The prevalence of horizontal violence in New York State registered nurses.
Abstract: The purpose of this descriptive study was to examine the knowledge of nursing administrators about horizontal violence (HV) among New York Organization of Nurse Executive members and to ascertain if they used evidence-based leadership in their roles. In this paper the authors describe the research conducted and examine evidence-based leadership with regard to HV. The authors discuss what HV is, the theories that explain HV, and the impact of HV on the nurse, the nursing profession, and patient care. Research findings were consistent with the theoretical literature, which suggests that HV is so ingrained in nursing's organizational culture that it is not recognized. Until a phenomenon is recognized and named little can be done to alter it.
Subject: Registered nurses
Corporate culture
Medical research
Medicine, Experimental
Authors: Sellers, Kathleen
Millenbach, Linda
Kovach, Nancy
Yingling, Jennifer Klimek
Pub Date: 09/22/2009
Publication: Name: Journal of the New York State Nurses Association Publisher: New York State Nurses Association Audience: Academic Format: Magazine/Journal Subject: Health; Health care industry Copyright: COPYRIGHT 2009 New York State Nurses Association ISSN: 0028-7644
Issue: Date: Fall-Winter, 2009 Source Volume: 40 Source Issue: 2
Product: Product Code: 8043110 Nurses, Registered; 8000200 Medical Research; 9105220 Health Research Programs; 8000240 Epilepsy & Muscle Disease R&D NAICS Code: 621399 Offices of All Other Miscellaneous Health Practitioners; 54171 Research and Development in the Physical, Engineering, and Life Sciences; 92312 Administration of Public Health Programs
Accession Number: 242592191
Full Text: Nursing leadership is important to the recognition and prevention of horizontal violence (HV). Unfortunately, there is little evidence or proven strategies to guide nurse leaders in dealing with HV in the professional practice environment. Evidence-based leadership (EBL) is a construct that incorporates "a transformational relationship involving organizational stewardship, decision-making, and vision translation through reasoned application of empirical evidence from management, leadership, and patient care research." (DeGroot, 2005, p. 40). Examples of EBL in the research literature focus on such phenomena as shared governance (Porter-O'Grady, l992), relationship-based care as a care-delivery system (Kolorutis, 2007), the Magnet hospital literature (Scott, Sochalski, & Aiken, 1999), and the sentinel research by Aiken (2002) that correlates education and numbers of registered nurses scheduled to mortality rates in the surgical population. EBL is essential to sustain a mature and professional nursing practice environment.


HV, also known as bullying, is described as aggressive behavior towards individuals or group members by others (Hastie, 2002). Examples of HV include acts of unkindness, discourtesy, and divisiveness such as gossip, verbal abuse, intimidation, sarcasm, elitist attitudes, and fault-finding. Farrell (1997, 2001) considers HV as interpersonal conflict that is repeated and systematic and includes persistent lack of respect for another individual. Given the varied constructs of HV Vessey, DeMarco, and Budin (2007) recommend the following definition for use in scholarly projects: "Repeated, offensive, abusive, intimidating, or insulting behavior, abuse of power, or unfair sanctions that makes recipients upset and feel humiliated, vulnerable, or threatened, creating stress and undermining their self-confidence."

Review of the HV literature

Literature examining the existence of HV in the nursing work environment continues to expand. According to Woelfle (2007), HV is a phenomenon that has been documented in the literature for more than 20 years. HV is workplace violence that is performed by nurses towards other nurses (Thobaben, 2007). Briles (1994) determined both men and women participate in sabotaging behavior; men tend to be open about undermining a coworker, while women tend to target other women and their style tends to be covert.

Nursing is primarily a female profession; feminist and oppression theories have attempted to explain the occurrence of HV within nursing (Farrell, 2001). Oppressed groups lack autonomy and control of the work environment, causing cycles of low self-esteem and feelings of powerlessness leading to conflict directed from coworker to coworker (Demarco, 2003). The oppression theory explains that HV is not directed necessarily at the individual but is more of a response to the situation in which a nurse is found (Longo, 2007). Farrell (2009) believes that fear of retaliation and punishment prevents the nurse from responding to the act of oppression, leaving hurt feelings and vulnerability. This continues the cycle of powerlessness (Longo, 2007).

Lewis (2006) states that bullying or HV is a learned behavior that develops within the work environment and found that there was an overall perception that bullying is not taken seriously and there is no effort to deal with the problem. Lewis (2006) concludes that this adds to the elusive nature of the phenomenon. Thus, victims or perpetrators of HV may not be aware of the situation, and the behavior continues. As a newcomer to nursing culture, one must take on or adapt to these behaviors or leave.

