Horizontal Violence in Nursing - Essay Example

? Horizontal Violence in Nursing Rita Marakovitz South Literature indicates that horizontal violence is rampant among registered nurses and is accompanied by very serious consequences to the nurse, hospital facility and healthcare industry in general. People might say that there is a link between horizontal violence and hospital nurse retention. This study will attempt to show a relationship of cause and effect to investigate whether this link exists. Based on a correlation model, Riggleman et al (2010) Horizontal violence measuring tool will be used to evaluate perceptions of horizontal violence which is then correlated with medical-surgical unit retention data from the human resource department of a hospital. Horizontal Violence in Nursing Among the many challenges hospitals face, it is now emerging that scapegoating or bullying and other forms of harassment are a serious problem. This is especially true in the hospital setting with different ranks between and within such professions. Despite being discouraged and restricted by various professional codes of ethics, workplace violence in the healthcare industry remains rampant. It may take several forms including “verbal abuse, threats, intimidation, bullying, humiliation, excessive criticism, innuendos” and exclusion among others (McKenna et al., 2003). Horizontal violence amongst nurses has very serious consequences and can significantly inhibit the quality of healthcare provided to the patient. It has been implicated in poor nurse retention in hospitals, although this has mainly been theoretical; opening the door for more research. This study will review the literature available on horizontal violence among registered nurses and its effects. A non-experimental correlational study design will then be established to investigate the link between horizontal violence among nurses and hospital retention of nurses. Horizontal violence describes the aggressive actions of a group of people who work together and hold a similar status in their work environment. What makes the problem troubling is the fact that registered nurses are thought to be caring professionals. Most people would say that registered nurses do not bully, use abusive language and other disruptive behavior against their own. Although many healthcare stakeholders are aware of rampant horizontal violence, many of them are oblivious of its extent. Ditmer (2010) provides an overview of the scope of horizontal violence among nurses, establishing that “75%” of nurses have experienced aggression, harassment and bullying during their careers. To further exacerbate such grim statistics, majority of such acts go unreported. Besides, such horizontal violence may not be interfered with a reported “40%” of leaders remaining passive or quiet when witnessing such acts (Ditmer, 2010). Several explanations have been provided for the cause and nature of horizontal violence. In certain situations conflict within the group arises and horizontal violence is a symptom of an underlying problem. The ultimate result is that horizontal violence persists in the nursing workplace and the individual nurses learn it as an expected behavior, being oblivious that it should not be part of their culture. As a result the nurses are vilified for this and develop a low self-esteem, such that by the time they enter the nursing practice they are already negatively socialized to certain submissive roles. Horizontal violence such as “disruptive and unprofessional behavior” is allowed to enter due to two factors; through acts of omission; and new nurses’ deficient of formal instruction to handle conflicts and assert their rights. In the former case, it is noted that failure of the management to act even after observing manifestations of horizontal violence contributes to its pervading and perception as part of normal culture in nursing practice. In the latter case, new graduate nurses are observed to lack the necessary skills to deal with being victims of horizontal violence. Some of them also tend to assume that this is part of their orientation into practice as evidenced by the large numbers of incidents that go unreported (Walrath, Dang & Nyberg, 2010). The consequences of horizontal violence among nurses can be classified according to their impacts on the individual nurse and the healthcare industry, with the effects on the former that influence the latter. The nurse may suffer from reduced self esteem and confidence, fear, anxiety, nervousness, depression, fatigue, weight loss, mistrust, eating disorders, hypertension, irritability, low morale and burn out, disappointment with the nursing profession among other consequences. Such impacts on the nurse translate to compromise of patient safety. It is argued that horizontal violence is a major explanation behind the quoted figure of 60% new entrant nurses leaving their first position within the first 6 months. Problem statement: It can be said from the outcome of this study, horizontal violence among nurses is a serious