Lateral Violence

[Sensibility]

I have posted on this discussion board before about passive aggression not realizing that the term everyone would understand is "lateral violence." So we all know what it is. I have been dealing with this hell for 2 years now. I felt so locked into my job because it took me so long to get a job. I have gone up as far on the chain of command as I can. I have put in for a transfer. I have tried to appeal to these people but my head nurse is a master manipulator and no matter how many times I try, I am always put in a negative light. The meaner she is, the more I am forced to either pretend it isn't happening and ignore her or deal with it. She crosses the line when she messes with me professionally. I am so afraid of retribution. I work nights and nights are very difficult to staff. So that is yet another reason I can't deal with this. The hospital is unwilling to let her go even knowing how horrible she has been to me. The rest of the group of my peers gives in to stay on her good side because nobody wants to be on her bad side.

Has anyone dealt with this and if so, what worked? I am especially interested in people who have successfully gotten the administration to deal with the person without losing the respect of their peers.

Thanking you in advance.

[Sensibility, BSN, RN]

CONCLUSION. This concept analysis

demonstrates that nurse-to-nurse LV is

nurse-to-nurse aggression with overtly or

covertly directing dissatisfaction toward another.

Origins include role issues, oppression, strict

hierarchy, disenfranchising work practices, low

self-esteem, powerlessness perception, anger, and

circuits of power. The result of this analysis

provides guidance for further conceptual and

empirical research as well as for clinical practice.

Organizations must learn how to eliminate

antecedents and provide nurses with skills and

techniques to eradicate LV to improve the

nursing work environment, patient care

outcomes, and nurse retention.

Search terms: Bullying, concept analysis,

horizontal hostility, horizontal violence, lateral

hostility, lateral violence, nurses eating their

young

Jennifer L. Embree, RN, MSN, CCNS, NE-BC, is a

University of Southern Indiana DNP Student, Indiana

University School of Nursing Adjunct Faculty,

Campbellsburg, IN. Ann H. White, RN, PhD, NE-BC, is

Assistant Dean for Nursing, University of Southern

Indiana, Evansville, IN.

Introduction

In order to stop lateral violence (LV), nurses must recognize LV and its consequences (Rowell, 2008). Approximately 60% of new nurses leave their first place of employment within the first 6 months because of LV that is perpetrated in the workplace

(Beecroft, Kunzman, & Krozek, 2001; McKenna, Smith, Poole, & Coverdale, 2003; Winter-Collins &

McDaniel, 2000).

Disruptive behaviors associated with LV continue to increase, are toxic to the nursing profession, and have a negative impact on retention of quality staff. These behaviors have been present in the literature for over 20 years (Bartholomew, 2006; Center for American Nurses, 2008; Needham et al., 2008; Farrell, 1997). Lack of a universal term and multiple closely related terms

in the literature makes research integration regarding LV difficult (Bartholomew). Disruptive behaviors associated with LV continue to increase, are toxic to the nursing profession, and have a negative impact on retention of quality staff.

AN INDEPENDENT VOICE FOR NURSING

166 © 2010 Wiley Periodicals, Inc.

Nurse-to-nurse LV concept analysis clarifies the existing state of knowledge regarding this concept and identifies direction for further interventions (Griffin, 2004). Significant among nurses, LV results in social, psychological, and physical consequences, negative

patient outcomes, and damaged relationships. Understanding personal, interpersonal, and organizational factors impacting LV will lead to future interventional research and could positively impact retention and recruitment and lead to improvement

of the disenfranchised nursing work environment (Leiper, 2005). Nurses will leave a workplace if LV is allowed to continue. Turnover is costly in terms of the stress of increased workload on remaining staff, and results in expense to the organization. Registered nurse (RN) turnover costs up to two times a nurse’s salary, and the cost of replacing one RN ranges from $22,000 to $145,000 depending on geographic location and specialty area (Jones & Gates, 2007).

For more information, check this source: Embree, J., & White, A. (2010). Concept analysis: nurse-to-nurse lateral violence. Nursing Forum,45(3), 166-173. doi:10.1111/j.1744-6198.2010.00185.x

[Sensibility, BSN, RN]

.one day I had had enough....I paged him to my room and proceeded to let him and the MD"s staff know I had had enough and if he did it again I would be calling HR each and every time for harassment that his insecurities/inferiority would NOT be cured by childish eighth grade behavior....and will no longer be tolerated. It stopped when I made sure every glaring mistake/misstep of his was brought to everyone's attention. He quit being a jerk.

