Horizontal Violence

Horizontal Violence
Joy Longo DNS, RNC- NIC
Christine E. Lynn College of Nursing
Florida Atlantic University

Four Categories of Workplace
Violence
(University of Iowa Injury Prevention Research Center, 2001).
Type 1 Criminal intent
Type II Customer/client, such as patient to
healthcare worker
Type III Worker-on-worker
Type IV Personal relationship

Joint Programme on Workplace
Violence in the Health Sector (2002)
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.

The Joint Commission
Sentinel Event Alert
July 9, 2008
Behaviors that Undermine a Culture of
Safety

Terms Used to Describe
Disruptive Behavior
Bullying (Lewis, 2001; Stevens, 2002)
Mobbing (Yildirim & Yidirim, 2007)
Horizontal Violence (Roberts, 1983; Skillings, 1992)
Horizontal Hostility (Thomas, 2003)
Lateral violence (Griffin, 2004)
Incivility (Clark, 2008)

Horizontal violence between nurses
is an act of aggression that is
perpetrated by one colleague
towards another. It can be
comprised of physical, verbal, or
emotional abuse that may be
subtle or overt.

Why These Behaviors Occur
• Power Imbalance
• Oppression
• Perpetuation of learned behaviors
(McCall, 1996; Roberts, 1983; Skillings, 1992;).

Literature Review - Incidence
A survey found that more than one-third of staff reported
experiencing one or more types of bullying in the past
year. (Quine, 1999)
In a study of Australian nurses it was reported that 95%
were involved in several episodes of verbal aggression
in the last 12 months, 25 % reported weekly occurrences
of verbal abuse, 32.4% reported monthly occurrences,
and 37.7% reported incidences 1-4 times a year. (O’Connell,
Young, Brooks, Huchings, and Lofthouse, 2000).

Literature Review - Source
• In a study by the Maryland Nurses Association, the most prevalent
source of physical assault, verbal violence, threats, and intimidation
at work was the patient (67.6%), followed by a family member
(41.3%) and co-worker (29.5%) (Distasio, Hall, and Beachey, 2005).
• The most frequent perpetrators of non-physical violence were the
medical doctor and co-workers (Hesketh et al., 2003)
• In a self-report study of workplace violence in Queensland, nurses
were found to be a major source of the violence. (Hegney, Plank and Parker
2003)
• In another study, nurses were found to be the most frequent source
of verbal abuse. (Rowe and Sherlock, 2005)

Literature Review – Type of
Violence
• In a study of nurses in Alberta and British Columbia, the most
frequently reported type of violence was emotional and the highest
incidence occurred with medical surgical nurses. (Hesketh et al.,2003)
• In a study of Australian nurses it was reported that 95% were
involved in several episodes of verbal aggression in the last 12
months, 25 % reported weekly occurrences of verbal abuse, 32.4%
reported monthly occurrences, and 37.7% reported incidences 1-4
times a year (O’Connell, Young, Brooks, Huchings, and Lofthouse, 2000).
• Most frequently reported type of workplace violence was emotionalverbal,
followed by sexual and physical.(Anderson and Parish, 2003)
• 48% of hospital-employed nurses perceived verbal abuse as a
threat in the workplace (Buerhaus, Staiger, & Auerbach, 2009)

Literature Review -
Consequences
• In one study 73% of the participants responded to aggression with
frustration, 70.6% were angry, and 46.6% were hurt. (O’Connell, Young,
Brooks, Hutchings, and Lofthouse, 2000)
• In a study of perioperative nurses, a significant positive correlation
was found between being the victim of sabotage and job
satisfaction. (Dunn, 2003)
• Having not experienced workplace violence was associated with the
highest job satisfaction, and those who experienced emotional
abuse and one other form of workforce aggression had the lowest
job satisfaction. If the participant experienced only emotional
violence, job satisfaction was lower than associated with any other
form of violence. (Hesketh et al, 2003).

