Horizontal Violence in Nursing: What Is It and How Can We Prevent It?

Horizontal violence in nursing is a pervasive issue, yet it often goes by many names: lateral violence, workplace bullying, incivility, hazing and relational aggression, to name a few. While the terminology may change over time, the problem remains deeply ingrained in nursing culture, where it often goes unaddressed.

Have you ever witnessed a nurse being bullied by a colleague? If so, you’ve seen firsthand a form of horizontal violence—an issue that’s more common than we’d like to admit. Despite its prevalence, research shows that more than half of incidents are never formally reported, and over 80% of nurses have experienced some form of workplace violence (NNU). What’s more alarming is that an even higher percentage of nurses (93%) have witnessed horizontal violence in their workplaces (Online Journal of Issues in Nursing).

How to Identify Horizontal Violence 

Given the widespread nature of horizontal violence and its serious impact on both nurses and health systems, it's crucial to understand how to recognize it when it occurs. 

In her article, “Nurses’ Perception of Horizontal Violence,” Rosemary Taylor, PhD, RN, spent time observing and interviewing nurses in two 28-bed inpatient hospital units. Her goal was to clarify the definition of horizontal violence as nurses truly experience it, documenting the various manifestations of workplace bullying. This led Taylor to identify nine types of horizontal violence:  

1. Nonverbal cues and innuendos such as eye-rolling or making faces in response to questions 
2. Verbal remarks including snide, demeaning comments, shouting or using a patronizing tone of voice 
3. Actions/inactions including refusing assistance, allocating unrealistic workloads or hoarding/hiding supplies 
4. Withholding information, which involves fellow nursing staff deliberately keeping important information to themselves 
5. Sabotage including deliberately setting up another nurse for failure 
6. Infighting such as excluding members of staff from communication to create friction 
7. Scapegoating, which involves blaming negative outcomes on one identified nurse without regard to their actual responsibility for those outcomes 
8. Passive aggressive behaviour, which may manifest as backstabbing or complaining to others about a person without speaking to that person directly 
9. Broken confidences including gossiping or sharing information that is meant to be private 

Now that we have a clearer understanding of the different forms horizontal violence can take, it's important to examine its broader impact. Recognizing these behaviours is just the first step; understanding how they affect nurses, and the health care system as a whole, can highlight the urgency of addressing this issue. 

Horizontal violence doesn’t just create a toxic work environment. It can lead to serious consequences for both individual nurses and the organizations they work for. 

How Does Horizontal Violence Affect Health Care Organizations? 

Nurses face the greatest risk of lateral violence compared to any other profession. It adversely affects staff morale, personal health and self-esteem—and puts a measurable damper on hiring and retention. 

Research published in Frontiers in Public Health showed that 87.4% of nurses exposed to horizontal violence exhibited physical and psychological symptoms, with about 10% showing symptoms of post-traumatic stress disorder. Unfortunately, many nurses who experience horizontal violence end up leaving the profession entirely—well before retirement age. 

These negative effects have tangible, real-world consequences for both individual nurses and health care systems at large. How horizontal violence can manifest in measurable ways: 

• Lost work hours: Nurses who experience horizontal violence often take time off due to stress, anxiety and physical health issues. 
• Poor performance: The stress and anxiety caused by horizontal violence can negatively affect a nurse’s job performance, leading to mistakes and decreased productivity.  
• Turnover: High turnover rates result in significant costs. The cost to replace a nurse in 2024 is estimated to be $56,300 per registered nurse who leaves their job. For the average hospital, this can equate to roughly $3.9 to $5.8 million in losses per year due to nurse turnover. These costs include expenses related to recruiting, hiring, and training new staff, as well as the impact of vacancies on patient care and overall hospital operations. 
• Legal and administrative costs: Organizations may face legal challenges and administrative costs related to addressing complaints. 
• Patient care: Horizontal violence can compromise patient care, leading to potential medical errors and decreased patient satisfaction. 

Despite its clear negative impact on staff and patient care, horizontal violence remains underreported and insufficiently addressed in many health care settings. So, why is this issue so difficult to talk about and tackle head-on? 

