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Horizontal/Lateral Violence in Nursing Profession


According to Duffy (1995), horizontal or lateral violence can be widely defined as the unreceptive and antagonistic behavior remitted towards an individual or group by another individual or group perceived or thought to be superior to the latter. In essence, horizontal violence is described as an inter-group struggle for dominance and authority. Horizontal or lateral violence is prevalent in the workplace, and it is an intolerable, obnoxious, destructive, and distasteful phenomenon. Employees in all organizations should unite and work together against this social vice of oppression and exterminate its insalubrious behavior from organizations. The term horizontal violence, which is also referred to as lateral violence, is a new phrase or terminology. However, the character it describes is not new. The term was coined to illustrate repugnant behavior that nurses occasionally portray towards their colleagues. Horizontal violence comes in various forms and characteristics. In essence, it is a blatant and concealed nonphysical aggression. This may include sabotage; finger-pointing; bickering; condemnation and blame (Vonfrolio, 2005).

Various people have been embarrassed, ridiculed, or scorned by other medical practitioners. One of the most affected workgroups that experience horizontal violence is the new nursing graduates. In any workforce, it is very essential for the experienced staff to welcome and support the new graduates to encourage them in their new profession. Usually, the first year of nursing practice is when new grandaunts develop, build, and establish their confidence and self-esteem. As a new graduate, a person lacks experience, knowledge, and appropriate skills to defend themselves. As a result, they are often dehumanized. Regrettably, all new graduates openly accept this treatment as a ritual of passage. It is disappointing that they also emulate their predecessors and commit the same abuse to others who join after them (Duffy, 1995).


Horizontal or lateral forms of violence have been widely and extensively described as any unsolicited abuse or aggression within the work environment (Stanley, Martin, Nemeth, Michel & Welton, 2007). According to Thobaben (2007), horizontal violence refers to any intimidating, unreceptive, inimical and aggressive behavior exhibited by a nurse or a group of nursing practitioners directed towards an individual or group of fellow workers through arrogance, thoughts, opinions, mindsets, and behavior. Horizontal violence is illustrated by the presence of a sequence of undermining occurrences over a certain period, as compared to single isolated disagreement in the workplace (Jackson, Firtko, & Edenborough, 2007).

This continuous conflict usually makes horizontal violence irresistible, prodigious, and devastating. Eventually, this leads to signs of dejection, hopelessness, gloominess and might even cause post-traumatic in the affected person. Horizontal violence tends to be hidden, hard to conceptualize, realize, and ascertain. The affected party subsequently has problems or difficulties in obtaining help within the work environment. Horizontal violence has also been depicted as an inter-group struggle with elements of blatant and hidden aggression (Joint Commission, 2008). The nursing profession has been termed to be composed of an oppressed lot that mainly includes female workers. Proponents of the oppression theory argue that lack of independence and control over their working area; hopelessness, defenselessness, and low personal self-esteem facilitate the development and expansion of horizontal violence inside the nursing profession (St-Pierre & Holmes, 2008). However, this has not been able to explain why horizontal violence is manifested in various professions and includes organizational, social, and individual traits (Wilson, Diedrich, Phelps, & Choi, 2011).

Horizontal violence that generates repeated incidents of aggression directed at workmates is also referred to as workplace bullying (Longo & Sherman, 2007). According to Vessey, Demarco, and DiFaizo (2010), a bully can be defined as a person who openly or secretly demeans another colleague. They described the bully’s behavior as being intentional, to generate body or mental suffering to the victim. The threatening behavior of persons engaged in bullying is evident throughout their lifespan. Bullies often seek support from other persons as a means of legitimizing their behavior. The support obtained from their peers further goes to provide an audience that strengthens aggression. In turn, this fosters further segregation of the victim and enables the aggressor to operate and expand their influence (Randle, Stevenson & Grayling, 2007).

