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Chapter II: Literature Review
Chapter Roadmap
This study will take a look at a perennial problem new nurses cannot seem to
avoid, horizontal violence. Also, in an effort to better understand nurse-on-nurse
horizontal violence, a literature review has been conducted to gather the major themes
encompassing horizontal violence. A review on literature that expounds on the concept
of horizontal violence and its historical aspects will first be presented. Then, a broad
overview of articles that single out nurse-on-nurse horizontal violence will be
incorporated to further strengthen its existence as researched and documented by various
experts. These written works will also establish the culture of horizontal violence in the
nursing profession.
Following the overview on horizontal violence is a focus on literature that
presents studies that made use of the same methodology used in this paper. The next set
of literature to be presented will serve as support to this study’s theoretical framework as
well as those that serve as scholarly answers to the research. Then, a review of the most
current articles dealing with horizontal violence will be reviewed. Finally, a discussion
about the all the literature presented will follow to serve as the chapter’s summary.
History and Concept of Horizontal Violence
Horizontal violence, otherwise known as lateral violence or bullying in the
nursing profession, has been in literature for over 25 year now. Nursing was founded in a
society that is basically patriarchal in nature which up to the present composed mainly of
females. Even at the onset, the profession calls for a position that has a subordinate role.
At the beginning, women are yet to be given many rights as men and the nursing
profession is a way for them to “stand on their own” (Johnston, 2010, p.38). However,
the profession can only be acceptable, basically because the women nurses are going to
be caring for, among others, male strangers, the profession is depicted to be "God's work"
and a "calling. Consequently, the nurses are the angels of mercy. As angels, they are not
expected to get mad. This gave nurses during those times the image that they are always
caring, are willing to work long hours, will reject their own needs in favor of others, do
not complain, speak only when spoken to and are always subordinate (Bartholomew,
2006). This situation made it easy for horizontal violence to proliferate in no time.
The term "horizontal violence" was first used by theorist Paulo Freire in 1972. It
was used to explain the ongoing conflict among the African population at the time. Freire
observed that power imbalance results into two groups where one is dominant and the
other subordinate. He therefore theorized that in such situations, where one group is more
powerful than the other, oppression occurs when values of the subordinate group are
repressed by the dominant one. Freire believed that since the subordinate group was
pushed to have their own ideas and values rejected in favor of the values and ideas of the
dominant group, they developed a feeling of inferiority. When the inferior group started
acting out their self-hatred, internal conflict ensues and will spread. This is how
Bartholomew (2006) explained the beginnings of horizontal violence in the nursing
profession. To get a clearer understanding of the concept of horizontal violence, the next
set of literature defining it will be reviewed.
Horizontal violence (Dunn, 2003; Farrell, 1997; Hastie, 2002; Longo and
Sherman, 2007), lateral violence (Griffin, 2004; Stanley, et al., 2007; Rowell, 2007) and
horizontal hostility (Bartholomew, 2006; Thomas, 2003) are terms commonly used to
describe the verbal, physical or emotional abuse of an employee. When applied to the
nursing profession, horizontal violence is defined as a nurse to nurse aggression. The
violence involved may be both in verbal or nonverbal behaviors. The ten most common
forms of lateral violence in nursing are undermining activities, verbal and non-verbal
innuendos, withholding information, scapegoating, infighting, backstabbing, etc. (Griffin,
2004, p.257).
The definition of horizontal violence among nurses is any act or behavior of
hostility or aggression, which could be oral, emotional, or physical, carried out by a
coworker towards another coworker. This act or behavior can either be blatant or subtle
and takes place because of power imbalance, the carrying on of learned behaviors, and
oppression (McCall, 1996; Roberts, 1983; Skillings, 1992).
Lateral violence is also referred to as aggression, bullying, or horizontal violence
(Griffin, 2004). Other literature terminologies relevant to lateral violence are “nurses eat-
ing their young”, verbal abuse, and horizontal hostility. The occurrence of lateral vio-
lence has been expressed in nursing literature for over 25 years (Farrell, 1997; Roberts,
1983). Lateral violence is defined in literature as explicitly or vaguely expressing their
displeasure inward toward: (1) themselves, (2) those lower than them with regards to au-
thority, and (3) each other (Griffin). Incorporating studies on lateral violence is a chal-
lenge because of the absence of a universal term to include all the said actions
(Bartholomew, 2006). Lateral violence reveals itself in a range of mean, hostile relations
that take place among nurses at the same organizational chain of command (Alspach,
2007); these relations may be expressed either overtly or covertly (Bartholomew; Grif-
fin). Since majority of the interactions among nurses are nonverbal, the form of lateral vi-
olence that has the most impact are those expressed covertly (Bartholomew). Lateral vio-
lence is an action or behavior of hostility expressed by a nurse against another nurse. The
usual expressions of lateral violence have been described by Griffin (2004) as verbal in-
sult, nonverbal insinuation, undermining tasks and activities, backstabbing, infighting,
sabotaging, refusal to give information, broken confidentialities, and failure to give pri-
vacy. Generally, lateral violence is emotional or verbal abuse, but there are times when it
is expressed as physical mistreatment (Longo and Sherman, 2007). Lateral violence is an
issue prevalent in nursing (Stanley, Dulaney, & Martin, 2007; Woelfle & McCaffrey,
2007).
The aforementioned definitions given by various experts on the field are one in
saying that violence in the field of nursing exists. The history cited attributes the begin-
nings of the said violence in the structure of the profession itself wherein nurses are com-
monly female and the job description entails them to be submissive. For a deeper under-
standing of the problem, the next set of literature to be reviewed will be an overview of
nurse-to-nurse horizontal violence.
Overview
Horizontal violence among nurses is basically similar with how bullies act in
other settings; they intentionally speak and behave the way they do to discredit or
intimidate the victim. They have the tendency to be cunning and falsehearted, which is
why they are usually called “two-faced”. More frequently, they bully the victim verbally
or by isolating him or her.
The bully will get in the way of the victim’s work activities and present consistent
sarcasm, hostility, criticism, and invention of complaints, to set up the victim for
disappointment with the intent of humiliating the victim and breaking down his or her
self-confidence. Such deeds are damaging and are usually done gradually. They
frequently happen in settings where there can be no witnesses. The one bullying is
continually aware that he or she is inflicting damage and will keep on belittling the victim
to become more dominant. There are varying time intervals for bullying behavior,
ranging from a number of months to a number of years (Lewis, 2006)
It is interesting to note that in most of the studies made about all types of bullying
and horizontal violence which are in existence, e.g., nurse-to-visitor, physician-to-nurse,
patient-to-nurse and nurse-to-nurse, most nurses who experienced horizontal violence
reported that it is the latter type that is most distressing to handle. It is ironic that nurse to
nurse aggression is quite prevalent and that nurse themselves, who are supposed to -
understand the other nurses more, are the ones that will show aggression to their
colleagues. In a study made, 50% of all the bullies are female and those bullied are 84%
women (Johnston, 2010, p. 38).
