Imagine for a moment that you have stepped back in time to your nursing school days. It’s your first day on a new clinical rotation on a medical-surgical unit. The primary nurse whom you will collaborate with on patient care meets you with sighs, snide remarks, and annoyed glances. Unsure of what to do to make things better between you and the staff nurse, you quietly continue to care for your patient’s needs, while you wonder why you selected this profession. This is characteristic of the phenomena termed vertical violence.
What is vertical violence?
Vertical violence is defined as any act of violence, such as yelling, snide comments, withholding pertinent information, and rude, ignoring, and humiliating behaviors, which occur between two or more persons on different levels of the hierarchical system and prohibits professional performance or satisfaction in the work environment.
This type of violence is permeating the nursing profession like an infectious epidemic. Student nurses are being subjected to this type of treatment, whether on a medical-surgical unit or in a community setting. I submit that continuation of these behaviors will leave a negative impact on nursing students, healthcare organizations, and nursing as a whole.
What’s the impact of vertical violence?
Vertical violence has several negative effects. First, let’s think about the impact of violent behaviors on the student nurse, while we place ourselves in the student’s position. Feelings of inadequacy and depression may surface after being victimized. These feelings lead the student to question his/her abilities and whether he/she can care for patients adequately. Hurt feelings can lead to tearfulness and the student may want to seek out a hiding place after such victimizations so no one knows how these actions affected them. Physical symptoms may manifest after the act, with the student possibly feeling fatigue, insomnia, and an array of other physical and emotional complaints. Last, students’ learning may be affected as dread appears every time they must enter the clinical agency for learning experiences, leading to withdrawal from the learning process.
Second, consider the impact on employers and healthcare in general. Recruitment and retention of the healthcare workforce is directly impacted by vertical violence. When students encounter vertical violence during their clinical rotations, they become very hesitant and then resistant to join that particular organization. They begin to question if they are treated in this way as a student, how could it be any better as a nurse in that organization? Even if they were to seek employment at a facility as a student nurse before graduation, they are unlikely to go to a facility where they have been subjected to violent acts. Another area of concern for employers is that students have close contacts within their student peer group. Word travels through nursing classes that certain organizations have clinical staff nurses who do not appreciate students; therefore, word of mouth injures the organizations’ chances of recruiting students for future nursing positions as well.
Last, as we consider vertical violence as an epidemic plaguing the nursing profession, the effects of this affliction can wound the profession. As seen, the victim’s experiences feelings of degradation and lowered self-esteem, which can lead to physical manifestations in student nurses. This means that a student may decide not to finish his/her academic goal to become a nurse, which leaves the profession with one less future nurse. However, should the student complete the degree and begin work as a new nurse, if violent behaviors continue, the nurse could go from one job to another seeking satisfaction. Certainly, the worst-case scenario would be if the nurse decides to leave the profession altogether. Not only does the profession have to worry about losing nurses, but for those students and new nurses who continue in the profession who have been victims of vertical violence, the concern is whether they have internalized these violent behaviors. Effects of vertical violence parallel the cycle of physical abuse with patterns of abusive behavior traveling from one generation to the next. Just as treatment for victims of physical abuse is concerned with breaking the cycle of violence, so should we as a profession be concerned with breaking the cycle of vertical violence. This is not a practice that we want to pass on to our "baby" nurses.
How can we halt vertical violence?
To halt the progression of this epidemic, the nursing profession and the healthcare system must initiate measures to identify, counsel, and altogether eliminate vertical violence. A zero tolerance policy should be adopted to prevent violent behaviors. Through organizational forums and unit staff meetings, vertical violence behaviors could be identified, producing staff awareness of this phenomenon. As recognition occurs with staff, this could invite open discussions on the issue. Hopefully, this would instill in nurses, as well as student nurses, a feeling of obligation to report such violent acts without being fearful of repercussions.