You did deal with it but not as quickly as you may have liked. Note that is sabatoging for anyone who wants to know. The fact that this man was willing to go after this employee through a patient is unconscionable. And like you said, there are lots of nice people out there looking for work. Why should you and I be the ones leaving? They should for workplace bullying and lateral violence.

I did post this under a different name at one time because I didn't know what to do and I was so upset. This was two years ago. I personally do not believe that this should have gone on this long or been some sort of psuedo initiation into the nursing culture. We need to stop this junk because it can harm patients, costs the healthcare industry hundreds of thousands of dollars, and is like you said, 8th grade ridiculousness. But this woman in my case was getting away with it because a) she was in charge b) others would rather be on her good side than bad and so they would comply to whatever she wanted and c) her methods are very covert.

I did get that reaction though where I tried to explain the situation. That's why I didn't want to share the details.

[Sensibility, BSN, RN]

Some other examples are:

Public humiliation

Writing someone up by falsifying information

Non verbal innuendos like rolling the eyes

Ignoring questions or failure to respond

Refusal to help

Giving out patient assignments to the favored of the best clients and giving the difficult patients to the target

No team work. IOW, not helping the target who is bogged down with patients

Hogging the CA leaving the target to do all their work without an assistant

Refusing to give important information especially to someone new

Refusing to organize other areas of the hospital such as the lab, phlebotomist, IV team, or xray when there is a need

Pretending to forget important matters leaving the target as the one responsible for these actions - ie scapegoating

Gossiping about the target

Unfair judgments about the target but not judging friends in the clique in the same way. For example, a charting error might be dramatically written up but others in the clique are covered as they watch each other's backs.

Now in the hospital setting there are social events such as birthday parties, graduation parties, kudos, thank you notes, words of affirmation, baby showers, weddings, etc. We all know that some people socialize outside of work with others that they don't socialize with in work. This is normal. However, if the hierarchy are giving out kudos and thank yous to a vast majority of employees and for example, graduation cakes and words of congratulations when people make nursing accomplishments, it is inappropriate to leave one person out. These actions by a laterally violent individual are deliberate. They are meant to hurt the person to get them to quit.

These people are horrible and they should not be allowed to work with the rest of the group any longer if they refuse to be counseled and change. And unfortunately, it usually takes a bold individual to step forward and declare (as I did), "I am documenting every single time you use this behavior against me and if you don't stop, I am going to report you to the state board of nursing." The end.

[Esme12, ASN, BSN, RN]

I dealt with it in a timely and effective manner and I was pleased with the result. Is this the same incident from 2 years ago that continues to plague you? or another one all together. I am not sure the board will be interested that these group of nurses are jerks and means girls with a high school mentality. I am not sure the BON will be interested that your co-workers exclude you.

I saw an old post of yours.....and you got a great answer.....rn/writer https://allnurses.com/nursing-career-advice/i-desperately-need-615021-page3.html#post5614169

You sound like a very nice person who is caught in the trap of being a people pleaser. You thought your employer would be so pleased and happy that you took this ALS course. It's good to look for ways to improve yourself and keep your training fresh and up to date. But this may be a case of trying to run before you can crawl.

Here are a few suggestions for getting yourself back on track:

1. Stop trying to make other people happy. Stop trying to please them and have them care about you. Stop worrying about their opinions and whether or not they like you. Does that mean you give up and stop trying to learn how to do your job better? No. It means that you keep learning and orienting and improving because it's the right thing to do and because it will please you to become better at what you do. Does it mean that you become cold and disdainful toward your peers? No, it means you be pleasant and kind, but you don't spend a lot of time trying to make friends or get close to others. There will be time for some of that later when your job is more secure and you are feeling safer.

2. With your manager's help, pick one or two wise nurses who have some emotional maturity and seek them out for any feedback that you need. This should help cut down on your confusion. Do not look for affirmation of your feelings but rather of your knowledge and skills. Keep your emotions in check and deal with them off the clock. We read other people, so if you go around with your heart on your sleeve, you're going to be way too vulnerable and you will telegraph your neediness to those who can be unkind.

3. Carry a small notebook in your pocket. Write down any questions you may have so you can look them up when you have a chance. Try to do this before you ask someone else. It will stay with you longer if you have to seek the information out. And you will not come off as someone who relies on others rather than doing the legwork yourself. Yes, there will be times when you have no choice but to ask, but if you have kept your inquiries to the minimum, this shouldn't be a problem.

