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Work 51 (2015) 91–97 DOI 10.3233/WOR-152015 IOS Press

Perceptions of horizontal violence in staff nurses and intent to leave Francesca Armmer∗ and Charlotte Ball Department of Nursing, Bradley University, Peoria, IL, USA

Received 12 February 2013 Accepted 19 December 2014

Abstract. BACKGROUND: The impact of horizontal violence is multifaceted. From the impact upon the individual, the unit, and the institution, horizontal violence affects professional nursing activities in a variety of aspects of health care. OBJECTIVE: To examine registered nurses’ experiences with horizontal violence and explore the relationship between horizontal violence and intent to leave. PARTICIPANTS: A random sample of 300 registered nurses from a Midwestern hospital received the Briles’ Sabotage Savvy Questionnaire (BSSQ), the Michigan Organizational Assessment Questionnaire (MOAQ) Intent to Turnover measure, and a Demographic questionnaire. METHODS: Descriptive correlational study was implemented. Questionnaires were distributed to the selected registered nurses. Descriptive and correlational statistics were calculated. RESULTS: Horizontal violence had been experienced by nurses of all ages and experience. Based upon measurement tools, examples of horizontal violence were: Being held responsible for coworkers’ duties; Reprimanded or confronted in front of others; Failure to be acknowledged or confronted in front of others; and Untrue information about you being passed or exchanged. Correlations indicated a significant, positive relationship between perceptions of horizontal violence and intent to leave. Results also indicated the longer nurses were employed the more likely to perceive themselves as victims of horizontal violence. Additionally, results associated with the MOAQ, age and years employed indicated that older nurses and those with increasing years of employment were less likely to leave. Younger nurses indicated more willingness to leave a position due to perceived horizontal violence than older nurses. CONCLUSIONS: Activities to address the impact of perceived horizontal violence are needed. Workplace strategies may include mentoring, ongoing assessment of organizational climate, and zero tolerance for horizontal violence. Keywords: Aggression, retention, oppression, co-workers

1. Introduction and related literature Nurse to nurse violence, referred to as horizontal violence, is prevalent in healthcare organizations [1–8]. Violence in healthcare organizations is not a new phenomenon. Knowledge of the full extent of the problem ∗ Corresponding author: Francesca Armmer, Department of Nursing, Bradley University, Peoria, IL 61625, USA. Tel.: +1 309 677 2541; Fax: +1 309 677 2527; E-mail: [email protected].

is hampered by underreporting [9,10]. Yet it is known that the United States, along with other countries, faces a severe shortage of nurses with the expectation that the shortage will worsen. At the time of this writing, approximately 118,000 RNs are needed to fill vacant positions nationwide [11]. While the problem of a nursing shortage is multifaceted, the central premise of this research project is that horizontal violence has a role in the RN shortage. Horizontal violence has been present for many years. Research on this subject, particularly in the United States, continues [12,13].

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The purpose of this study was to describe registered nurses (RNs) perceptions of horizontal violence and to determine if there is a relationship between horizontal violence and intent to leave. The exodus of nurses from the profession is due in part to the refusal by nurses to continue working in their current environment [14,15]. Another study showed 40% of nurses working in hospitals reported dissatisfaction with their jobs. The study also indicated one of every three hospital nurses under the age of 30 was planning to leave their job within the next year [16]. A report released by the American Organization of Nurse Executives, showed the average turnover rate for RNs in acute care hospitals to be 21.3% [17]. Results of a national poll of 138 health care recruiters found the average RN turnover rate was 13.9%, the vacancy rate was 16.1%, and the average cost per hire for RNs was $2,821 [18]. Recent cost estimates have indicated that an average hospital may lose about $300,000 per year for each percentage increase in the annual nurse turnover rate [19]. One challenge to the identification and reporting of horizontal violence is the number of descriptors associated with horizontal violence. These descriptors include, but are not limited to bullying, professional terrorism, interpersonal conflict, workplace violence, aggression, intergroup conflict, lateral violence, and dysfunctional nurse to nurse relationships [1–3,20–22]. This multiplicity contributes to the challenge of understanding what defines horizontal violence. Duffy describes horizontal violence as intergroup conflict that is manifested in “overt and covert non-physical hostility such as sabotaging, infighting, scapegoating, and bickering” (p. 9). Bullying is a term used for horizontal violence [23]. Definitions of bullying have three elements in common. First, it leaves the victim feeling bullied or harassed as a result of being subjected to these behaviors; second, the bullying has a negative effect on the victim; and third, the bullying is ongoing [24,25]. Within the healthcare setting the RN is faced with choices that include tolerating the oppressive acts (horizontal violence), assertively addressing the oppressive acts, or planning/intending to leave the environment [26]. Intent to leave is defined as “RN anticipation of vacating a job in the foreseeable future” [30, p. 272]. The leading predictor of intent to leave was reported to be the level of satisfaction with the job [31– 34]. In initial studies researchers concluded that experiences of horizontal violence clearly impacts upon job satisfaction and intent to stay [33,35–37]. Chapman

