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Q & A: Ending Nurse-to-Nurse Hostility

Editor’s Note: Strategies for Nurse Managers recently sat down with Kathleen Bartholomew, RN, MSN, author of Ending-Nurse-to-Nurse Hostility, Second Edition to discuss strategies to end hostility in the workplace. The following is an edited version of our conversation.

Strategies For Nurse Manangers: What inspired you to write Ending Nurse-to-Nurse Hostility?

Kathleen Bartholomew:
I wrote “Ending Nurse-to-Nurse Hostility” because of my deep love and respect for Nursing. The intimate and poignant moments that nurses share with their patients as well as their high level critical thinking skills have always blown me away. Yet I also witnessed occasions when nurses took each other down – mostly in subtle ways. I wanted to understand why. I wanted to discover and illuminate these unconscious learned behaviors so that we could all lift each other up and show the world the best of humanity.

SFNM: What is nurse-to-nurse hostility?

KB: A formal definition is: “…any behavior that interferes with effective communication among healthcare providers and negatively effects performance and outcomes.” (The Center for American Nurses)
An informal definition would be: Any interaction or behavior that leaves you feeling ‘less than’ the capable, skilled, caring person that you really are – like eye-rolling. Some people unconsciously try to make someone feel smaller so they can feel bigger (remember middle school?).  Some other examples would be: raised eyebrows, making faces behind someone’s back, withholding information, bickering, fault-finding, back-stabbing, intimidation, put downs, ignoring someone’s greeting, blaming or an unfair assignment. These are all unconscious behaviors.  No one thinks to (themselves, “I’m going to roll my eyes at her right now”. The insidious nature of these hostile behaviors is what makes them so dangerous because we don’t even realize that we are taking each other down.

SFNM: How does it differ from regular bullying? 

In the United States, bullying is a term used to describe someone a power level above you like a manager or physician who uses overt and covert behaviors to ‘put you in your place’. “Horizontal” hostility refers to the way your peers try to take away or under-mine each other’s power. It is more common in a unit where the manager has an authoritarian or laisse-fare style of leadership and where nurses do not have the resources or staffing to do their job.

SFNM: What are some examples of hostility in the workplace that are often overlooked?

Many nurses don’t recognize that talking about someone when they are not present is a form of hostility. Gossip erases trust as the underlying message to our psyche is “If they are talking about people who are not here, then they are probably talking about me when I am not here. “
Other covert forms of hostility are withholding information (let’s see how good she/he is), refusing to work with other people, and cliques. If you have cliques in your department, then you are not a team – and high reliability standards have consistently proven that only collegial teams can keep patients safe. People join cliques for two reasons: to elevate their own self-esteem, and/or to stay safe. So become inclusive by letting everyone belong, look for the good in each other, and compliment freely.

SFNM: What can a manager do to prevent bullying and horizontal hostility in their department?

KB: These three strategies and tactics set the foundation for trust and therefore civility:

  1. Say what you see.  If you see someone rolling their eyes, stop and say, “I noticed that you rolled your eyes…”   These covert behaviors lose their power when we call them out into the open.
  2. Dismantle the hierarchy. We may have different roles, levels of education and paychecks, but each and every single person is a critical member of the team.  The fastest way to even the power play is to ask for feedback by individually asking his/her staff: What do you like that I do well? And what would you like to see more of?

    Another way to equal the playing field (which is critical to Millennials especially) is to job shadow. This sends a strong message that you care about their world when you ‘walk in their shoes.”  And if you walk onto the unit and everything is chaotic, ask the charge nurse what you can do and then do just that.

  3. Nothing About Me, Without Me. Gossip undermines trust. If someone comes into your office to complain about someone else, ask them to go get that person and explain that you would do the same for them. This is the most fundamental leadership behavior because it sets up the conditions for trust. Furthermore, it emphasizes that we are adults who should be able to bring our concerns or observations to each other. The AACN standards say that we must be as competent in our communication skills as we are in our clinical skills – but we are not. Encourage, roll play and coach staff to speak with each other about the important stuff.

SFNM: Do you have any suggestions for a manager that suspects their staff is experiencing hostility?

Yes! I can’t tell you how many managers ask their staff is a problem and the group says “no”. Group think doesn’t allow it. The best way to evaluate the presence of hostility is to send out a simple Survey Monkey (there are two short surveys in “Ending Nurse-to-Nurse Hostility”). After you have compiled the results, share them at a staff meeting. As managers, we need to hold up a virtual mirror so that staff can see how their behaviors affect each other and patient care.

The second step would be awareness training. There are three free educational videos, each only ten minutes long on my website complete which end with a question for the group. Show one each month at a staff meeting; or include in your annual education and new hire curriculum.

SFNM: What advice would you give someone who was experiencing horizontal hostility in the workplace?