Characteristics of Nurse-to-Nurse Horizontal Violence
• “Criticism, sabotage, undermining, infighting, scapegoating, and bickering” (Duffy,
1995, p. 9)
• “Intimidation, humiliation, excessive criticism, exclusion, innuendo, denial of access to
opportunity, disinterest, discouragement, and the withholding of information;” (as quoted
in McKenna, Smith, Poole, & Coverdale, 2003, p. 91)
• “Learning opportunities blocked, felt neglected, were given too much responsibility
without appropriate support… rude[ness]” (McKenna et al., p. 93)
• “Raising of eyebrows… abrupt responses… not being available… withholding informa-
tion about practice or about patients… sabotage… in-fighting… failure to respect privacy
… broken confidences” (Dunbar, 2005, p.1)
• “Dismissing, belittling, undermining, humorous ‘put downs’… gossiping… sarcastic
comments… nitpicking… minimizing another’s concerns… slurs and jokes based on
race, ethnicity, religion, gender, or sexual orientation… withholding support… limiting
right to free speech and right to have an opinion… “better than” attitude… chronic under-
staffing” (Hastie, 2002, pp. 2-3).
The power of horizontal violence in nursing is now being countered by awareness, educa-
tion, and on-the-job zero tolerance for abuse. “We’ve always cared for others. Now let’s
care for each other” (Leiper, 2005, p. 45).
Horizontal Violence: An Issue of Oppression
Dr. Martha Griffin, an educator in nursing and an activist, supposes that oppressed
group behavior is the reason behind the occurrence of lateral violence. Oppressed group
actions and behavior happen when one group has developed the belief that it has been
eliminated from the authority structure (Ratner, 10). According to Griffin, nurses hardly
have control over their work environment yet they still are held responsible when prob-
lems arise, causing personal trauma and anxiety. The oppressed group member acts im-
pertinently and nastily towards colleagues and peers of lower status or authority because
he or she is afraid to address the source of the distress that affects him or her. As a result,
the oppressed group member strikes out at colleagues, unlicensed assistance staff, stu-
dents, patients, etc.
Horizontal Violence: An Issue of Gender
Horizontal violence may also be understood as a gender issue since according to
the National Sample Survey of Registered Nurses (RNs) conducted in 2000, only 5.4% of
registered nurses are males (DHHS/HRSA/BHP/DON, 2000 p.8). The gender theory
states that horizontal violence in nursing takes place because females did not grow up ap-
preciating themselves socially or the roles they perform. Often, females are socialized to
think of themselves as less smart and weaker than males and that their duty in life is to
serve and submit to males.
Horizontal Violence: A Role Issue
During the first year of nursing education, the nurses are already being trained to
work in teams. Physicians, on the other hand, have traditionally been taught and trained
to think of themselves as the ones with authority. These traditional professional principles
contradict each other and provide the basis for conflicts between physicians and nurses. It
is the expectation of nurses that they would be working with physicians as colleagues.
The physicians, however, are not very enthusiastic with that idea.
Nurse-to-nurse horizontal violence and horizontal violence among nurses take
place for a variety of reasons. Because in a nursing workplace, a lot of roles and duties
are involved, role issues can crop up between and among nurses; between advanced prac-
tice registered nurses (APRNs) and managers; between managers and staff nurses; and
APRNs and staff nurses.
Horizontal Violence: An Issue of Self-Esteem
The theory of self-esteem is quite complicated. Self-esteem is a foremost factor in
the aforementioned approaches to the issue of horizontal violence.
The main themes of self-esteem are that: (1) it is a key element in predicting be-
havior; (2) it takes place along a continuum and not a polarizing entity; (3) and that it in-
cludes different ‘selves’, in that a person can think of himself differently as a nurse, than
he does as a parent.
One’s self-esteem can either be boosted or degraded in social interaction, as he or
she receives opinions about how other people see him or her and judge his or her actions
and activities (Randle, 395). Self-esteem is subjective and created at the same time in the
sense that a person’s self-esteem is partially what he or she thinks of himself or herself
based on how other people act in response to him or her, and partially based on his or her
own experiences in life.
A nurse develops his or her professional self-esteem largely by his or her commu-
nications and dealings with mentors, instructors, superintendent nurses, and student col-
leagues. As students of nursing watch those higher than them, they cultivate a starting
idea of how a professional should act and behave towards colleagues, students, and pa-
tients.
The aforementioned literature establishes the existence of horizontal violence and
proves that it abounds. Yet, what has been included is only a small fraction of what is
available. In the succeeding topics, more instances of horizontal violence will be presented,
this time even made concrete with evidences produced by methodologies and in depth
analysis of the problem.
Methodology
Violence in the workplace is damaging to healthcare dynamics and is now an issue that
cannot be disregarded. The form of violence in the workplace that is becoming
increasingly practiced is horizontal violence among nurses. Nurse bullying is bringing
about upshots that are unsafe to patient care, for the nursing profession itself, and to
healthcare establishments.
Having been in existence for many decades already, many studies and researches
on the subject of horizontal violence have been done worldwide. One of those who
conducted such study was Cheryl Dellasega (2009, p. 52). She has completed a literature
review on horizontal violence with female nurses. Her work showed that indeed, the
problem is being experienced by most nurses that are new in the profession. The
examples she gave of this violence are sabotaging of a nurse to effect failure, name-
calling, gossiping and eye-rolling.
Still another work on measuring mobbing experiences of academic nurses was
done in 2008. This study was prepared not only to learn of such experiences but also to
develop a mobbing scale that can be used for further studies (Ozturk, H., Sokmen, S.,
Yilmaz, F., Cilinger, D., 2008, p.235). This study used Leymann, one of the founders in
the research of horizontal violence, later violence and mobbing behaviors, to define what
mobbing behaviors are. According to him, “mobbing or psychological terror is hostile
and unethical communications directed in a systematic manner towards a person”
(Ozturk, H., &al., 2008, Yilidirim, D., & al., 2007, p.451). This study was prepared to be
able to develop a mobbing scale for academic nurses and to determine whether academic
nurses experience mobbing and to what extent mobbing existed at the university nursing
schools in Turkey.
The findings of the study noted that one hundred and sixty-two academic nurses
with an average age of 33 years and had an average of 11 of experience sixty-one percent
had stated that they were victims of a mobbing experience. After the questionnaire had
been evaluated 34% of the 61% of academic nurses who participated stated that they
were mobbing victims scored to have been mobbing victims. Of those surveyed, 49%
were still experiencing mobbing while 67% were exposed to mobbing for three years or
more (Ozturk, H., & al., 2008, p.438). The study also showed that the participants had
suffered psychological effects from mobbing behaviors “this means that the participants
suffered psychological effects that resulted in fatigue” (Ozturk, H., & al., 2008, p.438).
With all of the data, it shows that nurses of an academic status regardless of age are
falling victim to mobbing behaviors in the Turkish Universities.
An older study that was done in New Zealand by Mckenna, B. G., Smith, N. A.,
Poole, S. J., & Coverdale, J.H., (2003) Horizontal Violence: experiences of registered
nurses in their first year of practice has been referenced in several of the studies that were
mentioned before. This study conducted by McKenna, et. al., was to get a picture of
what the novice nurse was experiencing in relation to horizontal violence in the first year
of practice.
The study was conducted in New Zealand. They decided to mail out
questionnaires to 1,169 individuals who registered as new nurses that year. The
researchers had a forty-seven percent of their surveys returned and the results of what
those surveys stated were astounding. The descriptive study was conducted with open
ended questions pertaining to the type of horizontal violence that the graduate nurse had
experienced. The researchers also wanted to know the reaction of the graduate nurse to
the horizontal violence that was experienced. Ninety-four percent of the respondents
were female and six percent were male. Forty-six percent of the populations of graduate
nurses were under the age of thirty.
