This paper presents a research funding proposal addressing horizontal violence (HV) in the nursing profession. It defines HV as nurse-to-peer bullying involving behaviors that humiliate and demean colleagues, then outlines the core problems: a cycle of silence among victims, long-term psychological damage including depression and low self-esteem, and estimated annual costs of approximately $24 billion in the United States alone. The paper reviews theoretical frameworks—including the wounded healer, nursing as an oppressed discipline, and disenfranchising work practices—alongside empirical studies. It proposes a mixed-methods research design using online surveys, interviews, and hospital performance data, and closes with a detailed budget justification for the requested funding.
Horizontal violence (HV) has been defined by many authors, and despite variations in definition, the term is most commonly described as actions, words, or other behaviors directed at one's peers (Becher & Visovsky, 2012; Dumont, Meisinger, Whitacre, & Corbin, 2012). These specific behaviors, words, and actions are intended to humiliate and injure the recipient's dignity. Horizontal violence is aimed at demeaning individuals and showing total disrespect toward them.
Tedone (2020) defines horizontal violence in nursing as nurse-to-peer bullying. The author argues that bullying among nurse peers is an uncivilized act that has persisted over the years and has been termed a plague in the nursing profession. It is unfortunate that demeaning a fellow nurse has become an acceptable act carried out without fear of consequence. One of the most important questions one might ask is whether human psychology allows one nurse to bully another. Nurses are always under pressure to provide optimum care to patients, and most are mentally prepared to carry out their responsibilities without interruption. However, when they encounter stress from the clinical environment or from external factors, the quality of their care decreases — a critical issue affecting overall performance.
This paper presents a proposal to a funding agency addressing the problems that nurses encounter in their profession and establishing reasons for the requested funding.
One of the major problems with HV among nurses is that a cycle of silence surrounds it. Tedone (2020) states that most nurses prefer to minimize confrontation with peers because they fear being labelled as snitches by their colleagues. Despite the existence of a code of conduct in the nursing profession, HV has become so entrenched that crucial strategies may need to be implemented to mitigate its effects.
Another significant problem is that HV results in long-term damage among nurses. Tedone (2020) argues that nurses have been accused of "eating their young ones" — a phrase used to describe the mistreatment of newly qualified nurses. The victim, "the young one," ends up suffering psychological trauma and low self-esteem. A report by Sanner-Stiehr and Ward-Smith (2014) shows that HV is not only a workplace stressor but also causes long-term psychological damage. Victims are likely to experience depression, very low self-esteem, reduced productivity, and absenteeism. Bloom (2019) concurs with these findings and adds that victims are likely to suffer from poor concentration, increased stress levels, and frequent frustration.
The financial cost of horizontal violence among nurses is a problem the funding agency must understand. A study by Hassard, Teoh, Visockaite, Dewe, and Cox (2018) found that the total cost of psychological aggression in the workplace ranges from $114.64 million to $35.9 billion, based on data from five developed countries: the United States, the United Kingdom, Spain, Italy, and Australia. The study notes that incivility among nurses in the United States costs approximately $24 billion annually, and that the cost per nurse in the ICU is approximately $145,000. These figures encompass both the cost of treating nurses who have been bullied and the productivity lost by health facilities as a result of HV.
Stopping the cycle is a key challenge for healthcare institutions. Many institutions prefer not to publicize the fact that nurses are mistreating their junior colleagues, as this may damage their public image. It would seem contradictory to the public that caring professionals fail to care for one another.
The most significant barriers that victims of HV face include confronting their aggressor, making a formal complaint to the organization, taking legal action, seeking help from their employer, and regaining control of their situation. HV is most commonly associated with intimidation, and those affected are often new nurses. New nurses may require motivation and empowerment to advocate for their rights. Psychological trauma is a serious concern, as it can have lasting negative effects on both performance and the long-term wellbeing of an individual (Weaver, 2013). The trickle-down effects of HV on institutions accumulate gradually and cause both psychological and financial harm.
