Impacts of Workplace Violence in Nursing

Introduction (1/2 page)

In this paper, I will explore the concept of the Workplace Violence with three following issues of sense of powerlessness, job satisfaction and psychological and physiological effects on the victim’s well-being. An example of the clinical situation detailing an environment, facts and events leading to the development of the clinical situation will be provided, followed by the short discussion of relevance of this topic to myself both clinically and personally. The evidence from existing literature will be incorporated into the detailed identification, discussion and analysis of each of the three issues. A special section with a discussion on how my further practice as a registered nurse influenced by the lessons learned from these events will follow. Conclusive remarks with some key elements in the paper will be elaborated at the end.

Description of the Clinical Situation (1 page)

While working as a newly recruited registered nurse (RN) in the short stay unit at our local hospital I was providing care for a 25 years old woman. She was 13 weeks pregnant and a missed abortion. The patient was in the process of passing products of conception, experiencing a severe pain, constantly screaming and demanding me to provide her with much stronger pain medication. I have explained that I have already administered painkillers, as prescribed, and it would take time for them to kick in. Yet, patient was not listening and continuously demanded to see the physician. After numerous unsuccessful attempts, I contacted the physician, explained the situation and was immediately yelled at, instantly being labeled as “unworthy, not knowing anything, unable to do my job” with many other degrading and demeaning remarks at each phone call. Shocked, I contacted my supervisor and asked for an advice, but got the reply that “these things happen… welcome to the real RN life, calm down and try to contact him again”. I did it again and got exactly same treatment. I have documented and reported these incidents on the same day. I learned that, apparently, the yelling, and name-calling was an acceptable pattern of behavior from this physician directed at all new RNs and I was told to accept the “facts of life “ that, hierarchically, nurses are at the bottom of the “feeder” (Christie & Johnes, 2009) and should not go against the physicians, advise them or even ask for help. This news really threw me off. The following day I called in sick. I felt emotionally distressed, powerless, unprotected and could not convince myself for making a right decision by choosing RN as my profession in Canada. I have never encountered these kind of physician-nurse relationships before.

Discussion of Relevance of Clinical Situation/ Topic Both Personally and Professionally (1/2page)

The situation of the workplace violence speaks to me directly as it affects not only my personal wellbeing, but also impacts the quality of care I provide. Unsafe workplace environment allowing for re-occurring violence outbreaks in any form ultimately leads to deteriorating outcomes in emotional and mental health of the nurse, personal well-being and patient safety.

As a nurse and a human being, I have a full right to work in a safe workplace environment, protected from any form of physical and emotional abuse from either my clients (patients, visitors) or my co-workers and supervisors. The fact that doctor continuously treated me as having less knowledge and his ongoing demeaning remarks as well as forcing me by staff nurse to accept such oppressing behaviour I consider as acts horizontal violence. (Johnson, 2009). (2)

Review of literature(1/2 page)

I have reviewed the available literature on the topic… and …found….list here statistical information of the prevalence of the horizontal violence, resulting powerlessness, nurse dissatisfaction, effects on the physical and mental state of nurses.

The frequency with which hospital violence occurs is rather shocking. The Emergency Nurses Association (ENA, 2010) has conducted a study that found that 8%–13% of emergency department nurses are victims of violence every week. According to the U.S. Bureau of Labor Statistics, 46% of all violent acts in the workplace that necessitated time off were against RNs. (1)

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Identification, Discussion and Analysis of 3 Issues of the Concept Within the Clinical Situation (6-9)

Issue 1: Powerlessness (2 pages)

Hincherberger (2009) identified that one of the symptoms of the dynamics surrounding oppression that creates a sense of powerlessness in its victims is a horizontal violence. In order for the horizontal violence to occur a formalized working relationship, where individuals are mutually working to achieve a certain goal, must be present. (Ventura-Madangeng &Wilson, 2009,p.40). Evidently, in my situation, we had a formalized working relationship between physician and myself as a nurse, working together to achieve a common goal of helping our patient to overcome severe pain followed by the procedure. An understanding how to deal with nurses’ experiences of powerlessness within the workplace resulting from the acts of horizontal violence is essential for nursing practice and ultimately effective delivery of patient care (Coursey, Dieckmann, Austin & Rodriguez, 2013). While horizontal or lateral violence is generally defined as any type of unwanted abuse or hostility within the workplace it is considered as an act of aggression among healthcare professionals (Becker &Visovsky, 2012). Experiencing an aggression makes a nurse feel powerless. Some of the characteristic circumstances leading to the experience of the powerlessness involve evidence of the exercising physician control or dominance in incidents involving fundamental human situations triggering strong emotions in all involved (Coursey et all, 2013). Pain and miserable condition exhibited by my patient has stimulated strong emotions and desire to provide better patient care. Another defining attribute of horizontal violence is the use, misuse and abuse of power in an attempt to disempower the individual, to elicit favourable response and that is used within formal relationships to achieve goals and objectives through an interpersonal process (Ventura-Madangeng &Wilson, 2009, p.40). Doctors have traditionally dominated those groups lower in the hierarchy, most notably nursing (Dykema, 1985). Diminishing of nursing care and disregard for nursing decisions are often manifested through power plays (Dwyer, 2011). Newly recruited nurses, myself not exception, frequently see themselves as having little or no power while in the role. Physician’s continuous degrading statements about my practice quality and methods in an attempt to force me to act independently or convince the patient clearly demonstrated physician’s power control and push for dominance. Subsequent supervisor’s comments about the general acceptance of the existing unhealthy hierarchical relationship created frustration, unwanted feelings of being out of control, understanding of non-existent collegial support, pressured, isolated, hopeless, demoralized and invalidated. A detailed analysis of the impact of powerlessness arising from incidents involving horizontal violence has helped to identify its numerous effects. Being constantly subjected to the effects of horizontal violence nurses, in general, feel oppressed (King-Johnes, 2011). The oppression of nurses is perpetuated by both the hierarchical structure of health care organization they work in, and by nurses’ internalized oppression. The greatest impact is on the nurse as victim, professional practice, and the implications for patient care. Zerabvel & Wright (2012) believed that being exposed to harmful effects of horizontal violence made nurses less empathetic to the wounds of others. And what is more alarming is that coping with feelings of powerlessness members of the oppressed group contributed to displacing all aggressiveness and negative emotions onto each other rather than onto actual perpetrators or members of the dominant group (King-Johnes, 2011).

