It’s no secret that the healthcare industry in the United States is rife with problems, and nowhere are these issues more evident than in the nursing profession. High-stress environments, long hours, and relatively low pay scales mean nurses have to bear the brunt of multiple obstacles while trying to provide quality patient care.

Making matters more challenging, though, is the prevalence of horizontal violence, aka workplace bullying. This perfect storm of factors leads to higher rates of horizontal violence within healthcare settings, but it doesn’t have to be that way.

Healthcare organizations, including administrators and managers, can provide a more supportive environment that mitigates these underlying problems. This article will dive deep into horizontal violence in nursing, including how to recognize and prevent it.

Table of Contents

Definitions: Horizontal Violence, Lateral Violence, and Workplace Violence

There are three terms that are often used when discussing violence in the nursing profession: horizontal violence, lateral violence, and workplace violence. Here’s a quick rundown of these definitions.

Workplace Violence – This refers to any physical assault, verbal abuse, or threatening behavior in the workplace, regardless of who initiates it or is involved. Workplace violence is broken down into four categories: criminal, client-to-worker, worker-to-worker, and personal relationship.
Horizontal Violence – This is workplace violence that occurs between co-workers, which is often referred to as workplace bullying. This is also different from violence between management and employees.
Lateral Violence – This term can be used interchangeably with horizontal violence, as it refers to peer-to-peer violence.

How to Recognize Horizontal Violence in Nursing

A big reason why addressing workplace bullying and horizontal violence is a challenge is that it often happens in small moments across a long period. So, to build a more respectful workplace culture, it’s imperative to recognize signs of horizontal violence, such as:

Overt Harassment – Things like arguments, verbal abuse, or physical altercations between healthcare workers.
Covert Violence – This may include actions like spreading rumors, withholding information from specific people, or excluding people from conversations and activities.
Hazing – Horizontal violence is quite common among new nurses. In fact, the American Nurses Association warns that hazing can lead to lower job satisfaction and higher burnout rates among new hires.
Violence in High-Stress Departments – Areas like emergency departments are much more stressful than other parts of the clinic or hospital. As a result, workplace violence is more common, so administrators must pay closer attention to these interactions.

Overall, it’s imperative to recognize horizontal violence as a persistent, ongoing problem, not an isolated incident. Additionally, the methods to address horizontal violence require systemic changes, not specific conflict resolution.

Why Horizontal Violence Happens: Systemic Causes

Trying to prevent horizontal violence is more challenging because of deep-rooted systemic issues that are unique to healthcare professionals. Examples of these issues include:

High-Pressure Environments – Nursing is stressful and physically exhausting, which can cause individual nurses to lash out, particularly when enduring staffing shortages.
Leadership Gaps – Because of the heavy workload, nurses have more autonomy, meaning supervisors and managers aren’t present when horizontal violence occurs.
Normalized Bullying Behaviors – Since horizontal violence is so common within nursing culture, it’s not always treated as a serious issue.
Lack of Disciplinary Options – Staffing shortages and patchwork legal regulations make it hard for nurse managers to discipline workers for bullying or horizontal violence. In most cases, only an organizational commitment to improvement can lead to any significant results.

Impact on Nurses, Quality of Care, and Patient Safety

As you might imagine, persistent horizontal violence can have multiple negative impacts on both workers and patients. Some of the adverse symptoms of this type of workplace violence include:

Reduced Job Satisfaction – Nurses want to provide quality care, but working in a violent environment leads to burnout and negative attitudes.
High Turnover Rates – According to research, up to 60 percent of new healthcare workers quit because of horizontal violence, leading to more staffing shortages and higher stress.
Reduced Patient Satisfaction – If nurses aren’t happy, they’re less likely to provide quality patient care.
Unsafe Work Environments – While most horizontal violence is verbal or confrontational, it can lead to physical violence and low occupational safety, creating even more burnout and job dissatisfaction.

Prevention Framework: Building Safer Healthcare Settings

Although horizontal violence may be prevalent in the healthcare industry, administrators and nurse leaders can implement real changes to reduce negative outcomes. Some prevention options include:

Conflict Management Training Sessions – Nurses and supervisors can learn how to address conflicts as they arise.
Building a Strong Support System – When leaders empower nurses to report bullying and take action to reduce it, workers feel valued and respected.
Reducing Stress Levels – While staffing shortages are a persistent obstacle, administrators can adjust workflows to minimize stress with breaks and stress-relief techniques.
Anti-Bullying Messaging Built Into Onboarding – In some cases, reducing horizontal violence can be as easy as reinforcing anti-bullying tactics in the workplace culture.

Zero Tolerance Policy and Response Process

Typically, when leaders hear the term “zero tolerance,” they imagine harsh crackdowns and severe penalties. However, this policy can be much more proactive and supportive with the right methods, such as:

Providing Anonymous Reporting Channels – Encourage nurses to report bullying anonymously to minimize the potential of retaliation.
Crafting Clear Investigation Procedures – Managers must investigate each claim thoroughly to determine the best course of action.
Consistent Enforcement – Leniency can lead to worse bullying and make nurses feel devalued. Leaders must always enforce the policy, no matter the situation.
Fair Remediation – Punishment should be reframed as support and guidance with the goal of more positive outcomes.
Structured Follow-Up – Since horizontal violence is often an ongoing problem, nurse managers must follow up with victims and perpetrators to ensure long-term success.

Support, Measurement, and Implementation

Reducing horizontal violence in the workplace requires systemic changes and consistent effort. Here are a few ways administrators can facilitate these changes effectively:

Confidential Counseling and Peer Support – Nurses should be able to express themselves freely and receive guidance and support during one-on-one sessions.
Monthly Tracking – Monitor bullying reports and see how they change from one month to the next.
Quarterly Job Satisfaction Surveys – Solicit confidential feedback from nurses about these policies and how they’re affecting job satisfaction.
Audit Patient Safety Indicators – Horizontal violence can often lead to worsening patient care and safety. Monitor these indicators for warning signs of bullying.
Assign Executive Ownership – Change is more likely to succeed when one person is in charge of making it happen.

Here is a quick checklist to help you stay on track when building these systems: