Over the course of the last few years, we’ve been privy to a series of scandals where doctors abuse their authority and take advantage of nurses. Fortunately, with the proliferation of the #MeToo movement, these cases of power abuse rarely go undiscovered and the perpetrators are usually punished appropriately. However, with the intense focus on vertical violence (doctors abusing nurses), we’ve inadvertently left out an important source of workplace discomfort: lateral violence.

If vertical violence is when a doctor abuses or overexerts their authority on those in lesser positions, lateral (or horizontal) violence is when a nurse directs their discontent towards their fellow nurses. Specifically, experts define lateral violence as when “nurses covertly or overtly directing their dissatisfaction inward toward each other, towards themselves, and toward those less powerful than themselves.” In other words, nurses abusing nurses.

Shockingly, while cases of vertical abuse have been the most scandalous in the past few years, they are far from being the most common in a healthcare setting. It is estimated that lateral violence encompasses around 46 to 100 percent of abuse cases in many hospitals, which means that, potentially, the people abusing their authority and bullying nurses are, in some cases, the nurses themselves. However, in an environment where equality and proper behavior is being promoted so fiercely nowadays, how can the abuse be performed by those that these measures are meant to protect, specifically?

There are many theories that try to understand this, most of which are related to the antiquated hierarchy system that most hospitals functioned with in the past. Specifically, the system that put doctors in positions of power and on top of every other staff member, while nurses were always in the bottom—the metaphorical worker bees of the hospitals. These years of abuse and mistreatment have ingrained lateral violence into the psyche of the standard nurse and, when they gain the slightest bit of authority, they perpetuate the trend by mistreating their charges. In the heart of the matter, there is an overbearing sense of helplessness and fear, which drives the nurses to mistreat their peers, says Cynda Rushton, PhD, RN, FAAN, Anne and George L. Bunting Professor of Clinical Ethics at the Johns Hopkins School of Nursing.

This theory is so popular that it spawned the term “ethical relativism,” which states that the morality of an act is determined by the culture in which it is performed. In other words, nurse power abuse towards other nurses has become a staple of nursing culture and is regarded as a kind of “rite of passage” that other nurses must endure before being considered a “part of the group.” The exact connotations vary from group to group, but the basic principle remains: new graduates, who are most vulnerable to bullying are abused until they become veterans, only for them to abuse the new arrivals when the acquire a standing within the hospital.

Regardless of the origins of lateral violence, these acts have a very significant effect on the staff of any given hospital, leading to higher absenteeism, stress, a desire to abandon the profession, reduced work satisfaction, and a 17.2 percent turnover increase by 2015. These consequences, in turn, cause ripples in the entire national healthcare system by increasing costs. Specifically, every nurse quitting their jobs costs a hospital around $37,700 to $58,400.

Financial issues aside, the emotional repercussions that this abuse breeds can significantly limit the potential of the new personnel, even if they decide to remain working in the hospital. Instead of working in a place that fosters adequate service, employee satisfaction, and proactivity, the nurses are limited by the fear of being bullied or abused, especially for new graduates who may experience real or perceived constraints on how they should respond to the said abuse. Consequently, those who can’t endure the abuse simply quit, while those who remain work at very limited capacity, and are more liable to take days off, as well as result in a higher risk for workplace accidents, endangering the lives of the patients and themselves.

Keep in mind that not all acts of abuse necessarily imply physical or verbal abuse; some of these acts can be as simple as a rude gesture. For instance, Ellie Falletta, RN, a contributing author for Johns Hopkins Nursing, wrote the following: “In my clinical rotations, I have observed and personally experienced violence between nurses. Sometimes it was an eye roll when a question was asked, an incomplete patient handoff, or gossiping about a coworker. As harmless as that may sound, it is the small actions and inactions between coworkers that shake the moral integrity of a workplace.”

Nurses must not only be knowledgeable in the field of healthcare, but they must also study and embrace the code of ethics issued by the ANA. By practicing the guidelines written within this code, nurses can effectively contribute to creating a healthier workplace where everyone can learn, grow, and thrive, and unleash the full potential of every staff.