The relationship between continuing professional education and horizontal violence in perioperative practice.
Abstract: Continuing professional development must be undertaken by all registered perioperative practitioners. However, interviews with 23 perioperative nurses employed by one NHS trust suggested a link between workplace culture and intra-professional conflict which was associated with horizontal violence and perceived as a direct consequence of formal study. Such experiences appeared to affect participants' study and their psychological well being. Further work is required to explore this concept.

KEYWORDS Continuing professional development / Horizontal violence / Perioperative nursing
Article Type: Report
Subject: Continuing education (Social aspects)
Continuing education (Research)
Nursing education (Social aspects)
Nursing education (Research)
Bullying (Research)
Surgical nursing (Social aspects)
Surgical nursing (Research)
Author: Tame, Susan
Pub Date: 07/01/2012
Publication: Name: Journal of Perioperative Practice Publisher: Association for Perioperative Practice Audience: Academic Format: Magazine/Journal Subject: Health; Health care industry Copyright: COPYRIGHT 2012 Association for Perioperative Practice ISSN: 1750-4589
Issue: Date: July, 2012 Source Volume: 22 Source Issue: 7
Topic: Event Code: 290 Public affairs; 310 Science & research Canadian Subject Form: Continuing education centres; Continuing education centres
Geographic: Geographic Scope: United Kingdom Geographic Code: 4EUUK United Kingdom
Accession Number: 300545550
Full Text: Introduction

In recent years there has been increased emphasis on continuing professional development (CPD) for health professionals within the UK (DH 2008, 2010, 2011). CPD covers a range of activities, from informal work-based learning to formal education in university settings. It is this latter formal, accredited study, termed continuing professional education (CPE), on which this paper is focused.

Nurses have always been required to demonstrate their competence, however the integration of lifelong learning into healthcare (DH 2001) represented significant cultural change within the NHS. This is currently being further strengthened by discussion about who should assess nurses' competence when they re-register (Waters 2011). Despite these initiatives, discorde may exist between lifelong learning in nursing and in society in general. The National Institute of Adult Continuing Education (NIACE 2004) stated that British people's attitudes towards lifelong learning changed following government initiatives which assumed that people wish to learn (DfEE 1997a,b, 1998). However, despite this statement, social and cultural factors also influence whether learning is undertaken (Titmus 1999). Participation in formal, intentional, learning fell from 23% of the population in 1996 to 19% in 2004 (NIACE 2004), suggesting that societal attitudes remain unchanged. British nurses' attitudes towards lifelong learning therefore may remain, despite CPD being emphasised.

Literature review

Clinical environments have long been recognised as either conducive or not conducive to learning (Orton 1981), with values and norms and power inequalities being perpetuated through socialisation (Houle 1980) and creating cultures which either accept or reject lifelong learning. Despite a changing emphasis on lifelong learning both within and outside nursing, more recent work confirms that this still occurs, with some studies identifying the practice milieu as the most important determinant of change (Ellis & Nolan 2005, Spencer 2006, Gould et al 2007, Lee 2011).

Social inclusion is important to nurses in consideration of CPE (Hardwick & Jordan 2002, Gopee 2003, Ellis & Nolan 2005). The attitudes of both managers and colleagues have an impact on access to CPE as well as on change following formal study (Stanley 2003, Spencer 2006, Gould et al 2007, Cooley 2008, Lee 2011). Although Gopee (2003) asserted that nurses' attitudes towards academic and practical skills are changing, Miers (2002) describes anti-intellectualism in nursing which appears to persist as there is discordance between practice and academia (Spencer 2006). Indeed Hardwick & Jordan (2002) discovered that negative attitudes and resentment from managers and peers relating to nurses undertaking post-registration degrees were 'manifest', with those who attempted to instigate change in unsupportive environments being perceived as 'troublemakers' and 'argumentative'. Such attitudes may arise from professional jealousy, or from a perception of colleagues as threatening following CPE (Nolan et al 2000, Spencer 2006). Alternatively nurses may not appreciate the value of academic study to clinical practice (Spencer 2006, Gould et al 2007, Cooley 2008), with managers described as gatekeepers to course admission (Gould et al 2007).