The study revealed horizontal violence is present and very real to graduate nurses
coming into the work force with seasoned nurses. The experiences that were described
were backstabbing, bullying, humiliation, and withholding opportunities for learning.
Some of the highest types of horizontal violence experienced were learning being
blocked; in the surgical units this would include intensive care units. The surgical units
were also high with emotional neglect, and lack of supervision. Through this study they
found that the type of horizontal violence that was experienced was covert in nature. The
new graduates also reported that they had been absent to work due to horizontal violence.
The graduate nurses had also reported that constructive criticism was not perceived as
such, they felt they were being talked down to. The worst and most disturbing result was
the graduate nurses had thought about or already had left the nursing profession due to
the horizontal violence experienced. Twelve percent of the graduate nurses had stated
that they had to have counseling due to the distressing events that was experienced.
Another study made on the subject that is of the same type of methodology as I
used in my dissertation is one made by Kathleen Sellers, PhD, RN, wherein she made a
descriptive study to examine the prevalence of horizontal violence in RNs who are
members of NYONE (New York Organization of Nurse Executives). Knowing the nurse
administrators' knowledge on the subject and the degree of encounter they had is the aim
of the study. The theoretical framework made use of was the transformational leadership
theory. The methodology made use of a convenient number of RNs as sample, all of
which are members of NYONE. They completed a Briles' Sabotage Savvy questionnaire
that included their demographic information among others. Likert model was also used
in this study. The study established the existence of horizontal violence in the profession
of nursing in consistence with what was already written about it. The study even showed
that the problem is already deeply rooted that it has already become a culture and is not
easily recognized. This makes the problem even harder to solve since it is not even
known to be a problem anymore.
Another research made on the nurse on nurse horizontal violence written by Cheryl
Woelfle and Ruth McCaffery (2007). They wanted to know if horizontal violence really
existed among nurses in the workplace and if it did what were the consequences of
horizontal violence among nurses in relation to patient care. They reviewed specifically
four different research articles the first article used was a “descriptive correlation design
that was used to examine the possible relationship between the perceived acts of
horizontal violence and the different levels of job satisfaction as reported by preoperative
nurses” (Woelfle, C., McCaffery, R. 2007, p.124). Participants are 145 preoperative
nurses from the preoperative nurses association for registered nurses (AORN) and their
ages ranged from 31 to 68, and ninety-eight of these nurses were female. They were
given a questionnaire to fill out containing forty questions to find out if the surveyed
nurse had ever been a victim of horizontal violence or bullying in the work place.
The surveys reported that the most common type of sabotage or bullying was one
expecting another to do their work. The “saboteurs reported that their most frequent form
of victimizing was to stop talking when others entered into the room, and they
complained about others without discussing it first with that person” (Woelfle, C.,
McCaffery, R., 2007, p.124). With the survey, they did not find a direct correlation with
satisfaction of nurses in the preoperative area and dissatisfaction with their current jobs.
They did find that preoperative nurses did act inappropriately and unprofessionally
amongst each other in the preoperative environment, “the study represents a significant
positive correlation between the IWS scores and reported sabotage” (Woelfle, C.,
McCaffery, R., 2007, p. 126). The weakness in this study was noted that maybe the
preoperative nurse was not being completely honest on the survey that was taken in
relation to the job satisfaction and significant sabotage in the working environment.
Theoretical Framework
As sensitivity and caring (Bartholomew, 2006) are the focus of the nursing profes-
sion, LV occurring at all is ironic (McKenna, Smith, Poole, & Coverdale, 2003; Woelfle
& McCaffrey, 2007). Although other theories describe why LV occurs, the most cited
theory to describe the origins of LV can be found in the oppressed-group model (Roberts,
1983). The model suggests that nurses are an oppressed and powerless group dominated
by others (DeMarco & Roberts, 2003). Oppression exists when a powerful and dominant
group controls and exploits a less powerful group. Nursing has been described as an op-
pressed group because the profession is mostly women, and nurses report to mostly male
physicians and administrators (Farrell, 1997). Cherished nursing characteristics, such as
sensitivity and caring, are viewed as less important or even negative when compared to
those of medical practitioners, who often are seen as the central culture in health care
(Woelfle & McCaffrey).
The literature supports this view, stating that nurses lack autonomy, control over
their work, and self-esteem and subscribe to submissive-aggressive syndrome to affect
change (Freshwater, 2000). Submissive-aggressive syndrome is a term that describes
when nurses feel they have lost their power (submissiveness), and react by overpowering
others through aggressiveness (Bartholomew, 2006). Roberts (1983, 2000) has described
the application of Freire's (1971) oppression theory to nursing. The theory explains that
members of an oppressed group display common behavioral characteristics, such as low
self-esteem and self-hatred (Roberts, 1983; Woelfle & McCaffrey, 2007). LV among
nurses evolves from feelings of low self-esteem and lack of respect from others in the
work environment (Longo & Sherman, 2007). Oppression theory proposes that nurses
perceive themselves as powerless and oppressed in the healthcare setting. As an op-
pressed group, nurses feel alienated and have little control of their practice. This leads to
a cycle of low self-esteem and feelings of powerlessness (DeMarco & Roberts, 2003).
Rather than confronting the issue (and risking retaliation by leadership in the healthcare
system), the oppressed group manifests their frustration on other nurses lateral to them.
One explanation of why lateral violence is so prevalent in nursing focuses on the profes-
sion as an oppressed group. Nurses have often been considered an oppressed group as
historically the profession is primarily female and has long been subordinate to male
physicians, administrators and marginalized nurse managers (Longo & Sherman, 2007,
p.35). Symptomatic of an oppressed group mentality, feelings of low self esteem and
powerlessness develop when members feel alienated and removed from autonomy and
lack control over their working environment (Longo & Sherman, 2007, p.35). From op-
pression, emerge nurses who are socialized into relationships of unbalanced power fur-
ther internalizing their feelings of inferiority; resultantly stifling their ability to assert
control over their own future and turning against colleagues (Hutchinson, Vickers, Jack-
son, & Wilkes, 2006, p.120).
One explanation of why lateral violence is so prevalent in nursing focuses on the profes-
sion as an oppressed group. Nurses have often been considered an oppressed group as
historically the profession is primarily female and has long been subordinate to male
physicians, administrators and marginalized nurse managers (Longo & Sherman, 2007,
p.35). Symptomatic of an oppressed group mentality, feelings of low self esteem and
powerlessness develop when members feel alienated and removed from autonomy and
lack control over their working environment (Longo & Sherman, 2007, p.35). From op-
pression, emerge nurses who are socialized into relationships of unbalanced power fur-
ther internalizing their feelings of inferiority; resultantly stifling their ability to assert
control over their own future and turning against colleagues (Hutchinson, Vickers, Jack-
son, & Wilkes, 2006, p.120).