4. In this same notebook, write down your successes. If you tackled something new and it went well, write it down. If someone says something nice (even though you're no longer seeking that), write it down. If you caught a problem and fixed it or at least alerted others to it, write it down. We are far too good at remembering our failures and beating ourselves up with every replay. We need to keep better track of our victories and run through them from time to time. This helps on one of those days when you don't think you can do anything right.

5. Do not allow anyone a vote on whether you're an okay human being. You decide that you are, and that's that.

6. You do accept input on your nursing skills, but even that should be tempered with caution. Consider the source. Examine the content of any negative input. Take in what is valid and toss the rest.

7. Get your emotional affirmation away from the job. If you don't, you will be putting your equilibrium in the hands of others who may or may not have your best interests at heart.

8. Tell yourself the truth--that it would be nice, wonderful even, to get some positive feedback and personal attagirls on the job--but it may never happen, and you can do this job even without them.

How do I know this is the truth? I started my first acute care job eleven years after becoming a nurse (I did psych before that). Although the people I worked with were nice, for the most part, there were a few who were kind of snarky or distant. During my first year I made a couple of mistakes and was spoken to about them. I felt terrible. I felt even worse because nothing was ever said when you did things right or well. It felt very unbalanced, especially to someone who had not previously worked in acute care.

This was a battle that I waged in my spirit for several years. To this day, I still say it would have helped me tremendously to have someone soften the correction with something good, so that I would not feel like a trapdoor could open beneath me at any moment. But I learned to keep going and have now been on this unit for more than six years.

You do not need your co-workers' approval. You can get through this and accomplish your goals.

I wish you the best.

Personally I keep my personal life and professional life as separate as I can....the one time I didn't I was sorry. I have some favorite quotes.......

"No one can make you feel inferior without your consent"........ Eleanor Roosevelt

"Let me never fall into the vulgar mistake of dreaming that I am persecuted whenever I am contradicted".......Ralph Waldo Emerson

"That which does not kill us makes us stronger"......Nietzsche

[Sensibility, BSN, RN]

Yes, that was the start of this but it was so much more than what I said that day. You know, when that first happened, I sincerely thought that there was this major high standard that everyone was holding to and that I was missing something that I needed to correct and once I corrected it, all would be well. Then one day about a year ago, I saw a nurse chart a diagnosis. Did she get written up? No. I saw a nurses and care assistants watching movies, writing papers, sleeping and so on in the unit. Did they get written up for not holding this high standard of expectation? No. Not one thing happened. Also since that day, I have caught two incidences of EKG issues that others missed and one was PVCs. I thought the monitor might have been malfunctioning at that time. So I was at times looking to see if I saw that same pattern but never did again until one day, I saw it. And sure enough, it was PVCs.

After two years, I know that I was singled out to discourage me, destroy my reputation, put me in a position where I felt my job was on the line and ruin my reputation. My job was literally verbally threatened and those in the higher up area did not know. How can someone do that without the sanction of those people? I know that now because finally the door opened to share what had happened.

So at that time, I actually was trying to find some advice on charting. Then it began to evolve into this situation where I saw that I was being targeted but not outright such as yelling at me in public. It was all this subversive kind of behavior such as not answering a question when asked or ignoring me when I asked for help or being conveniently unavailable when the person knew I would need help. I would get the busiest patients and while I was running around like a crazy person, others were sitting and chatting. There were some issues that were petty and others that could have been serious. If you follow the whole thread, it starts out with me in shock. Then I began to see some issues with the whole incident such as the IV nurse lying. I now know that this was a group of nurses working together and not just one person and it was done because I had asked that one of these nurses answer questions if I needed her to after she totally had a meltdown when I asked a simple newbie question.

This behavior has a name that the Joint Commission has identified and it is labeled lateral or horizontal violence. If you go to Youtube, there are a number of role plays of this behavior. This is a great set of examples and one of my favorites. I hope that one day that someone else will come here looking for answers and find them on this thread.