In general, horizontal violence is known to happen within peer groups of the same job grade. In a study conducted by Wilson and his associates, it was observed that about 61.1% of the interviewed nurses confirmed to have witnessed or experienced horizontal violence within their work unit. This was extended to colleagues who worked in close relations with nurses such as physicians (49.1%) and supervisors (26.9%) (Wilson, Diedrich, Phelps & Choi, 2011). In contrast, horizontal violence has not been restricted to those in lateral positions. Horizontal violence has been evidenced to project from the nursing management to the juniors that they supervise. In a study carried out by Stagg, Sheridan, Jones, and Speroni (2011), it was observed that 28% of the nurse respondents had at one stage been bullied by a representative of the leadership (Wilson, Diedrich, Phelps & Choi, 2011).

Incidence and prevalence

The extent of incidence and prevalence of horizontal violence within the nursing profession is almost anonymous. In this case, horizontal violence is often undocumented, unreported, and unpredictable. However, recent studies have affirmed that horizontal violence is quite extensive affecting between 65% and 80% of all nurses interviewed (Stagg, Sheridan, Jones & Speroni, 2011; Vessey, Demarco, Gaffney & Budin, 2009; Wilson, Diedrich, Phelps, & Choi, 2011).

A study carried out by Johnson and Rea (2009) on horizontal violence amongst 249 nurses who were registered nurses of the Washington State Emergency Nurses Association. In this study, it was observed that 27.3% had been subjected to bullying at the workplace. Notably, 18% of the nurses from the sample population confirmed that they encountered at least two demeaning acts on a weekly or daily occurrence. On the other hand, about 50% of the nurses reported encountering three or more demeaning acts on a daily or weekly occurrence (Johnson & Rea, 2009). In a separate study conducted on nursing students in Australia, it was observed that an estimated 50% of the undergraduates encountered horizontal violence throughout their clinical rounds (Curtis, Bowen & Reid, 2007).

Students also confirmed feeling hopeless, humiliated, and embarrassed as they encountered these actions at the workplace. In a study carried out on junior nursing students by Thomas and Burk (2009), it was revealed that horizontal violence takes place as early as the first meeting between the students and the professional nurses in the job setting (Thomas & Burk, 2009). It is also reported that most of the new graduates who encounter horizontal violence thought of leaving the nursing profession. They were also observed to have a high incidence of absenteeism (Curtis, Bowen & Reid, 2007).

Effects of horizontal violence

Horizontal violence destroys the self-esteem of the individual and is consequently detrimental to the nursing practice. In this case, belligerence and violent behavior increase from fellow workers who ought to be offering guidance and encouragement (Thomas & Burk, 2009). Horizontal violence has profound implications for newly graduated and current students of nursing. These individuals are new in the field and require constant guidance and advice to enable them to achieve their potential. New graduate nurses who encounter horizontal violence may have problems in achieving success due to the nature of constant aggression (Thomas & Burk, 2009).

Horizontal violence has a detrimental effect on the entire health system because of the ever-increasing rift amongst employees or groups of co-workers. Horizontal violence results in various effects that project from the victim towards the health care group and finally to the patient (Joint Commission, 2008). It can be noted that victims of bullying mostly suffer from low self-esteem, sleeping disorders, powerlessness, and absenteeism from work amongst many other symptoms (Thobaben, 2007). As part of the psychological consequences, some of the victims of horizontal violence have been associated with suicidal tendencies (Vessey, Demarco & DiFaizo, 2010).

It was reported by the Joint Commission (2008) that inadequate communication was the prime factor in the lookout incidents influencing health care groups and negating patient safety. When critical information about a patient is withheld as a tool of horizontal violence, the victimized nurse will not be able to discharge her duties effectively. This will greatly compromise the safety of the patient. The chain effect is that the patients, patient’s family, and the institution are bound to incur additional financial costs notwithstanding the risk of potential legal prosecution. It is estimated that about half of all horizontal violence incidents are not reported. With strict codes of conduct that deter retaliation, most of the victims are left with no options or avenues to report or defend themselves (Stagg, Sheridan, Jones & Speroni, 2011; Vessey, Demarco & DiFaizo, 2010).

