Running head: INCIVILITY

Incivility in the Workplace: The Loss of an Innocent Infants Life

Revised by: Stephanie Rebeiro, Carla VanderHelm, Kathryn Vaughn, and Ashleigh Weeda
California State University, Stanislaus

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Workplace Violence Related Death: Sentinel Event

Teamwork is an essential part of nursing, and more specifically the interdisciplinary team
that aims to deliver high-quality patient care. Several disciplines coming together for the
common goal of the patient provides the patient well-rounded care, however it cannot be
effective if all members of the team are unable to collaborate and cooperate in order to achieve
the common goal. Nurses work together with doctors, respiratory therapists, physical therapists,
pharmacists, social workers, case managers, and most often, with one another. But what happens
when nurses do not respect one another and refuse to work together? Incivility, or workplace
violence, is a long-standing problem that is still prevalent in hospitals throughout the country
today. Acts of incivility include rude or disruptive behaviors that often result in psychological
and physiological distress for people involved (Fidelindo & Bernstein, 2014). Whether these
acts are verbal, physical, or passive aggressive, patient outcomes and safety are at risk.
According to Lamontagne (2010), approximately 98,000 people die every year in the United
States because of preventable medical errors. There are many reasons that medical errors occur,
but incivility and intimidation are two very important factors that contribute to these errors.
Incivility increases the likelihood of poor patient outcomes and it is important that the facility
works with department leaders and The Joint Commission (TJC) to prevent future sentinel events
related to these behaviors.
Sentinel Event
A sentinel event can be described as an event that results in an unexpected death, serious
injury, or the risk of injury to a patient (The Joint Commission [TJC], 2011). Sentinel events are
caused by medical errors, but not all medical errors lead to sentinel events. They require
immediate investigation and response because they cause serious adverse effects. Sentinel

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events that should be reviewed include, but are not limited to: suicide of any patient receiving
care or within 72 hours of discharge, surgery on the wrong patient or wrong body part, rape, and
abduction of anyone receiving care (Chinn, 2014). Accredited organizations should report
sentinel events to TJC and conduct a root cause analysis (RCA). This process helps the facility
develop a plan of action to implement policies and procedures that will reduce the risk of this
particular sentinel event from reoccurring. TJC will then determine if the plan is acceptable and
will assign follow-up activities for the facility that will help measure the success of the
implemented plan (TJC, 2008).
Loss of an Innocent Life
On September 1st, 2014, in a Neonatal Intensive Care Unit (NICU) in a Bay Area hospital
in California, a patients life was lost when two nurses refused to communicate and work
together (D. Martinez, personal communication, September 1, 2014). Nurse A and Nurse B were
friends until they got into a fight outside of work one day. They were traveling together and
Nurse A asked Nurse B to look at a map to ensure that they were going in the right direction.
Nurse B could not figure out how to read the map, which caused them to go in the wrong
direction. This caused a fight between the two and they refused to speak to one another after this
occurrence. When Nurse A returned to work, she gossiped about Nurse B. Nurse A told other
nurses that Nurse B was illiterate and called her inappropriate names. Nurse B had never said
anything bad about Nurse A and did not understand why Nurse A would talk so poorly of her (D.
Martinez, personal communication, September 1, 2014).
This unprofessional conduct continued to escalate up to the point that the two nurses
refused to communicate with each other, cover each others patients during meal break, or even
work in nurseries that were deemed by them to be too close in proximity (D. Martinez, personal

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communication, September 1, 2014). The nurse manager took this predicament into account
when scheduling the two nurses and made sure that these requests were made accordingly, so
that taking care of their patients would be their sole focus while working. But one day, the two
nurses came to work only to find that their primary patients were assigned nurseries next to one
another. Both nurses wanted to continue providing care to these patients since they had been the
primary nurse of these patients for quite some time. In the NICU, one large room accommodates
three patients separated by a glass sliding door to the adjoining room. Nurse A was assigned to
Nursery A, and Nurse B was assigned to Nursery B (D. Martinez, personal communication,
September 1, 2014).
As soon as the two nurses received report on their patients, Nurse A slammed the door
between the two rooms because she did not want to have anything to do with Nurse B (D.
Martinez, personal communication, September 1, 2014). Nurses are supposed to help their
roommates throughout the day with medications and feedings. This occasionally requires
double-checking as well as co-signing from the nurse next door. In addition, keeping an eye on
their roommates patient whenever they need to leave the room for any reason is also part of
the NICU norm. On this particular shift, Nurse B left her room to get breast milk for her patient
without telling Nurse A, or any other nurse, that she was leaving her room. The reason she did
this was because she felt intimidated by Nurse A and did not want to ask her, of all the nurses on
the unit, to co-sign the breast milk. Instead, she walked around the unit looking for a nurse, other
than Nurse A, who could co-sign for the breast milk she was going to administer. During this
time, Nurse Bs patient self-extubated and coded. The alarms on the ventilator were ringing
loudly, but were unable to be heard by Nurse A since the door had been shut between the two
nurseries. The nurses in the nurses station heard the alarms, but assumed that Nurse B was in

