Analysis of Catalysts for Worker-to-Worker Violence in Hospitals

This report, based on a study published in the Journal of Clinical Nursing, investigates the catalysts of worker-to-worker violence and incivility in hospital settings. The research, conducted through a retrospective descriptive study, analyzed 135 incident reports from a large American hospital system. The findings reveal two primary themes: Work Behaviour and Work Organisation. Incidents related to Work Behaviour often stemmed from unprofessional conduct, disagreements over work responsibilities, and dissatisfaction with co-worker performance. Incidents in the Work Organisation category were linked to protocol failures, patient assignment issues, resource limitations, and high workloads. The study underscores that incidents of worker-to-worker mistreatment are influenced by both employee behavior and organizational practices, highlighting the need for interventions to address these issues and improve workplace productivity. The report emphasizes the importance of addressing poor communication and collaboration to mitigate worker dissatisfaction and frustration.

Catalysts of worker-to-worker violence and incivility in hospitals
Lydia E Hamblin, MA [Graduate Research Assistant],
Department of Family Medicine and Public Health Sciences, Wayne State University School of
Medicine and Doctoral Candidate, Department of Psychology, Wayne State University, Detroit
Lynnette Essenmacher, MPH [Senior Data Analyst],
Detroit Medical Center Occupational Health Services, Detroit
Mark J Upfal, MD, MPH [Corporate Medical Director],
Detroit Medical Center Occupational Health Services and Associate Professor of Occupational
Medicine, Department of Emergency Medicine, Wayne State University School of Medicine,
Detroit
Jim Russell, BSN [Executive Director of Occupational Health Services],
Detroit Medical Center Occupational Health Services, Detroit
Mark Luborsky, PhD [Professor],
Institute of Gerontology, Wayne State University, Detroit, and Department of Neurobiology, Caring
Sciences and Society, Karolinska Institutet, Stockholm, Sweden
Joel Ager, PhD [Professor and Statistical Consultant], and
Department of Family Medicine and Public Health Sciences, Wayne State University School of
Medicine, Detroit
Judith E Arnetz, PhD, MPH, PT [Professor]
Department of Family Medicine and Public Health Sciences, Wayne State University School of
Medicine, Detroit, and Department of Public Health and Caring Sciences, Uppsala University,
Uppsala, Sweden
Abstract
Aims and objectives—To identify common catalysts of worker-to-worker violence and
incivility in hospital settings.
Background—Worker-to-worker violence and incivility are prevalent forms of mistreatment in
healthcare workplaces. These are forms of counterproductive work behaviour that can lead to
negative outcomes for employees, patients and the organisation overall. Identifying the factors that
Correspondence: Lydia E Hamblin, MA, Graduate Research Assistant, Department of Family Medicine and Public Health Sciences,
Wayne State University School of Medicine, 3939 Woodward Avenue, Detroit, MI 48201, USA. Telephone: [phone].
[e-mail].
Disclosure
All authors contributed to manuscript preparation and review of the final version for submission. LEH, LE, and JEA were responsible
for study design and data analysis.
Conflict of interest
The authors report no conflict of interest.
HHS Public Access
Author manuscript
J Clin Nurs. Author manuscript; available in PMC 2016 August 31.
Published in final edited form as:
J Clin Nurs. 2015 September ; 24(17-18): 2458–2467. doi:10.1111/jocn.12825.
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lead to co-worker mistreatment is a critical first step in the development of interventions targeting
these behaviours.
Design—Retrospective descriptive study.
Methods—Qualitative content analysis was conducted on the total sample ( n= 141) of employee
incident reports of worker-to-worker violence and incivility that were documented in 2011 at a
large American hospital system.
Results—More than 50% of the incidents involved nurses, and the majority of incidents did not
involve physical violence. Two primary themes emerged from the analysis: Work Behaviour and
Work Organisation. Incidents in the Work Behaviour category were often sparked by
unprofessional behaviour, disagreement over responsibilities for work tasks or methods of patient
care, and dissatisfaction with a co-worker’s performance. Incidents in the Work Organisation
category involved conflicts or aggression arising from failure to following protocol, patient
assignments, limited resources and high workload.
Conclusion—Incidents of worker-to-worker violence and incivility stemmed from
dissatisfaction with employee behaviour or from organisational practices or work constraints.
