Environmental factors

HEALTHCARE ENVIRONMENT
High-quality healthcare organizations are driven by attention to their customers, excellent workmanship, empowered workforces, and
innovation and change as a response to their environment. The Patient Protection and Affordable Care Act of 2010 established the mandate
of increasing access to care while decreasing costs. Ongoing healthcare reform emphasizes the importance of collaborative teams in the
redesign of healthcare delivery systems that provide high-quality, client-centered, mutually accountable care across the lifespan (Roussel,
Thomas, & Harris, 2016). Consequently, healthcare providers are challenged to focus on quality, cost-effectiveness, and responsiveness to
the voice of the consumer in all aspects of care.
The overall goal of transforming the healthcare system is to develop a seamless, coordinated care approach for clients by: 1) improving
population health and client outcomes, 2) enhancing the client experience, and 3) continued improvements in providing high-quality services
at a lower cost (Stiefel & Nolan, 2012). Traditional measures of these outcomes are now being combined into value-based competitive
reimbursement models from third-party payors and regulatory agencies. It is generally accepted that in order to survive financially and
competitively, healthcare organizations must break down traditional organizational hierarchies and embrace a culture of collaboration and
teamwork among providers and stakeholders (including consumers) at all levels. High-quality healthcare organizations recognize the
environmental factors inherent in maintaining competitive advantage and ensuring financial viability include an examination of organizational
culture with an emphasis on team-building, group dynamics, conflict resolution, negotiation, reframing historical sources of power,
environmental issues, cultural competence, and diversity.

ORGANIZATIONAL CULTURE AND ENVIRONMENT
It is impossible to promote high-performing teams without true commitment to teamwork at all levels. Shared vision, open dialogue, trust, and
a sense of belonging are critical elements for overcoming organizational challenges and ongoing strategic development. Consequently, it is
important to insure that the culture, alignment of corporate objectives, and educational/technical supports are congruent with establishing a
culture of teamwork and collaboration. Longstanding paradigms of organizational hierarchies, privileged conversations, and discipline-
specific silos must be replaced by an organizational climate that fosters equalization of power, shared governance, participative
management, transparency, open communication, and individual/group contributions to organizational goals. Synergy of vision and desired
outcome is essential. Team-related activities and organizational objectives must also be aligned. Stakeholders must understand how their
contributions align with corporate objectives and feel that their efforts are valued. It is increasingly recognized that alignment of the culture
and capabilities of an organization are derived from philosophies and practices related to the strategic management of human capital
(including the free flow of information, job security, selective hiring practices, elimination of status differences between groups,
decentralization of authority, and team-building) as basic elements of organizational design (Pfeffer & Veiga, 1999).

TEAMBUILDING
“A team remains the most flexible and most powerful unit of performance, learning, and change in any organization” (Katzenbach & Smith,
2003, p. XIX). The abilities to express one’s ideas clearly and decisively, to listen attentively and respectfully, and to invite a range of
opinions are among the communication skills that help managers build team cohesiveness. Teams usually are developed reflecting the
diversity and culture of the organization, and although the chief executive may be fundamental in the formation of high-performance teams,
he or she is not always a team leader.
According to Katzenbach and Smith (2003), developing a team is the inclusion of “a small number of people with complementary skills who
are committed to a common purpose, performance goals, and approach for which they hold themselves mutually accountable” (p. 275). A
team develops around the task to be accomplished while taking into account the mix of personalities and competencies; the desired
performance outcomes; and the processes of communication, involvement, performance orientation, and enabling leadership (Higgs, 2006).
Central to a team’s success will be its members’ work behaviors such as constructive listening and giving the benefit of the doubt to others
(Katzenbach & Smith, 2003). Team members need to not only be mature and self-motivated, but also be aware of their social and cultural
differences, appreciate each other’s cultural diversity, and have a basic understanding for each other’s value systems. Only through an active
display of this understanding and open and nonjudgmental communication can a team develop its highest potential to meet group goals and
complete its mission.
The team leader can facilitate this process by using good meeting skills and appropriate meeting behaviors. The task of reminding team
members of their mission, goal, and tasks falls to the leader as well.

