Horizontal Violence Among Direct Care Workers





In my last post, I suggested that there may be something about the Long Term Care work environment that makes conflict among caregivers almost inevitable. Some – or perhaps even most – of the behaviors associated with this conflict could be described as “horizontal violence.”

Horizontal violence is a form of hostile and aggressive behavior exhibited by individuals or groups toward others within the same peer group. It is usually not a physical kind of violence, but relies more on emotional and social pressure. It includes a wide range of negative behaviors, both overt and covert. Examples include such things as direct verbal abuse, belittling gestures, threats, intimidation, gossip, “humorous” put-downs, sarcastic comments, social exclusion, nitpicking, ignoring legitimate concerns, withholding support, and slurs based on race, ethnicity, religion, physical appearance, gender or sexual orientation. In a word: bullying.

The thing that makes horizontal violence “a thing” is not a big list of nasty behaviors. These can happen anywhere and for a lot of different reasons. Horizontal violence is a phenomenon that occurs within oppressed groups. That is, groups of people who do not feel as though they have the means to adequately address the most significant problems and issues associated with their group. Some respond to this sense of powerlessness by becoming submissive and exhibiting learned helplessness. Others respond by adopting feelings and attitudes of superiority over others within their group. In a sense, both are coping mechanisms, characterized by inappropriate and self-defeating behaviors.

If a sense of powerlessness is at the heart of what it means to be an oppressed group, than direct care workers certainly qualify. Overworked, underpaid, and unsupported, LTC caregivers generally do not believe that they have the means to independently create the kind of fundamental change that would address these issues in a meaningful way. You either accept “that’s just the way it is” and learn to do what you can with what you have – or you leave.

At the bottom of the LTC hierarchy, the caregiver brand of horizontal violence plays out in one of two ways. The first way is the classic division of Older Workers vs. Newer Workers. This divide is typical in nursing in general and most of the literature I’ve come across regarding horizontal violence has to do with career RNs, but it applies just as well to nursing assistants.

New workers enter the field with a set of expectations of what caregiving is all about and are soon disillusioned by the reality of what they witness on the units. If they are unable to adapt to “the way things really are,” the more experienced caregivers have ways of putting them in their place. Newer workers are regarded as both naïve and judgmental – and perhaps even threatening – because they base their impressions of experienced workers on unrealistic expectations.  They often become victims of horizontal violence, not fully comprehending why they are being mistreated.

The second situation is created by the absence of adequate and appropriate involvement of management in the typical LTC work environment. The formal rules and standards are enforced inconsistently, sometimes capriciously, depending more on personality and circumstance, such as inspections or any other time the facility is under public scrutiny. Good workers go unnoticed and poor workers go uncorrected.

By default, caregivers are left to fill the vacuum and develop their own norms and standards. These can be very different from facility to facility and even from unit to unit within the same facility. To one degree or another, they are informally enforced by the strongest personalities among the established caregivers.  In the best circumstances these norms and standards are communicated through example and positive leadership, but often they are enforced by various forms of horizontal violence.

Caregivers frustrated by their inability to formally address the larger problems of the Long Term Care workplace find an outlet by dominating their coworkers. Others simply acquiesce, doing their best to keep to themselves as they struggle to find a balance between the official standards, pressure from their workgroup, and their own sense of right and wrong.

In my next post, I will share my take on how we as caregivers should approach the problem of horizontal violence in the LTC workplace.

For more information on horizontal violence:




2 thoughts on “Horizontal Violence Among Direct Care Workers

  1. minstrel

    True, true, and true again. One reason that newer aides have a hard time adjusting to a workplace that includes many aides with ten or twenty or more years of experience, is that what is considered good care has changed. No longer is rushing through the ADLs what good care is all about; it’s about engaging with the resident, learning what makes him or her comfortable, secure-feeling, happy. This takes time and aides who for years have worked to get through the ADLs to get back to their TV shows or the socializing, don’t like working with newer aides who’ve been trained in a different way of care. Older aides do band together to ostracize anyone who tried to do things differently. And Management usually doesn’t have a clue, they are up to their ears in paperwork and avoiding the substandard care they know is being offered on their units.

    1. Yang Post author

      Yes, I remember working on some units where the “socializing” was almost required by the dominant clique. If you didn’t participate, not only were you considered antisocial, but also a kind of threat. And yes, management is usually buried in some kind of paperwork, one of the facility’s main bulwarks against external threats. Combine that focus with willful ignorance regarding what is really going on down the hallways and you have a recipe for serious disconnect.


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