Remember the old expression about nurses “eating their young?” Unfortunately, a growing body of evidence on topics such as horizontal (also called lateral) violence, bullying, incivility, and unhealthy work environments in nursing continue to emerge in spite of efforts and measures taken to eradicate the problem. Under the American Nurses Association standards of practice, nurses have an obligation to mentor colleagues and treat colleagues with respect, trust, and dignity.1
Horizontal violence has been described as acts of aggression by one colleague against another: talking behind someone's back, sabotage, criticizing or belittling a colleague in front of others, and isolating a colleague out of group activities.2 Bullying in the workplace differs from horizontal bullying, but the terms are used interchangeably in the literature. Bullying involves a real or perceived power differential or gradient between the individuals involved; horizontal violence occurs among peers.3 Both share the same disruptive behaviors, including scapegoating, excessive criticism, sabotage, abusive language, public humiliation, and intimidation.2,3
Although horizontal violence has been recognized as a widespread occupational health problem, affecting 37% of the U.S. workforce, nurses are a vulnerable group.4 In a recent survey, 70% of nurses reported being bullied at work.4 The issue isn't isolated to one nursing specialty or group, but extends from nursing students to senior practicing clinicians and nurse faculty and scholars.
Forms of horizontal violence among nursing faculty include lack of recognition, bullying, devaluation of accomplishments, blaming, and silencing.5
Although the effects of horizontal violence are harmful to all nurses, they're increasingly damaging for new nurses entering an already complex, overwhelming, and unfamiliar work environment. Unfortunately, high job turnover among new nurses can negatively affect patient outcomes and a facility's finances. New nurses' ability to successfully assimilate into their new role is a key retention issue.6 The National Council of State Boards of Nursing reported that 122,601 RNs were newly licensed in 2010, with 90% of newly licensed RNs beginning their careers in hospital settings.7 Among this new entering workforce, turnover is high—26% leave their new job within 2 years of hire.8 Three work attributes have consistently been shown to affect turnover: job satisfaction, organizational commitment, and intent to stay. However, nurses ranked job stress as a major reason for leaving their employers.8
Significant financial implications are associated with hiring and training of new employees who leave an organization within 1 year of hire. Estimated costs of replacing a general medical-surgical nurse average $42,000; replacing specialty nurses averages $64,000 and up.9 Unhealthy work environments and bullying in the workplace have been identified as reasons nurses have provided for leaving their positions.3 The Center for American Nurses stated that horizontal violence can hurt the nursing profession's ability to retain both new and veteran nurses.10 Additionally, implications of this dilemma often are transferable to undesirable patient outcomes, as lack of staff continuity, lack of interdisciplinary collaboration, and communications breakdowns jeopardize process improvement initiatives aimed at patient safety and quality of care.3,11
The American Association of Critical-Care Nurses has identified healthy work environments as one of three major advocacy initiatives, stating that positive practice environments improve employee well-being, productivity, retention, and patient outcomes.12 In 2008, The Joint Commission also issued a sentinel event alert to warn healthcare organizations of the safety risks posed by disruptive behaviors, and charged organizations to address these behaviors.11
A number of qualitative studies have highlighted the detrimental effects of horizontal violence on new nurses' self-images and career intentions.13 Simons and Mawn examined the stories of bullying among 184 newly licensed nurses.14 One theme identified in the study was the effect of bullying on retention. Some nurses wrote about leaving their jobs while others wrote about leaving the profession altogether as a result of being victims of bullying behaviors. Job satisfaction, management style, supervisory support, and relationships among coworkers were identified as other factors influencing nurses' decisions to leave their position.3,6
The Institute of Medicine recommends a seamless transition for nurses into new clinical practice areas.15 Nurses who've been effectively assimilated into new organizations will be less likely to voluntarily resign within the first year of employment, saving the organization thousands of dollars in orientation costs (turnover costs per RN can be as much as 1.3 times an RN's salary).16,17 In addition, nurses who feel like part of the team in a new work environment and the profession as a whole experience higher levels of job satisfaction and job performance.17 These nurses are more likely to pursue continuing-education opportunities to improve their knowledge, skills, and proficiency, leading to improved patient outcomes.
Strategies for seamlessly transitioning new nurses into the work environment include mitigating horizontal violence. Nurse residency programs, mentorship experiences, nurse extern, nurse co-op, and preceptor programs are examples of programs that can successfully integrate new nurses into the profession.15,17 These programs offer educational and emotional support that supplements and enhances a new nurse's knowledge and builds competence and confidence.
