Lateral Violence in Healthcare: Policy, Duty, and Risk Prevention

Introduction: Tarasoff and the Duty to Warn

This research proposal examines lateral violence in U.S. healthcare institutions through the scope of policy formation as it pertains to medical malpractice and organizational behavior. In recent years, investigations into lateral violence (LV) in the practice setting have become increasingly important as professional liability and the concept of "duty" in patient care have come under close scrutiny.

In Tarasoff v. The Regents of the University of California [S.F. No. 23042, Supreme Court of California, July 1, 1976], a wrongful death action was filed against the Regents of the University of California, alleging that psychotherapists at a university hospital and campus police officers had failed to respond adequately to a patient's stated intention to commit murder. Specifically, the charges alleged that patient Prosenjit Poddar had confided homicidal ideation toward victim Tatiana Tarasoff to Dr. Lawrence Moore, a psychologist employed by the Cowell Memorial Hospital at the University of California at Berkeley. At Moore's request, campus police briefly detained Poddar but released him after a cursory assessment. The plaintiffs further charged that Dr. Harvey Powelson, Moore's superior, also took no further action to follow up on the threat. Poddar subsequently murdered Tatiana Tarasoff in October 1969.

In the initial trial court decision, the defendants' demurrers to the complaint were sustained without leave to amend, and judgment was entered in favor of the defendants. On appeal, the California Supreme Court affirmed the judgment in favor of the police officers but reversed the earlier decision in favor of the therapists and the Regents. The reversed decision held that the plaintiffs could amend their complaints to state a cause of action against the defendants based on the threat of imminent danger to a third party who had been put in serious peril. The court maintained that professional duty to a standard of reasonable care should have compelled the defendants to take protective action and that they had nevertheless failed to exercise a reasonable response toward protecting a third party threatened with intentional harm.

In this landmark negligence ruling, the court held that when a therapist determines — or is forced to confront an ethical dilemma arising from — a patient's express intent to cause serious harm or danger of violence to another person, the therapist incurs an obligation to exercise fair warning within the scope of "duty" defined by reasonable care. The case was instrumental in further defining the obligation to warn, establishing that such a duty was not a discretionary act protected under the immunity provisions of California Government Code § 820.2. The judicial reinterpretation that reversed the original decision cited a breach of duty in the failure to communicate danger, while also holding that defendants were insulated from substantial liability under Government Code § 856. The decision further redefined nondisclosure (§ 5328) as a measure for ensuring greater safety where healthcare organizations are involved. The policy definition of the case is articulated in the Healing Arts and Institutions § 30, "Medical Practitioners and Duty of Therapist to Dangerous Patient's Intended Victim," which sets standards for professional conduct, including appropriate disclosure where serious danger of violence to another person may be present.

This research proposal advances that topic and examines the general field of duty to disclosure as it applies to healthcare practitioners. Of key importance to the outcomes of the 1976 ruling is the recent trend in best-practices policy recommendations directed at risk mitigation of violence in healthcare settings. If Tarasoff set the pace for future decisions on patient consent and disclosure where imminent danger may be present, the expansion of the topic over the last thirty years now permeates the clinical practice setting. In keeping with contemporary interest in violence as a pronounced dimension of healthcare policy, this study turns the disclosure issue toward questions of ethical obligation where peer-to-peer or lateral violence is present, and toward the substantial work that healthcare administrators, policymakers, and practitioners are undertaking to ensure that "duty" is adequately addressed.

According to the Center for American Nurses (CAN, 2008), the prevalence of lateral violence in healthcare organizations has increased exponentially over the last several decades. Nearly half of all nonfatal injuries in the workplace result from violent acts committed by co-workers in the healthcare sector. The U.S. Bureau of Labor Statistics reports that in many states, the healthcare sector ranks among the top five sectors for workplace violence. Nurses, nurses' aides, and orderlies are consistently reported as the most frequent victims of such injuries (OSHA, 2004). Incidences of disruptive and antisocial behaviors experienced by staff in high-demand healthcare institutions are indexed as "serious" in the United States, with negative behavior and misconduct cited as the norm rather than the exception.

As a result, much attention to bullying and sexual harassment stems from patient-related stressors where malpractice litigation is already in process. Because the reported occurrences have reached what many describe as "epidemic" proportions, policymakers have been tasked with crafting adequate legislative responses to excessive risk and misconduct. This movement toward deeper policy addressing violence — and especially lateral violence — is of real concern to healthcare organizations, as conflict resolution and protection from liability suits are both fiscally impactful and potentially damaging to comprehensive patient care. Staff shortages, long hours, and stressful circumstances in hospital environments contribute to interpersonal conflict among employees.

