A nurse rolls her eyes when you ask her for help. A new nurse is given the most difficult patient on the floor so others can, “See what she’s made of.” A circulator doesn’t tell the scrub nurse that the instrument the surgeon selected has fallen on the floor. Are these behaviors common in nursing, or part of a nurse’s rite of passage? Or are they something more insidious – horizontal hostility?

After giving several speeches in Canada over the last two years, nurses began writing to me with their stories of incivility:

“After I told the younger nurse that I couldn’t pick up extra days to cover her vacation, my hair was pulled three times during the shift.”

“I can’t ask questions, or the older nurses look at me like I am stupid.”

“I’m an ICU nurse and my patient was crashing. I ran out to the hall and asked my coworker if she could help – but she refused saying, “Going on smoke break now.”

A significant body of research suggests these behaviors are prevalent and destructive to the team, yet hidden from view. While roughly 10 per cent of all professions report disruptive behaviors, the number is higher in healthcare – about 30 per cent. And according to one study (Porath), it is higher in Canada than the United States (perhaps because Canadians have a cultural norm of being much more polite so the behaviors are driven further underground.)

Why would these behaviors happen more frequently in healthcare than the general workforce? Because they are directly linked with stress and the medical field abounds with high stressors, both internal and external: increased acuity of patients, decreased length of stay in hospital, more chronic and complex illnesses, not enough resources, sick time and the emotional work of nursing. And the second major cause is power: when any group of people has been without the power to improve or change their situation over many decades, they unconsciously lash out at each other. We know so much about our patients, yet so little about how we ourselves function as social animals in groups (Oppression Theory).

Significant research exists to confirm the damage caused by relationship conflict in healthcare; particularly aggression, verbal abuse, and horizontal hostility. Relationship conflict affects morale, satisfaction, patient safety, and quality of care. Nurses who report the highest degree of conflict also experience the highest degree of burnout (Hillhouse). This data is no surprise to managers who spend 30-40 per cent of their workday dealing with some form of workplace conflict (Thomas). Because resolving the quarrels that result from poor relationships can be exhausting and time consuming, many managers tend to ignore nurse-to-nurse conflict, or act like a third party and negotiate compromise in order to end an energy-draining situation quickly. But neither of these strategies is effective, and the responsibility for creating a professional work environment ultimately lies with each individual nurse. If you see it, you own it.

First do no harm

Horizontal behaviors can be overt or covert and are extremely hurtful. Gestures such as raised eyebrows, cliques, sarcasm and eye-rolling have a profound and detrimental effect on teamwork, retention, quality, safety and satisfaction and are the source of a great deal of conflict.

A core tenant of all health care workers, whether physician or nurse, is “First Do No Harm”. Bullying is a term used when someone has more perceived power than you do like your manager or a doctor. Horizontal hostility is used to describe disruptive behaviors between peers. Both are part of a category called disruptive behavior and are extremely hurtful to the patient – because human beings can’t think straight when they are upset. ‘Simply witnessing rude behaviors in the workplace significantly impairs our ability to perform cognitive tasks’ (Porath).

One day on morning rounds I discovered a patient had just been rushed to the intensive care unit with an oxygen saturation of only 52 per cent. I took the pain machine into my office and was shocked to find that the patient received many times the prescribed dosage. When the young nurse came into my office she told a story I will never forget:

“I was about 7 or 8 minutes late for my shift last night. When I came around the corner of the nurses’ station, a group of nurses who had been talking suddenly stopped when they saw me. I don’t mean to be paranoid, but the conversation never picked up again. I went into the ladies room – you can hear from there you know. Ellie said, “She’ll never make a good nurse, will she?” Then someone else whose voice I didn’t recognize said, “She just doesn’t have what it takes. Does she?” I let those words destroy me. This is all my fault…”

Nurse-to-nurse hostility: Under the radar

Unfortunately, in the health care culture, many times these behaviors are viewed as “normal” because they have existed for generations. Nurses simply do not recognize the tremendous impact of hostile behaviors on their self-esteem, patient safety, or performance – nor do most nurses possess the skill set necessary to confront each other. The Bully Busting Bill passed in 2010 in Canada requires all employees to respond to these insidious behaviors after a nurse died as a result of complacence.

