Running head: HORIZONTAL VIOLENCE Arce

Horizontal Violence in Nursing

Cynthia Arce

NURS 20100
HORIZONTAL VIOLENCE Arce 2

Abstract

This paper focuses on workplace bullying between nurses, also known as horizontal violence.

Horizontal violence happens frequently and it has many effects not only on nurses but their

patients too. According to nursing studies, nurses experience horizontal violence frequently,

including new nurses and nurses from any specialty. The effects that horizontal violence gives

could be fatal, and could potentially cause harm to others. Those effects target the emotional and

physical wellness of nurses, which can effect the care that patients receive. Medical errors can

happen and patient outcomes can be affected, due to the stress and psychological state that nurses

are getting from this type of violence. There are factors that contribute to workplace violence,

and they go against nursing ethics. There are also many approaches that can be taken to stop the

violence between nurses. Horizontal violence could potentially become a less frequent issue if

nurses start taking action like working together and reporting the violence.
HORIZONTAL VIOLENCE Arce 3

Registered nurses face many issues in today’s time. One of the biggest issues that nurses

face today is horizontal violence. Horizontal violence, also known as lateral violence, is defined

as “behaviors intended to demean, undermine, and/or belittle a targeted individual working at the

same professional level” (Sanner-Stiehr, 2018). Horizontal violence can happen at a workplace at

any time, and individuals of any profession can experience this type of violence. Nursing is a

profession known to be caring towards each other and their patients. However, nursing is also

known to be one of the professions that see horizontal violence very often. There are many ways

that nurses experience lateral violence. Nurses may also have different reasons for bullying other

nurses. Nurses that are just beginning their careers may experience lateral violence more than

other nurses. This type of violence can be experienced by nurses of any specialty in the

workplace, and it can affect the work that nurses do. Horizontal violence can affect care, the

speed of care, and patient outcomes. Even though horizontal violence happens, there are actions

that a nurse can take to stop it. The purpose of this paper is to explain the issues of horizontal

violence between nurses, how it affects nurses physically and emotionally, how it affects their

patients, the contributing factors, how it violates nursing ethics and give potential approaches

that nurses or future nurses can take to decrease or find a solution for lateral violence between

nurses.

Nurses at all levels experience horizontal violence. It was found that almost all nurses

will experience lateral violence in their careers (Rainford, 2015). It is known that nurses

experience horizontal violence more than other “helping professions” (Butts, 2016). New Nurses

are especially at risk for being bullied by other nurses. There is a phrase known to the nursing

profession that says “nurses eat their young.” This means that nurses bully new nurses. Nurses

that have been nurses for a longer amount of time, are known to be the one bullying, while the
HORIZONTAL VIOLENCE Arce 4

new nurse is the one getting bullied (Christie, 2013). Since new nurses have questions and need

help from other nurses, they are more prone to bullying since they do not know any better

(Becher, 2012). It is also known that “student nurses and new nurse graduates are at a particular

risk for loss to the profession if they experience horizontal violence” (Becher, 2012). This shows

that horizontal violence is seen in nursing without even entering the nursing profession officially.

New nurses are not the only ones who experience lateral violence in the workplace. In the

nursing profession, this type of violence can happen to any nurse. In one study, it was found that

“horizontal violence in the form of bullying occurred most frequently in medical/surgical (23%),

critical care (18%), emergency (12%), operating room/post anesthesia care unit (9%), and

obstetrical (7%) areas of care” (Taylor, 2016). Therefore, anyone can experience lateral violence

no matter what level they are on. There are many affects that lateral violence has on nurses.

Lateral violence can happen more than once and it can get worse over time (Christie, 2013). One

affect that lateral violence has on nurses is that they might want to stop working and quit their

job. Nurses also might feel discouraged. They may become afraid of the nurses who are bullying

them and not receive the recognition they deserve (Butts, 2016). Nurses who experience

horizontal violence also may feel that it damages their dignity (Becher, 2012).

Horizontal violence affects nurses emotionally and this can cause many problems not

only for the nurse, but for the patient too. It contributes to many consequences toward nurses

such as depression, sleep problems, and anxiety (Sanner-Stiehr, 2018). If nurses experience

stress and it is not dealt with, this may lead to “unproductive coping and unresolved issues”

(Butts, 2016). Nurses may also experience “low self-esteem, anxiety, depression, and sleeping

disorders” (Becher, 2012). Nurses who feel like this may want to switch to another workplace, or

even leave the profession (Becher, 2012). Bullying affects a nurse’s psychological state and
HORIZONTAL VIOLENCE Arce 5

these behaviors may include “gossiping, targeted, personal jokes, ostracism, insults,

unwarranted, criticism, belittling, and verbal aggression” (Rainford, 2015). Nurses may feel so

stressed that they become angry and feel powerless. Some may even miss days of work because

they are so stressed from the bullying that they are experiencing at work (Becher, 2012). The

stress has become so bad for some people that there have been reports of suicidal behavior

(Becher, 2012). This shows that horizontal violence really affects nurses psychological state.

