Board of Directors. Results were analyzed through a Microsoft Excel 2007 spreadsheet (Microsoft Corporation, Chevy Chase, Maryland) and the software MedCalc (MedCalc Software, Version 12.3.0, Ostend, Belgium). Bivariate analyses was performed through Mann-Whitney test for independent samples related to continuous variables and # 2 test for discrete variables.
RESULTS Demographic Details of Respondents The number of nurses who participated in the survey was 1504. A total of 1202 (79.9%) completed and valid questionnaires were included in the analysis. The sociodemographic characteristics of the sample are reported in Table 3. A total of 739 (739, 61.5%) of the respondents were women. Seventy-three percent of the respondents ranged in age between 31 and 50 years. The Italian regions of South and Islands were the least represented (8.1%). Most respondents reported working in ICUs (605, 50.3%), followed by the emergency areas (ED and EMS), and lastly the OR. Nurses working night and day shift comprised majority of the sample (938, 78%).
LH and Its Effects on Nurses A total of 951 (79.1%) participants had experienced at least some form of LH in the last 12 months. The reported forms of LH (median, 4; range, 1-23; interquartile range, 2-6) are listed in Table 4. In the same table, we report the forms of LH thought to be the most severe. We recorded a drastic drop in the rates of nurses who felt to have been victims of abuses at least once a week for a period of not less than 6 months (269, 22.4%). Moreover, a great percentage of nurses had witnessed at least an LH episode toward other nurses (985, 81,9%). Lastly, 361 nurses (30%) reported to be still victims of LH at the moment of completing the questionnaire. TABLE 2
Psychophysical Disorders Correlated to Lateral Hostility19
Chronic illnesses Absence from work Generally high stress levels Reduced self-confidence Psychological symptoms Psychosomatic symptoms Reduced work satisfaction Cardiovascular illnesses
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TABLE 3
Sociodemographic Characteristics of Participants
Variable
n
TABLE 4
Forms of LHs Experienced by Respondents Over the Last 12 Months
%
The One Considered Most Experienced Severe
Age 20-30 y
207
17.2
31-40 y
452
37.6
41-50 y
425
35.4
51-60 y
117
9.7 0.08
960 y
1
Sex Male
463
38.5
Female
739
61.5
Geographical areas of Italya
Forms of LH
n
%
n
%
Complaints shared by others without first discussing it with you
415
34.5
50
4.2
Gossip, false information shared with others
354
29.5
38
3.2
Not acknowledged/credited for work done 327
27.2
69
5.7
Snobbish attitude regarding the quality of work, education, experience
325
27.0
44
3.7
Sarcastic comments
292
24.3
10
0.8
North
567
52.5
Conversations stop when you enter/arrive
265
22.0
9
0.7
Center
425
39.4
258
21.5
48
4
87
8.1
Important messages/information withheld or delayed Ignoring or discounting your input, ideas
241
20.0
25
2.1
Revealing confidential information to others
204
17.0
18
1.5
Frequent/habitual criticism attitude, belittling, patronizing attitudes
171
14.2
31
2.6
Indifference, discouragement and refusal to help
163
13.6
61
5.1
Restricted ability to express opinions or ideas
159
13.2
35
2.9
South and Isles Overall length of service G6 y
241
20.0
6-10 y
208
17.3
11-20 y
382
31.8
21-30 y
302
25.1
69
5.7
G6 y
347
28.9
Reneging on previous commitment
157
13.1
18
1.5
6-10 y
282
23.5
Mortifying attitudes
156
13.0
49
4.1
11-20 y
390
32.4
Isolating and segregating attitudes
127
10.6
66
5.5
161
13.4
Inequitable work/patient assignments
127
10.6
6
0.5
22
1.8
Reprimanded in front of others
117
9.7
25
2.1
Unwarranted criticism, scapegoating
116
9.7
28
2.3
Work judged in an unjust or offending manner 101
8.4
18
1.5
Humiliations, embarrassment
99
8.2
57
4.7
Professional or social segregation, exclusion from activities or conversations
79
6.6
113
9.4
Sabotage, undermining the work and/or personal field
61
5.1
158
13.1
Intimidation, threats
49
4.1
206
17.1
Others
24
2 20
1.6
930 y Length of service in EMS, ED, ICU, OR
21-30 y 930 y Type of service ED
264
22
OR
119
9.9
118 EMSs
214
17.8
General ICU
391
32.5
Specialty ICU
214
17.8
Night and day shift nurses
938
78
Day shift nurses
142
11.8
Head nurses
122
10.1
Total respondents
1202
Position
Missing/not valid answers given Total
4387 100
1202 100
Abbreviation: LH, lateral hostility. Abbreviations: ED, emergency department; EMS, emergency medical system; ICU, intensive care unit; OR, operating room.
