Violence in the Nursing Profession - Essay Example

? Violence in the Nursing Profession Despite numerous researches done on this the issue of violence in the Nursing profession, the vice still carries on still unabated. This summary paper will delve into this issue by critically analyzing three reports based on the same topic. A critical appraisal of these research articles will be presented with thorough quantitative and qualitative analysis of the scope, methodology, findings. Subsequent implications of these findings on the Nursing profession will also be elaborated in detail. This paper has divided the three articles into three study cases for ease of in-depth analysis of each. Introduction Violence in the workplace has become a topic of great concern as it has been witnessed in many sectors. Nurses are prone to violence in their workplace either intentional or due to the nature of their jobs. It has been noted that nurses are easily exposed to violence in certain scenarios in the course of dispensing their duties, thereby increasing their vulnerability (Carter, 2000). The healthcare sector is faced with many challenges including limited budgets, low work motivation, low pay and understaffing. These challenges on their own create tension in the work environment and in most cases; nurses bear the brute of the frustration. Violence is in many forms including physical, psychological, sexual harassment, isolation and intimidation. The patriarchal medical model has contributed a great deal to this vice as nurses are seen as doctor’s handmaidens (O’Connell et al 2000).In this sense, doctors may form a condescending and intimidating attitude toward nurses whereby they feel their qualification and status is superior to those of nurses. Nurses also face violence from hospital visitors and patients, some of who express their grief, frustrations and misgivings to the nurses, who tend to be more available than doctors. Horizontal violence is also rampant, where nurses themselves administer violence on each. Studies show that nursing students during their clinical assignment in their courses are the most vulnerable to violence (Randle 2003). CASE STUDY 1 SUMMARY The first case study will look into the article dubbed “Aggression in the Workplace: A study of Horizontal Violence Utilizing Heideggerian Hermeneutic Phenomenology.” The article sought to ascertain the existence and rampant widespread of horizontal violence amongst nurses in healthcare institutions. One or more group members towards another member or section of the larger group (Duffy 1995) define horizontal violence as hostile or aggressive behavior. Studies show that the prevalence is high but majority of the cases go unreported due to fear of stigmatization and/or retribution (Farrel 1997).This case study also seeks to identify the impact of horizontal violence on the victims’ work performance and relationships with others. Study Design The Heideggerian hermeneutic phenomenology was the chosen method of research in this article. This qualitative approach by Heidegger, a German philosopher, proposes that all knowledge comes from people in the world and the attempt to understand other people in the world. It thus means that we are always within the hermeneutic circle of Interpretation (Leonard 1989).With this design the researcher has a preliminary understanding of horizontal violence (Leonard 1989) and will be able to add personal experience and understanding to the research (Walter 1995). Sampling Strategies and Data collection In compiling information for this article, the use of questionnaires was employed. The sample size comprised of two registered nurses who had consensual agreed to take part in the study based on their expertise in the field (Field and Morse; 1985). The sample size was relatively small but since it was a qualitative analysis, sample size depended on the accuracy of the information given by the respondents and their abilities to do so. Data collection was done using recorded audio tapes. This method was the most viable since it was of great importance to maintain the spontaneity of the respondents to ensure accuracy and continuous flow of the information (Oiler 1982). The method also enables further analysis based on the raw data, which is always available. The audiotapes were transcribed, written by hand and cut into phrases for analysis. The context of the study was maintained by constantly referring back to the questions forming the basis of research Results The statements were clustered into themes based on the interpretation of the researcher. Six themes stood out: Stress Guilt Fear Enculturalisation Power/control Reflection/rationalization Strengths and Limitations The Heideggerian phenomenon approach proved very valuable since it relied on lived experience that was able to probe into the conscious of the subject and bring about the themes mentioned above. The approach was also very useful in determining the impact of horizontal violence on the nurses and its implication in the wider context of healthcare. However, the approach had a limitation in that the