Running head: HORIZONTAL HOSTILITY AND NURSING
Horizontal Hostility and the Nursing Profession: Why Do Nurses Eat Their Young?
Nicki Croel
Ferris State University
1
HORIZONTAL HOSTILITY AND NURSING
2
Abstract
This paper focuses on horizontal hostility in the nursing profession. Nurses are one of the most
trusted professionals, and nursing itself is thought of as caring, compassionate, and trustworthy.
Why then, are nurses known for “eating their young?” This paper will focus on the incidences of
horizontal hostility and the problems that arise from that behavior. Both nursing and
interdisciplinary theories that relate to horizontal hostility will be explored. Policies, resources,
quality, and safety issues that horizontal hostility impact will be examined, as well as inferences,
implications, and consequences. Finally, recommendations with a basis in the American Nurses
Association (ANA) professional standards and Quality and Safety Education for Nurses (QSEN)
competencies will be presented.
HORIZONTAL HOSTILITY AND NURSING
3
Horizontal Hostility and the Nursing Profession: Why Do Nurses Eat Their Young?
Horizontal hostility is also known as lateral violence, bullying, verbal abuse, interactive
workplace trauma, relational aggression, and covert impersonal conflict (Bartholomew, 2006;
Dellasega, 2009). Horizontal hostility is defined as “a consistent pattern of behavior designed to
control, diminish, or devalue a peer (or group) that creates a risk to health and/or safety”
(Bartholomew, 2006, p. 4). Townsend defined bullying as “repeated, offensive, abusive,
intimidating, or insulting behaviors; abuse of power; or unfair sanctions that make recipients feel
humiliated, vulnerable, or threatened, thus creating stress and undermining their self-confidence”
(2007, p. 12) This paper will use the term horizontal hostility to describe behavior that fits these
definitions. There are many different behaviors that can fall into the definition of horizontal
hostility, but generally the behavior is either overt or covert.
Overt behaviors are readily apparent, and are easily quantified. For example, behaviors
like “name-calling, bickering, fault-finding, backstabbing, criticism, intimidation, gossip,
shouting, blaming, using put-downs, raising eyebrows, etc.” are all considered overt behaviors
(Bartholomew, 2006, p. 5). Covert behaviors can be more subtle, therefore more difficult to
determine. Behaviors like “unfair assignments, sarcasm, eye-rolling, ignoring, making faces
behind someone’s back, refusing to help, sighing, whining, refusing to work with someone,
sabotage, isolation, exclusion, fabrication, etc.” are all considered covert behaviors of horizontal
hostility (Bartholomew, 2006, p. 5). This behavior can have several negative consequences for
nurses, patients, and healthcare as a whole.
HORIZONTAL HOSTILITY AND NURSING
4
Impact
Nursing
Horizontal hostility can have numerous negative health implications on nurses who
experience and witness this behavior. Health problems can include insomnia, low self-esteem,
poor workplace morale, a feeling of disconnectedness, depression, increased absenteeism,
headaches, digestive problems (such as irritable bowel syndrome), irritability, anxiety,
depression, loss of concentration, weight changes, alcohol and/or drug abuse, and hypertension
(Barton et al., 2011; Longo, 2013; Townsend, 2007; Vogelpohl, Rice, Edwards, & Bork, 2013).
Townsend goes on to state, “Bullying affects bystanders as well, making them wonder if they’ll
be the bully’s next victim; this stress can lead to depression and anger” (2007, p. 14). Many
witnesses are afraid to report unacceptable behavior to avoid being the bully’s next target
(Townsend, 2007).
Rates of horizontal hostility between nurses are quite eye-opening. In one study “60% of
RNs in the United States were found to leave their first position within 6 months because of
horizontal violence” (Vogelpohl et al. 2013, p. 415). Vogelpohl et al. go on to report that
according to a 2008 Joint Commission survey “50% of nurses had been a victim of bullying
and/or disruptive behavior in the workplace, and 90% stated that they witnessed others being the
brunt of abuse within their organization” (2013, p. 415). According to Longo, RNs who have
worked less than 5 years were most at risk of bullying behavior, but nurses with longevity,
therefore greater nursing knowledge, are also leaving units, organizations, or nursing because of
bullying (2013). This exodus from nursing impacts patient care.
