Newly graduated nurses’ experiences of horizontal violence

Abstract

Background:

Horizontal violence, defined in the literature as ‘interpersonal conflict between two nurses at the same hierarchical levels in organizations’, often associated with bullying, affects the well-being of nurses, care recipients and the professional image of nursing and the organization due to increased turnover. One in every three newly graduated nurses is a victim of horizontal violence, although they do not always know how to define it.

Aim:

To investigate the direct and indirect experiences of horizontal violence in newly graduated nurses as well as to shed light on the phenomenon, on its awareness and recognition.

Methods:

A qualitative phenomenological study was conducted between September and October 2018 with newly graduated nurses, with a work experience ranging between 6 months and 3 years. The interviews were conducted face-to-face, consisting of a first open general question, followed by semi-structured questions.

Ethical considerations:

The study was conducted in accordance with the Declaration of Helsinki, and the protocol was approved by the Institution Review Board.

Results:

From the analysis of the interviews of the 21 participants, four main themes were identified: the ‘enemies’, that is those who exercised violence, the ‘weapons’ used by them to exercise violence, the ‘effects’ and the types of ‘armor’ identified to protect themselves.

Discussion:

Horizontal violence is rarely recognized by newly graduated nurses, even though our sample had directly or indirectly experienced horizontal violence. Tackling the phenomenon starting from the undergraduate degree courses, focusing on effective support and more protection by the organization leaders were the silent requests that emerged from this study.

Conclusion:

Preventing horizontal violence is important for nurses’ professional and private well-being, for professional conduct and for the quality of care provided to patients.

Keywords

Bullying horizontal violence interpersonal conflict interprofessional relations newly graduated nurses

Introduction

Workplace violence in the social and healthcare sector, by citizens against health professionals, is an emerging global phenomenon. The growing number of cases of violence are raising concerns also in Italy, to the point that the Italian Ministry of Health and the Italian Regulatory Body of Nursing (FNOPI)^1,2 have started to take measures to counter this phenomenon. A particular form of violence in the workplace, but to which less attention is paid and fewer prevention strategies are in place, is horizontal violence.

The workplace bullying and horizontal violence are serious problems to nurses’ health and well-being, and there is a need to prevent and eliminate them. Increasing levels of horizontal violence are present in the general nursing population, and newly graduated nurses are particularly exposed in the transition period from student to clinical settings.

Background

Horizontal violence has been described as ‘a negative interaction, an interpersonal conflict between two nurses of similar positions, same hierarchical levels’,³ and it may be psychological, verbal, physical or characterised by discrimination, prejudice and insufficient support.⁴ Its impact on nurses’ well-being is greater than when it is perpetrated by patients or their family members, referred to as ‘external’, especially if it manifests itself under psychological and verbal forms.⁵ Among the various definitions that have described this phenomenon in the literature, there is its association with bullying, considered as an event that is perpetuated over time, as opposed to horizontal violence that may occur also occasionally.⁶ The nurses who are mostly affected by horizontal violence are newcomers to a given work environment,^7,8 and more than one-third of the newly graduated nurses are victims of horizontal violence.^9,10 The violent attitudes, perceived and suffered by new graduate nurses, mainly involve the lack of proper consideration and not being treated as equals. This entails isolation, gossip and conjectures, with excessive criticism and sarcastic comments aimed at diminishing their self-esteem, with a lack of understanding and patience and, above all, threatening the assignment of disproportionate workloads and assignments, without any professional support.^4,7,8,11,12 The deliberate assignment of disproportionate workloads and patients with complex care needs that are not commensurate with new graduates’ level of experience also exposes patients to unnecessary risks and inadequate care. Such actions are perpetrated at the expense of newcomers solely to put them to test and under strain¹³ or are the result of senior nurses’ low awareness and excessive expectation towards new graduates.¹⁴ In this way, patients become the ‘unconscious victims of a weakened care environment’.¹⁵

Horizontal violence also has a considerable impact on the physical, mental and social health of novice nurses,⁷ resulting in an increase in absenteeism, turnover and intention to leave the profession.^{8,12,14,16
–18} In addition, quitting the workplace leads to a vicious cycle that increases the workload of the nurses who remain, reducing job satisfaction and irritability and resulting in decreased tolerance towards those who remain.^9,10

