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Eliminating horizontal violence from the workplace

Tedone, Deborah A. MS, RN

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doi: 10.1097/01.NURSE.0000668440.64732.39
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WHY DO SOME PEOPLE feel it is acceptable to bully a peer or to allow others to bully without consequence? What part of the human psyche allows one person to demean another?

The term horizontal violence(HV) is synonymous with nurse-to-peer incivility or bullying and is often used interchangeably with the term lateral violence. In contrast, vertical violence represents bullying or incivility by any person of authority against a person of lower position or rank, such as RN to CNA or physician to RN. Focusing primarily on HV, this article examines why bullying continues to plague the nursing profession and discusses tools and strategies for eliminating this toxic behavior from the workplace.

Incivility in the “caring profession”

Men and women who long to become part of nursing, the “caring profession,” work very hard to achieve this goal. Clarke states that most nurses are proud of earning their credentials and are eager to dive into the world of nursing.1 But the reality is, nursing can be intensely stressful, creating a breeding ground for HV.2

Stiehr and Smith have described bullying in the workplace as verbal (such as persistent criticism, gossiping, or berating) or nonverbal, “including the behaviors of undermining, sabotaging, clique formation, failure to respect privacy or keep confidences, and assigning unmanageable workloads.”3 One study performed with 78 hospital-based nurses revealed that most had experienced HV during their nursing careers, often early in their careers when they were novice nurses.4 Dr. Susan Roberts, a seasoned expert on this subject, declared HV to be a significant problem for healthcare professionals.1

Berry and colleagues conducted a survey with 197 new nurses and found that 147 of them said that within the last month they had been bullied at work.5 In another study, Balevre and colleagues found that at least 40% of US nurses have experienced bullying.6

As an RN-to-BS nursing professor, I work with students who are already RNs. Over the past 6 years, several open classroom discussions have revealed a harsh reality: Most have experienced some form of HV, especially at the beginning of their careers. Some seasoned RNs shared stories of HV while subbing for a nurse in unfamiliar units. While upset over this phenomenon, almost all say, “that's just the way it is.”

It is depressing to think that nurses not only anticipate nurse-bullying but have learned to accept it.7 Treating others unkindly should never be accepted, especially in a “caring” profession such as nursing.

Precepting adds to the pressure

Many nurses admit that when starting an 8- or 12-hour shift, they are mentally prepared and organized, and do not like interruptions. Adding the additional demands of precepting a new nurse without any decrease in other responsibilities may result in unfavorable outcomes. For example, a preceptor without a decreased caseload will simply not have enough time to provide both optimal patient care to his or her assigned patients and adequate teaching to the newly hired nurse. Providing less time with the patient can be detrimental to the patient's well-being and is not an acceptable trade-off.

Many precepting nurses say they resent having to “babysit” a new nurse while shouldering their usual workload. However, rather than complain to a busy supervisor, a seasoned nurse may reluctantly take on a preconceived burdensome task. Before even meeting the fledgling nurse, the nurse preceptor may have formed a negative view of him or her. The hostile encounter that ensues will interfere with much-needed professional socialization.8

Expecting, and sometimes demanding, seasoned nurses to precept newly hired staff without decreasing burdensome caseloads can add stress. The preceptor-preceptee relationship may start out as unprofessional resentment and blossom into HV. High stress, perceived powerlessness, and role issues may be the perfect ingredients for HV.9

New nurses need to learn from their preceptors. A good preceptor is a mentor, not a babysitter.

Everyone agrees that nursing is a high-stress job. Patients' lives are on the line. All nurses would also agree that additional stressors are not helpful as they strive to provide optimal patient care. Interpersonal conflict associated with HV adds unwanted stress and drama to a nurse's already busy day.10 Nurses do not want or need drama to interfere with patient care.