HORIZONTAL HOSTILITY AND NURSING
5
Patients
Horizontal hostility not only affects nurses, patient safety and care are at risk when a
culture of incivility has been allowed to persist. “Health-care workers have associated
incidences of inappropriate behaviours, such as bullying, with potential or actual errors, specific
adverse outcomes and patient mortality” (Longo, 2013, p. 951). Other adverse outcomes from
horizontal hostility include “complications from errors, accidents, or poor work performance”
(Barton et al., 2011, p. 356). Both nurse performance and patient outcomes affect healthcare as a
whole.
Healthcare Organizations
Healthcare organizations need to address their workplace culture to determine if
horizontal hostility occurs. “Roughly 60% of new RNs quit their first job within 6 months of
being bullied” (Townsend, 2007, p. 12). Research from Nursing Solutions, Incorporated
indicated that over 80% of nurses who have left an organization indicate peer and nurse manager
relationships as the reason for leaving, and “79% cite a more desirable work culture elsewhere”
(Bennett &Sawatzky, 2013, p. 144). The cost associated with turnover, hiring, and training is
enormous and this cost is a waste of money which could be better spent elsewhere in healthcare.
Theoretical Base
Nursing Theory
Dr. Marion Conti-O’Hare’s Theory of the Nurse as the Wounded Healer, applies the idea
that every nurse has experienced trauma in their professional life, personal life, or both. If this
trauma is left unresolved, the person’s coping mechanisms are ineffective. Nurses thereby
function as ‘walking wounded’ and “experience problems in their social, intimate, and work
relationships” (Christie & Jones, 2013, Overview of the Theory of the Nurse as a Wounded
HORIZONTAL HOSTILITY AND NURSING
6
Healer section, para. 1). Nurses are “projecting their woundedness on both patients and
colleagues while considering themselves unharmed, yet being less able to empathize with others”
(Christie & Jones, 2013, Overview of the Theory of the Nurse as Wounded Healer section, para.
1).
Resolving the pain associated with trauma, transforms and transcends it into healing.
“Although the injury has occurred, the wounds have been sufficiently understood and processed
and will not interfere with providing care” and the nurse is better able to provide care (Christie &
Jones, 2013, Overview of the Theory of the Nurse as Wounded Healer section, para. 2). The
nurse can better build a therapeutic relationship with others because of understanding the
personal pain and suffering they have gone through (Christie & Jones, 2013).
Nursing is considered a highly stressful work environment and “nurses are in need of an
‘outlet’ in which to vent their negative emotions and cognitions. Unfortunately vulnerable peers
and co-workers frequently end up being this outlet, thus becoming victims of lateral violence”
(Christie & Jones, 2013, Theory Application to Lateral Violence in Nursing section, para. 1).
Student nurses, newly registered nurse, nurses new to the organization or unit, and night shift
nurses are at greater risk to experience horizontal hostility (Christie & Jones, 2013; Sauer, 2012).
According to Christie and Jones (2013) horizontal hostility behavior may initially start as
passive aggression or minor bullying to the aforementioned risk groups. Apologies may be
issued, but the aggression can escalate into either covert or overt forms of horizontal hostility,
eventually becoming the norm of the unit. Nurses begin to regularly experience or witness this
behavior, all becoming the walking wounded. Each nurse, according to this theory must go
through recognition, transform, and finally transcend this pain in order to become the wounded
healer (Christie & Jones, 2013).
HORIZONTAL HOSTILITY AND NURSING
7
According to Christie and Jones, recognition of the event helps the nurse realize what
happened, what could be changed, and how should it have been handled (2013). The next step,
transformation, helps the nurse change the pain into understanding, by asking what can be
learned from this incident, has this changed me or the people I care about, and how can this be
used to make things better (Christie & Jones, 2013). When the first two steps are complete,
transcending the pain, obtaining insight, and learning can happen. The nurse can say “I
understand your pain, and how can I make things better for you” (Christie & Jones, 2013, Theory
Application to Lateral Violence in Nursing section, para. 5).
Oppression Theory
According to Charney, Paulo Freire’s oppression theory can explain how a profession
that cares for others, can turn on their own (2012). Oppression theory states a dominant group
creates a culture based on their values and beliefs. The members of the dominated group begin
to change themselves and reject their beliefs and values. This behavior can lead to a lack of selfesteem and decreases the respect for each other within their own group. The dominated group
feels aggression, but they are unlikely to confront the dominant group’s authority and power.
