Introduction
Horizontal violence in nursing is harmful, hostile, or aggressive behavior by a nurse or group of nurses toward another nurse or group of nurses. Many nurses have first-hand experience with horizontal violence in nursing, which is also known as lateral violence, workplace bullying, incivility, or hazing.
This is an important issue in healthcare environments for many reasons. Good healthcare depends on clear communication, and when nurses are being bullied, it has an impact on staff wellbeing, psychological safety, and retention. Ultimately, horizontal violence can reduce the effectiveness of patient care.
This article provides a practical leadership-oriented guide to recognizing horizontal violence in nursing and improving team culture.
What Is Horizontal Violence, Lateral Violence, and Workplace Violence?
Nursing can be a high-stress career, and tension on the job isn’t uncommon. Horizontal violence in nursing refers to hostile or demeaning behavior or verbal and emotional abuse between nurses of similar status. It’s not a single incident but a pattern of behavior that damages team unity over time.
Lateral violence in nursing is a similar term that usually refers to aggressive or hostile behavior toward other nurses who may not be peers, such as inexperienced nurses just starting on the job.
Both these terms differ from broader workplace violence, which typically refers to physical threats, verbal abuse, or assault directed at staff, which may be done by patients, families, or visitors. Horizontal and lateral violence are internal to the team, and they can be harder to address since they happen between colleagues who must continue working together.
How to Recognize Horizontal Violence in Nursing
Horizontal violence in nursing manifests in many different ways. It’s often directed at nurses who lack confidence in their own nursing skills. Some of the behaviors that indicate horizontal violence in nursing include:
- Exclusion. This manifests as leaving a nurse out of huddles and team discussions.
- Gossip. Rumors may be spread about a nurse’s competence or character.
- Passive-aggressive communication. Hostility may be expressed through sarcasm or backhanded comments.
- Dismissiveness. Signs of dismissiveness include ignoring questions, minimizing concerns, or refusing to engage.
- Undermining coworkers. One nurse may sabotage another’s credibility by contradicting them or mocking a mistake in front of others.
- Withholding information. A nurse may deliberately neglect to share updates or policy changes that another nurse needs to know to do their job.
When this conduct is persistent and targeted, it’s known as nurse-to-nurse bullying. It often includes microaggressions, which seem to be minor at first but accumulate into significant harm over time. This overlaps with incivility in nursing, which includes all rude or disrespectful behavior.
Warning Signs Nursing Leaders Should Watch For
Horizontal violence in nursing isn’t always obvious, but there are some warning signs that nursing leaders should watch for between staff members. Bullying may not happen when leaders are present, but leaders may notice declining morale and communication breakdown. A nurse may seem to be tense or emotionally withdrawn.
There may be avoidance behaviors, such as rearranging schedules to avoid working with a particular staff member or being reluctant to ask others for help. Tension on the job increases turnover risk, and leaders may notice increased absenteeism and requests for shift changes. As trust and communication break down, patient safety becomes at risk.
Common Examples of Horizontal Violence in Healthcare Settings
There are many ways horizontal violence may occur in a healthcare environment. Here are a few scenarios:
- A float nurse fills in for a busy unit. The nurses on staff communicate in a group chat, and the float nurse isn’t added.
- Nurses gossip among themselves about a newer staff member, undermining team trust.
- When newer nurses ask for guidance, staff members are dismissive.
An example of communication repair is a nurse noticing others treating a new team member dismissively, so the nurse steps in to offer guidance to the new nurse.
Why Horizontal Violence Happens
A combination of stressors may lead to horizontal violence. Healthcare professionals often face emotional exhaustion and chronic stress. When there are staffing shortages, staff members may experience fatigue and burnout, and nurses may start to take out their stress on each other.
A negative working environment can snowball and trigger unresolved workplace conflict. Lack of teamwork can create a culture that’s hostile and psychologically unsafe.
The Impact on Patient Safety and Job Satisfaction
Horizontal violence is a direct result of breakdowns in communication and teamwork. Staff members who don’t trust each other become emotionally exhausted.
Communication failures lead to lower job satisfaction, which can ultimately lead to problems retaining staff. Any healthcare environment that has inadequate staff and/or colleagues who are unable to work together isn’t giving the best possible patient care.
How Leaders Can Address and Reduce Horizontal Violence
Leaders can help to address and reduce horizontal violence by setting clear behavioral expectations and by modeling respectful communication. Issues that come up should be addressed early and not allowed to escalate.
Leaders also need to create psychologically safe reporting systems so that team members feel they can speak up and ask questions. Healthcare employees should also feel they can make mistakes without fear of humiliation.
Strategies for Building Psychological Safety in Healthcare Teams
Some strategies to help prevent horizontal violence and build psychological safety in healthcare teams include:
- Start with regular team meetings to encourage nurses to voice concerns.
- To create a supportive environment, leadership should be empathy-based, letting staff know leaders genuinely care about their challenges and concerns.
- Establish clear communication norms to help create a respectful workplace culture that includes treating each other with respect at all times.
- When conflict occurs, use debrief processes to make sense of an experience and identify what might have been done differently and can be done differently in the future.
When to Bring in Additional Support
There are times when resolving conflict requires additional resources. HR involvement is appropriate when behavior has been documented but hasn’t changed, particularly when behavior patterns are affecting patient care or staff retention.
Coaching can help a nurse develop needed communication skills. A trained mediator can help arrive at a shared solution when two nurses are in a conflict that they haven’t been able to resolve.
Leadership development addresses horizontal violence when the work culture has deteriorated or when leaders are contributing to the problem. Outside conflict resolution support through de-escalation training is a good way to obtain an outside perspective to help a team see patterns that may not be recognized from within and to help staff be better prepared to handle conflict as it arises.
Effective leadership matters, and leadership training helps leaders provide an environment that includes psychological safety and improves team functioning. Small communication changes compound over time, and healthier communication cultures can be built when everyone works together.
