Problem identification

199International Journal for Human Caring, Volume 26, Number 4, 2022 © 2022 International Association for Human Caring http://dx.doi.org/10.20467/HumanCaring-D-20-00069

New Nurses’ Experience with Lateral Violence and Their

Decision to Remain in Nursing

Lorraine A. Hover, PhD, RN Aspen University, Phoenix, AZ

Gail B. Williams, PhD, RN University of Phoenix, Tempe, AZ

Abstract: Lateral violence or bullying in nursing is the antithesis of caring and a profound, pervasive global concern. Survivors of lateral violence exhibit significant negative emo- tional and physical effects. Approximately one-third of new nurses leave the profession within the first 3 years of practice, citing lateral violence as a determining factor. This study explored the reasons new nurses decided to remain in the profession despite their experiences. Through one-on-one interviews (N = 9), the lived experiences were explored. Six themes emerged: the patients, needed the experience, I got counseling, there was an end, I cried, and nothing changed.

Keywords: lateral violence; bullying; new nurses; caring; phenomenology

Background

Lateral violence, bullying, eating our young, inci- vility, and many more names are used to describe the phenomenon of nurse-on-nurse violence. Lateral violence is defined as workplace conflict, which is either overt or covert, is repetitious, and involves emotional, psychological, physical, or even sexual abuse (Rainford et al., 2015). Workplace bullying is defined as uncaring encounters that result in ongoing health and career challenges for the recipient and can endanger the interdisci- plinary team and patient care (Adams, 2015). The many names used to define nurse-on-nurse vio- lence, while having nuanced differences in mean- ing, are used interchangeably. The names only hint at the underlying damage inflicted on nurses, the

nursing profession, the healthcare industry, and the patients themselves (Davidson et  al., 2020; Davidson et al., 2018; Thew, 2018). Lateral violence is a global phenomenon reported in nearly every country (Gupta et  al., 2017; Karatza et  al., 2016). According to Kusy and Holloway (2009), 94% of healthcare leaders reported dealing with a toxic work environment. Research reported that up to 90% of all nurses have experienced some form of lateral violence during their careers (Alameddine et  al., 2015; Buck-Hooper, 2018; Pfeifer & Vessey, 2017).

Nurses are seen by the public as caring, altru- istic, and empathetic. The profession is predi- cated on the ability to care for others. The Theory of Human Caring (Watson, 2008) promotes the

200 Hover and Williams

art and science of caring through the 10 Caritas Processes® and provides the foundation for the car- ing interactions between all healthcare profession- als and those in their care. The 10 Caritas Processes® promote caring by encouraging the development of a caring and healing environment through being authentically present, developing trusting and caring relationships with colleagues and patients, practicing forgiveness and empathy, placing value on humanity, and being open to the unknowns and miracles found in life (Wei & Watson, 2019). Nurse-on-nurse/lateral violence is the antithesis of this very foundation (Adams & Maykut, 2015).

Nurses who report having experienced lateral violence report a diminished engagement with patients, the workplace, and the profession itself. Decreased nurse engagement disrupts the ability to function at the required level to provide proper professional care and caring to patients. Nurses who are not engaged with their patients and workplace are more likely to deliver sub-standard care. Nurses with decreased engagement report a lack in ability to experience empathy, caring, and a connection with their patients (Fountain, 2017). The ability to effectively perform the needed skills of the job is impaired, resulting in errors (Joint Commission, 2016).

Lateral violence behaviors affect nurses, the nursing profession, organizations, healthcare industry, and patients due to diminished patient outcomes, decreased staff morale, increased costs associated with injuries and absenteeism, high turnover, higher insurance and indemnity costs, and monetary, professional, and personal costs associated with errors committed, which may result in permanent injury or death (Fountain, 2017; Longo & Hain, 2014). Professional caring is an essential aspect of nursing and serves to improve the healing of the patient, the personal and professional growth of the nurse, and elevates the nursing profession (Adams & Maykut, 2015; Watson, 2005). Nurses who reported experiencing lateral violence had decreased mental and physi- cal health Trépanier et al. (2015; Ward-Smith et al., 2018). Nurses have a higher divorce rate than phy- sicians and other healthcare professionals (Nanda et  al., 2017). United Kingdom statistics revealed that nurses were four times more likely to commit suicide when compared to the general population (Office of National Statistics, 2018). This negative impact on nurses results in the diminished health of the general population.

