CNE Objectives and Evaluation Form appear on page 13 SERIES Nancy Walrafen
M. Kathleen Brewer
Carol Mulvenon Sadly Caught Up in the Moment:
An Exploration of Horizontal Violence
EXECUTIVE SUMMARY
The behaviors associated with
horizontal violence can have negative consequences for nurses,
patients, and organizations.
Participants in this study were
sent a survey that listed nine
behaviors associated with horizontal violence.
They were asked if they had witnessed, experienced, or neither
witnessed nor experienced the
nine behaviors.
Participants were also asked to
respond to three open-ended
questions intended to capture their
uniquely personal experiences
with horizontal violence.
For all but one behavior, the
majority of participants stated they
had witnessed or experienced
eight of the nine behaviors associated with horizontal violence in
their workplace.
In response to the findings of this
study, an educational program
was developed to assist nurses in
recognizing and responding to
horizontal violence.
NANCY WALRAFEN, MS, RN, OCN, is a
Clinician 5, St. Joseph Medical Center,
Kansas City, MO.
M. KATHLEEN BREWER, PhD, ARNP, BC,
is a Professor, Saint Luke’s College of
Health Sciences, Kansas City, KS.
CAROL MULVENON, MS, RN-BC, AOCN,
ACHPN, is a Clinical Nurse Specialist,
University of Kansas Hospital, Kansas
City, MO.
NOTE: The authors and all Nursing
Economic$ Editorial Board members
reported no actual or potential conflict of
interest in relation to this continuing
nursing education article. 6 HILE RESEARCHERS continue to explore horizontal
violence for a more
comprehensive understanding of the phenomenon and
its root causes, there is currently
agreement on two issues. Horizontal violence is prevalent in the
nursing profession, and the experience of this behavior is psychologically distressing, threatening
patient safety, nurse moral, and
nurse retention (Joint Commission,
2008; McKenna, Smith, Poole, &
Coverdale, 2003; Simons, 2008).
While discussing this phenomenon at a nursing retention committee meeting, all but one of the 15
members present had a story to
relate about a time when they
experienced bullying. Strong emotions were evident in the telling of
these stories; whether they occurred in the recent or far distant past.
This led members of the committee to the central question of this
study: Is horizontal violence
occurring within our organization,
and if so, how prevalent is it?
Griffin (2004) defined horizontal
violence as overt and covert
actions by nurses toward each
other and especially towards those
viewed as less powerful. Based on
this definition and using the most
common behaviors, Griffin (2004)
identified from the nursing literature, the nurses in our hospital system were surveyed to further
explore this phenomenon. W Review of Literature
A review of the scientific
nursing literature presented a picture of horizontal violence which
can be delineated into three distinct categories: (a) prevalence and
consequences, (b) root causes, and
(c) how best to address the phenomenon in the workplace.
The prevalence of horizontal
violence has been identified as ranging from 5%-38% in Scandinavian
countries, the United Kingdom,
and the United States (Johnson,
2009; Simons, 2008). Two Australian
studies report 50% and 57%
prevalence rates, and 86.5% of
participants in a Turkish study
reported experiencing aggressive
behaviors at work (Johnson, 2009).
In a study conducted by Farrell
(1997), the majority of subjects
described experiencing intra-staff
aggression which was more troublesome and harder to deal with
than aggressive behaviors from
patients or their families and contributed to a work environment
that was hostile. Nursing students
reported being the target of verbal
or emotional abuse from staff
members in the clinical environment (Longo, 2007), and McKenna
et al. (2003) discovered that new
graduates are also likely to experience horizontal violence.
Recognizing that aggressive
behavior in the workplace jeopardizes patient safety, the Joint
Commission (2008) issued a sentinel event alert calling for organizations to address the behaviors NURSING ECONOMIC$/January-February 2012/Vol. 30/No. 1 Sadly Caught Up in the Moment: An Exploration of Horizontal Violence SERIES
that “undermine a culture of safety.” In a similar vein, the Center for
American Nurses (2008) published
a position statement acknowledging the affects on patient safety,
quality of care, and how this phenomenon directly affects the organization’s and profession’s ability
to attract and retain nurses.
Hutchinson, Jackson, Wilkes, and
Vickers (2008) developed a new
model of bullying in the workplace. Embedded in this model is
the notion that experiencing horizontal violence has negative health
effects in addition to interruptions
in work settings and career goals.
