Running head: INCIVILITY IN THE WORKPLACE

IncivilityintheWorkplace:TheLossofanInnocentInfantsLife
CaitlinA.Martinez
CaliforniaStateUniversity,Stanislaus

INCIVILITYINTHEWORKPLACE

WorkplaceViolenceRelatedDeath:SentinelEvent
Teamworkisanessentialpartofnursingandrequiresallteammemberstocollaborate
andcooperateinordertoachieveacommongoal.Nursesworktogetherwithdoctors,respiratory
therapists,physicaltherapists,andmostoften,withoneanother.Butwhathappenswhennurses
donotrespectoneanotherandrefusetoworktogether?Incivility,orworkplaceviolence,isa
longstandingproblemthatisstillprevalentinhospitalsaroundthecountrytoday.Actsof
incivilityincluderudeordisruptivebehaviorsthatoftenresultinpsychologicalandphysiological
distressforpeopleinvolved(Fidelindo&Bernstein,2014).Whethertheseactsareverbal,
physical,orpassiveaggressive,patientoutcomesandsafetyareatrisk.
AccordingtoLamontagne(2010),approximately98,000peopledieeveryyearinthe
UnitedStatesbecauseofpreventablemedicalerrors.Therearemanyreasonsthatmedicalerrors
occur,butincivilityandintimidationaretwoveryimportantfactorsthatcontributetothese
errors.Incivilityincreasesthelikelihoodofpoorpatientoutcomesanditisimportantthat
thefacilityworkswithdepartmentleadersandTheJointCommission(TJC)toprevent
futuresentineleventsrelatedtothesebehaviors.
SentinelEvent
Asentineleventcanbedescribedasaneventthatresultsinanunexpecteddeath,serious
injury,ortheriskofinjurytoapatient(TheJointCommission[TJC],2014).Sentineleventsare
causedbymedicalerrors,butnotallmedicalerrorsleadtosentinelevents;sentinelevents
requireimmediateinvestigationandresponsebecausetheycauseseriousadverseeffects.
Reviewablesentineleventsinclude,butarenotlimitedto,suicideofanypatientreceivingcare

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orwithin72hoursofdischarge,surgeryonthewrongpatientorwrongbodypart,rape,and
abductionofanyonereceivingcare.Accreditedorganizationsshouldreportsentineleventsto
TJCandconductarootcauseanalysis(RCA).Thisprocesshelpsthefacilitydevelopaplanof
actiontoimplementpoliciesandproceduresthatwillreducetheriskofasentinelevent.TJCwill
thendetermineiftheplanisacceptableandwillassignfollowupactivitiestothefacilitythat
willhelpmeasurethesuccessoftheimplementedplan(TJC,2014).
LossofanInnocentLife
OnSeptember1st,2014,inaNeonatalIntensiveCareUnit(NICU)inaBayAreahospital
inCalifornia,apatientslifewastakenwhentwonursesrefusedtocommunicateandwork
together(D.Martinez,personalcommunication,September1,2014).NurseAandNurseBwere
friendsuntiltheygotintoafightoutsideofworkoneday.Theyweretravelingtogetherand
NurseAaskedNurseBtolookatamaptoensurethattheyweregoingintherightdirection.
NurseBcouldntfigureouthowtoreadthemap,whichcausedthemtogointhewrong
direction.Thiscausedafightbetweenthetwoandtheyrefusedtospeaktooneanotherafterthis.
NurseAwentbacktoworkandgossipedaboutNurseB,tellingothernursesthatshewas
illiterateandcalledherinappropriatenames.NurseBhadneversaidanythingbadaboutNurse
AanddidntunderstandwhyNurseAwouldsaysuchhurtfulwords(D.Martinez,personal
communication,September1,2014).
Thisunprofessionalbehaviorworsenedandthetwonursesrefusedtocommunicatewith
eachotheratall,mealbreakforoneanother,orworkinnurseriesnexttoeachother(D.
Martinez,personalcommunication,September1,2014).Thenursemanagerworkedtheschedule
aroundthisproblembetweenthetwonursesandmadesurethattheserequestsweremet.Butone
day,thetwonurseswereforcedtoworkinnurseriesnexttooneanotheriftheywantedtotake