et al. reported that in examining nurses’ experience in adjusting to workplace violence, senior nurses who participated considered themselves better able to manage workplace violence than their less experienced colleagues [25]. Horizontal violence has been reported to negatively influence job satisfaction, retention, and recruitment of nurses, thereby indirectly, if not directly, contributing to the present shortage of nurses. Some nurses are abandoning jobs, as well as the nursing profession, to escape the situation of horizontal violence [1,13,41].

2. Methodology A descriptive, correlation design was used to identify staff nurses’ perceptions of horizontal violence and their intent to leave. This design also explored the possibility of a relationship between perceptions of horizontal violence and intent to leave by staff nurses. The participants for this study were a random sample of 300 staff nurses. Randomization was conducted by a representative from the agency’s Human Resource Department. A basic process of every third possible participant was selected for possible inclusion in the study. This sample was taken from a population of 1,500 nurses who were employed full time or part time for at least one year in a medical facility in the Midwest U.S. Nurses working in management positions were excluded. A research study packet was mailed to selected staff nurses. Materials in the packet included a cover letter, questionnaires, and a stamped, self-addressed return envelope. Completion of the packet of questionnaires was explained to take approximately 20 minutes. The questionnaires, included a demographic information form, the Briles’ Sabotage Savvy Questionnaire (BSSQ), and Michigan Organizational Assessment Questionnaire (MOAQ). Demographic information collected included gender, age, ethnicity, education, length of time employed at present job, whether employed full or part time, and if the individual has participated in any work activity relating to horizontal violence Due to this study’s focus on the recipient and not the perpetrator, only the first twenty questions of the BSSQ questionnaire were used. From this portion of the BSSQ, participants in the study responded to items pertaining to the presence or absence of horizontal violence in their work relationships. Answer options for the BSSQ were “yes”, “no”, or “not sure” for each

F. Armmer and C. Ball / Perceptions of horizontal violence in staff nurses and intent to leave Table 1 Ethnicity and highest education level of participants Ethnicity Caucasian Asian Pacific Island Other Education level Associate Diploma Bachelor Master

N

Percent

97 5 2

93.3 4.8 1.9

16 17 70 1

15.4 16.3 67.8 1.0

question. Yes items were summed to yield a BSSQ score. A review of the BSSQ questionnaire for clarity, internal consistency and reliability resulted in a significant Cronbach’s alpha score of .86 in prior research [20]. Intent to turnover was measured by the MOAQ (Cronbach’s alpha of 0.83 [43]). This instrument was a three item questionnaire. Items one and two were scored on a seven-point Likert Scale with answer options of “strongly agree” to “strongly disagree”. Item three was scored on a scale from one to seven with one indicating “not at all likely” and seven indicating “extremely likely”. Scoring resulted from the sum of the 3 items (Range 3–21). The lower the score the greater the organizational commitment and the less likely the individual is to leave.

3. Results The Statistical package for Social Sciences was used to analyze the data. Descriptive statistics (means, standard deviations [SD]), and percentages were used to describe the sample. The Pearson’s Product Moment Correlation was used to calculate relationships between BSSQ scores, MOAQ data, and selected demographic data. Of the 300 mailed surveys, there were 108 surveys returned; with 104 (36%) useable for data analysis. In order to strengthen the study, incomplete questionnaires were not a part of the study analysis. The vast majority of the sample was Caucasian (93.3%) and female (96.2%). Over two thirds (67%) of respondents had a Bachelor’s Degree (see Table 1). The majority of respondents worked full time (88.5%). The age of the respondents ranged from 21 to 58 years with a mean of 38.9 years (SD = 10.3). Length of service ranged from 1 to 35 years with a mean of 13.7 years (SD = 10.3). The hospital where data collection occurred had recently conducted a campaign on lateral violence with

