Running head: LATERAL VIOLENCE ANESTHESIA CARE TEAM
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Lateral Violence within the Anesthesia Care Team
Peter Strube CRNA MSNA APNP ARNP
Matthew Burkart CRNA MSN
Jacob Szafranski CRNA MSN
All correspondence is to go to Peter Strube CRNA at pstrube3000@yahoo.com or via cell
phone at 608-469-1750
There is no Financial interest in the paper. We certify that all financial material would be
disclosed in the future if any would arise: We have no relevant financial interests in this
manuscript.
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Lateral Violence within the Anesthesia Care Team
Stress is a common occurrence in anesthesia practice, and has been implicated as a
major culprit in the event of lateral violence amongst healthcare providers. Between the
demands of increased patient volumes, quality improvement measures, financial sustainability,
and ever-changing organizational policies, nearly all anesthesia providers experience the toll of
work related stress day in and day out. Yet, in the already high stress culture of anesthesia, the
inherent consequences of such demands go unchecked. Systematically, to better meet the
diverse and growing needs of both patients and hospitals, nearly all practice models are
transitioning to blended care teams. Within this transitioning, anesthesia care teams (ACT)
comprised of both physician and non-physician providers now more so than even work closely
to support one another to meet the needs of their patients in the most appropriate fashion
achievable. With patients, hospitals, insurers and governmental agencies embracing the notion
of care teams, there has been a new found call for non-physician providers to practice to the
utmost of their abilities and training. As a result, a blended approach to the delivery of
anesthesia has long been under way, moving away from the group dynamics of the previous 40
years. In light of such organizational changes amongst anesthesia teams, are nurse anesthetists
more vulnerable within the care team model of being the victims of lateral violence? This
process continues to help shape the group setting in which nurse anesthetists practice in.
Nurse anesthetists were once primarily hospital employed anesthesia providers working
in collaboration with physicians to provide anesthesia services to patients. However, nurse
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anesthetists are now more than 70% of the time employed by anesthesiologists within an ACT
practice structure (Del Risco 2000). This relationship is one that historically has been tenuous
at times due to various professional measures taken by anesthesiologist the the practice of
nurse anesthetists who have at times been viewed as competitive providers of anesthesia (Jones
& Fitzpatrick 2009). The ACT model has already been debated on the merits of its need,
efficiency and value. So how does it measure up to the scrutiny of its ability to foster healthy
work relationships amongst its providers and mitigate the perils of lateral violence amongst
anesthesia providers?
Lateral violence has a broad scope of inclusion criteria of what constitutes workplace
violence. Classically the definition of violence has been defined as words and actions that hurt
people (Findorff et al., 2005). This, however, is quite imprecise and more specifically includes
other forms of work place violence such as bullying, verbal abuse and harassment. An even
more specific definition describes lateral violence as behaviors that both “interferes with
effective communication among healthcare providers” and “which makes the victim feel upset,
threatened, humiliated or vulnerable… and cause them to suffer stress” (Center for American
Nurses Position statement on Lateral Violence and Workplace Bullying, 2008, and Task Force
on the Prevention of Workplace Bullying, 2001, p. 10). Lateral violence, as opposed to other
forms of workplace violence, typically occurs between those who are in similar positions or
job related duties within the workplace. To further describe what lateral violence is and looks
like, Griffin identified the ten most common forms of lateral violence in nursing. These
behaviors include: “non-verbal innuendo,” “verbal affront,” “undermining activities,”
“withholding information,” “sabotage,” “infighting,” “scapegoating,” “backstabbing,” “failure
to respect privacy,” and “broken confidences” (Griffin, 2004). These forms of lateral violence
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can very well apply to other practitioners within healthcare with little to no alteration in
content or intent.
The Center for American Nurses states within their 2008 position statement that lateral
violence and bullying have been extensively reported and documented among healthcare
professionals. In this position statement they endorse that all healthcare organizations
implement a zero tolerance policy related to such disruptive behavior due to its associated
serious negative outcomes. Additionally, the Center for American nurses also advocates for
hospital based initiatives be implemented to both educate and train staff regarding lateral
violence. However, according to Costello et al., physicians are often exempt from many
departmental and hospital training programs dealing with workplace respect and staff relations
(Costello, 2011). Which poses a valid question, how are physicians then to appreciate, and or
help prevent lateral violence within the workplace if not held accountable for a committed
effort in its organizational prevention? This issue of lateral violence is one that does not go
without consequence within healthcare institutions. For example, in 2006 the Joint
Commission set forth a leadership standard mandating that agencies recognize and correct
disruptive behaviors such as lateral violence in ordered to receive their top accreditation.
Historically, lateral violence within the workplace most frequently took the form of
verbal abuse towards subordinate staff at the hands of physicians (Cox, 1991). This frequently
occurring form of abuse also fits the CAN’s model that typifies the relationship potentiating
lateral violence within the workplace, where the associated perpetrator is in a perceived higher
level of authority than the victim (2007). Costello et al. believe the structuring of hierarchical
and unbalanced power relationships can also add stress to an already challenging work
environment and contribute to lateral violence within the OR by way of propagating further
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disruptive behaviors (Costello, 2011). To further this point, Bigony et al. (2009), in summary
of a 2007 JHACO release, state “nurses may be inhibited from communicating with
intimidating physicians when seeking to clarify information that is directly important to patient
care and safety” (Bigony et al, 2009, p. 690).