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careoftheirprimarypatients.Otherwise,theywouldhavetogivetheirprimarypatients,whom
theyhadbeentakingcareofforalongtime,toothernurses.Bothnurseswantedtocontinue
takingcareoftheirprimarypatients.IntheNICU,therearethreenurseriesineachlargeroom,
separatedbyslidingdoorsbetweenoneanother.NurseAwasassignedtoNurseryA,andNurse
BwasassignedtoNurseryB(D.Martinez,personalcommunication,September1,2014).
Assoonasthetwonursesreceivedreportontheirpatients,NurseAslammedthedoor
betweenhernurseryandNurseryBbecauseshedidnotwanttohaveanythingtodowithNurse
Bthroughouttheday(D.Martinez,personalcommunication,September1,2014).Nursesare
supposedtohelptheirroommatesthroughoutthedaywithmedicationsthatrequiredouble
checksfromtwoRegisteredNurses(RN),breastmilkthatrequiresacosignaturefromanother
RN,andwithkeepinganeyeontheirroommatespatientwhenevertheyneedtoleavethe
roomforanyreason.Onthisday,NurseBleftherroomtogetbreastmilkforherpatient,
withouttellingNurseAoranyothernursethatshewasleavingherroom.Shefeltintimidatedby
NurseAanddidntwanttoaskhertocosignthebreastmilkforher.Instead,shewalkedaround
theunitlookingforanursewhocouldcosignforthebreastmilkshewasgoingtoadminister.
Duringthistime,NurseBspatientselfextubatedandcoded.Thealarmsontheventilatorwere
unabletobeheardbyNurseA,sinceshehadshutthedoorbetweenthetwonurseries.The
nursesinthenursesstationheardthealarms,butassumedthatNurseBwasinherroomandhad
everythingtakencareof.NurseBreturnedtoherroom,tofindthatherpatienthaddied(D.
Martinez,personalcommunication,September1,2014).
RootCauseAnalysis
ItseasytosaythatthistragiceventhappenedsolelybecauseNurseBwasnegligent.Yet
wasitreallyjustnegligencethatcausedthispatientsprematuredeath,orwasitacombinationof

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manyfactors?In1997,rootcauseanalyses(RCA)weremandatedasatooltoinvestigateclinical
errors(Iedemaetal.,2006).RCAattemptstodraftcausalrelationshipsfromlatentfactorsthat
helpedformtheincidentanddeviseconclusionsandrecommendationsthattargetfailedsystems
andorganizationalprocessesinsteadofindividuals(Menigis&Nicolini,2010).Thisbroadens
thescopeofthesituationandtakesintoconsiderationtheclinicalpracticeasawhole.The
patient,inthisinstance,didntjustdiebecauseofthenursesnegligence;ahostileenvironment,
failedtechnology,poorleadershipandmanagement,andacomplexfloorlayoutalsocontributed
tothistragedy.
Communication
Lackofcommunicationandinappropriatecommunicationbetweennursesoccurs
frequentlyintheNICUwhereNurseBworked.Sheexperiencedhostility,intimidation,racial
slurs,andotherdemeaningformsofcommunication.AccordingtoAddisonandLuparell(2014),
communicationbreakdownisoneofthetopthreemostfrequentlyidentifiedrootcausesof
sentinelevents(p.67).Communicatingwithviolenceleadshealthcareworkersfeeling
frustrated,stressed,anxious,anddepressed.Disruptivebehaviorsandcommunicationcanalso
causealossofconcentration(Addison&Luparell,2014).Whennurseslosetheirconcentration
andtheirattentionisshiftedduetolateralviolence,patientsunintentionallybecomevictims
(Bigonyetal.,2009).Thosewhoarebulliedarelikelytorefrainfromcommunicatingwiththose
whoareintimidating,whichisalsodetrimentaltopatientsafety.NurseBfeltintimidatedby
NurseAanddecidednottoaskhertokeepaneyeonherpatientwhilesheretrievedbreastmilk
andlookedforanothernursetocosignthemilkforher,showingalackofcommunication.Open
communicationshouldbeencouragedbetweennurses,nursemanagers,andotherhealthcare
workers.Competenceincommunicationenablesnursestosolveinevitableconflictsthatoccurin