KB: Every month someone emails me with a story expressing the shear pain of being rejected from the group. Their letters are heart breaking. It is difficult to understand how in a profession based on caring, how nurses could be so downright mean.

My advice is to know without a doubt that it’s not about you. Horizontal hostility is a symptom of an unhealthy group. If you quit, they will just do the same thing to the next person. If you are different in any way, you become a vulnerable target. When humans work closely together under stressful conditions, have low self-esteem, have a bully for a manager, or a manager that doesn’t care what they do, or plays favorites, you can be certain that staff will be hostile.

About Kathleen Bartholomew
Kathleen Bartholomew, RN, MSN is the author of HCPro titles: Ending Nurse-to-Nurse Hostility, second edition, Speak Your Truth: Proven Strategies for Effective Nurse-to-Physician Communications, along with the Team Building Handbook: Improving Nurse-to-Nurse Relationships. Additionally, Bartholomew has recently published “The Dauntless Nurse: Communication Confidence Builder” with co-authors Martha Griffn and Arna Robins along with the Dauntless Communication Tool app on iTunes.


Excerpt: Dealing with the cyberbully

October is National Bullying Prevention Awareness Month, highlighting the dangers of bullying in all settings. The following is an excerpt from Ending Nurse-to-Nurse Hostility: Why Nurses Eat Their Young and Each Other by Kathleen Bartholomew, RN, MN that explores the dangers of cyberbullying in the nursing unit.

Facebook boasts more than 1.86 billion monthly users worldwide, with more than 40% of Americans logging in every single day. In 2007, Twitter reported 5,000 tweets a day; and in only six years, tweets jumped to more than 400 million. Ten years later in 2017, we tweet 6000 tweets per second. (Zephoria) Without a doubt, we have entered the digital world:

  • Fifteen nurses received letters of warning from their State Board of Nursing after they were reported by their nurse executive for “liking” a derogatory comment that one nurse posted about a husband who was uncaring and unsupportive during childbirth. They did not heed the first warning.
  • A nursing student was dismissed from the program after taking a picture of herself holding an unidentified placenta and proudly commenting how thrilled she was to assist at her first birth.
  • A group of nurses who were friends started a conversation on Facebook which included several disparaging comments about a nurse they didn’t like, as well as remarks on the safety of the organization’s staffing levels.

We talk to each other on online chat rooms in casual conversations that feel so real we forget that no discussion in this virtual world is ever private. Every one of the nurses in the above situations had no idea that they were violating professional ethical guidelines by breaching confidence.

As social networking becomes more integrated into our daily lives, the boundaries between social conduct and professional misconduct are becoming increasingly difficult to navigate.

—Rose Sherman, EdD

While it is generally accepted that we cannot speak about our patients, even anonymously, many nurses do not realize that it is also not professional to speak about a coworker. According to the National Council for the State Board of Nursing policy on Social Media, any online comments posted about a coworker may constitute lateral violence; even if the post is from home during non-work hours. Communication modes for cyberbullying include: instant messaging, email, text messaging, bash boards, social networking sites, chat rooms, blogs, and even Internet gaming.

Nurses often fail to realize that deleting a comment does not erase it. Talking about coworkers is unprofessional and contrary to the standards of honesty and good morals (moral turpitude). Depending on the laws of a jurisdiction, a Board of Nursing may investigate reports of inappropriate disclosures on social media by a nurse on the grounds of:

  • Unprofessional conduct
  • Unethical conduct
  • Moral turpitude
  • Mismanagement of patient records
  • Revealing a privileged communication
  • Breach of confidentiality

Guidelines for nurses victimized by cyberbullying

  • Save all evidence. Copy messages or use the “print screen” function. Use the “save” button on instant messages.
  • First offense: Ask to speak to the person in private and bring a copy of the evidence. Use the D-E-S-C communication model.
    • Describe: “I was on Facebook yesterday and my friend sent me this post because it was about me.”
    • Explain the impact: “I was really surprised because I had no idea that you didn’t like working with me, or that that was the reason you switched weekends.”
    • State what you need: “No one is perfect. Next time could you come to me privately and let me know if you are having any issues so that we can work together to resolve them?”
    • Conclusion: “I am willing to learn how we can be more mutually supportive of each other for the sake of our relationship, our team, and our patients.”
  • Document the conversation and the outcome.
  • Second serious offense: Report to manager (if not serious, try a mediated conversation).
  • Third serious offense: Report to the chief nursing officer.

Manager guidelines

  • Verbalize that no bullying or hostility of any kind will be tolerated, including online.
  • Set the expectation that all staff are responsible for monitoring their virtual world. Don’t assume the parental or vigilante friend role.
  • Educate staff on standards and policies, and provide examples.
    • National Council of State Board of Nursing Guidelines
    • Hospital/organizational policy (including use of hospital computers, cell phones, etc.)
    • Review common myths. Use case studies from NCSBN YouTube.
  • Be supportive of online targets and take derogatory online comments seriously.


