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Horizontal violence: Can anything be done?

Amrein, Kathleen R. MSN, BS, BSN, RN, CCRN-CMC

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doi: 10.1097/01.NURSE.0000418620.83970.1c
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VIOLENCE AND ABUSE between healthcare workers in the workplace, also known as horizontal violence, isn't new. Offensive and aggressive behavior in healthcare settings had become so disruptive that on January 1, 2009, The Joint Commission (TJC) established unique standards that address belligerent and inappropriate behavior in a Sentinel Event Alert.1

New guidelines have been established requiring more than 15,000 accredited healthcare facilities to formulate a code of conduct focusing on horizontal violence. These codes of conduct define appropriate and unacceptable behaviors, and establish a formal process for managing inexcusable conduct.2

Intimidating and undisciplined behavior in the healthcare industry results in more than just hurt feelings. It contributes to medical errors and poor patient satisfaction.3 This article looks at how horizontal violence impacts nursing care and what you can do to improve conditions where you work.

Taking a stand

In the position paper Zero Tolerance for Abuse, the American Association of Critical Care Nurses (AACN) defines “abuse” as intimidating behaviors such as condescending language, impatience, angry outbursts, reluctance or refusal to answer questions, threatening body language, and physical contact.3 The International Council of Nurses (ICN), representing nurses in more than 128 countries, strongly denounces acts of horizontal violence in the health workplace, including verbal abuse. The ICN's position statement on abuse and violence against nurses firmly states that this behavior threatens the effective and safe delivery of patient care.4

In January 2005, the AACN published national standards for establishing and maintaining healthy work environments. These standards state that communication, collaboration, support for continuing education and certification, effective decision making, and recognition are key measures of a healthy workplace.5

These principles support the American Nurses Association (ANA) Code of Ethics for Nurses and Institute of Medicine (IOM) recommendations. The Center for American Nurses published a position statement in 2008 denouncing horizontal violence and bullying among healthcare professionals.6

In 2004, the IOM published Keeping Patients Safe: Transforming the Work Environment of Nurses.7 It explores strategies for a safe work environment for nurses, which results in the delivery of safe, effective care. These strategies include eliminating any type of threat or mistreatment directed at nurses that exists in the workplace. Mistreatment of nurses—including verbal abuse, intimidation, and passive-aggressive behavior—directly affects the collaboration needed between nurse and healthcare provider. Studies of ICUs have recognized that healthy nurse-healthcare provider collaboration is a component of a healthy work environment and ultimately leads to reduction in patient mortality.8

The IOM concluded that abusive behavior and fear of retribution impacts both the quality and timeliness of reporting patient complications and that in some cases, this withholding of information has resulted in patient death.9

Making a change

To support a healthy work environment, nurses must report all forms of abuse directed at nurses by other nurses, physicians, and other healthcare workers. Nurses need to recognize that they're at the front line of establishing a healthy work environment.

Assessing the existence of verbal abuse and disruptive behavior is the first step toward responding to and changing an unhealthy workplace into an effective, safe work environment. All facilities should have a well-defined channel for reporting violations of the conduct code. Many facilities support their staff by providing education and coping strategies for aggressive behavior, and empowering workers with the skills needed to effectively manage any type of abuse.

Recommendations from TJC in the Sentinel Event Alert include specific steps to help put an end to intimidating and disruptive behaviors that undermine patient safety among physicians, nurses, therapists, support staff, and administrators.1 Some of TJC's recommendations include:

  • educating all healthcare team members about professional behavior
  • enforcing codes of conduct
  • adopting a zero-tolerance policy
  • providing supportive involvement from physician leadership
  • developing a process for reporting unprofessional behavior without fear of retribution.1

Diffusion of horizontal violence isn't simple. It's imperative, however, not to allow intolerable and offensive conduct to continue. Before any confrontation occurs, think about what the objective of the conversation will be and how to articulate concerns in a nonintimidating manner. Confronting the behavior at an appropriate time, in a timely manner, may lead to resolution of the abuse. Discussing the incident privately, with the offender, is important. If the situation has been particularly volatile, having a superior present is beneficial. While speaking with the offender, be aware of body language, positioning while speaking, and intonation.10

Get involved

Clinical educators and administrators have a responsibility to provide a safe and productive workplace environment free from horizontal violence. However, direct care nurses also have a responsibility to report any horizontal violence that occurs so it can be dealt with appropriately. Learning effective methods of dealing with horizontal violence, including physician verbal abuse, can help change the culture of the workplace, improve nurse/physician relationships, and ultimately enhance patient outcomes and safety.


1. The Joint Commission. Sentinel Event Alert, Issue 40. Behaviors that undermine a culture of safety. 2008; July 9.
2. Standards target hostile healthcare worker behavior. Advance for Nurses. 2008; July 9.
3. American Association of Critical Care Nurses. Zero tolerance for abuse. 2004.
4. International Council of Nurses. Abuse and violence against nursing personnel. 2006.
5. Ulrich BT, Woods D, Hart KA, Lavandero R, Leggett J, Taylor D. Critical care nurses' work environments: value of excellence in Beacon units and Magnet organizations. Crit Care Nurse. 2007;27(3):68–76.
6. Center for American Nurses. Lateral violence and bullying in the workplace. 2008.
7. Finkelman A, Kenner A. Incorporating the core competencies in nursing education. In: Jent SA, ed. Teaching IOM: Implications of the Institute of Medicine Reports for Nursing Education. Silver Spring, MD: American Nurses Association; 2007:27–57.
8. Schmalenberg C, Kramer M, Brewer BB, et al. Clinically competent peers and support for education: structures and practices that work. Crit Care Nurse. 2008;28(4):54–60, 62–65.
9. Christmas K. Workplace abuse: finding solutions. Nurs Econ. 2007;25(6):365–367.
10. Brunt B. Breaking the cycle of horizontal violence. ISNA Bulletin. 2011;37(2):6–11.
© 2012 Lippincott Williams & Wilkins, Inc.