However, nurses do not recognize themselves as violent people, nor do they consider themselves bullies,⁶ especially the senior ones, because they consider these negative behaviours as a requirement in order to test the new colleague,⁷ disseminating the culture of hazing, with the intention of making new graduates become independent, and competent, defining this attitude as Tough Love.¹⁴ Recognising horizontal violence is difficult even for the new graduates themselves, with the risk of taking the form of a silent epidemic⁶ within health organizations and the nursing culture, becoming a generational phenomenon.¹⁴ Persistent criticism is seen by some as a constructive attitude,¹⁹ while gossip as a way to vent and distract from work stress. Bullies are considered, in a reductive way, as those who ‘make you do their job’.^11,20

Horizontal violence cannot go unnoticed and must be eradicated, especially if you consider the serious consequences it may have on the psychological and physical well-being of newly graduated nurses, patient safety and the image of health organizations. These attitudes run the risk of fuelling distrust in the team, eroding professional behaviour and creating hostile work environments.²¹

In the Italian nursing context, horizontal violence is still a phenomenon that is still poorly studied and known, and as suggested by Bambi et al.,⁸ it is appropriate to analyse horizontal violence with a qualitative methodology to gain a thorough understanding of this problem, if it actually exists and what are its characteristics. Since tools that enable to recognize horizontal violence are lacking, it could be useful to compare the Italian cultural aspects with those of other countries to identify horizontal violence and consequently prevent and manage it.⁶

Aim

The aim of this study was to describe and understand the lived experience of newly graduated nurses, either as victims or witnesses of horizontal violence in the work environment.

Methods

A qualitative descriptive phenomenological study was conducted to gain a deeper understanding of newly graduated nurses’ daily experiences of horizontal violence.²²

Sample description and setting

A proactive sample of newly graduated nurses, with either a direct or indirect lived experience of horizontal violence, was selected among those who had graduated from the University of Milan and who had already worked in teams, in any context (acute hospital, long-term hospital or nursing homes), for a period ranging between 6 months and 3 years. The nurses were invited via email to participate until there was no redundancy in the information and data saturation was achieved.²²

Data collection

Face-to-face and in-depth interviews were conducted individually, audio-recorded and then transcribed verbatim. The lived experience of newly graduated nurses who were victims and/or witnesses of horizontal violence was investigated considering also the respective work environment. The interviews were conducted outside the working hours, in a quiet and relaxing environment in a university hospital in Milan, to ensure privacy and where interviewees would feel comfortable and at ease. Interviewees were given all the time they needed to talk about what they thought was important. The interviews lasted between 45 and 120 min with an average of about 80 min. The interviews began with a general open but focused question, to start talking about their experience of horizontal violence with the maximum discretion: ‘I would like to talk to you about your first clinical work experience regarding your relationship with the rest of the nursing team’. Then, if necessary, semi-structured questions were asked, following the example of Griffin’s study,²³ to gain a deeper understanding of their experience with horizontal violence. After each question, the interviewees could talk freely about their experiences in their own way,²³ leaving them free to link their experience to other topics, talk about themselves and their work experiences in their clinical settings and about indirect episodes of horizontal violence.

Data analysis

The data were analysed as we proceeded with the interviews, until no new information was obtained. After faithfully transcribing, listening and repeatedly reading the data, relevant concepts relating to personal experience were identified.²⁴

The analysis was conducted using the phenomenological method of analysis derived from Giorgi,²⁵ which involves: reading the entire description of the lived experience to gain a general sense, returning to the data, rereading the text to identify the units of meaning in relation to the search query, examining the units of meaning to express the specific content and synthesising the contents into a single text capable of expressing the quality of the experience investigated.²⁶

The analysis was conducted separately by three researchers (A.C., S.R. and I.M.R), to identify any significant parts and emerging issues while setting aside any pre-established subjective perspectives. The results of the analytical process were shared with the rest of the research team to identify any issues. In case of disagreement between the researchers, the original words of the interviewees were retrieved and discussed until full agreement on their ultimate meaning was achieved. Scientific rigour was ensured by the confirmation of the integrity of the data, through credibility, appropriateness and reliability. Credibility was ensured through the description and faithful interpretation of the actual lived experience and the conduction of multiple interviews and giving participants the opportunity to review and possibly correct the descriptions and themes that emerged from the analysis of the data. Appropriateness was achieved by using direct quotes from the participants. Reliability was pursued by setting aside previous knowledge and personal assumptions regarding horizontal violence (i.e. bracketing), to remain impartial.²⁴