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her room, and had been made aware that everything was under control. Upon returning back to
the room, Nurse B discovered that her patient had self-extubated and was laying there lifeless (D.
Martinez, personal communication, September 1, 2014).
Root Cause Analysis
Certainly, this situation could be perceived as the fault of Nurse B and her negligence.
However, was it really just negligence that caused this patients premature death, or was it a
combination of many factors? In 1997, RCAs were mandated as a tool to investigate substantial
clinical errors (Iedema et al., 2006). RCAs attempts to draft causal relationships from latent
factors that helped form the incident, devise conclusions and recommendations that target failed
systems and organizational processes instead of individuals (Mengin & Nicolini, 2010). This
broadens the scope of the situation and takes into consideration the clinical practice as a whole.
The patient, in this instance, did not just die because of the nurses negligence; a hostile
environment, failed technology, poor leadership and management, and a complex floor layout
also contributed to this tragedy.
Communication
Both inappropriate communication and lack thereof occurred frequently at this hospital
in the Bay Area (D. Martinez, personal communication, September 1, 2014). Nurses here
experienced hostility, intimidation, racial slurs, and other demeaning forms of communication.
According to Addison and Luparell (2014), communication breakdown is one of the top three
most frequently identified root causes of sentinel events (p. 67). A survey taken from registered
nurses, physicians, and administrators showed that between 83% and 94% experienced
disruptive behaviors creating things such as, stress, frustration, loss of concentration, reduced
team collaboration, reduced information transfer, reduced communication, and impaired nurse-

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physician relationships (Rosenstein & ODaniel, 2005, p. 57). Disruptive behaviors and
communication can also cause a disturbance of concentration (Addison & Luparell, 2014).
When nurses have insufficient concentration, and their attention is shifted due to lateral
incivility, patients unintentionally become victims (Bigony et al., 2009). Those who are bullied
are likely to refrain from communicating with those who are intimidating, which is also
detrimental to patient safety. Nurse B felt intimidated by Nurse A and avoided asking her to cosign the breast milk or even watch her babies while she stepped out; this represents a lack of
communication between nurses. Open communication should be encouraged between nurses,
nurse managers, and other health care workers. Competence in communication enables nurses to
solve inevitable conflicts, maintain patient safety, and prevent human related errors that can
occur in the healthcare setting (Tsai, Tsai, Weng, & Chou, 2013).
Management
Management is an essential aspect for high functioning teams. The nurse manager of the
NICU where this incident occurred ignored the uncivil behaviors. She even contributed to them
by accommodating the nurses and meeting their requests not to work near one another.
Frequently in health care, inappropriate behavior is excused and normalized, even being
accepted as a status of the profession (Addison & Luparell, 2014, p. 67). Sometimes managers
are even more willing to tolerate incivility from nurses who excel at the bedside (Ceravolo,
Schwartz, Foltz-Ramos, & Castner, 2012). However, many nurse managers are not properly
equipped to handle incivility issues in the workplace. Nurse managers often report feeling
undereducated about bullying and lateral violence and do not feel supported by their
organization as a whole (Croft & Cash, 2012, p. 234). In order for this behavior to stop, action
needs to be taken by nurse managers and the wider organization. Managers need to have the

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skill set to lead by example and properly guide the staff to allow for a safe and civil work
environment, instead of contributing to inappropriate behavior.
Equipment & Technology
In todays society, technology is relied upon for several day-to-day tasks; however,
sometimes equipment and technology can be faulty and unreliable. According to Silva, Reis,
Aguilar, & Fonseca (2012), unplanned extubation requiring reintubation is the fourth most
common adverse event (p. 5). Endotracheal (ET) tubes are often used in the NICU due to the
underdevelopment of the lungs in the premature infants and their inability to oxygenate properly.
Up to 13.3% of mechanically ventilated patients could experience an unplanned extubation,
which is approximately equivalent to a rate of two to three events every 100 days (Oliveira,
Cabral, Schettino, & Ribeiro, 2012). Two of the most common causes of an unplanned
extubation are inadequate securement and dislodgement of the ET tube (Veldman, Trautschold,
Weib, Fischer, & Bauer, 2006). Infants in the NICU have very thin, fragile skin, requiring ET
tubes to be taped down using skin protectant tape. Since humidification is used in conjunction
with ventilation, the skin protectant tapes do not adhere well and are easily removed. Infants
have a tendency to bring their hands to their face and become especially active when they are
agitated; which increases the incidence of ET tube dislodgement. Subsequently, the most
effective adhesives should be implemented to preserve their skin integrity and decrease the
incidence of unplanned extubation.
Environment
In the NICU, there are three main design layouts: open-bay wards, semi-private rooms
and single family rooms (Jobe, 2014). The hospital where this incident occurred has single
family rooms with sliding doors between three of the rooms, connecting them to one another.