sample size was too small and therefore cannot be taken to be a representation of the whole fraternity, and may risk passing off as isolated cases. CASE STUDY 2 SUMMARY This case study is based on an article by Dr. Martha Griffin, titled “Teaching Cognitive Rehearsal as a Shield for Lateral Violence: An Intervention for Newly Licensed Nurses.” The aim of this study was to investigate lateral violence in nursing using a theoretical model that would provide the basis of origin and manifestations of lateral violence in the nursing fraternity. Secondly, the experiment was meant to ascertain the vulnerability of newly registered nurses to this vice. The research was also aimed at teaching on the use of cognitively prototypical prescribed responses to the common manifestations of lateral violence. There is a consensus on the definition of lateral violence that is also referred to as bullying, aggressiveness or horizontal violence. Infighting amongst nurses, critiscm, scapegoating, failure to respect privacy and confidentiality (Duffy 1995, Farrell; 1997) are some of the key manifestations of lateral violence in the nursing practice. Study design The design of study bases on cognitive rehearsal that is an applied behavioral cognitive technique. This technique was first used as an intervention technique and as a theoretical basis to this study. The subjects learned about lateral violence and the use of cognitive behavioral technique as an identification and defense mechanism in socialization and learning contexts. To facilitate this, they each got two small written cards with visual cues that would enable them to appropriately discern lateral violence and respond to it appropriately. One card contained a list of acceptable professional conduct while the other contained a list of the most common forms of lateral violence experienced in the nursing fraternity. The new nurses agreed to report and record lateral violence in the workplace and were instructed to come back after one year for the experiment. Consent from the participant was required and all participants signed the consent form and agreed to adhere to the set out guidelines. The institution where the participants were working also gave its consent and the experiment could thus be carried out. Sampling and Data collection A sample size of twenty-six recently hired nurses was used for the study. All the nurses were employees of an acute care tertiary hospital in Boston, Massachusetts. The subjects were then divided into three focus groups that met the threshold of equitable distribution based on age and gender. The division into three focus groups was necessary due to their busy work schedules. Each focus group had a meeting of one hour. The nurses were given six questions in their respective focus groups and videotaped. The questions were designed to elicit their experiences with lateral violence, the use of cognitive rehearsal as an intervention and their normal socializing process in the past one year. Data collection was based on the video tapes recorded during the experimentation. This was advantageous to the researchers as they could review the video tapes repeatedly in their quest to arrive at logical conclusions. Strength and Limitation The cognitive approach was intrinsic and vital in educating and spreading awareness of the vice of lateral violence against new nurse employees. The sample could however include a few of the experienced nurses who may also be experiencing lateral violence. The senior nurses could also have been instrumental in concluding the reasons behind this vice. Data Analysis and Findings The total number of participants was 26, 24 females and 2 males. This was deliberate in order to accurately represent the 39% of new nurses who were employed during that year. Furthermore, all the participants had been employees for at least more than 6 months. The six open-ended questions were used to synthesize dominant ideologies that formed the basis for the study.96.1percentage said they had witnessed lateral violence within the first year, 46 % of these saying that the lateral violence was directed towards them. They named sabotage, undermining, unreasonable assignments and lack of availability by senior staff members as t he top most manifestations of lateral violence. One member of the participant said she did not witness lateral violence in workplace while another one experienced the vice, but could not accurately classify it. Another interesting finding was that all the 100% who experienced lateral violence responded to the perpetrator(s) of the act. They agreed that the confrontation was a rather difficult task and most were very emotional while doing so. Interestingly an overwhelming majority of those nurses who were confronted ceased further acts of lateral violence against their peers. 75% of those confronted were genuinely shocked that the new nurses felt that way, 58% apologized, and 25% had no retort while 17 % simply shunned the new nurses. In the overall sense though, lateral violence ceased. Asked whether they used the cue cards on the spot, all the participants agreed that they did not, though they knew what was on them and applied it appropriately. As to whether the lateral violence impeded their learning, 46 % of those who had experienced said they had continued learning in spite of it while 15 % experienced problems and had to be transferred to another hospital. The latter group were so demoralized that they contemplated leaving the profession altogether. The participants cited satisfaction with the program and recommended that all nurses in the hospitals be trained on lateral violence. Majority cited lack of knowledge by the more experienced nurses, who simple quipped that the term was made up. The conflict between nurses and physicians was also an area that needed discussion, according to the participants. CASE STUDY 3 SUMMARY Healthcare systems across the world have witnessed a dramatic shortage of nurses (International council of Nurses; 2006). The shortfall is attributed to many factors with horizontal violence being a rising concern and a real threat to retention of new nurses. This paper will attempt to highlight the effect of horizontal violence in the choices of career of nursing students and the overall effect it has on the nursing fraternity. Horizontal violence, also known as bullying or lateral violence, is defined as the hostile and aggressive behavior by one or more group members towards another member or section of a larger group (Duffy; 1995).This form of violence manifests itself mainly as psychological as opposed to physical violence(Farrel; 1997,1999,2007). The medical hierarchy puts nurses at the bottom of the ladder and this in itself forms the basis by some of the perceived violence which is meted against nurses from all quarters(Jackson et al 2002) .Nurse to nurse violence seems to be more tolerated in comparison to other professional practices(Stevens; 1998). Study Design The research was centered on undergraduate students from the University of Wollongong. The sample size encompassed both 3rd and 2nd year nursing students. A qualitative approach was chosen as the most appropriate and questionnaires were administered to students (Burns and Grove; 2011). Ethical consideration was taken into account whereby students’ verbal consent was sought from the participants as well as from the administration and relevant departments in the university. Students were also made to understand that the information given would be confidential. Sampling and Data collection The sample of the participants was based on those who returned completed questionnaires and the number stood at 152,which accounted for 61% of the 2nd and 3rd year students (Curtis et al ; 2007) In compiling the sample group, researchers balanced demographic concerns with regard to age, gender and academic level. The integral point here was to ascertain the key experiences of these nursing students during clinical attachments. The questionnaires formed the main data collection method as students insights on the key questions were written on the sample papers. Findings and Data analysis A thematic data analysis was employed whereby coding of data was facilitating to come up with a new representation of data rather than have an imposition of the same (Curtis and Harrison; 2001). Common and significant statements were noted and both researchers undertook to verify the new emergent themes. 57% of the respondents acknowledged to have faced horizontal violence during their clinical assignment period. The key themes that arose from this research were: Hierarchal nature of horizontal violence Humiliation and lack of respect Powerlessness and becoming invisible Coping strategies Future employment choices. Strengths and limitations The qualitative approach of using questionnaires was efficient in terms of flexibility and practicality of surveying such a high number of students with relative accuracy. The approach also facilitated elements which could not be quantified (Burns and Grove; 2011) hence the accuracy of the research was not undermined. Synthesis All the three articles have vividly captured the plight of some nurses who have now become adept with dealing with horizontal violence. There is a consensus as to the key factors that lead to the propagation of this vice, and as to why it is so rampant in the profession. The medical hierarchy is widely cited in all the three studies as a key factor. The presumed hierarchy with doctors being at the top, followed by hospital administration, senior nurses and newly employed nurse in that order, leads to development of a condescending attitude towards nurses. Nurses then divert this attitude to each other, hence the epitome of horizontal violence. The studies also agree that nurses work under very stressful conditions and experience traumatizing events such as death. The career therefore calls for one to be thick-skinned and able to work under pressure. This is the perspective that some senior nurses have when being aggressive with newly licensed nurses. The studies show that there is lack of awareness of this kind of violence or infringement. It is noted that most of the victims