These incident descriptions reflect worker dissatisfaction and frustration, resulting from poor
communication and collaboration between employees, all of which threaten work productivity.
Keywords
healthcare workers; hospitals; incivility; mistreatment; worker-to-worker; workplace violence
Introduction
Violence and incivility between employees are prevalent in hospital settings, where high
stress situations may lead to mistreatment (Rowe & Sherlock 2005, Rosenstein & O’Daniel
2008, Arnetz et al.2011b), ranging from incivility (Andersson & Pearson 1999) to physical
assault (Jackson et al.2002). These behaviours undermine a culture of safety (The Joint
Commission 2008), reduce productivity (Sliter et al.2012) and employee well-being (Arnetz
& Arnetz 2001, Hesketh et al.2003, Gerberich et al.2004), and foster a hostile workplace
environment (Ceravolo et al.2012, Khadjehturian 2012). Interventions to reduce worker-to-
worker violence and incivility require an understanding of its root causes; however, there is a
lack of research based on actual, reported incidents in health care. This study was designed
to identify common catalysts and circumstances of co-worker violence and incivility in a
hospital setting.
Background
The term ‘mistreatment’ is used throughout the study to represent both worker-to-worker
violence and incivility. Workplace violence has been categorised into types, according to the
perpetrator’s relationship with the organisation and its employees. Overt aggressive
behaviour targeting a co-worker falls under Type III workplace violence (IPRC 2001), while
more ambiguous acts of mistreatment that lack the overt intention of workplace violence are
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characterised as workplace incivility (Andersson & Pearson 1999). Co-worker mistreatment
is prevalent across healthcare systems internationally (see Arnetz et al.2011b).
Type III violence among healthcare workers
Type III (worker-to-worker) workplace violence encompasses a wide variety of events,
including physical assault, verbal aggression, harassment, intimidation, threats and bullying
(Jackson et al.2002). For example, novice nurses may be bullied by more senior nursing
staff (Ditmer 2010); medical residents may be victimised by more senior physicians (Acik et
al.2008); and nurses may be targeted by physicians via disruptive or disrespectful behaviour
(Rosenstein 2002, Hegney et al.2006). Type III violence can also occur between employees
of the same professional rank: ‘horizontal violence’ (Ditmer 2010) and ‘lateral violence’
(e.g. Dimarino 2011). This type of violence is most often nonphysical and includes verbal
abuse (Rowe & Sherlock 2005), emotional abuse (Roche et al.2010) and bullying (Hogh et
al.2011). One qualitative study found nurses were more distressed by violence from fellow
nurses than from patients (Farrell 1997), which could have consequences for both the
individual and organisation. While Type III violence may or may not include physical injury,
it encompasses a psychological component that can be detrimental to worker well-being
(Arnetz & Arnetz 2001, Hesketh et al.2003, Gerberich et al.2004). Workplace bullying
(Kivimaki et al.2000) and verbal abuse (Rowe & Sherlock 2005) have been associated with
increased absenteeism, while disruptive behaviour has been shown to negatively impact both
work satisfaction and retention among nurses (Rosenstein 2002).
Workplace incivility
Incivility has been defined as a low-intensity deviant behaviour with an ambiguous intent to
cause harm (Andersson & Pearson 1999). Experience of incivility can lead to negative
cognitive and behavioural outcomes for employees, including decreased job performance
and increased absenteeism (Sliter et al.2012). Uncivil acts that are allowed to continue can
perpetuate into an ‘incivility spiral’ (Andersson & Pearson 1999) when the mistreatment
escalates into more aggressive behaviours.
The importance of reporting worker-to-worker mistreatment
Worker-to-worker mistreatment, encompassing both violence and incivility, represents a
threat to employees (e.g. Sabbath et al.2014) and organisational interests (e.g. Haines et al.
2007). However, without descriptive data of the actual incidents occurring between hospital
employees, hospital system stakeholders lack knowledge of the problem’s causes and
effective interventions cannot be developed (Rosenstein & O’Daniel 2008). Many healthcare
organisations do not have systems in place to systematically collect and analyse worker-to-
worker mistreatment incidents (Arnetz et al.2011b). This study was conducted at a hospital
system that houses a unique reporting system with established methods for reviewing and
responding to employee reports of adverse events, including worker-to-worker mistreatment.