Nurses may start feeling uncomfortable in their work environment (Budin, 2013). In a study on

nurses by Taylor, she found that “Passive aggressive behavior in the form of backstabbing and

broken confidences in the form of gossip were occasionally overhead in the break rooms”

(Taylor, 2016). The study explained how during lunch one day, a nurse explained to the observer

that “gossiping was how nurses let off steam” and “another explained that it’s what they do for

fun” (Taylor, 2016). These were things that could have been reported because gossiping about

other nurses was prohibited to their code of conduct (Taylor, 2016). This shows how their code

of conduct was not enforced and that the nurses could have gotten in trouble. However, since it

was not reported, they did not get in trouble. Therefore, the gossiping would continue and there

would not be justice for the victims.

Not only does horizontal violence affect nurses emotionally, but it also affects them

physically. Nurses may experience “a decreased sense of well-being, and physical illnesses”

(Budin, 2013). Not only are nurses affected by bullying each other, but patients are affected by

nurses bullying each other too. If nurses are affected physically then this can affect the speed of

care in many ways. Patient’s safety can be affected because the nurses’ ability to perform her

duties correctly will be affected (Butts, 2016). When a nurse is in an emotionally bad condition,

the nurse may be in a bad position to be taking care of a patient, and there may be concern for the
HORIZONTAL VIOLENCE Arce 6

patient’s safety (Becher, 2012). Medical errors are seen by nurses who work with with nurses

that they don’t get a long with (Rainford, 2015). Nurses are supposed to help patients and care

for them in order for them to feel better. The speed of care is affected for some nurses because

they may get “sabotaged” by other nurses. Some examples of nursing getting sabotaged by other

nurses are “scheduling excessive workloads, misinformation, loss of records, violation of

privacy, and breach of confidentiality” (Rainford, 2015). This shows how patients can be really

affected by nurses having problems with each other. If there are records lost on purpose from

another nurse, this can be really bad for the patient, and the nurse who is the victim will be to

blame. This also shows how horizontal violence can affect nurses emotionally and physically at

the same.

There are many factors that contribute to lateral violence. One contributing factor is the

environment that nurses work in. Some nurses might be oppressed by other nurses or colleagues

that have more power than them (Rainford, 2015). For example, colleagues who have worked

there longer than the newer nurse may feel that they have more power or dominance over the

newer nurse. Management could also be a contributing factor. Nursing managers are the ones

that are above nurses, so they are the ones that have more power. Therefore, nurses may get

bullied from the more dominant group (Rainford, 2015). This can lead to a problem of it being

difficult to report since they are at a higher position (Christie, 2013). Lateral violence may also

happen between nurses because they might feel out of place by “dominant” groups of nurses,

become angry, and take their anger out on each other (Butts, 2016). Some nurses bully other

nurses because they are afraid they might be better than them and “outshine” them (Butts, 2016).

According to statistics, nurses that have low self-esteem seem to be bullied more than others.

Having low-self esteem makes nurses more vulnerable to harass and bully (Rainford, 2015).
HORIZONTAL VIOLENCE Arce 7

Another contributing factor is blaming other nurses. According to a study done on nurses,

scapegoating was seen between the nurses. The nurses blamed the groups of nurses from other

shifts for work not being completed (Taylor, 2016). This shows how nurses blame each other for

things, and this can lead to more violence. Nurses may become angry at the nurses and not get

along with them, resulting in not being able to work together properly.

By demonstrating horizontal violence, nursing ethics are broken. Nurses are supposed to

have good relationships with everyone in order to communicate effectively. Having good

relationships with patients is a necessity, and “good relationships with other nurses and with

other healthcare professionals are necessary for the successful follow-through of the

responsibility of the patients” (Butts, 2016). Horizontal violence between nurses break the ethical

principle of beneficence because the nurse’s job is to do good and help the patient in every way

that they can. It also breaks this principle because nurses are not working together properly and

having good relationships with each other. According to provision one of the ANA code of

ethics, nurses have to “maintain professional, respectful, and caring relationships with colleagues

and are committed to fair treatment, transparency, integrity-preserving compromise, and the best

resolution of conflicts” (Butts, 2016). Horizontal violence goes against this code of ethics

because by demonstrating violence, respect is broken for each other, and relationships are not

handled with care. Instead, violence toward each other brings disrespect and problems. This

relates to nonmaleficence because by demonstrating horizontal violence nurses are doing harm to

the patient and to each other rather than doing good. They could potentially be putting patients

lives at jeopardy by not getting along, and hurting each other emotionally. Provision one also

explains that morally unacceptable behaviors include “bullying, harassment, intimidation,

manipulation, threats, and violence” (Butts, 2016). These are all examples of horizontal violence,
HORIZONTAL VIOLENCE Arce 8

therefore, it is morally unacceptable for nurses to be displaying these kinds of acts. According to

provision five of the ANA code of ethics, the nurse has a duty to their self and others (Butts,

2016). Horizontal violence breaks this code because nurses are not having a duty to their self or

others because they are being violent toward each other. By bullying others, nurses are not

continuing personal or professional growth (Butts, 2016).

