Excerpt from Ending Nurse to Nurse Hostility, Second Edition

Awareness: Ability to See the Problem

“Managers are the culture carriers of the organization.”

—Farrell (2005)

Researchers often use the word “insidious” to describe horizontal hostility because it has existed as an undercurrent of our profession for years. Not only is the behavior hidden, but the costs are hidden as well, as the financial impact lags behind the actual events. And when its destruction becomes obvious, it is usually too late—a high turnover results not only in a mass exodus of staff but also in a crucial break in the unit’s knowledge base.

Indications of Horizontal Hostility

Poor employee satisfaction scores

Satisfaction surveys differ in content from facility to facility, but there are usually some similarities. The scores you should be most interested in are “intent to leave,” “sense of belonging,” “meaningful work,” “morale of self,” and “morale of others.” One of the telltale signs of horizontal hostility on the unit is when staff rate “others’ morale” significantly lower than their own. This is because staff who hear a lot of gossip and negativity naturally conclude that their peers’ morale is much lower than theirs.

High turnover rates

This is an obvious indicator of horizontal hostility. Staff who feel that they belong will clearly want to stay—and vice versa. The key to retention is to follow up with an employee the moment you get the heads up that he or she may be leaving. Timely follow-up is crucial at this point, as the staff member’s reasons for leaving may alert you to a larger problem—a problem that, if continued, could lead to more resignations.

On my unit, it was not until after a staff member left the floor for another unit that I discovered the true cause of her transfer: Two employees who ate together, covered each other’s patients, and took breaks together had formed an impenetrable clique. Without the support of these nurses, her responsibilities became insurmountable.

Dueling units, dueling shifts

I was in charge of two floors. For the first six months in my new position as manager, I heard numerous complaints as staff whined they didn’t want to float “there.” In between the lines was the message that both floors felt that “our floor is harder than yours.”

Weary of the lack of respect between shifts, I asked the charge nurses to switch shifts for a week. After only one day, the charge nurses asked to return to their normal floors, but we held firm to the original plan. The charge nurses quickly learned that the floors each had different challenges of their own, and a new respect for those challenges emerged. I never heard another complaint.

The same plan worked beautifully when shift-to-shift complaints starting filtering through. “Walking in each other’s shoes” was a powerful tool to help staff understand that different floors and different shifts each have their own unique set of challenges.

Presence of cliques

A clique can include anywhere from two people to an entire floor. Members of the night shift often form a particularly tight group because they depend so much on each other that group cohesiveness is strong. Years of working together result in a finely choreographed ballet as the nurses cover each other and the unit. Signs of a clique include:

  • Staff who consistently refuse to work with someone or prefer to work with someone specific
  • A staff member who always volunteers to float
  • Exclusive meal breaks (i.e., same people, all the time, others not invited)
  • Refusal to help, which results in nurses feeling like they are sinking due to a lack of teamwork
  • Staff who change assignments or the schedule to work (or not work) with certain people

The presence of cliques is common in fear-based cultures. Human beings will always band together to increase their level of psychological, emotional, physical, and social safety when they perceive a dangerous situation. Managers with long tenures may be so accustomed to the cliques on their unit that they fail to act or intervene. If you have an “in group,” then by its very existence, you have an “out group.” There is no harm more devastating than ostracism and isolation. Last year a nurse took her own life when the group wouldn’t let her in. She lived in an isolated region and it wasn’t an option to find another hospital because there wasn’t one for 200 miles.

If you have cliques, then you are not a team. Teams are inclusive, respectful, and communicate seamlessly with all members in an open, safe system of interactions with the common goal of providing excellent, safe patient care and supporting each other in the process. It is the role of the manager to point out the cliques, speak to the leaders of those cliques in private, and ask for their leadership and support in creating a healthy team. Hospitals, clinics, and ambulatory surgery centers are all high-reliability organizations where harm and error can be mitigated by the presence of collegial teams.