Decoding Horizontal Violence in Nursing

October 30, 2017
Stethoscope and mask both on a table

Horizontal violence has many aliases, but is rarely called by name.

Lateral violence. Workplace bullying. Incivility. Hazing. Relational aggression. Over the years, horizontal violence in nursing has taken on many synonyms as clinical and marketing lingos evolve, yet by any name, it’s so deeply ingrained in nursing culture that it goes vastly unacknowledged. Yet it happens with worrisome frequency—it’s estimated that more than half of the incidents that occur are never reported, and statistics indicate that as many as 80% of nurses have experienced some form of workplace bullying, with an even higher percentage having witnessed events of horizontal violence on the job.
In fact, nurses face the greatest risk of workplace bullying compared to any other profession. It adversely affects the staff morale, personal health, and self-esteem of nurses—and puts a measurable damper on their hiring and retention. According to the U.S. Bureau of Labor Statistics, approximately 1.1 million new RNs will be needed to replace the population of experienced nurses who are retiring. Unfortunately, many nurses who experience horizontal violence end up leaving the profession entirely—well before retirement age.
According to an article by Jennifer Becher, MSN, APRN, and Constance Visovsky, PhD, RN, ACNP-BC, the cost of horizontal violence can range from $30,000-$100,000 per year per nurse—in the form of absenteeism, mental health treatment, poor performance, and burgeoning turnover—and that doesn’t even approach the cost of replacing a specialist nurse who works in surgery or the ICU, for example.
The universal challenge in addressing workplace bullying is that there’s scant regulatory precedent that employers can reference if they want to do something about it. As a result, it falls to individual organizations to thoughtfully develop and enforce unique codes of conduct that address horizontal violence. As one recent study showed, it’s been an uphill battle—but one that’s worth fighting.
In her 2016 article, “Nurses’ Perception of Horizontal Violence”, Rosemary Taylor, PhD, RN, spent time observing and interviewing nurses in two 28-bed inpatient hospital units. Her goal was to clarify the definition of horizontal violence as nurses truly experience it. She attempted to document the various manifestations of workplace bullying and the major themes that fueled those events.

What does horizontal violence in nursing look like chart

Conflict avoidance perpetuates cycles of silence.

Taylor’s study noted that 21 of 22 participating nurses voluntarily self-identified as “conflict avoidant”, a description which might indicate how cultures of bullying can thrive unchecked in nursing. The desire to minimize confrontation can amplify a nurse’s fear of not only reporting horizontal violence, but of being negatively labeled by their colleagues for doing so. Some of the nurses interviewed stated they believed that reporting accomplished nothing—and if it wouldn’t change anything, why bother?
Deficits of respect and support fuel the perpetuation of this cycle—a real or perceived lack of teamwork can impact many layers of hospital staff. Taylor shared the example of a nurse manager who closed a bed on her unit because the lone patient in a shared room was displaying intense verbal and physical aggression. (CPI-trained nurses will recognize that this is also a practice that aligns with Nonviolent Crisis Intervention® training, which encourages removing immediate bystanders as an effective means of de-escalating aggression.)
But shortly after the nurse manager made the call, a different administrator elected to reopen the bed despite the safety concerns. This lack of alignment between crisis prevention efforts and prescribed hospital procedure served to inflame dynamics between hospital departments and discouraged nurses from taking similar preventive measures.
Nurses and nurse managers reported that they felt similarly let down when funding was cut for continuing education, or when associate chief nursing officer positions were eliminated at their hospitals. Low morale could spread like a contagion—one nurse even vented that since it seemed management didn’t care about supporting nurses, why should the nursing staff care about supporting the goals of the hospital?
Of course, not all nurses feel that way. But it’s understandable that feeling undermined or unsupported can wear down anybody’s ability to stay motivated and effective in their work. The term “organizational chaos” ostensibly describes the series of bureaucratic layers and communication breakdowns that occur in the complex staff structures of health care facilities, especially hospital systems. It impacts everything from personal accountability on the job to adequately stocked supply cabinets. Nurses in Taylor’s study described a “mutual lack of understanding and disrespect” between departments and floors—and understandably, this directly contributed to conflict among staff members.

Culture change requires more than a code of conduct.

Knowing the manifestations and themes of lateral violence is just the first step in solving this systemic problem. Codes of conduct alone may not address the cultural issues that have allowed horizontal violence in nursing to fester relatively unabated.
Why is this? For one thing, research shows that nurses don’t tend to perceive workplace bullying as bullying. Rather, many nurses interpret incidents of horizontal violence as part and parcel of the offending individual’s persona, not as inappropriate behaviors that could be successfully curtailed or corrected.
No matter where you work, it can feel easier to minimize the experience of bullying by thinking about it in such terms. It can be hard to accept that professional adults would treat each other in this way. And with the rigors of orienting to the challenges of the profession, perhaps bullying among nurses just feels like another series of hoops they’ve got to jump through to earn respect and credibility on the job.
“I just don’t get along with that person” is a statement of fact that can be accepted and compartmentalized, whereas “That person’s behavior toward me was abusive and unacceptable” is an acknowledgment that merits an action or reaction of some kind.
And that’s why workplace bullying among nurses frequently takes place right out in the open. Taylor observed repeated incidences of lower level horizontal violence between nurses occurring in high-traffic, public areas, sometimes even in front of patients and visitors.

