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Nurse‐to‐nurse horizontal violence in Chinese hospitals and the protective role of head nurse's caring and nurses' group behaviour on it: A cross‐sectional study

Abstract Aims This study aimed to analyse the prevalence of nurse‐to‐nurse horizontal violence in Chinese hospitals and examine the effects of head nurse's caring and nurse's group behaviour on horizontal violence. Background Horizontal violence is a serious global problem affecting the nursing profession, but little is known of the issue in Chinese hospitals. Increasing evidence has showed that leadership and group factors are important in facilitating horizontal violence. Whether the head nurse's caring and group behaviour perceived by nurses has protective effects against horizontal violence remains unclear. Methods A cross‐sectional online‐based questionnaire study was performed in seven general hospitals in Hubei Province, China. Data related to the demographic information, horizontal violence, head nurse's caring and group behaviour were collected. Descriptive analyses, chi‐squared tests and logistic regression were used for data analysis. Results In total, 1942 valid questionnaires were collected, with a 92.70% effective response rate (1942/2095). Of those, 59.1% (1148/1942) of respondents had experienced horizontal violence at least once in the previous 6 months. Covert negative behaviours were more frequently reported. Compared with the low level, moderate and high levels of the head nurse's caring showed a lower risk of horizontal violence (odds ratio [OR] = 0.400, p < .001; OR = 0.128, p < .001); moderate and high levels of group behaviour also showed a reduced risk (OR = 0.601, p < .001; OR = 0.221, p < .001). Conclusion Horizontal violence is common among Chinese nurses. The head nurse's caring and maintaining a good climate of nurses' group behaviours could serve as protective factors for preventing horizontal violence. Implications for Nursing Management This study helps nursing managers identify which specific negative behaviours occur frequently and require special attention. It suggests that nursing managers attach importance to improving their caring ability towards nurses and to creating an amicable climate of group behaviour to buffer against horizontal violence.

Conclusion: Horizontal violence is common among Chinese nurses. The head nurse's caring and maintaining a good climate of nurses' group behaviours could serve as protective factors for preventing horizontal violence.
Implications for Nursing Management: This study helps nursing managers identify which specific negative behaviours occur frequently and require special attention. It suggests that nursing managers attach importance to improving their caring ability towards nurses and to creating an amicable climate of group behaviour to buffer against horizontal violence.
caring, group behaviour, head nurse, horizontal violence, nursing staff, hospital

| INTRODUCTION
Horizontal violence (HV), a kind of interpersonal conflict, is a serious global problem in the nursing profession (Blair, 2013;Doo & Kim, 2020;Rosi et al., 2020). It affects all areas of nursing: For the victims, HV can result in low self-esteem, depression, self-hatred and feelings of powerlessness and even cause physical health problems; for the health care organizations, HV leads to impaired personal relationships and lack of cooperation, toxic working environments, poor patient outcomes, increased turnover and financial damage; and for society, HV reduces the attractiveness of nursing profession and intensifies the shortage of nursing human resources, especially in the context of global aging (Embree & White, 2010;Pien et al., 2019;Woelfle & McCaffrey, 2007). Therefore, it is worth exploring any solutions to HV.
Nursing scholars, mainly in Western countries, have examined the incidence of HV among nurses based on its definition, prevalence, causes and strategies to combat it; however, there is little known internationally of HV in Chinese hospitals. Prior studies have identified variations of negative behaviours in workplace in different cultural contexts (Karatuna et al., 2020;Terzioglu et al., 2016). There are nine major cultural clusters (Confucian Asia, Southern Asia, Middle East, Anglo, Latin Europe, Eastern Europe, Nordic Europe, Latin America and Sub-Saharan Africa) in the world (Karatuna et al., 2020).
Confucian culture originated in China and deeply influenced the Chinese people. Chinese working culture emphasizes collectivism, cooperation, protecting face and performance orientation and promotes the ideas of Confucian benevolence, which may lead to HV in the Chinese cultural context having different characteristics from those of other countries (Cheng et al., 2017;Karatuna et al., 2020;Leong & Crossman, 2016). Thus, conducting a well-designed survey on HV in Chinese hospitals will contribute to the worldwide understanding of this problem.
Another research issue that is not yet clear but worth exploring is the role of head nurse's caring and nurses' group behaviours on HV. It is well known that the head nurse and nursing colleagues are the long-term colleagues of every staff nurse in the workplace. Wilmot and Hocker (2017) found that intrapersonal perceptions were the foundation for conflicts such as HV. Whether the degree of caring by the head nurse and group behaviour of other nurses could serve as the protective factors against HV remains unclear. Clarification of this issue will assist in combating HV and is of great significance.