issue on many standpoints; the impact on registered nurses, the hospital facility, the patient and healthcare as whole. In relation to the hospital, it has to be appreciated that the high rate of turnover quoted to be many within the first 6 months is very regrettable especially considering the fact that nurses as a human resource in hospitals are already constrained (Stanley, 2010). Such levels of low retention also lead to losses on the training and development that the hospital may have invested on the nurses. There is a need to confirm whether there is a significant link between horizontal violence and nurse retention in hospitals Purpose of the Study: This study will investigate whether there is a significant link between horizontal violence among nurses and nurse retention in hospitals. A cause-effect model will be followed where the independent variable will be horizontal violence and the dependent variable will be nurse retention. The study will contribute useful information in the field of nursing that will add impetus to solving the pertinent issues of horizontal violence and nurse retention, and thus overall lead to improvement of the quality of services in the healthcare industry. Significance of the Study: Earlier studies done by researchers reveal that horizontal violence largely persists despite considerable efforts being made to control it, with Skinner (2011) reckoning that it has been documented in literature for about the last two decades. Similarly, nurse retention in hospitals has caught the attention of many scholars hence its extent, causes and effects have been under investigation. This study will build upon these two sets of nursing knowledge and then seek to contribute to nursing literature through investigating the link between the two areas of inquiry, thus helping fill an area that has not received the necessary level of attention it deserves. I. Research Question: This research study will answer the following question: Is there a significant link between horizontal violence among hospital nurses and hospital nurse retention? To determine the strength of this research question in guiding this study, its testability is established by using it to generate the hypothesis that will be tested in this study. Basing on this, the null and alternative hypotheses will be as follows: H0: There is no significant link between horizontal violence among hospital nurses and hospital nurse retention. H1: There is a significant link between horizontal violence among hospital nurses and hospital retention. II. Literature Review Previous research related to this study indicates that a lot of effort has been placed in the horizontal violence and hospital nurse retention separately instead of investigating the link. The literature reviewed here follows the pattern of research into horizontal violence and its link to several aspects that may contribute to low retention. Stelmaschuk (2010) investigated the relationship between workplace bullying among nurses and exhaustion. A cross-sectional “54-item survey” was used to investigate the incidence and variation of workplace bullying and its link to exhaustion, with “71 registered nurses” participating in a hospital setting. After data analysis through the statistical package for the social sciences (SPSS), it was established that a significant moderate positive correlation existed between emotional exhaustion and bullying. This study is important since it establishes that horizontal violence in the workplace can be significantly linked to emotional exhaustion among nurses. The current study will however investigate more specifically the link between horizontal violence and nurse retention and hence will contribute more information. Griffin (2004) investigated the effectiveness of using cognitive rehearsal, as a shield for lateral violence among new nurses to intervene and help reduce hospital nurse turnover. Cognitive rehearsal is a strategy through which individuals are asked to hold mind information that has just been received and process it basing on what they have been taught about the incoming information. Cognitive rehearsal lets the nurse take in what was just heard or experienced but reserves to answer the challenge. This allows individual’s time to process the information” (Griffin, 2004). The person has time to formulate a response to the confrontation. “Twenty-six” newly registered nurses participated in an exploratory descriptive study where they were taught about lateral violence and use of cognitive rehearsal techniques to manage it. The information provided to the nurses in this study was on non-verbal innuendos, verbal affronts, withholding of information and undermining activities from co-worker nurses. The newly registered nurses were given information on what would count as poor reactions, including sabotaging, scapegoating, in-fighting and backstabbing. Instead, accepting fair share of work, respecting privacy and confidential information, not denigrating seniors, looking coworkers in the eye and working cooperatively