1. Horizontal Violence or Generational Conflict: Is Care-Fronting the Answer
Yvonne Wesley, RN, Ph.D., FAAN
Independent Health Consultant

2. Overview
Upon completion of this session, participants will be able to:
Define Horizontal Violence and Generational Conflict
Compare and contrast HV and GC similarities and differences
Illustrate the effect of Care-Fronting on HV and GC

3. Horizontal Violence Antagonistic behaviors such as:
Weinand, M. R. (2010). Horizontal violence in nursing: history, impact, and solution. JOCEPS: The Journal Of Chi Eta Phi Sorority, 54(1),
Antagonistic behaviors such as:
Gossiping, undue criticism,
Innuendo, scapegoating,
Undermining, passive aggression,
Bickering , blaming behaviors
Sabotage
Emotional dumping, indiscriminate venting

4. Weinand, M. R. (2010) Why susceptibility among nurses
Antagonistic behaviors among oppressed people i.e.: women
Nursing predominately women
Antagonistic behaviors, a form of self-hate
Demonstrated in the classroom with faculty dominating student nurses.
Nurse managers and supervisors cited as frequent users of bullying culture & top down style

5. Weinand, M. R. (2010) End Product from HV
Overwhelming sense of negativity cultivated
Aggression breeds aggression
Low morale
High turnover
Increased absence
Low productivity

6. vs. identification of problems
Weinand, M. R. (2010)
Formal training in teamwork, positive feedback, conflict management and confrontation
skills
Solutions to the problem
Embrace transformational leadership
Inspire and challenge staff;
Utilize active listening,
Advise and coach staff;
Have a positive vision
Reward resolution
vs. identification of problems

7. King-Jones, M. (2011)
King-Jones, M. (2011). Horizontal Violence and the Socialization of New Nurses. Creative Nursing, 17(2),
overt and covert nonphysical hostility,
criticism, sabotaging, undermining, infighting, scapegoat, and bickering
unkindness, discourtesy, divisiveness, and lack of cohesiveness
belittling gestures, verbal abuse, gossiping, sarcastic comments, faultfinding, devaluing comments,
disinterest and discouragement, and controlling behaviors

8. King-Jones, M. (2011) HV stems from oppression
HV is how oppressed people cope with powerlessness
HV, a display of powerlessness & negative emotions
Knowledge is power -- a cycle of power and resistance
To resolve HV, address the dynamics of power and conflict

9. Generational Conflict
Hahn, J.A. (2011), Managing Multiple Generations: Scenarios From the Workplace. Nursing Forum, 46(3),
Increased numbers of generations working together creates more opportunity for misunderstanding
Veterans, [born before 1945]
Baby Boomers, [born ]
Generation X, [ ]
Gen Y/Millennials [ ]

10. Hahn, J.A. (2011) Veterans – before 1945 Baby Boomers – ‘46 to ‘64
Grew up in times of political and economic uncertainty,
lived experience of the Great Depression and World War II
Nursing as a helping profession and unselfish
Expect rewards for hard work
Baby Boomers – ‘46 to ‘64
Strong sense of duty, called workaholics
Lived experience of prosperity
Look to empower
Arrive early to work

11. Hahn, J.A. (2011) Generation X – ’65 to ‘76
Independent, self-directed, and techno-savvy
Latchkey kids
Grew-up quicker and stayed adolescents longer
Quality of life important their parents work long hours and experienced downsizing
Millennium/Gen Y – ’77 to ‘97
Technology and instant communication
Accepting multiculturalism
After-school activities, such as swimming, soccer, dance
Want work-life balance

12. Generation
Generational styles
Veterans
<1945
Stable
Reliable
Practical
Loyal
Baby Boomers
1946–1964
Involvement
Personal growth
Optimism
Mentors
Generation X
1965–1976
Think globally
Techno-literacy
Pragmatic
Asynchronous communication
Skeptical
Millennials
1977–1997
Multitasking
Technologically savvy
Outcome driven
Determined