All too often, administrators continue to fail to see the impact on patient safety (32 per cent linked disruptive behavior to an adverse event) – or cost (over $11,000 per nurse per year) – if they did, they would move swiftly to end these behaviors with the urgency of calling a code. Instead, senior leadership has historically perceived relationship issues as ‘soft stuff,’ or a “HR issue”, and therefore not worthy of serious budget allocations.

Another reason that leaders do not see the impact is that staff rarely, if ever, share the real reason why they left a position for fear of a bad reference or not being a team player. Staff who have experienced hostility leave many weeks or months after the specific incident so that no one can identify the real reason for their departure (Porath and Pearson).

Since the most common communication style of nurses is passive-aggressive, and the most common way nurses deal with conflict is avoidance (Forte), nurse-to-nurse conflict is seldom resolved in the workplace. Instead, it runs underground – undermining the very relationship bonds that are the foundation of a healthy workplace. As professionals, nurses must demonstrate the healthy relationships that are mandatory in today’s complex and fast paced health care setting. However, often you will hear nurses excuse these behaviors by saying “She’s a good nurse”. As one American Association of Critical Care essential standard states, “Nurses must be as proficient in communication skills as they are in clinical skills.” Proficiency in communication and conflict management skills would eliminate the majority of hostility.

Even if staff have been given the tools to communicate effectively we know that people tend to revert back to their old styles of communicating when under pressure. Monitoring the social health and well-being of a unit requires constant vigilance. In all honesty, most managers or directors are rarely on the floor due to a heavier workload that keeps them at meetings, traveling, or in their office. So another barrier to resolutions is that no one with any authority, skill or power is witnessing hostile behaviors.

One of the most vulnerable populations for hostility is new nurses, of which up to 60 per cent leave their first position within the first 6 months specifically because of some form of lateral violence. In a global nursing shortage, this statistic is particularly disheartening. However, research shows that raising awareness of horizontal hostility and teaching a set of skills to help new nurses deal with the non-verbal assaults allows them to depersonalize the attack and continue to learn (Griffin). The key is awareness and communication.

Solutions to reduce nurse-to-nurse conflict

The first step in creating healthy work place relationships is to point out the behaviors that are unacceptable. Put up a flyer that describes the hostile behaviors. It is critical that the manager have the same rules for all roles – regardless of position or years of experience. It’s not easy to pay attention, act upon, and follow-up with staff who roll their eyes, make sarcastic comments (or otherwise alienate co-workers) when you’re juggling so many other priorities. And it takes time, consistency and masterful communication skills to alter the current nursing culture.

Tip: Say what you see

“Julie, I noticed that you rolled your eyes when you picked up the assignment sheet. Did that mean you are unhappy with the assignment?

Ninety-three percent of all communication is non-verbal- and it’s the non-verbal behaviors like sighing or turning away that are the most upsetting. “Unmanaged conflict results in the high costs of personnel turnover, absenteeism, loss of productivity, and in some instances, loss of life” (Haraway). Clearly, investing time and energy to end negative and destructive behaviors has a tremendous payoff: retention, healthy relationships, cohesive teams, and most of all – safe patients.

The manager’s role

Leaders who encourage nurses to resolve their own issues and who provide education on communication and confrontation skills will find that the investment far exceeds their expectations. A major cause of conflict is a sense of powerlessness (“That’s the way it is around here”, “Nothing will change” attitude). Consistent with the oppression theory, staff who lack authority or power will act out their frustrations toward each other. In response, the most important action a nurse manager can take is to empower staff to take care of their own relationships, as well as the quality and safety of the workplace.

To do this, nurses will need assertive communication skills. Because managers are not omnipresent, it is critical to first ensure that head nurses possess the skills and tools they need to feel confident in confronting conflict on the unit before initiating staff education. Then, provide education on conflict-management and assertive communication for staff (or incorporate these classes as part of a staff education day.) Post a flyer which defines horizontal hostility and reminds staff of the behaviors that are unacceptable.

If a staff member comes to you for help in resolving an issue, offer to role-play the conversation and provide coaching – but set the expectation that THEY will be solving the problem and that your role is supportive. Another proven strategy is to ask staff to develop a unit based philosophy which clearly states unit behavioral standards. No where is guidance more needed than in leading staff to realize that they themselves have the power and ability to create a work environment where every single team member is valued, appreciated and acknowledged.