Why Horizontal Violence is Often Overlooked in Health Care Settings 

The universal challenge in addressing workplace bullying is that there are few regulatory precedents that employers can reference if they want to do something about it. As a result, it falls to individual organizations to thoughtfully develop and enforce unique codes of conduct that address horizontal violence. 

To understand why horizontal violence remains so prevalent, let’s explore the key barriers to reporting and addressing it. Rosemary Taylor's research sheds light on five major reasons why nurses often stay silent in the face of bullying: 

1. behaviours are minimized and not recognized 
2. Fear inhibits all reporting 
3. Avoidance and isolation are coping strategies 
4. Lack of respect and support 
5. Organizational chaos 

These findings highlight the need for interventions that specifically address the numerous factors perpetuating horizontal violence in nursing. The study emphasizes the complexity of the issue as well as the importance of creating a supportive and respectful workplace culture that extends horizontally rather than only focusing on patient-on-nurse violence.

While health systems may say their workplace violence prevention programs encompass horizontal violence, making that portion of policies known is critical to helping nurses feel supported and empowered to report bullying. 

So, how can we change hospital culture to help lessen bullying? 

How Culture Change Can Lessen Horizontal Violence 

While codes of conduct are important, they often fall short in addressing the deeper cultural issues that allow horizontal violence to thrive. Nurses frequently fail to perceive workplace bullying as horizontal violence, often dismissing bullying behaviours as personality traits rather than issues that can be corrected. This mindset needs to change if we are to reduce the prevalence of horizontal violence. 

There are ways to prevent and lessen bullying to strengthen teamwork, foster morale, and uphold quality patient care. Meaningful culture change within health care organizations can significantly reduce the incidence of horizontal violence. Here’s how: 

• Promote open communication. Encourage nurses to speak up about their experiences without fear of retaliation. Regular team meetings and feedback sessions demonstrate that supportive setting where open dialogue can thrive.  
• Leaders must commit. Leadership is key to driving culture change. Training leaders to not only recognize horizontal violence, but to address it, ensuring respectful behaviour is modeled from the top-down.  
• Integrate system-wide training. Programs such as Nonviolent Crisis Intervention^® Training focus on proactive de-escalation techniques that result in empowered staff and improved collaboration within and across departments. 

A culture that emphasizes teamwork and collaboration can reduce the likelihood of horizontal violence. When nurses feel supported by their colleagues, they are less likely to engage in or tolerate bullying behaviour.  

Offer support systems for nurses. This can be done by establishing peer support groups and providing access to counseling services for staff affected by horizontal violence.  

Celebrate positive behaviour. By recognizing positive behaviour, you’re reinforcing the desired culture of respect and collaboration. Recognition programs are one way you can highlight the respectful and supportive interactions among staff.  

Implementing a culture of safety requires more than just good intentions—it takes concrete action. One effective strategy to prevent horizontal violence is integrating comprehensive training programs that equip staff with the tools to identify and manage conflict while fostering collaboration. 

Using CPI Training to Combat Horizontal Violence 

CPI training grounds participants in practices like Rational Detachment, thoughtful decision-making, and practical, effective debriefing to foster a culture of open communication where conflict is approached constructively. This comprehensive approach helps in addressing horizontal violence by equipping nurses with the tools they need to manage and resolve conflicts effectively. 

A team approach is critical to successfully implementing these de-escalation techniques, which bonds colleagues together in both knowledge and empathy. Hospitals that implement CPI training have noted that improved collaboration between colleagues reduces incidents of violence and bullying at every layer of the organization. By focusing on behaviours that trigger anxiety and learning proactive strategies to address them, health care teams can create a safer, more supportive environment for both staff and patients. 

Taking the First Step: Ending Horizontal Violence Starts with Us 

Horizontal violence in nursing is a complex and deeply ingrained issue, but it’s not unbeatable. The first step is to recognize the problem, and the next is to take action—because a healthier, more collaborative work environment is not only possible, but also essential for providing the best care to our patients. Let’s work together to create a culture where nurses feel safe, supported and respected.