GROUP DYNAMICS
Teams tend to evolve through a predictable development process that was first described by Tuckman in 1965 and then modified by
Tuckman and Jensen in 1977 (Smith, 2005). The five stages include: Forming, Norming, Storming, Performing and Adjourning. In the
Forming stage individuals come together and begin to establish team relationships. While there is often a sense of enthusiasm for the task at
hand, individuals tend to be cautious in their communication with one another; as they may be relative strangers and may need purposeful
teambuilding activities. A skilled team leader or facilitator may be needed to clarify team purpose, goals, and to assist the team in
establishing rules of engagement.
As the group proceeds through the maturation process, it arrives at the second stage, known as Storming. In this stage, members of the
group compete for position, power, and status; informal leaders may emerge. When team members come from differing backgrounds there is
a tendency to approach critical issues from differing standpoints and opinions that cause uneasiness and conflict among group members.

These differences need to be openly confronted and addressed proactively so that effective resolution can be achieved occur in a timely
fashion (Kelly, 2008). The storming phase of group work is critical to team success. Katzenbach and Smith (2003) assert that real teams
don’t emerge unless individuals take risks, address conflict, and develop a sense of trust and interdependence.
The third stage of group formation, Norming, is where the rules for working collaboratively are made explicit; structure, roles, and
relationships are further clarified resulting in a sense of cohesion. Team members become more adept at resolving conflict, respect
differences in opinion and work cooperatively to achieve team goals. The leader’s role during this stage of group development focuses on
relationship building and assisting the group in overcoming barriers.
As the group matures, it enters the Performing stage. In this phase, group cohesion, collaboration, and solidarity are evident. Personal biases
are overshadowed in an effort to achieve team goals (Kelly, 2008). The leader’s role is to provide feedback on the work that the group is
accomplishing, redirect group energy when necessary, and further cultivate interpersonal relationships.
The final stage of team development, Adjourning, addresses the individual and group tasks associated with completion of the team’s specific
charge and dissolution of the formal team structure. During this phase of termination and consolidation, the ream reviews their activities and
evaluates the outcome of their efforts (Kelly, 2008). The development of strong interpersonal relationships inherent in team-building and the
loss of team structure may be difficult for some team members. Consequently, a focus on closure is paramount. At this stage it is appropriate
to recognize team accomplishments and to facilitate an ongoing culture of collaboration and teamwork (Roussel, Thomas, & Harris, 2016).
Celebration of both successes and failures are essential for building a culture of inclusion and cooperation by: valuing the process and the
contributions of individuals involved, supporting an ongoing, proactive culture of change, celebrating insights gained and providing a sense of
renewal that will serve as the cornerstone for ongoing collaboration and teamwork necessary to meet the inherent challenges of redesigning
healthcare delivery now and in the future.
Team development and function rarely proceed in a completely linear fashion. Changing circumstances and intervening variables may have
a profound impact on team function, alignment, and outcomes. Consequently, management intervention may be needed when teams regress
or encounter seemingly insurmountable barriers to performance. In these instances the leader should consider strategies to assist teams in
overcoming obstacles, evaluate whether modifications to team membership are needed, and in extreme cases, determine whether planned
abandonment of the team activity is needed. Experts have also suggested that the group formation process, and thus the productivity of the
group, can be accelerated under the guidance of a skillful facilitator or in the face of actual or fabricated crisis (McKnight, Kaney, & Brewer,
2010).

CONFLICT AND CONFLICT RESOLUTION
Conflict occurs naturally in and among groups and individuals; it is inevitable and a condition essential to change. Although conflict is often is
viewed negatively, if managed constructively it can provide a sound foundation for the evolution of high-performing teams as members bring
their unique insights, perspectives, and values to develop a shared vision and plan of action. New paradigms for constructive conflict
resolution include replacement of old attitudes of competition with new approaches that foster collaborative problem-solving, shared
accountability, respect, open and honest communication, a willingness to let go of past paradigms in favor of exploring new possibilities; and
developing a mutually agreed-upon plan of action (Katzenbach & Smith, 2003).
Conflict may be intrapersonal (within oneself), interpersonal (between the self and another person), intragroup (among members of a
particular group), or intergroup (among members of two or more groups). Other types of conflict include competitive conflict and disruptive or
destructive conflict. In both instances, the desired outcome is to overcome one’s opponent (i.e., to “win”).
Conflict management occupies a significant portion of a leader’s work. Some suggest that at least one-quarter of the leader’s time is spent in
conflict management activities. The challenge for the leader is, of course, to help her or his subordinates reach a “win–win” outcome in which
the parties to the conflict each believe they have come away from the encounter with a sense of resolution. Strategies include

• Focusing on goals, not personalities;
• Meeting the needs of both parties, equally if at all possible; and
• Building consensus.