despite feelings of dislike among other avenues were taught to the nurses. Qualitative data was “collected one year later” through video-taped focus groups and analyzed (Griffin, 2004). The literature suggests that successful confrontation of horizontal violence will contribute to nurse retention. Furthermore, the results indicated that the newly registered nurses were able to confront horizontal violence successfully, and that there was a positive effect on retention rate on the study participants. This study is important due to the fact that it establishes that intervening in lateral violence contributes to more nurse retention and thus there is a link between the two. However, it does not focus on this link and hence the need for the current study. Lea and Cruickshank (2007) investigated the experience of new nurses in “rural practice” to determine the factors behind low nurse retention in rural hospitals. Among the many manifestations of horizontal violence is unfair workload to new or student nurses. The qualitative inquiry involved sampling of eight rural healthcare facilities for ten new graduate nurses in the hospital setting. Data was analyzed to reveal that workload played a significant role, influencing new graduate nurses to leave and thus explaining the poor retention after recruitment in rural hospitals. The participants stated that their initial perception of receiving more workload was a way of establishing whether they could cope with nursing practice. However, they later realised that the unfair distribution of workload was a reflection of hostility towards them and thus reacted by shifting from their first places of employment. This study is important for the current one as it establishes that horizontal violence, in this case through issuing of more workload to new nurses, plays a significant part in nurse turnover. It is different because it focuses on new nurses and does not specifically investigate horizontal violence. The current study will contribute in filling data gaps left by such studies and providing new perspectives of looking at the issue. McKenna et al. (2002) investigated horizontal violence experience among registered nurses in their first year of practice. Among other aims of the study, the scholars sought to know the consequences of lateral violence on new graduate nurses. Data collection was through an anonymous survey to nurses who had registered a year prior to the study with a sample size of 1169 and achieving a response rate of 47% (551 completed questionnaires). The information sought through the questionnaires was on the frequency of lateral violence, the consequences of it and training to manage such events. The results indicated that many of the new nurses experienced lateral violence. The consequences of the behaviour were absenteeism from work and, of interest to this study, the “high number of respondents who considered leaving nursing” (McKenna et al. 2002). This study is of importance since it finds a link between lateral violence and nurses considering leaving the practice. It however does not report actual leaving with this only being extrapolated from the link established. Simons (2008) also investigated horizontal violence and the consequences on newly registered nurses in terms of its relationship to the intention of leaving the organization. The researcher undertook a descriptive study to study bullying behavior among nurses, testing its influence on the intentions of new nurses to leave their first places of work. Data collection was through the Revised Negative Acts Questionnaire, an instrument designed to measure perceived exposure to bullying at work. A sample of 511 randomly selected newly registered nurses participated in the study. The results indicated that a significant 31% of the nurses reported horizontal bullying and that bullying was a significant determinant in prediction of their intent to leave the organization. Hence, the researcher concluded that effective interventions need to be put in place to stop the behavior which is a contributor to the high rates of nurse turnover. The last study reviewed is by Nachreiner et al. (2007) who investigated the perceptions of workplace violence and the work environment among nurses. The study’s aims were to establish the extent of the behavior, nurse perceptions of the work environment and the consequences. Through a sample size of 6300 randomly selected nurses, data collection in terms of experience of violent behavior within the last year and their perceptions evaluated through a nested case-control study which compared assaulted and non-assaulted nurses. The results indicated that nurses frequently went through work related violence and that there were significant perception differences between the two groups. Of particular interest to the current study, it was found out that 28% of the nurses “indicated planning to leave their positions within the next three years” (Nachreiner et al. 2007). Hence, the researchers proposed further studies to investigate the link between