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48.1% (50) of this study’s respondents participating, 46.2 (48) not participating, and 5.8 (6) were not sure. This was important in this study as a potentially confounding factor. From the BSSQ, the number of horizontal behaviors reported by participants ranged from 0–18, with a mean of 8.1 (SD = 4.5). Seven of the 20 items on the BSSQ were answered positively by over half of the respondents. “Feeling responsible for a coworker’s duties” had the highest positive response rate with 80.8%; followed by variable item “Reprimanded or confronted in the presence of others” (69.2%), “Reneged on commitment to you” (62.5%), “Untrue information about passed or exchanged” (59.6%), and “Failure to acknowledge or confronted in front of others” (59.6%) (Table 2). The MOAQ instrument had a calculated Cronbach’s alpha 0.75 for this sample. Summative scores ranged from 3 to 21 with a mean score of 11.12 (SD = 4.10) suggesting that respondents have a middle of the road organizational commitment. MOAQ Item one asked respondents how likely they were to leave their current position within the year, mean response 3.0 out of 7 (SD = 2.1). MOAQ Item two asked respondents do you think about leaving, mean response 3.5 out of 7 (SD = 1.9). MOAQ Item three asked respondents how likely it is that they could find a job with another employer with the same pay and benefits, mean response 4.6 on 7 point Likert scale (SD = 2.2) (Table 3). Pearson’s Product Moment Correlation was used to calculate relationships in this sample. The correlation between MOAQ total and BSSQ total was positive, significant at the 0.05 level and weak. The correlation between MOAQ total and years employed was negative, significant at the 0.01 level. Sixty eight percent of the total MOAQ variance is explained by MOAQ1. Length of employment correlated positively with the total BSSQ score, indicating the longer the respondents were employed, the more likely they were to perceive themselves as victims of horizontal violence (see Table 4). A single sample t-test compared the mean 8.1 (SD = 4.5) sabotage scores from the BSSQ between participants who had and had not participated in a campaign on lateral violence. The difference was not significant (t (96) = −0.415, p > 0.05). The mean sabotage score was 7.92 (SD = 4.52) for those participating in the campaign on lateral violence compared to 8.29 (SD = 4.34) for those not participating. The strength of data analysis calculations has presented a consistency within the reliability and valid-

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F. Armmer and C. Ball / Perceptions of horizontal violence in staff nurses and intent to leave Table 2 BSSQ responses (N = 104) Variable number 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

Variable description Neutral or negative referral from negative reference Job information withheld or bypassed you Personal items in your workplace used without permission Coworkers’ conversation ceased when you approached Untrue information about you passed or exchanged Someone taking credit for your work Failure to acknowledge or confronted in front of others Reprimanded or confronted in front of others Threatened for failing to support demands contrary to your values Not given important messages Reneged on commitment to you Unclear job expectations Coworker nonsupport of group decision when meeting with boss Responsible for coworker’s duties Consistently criticized but not praised for positive work Attempts to damage or destroy credibility Terminated without cause Personal confidential information shared Excluded from meetings which included your ideas or plans Lodged a complaint without discussing it with you

Yes % (n) 4.8 (5) 40.4 (42) 17.3 (18) 47.1 (49) 59.6 (62) 43.3 (45) 59.6 (62) 69.2 (72) 14.4 (15) 57.7 (60) 62.5 (65) 36.5 (38) 38.5 (40) 80.8 (84) 37.5 (39) 30.8 (32) 1.0 (1) 50 (52) 12.5 (13) 46.2 (48)

No % (n) 84.6 (88) 49.0 (51) 73.1 (76) 41.3 (43) 18.3 (19) 34.6 (36) 33.7 (35) 29.8 (31) 81.7 (85) 32.7 (34) 34.6 (36) 54.8 (57) 52.9 (55) 16.3 (17) 54.8 (57) 55.8 (58) 99.0 (103) 31.7 (33) 44.2 (46) 44.2 (46)

Not sure % (n) 10.6 (11) 10.6 (11) 9.6 (10) 11.5 (12) 22.1 (23) 22.1 (23) 6.7 (7) 1.0 (1) 3.8 (4) 9.6 (10) 2.9 (3) 8.7 (9) 8.7 (9) 2.9 (3) 7.7 (8) 13.5 (14) 0 (0) 18.3 (19) 14.4 (15) 9.6 (10)