Nurses experience both physical and psychological consequences when they are the victims of HV. Physical symptoms include weight gain or loss, hypertension, cardiac palpitations, and irritable bowel syndrome (Rowell, 2005). Victims have also been diagnosed with psychological disorders such as depression, acute anxiety, and posttraumatic stress disorder (Rowell, 2005). Nurses who experience the greatest amounts of conflict also experience the highest rates of burnout, and may develop sleep disturbances, low self-esteem, and poor morale, and might feel disconnected from other staff (Longo, 2007; Thomas, 2003).

Because of the impact of HV on recruitment and retention issues, it can then be considered one of the causes of the nursing shortage. When organizations allow HV to continue without intervention, it undermines institutions' attempts to provide a safe, supportive work environment (Thomas, 2003). Nurses who feel the work environment has become unbearable often leave their institution, creating increased rates of turnover. Some leave the profession permanently (Woelfle, 2007). The ability to attract new nurses is also hindered by HV (Longo, 2007). If a student has been subjected to bullying and hostility during clinical rotation, a strong message is sent that the culture is not supportive of novice nurses (Longo, 2007). Randle (2003) found that bullying behaviors acted out on nursing students were significant and the impact of such acts greatly affected their self-esteem and caused some to consider leaving nursing. Randle (2003) asserted that nurses are socialized into this phenomenon, which undermines nursing standards. Randle's (2003) recommendation called for an increased awareness of the issue and the need for nurses and educators to transform their practice.

Dunn (2003) attempted to correlate a relationship between acts of sabotage and job satisfaction. The study unexpectedly found a positive relationship between sabotage and job satisfaction scores (Dunn, 2003). The author speculated that nurses might minimize or under-report the significance of sabotage and its effect on work satisfaction. The limitations cited were the difficult nature of the subject matter and individuals' possible discomfort in revealing the awareness of bullying acts they had perpetrated on others.

The leadership literature shows that nursing management is often part of the problem when discussing HV. Baltimore (2006) writes that administrators sometimes engage in hostile, punishing behavior by providing chronic understaffing, by belittling nurses' concerns, and by showing a disregard for nurses' safety and mental or physical health. Farrell (2001) found that respondents were concerned that managers failed to implement supportive structures to deal with hostilities that occurred and felt that appropriate actions were not taken to prevent their reoccurrence. In a study of registered nurses in their first year of practice, the participants reported rude, abusive, or humiliating comments by those holding positions of charge nurse, nurse coordinator, supervisor, unit manager, and acting charge nurse (McKenna, Smith, Pole, & Coverdale, 2002). These are traditionally the leadership roles at the unit or division level in settings where new registered nurse employees first experience HV as well as where they first encounter types of nursing leadership styles.

Patient safety can be threatened when cultures of bullying exist. New nurses who feel powerless may be less apt to seek advice and help from their co-workers, increasing the likelihood of medical errors (Longo, 2007). Disruptive behaviors lead to potentially preventable adverse events, errors, compromises in safety and quality, and patient mortality (Rosenstein & O'Daniel, 2008). Sixty-seven percent of the respondents in their study agreed that disruptive behaviors were linked with adverse events; the result for medical errors was 71 %, and patient mortality was 27%.


In its inaugural year, the New York Organization of Nurse Executive (NYONE) Research Committee was charged by the Board of Directors to develop a program of research focused on evidence-based leadership. The committee undertook this descriptive study to examine the knowledge of and prevalence of HV among registered nurses in New York State (NYS) who were members of NYONE.


After approval of the Institutional Review Board was obtained, a pilot study was conducted. The study employed the MacGregor-Burns (1978) Transformational Leadership theory, which focuses on the interaction of leaders and those being led as collaborators working toward mutual benefit, as a theoretical framework. In the pilot, a convenience sample of registered nurses in New York State who are members of NYONE completed demographic information and part one of Briles' Sabotage Savvy Questionnaire, a tool that measures occurrences of HV and nurses' knowledge of HV (Briles, 1994). Part one (40 questions) of the questionnaire determines if the study participant has ever been sabotaged or has knowledge of sabotage in the work setting.

Dunn (2003) established validity in a study of HV in operating room nurses. The instrument was reviewed by faculty of Seton Hall University for clarity, ease of use, and content validity. Cronbach's alpha score was .86 for part one of the Sabotage Savvy Questionnaire (Dunn, 2003).