violence and nurse choice to leave so as to improve retention. Theoretical Framework Horizontal violence among nurses is a complex issue, and when narrowed down to its impact on nurse retention in hospitals, it becomes difficult to isolate a specific conceptual framework from literature that can specifically encompass the link being investigated. However, through adoption of Walrath, Dang and Nyberg’s (2010) version of the conceptual framework of workplace rudeness in the hospital, an appropriate framework for this study can be established. The three researchers developed a framework for disruptive behavior based on triggers, behavior, responses and impacts. The trigger for hospital workplace incivility is a trait, precedent or contributory condition towards the incivility. The behavior for the purpose of this study is horizontal violence, but may also be in the form of disruptive behavior or any other form of harassment and aggression. The response is the reaction of the individual victim to the discourtesy, and lastly the impact is made up of the direct or indirect effects on the stakeholders in the healthcare industry. For the purpose of this study, the conceptual framework based on workplace lack of respect in hospitals can be explained as follows: underlying causes of horizontal violence as explained in the study’s background are the pre-conditions for the lack of respect. The behavior in question is horizontal violence, and the response from the nurse is leaving the hospital thus explaining the low retention. The impact of the behavior is varied as discussed in the study’s background, although for this study the impact is narrowed down to the medical-surgical units of a local hospital. To investigate the link between horizontal violence and hospital retention of nurses, this study utilizes the behavior and response aspects of the just explained framework. Limitations and weaknesses The weaknesses of this study that may affect its capacity to be generalized result from the research design of choice. A non-experimental research design is accompanied by various issues that may weaken the study. To begin with, this research design investigates a phenomenon in its natural setting and without interfering with any variables, such that a number of extraneous variables exist as they are not held constant during the study. For example, the explanations for low hospital nurse retention are not only limited to horizontal violence; they may include financial considerations and geographical relocations by the individual nurse. The sample size used in the study (50 nurses) is also a source of limitation since it may be representative of the two medical-surgical units and not the entire nursing population of the hospital. The study is being conducted in a rural hospital and thus its generalizability is limited to hospitals in the rural setting. Provisions for pretesting the questionnaire to determine its applicability to the situation (rural setting) in question have not been made, which may lead to problems being detected when the study is being conducted. An assumption is also made in the hypothesis that horizontal violence determines retention of nurses in terms of the view that horizontal violence could be acting in synchrony with a number of other factors such as other forms of violence including that emanating from patients and doctors. Methodology Research Design The study seeks to examine a present situation as it naturally exists in a population and will use a non-experimental research design. This study will use a correlational model in which horizontal violence will be measured in two Medical-surgery units of the hospital and correlated with retention data obtained from the human resource department of the hospital. Significant correlations between the two (high incidence of horizontal violence and low retention) or lack of it thereof will be used to test the hypothesis and come to a conclusion on the issue. Setting, Population, Sample and Participation The setting for this study will be on two medical-surgical unit of the same rural hospital. The populations will be differentiated only by the nursing unit they work on. Previous experience with horizontal violence will not be a factor for this study. For the purpose of this study a sample of 25 nurses will be obtained from each population to make a total sample size of 50. The nurses will be drawn from both the day and night shifts so as to achieve the desired sample size. The selection will be done by voluntary sign-up and dropped into a locked box as to keep participants secret. Participation will be restricted to seasoned nurses of the hospital population. The rationale for this participation requirement is based on the view that seasoned nurses have stayed in their careers long enough to have had considerable chances for experiencing horizontal violence. Protection of Human Subjects IRB Review: as an institution in which federally regulated research takes place, the hospital has an institutional review board to ensure the protection of