Researchers’ interest has been
piqued about horizontal violence
for the past several decades with
varying viewpoints on the cause.
While some researchers believe
this is a direct result of oppressed
group behavior (Duffy, 1995;
Roberts, Demarco, & Griffin, 2009),
others contend that in order to
fully understand and address the
behaviors and potential outcomes
associated with horizontal violence it is important to look at
structures and circuits of power
within organizations (Hutchinson,
Vickers, Jackson, & Wilkes, 2006). Reducing Horizontal Violence
The presence of horizontal
violence in the workplace makes it
difficult for an organization to
improve the quality of care they
provide or create a satisfied work
force (Woelfe & McCaffrey, 2007).
It is also difficult to decrease nurse
turnover and attract the most
desirable employees in an organization where horizontal violence
exists (Center for American Nurses,
2008). The average cost of replacing a nurse who has left to work at
a competing institution ranges
from $22,000 to $64,000 (Jones &
Gates, 2007).
Increased awareness has been
cited as a first step in formulating a
plan to decrease the incidence of
horizontal violence in the workplace (Johnson, 2009; Simons,
2008). Cognitive behavioral techniques have been used successful- Figure 1.
Horizontal Violence Intervention Model Behavior Has Positive or
Negative Consequences
for Individuals Individuals Model
New Behaviors Individuals Learn
Behaviors by
Observation Individuals Learn
New Behaviors Individuals Model
Behaviors of Those With
Whom They Identify
Intervention ly by nurses (Griffin, 2004). Jackson,
Firtko, and Edenborough (2007)
described the use of individual
resilience strengthening as a way
to decrease susceptibility to adversity within the workplace. Farrell
(2001) advocated individual nurses can and should play an important role in changing their work
environments. Theoretical Framework
Bandura (1969), the author of
Social Learning Theory, emphasized the importance of observing
and modeling the behaviors, attitudes, and emotional reactions of
others as a way to assimilate into a
particular group. Much of our
learning to navigate interpersonal
situations is a result of emulating
the behaviors we observe in the
group to which we want to be
accepted as a member (Bandura,
Ross, & Ross, 1961; Bandura, 1969,
1977). Also known as reciprocal
determinism, the aforementioned
researchers believe the world and
a person’s behavior cause each NURSING ECONOMIC$/January-February 2012/Vol. 30/No. 1 other. Believing this to be true as
well, this framework was selected
to guide our study.
The literature about horizontal
violence in the workplace revealed
that individuals tend to emulate
the behaviors of the group members they most intimately engage
with as a way to be accepted by
them. Stated another way and
based on Bandura’s theory, the
workplace (world) and the employees (individuals) on some
level cause each other’s behavior
(reciprocal determinism). When
maltreatment of an employee(s) is
occurring, members of the work
unit may model the behavior of the
individuals participating in the
negative behavior as a way to be
accepted by them (see Figure 1). Methods
Design. A mixed-method descriptive design was used to fully
describe the participants’ experiences with horizontal violence and
to achieve a more thorough and
explicit understanding of the com- 7 Sadly Caught Up in the Moment: An Exploration of Horizontal Violence SERIES
Table 1.
Quantitative Results
Behaviors
Nonverbal negative innuendo (i.e., raising eyebrows, face-making)
Have witnessed this being done to someone.
Have personally experienced.
Have neither witnessed this being done nor experienced myself.
Covert or overt verbal affront (i.e., snide remarks, withholding information, abrupt responses)
Have witnessed this being done to someone.
Have personally experienced.
Have neither witnessed this being done nor experienced myself.
Undermining clinical activities (i.e., not available to help, turning away when asked for help)
Have witnessed this being done to someone.
Have personally experienced.
Have neither witnessed this being done nor experienced myself.
Sabotage (i.e., deliberately setting up a negative situation)
Have witnessed this being done to someone.
Have personally experienced.
Have neither witnessed this being done nor experienced myself.
Bickering among peers
Have witnessed this being done to someone.
Have personally experienced.
Have neither witnessed this being done nor experienced myself.
Scapegoating (i.e., always assigning blame to one person when things go wrong)
Have witnessed this being done to someone.
Have personally experienced.
Have neither witnessed this being done nor experienced myself.
Backstabbing (i.e., complaining to others about one individual).
Have witnessed this being done to someone.
Have personally experienced.
Have neither witnessed this being done nor experienced myself.
Failure to respect the privacy of others (i.e., gossip/talking about others without their permission)
Have witnessed this being done to someone.