The questionnaire was completed via an e-mailed survey and through distribution to those attending the 2008 Annual Leadership Meeting of NYONE. Descriptive statistics including percentages, mean, median, mode, and standard deviations, and other measures of dispersion were calculated. In addition, Chi Square analysis, where appropriate, was used to determine the presence of differences in frequencies among groups.


The sample consisted of l08 participants, the majority of whom were women (n = l03), white/non-Hispanic (79%), and 50-60 years of age (52%) (Tables l and 2).

Respondents most frequently were nursing administrators (46%) and least commonly staff nurses (2%) (Table 3).

The majority of subjects worked in acute care settings (90%) with greater than 200 beds (8l%) (Table 4). The healthcare facilities were mostly union (57%) rather than non-union (40%) (Table 5). Time served by the subjects was found to be between l and 477 months, with mean months employed as 96 months or approximately 8 years of service. The authors found that the facilities were relatively evenly distributed between having an HV policy (55%) and not having a formal HV policy (43%) (Table 6). In the facilities that had policies, it was reported that the HV policy was known to be enforced in less than half of the facilities (42%) and, despite having a formal policy, known not to be enforced by l 5% of the respondents (Table 7).

Survey results

The percentage of respondents that reported knowledge of the following items occurring "often" and "frequently" were in the following areas:

* Being expected to do other's work (28.4%)

* Being reprimanded in front of others (29.7%)

* Not being acknowledged for work (33.7%)

* Untrue information exchanged (36.7%)

* Talking ceasing upon arrival (27.5%)

The percentage of respondents that reported being victims of the following items "often" and "frequently" were in the following areas:

* Expected to do other's work (26.3%)

* Not acknowledged for work (29.4%)

* Untrue information exchanged (28.4%)

* Information withheld (24.3%)

An independent t test was conducted to evaluate nurses' HV experiences in union versus non-union settings. The test was significant t (90)= 2.l89, p =.03; those working in union facilities reported higher occurrences of victimization involving being expected to do other's work.


Findings are consistent with the theoretical literature that suggests that HV is so ingrained in nursing's organizational culture that it is not recognized; until a phenomenon is recognized and named little can be done to alter it. Nurses pride themselves in being part of a caring profession. It is incongruous then, and most likely creates cognitive dissonance among practicing nurses, if behavior such as HV is endemic.

Despite these beliefs, this small pilot study demonstrated that HV is present among practicing registered nurses in New York State. In fact, it is believed that the NYONE population of nurse administrators and managers underreported the prevalence, most likely due to lack of recognition of the phenomenon and/or acceptance of the behaviors as historically and culturally acceptable in nursing.

The characteristics of the problem are not necessarily confined to nursing or the healthcare industry, because other industries are presented with similar concerns. The problem is multifaceted. In addition to he existence of HV there are issues in how the healthcare industry views the problem, if at all.

Studies show similar outcomes regarding HV for both physician assistant students (Asprey, 2006) and hospital administrators (Harlos & Axelrod, 2005). Rosenstein and O'Daniel, (2008) conducted a survey to assess the significance of disruptive behaviors and their effect on communication and collaboration and impact on patient care. They found that a total of 77% of the respondents reported that they had witnessed disruptive behavior in physicians--88% of the nurses and 5l% of the physicians. Sixty-five percent of the respondents reported witnessing disruptive behavior in nurses at their hospitals--73% of the nurses and 48% of the physicians. The prevalence of workplace violence or disruptive behavior (regardless of the name used to label it) stretches across the spectrum of the healthcare industry both internationally and in the United States. It becomes apparent that the healthcare industry has not placed value on the need to deal with these issues. Until organizations address HV there will continue to be a negative impact on professional and patient-care outcomes. As studies are analyzed and emergent evidence appears, the need for change is overwhelming.

There is concern regarding the impact of disruptive behavior on the patient safety. Effective January 1, 2009, the Joint Commission has a new Leadership standard regarding disruptive behavior (LD.03.01.01). As nursing shortages continue, it does not make sense for the healthcare industry to discount the evidence and adversely impact nurse retention.

The literature has shown, however, that HV can be addressed. Bourdieu's Theory of Practice (1977) suggests that there are ways to change this destructive group behavior and that we live and work in relational fields. Further, individuals are situated within structured social fields. The director or nurse manager sets the cultural tone for these fields. The leader has capital with which to reward members for their behavior within the field or practice unit. The cultural leader uses this capital to change the "habitus," behavior of the members of the field from "we've always done it this way," to more professional, evidence-based behavior. Griffin (2004) reported on 26 newly licensed nurses at an acute care hospital who were taught the techniques of cognitive rehearsal, an applied cognitive-behavioral technique. The technique was used as a teaching tool to combat HV and measured for its success. After training the nurses were sent out into the workplace. One year later the conclusions of the study offered new hope, as the participants were able to depersonalize from the situations and confront the lateral violence behavior. Retention rates of this study group were positively influenced (Griffin, 2004).

