RunningHead:HORIZONTALVIOLENCE

HorizontalViolence:RetentionofNewNursesandEffectsonPatientCare

TaraShrader,EmilyVela,JasmineHarrison,KaitlynFetchet

14March2016

YoungstownStateUniversity

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Abstract

The goal of this study is to contribute additional information and suggestions to resolve the

growing concern of Horizontal violence, its effects on the retention of new nurses and its

influence on quality patient care. Horizontal violence in nursing is behavior that may degrade,

intimidate or show a lack of respect for and worth of a fellow nurse. Thisbehavioris becoming

more prevalent in the nursing field and is called horizontal because it is done by nursing peers.

Novice nurses are feeling intimidated, degraded, and even bullied while attempting to provide

quality patient care to the best of their knowledge and ability. As a new nurse, knowledge

deficits due to little experience should be expected. However, horizontal violence leaves the

entry level nurse feeling intimidated by more experienced nurses. Horizontalviolencedecreases

the effectiveness of communicationbetweennurseswhoarevictimsofit andtheirnursingpeers,

which is essential for taking proper informed care of their patients. Therefore, quality patient

care is also compromised. Strategies to resolve this ongoing problem will need to be developed

in order to keep the nursing shortage from declining even further and prevent unwanted

additionalerrorsinthequalityofpatientcare.

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Introduction

Horizontal Violence is becoming more prevalentcausinganguishinnovicenurseswhich

in turnisaffectinghealthcareprovidedtopatients.Policiesneedtobedevisedtofixorovercome

this growing problem. Experienced nurses often feel that anewnurseisincompetentandcannot

handle their workload because of inexperience. When a newly graduated nurse enters the

workforce, it can be very intimidating, especially when a skilled conurse demonstrates

horizontalviolence.

Reynolds, Kelly and SinghCarlson define horizontal violence as repeated, offensive,

abusive, intimidating or insulting behavior between individuals on the same power level that

makes the recipient upset, humiliated, vulnerable,orthreatened,creatingstressandundermining

their selfconfidence (2013, p 24). Horizontal violence in laymans terms is bullying or

harassment. This is accomplished by using aggressive verbal language, not giving the correct

information, fighting, backstabbing, scrutinizing, rolling eyes at and/or ignoringandjudgingthe

new nurse (Reynolds, G., Kelly, S., & SinghCarlson, S. 2013, p 24). Actions of this type can

cause the new nurse to doubt their knowledge and abilities as a professional whichcausesthem

to second guess themselves while taking care of patients or wondering if nursing is the right

careerforthem.

Violence of this magnitude amongst nurses has become a relevant and growingproblem

in thehealthcarefield.Itis affectingcommunicationbetweennurses,retentionofnewnursesand

furthermore patient outcomes. Horizontal violence causes decreased confidence andwillleavea

beginner nurse in fear of being scorned and out of this fear of being ridiculed, they willnotask

critical questions that may be crucial in the care and outcomes of their patients. A nurse is
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supposed to encompass compassion and empathy in all areas of practice. The importance of

these characteristics should be emphasized in the workplace andshownnotonlythepatientsbut

coworkersaswell.

ReviewofLiterature

There are many articles, surveys and studies conducted that support the need to find a

solution for horizontal violence among nurses. New nursesaswellaspatientsbecomecasualties

of horizontal violence. Becoming a nursetakescompassionandcertainlya caring demeanor,but

whensubjecttoemotionalstressesfromthetransitionintotheworkforceaswellasbeingatarget

of horizontalviolencethesecharacteristicsarehardtokeepontheforefront.Whenpsychological

andphysicalwelfareareatstake,changesobviouslyneedtobemade.

HorizontalViolence,NewNurseRetentionandPatientOutcomes

Reynolds and her colleagues (2013) as well as Weaver (2013) mention the factthatnew

nurses are the ones mostly affected by horizontal violence. Any nurse can becomethevictimof

horizontal violence, but new graduates tend to become the main victims due to lack of

confidence and experience. According to Reynolds New nurses are vulnerable to horizontal

violence because they have known areas of knowledge deficits and no previous experience,

which subjects their work to constant scrutiny and micromanagement (2013, p25). Weaver

(2013) uses the term horizontal violence to describe an interaction that results between two

nursesofsimilarstanding.

