Describing Perceptions of Horizontal Violence in a Military Treatment Facility

Describing Perceptions of Horizontal Violence in a Military Treatment Facility


Name: Francisco Aguirre


Presenter/Poster: Podium

Year: 2014


Introduction: Horizontal violence (HV) behaviors within the nursing work environment can lead to negative psychological and physical outcomes for nurses including; decreased job satisfaction, intention to leave the job, and poor patient outcomes. The occurrence of HV within the hierarchical military health care work environment as well as effective interventions to alleviate any HV behaviors, however, have not been established.Purpose: The purpose of this study was to explore the perceived experience of HV by nursing staff and to determine if HV education changes the perceived experience of HV by nursing staff in a Military Treatment Facility.

The specific aims of the study were to 1) determine the reliability and validity of the Horizontal Violence Workload Inventory-Modified (HVWI-M) in a military nursing environment, 2) describe the perceived experience of HV as measured by the HVWI-M, 3) measure the relationship between HV and job satisfaction and intent to leave, and 4) determine if HV education changes the perceived experience of HV.

Population: A convenience sample consisting of the entire nursing staff at LRMC (N=790), including nurse supervisors, managers, nurses, nursing assistant and medics, both inpatient and outpatient, were invited to participate in the survey and the educational intervention.Design: This exploratory prospective descriptive pilot study used a one group before-after design to describe HV and to explore the effectiveness of an educational intervention. The research team adapted the Horizontal Violence Workplace Inventory to ensure face and content validity as well as military relevance. Data regarding perceived experience and/or witness of HV was collected via this 52-item anonymous electronic survey over one month (HVWI-M). After the survey closed, an educational intervention designed by the research team based on evidence was conducted for 2 months to increase HV awareness and to train staff using cognitive rehearsal techniques. The HV survey was redistributed 5 months after the close of the first survey (pending closure on 16 July 2014).Data Analysis: Data analysis includes a) reliability and validity analysis of the HVWI-M, b) descriptive statistics to describe the perceived experience of HV (covert, overt, personal effects, and perpetrators), c) tests for dependence using demographic, job satisfaction, and intent to leave items, and d) statistical modeling to determine differences in HV before and after the intervention.

Theoretical Framework: HV within nursing has been hypothesized as an outcome of oppression of nursing both as a predominantly female and a caring profession. It has been proposed that physicians and administrators hold power and control positions within hospitals. In contrast, nurses carry a large workload demand in terms of responsibility for direct patient care with less autonomy, power or control. The oppression experienced by nurses within a hierarchical health care system can lead to behaviors that intimidate or demean their peers and subordinates as an outlet for the stress - horizontal violence.

Preliminary Results: Of the 142 nursing staff who responded to the initial HV survey, the majority of respondents were registered nurses (n=93) and medics (n=22) in their current position for 1-2 years (n=42). The nursing staff reported experiencing HV behaviors an average of once to a few times over the past 3 months—both overt (M=2.8, SD=1.2) and covert (M=2.5, SD=1.3). They felt personally affected (M=2.1, SD=1.2) by these behaviors an average of once to a few times as well. The respondents identified staff nurses and supervisors as the most frequent perpetrators of HV, observing them exhibiting these behaviors a few times to monthly over the past 3 months. The HVWI-M had a Crohnbach’s alpha of 0.96. Job satisfaction was 2.3 (SD=0.1) on a scale of 1 (very satisfied) to 4 (very dissatisfied). The respondents reported intent to leave their current job (M=2.3, SD=1.2) and intent to leave DoD employment (M=2.6, SD=1.2) between likely (2) and unlikely (3) on a 4 point scale. The final data analysis for all aims will be completed after closure of the post-survey on 16 July 2014.