Have personally experienced.
Have neither witnessed this being done nor experienced myself.
Broken commitments and/or broken confidences (i.e., repeating something that was meant to be
kept confidential)
Have witnessed this being done to someone.
Have personally experienced.
Have neither witnessed this being done nor experienced myself. plexities surrounding this phenomenon (Connelly, Bott, Hoffart, &
Taunton, 1997). Based on the seminal work of Duffy (1995) and Griffin
(2004), the researchers developed a
survey to answer their research
question (see Table 1). The nineitem Horizontal Violence Behavior
Survey was constructed from generated items carefully examining the 8 wording and sequencing of each
item put forth by Fink and Kosecoff
(1988). For each of the nine negative
behaviors listed, respondents were
asked to choose from three responses namely, experienced, witnessed,
neither experienced nor witnessed
with the potential for multiple
responses in each category. In addition to completing the quantitative Response Response
%
Count
72.2%
54.1%
8.3% 148
111
17 66.7%
58.3%
11.3% 136
119
23 50.0%
46.1%
32.4% 102
94
66 28.4%
19.9%
64.2% 57
40
129 72.1%
48.0%
10.8% 147
98
22 56.5%
26.0%
36.5% 113
52
73 77.0%
53.4%
8.3% 157
109
17 76.0%
46.1%
10.8% 155
94
22 52.2%
28.6%
37.9% 106
58
77 survey, the participants were asked
to respond to three open-ended
qualitative questions.
Seven experts from various
educational institutions, and qualified to judge the questions for relevancy, were asked to respond to
the appropriateness of the instrument (Okoli & Pawlowski, 2004).
Six experts rated each item on the NURSING ECONOMIC$/January-February 2012/Vol. 30/No. 1 Sadly Caught Up in the Moment: An Exploration of Horizontal Violence SERIES
instrument a 4 on a scale of 1 (low)
to 4 (high) with relevance and clarity; one expert rated each item 3.5.
Based on the feedback from the
experts, the researchers refined the
items for clarity and word choice.
The verbiage was changed in two
of the nine items. Regarding survey question number two, the
word action was replaced with
affront. In the second instance, in
question number six scapegoat
was changed to scapegoating.
These changes were made based
on the belief of one expert reviewer that affront and scapegoating
would more accurately capture the
essence of the experience.
Setting, sample, and data
analysis. With institutional review
board approval, all nurses in the
multi-institutional health care system were invited to participate in
the study (see Table 2). An e-mail
providing a link to the survey was
distributed with three subsequent
reminders over a 30-day time
frame when data were collected.
The quantitative data were analyzed using frequency and central
tendency. The responses to the
open-ended qualitative questions
were thematically synthesized
using the steps for qualitative
analysis prescribed by van Manen
(1991). Qualitative content analysis is a descriptive analytical technique that serves to identify the
manifest and latent content of a
text; in this case the answers to the
open-ended questions (Brewer,
2006; Denker, 1995; Graneheim &
Lundman, 2004; Reineck, Finstuen,
Connelly, & Murdock, 2001). Findings
Quantitative. The respondents
(N=227) provided data on the nine
identified horizontal violence
behaviors. The highest reports of
affirmative responses were in the
category of personally having witnessed a peer as the victim of a
negative behavior (28.4%-77%). In
eight of the nine categories, a
majority of respondents reported
having personally witnessed the
horizontal violence activity with Table 2.
Demographics of Sample
(N=227) White 96 Black 3 Asian 1 tive innuendos (54.1%), and backstabbing (53.4%).
The data revealed that 8.3%64.2% of respondents had neither
witnessed nor experienced horizontal violence. The only type of
horizontal violence not witnessed
or experienced by the majority was
sabotage (64.2%) (see Table 1).
Qualitative. The nurses were
forthcoming in their responses to
the three open-ended qualitative
questions providing specific examples of behaviors they had witnessed or experienced. From the
responses to these qualitative
questions, the following themes
were generated: (a) sadly caught
up in the moment, (b) overt and
covert maltreatment, and (c) commitment to positive change in their
workplace. 9 Theme 1: Sadly Caught Up
In the Moment Characteristics % Age Group (years)
Up to 25 7 26-35 17 36-45 19 46-55 39 56-65 18 >65 1 Gender
Female
Male 93
7 Race Highest Education
Diploma
AD 19 BSN 63 Masters 9 Years of Experience
in Nursing
0-10 years 31 11-20 years 25 21+ years 45 Years of Employment
at Organization
0-10 years 61 11-20 years 23 21+ years 16 scores in excess of 70% that
included backstabbing (77%), failure to respect the privacy of others
(76%), nonverbal negative innuendo (72.2%), and bickering among
peers (72.1). The only behavior
that was not witnessed by a majority was sabotage (28.4%).
