Workplace & Horizontal Violence

Snapshot: This article reviews the definition and scope of workplace and horizontal violence, its causes and consequences, and how to combat it.

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Background & Definitions Classifications of Workplace & Horizontal Violence Risk Factors for Workplace & Horizontal Violence Impact of Workplace & Horizontal Violence Strategies for Combating Workplace & Horizontal Violence Resources & Further Reading

Background & Definitions

  • two doctors discussingWorkplace violence is any behavior perpetrated in the workplace by one individual against another that is meant to intimidate, bully or harm. Workplace violence may be overt or covert, and ranges from physical assault to verbal abuse. The most common form of workplace violence in the healthcare sector is covert, verbal harassment.
  • Horizontal violence is workplace violence that co-workers with roughly equivalent levels of authority perpetrate against one another. Horizontal violence stands in contrast to ‘vertical violence,’ which is workplace violence that an individual in a position of authority perpetrates against an employee or subordinate with a lower level of authority.
  • Unfortunately, the healthcare sector is a “leader” in workplace violence. The Bureau of Labor Statistics reports that 45% of all non-fatal assaults against workers resulting in lost work days in the U.S. occurred in the healthcare sector (Bureau of Labor Statistics, 2006). Healthcare workers, including Registered Nurses, are far more likely to suffer from workplace violence compared to individuals in other sectors of the economy.
  • While healthcare organizations often focus on patient safety, they sometimes neglect the safety of their own staff. The evidence, both anecdotal and from studies of the phenomenon, suggests that workplace violence is a ‘silent epidemic’ in many healthcare organizations. Much workplace violence is likely under-reported, as many nurses express the attitude that such behavior is ‘normal’ and therefore unlikely to change; others may not report workplace violence for fear of retaliation.

Classifications of Workplace & Horizontal Violence

Workplace violence takes many forms. The following are some of the more common types of violence that Registered Nurses face in the workplace.

  • Verbally abusive language. This can range from demeaning comments to name-calling and is usually meant to humiliate, harass or belittle a person.
  • Belittling gestures. These are non-verbal forms of abuse that include eye rolling, raising eyebrows, or even folding arms when another is speaking.
  • Shouting or yelling. This is obvious to recognize, although it’s surprising how common such behavior can be in healthcare settings; no matter the stress, there’s no excuse for this behavior.
  • False or misleading statements. This includes gossiping, backbiting, or ‘setting someone up to fail,’ e.g. by deliberately providing inaccurate or incomplete information about a patient or clinical situation.
  • ‘Freezing out.’ This is behavior that deliberately excludes individuals from professional discussions, or withholding needed information.
  • Discrimination. This is intentional discrimination against a protected class of individuals under U.S. law, and includes discrimination on the basis of age, ethnicity, race, gender, sexual orientation, religious beliefs, or physical appearance. Such discrimination can affect performance evaluations, promotions, demotions, and termination, and is illegal.
  • Assault. This is any act that creates an apprehension in another person of imminent, harmful or offensive contact. It includes, for example, threatening body language or gestures, and may result in criminal and/or civil liability.
  • Battery. This is harmful or offensive touch of another person, and includes actual physical violence. Contact is an essential element of battery, and distinguishes it from assault. Battery also may result in criminal and/or civil liability.

Risk Factors for Workplace & Horizontal Violence

Workplace and horizontal violence doesn’t occur randomly. Certain factors make it more likely to occur, and must be mitigated to make improvements.

  • Poor staffing. Inadequate staffing makes workplace violence more likely by leading to unsafe clinical situations that prompt stress and derail effective communication among both staff and patients. All else being equal, inadequate staffing also makes it more likely that workplace violence will escalate, as there are fewer individuals to keep potentially volatile situations in check.
  • Inadequate security. Inadequate security is another risk factor for workplace and horizontal violence. Especially in acute care settings, it is vital that nurses know they have ‘back up’ from a trained security force to impose order as needed and to prevent unstable or threatening individuals from escalating violence. Often, the presence of security personnel can prevent violence from occurring in the first place.
  • Isolated work areas and poor lighting. The physical layout and appearance of work environments can influence the likelihood of workplace violence. Patients, family members and even coworkers are less likely to initiate or sustain harassing or violence behavior if such behavior is easily visible by others. Long corridors, isolated rooms, and poor lighting all decrease workplace transparency and visibility, and can make violence more likely.
  • Moveable furniture/objects. Furniture or objects that are not secured or bolted down, and can potentially be used as weapons, are a risk factor for physical violence (i.e. battery). This is especially true in critical care areas with highly emotional patients and family members, such as in emergency rooms.
  • Early morning or late evening hours. Work hours can affect the likelihood that workplace violence will occur or escalate because work hours are often negatively correlated with staffing levels, security levels, and lighting. Early morning and late evening hours are higher risk times for workplace violence because of these factors.
  • Sub-standard training. While nursing and healthcare are often stressful, skilled training can greatly reduce the risk of violence by teaching nurses how to appropriately respond to and de-escalate violence. Training should focus on “problem solving” approaches that quickly respond to and limit violence.
  • Inadequate policies and procedures. Closely connected to training are policies and procedures at the organizational level. Organizations should implement a “zero tolerance” policy for workplace violence, and encourage prompt reporting to track, address and eliminate unsafe, harassing or violent behaviors.

