Mar 22, 2021
By Anthony Renda , Tara Endeman

We are all essential: reinforcing the collective value of nurses

istockphoto.com/johnnygreigWhile nurses have long sought for the autonomy with which we now practise, and fought even longer to transcend antiquated stereotypes, it is critical to not use one another as a means to gain individual credibility if it comes at the expense of the entire profession and the patients we care for.

Takeaway messages

  • Nurses suffer from lateral violence driven by a perceived hierarchy, suggesting that nurses rank in importance depending on the social worth of their patient population.
  • The hierarchy between care areas and nurse specialties is not an accurate reflection of the critical value of each nursing role in maintaining the functional interdependence of the health-care system. This notion has been demonstrated during the COVID-19 pandemic.
  • To foster empathy and decrease conflict, nurse leaders should consider cross-training staff, which will have a secondary benefit during staffing crises.

Daily, nurses witness trauma, illness, and suffering. Sadly, we also inflict pain on one another in the form of lateral violence and bullying. The proverbial phrase “eating our young” is a disturbing analogy for this phenomenon.

Lateral violence is a well-known cause of nursing turnover, burnout, mental health deterioration, and even abandonment of the profession (Embree & White, 2010). These are unnecessary casualties, especially considering the national nursing shortage, which is worsening with the ongoing COVID-19 pandemic.

But still, we berate our new grads for their lack of experience and practical skills, just as we dismiss our senior staff for their antiquated practices and presupposed bitterness. We discount both the passion and eagerness of new nurses as well as the experience and dedication of professional veterans, much to the detriment of both patient care and staff well-being.

In addition to lateral violence within a nursing team, there is equally destructive conflict between nurses from different specialties and care areas. This intraprofessional nurse-to-nurse conflict is present at a systemic level and threatens to deteriorate the collective value of our profession. Often overlooked, the conflict between nursing care areas and subspecialties is rampant and risks discounting the crucial role each individual nurse has in maintaining the functions of the health-care system.

The driving force of this conflict is an intraprofessional hierarchy suggesting that nurses rank in importance depending on the perceived social worth of the population they care for. However, the COVID-19 pandemic has highlighted nurses who are overlooked and undervalued by both their peers and society. Recognition of these biases allow us to challenge toxic nurse-to-nurse bullying in the hope of promoting change and reinforcing our collective value as essential health-care providers.

A nursing hierarchy based on the patient’s stigmatized social worth

Despite the interconnectedness of disparate health-care teams, hierarchies created by ingrained social prejudices persist and drive conflict between nursing teams with harmful, systemic effects.

Within the nursing community a belief exists that nurses’ value correlates with society’s prescribed worth of the population they care for. Consistent with social stigma regarding mental health and substance use, psychiatric nurses are often condescended to as pandering to “addicts,” coddling those who “overcrowd” the system with their inability to cope, or suffering from the same stigmatized illnesses they treat. Mental illness disproportionately affects marginalized populations, people of colour, and the LGBT2Q+community, so it is unsurprising that the role of nurses who care for these populations is similarly pushed to the margins of the profession.

We hear similar opinions regarding nurses caring for long-term care (LTC) residents. The terminus of health care, LTC is the destination for patients for whom community care is insufficient, and both acute care and palliation are not a timely necessity.

Not even defined as an essential service under the Canada Health Act, for years LTC (and elder care in general) has been defunded and disregarded. These viewpoints seep into nursing culture, beginning even in nursing school, where most students strive for placements in fast-paced, high-acuity units.

These beliefs are so widespread within the nursing community that the Registered Nurses’ Association of Ontario has a web page to dispel common myths about working in LTC, including “I’ll lose my skills if I get into LTC nursing” and “residents go to LTC to die” (Young, 2018). Geriatric nursing requires an extraordinary amount of skill and time management to blend complex care needs with dignity and quality of life. This is an area of nursing that is experiencing a steady increase in patient acuity and care needs, in environments where front-line funding gets slashed, resources are limited, and residents are often seen as expendable.

Why would any new nurse choose to work in an area that is constantly devalued by society in general, and by their peers? Not only does this undermine the value of specific nursing roles and specialties within the organizational team, but it erodes confidence in nursing practice, drives behaviour between nursing teams, and perpetuates social prejudice regarding the value of specific populations.

Geriatric nursing requires an extraordinary amount of skill and time management to blend complex care needs with dignity and quality of life.

The positive and negative effects of social media

Nursing stereotypes specific to care area (#nursememes) are rampant on social media. They range from lighthearted (poking fun at the eccentricities and “here we go again” situations we encounter) to degrading, where nursing teams are lambasted for stereotypes such as their pretentiousness, lack of “true” nursing skills, or even insignificance to the profession.

