Reframing and addressing horizontal violence as a workplace quality improvement concern.

AIM: To reframe horizontal violence as a quality improvement concern. BACKGROUND: Although the number of studies exploring horizontal violence has increased, evidence supporting the effectiveness of current interventions is weak and the problem persists. Often framed as an individual or interpersonal issue, horizontal violence has been recognized as a complex phenomenon that can only be understood through an examination of social, individual and organizational factors. As such, interventions to address horizontal violence must be applied systemically and address contributions from all sources. DESIGN: This is a discussion paper. DATA SOURCES: This discussion is based on results of a study of nurses' perceptions of horizontal violence and review of the literature. IMPLICATIONS FOR NURSING: Context is recognized as a contributing factor in human behavior, yet often overlooked in interventions to address horizontal violence. Moving the focus away from the individual and investigating systems contributions to horizontal violence using existing quality improvement frameworks is suggested. CONCLUSION: To date, efforts to address horizontal violence have not been proven effective. There is a call for a wider application and investigation of interventions. This reframing provides the system level application suggested and would address a broader range of factors contributing to the perpetuation of the phenomenon.

Enactors of horizontal violence: The pathological bully, the self-justified bully and the unprofessional co-worker.

AIM: To suggest an alternative approach to improving recognition of horizontal violence using enactor types identified in a study exploring nurses' perceptions of horizontal violence. BACKGROUND: Horizontal violence is an umbrella term used to describe a range of aggressive behaviours between nurse colleagues. It is suggested that nurses do not recognize the phenomenon when they witness or experience it, contributing to its perpetuation. DESIGN: This was a qualitative, descriptive study undertaken to inform theory development and the design of future interventions to address horizontal violence. METHOD: Observation, document review and semi-structured interviews took place in two inpatient hospital units in the Northeastern United States between June - November 2012. Ongoing analysis identified three distinct types of enactors of horizontal violence. FINDINGS: Nurse participants rarely used terms from hospital policies or nursing literature to describe behaviours associated with horizontal violence but identified behaviours by describing the attributes of the enactor and the situation. Three enactor types were disaggregated from the data: the pathological bully, the self-justified bully and the unprofessional co-worker. CONCLUSION: Findings support previous research suggesting nurses do not recognize aggressive behaviours when they witness or experience them and do not have a name for those who enact these behaviours. This disaggregation of enactors of horizontal violence into recognizable types introduces an alternative approach to addressing the phenomenon. Development of instruments to identify these enactors, as well as testing of these instruments, is required to establish the utility of this disaggregation in nursing practice and in designing future interventions.

Making power visible: Doing theatre-based status work with nursing students.

As part of a senior leadership class in an undergraduate baccalaureate nursing program in the northeastern United States, we conducted an experiential, theater-based workshop designed to increase student awareness of the micro-dynamics of power and the enactment of status in their day-to-day lives. These exercises allowed student participants to embody status and power and understand it in ways that they did not after simply completing assigned readings. At the conclusion of the workshop the participants were asked to reflect on their status habits and the consequences of these habits in a single hand-written page. The participants' reflections showed two interesting trends. The first is that a relatively short workshop dramatically increased participants' awareness of power and status as ever present, including a substantial normative move from seeing using power as being a generally bad thing that can be justified in the interests of the organization's mission to a more neutral stance that power and status are at work in all of our interactions. The second trend that emerged was the tendency for participants to focus on agency-based explanations of power dynamics.

Helping without harming: the instructor's feedback dilemma in debriefing--a case study.

INTRODUCTION: Simulation instructors often feel caught in a task-versus-relationship dilemma. They must offer clear feedback on learners' task performance without damaging their relationship with those learners, especially in formative simulation settings. Mastering the skills to resolve this dilemma is crucial for simulation faculty development. METHODS: We conducted a case study of a debriefer stuck in this task-versus-relationship dilemma. DATA: The "2-column case" captures debriefing dialogue and instructor's thoughts and feelings or the "subjective experience." ANALYSIS: The "learning pathways grid" guides a peer group of faculty in a step-by-step, retrospective analysis of the debriefing. The method uses vivid language to highlight the debriefer's dilemmas and how to surmount them. RESULTS: The instructor's initial approach to managing the task-versus-relationship dilemma included (1) assuming that honest critiques will damage learners, (2) using vague descriptions of learner actions paired with guess-what-I-am-thinking questions, and (3) creating a context she worried would leave learners feeling neither safe nor clear how they could improve. This case study analysis identified things the instructor could do to be more effective including (1) making generous inferences about the learners' qualities, (2) normalizing the challenges posed by the simulation, (3) assuming there are different understandings of what it means to be a team. CONCLUSIONS: There are key assumptions and ways of interacting that help instructors resolve the task-versus-relationship dilemma. The instructor can then provide honest feedback in a rigorous yet empathic way to help sustain good or improve suboptimal performance in the future.