A nurse eleven weeks into her first job checks a potassium result she does not like. She wants to ask the charge nurse whether to hold the morning dose or call the physician first. She has watched the charge nurse answer three questions today. The first got an answer. The second got an answer and a sigh. The third got "did you look it up?" said loudly enough for the unit clerk to hear.
She decides to look it up. She spends nine minutes on a policy document that does not quite address her situation, gives the dose, and it is fine. Nothing happened. No incident report, no harm, nothing to review. What happened is that the unit taught a new nurse that asking has a price, and she learned it in under three weeks.
That is the whole mechanism. Nursing has a phrase for this, and the phrase is itself part of the problem, because it makes a safety failure sound like a quirk of the profession. What follows is where it came from, why the behaviour is more organised than it looks, what it costs in errors rather than in feelings, and what actually works.
It entered the literature in 1986, when Judith Meissner published "Nurses: Are we eating our young?" in Nursing. She was not coining a joke. She was naming a pattern experienced nurses recognised immediately, which is why the phrase spread and why forty years later it is still the first thing a student hears about the culture they are joining.
The trouble is what the phrase does to the problem. "Eating their young" sounds like weather. It is something nursing does, the way a species behaves, and you either survive it or you do not. Framed that way, there is nobody to hold responsible and nothing to change. Framed accurately, it is a set of specific behaviours, performed by identifiable people, in an organisation that has a legal obligation to address them.
The framing test. If a behaviour is described as "just how this unit is", ask who would have to do something differently tomorrow for it to stop. If that question has an answer, it is not culture. It is conduct.
The most useful account of why this happens came a few years before the phrase did. In 1983 Susan Jo Roberts applied oppressed group behaviour theory, drawn from Paulo Freire's work on colonised populations, to nursing. The argument runs like this.
A group with low control over its own working conditions, whose expertise is real but whose authority is granted by others, cannot direct its frustration upward without cost. Challenging the people who set staffing, budgets and schedules carries a risk that most individuals cannot absorb. The aggression does not disappear. It moves sideways, onto the members of the group who are least able to retaliate, which in nursing means students, new graduates, agency staff and anyone visibly out of their depth.
This is why the behaviour is called lateral violence or horizontal violence rather than bullying. Bullying suggests a personality. Lateral violence names a direction, and the direction is the finding. It also explains something that puzzles people arriving from other industries: the nurses doing it are frequently the ones who were treated worst themselves, and frequently, in every other respect, excellent clinicians. Two things follow. Hunting for bad people will not fix it, and because the pattern is predictable, it can be designed against.
When incivility is discussed, people picture shouting. Shouting is the rarest form and the easiest to deal with, because it is witnessed and undeniable. The forms that do the damage are the ones that can be denied afterwards.
Martha Griffin's 2004 study of newly licensed nurses, building on earlier work by Duffy, set out the behaviours new nurses actually reported. They are worth listing in full, because the list is the first time most nurses see their own experience described in words that are not "I am probably being oversensitive":
Non-verbal innuendo, such as raised eyebrows or face-making. Verbal affront, whether snide remarks or abrupt answers. Undermining activities, such as turning away or being repeatedly unavailable. Withholding information a colleague needs. Sabotage. Infighting. Scapegoating. Backstabbing. Failure to respect privacy. Broken confidences.
Every behaviour at that end has an innocent explanation available on demand. She was busy. She did not see you. You misread her face. Raised individually, any of it makes the person raising it sound aggrieved, which is why she stops, and why unit leaders can honestly believe their unit does not have a problem.
Here is the part that changes how seriously an organisation treats this. Incivility is usually argued as a wellbeing issue, and it is one. It is also a patient safety issue, and the mechanism is short enough to fit in a sentence: a clinician who has learned that asking carries a social cost asks less, and clinical questions are how errors get caught before they reach a patient.
The second cost is first-year turnover, the expensive kind. Marlene Kramer named reality shock in 1974 and Judith Duchscher later mapped transition shock: a new nurse arrives with an idea of the work that collides with the unit as it actually runs. A supportive unit gets her through the collision. A hostile one converts it into a resignation, and the organisation pays to replace her with someone who arrives into the same conditions.
Worth saying out loud in an interview. "How does this unit handle it when a new nurse asks the same question twice?" The answer, and the speed of the answer, tells you more than any recruitment page will.
For most of the history of this conversation, incivility was managed as a matter of individual temperament. That changed formally in July 2008, when The Joint Commission issued Sentinel Event Alert 40, "Behaviors that undermine a culture of safety". The alert stated that intimidating and disruptive behaviours foster medical errors, contribute to poor patient satisfaction and preventable adverse outcomes, and drive qualified clinicians away.