No studies were located which investigated CPE in perioperative practice, however the culture of perioperative nursing is greatly affected by professional relationships and the associated power of these professions both in the UK and elsewhere (Tanner 2003, Coe & Gould 2007, Gardezi et al 2009, Collin et al 2011). Given that CPE appears to be embedded in the culture of the clinical environment and is affected by individuals' attitudes and reactions, it would be logical to assume that the culture of perioperative practice similarly influences perceptions of continuing professional education.



Design A descriptive qualitative framework was used during data collection and analysis. Although Baker et al (1992) argue for purity in methodological approach, Silverman (2005) believes that qualitative research is now sufficiently established to break from the traditional approaches which were used to reinforce its credibility. Whilst Baker et al (1992) describe 'method slurring' may compromise rigour, advocates of more pragmatic, pluralistic, approaches to qualitative research (Sandelowski 2000, Johnson et al 2001, Silverman 2005) believe that they are no less rigorous than an assumption of rigour purely by stating a traditional theoretical approach. Johnson et al (2001) argue that to adopt multiple methods provides both flexibility and rigour to research.


Participants A purposive sample of perioperative nurses employed in one large teaching NHS trust in the north of England was chosen. Personal letters of invitation were distributed to nurses who appeared from a local database to be currently undertaking CPE or who had done so in the last three months. Letters were also sent to nurses whose names did not appear on this database, who were assumed to have not studied at university, at least in the lifetime of that database. Letters were sent in batches of 10 to prevent participants waiting for longer than three months to be interviewed. Potential participants were given four weeks to express their interest in participating.

Data collection

Data collection Data collection took place from February 2006 to January 2007 through in-depth, unstructured, individual, face-to-face interviews, supported by a topic guide. Interviews were conducted at times to suit participants in private rooms in their workplaces, and were audio-taped in their entirety. The pace and length of these interviews were determined by participants, and ranged from 40-90 minutes. Participants were encouraged to illustrate their experiences using examples. Immediately following each interview, the audiotapes were listened to and field notes made of salient points. Revision of the topic guide at the end of each interview allowed emergent themes to be explored in later interviews with subsequent participants.

Data analysis

Data analysis Audiotapes were transcribed verbatim into the Ethnograph following each interview, ensuring accuracy by reading the transcripts whilst the audiotapes played. The familiarity required for constant comparative analysis (Strauss & Corbin 1998) occurred through re-reading transcripts prior to annotating each phrase, sentence or paragraph with codes which arose from the data (Dey 1993). Similar codes were clustered into subcategories and categories (Miles & Huberman 1994) which in turn were grouped into themes, allowing a larger picture of CPE to emerge. Where necessary, codes, subcategories, categories and themes were refined through splitting (subdividing) and splicing (merging) to ensure that they remained relevant, inclusive, exclusive and exhaustive of data (Dey 1993, Seidel 1998). This process allowed transcripts to be analysed to delineate points of interest between participants, and also significant passages within an interview.

As transcripts were read, memos were attached to the text, and Word documents kept detailing emerging categories and themes. Upon saturation paragraphs were written which described categories and themes. These memos and paragraphs were also searched for connections and relationships between categories and themes, identifying similarities and variations, until no new interpretations were found.

Ethical considerations

Ethical considerations Ethical approval was obtained from the local research ethics committee and the trust in which the study was conducted. Participants were sent full study details with their letter of invitation, and their voluntary participatory consent was affirmed prior to data collection, along with their right to withdraw at any time. Confidentiality was maintained throughout, and all data were anonymised. A summary of the findings was sent to all participants.


Data collection continued to saturation (Morse & Field 1995), and as participants represented different departments and levels of seniority sufficiency was indicated (Seidman 2006). Involving participants with recent experiences of CPE allowed these not retrospective accounts of previous study to be explored. Constant comparative analysis also aided credibility (Lincoln & Guba 1985), allowing data to be reanalysed to develop an understanding of participants' experiences.


Indings In total, 23 nurses who participated in CPE were interviewed: No potential participants who appeared not to undertake formal study replied to their letter of invitation, the reasons for which are unknown. Participants had between 21/2 and 30 years experience, of which between 21/2 and 25 years were within perioperative care. Participants' experiences suggested that the culture of perioperative practice was not always conductive to nurses' educational development, with some describing the presence of horizontal violence, which they perceived as a direct consequence of their academic study.

