DOI: 10.1111/nuf.

12300

ORIGINAL ARTICLE

Horizontal violence among nurses: Experiences, responses,

and job performance

Elizabeth M. Bloom PhD, RN

Department of Nursing, Salve Regina

University, Newport, RI
Correspondence
Elizabeth M. Bloom, Department of Nursing,
Salve Regina University, 100 Ochre Point
Avenue, Newport, RI 02840‐4192.
Email elizabeth.bloom@salve.edu
Abstract
Horizontal violence (HV), or nonphysical intergroup conflict expressed in overt and
covert behaviors of hostility, is pervasive in nursing and has been discussed in the
literature for more than two decades. It is costly and has potentially devastating
effects including high nurse turnover rates, increased illness, decreased productivity,
and decreased quality of patient care. Recognizing how these behaviors are
established and sustained is necessary if nurses are to overcome these types of
behaviors. This mixed methods study used an online survey to examine 76 hospital
nurses’ experiences and responses to episodes of HV as well as its effects on job
performance. Seven of these nurses answered more in‐depth questions during a
follow‐up interview. Nurses in this study recognize HV as a phenomenon that
occurred early in their careers as novice nurses. The literature suggests that these
behaviors are evident during nursing education. The academic environment is an ideal
place to teach the skills necessary to respond appropriately to HV with peer support
being essential. Nurses also reported that manager and staff support and workplace
education were the most helpful in reducing HV. Increased workload and stress and
HV being accepted practice on the unit were factors identified as most important in
promoting HV. Further, nurses cited reasons why they continue in their jobs after
episodes of HV. Intervention studies are needed to test effective ways of reducing
this very difficult behavior among nurses in the workplace.

