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July-August 2012 • Vol. 21/No. 4210

Jennifer Becher, MSN, APRN, is Acute Care Nurse Practitioner, University of Nebraska Medical Center, College of Nursing, Omaha, NE.

Constance Visovsky, PhD, RN, ACNP-BC, is Associate Dean, Student Affairs and Community Engagement, University of South Florida, College of Nursing, Tampa, FL.

Horizontal Violence in Nursing

T o achieve high-quality care, professional team- work among nursing staff is imperative. Teamwork is

a critical element for achievement of positive patient outcomes (Joint Commission, 2008). Teams achieve success through a shared vision, a positive attitude, and respect for each other (Phillips, 2009). Conversely, negative workplace relationships can disrupt team performance, creating a work environment that can lead to burnout, increased staff turnover, and poor patient outcomes. Acts of aggression by one nurse colleague against another is termed horizontal violence (HV) (Longo & Sherman, 2007). In this article, the occurrence of horizontal violence in nursing will be described, and strategies for preventing and ameliorating its effects will be provided.

What Is Horizontal Violence?

Horizontal or lateral violence has been described broadly as any unwanted abuse or hostility within the workplace (Stanley, Martin, Nemeth, Michel, & Welton, 2007). Thobaben (2007) defined horizontal violence as “hostile, aggressive, and harmful behavior by a nurse or group of nurses toward a coworker or group of nurses via attitudes, actions, words and/or behaviors” (p. 82). Horizontal violence is characterized by the pres- ence of a series of undermining inci- dents over time, as opposed to one isolated conflict in the workplace (Jackson, Firtko, & Edenborough, 2007). This repeated conflict makes HV overwhelming, leading to symp- toms of depression and even post- traumatic stress syndrome in the vic-

tim. Horizontal violence tends to be covert, hard to discern, or discover; the victim thus has difficulty in seek- ing assistance within the job setting. Horizontal violence also has been portrayed as an intergroup conflict with elements of overt and hidden hostility (Joint Commission, 2008). Members of the nursing profession have been described as an oppressed group, having mostly female mem- bers. Oppression theory suggests that powerlessness, lack of control over the working environment, and sub- sequent low self-esteem contribute to the development of HV within the nursing profession (St-Pierre & Holmes, 2008). However, this fails to address the notion that HV occurs across many professions, and encom- passes individual, social, and organi- zational characteristics (Wilson, Diedrich, Phelps, & Choi, 2011).

Horizontal violence that results in repeated acts of aggression toward colleagues also is known as work- place bullying (Longo & Sherman, 2007). Vessey, Demarco, and DiFazio (2010) defined personality character- istics of a bully to be one who publi- cally or privately demeans another employee. They suggested the bully’s

behavior is deliberate, with the intention to cause physical or psy- chological stress to the victim. Intimidating behaviors of individu- als engaged in bullying often are present across the lifespan. Bullies may rally support from others as a means of endorsing their behavior. This group support provides an audi- ence that reinforces aggression, fur- ther isolating the victim and enabling the bully to operate and extend his or her influence (Randle, Stevenson, & Grayling, 2007).

More recently, the specific behav- iors that constitute HV have been described (Center for American Nurses, 2008; Edwards & O’Connell, 2007; Vessey et al., 2010). These behaviors may include criticizing, intimidation, blaming, fighting among co-workers, refusing to lend assistance, public humiliation, with- holding behavior, and undermining the efforts of targeted individuals (Edwards & O’Connell, 2007). Other actions displayed by a perpetrator may include name calling, threaten- ing, gossiping, isolating, ignoring, unreasonable assignments, using silence, and making observable physical expression such as eye

Professional PracticeProfessional Practice

Jennifer Becher Constance Visovsky

Horizontal or lateral violence is considered an act of aggression among nursing professionals. Horizontal violence creates a negative work envi- ronment impairing teamwork and compromising patient care. The effects of horizontal violence and strategies for prevention and man- agement are addressed.