Long-term damage

Nurses have been accused of “eating their young” when interacting with new nurses first entering the workforce.11 This has detrimental effects not only for the new nurse, but also for the perpetrator, patients, healthcare facility, and nursing profession.12 Stiehr and Smith report that HV can not only be a stressor in a work environment, it can also result in long-term psychological damage to the victim manifested as anxiety, depression, loss of self-esteem, decreased productivity, and absenteeism.3

Tools and strategies to battle HV1,17

Bouret and colleagues add to the list of negative effects to include insomnia, physical complaints, and posttraumatic stress disorder.13 To escape an environment of HV, many nurses quit their jobs and may even leave the profession.4

An additional but seldom discussed consequence of HV is that it contributes to nurses working in silos and not as teams. Working in silos is lonely and lacks comradery. Rahn concurs that teamwork is fundamental to nursing.10 Maintaining high morale and a sense of belonging requires effort by all nurses.8 When silos are knocked down, team-building can begin.

HV is costly

The financial cost of HV is shocking. Hassard and colleagues analyzed 12 studies from 5 developed nations: the US, United Kingdom, Australia, Spain, and Italy. They concluded that the annual cost of psychosocial workplace aggression ranged from $114.64 million to $35.9 billion.14

According to Caristo and Clements, the cost of workplace incivility in the US has been estimated at a staggering $24 billion dollars per year. The estimated cost to replace one ICU nurse is $145,000.15 These estimates are not stagnant and will increase.

Taking action

HV in the workplace is widely acknowledged by the nursing community, but do nurses want to accept this black mark against their profession? The answer is “no.” Nurses want to eliminate the offensive concept of eating their young from the terminology associated with nursing.

A survey of 126 RNs found that they want change and “asked for tactics to resolve HV within their institutions.”9 Nurses do not want to be in a profession that allows unprofessional behavior. Nurses are tired of accepting HV as a common phenomenon and want to make it a rare exception rather than the norm. In short, nurses want change!

To fight the battle of HV, nurses need to be fully armed with creative strategies and effective tools.1 Many organizations have created programs aimed to diminish, and hopefully eliminate, HV.

One example of an institutionally based incentive program uses nursing surveys geared to measure perspectives of workplace bullying.12 This can be introduced during staff meetings. Offer complete anonymity as each nurse completes a survey and give suggestions on how to fight this battle. Offer locked drop boxes for nurses to privately submit their recommendations. Have a task force ready to analyze the results.

The next step is to not ignore the results. Nurses must roll up their sleeves and become personally involved as solutions are explored. Do not lose hope; if one strategy is ineffective, another option may work better.

Adopting a zero-tolerance policy aimed at eliminating HV is another key strategy.15 Many healthcare facilities have instituted antibullying campaigns and have added zero-tolerance policies for the entire organization. For this policy to be successful, however, lines of communication must clearly convey the zero-tolerance policy with a strong message that HV will not be tolerated on any level within the organization. Along with consequences for not following a zero-tolerance policy, incentives must also be woven into the program, such as a bonus or extra time off.

Nurse managers play a crucial role in identifying problematic staff and providing a safe environment for staff to report possible incidents of HV.15 If nurse managers are not approachable and open to discussions about HV, staff will hesitate to bring up the issue. A study by Bloom revealed that 77.3% of nurses surveyed believed that manager awareness and support were the most helpful strategies in fighting the HV battle.4 This is an important finding. Without the manager or supervisor's awareness and support, policies and programs designed to fight HV will not succeed.

But what if nursing staff point to their nurse manager as the bully? This is an example of vertical violence.16 When the manager is the perpetrator, the manager's supervisor must take steps to identify the reason and correct the behavior. Although vertical violence is beyond the scope of this article, it is important to note that a zero-tolerance policy must be strictly enforced regardless of the perpetrator's rank or position.16

Many tools are available to battle HV, such as stress reduction activities, preceptor support and training, and regular communication between managers and new employees. For more details, see Tools and strategies to battle HV.

Taking care of each other

HV is never an acceptable nursing practice. Nurse leaders need to be proactive in the prevention of HV and have a zero-tolerance policy for HV on their units. Nurses who take on the responsibility as preceptors need to be supported, monitored, and rewarded for a job well done. Finally, all nurses need to remember that taking care of themselves and treating others with kindness are fundamental elements of optimal patient care.


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    abuse; bullying; horizontal violence; HV; incivility; lateral violence; precepting; vertical violence

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