Horizontal violence among nurses in the operating room

AORN Journal, Dec, 2003 by Herbert Dunn

Sabotage is a dysfunctional but common method of dealing with frustration and anger. When sabotage is directed at coworkers who are on the same level within an organization's hierarchy, it is called horizontal violence. Understanding the causes behind horizontal violence requires an understanding of oppression theory.

Horizontal violence, oppression, and their effects have been reported in the nursing literature for more than 20 years. (1-6) Recognizing how these behaviors are established and sustained is mandatory if nurses are to overcome these types of behaviors. The presence of sabotage is an indicator that horizontal violence and oppression exist in the workplace. To that end, a study was undertaken to describe the effects of oppression with subsequent displays of horizontal violence as measured by the degree of sabotage in the OR and how it relates to job satisfaction.

OPPRESSION

Oppression exists when a powerful and prestigious group controls and exploits a less powerful group. (2) According to one author, the oppressor controls others out of self-interest and prescribes and defines reality to achieve this goal. (7) The outcome is that members of the oppressed group internalize the oppressor's values as righteous and desirable societal standards. Another author describes members of oppressed groups as "indistinct masses" who lack identification within their own culture. (8) The result is that members of oppressed groups demonstrate certain common behavioral characteristics (eg, low self-esteem, self-hatred) that can create a fragmented and divisive group.

Nursing characteristics, such as being warm, nurturing, sensitive, passive, and submissive caregivers, are viewed as less important or negative characteristics when compared with those of medical practitioners, who often are seen as the dominant culture. The result is that nurses often lack autonomy, accountability, and control over their profession. When nurses who are oppressed internalize the values of the dominant medical practitioner culture as being right, they lose their cultural identity as nurses, and self-hatred may be the result. (7) Characteristics such as divisiveness and fear of confrontation with powerful groups are common among members of oppressed groups. The nursing profession has evolved to embody these dysfunctional attributes. (7,8)

When feelings of aggression against a powerful group arise, members of the oppressed group often are unable to confront the dominant group for fear of reprisal. (2) This fear represents the basis of the submission to authority. In addition, as the oppression continues, the fear of change itself manifests.

One researcher describes three major characteristics of oppressed groups. (1) First, oppressed groups often exhibit self-hatred and dislike for members of their own group. A lack of pride in one's own group may result in a desire not to be associated with it. It is considered unwise to align with other powerless members of a group, especially when that group is one's own.

The second behavior of oppressed groups is a member's own fear of change when success may be the result. Despite the pain of oppression, the fear of change or success with a subsequent alteration to the status quo is even more uncomfortable. These concerns may result from a lack of belief in one's own ability and responsibility and a lack of self-confidence inherent in an oppressed individual.

Finally, when given the opportunity to effect change, many powerless people choose the path of least resistance. It is reasonable to assume that nurses, like members of other oppressed groups, are fearful because they do not believe that alternatives to the status quo exist. Additionally, complaints by others rarely result in direct confrontation with the oppressor. The oppressed person, who has aggressive feelings such as bitterness and anger toward the oppressor, is unable to confront these emotional hostilities. (1) The result is displaced and self-destructive aggression within the oppressed group with subsequent infighting and self-criticism. Horizontal violence is the outcome by default. (7)

HORIZONTAL VIOLENCE

Women often are considered to be a subordinate group within society in general (9) and the health care arena in particular; (1,2) thus, it is not surprising to observe frequent acts of sabotage within the nursing profession because women comprise at least 90% of the nursing profession. (10) Acts of anger, such as sabotage, are common among members of oppressed groups. These behaviors, described as horizontal violence, (3) take the form of devaluing, discouraging, scapegoating, backstabbing, complaining, and other forms of nontherapeutic and destructive communication.

   ... nurses exhibit oppressed group
   behavior such as horizontal violence
   so commonly that it has become an
   accepted mode of behavior for many
   individual nurses, and indeed Jar
   nursing in general. (4)

Lack of respect for colleagues has had damaging effects on the development of the nursing profession.