[Sensibility, BSN, RN]

[labordude, BSN, RN]

One of the biggest issues I see in people dealing with lateral/horizontal violence is the pervasive weakness in conflict resolution and "crucial conversation" skills. As a group, people (not just nurses) are notoriously bad at dealing with conflict around them. A bigger part of the issue is that there are often people working above us who are just as bad at it. There actually was one point she made that is key, "passive tolerance is NOT a neutral act." Passive tolerance comes from others around us being unsure how to respond. I have seen a change in communication strategies after people are taught how to communicate, but they also have to know that they will be supported by those above them. An organization needs to make a safe, effective work environment a priority. In one of my prior jobs, I taught a class that involved interpersonal communication strategies and conflict resolution techniques with error reduction as the main goal. I have seen firsthand what can happen when you equip the entire team from housekeeper to chief surgeon with the exact same set of tools for handling difficult situations, LIVES GET SAVED. That's what matters...okay, that's the end of my politically correct response.

Here's my non-"pc" response as if you were one of my closest friends: (I'm not a lawyer, this is not legal advice, blah blah, I'm just your best friend and you need to hear what I have to say!)

1)First, grow a pair and make sure your skin is relatively thick. Chances are the insults and problems being levied back at your are due to the insecurity of those around and above you. Amazing how that works, feel insecure so you demean and reduce those around you so they feel lesser too.

2)Since you've already made complaints, your name is known to those above you and it seems like nothing has been done.

3)Make sure you've followed your hospital/org policy on complaints

4)Why not request a meeting with ALL of the following at the same time: a) the person who you make complaints against, since it's your manager, it is not lateral violence, it becomes something very different; b)HR rep, preferably a manager; and c) risk management, who is often an attorney. One poster mentioned "hostile work environment", be very careful with that, it's notoriously difficult to prove. Oh and if other people have issues with this same person, jackpot!

5) Oh wait there's more, make sure the problems you are having are ACTUAL problems. If you were to tell me about them and I roll my eyes and say "seriously?!, you're bothered by that" you might want to rethink if it's your reaction to the situation or an actual issue.

6) Don't flaunt the EBP project, etc. Everyone already "knows" that lateral violence is an issue and we're taking it "very seriously."

Ok, I'm good.

[Sensibility, BSN, RN]

One of the biggest issues I see in people dealing with lateral/horizontal violence is the pervasive weakness in conflict resolution and "crucial conversation" skills. As a group, people (not just nurses) are notoriously bad at dealing with conflict around them. A bigger part of the issue is that there are often people working above us who are just as bad at it. There actually was one point she made that is key, "passive tolerance is NOT a neutral act." Passive tolerance comes from others around us being unsure how to respond. I have seen a change in communication strategies after people are taught how to communicate, but they also have to know that they will be supported by those above them. An organization needs to make a safe, effective work environment a priority. In one of my prior jobs, I taught a class that involved interpersonal communication strategies and conflict resolution techniques with error reduction as the main goal. I have seen firsthand what can happen when you equip the entire team from housekeeper to chief surgeon with the exact same set of tools for handling difficult situations, LIVES GET SAVED. That's what matters...okay, that's the end of my politically correct response.

Here's my non-"pc" response as if you were one of my closest friends: (I'm not a lawyer, this is not legal advice, blah blah, I'm just your best friend and you need to hear what I have to say!)

1)First, grow a pair and make sure your skin is relatively thick. Chances are the insults and problems being levied back at your are due to the insecurity of those around and above you. Amazing how that works, feel insecure so you demean and reduce those around you so they feel lesser too.

2)Since you've already made complaints, your name is known to those above you and it seems like nothing has been done.

3)Make sure you've followed your hospital/org policy on complaints

4)Why not request a meeting with ALL of the following at the same time: a) the person who you make complaints against, since it's your manager, it is not lateral violence, it becomes something very different; b)HR rep, preferably a manager; and c) risk management, who is often an attorney. One poster mentioned "hostile work environment", be very careful with that, it's notoriously difficult to prove. Oh and if other people have issues with this same person, jackpot!

5) Oh wait there's more, make sure the problems you are having are ACTUAL problems. If you were to tell me about them and I roll my eyes and say "seriously?!, you're bothered by that" you might want to rethink if it's your reaction to the situation or an actual issue.

6) Don't flaunt the EBP project, etc. Everyone already "knows" that lateral violence is an issue and we're taking it "very seriously."

Ok, I'm good.

I really appreciate your reply and am going to use it as an example of how not to respond to someone who is dealing with this. I know you mean well but people who are nice don't want to "grow a pair." I don't want to be that person. I'm a nice person and I expect everyone around me to be nice too. This idea that being a nurse is being a tough guy needs to be tossed out the window.