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thehealthcaresetting(Tsai,Tsai,Weng,&Chou,2013).
Management
Additionally,thenursemanageroftheNICU,inthisBayAreahospital,ignoredthe
uncivilbehaviorsandevencontributedtothembyworkingaroundthenursesandmeetingtheir
requestsnottoworknearoneanother.Oftentimesinhealthcare,inappropriatebehavioris
excusedandnormalized,evenbeingacceptedasastatusoftheprofession(Addison&
Luparell,2014,p.67).Sometimesmanagersareevenmorewillingtotolerateincivilityfrom
nurseswhoexcelatthebedside(Ceravolo,Schwartz,FoltzRamos,&Castner,2012).However,
manynursemanagersarenotproperlyequippedwithmanagementskills,whichiswhyincivility
istypicallynotaddressed.Nursemanagersoftenreportfeelingundereducatedaboutbullying
andlateralviolenceanddontfeelsupportedbytheirorganizationasawhole(Croft&Cash,
2012,p.234).Inorderforthisbehaviortostop,actionneedstobetakenbynursemanagersand
thewiderorganization.Managersneedtohavetheskillsetstoleadbyexampleandproperly
disciplinestaff,insteadofcontributingtoinappropriatebehavior.
Equipment&Technology
Intheworldtoday,technologyisdependeduponforjustabouteverything;however,
sometimesequipmentandtechnologycanbefaultyandunreliable.AccordingtoSilva,Reis,
Aguilar,&Fonseca(2012),unplannedextubationrequiringreintubationisthefourthmost
commonadverseevent(p.5),intheNICUintheUnitedStates.Endotracheal(ET)tubesare
usedoftenintheNICU,duetotheunderdevelopmentofthelungsintheprematureinfantsand
theirinabilitytooxygenateproperly.Approximately0.6to13.3%mechanicallyventilated
patientsexperienceaunplannedextubation,whichisequivalenttoarateof1.98to3.0events
every100days(Oliveira,Cabral,Schettino,&Ribeiro,2012).Twoofthemostcommoncauses

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ofanunplannedextubationarepoorfixationoftheETtubeanddislocationoftheETtubeasa
resultofanactiveinfant(Veldman,Trautschold,Weib,Fischer,&Bauer,2006).Infantsinthe
NICUhaveverythin,fragileskin,requiringETtubestobetapeddown,usingskinprotectant
tapes,topreventtheirskinfrombreakingdown.However,sincehumidificationisusedin
conjunctionwithventilation,theskinprotectanttapesdonotadherewellandareeasily
removable.Inaddition,infantshaveatendencytobringtheirhandstotheirface;this,alongwith
thefactthatinfantsbecomeespeciallyactivewhentheyareagitated,increasestheincidenceof
ETtubedislodgement.Themosteffectiveadhesivesthatpreserveskinintegrityshouldbeused
todecreasetheincidenceofUE.
Environment
IntheNICU,therearethreemaindesignlayouts:openbaywards,semiprivaterooms
andsinglefamilyrooms.TheBayAreahospital,inwhichthisincidenceoccurred,hassingle
familyroomswithslidingdoorsbetweenthreeoftherooms,connectingthemtooneanother.
Althoughsinglefamilyroomsaremoreconducivetofamilycenteredcareandprivacy,theypose
risksforpatientsafety.Nursesfeelmoreisolatedfromtheircolleaguesandhaveanincreased
dependenceonelectronicmonitoring(Domanico,Davis,Coleman,&Davis,2010).Inaddition,
nursesexpressaconcernforadequatelycaringforpatientsanddetectingmedicalcrisesearlyin
singlefamilyrooms(Domanicoetal.,2010).Inorderforinfantstobemonitoredatalltimes,
morestaffmemberswouldbeneeded.However,manyhospitals,includingthisBayArea
hospital,areunderstaffedwithhighcensus.Itisnotpossibleforeveryinfanttobemonitoredat
alltimes.Centralmonitoringsystemsandcommunicationsystemsneedtobeestablishedto
providenursesstatusupdatesontheirpatients,evenfromdistantlocations(McGrath,2005).In
addition,policiesneedtobeinstitutedonthedoorsinbetweentheserooms.Thereneedtobe