KEYWORDS
abuse/bullying/harassment/incivility, education, professional issues

1 | INTRODUCTION
Horizontal violence (HV), or nonphysical intergroup conflict that is
expressed in overt and covert behaviors of hostility, is pervasive in
nursing and has been discussed in the literature for more than two
decades. It is costly and has potentially devastating effects including
high nurse turnover rates, increased illness, decreased productivity,
and decreased quality of patient care. Recognizing how these
behaviors are established and sustained is necessary if nurses are
to overcome these types of behaviors.
HV has been described in the literature by various authors, and
although the definitions vary, there is agreement that HV is violence
Nurs Forum. 2019;54:77–83. wileyonlinelibrary.com/journal/nuf
in the form of action, words, and other behaviors that is directed
toward one’s peers.1–6 These behaviors control, humiliate, denigrate,
or injure the dignity of another person. HV reflects a lack of respect
for the individual.
HV directed at nurses in the workplace come from a variety of
sources including patients and their families7,8; physicians and other
hospital staff8–10 and between nursing colleagues.7,8,11,12 These
negative behaviors pose a threat to patient safety,13–16 and result
in increased stress levels, frustration, loss of concentration, and
breakdown in communication.9,17–19 Nurses report that HV between
nurse colleagues is the most emotionally devastating of all the forms
of workplace aggression.7
© 2018 Wiley Periodicals, Inc. | 77
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Repeated incidents of HV are overwhelming to the recipient and
5,20,21
may lead to depression. Nurses can also experience physical
symptoms. One of the most difficult consequences of HV is leaving
one’s job. According to Embree and White,22 approximately 60% of
new nurses leave their first place of employment within the first 6
months because of HV. New nurses who remain in their positions
also may be experiencing this type of behavior but choose not to
leave. Questions about why a nurse stays within an organization after
experiencing HV remain unclear. A clear understanding of this
phenomenon may lead to interventional studies that could lead to
improved work environments and improved retention.
Studies to date have shown that HV has detrimental effects on
workplace satisfaction and workforce retention;18,21,23–26 on the
psychological and physical health of nurses8,19,20,27,28 and on the
29–31
quality of patient care health outcomes. Most of these studies
focus on prevalence, causes, and effects of HV using quantitative
methods without exploring the actual experiences of nurses during
episodes of HV, or on their short‐term and long‐term responses to
these incidents.
Although the literature confirms that HV is recognized as a
problem in nursing, there is lack of evidence as to what nurses have
found to be helpful in combating episodes of this behavior. Careful
attention should be given to implementing strategies to empower
nurses to confront, diffuse, and resist these negative behaviors.
Nurses as healthcare professionals are in a position to identify when
HV occurs. With increased awareness and sensitivity, nurses may be
better able to monitor themselves, as well as to assist their peers to
recognize when they are displaying negative behaviors.
This study contributes to the understanding of HV and ways to
combat this behavior. Reasons why a nurse stays in an organization
after experiencing this type of behavior will contribute to nursing’s
knowledge about this sensitive topic.
2 | BACKGROUND
The nursing work environment involves complex interpersonal
relationships within a social and political context.30 Nurses balance
a multitude of tasks and are accountable to many people. Most agree
on the hectic nature of nursing practice and the constraints nurses
face every day in delivering quality care. As a result of these
demands, the practice environment can be stressful. This, in turn,
may lead to HV.
A review of the literature reveals that HV has been identified as a
significant issue within healthcare settings worldwide.32 Studies
conducted in Australia and Canada have shown that the frequency of
conflict in nursing is cause for concern.28,32–36 Lambert et al37
reported on nurses in Japan who experience conflict with other
nurses and their intent to leave their current nursing position.
McKenna et al20 found high levels of interpersonal conflict within 1
year after graduation in New Zealand’s new nurse population. In a
33
study conducted by Croft and Cash, the researchers sought to
identify factors contributing to bullying and lateral violence in British
Columbia. The authors found that bullying and lateral violence were
deeply institutionalized and that nurse managers and organizations
need to create a civil workplace. Canadian researchers have
identified incivility and bullying behaviors as a concern with regard
to recruitment and retention issues.34 That study found that a major
cause of turnover among nurses is related to unsatisfying workplaces
and incidents of incivility.
Several studies conducted in the United States demonstrate that
HV is a pervasive and harmful feature, which exists in most
workplaces. Armmer38 examined the nursing shortage and discussed
HV as being a common experience by registered nurses (RNs). RNs
reported a greater intent to leave the organization after these types
of experiences. Sheridan‐Leos17 reported on a study of new RNs who
were subjected to rude, abusive, and humiliating comments. Over a
third of the participants reported blocked learning experiences, felt
neglected, and felt that they were given too much responsibility
without appropriate support.
This review confirms that HV is a global issue, and the preponderance
of the literature supports that this type of behavior is a significant
problem in nursing. Quantitative research has provided a foundation
describing the frequencies, trends, and relationships associated with HV
in the nursing workplace.39 These studies clearly support the existence of
these negative interactions between nurses. While this is well
documented in the literature for over 20 years, there is a paucity of
research on how nurses describe their experiences with HV or their long‐
