As surprising as it may be, healthcare professionals don’t always treat each other with kindness and respect. In fact, research suggests that lateral violence in healthcare is a serious issue. Also referred to as horizontal violence or bullying, lateral violence is defined as non-physical, aggressive, hostile, and/or harmful behavior between coworkers. While individual acts of lateral violence can appear relatively harmless, they create a toxic environment that takes a toll on employees’ morale, hindering the success of the healthcare institutions for which they work.
Studies estimate that somewhere between 46% and 100% of nurses have experienced lateral violence at some point during their careers. In fact, one study found that more than 27% of nurses had experienced lateral violence within the previous six months.
Workplace bullying and lateral violence among nurses heighten tension within an already high-stress environment. To create healthier, more positive workplace environments, it is essential for healthcare administrators to take the time to truly understand lateral violence in nursing and the significant adverse effects it can have on patients and practitioners alike.
Who are the main perpetrators of lateral violence in nursing?
While anyone can engage in lateral violence, it is typically perpetrated by individuals who view themselves as superior to other members of their team. Organizational managers and directors are the most frequent perpetrators of lateral violence against nurses, making it difficult for lower-level nurses particularly, to report their abuse. However, nurses with the same job title also commit lateral violence against their peers. In these cases, it is typically the seasoned nurses who victimize those who are new to the profession or new to their organization.
When lateral violence is perpetrated by superiors or more experienced employees, victims are often uncomfortable reporting their abuse for fear of retaliation. Many feel alone, with no one to turn to for support. This silence further escalates an already pervasive problem.
Why does lateral violence occur in healthcare?
There is no single explanation for the prevalence of lateral violence in nursing, but there are several theories on the phenomenon, one of which addresses deeply entrenched power structures within healthcare.
For decades, both hospital administrators and patients considered nurses inferior to physicians. Physicians received all the praise, while nurses—whose skill and diligence directly improved patient outcomes—were kept behind the scenes and often disregarded entirely. Although we’ve seen a shift in this mentality in recent years, it has not been completely eradicated. As a result, many nurses continue to feel powerless and undervalued, leading to significant internal frustration. Some researchers believe that lateral violence is the outward expression of this frustration.
The theory of ethical relativism is another plausible explanation for the prevalence of lateral violence between nurses. This theory asserts that the perceived morality of an act is influenced by the culture in which it occurs. Subscribers of this theory believe that lateral violence has been present in nursing for so long that it has become an ingrained part of the nursing culture. Those who engage in bullying may not view it as immoral, but rather as a rite of passage and an exercise that builds resilience—essentially a form of hazing. When a workplace culture normalizes lateral violence, it can be difficult for individuals to see how toxic it truly is.
Many believe that the stress associated with nursing also contributes to lateral violence. According to a recent survey, 80% of nurses report having no time to rest and 75% believe that inadequate salary compounds their stress. Combined with the psychological toll of working in a high-pressure environment, these stressors may make nurses more prone to interpersonal conflict and lateral violence. As budget concerns and widespread nursing shortages persist, many practitioners fear that lateral violence will only escalate if organizations do not take direct action.
The Journal of Nursing Education published a research article documenting the history and use of the expression, “Nurses eat their young.” The expression refers to the generational phenomenon of bullying behaviors experienced and then reenacted by nurses on others. This idea draws from a natural phenomenon. Biologists have studied filial cannibalism, where some species actually do eat some of their offspring. Theories suggest a possible evolutionary basis for this phenomenon, which eliminates weaker individuals, reduces competition, and strengthens those who remain.
What are the implications of lateral violence in nursing?
Lateral violence in nursing has serious implications, both for victims and the organizations for which they work. These implications can be physical, psychological, or structural, and include the following:
Compromised physical health
According to a recent study, individuals who experienced bullying in the workplace were 59% more likely to suffer adverse health effects as a result. Cardiovascular disease, weight gain or loss, cardiac arrhythmias, musculoskeletal problems, insomnia, gastrointestinal disorders, and headaches can lead to employee absences that leave healthcare organizations short-staffed.
Mental health challenges
Research has also shown that lateral violence can also lead to poor mental health among victims. Symptoms of lateral violence include a decreased sense of well-being, negative self-image, and depression. Victims also report symptoms and effects consistent with post-traumatic stress disorder, including anxiety, insomnia, suicidal behaviors, and substance use disorders.
High turnover
Bullying significantly reduces job satisfaction and one’s sense of commitment to their employer. It also leads to a high rate of turnover within an organization. According to one recent study, over 30% of nurses strongly considered leaving their jobs due to lateral violence. Given the current nursing shortage in the U.S., healthcare organizations can’t afford to lose nurses to this preventable problem.
According to the 2023 NSI National Health Care Retention and RN Staffing Report, the average cost of turnover for a bedside registered nurse is $52,350. It can be double or triple that for medical-surgical nurses and specialty nurses, such as those working within emergency departments or critical care units.
Even if you don’t lose nurses, lateral violence can still take a financial toll. According to one study, workplace turnover paired with reduced productivity and lost time as a result of lateral violence among nurses costs the healthcare industry more than $4 billion each year.