The culture of perioperative practice

The culture of perioperative nursing along with managers' and colleagues' attitudes pervaded all aspects of CPE from entry through to completion. Managers' attitudes appeared to be pivotal in determining the cultural milieu, and whilst some were perceived as supportive, a lack of interest and support was a source of discontent for many, who spoke sadly of their situations:

I'm being prevented from progressing as much as I'd like to academically [Participant 1, senior practitioner]

l was interested in doing my degree and [my manager] just said 'No' [Participant 5, senior practitioner]

Participants attempted to justify these attitudes, with some believing managers may feel threatened or jealous if their staff gained qualifications they themselves did not possess:

[T]hey are frightened to death that people'll come and tell them that they can do the job better, because they've got more knowledge [Participant 12, charge nurse] Some are jealous [Participant 23, senior practitioner]

As Gould et al (2007) reported, in some departments participants felt explicit inequality existed in terms of access to CPE, and some senior participants described how certain colleagues were repeatedly favoured for development opportunities:

I think the NHS ... has earmarked people for certain roles.... If your face fits you can get on ... and if it doesn't you won't. ... [T]he same people get on the same courses all the time [Participant 12, charge nurse]

Alongside managers' attitudes, other nurses' attitudes also appeared integral in shaping cultural values. Several participants described how their desire to gain academic qualifications was seen as inappropriate:

[S]ome of my colleagues, were ... of the opinion I was having a day off ... that I was ... shirking [Participant 6, senior practitioner]

I got gripes that they were busy ... [I]t was 'why do you need to go and do a theatre course? You can learn everything here.' [Participant 14, charge nurse]

Rather than enhancing nurses' ability to care for patients, some participants supported Ryan's (2003) statement that 'moving CPE into universities emphasises the distance between theory and practice, moving nurses away from patient care':

[S]ometimes, nursing does deviate ... from practical nursing into more academic ... [Making away from the job that we were first qualified for-being actually ward level, hands on.... [People] tend to become more office based ... [o]nce they've gone to do degrees [Participant 21, perioperative practitioner]

As a part of the perioperative multidisciplinary team, medical staff's attitudes also contribute to the cultural milieu:

[T]he medical staff are oblivious to our qualifications. ... They may even pass comment 'you go to university, and for what [emphasis]?' ... Some who did know were supportive, and curious [Participant 6, senior practitioner]

Participant 1, Senior practitioner: I'm being prevented from progressing as much as I'd like to academically. A couple of times I've asked about doing degree units and been told I can't [sounds upset]. They can't understand why I'd want to study. I've thought about it lots and it can't be purely because they're not interested themselves, because there are a lot of things I'm not interested in but I'd never wonder why someone else wanted to do it. I've wondered often if do they not want you to progress, and if so why not? It makes me angry, and I feel that I'm not valued by my manager. I also worry that if I got a place my manager might make life difficult by arranging the off duty so I can't attend

Participant 8, Perioperative practitioner: Not all of my colleagues have been supportive. I don't know whether it's angered them, annoyed them, frustrated them that they're not doing it, or maybe they feel threatened that I will have a qualification they don't. I think some people don't see the necessity for the academic side, that it's just experience which counts in the workplace. Sometimes, colleagues have said something negative about my study days within my ear-shot, or asked me what I am studying. They are not asking because they want to help, they ask quite spitefully, like they don't think I should be studying. That doesn't make me feel good about myself or about studying

Participant 18, Senior practitioner: I didn't train in this country, so I didn't know how British universities worked. Before I went to university, I asked my colleagues what I would be expected to do, and no one would tell me. They just said that I would learn when I got there. I didn't have the opportunity to look for books and didn't know what I could expect from the work, or the sort of questions I should be asking. It was really a struggle for me. The first three months were like a hell because I didn't understand

Participant 23, Perioperative practitioner: My colleagues are mostly supportive, but not everyone liked that I was studying. One day a colleague from the next department asked me whether I was doing the mentorship course. Then she asked me how long I had been working in theatres. I don't know why she asked me that question, but I don't think she thought it was right that a band 5 was doing the mentorship course. Some of my colleagues seem to be jealous too, or seem to disapprove. Or, sometimes, somebody will say they want to do the mentorship, and because I'm doing it they haven't got the chance

[H]e [surgeon as mentor] was really good ... and ... took time and went through things with me [Participant 10, team leader]

In general, perioperative nurses perceived medical staff as either apathetic towards or supportive of their development. As Hardwick & Jordan (2002) also reported, there appeared to be less resentment from medical staff than from nursing colleagues towards nurses' CPE, even where this encroached on traditional medical territories.