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rolling (Gerardi & Connell, 2007; Thobaben, 2007). The more mini- mal, rude behaviors may be ignored, thus contributing to the underre- porting of horizontal violence (Araujo & Sofield, 2011).

Horizontal violence occurs most frequently among peer group workers within the professional structure. A study by Wilson and colleagues (2011) found 61.1% of surveyed nurs- es reported HV observed between co- workers on their unit. Horizontal vio- lence can extend to persons who work closely with nurses, including physicians (49.1%) and staffing supervisors (26.9%). However, HV is not confined to those in lateral posi- tions. Horizontal violence has been known to extend from the nurse lead- ership to the staff they supervise. Stagg, Sheridan, Jones, and Speroni (2011) reported 28% of nurse respon- dents had been bullied by a member of leadership.

Incidence and Prevalence of Horizontal Violence

The actual incidence and preva- lence of horizontal violence in nurs- ing are relatively unknown, as HV often is unrecognized and underre- ported. However, recent investiga- tions assert that horizontal violence is fairly widespread at 65%-80% of nurses surveyed (Stagg et al., 2011; Stanley et al., 2007; Vessey, Demarco, Gaffney, & Budin, 2009; Wilson et al., 2011). Johnson and Rea (2009) examined HV among 249 nurse members of the Washington State Emergency Nurses Association. They concluded 27.3% had experienced bullying in the workplace, with 18 nurses in the sample reporting expe- riencing two negative acts daily or weekly and as many as 50 nurses experiencing three or more negative acts on a daily or weekly basis. In another study of nursing students in Australia, approximately 50% of stu- dents experienced horizontal vio- lence during their clinical rotations (Curtis, Bowen, & Reid, 2007). Students also reported feeling power- less and humiliated as they began to assimilate these behaviors into the workplace. A survey of junior nurs- ing students shows horizontal vio-

lence occurs as early as the first inter- action of a student with professional nurses in a clinical setting (Thomas & Burk, 2009). New graduate nurses experiencing HV reported a higher level of absenteeism and considered leaving the profession altogether (Curtis et al., 2007).

What Are the Effects of Horizontal Violence?

Horizontal violence damages the dignity of the individual and ulti- mately is detrimental to the profes- sion, as aggression arises from co- workers who should be providing guidance and support (Saltzberg, 2011). Horizontal violence has spe- cial implications for student and newly graduated nurses, who have many questions and require profes- sional development to reach their full potential. New graduate nurses experiencing HV may have difficulty attaining success due to an environ- ment of continual conflict (Khalil, 2009; Thomas & Burk, 2009). Horizontal violence affects the entire health care team due to an ever- widening rift between employees or groups of employees. Horizontal vio- lence causes a wide array of effects that extend from the victim to the health care team and ultimately, to the patient (Joint Commission, 2008; Roche, Diers, Duffield, & Catling-Paull, 2010). The victim of HV may experience low self-esteem, anxiety, depression, and sleeping dis- orders (Thobaben, 2007). Many nurses who have experienced HV subsequently have considered leav- ing or have left the profession, con- tributing to the national nursing shortage (Huntington et al., 2011). Powerlessness, anger, and work absences have been reported with repeated acts of bullying. In addition to the psychological effects of bully- ing, HV suicidal behaviors have also been reported (Vessey et al., 2010). The Joint Commission (2008) indi- cated poor communication is a main factor in sentinel events affecting health care teams and compromis- ing patient safety. When essential information related to patient care is omitted as an act of HV, the victim- ized nurse is in a poor position to

care for the patient and patient safe- ty is compromised. The subsequent cost to patient, family, and institu- tion from compromised care, as well as the potential legal action, can be staggering. Over half the events of horizontal violence are never report- ed. Even with “no retaliation” poli- cies in place, victims may not know the appropriate steps to take to report HV (Stagg et al., 2011; Vessey et al., 2010). The financial cost of HV has been estimated to be $30,000-$100,000 per year for each individual. Costs are incurred as a result of work absenteeism, treat- ment for depression and anxiety, decreased work performance, and increased turnover (Gerardi & Connell, 2007). Pendry (2007) esti- mated the cost of replacing one spe- cialty nurse (e.g., ICU or surgical) may exceed $145,000.