term and short‐term responses to these incidences.
2.1 | Research Questions
To understand the characteristics of HV experienced by RNs and
explore their responses, several research questions were developed.
These questions were:
1. What is the prevalence of HV experienced by RNs during their
career?
2. Who are most likely to be the perpetrators reported by RNs?
3. What are the characteristics of the victims reported by RNs?
4. What factors do nurses describe as fostering the occurrence of
HV in the workplace?
5. What factors do nurses describe as helpful in reducing the
occurrence of HV in the workplace?
6. In what way is job performance affected by experiences with HV?
7. What protective factors do nurses identify as the reason for
remaining in their jobs after experiencing HV?
3 | METHODS
3.1 | Design
This was a mixed methods study beginning with an online anonymous
survey of nurses and followed by a qualitative study of a subsample
who volunteered to participate in post‐survey interviews. The aim of
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the interviews was to describe the incidents of HV and nurses’
responses to them.
4 | SA M PL E AN D S E T T I N G
The study used a convenience sample of nurses (n = 76) used in two
city hospitals in northeastern United States. The hospitals are
affiliated and administer care across a variety of settings including
oncology, psychiatric, geriatric, and medical/surgical services. The
study was approved by the author’s University Institutional Review
Board (IRB) and the hospitals’ parent organizations’ IRB. Those
agreeing to be interviewed signed a written consent.
4.1 | Instruments and interviews
There were a total of 15 questions on the online questionnaire
including five demographic questions and eight related to HV. The
general demographic characteristics of the study population included
gender, age, number of years as an RN, number of years worked in
the institution, type of unit currently working on, and level of
education. Additional questions on the survey were modified from
the Lateral Violence in Nursing survey developed by Stanley et al4
and the seminal work of Griffin.40 The survey provided the following
definition: HV/lateral violence is the persistent demeaning and
downgrading of another through vicious cruel acts.41 It is manifested
through overt and covert behaviors such as withholding pertinent
information, criticism, and failure to respect confidences, and covert
behaviors such as eyebrow‐raising, snide remarks, and turning
away.40
The questionnaire identified RNs who would agree to be
interviewed. In the interviews, initially all participants were asked
the same three questions: (1) “Have you personally experienced HV?
If yes (2) “Can you describe the two most distressing incidents that
you remember?” and (3) “Are there any other incidents that you
would like to tell me about?” Subsequent questions were more
focused and guided by the responses made to the initial question.
Probes such as “What was your response to these incidents?” and
“What happened as a result of your response?” were used to help
manage the conversation, clarify unclear statements, and keep the
conversation on topic. Other questions that were asked to help
answer the main research questions were: (1) Did the behavior
continue or were you successful in stopping it? (2) What, if any, were
the responses that were successful in stopping the behavior? (3) How
did these incidents affect your job performance?
4.2 | Data analysis
Data were entered and stored in REDCap. REDCap is a secure, web‐
based application for building and managing online surveys and
databases. Descriptive statistics were used to summarize the
demographic characteristics and the responses to the Likert scaled
items.
| 79
The qualitative data interviews were audio‐taped, transcribed
verbatim, and analyzed using conversational analysis. Rubin and
Rubin’s42 model guided the analysis of this data. After the
transcription was completed, the data were coded. Coding involves
defining, finding, and marking in the text excerpts that have relevant
themes, events, examples, names, places, or dates. Themes identified
were placed in groups according to causes, characteristics, when,
who, consequences, and responses. In the final stages, excerpts of the
participants were compared, and the descriptors from the different
interviews were integrated to create a complete picture. This analysis
took the researcher step‐by‐step from the data obtained in the
interview to clear answers to the research questions.
5 | RESULTS
There were a total of 76 respondents to the online survey. Seven RNs
were interviewed about their experiences with HV. The majority of
the respondents to the online questionnaire were female (n = 68,
89.5%). The highest level of education completed was an associate
degree (n = 19, 25%) and a bachelor of science in nursing (n = 19,
25%), followed by master’s degree in nursing (n = 17, 22.4%). A
smaller percent (14.5%) had attained a diploma, with 13.2% having a
nonnursing baccalaureate degree.
The majority of the respondents (n = 42, 60.9%) worked as RNs
for more than 20 years. A smaller percentage of nurses (n = 18,
21.7%) had between 5 and 19 years of experience, with 17.3%
(n = 16) working in nursing from less than 4 years as an RN. Many of
the nurses (n = 21, 28%) worked in the current organization for 20+
years while 22.7% (n = 17) worked there between 10 and 19 years.
Other nurses (n = 29, 36%) worked in their current institution from 1
to 9 years with 13% (n = 9) working there for less than 1 year.
Respondents were located throughout the hospital with the majority
of nurses (n = 28, 37.8%) on primarily surgical or medical units.
The majority of the respondents (n = 53, 67.9%) had experienced
HV. Many of these nurses indicated that they had experienced it
recently with a smaller number (n = 18) stating they were exposed to
HV throughout their careers. Some nurses listed specific instances
where they experienced HV such as “getting and giving report” or in
the recovery room.
The majority of nurses (n = 53, 72%) also had seen others
subjected to HV. Further, many of these respondents reported
witnessing HV daily or at least once a week. When asked who was
most likely to exhibit this negative behavior, most respondents
(n = 65, 85.5%) reported the behavior was perpetrated by a peer or
