OR nurses eat their young. And each other. You know who you are. Not all of you. But some of you. You can level a colleague simply by rolling your eyes or clearing your throat. You're a backstabbing, backbiting bully. A cowardly, cunning sneak who's not above sabotage - deliberately setting up a negative situation in the OR to make your co-workers look bad and to compensate for your own inadequacies.

You intimidate. You shun. You manipulate. You're spiteful and rude. You set up alliances and shut others out. You think you're better than everyone else and will stop at almost nothing to prove it. A favorite ploy of yours is to set others up to fail. Makes them look bad so you look good.

It's simple, really. Removing an instrument from the field so the scrub who relieves you is left scrambling. Not telling where needed equipment is. Setting up a room wrong to get your coworker in trouble. Swiping another's equipment for your own cases. Withholding information so you can look like the nurse who saved the day.

"Surgery staff co-workers can be evil," says an administrator with a tale to prove it: She says someone in her department poured Cidex in a co-worker's water cup and the person actually drank it.

Traveling nurse Brandy Miller, RN, BSN, remembers you from an assignment long ago. You kept some key bits of info to yourself so you looked good in front of the docs. You made degrading, rude and demeaning comments under your breath. You were almost aggressive in your work habits.

"It was sad to see someone so miserable and working so hard to make others as miserable as she was," says Ms. Miller.

There's a name for what you do. Lateral violence. Professional terrorism. Nurse-on-nurse hostility. "It's bullying is what it is. They do it because they can get away with it. And it has to stop," says anesthesiologist Sheryl Walker, MD, medical director and chief of anesthesia at the SurgiCenter of Baltimore in Owings Mills, Md.

"It's important we call it what it is. It's very hurtful and hateful," says Karen Stanley, APRN, BC, psychiatric consultation liaison nurse at the Medical University of South Carolina in Charleston, S.C.

You didn't need a survey to tell you that OR nurses who are abusive to their co-workers and delight in the misfortune of others are a growing breed, but we went ahead and sent one out anyway. We received 500 responses (a record for our Web-based reader surveys), some of them probably from your victims. Nearly two-thirds (64 percent) say they've witnessed or been the victim of an act of violence while working in a surgical facility of any kind (see "The Cycle of Lateral Violence" on page 37).

Apparently you can't help yourself. Researchers say you're depraved because you're deprived. You're a victim of your environment and your behavior is a learned defense mechanism. In your OR, it seems, it's either trample or be trampled.

What is it about the OR?
Lateral violence happens when people who are both victims of a situation of dominance turn on each other rather than confront the system that oppresses them both. It occurs when oppressed groups or individuals internalize feelings such as anger and rage, manifesting their feelings through behaviors such as gossip, jealousy, putdowns and blaming. But what is it about surgery and OR staff that makes them behave badly?

For starters, gender plays a huge role, say researchers. Lateral violence in the nursing community is connected to the behaviors of oppressed groups. Nurses are dominated or oppressed by a patriarchal system headed by doctors, administrators and nurse managers. It results in nurses lower down on the hierarchy of power taking out their aggression on each other. They garner power at their peers' expense, says Martha Griffin RN, CS, PhD, program coordinator for nursing and professional development at Brigham & Women's Hospital in Boston.

Readers weighed in with their theories, too.

• "Female nurses, especially those with low self-esteem and a low socio-economic status, vie for attention from male physicians, and this results in an emotional form of violence," says one.
• "Nurses learn that the best way to get out from under the spotlight is to prove someone else is the weaker link," says another.

There's more to the gender issue. There's never been a time when less than 90 percent of the nursing workforce wasn't female. While women go about aggression differently than men, studies show they're just as aggressive.

At a young age, girls aren't held as accountable as boys for their aggression. The boy who bops another kid on the head with a book is reprimanded. But the covert ways a girl shows aggression - shunning another child at recess, for example - aren't chastised even though they can be just as hurtful. Females have continued those passive-aggressive acts through adulthood, says Dr. Griffin.

Overt acts of aggression - making faces and other non-verbal innuendos; unresponsiveness and other verbal affronts - top the list of forms of lateral violence in nursing. Other frequent forms include undermining another's activities, withholding information, sabotage, scapegoating, bickering and backstabbing.

Studies show that a decrease in trust is the greatest damage that occurs - the victim is never sure when someone is trying to help her or set her up for a fall.

"During training experiences, the experienced team members strategized to arrange potentially harmful patient situations with med delivery, treatment plans and missing orders to 'test' the new nurse as opposed to developing peer trust and team support," says clinical consultant Ellen Kelley, RN, BS.

In some cases, bullies might believe they're doing younger nurses a favor by making them tougher. "Knowledge is power, and older nurses don't want to share that power. They have an attitude of 'I had to struggle. You have to struggle,'" says Beverly Kirchner, RN, BSN, CNOR, CASE, who's studied aggression's impact on an OR.