What Can Be Done to Deter Horizontal Violence?

The American Nurses Association Code of Ethics (ANA, 2001) directs the behaviors expected from profes- sional nurses. Standard 6 of this code indicates professional nurses are responsible for attaining and main- taining work environments consis- tent with professional values. The Center for American Nurses (2008) issued a position statement with an associated example policy for stan- dards of healthy work environment. These standards apply to all levels of nursing practice, from the chief nursing officer to the individual staff nurse. The current health care envi- ronment poses many challenges that contribute to horizontal violence. Poor staffing, increased patient acu- ity, and reduced resources combine to increase stress and conflict (Huntington et al., 2011).

Nurse leaders are in a unique posi- tion to prevent and eliminate HV by providing resources in terms of sup- port and education. Leaders who demonstrate trusting behaviors allow staff to feel supported. Providing resources to decrease job stress and anxiety can prepare nurses to care for their patients (Longo & Sherman, 2007). Nurse leaders should support staff by providing constructive, real-

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time feedback when needed (Randle et al., 2007). Providing ample oppor- tunities for education and profes- sional development is important in planning to prevent or eliminate HV in the workplace (Cleary, Hunt, Walter, & Robertson, 2009). Nurse educators should be an integral part of the training process as they under- stand the specific hospital system and how to navigate it (Longo, Dean, Norris, Wexner, & Kent, 2011). Formal education sessions defining HV, direct approaches to modifying behavior, and review of conse- quences are needed (Edwards & O’Connell, 2007). Stagg and co- authors (2011) offered predeter- mined responses based on the type of HV through formal education ses- sions. Using cognitive rehearsal, nurses were better prepared for a response to HV when it occurred. Informal education including posters and fliers enable reinforcement after classes (Cleary et al., 2009).

Nurse leaders must hold them- selves and their peers accountable for modeling acceptable professional behavior. When unprofessional be - haviors are displayed, a corrective plan must be instituted. Once prob- lems related to HV have been identi- fied within an organization, a plan must be initiated to change the cul- ture that supports acts of HV. In approaching complaints or situations involving HV, nurse leaders must maintain an objective stance and assess all related facts (Cleary et al., 2009). They must be familiar with organizational policies directly relat- ed to HV (Vessey et al., 2010). Most importantly, they must be prepared to enforce policies with appropriate disciplinary action when acts of HV threaten the integrity of the work- place. Managers must participate in the same HV education as their employees to keep themselves alert for its occurrence (Stagg et al., 2011).

To facilitate discussion of preven- tion and elimination of HV in the workplace, focus groups can be held to identify areas for improvement and initiate an action plan (Longo & Smith, 2011; Maxfield, Grenny, McMillan, Patterson, & Switzler, 2005). The focus group can aid in developing a philosophy and code of

conduct applicable to every employ- ee within the institution. The American Association of Critical- Care Nurses developed a resource to assist health care leaders in dis- cussing means for decreasing errors, improving quality of care, decreasing nursing turnover, and improving productivity (Maxfield et al., 2005). Four topics within this document are related directly to horizontal vio- lence, including lack of support, poor teamwork, disrespectful behav- ior, and micromanagement of employees. These four topics could form the basis of focus group discus- sions, or provide a forum for nurse managers to address expectations for behavior with new employees.