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specificationsonwhenthesedoorsaretoremainopenandwhentheycanbeclosed.
TargetedChange,Stakeholders,andTheirConcerns
Thetargetedchangeistopreventfuturesentinelevents,specificallyrelatedtoworkplace
incivility.Stakeholders,inthiscase,includeanyonewhohasavestedinterestinaclinical
decisionandtheevidencethatsupportsthatdecision(AgencyforHealthcareResearchand
Quality[AHRQ],2014,p.11).Patientsareoneofthemainstakeholderssincetheyareunderthe
directcareofnursesandareoftentimestheinadvertentvictimsofincivility.Thecommunityand
thepublicarealsostakeholders,astheyarepotentialpatientsandusersofhealthcare.Incivility,
incommunities,especiallyinschoolsystems,hasbecomeproblematicandledtotheformation
ofactivistgroupsandawarenesscampaignsincommunitiesacrossthenation(Maughan,2012).
Thisheightenedawarenessreachednationallevels,andledtotheestablishmentofNational
BullyingPreventionMonth,whereactivitiesareheldacrossthenationinanattempttounite
communitiesandstopbullying(Maughan,2012).Communitiestakeincivilityseriously,andare
alsoconcernedwithincivilityinhealthcareandtheassociatedpatientdeaths,andwanttoknow
whatactionsaregoingtobetakentopreventthem.Healthcareproviders,suchasnurses,are
stakeholdersandarethemaintargetsforinitiatingchangebecausetheyprovidedirectpatient
careandareattheheartofmedicaldecisionmaking.Theprovidersareworkinginunhealthy,
hostileenvironments,andmakingmistakes,andwanttoknowhowtheycanmaketheir
environmentsafeandcomfortable,inordertoprovidethebestpatientcare.Thegovernmentisa
stakeholder,asitisthehealthcarepolicymaker,createspublichealthprograms,anddetermines
healthinsurancecoverage.Insurers,manufacturers,andresearchersareamongother
stakeholders.Stakeholderinvolvementimprovestheresearchprocessandalsoensuresthatthe
proposedchangeplanisapplicable(AHRQ,2014).

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TargetPopulationandTheirAttitudes,Beliefs,andKnowledge
Nurses,nursemanagers,andhospitaladministrationarethemainpopulationsthatwillbe
targetedinordertoproducethedesiredoutcomes.Providersarewellawareoftheincivility
occurringintheworkplace,withmanyofthemhavingpersonalexperiences.Accordingto
NikstaitisandSimko(2014),morethan85%ofnurseshavebeenvictimsofincivility.
Furthermore,nursesarewellawareofthepotentialoutcomesrelatedtoincivility;upto46%of
nursesknowofanadverseeventthatoccurredbecauseofincivility.Disruptivebehaviorand
bullyingcreatesanunhealthyworkenvironment,causingproviderstobedissatisfiedwiththeir
job.Thisjobdissatisfactionoftenresultsindecreasedretentionratesofemployees.
Inaddition,nursemanagers,havemanyrolesandaccountabilities,oneofwhichis
addressingincidentsandcomplaintsinordertomaintainasafeenvironment(Ostrofsky,2012).
Inorderforchangetooccur,nursemanagersneedtohavetheskillstomodelandreinforcecivil
behavior.However,manynursemanagersfeelthattheydonthavesufficientsupporttostop
theseuncivilbehaviors(Ostrofsky,2012).Nursemanagersneedthesupportofhospital
administrationandneedtobementoredbytheseleaders.Thehospitaladministrationis
responsibleforsupportingnursemanagersandprovidingthemwiththetoolstheyneed,which
willcreateamoresupportiveenvironment.However,hospitaladministrationmaynotbeaware
ofthesignificanceofincivilityintheworkplace,asitisoftenunderreported(Nikstaitis&
Simko,2014).Awarenesssurroundingincivilityisthefirststepinperpetuatingchange.
LewinChangeTheory,PlanforChange,andImplementation
Thereareamultitudeofchangetheoriesthatcanbeusedtodirectchangeinhealthcare.
KurtLewinsTheoryofPlannedChangeisaframeworkconsistingofthreestages:unfreezing,
moving,andrefreezing(Shirey,2013).