Recurring themes of horizontal violence in nursing chart

“I guess everybody has to earn their stripes.”

Nursing is currently the profession with the highest risk of horizontal violence, which means that there is tremendous potential for organizations to implement lasting, positive change by not only improving their awareness and education about this issue, but by tailoring policies and administrative actions accordingly.
In their article, “Lateral Violence in Nursing and the Theory of the Nurse as Wounded Healer”, Wanda Christie, MNSc, RN, and Sara Jones, PhD, PMHNP-BC, RN, emphasized that empowering nurses to thrive not only benefits their organization, but their patients as well. As they researched the patterns of horizontal violence, they concluded that a supportive environment aids prevention, and is achievable with training, insight, and compassion.
The consequences of unchecked horizontal violence unfortunately stretch far beyond the health and well-being of the nurses affected. “Patient care that is compromised is an even greater loss,” wrote Christie and Jones. “When the safety of patients is at risk, all avenues of resolution of lateral violence need to be taken.”
They cited a disturbing example, in which a nurse who experienced horizontal violence and reported it was ostensibly told that this behavior was simply a part of her profession, even though it put a patient at risk:
One day, I didn’t want to go to lunch because I thought a patient might have an internal bleed and the doctor didn’t seem concerned. I had suggested lab work and was awaiting the results to make sure the doctor was made aware of any abnormal values. Leah encouraged to me to go to lunch and promised to watch for the results. While off the floor, I heard a code called in ED. When I got back, my patient was being rushed to the operating room. The doctor reamed me out for not reporting the critical lab values immediately. “The lab just called a minute ago,” Leah said, but I saw her half smile and shoulder shrug to the unit coordinator. I definitely wondered if she was being honest. When I said something to another staff RN, she replied: “I guess everybody has to earn their stripes.”
I decided to talk to my manager about this and similar incidents. I ended up crying in her office. She told me she knew that Leah could be “hard on new people” and that “her bark was worse than her bite.” She said Leah was a crackerjack nurse with a heart of gold and for me to give it some more time. She told me that I was “showing some great potential, but should try not to be so sensitive.” I felt awful leaving her office.
In a 2016 TED talk, actress and activist Ashley Judd made a poignant observation about the failure to address bullying behaviors: “Trauma not transformed will be trauma transferred.” This is surely true of all forms of abuse—but in the field of nursing, there is a particularly harrowing implication if steps are not taken to address the cultural issues that allow horizontal violence to fester unmitigated.
Horizontal violence. Lateral violence. Workplace bullying. Incivility. Hazing. Relational aggression. If we don’t transform these attitudes and behaviors, we’re merely transferring them to somebody else. And that person could be a patient.

Training can strengthen your team—and stop bullying.

CPI’s own research has shown that training can provide a critical layer of connective tissue between the cultural issues within the field of nursing and the health care organizations that nurses serve. Nonviolent Crisis Intervention® training emphasizes that behavior impacts behavior—learning what triggers Anxiety in others, and how to proactively address it before it escalates into aggression, has as much of a positive impact on coworker dynamics as it does caregiver-patient exchanges.
CPI training grounds participants in practices like Rational Detachment, thoughtful decision making, and practical, effective debriefing to foster a culture of open communication where conflict is approached constructively, instead of taken personally. A team approach is critical to successfully implementing these de-escalation techniques, which bonds colleagues together in both knowledge and empathy. Hospitals that implement training have noted that improved collaboration between colleagues reduces incidents of violence and bullying at every layer of the organization.
In a recent episode of Unrestrained, a CPI podcast, nurse educator Sara Holland shared a powerful example of how training enabled staff to collaborate seamlessly between departments when a patient was escalating into crisis. In addition to facilitating a drastic reduction in Code Grays within a year of training, the facilitation of Nonviolent Crisis Intervention® training across all departments and all levels of staff in her hospital has ensured that coworkers now share the same goals and approach conflict consistently—and supportively.
Holland asserts that through training, the issue of horizontal violence in her hospital was finally and effectively illuminated. “We started recognizing that the issues weren't just patients. The people are saying, ‘I've had doctors get confrontational and screaming at me. I've had people follow me into the elevator. I had a nurse back me up against the wall.’ So it was workplace violence, too.”
By looking at the complete picture of how violence can wind its tendrils through layers of hospital culture, staff were able to see the immediate value of crisis prevention training—particularly through a rapid drop in conflict throughout their hospital. Said Holland, “It's a reality check for a lot of people when they go, ‘Oh. My attitude is going to affect what's going on in front of me, how I'm behaving.’”
Nursing is a phenomenally challenging and demanding profession. As Donna Cardillo says, “Nurses are the heart of healthcare.” They deserve to enjoy the same tireless compassion and care that they strive so inexorably to give to their patients. They deserve the support of thoughtful leadership, consistent training, and coordinated collaboration with the departments and staff they serve, because a truly safe environment of care belongs to all staff and all patients. 

They’re also members of a field that faces the highest risk of horizontal violence—and they deserve for that to change.

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