fellow nurse. Physicians (n = 42, 55.1%) and nurse managers (n = 29,
37.7%) were also identified as exhibiting this type of behavior against
nurses.
When asked about the response of the victim to this type of
behavior, most victims walked away (n = 55, 76.2%) followed by
remaining silent (n = 44, 58.6%). Factors that increased HV in the
workplace included increase in workload/stress (n = 55, 72%),
accepted practice on the unit (n = 48, 62.7%), followed by manager
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attitude (n = 37, 49.3%). Interestingly, manager awareness and
support were cited as the most helpful strategy in reducing HV
(n = 59, 77.3%). Other factors identified as helpful in reducing HV
were staff support (n = 56, 74.7%), education in the workplace
(n = 52, 69.3%), workplace policy (n = 43, 57.3%) and education in
nursing programs (n = 40, 53.3%). A small percentage (n = 7, 9.5%)
responded that nothing helps.
Seven semistructured interviews were conducted over a 4‐week
period. Each of the RNs experienced HV themselves and also
witnessed episodes of this in their agencies. Six of the respondents
reported that nurse managers were the perpetrators and described
incidents of humiliation in front of others and yelling. All seven of the
respondents experienced HV as new nurses with disrespectful
communication frequently cited with several stating that the nurses
tended to “snap” at them. One nurse commented: “You are doing all
you can, and they just snap at you.”
When participants were asked what they thought the cause of
HV was, many of them identified the same issues. The most
frequently cited was stress; in fact all seven participants felt that
high‐stress levels lead to unprofessional behaviors on the units. For
example, three nurses stated: “I think we work in very stressful
environments”; “The stress, I think the stress, the hurrying, I’ve got to
get this done, and how am I going to do this? Now he wants me to do
that and you’re cutting staff—it is just a lot of pressure”; and “If
you’re at this high stress level and somebody comes to you with one
more thing, you’re usually going to snap.”
Another cause of HV identified by some of the interviewees was
older and younger nurses working together—generational differ-
ences. “Younger nurses are really being taught to be confident and
come forward and that creates another conflict with that seasoned
nurse because now she’s saying what does this new one think, she
knows everything.” Another nurse stated: “It’s very difficult
generationally. You have baby boomers who no matter what they
told you to do, you did it; it was all about work. The younger
generation seems better than us at having a work/life balance, and
the baby boomers resent that. It’s gotten better, but there is still a
perception that I went through it, and you need to go through it.”
During the interview, the nurses were asked how they responded
to the incidents that they either experienced or witnessed.
Interestingly, several respondents stated that they stepped in when
it was happening to someone else but remained silent or walked
away when they were experiencing it. One stated: “I find it difficult to
approach the nurse who’s been that way to me, but if I see it
happening to someone else, yes, I’ll talk to that nurse.” The nurses
were also asked if they felt that this type of behavior affected job
performance and had a negative impact on patients. All seven
participants agreed: “It does affect patients because they can sense
that you are having a bad day, and they don’t want to bother you
even though they might need something.” Another nurse commen-
ted: “It definitely affected my job performance, it made me on edge, it
made me scared, it made me afraid to ask questions; it made me
afraid to make decisions because I might get yelled at; it kept me
from growing.”
When asked about continuing to work for the organization after
experiencing HV, several of the nurses stated that the “good” people
outweighed the “bad” people. Sample comments included: “I thought
about leaving once, but there are too many good people who work
here” and “There are other people you work with, who are fantastic,
really helpful.”
All of the nurses interviewed indicated that managerial support
was lacking: “I think there is a big problem with nurse managers, they
don’t get “dirty” anymore. They just make schedules and walk around
and go to meetings. I call them clipboard nurses.” Another nurse
recommended that nurse managers become more involved: “I don’t
see a lot of nurse managers being visible on the floor, and I think they
need to be.”
In an attempt to identify an intervention to assist the victims of
HV, a question was asked about stopping the behavior. Did they try
to stop the behavior, and if so, were they successful? Several of the
nurses indicated that proper communication worked especially in the
event that the perpetrators were not aware of their actions. One
commented: “Communication has to be respectful, keeping your
voice calm and emphasizing respectful communication.” Another RN
suggested, “Sometimes I think a lot of it is setting up a communica-
tion network and having a safe zone where it’s ok to say what’s going
on here and do you realize this is happening? Some people will say
that they didn’t realize that they were coming across that way.”
6 | D I S C U SS I O N
The results of this study found that peers of fellow nurses were likely
to be the perpetrators of HV. The literature supports this finding,
nurses are major perpetrators of some forms of workplace violence
toward other nurses.43 This intercollegial aggression has been
identified as a major source of work‐related distress for nurses and
is common in many clinical settings.44–47
For HV in healthcare settings to be reduced, organizational
processes must change. Nurse managers and administrators cannot
overlook episodes of unprofessional behavior. Managers should have
a presence on their nursing units and offer support to nurses who are
stressed and overworked. Each of the nurses interviewed felt that
manager support was lacking, with one nurse actually describing an
incident that involved the nurse manager. No tolerance policies are in
place at the two facilities; however, several of the nurses felt the
policies were not enforced. No tolerance policies must be enforced.