Horizontal violence

If socialisation involves identifying acceptable practices within a culture (Lafont 2005), it inevitably highlights those standing outside these practices. Even in cultures identified as generally supportive of CPE, many participants felt some colleagues were unsupportive and displayed both anger and resentment, something one participant associated with horizontal violence:

That to me sounds like a power thing. ... [Y]ou stress the negatives about the course, put everybody off, and then you will be the only one with this qualification. ... Have you come across 'horizontal violence?' [Participant 4, team leader]

Horizontal violence has previously been identified within perioperative care (Hamlin 2000), and may be attributed to or associated with patriarchal dominance and consequent feelings of oppression (Freire 1970). Those affected are unable to exert their anger towards their oppressors and instead direct this towards colleagues who are less powerful or stand outside dominant discourses (Bartholomew 2006). As the vignettes (Figure 1) illustrate, colleagues' behaviours left participants feeling angry, frustrated, and upset; emotions which can be associated with horizontal violence (Bartholomew 2006) and which existed across and between all grades of nurses:

[Managers] might make it impossible for your requests to be granted on the off duty [Participant 5, senior practitioner]

[0]ne girl [asked] me 'are you doing the mentorship now?, [said snidely] I said 'yeah, I am' and she did ask me 'are you band 6?'.... [S]he's a band 7 [Participant 23, senior practitioner

'Fixing the off duty', was mentioned by many participants and is something which Hamlin (2000) relates to horizontal violence and terms 'sabotage', and resulted in participants being unable to attend study days. However, although managers were seen as obstructive, the perpetrators of the majority of horizontal violence appeared to be from similar grade nursing colleagues.

As participants began to discuss their negative experiences, they became visibly agitated and anger could be heard in their voices. The depth of emotion was so strong for one participant that she began to cry. This participant spoke of her pride in successfully completing CPE, having not excelled at school or in pre-registration education, and of her sadness she could not share this with colleagues:

[I] try ... to bury it a little bit ... I suppose. ... [S]omeone ... bought me a card ... when I'd got my diploma ... and I .. put it in my locker. ... The only words [said] were '... So-and-so's nearly got her degree'. ... [Y]ou ... perceive ... they've got bad vibes about it ... [I]nwardly you see the [clenches fists in lap] [Participant 8, perioperative practitioner]

Such suppression of achievement and others' negative attitudes concur with Cooley's (2008) findings and suggest that the anti-intellectualism in nursing described by Miers (2002) is present in perioperative nursing. Often participants described how only negative aspects of CPE were vocalised, which they acknowledged may deter others from accessing CPE:

I wonder ... if sometimes whether the ones of us who do ... the courses put people off, because all they must hear is us complaining about how much work we've got to do, and how irritated we are by it! [Participant 6, senior practitioner]

Some participants went further to explain that such comments may have greater consequences, stalling both the progression of nurses and of nursing in the perioperative environment:

[Y]ou stress the negatives about the course, put everybody off, and then you will be the only one with this qualification. ... [N]urses kind of keep nurses at a lower level, and it's basically our fault [Participant 4, team leader]

[I]t's a bit of reverse psychology ... I'm enjoying it, but I want you to know that it's tough, because I don't want you to ... do the same course because I want to be better than you [Participant 14, charge nurse]

Thus, the findings suggest that through the creation of an oppressive environment only certain nurses may access and gain formal post-registration qualifications. As a result, the culture and the presence of horizontal violence may also serve to maintain the subservience of nursing to medicine within perioperative care.



Despite precautions, some interviews were interrupted, which may have limited the information divulged. No non-participants were recruited. Whilst there was consistency in participants' descriptions, these may not accurately reflect perceptions of perioperative nurses who do not access CPE. Although interviews were conducted and data collected six years ago as a part of a doctoral study, there is no evidence that the situation has changed in the interim.

