Applying a Multidimensional Strategy to Mitigate Lateral Violence in a Small Rural Community Hospital in Western New York

Providing registered nurses with education and strategies to mitigate lateral violence is an evidencedbased method for creating a culture of civility. A descriptive pilot study with registered nurses was conducted on two medical/surgical units at a small rural community hospital. Strategies included a review of organizational policies, a one-day educational retreat for unit managers and registered nurse champions, and an online educational toolkit on lateral violence for the staff nurses on the pilot units. Document Type Dissertation Degree Name Doctor of Nursing Practice First Supervisor Nancy Wilk Subject Categories Nursing This dissertation is available at Fisher Digital Publications: https://fisherpub.sjfc. edu/nursing_etd_doctoral/7 Running head: APPLYING A MULTIDIMENSIONAL STRATEGY 1 Applying a Multidimensional Strategy to Mitigate Lateral Violence in a Small Rural Community Hospital in Western New York Nicole M. Lewis, BS, RN DNP Student St. John Fisher College APPLYING A MULTIDIMENSIONAL STRATEGY 2 Abstract Providing registered nurses with education and strategies to mitigate lateral violence is an evidenced-based method for creating a culture of civility. A descriptive pilot study with registered nurses was conducted on two medical/surgical units at a small rural community hospital. Strategies included a review of organizational policies, a one-day educational retreat for unit managers and registered nurse champions, and an online educational toolkit on lateral violence for the staff nurses on the pilot units.Providing registered nurses with education and strategies to mitigate lateral violence is an evidenced-based method for creating a culture of civility. A descriptive pilot study with registered nurses was conducted on two medical/surgical units at a small rural community hospital. Strategies included a review of organizational policies, a one-day educational retreat for unit managers and registered nurse champions, and an online educational toolkit on lateral violence for the staff nurses on the pilot units. Introduction Using a multidimensional approach when developing and implementing a program to mitigate lateral violence (LV) supports a culture of civility to promote a healthy work environment and improve patient outcomes. Mitigation of LV is a complex process that involves every employee level within an organization and requires a variety of strategies. To change disruptive behaviors in an organization, multidimensional strategies are needed that include organizational policies on workplace violence, leadership support, staff and leadership education, and communication skills. Small rural hospitals have limited access to resources to develop and implement programs for mitigation of LV. The following is a description of a pilot study conducted in a small rural hospital with registered nurses (RNs) on two medical/surgical units. The pilot study identified baseline RN satisfaction and sabotage behaviors on the two units, implemented three strategies to mitigate LV, and measured knowledge and intent to change behavior before and after an online educational toolkit on LV. The goals of this project were: • Review organizational policies and procedures related to disruptive behavior. • Conduct a one-day retreat for managers and selected RN champions from the pilot medical-surgical units. APPLYING A MULTIDIMENSIONAL STRATEGY 3 • Provide evidence-based resources in an online toolkit format for the staff nurses on the pilot units. Shared are the lessons learned from the program implementation. Literature Review In today’s nursing profession, it is important to understand that teamwork, collaboration, and professionalism are the foundation for providing safe, quality patient care that supports a culture of safety in health care organizations (Agency for Healthcare Research and Quality, 2013). To encourage these types of behaviors in the nursing profession, it is important to eliminate disruptive behaviors, such as lateral violence (LV) that undermine a culture of safety. Lateral violence is defined by Lachman as “unkind, discourteous, aggressive interactions between nurses who work at comparable organizational levels and commonly characterized as disruptive, backstabbing and bickering” (2014, p. 57). Examples of LV behavior may include “complaints shared with others without first discussing with the individual, sarcastic comments, withholding support, ignoring or discounting individual’s input, and insulting, condescending, patronizing behaviors” (Lachman, 2014, p. 57). The Joint Commission (TJC) in 2013 defined disruptive behaviors as “overt actions such as verbal outbursts and physical threats, as well as passive activities such as refusing to perform assigned tasks or quietly exhibiting uncooperative attitudes during routine activities” (p.1) Disruptive behaviors, such as LV, are a national focus in health care. For example, in 2008, TJC