Qualitative analysis of documented incident reports of worker-to-worker mistreatment may
provide insights to researchers and hospital administrators into common catalysts and trends
in these behaviours. The aim of this study was to examine a sample of documented worker-
to-worker mistreatment incidents in a large hospital system to identify common catalysts.
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Methods
Setting
This study was conducted at a large, metropolitan hospital system in the Midwestern United
States. The hospital system includes seven hospitals and nearly 15,000 employees.
Data collection
The hospital system houses an electronic, central reporting system for all adverse work
events, including workplace mistreatment. Employees can access this standardised system
from any hospital computer, and all reports are received by Occupational Health Services
(OHS). The report gathers data such as location of the event, time, witnesses and if there
were any injuries resulting. Employees fill in details using drop-down menus and entered
text. An open text box is provided for employees to describe the incident in free text.
Hospital system policy requires that employees report incidents of workplace mistreatment,
either into the electronic central reporting system or to their supervisor within 72 hours.
Supervisors are required to report adverse events via the electronic system within 24 hours
of their shift. A thorough description of this reporting system has been reported previously
(Arnetz et al.2011a,b).
The hospital system defines workplace violence as acts of physical assault, harassment/
sexual harassment, intimidation, threats and verbal aggression (Arnetz et al.2011b) that
occur on their property or during the course of an employee’s work-related activities on
behalf of the hospital system. All incidents of workplace violence are categorised by OHS
data analysts according to types (I–IV), where Type III denotes worker-to-worker violence
(IPRC 2001). For this study, the total sample of 141 Type III incidents from 2011 was
collected from OHS following de-identification by a hospital system data analyst.
Data analysis
Analyses were conducted on the free-text portions of the total sample of 141 incident
reports. A data-driven inductive approach was employed (Boyatzis 1998). Qualitative
content analysis was used to establish themes for the most prominent reasons that violence
or incivility between employees was initiated. First, two researchers independently
examined each report with an aim of identifying a possible catalyst for the violent event,
recording them as codes. Each incident was coded with only one theme, for parsimony.
Second, this process was repeated until incidents with similar codes became apparent,
aggregating into larger themes. Once no new themes emerged, the data set was considered to
be saturated (Corbin & Strauss 1990). Finally, the researchers shared their findings and the
themes of catalysts were discussed until consensus was reached. A third researcher later read
the incidents and validated the findings of the first two.
Qualitative rigour
Qualitative rigour was maintained following Guba and Lincoln’s (1989) criteria for judging
the quality of qualitative evaluation: credibility, transferability, dependability and
confirmability. Credibility is analogous to internal validity and was achieved using actual
incident reports, verbatim, that were submitted by employees. Transferability parallels
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external validity and was achieved using incidents from various locations in multiple
hospitals within the hospital system. Dependability is similar to reliability and was achieved
using data from a standardised reporting system and documenting the methods used to
analyse the reports. Finally, confirmability parallels the criterion of objectivity, reducing
researcher bias, and was achieved using the verbatim reports, removing all personal
identifiers and validating findings between independent researchers.
Ethical approval for this study was granted by the Human Investigation Committee of the
university and the Clinical and Translational Research Office at the hospital system. Funding
was provided by CDC/NIOSH.
Findings
After coding each incident, those with no identified catalyst were removed ( n= 6), resulting
in a final sample of 135 reported incidents. Of the employees who reported incidents, 81%
were female; 52% were in nursing; and 41·3% worked part-time; the mean age was 40·76
years, and mean tenure at the hospital system was 9·31 years. Some employees filed more
than one report; there were 110 (90·9%) one-time reporters, 8 (6·6%) two-time reporters and
3 (2·5%) three-time reporters. Only five incidents (3·7%) included physical violence, none
of which resulted in physical injury requiring treatment. All seven hospitals reported worker-
to-worker mistreatment in the year sampled.
Through qualitative content analysis, two primary themes emerged, each with four
subthemes: Work Behaviour and Work Organisation. Definitions of primary themes and
subthemes are provided in Table 1. Work Behaviour had to do with conflicts related to the
actions of employees in the course of their work; these were typically job-related, but at
times were simply unprofessional. Subthemes of Work Behaviour were Unprofessional
Behaviour, Duties and Responsibilities, Methods of Patient Care and Poor Work
Performance. Work Behaviour was the larger primary theme, with a total of 92 incidents
identified (Table 2).