Ethical considerations

The present study was conducted in accordance with the Declaration of Helsinki, and the protocol was approved by the Institution Review Board of the University Hospital of Milan. Prior to the start of the interviews, consent was obtained to collect data through interviews and consent to audio-recording. Interviewees were totally free to withdraw from the study at any time and to seek clarification. Confidentiality of personal data and privacy were guaranteed, according to the provisions of current Italian legislation (Legislative Decree n. 196/2003, subsequently amended by Legislative Decree n.101/2018). The data were handled anonymously, making it impossible to identify participants and protect the subjects’ privacy.

Results

A total of 21 (15 females and 6 males) nurses were interviewed, with an average age of 34 years (range, 24–45 years) and with a working experience ranging between 8 months and 3 years (Table 1). Horizontal violence and its perception, according to the experience reported by recently graduated nurses, was described through four main themes: (a) ‘the enemies’; (b) ‘the weapons used by those who offend’; (c) ‘the effects it causes’ and (d) ‘the armour’ used to protect oneself.

Table 1.

Characteristics of the study participants (N = 21).

Nurse	Sex	Age	Working experience in months	Number of working experiences	Current unit
I1	F	26	22	1	Medicine ward
I2	M	28	22	2	Medicine ward
I3	F	26	22	2	Medicine ward
I4	F	33	33	2	Medicine ward
I5	F	26	21	4	Long-term care hospital
I6	F	28	36	2	Surgery ward
I7	M	38	10	1	Long -term care hospital
I8	F	36	22	3	Emergency department
I9	F	26	22	1	Medicine ward
I10	F	26	22	3	Medicine ward
I11	M	42	10	1	Medicine ward
I12	F	25	8	1	Surgery ward
I13	F	45	36	4	Emergency department
I14	F	26	22	3	Medicine ward
I15	M	35	22	3	Long-term care hospital
I16	M	32	29	3	Medicine ward
I17	F	29	33	2	Surgery ward
I18	M	27	18	3	Surgery ward
I19	F	27	30	2	Surgery ward
I20	F	24	22	3	Emergency department
I21	F	24	32	4	Medicine ward

The enemies

Those who perpetrated horizontal violence were defined by respondents as ‘enemies’. The more senior nurses were those who were most frequently described as offenders, considered ‘senior’ for their age and clinical experience, and for this reason was often the person who was in charge of supporting the integration of the newcomers. According to our interviewees, ‘seniors’ were considered an elite group within the nursing teams, not only the legitimate authority that dictated rules on how to provide nursing care but also those who felt threatened by whoever wanted introduce an innovation that would subvert their daily routine and usual practice.

The more senior nurses fear that it will ruin them…They fear that others will occupy their territory. They also fear that you will force them to innovate certain mechanisms, because once you have a certain organization of the work, you do it blindfolded, in as little time as possible. But when a recent graduate arrives, a newly hired…(I13)

Interviewees claimed that both the prejudice against newly graduated nurses, considered incompetent and not an equal, and the excessive expectations compared to their skills, were often used as excuses for horizontal violence. Sometimes, also very young and recently hired nurses were reported to exercise horizontal violence because of the competition, mostly coming from precarious employment contexts, such as nursing agencies, or as a result of what they had previously experienced and, now they themselves have learned to use horizontal violence:

The young nurse did it because she said ‘how I suffered it, also everyone else must go through it. There are some who are victims and then carry them on as well. For them it is a right to use violence on the new ones’. (I11)

The third type of horizontal violence perpetrator that was identified by the interviewees was unlicensed assistive personnel (UAP), whose role is to support to nurses’ activities. UAPs, who are often older than the nurses, attempt to bully and replace nurses, thinking that they are more experienced in health care than newly graduated nurses. Therefore, novice nurses have difficulty relating with UAPs, especially when they have to assign them specific tasks.

