Iranian Nurses’ Perceptions of the Consequences of Horizontal Violence for Nurses: A Qualitative Content Analysis Study

Abstract

Background:

Horizontal Violence (HV) in healthcare settings is any type of violence among healthcare providers. It has many different negative consequences for nurses. This study aimed at exploring Iranian nurses’ perceptions of the consequences of HV for nurses.

Materials and Methods:

This qualitative content analysis study was conducted in 2022–2023 on twelve nurses purposively selected from five hospitals affiliated with Hamadan University of Medical Sciences in the west of Iran. In-depth semi-structured interviews were conducted for data collection. The main interview question was, “Have you ever experienced HV in your relationships with your colleagues?” Graneheim and Lundman’s conventional qualitative content analysis was used for data analysis.

Results:

Iranian nurses’ perceptions of the consequences of HV for nurses fell into three main categories, namely erosive tension (with four categories), professional repulsion (with two categories), and low-quality patient care (with two categories). The subcategories of these categories were, respectively, psychoemotional tension, mental tension, physical tension, social tension, low organizational belongingness, low professional interest, hesitation in performing care measures, and endangered patient safety.

Conclusions:

The main consequences of HV for nurses are erosive tension, professional repulsion, and low-quality patient care. Nurse leaders can prevent HV by providing strong support and quality education to nurses. Interventional studies are recommended to determine the most effective methods to reduce HV in nurses’ workplace.

Introduction

Horizontal Violence (HV) is a significant problem in various professions,[1] including nursing.[2] HV, also known as lateral violence or bullying,[3] is defined as “hostile, aggressive, and harmful behavior by a nurse or group of nurses toward a coworker or group of nurses via attitudes, actions, words, and/or other behaviors.”[4] HV is a type of non-physical conflict expressed through manifest and latent hostile behaviors.[5] The different types of HV are nonverbal sarcasm, verbal insults, weakening behaviors, sabotage, sacrificing, backstabbing, non-secrecy, humiliation or criticism in front of others, postponing others’ career advancement, and isolation.[6] The prevalence of HV varies in different countries.[7] A review study reported that HV has turned into a cultural norm in nursing and 65%–80% of nurses have experienced or witnessed it.[8] Another study in Saudi Arabia also noted that 94% of nurses had witnessed at least one violent behavior during their work.[9] A study on Iranian nurses also found that 34.9% of them experienced at least one case of violence per month.[10] Although HV is highly prevalent in nursing, the American Occupational Safety and Health Administration highlights that the organizational process of reporting HV is inappropriate, victims have a fear of revenge, and HV is usually underestimated and underreported.[11]

HV in nursing is a multifactorial phenomenon. A strict hierarchical system in nursing may lead to inequity and HV among nurses. Nurses also have heavy workload and low professional status, which may lead to negative emotions and may be manifested in HV during the process of emotion release.[12] Moreover, most nurses are women, and women are usually more emotional and sensitive and may show extreme reactions even to minor events, which in turn may lead to interpersonal conflicts.[7] Contextual factors such as organizational policies[11] and organizational culture can also lead to HV, while they usually remain hidden due to hierarchical structures in healthcare organizations.[13] Cultural factors may also contribute to HV.[14,15] A study reported that HV in heterogeneous cultures is significantly more prevalent than in homogeneous cultures.[15] The most prevalent contributing factors to HV include hierarchical organizational culture, ineffective management, and personal insecurity.[16] Complex interpersonal relationships as well as the need for creating a balance between different professional responsibilities and public accountability and between difficult work conditions and quality care provision cause great stress for nurses and contribute to HV.[5]

HV in nursing has different consequences which annually affect 85% of nurses.[17] A study on new graduate nurses showed that HV had destructive consequences, including high job turnover, financial problems, and negative effects on physical and mental health.[16] Moreover, it can cause nurses serious mental health problems, particularly anxiety, depression, and posttraumatic stress disorder.[18] A study reported that 87.4% of nurses were at risk for HV which caused physical and mental symptoms in 75% of cases and posttraumatic stress disorder in 10% of cases, and highlighted that it may eventually require them to quit their profession.[19] Two studies found that the most prevalent consequences of HV included fear of revenge and mockery, disappointment, job dissatisfaction,[9] discomfort, impaired concentration and judgment, reduced collaboration, and endangered patient care.[5] HV can also increase the number of absences from work and the risk of job turnover.[19] Job turnover in turn exacerbates staff shortage, which increases workload and irritability, reduces job satisfaction, and provokes HV among the remaining nurses.[20] HV in nursing also affects the workplace environment, causes insecurity among nurses, and leads to serious physical and mental consequences. Unmanaged HV can negatively affect nurses at all personal, professional, and organizational levels.[21] Despite the long history of studying HV in nursing, many aspects of it, including its consequences, still need further investigation.[22] Moreover, most studies in this area were conducted using quantitative studies, while qualitative studies are most useful and appropriate for studying HV, its contributing factors, and its consequences.[19,23,24] Besides, there is limited information about the consequences of HV for Iranian nurses. The present study was designed and carried out to narrow these gaps. This study aimed at exploring Iranian nurses’ perceptions of the consequences of HV for nurses.