New graduate nurses often deal with patients who require complex care due to

multisystem illnesses. These high acuity patients, combined with low nursing staff, often leave

the experienced nurses withlittle timetohelpthenewgraduatenurses,leavingthenewnursesto

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feel overwhelmed and uncertain. Because of this, the new graduate nurses tend tobeperceived

as clinically untested by others, causing experienced nurses to feel justified in their actions of

horizontal violence. New graduates often become the target for negative comments, excessive

criticismandscapegoatingfrommoreexperiencednurses(Weaver,2013).

Due to the overwhelming duties of a new nurse there is a positive correlation between

hostility and poor patient outcomes as hostility increases so do poor outcomes or near misses

(Reynolds, G., Kelly, S., & SinghCarlson, S., 2013).Whentheworkenvironmentishostileand

nurses feel like they cannot speak up, patient outcomes are affected because they are afraid to

discuss patient care. New nurses need to feel as though their voices are being heard in order to

properlyparticipateinthecareoftheirpatients.

Horizontal violence begins to affect the physical and psychological health of the nurses

who experience it. The nurses who experience the interpersonal violence reported feelings of

nausea, irritability, depression, poor selfesteem and anxiety (Weaver, 2013). Weaver (2013)

went on to discuss how the negative comments, criticism and scapegoating all forms of

horizontal violence can affect nurse retention. Weaver referenced a research study that showed

nurseretentionrelatedto interpersonalviolence.Withinthefirstyear ofemployment,therewasa

turnover rate of 17.7%, a turnover of 33.4% for second year nurses and turnover rate of 46.3%

for third year nurses. Itwasfurtherdiscoveredthatonethirdofnovicenurseshavetheintentions

ofleavingtheirpositionwithinayearbecauseofhorizontalviolence(Weaver,2013).

StrategiestoAddressHorizontalViolence

Some advice offered by Reynolds, Kelly&SinghCarlsonconsistofeducatingnurseson

acceptable behaviors in the workplace and holding the offender accountable when professional
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misconduct is discovered. Reynolds and her colleagues recommend that the environment in

which a nurse works needs to feel safe in order for them to adequately practice their skills and

act as a patient advocate without having to worry about being scrutinized (Reynolds, G., Kelly,

S.,&SinghCarlson,S.,2013).

KingJones also touched on how horizontal violence affectsretentionofnurses,andhow

further education and preceptorship may be needed in order to overcome or deal with the

devastating effects it has (2011). She refers to it as an undue stress that is not needed because

there is already a shortage in the nursing field. She also suggests that we all as nursing

professionals need to support each other, get involved politically and contributebyempowering

andmentoringstudentnurses.

Weaver (2013) suggests the need tobegintoaddressthetopicinnursingschool.Nursing

students are often the targets of bullying from nurses, and thus are in a position to receive

education that teaches them coping skills, healthy communication and how to respond to the

threat ofhorizontalviolence(Weaver,2013).Furthermore theindividualneedsto beresponsible

for their own actions. This includes intervening in incidents of horizontal violence and being

willing to report the incidents without fearofreprisal(Weaver,2013).AnotherwaythatWeaver

(2013) suggests to improve the issue of horizontal violence is by having an organization that

ensures a safe environment and works to prevent interpersonal violence. The fear of reprisal is

one of the main reasons that horizontal violence is ignored. Some nurses can be poised to

educate new graduate nurses and seasoned nurses in the importanceof maintaininganonviolent

environment (Weaver, 2013). They can also implement mentorship programs, which place a

new nurse with an experienced nurse. By doing so, new graduate nurses will build positive
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relationships with experienced nurses and further increase their knowledge, and nursing skills,

resultinginahighersatisfactionandnewnurseretention(Weaver,2013).

Egues and Leinung (2013) addressed several strategiesinordertodecreasetheincidence

of horizontal violence. Horizontal violence leads to an increase in absenteeism, anxiety,

emotional distress, job termination, low moraleandpsychosomaticillness(EuguesandLeinung,

2013). There are several strategies brought up by EguesandLeinung(2013)toaddressthetopic

of horizontal violence. These strategies are all geared to diminish the effects of horizontal

violenceandincreasethejobsatisfactionofnursesandpatientoutcomes.