In the beginning of this thing, I didn't know what to do. I thought if I spoke up and said anything, I would be considered the problem and asked to leave. I felt very vulnerable and isolated. I have a strong personality but that didn't matter in this context. Many of these things can't be proven because they are done under the radar. The victim knows that the actions are deliberate but nobody else sees it. These people are masters at manipulation and when their tactics don't work, they fall back on other manipulative tactics. Note in the video how the man is gossiping about this girl and then she walks up and nobody is talking anymore. It is so obvious that this person is being talked about but can she prove it? No. What about the girl who is busy and nobody will help her?

I followed the hospital's policy to the letter and I was nearly fired because of this one individual. At the end, I finally did get someone's attention and was able to talk to someone about what happened. If nothing else, my name was cleared and that made me very happy.

I am going to flaunt the EBP materials to the moon because that is what gets these people's attention. If I walk in there with my opinion, it counts for nothing. For those of you dealing with this, if you bring up the words "Joint Commission," they have to take you seriously. Otherwise, you get horrible letters like the one above telling you to suck it up and figure it our or quit. Well, that is costing our system thousands of dollars not to mention creating a whole lot of mess. It solves nothing. These people will continue on until they have to stop. It is not the solution as this board continuously tries to give this advice. It is bad advice.

The only piece of advice in this letter that was good was getting into a meeting and talking about this but one has to come prepared with EBP materials. I did. It worked.

[labordude, BSN, RN]

I really appreciate your reply and am going to use it as an example of how not to respond to someone who is dealing with this. I know you mean well but people who are nice don't want to "grow a pair." I don't want to be that person. I'm a nice person and I expect everyone around me to be nice too. This idea that being a nurse is being a tough guy needs to be tossed out the window.

In the beginning of this thing, I didn't know what to do. I thought if I spoke up and said anything, I would be considered the problem and asked to leave. I felt very vulnerable and isolated. I have a strong personality but that didn't matter in this context. Many of these things can't be proven because they are done under the radar. The victim knows that the actions are deliberate but nobody else sees it. These people are masters at manipulation and when their tactics don't work, they fall back on other manipulative tactics. Note in the video how the man is gossiping about this girl and then she walks up and nobody is talking anymore. It is so obvious that this person is being talked about but can she prove it? No. What about the girl who is busy and nobody will help her?

I followed the hospital's policy to the letter and I was nearly fired because of this one individual. At the end, I finally did get someone's attention and was able to talk to someone about what happened. If nothing else, my name was cleared and that made me very happy.

I am going to flaunt the EBP materials to the moon because that is what gets these people's attention. If I walk in there with my opinion, it counts for nothing. For those of you dealing with this, if you bring up the words "Joint Commission," they have to take you seriously. Otherwise, you get horrible letters like the one above telling you to suck it up and figure it our or quit. Well, that is costing our system thousands of dollars not to mention creating a whole lot of mess. It solves nothing. These people will continue on until they have to stop. It is not the solution as this board continuously tries to give this advice. It is bad advice.

The only piece of advice in this letter that was good was getting into a meeting and talking about this but one has to come prepared with EBP materials. I did. It worked.

You completely misunderstand my statement of "growing a pair." I was in no way suggesting that you needed to be a "tough girl." Additionally, being a nice person doesn't mean that you accept being treated poorly because you expect the people around you to be nice. I'm known as a very nice guy, but the people around me know that I will not allow myself or anyone else to be treated poorly or in an unprofessional manner. I also never stated remotely "suck it up and figure it out or quit." I'll just assume you were addressing another reply there. I very rarely tell people to "suck it up", generally only when they are making an issue out of nothing. I was simply asking if you were doing this and it is a valid question. Apparently my humor doesn't carry across the interwebs, my bad.

As to the video, we only know that he was gossipping about her because we were watching the video as outsiders. If this situation occurred in real life, the incoming nurse could only assume they were talking about her. What if they weren't and their discussion simply didn't need to include her in it? Or what if they were planning a surprise for her? She simply wouldn't know and to dwell on it is utterly useless. In the case that they were talking about her, it's up to those involved or in earshot to call out the offending parties which requires that people are equipped with the tools and confidence necessary to do so; that is sorely lacking in our healthcare organizations. How can we blame an individual if the entire structure is faulty? What should be done is to educate everyone and THEN you can hold them accountable for their behavior. It also sounds like a completely ineffective management structure which is a whole different can of worms.