The ongoing nursing shortage prevents patients from receiving the required level of care

in whatever setting is needed. The nursing short- age is exacerbated through the lack of retention of new nurses. Approximately one-third of new nurses leave the nursing profession within the first 3 years of beginning professional practice (Blegen et  al., 2017; Robert Wood Johnson Foundation [RWJF], 2014; 2016). The majority of new nurses cited lateral violence as a determining factor in their decision to not just leave the initial profes- sional position but the nursing profession (Chang & Cho, 2016; Rainford et al., 2015).

Research indicates that while there is a good understanding of the effects of lateral violence there is a lack of understanding of why nurses choose to remain in the profession despite experiencing lateral violence. The anecdotal commentary was noted in four studies on why nurses might choose to remain in the profession; however, no study focused on why nurses may choose to remain in the profession despite lateral violence (Berry et al., 2016; Dotson et  al., 2014). Recent research stud- ies reported generally why nurses remain in the nursing profession (Loft & Jensen, 2020; Reinhardt et al., 2020). However, these studies did not focus on new nurses or lateral violence.

Purpose

The purpose of this qualitative descriptive phe- nomenological study was to explore the reasons new nurses (N = 9) decided to remain in the nurs- ing profession despite experiencing lateral vio- lence. The research question used to guide this study was: What are the lived experiences of new registered nurses, within 2 years of beginning professional practice, with lateral violence, and their decision to remain in the nursing profession? Research into understanding the reasons new nurses choose to remain in the nursing profession despite experiencing lateral violence has been a missing aspect as nursing examines the impact of such uncaring behaviors on all concerned.

Lateral violence in nursing negatively impacts the lives and careers of those who have been tar- geted. The short- and long-term effects range from mild to severe emotional, psychological, and physical manifestations. The most severe outcome is suicide. There is ample research into why nurses leave their position or even the nursing profession, negative impact on mental and physical health, and mitigation techniques. There has been little research into why nurses remain in the profession despite lateral violence and virtually no research on why new nurses choose to remain.

201New Nurses’ Experience with Lateral Violence and Their Decision to Remain in Nursing

Theoretical Framework

Two theoretical frameworks were chosen to guide this study, Freire’s Oppressed Group Theory (OGT), as applied to nursing by Roberts (1983), and Conti-O’Hare’s Nurse as Wounded Healer (NWH) (Christie & Jones, 2013). OGT provided the structure to understand the historical basis and background for lateral violence behaviors. NWH provided the structure to help understand the lived experiences of the participants.

Roberts (1983) contended that OGT aids in understanding how oppression by those in power leads to the negative behaviors and the perception of little to no power seen in the oppressed group. It was further contended that nurses were easily marginalized within the paternalistic hierarchical healthcare system. Roberts suggested that under- standing the oppressed group behaviors made in response to the perceived oppression could not only explain nurses’ behaviors, but it could also empower nurses to regain the power needed to affect change. Conti-O’Hare (Christie & Jones, 2013) developed NWH based on the belief that each nurse’s healing power results from their own wounds, and when those wounds go unre- solved, negative behaviors occur. NWH is a reflec- tive pathway that encourages nurses, and other healthcare professionals, to move through healing in order to resolve the negative behaviors.

Watson’s Theory of Human Caring (Watson, 2007; 2009) can be applied to further understand the core themes in the structure of the founda- tional value of nursing, professional caring. This understanding and insight can be used to explore and apply the core themes which emerged in the study into workable solutions to improve the car- ing and healing environment for nurses and the patients in their care.