Some UAPs once told me ‘hey you have to do this’ when maybe I’d already been doing it for an hour. They also try to manage your work. For them we are novices and that’s why they do it, in my opinion, because they’ve been working there for a longer time, but that doesn’t mean you have to come and tell me how to manage my job. I saw this as a kind of violence, because it made me feel humiliated. (I14)

Also charge nurses were defined as an ‘enemies’, when they abuse their power and use the complicity of other nurses to implement horizontal violence or when they deny and minimize the violence of they have witnessed.

She used to plan our shifts month by month and if you misbehaved, or you wouldn’t do her a favour,…you’d notice from the shifts. (I6)

Part of our sample stated that they had been victims of hazing by nurses, UAPs and charge nurses, that they had to ‘pay the penance’ for being a recent graduate and the latest newcomer in the ward:

Usually the attitude of colleagues, especially among the senior ones, is ‘we’ve all been there’…as if to become a nurse you must be brutalized first, feeling afraid throughout the day at work because you can’t do things, and no-one shows you how to do it. That’s the key step to becoming a nurse, according to them. (I13)

The interviews showed that there was personal and professional frustration in those who engaged in violence, often due to excessive workload or insufficient recognition; a desire for approval and self-assertion, which finds space and vent in horizontal violence, especially when ‘the group’ becomes complicit for fear of retaliation, finding their strength with the support of the ‘gang’.

The weapons

‘Weapons’ represent the various ways horizontal violence is used by perpetrators against their victims.

Verbal aggression was the most widespread ‘weapon’ reported by the interviewees. Newly graduated nurses talked about the attempts to put them in difficulty during handovers, the use of impertinent tones when providing explanations, complaints made to others and not to them directly, non-constructive and pretentious criticism, with the sole intent to inflict harm. In particular, new graduate nurses reported threats by the charge nurse, including negative assessments, repercussions on shifts or non-compliance, removal and dismissal, and denigration. Other forms of verbal violence reported by new graduates included personal insults, jokes aimed at mocking their appearance, physical limitations and sexual orientation, the use of excessive and offending tones, and verbal assaults, often made in front of third parties and shouting.

Who do you think you are, you’ve been here for less than three months and you tell us how we should organize our work. You really have to shut up. (I11)

Part of the sample also defined violence as being ‘left to one’s devices’ by the tutor, who instead should have supported them, or by the charge nurse for the inadequate supervision of the newly enrolled nurses. ‘Unloading work on others’, especially by UAPs or nurses at change of shift, by not reordering the material used, giving orders, and not reporting the requested information, described as other forms of violence by the interviewees.

I still remember the first day: he [a ward nurse] said to me ‘look I don’t really care, you’re new, you’re a nurse, you’re on your own. It’s your business. You earn your salary just as I earn it, why do I have to do your job?’ (I11)

Of all the forms of violence, however, indifference in all its facets was often highlighted by new graduate nurses. Part of the sample reported that they had been avoided, excluded or ignored, without even saying a word or hello throughout the workday.

There was no smile, there was no ‘good morning’…He wouldn’t swear at us, but if he could hit a you in some other way, he’d do it. (I6)

Also not listening to the needs and requests of the new graduate nurses have been reported as a form of violence used by the team and the charge nurse.

I think there is something worse, which is indifference…I don’t know if I can call it bullying, but it’s still limiting your ideas, your work, your expression. (I14)

The effects

In the words of the interviewees, horizontal violence showed that it has an impact on the emotional, physical and social sphere of the new graduate nurses, resulting in less enthusiasm and motivation, stronger feelings of failure and personal defeat, which lead to voluntary resignations and increased shift turnover:

You get into that vortex that makes you wake up in the morning, you have to go to work and you don’t want to anymore. You start sweating, you start feeling sick, you don’t sleep at night. (I11)

I even gone as far as saying a whole bunch of things, such as: ‘why did I graduate in nursing? What a horrible job’. (I17)

An important consequence of horizontal violence highlighted by the interviewees was that it affected the quality of care. They reported that the risk of error increased due to the stress and anxiety with which the newly graduated nurses had to work and the lack of communication and support by colleagues and UAPs:

It occurred to a colleague of mine that she had a discussion after which she no longer communicated with her colleague. There was no proper handover and because of this incorrect communication a patient fell and got badly hurt. (I5)