I was looking at this from both your side and the mindset of those you might have talked to about it. If I'm the manager or whoever and you come into my office with a stack of EBP information, that's great, how does it help solve the problem? I'm not being sarcastic here, I want to know how it helps? As I said before everyone "knows" that lateral violence is a thing and that there are studies that show the damaging outcomes. The question isn't SHOULD we do something about it, it's HOW should we do something about it? What steps must be taken at different levels of the organization to fix this issue? If those in positions to work on stopping the behaviors are unwilling to do anything, it becomes incredibly difficult to change a culture.

A very good book that talks about dealing with surviving difficult work environments is called the "No ******* Rule" by Robert I Sutton. It's excellent, highly recommended.

[OCNRN63, RN]

Thanks everyone who responded. I am about to get my BSN in a couple of weeks. Yeah. I have been learning a great deal about this topic. There have actually been about 78 evidence based research papers on the topic of lateral and horizontal violence. MJH3483, it is covert in nature. It is gossip, not answering questions, refusing to help, sabotage, giving your favorite nurse the best assignments, the silent treatment, and a whole lot more. It can be petty or very serious if it involves patients. The victim often feels isolated and suffers with low self esteem, which is the goal of the bully. The bullies are usually the older nurses and the victim is typically either a new grad or new to the hospital. This is a major problem for hospitals because the nurse will ultimately leave after the hospital has invested hundreds of thousands of dollars in training this nurse. Retention in the hospital setting should be a priority, which is why hospitals need to take this seriously. I took that EBP research to the human resources department and it made a difference. I at least feel that my name has been restored and that this cannot happen easily again. So for that, I am grateful. People should not have to hire attorneys or quit to get this resolved, in my opinion. So I worked to try and help my hospital get a perspective on it. Thank you again for your very kind words. It meant a lot to me!!

THIS. FWIW, the few times someone tried to bully me at work, it was a younger nurse doing it.

Almost every day, someone here references older nurses, usually getting in a dig or two about their appearance ("old hag" was one I spied today). Bullies come in all ages and education levels. They can be staff nurses, managers, even unit secretaries. Heck, I had a chaplain try to bully me. So, I don't buy that all victims of bullying are young, wide-eyed innocents suffering at the hands of old crones. In my one case, the chaplain was conspiring with a young secretary. I wound up getting fired from that job, but in the long run it was the best thing that could have happened to me because I got a much better job later.

[Sun0408, ASN, RN]

I would have to stop and ask myself, "is it worth it to continue to be treated this way after 2 years". OP, you can talk about EBP and cost all you want but the fact is, it is not helping you in this situation. While I don't know the details, I can tell you are obviously upset. This will lead if it hasn't already to stress, family/home issues, as well an overreaction to normal daily dealings with those we work with.. Save yourself and walk away.

You may be playing a role in this lateral violence/harassment or bullying yourself and just not recognizing it. You are getting something out of all of this simply because you stay. I by no means am saying this to be mean but is there a chance you are taking this too personal?? Negative attention is still attention..

[Destiny'skid]

I have experienced bullying at work and here are my thoughts. There is personal and there is professional issues. Personal issues cannot be dealt with the same way. The example of being left out of activities outside of work or conversations pretty much you just have to ignore. You have to accept that you may not be friends with everyone at work. The goal is to create boundaries and gain the respect of others not get them to like you. I dealt with this stuff by letting it be water off my back. If people gossiped about me or called me out on things I didn't do I didn't try to defend my self as long as its threats they do nothing. Defending yourself and getting upset wot help. If they try to write you up that's when you go to a higher authority you show their error ( doing by hear say ect) and they can get in trouble they can't right u up from hearsay they can threaten bit u can ignore them.

There are third party organizations who can help to. I have a friend who used this route, but I think you will have much more success with whatever route/process you go through if you stick to the professional problems. Your boss or coworkers don't have to be nice or like you but they have to work as a team. So instead for example of saying how snooty they are keep track of and report real examples of how a person ignored you and it hindered a patient from being cared for. I think if you keep the two issues separate it will help. Personal bullying is bad but there's not always much that can be done. Many bullies don't care. So stick to the stuff that actually breaks the rules.

One last thing. I you make a mistake and are written up when others get away with it, try to remember two wrongs don't make a right. Ie it's still wrong when you do it. If others sit around and chat remember you aren't being paid for this. Take advantage of your alloted breaks and don't be bullied put of them they are yours BY LAW. Any way hope this helps just my two cents. You can't fix everyone else but you can keep yourself above reproach. These methods have really helped me at work.