Work Organisation involved conflicts related to work tasks and procedures, environmental
and organisational constraints, or the interdependence between workers. Subthemes of Work
Organisation were Following Protocol, Patient Assignments, Limited Resources and High
Workload. A total of 43 incidents were coded within this primary theme (Table 2).
Subthemes of each primary theme are defined and supported with quotes from actual
incident reports below.
Work Behaviour
Unprofessional Behaviour describes actions that deviate from the norms of civility and
respect in the workplace and was the largest subtheme identified. Incidents falling under this
subtheme were initiated by a co-worker’s unprofessional behaviour:
(During a surgical procedure), my attending spontaneously head butted me
claiming that I was “in his space” and that I stood too close. I stood to his left, and
was assisting with the procedure by retracting the skin over the incision site. (A
visiting student) described the attack as being “vicious” and produced a loud noise.
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During that time, (Doctor) struck his forehead to the right side of my head while I
was focused and looking down to the surgical field. (Surgery Resident)
Duties and Responsibilities emerged as the second-largest subtheme. This involved
disagreement or miscommunication over whose responsibility it was to perform certain work
tasks. In some instances, an employee believed their co-worker was failing to perform their
assigned tasks, and in others, employees believed their co-worker had no business
performing certain tasks:
Employee refuses to take direction regarding patient care. I asked to update/inform
her regarding team plan of care, she refuses…Her demeanor is loud, rude and
hostile to the point that patients notice and question the behavior…She upset an on-
coming PCA [patient care associate] that asked a direct question regarding
equipment. She refused to inform them of the equipment mal-function. (Patient
Care Associate)
The following incident was reported by a third party:
(Pharmacy Technician) was in medication room completing “cart exchange.”
During her duties, she was approached by a nurse who grabbed her hands/wrists,
stopped her from completing her duties, while she questioned her about her activity.
Technician explained duties, and nurse finally let go. (Pharmacy Manager)
Methods of Patient Care emerged as a catalyst for conflict based on co-worker disagreement
about how patient care should be provided. This included opposing orders from physicians,
and arguments over medication or treatment options:
The physicians were (Doctor A) and (Doctor B) and they were arguing over the
patient and could not agree on the patient’s care. When (Doctor B) would suggest
one thing, (Doctor A) would suggest something different. (Doctor B) wanted the
patient to go to CT scan and (Doctor A) wanted the patient to go to ICU. After 20–
30 minutes of this constant bickering, (Doctor B) storms out the room and stops
just outside the patient’s room and yells as loud as he could, “SHUT … UP, I’M
THE DOCTOR!” (Administrative Supervisor)
Poor Work Performance incidents were initiated based on dissatisfaction with a co-worker’s
quality of work. Employees were angered when a co-worker was not performing their tasks,
was performing their tasks incorrectly or simply refused to help:
(Doctor) was on the phone shouting, “These nurses are incompetent! …This is a
consistent problem! The doctors are always getting blamed when the nurses are the
problem!” I told him he was so loud that the visitors told me, “that doctor is saying
the nurses (here) are incompetent.” (Clinical Coordinator)
Work Organisation
Under Work Organisation, four subthemes were also identified through the coding process:
Following Protocol, Patient Assignments, Limited Resources and High Workload. Incidents
identified under the Following Protocol subtheme had to do with not adhering to policies or
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practices of the hospital system or medical field. This was the largest subtheme of the Work
Organisation primary theme:
Security Officer entered the unit and was in the process of restraining a patient
when it was noted that he had his weapon still on. When asked to leave the unit he
responded it’s not loaded when asked to leave again he became angry and threw a
watch across the nursing desk, pulled off his gloves and threw them hitting one of
our nurses in the head. (Registered Nurse)
The Patient Assignments subtheme encompassed conflicts over the patient to which an
employee was assigned for their shift. This included complaints about difficult cases and
disputes over who would take a particular assignment:
Another nurse signed up for same assignment. I approached her to let her know that
I planned on taking back the same patient for continuation of patient care. She
refused, saying she refused to work in [another part of the unit]. I talked about the
policy with clinical coordinator and another employee…As I was leaving the office
the nurse saw me in the hallway. She gestured at me with her left hand in a diagonal
downward gesture with a pointed index figure, saying in a loud, elevated voice, “if
you ever come at me like that again you better watch your [expletive] back or else.”