Method

Qualitative descriptive phenomenology was used to explore the lived experiences of new nurses and their decision to remain in nursing. Descriptive phenomenology aims to comprehensively explore

and describe a phenomenon (Van Manen, 1990). Phenomenology is inductive analysis in nature and lends itself to allowing the researcher to gain a deeper understanding of the experiences of those who have lived a phenomenon. The researcher becomes the instrument that allows the individual to share their truth and provide meaning to the phe- nomenon by setting aside of own beliefs and biases.

After institutional review board approval was obtained, data were collected from new nurses who had graduated from a baccalaureate pre- licensure program within 3 years and had begun professional practice within 2 years of the study. The time difference between graduating and beginning professional practice was due to some nurses having difficulty obtaining their first posi- tions as professional nurses. All participants lived in central or southern Arizona. Nurses with pre- vious experience as an LPN/LVN were excluded. The Arizona Nurses Association emailed nurses from the Emerging Nurse Professionals Chapter. Respondents who met the criteria were contacted and informed consent was obtained. Data satura- tion was achieved after nine interviews.

This purposive sample included females between the ages of 21–60 years, with a mean age of 39 (Table 1). The wide range of ages reflects the nursing profession as not only a first career, but also a second, or even third, career. The ethnic/ cultural identity of the participants included two each African American, White, and multiple, and one each Asian, Hispanic, and Native American. Five of the participants worked in the hospital setting; two worked on medical/surgical units, one worked in surgery/pre-post op, one worked in the emergency room, and one worked in labor and delivery. Two participants worked in long- term care, one worked in public health, and one in another setting but still in nursing. Eight worked full-time. The sample was not representative of the nursing population of the area regarding gender; however, it was representative of age range, area of practice, and prior educational backgrounds. While the sample had an ethnic diversity, those of Hispanic backgrounds were under-represented.

TABLE 1. Participant Demographics

Note. S = Single; D = Divorced; M = Married; SO = Significant Other

Characteristic

Participant Age in Years 23 33 34 36 38 42 44 47 56

Marital Status S S D M M D M M SO

Months in Professional Practice 5 11 12 10 8 17 10 15 4

202 Hover and Williams

Data Collection

The data collection of this study included semi- structured, one-on-one interviews, which were conducted at local public libraries to provide a neutral location and ensure privacy. Each inter- viewee was encouraged to ask questions at any time during or after the interview. Each interview began by asking the interviewee the broad research question of “What is your lived experience with lateral violence in the workplace and your deci- sion to remain in the nursing profession?” An interview guide, which was reviewed by three doctorally prepared nurses, was used. Interviews were audio-taped, and field notes were taken. The researcher maintained a reflective journal. This journal accounted for bracketing and provided an audit trail in the analysis and description phases of the study (Denzin & Lincoln, 2013). Member checking was completed.

The sensitivity of the topic could have caused distress in the participants. While no participant displayed signs of distress, information for men- tal health counseling and support was provided to each participant at the end of the interview. No respondent reported the need to contact the mental health counselor when follow-up was con- ducted. The reasonable guarantee of confidenti- ality encouraged the participants to be candid in their discussions and descriptions.

Data Analysis

The Modified Stevick–Colaizzi–Keen Method was used for data analysis. The analysis began with the first interview and was simultaneous and ongoing until data saturation was reached. The researcher maintained a reflective journal. Horizontalization was used to extract significant statements and themes to bring forth the core themes. Horizontalization provides a means to understand the data by reducing the number of words, finding similar terms, and placing equal value to each piece of data. After each interview,

theme clusters were identified through the use of color-coding, aggregation of formulated mean- ings, and extraction of significant statements and meanings.

Findings

Six core themes (Table 2) emerged from the data: (1) The patients, (2) Needed the experience, (3) I got counseling, (4) There was an end, (5) I cried, and (6) Nothing changed.