Achieving a win–win outcome is much easier in the abstract than in the workplace setting. Nonetheless, it is a worthwhile goal.
Conflict is a state of disharmony or disequilibrium. Managing conflict requires maintaining the level of conflict neither too high nor too low,
with the ultimate goal being to stimulate growth and coping behavior without reaching the point where the conflict seems overwhelming.
Common conflict resolution strategies include compromise, competing, cooperating, smoothing, avoiding, and collaborating. The choice of
the most appropriate strategy depends upon many variables such as the urgency of the decision, inherent power and status disparities, and
the maturity of individuals involved in the conflict (Marquise & Huston, 2009).

NEGOTIATION
Negotiation can be thought of as a formal process; one example is the negotiations that take place at the time of contract deliberations
between unions and management. Negotiation also can be thought of as a political process in that it is a “power play” among individuals who
compete to “win” but generally compromise in the end.
The keys to successful negotiations include the principles of

• Separating the people from the problem,
• Focusing on interests, not positions,
• Inventing options for mutual gains, and
• Insisting on objective criteria.

Interest-based negotiation is a somewhat newer concept, the principles of which were outlined by Fisher, Ury, and Patton (1991) in Getting to
Yes: Negotiating Agreement Without Giving In. Bizony (1999) has distilled the principles listed below from Fisher and colleagues’ work on the
Harvard Negotiation Project; their value has been convincingly promulgated through the years.

• Treat people as equals.
• Resolve issues on their merits.
• Define issues with a definition that is acceptable to all parties.
• Focus on interests, not on conclusions or positions.
• Develop options that may meet the interests of both parties.

• Apply objective standards to resolve conflicting interests.

Twelve points of negotiation can prepare leaders for successful negotiations.
1. The greatest failure in negotiation is failing to negotiate.
2. The most important person to know in negotiation is yourself.
3. Everyone has power in negotiation.
4. Single-issue bargaining leaves both parties unsatisfied.
5. Urgency drives decisions.
6. Agreement is the end; trade-offs are the means.
7. The best results are obtained by keeping the other party on a need-to-know basis.
8. The value of something is always in the eye of the beholder.
9. Success in negotiation is directly related to the amount and kind of preparation preceding it.
10. Being able to walk away or select an alternative to a negotiated agreement puts a negotiator in a very strong position.
11. Two sides can always agree on something, even when they are far apart on major issues.
12. Conflict is a part of meaningful negotiation.

Mediation as a method of dispute resolution uses a neutral third party who attempts to bring parties together to solve a conflict. The
mediator’s role is to fact-find, make suggestions, and draft a solution that is agreeable to both parties (Epstein, 2003).

SOURCES OF POWER AND EMPOWERMENT
Power is the capacity to act and the energy to mobilize resources to create change and achieve goals (Kelly, 2008). Whether power has a
positive or a negative connotation depends on how it is used. The most widely accepted power-base classification identifies five sources of
power inherent in interpersonal interactions. The categories include: legitimate power, reward power, coercive power, referent power, and
expert power (Huber, 2010).

• Legitimate power is the right to command within an organizational structure or setting based upon the position held. The reciprocal
nature of this power obligates employees to comply with legitimate orders.

• Reward power is based on the ability to deliver desired rewards or the ability to compensate others in some way. Compensation need
not be monetary.

• Coercive power is derived from the ability to threaten punishment or deliver penalties. It is a source of power used to apply pressure so
that others will meet what is demanded.

• Referent power means that the individual has characteristics (charisma) that appeal to others resulting in the ability to influence without
having to offer rewards or threaten punishment.

• Expert power means that the individual has specialized expertise or knowledge that can influence the actions of others toward certain
outcomes or goals.

