by Nicole (Nikki) Mahr, RN, MS, OCN
Clinical Resource Nurse/Infection Preventionist, UC Davis Health System

Last December, nursing was ranked as the most trusted profession for the 15th consecutive year. This isn’t surprising because nurses provide consistent support and comfort in a patient’s most vulnerable moments. They also go beyond providing physical healing to promote social, emotional, intellectual, occupational and spiritual wellness for the people in their care. It seems natural to assume that nurses would provide this same support to one another. Unfortunately, this is not always the case.

Most nurses have heard the phrase ‘nurses eat their young,’ a way to describe negative behaviors directed at novice nurses by their more experienced colleagues. Often dismissed as a way to “toughen up” new nurses, this phrase actually represents a dangerous phenomenon in the nursing profession known as horizontal violence.

Horizontal violence is recognized by the Centers for Disease Control (CDC) under the worker-on-worker violence category. It is defined as harmful peer-to-peer behavior that demeans or devalues the victim. Two terms commonly used interchangeably with horizontal violence are incivility and bullying.

Horizontal violence is a persistent problem among nurses … and it doesn’t just happen to new graduates. The statistics tell the story. Nearly 100 percent of nurses have experienced some type of horizontal violence in their career. Several studies indicate that 20 to 30 percent of nurses experience frequent (weekly or daily) abuse from their peers. Of those who experience frequent abuse, 56 to 78 percent will resign their position. One in three of them will leave nursing altogether. We can’t let this happen!

Incivility, bullying and horizontal violence also threaten patient safety by causing mistrust and damaging communication among nurses. As a result, nurses avoid asking one another for help, which can cause delays and errors in care.

I have experienced horizontal violence in my career. The first time it happened, I was eight months into my first nursing job, reporting to two older nurses with extensive experience. I had just gotten off orientation and had taken care of a difficult patient assignment. When giving report, one of the oncoming nurses noticed I had not given blood to a patient who had hemoglobin below our normal transfusion threshold. Though the physician had not written a transfusion order, I was supposed to have known this standard and directed him to write the order. Another nurse overheard and both of them berated me for more than 15 minutes in front of my peers. I went from feeling proud of myself for completing a difficult shift to feeling deflated and questioning my ability to be a nurse. The experience also changed my interaction with these nurses. When reporting to them, I was fearful of making a mistake, and that anxiety distracted me from caring for my patients.

Fast forward eight years: I was an experienced nurse leader, and began a new position in a different nursing specialty within the same hospital. There was a bully within the department and when I reported the behavior to my supervisor nothing was done.  I eventually began to distrust my coworkers and I stopped speaking up. This experience highlights the crucial role leadership and environment play in the occurrence of incivility and horizontal violence.

Do these stories sound familiar? Have you experienced or heard about horizontal violence and wondered what you could to do prevent it? Here are two critical factors for success in dealing with the problem.

1. Leadership must be engaged: Nursing leadership needs to be committed to ensuring a violence-free work environment. Negative behaviors must be addressed promptly and consistently.  A helpful component for this is a no-tolerance policy that is communicated and enforced with specific guidelines for reporting and addressing the behaviors. In addressing negative workplace behaviors, I recommend a restorative justice approach, which allows for the opportunity to repair harm caused and restore/strengthen relationships among coworkers by allowing the perpetrator to make amends for bad behavior and restore relationships with coworkers.

2. Do your part: Nursing can be a stressful profession and even the best of us have bad days. When you recognize your own bad behavior, be quick to apologize to your coworkers. Additionally, the most common reason nurses avoid addressing bad behavior in the workplace is that they don’t know how to react — so they freeze. The best way to avoid this is to be prepared. Think about situations you have heard about or witnessed. How you would react if confronted again? Rehearsing some of those things in your mind will help you avoid being caught off guard. When you recognize bad behavior in others, address it promptly and respectfully in a way that is supportive of the victim. Ask for help if you need it.

At the end of the day, nurses have to take responsibility for our behaviors and how they contribute to the work environment. It is our responsibility to our profession, our colleagues, and our patients to foster a supportive environment where we eliminate bullying/horizontal violence and work as a team to provide excellent care. To accomplish that, follow the points listed above.

In addition, check to see what resources your organization may have available if job stress is affecting your professional relationships and interactions. Two books I have found valuable in learning how to approach difficult conversations are Crucial Conversations and Crucial Confrontations, both authored by Patterson, Grenny, McMillan and Switzler. The Little Book of Restorative Justice (Zehr, 2002) is also an excellent resource to learn about the restorative justice model, and training in these techniques is offered throughout the country. Finally, the CDC’s National Institute for Occupational Safety and Health (NIOSH) has a program on workplace violence prevention that includes useful information regarding worker-on-worker violence. 

About the author. A clinical resource nurse at UC Davis Medical Center, Mahr obtained her master’s degree in nursing science and health care leadership from the Betty Irene Moore School of Nursing at UC Davis and is currently in her third year of the doctoral program. Her master’s thesis focused on the impact of workplace empowerment on the prevalence of horizontal violence among nurses. Her related research interests include the study of incivility/horizontal violence in health care education and practice, and the impact of inter- and intra-professional relationships on patient care quality and safety. She also serves as a consultant on conflict resolution for inter- and intra-professional teams in hospital and academic environments. Mahr has presented her work regionally and nationally. 

Published: June 29, 2017