Nursing is predicated on the care of, and car- ing for, individuals, families, and communities. Each participant discussed how they felt that nurses should be focused upon the patients and how lateral violence negatively impacted their sense of safety, security, and the actual care each patient received. Participants discussed behav- iors they had been subjected to, including being ignored, not receiving help, not receiving critical patient information, being yelled at, and being humiliated in front of patients, colleagues, and visitors. Participants shared that humiliation was felt most highly by being questioned about their intelligence and professional capabilities in pub- lic areas of the unit. It was further shared that the abuse was experienced on an almost daily basis. Participants expressed concern for the continuity of care and the functioning of the team in relation to patients and patient outcomes.

Watson’s Theory on Human Caring (2008) refers to the 10 Caritas Processes®, which place the act of human caring at the center of all interactions within the healthcare setting. The core concept of the theory provides for the caring of self and oth- ers through the mindful upholding of human dig- nity and respect. Additionally, the concept of care for self and the maintaining of inner harmony is important to maintain the authentic presence and relational caring needing in the relational inter- actions with others. Human caring, according to Watson (2008), includes the practice of loving- kindness, the development of caring and trusting

TABLE 2. Participant Endorsement of Themes

Theme P1 P2 P3 P4 P5 P6 P7 P8 P9 Total

The patients X X X X X X X X X 9

Needed the experience X X X X X X X X X 9

I got counseling X X X X X X X X 8

There was an end X X X X X X X X 8

I cried X X X X X X X 7

Nothing changed X X X X X X X 7

203New Nurses’ Experience with Lateral Violence and Their Decision to Remain in Nursing

relationships, the ability to express both positive and negative emotions, and the active creation of a positive and healing environment. Application of these core concepts to study findings can pro- vide additional understanding and promotion of a healing environment for nurses who experience lateral violence.

Theme 1: The Patients

Each participant shared that they felt a responsi- bility toward the patients under their care, that they had come into nursing to help patients, and that they had concerns regarding the level of care and outcomes for the patients. Participants expressed how lateral violence impacted the nurs- ing team, explaining that patient care, and thus patient outcomes, were fractured. Seven partici- pants expressed concerns regarding medication errors and near misses related to the lateral vio- lence occurring on their units. One participant shared, “They’re (patients) supposed to be first. It breaks down the morale, um, and it break down your surveys. It seems, um, like it’s all about those scores”. They further emphatically stated, “I CHOOSE to be there for the patients.” Another participant stated, “I got into nursing to take care of people. I mean, isn’t that why we’re supposed to be here? I just couldn’t think about ever leaving the patients.”

Theme 2: Needed the Experience

Nurses entering their professional practice for the first time need practical working experience to further their careers and goals for future practice. Participants discussed the need for this experience as part of the reason they remained in their jobs and thus, in the nursing profession. One partici- pant explained that the specialty they chose was difficult to get into, so they remained in the posi- tion in order to remain in their chosen area and achieve a needed certification. Another partici- pant stated, “This was a steppingstone. I needed to stay there a while to get experience. I needed six months on that unit before I could transfer, um, and I knew I could do just about anything for six months. I needed, um, really needed this job. I needed experience, um, needed it to move on.”

Theme 3: I Got Counseling

Nurses shared how they needed coping mecha- nisms to deal with difficult situations and the stress of a first job. They shared that suffering

lateral violence often required them to seek out- side resources. Participants discussed the counsel- ing and use of a therapist/counselor as a factor in their ability to remain on their jobs and in the nurs- ing profession. The term Post-Traumatic Stress Disorder (PTSD) was used by six participants to describe the symptoms they were experiencing as a result of lateral violence. One participant shared that she had been diagnosed with PTSD related to the lateral violence she had experienced, “Who gets PTSD from a supposed caring profession? Obviously, nurses do!” Another participant shared, “My therapist saved me …. She’s using techniques used with PTSD sufferers. To think on that, that is so weird to me.” Four participants shared they experienced suicidal ideation and credited coun- seling and support of friends and family for still being alive. One participant shared, “I’m so glad I did (receive counseling), you know…. without the family and my therapist, I might not be here to tell you about this (referring to ending her life).” Another participant shared, “I hate to admit this, but I felt suicidal.”