the rights and welfare of human participants in research. Federal regulations categorize review of research projects into exemption, expedited review and full review. Exempt review involves research projects that have least risk to the welfare of the human participant; expedited review involves minimal risk projects; lastly, full review is for projects with more than minimal risk (Indiana University, 2006). This study involves minimal risk due to its use of personal data of the human participants and thus will require expedited review by the IRB. However, the fact that it is investigating violence- a thorny and sensitive issue that may have implications on the management of the hospital- it will be important to provide assurance to the IRB of protection of individual and organizational identity. Through a formal letter (Appendix 3), permission to conduct the study in the hospital will be sought from the hospital manager and the IRB with the researcher providing formal written commitment to adhere to hospital policy and the Institutional Review Board (IRB) regulations for conducting research. The purpose of the study and the implications of its results will be sufficiently explained to the relevant authority before seeking permission to undertake the research in the hospital. Informed consent will be sought from the nurses after sufficiently explaining the purpose of the study. They will be made aware of their right to withdraw from the study at will. They will also be provided with assurance that personal information such as age, sex, identity, contacts and residence will not be divulged and confidentiality will be maintained. The study participants (nurses) will also be assured that the information sought from them will not be used for any other purposes other than this research. In doing this, the researcher will have fulfilled the IRB federal requirements for non-biomedical studies involving humans (Indiana University, 2006) besides fulfilling the researcher’s own commitment to ethical research. Instrument and Materials The instrument used to collect data will be adopted from Riggleman et al (2010) Horizontal violence measuring tool (Appendix 1). This is a 6-point likert scale providing for: 1 = never, 2 = once, 3 = a few times, 4 = monthly, 5 = weekly, 6 = daily. The instrument does not mention horizontal violence so as to maintain objectivity, with its stem being “In the last 12 months or less at this institution how often have you experienced or witnessed yourself or someone else …..” (Riggleman et al., 2010). The tool has 2 parts; Part A- overt behaviors, Part B- covert behaviors. It has been tested for reliability and validity achieving scores for Cronbach’s Alpha as follows: Overt behaviors = 0.865, covert behaviors = 0.916 and overt and covert overall = 0.913. Through this instrument, the behaviors that generally characterize horizontal violence can be investigated in terms of frequency of acts. For instance, Riggleman et al (2010) used this instrument to study the frequency of covert acts such as exclusion and being ignored and overt actions such as making negative remarks and threatening verbally. They also sought to establish the impacts of such acts on nurses, for instance in terms of leaving work feeling bad at the end of a shift and having looked for another job; obtaining responses of 2.99 and 2.11 respectively out of a likert score of 6. After collection of the frequencies on horizontal violence acts through the instrument, the researchers correlated them with NDNQI statistics on nurse satisfaction as a way of further establishing the impacts of horizontal violence. This serves as a guide to establishing how the instrument will be effectively used in this study. Data Collection Procedures After seeking permission from the hospital management, the researcher will attend a staff meeting in order to explain the study and protection of participants. Informed consent will be officially sought through the Informed Consent Form (Appendix 2) distributed to participant nurses. The questionnaires will be distributed to the nurses in the staff meeting and collected through depositing them in sealed envelopes in a locked box at the nurses’ work stations in order to maintain anonymity. The next step will be to set a meeting with the human resource manager or the officer in charge through formal permission from the hospital manager and explain the study to them. They will be then requested to provide data on retention from the two medical-surgery units from which the sampling will be done. Data Analysis Strategies After collection of all the surveys, data will be fed into a password protected computer for storage and analysis, which will be through the statistical package SPSS to establish the incidence of horizontal violence in the two medical-surgery units in the hospital. The prevalence (percentages) will be established to digest the data further and make it easier to interpret. Correlation analysis will then be done between the frequency of horizontal violence and retention while