To understand the strategies to prevent horizontalviolence,onemustfirstunderstandthe

roles that the nurse plays in the interpersonal violence. Egues and Leinung (2013) stated that

bullying involved three roles: that of the bully, that of the victim and that of the bystander.The

bully uses aggressive behavior and targets the victim, who is on the receiving end of the

bullying. The bystander is the largest group of nurses, who watch or ignore the abuse without

interfering. By doing so, their silence empowers the bully (Egues and Leinung 2013). In any of

theseroles,itleavesthenurseinanegativelight.

Nurses need to make an effort to model exemplary behavior, not negative behavior.

Nursing leaders must be role models for their fellow nurses. According to Egues and Leinung

(2013), many nurse leaders are forced in the position of management before they are ready to

lead. This leads to them feeling unprepared and being unable toappropriatelyaddresstheissues

of horizontal violence that is present on many nursing floors. Nurses must also call upon

themselves to advocate for education on bullying. Egues and Leinung (2013) found that formal

education on bullying is an effective way to get information to others about how to end
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horizontal violence. Education about horizontal violence must include selfreflection, which

would involve the nurses reflecting on and discussing their own behaviors and their roles in

horizontal violence (Egues and Leinung 2013). The nurses must be willing to be open to

discussion in order to learn to handle conflict. Egues and Leinung (2013) encourage nurses to

address conflict by confronting the bully, as some might not even realize that their behavior is

harmful. Opportunities must exist for nurses toparticipateintheformationofeducationthatwill

addressthecessationofbullying(EguesandLeinung2013).

Egues and Leinung (2013) believe that once nurses are open to discussion and

selfreflection, they need to continue to support their positions against bullying by creating

guidelines for reporting, enforcing and disciplinary actions for those who are involved with

horizontal violence. Nurses need to keep records of incidents and be willing to report those

incidents to the appropriate supervisors (Egues and Leinung 2013). It is important for all

incidents to be analyzed and have corrective, disciplinary measures in place to ensure that the

incident does not recur. Nurses must also have a system that allows open communication

between employers andstaff andshouldalsobewillingtorallyaroundthosewhoarethevictims

ofhorizontalviolenceinordertoprotectthatpersonandstoptheincidentsfromhappening.

Egues and Leinung (2013) encourage nursestolearnhowtoworkasateam.The nursing

staff needs to learn to communicate honestly, openly and respectfully with one another. They

must hold themselves and eachotheraccountableforunacceptable behavior(EguesandLeinung

2013). By working as a team and supporting one another, it leaves little time for horizontal

violencetohappen.

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Conclusion

Horizontal violence is a huge determining factor in nurse retention and keeping patient

outcomes positive. While many plans have been proposed such as nurse residency programs,

team building strategies, and giving nurses a safe place to come to where they can report

instances ofhorizontalviolencewithoutfearofreprisalitstillremainsaproblemthatneeds tobe

addressed. Once everyone in the nursing community gets on the same page about howtotackle

this problem, horizontal violence can decrease. A reduction in horizontal violence will result in

an improved workplace environment, better patient outcomes and a decrease in nurse retention.

It is important for nurses to be apartofthecalltoaction,includingselfreflectionand education

inordertoempowerallnursesandstoptheinterpersonalviolence(EguesandLeinung2013).

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References

Egues,A.L.,&Leinung,E.Z.(2013).TheBullyWithinandWithout:StrategiestoAddress

HorizontalViolenceinNursing.NursingForum,48(3),1851906p.doi:10.1111/nuf.12028

KingJones,M.HorizontalViolenceandtheSocializationofNewNurses.(2011).Creative

Nursing

Reynolds,G.,Kelly,S.,&SinghCarlson,S.(2014).Horizontalhostilityandverbalviolence

betweennursesintheperinatalarenaofhealthcare.NursingManagementUK,20(9),24307p.

Weaver,K.B.(2013).TheEffectsofHorizontalViolenceandBullyingonNewNurse

Retention.JournalForNursesInProfessionalDevelopment,29(3),1381425p.

doi:10.1097/NND.0b013e318291c453