Theme 4: There Was an End

When discussing what helped the new nurse to remain in the job or in the nursing profession, participants shared how knowing that there was an end to the current position and that they could search for a different position once the end was reached. A participant stated that they were able to visualize “better things at the end” as a means to cope. One participant shared, “I could see that there was an end, and I knew there was…well…an end point. This was not permanent, Better things would come…and I believed that. For me, the end- point was being able to leave with some experi- ence.” They further shared, “I knew it would end and I could leave. I guess we can get through any- thing if we know it will end – sort of like being in labor with a baby – it hurts like hell during it all and then the endpoint is that baby. I am able to use my knowledge and skills…this is the end- point I had hoped for. This is the ‘baby’ at the end of labor. I am happy.” Another participant stated, “Knowing it would end helped a lot. Having that finish line in sight made it bearable.”

Theme 5: I Cried

This theme was identified when participants shared how they dealt with the events surround- ing lateral violence on their units. There are many coping mechanisms that one can use to release

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emotions or frustration; most participants identi- fied one such mechanism as crying in response to lateral violence. Two participants expressed that the crying was out of frustration and acted as a release to their emotions. One participant stated, “I cried every single day I worked. I would go into the bathroom to cry, or even patient rooms…...You just go into the bathroom and cry……and move on.” Another participant stated, “You know what? I cried almost every single day! I was heartbroken. Why are they so mean to new people?”

Theme 6: Nothing Changed

The participants stated that while they did report the incidents of lateral violence, they felt that noth- ing was done in response to their reports and thus, nothing changed in the behaviors being perpe- trated on them. This theme reveals the hopeless- ness many felt and how difficult it was to try to change the behaviors occurring on their units. Two participants shared they felt like they were not heard and that they had no voice. One par- ticipant expressed their view that the reason noth- ing changed in the way staff treated them was because management didn’t enforce consequences to the behaviors. One participant shared “Nothing ever happened.... I went up my change of com- mand like I was taught was proper to do, um…... Nothing happened. Nothing changed. I didn’t take it up any further. I guess I could have gone to the CNO (Chief Nursing Officer) after, um, everyone didn’t response, um, well…… I just gave up. I, um, felt like I wasn’t heard, like, um, I didn’t have a voice. I felt like nothing would get done. Nothing changes.” Another participant shared, “You know, you’re told to take it up the ladder of command. Nothing ever changes. You know, you just get labeled a ‘snowflake’ or a ‘troublemaker’. Nothing was ever done to make it better, you know.”

Discussion

This study highlights the impact lateral violence, or nurse-on-nurse violence, has on the survivors. Participants shared how they dreaded coming to work and how they wanted to leave their posi- tion as quickly as possible. Some shared that they had experienced PTSD and others shared that they had felt suicidal. Participants shared the fre- quency and types of abuse they were subjected to. They discussed the need to cry and release their feelings and others shared how counseling and support from others helped them through. The participants shared the frustration of reporting

the abuse and having the administration be silent on the matter, in essence, nothing changed. These nurses discussed feeling like they had lost their voice because they were not listened to. They were able to find a way to get through and survive the abuse so that they could continue caring for their patients.

Some nurses are not able to come through the abuse. According to studies in the United Kingdom (UK), nurses are four times as likely to commit suicide when compared to the general population. Many new nurses choose to leave the profession. Nursing is about caring for oth- ers and reflects respect for the dignity of all per- sons (Adams, 2016). Watson’s (2008) 10 Caritas Processes® provide a road map to the caring inter- actions between nurse, patient, and colleagues. A healthy and healing work environment is not pos- sible when lateral violence exists. The acts of care and caring are inhibited, and negativity transpires.