(Registered Nurse)
Limited Resources emerged as a catalyst of worker-to-worker conflict based on the need to
compete for equipment and other items. Competition for resources created tension and
sometimes conflict between co-workers who were trying to care for their patients. The
following incident was reported by both parties involved. Only one quote was chosen to
represent the incident:
(Respiratory Therapist) took my (charting computer); I had logged off and stepped
away to use the restroom. My papers were on the (charting computer) turned over. I
stated that I was using that computer and he rudely said that since I logged off, he
could use it. I walked away. A bit later I was speaking to a coworker about the
incident, and the (Respiratory Therapist) came flying out of a room yelling at me
that he would write me up. (Registered Nurse)
High Workload was found to be a catalyst for worker-to-worker conflict based on the stress
of having too many job demands, such as number of tasks, paired with low resources, or
limited time:
(RN) called me from patient’s room for help and I explained I was in the middle of
(giving) a bath. While she was telling me where she was I dropped my phone in the
patient’s bed. The RN immediately called me back and started screaming into the
phone “How dare I hang up on her and to never do that again, get to (her room) as
soon as possible.” I found her patient sitting in the chair with the privacy curtain in
her [the patient’s] lap. She was crying. She asked the nurse for a toothbrush and the
nurse said “I just can’t take this place anymore” and then pulled the curtain out of
the wall and left it lying in her lap. (Unknown Reporter)
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Discussion
The purpose of this study was to better understand the reasons behind worker-to-worker
mistreatment in a hospital setting. Previous studies of mistreatment typically gathered data
using self-report, retrospective questionnaires or interviews (e.g. Farrell 1997, Hogh et al.
2011). While these studies offer some evidence of the prevalence of worker-to-worker
mistreatment among healthcare workers, they do not provide details on the causes and
circumstances surrounding such events. Mistreatment between co-workers is a sensitive
issue and victims may be hesitant to report such incidents (Hesketh et al.2003), especially
when there has been no physical injury (Arnetz et al.2011b). Asking employees to recall
multiple incidents of conflict over a large span of time (e.g. in the last 12 months, Hogh et
al.2011) may be less effective in limiting recall bias than recording incidents within days
after their occurrence, such as in the current study. Some incidents may be misremembered
or forgotten altogether, and underreporting leaves researchers and stakeholders with
incomplete knowledge of the extent and nature of the problem (Arnetz et al.2011b).
The current study aimed to fill this methodological gap by conducting content analysis of
actual incident reports filed within 72 hours of occurrence. Two primary themes emerged:
Work Behaviour and Work Organisation. Catalysts identified revealed that these co-worker
behaviours can be sparked by a range of work-related activities or circumstances. There
were also incidents that did not directly relate to work – those categorised under
Unprofessional Behaviour. These were incidents largely initiated by rude and inconsiderate
actions taken by co-workers that had no tangible source; it was simply employees behaving
unprofessionally. Previous studies have found that seniority or assumed superiority is linked
to mistreatment, such as bullying from more senior nursing staff (Ditmer 2010) or
aggression from physicians towards nurses (Hegney et al.2006), which may be the
underlying catalyst for these incidents.
The other Work Behaviour subthemes encompassed work-related activities that are integral
parts of the job. These routine tasks and procedures reflect the nature of hospital work,
which often necessitates cooperation and collaboration between workers. Duties and
Responsibilities concerned basic tasks performed by workers to accomplish their work
goals. Disputes over who was accountable for certain tasks led to mistreatment between co-
workers, suggesting that role ambiguity was a potential source of mistreatment for
interdependent employees. Role ambiguity includes unclear expectations about the job or
performance, including responsibility for certain tasks (e.g. House & Rizzo 1972). It is a
common work stressor that has previously been linked to workplace harassment among co-
workers (Bowling & Beehr 2006). In their meta-analysis, Bowling and Beehr (2006) found
that role ambiguity was positively related to co-worker harassment; the negative effects of
role ambiguity on physical and mental health were also mediated by co-worker harassment.