All sources of power are potentially important, and the assumption is that the most powerful leaders are those who have high legitimate,
reward, or coercive power. However, one should not underestimate the strength of referent and expertise power. These sources of power are
more closely related to personal motivation and may, in the long run, make a greater and more lasting difference within a company or
organization. It is not necessarily the leaders whose names are well known or who sit atop the organizational chart who exert the most power
of this type.
In today’s healthcare environment it is important that all staff are empowered to make decisions, especially those decisions that positively
influence client outcomes. An understanding of the concepts of power and empowerment is also essential if nurses are to realize their full
potential for leadership and ongoing professional advancement.

ADAPTING TO CHANGE
Change is the province of leaders. It is the work of inspiring people to do things differently, to struggle against uncertain odds, and to
persevere toward a misty image of a better future (Kouzses & Posner, 2012). Consequently it is imperative that nurse executives understand
and use strategies that will support staff members in proactively adapting to change.

Appreciative Inquiry
Appreciative inquiry is the process in which an organization asks questions of its members in seeking information that can be used to
anticipate and identify areas of potential strengths. The four characteristics of appreciative inquiry include

• Appreciative,
• Applicable,
• Provocative, and
• Collaborative.

Appreciative inquiry is best described through the 4 Ds:
1. Discovering the best of what is,
2. Dreaming what might be,
3. Designing what should be, and
4. Creating a destiny of what will be.

Appreciative inquiry is to organizations what creative visualization is to individuals; both are positive approaches to foster change.
Appreciative inquiry is considered to be a “soft business strategy” that can be used to create organizational visions, build cultures, and align
groups to achieve organizational goals. Through imagination and thoughtful analysis, appreciative inquiry can contribute to measurable
results for organizations.

Crisis Management

A crisis is anything that has the potential to significantly affect an organization. Organizations with crisis management plans are better able to
work effectively with local responders, promptly attend to the needs of those affected, assist investigating bodies without jeopardizing the
organization’s legal position, provide for accurate and timely information, and minimize damage to the organization’s reputation.
The four objectives of crisis management are

1. Reducing tension during the incident;
2. Demonstrating organizational commitment and expertise;
3. Controlling the flow and accuracy of information; and
4. Managing resources effectively.

Managing a crisis begins with the creation of a crisis management team and assessing potential crises before they occur. Managing a crisis
also includes

• Developing crisis management team plans;
• Establishing guidelines for gathering information and beginning an internal investigation;
• Providing periodic crisis training evaluation; and
• Developing guidelines for crisis communication.

The key points for crisis management of any dimension include
• Having a flexible structure capable of responding to any crisis quickly, decisively, and in a coordinated manner;
• Preparing operational contingency plans;
• Creating and communicating a document retention policy (e.g., nothing is thrown away that might enhance an investigation or document

the event);
• Developing training that includes addressing legal issues before they occur, developing investigational procedures, identifying necessary

equipment and systems before a crisis, and developing good media relations skills;
• Preparing to communicate with a variety of constituents, including employees, the media, neighbors, investors, regulators, and

lawmakers; and
• Preparing a business contingency plan to minimize disruption and damage.

Because crisis management is the manner in which organizations respond to unexpected events over which they have little or no control,
and “uncontrollable” situations occur with relative frequency in health care, developing purposeful intervention strategies seems prudent. The
“truthful disclosure” approach is one that healthcare organizations take in order to maintain public trust.
A classic example of a crisis management in healthcare products can be seen in the Johnson & Johnson’s handling of the Tylenol®
tampering crisis (Kaplan, 1998). In 1982, seven people in the Chicago area died after taking Extra-Strength Tylenol capsules that had been
injected with cyanide. The containers had been tampered with after they left the manufacturing plant. Rather than claim that the company
was not to blame, Johnson & Johnson immediately launched a public relations program to preserve the integrity of the product and the
company.
Marketing experts believed that Tylenol would disappear from pharmacy shelves, never to be mentioned again except in negative terms.
However, Johnson & Johnson’s leaders put public safety first and worried about financial impact later. They alerted consumers throughout
the nation to avoid the consumption of any Tylenol product until the extent of the tampering could be determined. They stopped production of
all Tylenol products and recalled all Tylenol capsules from the market at a cost of more than $100 million. They offered to replace any Tylenol
capsules people had already purchased with Tylenol tablets. They quickly began working with the Chicago Police Department, the Federal
Bureau of Investigation, and the Federal Drug Administration. They put up $100,000 in reward money to help catch the perpetrator of the
crime.
Not only did the company survive and thrive, Tylenol remains one of its biggest-selling and most profitable products. The forthright approach
of the company reassured the community that its safety came first and that Johnson & Johnson cared enough to be publicly open and truthful
about the crisis (Kaplan, 1998).
Crisis management by companies such as Qantas Airlines, Exxon-Mobil, and Boeing demonstrates the effectiveness of the four objectives of
crisis management in responding to the crisis in an organized format, protecting an organization’s reputation, communicating effectively
through company channels to resolve the crisis, and normalizing operations following catastrophic events.