13. Carefronting
Kupperschmidt, B. (2006). Addressing multigenerational conflict: mutual respect and carefronting as strategy. Online Journal Of Issues In Nursing, 11(2),
Kupperschmidt argues that professional nurses must care enough about their patients, profession, colleagues, and themselves to ‘carefront’ disrespectful behavior

14. Kupperschmidt, B. (2006).
Treating each other with respect is a nurse's ethical responsibility
Carefronting, a model of communication used when professional nurses care enough about themselves and their patients to confront disrespectful behavior face-to-face

15. Kupperschmidt, B. (2006)
Failure to confront is dishonest communication
Carefronting embodies forgiveness, caring and valuing, while addressing the anger in the disrespectful behavior, and focuses on the here and now

16. Kupperschmidt, B. (2006)
The goal is the ability to work together to provide safe patient care in an environment based upon mutual respect
Kean University Graduates
Bivins & Primus Developed the:
Perceived Carefronting Ability Questionnaire

17. A newly registered nurse Renee is working alongside Jeanette, a nurse of twenty five years in a busy trauma emergency room. Patient Glendale, a frequent flyer, presents complaining of chest pain radiating to his right arm, his history includes hypertension managed with a beta blocker and drug seeking behavior.
Jeanette blurts out, “Back so soon. Ran out of your Percocets in three days did you?” Renee goes to his bedside places him on the cardiac monitor, performs and EKG and tells the physician the patient may be experiencing a heart attack.
Jeanette waltzes over, rolls her eyes, sighs and sarcastically says, “This rookie needs to go back over there and complete his history and physical before jumping to conclusions. Embarrassed Renee walks away. Later she seeks out Jeanette and asks to speak to her in a private area.

18. Yvonne Bivins MSN RN Nadia Primus MSN RN
Carefronting Techniques based on Kupperschmidt (2006)
When you called me a rookie and said I jumped to a conclusion (what was the action). I felt humiliated (your reaction).
Because it portrays me as someone in a rush (what does it look, sound or feel like).
Was it your intention to embarrass or humiliate me? (repeat what the action was, STOP! wait for a response)
In the future talk to me in private (what behavior you want to see).
Are you committed to treating me as respected colleague? (What you want them to do?)
If there isn’t a change, I will arrange a meeting with the supervisor to discuss your actions (what is the consequence).

19. Number of Participants
Pre-test
Post-test
Baby Boomer RNs 7 4
Generation X RNs 17 8

20. Yvonne Bivins MSN RN Nadia Primus MSN RN
A paired t test compared pre and post mean scores of the participants’ perceived ability to utilize Carefronting
pre-test M= , SD=4.15
post-test M= 43.08, SD=3.08
Highest possible score being 50 and the lowest 10
Alpha set at p<0.05
There was no significant difference t(11) = -2.17, p = The 95% confidence interval for the mean difference between the two means was to 0.03.

21. Yvonne Bivins MSN RN Nadia Primus MSN RN
An independent t test compared Baby Boomer to Gen X mean scores on perceived ability to utilize Carefronting
No significance difference in the Baby Boomer & Generation X mean scores
pre-test t(24) = .992, p = .33
post-test t(11) = .154, p = .88

22. Carefronting Techniques based on Kupperschmidt (2006)
When you called me a rookie and said I jumped to a conclusion (what was the action). I felt humiliated (your reaction).
Because it portrays me as someone in a rush (what does it look, sound or feel like).
Was it your intention to embarrass or humiliate me? (repeat what the action was, STOP! wait for a response)
In the future talk to me in private (what behavior you want to see).
Are you committed to treating me as respected colleague? (What you want them to do?)
If there isn’t a change, I will arrange a meeting with the supervisor to discuss your actions (what is the consequence).

23. Take home Message Caring enough to confront may help
Carefronting comes from a place of love, not bitterness or hate
Horizontal Violence and Generational Conflict are a problem within nursing
Both are highly detrimental to the body of Black nurses