Literature Review
Do Nurses Eat Their Young?
A study of 59 student nurses found that all of the students
identified the existence of a bullying attitude in nurses.
The students found this very distressing, and without
personal and professional resources available to
challenge the practices, the students assimilated the
same tactics in their practice.
(Randle, 2003)

• Student Nurses
Who is Affected?
• Newly Graduated Nurses
• Experienced Nurses

Examples of Horizontal Violence
�Talking behind one’s back*
�Belittling or criticizing a colleague
�Blocking information or chance of
promotion
�Isolating or freezing out of group activities

Actions to Combat Horizontal
Violence
�Recognize the behaviors when they occur. Give
it a name.
�Prepare to address the issue.
�Confront the perpetrator if appropriate.

First Step: Recognizing the
Consciousness raising
in regard to the
situation of
oppression and the
acts of horizontal
violence is the first
step in addressing the
issue.
Behavior

Cognitive Rehearsal (Griffin, 2004)
Study: 26 newly licensed nurses taught
about lateral violence in nursing practice
and the use of cognitive rehearsal
techniques as a shield.

Results (Griffin, 2004)
� 96% witnessed lateral violence
� 100% confronted the lateral violence
� The lateral violence behavior stopped
�Nine nurses were shocked new nurse felt that way
�Seven apologized
�Three shunned new nurse for 2 weeks
Recommendation: Educate all of the hospital
nurses about lateral violence

Another Way to
Address the Issue:
Supporting
Colleagues
If you witness an incident of horizontal
violence, offer support to the victim.
Do something. Do not ignore it.

What to Do Next
�If the issue is not resolved by confronting
the perpetrator, the incident should be
reported by following the chain of
command.
�This can be facilitated by learning about
policies in the facility that address these
behaviors.

Role of Nurse Manager
• Risk Assessment: Ensure that environment does not
support this type of behavior.
Is there an underlying hierarchy that exists?
Are stories of horizontal violence taken seriously?
If a perpetrator is identified, how is this dealt with?
• Introduce the topic as a way to educate nurses in
identifying behaviors. Allow staff to tell their stories.
• Ensure that there is a process that addresses this issue
and be responsive when there is an issue.
• Address perpetrator through problem-solving approachopportunity
for skill development.
(Longo & Sherman, 2007; CAN, 2007)

Role of the Organization in
Addressing Bullying/Horizontal
Violence
Adopt “zero tolerance”
stance

Zero Tolerance
“Specified behavior will not be tolerated
under any circumstances, and that there
will be a nonnegotiable sanction imposed
whenever that behavior occurs.”
( Holmes, 2006)

Legislation/Laws
That Address
These Behaviors
Codes and Laws: Sweden, Australia, France, Britain, and
Canada
United States: 13 states have introduced “Healthy
Workplace” legislation since 2003. None have passed.
(Workplace Bullying and Trauma Institute)

Workplace
Policies
• Threat of Violence Program
• Verbal Abuse of Employee Policy
• 2009 Joint Commission Standards

Center For American Nurses
Position Statement
Lateral Violence and Bullying In the Workplace (2008)
“It is the position of the CENTER for American
Nurses (The CENTER) that there is no place in a
professional practice environment for lateral
violence and bullying among nurses or between
healthcare professionals.”