comparing the results for the medical-surgery units for significant differences in order to test the hypothesis. Further analysis will be through correlating data for the day and night shifts as well as registered nurses and technical nurses. Correlations will also be done according to age category of nurses in the work place: baby boomers, generation X and generation Y, with the view of establishing which group is most affected by horizontal violence since it is appreciated that generational differences exist in terms of how these groups act and react in the workplace (Major Cities Chiefs HRC, 2007). Such analyses will result in relevant and constructive recommendations according to the implications that wil be realized from this study. Conclusion Horizontal violence is a widespread and pertinent issue despite being addressed by legal and healthcare policies. Literature is indicative that it is the result of powerlessness and marginalization of nurses at the workplace accompanied by laxity or disregard of its impact by the management. It has very serious consequences on the individual nurse and quality of patient care availed besides translating into massive losses whenever nurses quit the field. On an institutional level, it is argued that horizontal violence contributes to poor retention. Research evidence for this is limited, and thus justifies an inquiry into it. This study develops a correlational research design to be used to study whether there is a link between horizontal violence among nurses and hospital nurse retention in two medical-surgery units. A horizontal violence measuring tool whose reliability and validity has been tested is proposed for use in data collection after assuring participant protection through the IRB and hospital management. Data analysis will be through SPSS after which the results will be used to test the hypotheses leading to discussion of implications and applications. References Ditmer, D. (2010). A safe environment for nurses and patients: Halting horizontal violence. Journal of Nursing Regulation, 1(3), 9-14. Retrieved from jnr.metapress.com/index/280356777R49172M.pdf Griffin, M. (2004). Teaching cognitive rehearsal as a shield for lateral violence: An intervention for newly licensed nurses. Journal of Continuing Education in Nursing, 35(6), 257-263. Retrieved from http://www.mc.vanderbilt.edu/root/pdfs/nursing/m_griffin_article_to_share.pdf Not helpful? You can block www.ncbi.nlm.nih.gov results when you're signed in to search.www.ncbi.nlm.nih.gov Indiana University (2006). Protection of human subjects in non-biomedical research: A tutorial. Retrieved from http://www.indiana.edu/~rcr/files/hspt-nbm.pdf Johnson, B. (2001). Toward a new classification of non-experimental quantitative research. Educational Researcher, 30(2), 3–13. Retrieved from http://education.astate.edu/dcline/slides/Johnson_Nonexperimental.pdf Lea, J. and Cruickshank, M. T. (2007). The experience of new graduate nurses in rural practice in New South Wales. Journal of Rural and Remote Health Research, 7(814), 1-11. Retrieved from http://www.rrh.org.au/publishedarticles/article_print_814.pdf Major Cities Chiefs HRC, (2007). Retention: understanding the generations, recruitment and selection employee and leadership development. Retrieved from www.neiassociates.org/rrredl.pdf McKenna, B. G., Smith, N. A., Poole, S. J., & Coverdale, J. H. (2003). Horizontal violence: experiences of Registered Nurses in their first year of practice. Journal of Advanced Nursing, 42(1), 90-96. doi:10.1046/j.1365-2648.2003.02583.x Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/12641816 Nachreiner, N. M., Gerberich, S. G., Ryan, A. D. and McGovern, P. M. (2007). Minnesota nurses’ study: perceptions of violence and the work environment. Industrial Health, 45: 672–678. http://www.jniosh.go.jp/en/indu_hel/pdf/IH_45_5_672.pdf Polit, D. E., Beck, C. T. (2008). Nursing research: Generating and assessing evidence for nursing practice (8th Edition). Philadelphia, PA: Lippencott, Williams & Wilkins. Riggleman, K., Meisinger, S., Tagnesi, K. and Dumont, C. (2010). Horizontal violence (bullying) and relationships to nurse job satisfaction in an acute care hospital. Winchester Medical Center, Valley Health, 3393: 1-15. Retrieved from https://ana.confex.com/recording/ana/ndnqi10/pdf/free/4db77adf5df9fff0d3caf5cafe28f496/paper3393_1.pdf Simons, S. (2008). Workplace bullying experienced by Massachusetts registered nurses and the relationship to intention to leave the organization. Advances in Nursing Science, 31(2): 48-59. Retrieved from http://journals.lww.com/advancesinnursingscience/Abstract/2008/04000/Workplace_Bullying_Experienced_by_Massachusetts.14.aspx Skinner, T. C. (2011). Lateral violence in nursing. Nursing news and views. Retrieved from http://www.bon.state.nm.us/pdf/news_winter2011.pdf Stanley, K. M. (2010). The high cost of lateral violence in nursing. Nursing Society. Retrieved 8 November 2011 from http://www.nursingsociety.org/STTIEvents/LeadershipSummit/Documents/The%20High%20Cost%20of%20Lateral%20Violence%20in%20Nursing_Stanley_4-24-2010.pdf