Impact of Workplace & Horizontal Violence

The impacts of workplace and horizontal violence are varied and include:

  • Physical injury. This is the most tangible consequence of workplace violence, and can range from scuffles to interactions resulting in serious bodily injury. Any type of unwanted physical contact in the workplace, however, is a form of battery and is very serious.
  • Depression. Research shows that individuals who are subject to workplace and horizontal violence, including “milder” forms of violence such as verbal abuse, are far more likely to suffer not only job dissatisfaction, but depression too.
  • Insomnia and other physical ailments. By causing stress, workplace violence can contribute to insomnia and other physical ailments such as body aches and pains. These physical ailments can beget a cycle of anxiety that in turn reduces individuals’ coping abilities in dysfunctional workplacs.
  • Low staff morale and poor performance. Not surprisingly, workplace violence results in poor morale among workers, which affects everything from job performance, to job productivity, to increased absenteeism and turnover.
  • Secondary impacts on one’s personal life and relationships. Workplace violence rarely “stays” in the workplace; almost inevitably, it tends to “spill over” into a person’s non-work life, and disrupts other relationships too.
  • Poor patient care and safety. Workplace violence isn’t just bad for workers; by fostering unnecessary conflict, anxiety, stress and depression, it is associated with sub-standard patient care and clinical outcomes.
  • Perpetuation of the cycle of violence. Violence, whether verbal or non-verbal, tends to beget more violence, unless deliberately held in check. Workplace and horizontal violence therefore tends to be “self sustaining” until organizations, often at the behest of courageous individuals, stand up to change course and break the cycle.

Strategies for Combating Workplace & Horizontal Violence

Combating workplace and horizontal violence must occur on both the individual and organizational levels. Here are some important principles for implementing positive change:

  • Have a zero tolerance attitude. Workplace violence of any kind – from verbal altercations to harassing or discriminatory behavior to outright physical violence – must not be excused or tolerated in any way. Organizations that adopt a ‘zero tolerance’ attitude, and follow through by penalizing or expelling individuals who engage in violent behavior, are far more likely to be successful in combating workplace and horizontal violence than organizations that adopt a more lenient stance.
  • Report such behaviors immediately to supervisors. On an individual level, it is important to not explain away, delay or fail to report violent behavior in the workplace. Individuals should know they will not be penalized for reporting such behavior, and organizations must take disciplinary action promptly and consistently.
  • Stand up, get help, and work together. While prompt reporting of violent behavior is important, it’s also critical to make it immediately clear to any individual perpetrating violence that the behavior is unwelcome and unacceptable. Your goal should be to obtain needed help, and working together, calmly but firmly work to de-escalate the situation to ensure staff and patient safety. Letting violent behavior ‘slide’ allows it to worsen, and makes it harder to contain.
  • Be familiar with your organization’s rules and policies. Part of preventing and eliminating workplace violence depends upon employees clearly understanding the rules and policies that govern acceptable workplace behavior. Such rules have a formal component, in the form of regulations and disciplinary actions, and a cultural component, in the form of the values that inform the organization’s work and mission. As stated, organizations that adopt a ‘zero tolerance’ approach to workplace violence tend to be the most successful at preventing it.
  • Know the law. Even if your organization or your superiors are deficient, know that workplace violence is illegal. If you must, you can and should turn to legal action to protect yourself, your co-workers, and your patients. In 1970 the Occupational Safety and Health Administration issued basic workplace safety standards that includes a ‘General Duty’ clause to ensure basic worker safety. The Joint Commission (which accredits most hospitals and many other healthcare organizations) now has a leadership standard that addresses horizontal violence. In addition, some states have enacted laws that mandate employers run workplace violence programs, and strengthen penalties for acts of workplace violence, in addition to federal and professional standards.

Resources & Further Reading

  • U.S. Department of Labor:
    • This is a sub-section of the much larger website for the U.S. Department of Labor, and provides a useful overview of workplace violence for healthcare workers, applicable federal law, and a variety of strategies and resources to organize and implement workplace violence prevention programs.
  • Emergency Nurses Association:
    • This is a sub-section of the Emergency Nurses Association (ENA) website that highlights research on workplace violence. ER nurses suffer some of the highest rates of workplace violence, and this webpage aggregates and summarizes several important research initiatives to better understand and combat workplace violence that nurses of all backgrounds will find useful.