Conclusions: The results of this pilot study provided evidence that HV does exist within an MTF, will indicate if there is a relationship between HV behaviors and job satisfaction or intent to leave, and may have identified a method to effectively and professionally address instances of experienced or witnessed HV.Implications: The nursing implications from the preliminary results suggest that even within military nursing with hierarchical rank structure, perceptions of HV exist. Therefore, steps must be taken to educate nursing staff on HV, to include their own role as potential perpetrators and in acting to alleviate it. Recommendations: The recommendations will be based on the final results. It is anticipated that the recommendation will be for face-to-face training, using cognitive rehearsal techniques (such as those identified in TeamSTEPPS) to assist in decreasing the incidence of HV within MTFs.

Chiu YL, Chung RG, Wu CS, & Ho CH. The effects of job demands, control and social support on hospital clinical nurses’ intention to turn over. Appl Nurs Res. 2009;22(4):258-263.Huntington A, Gilmour J, Tuckett A, Neville S, Wilson D, & Turner C. Is anybody listening? A qualitative study of nurses’ reflections on practice. J Clin Nurs. 2011;20(9-10):1413-1422.AbuAlRub RF. Job stress, job performance, and social support among hospital nurses. J Nurs Schol. 1st Qtr 2004;73-78.Vessey JA, DeMarco R, & DiFazio R. Bullying, harassment, and horizontal violence in the nursing workforce: a state of the science. Annual Review of Nursing Research, Chap 6. 2011;28:133-157.Walrafen N, Brewer MK, & Mulvenon C. Sadly caught up in the moment: an exploration of horizontal violence. Nurs Econ. Jan/Feb 2012;30(1):6-12,49.Griffin M. Teaching Cognitive Rehearsal as a Shield for Lateral Violence: An intervention for newly licensed nurses. J Cont Ed Nurs. 2004;35(6):257-263.Stanley KM, Martin MM, Michel Y, Welton JM, & Nemeth LS. Examining lateral violence in the nursing workforce. Iss Ment Hlth Nurs. 2007;28:1247-1265.Hogh A, Hoel H, & Carneiro, IG. Bullying and employee turnover among healthcare workers: a three-wave perspective study. J Nurs Manag. 2011;19:742-751.Simons S. Workplace bullying experienced by Massachusetts registered nurses and the relationship to intention to leave the organization. Adv Nurs Sci. 2008;31(2):E48-E59.Sofield L & Salmond SW. Workplace violence: a focus on verbal abuse and intent to leave the organization. Ortho Nurs. Jul/Aug 2003;22(4):274-283.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(1):90-96.Hegney D, Tuckett A, Parker, D, & Eley RM. Workplace violence: differences in perceptions of nursing work between those expose and those not exposed: a cross-sector analysis. Int J Nurs Prac. 2010;16:188-202.Dumont C, Meisinger S, Whitacre MJ, & Corbin G. Horizontal violence survey report. Nursing2012. 2012;January:44-49.Curtis J, Bowen I, & Reid A. You have no credibility: Nursing students’ experiences of horizontal violence. Nurs Ed Prac. 2007;7:156-163.Vessey JA, DeMarco R, 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 Nur. Sep/Oct2009:299-306.The Joint Commission. Behaviors that undermine a culture of safety. Sentinel Event Alert, Issue 40; 2008, July 9.Rosenstein A. The Joint Commission disruptive behavior standard: Intent and impact. J of the ASPR. 2009;16(3):6-7.Purposa C, & Blegen MA. Horizontal violence and the quality and safety of patient care: A conceptual model. Nur Res & Prac. 2012;1-5. Wilson BL, Diedrich A, Phelps, CL, & Choi M. Bullies at work: the impact of horizontal hostility in the hospital setting and intent to leave. JONA. 2011;41(11):453-458.Brunt B. Breaking the cycle of horizontal violence. ISNA Bull. 2011;Feb/Mar/Apr:6-10.Gaffney DA, DeMarco