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Lateral Hostility Among Nurses in Different Departments
The effect of LH on the quality of professional life was assessed through the number of requests for transfer to other departments/services due to LH over the last 12 months (136,11.3%). However, the actual change in departments/ services of assignation was only 43 (3.6%). Finally, 157 nurses (13.1%) considered leaving the nursing profession definitively during the last year. A total of 829 (829, 69%) reported psychophysical disorders, attributing them to LH experienced in the span of 1 year (median, 2; range, 1-11; interquartile range, 1-3) (Table 5).
Explorative Statistics We did not find any statistically significant differences in the experience of LH based on sex, age groups, length of service, or geographical areas, even though the South and Isles seem to be the most affected, with 88.5% (# 2 = 5.887, P = 0.0527) reporting experiences of LH. Moreover, respondents from the South and the Isles report the highest incidence in nurse-to-nurse bullying (31%; # 2 = 6.188, P G 0.05). Nurses who experienced LH witnessed LH perpetrated against other colleagues more frequently than did respondents who did not experience LH (84.7% vs 53.4%; # 2 = 103.664, P G 0.01). Furthermore, they reported a higher median of LH forms (3 and 1, respectively; Mann-Whitney test = 57,162.00; P G 0.01). There were no statistically significant differences based on sex, geographical areas, age groups, and length of service in regard to nurses who had requested to change unit/ service because of the LH experienced. However, nurses from ORs reported the highest percentages of formal request TABLE 5
Frequency of Disorders Attributed to Lateral Hostility and Experienced by Participants Over the Last 12 Months
Forms of Psychophysical Disorders
n
%
Low morale
465
38.7
Anxiety
277
23.0
Sleep disorders
256
21.3
Frequent flashbacks of the lateral violence experienced
249
20.7
Reduced self-esteem
248
20.6
Gastrointestinal disorders
166
13.8
Headaches
147
12.2
Apathy
119
9.9
Depression
73
6.1
Sensation of remoteness/alienation
64
5.3
Intentional absence from work
35
2.9
Total
2099
100
to leave their units (16.8%; # 2 = 13.428, P G 0.01). Similarly, the proportion of victims of nurse-to-nurse bullying who requested to leave their units was higher than respondents who did not experience bullying (29.3% and 6.1%, respectively; # 2 = 110.262, P G 0.01). The number of nurses who did indeed change their departments/services of assignation over the last 12 months was highest among those with shorter lengths of service (G6 years, 5.7%; # 2 = 13.328, P G 0.01), followed by the group between 21 and 30 years (5.5%). Head nurses changed unit of assignation more than did nurses in any other nursing positions (7.3%; # 2 = 6.233, P G 0.05). The same results emerged also among the victims of bullying, as compared with those who were not (8.5% and 2.1%, respectively; # 2 = 23.022, P G 0.01). There was a wide gap between the median rates of LH typologies among nurses who changed unit of assignation within the year, compared with those who did not (7 and 3, respectively; Mann-Whitney test = 12,345.00; P G 0.01). The desire of definitively leaving the nursing profession because of the LH experienced over the last year affects a far greater number of women than men (15.5% and 9%, respectively; # 2 = 9.996, P G 0.01). Similar results were reported with nurse victims of bullying, as compared with the others (31.2% and 7.8%, respectively; # 2 = 98.654, P G 0.01). There was also a statistical significance difference in median rates of LH forms between those who thought of leaving the job and those who did not (6 and 2, respectively; Mann-Whitney test = 33734.50; P G 0.01). The effects of LH on the quality of psychophysical life is a major finding from this study, as 82.5% of the LH victims claimed to have experienced at least 1 symptom or disorder attributed to this phenomenon within the past 12 months. Most affected by symptoms and disorders were OR nurses (85.7%; # 2 = 26.822, P G 0.01). Moreover, the percentage of victims of nurse-to-nurse bullying who reported related disturbances was very high (95.1%; # 2 = 109.573, P G 0.01). Individuals who had experienced symptoms and disorders were more likely to request a change in unit of assignation more than did nurses without any kind of symptoms and disorders (15.5% vs 1.8%; # 2 = 46.654, P G 0.01). In addition, they obtained the change in unit of assignation within the year (4.8% vs 0.8%; # 2 = 10.920, P = 0.01), and they expressed the desire to leave the nursing profession more frequently (18.5% and 0.8%, respectively; # 2 = 69.998, P G 0.01).