Nursing staff must take a role in combating horizontal violence. Nurses must know the policies that govern professional conduct in the workplace (Maxfield et al., 2005), and feel empowered to take actions against HV. Strategies for empower- ment consist of confronting and teambuilding (Kupperschmidt, 2006), mentorship programs (Latham, Hogan, & Ringl, 2008), and cognitive rehearsal (Stagg et al., 2011). Maxfield and colleagues (2005) found only 5%- 15% of nurses would confront a col- league concerning unprofessional behaviors. Only 10% of nurses felt comfortable enough to confront a co- worker displaying HV (Wilson et al., 2011). Most nurses believed it either was not possible or not their responsi- bility to confront issues concerning unprofessional conduct. Co-worker support was cited as a reason to stay in the current position even when stress levels were high (Huntington et al., 2011). Student nurses and new nurse graduates are at particular risk for loss to the profession if they experience horizontal violence. In the process of undergoing role tran- sitions and increased role expecta- tions, they experience increased stress in the workplace. Students and new graduate nurses need to be exposed to professional behaviors that deter horizontal violence in the workplace (Thomas & Burk, 2009). Preceptors assigned to new graduates must understand the negative impact of HV on new professionals. Preceptors of students and new grad-

uates should model professional behavior with the intent of provid- ing guidance and support (King- Jones, 2011). Preceptors also must be knowledgeable in methods to deter horizontal violence among staff, and exhibit professional behavior that builds trust and teamwork. Providing new graduates with a mentor located on another unit may offer a resource within the organization for coping with potential issues of HV. Some essential mentoring responsibilities include counseling, teaching, protect- ing, coaching, and sponsorship (Bally, 2007).

Victims of Horizontal Violence

At an institution where horizon- tal violence has not been addressed, steps can be taken by nurses who are experiencing bullying behavior. First, they should maintain a healthy view of self, so as not to personalize attacks of HV (Kerfoot, 2007). In sit- uations of HV, talking with a trusted colleague or friend may be helpful (Randle et al., 2007). Talking about situations of HV helps the individual confirm if circumstances do consti- tute acts of horizontal violence, and may establish a witness to the events. Counseling may be indicated to support the emotional needs of the victim and should be sought rel- atively quickly to avoid unnecessary emotional turmoil. Counseling ses- sions may help the victim to learn to be assertive in situations of horizon- tal violence. Journaling, another strategy to address HV, can serve dual purposes. First, keeping a detailed journal will help the victim main- tain a timeline of events (Cleary et al., 2009). Second, journaling may provide an emotional outlet for the psychological distress associated with HV. Good documentation requires a list of witnesses to the accounts and all notes, texts, or emails from the perpetrator also be kept as part of the journal (Cleary et al., 2009; Edwards & O’Connell, 2007).

Exhibiting assertive behavior at the time of the event is considered an acceptable response to HV behav- iors. If possible, actions that consti- tute bullying should be confronted

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during or immediately following the incident. Conversation must remain both empathic and factual (Randle et al., 2007). The victim must insist that all bullying behavior cease, and be specific about the behavior exhib- ited without talking about the way the behavior made him or her feel. Only factual events that constituted the horizontal violence should be discussed, with a focus on the specif- ic unprofessional behaviors and the return to a more professional, colle- gial environment (Cleary et al., 2009).

Reporting HV through proper channels is encouraged. Severe inci- dents, such as public slander, physi- cal abuse, or criminal offenses, require reporting through the facili- ty’s proper channels. The victim should not retaliate toward a bully in order to avoid escalating the inci- dent into legal action against the original victim (Kerfoot, 2007). Nurse leaders must work with staff to distinguish subjective from factual information, and assure policies per- taining to the horizontal violence are followed and appropriate disci- plinary action is taken. If a nurse manager is the perpetrator of the HV, staff in the human resources depart- ment can serve as a resource for employees. All employees involved in situations of HV need to be kept abreast of the situation and know that addressing HV may take several weeks (Cleary et al., 2009).

Conclusion Horizontal violence can exist to

some extent in any institution, with the potential to disrupt the integrity of the nursing profession and ulti- mately compromise patient care (Joint Commission, 2008). Failing to address HV can discourage students and new graduate nurses, who may leave the profession (Thomas & Burk, 2009). Nurses must acknowl- edge the existence of horizontal vio- lence, confront horizontal violence, and take appropriate actions to miti- gate it (Vessey et al., 2010). A policy of zero tolerance for any sort of hor- izontal violence in the workplace is the goal (Center for American Nurses, 2008).

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