For the fear of repercussion, mistakes are sometimes not reported and resolved, while some activities are omitted by newly graduated nurses so that they appear they are as quick as older colleagues; emotional commitment, necessary to deal with the phenomenon, compromised their ability to listen properly to patients. In addition, competition with newly graduated nurses, especially by a senior nurse, could have a direct impact on the patient:

They [senior nurses] tend to diminish the contribution of new graduates. Sometimes, they undo what you’ve already done, even at the expense of patients. (I13)

One form of humiliation particularly suffered by the interviewees was disqualification, in other words, being treated as students receiving excessive support and supervision, defined as ‘intrusive’

When she was on duty with one of the senior colleagues, she said he was asking her questions like ‘before you do this, reply to my question’, like when you’re on an internship. He had no authority to do so, he’s still your equal. (I2)

All this, accompanied by reproaches made in front of relatives, patients and physicians, was perceived as a denigration not only of one’s work, but as an element that fuels distrust, compromises care and proves to be an obstacle for the recognition of the nursing profession.

The armour

The interviewees described the strategies used to defend themselves from their colleagues’ attacks. Such strategies were mainly rooted in their resilience and in the support offered by the younger members of the team and, on the other hand, what they thought would be necessary to prevent horizontal violence.

Defence mechanisms

The strategies used by newly graduated nurses to defend and protect themselves were often not decisive but provided some psychological relief. Avoiding and escaping the enemy, until quitting the job in extreme cases, showing the ‘red signal’ while maintaining a non-confidential attitude or, on the contrary, defending themselves aggressively by claiming their rights and using as a weapon their theoretical preparation were the most common mechanisms reported by the interviewees: ‘We were trying to improve ourselves a little bit to earn their respect and esteem, and also for ourselves’.

For the fear of losing their jobs, our interviewees reported how they tolerated violence, to the point of humiliating themselves and deskilling their role, but above all their attempt to conform to the group’s behaviour to be accepted, and becoming violent towards newcomers.

By trying to minimize episodes with justifications and emphasizing the positive aspects, conceiving the phenomenon as generational, as well as internalizing or blaming, newly graduated nurses become unable to recognize these behaviours as horizontal violence.

Prevention

According to the interviewees, their first year of work experience was described as being the most difficult one. To counter horizontal violence, our findings showed that personalized training tailored to the individual needs of newly graduated nurses and in a timely fashion, with the support of a dedicated, motivated and specifically trained mentor, is essential for the safety of both the novice nurse and the patients. Nevertheless, most of our interviewees reported that as newcomers they had not received any kind of mentoring, or if they did, it was totally insufficient. The presence of positive nurse leaders, especially charge nurses, was also described as instrumental to prevent horizontal violence, because they are in the position to control the dynamics among the nurses working in the ward, and should be able to recognize and prevent horizontal violence:

I think it is something that can be prevented and managed; but it requires more control from above. (I17)

Those who decided to leave their jobs reported that they had done so after asking their line managers for help but in vain. Those who decided to stay did so only because they had no other choice. The lack of protection and the need for a psychological listening desk was felt especially by those working for nursing agencies:

Here I can ask for help to many people, I can speak to the charge nurse, to the head of department, and to the Nursing, Technical and Rehabilitation Service of the hospital. Instead, in the nursing agency, the director was the absolute lord and master, and there was no-one else I could speak to. (I6)

In addition to the need for a psychological listening desk, we found that also having an adequate knowledge of horizontal violence and how to deal with it was essential, and should be provided to nursing students during their undergraduate programme. All our interviewees, who were newly graduated nurses, reported having experienced negative behaviours, but not everyone identified it as horizontal violence, despite suffering from it.