Research regarding the incidence of violence lateral or otherwise within the workplace,
are quite numerous and ever-growing including the previous works by Bigony et al., 2009;
Croker & Cummings, 1995; Erickson & Williams-Evans, 2000; Jenkins, Rocke, McNicholl, &
Hughes, 1998; Pozzi, 1998; Rose, 1997. Though there are numerous studies, Findorff and
McGovern state these previous studies fail to examine the shared factors that both illustrate the
circumstances of the violent encounter and that characterize the shared traits amongst victims
(Findorff et al., 2005). The significance of such, at least in their opinion, would provide insight
to which particular individuals or settings could potentiate lateral violence within the
workplace and to help guide future research and interventions to prevent lateral violence.
Understanding these shared factors that propagate lateral violence and bullying in the
workplace is key to its prevention. So why then is a physician lead anesthesia team so
commonly endorsed if it would continue this potentially toxic and antiquated hierarchy
amongst anesthesia providers? Contrary to the model of physician lead ACT’s, no single state
mandates by law that nurse anesthetists have anesthesiologist supervisors to direct their
practice (American Association of Nurse Anesthetists 2002). In this same regard, wouldn’t
nurse anesthetists being in a subordinate position under the supervision of an anesthesiologist
be more likely to be the victims of the most commonly occurring form of lateral violence
(verbal abuse)? How could this dynamic within the ACT model not potentially inhibit the
communication that is so vital the safety of patients, which could then adversely affect patient
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risk-adjusted mortality rates (Institute for Safe Medication Practices, 2004, and Knaus et al
1986)?
Parsons and Newcomb identified role clarity as being essential in order to foster
positive inter-professional relationships and joint collaboration amongst the perioperative
team. One of the hallmark areas of contention concerning job satisfaction amongst nurse
anesthetists involved in ACT settings deal with scope of practice issues (Parsons and
Newcomb, 2007). Other studies have also shown conflict when attempting to satisfy differing
job demands and unclear work responsibilities contributing to the overall level of perceived
stress experienced by nurse anesthetists (Kendrick 2000, and Alves 2005).
When evaluating other advanced practice nurses, who practice to the fullest extent of
their training and knowledge, they have been shown to have higher job satisfaction rates as
opposed to their colleagues who have restricted rolls (Kacel, Miller, and Norris 2005). It could
be reasonably surmised that the same would apply to nurse anesthetists who work within
ACT’s under supervision of an anesthesiologist who allow them a greater scope of practice,
which contributes to less job related stress and overall improved job satisfaction (Taylor,
2009). However, when questioned on their perceived need for medical direction of nurse
anesthetists, anesthesiologist even agreed that roughly 70% of cases required no supervision of
nurse anesthetists (Fassetts & Calmes 1994). Despite these previous studies, Jones and
Fitzpatrick believe in conclusion of their research that further comparison of nurse anesthesia
job satisfaction related to scope of practice issues would be of value in the future (Jones and
Fitzpatrick, 2009).
This tenuous relationship between anesthesiologists and nurse anesthetists is one that
could easily be likened to that of competitors in anesthesia practice as stated earlier by Jones
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and Fitzpatrick (2009). However, the overwhelming shift over the last forty years has been to
transition away from hospital employed nurse anesthetists to ACT’s where physicians not only
supervise, but also employ nurse anesthetists (Shumay & Del Risco 2000). Although this group
model in anesthesia is more and more common place, the perceived satisfaction amongst
providers is opposite of what one might think. When examining differences in attitudes toward
collaboration based on participation in ACT practice, Jones and Fitzpatrick found an inverse
relationship with anesthesia providers who practiced in ACT models more than 50% of the
time. These nurse anesthetists had a less favorable attitude toward collaboration than those
who practiced in ACT models less than half the time (2009). Recurrent themes were noted by
Jones and Fitzpatrick in their evaluation of the perceptions of anesthesia providers within ACT
models regarding issues of conflicts between anesthesia providers were related to topics of
nurses’ autonomy, and physician’s authority (2009).
Accepting the unique and often challenging settings a growing majority of nurse
anesthetists work in, one can see the difficult nature of ACT’s that Meeusen et al. believe
contributes to role conflict and can directly contribute to feelings of work related burnout
(Meeusen et al., 2011). Furthermore, job satisfaction amongst nurse anesthetists was
significantly related to a series of work context variables, least of which was salary. So money
does not seem to play a role in the job satisfaction of nurse anesthetists despite inflammatory
comments made citing money as the prime motivator for independent nurse anesthetist
practice. Meeusen et al. concluded, in review of their study which involved nearly half of all
Dutch nurse anesthetists that personality dimensions, work climate and work context factors
mediated by burnout and job satisfaction predict turnover intention, not money (2011).