Materials and Methods

This qualitative content analysis study was carried out in 2022–2023 to explore Iranian nurses’ perceptions of the consequences of HV. Participants were twelve nurses purposively selected from five hospitals affiliated with Hamadan University of Medical Sciences, Hamadan, Iran. Selection criteria were a clinical work experience of at least one year, working in a hospital ward, and an agreement to participate in the study.

The corresponding author collected the data through semi-structured face-to-face interviews held in a private room in participants’ workplace and after their working shifts. She commenced the interviews using general questions like, “May you please explain about one of your working shifts?”, “Have you ever experienced HV in your relationships with your colleagues?”, and “What were the effects of HV on your personal and professional lives?” Then, interviews were continued using probing questions such as, “May you please explain more?” and “May you provide a clear example about this?” Finally, participants were asked whether they wanted to add any more points. Interviews lasted 45–60 minutes, were continued until data saturation, and were recorded using a smart phone.

The interview data were analyzed using Graneheim and Lundman’s[25] conventional qualitative content analysis. The five steps of this method are transcription of each interview immediately after conducting it, perusing the interview transcript to obtain a general understanding of its content, determining its meaning units and coding them, categorizing the codes according to their similarities, and determining the latent content of the data.[26] Immediately after conducting each interview, we transcribed it word by word and perused the transcript. Then, we determined and coded its meaning units. The codes were frequently revised, combined, and categorized according to their similarities. Categories were also categorized into larger categories.

Credibility was ensured through member checking and concurrent data collection and analysis, and dependability was ensured through immediate transcription of the interviews, member checking, and peer checking. Moreover, confirmability was ensured via peer checking and documenting all steps of data collection and analysis, and transferability was ensured via providing direct quotations from the interviews.

Ethical considerations

This study has the approval of the Ethics Committee of the University of Social Welfare and Rehabilitation Sciences, Tehran, Iran (code: IR.USWR.REC.1400.240). Participants were ensured of data confidentiality, deletion of the interview audio files after reporting the findings, their access to the study findings, and their freedom to voluntarily withdraw from the study. Verbal and written consent was obtained from all participants.

Results

Participants were twelve nurses with an age range of 20–55 years and a mean (SD) work experience of participants was 18.66 (5.83) years. Most of them were female (n = 9) and married (n = 7) [Table 1].

Table 1.

Participants’ characteristics

Age (Years)	Gender	Work experience (Years)	Educational level	Ward	Marital status
32	Male	4	Bachelor’s	Intensive care	Married
46	Female	20	Bachelor’s	Internal medicine and intensive care	Single
30	Female	9	Bachelor’s	Internal medicine and intensive care	Single
28	Male	5	Bachelor’s	Emergency	Married
26	Female	2	Bachelor’s	Internal medicine	Single
50	Female	27	Bachelor’s	Emergency and transplantation	Married
40	Female	16	Bachelor’s	Intensive care	Single
50	Female	24	Bachelor’s	Emergency and transplantation	Married
40	Female	15	Master’s	Intensive care	Single
32	Female	10	Master’s	VIP	Married
32	Female	11	Bachelor’s	Security	Married
33	Male	10	Bachelor’s	Security	Married

Participants’ perceptions of the consequences of HV fell into eight subcategories and three main categories. The main categories were erosive tension, professional repulsion, and low-quality patient care [Table 2].

Table 2.

The consequences of horizontal violence for nurses

Categories	Subcategories
Erosive tension	Psychoemotional tension
	Physical tension
	Social tension
Professional repulsion	Low organizational belongingness
	Low professional interest
Low-quality patient care	Hesitation in performing care measures
	Endangered patient safety

Erosive tension

This category refers to the different tensions that occurred due to HV. Its subcategories are psychoemotional tension, mental tension, physical tension, and social tension.