The content curators, whether they know it or not, function as influencers in nursing culture around the world, outside the professional setting. In short, they are a voice for nurses outside the confines of professionalism and political correctness.

In the early days of the North American COVID-19 response, many #nursememes profiles were rallying points fostering solidarity among nurses worldwide who felt unsafe and unheard as they experienced PPE shortages, worsening staffing crises, and oblivious and/or neglectful governing bodies. However, while these social media posts unite us with valuable catharsis for the (often unbelievable) situations we experience, as well as our insecurities and patterns of behaviour, many also continue to inadvertently spread lateral violence by perpetuating toxic nursing hierarchies.

COVID-19 has highlighted undervalued nursing roles and reinforced our interdependence

Risk of exposure to COVID-19 is heightened in particular care areas: intensive care units (ICUs), emergency departments (EDs), and LTC. While not intentionally under-reported on, other care areas maintain high exposure risks due to patient type, such as medical-surgical, mental health, and community care. These are the same nursing roles that care for society’s “expendable” marginalized people.

The care provided prevents their patients from contracting or spreading the virus and/or decompensating and overwhelming the nation’s ICUs and EDs. Therefore, nurses in sub-acute areas are critical to prevent emergency departments and intensive care spaces from being overwhelmed. No area is an island — nurses rely on one another for the system to work.

The virus spreads quickly in congregate areas such as LTC and in shelters, and within their vulnerable populations who struggle with safety measures, such as social distancing, because of limitations related to mental status, physical ability, and socio-economic marginalization. The nurses working tirelessly to reduce transmission within these populations thus serve a critical role in preserving our acute-care hospital capacity.

These are the nurses adhering to the call from society to care for the most vulnerable: the elderly, homeless, disabled, and immunocompromised. Cynics dismiss this need, saying the virus will “only” harm these seemingly expendable populations. But their loved ones have responded with “Your ‘only’ is my everything.” The nurses within these care areas are not only caring and advocating for the most vulnerable, but also protecting the emergency and intensive care areas from becoming overburdened.

Very few, if any, nurses would be surprised by the reports from the military of the state of Canada’s long-term care facilities. We have sounded the alarm for the Ontario Ministry of Health’s blatant negligence in oversight and quality control on long-standing issues (Registered Nurses’ Association of Ontario, 2020). The Wettlaufer report (Gillese, 2019) describes how gross systemic oversight resulted in the harm or death of 14 persons at multiple facilities. Patients in our LTC sector are susceptible to harm in various ways due to their unique bio-psycho-social vulnerabilities, notwithstanding the added risk from an ill-managed environment.

Advocacy for our vulnerable loved ones, and our nursing peers who provide their care, needs to overflow into our interactions with and about them, where compassion, respect, and trust are at the forefront. The COVID-19 pandemic has illuminated the struggles facing our undervalued nursing teams — how vital they are to the stability of our health-care system, but also how equally vital each nursing role is to the continued strength of the nursing profession within that system.

Ongoing conflict affects nurses, patients, and our professional credibility

Much like a community, the disparate sectors of health care cannot function independently. There is no sector or clinician more important than others, and individuals who cannot recognize their limitations are a risk to the persons they care for. The reliance, respect, and appreciation for those differently skilled than us is what allows the system to function.

Unfortunately, the lack of this respect, and the resulting impact of lateral violence between care areas, is widespread. Patient care outcomes are known to be negatively affected by lateral violence (Embree & White, 2010). Bullying and lateral violence cause increased health-care expenses, staff turnover, burnout, and a toxic environment that further perpetuates this behaviour. Finally, it also threatens the legitimacy of the profession within interdisciplinary health care.

The lasting effect on the legitimacy of the profession from intraprofessional lateral violence between nursing teams is not missed by other professionals. While nurses have long sought for the autonomy with which we now practise, and fought even longer to transcend antiquated stereotypes, it is critical to not use one another as a means to gain individual credibility if it comes at the expense of the entire profession and the patients we care for.

Developing a reciprocal, trusting relationship between teams will allow nurses to better appreciate the unique skill set and challenges of their intraprofessional partners.

Cross-training nurses as a means of addressing lateral violence

Unfortunately, lateral violence is common among nurses, and new grads are especially vulnerable. The cause is complex and multifactorial. Nevertheless, there is a wealth of information for nurse leaders on managing intraprofessional conflict among nurses, and educators should incorporate simulations and interpersonal coping skills into nursing education (Sanner-Stiehr & Ward-Smith, 2017).

However, we also suggest that leadership address sources of lateral violence directly. By confronting the stigmatization of patient populations, intraprofessional teams can challenge this toxic nursing hierarchy. An empathic response, grounded in best practice policy, should be considered by nursing managers and educators. Nurses report conflict most commonly during transfer of care and intra-hospital transfer (as well as discharge and repatriation); these are focal points for patient safety risks along the care continuum (Ong, 2011).