What followed mattered more than the alert. Accredited organisations were required, under leadership standard LD.03.01.01, to define acceptable and unacceptable behaviour in a code of conduct and to have a process for managing behaviour that undermines a culture of safety. That converted the problem from something a nurse endures into something an organisation is accountable for having a system to address.
The American Nurses Association went further in 2015 with its position statement on incivility, bullying and workplace violence, grounded in the Code of Ethics. Its position is uncomfortable and clear: nurses have an ethical obligation to create a culture of respect, and that obligation is not restricted to managers. It applies to the nurse watching it happen at the other end of the station.
The intervention with the best-established track record in nursing education is cognitive rehearsal, which is what Griffin tested in 2004. It works on a simple observation: in the moment, a nurse subjected to a snide remark or an eye-roll almost never produces a useful response, because the moment is charged and the response has to be invented under pressure. So the response is written in advance and practised.
The scripts are unremarkable, which is the point. To non-verbal innuendo: "I sense from your facial expression that there may be something you wanted to say to me. It is okay to speak directly to me." To withheld information: "I would appreciate it if you shared that with me. I need to know so I can look after the patient properly." To a public reprimand: "I would like to talk about this somewhere private."
Read cold, these sound stilted. Delivered by someone who has rehearsed them, they do two things at once. They name the behaviour without accusing anyone, which makes the exchange difficult to escalate. And they remove deniability, because once a behaviour has been described out loud it cannot be maintained as an accident.
Cognitive rehearsal is taught, not read. It needs practice with a colleague, out loud, until the words arrive without being assembled. That is exactly what a facilitated session does well and a handout does badly, which is why we build it into our New Graduate Transition to Practice course rather than listing it as reading.
Why it has to be practised. Under pressure people do not perform their intentions, they perform their habits. A script you have said out loud ten times is a habit. A script you have read once is a good intention.
Most advice on this subject fails by giving the same instruction to everybody. The useful version separates what is genuinely in each person's hands.
A new nurse controls two things. Whether she has rehearsed responses before she needs them, and whether she writes down what happened, when, and who saw it. Documentation is not about building a case. It is about converting a series of deniable moments into a pattern, because a pattern is the only form of this a manager can act on.
A colleague who witnesses it controls the most important variable of all. Lateral violence depends on the silence of everybody who is not involved. A single person saying "that was a fair question" in the moment does more than any policy, because it removes the audience effect the behaviour relies on. This is the ANA's point about an obligation that is not limited to managers, and it is the cheapest intervention available.
A charge nurse controls the response time. Behaviour addressed the same shift is a correction. Behaviour addressed at an appraisal three months later is a grievance, and everyone involved will remember it as unfair.
A manager or educator controls whether the unit has a script: not a values poster, but a code of conduct naming behaviours specifically enough to be recognised, and a reporting route that does not require the newest nurse to also be the bravest.
None of this makes a difference on a unit that is chronically short-staffed, and it would be dishonest to imply otherwise. Pressure is what turns an ordinary irritable colleague into a hostile one. The same honest limit applies here as with fatigue: individual skills raise the floor, and only staffing raises the ceiling.
Not quite, and the distinction is useful. Bullying describes a power relationship and often a repeated campaign by one person. Lateral violence describes a direction of travel: aggression moving across a peer group rather than up the hierarchy. A unit can have a great deal of lateral violence and no identifiable bully, which is exactly why looking for one person to remove usually fails.
They very often are, and that is the reason it goes unaddressed for years. Clinical excellence and behaviour that undermines safety are separate assessments. Sentinel Event Alert 40 exists because the second one has patient consequences regardless of how strong the first one is.
This is a reasonable fear and it deserves a straight answer rather than reassurance. A rehearsed, non-accusing response delivered once is low risk, because it is difficult to escalate against and difficult to characterise as insubordination. Repeatedly confronting a senior colleague without support is a different proposition. Rehearse the first, and for anything beyond it, document and take it to someone with authority rather than carrying it alone.
For the individual, usually. Once you stop being visibly new, the behaviour tends to move on to the next person who is. That is the trap in the phrase itself. Surviving it feels like a rite of passage, and a rite of passage is something people go on to defend rather than dismantle.
Ask the newest three nurses separately, and ask about specific behaviours rather than about culture. "Has anyone withheld information you needed?" gets an answer. "Do you feel supported?" gets a yes from someone who has correctly worked out what it costs to say no.
Cognitive rehearsal is a skill, and skills are built by practising them with someone watching, not by reading about them. Our live sessions run with a nurse educator and a small group, which is the setting this particular skill needs.
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This material is published by Wahero Health Institute for professional education. It describes workplace behaviour and the standards that govern it, and it is not legal advice, an employment policy, or a substitute for your organisation's own reporting procedures. Follow your facility's code of conduct and human resources process, and seek advice from your union or professional body where one is available. See our Terms of Use.