Methods of Patient Care emerged as a distinct subtheme including arguments and
mistreatment over the way another professional was providing care to a patient. Lack of
communication and collaboration can lead to mistreatment in the process of care.
Disagreements such as doctor’s conflicting orders or the preferred treatments of multiple
employees may lead to disputes over what is best for the patient. Previous research found
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that uncertainties about care or disagreements about how to proceed stemmed from
physicians’ disruptive behaviours towards nursing staff in the process of giving directions
for patient care or ordering treatments (e.g. Rosenstein & O’Daniel 2008). Based on staff
questionnaires, Rosenstein and O’Daniel (2008) found that poor communication was an
underlying factor of disruptive behaviour in healthcare organisations, and the current study
replicates this finding.
The Poor Work Performance subtheme reflects the highly interdependent nature of health
care. Registered Nurses rely on other staff to assist in patient care. Previous qualitative
research has found that nurses may consider ‘not sharing the workload’ an instance of
mistreatment (Farrell 1997). Other workers may need to pick up their slack and add to their
own workload, potentially leading to anger towards the individual who is underperforming
and reactions in the form of mistreatment.
The Work Organisation theme differed from Work Behaviour in that it accounted mostly for
circumstances and understanding of work procedures more so than the actual performance
of job tasks. Subthemes falling under this theme reflected mostly situational catalysts.
Following Protocol included incidents in which an employee failed to adhere to established
procedures at their hospital or for their job position. Patient Assignments included incidents
initiated over characteristics of a patient (i.e. difficulty of care) or conflicting tasks between
co-workers in charge of the patient’s case. High Workload incidents revolved around the
stress of managing multiple tasks. Workload has been related to acts of violence and
incivility between healthcare workers in previous studies (Hegney et al.2006, Roche et al.
2010). Roche et al.(2010) likewise found that nurses’ working environment, such as
changes in the patient population, related positively to co-worker mistreatment.
Limited Resources is a common issue in many workplaces. In particular, hospitals use many
types of equipments for patient care and monitoring, and lack of these valuable resources
may lead to disputes over who may use the few tools available. Using quantitative data, Fox
and Spector (1999) found that situational constraints at work (e.g. limited resources) were
positively related to counterproductive responses such as aggressive interpersonal
behaviours. Their model of work frustration–aggression posits that workers frustrated with
work constraints experience an affective reaction to frustration, such as anger, that is then
directed towards their co-workers.
None of the worker-to-worker mistreatment incidents resulted in physical injury requiring
medical attention, and only five incidents had a physical component at all. Why should
hospital stakeholders and clinical practitioners care about these types of incidents? Evidence
from previous literature points to the negative effects co-worker mistreatment may have on
employees (e.g. Sabbath et al.2014) and the organisation (e.g. Haines et al.2007). Sabbath
et al.(2014) found a significant relationship between hospital workers who were ‘yelled at’
by a co-worker or physician and risk of work-related injuries. Haines et al.(2007) found that
incivility among operating room staff correlated with lower safety climate and also less use
of recommended practices in the operating room. Clearly, employees were disturbed enough
by the incident to take the time to report it, and incident reports were often long and detailed.
In the incident under High Workload, the reporter gave a detailed visual description of what
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she experienced that day, and even reported the words of the patient, claiming that her nurse
stated, ‘I just can’t take this place anymore’ before abandoning her work. This is a clear
example not only of how coworkers are negatively affected by mistreatment, but also
patients, who may endure some consequences of hospital workers lashing out against each
other.
Another interesting finding of this study was the third-party reports. Some incidents (11%)
were reported by employees who witnessed but were not directly involved in the violence or
incivility. These incidents were upsetting enough to other workers that they took the time to
file a report in the system, providing names and details of what occurred. For example, the
incident under Methods of Patient Care was reported by an Administrative Supervisor
regarding the aggressive actions of two physicians. This finding provides some insight into
how worker-to-worker mistreatment has a broader impact on the unit and organisation, not
only the individuals involved. Witnessing violence or incivility between co-workers,
particularly if management does not intervene, can lead to climates of mistreatment (Yang et
al.2014) and fear of being targeted.