Discussion

Through this study, we found that newly graduated nurses had very little knowledge about horizontal violence and of the various forms through which it can manifest itself. Despite everyone had directly or indirectly suffered and experienced horizontal violence, only few had perceived the seriousness of those negative behaviours to the point of defining it ‘horizontal violence’ and, similarly to the findings of Taylor RA and Taylor SS,¹¹ most of our interviewees were unable to define what they had experienced. According to our interviewees, horizontal violence is often considered by senior nurses as an obligatory rite of passage into the professional nurse’s role:^19,27 something that forms, that allows you to ‘cut your teeth’ and get prepared.¹³ Victims perceive this attitude as wrong, inadequate, but fail to define it, they passively suffer it but at the same time feel anger for their repressed rebellion, rejecting the concept of Tough Love,¹⁴ which indicates that such behaviour is judged necessary to prepare new graduates to earn their professional independence.²⁸ If the attitude is common and involves all newly graduated nurses, the victims feel relieved, and although they do not approve it, they accept it, waiting until it fades away, letting it take its course, until another newcomer takes their place.

Subtle forms of violence, such as gossip about private life or work done, are not recognized as such or as a violation of privacy, although they are far from the principles and values that characterize professional conduct.⁴ The interviewees reported that those nurses who use forms of violence do it to mask their professional insecurity and personal emptiness, which can be confirmed by the theory of the Oppressed Group Behaviour, considered a risk factor for horizontal violence.²⁹ Low self-esteem and feelings of helplessness, recalled by the narratives of new graduates, portray nurses as an oppressed group, as also reported by Ebrahimi.⁴ Therefore, frustration and repressed anger end up being redirected against the more fragile colleagues, such as new graduates, probably due to the lack of consolidated relationships within the team.⁶

With regard to the forms of violence found, our results confirmed the findings reported in the literature,^{3,4,7,8,9,11,12} where the most frequent forms of violence included speaking behind the back, verbal abuse, isolation and using silence.^9,28,30

Although ‘horizontal’ means violence against equals,³ interviewees included also charge nurses because they were considered an integral part of the nursing team. Horizontal violence gets out of control when leadership is inadequate, confirming the hypothesis of a correlation between the lack of leadership and bullying.¹⁷ The literature shows that high levels of psychosocial security within the organization, intended as an aptitude for listening to the needs of employees and solving the problem, can promote coping strategies, in particular complaints and prevention of horizontal violence, because the employee feels protected and confident that he can voice his concerns.^5,21,31 Several authors underline the fundamental role of the nursing manager in teaming and sharing goals and values.^32,33

Unlicensed assistive personnel (UAP), as a perpetrator of violence, has never been reported in the literature, highlighting this as an Italian peculiarity probably determined by a distorted conception of the collaboration between nurses and UAPs³⁴ and by their difficulty in clearly defining each other’s scope of practice. In addition, especially the more senior UAPs tend to not recognize in new graduates the authority that distinguishes the more experienced nurses or, perhaps, newly graduated nurses have difficulty relating themselves properly with UAPs, a situation which is often exacerbated by their clinical inexperience. In agreement with Ebrahimi,⁴ to avoid being picked on, novice nurses carry out the tasks of UAPs. Again, the manager of the nursing unit has a powerful role that influences the general attitude of the staff, determining what is the acceptable behaviour expected by all the staff working in that ward.²⁸

Although horizontal violence may appear like a ‘generational phenomenon’, in reality, even nurses having the same work experience, fellow new graduates, in order to defend themselves, take on the role of the ‘enemy’, cyclically exercising horizontal violence over time and in the same way. On the contrary, in the literature, those commonly reported to use violence are only the ‘senior’ nurses and charge nurses or ward managers,^{4,7,9,14,15,18,19}

One of the reasons that exacerbates hostility between novices is to be hired on a fixed-term basis: a temporary job involves a hostile and competitive attitude towards a newly hired colleague, to protect one’s own work position and not be ‘replaced’. This is an emerging problem in Italy, because temporary work has affected the nursing profession only in recent years, whereas before the availability of more employment opportunities did not give rise to this kind of competition. Prevention, through various strategies, is essential to avoid transforming new graduates into new perpetrators of horizontal violence.³⁵ Unlike other studies,^9,19 no physicians, patients or their families were reported to use violence, but only as witnesses of episodes of violence, especially verbal abuse.