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UnfreezingStage
Theunfreezestageinvolvespreparingforchange.Nursemanagersneedtorecognizethat
incivilityis,indeed,aproblem,andthatthereisaneedtochangethesebehaviors.In2008,The
JointCommissionstated,organizationsthatfailtoaddressunprofessionalbehaviorthrough
formalsystemsareindirectlypromotingit(p.1).Hospitalsarerequiredtorecognizeandaddress
lateralviolence.Recognizingthesebehaviorscallsattentiontothemandhelpsnursesidentify
themasnegative,insteadofnormal.Teachingnursesaboutwhatconstituteslateralviolencewill
alsoeliminatediscrepanciesrelatedtodifferingthoughtsandopinionsaboutwhatlateral
violenceis(Dimarino,2011).Thiswilldecreaseconfusionandallowemployeestoseetheneed
forinterventions.Unfreezingalsoinvolvesgatheringotherstoseethatthereisaneedforchange
(Shirey,2013).Nursemanagersshouldgatheremployeestoformapowerfulgroupthatcan
initiatechange.Thiscanbedonethroughmotivatingstaffmemberstospeakupabouttheir
experienceswithincivility,andempoweringthemtotakeastand.Byactivelyparticipatingin
thisprocess,nursemanagerscanunderstandthebehavioralproblemsoccurringontheunitand
beapartofthesolution.AccordingtoCoursey,Rodriguez,Dieckmann,andAustin(2013),staff
membersmustperceivemanagersasactiveparticipantsinthechangeprocess,andintheirdaily
duties,inorderforalateralviolencepolicytobeeffective.Inaddition,clinicalsettingshavea
highlycomplexsocialnetworkandworkingtogetherstrengthenscommunicationandrelational
skills(Courseyetal.,2013).Onceastrong,coregrouphasbeenformed,membersneedto
approachhospitaladministratorswithinformationabouttheprevalenceofincivilityontheirunit
inawaythatconveysanurgencyforchange.
MovingStage

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ThenextstageofLewinstheory,themovingstage,looksatchangeasaprocess(Shirey,
2013).Inthisstage,aplanofactioniscreatedanddetailed,andthecoregroupinitiatingthe
changemustengageotherstoparticipateinthechange.However,manynursemanagersfeelthat
theydonthavetheappropriatesupportfromadministrationandlackskillsthatapplyto
incivilityanddealingwithdisruptivebehaviors.Therefore,nursemanagersmustfirstadvocate
forthemselvesandaskadministratorsforthepropertrainingandtoolsthattheyneedinorderto
besuccessfulleadersofchange.Inaddition,theymustbewillingtolearnandchangetoo.
AccordingtoBlair(2013),educationandchangedevelopmentarenoteffectiveunlessthe
leadersareonboardtosustainchange(p.77).Nursemanagersmustbefamiliarwith
organizationalpoliciesrelatedtoincivilityandbepreparedtoenforcethesepolicieswith
appropriatedisciplinaryactions.Theymustalsoparticipateinthesameeducationasother
employeestostayinagreementaboutthechangeplan.
Oncenursemanagershavereceivedthepropertraining,acorrectiveplanmustbecreated
andputintoaction.Theoverallgoalistohaveazerotolerancepolicyfordisruptivebehavior.
Actionstepstoachievethisgoalincludecreatingacodeofconduct,settingupfocusgroupsand
workshops,andencouragingaccountability.
TheJointCommission(2008)creatednewaccreditationcriteria,effectiveJanuary1,
2009,requiringallorganizationstohaveacodeofconductthatdefinesacceptableand
inappropriatebehaviors,andleadersarerequiredtocreateandimplementaprocessformanaging
thesedisruptivebehaviors.Focusgroupsshouldbeformedandtakeplaceatcertaintimeseach
month.Thesegroupsareusefulforemployeestogivetheirinputonacodeofconductthatis
applicabletoeveryoneandtodevelopaphilosophyfortheirunit(Becher&Visovsky,2012).
Theyarealsoareliablewaytofacilitatediscussionofincivility.Groupdiscussionscanaddress