Issue 2: effects on physical and psychological well being (2 pages)

Boykova (2011) indicated that based on hospital power hierarchies, nurses as a group, are always subject to various types of oppressions. She also, suggested that nursing continues being perceived inferior to the medical profession. Oppressors are always clearly identified, but are not frequently reprimanded. Various researchers have identified members of medical team and nursing management as a valid oppressor of other nurses in an attempt to absorb lower status nurses into existing hospital power hierarchies (Roberts, Demarco, & Griffin, 2009). Being repeatedly told that all new nurses with this doctor “have gone through similar events” and indirect indication that these events were not to be taken personally, but to be accepted “as is” created an unwanted psychological effect of viewing myself as a weak and unable to provide good care nurse.

Hutchinson, Vickers, Wilkes & Jackson (2010) found that horizontal violence exercised by the members of medical team and management can ultimately affect nurse well‐being. Effects of exposure to horizontal violence include psychological and physiological impacts on victim’s well-being often results in health and mental problems.

Many psychological unintended consequences occurring sometime after an event affect the victim with such outcomes as increased fatigue, frequent mood swings, negative changes in personal life and values and frequent ranting to partner. Faced with organizational resistance to support me, I emotionally reacted manifesting not one but several symptoms at once including sadness, frustration, irritability, hurt, anger and most importantly stress.

An analysis of several studies confirmed that approximately 80% of health care employees experienced at least one adverse symptom in response to work-related violence, while 25% of victims of nonphysical violence experienced five or more troublesome symptoms (Kitaneh & Hamdan, 2012; Findorff, McGovern, & Sinclair, 2005; APNA, 2008).

Additionally, Thomas and Burke (2009) examining narratives of nurses experiencing horizontal violence stated that the greatest impact of horizontal violence is stress. Stress-related health and workplace problems include increased blood pressure, avoidance of professional relationships, depression, anxiety, lowered work performance, toxic work environment, and an emotionally oppressive environment (Broome, 2008).

Physical and psychological maladies deriving form exposure to stress include weight loss/gain, hypertension, cardiac problems, gastro-intestinal disorders, headache, insomnia, chronic fatigue, anxiety, depression, substance abuse, and feelings of isolation, insecurity, low self-esteem, post traumatic stress disorder, and suicidal and homicidal thoughts (Bigony et al. 2009). One of the emotions shared by the bullied and bystanders is fear. Fear is a very real and powerful emotion that can result in negative consequences.

Exposure to horizontal violence can result in anxiety, weight changes and exacerbation of previously controlled conditions such as hypertension or irritable bowel syndrome (Faminu, 2011). Randall (2001) studied the effects of bullying in adulthood and states that targets of bullying may develop autonomic reactions (e.g., feeling out of breath, blood pressure changes) muscle manifestations (e.g., backache, neck pain), cognitive reactions (e.g., inability to concentrate, irritability, sensitivity) up to and including post-traumatic stress disorder.

Intimidation and fear of retaliation prevents reporting of bullying behavior by both the target and the witnesses allowing the negative behavior to continue (Lally, 2009). The greatest danger of fear in healthcare is the fear of conflict that can result in medical errors if those intimidated by aggressive behavior fail to speak up (Langlois, 2009). Adult targets often do not have the capability of productively handling a bullying situation. Their attempts to manage the situation frequently escalate the conflict, particularly if the bully has greater authority. The negative behavioral effects on the target progress from anxiety to loss of motivation and to outbursts of emotion. Loss of emotional control can result in the target displaying aggression and escalating the conflict and bullying behavior (Lee & Brotheridge, 2006).