DISCUSSION A higher percentage of nurses in this study (79.1%) reported being LH victims than previously reported in the international literature. This rate is substantial when compared with 65% reported by a study performed in the November/December 2014
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United States on 1850 nurses covering all nursing positions and in various clinical settings.13 Our results are also much higher than the 5.6% incidence of ‘‘horizontal harassment’’ in Italy that emerged from the longitudinal European Nurses’ Early Exit study.12 Some of this variation may be attributed to the presence of different kinds of psychometric tools and questionnaires used in the literature to measure LH and LV.12,15,17 Another cause of this wide variation can be the singular features of the settings explored by the international studies.12,15,17 We found that 3 typologies of LH considered the most severe (‘‘intimidation, threats,’’ ‘‘sabotage,’’ and ‘‘professional and/or social isolation’’) were the least frequently reported by nurses (Table 4). These results could suggest that the level of damage aimed by perpetrators is, at least first glance, relatively low. Only 30% of the participants (37.9% of the victims of LH) were still affected by LH at the time of completing the questionnaire. These data may explain the 22.4% of respondents (28.2% of LH victims) who experienced a more intense and frequent pattern of LH falling within the definition of bullying by peers. Presently, there is not a single definition of bullying in literature. As a result, we arbitrarily chose ‘‘the occurrence of harassment at least once a week for a period of not less than 6 months’’10 instead of ‘‘at least twice a week.’’11 This choice may have affected the discrepancies in the percentage of nurses who complained about bullying by peers. Despite the fact that the South and the Isles are the geographic areas least represented within the survey (8.1%), the proportion of nurses who were victims of bullying in these areas significantly exceeds that of the Center and North of Italy, suggesting the need for further investigations. Younger age and shorter lengths of service have been identified as risk factors for LH and LV in the published literature32-34; however, similar results did not emerge in our study. This may be a result of cultural issues typical of Italy or simply to the specific workplace settings (ie, emergency, OR, and critical care areas). In our study, the OR seemed to be the ‘‘most toxic’’ workplace. Operating room nurses experience most LH and its psychophysical effects. Conversely, in international literature, EDs seem to be the workplaces most affected by violence and emotional abuse.14,17 Currently, we have no elements to explain these differences, as this issue needs more research. In this study, witnessing of LH toward other colleagues resulted in the greatest response, with 81.9% of all the participants reporting that they had witnessed LH , whereas other authors reported percentages not higher than 77%.35 One of the most feared effects of bullying and LH is the damage to institutions due to high rate of workplace turnovers. This survey instead shows that the requests of changing unit during the last year were forwarded by 11.3% 352
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of respondents (14.3% of LH victims). Moreover, the percentage of those who effectively were assigned to another unit dropped to just 3.6%. Actually, the more important issue related to LV and LH is the risk of nurses leaving the nursing profession. In the literature, the percentage of nurses who decide to quit their current job or to leave the nursing profession altogether varies from 14% to 34%.13,36,37 Our survey found that 13.1% of nurses (16.5% of LH victims) had thought about leaving the profession during the previous year. On this point, we acknowledge that there are cultural and lifestyle differences between the United States and Italy. Whereas in our country, there is a widely held notion that one should have a permanent job for the rest of one’s life, in the United States, there is much more job mobility. Furthermore, this ‘‘low’’ percentage could be a result also of the current economic crisis, increasing the fear of leaving a ‘‘stable’’ job. The presence of symptoms and disorders related to LH accounts for the 69% of respondents of this survey (87.1% of LH victims). We have highlighted that psychosocial complaints are significantly related to the presence of bullying and changing of unit/service, as well as to the thought of leaving the profession. Although our survey has a notably high participation rate, there are still several limitations. First, the validation study of the Italian version of LH questionnaire was performed on a small sample (22 nurses from ED and ICU) and was limited to face validity, test-retest validity, and internal consistency.30 Second, online surveys may be affected by selection bias. In fact, despite the fact that this approach strongly attracts response from users because of the ease and speed in filling the questionnaire, it completely ‘‘cuts out’’ those who do not have an Internet access.38 Moreover, we cannot exclude the presence of self-selection bias, which could overestimate the proportion of victims of LH respondents.39 Finally, the lack of a password or other protection system for access to the online questionnaire could have exposed the data to the risk of deliberate manipulations through repeated (and potentially unlimited compilations) responses from anybody who accessed it. When the collected data were closely examined, some incongruences were evident in the compilation of the questionnaires. They were presumably attributable to errors in interpretation of the questions rather than to mistakes made in filling out the form itself. In particular, whereas 251 (20.9%) respondents affirmed that they had not experienced any form of LH, there were only 241 (20%) nurses who did not select any form of LH in the questionnaire items. A similar discrepancy emerged between participants who stated they did not experience any disorder related to LH over the last 12 months (373, 31%) and those who did not tick off any kind of disorder in the same question (395, 32.8%).