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differentspecifictopicssurroundinglateralviolenceduringeachsession.Someusefultopicsof
discussionmayincludelackofsupport,poorteamwork,disrespectfulbehavior,and
micromanagementofemployees(Becher&Visovsky,2012,p.212).Focusgroupsarealsoa
waytoteachnewtechniquesonhowtodealwithlateralviolence.
Mandatoryworkshopsneedtobeheldtoteachemployeesnewtechniquesonhowto
appropriatelyrespondtolateralviolence.AccordingtoGriffin(2004),cognitiverehearsal
techniquesempowernursestoconfrontotherlaterallyviolentnurses.Cognitiverehearsalallows
individualstoconsciouslynotrespondtoactsofviolence,butinsteadstopandthinkaboutthe
actandnotprocessitasapersonalattack.Thisallowsindividualstorespondprofessionallyto
theviolence.Only10%ofnursesfeelcomfortableenoughtoconfrontacolleaguethatisbeing
disruptive(Becher&Visovsky).Assertivecommunicationalsoneedstobetaughttoallnurses
inordertohelpthemfeelmorecomfortablerespondingtodisruptivebehaviors.Astudydoneby
Ceravoloetal.(2012)revealedthatafternursesattendedworkshopsonincivility,theproportion
ofnurseswhobelievedthatincivilitycouldaffectpatientcareincreasedby21%.Workshopswill
helpempowernursesandholdoneanotheraccountableforinappropriatebehavior.
Lastly,employeeswillbeheldaccountablefortheiractions,forreportinginappropriate
actions,andforknowingthepoliciesregardinginappropriatebehavior.Nursemanagershavean
addedresponsibilityofbeingaccountableforappropriatelydisciplininginappropriatebehavior.
Adetailedpolicywillbefollowedtodealwiththesebehaviorsandnursemanagerswillnotuse
avoidanceasawaytodealwiththeproblem,asitcontributestoincivility(Nikstaitis&Simko,
2014).Documentationofdisciplinebythenursemanagermustbedoneforeachincident,
accordingtothepolicy,toshowthatinterventionshavebeeninitiated.Nursemanagersmustalso
exhibitongoingwillingnesstostateclearexpectationsofemployeesandmustlistenwithanopen

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13

mind,withoutjudgment,inordertoreceivethefullinformationabouttheincident.Surveysneed
tobegivenouttoemployeesontheunit,beforeandafterthechangestoevaluatehownursesand
nursemanagersarerespondingtothechanges,howtheworkenvironmentandculturehas
changed,andhoweffectivetheinterventionsare.
RefreezingStage
ThelaststageofLewinstheoryistherefreezingstage,whichmeansthatthechanges
madeareincorporatedintothecultureoftheunitandutilizedatalltimes.Nursemanagersand
leadersmustensurethatthereiscontinuoustraining,support,andfeedbackinordertomakethis
changesuccessful.Thesechangesshouldleadtoasafer,morecomfortableworkenvironment
leadingtosaferpatientcare,withzerofuturesentinelevents.However,thesechangesmaynot
workforthisfacilityorfortheemployeesworkingatthisfacility.Someadjustmentsmayneed
tobemadedependingonthecomplianceofemployees,managerpreparednessand
accountability,andflexibilityofthechangeplanregardingtimesworkshopsareheld,howoften
employeesneedtoattendtheseworkshops,etc.Therewillundoubtedlyberesistancefromnurses
havingtoattendsomanyworkshopsandbeapartoffocusgroups,butthisariskthatcomes
alongwithcreatingachange.
Budget
Aprospectivebudgetwasformulatedtodeterminethecostsoftheactionsoutlinedinthe
changeplan.Anapproximatecostof$138,309willbeneededinordertoinitiateandimplement
thesechanges,andreduceincivility.Noamountofmoneycanbringbacktheinfantwhoselife
wastakenasaresultofdisruptivebehaviors.However,futuredeathscanbepreventedifchanges
areimplementedandthestaffisheldaccountable.Withthisbudget,staffmemberscanbe
properlytrainedandeducatedonthetragiceffectsofincivility.