The aggression and anger are turned inward to their own group (Charney, 2012).
“Nursing as a group has been viewed as oppressed because of its lack of power and
control in the workplace” (Charney, 2012, p. 214). Horizontal hostility is the outcome from
frustrations stemming from confrontations with other, non-nursing co-workers (Charney, 2012).
It is contended that nurses are dominated, therefore oppressed, by a patriarchal system
headed by doctors, administrations, and marginalized nurse managers, nurses lower down
the hierarch of power resort to aggression among themselves. It is believed that nurses
have little control over their work environment and yet are held responsible for a great
HORIZONTAL HOSTILITY AND NURSING
8
deal, resulting in personal stress. The members of the oppressed group are abusive to
peers and those individuals with lesser status because they are unwilling to confront the
source of their frustration. (Charney, 2012, p. 215).
Assessment of the Healthcare Environment
Policies
Horizontal hostility has not gone unnoticed by policy makers in the healthcare field. The
ANA issued a position statement regarding this type of toxic workplace. In 2006 the House of
Delegates passed a resolution stating all nurses have the right to work free of harassment, which
includes bullying and horizontal hostility (American Nurses Association [ANA], 2006). The
Resolution goes on to state the Code of Ethics applies in all workplaces and supersedes any other
institutional or workplace policies (ANA, 2006). Finally, the resolution states nurses should
have protection from retaliation when reporting behavior that violates this standard (ANA,
2006). The ANA’s position statement gives guidance to nurses and provides a framework to
shape institutional policies.
The Joint Commission has also weighed in on horizontal hostility. In 2008, Sentinel
Event Alert #40 was issued titled “Behaviors that undermine a culture of safety” (The Joint
Commission, 2008). The alert highlights some of the troubling healthcare worker and patient
outcomes that can arise when horizontal hostility is not addressed. Sentinel Event Alert #40
states “Intimidating and disruptive behaviors can foster medical errors, contribute to poor patient
satisfaction and adverse outcomes, increase the cost of care, and cause qualified clinicians,
administrators and managers to seek new positions in more professional environments” (The
Joint Commission, 2008, p. 1). The Joint Commission recognizes this behavior is detrimental to
collaboration and teamwork. In order to be accredited by The Joint Commission organizations
HORIZONTAL HOSTILITY AND NURSING
9
must do the following: “The hospitals/organization has a code of conduct that defines acceptable
and disruptive and inappropriate behaviors” and “Leaders create and implement a process for
managing disruptive and inappropriate behaviors” (The Joint Commission, 2008, p. 2). These
processes help to interrupt the cycle of horizontal hostility thereby making hospitals safer.
Resources
The ANA has several resources for individuals to increase their knowledge of horizontal
hostility. There are three continuing education modules available on the ANA’s website.
“Navigating the Work Environment: Embracing a Zero Tolerance for Bullying” is the title of the
first module and it is described as teaching one how to address behaviors like gossiping and
information withholding (ANA, 2014, Take Action Now section, para. 1). Secondly, “Lateral
Violence: Nurse Against Nurse” is a module that helps one “Learn to recognize and address
lateral violence in the nursing workplace” (ANA, 2014, Take Action Now section, para. 2).
Lastly, the module titled “Workplace Violence: The Nurse Victim” is a module that is focused
on “the signs, interventions, and prevention of secondary traumatization of care providers”
(ANA, 2014, Take Action Now section, para. 3). The ANA also has an e-book available on their
website titled, Bullying in the Workplace: Reversing a Culture and is described as enabling
“nurses to understand and deal with bullying and its perpetrators and to counter the culture of
bullying in their work environment” (ANA, 2014, Tools You Need section, para. 3).
Quality and Safety
Several quality and safety issues have already been addressed prior in this paper. This
behavior can have several adverse outcomes for both nurses and patients. This behavior
especially impacts new nurses. Horizontal hostility prohibits them from asking clarifying
HORIZONTAL HOSTILITY AND NURSING
10
questions, increasing their knowledge, seeking validation of known knowledge, and feeling like
they fit in, which all negatively impact their learning (Griffin, 2004).
