For nurse managers and hospital nurses: lateral violence and patient safety

Violence without a formal superior

On a hospital ward, violence does not always follow the formal hierarchy. Nurses in similar roles may repeatedly withhold information from a colleague, ridicule her in front of patients, or humiliate her while working together. It is important to distinguish this pattern from a disagreement about how to perform a task: differences of opinion call for discussion, but do not in themselves amount to a persistent attack on a colleague. A review of 51 studies on factors associated with workplace bullying suggests that leadership and work organization may also matter, not just the relationship between two people. Because the review was dominated by observational studies, it cannot attribute any particular case to a single cause. For a nurse manager, the starting point is therefore to describe the behaviors and the conditions in which they recur.

Ostracism in everyday work

Ostracism can be subtle: someone is left out of a conversation or excluded from an exchange of information needed during a shift. A meta-analysis of 95 samples involving 26,767 people linked workplace exclusion with poorer functioning and well-being, but it cannot determine what any single instance of silence means. A brief answer given under time pressure or a one-off failure to include someone is not automatically evidence of deliberate exclusion. On the ward, both the recurring pattern and its effect on work matter. Failing to answer a question about a medication or an order carries different weight from a personal dispute. That is why it is important to record what information was requested, what happened, and whether the person was able to obtain it.

Why team learning suffers

If a nurse fears a particular colleague's reaction, she may stop asking that colleague for clarification, even if the colleague knows how things are done on the ward. It is worth checking whether requests for help with a task receive similar responses from everyone, or whether the response depends on belonging to an informal group. Psychological safety was associated with team learning in a field study of 51 teams at a manufacturing company. This offers a useful basis for asking questions about collaboration, but it is not a direct measure of the effects of violence among nurses. In a hospital, the specific path by which knowledge is shared therefore needs to be observed: who can ask, who responds, and whether the necessary explanation arrives in time. The possible impact on patient safety remains a hypothesis about the mechanism, not a finding of that study.

Signs that call for action

The decision to respond need not hinge on whether someone has a “difficult personality.” Dates and descriptions of words, actions, and their effects are more useful: who was left out when information was handed over, who was refused help, and in whose presence a mocking remark was made. A nurse manager can ask witnesses what they saw and whether they had an opportunity to respond, without suggesting an interpretation. The absence of a formal complaint does not prove there is no problem; staff may mention incidents in conversation or may not label them at all. At the same time, a single disagreement about how to work is not enough to establish bullying. What should draw attention is a recurring pattern of exclusion, refusal to help, or public ridicule.

How a manager should respond

A manager should stop overt mockery and make it clear that information important to care must be shared regardless of personal relationships. The next steps are a safe way to report incidents and an impartial examination of the facts that hears both sides. It is unhelpful to bundle everything together as a “conflict”: refusing help, withholding information during a shift handover, and mocking someone in public are separate incidents. For each, the manager needs to establish what happened, identify possible witnesses, and decide on the next step. Resolving a disagreement about a task is different from investigating repeated bullying. While looking into the situation, the nurse manager must also ensure that important clinical information can still flow and state the standard of cooperation expected of everyone.

Changing ward norms

Responding to an incident is not enough if the ward continues to tolerate selective help. At a team briefing, staff can agree on a simple rule: a question about patient safety must be answered, or the person asking must be directed to someone who can help. Helping one another should be an explicit part of the shift, not a favor dependent on personal affinity or length of service in the team. A new nurse needs particular attention: it is worth checking that she has the same access as others to the knowledge she needs for her work. The team should also know what to do when someone does not get an answer to a question needed for care. This rule governs what happens during a shift; it is not about deciding who likes whom.

How to measure improvement

Improvement cannot be judged by the number of complaints alone: silence may reflect positive change or fear of reporting. Anonymous questions can help establish whether nurses can get help and report exclusion. Documented managerial responses should also be compared before and after new rules are introduced: was the incident described, were the facts checked, and was a follow-up action agreed? Staff departures should be considered alongside information about behaviors, without attributing them to a single cause. The most immediate test in day-to-day work is whether a staff member gets the information she needs during the same shift, even when relationships in the team are strained.

Lateral violence does not require a formal difference in rank. On a ward, it may involve repeated ridicule, withholding information, or offering help selectively.

Empatyzer in conversations about violence among nurses

A nurse manager who hears repeated mocking during shift handovers can start by preparing a conversation with Em. With Em's help, she can draft questions for those involved about the specific words used, the circumstances, and the effects, as well as a brief statement reminding them of their duty to share important information. In team mode, Em can help her prepare a discussion about standards for working together among people in equivalent roles: how to answer questions and what to do when someone is left without help. The “About me” view lets the manager examine her own tendency to put off responding to exclusion. Micro-lessons can support practice in asking for help and stopping mockery in a matter-of-fact way. She can also rehearse with Em how to respond when someone dismisses the behavior as “a joke,” without assuming that person's intentions in advance. This is preparation for a conversation, not a substitute for establishing the facts, protecting those who report incidents, and ensuring that clinical information continues to flow.