The workload and organization of the department also plays an important role in generating conflict. In fact, we found that over-responsibility leads to lower professional satisfaction, as also shown by Laschinger et al.¹⁰ In fact, understaffing often involves having less patience with those who are learning and inevitably slower in performing tasks, perceiving it as an obstacle to their work. In particular, when expert nurses realize that a novice does not meet their expectations, they begin to exercise horizontal violence and no longer treat then as peers, but as students, a form of violence also reported by McKenna et al.¹²

New graduates have positive expectations towards the work environment and the people who will welcome them, based on their experience during the internship,⁹ and this confirms the lack of awareness of the phenomenon in the field of nursing. New graduates feel disappointed when they fail to meet senior nurses’ expectations and, at times, betrayed by those they consider ‘partners’.²⁸ If this kind of situation is not kept under control, the defence mechanisms put in place can, according to our interviewees, become detrimental for the person, the patient and also the profession. For example, the fear of being judged hinders the reporting of errors made, preventing detection and correction.²⁷ Many adapt to the situation to be accepted by others and absorb norms, values and ways of working dictated by the group that are not always acceptable and hinder the advancement of the profession.³¹ Some absorb norms, values and an attitude contrary to the ethical principles of the nursing profession.

As reported in the literature,¹⁷ horizontal violence involves so much physical and emotional suffering that it forces nurses to leave the job,¹⁴ in fact turnover is another significant and inevitable consequence of horizontal violence. Those who have the possibility to find another job, resolve the problem by leaving their job, but their untimely exit results in the entry of new inexperienced nurses, who in turn become targets of horizontal violence.

Through the present study, we found that the first year of work experience was the most difficult phase for newly graduated nurses, showing the importance of building trust with peers during that period.¹² Therefore, receiving appropriate support during the initial phase of integration into the new work environment was reported to be fundamental for the newly graduated nurses, in agreement with D’Ambra and Andrews,³⁶ but the majority of our interviewees did not receive this kind of support by specially trained mentors.¹⁹ Effective mentoring reduces anxiety and the fear of not being a good nurse, which are common feelings in those who have no experience. Mentoring probably does not totally prevent violence but can significantly mitigate the phenomenon and help novices adopt strategies to deal with the phenomenon.³⁷ Surely heavy workloads and understaffing do not facilitate prolonged periods of coaching, but if the consequence of the violence is excessive turnover and burnout, perhaps it is worth investing more resources in favouring the successful acclimation of new graduates. Horizontal violence will go unpunished as long as it is avoided¹² and left unreported. Confirming Stokowski’s⁶ hypothesis, any obstacle to action against horizontal violence is an accessory to its tacit acceptance.

Conclusion

In the nursing profession, horizontal violence has important consequences for all those involved: on patients, because it compromises the quality of care and active listening; on newly graduated nurses (i.e. the direct victims of horizontal violence), with repercussions on their physical, mental and social well-being; on healthcare organizations for the negative effects of high turnover rates and on the entire profession as it goes against the ethical principles of solidarity and respect among professionals set out in the Code of Conduct.⁴

New graduates are an important resource for the health system, a resource that must be supported and protected to reduce attrition and turnover. It is therefore instrumental to put in place strategies to reduce horizontal violence and its effects. To stem this phenomenon, its existence should already be explained to nursing students during the undergraduate programme to facilitate the prevention of workplace violence.^12,35 Prevention is also implemented through authentic leadership practices.^28,32 More attention must be given to the important role of mentorship,¹⁹ on providing protected and compulsory coaching in all facilities, informing new graduates about reporting tools and to whom they can refer to whenever horizontal violence occurs, with the proactive support of the top management of the hospital.^5,13 An attitude of ‘zero tolerance’^27,28 and codes of professional conduct that explicitly condemn unacceptable behaviour³⁰ are needed to reduce horizontal violence, and not only just against new graduates. Tackling horizontal violence against new graduates is a challenge for nursing managers to avoid losing new precious workforce and to succeed in annihilating a culture that ‘eats their young’.²⁸

Footnotes

Acknowledgements

We thank all participants for their contribution to this study.

Conflict of interest

The author(s) declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Ethical conduct of research

The study was conducted in accordance with the Declaration of Helsinki, and the protocol was approved by an Internal Professional Board of the University Hospital. Respect for privacy was guaranteed in accordance with the current legislation (Legislative Decree 196/2003 as amended by Legislative Decree 101/2018).

Funding

The author(s) received no financial support for the research, authorship and/or publication of this article.

ORCID iDs

Ivana Maria Rosi

Adriana Contiguglia

References

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