ENVIRONMENTAL FACTORS
Cultural Competence
Cultural competence can be defined as the ability to interact effectively with people of different cultures with a focus on personal awareness
of one’s own culture and attitude toward culture, and development of knowledge and skill across multiple cultures. Cultural competence is
essential as a leadership strategy in today’s healthcare environment. Our “shrinking” planet, globalization, and population movement bring
people from different cultures throughout the world together in the workplace, and people may have widely divergent understandings of
identity and society. Globalization has increased the need for awareness of cultural ideas and expectations other than our own in an
environment where intermixing national, religious, and ethnic identities may lead to conflict.
The world’s population is expected to double by 2050 (Kotlikoff & Burns, 2004). Industrialized nations are “graying,” while 80% of the world’s
population growth is in developing nations. Challenges for the workplace include language and cultural differences, increasing incidence of
chronic illness, generational issues, maximization of resource use, and ethical differences.
Strategies for success in cultural competence include

• Know your own culture, values, and biases.
• Listen and observe.
• Emphasize corporate values at all times.
• Be a teacher and a learner.
• Hold up your end of the bargain by displaying awareness of personal cultural practices.
• Give clear directions and provide resources.

• Delegate the responsibility for outcomes.
• Give the big picture.
• Consider the rules and procedures from all perspectives.

A leader’s responsibility in cultural competence includes
• Managing personal expectations,
• Providing straightforward steps for decision-making,
• Being courageous and displaying correct behavior,
• Applying leadership and management skills according to values and attitudes, and
• Providing employees the opportunity to grow.

Because today’s workforce consists of four generations (i.e., mature, baby boomers, generation x, millennials), for the first time, a leader also
must consider generational diversity as well as cultural diversity. There are challenges relating to work ethics, duty, and sacrifice for the job.
A leader’s role in cultural and generational competence in today’s healthcare organization includes

• Creating a culture that has a diversity-sensitive orientation;
• Building the blocks of culturally and linguistically competent healthcare delivery;
• Recruiting and retaining a diverse workforce; and
• Ensuring the success of a culturally competent organization.

Effective leaders are aware of and make use of cultural competence to maximize the benefits of diversity in their staff and client population
and minimize the costs in delivering healthcare services today. In nursing practice, nurse leaders should encourage members of other
cultures to become nurses, discuss the benefits of nursing, and support efforts of nurses from other cultures to assimilate into nursing’s
culture.
The time to consider cultural and generational diversity is now. The nurse leader must consider the change in the population demographics,
that industrialized nations are “graying” and the workforce is too. A survey of staff demographics can help the nurse leader prepare for an
increase in chronic illness among the workforce as well as generational workforce issues and language and cultural challenges that might
disrupt optimal effectiveness of operations (Kotlikoff & Burns, 2004).

Leveraging Diversity
Leveraging diversity is the ability of an organization to become culturally competent and, in doing so, value diversity from both a personal (the
organization) and business (the customer base) perspective (Shipp & Davidson, 2001). This business strategy links the workforce, the
workplace structure, and the marketplace and displays the ability of organizations and their leaders to recognize and use every advantage to
ensure success. Leveraging diversity maximizes all talents and intellectual capital within an organization and ensures that all persons are
included in every aspect of the organization.
Leveraging diversity is known to boost employee morale, reduce grievances, and enhance problem-solving and decision-making abilities.
This approach to management of human capital in an organization reduces barriers, enabling all employees to fully use their talents on
behalf of the organization.
Leveraging diversity in the marketplace includes serving customer groups with a sensitivity to their cultures and allows an organization to
maintain a multicultural perspective. Cultural diversity can be leveraged for bottom-line impact and therefore ties directly to business strategy
and practices.
There are three leadership behavioral elements of leveraging diversity.

