The greatest impact on who we become as nurses evolves from the transition from nursing school to graduate nurse, a stage of intense vulnerability, uncertainty of expectations, and lack of self-confidence. And a stage that cultivates practice and guides our approach to care. During transition, we’re also exposed to professional relationships between nurses, sometimes subjected to lateral violence, or bullying, as it is more commonly known.
Coursey and colleagues note that lateral violence includes many low-level types of hostile behavior including using innuendo, ostracizing, sabotaging, making verbal affronts, and withholding information. Lateral violence causes dissatisfaction because it can result in poor communication, poor patient care, and increased staff turnover. Lateral violence can occur at any level, from nursing student to experienced nurse; however, strategies that support the next generation can mitigate the risk of ongoing harassment throughout a nurse’s career.
Here’s a look at the issue of support from the perspective of nursing students and nurses.
First impressions count for nursing students
As a nursing student on clinical rotations, you maintain the safety net and support of an instructor while performing skills with patients, knowing that at any given moment “a real nurse will jump in and save the day,” in addition to participating in simulations in a non-threatening environment. You’re also observing how the primary nurse handles his or her role, noticing mood, and behavior. But first and foremost, you are observing how you are received when you walk on the unit, noting the overall vibe of the unit, the passive aggressive commentary surrounding nursing students, or refusal to interact.
The premise of being a student embraces an outlook that is inquisitive, enthusiastic, and embraces the hope that you will see and perform as much as possible during your limited time on clinical rotations. In an uncivil environment, staff nurses perceive your time with them as an interruption of flow with the patients they are directly responsible for; this can result in refusal to have students practicing on patients or innuendo that students don’t belong on their unit.
These types of reactions lead to tension between students, nurses, and instructors that is visible to patients and their families, creating an unsafe environment for practice, and lessening trust from the perspective of a patient. As a student, you experience disappointment, as you were hoping to visualize concepts previously only read about or seen only in a simulated experience. Ultimately, this sends the message that this unit is not comfortable with mentoring the incoming generation of nurses.
As the nursing student, you’re also observing interactions between fellow nursing students and nurses, scrutinizing how a nurse responds to a simple question, discerning if this nurse is approachable or one to be feared. Essentially, as a beginner to this profession, you’re learning what is acceptable conduct and culture on the unit, whether it leads to a positive or negative impression of the nursing profession, You also see firsthand complacency with lateral violence versus a unit and hospital that honors a zero-tolerance policy.
Taylor states, “A supportive environment is a prerequisite for learning.” During the transition to the world of professional nursing, you’re still in the window of impression, a vital opportunity for an experienced nurse or preceptor to recognize and examine what kind of a supportive experience was had while on nursing school clinical rotations—and an opportunity for you as a student to speak up about any incivility you may have experienced. An open-ended discussion of shared experiences as a beginner is a strategy that establishes trust on both sides.
It’s during this initial interaction with your first preceptor that you note who is patient, and whom to avoid, largely determining survival tactics on this unit. As a graduate nurse, you begin to build your experience by observing the nuance of the unit and preceptors, shaping details of everyday practice and how you will onboard the next generation, when that time comes.
As orientation progresses, you may encounter challenges with preceptors, in the form of short cuts, leading to confusion in charting or misunderstanding of safety and correct policy, for example, a preceptor who interrupts hand-off report, chastising you in front of other nurses for providing too much information, hastening you to skip vital information, resulting in an impression that this information doesn’t count, placing you at risk for implementing unsafe habits into your own practice. Uncertainty increases with inappropriate feedback, overheard gossip, disjointed evaluations, or missing end of day summary of progress.
Thomas & Hofler discussed the effects of no support, noting that novice RNs who care for complex patients often feel overwhelmed and exhausted, and they may suffer from significant anxiety, all of which can lead to attrition. This may lead to decreased job satisfaction, increased errors, and increased job turnover.
What can nurses do?
The greatest impact of supporting others begins when experienced nurses recall what it felt like to be a beginner, what it felt like to be that enthusiastic nursing student, or an uncertain graduate nurse. Experienced nurses and preceptors break ground when they simply say, “I remember what it felt like to be in your shoes.”