Watson’s Theory on Human Caring (2008) describes the 10 Caritas Processes®, which place the act of human caring at the center of all interac- tions within the healthcare setting. At the core of the theory is the care of self and others through mindful upholding of human dignity and respect. Caring for self and maintaining inner harmony are important to maintain the authentic presence needed in interactions with others. The practice of loving-kindness, developing, and maintain- ing caring and trusting relationships, expression of positive and negative feelings/emotions, and active involvement in the creation of a positive and healing environment are aspects of human caring (Watson, 2008; Wei & Watson, 2019). While lateral violence is the opposite of caring, the core concepts of Watson’s theory provide a template on how to improve caring for one’s self and thus, car- ing for others.

The Patients

The nurses voiced concerns regarding patient safety, medication errors, and the erosion of the healing environment. Wright and Khatri (2015) reported that nurses who experienced workplace bullying experienced an increased rate of medica- tion errors. Fountain (2017) reported that RNs who experienced moderate levels of lateral violence were more likely to exhibit diminished patient and work engagement. Fatigue caused by lateral violence resulted in frequent concerns about the quality of patient care, including failure to rescue, medication errors, and patient care delays (Wolf

205New Nurses’ Experience with Lateral Violence and Their Decision to Remain in Nursing

et al., 2017). The ability to provide safe and effec- tive patient care and nurture caring interactions is compromised by the experience of lateral vio- lence. Wei and Watson (2019) noted that the appli- cation of the 10 Caritas Processes® can deepen and strengthen the caring-healing environment for the multidisciplinary team. Excellence in patient care is dependent on a collaborative team that respects and honors the knowledge and expertise of all members.

Needed the Experience

Each nurse shared that a driving reason for not leaving was the need to gain experience. Difficulty in obtaining their initial position made the position more important. No studies were located, which reporting this finding. Simons and Mawn  (2010) noted that the initial employment period was an especially vulnerable time for new nurses and that the experience of lateral violence during this early stage of the career caused many to seriously con- sider leaving the profession. New nurses’ mastery of skills and level of burnout are related to the level of support from colleagues and administra- tion Frögli et al., (2019). Maintaining a caring and healthy relationship with colleagues enhances the nurse’s ability to successfully transition to profes- sional practice Sitzman & Watson, (2018). The abil- ity to care for one’s self includes the ability to grow and learn. Lateral violence makes the attainment of professional growth increasingly difficult.

I Got Counseling

The nurses who shared they sought counseling referred to it as “life-saving” and expressed that psychological support was vital in dealing with lateral violence/bullying. The nurses stated they would encourage anyone to seek counseling under similar circumstances. Several studies discussed the psychological impact of lateral violence on mental health which resulted in depression, PTSD, anxiety, and suicidal ideation or suicide (Davidson et al., 2020; Davidson et al., 2018; Wallace & Gipson, 2017). Watson’s theory supports the use of coun- seling in that it allows the nurse to express both negative and positive feelings and work towards inner harmony. The forgiveness of self and oth- ers is achieved through the nonjudgmental accep- tance of these feelings (Wei & Watson, 2019) and helps move the nurse to the journey toward heal- ing. This journey toward healing is also embraced by Conti-O’Hare’s NWH theory.

There Was an End

Participants discussed seeing an endpoint to the lateral violence and the knowledge that there would be better things after the negative experi- ence helped them remain in nursing. Pellico et al. (2009) identified the theme “change is on the hori- zon” which supports this finding.  Sanner-Stiehr and Ward-Smith (2014) concluded that nurses may remain in their positions when benefits out- weigh the risk of leaving. Remaining open to the unknowns ahead and being hopeful of the future is an important aspect of the Caritas Processes® (Wei & Watson, 2019). The uncertainties involved in being a new nurse layered with the experiences of lateral violence make the hopefulness of better things important to the continued career of these nurses.

I Cried

The terms “frustration,” “relief,” and “release” were used by these nurses to describe why they cried. Anecdotal evidence in Pellico et al.’s (2009) study presented crying in response to verbal abuse. However, the crying was a response to stressors and not as a means to deal with the abuse. Gračanin et al. (2014) found emotional tears were cathartic to the individual, further relieving stress and enhancing their mood. These studies, while not specifically researching new nurses experienc- ing lateral violence, support the theme. Tears are an expression of negative emotions and can lead to an improvement of mood.