There are also negative patient outcomes that affect quality and safety. Nurses have
reported reluctance to clarify orders, used new equipment with which they were unfamiliar,
ambulated or lifted dependent patients without asking for help, and carried out orders they did
not think was in the patient’s best interest (Wilson & Phelps, 2013). These behaviors all
jeopardize the healthcare system’s best intentions to reduce adverse patient outcomes.
Inferences, Implications & Consequences
Nurses who experience and witness horizontal hostility suffer ill effects (Dellasega,
2009). Some of the literature compares these effects to post traumatic stress disorder, “50%
continue to suffer from stress five years after the incident” (Bartholomew, 2006, p. 13).
According to Townsend witnesses wonder “if they’ll be the bully’s next victim; this stress can
lead to depression and anger” and they are afraid to report abuse out of fear of retaliation (2012,
p. 14). Refer to the Nursing Impacts section for previously stated health outcomes for nurses.
Another major problem of horizontal hostility is the loss of experienced nurses who move
to other units, organizations, or leave nursing altogether. This exacerbates the nursing shortage
which is projected to be as great as 260,000 by the year 2025 (Longo, 2013). The vacancies take
time to be replaces, trained, and orientated, which leaves units and organizations short staffed.
Hiring and training nurses is expensive. One study places the cost of nurse turnover at
$64,000 per nurse (Barton et al., 2011). According to Vogelpohl et al. “A hospital with a poor
nursing retention rate could spend annually an average of $3.6 million more than a hospital with
a good nursing retention rate” (2013, p. 414). Another study estimated the cost of replacing a
specialty nurse to be as great as $145,000 (Becher & Visovsky, 2012). Research by Bennett and
HORIZONTAL HOSTILITY AND NURSING
11
Sawatzky (2013) indicate that for every percentage point increase in nurse turnover, it costs
healthcare organizations $600,000. In an era of shrinking margins and reimbursements, time and
money spend on reducing nurse turnover could be better spent on patient care
Recommendations for Quality and Safety Improvements
Upon review of the literature there are several recommendations to counter horizontal
hostility. The recommendations include education, training, conflict management techniques,
and teambuilding. Initiating these recommendations will help to improve the culture of our
nation’s healthcare organizations.
The Joint Commission listed several recommendations in Sentinel Event Alert #40.
These recommendations include education of all staff members, including physicians. This
education should focus on the appropriate behavior, etiquette, phone, and people skills. The
code of behavior mandated by The Joint Commission needs to be applied equitably to all
professional in healthcare organizations. There should be a zero-tolerance policy regarding
horizontal hostility, protection for whistleblowers, and policies for addressing patients or their
families who witness or are involved in incidences of horizontal hostility. There must be
processes in place for employees to report horizontal hostility, possibly anonymously. Managers
should be educated in ways to provide feedback to their employees regarding unprofessional
behaviors. Collaboration between disciplines should be encouraged (The Joint Commission,
2008).
Bartholomew has several recommendations for new nurses in healthcare organizations
(2006). These recommendations include addressing behaviors towards student nurses,
addressing horizontal hostility in nursing schools, and new resident nurses. Education,
HORIZONTAL HOSTILITY AND NURSING
12
increasing opportunities for communication, establish relationships and expectations, revising
curriculum, and debriefing (Bartholomew, 2006).
Organizations should address horizontal hostility during orientation. In a study by
Griffin, new nurses at a Boston hospital were given scripted responses addressing some of the
most commonly seen horizontal hostility behaviors (2004). After following the new nurses for a
year, the researches performed a follow up interview. All of the nurses addressed hostile
behavior with another nurse. They all reported the confrontation was difficult, but the unwanted
behavior ceased. Providing new nurses tools and education to address this behavior was
effective in this study (Griffin, 2004).
In another research article an ambulatory surgical center (ASC) reported on their efforts
to decrease horizontal hostility and increase workplace morale (Dimarino, 2011). After a new
manager took over, the code of conduct at the ASC was revised and a zero-tolerance policy was
initiated. New hires were educated about the expectations in adhering to the code of conduct and
an open door policy was instituted by management. After making these changes, the ASC
reported no staff turnover, staff reports feeling satisfied and recommends their friends for open
positions at that ASC, and patient satisfaction has improved (Dimarino, 2011).
Conclusion
Horizontal hostility is an insidious and toxic problem in our nation’s healthcare
organizations. There are several documented incidences of negative outcomes from nurses,
patients, and organizations. The increased risk of errors and the cost hostility and nurse turnover
imposes on organizations is a big problem. Fortunately managers, administrators, and others in
leadership positions are looking at ways to address this issue. There have been numerous
instances of organizations addressing behavior and improving behaviors seen between nurses.