There were also multiple reports of some of the incidents, from various employees. For
example, the incident under Limited Resources involved two co-workers in dispute over a
piece of equipment. Each employee reported the incident, providing their perspective of the
situation. This also points to the counterproductive nature of worker-to-worker mistreatment.
More than one individual is disturbed by the interaction and takes the time to report the
details. Both workers could have experienced stress following the incident that could hinder
their job performance.
Implications
There are certain implications of this research. First, hospital system stakeholders should
recognise the need not only for establishing policies regarding worker-to-worker violence
and incivility, but the systematic enforcement of those policies. Rather than using effective
communication and maintaining a professional demeanour, co-workers lashed out at each
other over routine tasks and circumstances. If co-worker violence and incivility are allowed
to continue without repercussions, then the behaviour will likely persist and even escalate.
The incivility spiral (Andersson & Pearson 1999) typically unfolds when there is no direct
intervention from management. Persistence of these counterproductive work behaviours can
also lead to mistreatment becoming the behavioural norm, developing broadly across the
organisation (Yang et al.2014). Work units may develop cultures of incivility (Ceravolo et
al.2012, Khadjehturian 2012) in which employees perceive their unit to accept uncivil acts
as the status quo, leading to further perpetration. A zero-tolerance culture provides explicit
behavioural guidelines for employees and clear consequences for violation of positive social
norms (Dimarino 2011).
However, a zero-tolerance policy will not suffice unless hospitals make use of the incident
reports filed. Hospital system stakeholders need actual documented incidents to understand
and respond to worker-to-worker mistreatment, but collection of incident reports is not
enough; reports must be systematically reviewed and acted upon. Awareness of the
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behaviours and circumstances leading to violence and incivility between co-workers enables
stakeholders to develop effective policies and procedures for preventing and treating such
behaviours (Rosenstein & O’Daniel 2008). Supervisors of individual units may also use the
reports to educate staff about inappropriate co-worker interaction and behaviours that may
undermine a supportive work climate. In a randomised controlled intervention, Arnetz and
Arnetz (2000) found that regular feedback to staff about violence incident reports led to
greater awareness for individual preventive behaviours. Units with high reports of co-worker
mistreatment may benefit from interventions aimed at fostering teamwork and respect for
co-workers (e.g. CREW, Osatuke et al.2009). The hospital system in this study continuously
collects incident reports filed by employees, which allowed researchers to conduct
qualitative analyses of detailed incidents that were reported directly after the mistreatment
occurred.
Third, although the incidents described here did not result in physical injury, they should be
taken seriously by management. Worker-to-worker mistreatment is a form of
counterproductive work behaviour that has many implications for the hospital employee, the
organisation and patient care. Taking the time to file an incident report reflects a disruption
in an employee’s work tasks, disturbance over what occurred and a care for the workplace
on the part of the reporter.
Strengths and limitations
A strength of the current study is the use of the total sample of actual, documented incidents
of worker-to-worker mistreatment across multiple hospitals and over the span of a year.
Employees are also required to report the incident to their supervisor or the electronic
central database upon occurrence, in effort to limit recall bias. However, there may still be
bias on the part of the reporter, as employees may provide their own version of an incident.
There were instances in which multiple employees, involved in or witness to a dispute, have
reported their own perspective of the incident. This information may reflect accurate
perspectives of each party involved, leading to unique consequences for each individual.
Having both sides of the story provides a richer description of the situation, allowing
stakeholders to identify more specific points of intervention.
However, one limitation of the reporting system concerns the intent of the reporter. As seen
in the incident under Limited Resources, employees may use the system as a means to
threaten co-workers with ‘writing them up’ or otherwise to simply complain about other
employees via the incident reports. There were six incidents that described a similar threat of
reporting a co-worker. As this hospital system has established routines for responding to
incident reports, some individuals may abuse the system to draw negative attention to a co-
worker.
Underreporting may also be a limitation. A recent study found that underreporting of
workplace violence events via documentation was as high as 88% among hospital personnel,
although 45% of employees reported incidents informally to their supervisors (Arnetz et al.
in press). Missing data due to underreporting may hinder the development of intervention
programmes for mistreatment.