To remain current with changing healthcare trends, hospitals and other healthcare organizations should routinely reevaluate their existing programs to determine if they meet the needs of the entering workforce.
Mentoring as a strategy
Strategies to eliminate horizontal violence and unhealthy work environments begin with nurse leaders knowing about the causes and effects of the problem. Creating a zero-tolerance culture and enforcing policies against work violence are key. Equally important, staff should embrace a zero-tolerance culture and advocate against bullying behaviors.2
One way nurses can advocate for their new peers is through mentoring, which has been recognized as a key to integrating new nurses into practice settings and critical for retention.18 Mentorship in nursing refers to a formal or informal learning relationship in which a senior nurse serves as an advocate, educator, and support person for the nurse entering a new work environment.16 In this nurturing process, mentors coach, counsel, and sponsor the mentee.9
Latham and colleagues described a 3-year academic hospital partnership where frontline RN mentor-mentee teams and an advocacy program were instituted to improve the nurse work environment and patient outcomes.19 As a result of the partnership, dedicated mentors improved the culture of support for their colleagues with effective communication, conflict resolution, mutual respect, and collaboration. The organization experienced improvements in patient and nurse satisfaction and reductions in nurse vacancy rates.
Mentorship offers a win-win-win for organizations, providing benefits to the mentor, mentee, and the patient, and ultimately benefiting the organization as a whole. Nurses who have participated in mentorship experiences reported decreased feelings of isolation and an increased sense of security. This led to higher levels of job enjoyment and self-confidence, contributing to improved productivity and retention.18 For the mentor, the experience offered critical development opportunities. Mentors have reported feelings of expertise validation, enhanced skills, competencies, and retention with an increased capacity to develop supportive learning environments.20,21
A 3-year pilot project known as the California Nurse Mentor Project aimed to create a replicable program to improve the quality of patient care through enhanced nurse retention.9 Outcomes of this successful program included reported job satisfaction and professional confidence of both mentors and mentees. Mentors reported that taking on the role of mentor had revitalized their enthusiasm for their roles and nursing as a career; both mentors and mentees experienced significant changes in key areas, including sense of achievement, perceived appreciation and respect from others, sense of work fulfillment, and autonomy at work.9
The mentorship relationship can either occur informally, developing gradually over time, or through a formal program introduced through the organization. According to Harrington, being a seasoned practitioner doesn't necessarily equate to being a good mentor.22 Good mentors have a personal commitment to mentoring, knowledge, skills, a positive attitude, and should be willing and able to reflect on their skills as mentors in order to ensure a positive experience for mentees.
If you're interested in mentoring, find out if your organization offers a formal or informal mentoring program and make your interest known. If your organization doesn't offer a formal program, you can still be a mentor. Identify a peer who you feel could benefit from mentorship. This may be a new nurse, or one who's expressed or demonstrated difficulty during the new role transition. Establish a relationship with the nurse and position yourself as coach, advocate, and supporter. In your mentor role, embrace zero tolerance to bullying in the workplace and encourage other nurses to do the same. Give your mentee the opportunity to discuss issues with bullying.
If you're a nurse manager, ensure that your staff has the necessary conflict resolution training to deal with difficult situations. Enforce antibullying policies and provide a forum (such as a staff meeting) for discussion and education of healthy and unhealthy behaviors. Empower your staff to hold each other accountable in promoting healthy behaviors.2 Encourage mentorship by formally referring senior nurses to your organization's mentor program or by pairing mentors and mentees upon hire of newly licensed nurses.
Resources available to staff nurses who wish to pursue mentoring opportunities and managers or hospital administrators interested in initiating a program include the Academy of Medical-Surgical Nurses' toolkit for starting a mentoring program (http://amsn.org/professional-development/mentoring). Sigma Theta Tau International also offers a number of mentoring resources useful for both mentors and organizations interested in initiating a formal mentorship program. These resources, which can be found on the organization's website (http://www.nursingsociety.org), include information on finding and being a mentor, starting a mentoring program, and examples of mentoring programs and networks.
Supporting our young
Horizontal violence affecting newly licensed nurses increases the likelihood of turnover in this group. Healthcare organizations need to be aware of the implications associated with this issue and implement strategies to mitigate the problem. The evidence suggests a positive correlation between having support structures and programs in place for new nurses and retention.17 Programs designed to provide additional learning experiences and clinical mentoring can improve nursing satisfaction, engagement, and clinical performance.9 Modern nursing calls for change and a heightened level of accountability for nurses in all roles. The time is now to make the change: stop eating the young and new, and start mentoring. Let the old cliché become just that and begin promoting healthy environments through healthy behaviors.
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