HORIZONTAL HOSTILITY AND NURSING
13
Some of the most effective policies implemented are a combination of education,
management commitment to improve behaviors, and equal enforcement between all disciplines
working in health care. The Joint Commission and the ANA focus time and attention to provide
recommendations and guidance.
Those most vulnerable to horizontal hostility should identify their resources and be
willing to confront nurses’ if incivility is present. Those who have reported confrontation said it
was difficult, but addressing the behavior is one of the most effective ways to change the culture.
HORIZONTAL HOSTILITY AND NURSING
14
References
American Nurses Association. (2014). Bullying and workplace violence. In ANA: American
Nurses Association. http://www.nursingworld.org/MainMenuCategories/
WorkplaceSafety/Healthy-Nurse/bullyingworkplaceviolence
American Nurses Association. (2006). Workplace abuse and harassment of nurses.
http://www.nursingworld.org/MainMenuCategories/WorkplaceSafety/HealthyNurse/bullyingworkplaceviolence/WorkplaceAbuseandHarassmentofNurses.pdf
Bartholomew, K. (2006). Ending nurse-to-nurse hostility: Why nurses eat their young and each
other. Marblehead, MA: HCPro.
Barton, S. A., Alamri, M. S., Cella, D., Cherry, K. L., Curll, K., Hallman, B. D.,… & Zuraikat,
N. (2011, August). Dissolving clique behavior. Nursing Management, 42(8).
doi:10.1097/01.NUMA.0000399677.43428.73
Becher, J., & Visovsky, C. (2012, July). Horizontal violence in nursing [Electronic
version]. MEDSURG Nursing, 21(4).
Bennett, K., & Sawatzky, J. V. (2013, April). Building emotional intelligence: A strategy for
emerging nurse leaders to reduce workplace bullying. Nursing Administration
Quarterly, 37(2). doi:10.1097/NAQ.0b013e318286de5f
Charney, W. (Ed.). (2012). Epidemic of medical errors and hospital-acquired infections:
Systemic and social causes. Boca Raton, FL: CRC Press.
Christie, W., & Jones, S. (2013, December 9). Lateral violence in nursing and the theory of the
nurse as the wounded healer. OJIN: The Online Journal of Issues in Nursing, 19(1).
doi:10.3912/OJIN.Vol19No01PPT01
HORIZONTAL HOSTILITY AND NURSING
15
Dellasega, C. A. (2009, January). Bullying among nurses [Electronic version]. American Journal
of Nursing, 109(18).
Dimarino, T. J. (2011, May). Eliminating lateral violence in the ambulatory setting: One center's
strategy. Association of PeriOperative Registered Nurses, 93(5).
doi:10.1016/j.aorn.2010.10.019
Griffin, M. (2004, November). Teaching cognitive rehearsal as a shield for lateral violence: An
intervention for newly licensed nurses [Electronic version]. The Journal of Continuing
Education in Nursing, 35(6). doi:10.1097/NHL.0b013e3182861503
Longo, J. (2013, August). Bullying and the older nurse. Journal of Nursing Management, 21.
doi:10.1111/jonm.12173
Sauer, P. (2012, January). Do nurses eat their young? Truth and consequences [Electronic
version]. Journal of Emergency Nursing, 38(1). doi:10.1016/j.jen.2011.08.012
The Joint Commission. (2008, July 9). Sentinel event alert, issue 40: Behaviors that undermine a
culture of safety. http://www.jointcommission.org/assets/1/18/SEA_40.PDF
Townsend, T. (2012, January). Break the bullying cycle [Electronic version]. American Nurse
Today, 7(1).
Vogelpohl, D. A., Rice, S. K., Edwards, M. E., & Bork, C. E. (2013, November). New graduate
nurses' perception of the workplace: Have they experienced bullying? Journal of
Professional Nursing, 29(6). doi:http://0dx.doi.org.libcat.ferris.edu/10.1016/j.profnurs.2012.10.008
Wilson, B. L., & Phelps, C. (2013, January). Horizontal hostility: A threat to patient
safety. JONA'S Healthcare Law, Ethics, and Regulation, 15(1).