According to the ICN code of ethics for nurses, the fourth element explains that the nurse

needs to collaborate and respect co-workers (Butts, 2016). This element is broken because nurses

are not having respectful relationships toward each other. This element also explains that nurses

are to “take appropriate action to support and guide co-workers to advance ethical conduct”

(Butts, 2016). Rather than proving support for each other, nurses that display horizontal violence

are taking actions that are getting further away from advancing ethical conduct.

According to the the Joint Commission, “intimidation and disruptive behaviors can foster

medical errors, and contribute to poor patient satisfaction” (The Joint Commission, 2008). This

shows how the behavior of nurses can really affect patient care. The Joint Commission also

stated that patient’s care is dependent on teamwork (The Joint Commission, 2008). Therefore, by

not working together, this could bring on horizontal violence because nurses are not getting

along with each other.

Nurses can do something about this kind of violence, and that is to report the violence.

By reporting violence, it can be stopped and the abuser can get serious consequences. However,

sometimes nurses do report violence but nothing is done to fix the situation. If nurses report the

violence and nothing changes to help solve the problem to get rid of violence, nurses may want

to leave (Sanner-Stiehr, 2018). If this happens, then nurses may choose to leave their workplace,

and find work elsewhere. Since lateral violence is happening more often, it is considered normal
HORIZONTAL VIOLENCE Arce 9

to experience it in the nursing field. This is one of the reasons why nurses don’t report it

(Christie, 2013).

There are approaches that can be taken in order to stop horizontal violence. In order for

horizontal violence to be put to a stop, all nurses have to work together. Schools can also teach

their students about lateral violence and how they should handle it. Some recommendations for

nursing educators are to be good role models and show how to have “respectful communication.”

Educating about lateral violence and practicing how to address it is also a recommendation for

nursing educators (Sanner-Stiehr, 2018). Lateral violence can affect a person so much that some

people even go to counseling sessions. Talking about the problems that people are having helps

some people, and receiving counseling may help nurses deal with it better. Since “over half the

events of horizontal violence are never reported,” there are nurses out there who are still dealing

with violence (Becher, 2012). According statistics, since there are nursing shortages, constant

changes, and restructuring, lateral violence is likely to continue to increase in the workplace

(Rainford, 2015). Therefore, teaching nursing students about how to deal with horizontal

violence is very important, and should be taken seriously.

An approach that I would personally take to improve this issue is to start getting more

people to report being bullied by letting them know that it is okay to report it. If nurses become

comfortable to start reporting the issues that they are having at their workplace, other nurses may

follow and start reporting it too. Also, I think that nurses who bully others should receive

consequences, and nurses should know about the consequences they they could potentially get so

nurses will know what will happen if they bully other nurses. This approach might make nurses

realize that they should stop bullying other nurses. I think this approach will be effective because

if the nurse that is the abuser is not getting in trouble for their actions, then it is likely that they
HORIZONTAL VIOLENCE Arce 10

will continue to abuse (Rainford, 2015). I also believe that lateral violence needs to be taught to

nursing students more. If students learn about the violence that is happening, they can learn how

to deal with it better. If students are educated properly about horizontal violence, they can learn

how to report it. Horizontal violence affects not just nurses, but the care that patients receive. By

demonstrating horizontal violence, the codes of the ethics are broken. Nurses are affected

emotionally and physically and this may cause harm to the patients care. Horizontal violence

does not have to be an increasing issue in nursing, and there are many approaches that can be

taken to decrease violence in the workplace. Reporting the violence is very important. Overall,

working together and getting along with each other is what could stop horizontal violence. If

horizontal violence can be put to a stop, nurses can help each other more efficiently, and the care

that patients receive will be more effective.

HORIZONTAL VIOLENCE Arce 11

Works Cited

Becher, J. (2012). Horizontal Violence in Nursing.

https://www.amsn.org/sites/default/files/documents/practice-resources/healthy-work-

environment/resources/MSNJ-Becher-Visovsky-21-04.pdf/

Budin, W. C. (2013). Verbal Abuse From Nurse Colleagues and Work Environment of Early

Career Registered Nurses.

https://sigmapubs.onlinelibrary.wiley.com/doi/full/10.1111/jnu.12033

Butts, J. B., & Rich, K. (2016). Nursing Ethics. Jones & Bartlett.

Christie, W., Jones, S., (2013) Lateral Violence in Nursing and the Theory of the Nurse as

Wounded Healer. The Online Journal of Issues in Nursing, Vol 19 No. 1.

Rainford, W. C. (2013). The Disruptive Force of Lateral Violence in the Health Care Setting.

https://www.npjournal.org/article/S1555-4155(14)00688-6/pdf

Sanner-Stiehr, E. &Ward-Smith, P. (2018). Lateral Violence in Nursing: Implications and

Strategies for Nurse Educators.

Taylor, R. (2016). Nurses' Perceptions of Horizontal Violence.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5342647/
HORIZONTAL VIOLENCE Arce 12

The Joint Commission. (2008, July 9). Behaviors that undermine a culture of safety.

https://www.jointcommission.org/assets/1/18/SEA_40.PDF