Table 3 MOAQ results (N = 104) Values∗

MOAQ1 Look new job % (n) 33.7 (35) 23.1 (24) 6.7 (7) 7.7 (8) 9.6 (10) 10.6 (11) 8.7 (9)

Strongly disagree/Not at all likely Disagree Slightly disagree/Somewhat likely Neutral Slightly agree/Quite likely Agree Strongly agree/Extremely likely

MOAQ2 Think quitting % (n) 18.3 (19) 26.9 (28) 6.7 (7) 10.6 (11) 21.2 (22) 9.6 (10) 6.7 (7)

MOAQ3 Find another job % (n) 13.5 (14) 4.8 (5) 20.2 (21) 1.0 (1) 22.1 (25) 3.8 (4) 34.6 (36)

Table 4 Correlations MAOQ1 Pearson correlation Sig. (2-tailed) N MAOQ Total Pearson correlation Sig. (2-tailed) N BSS Total Pearson correlation Sig. (2-tailed) Age Pearson correlation Sig. (2-tailed) N Years employed Pearson correlation Sig. (2-tailed) N ∗ Correlation

MOAQ1

MOAQ total

1

0.825∗∗ 0.000 104

0.244∗ 0.012 104

−0.130 0.189 104

−0.294∗∗ 0.002 104

1 − 104

0.214∗ 0.029 104

−0.198∗ 0.044 104

−0.384∗∗ 0.000 104

1 −

0.157 0.111

0.227∗ 0.020

1 − 104

0.798∗∗ 0.000 104

104 0.825∗∗ 0.000 104 0.244∗ 0.012

0.214∗ 0.029

BSSQ total

−0.130 0.189 104

−0.198∗ 0.044 104

0.157 0.111 104

−0.294∗ 0.002 104

−0.384∗∗ 0.000 104

0.227∗ 0.020 104

is significant at the 0.05 level (2-tailed);

∗∗ Correlation

Age

0.798∗∗ 0.000 104

is significant at the 0.01 level (2-tailed).

Years employed

1 − 104

F. Armmer and C. Ball / Perceptions of horizontal violence in staff nurses and intent to leave

ity of the research process. Study limitations include sample size, which was acceptable for a descriptive study, but could be further strengthened; gender, in the predominance of female participants, and an absence of racial diversity. To address these limitations would broaden the scope of generalizations that may be made.

4. Discussion Research findings have raised questions of impact associated with the extent of horizontal violence; the challenge to nurse retention; and the strength and viability of staff education associated with horizontal violence. Interprofessional collaborations, institutional loyalty, and role modeling are examples of being affected by the presence of horizontal violence. The prevalence of horizontal violence that has been experienced by professional nurses compels nurse administrators to look more closely at the responses being made by nurses. Horizontal violence was found to have been experienced by nurses of all ages and degrees of experience. Nurses have a clear personal perception of what it means to experience “horizontal violence”. The impact of this perceived victimization has social, economic and professional ramifications. Additionally, nurse responses offer further evidence of the historical impact of oppression within the nursing profession. Types of horizontal violence have been categorized as inter-group manifestations of conflict seen in the context of being excluded from the power structure [38]. A focused review of nurse responses with an emphasis on the age of participant revealed a daunting outcome. When faced with horizontal violence, younger nurses were more willing to leave their positions than were older nurses [47–49]. An evolving paradigm shift to intentional intolerance for horizontal violence on the part of new/younger nurses entering the nursing practice world will challenge administrators to develop and implement standards for protection. Such standards, if appropriately developed, may become a valued contributing factor to nurse retention. The potential generational differences in nurse attitudes will present another dimension for nurse leader awareness and attention. Efforts to address horizontal violence from a formalized staff development perspective are in need of ongoing review and revision. The establishment of definitive outcomes associated with horizontal violence prevention will be the foundation for sustainable inservice programs.