issued a Sentinel Event Alert on disruptive behaviors stating that it “undermines a culture of safety”, and urged leadership in all hospitals to have a code of conduct and process for managing disruptive behaviors (Wyatt, 2013, para. 2). APPLYING A MULTIDIMENSIONAL STRATEGY 4 Specific to nursing, the American Nurses Association (ANA, 2015) issued a position statement on disruptive behaviors in the workplace encompassing incivility, bullying, and workplace violence. The ANA urged nurses to take a stand against these types of disruptive behaviors and to create a workplace culture of respect. The American Association of CriticalCare Nurses (AACN) called for “the creation and continual fostering of a healthy work environment as an imperative for ensuring patients’ safety and optimal outcomes, enhancing staff recruitment and retention, and maintaining health care organizations’ financial viability” (AACN, 2016, p. 1). National organizations published recommendations on disruptive behaviors; after reviewing LV literature, this behavior is still present in the nursing profession. Research has shown that LV is caused by environmental stressors such as poor staffing, increased workload, and individual stress (Blair, 2013; Christie & Jones, 2014; Dahlby & Herrick, 2014; Embree, Burner, & White, 2013; Roberts, 2015). Consequently, the lack of employee and leadership knowledge, organizational policies, and leadership support adds to an organization’s culture of incivility resulting in LV (Parker, Harrington, Smith, Sellers & Millenbach, 2016). The lack of support from the organization’s policies and leadership regarding this type of behavior leads to underreporting, increased staffing turnover, absenteeism, hostile work environments, and compromised patient care (Blair, 2013; Christie & Jones, 2014; Dahlby & Herrick, 2014; Embree et al., 2013; Roberts, 2015). Lateral violence occurs frequently in the nursing profession because of nurses’ lack of power and control in the workplace (Roberts, 2015). The novice nurse is commonly the victim; and the experienced nurse is likely the perpetrator. A literature review on lateral violence, completed by Roberts (2015) over the last three decades, found that 46 to 100 percent of lateral violence against nurses occurs within the workplace. Christie and Jones (2014) conducted a APPLYING A MULTIDIMENSIONAL STRATEGY 5 literature review on this type of behavior, which found that 44 to 85 % of nurses experienced LV and that 93 percent witnessed acts of LV. Embree et al. (2013) reported in their literature review that nearly 60 percent of newly licensed RNs will leave their initial employment within 6 months, most likely because of LV. Annually, 4.3 billion dollars are lost in nursing because of LV, which is nearly 250,000 dollars per incident (Embree et al., 2013). Subsequently, smaller organizations are at a higher risk for LV because of limited resources and limited access to new personnel (Embree et al., 2013). The 2015 National Healthcare Retention and RN Staffing Report released by Nursing Solutions, Inc. (NSI), revealed alarmingly high RN attrition rates. According to this report, the turnover rate of bedside RNs increased from 11.2 % in 2011 to 16.4 % in 2015. The survey indicated that the average cost of turnover for a bedside RN is between $36,900 and $57,300, which can cost the hospital between $4.9 million and $7.6 million, depending on its size and number of nurses. With the increasing attrition rates of RNs, there is a need to address the factors that are responsible for this loss in the RN workforce. Decreasing attrition rates will improve the quality of care, thus nurses need to understand disruptive behaviors and educate others to create a culture of civility. As reimbursement in the US healthcare system is tied to quality of care and patient outcomes, it is incumbent on leadership teams in healthcare agencies to review and enforce policies on disruptive behaviors, provide leadership and staff education on managing disruptive behaviors, sustain efforts to establish a culture of civility, and stem the attrition of nurses in the organization. In 2010, Congress passed the Patient Protection and Affordable Care Act (PPACA). This act established that hospitals were no longer reimbursed on the quantity but on the quality of care provided to patients. In improving the quality of patient care, the frontline nursing staff are APPLYING A MULTIDIMENSIONAL STRATEGY 6 major contributor to quality care and patient outcomes. The factors that prevent mitigation of LV behavior are the lack of effective policies, awareness or knowledge of the behavior, and training (ANA, 2015; Embree et al., 2013; Mitchell, Ahmed & Azabo, 2014). As a result of their investigations, many experts have concluded that lateral violence is a learned behavior which can be decreased by education and behavioral modification (ANA, 2015; Roberts, 2015). But despite all the research and recommendations, lateral violence still impacts the nursing profession (ANA, 2015; Mitchell