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Nursing Hostility

What is causing horizontal violence between nurses and what steps can individuals take to bring it to an end?

Nursing can be a strange profession.  We provide care to the sick or injured, we educate on a variety of health related topics, we nurture, we lead, and we're rated as the most trustworthy of all professionals by the American public.  How is it then that we are also known for eating our young?

Lateral or horizontal hostility (a.k.a., violence) occurs when people at the same level of hierarchy embark on discourteous or unkind interactions with each other.  This can occur at any level of nursing and is intended to undermine the self-confidence or self-esteem of the other person.  Examples include intimidation, humiliation, criticism, or any kind of angry outburst.

Hostile intentions can be more covert and insidious as in giving unfair assignments, withholding of information, ignoring someone, or the use of belittling gestures as in rolling of the eyes or other facial expressions.  Oftentimes cliques will form and divide units, which then leads to various forms of isolation and rejection.

Fifty-five percent of nurse respondents to a survey conducted by the American Association of Critical Care Nurses (AACN) reported having witnessed a nurse treating another nurse inappropriately in the previous 6 months.1 Another study, by Kathleen Bartholomew, MN, RN, RC, consultant, Swedish Medical Center / Convergent Knowledge Solutions, Seattle, found 60 percent of new graduates leave their first position within 6 months due to some form of horizontal hostility.2

Sources of Hostility

Many factors could be contributing to this sense of ill temper, such as long work hours, poorly staffed units, increased workloads, sicker patients or strained nurse-physician relations. Experts believe the real source of horizontal hostility trickles down vertically from the new corporate structure of managed healthcare that changed the very function of nursing nearly 30 years ago.3

Another possible factor could be that nurses have traditionally been women who've quietly accepted powerlessness. A lot of nurses cringe at confrontation and that makes them weak.  The first step is to learn effective, open communication.  Doctors yell at us, patients and their families yell at us and we are yelling at each other.  We must take back our power and learn how to communicate effectively and stop the yelling.  We are professionals, and we can speak up without being mean or hostile. 

We must stop this destructive behavior and begin to learn how to be more supportive and understanding with our fellow nurses.  I know I've been guilty of this and never stopped to realize the pain or humiliation I was inflicting on my co-worker.  I always felt it was harmless gossip, but I was wrong.  I will be the first one to take this advice. 

Call to Action

AACN issued a call to action in 2003 mandating a zero-tolerance policy for any type of rude or disrespectful behavior from co-workers, peers or colleagues to other critical-care nurses.  This two-part system includes one for nurses and one for the healthcare institution.  

In their effort to decrease nurse hostility, the AACN Call to Action calls on facilities to:

  • Implement and adopt zero-tolerance policies with multidisciplinary guidelines for reporting, enforcing and measuring all abusive behavior.
  • Encourage employees to promptly report any incidents, with the assurance that there will be no reprisal.
  • Establish multidisciplinary education that will develop and prevent such abuse.  This is to include a system for documenting the abuse, and procedures that will be taken in response to it. 
  • Provide an open forum where employers and staff can communicate openly.
  • Have a plan of action following the abusive behavior that includes disciplining the offenders, offering counseling to the victims and/or other employees, and setting up corrective measures to prevent the occurrence from happening again.1

AACN calls on nurses to:

  • Keep communication open, honest and respectful.
  • Hold others and yourself accountable for unacceptable behavior.
  • Investigate and analyze the abuse and seek solutions as a team.
  • Build up each others' strengths, and enhance personal skills by developing a mentoring system among peers, supervisors, physicians and other employees.
  • Develop strategies and skills that will change negative cultures, and share these best practices.
  • Develop and participate in multidisciplinary educational committees that work toward abuse prevention.1 

Don't Be Afraid

These are healthy communication techniques we can and must learn, and address inappropriate behavior immediately, letting the offender know what she said or did was wrong and that the behavior will not be tolerated.  Perhaps she didn't realize she'd behaved that way and will apologize. 

Don't be afraid to talk about it.  Discuss the issue at staff meetings or with your manager.  And finally, take care of yourself.  Eat a healthy diet; get plenty of exercise and good rest.  You'll feel better and will be less apt to act out abusively.  Also, don't be afraid to ask for help if you're feeling overwhelmed; we've all been there.

Today is the first day of the rest of your life.  Today is the day to make change a reality.  Start practicing healthy communication techniques and let's take back our power.  We can speak our minds and become one voice in nursing. We don't have to be enemies or belittle each other in order to rise to the top.  We can be friends, we can be mentors and we can be the compassionate and caring nurses the public believes us to be.

References cited in this editorial can be accessed here.

Melissa Moye is an ICU nurse at North Florida Regional Medical Center, Gainesville, FL. 

Articles Archives

"The nurses argue that givnig insulin requires a nursing education and certification, and to think or allow otherwise would somehow endanger kids' health and safety." Just like I was required to get nursing education and certification to bring my child home from the hospital, right?! The nurses unions want to protect their jobs, and that is understandable. However, there is not money for every school with a diabetic child to have a full-time nurse on staff every minute of every day. Instead of complaining about the possibility of losing jobs (which is what they did in Illinois), why not help procure funding to employ more nurses. It is also not reasonable for a parent to be on call. We parents of T1 kids need our jobs to afford health insurance and medications! The schools are charged with caring for our children from the time we drop them off until the time we pick them up. If funding isn't available to staff full-time nurses, then it is not unreasonable for willing staff to learn to care for the children. In an ideal world there would be a nurse at every school that needed one, but even with a nurse on staff, what happens if the nurse is not there. Schools (and government) must allow non-medical staff to become trained or the child's safety really is at risk.

Carrina Carrina,  "The nurses argue that givnig ,  "The nurses argue that givnig insulin requires a nMarch 06, 2012
"The nurses argue that givnig , UT

I read this article with interest. I hear the term "no tolerance" and other punitive terms. How do you all think conflicts are solved? You will have arguing and yelling at times in the work place. The pressure releases happen for a varity of resons. there may be unfair assignments given, people find out that some newer persons have been promoted over the seasoned one who never get a break. When you have the conflicts happen, our first thought does not have to be retribution to the "guilty party". This is time where some real problems could solved. First the two parties should brought togther and air there differences in a control setting. if this does not resolve the issue, bring in a mediator to discuss the matter. There will all be disagreements where we work , its how deal with them postively or negatively that determines the outcome.

scott ,  carpenterAugust 01, 2010

I have always felt that lateral violence is tolerated at most healthcare facilities because it is a way of keeping a large group of workers under control. If we are fighting each other we are not tending to the bigger issues that cause the behavior in the first place and that is just fine with institutional management. I agree that nursing is considered an "expense" and most of us do not control our own "practice/resources" at most facilities and thus we remain invisible. Nursing is basically treated like housekeeping or dietary, just a cost of doing business, you could think of Nurse Manager as the Shop Foreman. I've been in nursing for 20 years and have heard much talk and hand wringing abaout nurses attacking each other but not much action in regards to this issue, which leads me to believe that healthcare institutions gain from this and do not see it as a front burnner issue. I've heard some say "what else can you expect from a bunch of women working together". Nursing(ANA) in general does not show much interest in or have much to say about movements that address workplace violence/improvement or women and workplace issues, they usually support the status quo that butters their bread.

Barbara Keil,  RN,  VAMay 20, 2010
Topeka, KS

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