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Defeating horizontal violence in the emergency department


There is an aggressive behavior that sabotages and undermines another individual’s confidence or self-esteem—and no, we aren’t talking about teenage gang behavior. We’re referring to horizontal violence in nurses’ work environments.

Horizontal violence poses a significant threat to nurse retention and recruitment and to positive patient outcomes. As a result, the American Nurses Association, The Joint Commission, and other national nursing and healthcare organizations have called for solutions to decrease its incidence.

Knowing the detrimental effects of horizontal violence, we decided to develop a research study to take place in the emergency department (ED) of our 411-bed, tertiary care, regional referral hospital. We wanted to find out if interventions designed to improve the nursing staff’s perceptions of positive and negative behaviors among their coworkers worked and whether there was greater job satisfaction.

Study design

This was a prospective interventional study using a pretest/posttest design. After institutional review board approval, a convenience sample of ED nurses voluntarily and anonymously participated in the pretest survey (N = 32), interventions, and postsurvey (N = 41). The survey was a 30-item Likert-like survey that identified the perception of positive and negative behaviors that exist in the work environment. The nurses were asked to rate the behaviors on a scale of 1 to 5 with 1 being never and 5 being always. Internal reliability was validated with Cronbach’s alpha: 0.877 for positive behaviors and 0.911 for negative behaviors.

Pretest results

The pretest demonstrated that the nurses rated their perception of the occurrence of positive behaviors to be a mean of 3.4 (standard deviation [SD] 0.58), indicating positive behaviors occurred between sometimes and often. The perception of negative behaviors was rated a mean of 2.8 (SD 0.59), indicating negative behaviors occurred sometimes to rarely.

Each August, the nurses in this unit participate in the National Database for Nursing Quality Indicators’ (NDNQI®) RN Job Satisfaction Survey. Their 2006 and 2007 scores for job enjoyment were relatively low (in the 40s), and their scores for RN-RN interactions, professional status, and professional development were around 50.


The nurses taking the survey wanted to see positive behaviors rated between 4 and 5 (almost always) and negative behaviors reduced to between 2 and 1 (almost never). The ED uses a shared governance professional practice model. Therefore, the first step was to take the results of the surveys to the unit-based council and discuss solutions. The interventions the council designed to improve nurses’ perceptions of their work environment are classified according to the problems identified. (See Interventions to improve nurses’ perceptions of their work environment.)

Weighted Checklist

Education for staff

If nurses don’t understand what horizontal violence is and its manifestations, it can continue unopposed. So education is vital: It needs to begin in new staff orientation and be part of yearly mandatory education. We put a PowerPoint presentation on the ED intranet and gave contact hours for completing the presentation. A staff retreat held outside the institution included a session on horizontal violence. The retreat was also a method of building staff relationships.

Conflict resolution through peer mediation

The peer mediation group, which was developed by the clinical educator, is made up of nurses, physicians, ED technicians, and ED secretaries who have attended a two-day workshop on crisis intervention management. The group is involved with non-disciplinary staff mediation for conflict resolution, defusing staff after traumatic events, and facilitating relationship building.

To activate the peer mediation group, staff calls the patient advocate, who then notifies the members. Staff members received pamphlets and business cards that included the number to activate the group. A referral form, which can be completed anonymously, can also be given to the clinical manager. The peer mediation meeting provides a forum where individuals can discuss their problems and resolve issues under the guidance of an impartial group. If the persons involved refuse to attend the meeting, he or she is informed that the department director will address any continued conflict between the persons. The institution also offers conflict resolution classes, which provide employees with tools to address disharmony.

Facilitating collaboration

Collaboration is key if staff members are to work together effectively as a team. We created monthly “Power Wednesdays” to operationalize our shared governance model in the ED by hosting departmental meetings (staff, nursing council, trauma, and mass casualty). In addition, ancillary departments, such as the laboratory, safety and security, pharmacy, risk management, and radiology, are invited to present new developments and to discuss issues or concerns. Vendors are invited to the staff meeting to provide educational opportunities for the staff. “Power Wednesdays” provide a time when staff members take the initiative and channel their ideas into an effective working environment.

In January 2009, The Joint Commission developed two new standards for institutions to help promote a more healthy work environment. These standards call for behaviors constituting horizontal violence to be addressed in policy and for corrective actions to occur as a result of disruptive behaviors. Human resources, with our input, wrote a policy that addresses horizontal violence in the workplace.