| BACKGROUND
HV refers to any hostile, aggressive and harmful behaviour by a nurse or a group of nurses towards a co-worker or group of nurses via displaying negative attitudes, actions, words and/or other behaviours at the same hierarchical levels in an organisation (Embree & White, 2010;Longo & Newman, 2014;Taylor, 2016). Woelfle and McCaffrey (2007, p. 126) defined HV as 'interpersonal conflict' among nurses. This term is often used interchangeably with bullying in the nursing literature, but there are subtle differences in the meaning. Bullying is described as being more deliberate and repetitive and can occur across a power gradient, whereas in HV, it has been emphasized that the violence occurs among the workers at the same status and HV is not required to be repeated over time (Longo & Newman, 2014;Vessey et al., 2009). In this study, we focus on HV.
Diverse sources have shown that the prevalence of nurse-tonurse HV varies across different areas. In the United States, the prevalence of nurse-to-nurse HV ranged from 25.3% to as high as 87.4% (Dunn, 2003;Sellers et al., 2012). One survey in New Zealand revealed that over 50% of the staff nurses in their first practising year recognized that they were undervalued by other nurses (McKenna et al., 2003). Morrison et al. (2017), in Jamaica, found that 96% of registered nurses had been exposed to HV, and three quarters rated the exposure as moderate to severe. Ayakdaş and Arslantaş (2018), in Turkey, reported that 47% of nurses had suffered HV. Bambi et al. (2014), in Italy, found that 79.1% of nurses had experienced some form of HV at least once, whereas 22.4% experienced HV at least weekly. A survey performed in Spain showed that 74.2% of nurses had experienced HV at least once in the previous 6 months (Topa & Moriano, 2013). However, little is known about nurse-tonurse HV in Chinese hospitals. Scholars have pointed out that the occurrence of HV in the nursing profession is related to the local culture (Bambi et al., 2018). Chinese Confucian philosophy is a typical representative of the Eastern culture, which has a profound impact on the Chinese people. The ideas of collectivism and benevolence are highly valued by individuals and organizations in this kind of culture (Cheng et al., 2017). The question of whether nurse-to-nurse HV is less prevalent in Chinese hospital may thus be raised, together with the characteristics of HV in this context. This is a meaningful research topic worthy of exploration.
To date, there still is a global lack of systematic and effective prevention and management measures against HV. Exploring effective protective factors to prevent HV may assist in reducing its incidence.
According to the Society Ecosystems Theory, human behaviour involves multiple systems (i.e., micro, mezzo and macro systems) in the social environment, in which the nurse managers and co-workers form the mezzo system (Johnson, 2011;Zastrow et al., 2017). Increasing evidence has shown that leadership and group factors play important roles in facilitating HV; that is, HV is not just a binary issue between the victim and the perpetrator (Fontes et al., 2019;Kaiser, 2017;Samsudin et al., 2020;Topa & Moriano, 2013).
In China, the head nurse is the first-line nurse manager in an individual department and directs the other nursing staff in the performance of the nursing tasks in a ward. A recent study conducted by Kaiser (2017) found that the behaviours of the nursing leader can have a significant impact on the level of negative behaviours among the nurses. Nowadays, caring has been increasingly positioned as one of the core concepts for an evolved nursing science (Watson, 2009).
Some scholars have described caring as an affect, a feeling of compassion or empathy towards the recipient of care, and consider that the staff nurses' perceptions of nurse managers' caring influenced their job satisfaction and well-being (Cortis & Kendrick, 2003;Kostich et al., 2020;Turkel & Ray, 2004). To date, it is still not known whether the head nurse's caring as perceived by nurses can significantly affect the occurrence of HV.
Another important variable used in the present study was the nurse's group behaviour. Group behaviour is defined as collaboration and consensus in a group according to Stone's integrative model for organizational climate of staff working conditions (He et al., 2011;Stone et al., 2005). Nursing staff work as a group in a unit to provide the nursing care for patients. A previous study by Topa and Moriano (2013) identified that group support as a negative predictor of HV. In the same vein, researchers have underlined that work group factors create a favourable atmosphere for occurrence of HV (Blackstock et al., 2018;Crawford et al., 2019;Hutchinson et al., 2010;Topa & Moriano, 2013).
Based on this evidences, we hypothesized that the more positively nurses perceived the head nurse's caring and the nurses' group behaviour, the less HV would occur. However, as yet, there is no direct evidence to support this hypothesis. Bridging this gap will help nurse managers and policymakers recognize the importance of caring for subordinates and develop more effective approaches at the organizational level to mitigate HV. Therefore, the purpose of this study was to (a) investigate prevalence of nurse-to-nurse HV in Chinese hospitals over a 6-month period and to analyse it in terms of different demographics and (b) to examine the protective role of the head nurse's caring and nurses' group behaviour on HV from the perspective of HV victims.