1. The cultural element includes exerting influence within the organizational culture to set the tone for underlying values, beliefs, and
principles.

2. The leadership element includes giving employees a sense of direction, meaning, and purpose to navigate organizational waters as
well as recognizing and using the full potential of all persons in the organization.

3. The connectivity element includes building a bridge between cultural and leadership elements and organizational intellectual capital,
maintaining vision clarity, sharing power, and identifying and assessing problems.

The end result of leadership support and participation in leveraging diversity for an organization is an increase in productivity, efficiency, and
quality, and ultimately an improved work environment.
The nurse executive is a role model in setting the tone and direction of an organization’s daily work effort. The nurse executive acts as a
coach and supporter of diversity among all stakeholder groups to achieve the end goals and objectives of the organization and its
constituencies.
Personnel Matters While Leveraging Diversity in the Workforce
Leveraging diversity in the workforce overlaps with human capital and human resources management functions. Areas to consider include
writing and using objective documents, including job descriptions and performance appraisals. Leveraging diversity in the workplace should
be a consideration during personnel selection efforts and orientation and training of new employees. Addressing behavioral issues and
guiding employees to organizational support mechanisms such as employee assistance for alcohol, drug, or other issues are also times
when leveraging diversity can increase an organization’s productivity, efficiency, and quality, and ultimately lead to an improved work
environment. Providing the assistance or the mechanism for employee assistance to all employees promotes increased productivity and
leverages diversity.
Vulnerability audits and exit interviews offer opportunities to gather data about the work environment and consider whether this should be the
time of change for job enrichment, engineering, rotation, or enlargement opportunities. Enhancing the work environment through job
enrichment makes jobs more interesting and challenging, maximizes efficiency, and adds more variety to daily tasks. Goal-setting with
employees provides objectives to structure the job while considering that job rotation adds variety (Slocum, 1981).

Organizational Transparency
Current management literature defines organizational transparency intentionally shared information exchanged between two parties. It is
distinguished by the degree of information disclosed, clarity and accuracy (Schnackenberg &Tomlinson, 2014). A transparent organization

encourages behaviors that support access to information, participation, and decision-making. These behaviors create a higher level of trust
among all stakeholders.
Organizational transparency implies a trusting environment wherein transparency and trust are interconnected. Cultural trust in the
organization requires clarity and consensus about what constitutes success, open access to information, and confidence in the competence
of all involved. Leaders should consider creating an environment that fits the definition of success within the organization and for the
organization.
Other important leadership behaviors include

• Practicing nonmanipulative leadership,
• Communicating frequently and repeating important information,
• Opening up access to documents regarding decisions,
• Sharing background information about important decisions,
• Providing clear financial reporting, and
• Hiring and appointing trustworthy people.

Challenges to organizational transparency include
• Risks from potential distortion of the truth through increased access to information,
• A slower-than-usual decision-making process, and
• Additional organizational vulnerabilities.

Organizational transparency does not guarantee that the right decisions are being made and may require additional time and resources at all
organizational levels. Transparency may at some point have diminishing returns, when communication, information-sharing, and trust levels
reach a status quo and information flows in all directions. In the final analysis, the value of organizational transparency lies in the protection
and promotion of an organization’s reputation, a corporate culture of communication among all stakeholders, and the involvement of current
and future members in decision-making processes (Fung, Graham, & Weil, 2007).
Transforming healthcare delivery requires robust data collection, and analysis of a broad range of performance measures. Transparency is
critical is establishing a culture of safety embraced by all levels of staff and key stakeholders. Transparency affords healthcare organizations
with a complete view of operational performance that enables comparison with other like facilities and standards of practice (Kerfoot, 2009).
The publication of nursing outcomes and program evaluation reports is an example of organizational transparency. Nurse executives serve
as role models and should support transparency, promote communication in all directions, and participate in shared decision-making within
the organization.