Application of findings to future nursing practice

The American Nurses Association (ANA) has a code of ethics that stipulates the desired behavior and character of professional nurses. The sixth standard in this code suggests that nurses are accountable for attaining and sustaining work environments coherent with professional values (American Nurses Association (ANA), 2001). Currently, the modern health care scenario poses many challenges that aid horizontal violence. Inadequate staffing, lack of sufficient resources, and increased patient perspicacity tend to generate stress and aggression (Huntington, et al., 2011). Nurse leaders are perfectly positioned to avert and eradicate horizontal violence by availing resources in the form of encouragement and advice. Leaders who portray a trusting character allow the staff to experience support. Provision of resources to reduce job-related stress and anxiety can enable nurses to be empowered to care for their patients appropriately (Longo & Sherman, 2007).

Leaders should hold themselves and their juniors responsible for formulating satisfactory professional behavior. When unacceptable behaviors are observed, a corrective measure should be formulated immediately. Once the challenges of horizontal violence are noted in an organization, a formula should be worked out on how to change the nature that facilitates acts of horizontal violence. When tackling complaints or cases of horizontal violence, nurse leaders should ensure that they keep an objective stand and evaluate all facts from a neutral perspective. They should be conversant with the organizational policies specifically related to horizontal violence (Vessey, Demarco & DiFaizo, 2010).

Most importantly, they should be ready to implement policies with applicable disciplinary measures when incidents of horizontal violence jeopardize the integrity of the organization. Managers should also engage in similar horizontal violence seminars as their employees to ensure that they are adequately enlightened about the occurrences of horizontal violence (Stagg, Sheridan, Jones & Speroni, 2011). Focus groups can be constituted to categorize the major areas that need improvement and commence an action program. This will encourage the discussion on the prevention and eradication of horizontal violence within the organization (Longo & Smith, 2011).

Nursing students and newly graduated nurses are potentially at a high risk as most of them consider leaving due to horizontal violence. During the process of character transformation and increased responsibility and expectations, young graduates and nursing students encounter increased stress in their work environment (Thomas & Burk, 2009). Preceptors delegated to new graduates should be aware of the negative influence of horizontal violence on newly graduated professionals. Preceptors of new graduates and students should construct professional behavior with the objective of giving guidance and assistance (Curtis, Bowen & Reid, 2007). Preceptors should also have sufficient intelligence on how to deal with horizontal violence among coworkers, and always demonstrate professional behavior with a view to building trust and cohesiveness. The option of assigning new graduates to mentors from different units may be applied. This offers appropriate resources found within the organization capable of dealing with probable cases of horizontal violence. Some of the fundamental mentoring accountabilities may include teaching, coaching, counseling, offering protection and sponsorship (Curtis, Bowen & Reid, 2007).

Implications for identified specialty

In organizations where horizontal violence issues have not been addressed, measures can be instituted by the nurses who have experienced acts of bullying. First and foremost, they should uphold a healthy view of themselves. This will ensure that they do not personify the incidents of horizontal violence. During the occurrence of horizontal violence, sharing the experience with a trusted friend or colleague may be of great help (Randle, Stevenson & Grayling, 2007). Talking or sharing incidences of horizontal violence assists the person to ascertain whether the acts constitute incidents of horizontal violence or not. This may also be used to determine a witness to the proceedings. Counseling may be recommenced to encourage and address the emotional needs of the individual. This should be done hastily to prevent unnecessary emotional turbulence (Cleary, Hunt, Walter & Robertson, 2009).

Exhibiting aggressive behavior during the occurrence of an event may be regarded as an acceptable reaction to horizontal violence. It is recommended that actions or acts that comprise bullying should be confronted steadfastly when or just after they have occurred. The dialogue should remain both emphatic and honest (Randle, Stevenson & Grayling, 2007). The offended party should call for the bullying to be stopped. The offended party should also make specific reference to the offending act without revealing their emotions or feelings generated by the incident. Only the actual incidents that comprise horizontal violence should be discussed. However, there should be an emphasis on uncouth behaviors and the way back to a professional work environment (Cleary, Hunt, Walter & Robertson, 2009).


Every organization experiences some form of horizontal violence. This has the explosive potential of destroying the institutional integrity within the nursing profession, which finally culminates in poor patient care. Failure to address issues related to horizontal violence can profoundly hurt new students and grandaunt nurses. This may eventually push them out of the profession. Nurses and nursing leaders should acknowledge the presence of horizontal violence and instigate appropriate measures to mitigate the situation.


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