With this potential to confront negative behavior in mind, it is important to develop a database to determine staff nurses' perception of HV This can then be used to develop and measure the effectiveness of interventions that must be implemented within healthcare facilities to promote professional citizenship within the cultural context of organizations where nurses practice.

Conclusions and recommendations

HV is recognized to exist to some extent by nurse managers and nurse executives in New York State, although most likely underreported. Therefore, the NYONE Board of Directors recommended that a larger study be conducted of all practicing nurses in New York State. This recommendation has been adopted by a consortium of researchers including: the New York State Nurses Association (NYSNA), the Foundation of New York State Nurses, the Research Alliances of New York State, and NYONE. The goal is to heighten the awareness of the HV phenomenon so that solutions to combat it can be developed. By heightening the awareness of the existence of HV nurses can develop and implement strategies to decrease this harmful group dynamic; increase teamwork, which should improve patient outcomes; and, importantly, increase nurse retention.


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Table 1
Frequency and Percentage of Racial Status

                   Frequency   Percent    Valid    Cumulative
                                         Percent     Percent

non-Hispanic             84      77.8      78.5         78.5
Asian                     4       3.7       3.7         82.2
African American         16      14.8      15.0         97.2
Other                     3       2.8       2.8        100.0
Total 107              99.1     100.0

System                    1       0.9

Total                   108     100.0

Table 2
Frequency and Percentage of Age Category

        Frequency   Percent    Valid    Cumulative
                              Percent     Percent

20-30          1       0.9       0.9          0.9
30-40          8       7.4       7.4          8.3
40-50         34      31.5      31.5         39.8
50-60         57      52.8      52.8         92.6
60+ 8        7.4       7.4     100.0

Total        108     100.0     100.0

Table 3
Frequency and Percentage of Employees' Roles

                        Frequency    Percent      Valid    Cumulative
                                                Percent      Percent

Nurse administrator            48       44.4        45.7        45.7
Nurse manager                  40       37.0        38.1        83.8
NP                              1        0.9         1.0        84.8
CNS                             4        3.7         3.8        88.6
RN                              2        1.9         1.9        90.5
Nurse supervisor                2        1.9         1.9        92.4
Consultant                      1        0.9         1.0        93.3
Nurse educator                  2        1.9         1.9        95.2
Director, university            1        0.9         1.0        96.2
Nurse researcher                1        0.9         1.0        97.1
Director                        3        2.8         2.9       100.0
Total 105                    97.2      100.0

System                          3        2.8

Total                          108     100.0

Table 4
Frequency and Percentage of Horizontal
Violence by Size of Facility

               Frequency   Percent    Valid    Cumulative
                                     Percent     Percent
0-99 beds             7       6.5       6.5          6.5
100-199 beds         13      12.0      12.1         18.7
200+ beds            87      80.6      81.3        100.0
Total               107      99.1     100.0
Missing          System         1       0.9
Total               108     100.0

Table 5
Frequency and Percentage of Union and
Non-union Healthcare Facilities

                 Frequency   Percent    Valid    Cumulative
                                       Percent     Percent

.00                     2       1.9       1.9          1.9
Yes                    59      54.6      57.3         59.2
No                     41      38.0      39.8         99.0
Not applicable          1       0.9       1.0        100.0
Total                 103      95.4     100.0
Missing            System         5       4.6
Total                 108     100.0

Table 6
Frequencies and Percentages for Existence
of Horizontal Violence Policies

          Frequency   Percent    Valid    Cumulative
                                Percent     Percent

Yes             59      54.6       55.1         55.1
No              46      42.6       43.0         98.1
Unsure           2       1.9        1.9        100.0
Total          107      99.1      100.0
Missing     System         1        0.9
Total          108       100

Table 7
Frequencies and Percentages for
Enforcement of Horizontal Violence Policies

            Frequency   Percent    Valid    Cumulative
                                  Percent     Percent

No policy         43      39.8      40.2         40.2
Yes               45      41.7      42.1         82.2
No                16      14.8      15.0         97.2
No answer          3       2.8       2.8        100.0
Total            107      99.1     100.0
Missing       System         1       0.9
Total            108     100.0
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