The significance of this proposal is to encourage the funding agency to address the grievances of nurses who are substantially affected by HV. The proposal also aims to inform the funding agency about the healthy work environment that nurses require in order to care effectively for patients. Achieving this will require considerable financial and psychological support from institutions or willing sponsors.
Assessing the types of violent and abusive words and behaviors present in healthcare institutions will provide a clear picture of the overall problem and enable the development of strategic steps toward mitigating HV and creating a healthier work environment for nurses.
A funding agency would be the most reliable institution to help nurses who have already experienced HV recover from its effects. The funding agency would act as a sponsor for nurses dealing with psychological problems including depression, aggression, and low self-esteem.
Evidence gathered through the proposed research will help establish the extent to which nurses in the healthcare sector have suffered as a result of HV. The funding agency's support is needed to help cover the cost of treatment for affected nurses and to help bridge the resulting productivity gap in healthcare institutions.
Nursing is a profession that requires helping people in a vulnerable state. Christie and Jones (2014) argue that people are drawn to professions such as nursing by a desire to help others and relieve their suffering. The authors suggest that those who become nurses have often previously encountered people who experienced traumatic situations, and therefore feel compelled to act as problem solvers. Kalsched (2014) argues further that every individual has experienced trauma at some level in their life. Waldeck (2011) describes the wounded healer as a person who has been damaged by past experiences and channels that damage into providing solutions for others.
People often feel inferior when they occupy a lower position in a hierarchy. The healthcare system is hierarchical, and nurses are frequently at the bottom of that structure. Furthermore, hierarchy exists among nurses themselves (Tedone, 2020). Some nurses become aggressive toward peers as a way of relieving tension that has built up within the system.
Research indicates that the majority of nurses globally are women. Women have historically been regarded as the inferior gender, and professions dominated by women are often undervalued. This dynamic can give rise to low self-esteem among practitioners in such fields. People with low self-esteem are more easily angered and may struggle with self-regulation, making them more likely to lash out at others without consideration for the consequences.
Nurses face the pressure of attending to patients while simultaneously managing a range of other responsibilities. Many nurses become overwhelmed by their workload (Tedone, 2020). Nurses who are overworked may become easily irritable and, as a result, find themselves acting either as perpetrators or victims of HV in the workplace.
In a study by Bloom (2019), the author investigates HV as both an overt and a covert form of hostility. Using an online survey, the study examined 76 hospital nurses regarding their experiences with and responses to HV. Participants reported that HV most commonly occurred when they were new to their careers. Increased workload was identified as one of the major factors contributing to higher rates of HV, due to elevated aggression and stress. Despite the prevalence of HV, nurses in the study reported continuing to work at the same facilities. The study found that HV is costly, leading to increased nurse turnover, lower quality patient care, and higher rates of illness. A notable limitation is that the study does not fully account for why victims chose to remain at the facilities where they experienced HV.
A further study by Egues and Leinung (2013) examined the concept of the "bully within and without" in the context of lateral violence in nursing. Data and information were gathered from nurses during workshops, where participants described their personal experiences of horizontal violence. One key finding was that nurses are generally aware of horizontal violence and know what steps could be taken to address it. However, despite established protocols, facilities frequently fail to follow them. The study concludes that nurses need greater exposure to information about HV, and that victims require both protection and counseling.
"Theoretical frameworks and empirical studies on HV"
"Survey design, data collection plan, and budget breakdown"
Kalsched, D. (2014). The inner world of trauma: Archetypal defences of the personal spirit. Routledge.
Sanner-Stiehr, E. & Ward-Smith, P. (2014). Lateral violence and the exit strategy. Nursing Management, 45(3), 11–15.
Tedone, D. A. (2020). Eliminating horizontal violence from the workplace. Nursing2020, 50(8), 57–60.
Waldeck, C. (2011). Trainee clinical psychologists' experience of personal psychotherapy in the context of professional training (Doctoral dissertation).
Weaver, K. B. (2013). The effects of horizontal violence and bullying on new nurse retention. Journal for Nurses in Professional Development, 29(3), 138–142.
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