Psychoemotional tension

Nurses who suffer HV often experience emotional and mental health problems. Emotional problems may include feelings of silence, isolation, anger, irritability, low self-esteem, self-doubt, failure, crying, and discomfort due to unmet expectations. Mental health problems also include stress, depression, posttraumatic stress disorder, job burnout, personality problems, and loss of control. “One of our colleagues is not very proactive. When our workload is heavy, I have no option but to take on some of her responsibilities. This causes me feelings of anxiety, frustration, and irritability.” (P. 10).

In this regard, another participant stated, “People here is preoccupied with his/her own advancement and any comment on their practice may lead to their snitch on me. Therefore, I feel compelled to stay silent. Sometimes, I cry because of entering this profession and because I can’t defend myself. I have no more option but to tolerate these conditions and avoid conflicts.” (P. 4).

Physical tension

Participants reported that HV causes physical problems for nurses. They highlighted that HV alters their immune responses, reduces their resistance to infections, and causes them physical problems such as weight loss or gain, hypertension, irritable bowel syndrome, migraine and tension headaches, and sleep problem. “I experienced hypertension and palpitation due to the continuous aggressive behaviors of my colleagues who had the support of my manager as well.” (P. 17).

Social tension

Participants reported that HV negatively affects their relationships with their spouses, children, and friends, their trust in their colleagues, their help-seeking behaviors, and their perceived and received social support. “These hostilities cause distrust in all people which is in turn associated with social isolation. It is not a very good feeling.” (P. 4).

Professional repulsion

Another main category of the consequences of HV is professional repulsion, which refers to reduced organizational attachment and reduced professional interest. The two subcategories of this category are low organizational belongingness and low professional interest.

Low organizational belongingness

One of the symptoms of professional repulsion is low organizational belongingness characterized by resignation, job quitting, intention to change the workplace, intention to migrate to another country, and low job satisfaction. Participants reported that frequent exposures to HV reduced their organizational belongingness and led to organizational indifference. “Sometimes, I feel conflicts with colleagues. There is a constant sense of jealousy because I have a master’s degree in nursing management. According to my educational level, I think I deserve a better position. I frequently think about migration.” (P. 15).

Low professional interest

Low professional interest is another symptom of professional repulsion. Frequent HV may gradually lead to disinterest in work, indifference, intention to take sick leaves, and absence from work. “Sometimes, these discriminations between colleagues who have no difference with each other respecting experience and expertise cause me to have no sense of belongingness to the ward and no interest in doing my shifts.” (P. 3).

Low quality patient care

HV may also lead to a dangerous consequence, that is, hesitation or disinterest in providing quality patient care which in turn endangers patient safety. The two subcategories of this category are hesitation in performing care measures and endangered patient safety.

Hesitation in performing care measures

According to the participants, HV may lead to unhealthy competition for care provision and hesitation in performing care measures and reporting patient data to colleagues. “At the time of shift handover, I noticed that the staff of the evening shift had not performed some of her tasks. I asked her to complete her tasks before leaving the ward. She frankly answered that she couldn’t do those heavy tasks and then threw the Kardex and left the ward.” (P. 8).

Endangered patient safety

HV can negatively affect patient safety both directly and indirectly. According to the participants, indifference to colleagues who need help, particularly novice colleagues, non-adherence to the principles of safe shift handover, avoidance of seeking help from colleagues, unawareness of patients’ problems, concealing patients’ data, and avoidance from reporting patients’ data or nursing errors can endanger patient safety. “I feel extremely bad when colleagues do not report their errors. I also have fear over reporting their errors because it leads to a latent animosity. I feel sharp pangs of conscience and cannot forgive myself when I cannot report colleagues’ errors.” (P. 11).

Discussion

This study explored Iranian nurses’ perceptions of the consequences of HV. These consequences fell into three main categories, namely erosive tension, professional repulsion, and low quality patient care.

Study findings revealed that HV can cause different emotional problems for nurses, including mandatory silence, indifference, crying, aversion, anger, reduced self-esteem, and lack of motivation. They may also experience mental problems such as stress, depression, posttraumatic stress disorder, and job burnout due to HV. Previous studies also reported that most nurses experience different emotional and psychological problems due to HV. For example, a study showed that verbal violence among nurses was associated with low morale, job dissatisfaction, reduced sense of calmness and well-being in the workplace, interpersonal distrust, low self-confidence, and low support for each other.[27] Another study found that the victims of HV may experience low self-esteem, anxiety, depression, and sleep disorders.[4] Moreover, a study reported that HV negatively affected nurses’ mental health. Some participants of that study reported that their fear in the workplace caused them problems such as insomnia, anxiety, fatigue, and isolation.[28] The victims of HV usually have low mental health and experience problems such as anxiety, depression, and stress.[29] Depending on the severity of HV, the consequences of HV may vary in severity from mild (such as low stress or discomfort) to severe (such as anxiety, depression, and suicidal thoughts).[17] A study reported that from 87.4% of the nurses who were exposed to HV, 75% experienced physical and mental problems and 10% showed the symptoms of posttraumatic stress disorder.[30] Other studies also showed that nurses who experienced HV reported panic, depression, hypertension, anxiety, and low self-confidence.[31,32]