| Study design
A cross-sectional online-based questionnaire study was performed from 1 January to 31 January 2021. Four tertiary general hospitals and three secondary general hospitals from Wuhan, the capital of Hubei Province, and three prefecture-level cities located in the southeast, south-west and the north of Hubei Province were selected as target hospitals using a convenience sampling method, with a total of 4500 eligible nursing staff meeting the study criteria. The study was reviewed and approved by the Ethics Committee.

| Participants
According to previous studies, the HV rate in general hospitals was 78.2% (Xie et al., 2019). The sample size was calculated using the following formula: n ¼ z 2 1Àa=2 p 1 À p ð Þ=d 2 , where n is equal to the minimum required sample size, ɑ is equal to type I error (0.05), z 1 À ɑ/2 is equal to level of confidence (1.96), p is equal to parameter for sample calculation (78.2%) and d is equal to margin of error (0.03). Based on this formula, a sample size of 728 anticipated for the study. Considering the 15% dropout rate, the final minimum sample size was 857.
The inclusion criteria of the participants were as follows: registered nurses working in a hospital, who agreed to take part in the anonymous survey and who had worked in the clinical nursing unit for at least 6 months. Nurses with leadership positions (such as head nurses and nurse administrators) were excluded from the samples. An informed consent form which explained the study's purpose, risks, benefits, anonymity, voluntary participation and the right to withdraw participation was distributed to the participants before their participation.

| Data collection
The data were collected using a self-reported questionnaire via the '1 = never', '2 = very rarely', '3 = almost once a month', '4 = almost once a week' and '5 = almost every day'. The respondents were instructed to consider the behaviours of only fellow nurse co-workers and exclude the behaviour of their supervisor or nonnursing individuals (such as physicians and patients). The Chinese version of the nurse-to-nurse Negative Acts Questionnaire has been substantiated for validity and reliability, and the internal reliability of Cronbach's alpha coefficient was found to be .95 in the previous study (Li, 2011;Wang et al., 2018). Cronbach's alpha coefficient was .98 in this study.

| Head nurse's caring
The head nurse's caring was measured using a 36-item Chinese version of the Caring Assessment Tool-administration, which was originally developed on the basis of the American nursing population by Duffy and adapted and validated by Peng et al. (2020) for use with Chinese nurses (Watson, 2009). There were two items that were deleted from the original English version in the process of crosscultural adaptation. The scale had three different dimensions: decision making, human respect and noncaring behaviours, which were designed to capture staff nurses' perceptions of their managers, using a 5-point Likert-type response scale (1 = never; 2 = rarely; 3 = occasionally; 4 = frequently; and 5 = always). The respondents were asked about the degree of caring they had perceived from the head nurses in the workplace. Ten items were intentionally worded negatively to minimize the chance of errors. The available options were reverse coded during analysis to prevent misinterpretation. The higher the score, the more the caring was perceived by nurses from head nurses. Cronbach's alpha coefficient was found to be .97 in this study. The extreme group analysis method was used to classify the level of head nurses' caring: The scores equal to and below quartile 1 were classified as 'low' levels, the scores in the range between quartile 1 and quartile 3 were classified as 'moderate' level, and scores equal to and above quartile 3 were classified as 'high' levels.

| Nurses' group behaviour
An eight-item subscale derived from the Nurse's Organizational Climate Scale was used to measure nurses' group behaviour.

| Data analysis
The data were analysed using IBM SPSS Statistics software Version Lemeshow test (χ 2 = 6.247, p = .620) supported the model as well.
Following the Nagelkerke R 2 , the model explained 32.4% of the variance in exposure to HV behaviour.