Consider that novice nurses aren’t merely looking for the confident face in preceptors, nursing instructors, or charge nurses—they also, perhaps, looking for the humanity behind the nursing mask, looking to see that experienced nurses have stories to share from the days when they were facing the unknown, how they tackled lateral violence, and how they were supported throughout it.
If you are an experienced nurse, or preceptor, guiding a nursing student begins with a welcome to the unit. It’s also important to give a direct impression that there is a zero tolerance for lateral violence among nurses. Support occurs in any scenario, whether it’s allowing students to observe or to perform a simple skill; support will give them confidence when they next see this on their own, beyond graduation. Supporting a graduate nurse means allowing them to observe a patient resuscitation and clarifying all the roles affiliated with it, rather than aggressively telling them they have no place there, or asking them to watch over other patients. Support builds during the next resuscitation, where novices recall all they observed previously from a global perspective, now with the guidance of a preceptor at their side during the heightened chaos. As the preceptor, in this supportive role, you draw upon your own first resuscitation and the associated fear of being left alone.
Support also comes from introducing students to all the vital members of the team, highlighting how welcome they are on the unit, considering the integral role a new nurse will play in streamlining new techniques observed in nursing school, as well as offering them a vision of how they will support the ongoing generations in the future.
In a study conducted by Griffin on efforts to prevent bullying, cognitive rehearsal (rehearsed verbal responses) education helped stop acts of bullying. Examples of preferred strategies in this study were simulated role play and de-escalation process in managing conflict, where nursing students were placed in the role of novice targeted as the victim, with experienced nurses and provided with instructional cards. The learners were given an opportunity to debrief the process and discussed methods of addressing bullying behaviors.
Resources
Strategies if you are a student nurse, graduate nurse, or a bystander of those targeted by incivility includes speaking to the clinical instructor, or a trusted professor or dean of nursing if the clinical instructor is unapproachable.
As a novice nurse, or experienced nurse, resources are available at the Stop Bullying website (stopbullying.gov/research-resources/index.html), and a free interactive course for nurses offered through the Centers for Disease Control and Prevention includes how to recognize warning signs of violence in the workplace and skills to prevent and managing conflict. This gives you an opportunity to identify the type of conflict and the appropriate resource and response.
If you are a preceptor, or considering ways you can make a difference on your unit, explore your nursing education department’s classes on onboarding new nurses. Generally you will be exposed to a variety of strategies to support nursing students and new nurses during preceptor workshops or charge nurse workshops, where a portion of the classes focuses on the prevalence of lateral violence in the profession and ways to reduce it. During these workshops, participants work through conflict case scenarios and resolutions, in addition to learning about the varied ways learners may suppress uncertainty of practice when they feel chastised, ridiculed or aggressively spoken to. A measure of success is when an orientee successfully completes his or her orientation, citing the support and encouragement of unit staff and preceptor.
Encouragement and guidance during the transition from school is a constructive domino effect, not only on patients and families, but also on the subsequent students and novice nurses who will follow you into the next generation. It takes one person to change the shape of support.
We can be that change.
Michelle Perregrini is a nurse educator in the Center for Professional Nursing Practice at Weill Cornell Medical Center in New York.
Selected references
Centers for Disease Control and Prevention. Workplace violence prevention for nurses. 2017. cdc.gov/niosh/topics/violence/training_nurses.html
Cousey JH, et al. Successful implementation of policies addressing lateral violence. AORN J. 2013;97(1):109.
Griffin M, Clark CM. Revisiting cognitive rehearsal as an intervention against incivility and lateral violence in nursing: 10 years later. J Contin Educ Nurs. 2014;45(12):535-542
Hofler L, Thomas K. Transition of new graduate nurses to the workforce. North Carolina Medical Journal. 2016;77(2):133-136.
Taylor R. Stop the eye rolling: supporting nursing students in learning. Am J Nurs. 2017;117(1):11.