Sandra Roberts, PhD, RN, FAAN noted in 1983 that nurses generally display the traits of
that of an oppressed group. They show self-hatred, low self-confidence and
powerlessness. Roberts was the first to apply Freire's oppression theory to nursing. She
cited Bartholomew's idea that the concept of nursing being an oppressed profession is
traceable to the issue on gender and that this fact is evidenced by significant literature
(Roberts, 2009, p.388). She added that according to Bartholomew, since medicine is
male dominated (referring to the physicians), the female nurses are naturally the ones
who experienced oppression. Roberts stressed that with the modern times where more
are expected of the nurses, the discipline becomes more stressful and pressuring for them.
More are expected out of their profession and this is where the hostility may arise and the
nurses take it out on each other. That basically is the beginning of horizontal violence, at
least the documented part of it.
Origin Theories
• Oppressed-group model theory (Roberts 1983)
– Nurses are an oppressed and powerless group dominated by others
– Nursing profession mostly women and have to report to male physicians
and administrators
– Sensitivity and caring view as less important or even negative when
compared to those of medical practitioners
– Nurses lack autonomy, control over their work, and self-esteem and
subscribe submissive-aggressive syndrome
• Submissive-aggressive syndrome
– When nurses feel they lost power and react by overpowering others
– through aggressiveness
• Oppression theory
– Members of an oppressed group display common behavioral
characteristics low self esteem and self-hatred
– LV evolves from feelings of low self-esteem and lack of respect from
others in the work environment
– Nurse perceive themselves as powerless and oppressed in the health care
setting
• Leads to feelings of alienation and lack of control over practice
– Leads to cycle of low self-esteem and powerlessness
– Nurses manifest frustrations to other nurses lateral to them rather than
confronting the issue because of risk of retaliation by leadership in the
healthcare system.
Horizontal Violence Updates
Workplace violence is a central human rights issue and a source of inequality,
discrimination, stigmatization and conflict in the workplace.
The consequences of workplace violence in health care include the deterioration of the
quality of care provided and the decision of workers to leave the profession which can
result in the loss of health services to the general public and an increase in healthcare cost
(Longo and Lynn, 2010).
Reversing the bullying culture in nursing
By Lynda Olender-Russo, PhD(c), MA, NEA-BC, RN 2009
Leaders within healthcare organizations are struggling to manage disruptive behavior
and bullying in the workplace.
A serious situation is emerging in the health care system of the United States.
The country is bracing for a projected unprecedented shortage of more than 500,000 RNs
by 2025, due in part to baby boomer nurses retiring at the same time as the demand for
healthcare is rising. Moreover, despite the 3.3% increase in student enrollment and a sta-
ble RN vacancy rate of 8.1%, RN turnover rates range from 8.4% to 13.9%; and the de-
mand for registered nurses still is expected to increase 2% to 3% annually (AACN,
2009).
dissatisfaction and related intent to leave the work environment are believed to be key
factors contributing to the shortage. Moreover, exposure to incivility, including
workplace bullying, is one of the primary factors influencing RN dissatisfaction and
turnover rates, (Simmons, 2008, p. 48) and can be a reason why some leave the profes-
sion altogether (Duffield et al, 2004, p. 664).
Discussion
Impact of Lateral Violence: Emotional, Physical and Financial
The economic impact of lateral violence is not only costly but directly impacts patient
safety. According to Griffin (2004), of the new graduates who leave their first nursing po-
sitions, 60% leave because they have experienced some form of lateral violence. It is esti-
mated to cost $92,000 to recruit, hire, and orient a medical surgical nurse and the cost
rises to $145,000 to recruit, hire and orient a specialty nurse (Pendry, 2007). Current re-
search identifies the average voluntary nurse turnover rate in hospitals to be around 8.4%,
this average increases to 27.1% for first year nurses (Price, Waterhouse, Coopers, 2007).
The impact of this turnover not only erodes an organizations budget, but it impacts the or-
ganization’s ability to recruit and hire new staff once they develop a reputation for toler-
ating lateral violence (Bartholomew, 2006). Additional costs come from the emotional
and physical symptoms that result from lateral violence. This can cause an increased use
of sick leave which impacts staffing patterns and places a strain on the unit. (Rowell,
2007).
Lateral violence behaviors interfere with effective health care communication and there-
fore impact patient safety. This is costly to health care organization as the rate of medical
errors increase with communication failures (Wolf & McCaffrey, 2007).
The current healthcare environment, with nursing shortages looming and the uncertainty
of national healthcare reform, demands that leadership in the organization must do
everything possible stop the loss of nurses because of lateral violence. The answer is
obvious… we must implement strategies that support a healthy work environment. If
lateral violence is not addressed, for all involved it is “all pain and no gain”.
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Joy Longo DNS, RNC-NIC Christine E. Lynn College of Nursing Florida Atlantic University, 2010)
JONA’S Healthcare Law, Ethics, and Regulation / Volume 12, Number 2 / April–June 2010
III. Horizontal Violence Manifestations in Nursing
Horizontal violence and bullying exists and have been extensively reported,
studied and documented among medical professionals. This fact poses serious negative
outcomes for all concerned especially registered nurses, their patients and even the
employers. Such disruptive and unacceptable behaviors are toxic to the medical and
nursing profession and give a negative impact on quality staff retention. This kind of
violence in the workplace is something that should not be accepted in any professional
relationships and could never be taken as a normal act of socialization. The problem is in
existence and more literature on the subject will be included in this paper to prove the
point.
Bullying is taken to be a malicious, offensive, abusive, insulting and intimidating
behavior. It is taken to be an abuse of power done by a person or a group of people
against others to make the offended party feel upset, humiliated, upset or vulnerable.
These actions undermine the self-esteem of an individual and causes then stress. Such a
behavior is taken to be systematic, persistence and ongoing (Task Force on the
Prevention of Workplace Bullying, 2001, p. 10). Bullying and horizontal violence are
basically the same. In the nursing profession, the Bully is the one with a higher
authority or level, for instance, a nursing supervisor against a staff nurse (CENTER for
American Nurses, 2007).
Another article that reviewed was mobbing behaviors encountered by nurse
teaching staff. Dilek Yildirim, Aytolan Yildirim, and Arzu Timucin conducted this.
“The term mobbing behaviors is defined as antagonistic behaviors with unethical
communication directed systematically at one individual by one or more individuals in
the workplace” (Yilidirim, D., Yildirim, A., Timucin, A., 2007, p.447). This study was
taken from nursing mobbing behaviors as encountered by nursing school teaching staff in
Turkey.
This study was a cross sectional study conducted to realize the mobbing behaviors
that were encountered by ninety-one percent of nursing educators in the Turkish
University education system. The study sample included thirty-three professors, forty-
three associate professors, 59 assistant professors, thirty-five instructors, and thirty-five
research assistants. A questionnaire was prepared for the study and was then sent to the
participants. In Turkey, only women can perform as nurses in this country so the
sampling was purely women only. The data was then collected from April through June
of 2006. Two hundred and ten individuals answered the questionnaire and returned it
giving the percentage of returned sixty-nine percent. The questionnaire had four sections
to it. The first part was a list of mobbing behaviors and the participant had to answer
whether they had experienced any of these behaviors. The second part was to answer
what the reaction to these behaviors were. They had to rate from a six point Likert scale
to answer all of these questions. The third section was to try to understand what they had
done to escape the mobbing behavior. The fourth was the demographic criteria of the
individual taking the questionnaire.