Source: National Council for the State Board of Nursing:

Book Excerpt: Ending Nurse-to-Nurse Hostility

Years ago, at a National League of Nursing meeting, Loretta Nowakowski, former director for Health Education for the Public at Georgetown University School of Nursing in Washington, D.C., proposed that disease could be best understood by looking at hurricanes. She noted that, like a serious illness, hurricanes occurred only when many factors were present within relatively narrow parameters and that an appropriate intervention could alter the severity or course of a disease or hurricane. This discovery was encouraging to Nowakowski—it meant that an intervention, made at any point, could alter the final outcome.

And so it is with horizontal hostility. History, gender, education, work practices, interpersonal relationships, communication skills, and organizational structure all contribute to horizontal hostility. The “hurricane” of horizontal hostility cannot manifest without these predisposing factors, so to intervene anywhere in this vast array can change the outcome from hostile to healthy.

The good news is that no matter what our current role—whether CNO, staff nurse, director, educator, or manager—we can implement interventions that will decrease hostility. Multiple opportunities are available at various levels.

Framework for leading organizational change to eliminate hostility

Enacting a twofold method (i.e., increasing a healthy environment while simultaneously decreasing hostility) is the most effective approach that managers can take to enact change at the organizational level.

To increase a healthy culture, leaders must:

  • Firmly establish board and senior leadership team commitment
  • Make harm visible: Frame disruptive behavior as a safety issue; importance of teams:

       – Create infrastructures to support managers and staff: Include behaviors in annual reviews for all staff including physicians

  • Shift the power structure from a hierarchy to a team/tribe:

       – Provide a constructive feedback system for accountability and performance

       – Provide leadership training and confrontation skills training for managers

       – Provide assertiveness training and confrontation skills training for managers

       – Monitor the organizational climate

       – Increase social capital—build a strong informal network

 To decrease hostility, leaders must:

 Adopt a zero-tolerance policy for all disruptive behavior:

  • Same rules for all roles!
  • Transform power from a hierarchy to a tribe/team
  • Adopt a zero-tolerance policy for horizontal hostility
  • Provide leadership and conflict management training for managers
  • Educate staff about the etiology and impact of hostility
  • Create a system for reporting and monitoring the culture
  • Participate with other hospitals to pass state legislation

– See more at:

For more information or to order, visit the HCPro Marketplace.

Kathleen Bartholomew’s “Lessons from Nursing to the World”

Enjoy this Ted Talk given by HCPro author Kathleen Bartholomew. Listen to Kathleen discuss the importance of dismantling the nursing hierarchy that can devalue and shame caregivers and creating an atmosphere of open communication and respect between caregivers which ultimately improves patient care.


Editor’s Pick: Ending Nurse-to-Nurse Hostility: Why Nurses Eat Their Young and Each Other, 2e

The American Nurses Association (ANA) has recommended the second edition of Ending Nurse-to-Nurse Hostility: Why Nurses Eat Their Young and Each Other, by Kathleen Bartholomew, RN, MN, in its official position statement on Incivility, Bullying, and Workplace Violence as a resource for nurses. Now in its second edition, the cornerstone work has just been released as an eBook and offers 4 continuing education credits (CEU).

Ending Nurse-to-Nurse Hostility, Second Edition

The first and most respected book showing new and experienced nurses how to build a better workplace by facing and overcoming horizontal hostility is now updated.

Find out why this book is a best-seller and how it’s empowered thousands of nurses to create positive change for themselves and their peers!

Revised to reflect current research on horizontal hostility in the nursing field (also known as lateral violence), Ending Nurse-to-Nurse Hostility, Second Edition, provides staff nurses and their managers with techniques to create a workplace that promotes team relationships and career development while preventing burnout.

Ending Nurse-to-Nurse Hostility provides staff nurses and their managers with the knowledge they need to:

  • Identify verbal abuse, bullying, and other detrimental behaviors
  • Develop responses to defuse or head off such behaviors
  • Create positive alternatives to hostility

These skills support the success of the individual nurse, the unit, and patient care quality at a time when healthcare systems are publicly ranked on patient experience and outcomes.

Horizontal hostility, also known as bullying or lateral violence, is a major factor in nursing attrition rates. Healthcare organizations that don’t proactively create a healthy workplace face the expense of finding, hiring, and training new nurses to replace burned-out staff.