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The established routines for management’s response to incident reports may present a
barrier to reporting, especially when the employee’s supervisor is the actual perpetrator of
worker-to-worker violence or incivility. Unit supervisors are responsible for reporting co-
worker mistreatment promptly, and also review all incidents reported for their work unit. If a
supervisor is mistreating their subordinates, then employees may be less likely to report,
knowing that their supervisor will be aware of the report (e.g. Findorff et al.2005).
This study did not examine individual factors (i.e. personality) that may contribute to
initiation of conflict with co-workers. The workplace is a social setting, and employees
sometimes allow their personal issues to interfere with professionalism, as seen in the
Unprofessional Behaviour subtheme in particular. However, it is important to focus on
factors that are malleable and modifiable, such as specific behaviours and environmental
factors. This allows unit management and hospital system stakeholders to develop strategies
to address these behaviours or make changes to environmental constraints.
Conclusion
Qualitative content analysis of actual incident reports of worker-to-worker mistreatment
revealed common catalysts among hospital employees. Through this analysis, specific work-
related functions and procedures were identified as points of mistreatment among workers.
These represent potential targets of intervention and prevention efforts for mistreatment;
hospital system stakeholders may consider strategies such as education about why certain
procedures are used, or promoting teamwork among work unit employees. Some incidents
were initiated by bad behaviour rather than work-related factors. This points to the
importance of enforcing zero-tolerance policies for workplace mistreatment. Maintaining a
strict code of behaviour and consistently reviewing problem behaviours reinforce a more
positive work climate for employee safety and well-being, as well as a more positive care
environment for patients.
Relevance to clinical practice
Worker-to-worker mistreatment in hospitals has implications for employees, patient care and
the healthcare organisation overall. Registered Nurses work interdependently with a variety
of other healthcare professionals to conduct patient care; working in close proximity under
high stress may lead to mistreatment. Factors leading to co-worker mistreatment in a
hospital setting were found to be mostly work related and modifiable, providing points of
prevention and intervention for management. Identification of common catalysts of worker-
to-worker violence and incivility in hospitals is an important first step in developing targeted
interventions to reduce mistreatment among hospital employees.
Acknowledgments
This study was funded by The Centers for Disease Control-National Institute for Occupational Safety and Health
(CDC-NIOSH), grant number R01 OH009948. The content is solely the responsibility of the authors and does not
necessarily represent the official views of CDC-NIOSH.
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What does this study contribute to the wider global clinical community?
• Worker-to-worker violence and incivility in hospital settings may be
due to modifiable, work-relevant catalysts.
• Content analysis of incidents of worker-to-worker violence and
incivility recorded near the time of occurrence can assist hospital
system stakeholders in identifying catalysts to these events.
• Identification of common catalysts of worker-to-worker violence and
incivility in hospitals provides a first step towards the development of
targeted interventions for these forms of mistreatment.
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Relevance to clinical practice
Violence and incivility between hospital employees can contribute to turnover of top
performers, hinder effective teamwork and jeopardise the quality of patient care.
Identification of common catalysts for worker-to-worker violence and incivility informs
the development of mistreatment prevention programmes that can be used to educate
hospital staff.
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Table 1
Definitions of themes and subthemes
Primary theme Subtheme Definition
Work Behaviour Actions of employees in the course of their work
Unprofessional Behaviour Actions which threaten norms of civility and respect in the workplace
Duties and Responsibilities Disagreement or miscommunication over whose responsibility it was to
perform certain work tasks
Methods of Patient Care Disagreement about how a patient care should be provided
Poor Work Performance Low quality or incomplete work tasks
Work Organisation The structure of work, environmental and organisational constraints, or the
interdependence between workers
Following Protocol Not adhering to policies or practices of the hospital system or medical field
Patient Assignments Complaints about unfavourable patient assignments and disputes over who
would be assigned to those patients
Limited Resources Competition for finite resources that resulted in conflict
High Workload Work stress due to the number of tasks to be performed by a single employee
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Table 2
Number of primary themes and subthemes
Primary themes and subthemes No. of incidents
Work Behaviour 92
Unprofessional Behaviour 32
Duties and Responsibilities 29
Methods of Patient Care 16
Poor Work Performance 15
Work Organisation 42
Following Protocol 16
Patient Assignments 13
Limited Resources 7
High Workload 7
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