The results of the study was the “most common behaviors included attacks on
personal status eighty-five percent and attacks on personality was eighty-two percent; the
most frequently encountered behavior was using nonverbal behavior to belittle you in
from others, and the most common sources of this behavior towards sixty-eight percent of
the participants was from their managers, twenty-seven percent was from their co-
workers and five percent from the hierarchal positions” (Yilidirim, D., & al., 2007,
p.451). They also found that employees had the second most common mobbing behavior
towards demeaning others and dishonoring coworkers in some way. The third most
common was the blaming of others for things that were not their responsibility from
either managers or other co-workers. After establishing that the mobbing behavior does
exist, the questions that follow were, what was the response to the mobbing behavior and
what did you do to escape the mobbing behavior? The most common response to what
was the response to the mobbing behavior was they “felt tired and stressed by seventy
five percent, had headaches by sixty-nine percent, replayed or relived the behavior over
and over sixty-nine percent, and negatively affected their lives outside of work sixty-
seven percent” (Yilidirim, D., & al., 2007, p.453). The response to the how did you
respond to the mobbing behaviors? The most frequently used answer was “I just try to
work harder and harder, seventy-eight percent, I am being a lot more careful to avoid
criticism at work, seventy-eight percent, talk face to face with the person involved,
seventy-one percent and other thought seriously about resigning from their job, fifty
percent “(Yilidirim, D., & al., 2007, p.453). Overall it is evident that most of the nursing
educators had experienced some kind of mobbing behavior in their career.
Unfortunately for the nurses, organizations are basically hierarchical and have no
culture of professional collegiality. They also failed to make any move in advancing the
role of nursing. It is often the case that nurses simply accept the situation and have a
victim mentality, making them powerless. Many of these nurses have already expressed
concern about their supervisors' lack of action when it comes to addressing horizontal
violence in the workplace (Farrell, 1997; Stanley et al., 2007).
While the above study had nurses feeling other nurses' aggression that hardest to
handle, Sofield and Salmond (2003, p. 274) in their own researches, found that the foremost
abusers of nurses are physicians, then patients and patients’ families. One-third of the
participants consider resignation as their answer to the verbal abuse. They find from the
subjects that they lacked the skills needed in dealing with the abuse they are receiving and
see themselves to be powerless in changing the situation (Sofield & Salmond, 2003, p. 283).
The Institute for Safe Medication Practices published a survey in 2004
regarding workplace intimidation. Of the 2,095 respondents that included pharmacists, nurses
and other providers, about half remembers being abused verbally when inquiring from
physicians about prescription and medication specifications (Institute for Safe Medication
Practices, 2004a).
IV. Evidences of Existence of Horizontal Violence from Previous Studies
Having been in existence for many decades already, many studies and researches
on the subject of horizontal violence have been done worldwide. One of those who
conducted such study was Cheryl Dellasega (2009, p. 52). She has completed a literature
review on horizontal violence with female nurses. Her work showed that indeed, the
problem is being experienced by most nurses that are new in the profession. The
examples she gave of this violence are sabotaging of a nurse to effect failure, name-
calling, gossiping and eye-rolling.
Still another work on measuring mobbing experiences of academic nurses was
done in 2008. This study was prepared not only to learn of such experiences but also to
develop a mobbing scale that can be used for further studies (Ozturk, H., Sokmen, S.,
Yilmaz, F., Cilinger, D., 2008, p.235). This study used Leymann, one of the founders in
the research of horizontal violence, later violence and mobbing behaviors, to define what
mobbing behaviors are. According to him, “mobbing or psychological terror is hostile
and unethical communications directed in a systematic manner towards a person”
(Ozturk, H., &al., 2008, Yilidirim, D., & al., 2007, p.451). This study was prepared to be
able to develop a mobbing scale for academic nurses and to determine whether academic
nurses experience mobbing and to what extent mobbing existed at the university nursing
schools in Turkey.
The findings of the study noted that one hundred and sixty-two academic nurses
with an average age of 33 years and had an average of 11 of experience sixty-one percent
had stated that they were victims of a mobbing experience. After the questionnaire had
been evaluated 34% of the 61% of academic nurses who participated stated that they
were mobbing victims scored to have been mobbing victims. Of those surveyed, 49%
were still experiencing mobbing while 67% were exposed to mobbing for three years or
more (Ozturk, H., & al., 2008, p.438). The study also showed that the participants had
suffered psychological effects from mobbing behaviors “this means that the participants
suffered psychological effects that resulted in fatigue” (Ozturk, H., & al., 2008, p.438).
With all of the data, it shows that nurses of an academic status regardless of age are
falling victim to mobbing behaviors in the Turkish Universities.
An older study that was done in New Zealand by Mckenna, B. G., Smith, N. A.,
Poole, S. J., & Coverdale, J.H., (2003) Horizontal Violence: experiences of registered
nurses in their first year of practice has been referenced in several of the studies that were
mentioned before. This study conducted by McKenna, et. al., was to get a picture of
what the novice nurse was experiencing in relation to horizontal violence in the first year
of practice.
The study was conducted in New Zealand. They decided to mail out
questionnaires to 1,169 individuals who registered as new nurses that year. The
researchers had a forty-seven percent of their surveys returned and the results of what
those surveys stated were astounding. The descriptive study was conducted with open
ended questions pertaining to the type of horizontal violence that the graduate nurse had
experienced. The researchers also wanted to know the reaction of the graduate nurse to
the horizontal violence that was experienced. Ninety-four percent of the respondents
were female and six percent were male. Forty-six percent of the populations of graduate
nurses were under the age of thirty.
The study revealed horizontal violence is present and very real to graduate nurses
coming into the work force with seasoned nurses. The experiences that were described
were backstabbing, bullying, humiliation, and withholding opportunities for learning.
Some of the highest types of horizontal violence experienced were learning being
blocked; in the surgical units this would include intensive care units. The surgical units
were also high with emotional neglect, and lack of supervision. Through this study they
found that the type of horizontal violence that was experienced was covert in nature. The
new graduates also reported that they had been absent to work due to horizontal violence.
The graduate nurses had also reported that constructive criticism was not perceived as
such, they felt they were being talked down to. The worst and most disturbing result was
the graduate nurses had thought about or already had left the nursing profession due to
the horizontal violence experienced. Twelve percent of the graduate nurses had stated
that they had to have counseling due to the distressing events that was experienced.
Another study made on the subject that is of the same type of methodology as I
used in my dissertation is one made by Kathleen Sellers, PhD, RN, wherein she made a
descriptive study to examine the prevalence of horizontal violence in RNs who are
members of NYONE (New York Organization of Nurse Executives). Knowing the nurse
administrators' knowledge on the subject and the degree of encounter they had is the aim
of the study. The theoretical framework made use of was the transformational leadership
theory. The methodology made use of a convenient number of RNs as sample, all of
which are members of NYONE. They completed a Briles' Sabotage Savvy questionnaire
that included their demographic information among others. Likert model was also used
in this study. The study established the existence of horizontal violence in the profession
of nursing in consistence with what was already written about it. The study even showed
that the problem is already deeply rooted that it has already become a culture and is not
easily recognized. This makes the problem even harder to solve since it is not even
known to be a problem anymore.