Nothing Changed

These new nurses shared feelings they had no voice and that they were not heard when they reported lateral violence behaviors, and nothing changed in the work environment. The nurses also discussed the lack of support from multiple levels of administration. Studies have identified the vital role of management/administration in the development of a caring and healthy healing environment. Vogelpohl et al. (2013) reported that just over 35% of new nurses identified administra- tion as unsupportive of those who experienced lat- eral violence. A positive and healing environment includes support for those who are injured by the actions of others. Failure to intervene on the behalf of those who are injured by the actions of others is actively creating a hostile, rather than healing, environment. The ability of the nurse to have confidence in their administrative team is vital to

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optimal patient outcomes (Hepburn et  al., 2020; Joint Commission, 2017; King et al., 2019).

Limitations

The population of central and southern Arizona is unique and diverse. This may limit transferability to other populations. The nature of the phenom- enon may have limited participants’ openness and willingness to share concerning their experiences. The sample was not representative of the nursing population of the area. No males were included in the study.

Implications and Recommendations for Nursing

The findings of this study suggest that the devel- opment of a healthy and caring work environ- ment would enhance the ability of new nurses to effectively transition to professional practice and increase retention of these new nurses in the profession. The findings highlight the need for support of those who are targeted for lat- eral violence/bullying behaviors. The need for a responsive administration is paramount in devel- oping and maintaining a caring and healing work environment.

The development of a caring work environ- ment begins with the education of nurses. Caring behaviors must be role-modeled by didactic and clinical instructors. A zero-tolerance policy for negative behaviors needs to be implemented, including a clearly defined method of confidential reporting and defined consequences for students, instructors, and other persons involved in the educational process. Adding modules concern- ing lateral violence/bullying to the curriculum, including role-playing scenarios, can increase the resilience of the new nurse and prepare the next generation of nurses to not view lateral violence as part of the accepted nursing culture. Berry et al., (2016). Incorporating Watson’s 10 Caritas Processes® into the curriculum will provide a framework for this to occur.

Responsive administration of all levels begins with education regarding the identification of the overt and covert behaviors of lateral violence/ bullying. Identification is only the first step. It is important to develop and consistently enforce zero-tolerance policies. Policies must include clearly defined behaviors and consequences, including dismissal. A confidential reporting pro- cess is a vital aspect of a caring and healthy work setting. All personnel must be trained on hire and

periodically throughout their employment regard- ing these policies. It is further recommended that lateral violence/bullying discussions become a routine topic in staff meetings and communica- tions such as email and newsletters. (Blegen et al., 2017; Christie & Jones, 2013).

Further studies into the reasons new nurses decide to remain in the profession are needed. Finding out these reasons will help complete the view of lateral violence/bullying and may result in further mitigating the negative impact of these uncaring behaviors and enhancing the retention of new nurses. Studies that include male participants are needed to provide this unique perspective on the phenomenon.

All nurses are responsible for their behavior. Learning about caring behaviors, becoming versed in techniques to support and mentor new nurses, and being reflective of one’s behaviors will lead to a healthier nursing workforce. A healthier work environment becomes a caring and healing envi- ronment for patients and leads to better patient outcomes.

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Disclosure. The authors have no relevant financial inter- est or affiliations with any commercial interests related to the subjects discussed within this article.

Acknowledgments. The authors thank Dissertation to Publication Workshop, College of Doctoral Studies, University of Phoenix, for supporting the preparation of this journal article. Special thanks to the Workshop reviewer Dr. Pat D’Urso, for helping to prepare and finalize the manuscript.

Funding. The author(s) received no specific grant or financial support for the research, authorship, and/or publication of this article.

Correspondence regarding this article should be directed to Lorraine A. Hover, PhD, RN, Aspen University, Phoenix, AZ. E-mail: [email protected]

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