Problem Statement: Lateral Violence in Healthcare

The pervasiveness of LV is substantiated by the number of legal complaints filed against healthcare institutions, as reflected in the regulatory restrictions articulated by the Joint Commission, OSHA, and NIOSH beginning in 2001. In 2002, the Joint Commission extended its recommendations to encompass violent perpetration and threats of physical assault as "workplace terrorism" under the definition of the U.S. Federal Model Penal Code (MPC). The incorporation of MPC statute underscores the urgency promoted by advocacy specialists on behalf of healthcare professionals concerned about their own safety and the safety of their patients. The American Association of Occupational Health Nurses (AAOHN) replicated this amendment in 2003, publicly endorsing U.S. Federal Bureau of Investigation (FBI) language defining workplace violence as "any action that may threaten the safety of an employee, impact the employee's physical or psychological well-being, or cause damage to company property."

In an occupational study of the healthcare workforce, nursing was targeted for multidimensional analysis to interpret the "domino effect" that persists in clinical practice settings — one that begins with triggered stress in individuals but ultimately operates as a feedback loop, broadly compromising environmental safety. Proposed solutions to LV in healthcare organizations must therefore include the full scope of considerations, including the nurse-patient journey. Patient-related risk and intentional negligence by colleagues are closely linked. Exhaustion on the job is a standard complaint within nursing, and it is relevant to argue that LV's effects compound without adequate control measures in place.

Violations may include an entire range of behaviors: intentional humiliation, infighting, nonverbal innuendo, threats to safety, verbal affront, undermining activities, withholding job-pertinent information, sabotage, scapegoating, and efforts to make colleagues feel vulnerable (Griffin, 2004). Breach of privacy — or failure to respect the privacy of individuals — is consistently identified as a core root cause of detrimental misconduct and subsequent risk. Lateral violence in nursing practice is categorized by type and manifestation as follows:

Nonverbal cues (covert/overt): Raising eyebrows, making faces.
Verbal remarks (overt): Snide, rude, and demeaning comments; interruption of discussion.
Actions (overt): Actions that undermine the victim's ability to perform or to be recognized for performance.
Withholding information (covert/overt): Deliberately not disclosing critical information related to the job or to protection from risk.
Purposeful sabotage (overt): Blocking performance.
Group infighting (overt): Cliques and exclusion.
Scapegoating (covert): Blaming an identified colleague irrespective of actual responsibility.
Passive-aggressive behavior (overt): Failure to respond directly to conflict (e.g., backstabbing).
Broken promises/disrespect of privacy (covert): Sharing information without consent.

Source: Types of Lateral Violence (Griffin, 2004).

The proposed research examines the new policy directives dedicated to managing lateral violence risk in the healthcare workplace. It also examines "policy in practice" through change management strategies for combating malpractice litigation related to LV, through institutional adherence to protocols, morale building, and leadership within horizontal nursing teams. Following the Stanley/Martin Applied Model of Oppressed Group Behavior to Explain Lateral Violence in Nursing (2007), the study examines how policy influences healthcare practice in terms of group accountability to liability and duty to a reasonable standard of patient care.

Purpose and Significance of the Study

Interpretation of the practice setting through the lens of policy on disclosure — particularly where violence may pose danger to colleagues and patients — is the central intention of the proposal. The review of research on LV encompasses a range of evidence-based practice cases. Six Sigma diagnostic assessments of institutional best practices recommendations and their application will support the study and advance theoretical perspectives on the organizational and professional transformation of healthcare institutions through measures of expropriated evaluation (Ramos, 2006).

The purpose of this research investigation on lateral violence in the practice setting is to contribute to the professional dialogue on policy in the healthcare workplace. Study outcomes will provide valuable insights into the practical and policy dimensions of clinical practice, as well as hospital safety programs operating in adherence to national compliance standards. From a theoretical perspective, the study proposes to extend recent inquiries in common law nations on the "duty to a standard of reasonable care" as acknowledged within U.S. federal law and in other nations — such as Canada — that offer distinct interpretations of institutional and professional liability.

Patient care models also offer a site of investigation on the topics of violence and disclosure. Lateral violence or peer-to-peer abuse also affects patients: it is through the matrix of violence that parties find themselves compromised toward negligence or potentially worse outcomes. Professional relationships between medical practitioners and patients continue to be shaped by policymakers aware of the complications inherent in non-disclosure agreements. Contentious and rather complex rights, responsibilities, and protections all circulate through debates on the distinction between privacy, imminent danger, and professional immunity.

Legal records supply much of the information shared in the policymaking arena, and data generated from those cases will serve to inform the convenience sample survey and SWOT analysis dedicated to understanding policy in action. Replicable investigations already applied to the development of best practices supporting a "culture of safety" within institutional policy implementations will supplement the research by offering independent instances of lateral violence mitigation in healthcare organizations.

Conclusion and Summary

Since Tarasoff v. The Regents of the University of California, institutional task forces dedicated to policy-mandated planning in risk management have opened the doors on the liability question, where hospitals and other healthcare institutions are forced to think more carefully about adequate responses to lateral violence. The proposed research is intended to foster dialogue on risk management as an aspect of "duty" to professional conduct in the practitioner-patient relationship.