Another research made on the nurse on nurse horizontal violence written by Cheryl
Woelfle and Ruth McCaffery (2007). They wanted to know if horizontal violence really
existed among nurses in the workplace and if it did what were the consequences of
horizontal violence among nurses in relation to patient care. They reviewed specifically
four different research articles the first article used was a “descriptive correlation design
that was used to examine the possible relationship between the perceived acts of
horizontal violence and the different levels of job satisfaction as reported by preoperative
nurses” (Woelfle, C., McCaffery, R. 2007, p.124). Participants are 145 preoperative
nurses from the preoperative nurses association for registered nurses (AORN) and their
ages ranged from 31 to 68, and ninety-eight of these nurses were female. They were
given a questionnaire to fill out containing forty questions to find out if the surveyed
nurse had ever been a victim of horizontal violence or bullying in the work place.
The surveys reported that the most common type of sabotage or bullying was one
expecting another to do their work. The “saboteurs reported that their most frequent form
of victimizing was to stop talking when others entered into the room, and they
complained about others without discussing it first with that person” (Woelfle, C.,
McCaffery, R., 2007, p.124). With the survey, they did not find a direct correlation with
satisfaction of nurses in the preoperative area and dissatisfaction with their current jobs.
They did find that preoperative nurses did act inappropriately and unprofessionally
amongst each other in the preoperative environment, “the study represents a significant
positive correlation between the IWS scores and reported sabotage” (Woelfle, C.,
McCaffery, R., 2007, p. 126). The weakness in this study was noted that maybe the
preoperative nurse was not being completely honest on the survey that was taken in
relation to the job satisfaction and significant sabotage in the working environment.
V. Updates on Horizontal Violence
Even in the present times where women are known to have become more
independent and modern, instances of horizontal violence is still prevalent. An
international qualitative study was done in 2008 with the use of surveys. This study
showed that most of the victims of violence in the workplace are women. This count
accounts for almost 93% of the national average. On the other hand, it is the nurses
which are the victims of such kind of abuse in a healthcare setting. Those who have
received such abuse were subjected to bullying, verbal abuse, harassment and worse,
cases of physical contact. 80% of those who have taken the survey are nurse leaders who
have experienced some form of horizontal violence in the workplace. Of the said figure,
83% are more than 36 years old and 80% works in a hospital that big enough to
accommodate 101 to 500 beds (Hader, 2008, p. 15).
A disturbing 48% of non-fatal injuries received by nurses and their assistants
came from assaults that happened in their workplace. This is a finding from the study
done by the Bureau of Labor Statistics. Further studies reveal that nurses, compared to
other healthcare professionals, are 16 times more likely to experience abuse (Christmas,
2007, p. 365). In the same 2008 international survey, 22 out of 1000 nurses are found to
have fallen victim to horizontal violence in the hospital setting. The more common form
is that of verbal more than physical violence.
Bullying in the medical setting is said to happen most of the time in the top three
areas, i.e., medical or surgical units, intensive care units (ICU) and the emergency
department (ER). The occurrences of horizontal violence are lesser in the areas such as
child health and maternal health areas, psychiatry and operating rooms. This information
shows that horizontal violence is more prevalent in the areas with high stress and where
the action is fast paced. On the other hand, where the action is slower, the probability of
having violence is lesser. In any instance, the fact remains that violence is happening in
the healthcare setting and will remain to affect nurses in many nations unless something
is done about it. This makes the reality more apparent that safety does not really exist in
healthcare anymore.
Another study about violence towards nurses and the effect on patients was made
in 2009. The goal was to find out if there if violence was really a part of the workplace
atmosphere (Roche, et al, 2009, p.13). The study showed that more than 80.3 % of the
participants has really encountered during the last 5 work shifts they had perceived
emotional abuse. The result of the study also pinpointed certain situations which
antagonized such violence. Outcome showed unanticipated changes in the patient mix
during shifts.
Even the World Health Organization has been showing concern with the
horizontal violence happening in healthcare settings. It is aware of the problem
becoming an epidemic already and has started to think of solutions by first producing
guidelines in dealing with the violence when it happens. WHO touched on the patient to
nurse type of violence as well and the effects it has on the emotions of the nurses. The
results of the survey made by WHO also made a significant finding, that the highest
rating for workplace violence was in the areas of highest acuity like the intensive care
units.
Horizontal violence, has finally received the spot light in the United States as a
problem and a topic to be researched. Vessey, J. A., Demarco, R. F., Gaffney, D. A.,
Budin, W. C., (2009) thought it was time to shed light on the topic in the United States.
Their study entitled, “Bullying of staff registered nurses in the workplace: a preliminary
study for developing personal and organization strategies for the transformation of hostile
to healthy workplace environments”, validated the perceptions of horizontal violence
occurring in the registered nurses workplace. They had responses from three hundred
and three nurses with the mean age of forty-nine to compile data from. The top two
perpetrating units in the hospital setting were the medical surgical floor and the intensive
care units. Fifty seven percent of the participants of this study were employed for less
than five years.
With supporting evidence showing that damaging effects on the psychological
aspect of the novice nurses while in the work place environment by creating an
atmosphere that is less than encouraging we are also increasing the numbers for the
nursing shortage. Due to the less than encouraging environments that novice nurses are in
“new nurses are at significant risk, with resignation rates reaching sixty percent in their
first year of practice” (Vessey, & al., 2009, p.300). Over the last two decades we have
seen an increase in the data acquired pertaining to the nursing shortage. There has been
much commercializing and marketing of the nursing profession to promote an increase in
the enrollment for the profession. Yet when the novice nurse finally gets to participate
fully in her profession she/he finds themselves an active reciprocate of horizontal
violence. Therefore, the seasoned nurse has created a decrease in confidence in ability
and skill of the novice nurse while caring for the acutely ill patient and causing
psychological distress due to lack of support during the novice nurses shift. “When
individual’s contributions are ridiculed, their sense of professional mastery is threatened
and their self esteem is eroded. The results personal disenfranchisement and poorer job
satisfaction” (Vessey, & al., 2009, p.301) this would than encourage less effective leaders
in the nursing unit to seek jobs elsewhere.
In helping the nurses, particularly the novice ones, to overcome such violence or
to completely eradicate the problem of lateral violence in the medical profession, the
following literature which speaks of solutions are indicated hereunder.
In the literature by Vollers, et. al. (2009) entitles AACN'S Healthy Work
Environment Standards and An Empowering Nurse Advancement System, it is indicated
that nurses should be empowered in order for them to create a healthy working
environment. The advancement systems that hospitals should have are used as example
of how nurses would feel such empowerment if clinical advancement is indeed utilized
(Vollers, et al, 2009, p. 20). Through the said clinical advancement system, new nurses
will have goals that they would want to achieve and they would feel what it is really
meant to be have their profession. Through this advancement system where they have a
ladder they can go up to, these novice nurses can perform their professional roles easier
with the feeling of support from their coworkers. This results into a healthier and more
supportive working environment.
Nurses may be allowed to practice skilled communications by participating in the
grand rounds. This will give the nurses the opportunity to ask questions and more
importantly, to practice the skilled communication. Having true collaboration within the
teams belonging in the interdisciplinary healthcare as well as all levels of management
will result in a cohesive team that works together for the same goal. The new nurses
should be able to witness such good collaboration. Failure to find such a good teamwork
within all levels can create hierarchical oppression among them. This will be like setting
up the healthcare facility for lateral violence.
