Breaking the Cycle of Horizontal Violence on Nursing Units

By Rose O. Sherman, EdD, RN, FAAN

Recently, one of my nursing administration graduate students came to ask my guidance about a dilemma that she was experiencing in her work setting. She had recently been promoted to nurse manager position in a labor and delivery unit. One of the first steps that she took to learn about the unit was to interview all of her nursing staff. A troubling picture was emerging from these interviews. She seemed reluctant to name the problem as a unit culture of horizontal violence but felt that there was evidence to support that this was occurring. It was having a negative effect on staff morale, professional engagement and retention of new staff. “How can I break the cycle of horizontal violence when it has become a pattern of behavior”, she asked.

What is Horizontal Violence?

Horizontal violence (also called lateral violence) between nurses is an act of aggression that’s perpetrated by one colleague toward another colleague. Although horizontal violence is usually verbal or emotional abuse, it can also include physical abuse and may be subtle or overt. Repeated acts of horizontal violence against another are often referred to as bullying. You may also hear this referred to as “nurses eating their young” because the victims are often new graduates. If you think the situation that the nurse manager above described is rare, you would be wrong in your assumption. Karen Stanley (2010) who has studies lateral violence reports that in her research, 65% of the nurses she surveyed observed these behaviors in co-workers often or sometimes, and 18% acknowledged that they perpetrated these behaviors themselves.

Signs of Horizontal Violence

As a nurse leader, the challenge is to identify behaviors that should be characterized as horizontally violent in order to stop the cycle. Nurse leaders have a responsibility to analyze the culture of units and watch closely for verbal and nonverbal cues in the behavior of staff. Some common ones include:

Talking behind one’s back instead of directly resolving conflicts
Making belittling comments or criticizing colleagues in front of others
Not sharing important information with a colleague
Isolating or freezing out a colleague from group activities
Snide or abrupt remarks
Refusing to be available when a colleague needs assistance
Acts of sabotage that deliberately set victims up for a negative situation
Raising eyebrows or making faces in response to the comments of colleagues
Failing to respect the privacy of colleagues
Broken confidences

Breaking the Cycle

A culture of zero-tolerance for horizontal violence is the most effective leadership strategy to prevent its occurrence. It is important that the problem be labeled as “horizontal violence”. Staff need to be educated about the behaviors that constitute bullying to help break the silence. Raising the issue at a staff meeting and letting staff tell their stories is a key step to helping rebuild a culture. Staff need to know that you will quickly be responsive when you observe the behavior or when it is brought to your attention. Leaders need to engage in self-awareness activities to ensure that their own leadership style does not support horizontal violence. The selection of preceptors who will support a zero-tolerance policy is critical to orienting new staff about behavioral expectations.

When a unit culture has a history of horizontal violence as described above, there will need to be a culture change. Part of that change is promoting a new set of shared values and goals with staff that promotes staff empowerment. communication, collaboration and life-long learning. If your unit hires new graduates, provide opportunities for staff to talk about their own first year in practice and use these stories as powerful reminders to nurture our young. Nursing research indicates that exposure to horizontal violence has a high cost to the organization and often results in staff turnover. Nurses who are victims of horizontal violence may have problems sleeping, develop low self-esteem, exhibit depression, have poor morale and use excessive sick leave. It is also a patient safety issue when communication is compromised because of horizontal violence. Breaking the cycle of horizontal violence on a unit can help to both re-energize the staff with enthusiasm for their profession and create a healthier work environment.

Read to Lead

Brown, T. (February 11th, 2010). When the Nurse is a Bully. New York Times Blog.

Longo, J.,& Sherman, R.O. (2007). Leveling horizontal violence. Nursing Management, 38(3), 34-37; 50-51.

Stanley, K. (April 24, 2010). The high cost of lateral violence in nursing. Sigma Theta Tau Leadership Conference.