Support for new graduates

The graduate roundtable provides new graduates with the opportunity to discuss any issues that may occur during their orientation. The group meets on a monthly basis under the guidance of the clinical manager. The new graduates discuss case studies and are encouraged to present any interesting cases.


There have been numerous benefits from the staff initiatives. The NDNQI RN Job Satisfaction Survey scores showed progressive improvement: In the areas of RN-RN interaction and professional development, scores rose from 58.54 and 44.61 in 2007 to 64.90 and 52.44 in 2008, respectively (See Changes in the NDNQI scores of ED nurse satisfaction over the study’s three years.)

Changes in the NDNQI scores of ED nurse satisfaction over the study’s three years

Weighted Checklist

The perception of frequency of positive behaviors was higher in the postintervention group than the preintervention group, 3.9 (SD 0.59) versus 3.4 (SD 0.58), respectively, (Z = -2.894, p = 0.004). The perception of frequency of negative behaviors was lower in the postintervention group, 2.4 (SD 0.70) versus 2.8 (SD 0.59), respectively, (Z = -2.331, p = 0.020) (See Perceptions of positive and negative behaviors in the workplace in 2007 preintervention and 2008 postintervention.)

Perceptions of positive and negative behaviors in the workplace in 2007 preintervention and 2008 postintervention

Weighted Checklist

One serendipitous finding was that nurses who were older and had greater tenure reported perceiving higher frequencies of negative behaviors. As a result, a focus group of more experienced nurses is being formed to investigate the reasons the older nurses perceived more negative behaviors. We want to keep our older and more experienced nurses, so an action plan will be developed to address these perceptions along with interventions to improve the negative behaviors.


It is the consensus among researchers that horizontal violence produces a toxic, unhealthy work environment. Researchers have reported that horizontal violence can cause increased absenteeism and sick leave, which can affect patient care. The cost to an institution for a nurse who leaves his or her institution can range from $30,000 to $60,000. By using our shared governance model to execute this project, costs to the department were minimal and assumed into the usual work of the unit. The education budget is projected to include educational time for staff to attend the crisis intervention seminar.

Nurses pride themselves in providing the same kind of care for their patients that they would expect a family member to receive. Why not treat our coworkers with the same respect and support we want to receive? Horizontal violence has no place in the professional practice of nursing. More research needs to be done to provide interventions and follow-up that create a healthy work environment where nurses feel safe, supported, and excited to come to work.

Gloria Corbin is clinical nurse IV in the emergency department, Cheryl Dumont is director of nursing research/vascular access team, and Desiree Brunelle, is administrative director of emergency services at Winchester Medical Center, Virginia.

Selected references

Bartholomew K. Ending Nurse-to-Nurse Hostility: Why Nurses Eat Their Young and Each Other. Marblehead, MA: HCPro, Inc.; 2006.

The Joint Commission. Behaviors that undermine a culture of safety. The Joint Commission Web site. http://www.jointcommission.org/sentinel_event_alert_issue_40_behaviors_that_undermine_a_culture_of_safety. Accessed September 12, 2011.

Rosseter RJ. Nursing shortage fact sheet. American Association of Colleges of Nursing Web site. http://www.aacn.nche.edu/media/FactSheets/NursingShortage.htm. Accessed September 12, 2011.


  • Bullying is still going on between multiple groups of people in this society on a daily basis. Another area to consider is today’s public service professionals. Some of their behaviour is concocted and indecent towards one another making the recipients social workers observing this nutcase caregivers. (It’s amazing how well the patients are doing–compassion).
    The role of observation changes from impeding public servants to a nurse proposing change in the advocatcy of change for health promotion and adaptation.
    An examination of what/who is a public public servant? Mother Tersea is already gone.
    Please forward this to the BRN of California and Michigan and their Attorney Generals.
    Julie M. Dochtermann RN MSN
    UCSF School of Nursing
    Community Health Systems
    Nursing Informatics

  • Dear sir,
    I am Subph Ongtip, Head of Nursing Professional Training department of the Samitivej Sriracha Hospital. I have read and retrieved the horizontal violence survey form. I am very interesting for this and want to know that if we have this violence or not.
    I write this letter to consult you that if I collected these data by use this form, how I can analyze or could you advise me how to do next. Thank you very much.

  • This is a great example of an inexpensive study, easily coordinated without disruption of patient care with measurable results. Not only that, but it brought about POSITIVE CHANGE. This is a serious issue. It has been allowed far too long and has abuptly ended way too many outstanding nurses’ careers. No tolerance! Good Job!

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