The response range for personally experienced behaviors was
19.9%-53.3%. Six of the nine categories were 46% or more, and
three of the nine were 50% or
greater, including covert or overt
affronts (58.3%), nonverbal nega- NURSING ECONOMIC$/January-February 2012/Vol. 30/No. 1 When asked about their experiences with horizontal violence,
one-third acknowledged they had
indeed engaged in these negative
behaviors. The nurses who
responded to this question were
reflective in their comments,
speaking from the perspectives of
both perpetrator and victim. They
at times excused their personal
actions by reframing the circumstances that caused them to act in
such a negative manner. Nurses
used phrases such as “it’s the culture,” or “caught up in the drama.”
They expressed disappointment in
their inability to keep their frustrations in check which sometimes
resulted in behaviors that violated
their personal and professional
standards.
The nurses spoke of feeling
“sadly caught up in the moment”
about their participation in negative behaviors they generally would
not exhibit. Nurses expressed surprise and concern about some
examples of behavior on the survey
identified as bullying. A nurse stated she always believed her ranting
and venting were justified until
she saw this behavior listed as an
example of horizontal violence. 9 Sadly Caught Up in the Moment: An Exploration of Horizontal Violence SERIES
She stated, “I didn’t know what it
sounded like.” Many of the nurses
seemed confused that their conversations about their peers could be
construed as horizontal violence
when they believed they were only
offering constructive criticism. A
participant offered “When we talk
at work about staff problems and
difficulties, it’s not meant to be
gossip: It’s meant to share, to get
updated with what’s happening on
the unit.” Another reiterated this
confusion by injecting a comment
about face-making “…that is done
in fun.” This sense of uncertainty
about what was, and was not,
acceptable behavior illustrated a
need to clearly define horizontally
violent behaviors.
Honesty and self-disclosure
were conveyed in comments that
began with “…unfortunately” and
“…sadly.” “I may know at times I
am guilty of raised eyebrows and
face-making, I try not to be, but it
happens so fast.”
Some respondents expressed
awareness they had engaged in
this behavior, but offered justification for their actions. Statements
such as “They just weren’t doing
their job” and “They need to know
what it felt like” were used. A
nurse believed her unkind interactions with a peer were defensible.
She shared, “Her performance was
a hindrance to the unit.” These
respondents described negative
behaviors as a response to what
they perceived to be inadequate
work performance by their peers.
There was a sense they viewed
their aggressive behavior as a necessary means to an end, especially
if management failed to address a
grievance when reported to them. Theme 2: Overt and Covert
Maltreatment
Nurses were given an opportunity to share any negative behaviors they had personally experienced or witnessed which did not
fit into the category of behaviors
already described in the previous
questions. While no new categories of behaviors were identi- 10 fied, detailed descriptions were
provided of negative behaviors
they had observed, or been directly involved in.
The majority of overtly aggressive behaviors were verbal in
nature. They ranged from “…yelling aggressively” to the use of
“…verbally dismissive or demeaning remarks.” Personally denigrating terms were not identified individually, but adjectives such as
“slandering” and “degrading”
were used to describe witnessed
conversations. Some descriptions
were more specific, such as the
response from one nurse, “I have
been on the receiving end of taunting, and been singled out and
labeled.” While no physically
aggressive behaviors described in
the survey were aimed at individuals, one respondent described
“objects being thrown around the
nurses’ station.”
Covert and passive behaviors
described by participants centered
on a lack of communication and
included such things as “ignoring
my requests for help,” as well as
“general inapproachability and
cold demeanor.” One nurse explained, “I have witnessed someone refusing to talk to a co-worker.
No communication makes for a difficult day.” These comments
reflecting the inability to rely on
team members when providing
patient care created a sense of isolation for the nurse and were seen as
having an impact on patient safety.
One nurse described this experience, “Two nurses drew mustaches
on a staff member’s picture at the
desk. They were confronted about
their behavior and did not think
they did anything wrong.”