Reduced quality of care
Nurses are more likely to detach from their jobs when they experience lateral violence and other workplace stressors. This detachment directly impacts their ability to address patients’ diverse needs and fully perform their jobs.
Lateral violence also hinders productive working relationships by disrupting teamwork and communication between nurses. Without a strong sense of collaboration, organizations may experience an increase in medical errors and administrative mistakes that can compromise patients’ health and well-being.
Lateral violence: an example
In her book, The Nurses’ Guide to Improving Communication & Creating Positive Workplaces, registered nurse and author Beth Boynton provided a clear example of lateral violence. Boynton shared the story of Mary, a nurse who joined an emergency department (ED) after 30 years of nursing practice.
Mary described being frequently ignored or misinformed during her first two months of orientation. She claimed, “I was a new face in the ED and was subject to criticism and disdain as if it were my very first day as a nurse. I would say hello to staff members and they wouldn’t answer.”
Mary described how her coworkers gossiped about her and even put her patients in jeopardy as a way to get her in trouble and make her “earn her stripes.” When Mary reported these incidents, her manager told her that they were aware of her coworkers’ behaviors and that she should stop being so sensitive. Mary became depressed and began to dread going to work. She stayed at the job only because her family needed the income.
This example is one of many that speaks to the rampant culture of lateral violence within healthcare institutions. In an article for Johns Hopkins Nursing, nurse Ellie Falletta summed up the dangers of lateral violence. “I have observed and personally experienced violence between nurses. Sometimes it was an eye roll when a question was asked, an incomplete patient handoff, or gossiping about a coworker. As harmless as that may sound, it is the small actions and inactions between coworkers that shake the moral integrity of a workplace.”
More articles in this series
5 Ways to Reduce Horizontal Violence in Healthcare →
Reducing Workplace Violence in Nursing and Healthcare →
Combatting Workplace and Horizontal Violence in Healthcare →
How should nurses handle lateral violence?
To appropriately address lateral violence, a nurse must learn how to identify it and then know what do.
1 – Identify the behaviors
While the exact nature of lateral violence can vary between individuals and organizations, common behaviors include:
- Using power to manipulate or control others
- Intentionally withholding information to get a coworker in trouble
- Humiliating, mocking, or publicly shaming coworkers
- Intimidating coworkers through verbal threats of disciplinary action or violence
- Refusing to offer help or guidance when needed
- Yelling at a coworker or harshly demanding that they perform tasks
- Eye-rolling or refusing to look at a coworker when speaking to them
- Gossiping about coworkers
- Excluding coworkers and making sarcastic or belittling comments
2 – Use available resources
Dealing with lateral violence is challenging, especially in environments where such behavior is an accepted part of the culture. It’s up to organizations to address lateral violence and create a culture in which nurses feel comfortable reporting instances of bullying. If a nurse identifies even one of the above behaviors directed at themselves or others, administrators should encourage them to:
- Immediately call for help.
- Tell the perpetrator that their behavior is unacceptable — silence implies acceptance.
- Clearly communicate how you would like to be treated.
- Carefully document every detail of each instance of bullying.
- Follow the chain of command to register a complaint internally and then with a third-party organization, such as the Occupational Safety and Health Administration.
- Offer support and assistance to any colleagues who are experiencing lateral violence.
How can healthcare organizations create a safe workplace?
Supporting nurses when they report abuse is important. But leaders must take their efforts one step further to create a positive, healthy workplace culture that prevents lateral violence from occurring in the first place. To do this, organizations should:
Develop a zero-tolerance policy
Zero-tolerance policies for workplace hostility outline clear expectations for employee behavior. They also clearly outline the consequences for those who fail to meet these expectations. Having strong zero-tolerance policies in place also empowers employees to speak up without fear of retribution.
Lead by example
Managers and other leaders must commit to enforcing zero-tolerance policies and modeling positive workplace behavior. When leaders model positive behaviors, they signal to everyone that the organization does not tolerate lateral violence.
Assess the root cause
Organizations can use behavioral and situational assessments to help determine the root cause of violence in the workplace. This data can helps leaders create a more comprehensive framework for addressing lateral violence where it starts — such as within specific teams, departments, or roles.
Provide education
Effectively confronting lateral violence takes courage and tact. By providing conflict resolution training, healthcare leaders empower their nurses with the characteristics and skills they need to address and manage workplace violence.
Raise awareness
It’s important for all nurses (and especially new ones) to have a firm grasp of the signs of lateral violence. Training materials can help nurses better idenitfy unacceptable behavior and encourage them to report cases of abuse.
Promote team-building
Nurses who feel that they are part of a strong team are less likely to engage in lateral violence. Develop strong nurse leaders, emphasize the importance of support networks and create time and space for team-building. By doing so, organizations can help foster positive interpersonal relations among their staff.
Protect your team from lateral violence
Successfully reducing lateral violence in nursing requires an intentional culture shift. Employees at every level of an organization — from new hires to senior nurse administrators — must actively participate. Only when healthcare teams work together to learn how to identify, address, and mitigate lateral violence will lasting change occur.