References
Alspach, G. (2008). Lateral hostility between critical care nurses: A survey report. Critical Care Nurse, 28(2), 13-19.
Buerhaus, P.I., Staiger, D.O., & Auerbach, D.I. (2009). The Future of the Nursing Workforce in the United States: Data,
Trends, and Implications. Boston: Jones and Bartlett Publishers.
Center for American Nurses (2007). Bullying in the workplace: Reversing a culture. Silver Spring, MD: Center for
American Nurses.
Center for American Nurses (2008). Lateral Violence and Bullying in the Workplace.
Clark, C. (2008). Faculty and student assessment of and experience with incivility in nursing education. Journal of
Nursing Education, 47(10), 458-465.
Distasio, C.A., Hall, K., & Beachey, M. (2005). The Maryland Nurses Association Workplace Violence Survey Report.
Maryland Nurses Association. Available: www.marylandRN.org.
Dunn, H. (2003). Horizontal violence among nurses in the operating room. AORN Online. Retrieved May 5, 2004, from
Ovid database.
Griffin, M. (2004). Teaching cognitive rehearsal as a shield for lateral violence: An
intervention for newly licensed nurses. The Journal of Continuing Education in Nursing, 35, 257-263.
Hegney, D., Plank, A., & Parker, V. (2003). Workplace violence in nursing in Queensland, Australia: A self-reported
study [Electronic version]. International Journal of Nursing Practice, 9, 261-268.
Hesketh, K.L., Duncan, S.M., Estabrooks, C.A., Reimer, M.A., Giovannetti, P., Hyndman, K., & Acorn, S. (2003).
Workplace violence in Alberta and British Columbia hospitals. Health Policy, 63, 311-321.
Holmes, C.A. (2006, May). Violence, zero tolerance and the subversion of professional practice [Electronic version].
Contemporary Nurse, 21(2), 212. Retrieved February 28, 2008, from the galegroup.com database.
Joint Commission. Standard (2008). LD.03.01.01. Retrieved October 25, 2008, from
http://www.jointcommission.org/NR/rdonlyres/B22072D1-D146-457E-A791-E4F2DC6DFD5E/0/CAH_LD.pdf
Joint Commission (2008). Sentinel event alert. Retrieved November 12, 2008, from
http://www.jointcommission.org/Sentinelevents/SentinelEventAlert/sea_40.htm
Joint Programme on Workplace Violence in the Health Sector (2002). Framework guidelines for addressing workplace
violence in the health sector. Geneva: International Labour Organization
Lewis, M. (2001). Bullying in nursing. Nursing Standard, 15, 39-42.
Longo, J. & Sherman, R. (2007). Leveling horizontal violence. Nursing Management, 38(3), 34-37, 50, 51.

References (con’t)
McCall, E. (1996, April). Horizontal violence in nursing: The continuing silence. The
Lamp, 28-31
O’Connell, B., Young, J., Brooks, J., Hutchings, J., & Lofthouse, J. (2000). Nurses’ perceptions of the nature and
frequency of aggression in general ward settings and high dependency areas. Journal of Clinical Nursing, 9, 602-
610..
Quine, L. (1999). Workplace bullying in NHS community trust: Staff questionnaire survey. BMJ.com, 318, 228-232.
Retrieved November 21, 2001, from http://www.bmj.com/cgi/content/full/318/7178/228
Randle, J (2003). Bullying in the nursing profession [Electronic version]. Journal of Advanced Nursing, 43, 395-401.
Roberts, S.J. (1983) Oppressed Group Behavior: Implications for Nursing. Advances in Nursing Science, 5, 21-30.
Rowe, M.M., & Sherlock, H. (2005). Stress and verbal abuse in nursing: Do burned out nurses eat their young? Journal
of Nursing Management, 13, 242-248.
Skillings, L.N. (1992). Perceptions and feelings of nurses about horizontal violence
as an expression of oppressed group behavior. In J.L. Thompson, D.G. Allen, & L Rodrigues-Fisher (Eds.),
Critique, resistance, and action: Working papers in the politics of nursing (pp. 167-185). New York: National
League for Nursing Press.
Stevens, S. (2002). Nursing workforce retention: Challenging a bullying culture. Health Affairs, 21, 189-193.
Thomas, S.P. (2003). Anger: The mismanaged emotion. Dermatology Nursing, 15, 351-357. Retrieved September 22,
2003 from Ovid database.
University of Iowa Injury Prevention Research Program, (2001). Workplace violence: A report to the nation. Retrieved
October 8, 2005, from: httpa://www.public-health.uiowa.edu/IPRC/NATION.PDF
Workplace Bullying Institute (2007). http://bullyinginstitute.org/
Workplace Bullying Institute (2007). The Workplace Bullying Institute U.S. Workplace Bullying Survey Retrieved
November 11, 2008, from http://bullyinginstitute.org/zogby2007/wbi-zogby2007.html
Workplace Bullying Institute (2008). What Bullied Targets Can Do. Retrieved November 11, 2008, from
http://bullyinginstitute.org/education/bbstudies/3step.html
Yildirim, A., & Yildirim, D. (2007). Mobbing in the workplace by peers and managers: Mobbing experienced by nurses
working in healthcare facilities in Turkey and its effect on nurses. Journal of Clinical Nurses, 16(8), 1444-1453.

Thank You