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Lateral Hostility Among Nurses in Different Departments
This Italian national survey showed that LH among nurses is mostly diffused in emergency, critical care, and OR settings. Nonetheless, LH seems to be quite tolerated in terms of consequences on the job, even though it appears to markedly affect psychophysical quality of life. This is especially true when it is perpetrated with noteworthy intensity and frequency (nurse-to-nurse bullying). Lateral hostility affects all workplace settings and suggests for policies designed to at achieve an overall improvement of the workplace climate. In Italy, there is still a lack of acknowledgement about the spread and relevance of this issue, especially by nurse managers and the nursing academic area. At this moment, there is no hospital or university education program about the prevention of LH or bullying in nursing. This study can be a starting point to talk about LH and their consequences in our country and think about solutions. The ANIARTI took note of these results and is working on a specific position statement.
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ABOUT THE AUTHORS Stefano Bambi, MSN, RN, is a PhD candidate in nursing science at the University of Florence and is from the Emergency and Trauma Intensive Care Unit of Azienda Ospedaliero Universitaria Careggi, Florence, Italy. He is a staff nurse in the Emergency and Trauma Intensive Care Unit. He was formerly a lecturer in emergency and critical care nursing at University of Florence (Italy). Giovanni Becattini, MSN, RN, is from the Nursing Executive Floor, USL 7, Siena, Italy. He is a nurse manager, and he was formerly a lecturer in emergency and critical care nursing at University of Florence (Italy). Gian Domenico Giusti, MSN, RN, is from the Intensive Care Unit at Perugia Hospital, Perugia, Italy. He is a staff nurse in Intensive Care
Unit, and he is currently a lecturer in emergency and critical care nursing at University of Perugia (Italy). Andrea Mezzetti, MSN, RN, is from the Prehospital Emergency Service at Ospedale San Giuseppe, Empoli, Italy. Andrea Guazzini, Psych, is an associate researcher at the Centre for the Study Of Complex Dynamics (CSDC), Department of Science of Education and Psychology, at the University of Florence, Italy. He also collaborates to nursing studies designs and statistical analysis. Enrico Lumini, PhD, MSN, RN, is from University-Hospital Integrated Department at Azienda Ospedaliero Universitaria Careggi, Florence, Italy. He is currently a lecturer in emergency and critical care nursing at University of Florence (Italy). The authors have disclosed that they have no significant relationship with, or financial interest in, any commercial companies pertaining to this article. Address correspondence and reprint requests to: Stefano Bambi, MSN, RN, University of Florence, Emergency and Trauma Intensive Care Unit, DAI-DEA, Azienda Ospedaliero Universitaria Careggi, Largo Brambilla 3, 50134 Florence, Italy ([email protected]; [email protected]).
Call for Manuscripts If you are a critical care nurse, nurse educator, nurse manager, nurse practitioner, clinical nurse specialist, researcher, other healthcare professional, or knowledgeable about topics of interest to critical care nurses, Dimensions of Critical Care Nursing would like to hear from you. We are seeking manuscripts on innovative critical care topics with direct application to clinical practice, leadership, education, or research. We are also interested in any topic related to quality, safety, and healthcare redesign. Specifically, we are interested in manuscripts on the latest critical care technology, drugs, research, procedures, leadership strategies, ethical issues, career development, and patient/family education. Do not submit articles that have been previously published elsewhere or are under consideration for publication in other journals or books. Send your query letter, outline or manuscript to: Dimensions of Critical Care Nursing Kathleen Ahern Gould, PhD, RN Editor-in-Chief Dimensions of Critical Care Nursing [email protected] For more specific author guidelines, visit our Web site: www.dccnjournal.com Thank you for your interest in DCCN. We will make every effort to be sure you are satisfied with the service you receive from us! DOI: 10.1097/DCC.0b013e318299816b
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