Having an effective decision making within the healthcare organization’s
infrastructure is vital in order to have true collaboration as well as a positive working
environment. Such a decision making process must be quick and done in a shared
governance atmosphere. This means that all parties involves should be given a hand in
the decision making process with each ones input taken into consideration before
decision is reached. This also makes the nurses feel that the decision made is their own
and thus make then take ownership of patient satisfaction, nurse satisfaction and
retention.
Another way to make the nurses feel empowered is by correct staffing. This
means that there should be a proper ratio of nurse to patient. Nurses should not feel that
management is cutting cost by having to take care of a number of patients that is already
more than they can handle, then they would feel some aggression. Feeling such an
aggression can have them taking out their frustration or anger on other employees which
in turn is the start of horizontal violence in the healthcare setting. Having appropriate
staffing eliminates the feeling that nurses are undervalued and disconnected.
Being cognizant of the value of each nurse at work as well as their skills, talents
and intellect helps them see and feel that they are indeed valued. The result of such an
action would be for these nurses to feel empowered in doing a better work and provide
their patients the best care they can give. They would also feel like they are a part of the
facility where they are working for. When all the above steps are taken, the nurse will
surely become a provider of true leadership that will be very useful in all levels of the
medical system.
VI. Application of Theoretical Framework
The literature review made in this paper is chosen particularly in response to the
thesis questions I previously made. To reiterate, these questions are the following: (1)
While in orientation, do novice nurses experience horizontal violence in the ICU's in a
Midwestern magnet status hospital?; (2) Is bullying present during the orientation process
in the cardiovascular ICU?; (3) Do the novice nurses experience sabotage while in
orientation?; and (4) Has the novice nurses experienced feeling like an outcast or have
they experienced name-calling during their orientation in the cardiovascular ICU?
Answers to these questions are already very apparent with the literature included in the
paper. Horizontal violence is indeed existing in the nursing discipline, not only the ICU
department during orientation. Many incidents of horizontal violence were already
presented and I intend to prove that this also happens in the ICU, based on my own study
and methodology, further into my dissertation.
One theory that stands out when discussions on the theoretical framework with
regard to horizontal violence is Paulo Freire’s oppression theory. Under this theory,
Freire puts forward a pedagogy wherein a person learns to develop his own life via the
situations he goes through in his daily life which serves as his learning experience. What
his theory speaks of is the pedagogy of the oppressed more than the pedagogy for the
oppressed. He is saying a fact as it is, not suggesting something to solve a problem.
In Freire's proposed method, there are two implied moments, one that involves the
subject knowing his circumstances and being conscious of being oppressed and subjected
to decisions imposed by his oppressors and one that refers to the action of the oppressed
wherein he fights to free himself from his oppressors. Freire believes that the individual
involves does not take such an oppressive reality with just simple awareness but a need to
fight against status quo is inbred. The oppressed becomes concrete and focused with his
efforts. When they have a relationship, it is the oppressed that seems to be the instigators
of the violence that exists in the relationship though such condition will have them trying
to change their status.
Moreover, the oppressors blame those who are in opposition of their being
irresponsible, depraved, disobliging and at fault for being in such a situation. This is
despite the fact that even if those descriptions are at times apt. Those are actually the
response of one that is oppressed and is actually the outcome of the exploitation that
these oppressed individuals are subjected to. What makes the situation worse is when the
oppressed will just accept such a reality and simply adapt to it without a question or a
fight. This will generate in the oppressed an irrevocable emotional dependence. To be
able to fight such a situation, it is vital that a person get to know himself and start fighting
for their own emancipation.
Such is the idea of Freire as shown in the oppression theory that he
conceptualized. What Freire suggests is that the problem of horizontal violence is
already in existence, and may not even be as noticeable due to it being already deep-
rooted. However, he also is cognizant of the fact that such situation is a problem that
should not just be accepted. Instead, nurses who may be experiencing such kind of
problem should start knowing herself more and from there start having focus and fight for
what is right for her. This is how the problem of horizontal violence should be handled.
This is also the main reason for this study.
The need to establish and realize the existence of a problem is the foremost idea.
When this is done, things should not stop there. Instead, the study that will establish the
existence of horizontal violence in the workplace should be the starting point of its
solution.
VII. Final Remarks
The written literatures indicated in the preceding topics are clear indication that
horizontal violence has been in existence for a long time already and still persists to exist
in this modern world. While it is not only limited to the nursing profession, the focus has
been on the violence applied to nurses by nurses themselves. The phenomenon happens
not only in the ICU during orientation of these nurses by also in the other sections of the
medical world. The literature on the matter abounds and those included in this paper
more than sufficed to prove it.
Evidence suggests workplace bullying and related disruptive behavior are com-
monplace, and on the rise. The combination of a busy healthcare setting, difficult patient
situations, and the requirement for interdependent relationships can serve as a breeding
ground for incivility and bullying behaviors (Rau-Foster, 2004, 702). In response to a sur-
vey by the Joint Commission, more than 50% of nurses reported having been a victim of
bullying and/or disruptive behavior at work, and more than 90% stated that they wit-
nessed the abusive behavior of others (The Joint Commission, 2008). Despite the subse-
quent Joint Commission Sentinel Alert requiring healthcare facilities to design and imple-
ment a system wide approach to ensure employee awareness of disruptive and/or bullying
behaviors, bullying continues and still is perceived to be steadily on the rise (Lipley,
2005, p. 5). The implications for nurses' work environments are noteworthy, since the
health and availability of nurses are vital for the provision of a safe environment for our
most vulnerable population—the patients we serve (Beyea, 2004, p. 115; Jackson, 2002,
p. 13 and Simmons, 2008, p. 48).
Incivility is described as "rude or disrespectful behavior that demonstrates a lack
of regard for others" (Rau-Foster, 2004, p. 702). If left unabated, more aggressive behav-
iors, such as workplace bullying, can flourish and acculturate within a unit, department,
and even the organization at large. The definition of workplace bullying has evolved over
the years, from behavior that included open physical assault or violence, to more subtle,
even masked behaviors such as backbiting, blaming, disparaging, and exclusionary treat-
ment meant to do harm to another (Hoel, 2002, p. 270 and Randle, 2003, p. 395). While a
few researchers believe bullying only occurs horizontally among coworkers, the majority
feel that a real or imagined imbalance of power between the bully and the victim is a nec-
essary element of bullying behavior (Hutchinson, et al, 2006, p.118) and what makes the
phenomenon of workplace bullying separate and distinct from other disruptive behaviors,
such as incivility or workplace violence, is that these behaviors are not random acts. They
are intentional, occurring over a prolonged period of time, and targeted at an individual
who is unable to defend himself. Although bullying may seem harmless to an untrained
eye, a deliberate, ongoing pattern of negative behaviors can have a cumulative effect,
leading to serious harm to the intended victim in the long run (Hutchinson, et al, 2006,
p.118 and Woelfle & McCaffrey, 2007, p. 123).