Must ADD some line of how all of the above linked back to my clinical situation

Issue 3: decreased job satisfaction/motivation (1.5page)

Work-related violence in the health care system is a complex and dangerous occupational hazard and impacts the job satisfaction and motivation as well as the quality of the care provided (Arnetz & Arnetz, 2001; Needham et al., 2005).

Research identified multiple situations in which nurses felt unheard, unappreciated and disrespected by their medical colleagues that ultimately led to nurses’ re-examination of their stand on patient-organization loyalty. (Aytac & Dursun 2012; Rodwell & Demir 2012). As in my clinical situation, this manifested in moral distress and dilemma, as I felt my loyalty should be primarily to the patient.

It is obvious, that the greatest negative effects of workplace violence are felt by the victim (Kvas, 2011). Budin et al. (2013) confirmed that it not only affects the victim’s health, satisfaction with work and life, confidence, but also causes emotional exhaustion and burnout. Being subjected to this situation I was depressed, anxious and basically encountered a work-related stress (Aytac & Dursun 2012; Rodwell & Demir 2012).(kvas)

Many psychological unintended consequences arising from experiencing acts of non-physical horizontal violence have a strong impact on the victims with such outcomes as decreased job satisfaction, performance and absenteeism (Merecz, Drabek & Moscicka, 2009; Schat & Frone, 2011). The following day I felt tired, upset, unhappy and did not come to work reporting being sick. I believed that my knowledge and my skills deserved better recognition either from physician on call or from the nurse manager. When I finally went back to work I noticed my decreased job performance especially in the daily routine activities.

Gerberich et al. (2004) observed that workers exposed to nonphysical violence had high rates of quitting or job transfer. Continuous exposure to the disrespectful remarks and unwillingness of management to deal with situation as it arose I immediately started to research other departments at our hospital where I could transfer to work with physicians known to be more respectful of nurse’s skills.

An analysis of the issue clearly sheds a light to the fact that perceptions of violence affects job satisfaction and motivation. (Roche). Generally, nurses experiencing horizontal violence felt less happy at work, had greater work stress, lower morale, less respect for staff compared to unexposed nurses and perceived less supervisory support. The number of violent exposures is inversely correlated with feelings of job safety and satisfaction (Ienacco et al, 2013).

Violence is not a constituent part of the profession and nurses deserve to work in a safe working environment. To achieve this goal, all members of the nursing profession must, jointly with other stakeholders (doctors, patients, relatives), actively contribute to changes.(kvas).

Discussion of How My Future Practice May be Influenced (1-1.5 pages)

Nurses must acknowledge the existence of horizontal violence, confront horizontal violence, and take appropriate actions to mitigate it (Vessey et al., 2010). A policy of zero tolerance for any sort of horizontal violence in the workplace is the goal (Center for American Nurses, 2008).

Nursing staff must take a role in combating horizontal violence. Nurses must know the policies that govern professional conduct in the workplace (Maxfield et al., 2005), and feel empowered to take actions against HV. Strategies for empowerment consist of confronting and teambuilding (Kupperschmidt, 2006), mentorship programs (Latham, Hogan, & Ringl, 2008), and cognitive rehearsal (Stagg et al., 2011). Maxfield and colleagues (2005) found only 5%- 15% of nurses would confront a colleague concerning unprofessional behaviors. Only 10% of nurses felt comfortable enough to confront a coworker displaying HV (Wilson et al., 2011).

Based on the impact horizontal violence had on the me as a nurse, especially effects of psychological and physical on well being, sense of powerlessness and dramatic reduction in job satisfaction I learned important lessons from it.

First lesson was that I wanted to continue working as a nurse I have to stop thinking of myself as a member of the oppressed group, start being proactive, disallow any attempts on diminishing my efforts or stop any occurences of any demaning remarks directed at me from any member of medical team being so physician, supervisor or colleage.

Second lessond I should maintain a healthy view of self, so as not to personalize attacks of HV (Kerfoot, 2007). avoid unnecessary emotional turmoil, learn to be assertive (Exhibiting assertive behavior at the time of the event is considered an acceptable response to HV behaviors. If possible, actions that constitute bullying should be confronted during or immediately following the incident. Conversation must remain both empathic and factual (Randle et al., 2007).) in situations of horizontal violence. Journaling, another strategy to address HV, can serve dual purposes. First, keeping a detailed journal will help the victim maintain a timeline of events (Cleary et al., 2009). Second, journaling may provide an emotional outlet for the psychological distress associated with HV. Good documentation requires a list of witnesses to the accounts and all notes, texts, or emails from the perpetrator also be kept as part of the journal (Cleary et al., 2009; Edwards & O’Connell, 2007).

Final lesson, that influenced my further practice was job satisfaction…

Summary/Conclusion (1/2 page)

Text here

Kitaneh, M., Hamdan, M., (2012) Workplace violence against physicians and nurses in Palestinian public hospitals: a cross-sectional study, BMC Health Services Research 2012, 12:469 retrieved from

http://www.biomedcentral.com/1472-6963/12/469