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Issues involving practice setting have been cited by Kacel, Miller, and Norris as being
significant determinates in the evaluation of job satisfaction amongst other advanced practice
nurses (2005). And that evidence does indicate that the degree of job satisfaction, or lack
thereof, is related to turnover intention (Griffith et al 200, and Hoel & Cooper 2000). The
intention to leave positions due to job dissatisfaction by nurses are not just idle threats, but as
Hogh et al demonstrate make those dissatisfied more likely to actually vacate their positions
(2011). So the same inference could be made that those nurse anesthetists who work under
restriction by way of supervising anesthesiologists would reasonably have a lower overall job
satisfaction, and would be inclined to be at higher risk of lateral violence due to their
subordinate position within the ACT setting.
Given the vast correlative data that has been generated as result of lateral violence
within healthcare it is without question that violence, albeit lateral or otherwise, often goes
under reported. Furthermore, there is also a noted decreased odds for men compared with
women overall in the reporting nonphysical violence, and this too is unique to nursing
anesthesia due to 60% of its members being women (Findorff & McGovern 2005). Findorff
and McGovern believed, at least in the development of their study, that advanced practice
providers and physicians alike experienced an equal degree of job specific risk regarding
lateral violence. Other research contradicts such and has physicians as being a prime culprit in
the perpetuating of lateral violence towards subordinate staff members.
One could easily argue that nurse practitioners then do not experience the same
exposure to lateral violence as physicians, rather more. Because their job designation is one
defined as a mid-level provider, not a physician. Despite the job responsibilities of nurse
anesthetists mirroring so closely in some instances that of physicians. Since nurse anesthetist
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are clearly not physicians, yet practice and administer every type of anesthesia available to
patients, which has historically has been a point of contention, could this dynamic of restricted
scope of practice within the ACT be one that lends itself to higher workplace violence risks
amongst nurse anesthetists? There are still many factors aside from practice issues as
mentioned and simple job titles that are unique to lateral violence within anesthesia and in
ACT models.
Aside from the well-documented emotional costs of lateral violence there has been
without question a very real impact on the healthcare workforce as a whole as a result of
unchecked disruptive behaviors amongst providers. Absenteeism according to Ortega et al, was
92% higher for those who were frequently exposed to lateral violence (2011). Given such,
employees that are absent for long periods of time require other employees to pick up the
increased workload, which could contribute to unsafe working conditions such as burnout or
increase the margin for error in regard to patient safety (Ortega et al 2011).
Ortega’s suspicion that absenteeism, coupled with the findings put forth by Meeusen et
al and Roche et al, leads one to believe that an overall negative work climate and emotional
distress had the highest impact on factors of perceived burnout amongst nurse anesthetists,
directly contributing to job turnover (2011, 2009). It can be reasonably postulated that an
anesthesia care model that fosters a hierarchical structure of authority amongst providers,
impedes the practice of nurse anesthetists. And poorly defined rolls could very well then, as the
literature would suggest, negatively affect the work climate and increase burnout amongst staff
members due to increased sick time use and the burdens of appropriate staffing.
Although much is understood about lateral violence, its perpetrators, victims, methods
for effective reporting and corrective interventions, the vast majority of literature regarding
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such is within the context of nurse-to-nurse perpetuated lateral violence. Where both the
perpetrator and victim are employed by a single entity that can by way of organizational policy
force compliance at threat of discipline and or loss of employment (Coursey et al 2013). Little
to no knowledge or investigation into the unique circumstances specific to where physicians
could both perpetuate the violent behavior and be the immediate supervisor/ employer of the
victim has not been done. So the group dynamics of the ACT and the potential pitfalls of its
inherent organizational structure are still illusive and unknown at best. However, given the
correlative assumptions drawn from numerous other studies, the very structure of the ACT
could propagate a degree of lateral violence that is far more challenging for nurse anesthetists
when compared to other colleagues in advanced practice nursing.
Healthcare organizations should make serious efforts to work towards the
recommendations put forth by the Institute of Medicine and foster the professional
development of nurses to practice to the fullest extent of their education and training,
encourage the furthering of both the education and training of nurses, and above all else
encourage nurses to become full partners in collaboration with physicians and other nonphysician professionals in redesigning healthcare in the United States (2011). These efforts
would support the direction of team based care systems that validate what the current literature
states are ways to create safer work environments for both patients and providers alike. This
would inevitably reduce the incidences of lateral violence within the ACT if not healthcare as a
whole. So is lateral violence more likely to occur in the context of a physician lead ACT as
opposed to alternate care models in anesthesia where all anesthesia providers are assumed
equals? That still seems to be a question that has yet to be investigated or addressed to any real
extent. So why are healthcare providers endorsing a system of care that could have unforeseen
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consequences adversely affecting our ability to provide safe and effective anesthesia care to
our patients?
Final Statement: The next step in this project is data collection related to the amount if any of
lateral violence that occurs in the anesthesia care team.
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