Lateral Violence (Nurse Bullying)
Lateral violence is aggressive and destructive behavior, in this case, of nurses against each other (Woelfle & McCaffery, 2007). The end
result is damage to another’s dignity, confidence, and self-esteem. Often, those who experience lateral violence in the workplace then
transfer it to others.
Lateral violence in nursing can consist of a variety of behaviors, ranging from unintentional, thoughtless acts to purposeful, intentional,
destructive acts meant to harm, intimidate, or humiliate a group or individual. Behaviors can range from random instances to a pattern, and
such behaviors can create a hostile work environment.
Examples of behavioral lateral violence include

• Talking behind others’ backs;
• Scapegoating;
• Criticizing a colleague in front of others;
• Excluding a coworker from group interaction;
• Withholding pertinent information;
• Violating a coworker’s privacy and confidentiality;
• Making inappropriate, condescending remarks; and
• Displaying inappropriate nonverbal language, such as making faces or raising one’s eyebrows.

Any time there exists an “us vs. them” attitude or when an imbalance of power occurs, conditions are prime for lateral violence. Examples of
relationships in which lateral violence can occur include nurse manager to a staff nurse, nurse executive to a nurse manager or a staff nurse,
nursing faculty member to a student nurse, and peer to peer.
The consequences of lateral violence can manifest themselves as physical symptoms, increased absenteeism and, in extreme cases, suicide
of the targeted employee. Increased turnover of staff is also a symptom (Beecroft, Kunzman, & Krozek, 2001). Lateral violence can place
clients at risk for poor care and outcomes; for example, what might happen to a client when one nurse deliberately withholds pertinent
information about the client’s care that needs to be shared with another nurse?
Nurse executives must be aware of and address lateral violence in the workplace and implement strategies to prevent and stop such
behavior, such as

• Educating all staff and managers about this behavior;
• Disciplining any manager or staff member who engages in this behavior;
• Creating a culture that does not tolerate this behavior;
• Implementing organizational transparency, or having an open culture; and
• Implementing research to study this behavior in their own organizations.

The Health Work Environment
The health work environment is a topic that addresses nurses’ working conditions, which are linked to the quality of care that is provided to
clients and clients’ safety. Accrediting organizations and Magnet Recognition Program® include standards that address working conditions
because they are associated with health and safety outcomes for nurses and other healthcare providers (Geiger-Brown & Lipscomb, 2010).

Employers are charged with the responsibility to assess and address aspects of the nursing work environment that have been linked to
hazards and adverse exposures for nurses and the most common health and safety outcomes of nursing work. It is the responsibility of the
nurse executive to ensure a healthy work environment while facilitating a culture that values diversity and recognizes individual and group
contributions to organizational goals.

REFERENCES
Arrendondo, P. (1996). Successful diversity management initiatives: A blueprint for planning and implementation. Thousand Oaks, CA: Sage.
Beecroft, P. C., Kunzman, L., & Krozek, C. (2001). RN internship: Outcomes of a one-year pilot program. JONA, 31(12), 575–582.
Bizony, N. (1999). Interest-based negotiation: Moving beyond our scarcity model. OD Practitioner Online. Retrieved from

http://www.odnetwork.org/odponline/vol31n3/interestbased.html
Busche, G. D. (2007). Appreciative inquiry is not (just) about the positive. OD Practitioner, 39(4), 30–35.
Cooperrider, D. L., & Srivastra, S. (1987). Appreciative inquiry in organizational life. Research in Organizational Change and Development, 1,

129–169.
Covey, S. R. (2004). The 7 habits of highly effective people. New York: Free Press.
Epstein, D. G. (2003). Mediation, not litigation. Nursing Management, 34(10), 40–42.
Fisher, R., Ury, W., & Patton, B. (Eds.). (1991). Getting to yes: Negotiating agreement without giving in. New York: Penguin.
Fung, A., Graham, M., & Weil, D. (2007). Full disclosure: The perils and promise of transparency. New York: Cambridge University Press.
Geiger-Brown, J., & Lipscomb, J. (2010). The health care work environment and adverse health and safety consequences for nurses. Annual