What can a staff nurse do?

One of the most effective strategies in dealing with nurse to nurse conflict has been to teach staff about the role of the “silent witness”. As one nurse recently realized:

“I’ve never said anything bad about another nurse in my whole career, but on the other hand, I stand there and listen while one nurse is talking badly about another. I’ll never do that again.”

When staff witness gossip or backstabbing, the psychological safety of the workplace is in jeopardy. (If they are talking about someone who isn’t present, then they are talking about you when you are not present.) A culture of horizontal hostility can only occur when you have secrecy, shame and a silent witness. We can take away the secrecy and shame by openly discussing damaging behaviors, stopping the pretense that these behaviors are harmless and can be ignored, and setting the expectation that it is not only unprofessional to stand by and be a silent witness while another nurse is being criticized, but unethical. Why? Because there is no doubt that these behaviors are upsetting and human beings can’t think straight when upset. Our amygdala is hijacked when emotions take precedence because we are social animals whose greatest need is to belong to the group.

RN/MD relations

Because the quality of nurse-physician relationships has been directly linked to patient mortality (Baggs), both physicians and nurses have an ethical obligation not to tolerate anything other than collegial relationships from each other as well. Furthermore, poor physician-nurse relationships are a significant contributor to horizontal hostility because any group made to feel inadequate and powerless will always act out their frustrations towards each other.

Interestingly enough, while a significant number of nurses report witnessing disruptive situations (92.5 per cent) a very small percentage of physicians cause a disproportionate amount of damage. One bad apple does spoil the whole bunch because trust is undermined. Bullying creates fear as the victim becomes extra vigilant to protect themselves from a surprise attack and this takes our concentration away from the most important job of all – keeping our patients safe.

Attempts at improving physician-nurse communication and collaboration in the past have failed because the education failed to acknowledge that both assertiveness skills and courage are required to speak up to physicians. In addition, physicians have not typically perceived a problem with “the way things always are.”

Manager intervention in holding physicians accountable for their behavior is crucial because the damage is exponential and insidious – but often absent as managers struggle to maintain good relationships with their physician partners. In Canada, managers state that they hesitate to say anything because they are afraid the physician may leave – and therefore leave the clinic or hospital stranded with inadequate physician coverage. And so they tolerate the behavior. But there is no doubt that poor MD/RN relations inhibit communication and are detrimental to patient safety, teamwork and satisfaction.

Solutions to address nurse-physician conflict

Building collegial relationships begins with the relationship the manager has with the chief physician and then trickles down to staff. All health care workers, however, must shoulder the responsibility and can clearly state the impact of any poor relationships (use specific stories from your workplace). Every time you say ‘no’ to an old norm, you are creating a new one. One unit surveyed nurses and presented physicians with a list of five things that really bothered them – then the physicians came up with their own list. Both groups met for dinner with a facilitator and relationships on the unit were forever changed. And the whole process started with leadership.

Manager support: “I have your back”

Nursing leaders must empower staff to stand up for themselves and never make excuses for destructive or negative behaviors. Even the smallest of condescending mannerisms has a profound impact on the team. And research demonstrates that working as a team (or not), has a direct impact on patient mortality (VHA Study). If staff cannot approach a physician directly, leaders must stand ready to approach the physician on their behalf. Physicians respond very positively to the words: “May I speak to you for a moment in private?” State the specific behavior (e.g. raised voice). Then explain the impact on our common goal: safe, quality, patient care. In every single case of disruptive physician behavior I have heard or witnessed, the physician truly does not realize the impact of his/her behavior on staff and apologizes immediately. These unconscious learned behaviors are the antithesis of teamwork and can not be ignored because MD/RN collaboration has been directly linked to patient outcomes (Baggs). Only when both physicians and nurses truly feel respected and safe in a team environment will we be able to deliver the most optimal care.

A long history of power imbalance and inadequate communication skills in the health care culture manifests itself in nurse-to-nurse as well as nurse-physician conflict. But we can change history by insisting on professional behaviors at all times from every member of the team. By refusing to let conflict go underground and resolving our own issues, both managers and staff have an opportunity to create a new culture – one that is respected and acknowledged for its healthy teamwork; one that keeps its sacred promise to patients to guard their trust, and above all, keep them safe.