Stelmaschuk, S. (2010). Workplace bullying and emotional exhaustion among registered nurses and non-nursing, unit-based staff. OSU. Retrieved 8 November 2011 from https://kb.osu.edu/dspace/bitstream/handle/1811/45566/Workplace_Bullying_and_Emotional_Exhaustion_among_Registered_Nurses_and_Non_nursing_Unit_based_Staff_final.pdf Walrath, J. M., Dang, D. and Nyberg, D. (2010). Hospital RNs' experiences with disruptive behavior: a qualitative study. Journal of Nursing Care Quality, 25:105-116. Retrieved from http://www.psnet.ahrq.gov/resource.aspx?resourceID=17857 Appendix 1: Survey Questionnaire employed in the study Thank you for consenting to participate in this survey. The purpose of this study is to investigate whether there is a link between horizontal violence among hospital nurses and hospital nurse retention. You are assured that confidentiality will be maintained at all times and any personal information will not be divulged. Your information will also not be used for any other purposes except that of this study and you are free to withdraw consent at will. Please do not take part in the study if you have not practiced nursing as a registered professional for a minimum of 4 years. Frequency: 1= Never, 2= A few times, 3= Monthly, 4= Weekly, 5= Daily Question Frequency Part A: How often have you experienced or observed this happening to others in the last 12 months where you work? Making negative remarks Belittled in front of others Shouted at in front of others Someone refusing to help Making hurtful remarks Criticized without hearing both Was verbally threatened Part B: How often has a colleague done this to you or to other colleagues in the last 12 months where you work? Frequency Passed over for developmental opportunities Pretending not to notice needs for help Withholding important information Avoiding eye contact Raising eyebrows Excluding others from discussions Allowing to make a mistake without helping Belittling behind their backs Belittling (Riggleman et al 2010, pp. 6-7) Appendix 2: Informed Consent I am Rita Marakovitz, a researcher at South University, School of Nursing, interested in researching whether there is a link between horizontal violence among nurses and hospital nurse retention. Previous studies into the area indicate that the issue is of grave consequences to the healthcare industry if present owing to the importance of good working conditions for the nurse. There is thus a need to generate more insightful information through this study. Hence, I will need to conduct a survey on nurses in the hospital to collect data. Below is an informed consent form that as a participant nurse you will be required to read, understand, share concerns where necessary and fill to take part in this study. Consent Form I understand that I am being asked to participate in a research study at the Marakovitz Hospital in Mechanicsville, Virginia. This research study will evaluate the incidence of horizontal violence used against me during my regular work day. If I agree to participate in the study, I may have to complete questionnaire. I realize that my participation is entirely voluntary and I may withdraw from the study any time I wish, and continue working in the usual fashion. I understand that all study data will be kept confidential through collecting respondent-filled questionnaires in sealed envelopes in a locked box at nurses’ work stations in order to maintain anonymity as well as use of password protected to store and manipulate data. If I need to I can contact Rita Marakovitz, RN, BSN at South University, School of Nursing, any time during the study. This study has been explained to me. I have read and understood the consent form, all of my questions have been answered, and I agree to participate. I understand that I will be given a copy of this consent form. Signature of Subject Date Signature of Witness Date Signature of Investigator Date (Polit & Beck, 2008, p. 179) Appendix 3: Letter to the Hospital Manager and to the IRB To the Hospital Manager/IRB From Rita Marakovitz Dear Sir/Madam, Re: Request for Permission to undertake a research on “the link between horizontal violence and retention in nursing practice” at Hospital X I am Rita Marakovitz, a researcher at South University, School of Nursing. I am formally requesting for permission to carry out research investigating whether there is a link between horizontal violence among nurses and hospital nurse retention. Previous studies into the area indicate that the issue is of grave consequences to the healthcare industry if present hence the need to generate more insightful information through this study. It involves minimal risk and it has been designed to meet participant protection requirements effectively. The researcher will also observe the institutional codes of conduct throughout the study. I would be grateful to brief you on the details of the study and the participant protection in a formal meeting. Thank you. Yours sincerely (Signature) Rita Marakovitz Read More