Review of Nursing Research, 28, 191–231.
Goleman, D. (1997). Emotional intelligence. New York: Bantam Books.
Goleman, D. (2000). Working with emotional intelligence. New York: Bantam Books.
Gottlieb, M., & Healy, W. J. (1998). Making deals: The business of negotiating (2nd ed.). Greenwich, CT: Communication Project.
Greer, E. (2006). How to use the six laws of persuasion during a negotiation. Cary, NC: Global Knowledge Training.
Higgs, M. (2006). Beyond “high potential”: Successful talent management. Retrieved from http://eprints.soton.ac.uk/58008/
Huber, D. L. (2010). Leadership and nursing care management (4th ed.). St. Louis: Saunders.
Kaplan, T. (1998). The Tylenol crisis: How effective public relations saved Johnson & Johnson. Retrieved from

http://www.aerobiologicalengineering.com/wxk116/TylenolMurders/crisis.html
Katzenbach, J. R. (1997). The myth of the top management team. Harvard Business Review, November–December, 83–91.
Katzenbach, J. R., & Smith, D. (2003). The wisdom of teams: Creating the high-performance organization. New York: McKinsey.
Kedia, S., & Burns, N. (1999). Global managers: Developing a mindset for global competitiveness. Journal of World Business, 34(3), 230–

251.
Kelly, P. (2008). Nursing leadership and management. Clifton Park, NY: Delmar Cengage Learning
Kerfoot, K.M. (2009). What you permit, you promote. Nursing Economics, 27(4), 245–246, 250.
Kinni, T. (2003). Exploit what you do best: The art of appreciative inquiry. Harvard Management Update 8(9). Available online at

http://hbswk.hbs.edu/archive/3684.html
Kotlikoff, L. K., & Burns, S. (2004). The coming generational storm: What you need to know about America’s economic future. Cambridge,

MA: MIT Press.
Kouzes, J., & Posner, B. (2012). The leadership challenge (5th Ed.). San Francisco: Wiley.
Marquis, B. L., & Huston, C. J. (2009). Leadership roles and management functions in nursing. Philadelphia: Wolters Kluwer/Lippincott

Williams & Wilkins.
McKnight, R., Kaney, T., & Breuer, S. (2010) Leading strategy execution: How to align the senior team, design a strategy-capable

organization, and get all employees on-board. Philadelphia: TrueNorth Press.
Patient Protection and Affordable Care Act, Pub. L. No. 111-148, §2702, 124 Stat. 119, 318–319 (2010). Retrieved from

http://dpc.senate.gov/healthreformbill/healthbill52.pdf
Pfeffer, J., & Veiga, J. F. (1999). Putting people first for organizational success. Academy of Management Executive, 13(2), 37–48.
Roussel, L., Thomas, P. L, & Harris, J. L. (2016). Management and leadership for nurse administrators. Burlington, MA: Jones & Bartlett.
Salovey, P., & Mayer, J. D. (1990). Emotional intelligence. Imagination, Cognition, and Personality, 9, 185–211.
Schnackenberg, A.K., & Tomlinson, E.C. (2014). Organizational transparency: A new perspective on managing trust in organization-

stakeholder relationships. Journal of Management, 20(10), 1-27.
Shipp, P. L., & Davison, C. J. (2001). Leveraging diversity: It takes a system. Leadership in Action, 20(6), 1–5. Retrieved from

http://media.wiley.com/assets/51/56/jrnls_jb_lia_shipp.pdf
Slocum, J. W. (1981). Job redesign: Improving the quality of work. Journal of Experiential Learning and Simulation, 3, 17–36.
Smith, M. K. (2005). Bruce W. Tuckman-forming, storming, norming and performing in groups. Encyclopedia of Informal Education. Retrieved

March 3, 2016, from http://www.infed.org/thinkers/tuckman.htm
Steifel, M., & Nolan, K. (2012). A guide to measuring the triple aim: Population health, experience of care, and per capita cost (IHI Innovation

Series white paper). Cambridge, MA: Institute for Healthcare Improvement.
Woelfle, C. Y., & McCaffrey, R. (2007). Nurse on nurse. Nursing Forum, 42(3), 123–131.
Yoder-Wise, P. S., & Kowalski, K. E. (2006). Beyond leading and managing: Nursing administration for the future. St. Louis: Mosby.