Comments related to managers
and supervisors included examples of aggression being ignored as
illustrated by this nurse’s statement, “I reported a couple of incidents to my manager and nothing
was done, the co-worker then had
an even worse attitude toward
me.” While no nurse reported
being aware of overtly aggressive
behaviors aimed at her or him from a manager, many reported
feeling they were recipients of negative covert behaviors. These
included being ignored by a supervisor, not encouraged to apply for
advancement, and not mentored
professionally as were some of
their peers. Theme 3: Commitment to Positive
Change in their Workplace
When asked to share their
thoughts and suggestions about
ways to decrease the amount of
violence in their workplace, nurses spoke of their sincere commitment to improve relationships
with their colleagues. The high
number of responses to this question was interpreted as a desire on
the part of the nurses to be active
in the solution.
The nurses believed it was
important to appreciate and celebrate differences among their
ranks. Some nurses suggested hospital-sponsored continuing education programs focused on cultural
awareness. One nurse shared,
“What about a campaign to encourage all to ‘do unto others as you
would have done to you.’ No one
likes to be treated negatively so
don’t treat others that way either.”
Collectively the nurses who
completed the survey believed that
most, if not all, needed to take
responsibility for their part in perpetuating negative behavior. One
nurse said, “By not participating in
negative behaviors or condoning
them, in a non-confrontational
way, let the perpetrators know to
maintain professional treatment of
peers.” Another shared, “Nurses
need to take responsibility to do
the ‘right thing’ for fellow nurses.”
Survey participants provided
thoughts about how best to tackle
this dilemma. Their comments
reflected the strong belief that all
levels of management should be
involved in solving the problem of
horizontal violence in their particular workplace. One respondent
shared, “Nurse managers need the
tools to act on it and quickly stop
horizontal violence.” NURSING ECONOMIC$/January-February 2012/Vol. 30/No. 1 Sadly Caught Up in the Moment: An Exploration of Horizontal Violence SERIES
Finally, a nurse focused her
response on the necessity of encouraging personal responsibility
stating, “Treating staff well and
trying to minimize working short
staffed so people do not feel burnt
out and give themselves an excuse
to be concerned with self over others.” Another said, “I would suggest a strict ‘no tolerance’ policy
and make sure managers, supervisors, etc. enforce it. You would not
believe how much of this goes on
every day...how it affects retention,
and ultimately how it effects our
patients.” Discussion
Participants in this study
reported witnessing and/or experiencing many of the negative
behaviors associated with horizontal violence. The range of positive
responses in this study (19.9% to
77%) corresponded with what has
been reported by previous researchers exploring this phenomenon (Johnson, 2009; Simons,
2008). The results of this study validated the appropriateness of
Social Learning Theory as the
framework to guide this study.
According to Bandura (1969), individuals will mimic or role model
the behaviors exhibited by the
members of a group to which they
wish to belong. Clearly some of the
nurses in this study were surprised
they were maltreating their peers
by simply “going along with the
crowd.” Nurses freely spoke of
being “caught up in the moment”
and adopting the negative behaviors of their peers who were
engaged in maltreatment of others
in the workplace stating, “it’s the
culture.” Some of the participants
sought reasons to justify their
actions toward their peers, when
they emulated these negative
behaviors. Comments left by 26 of
the 65 nurses who responded to
the question “Have you personally
engaged in any of the described
behaviors?” revealed they were
unaware the behaviors they were
mimicking were demonstrable of
the tenets of horizontal violence Individual responses to the
qualitative questions provided
rich descriptions of the nurses’
experiences as observers and victims of this phenomenon. Survey
respondents reported that not only
did the single bullying incident
have an immediate impact on
nurse communication and team
function, but lasting consequences. Behaviors that impact patient
care specifically identified by the
nurses in this study included
being afraid to ask for help with a
patient or ask a question for fear of
being ridiculed, having requests
for help ignored, and general lack
of teamwork and communication.
These findings were congruent
with consequences identified by
the Joint Commission (2008) and
the Center for American Nurses
(2008). The reporting of predominantly non-physical acts of aggression in our study supports the evidence found by previous investigators (Farrell, 1997; Griffin, 2004).
In that personal resilience can
decrease vulnerability to workplace adversity (Jackson et al.,
2007), consideration must be given
to the role individual resilience
plays when determining whether
or not a hostile event has actually
occurred. A healthy, professional
work culture can provide an environment where it is possible to
place some negative behaviors in a
non-aggressive co...

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