Continuing professional education and horizontal violence

Through socialisation, individuals adopt the attitudes, values and unspoken messages within a group (Howkins & Ewens 1999, Mooney 2007) to become a part of that group. Whilst medicine can seemingly combine both academic qualifications and practical skills, in perioperative nursing these do not appear to be able to co-exist and many participants' experiences implied that pursuit of academic qualifications may be seen by colleagues as a negative aspiration, incompatible with the practice of nursing. It has been suggested that the move of nursing into higher education may change such negative attitudes and remove the anti-intellectualism in nursing (Hardwick & Jordan 2002, Miers 2002), however the findings of this study indicate that these attitudes persist in perioperative practice, as elsewhere (Cooley 2008) despite national initiatives to encourage lifelong learning (DH 2010, NMC 2011).

Horizontal violence was first described by Freire (1970), and was applied to nursing nearly 30 years ago (Roberts 1983). It may occur when nurses are viewed as an oppressed group (Bartholomew 2006, Rowell 2007) and subordinate to doctors (Hamlin 2000, Rowe & Sherlock 2005) with consequent powerlessness and low self-esteem (Freire 1970). Alternatively, it may arise as a result of the environment due to pressures of staffing and targets (Farrell 2001, Bartholomew 2006, Lewis 2006, Rowell 2007). Nurses are powerless to direct the resulting anger towards the perpetrators of that oppression (Bartholomew 2006). Instead the anger is vented towards nursing colleagues, in the form of horizontal violence, who appear to stand outside group norms as a reaction to the situation in which nurses find themselves.

Although alluded to previously (Gopee, 2003, Cooley 2008) explicit links between horizontal violence and lifelong learning have not been stated previously: This may appear to be a strong term to use in relation to CPE. However, evidence of the physiological and psychological manifestations of horizontal violence (Hamlin 2000, Dunn 2003, Griffin 2004,

Bartholomew 2006) was identified in many interviews, with devaluing of qualifications and achievement, and lack of interest and discouragement (Bartholomew 2006). Whilst managers are identified as pivotal in determining the cultural milieu (Stanley 2003, Gould et al 2007), and some describe that they are the usual source of horizontal violence (McKenna et al 2003, Fudge 2006), these findings support Rowe & Sherlock (2005) who found that the majority of horizontal violence was perpetrated by staff nurses, not managers. Nursing colleagues who do not access CPE may fear for their own futures within theatres, and displace these fears onto others who wish to study in the form of antagonistic behaviours. The inequality in terms of access to CPE, as also described elsewhere (Ellis & Nolan 2005, Gould et al 2007) prevented some nurses from undertaking formal study. Such actions allowed individuals to be the only ones in possession of (relatively) unique skills, which assisted in substantiating their future in perioperative nursing.

Specific techniques can reduce horizontal violence (Griffin 2004, Fudge 2006), however, participants appeared to adopt other techniques to limit the potential for becoming a victim of horizontal violence, including suppressing their achievements. It is reported elsewhere (Tame 2011) that some nurses studied in complete secrecy from colleagues, which may also be related to the need to avoid horizontal violence. These techniques are suggestive of a self-preservation strategy to avoid horizontal violence, and strengthen the argument that the pursuit of knowledge by perioperative nurses is perceived as a negative aspiration, and is an antecedent to horizontal violence.


This paper has illustrated a relationship between CPE and horizontal violence in perioperative practice, which has negative consequences in relation to academic study and perioperative nurses' psychological wellbeing Challenging the presence of horizontal violence in perioperative nursing culture could help more British perioperative nurses access CPE, strengthening their positions within theatre, renegotiating the boundaries of perioperative practice and consequently reducing oppression of perioperative nurses. Such action may be possible through a mentoring scheme, which pairs the student with a more senior colleague who is supportive of academic development.

Further work is required to illuminate the relationship between continuing professional education and horizontal violence within and outside of perioperative care, and to explore the notion of mentorship and clinical supervision during formal study. Additional research could also indicate whether changes to professional education have altered perioperative nurses' perceptions relating to horizontal violence associated with CPE since the original data collection.


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by Susan Tame

Correspondence address: Susan Tame, University of Hull, Cottingham Road, Hull HU6 7RX Email:

About the author

Susan Tame

PhD, PGDip, MSc (dist), BSc (Hons) PGCE (FE) RN (Adult)

Lecturer, University of Hull

No competing interests declared
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