| DISCUSSION
The current study measured the prevalence of HV over a 6-month period among staff nurses at the seven general hospitals in Hubei Province of China, involving a large sampling survey of 1942 respondents, and thus makes a significant contribution to the ever-increasing global information on HV in nursing profession. The study also examined the predictive effects of head nurse's caring and nurse's group behaviour on HV from the perspective of HV victims.
In this study, 59.1% of (n = 1148) nurses reported HV experience at least once, which is lower than the 74.2% who reported being subjected to HV in Spain, the 79.1% in Italy and the 87.4% in New Jersey, but higher than the 47% in Turkey and the 34% in New Zealand (Ayakdas¸& Arslantaş, 2018;Bambi et al., 2014;Dunn, 2003;McKenna et al., 2003;Topa & Moriano, 2013). Meanwhile, the percentage of nurses in this study who experienced HV at least once a week was significantly lower than the finding of 22.4% among Italian nurses (Bambi et al., 2014). A possible explanation for this might be that different countries and organizations have different cultures in terms of power distance, collectivism, and performance orientation (Karatuna et al., 2020). Confucian culture attaches much importance on performance orientation, which may increase the work-related stress, thus increasing the risk of exposure to HV (Karatuna et al., 2020;Topa & Moriano, 2013 This study reveals that covert type of HV behaviours was more common than overt types among Chinese nurses, which is consistent with the data reported in other similar studies (Bambi et al., 2014;McKenna et al., 2003;Xie et al., 2019). This may be related to the female-dominated nature of the nursing profession. Females are generally thought to be good at using indirectly aggressive strategies because successful indirect aggression can be very effective and it is difficult to identify the perpetrator, which could help the perpetrator to effectively avoid counter-attacks (Strandmark & Hallberg, 2007).
Another possible explanation is that nurses are reluctant to have face-to-face interpersonal conflicts with their colleagues because Chinese people concerned about face-saving under the influence of Confucian culture.
Moreover, the findings indicated that head nurse's caring and a good climate of nurse's group behaviour were indeed two negative predictors of HV, which supported the hypotheses tested. These relationships may partly be explained by the cultural value that Chinese people believe in reciprocity. That is, when nurses perceive that their efforts and gains are balanced in interpersonal relationships, benign interpersonal interactions will continue, thereby reducing the T A B L E 1 Demographic characteristics and variations of two groups among different characteristics (N = 1942) likelihood of HV. Although nursing managers may not be directly involved in the HV incidents, they set the tone and expectations in the work environment, which was found to be associated with HV (Lewis & Malecha, 2011). If head nurses show a caring attitude towards their subordinates, they will set a good example for the staff nurses to care for each other, which may create a healthy environment and act as a buffer to HV (Kostich et al., 2020). The findings of this study are promising because they highlight the importance of nurse managers' caring ability for subordinates, which is in accordance with the core concept of nursing profession and provide new insights to solve the problem of HV among nurses. Further work is encouraged to confirm the results in other cultural contexts.

| Study limitations
Several limitations are associated with this study. First, because this study used a self-reported survey method based on respondents' own T A B L E 2 The specific scores for each item and the frequency ranking of each negative behaviour (N = 1942)

| IMPLICATIONS FOR NURSING MANAGEMENT
This study may help nursing managers worldwide to learn about the status quo of nurse-to-nurse HV in Chinese hospitals and have a better understanding of the cultural differences related to HV. Another implication of the present study is that it helps the nursing managers identify which specific negative behaviours have a high prevalence and require special attention. Moreover, this study recommends that nursing managers might mitigate the occurrence of HV through significantly improving their caring ability towards nurses and creating an amicable climate of group behaviour. Last but not least, it suggests that hospital managers and policymakers should recognize the importance of the head nurses' caring ability for subordinates and include it as an indicator in their performance appraisals.

ACKNOWLEDGEMENTS
The authors thank all the nurses who participated in the study. This study was funded by 2020 scientific research project of Chinese Nursing Association (Project No. ZHKY202006) and 2021 Independent Innovation Fund Project from School of Nursing, Tongji Medical College, Huazhong University of Science and Technology.

CONFLICT OF INTERESTS
All the authors declare no conflicts of interest in this study.

ETHICS STATEMENT
The study was reviewed and approved by the Ethics Committee of