Developing a reciprocal, trusting relationship between  teams will allow nurses to better appreciate the unique skill set and challenges of their intraprofessional partners (Jerng et al., 2017). We suggest cross-training nurses on teams with whom they frequently interact, starting at the hiring process. Being informed about our neighbours’ workloads, policies, and standards of care will foster empathy, trust, and safer transfer of accountability. Likewise, cross-training will provide insight into the challenges (and fulfilments) of working with their population, and will ensure that no nursing role is undervalued.

The secondary benefit of cross-training nurses is a more substantial staffing pool for crises (Paul & MacDonald, 2014), such as during the ongoing COVID-19 pandemic. Nursing staffing correlates not only with patient safety and outcomes (Duffield et al., 2011), but with our own mental health and burnout rate (Embree & White, 2010).

Cross-training becomes difficult when neighbouring teams have a substantial difference in patient acuity or training requirements. In these cases, less extensive orientation, or shadowing, may achieve the same effect of building a positive, empathic relationship and decreasing intraprofessional lateral violence, albeit sacrificing the secondary gain of extra float staff.

Overall, we feel that guided, consistent cross-talk between nursing teams will build a strengths-based culture, where diversity, learning, appreciation, and praise are a regular part of day-to-day intraprofessional interactions.

Conclusion

Nurses are the largest clinical body, with our subspecialties and general care areas making up the greater health-care community. Our ability to function in each distinct role depends on the existence and competence of our peers who practise in other areas. This diversity allows us to use our expertise in a meaningful way — where efficiency, safety, and quality are optimized.

The COVID-19 pandemic has not only shone a light on those in our society who are exceptionally vulnerable to infectious disease, marginalization, and neglect, but has also emphasized the collective value of nurses, and our necessity throughout the continuum of care in order for the health-care system to function.

In a comprehensive quantitative analysis, Canada is ranked 12th worldwide in health, economic, and social stability amid the COVID-19 pandemic (COVID-19 Regional Safety Assessment, 2020). Let us learn from this historical event, for our control of the virus will not continue without ongoing unity and cooperation within the nursing profession.

References

COVID-19 Regional Safety Assessment. (2020, August 23). Retrieved from https://www.dkv.global/covid-safety-assessment-250-regions

Duffield, C., Diers, D., O’Brien-Pallas, L., Aisbett, C., Roche, M., King, M., & Aisbett, K. (2011). Nursing staffing, nursing workload, the work environment and patient outcomes. Applied Nursing Research24(4), 244–255.

Embree, J. L., & White, A. H. (2010). Concept analysis: Nurse‐to‐nurse lateral violence. Nursing Forum, (45)3, 166–173.

Gillese, E. (2019). Public inquiry into the safety and security of residents in the long-term care homes system. Retrieved from https://longtermcareinquiry.ca/en/final-report/

Jerng, J. S., Huang, S. F., Liang, H. W., Chen, L. C., Lin, C. K., Huang, H. F., ... & Sun, J. S. (2017). Workplace interpersonal conflicts among the healthcare workers: Retrospective exploration from the institutional incident reporting system of a university-affiliated medical center. PLOS ONE12(2), e0171696.

Ong, M. S., & Coiera, E. (2011). A systematic review of failures in handoff communication during intrahospital transfers. Joint Commission Journal on Quality and Patient Safety37(6), 274–284.

Paul, J. A., & MacDonald, L. (2014). Modeling the benefits of cross-training to address the nursing shortage. International Journal of Production Economics, 150, 83–95.

Registered Nurses’ Association of Ontario. (2020, May 28). RNAO calls for immediate action in response to the Canadian Armed Forces’ LTC report with Minister Fullerton’s July 31 report to legislature. Retrieved from https://rnao.ca/news/media-releases/rnao-calls-immediate-action-response-canadian-armed-forces-ltc-report-minister

Sanner-Stiehr, E., & Ward-Smith, P. (2017). Lateral violence in nursing: Implications and strategies for nurse educators. Journal of Professional Nursing33(2), 113–118.

Young, L. (2018). 7 Myths about long-term care nursing — busted. Retrieved from https://rnao.ca/news/blog/7-myths-about-long-term-care-nursing-busted

Anthony Renda, MSc, BScN, RN, is a registered nurse at McMaster Children’s Hospital in Hamilton, Ont. He is also associate faculty at Conestoga College in the School of Health & Life Sciences and an active independent researcher. Anthony resides in Guelph, Ont., with his family.

Tara Endeman, RN, BN, MPN, CPMHN(C), is a clinical nurse specialist at Homewood Health Centre and Guelph General Hospital in Guelph, Ont. Her research interests focus on the educational preparation for registered nurses working in mental health and addictions in Ontario. Tara resides with her partner, Alex, in Guelph, Ont.

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