But the reality is that it's not educational, it's cruel:

• 60 percent of new-to-practice nurses leave their first position within six months because of some form of lateral violence. "Some hazing goes on in the profession. Young nurses are appalled when they're treated badly," says Ms. Stanley. "They may not say anything. They'll just leave."
• A facility loses between $50,000 and $60,000 when a new nurse leaves in less than a year.
• One in three nurses internationally leaves her position because of lateral violence or workplace bullies.
• Some victims of lateral violence in nursing, similar to other victims of bullying, have resorted to suicide.

Could lateral violence be a major reason for staffing shortages in the OR?

"The talk about the shortage of nurses is why we are more focused on how we get along," says Dr. Griffin. "How people work together in the future will be so much more important."

The generation of nurses entering the workforce doesn't hold the organizational loyalties as their elders. "They grew up in a world of rapid change," says Peggy Dulaney, MSN, RN, BC, a private consultant and educator in Easley, SC. "Job mobility is just part of their norm. If they're not treated well by their colleagues and mentored and nurtured by the staff, they have no qualms about going somewhere else."

The OR's caste system
Dr. Walker has been providing anesthesia in outpatient ORs for nearly 30 years. She describes a "caste system" in the OR that pits nurses against each other.

Surgeons, not above intimidating or harassing the surgical staff, have the highest status. "As a colleague has told me, surgeons have to have a little bit of a sociopathic personality to be able to do what they do: Come in and cut on people and feel good about it," says Dr. Walker. OR nurses don't have the status to be righteously indignant when surgeons berate them. They have no choice but to take it. Their reaction? Please the surgeon at all costs. "People blame things on each other so they're not the ones being yelled at," says Dr. Walker.

The OR is not exactly conducive to learning, she says. "You can't admit a mistake or you'll get verbally abused. From then on, you'll get harassed constantly. If you don't do it perfect the first time, you never get a second chance to prove yourself."

The aggressive streak is instilled in surgery professionals early, says Ms. Kirchner. "Think of the way doctors are socialized in medical school. They are verbally abused in the teaching environment. A committee reviews any mistakes they make. Add into that the God syndrome, and you have a potent mix," she says.

Ms. Kirchner outlines aggression's outcomes: For the aggressor, self-satisfaction, affirmation of power, affirmation of self, emotional blackmail and control. For the victim, demoralization, intimidation, depersonalization, hopelessness and powerlessness.

Standing up to the bully
The best way to break the cycle of lateral violence may be to stop aggression before it starts. Ms. Kirchner shares this exercise to teach your staff and promote assertive communication.

I feel ______ (one word).
When _______ (the offensive behavior).
Because ______ (what makes the behavior offensive).
I would prefer _______ (desired change).

"It needs to start at the top - with administration, with the surgeons," says Dr. Walker. "We all need to look at our behavior and see what effect that has on other people. And if we're creating an environment where those kinds of behaviors are not tolerated, those kinds of behaviors would slowly go away."

Are you afraid to confront the bullies in your facility? If more of you would stand up to the bullies, then the behavior would stop, say many of our survey-takers. Surgeons can help, too. "The surgeon sets the tone for what the day is going to be like," says Dr. Walker. "If he's allowed to be snide and verbally abusive and disrespectful to the human beings in the room trying to get that surgery done, you can only imagine how that affects those in the room and others around them."

The OR culture can be changed, says Ms. Dulaney. Start with awareness of the issue. Then develop professional behavior standards regarding teamwork, communication, taking initiative and speaking positively about each other, for example. Educate everyone about it and build it into annual reviews. "Make it a standard of employment," she says.

A mentoring program can be helpful to new nurses as well, so they aren't thrown to the wolves right away. Here's a story from an OR nurse with 18 years' experience who'd never performed in neuro or heart procedures. "The young staff was constantly talking behind my back that, with all this experience, I should be able to walk in and without orientation do cases and work equipment that I have never worked," she says. "Well, no matter how many years of experience a nurse has, you require orientation to physician preferences, instrument sets and time to convert to everyone's voice behind a mask."

Dr. Griffin performed a yearlong study on a group of 26 newly licensed RNs hired at an acute-care tertiary hospital in Boston. She started the study with classes about lateral violence and then sent the nurses out onto the floor armed with laminated cue cards attached to their ID badges. Scripted conversations were printed on the cards for a guided response to the 10 most frequent forms of lateral violence (see "Top 10 Most Frequent Acts of Lateral Violence and What to Say to Stop Them" on page 35).

Crediting the classes, the cue cards or both, the new nurses said when they witnessed lateral violence taking place against them, they all confronted their aggressors. And after that, the behavior stopped.

"Confront them, no matter how difficult it is," says Dr. Griffin. "When confronted in a private way, in a professional demeanor, that behavior goes away."