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Conclusion

Incivilityisanormalcyintheworkplaceandhasdevastatingeffectsonpatientcareand
patientoutcomes.Inthecaseoftheinfant,intheBayAreaNICU,deathwastheconsequence.
Sentinelevents,liketheonementioned,canandshouldbeprevented.Arootcauseanalysis
outlinedunderlyingfactorsthatcontributedtoincivilityamongnurses,inanattempttomake
changestopreventfuturesentinelevents.Inordertoinitiateandimplementthesechanges,Kurt
Lewinschangetheorywasanalyzedandappliedtothisissue.Workshopsandfocusgroupscan
heightenawarenessandgivenursestheskillsthattheyneedtoconfrontdisruptivebehaviors.In
addition,propertrainingfornursemanagerswillallowthemtorecognizethesebehaviorsand
takeappropriatedisciplinaryaction.Thelossofaninnocentpatientslifecannotbereplaced,but
throughthesechanges,futuredeathsmaybepreventedandincivilitywillnolongerbetolerated.

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outcomeofunplannedextubationinventilatedpretermandtermnewbornsonaneonatal
intensivecareunit.PediatricAnesthesia,16,968973.

INCIVILITYINTHEWORKPLACE

18

Position based on
seniority

Management

Communication

Improper training
for nurse
Lack of clear code
managers
of conduct

Lack of
discipline
procedures

Thin, fragile skin

Use of skin
preserving tapes

Avoidance
type
management
skills

Poor fixation of ET
tube
Unplanned
selfextubation

Communication
expectations not
clear

Inappropriate or
lack of learship
training/building

Lack of
communcia
with manag

False alarming Doors closed

between rooms
Alarm fatigue

Humidification
decreases adherence

Alarm not heard

outside of room

Active movement
in infants

Bring hands to face

Agitation

More dep
Nurses
isolated from on electro
colleagues
monitorin

Need for more

nurses
Equipment/
Technology

Environment
Nursing shortage
and high censes

AppendixA

Appendix B. Preventing Incivility in the Workplace Budget

Year:
Organization
:
Submitted
by:

In
c
in

Incivility/intimidation

Lack of
management
and leadership
on the unit

Lack of support
from
administration

Stress, anxiety
depression

2014
Bay Area
Hospital
Caitlin Martinez
Total

INCIVILITYINTHEWORKPLACE

19
Budget:
Budget Planning

Lin
e
1

Item
Study on incivility on the unit

Nurse manager training

Materials for nurse manager

training

Focus groups

Description/Justification
A team will be responsible for performing and
evaluating/interpreting the results of the study. The
study will be performed by a group of four
individuals. It will be a qualitative study done
primarily through interviews and questionnaires in
order to better understand the problems on the unit.
The study will be done over one month. (4 team
members x $20/hr x 40hrs/week x 4
weeks=$12,800) (1 ream of paper (500
sheets)=$9)
The nurse managers will receive teaching through
a 4 hour course. This will include teaching on
organizational policies, disciplinary action, and
how to appropriately deal with disruptive
behaviors. (2 nurse managers x 4 hours x $80/hr)
Videos, paper materials, powerpoint presentation

Focus groups should meet for one hour, two hours a

month to create a code of conduct and a philosophy
for their unit. They will also address and discuss
different topics surrounding lateral violence during
each session. Each nurse manager will lead one
focus group every month and all staff must attend
one. (2 nurse managers x $80/hr x 2
hours/month=$320) (200 staff members x $40/hr x
1 hr=8,000)

Qty.
1

12

$8,

INCIVILITYINTHEWORKPLACE

20

Workshops for nurses

Workshops will be every three months and will

teach nurses skills that will help them deal with
lateral violence (assertiveness training, cognitive
rehearsal, how to report disruptive behaviors, etc.).
Every three months, there will be two workshops
held on two different days, and each workshop will
be four hours long; all nurses and nurse managers
are required to attend one and it will count towards
continuing education units. Two outside instructors
will lead the workshops. (2 outside instructors x
$20/hr x 16hr=$640) (200 staff members x $40/hr x
4 hours=3,200) (2 nurse managers x $80/hr x 4
hours=640)

$4,

Materials for workshops

Snacks, water, videos, paper materials, powerpoints

Tools for measuring outcomes

Paper materials for surveys, individuals to analyze

results, computer program

$5,

Grand T