Several of the nurses interviewed stated that this type of
behavior was the “norm” on their units. When managers and staff
nurses allow HV to continue, these behaviors can become the
behavioral norm of the unit. It indirectly promotes the behavior as
acceptable. New staff nurses are socialized into this culture and the
behaviors continue.
Episodes of HV left nurses feeling distressed and that their
concentration and judgment were impaired. Patient care can be
compromised because of the decrease in communication and collabora-
tion among the staff nurses. Further, Hughes48 suggested that episodes
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of HV are not limited solely to the two individuals involved: staff who are
bystanders are also affected and teamwork is undermined.
All of the nurses who participated in the semistructured interviews
stated that peer support after an episode of HV was key to their
decision to remain in their current position. This is consistent with a
49
study conducted by Purpora, Blegen, and Stott, which found that
supportive peer relationships are important to mitigate the impact of
HV. As this study found that nurses are more likely to step in when
witnessing HV, more studies are needed to combat this behavior.
Disruptive behaviors associated with HV continue to exist, are
toxic to the nursing profession, and have a negative impact on
retention. HV is detrimental to nurses’ well‐being and organizational
culture. It results in nursing dissatisfaction, interrupts communica-
tion, and has implications related to patient outcomes.
7 | IM P L I C A T I O N S F O R NU R S I N G
RESEARCH AN D PRA CTICE
Nursing research is needed to identify ways to improve RN work
relationships and increase the level of professionalism between
nurses. When one particular nurse was asked about how she
responded to an episode of unprofessional behavior, she replied
that she dealt with it on the spot in a “no‐nonsense manner.” When
asked if the other nurse might potentially see her as the aggressor,
she replied: “I don’t care.” Respondents were able to recognize the
behaviors in their coworkers but perhaps, not themselves. With
increased awareness, nurses may be better able to monitor
themselves, as well as assist fellow nurses to recognize when they
are exhibiting negative behaviors.
Although the study addressed protective factors that nurses
identified as the reason for remaining in their jobs after experiencing
episodes of HV, this area needs to be explored more thoroughly. The
nurses identified that peer support was essential; however, other
protective factors might also be important. Peer support can be
studied as a strategy to decrease HV.
Stress was identified by all of the interviewees as a cause of HV.
Nursing research examining different care environments consistently
identifies common sources of stress that nurses must manage at
work.50–52 Research needs to be conducted to identify protective
factors that can be used in the workplace to counteract the stress.
Nurse leaders have an important role in providing resources to help
nurses manage job stress and anxiety, to support nurses who have
experienced HV, and to act quickly when witnessing nurses who
exhibit negative behaviors on the unit that can lead to HV. Providing
ample opportunities for education and professional development is
important in planning to prevent or eliminate HV in the workplace.
Research on the experiences of nursing students may provide
information useful in answering the questions “When does this
behavior begin” and “Is it a learned behavior?” Clark and Davis
Kenaley53 noted that incivility in nursing education is not uncommon
and is “likely a give‐and‐take” between students and faculty (p. 158).
Further, a qualitative study conducted by Clark54 described student
| 81
and faculty experiences with incivility and found that stress was a
common precipitator of both faculty and student incivility. Nurses in
this study found that stress contributed to episodes of HV and
recognized HV as a phenomenon that occurred early in their careers
as novice nurses. Study participants also described incidents that
happened as new graduates that made them question the profession
they had chosen. The academic environment is an ideal place to teach
skills necessary to respond appropriately to HV between nurses at
work. The safe environment of the classroom can give students an
opportunity to discuss the different behaviors they have witnessed
and developed constructive strategies for recognizing and managing
these interactions.
Nurse leaders are in a position to prevent and eliminate HV by
providing resources to decrease this behavior in terms of support
and education. Providing resources to decrease job stress and
anxiety can prepare nurses to better care for their patients.
Providing ample opportunities for education and professional
development is important in planning to prevent or eliminate HV in
the workplace.
8 | SUMMARY
HV or behaviors that constitute HV in nursing have been present in
the profession for a long time making it a prominent issue in the field.
Throughout the years that the nursing profession has been discussing
HV, no definitive resolution to this recognized problem has emerged.
Although the terms used to identify the phenomenon have changed
over the years, the underlying problem of nurse‐to‐nurse hostility
and aggression have been a constant in the nursing work environ-
ment. This interferes with communication among nurses, which could
potentially affect patient’s care and well‐being. We need to work to
eliminate HV in nursing so nurses can be better able to fulfill their
professional commitments to patients, families, communities, and
themselves.
AC KNO WL EDG M EN T
The author was a participant in the 2018 NLN Scholarly Writing
Retreat, sponsored by the NLN Chamberlain University College of
Nursing Center for the Advancement of the Science of Nursing
Education.
ORCI D
Elizabeth M. Bloom http://orcid.org/0000-0003-4484-4902
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AUTHOR’S BIOGRAPHIES
How to cite this article: Bloom EM. Horizontal violence among

Elizabeth M. Bloom PhD, RN, Assistant Professor, Salve Regina nurses: Experiences, responses, and job performance. Nurs

University. Forum. 2019;54:77‐83. https://doi.org/10.1111/nuf.12300