Lateral-Horizontal Violence

Horizontal violence, also known as lateral violence, is described as an aggressive, hostile, and harmful behavior(s) towards others by means of negative attitudes, actions, and/or words. It can adversely affect nurse morale, confidence, sense of worth, physical, and psychological health. Behaviors associated with horizontal violence contribute to an unsafe work environment and poor patient outcomes. Respect for human dignity: nurses value others in every professional interaction. Relationships with colleagues and others: nurses uphold caring and professional associations. Collaboration: nurses require shared planning for provision of safe and quality patient care. Accountability for nursing decisions and actions: nurses are held responsible for moral principles, including fidelity, loyalty, and respect for dignity. Let’s imagine that it is your first day as a new nurse. You arrive to work early and quickly identify which client team assignment you will have for the day. A staff nurse, whom you will collaborate with on your client care team, meets you with sighs, arrogant remarks, and annoyed glances. You overhear her saying, “Really, I have to orient a new nurse again? I will never get anything done.” Unsure of what to do to make things better between you and the staff nurse, you decide not to discuss the interaction with anyone (fearing it will only make things worse for you) and quietly continue to care for your clients. You wonder and continue to question why you even selected this profession. This is characteristic of horizontal/lateral violence. Unfortunately, this can be a sad reality in the workplace– not only in the field of professional nursing, but in many other workplace environments. Most healthcare facilities and professional organizations have adopted a zero-tolerance policy for this type of behavior and continue to find ways to help reduce the prevalence of violence in the workplace. Horizontal/Lateral violence can take many forms. It has been defined as “nurses covertly or overtly directing their dissatisfaction inward toward each other, towards themselves, and toward those less powerful than themselves,” (Falletta, 2017). There are several theories as to why lateral violence is so pervasive in nursing, including a hierarchal power imbalance where nurses do not feel appreciated, valued, and perceived power residing with those in higher rank positions (physicians vs. nurses). This also includes violence within the same practice profession (expert nurse vs. novice nurse). Professionals who do not work to create a better power balance with clients (nurse vs. clients) also run the risk of harming shared decision-making. Clients who do not feel part of their decisionmaking process or feel inferior are less likely to participate in treatment decisions than clients who feel welcome. This can lead to powerlessness, helplessness, and fear. Covert or overt acts are not only dissatisfying and stressful for nurses, but it is in violation of provision six of the American Nurses Association (ANA) Code of Ethics (2015). This provision requires that nurses establish and maintain an ethical work environment and “conditions of employment that are conducive to safe, quality health care.” Hierarchal power imbalance where others do not feel appreciated, valued, and power resides with all the answer options. Power imbalances can also include violence within the same practice profession. This can lead to powerlessness, helplessness, and fear. We don't often think about a nurse or professional relating to the client, but there is a power imbalance. Professionals who do not work to create a better power balance run the risk of harming shared decision-making. Clients who do not feel part of their decision-making process or feel inferior are less likely to participate in treatment decisions than clients who feel welcome. To date, no single, uniform definition of “workplace” violence has emerged. You may hear the terms horizontal violence, lateral violence, vertical violence, and workplace violence. Most definitions do refer to both physical and psychological acts. These acts of violence may range from minor cases of lack of respect to criminal offenses, including homicide, physical assault, threats, verbal insult, harassment (bullying), sexual harassment, and discrimination. The U.S. Department of Labor defines workplace violence as an action (verbal, written, or physical aggression) which is intended to control or cause, or is capable of causing, death or serious bodily injury to oneself or others (USDOL, 2021). References to the term vertical violence is also commonly used in the healthcare industry. It is a form of horizontal/lateral violence that occurs between levels of authority or hierarchal systems. For example, manager-to-employee, physician-to-nurse, nurse-tounlicensed assistive personnel (UAP), instructors-to-students, and even expert nurses-to-novice nurses. Therefore, within the context of discussing horizontal/lateral violence, vertical violence also applies. Any form of violence prohibits professional performance and satisfaction in the workplace. Certain occupational groups appear to be more at risk than others, especially those with face-to-face interaction with others or those outside the work organization. Studies on workplace violence often rely on self-reports, using questionnaires, such as the “Negative Acts Questionnaire” (NAQ-R), or interviews to investigate and measure variables most associated with workplace violence. Studies also report on the frequency, intensity, and prevalence of workplace violence. According to one systematic review on bullying in nursing, Serafin and colleagues (2020), found the prevalence of bullying in nursing ranged from 17-94%, and variables most associated with bullying were age, educational level, and years of professional experience. Other tools in nursing used to assess horizontal/lateral violence include: Nurse Workplace Behavior Scale (NWS) Silencing the Self-Work Scale (STSS-W) Registered nurses and employers across multidisciplinary healthcare teams, including academia, have “an ethical, moral, and legal responsibility to create a healthy and safe work environment for registered nurses and all members of the health care team, health care consumers, families, and communities,“ (ANA, 2015). Individuals can have both physical and psychological effects from horizontal/lateral violence. The negative effects can increase the incidence of sick leave, absenteeism, high turnover job rate, poor job performance, decreased staff morale, and even abandonment of the nursing profession. Nurses commonly fail to seek treatment or report health effects after experiencing violence. Physical Effects Weight loss or gain Gastrointestinal problems (nausea, vomiting, diarrhea) Psychological Effects Reduced self-esteem & self-confidence Depression Insomnia Anxiety Chronic pain Stress Chronic fatigue Physical injuries (bruises, broken bones) Post-traumatic stress disorder (PTSD) Feelings of powerlessness Physical Effects Headaches Psychological Effects Suicidal ideation Substance abuse The work being performed, particularly in hospitals, is chaotic, crisisoriented, and can cause stress. These effects may cause a breakdown in teamwork, provoke directed anger and hostility, and decrease the quality and safety of patient care. Nurse-to-nurse horizontal violence occurs when oppressed individuals or groups internalize feelings, such as anger, and present their emotions through behaviors such as eye-rolling, gossiping, putting others down, and blaming others for their actions. This conceptual model is an illustration of a suggested causal relationship among variables hypothesized to be associated with horizontal violence. Directionality of the model flows from left to right. Overall, without taking action to address these violent acts, patient safety and quality of care is affected. Many health care and government organizations have adopted zerotolerance policies and rely on nurses to identify co-workers who exhibit violent behaviors. These are first steps in addressing horizontal violence in their workplace. The Joint Commission has taken a stance to recognize workplace violence as a hazard in the health care industry. Nurses who work in mental health cope with significant psychological and physical challenges, including exposure to verbal and physical violence in the workplace. Forms of violence can occur from co-workers and/or clients. During any nurse-client interaction, you could be faced with an aggressive or threatening situation. Remember what you have learned about crisis intervention, assertiveness training, and aggression management to help mitigate workplace violence issues. Nurses working in a psychiatric setting also have a high level of work stress and are therefore at a higher risk for symptoms derived from work stress. Verbal violence by patients was reported by 88.1% of the nurses, and 58.4% experienced physical violence in the past year (Itzhaki, et. al, 2015). Nurses who work in the mental health area, as with all areas of nursing, can have unanticipated job stress. Most importantly, continue to use the Chamberlain Care strategies you have learned throughout the program, as they will take you well beyond your nursing program studies. The goal is to have a fulfilling, positive work/life balance and identify ways to help you reduce job stress to support your physical and psychological health. In order to create and sustain a culture of trust and respect, free from violence, we must be kind, compassionate, and treat our colleagues and clients with the same level of respect and dignity as we would want to be given to us. Remember the golden rule, “Do unto others as you would have them do unto you?” This should apply across the healthcare continuum.