Friday, June 11, 2010

The Rest of the Equation

The statement "nurses eat their young" has been so often repeated it has become axiomatic. "Lateral" or "horizontal" violence is a very real issue in professional nursing (among other occupations), it has been heavily researched, and various interventions and corrective actions have been initiated with varying levels of success.
There are "zero tolerance policies;" there are defense strategies for new nurses to use to protect themselves. But are we missing half the equation?
Lateral (or horizontal) violence describes how members of an oppressed culture, unable to strike back at their oppressors, instead take out their anger and frustration on the more vulnerable members of their own group. In the nursing profession, this is usually new hires and those newly graduated from nursing school. The consequences of lateral violence are dire: new nurses are often driven out of a particular work environment and perhaps out of the profession altogether. As the current nursing shortage is likely to only worsen, this has grave implications for the accessibility and quality of health care.
As grave as the problem of lateral violence is, all the interventions are directed at the behaviors: how to defend against the behaviors, how to identify and punish perpetrators. Certainly, lateral violence is reprehensible, unacceptable, and professionally self-sabotaging. But what about the other side of the equation?
As lateral violence is endemic to oppressed cultures, shouldn't the issue of oppression be addressed? How might lateral violence be affected if there were other, more benevolent, more productive opportunities to wield power?
Certainly, there are many aspects of professional nursing practice that are non-negotiable: patients require care, competencies must be maintained, and standards must be met. However, it does not necessarily follow that in order to do everything that must be done, every step must be prescribed and every process delineated, with every deviation or innovation at least suspect if not outright punishable.
Nurses, by training and by licence, are independently accountable to the patient and are expected to exercise professional judgement and critical thinking. We are taught to negotiate with patients to develop a plan of care that best meets their needs. However, we are seldom extended the same courtesy.
Work schedules and shift availability is on a take-it-or-work-elsewhere basis, patients are assigned, seldom selected by the nurse. These sorts of problems are hardly unique to nursing, and professions that experience similar working conditions also have similar problems with lateral violence.
For nursing to be a profession, we must be responsible to our patients, our profession, society, and ourselves. As professionals, we have the right to negotiate how we meet each of those responsibilities. Every professional knows that these responsibilities often conflict, and the give-and-take among them is a part of professional reality.
Participating in this negotiation, both collectively as a profession and individually as a professional is the other side of the equation that must be addressed for effective control and eventual eradication of lateral violence. All the interventions addressing behaviors associated with lateral violence must continue to be addressed, but it's past time that addressed the rest of the equation.


  1. My daughter, Lara, heard about this in her nursing classes, here in Texas. However, because she was an extern at the hospital where she intended to work, she received only happy congratulations upon receiving her RN. She is currently working on her BSN.

    I think the grad nurses who had trouble were those who had never worked in a hospital setting, before.

    Pat Ragan

  2. It probably helps to have "proven yourself" a bit beforehand, but there are also a lot of instances where "you need to prove yourself but we don't trust you to handle situations where you can prove yourself."
    This can be further complicated by generational differences in needs and "the way things should be done."
    Just curious: is there anyone Laura just dreads doing change of shift report with or just working with on the same shift?

  3. I have heard of one area, the Surgical Intensive Care Unit in our large Metropolitan teaching hospital, where the "nurses eat their young." I have heard this from a few people who have had direct contact with these nurses: a resident, a former nursing assistant, and three former nurses that have worked there. It is such a discouraging thought to me, to work in that kind of environment, that I have altered my career plans to work there. I had been very interested in working in the SICU, but now just don't want to do it because of this issue. I was a straight- A student in nursing school, had the highest score in our class on the HESI (practice RN exam) and I feel that not only am I losing out on an opportunity, but they have lost out on the opportunity to have a very intelligent, dedicated RN working for them. This issue of lateral violence is a really big issue and was never even a consideration in my former career as a social worker. I feel very frustrated and angry about it!