Nurse leaders should constantly be observing for violent acts and should initiate counseling of the perpetrator and the victim, because both may have self-esteem issues relating to the occurrence of violence. For the perpetrator, counseling should occur in a nonthreatening manner with a collaborative action plan developed to eliminate negative workplace behaviors. There are instances where the perpetrator of violence may be unaware that his/her actions are perceived adversely. Committing vertical violence may be a way for the nurse to display some type of power over a situation, which may have occurred as a result of low self-esteem on the part of the nurse responsible for the violent act. Counseling for the victim is necessary as well. Again, this needs to occur in a nonthreatening manner with acknowledgment of the violent behaviors and a plan established for a response to a possible future attack. The person who has been victimized must use assertive communication techniques to let the perpetrator know that further abuse will not be tolerated. This will assist the victim with a better sense of self and avoid incorporating violent techniques into his/her own practice. Further educational measures can aid both parties in moving past violence as a part of their value systems and working on measures to eliminate this behavior.
A training program to avoid violent behaviors in the profession and workplace could be initiated in nursing programs and healthcare organizations. Education on how to deal with negative behaviors while in school and during clinical rotations can promote positive outcomes for the nursing student who may have to deal with vertical violence. Nurse educators can act as an advocate and buffer for students during clinical experiences, by explaining the phenomenon of vertical violence and providing reassurance to students who encounter any such act. Furthermore, role modeling appropriate behaviors during any given encounter is a responsibility of educators. This provides students with positive validation for interactions with others.
Healthcare facilities can provide an additional benefit to students and nurses by offering an educational program on avoidance of violent behaviors during orientation sessions for new hires. In addition to the orientation sessions, organizations can make available similar programs once or twice a year with continuing education units. This will assist to remind staff of a zero tolerance policy and to continually avoid the practice of violent behaviors. Preceptor and/or mentoring programs can incorporate this training, assisting experienced nurses in the proper way to support nursing students and new nurses. Nurses in these organizations would reap the rewards of embracing colleagues, not tearing them down. Improved retention and recruitment would be the positive outcomes for organizations, but also for the profession of nursing as well.
The right impression
Refer back to the case exemplar at the beginning of this article. Is this really the impression that we want to leave on our prospective nursing workforce or would this have been the way we wanted to be treated? On both accounts, no! Eliminating vertical violence practices in nursing and promoting the development of our nursing students into the next generation of nurses will help bring our profession together.
Sherri Williams Cantey is faculty/student success coordinator at East Central Community College in Decatur, Mississippi.
Berry PA., Gillespie GL, Gates D, Schafer J. Novice nurse productivity following workplace bullying. J Nurs Scholarship. 2012;44(1):80-87.
Cantey S. Vertical violence: A concept analysis. Unpublished manuscript, The University of Southern Mississippi, Hattiesburg; 2008.
Cho SH, Lee JY, Mark BA, Yun SC. Turnover of new graduate nurses in their first job using survival analysis. J Nurs Scholarship. 2012;44(1):63-70.
Ferns T, Meerabeau L.Verbal abuse experienced by nursing students. J Adv Nurs. 2008;61(4):436-444.
Hurley JE. Nurse-to-nurse horizontal violence: recognizing it and preventing it. NSNA Imprint 2006;53(4):68-71.
Longo J, Sherman RO. (2007). Leveling horizontal violence. Nurs Manage 2007;38(3):34-37, 50-51.
Lower J. Creating a culture of civility in the workplace. American Nurse Today. 2007;2(9):49-50, 52.
Farrell G.A (2001). From tall poppies to squashed weeds: Why don’t nurses pull together more? J Adv Nurs. 2001;35(1):26-33.
Jackson D, Clare J, Mannix J. Who would want to be a nurse? Violence in the workplace—a factor in recruitment and retention. J Nurs Manage;2002:10:13-20.
McKenna BG, Smith NA, Poole SJ, Coverdale JH. (2003). Horizontal violence: Experiences of registered nurses in their first year of practice. J Adv Nurs. 2003;42(1):90-96.