Characteristics of Nurse-to-Nurse Horizontal Violence
• “Criticism, sabotage, undermining, infighting, scapegoating, and bickering” (Duffy,
1995, p. 9)
• “Intimidation, humiliation, excessive criticism, exclusion, innuendo, denial of access to
opportunity, disinterest, discouragement, and the withholding of information;” (as quoted
in McKenna, Smith, Poole, & Coverdale, 2003, p. 91)
• “Learning opportunities blocked, felt neglected, were given too much responsibility
without appropriate support… rude[ness]” (McKenna et al., p. 93)
• “Raising of eyebrows… abrupt responses… not being available… withholding informa-
tion about practice or about patients… sabotage… in-fighting… failure to respect privacy
… broken confidences” (Dunbar, 2005, p.1)
• “Dismissing, belittling, undermining, humorous ‘put downs’… gossiping… sarcastic
comments… nitpicking… minimizing another’s concerns… slurs and jokes based on
race, ethnicity, religion, gender, or sexual orientation… withholding support… limiting
right to free speech and right to have an opinion… “better than” attitude… chronic under-
staffing” (Hastie, 2002, pp. 2-3).
The power of horizontal violence in nursing is now being countered by awareness, educa-
tion, and on-the-job zero tolerance for abuse. “We’ve always cared for others. Now let’s
care for each other” (Leiper, 2005, p. 45).
Lateral Violence as a Role Issue
As nurses we are familiar with role issues with physicians. Nurses are educated from the
first year of the educational process to work in teams; however, physicians have
traditionally been educated to believe they are the “captain of the ship”. These conflicting
professional cultural beliefs are a basis for stress between physicians and nurses. Nurses
expect to work as colleagues with physicians; however, physicians often do not see that
as desirable. Such differing cultural expectations breed conditions that are ripe for lateral
violence.
Lateral violence between and among nurses can occur for various reasons. Since there are
a number of roles within nursing, role issues can arise between staff nurses; between staff
nurses and managers; managers and advanced practice registered nurses (APRN), and
staff nurses and APRNs. For nurses who embrace the nursing culture of “eating its
young”, it might be demonstrated through abusive and demeaning behaviors towards
students and new graduates. The same types of behaviors can occur toward other nurses
if they vary from the “group norm”. Regardless of the nurse’s status, undercutting
behaviors and words which demean hurt all nurses and establish a toxic workplace.
Lateral Violence as an Oppressed Group Issue
Dr. Martha Griffin, RN, an activist and nurse educator, believes lateral violence is the
result of oppressed group behavior. Oppressed group behavior occurs when one group
believes it has been excluded from the power structure. (Ratner, 10). Griffin believes that
nurses have little control over their work environment and yet are held accountable
resulting in personal stress. The member of the oppressed group is abusive to peers and
those individuals with lesser status because she/he fears addressing the source of the
stress affecting her/him. Therefore, the nurse strikes out at peers, students, unlicensed
assistive personnel, patients, etc.
Lateral Violence as a Gender Issue.
This gender theory is applicable because as of the 2000 National Sample Survey of RNs,
only 5.4% of RN are men (DHHS/HRSA/BHP/DON, 2000 p.8). This theory states that
lateral violence occurs because women have not been socialized to appreciate themselves
or the roles they play. Women are often socialized to believe they are not as strong or
smart as men and their role in life is to serve men. In addition, nurses often are not
empowered during the educational and enculturation processes to value themselves as
people and as health care providers. To be able to engage a physician in a discussion over
differences in approaches to patient care, the nurse must feel equal in power, professional
stature, and professional knowledge. If nurses do not have such feelings and are
frustrated, angry, or fearful, they often will vent their feelings laterally or downward.
Lateral Violence as a Self-Esteem Issue
Self esteem is a major consideration in all of the above approaches to the problem of
lateral violence. Self-esteem theory is very complex.
The major threads of self-esteem “are that it is a major predictor of behavior; that
it is not a polarizing entity but rather occurs along a continuum; and that it consists of
different ‘selves’, in that an individual can feel differently about themselves as a nurse,
than they do as a parent. Self-esteem is built up or damaged in social interaction, as
people receive feedback about how others view them and judge their behavior.” (Randle,
395) “Self esteem-refers to self- evaluative attitudes that are integral to the individual or,
in a simpler form, it refers to the individual’s perception of themselves.” (Randle, 395-6)
Self-esteem is both subjective and constructed. This means that your self-esteem is
partially what you think of yourself based on how others react to you and partially based
on your own life experiences.
Healthy self-esteem is characterized by use of the authentic self, empathy, the
development of relationships, and the ability to face adversity (Randle, 396.) In nursing
practice, healthy self-esteem allows for empathetic behavior; the delivery of personalized,
holistic care, and the development of interpersonal relationships with patients, their
significant others, and their health care providers.
Professional self-esteem is largely developed by the nursing student’s interactions with
instructors, supervising nurses during clinical times, and student peers. As nursing
students observe those in power, they develop a beginning concept of how a professional
acts toward patients, students, and colleagues.
Research has demonstrated that the interactions that occur during the student’s education
will shape her/his professional image. One study demonstrated empirically that nursing
student clinical experiences were negative because the students were bullied. Much
negative damage was done to the students’ psychology, not only in their image of
themselves as nurses, but also as people. (Randle, 397) The lateral violence/bullying
behavior undermined their self-esteem, making them feel powerless; angry, anxious, and
stressed. Such an atmosphere can endanger patients. (Mc Kenna, et al., 2003)
Nurses “professionalized” in such abusive environments carry their bullying behaviors
into their patient care. They may choose to control patients by delaying their response to
the patient's needs – pain medications, toileting, etc. These disgruntled RNs can also
strike out at a patient’s family by refusing to keep them informed of the patient’s
condition or not providing support in other ways to them or the patient. This type of
behavior causes fear of retribution in both the family and patient. (Dunn, 2003).
The aforementioned literature establishes the existence of horizontal violence and
proves that it abounds. Yet, what has been included is only a small fraction of what is
available. In the succeeding topics, more instances of horizontal violence will be presented,
this time even made concrete with evidences produced by methodologies and in depth
analysis of the problem.
Nurse bullying is bringing about upshots that are unsafe to patient care, for the
nursing profession itself, and to healthcare establishments.
Workplace bullying is defined as repeated, health-harming mistreatment of one or more
persons by one or more perpetrators that takes one or more of the following forms: verbal
abuse; offensive conduct/behaviors (including nonverbal) which are threatening,
humiliating or intimidating; and work interference—sabotage—which prevents work
from getting done (Namie and Namie, 2008).
DiscussionReversing the bullying culture in nursing
By Lynda Olender-Russo, PhD(c), MA, NEA-BC, RN 2009
Leaders within healthcare organizations are struggling to manage disruptive behavior
and bullying in the workplace.
A DIRE SITUATION IS LOOMING in the US healthcare system. The country is brac-
ing for a projected unprecedented shortage of more than 500,000 RNs by 2025,
due in part to baby boomer nurses retiring at the same time as the demand for healthcare
is rising. Moreover, despite the 3.3% increase in student enrollment and a stable
RN vacancy rate of 8.1%, RN turnover rates range from 8.4% to 13.9%; and the demand
for registered nurses still is expected to increase 2% to 3% annually (AACN, 2009).
dissatisfaction and related intent to leave the work environment are believed to be key
factors contributing to the shortage. Moreover, exposure to incivility, including
workplace bullying, is one of the primary factors influencing RN dissatisfaction and
turnover rates, (Simmons, 2008, p. 48) and can be a reason why some leave the profes-
sion altogether (Duffield et al, 2004, p. 664).