cannot even tell when it happens to them. Reporting is also not a favorable option for fear of victimization. There is a lot of gray area in the definition of lateral/horizontal violence that even disciplining such cases becomes a quagmire. This however does not mean that the situation cannot be contained. Study 2 tested the cognitive behavioral model and it proved quite a success in reducing this vice and maintaining a high retention rate of trainee nurses. These methods, like those in the other studies indicate that ability to identify whenever the vice is perpetuated is vita in dealing with it. Immediate respectful confrontation is able to change the attitude of the perpetrator and foster a better relationship between victim and perpetrator. The studies however differ on the focus groups of their studies, hence the intervention criteria. Study one focuses on general horizontal violence in the hospital and bases its research on experienced nurses. Studies 2 and 3 focus on newly registered nurses and undergraduate nursing students respectively. The difference focus groups lead to different approaches towards curbing the vice. However, they agree on the effect the vice has in terms of personnel on the future of the profession. Conclusion and Recommendations Horizontal violence is a vice that should be rooted out from within the precinct of the healthcare system. The notion that horizontal violence is part of the nursing fraternity should be vehemently denied and instead students undertaking nursing courses should be taught on how to identify and respond to horizontal violence. Even after identifying it is still an uphill task to get it reported. An appropriate framework of defining this vice should be looked into (Hadikin and O’Driscall, 2000). Continuous propagation of this vice will only serve to increase the shortage of nurses while potential nurses will be forced to venture into other careers due to fear this aggressive vice. The deep rooted culture of ‘toughening up’ trainee nurses should also be discouraged and a more comprehensive method adopted. Indeed it has become so congenital in the profession that at times, those being bullied may not be aware it is happening to them. This may be attributed to the fact that nurses are perceived to be tough and able to handle stressful situations. Indeed senior nurses tend to mould younger nurses to fit into the traditions of the institution (Blane; 1986) through a series of aggressive selection and association. This is taken as a normal passage right into the hierarchy of nursing and therefore defining or determining where bullying had occurred was challenging. The Cognitive behavioral method is by so far the most applicable method in practice. The method has been successful in trimming down the vice by empowering trainee nurses on how to identify and respond to bullying. This fosters confidence in their abilities and they are more able to focus on their careers. The method was also seen to build a better relationship with more tolerance amongst senior and trainee nurses. This fosters better working condition, hence more competency. Following up on this is that, cognitive behavioral approach has led to a high retention rate of both experienced and newly licensed nurses with statistics at 91% and 95% respectively. This will help with the staffing problems and make nursing an appealing profession. The Heiddergerian approach is also a viable solution especially when applied together with the cognitive behavioral approach. This problem solving technique calls for unique and creative approaches of identifying and eliminating horizontal violence. With sustained thinking following the Heiddergerian hermeneutic phenomenology, pragmatic solutions can be realized and implemented. The three research based studies all merit a credit on their distinctive approaches towards horizontal violence. Perhaps an approach that encompasses the three approaches will be the most effective way to end the bullying. Taking the merits and strength of each method and blending them together may yield a sustainable solution to this problem. References 1. Carter R. (2000) “High risk of violence against Nurses “Nursing Management vol 6 No 8 pg 5 2. Curtis .J.Harrison (2001) Beneath the surface: Collaboration in Alcohol and Other Drug Treatment: An Analysis using Foucault’s three modes of objection. Journal of Advanced Nursing 34 (6) 737-744. 3. Farrell, G. A. (1997). Aggression in clinical settings: Nurses’ views. Journal of Advanced Nursing, 25, 501-508. 4. Freire, P. (1972). Pedagogy of the oppressed. Harmondsworth, England: Penguin 5. Hayes, C., & Lancaster, D. (2001). Year 2000 newly hired, employed nurses. Unpublished manuscript. 6. Joseph, D. H., Griffin, M., & Sullivan, E. D. (2000). Videotaped focus groups: Transforming a therapeutic strategy into a research tool. Nursing Forum, 35, 15-20. 7. McCall, E. (1996). Horizontal violence in nursing: The continuing silence. Lamp, 53(3), 28-29, 31. 8. Roberts, S. J. (1983). Oppressed group behavior: Implications for nursing. Advances in Nursing Science, 5(4), 21-30. Read More