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Approximately half of the participants in this study (51.9%) indicated that they were not thinking about leaving their current employment. Interestingly, while not thinking about leaving their current positions, respondents indicated a confidence that if they chose to leave, it was “quite likely” they could find a comparable job. This is a reflection of job security that is not surprising within the nursing profession. Nurses were not thinking about leaving their current employer, but they were confident that finding another position will not be difficult. Based upon the correlation data associated with intent to leave and horizontal behaviors evidence supported the understanding that as there is a positive relationship between experiences with horizontal violence and intent to leave. Within this context the evidence further indicated that the MOAQ total was negatively correlated with age and years of experience. Respondents were more likely to remain in a workplace setting from which they have perceptions of horizontal violence relative to their age and length of time employed. Challenges of nurse safety, creativity, and innovation may be sacrificed in lieu of perceived security. Conversely, the potential for “new nurses” to make decisions not to tolerate perceived horizontal violence has both professional and financial ramifications. 4.1. Implications for hospital administration The study found that the respondents were able to recognize horizontal violence and to identify instances where they perceived themselves as victims. These findings were similar to other studies where nurses perceived themselves as victims of horizontal violence. The implication for hospital administrators is a fundamental and yet an urgent one. An environment that fosters a culture of respect and safety is essential. Organizational credibility will be strengthened as nurses practice within a setting that acknowledges that nurses have clear perceptions when they are experiencing or witnessing horizontal violence [2,3,6,13,20,46]. The current study as well as a study by Dunn, found “feeling responsible for a coworker’s duties” to be the most frequent method of horizontal violence, followed by being reprimanded in front of others. Thus, one of the implications for hospital administrators and nurse managers is the need to strive for adequate staffing using an acuity-based staffing system while taking into account other components such as staff mix and competencies as they work to build a cohesive team. Frequent re-evaluation of staffing policies should be

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scheduled with procedures in place for resolving conflicts such as one staff member feeling responsible for another’s work. Reprimands should take place in private [44]. This study found that 28.8% of the participants agreed they were planning to leave within the year. Turnover should be a concern to the cost conscience administrator when noting the estimated cost for replacing a single RN to be between $62,100 and $67,100 [45]. Younger nurses indicated more willingness to leave a position than did older nurses. This should be taken seriously in view of the present nursing shortage combined with predictions of the situation worsening in the future. Administrators should implement programs such as mentoring and support groups which increase retention [44]. Hospital administrators and managers are accountable for the organizational environment. They should recognize and acknowledge the existence of horizontal violence in the nursing profession. It is unclear how the lateral violence program initiated in this hospital affected this sample. It is imperative that there is ongoing education on horizontal violence for nursing staff. It is important that zero tolerance policies be implemented regarding horizontal violence but care should be taken to ensure these policies are not used in a punitive manner which results in blaming the victim. Administrators should recognize the relationship between horizontal violence and oppression and strive to alter the power structure that exists which fosters the subordinate/dominant relationship in healthcare organizations. Administrators need to encourage unity among nursing staff and lend support to maintaining the integrity of the profession. Hospital administrator decisions to address horizontal violence will require a comprehensive plan that is characterized by a sustained commitment to behaviors that reflect a valuing of nurses; a zero tolerance of identified horizontal violence behaviors; and an ongoing continuing education program. The planned financial investment in the elimination of horizontal violence will reflect tangible results of retention and intangible results of motivation, support, and organizational commitment. 4.2. Implications for nursing practice Implications for nursing practice are embedded not only in how nursing care is delivered but also in how prospective nurses are educated. It is essential that nurses and nurse leaders/managers address “bullying”

behaviors whenever these behaviors are manifested. It will be at those first points of contact that nurses will have the choice to make regarding the identification of unacceptable behaviors and the initiation of measures to eliminate them. The return on the nursing investment to counter horizontal violence will be both tangible and intangible. The tangible component will be evidenced in the establishment of an organizational climate and ultimately an organizational culture that values the contributions of every member on the team. Thus, retention and recruitment activities will be strengthened. The intangible component will be evidenced in the attitude and personal professional pride that will be evidenced in communications with other health professionals, family and visitors. Another implication lies in the challenge that horizontal violence presents to the educational experience of nursing students. It is important that nurse educators who so excellently create a tapestry of curricular topics for nursing education, weave into clinical experiences the realities of horizontal violence; how to assess it and how to optimally address it.

5. Conclusion Horizontal violence is a problem, even when RNs have received formal education on horizontal violence. Left untreated, horizontal violence is likely to lead to nursing attrition. Future research includes replicating this study with larger samples and in urban and rural settings. In addition, intervention studies need to be conducted that will empower nurses to break the cycle of oppression evidenced by horizontal violence.

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Perceptions of horizontal violence in staff nurses and intent to leave.

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