Horizontal Violence Toward Emergency Medicine Residents

Gender as a Risk Factor

Ashley A. Jacobson, MD; James E. Colletti, MD; Neha P. Raukar, MD, MS


Western J Emerg Med. 2022;23(5):633-636. 

In This Article

Abstract and Introduction


Introduction: Horizontal violence (HV) is defined as "persistent exposure to interpersonal aggression and mistreatment from colleagues." Our objective in this pilot, single-site study was to identify sources of HV toward emergency medicine (EM) residents, using the Negative Acts Questionnaire-Revised (NAQ-R).

Methods: In this investigation we used a descriptive cross-sectional survey design to categorize HV. All voluntary participants were residents in an Accreditation Council for Graduate Medical Education-approved, three-year academic EM residency. Data were collected via electronic survey and occurred six months into an academic year. We collected demographic information and responses to the NAQ-R in 2020. Horizontal violence is subdivided into three categories: work-related; person-related; and physical intimidation. Emergency medicine residents answered questions as they related to their interactions with residents and support staff, which included nursing.

Results: A total of 23 of 26 residents responded (89%). Participants were 56% women, 78% white, 11% Hispanic, and 89% heterosexual. Participant clinical year was 39% first-, 39% second-, and 22% third-year residents. Women reported a higher frequency of HV compared to men (1.3 vs 1.1, P =.01). By category, women indicated higher incidence of work-related violence from other residents (P = .05) and staff (P =.02). There was no difference in reported frequency of violence for interns compared to senior residents.

Conclusion: Our pilot study demonstrated horizontal violence toward EM residents exists and is more prevalent in women.


The hierarchical structure of education in healthcare is a known risk factor for workplace bullying.[1–7] Workplace bullying is defined as "harassing, offending, socially excluding someone, or negatively affecting someone's work…occur[ing] repeatedly and regularly (weekly) and over a period of time (eg, about six months)."[8]

Horizontal violence (HV), "persistent exposure to interpersonal aggression and mistreatment from colleagues,"[9] has predominately been researched within the nursing field[10–11] with interest in resident-directed HV only recently gaining momentum.[7,12–13] Resident-directed HV is comprised of staff-to-resident and resident-to-resident bullying. This study focused on HV and did not evaluate vertical violence (attending-to-resident bullying). The general surveys globally used to assess attending and resident physician workplace bullying are the Negative Acts Questionnaire-Revised (NAQ-R),[4–6,12–14] a bullying scale predominantly used within the United Kingdom,[1,3] and various single-site questionnaires.[15–17]

Worldwide, workplace bullying of residents has been identified.[7] In the US, Daugherty et al[15] found that after intern year, 62.9% of residents had experienced mistreatment from any source (eg, medical student, resident, attending, nurse, patient). A subsequent study elucidated that 66% of US trainees across all years and specialties experienced at least one type of bullying behavior from either an attending, nurse, patient, peer, consultant, or ancillary staff, with female, non-white residents reporting higher frequency of these episodes.[1] Workplace bullying of resident physicians is associated with increased psychological distress, increased depressive symptoms, and a positive post-traumatic stress disorder screening.[3,18–19]

Overall, there is a paucity of data regarding HV specifically and its adverse effects on residents, especially residents in EM – a specialty that depends on frequent interactions with staff and residents from different services. In this pilot study we hypothesized that women residents in their first year of residency training would experience more HV, specifically from other residents and support staff, as measured by a tailored healthcare version of the 22-item NAQ-R.