RF, Hofmeyer A, Vessey JA, & Budin WC. Making things right: Nurses’ experiences with workplace bullying—a grounded theory. Nurs Res Prac. 2012. Retrieved from…Barber C. Use of bullying as a management tool in healthcare environments. Brit J Nurs. 2012;21(5):299-302.Hutchinson M, Wilkes L, Vickers M, & Jackson D. The development and validation of a bullying inventory for the nursing workplace. Nurs Res. 2008;15(2):19-29.Murray JS. Workplace bullying in nursing: A problem that can’t be ignored. MEDSURG Nurs. Sep/Oct 2009;18(5),273-276.Stagg SJ, & Sheridan D. Effectiveness of bullying and violence prevention programs: A systematic review. AAOHN J. 2010;58(10):419-424.Longo J, & Sherman RO. Leveling horizontal violence. Nurs Manag. Mar 2007;34-37,50-51.Dunn H. Horizontal violence among nurses in the operating room. AORN J. Dec 2003;78(6):977-988.Roberts SJ, DeMarco R, & Griffin M. The effect of oppressed group behaviours on the culture of the nursing workplace: a review of the evidence and interventions for change. J Nurs Manag. 2009;17:288-293.Croft RK, & Cash PA. Deconstructing contributing factors to bullying and lateral violence in nursing using a postcolonial feminist lens. Contemp Nurs. 2012;42(2):226-242.Sellers K, Millenbach L, Kovach N, & Yingling JK. The prevalence of horizontal violence in New York state registered nurses. J NY State Nurs Ass. Fall/Winter 2009-2010:20-25.Stagg SJ, Sheridan D, Jones RA, & Speroni KG. Evaluation of a workplace bullying cognitive rehearsal program in a hospital setting. J Cont Ed Nurs. 2011;42(9):395-401.Academy of Medical-Surgical Nurses. Workplace bullying and lateral violence among nurses. Healthy Work Environment Advocacy Guide. 2012.Barrett A, Piatek C, Korber S, & Padula C. Lessons learned from a lateral violence and team-building intervention. Nurs Admin Q. 2009;33(4),342-351.Shih, T. H., & Fan, X. 2009. Comparing response rates in e-mail and paper surveys: A meta-analysis. Educational Research Review, 4, 26-40.Choi JS, Flynn L,  Aiken LH. Nursing practice environment and registered nurses' job satisfaction in nursing homes. Gerontologist. 2012;52(4),484-492.Aiken LH, Clarke SP, Sloane DM, Lake et, & Cheney T. Effects of hospital care environment on patient mortality and nurse outcomes. JONA. 2008;38(5):223-229.Aiken LH, Clarke SP, Sloane DM, Sochalski J, & Silber JH. Hospital nurse staffing an patient mortality, nurse burnout, and job dissatisfaction. JAMA. 2002;288(16):1987-1993.Aiken LH, Clarke SP, & Sloane DM. Hospital staffing, organization and quality of care: cross-national findings. Int J Qual Health Care. 2002;14(1):5-13.Shu-Yuan, L, Chiang HY, & Chen IL. Comparing nurses’ intent to leave or stay: differences in practice environment perceptions. Nurs Health Sci. 2011;13:463-467.Patrician PA, Shang J, & Lake ET. Organizational Determinants of work outcomes and quality care ratings among army medical department registered nurses. Res Nurs Health. 2010;33(2):99-110.Agency for Healthcare Research and Quality. Pocket Guide TeamSTEPPS: strategies & tools to enhance performance and patient safety. AHRQ Pub. No. 06-0020-2. June 2010.Army Nurse Corps. Patient Caring Touch System: Intro. Powerpoint Presentation, September 25, 2012. Retrieved from

IRB Approval: This protocol received Institutional Review Board approval through Medical Research and Material Command M-10354 on 11 Oct 2013.Research Team Members: 1LT Caitlin Fuhrman, LTC Susan Hopkinson, Maj Michelle Langdon, 1LT Paul Merrill, COL Lori Trego, 1LT Amanda VanDeWalle.CONTENT DISCLAIMER: The views expressed in this abstract are those of the authors and do not necessarily reflect the official policy or position of the Department of the Army, Department of Defense, nor the U.S. Government.