Physical tension was another subcategory of the erosive tension main category. Participants reported that they experienced different physical problems such as chronic headaches, gastrointestinal and cardiovascular problems, and sleep disorders. HV usually does not directly affect its victims; rather, it indirectly causes them high levels of stress and thereby, causes them stress-related injuries and disorders. Frequent exposure to stressors alters immune function and increases the risk of cardiovascular disease, hypertension, and sleep disorders.[33] The victims of HV experience a wide range of physical, mental, emotional, and social problems, including irritable bowel syndrome, migraine, hypertension, allergy and asthma, arthritis, fibromyalgia, poor concentration, amnesia, sleep disorders, fatigue, anxiety, nightmares, and obsessive thoughts about the agent of violence.[27]

Participants also reported social tension due to HV. They highlighted that HV negatively affected their relationships with their children, spouses, and colleagues, caused them social isolation, required them not to ask for help from colleagues, reduced their emotional support, and altered their personal life. Two studies showed that nurses’ HV in the workplace could contribute to their misconduct toward their children,[34] destroyed their interpersonal relationships, reduced their job satisfaction, and led to patient dissatisfaction.[35]

The second main category of the study was professional repulsion. Participants reported that HV reduced their organizational belongingness and professional interest, increased their intention to leave their profession or change their workplace, and increased their absences from work. A study showed that frequent exposure to HV dampens nurses’ enthusiasm for nursing.[36] Several studies also showed that HV was associated with nurses’ intention to quit their job.[22,37] Besides, some studies reported that nurses with the experience of HV had more absences from work, thought about quitting their profession, and quitted it, and these in turn aggravated the nursing staff shortage.[19]

Our findings also indicated that HV reduces the quality of patient care, causes nurses to hesitate about performing care measures, and thereby, endangers patient safety. HV may require nurses to hide their errors due to their fear over their colleagues’ negative reactions, and this can endanger patient safety and cause stress for nurses.[28] HV affects patient safety directly as well as indirectly through the mediating role of organizational communication satisfaction and organizational silence.[36] HV significantly contributes to adverse events in nursing, reduces the quality of nursing services, increases the risk of clinical errors, and thereby, endangers patient safety.[29] The episodes of HV cause discomfort for nurses, alter their concentration and judgment, and endanger patient safety by altering nurses’ interpersonal communication and collaboration.[5] The Joint Commission[38] considers poor relationships as a major contributing factor to the near misses that endanger patient safety and highlights that HV may require nurses to conceal essential patient care-related data, weaken the position of the victims, and impose high costs on patients, families, and organizations. A study also reported that HV undermined the quality of care and active listening, negatively affected nurses’ physical, mental, and social health, increased job turnover rate, and violated the ethical principle of interpersonal respect.[31] As a long-lasting problem, HV alters nurses’ interpersonal relationships, damages the reputation and credibility of the nursing profession, and causes problems in nursing management.[5] It also causes a sense of humiliation, aggression, disability, and frustration in the workplace, undermines the effectiveness of nurse’ innovations, creates a continuous cycle of suffering and revenge, causes interpersonal conflicts, and thereby, negatively affects teamwork, patient safety, and care quality.[27]

Some participants took into account some organizational considerations when sharing their experiences. We attempted to reduce the effects of such considerations by considering a safe and calm environment for the interviews and ensuring participants of data confidentiality.

Conclusion

This study shows that HV has many different negative effects on nurses’ physical, mental, emotional, and social health and can reduce their professional interest and the quality of patient care. Therefore, healthcare organizations need to employ strategies to prevent and manage interpersonal conflicts and HV among nurses and to improve nurses’ workplace environment. Examples of these strategies are implementing educational programs on appropriate professional conduct, nursing ethics, conflict management, and systematic procedures for reporting and managing HV, developing regulations for nurses who commit HV, and providing psychological, medical, and social counseling services to nurses who experience HV. Integration of HV and its prevention and management into the nursing curriculum may also be effective in improving nurses’ HV-related knowledge and reducing the prevalence of HV in nursing.

Conflict of interest

Nothing to declare.

Funding Statement

The University of Social Welfare and Rehabilitation Sciences supported this study