This book provides the following benefits:

  • Skills: Nurses will learn skills for identifying and responding to verbal abuse, bullying, and other detrimental behaviors that undermine individual nurses, the unit, and the quality of patient care.
  • Real-world examples: Gain insightful reflections from individual nurses who have experienced horizontal hostility, presented in their own voices.
  • Author voice: Kathleen Bartholomew is a beloved nursing author who is authoritative yet approachable and always respectful.
  • Scholarship: Extensive references draw on the latest empirical and theoretical literature concerning horizontal hostility.
  • Culture change: Improve nurse retention, nurse productivity, and hospital rankings with an improved environment for patient care.

For more information or to order, visit the HCPro Marketplace.

Free tool from Ending Nurse-to-Nurse Hostility

As promised last week, we’ve added a free download downloadicon3from Kathleen Bartholomew’s Ending Nurse-to-Nurse Hostility, Second Edition, in honor of being the only book chosen by the American Nurses Association as a recommended bullying and horizontal hostility prevention tool.

To access the download site for a tool you can use to evaluate the health of your workplace as regards bullying, lateral violence, and other undesirable behaviors, click here.

To read last week’s story the ANA position statement on workplace violence and the nursing profession, click here.

New ANA Hostility Prevention Guide Recommends Bartholomew Book

On August 31, the American Nurses Association issued a press NTNH2 coverrelease announcing its updated position statement on workplace bullying and violence, stating that the “nursing profession will no longer tolerate violence of any kind from any source.”

Among the interventions recommended as “primary prevention” is the HCPro classic work by Kathleen Bartholomew,
Ending Nurse-to-Nurse Hostility, Second Edition. In fact, Ending Nurse-to-Nurse Hostility has the distinction of being the only book recommended to RNs and their employers in the statement as a front line tool for preventing incivility and bullying.

We are so honored to have published Kathleen’s work, and congratulate her for this wonderful recognition of a lifetime commitment to making the nursing workplace a healthier, more collegial place. If you would like to add your best wishes, feel free to comment below!

Try This: Build nursing team self-esteem

Hierarchy of Voice

Excerpted from Ending Nurse-to-Nurse Hostility, Second Edition, by Kathleen Bartholomew

Try the following exercise that I often use to encourage nurses’ self-esteem. I call it a “hierarchy of voice” because each step results in greater empowerment. Addressing specific behaviors that are a challenge to a nurse stimulates meaningful conversations about that individual’s stumbling blocks to empowerment and self-esteem.

In performance evaluations, share the following list and ask team members to pick 10 meaningful actions that they would like to [more]

Positive Pushback for Nurses

I’ve posted in the past on accountability strategies, communication techniques, and building team relationships, all of which can improve the workplace. Recently I ran across the term “positive pushback”—easy to remember thanks to those alliterative “p” words—and felt that the technique might be helpful in those potential conflict situations that arise from time to time.pushback2

The promise of positive pushback is that you can communicate your concerns in an unequivocally strong and clear manner that doesn’t damage your professional relationships. No yelling and certainly no retreating to an unassertive approach.

According to Susanne Gaddis, the Communications Doctor:

A “positive pushback” is the ability to deliver an appropriately assertive response to a potentially negative and/or harmful situation. A positive pushback is executed by looking someone straight in the eye, and saying with an even, non-stressed tone what you want or need. (If you want to be really assertive include the word “I,” such as “I really need for you to stop and review this now…”)

What resources do you need to use positive pushback? Self-esteem, self-confidence, and an ability to convey urgency without “emoting” your emotions. I highly recommend that you read this blog post from Susanne Gaddis, to see if this is a tool that you can add to your collection. As with all the “soft skills,” practice makes perfect.

If you try the techniques, please post a comment here to let us know how it worked out for you!



With thanks to Susanne Gaddis, PhD, CSP and CEO of The Communications Doctor, is an acknowledged communications expert who has taught the art of effective and positive communication since 1989.

And the survey says… Staff retention (try to break these 20 habits)

This week I have the pleasure of reading the incredible responses we received to our Nurses Week 2015 survey. So many of you shared your insights, challenges, and hopes for the coming year—thank you! We’ll be emailing the winners of copies of Kathleen Bartholomew’s Team-Building Handbook: Improving Nurse-to-Nurse Relationships in the next couple of days. Keep your eyes peeled for our email.

Your generous responses help us understand your needs and aspirations, and we will try to return the favor by covering those important topics in this blog and in our upcoming books, webinars, and e-learning. For starters, I’ve revived a popular post from the past that deals with retention, identified by many of you as a top priority. Let me know if you recognize any of the 20 bad habits in yourself!

Retain staff by breaking these 20 bad habits

Peter Druker, often called the Father of Modern Management, made the following observation, “We spend a lot of time teaching managers what to do. We don’t spend enough time teaching them what to stop. Half the leaders I’ve met don’t need to learn what to do–they need to learn what to stop.” We simply need to [more]