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Although single family rooms are more conducive to family-centered care and privacy, they
pose risks for patient safety. Nurses feel more isolated from their colleagues and have an
increased dependence on electronic monitoring (Domanico, Davis, Coleman, & Davis, 2010).
Furthermore, nurses express a deep concern for providing adequate care for their patients and
intervening before medical emergencies arise in single family rooms (Domanico et al., 2010). In
order for infants to be monitored at all times, more staff members would be needed.
Unfortunately, many hospitals are understaffed with a high census, with the majority of them
being high acuity (Ferrer et al., 2014). It is not possible for every infant to be monitored at all
times. Central monitoring systems and communication systems need to be established to provide
nurses with status updates on their patients, even from distant locations (McGrath, 2005). In
addition, policies regarding when doors can be safely opened and closed need to be encouraged
and implemented.
Targeted Change, Stakeholders, and Their Concerns
The targeted change is to prevent future sentinel events, specifically related to workplace
incivility. Stakeholders, in this case, include anyone who has a vested interest in a clinical
decision and the evidence that supports that decision (Agency for Healthcare Research and
Quality [AHRQ], 2014, p. 11). Communities take incivility seriously and are also concerned
with incivility in healthcare and the associated patient deaths. They want to know what actions
are going to be taken to prevent them. Patients are one of the main stakeholders since they are
under the direct care of nurses, and are often times the inadvertent victims of incivility. The
members of the community are also stakeholders, as they are potential users of health care.
Incivility in communities, especially in school systems, has become problematic and has led to
the formation of activist groups and awareness campaigns in communities across the nation

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(Maughan, 2012). This heightened awareness reached national levels, and has led to the
establishment of National Bullying Prevention Month, where activities are held across the nation
in an attempt to unite communities and stop bullying (Maughan, 2012). Healthcare providers,
such as nurses, are stakeholders and are the main targets for initiating change because they
provide direct patient care and are at the heart of medical decision-making. The providers are
working in unhealthy, hostile environments resulting in mistakes. They want to know how they
can make their environment safe and comfortable in order to provide the best patient care. The
government is a stakeholder, as they create healthcare policies, public health programs, and
determine health insurance coverage. Insurers, manufacturers, and researchers are among other
stakeholders. Stakeholder involvement improves the research process and also ensures that the
proposed plan is applicable for the situation (AHRQ, 2014).
Target Population and Their Attitudes, Beliefs, and Knowledge
Physicians, nurses, nurse managers and hospital administrators are the target individuals
that will be utilized in order to produce the desired outcome. Providers are well aware of the
incivility occurring in the workplace, with many of them having personal experiences.
According to Nikstaitis and Simko (2014), more than 85% of nurses have been victims of
incivility. Furthermore, nurses are well aware of the potential outcomes related to incivility; up
to 46% of nurses know of an adverse event that occurred because of this inappropriate behavior.
Disruptive behavior and bullying creates an unhealthy work environment, which causes
providers to be dissatisfied with their job, and often results in decreased retention rates of
employees. Additionally, many nurses will leave their job once they realize the damage that
incivility causes. However, when that option is unavailable or not easily attainable, nurses will
then consider avoiding work altogether. Absenteeism is becoming a mechanism that nurses use

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to cope with increasing amounts of bullying and conflict within the workplace (Felblinger,
2009). Nurses will often relate their absenteeism to being sick; therefore, they will still be
getting paid, making their decision to avoid workplace aggression as an easy and practical option
as a way to protect themselves from further incrimination (Felblinger, 2009).
Carrying a high sense fulfillment is important with any career; especially for nurses.
Often times, when aggressive and hostile behaviors are allowed to sustain and are avoided
within the hospital, nurses feel disconnected from their work which weighs heavily on their
sense of fulfillment, the hospitals overall productivity, and the financial repercussions that
follow from having a decrease in effective team members (Felblinger, 2009). Similarly, this
makes leaving work that much easier for nurses due to the lack of connection they feel to the
place in which they work.
In addition, nurse managers have many roles and responsibilities, one of which is
addressing incidents and complaints in order to maintain a safe environment (Ostrofsky, 2012).
In order for change to occur, nurse managers need to have the skills to model and reinforce civil
behavior. However, many nurse managers feel that they do not have sufficient support to stop
these uncivil behaviors (Ostrofsky, 2012). Nurse managers need the support of hospital
administration and need to be mentored by these leaders. The hospital administration is
responsible for supporting nurse managers and providing them with the tools they need, which
will create a more supportive environment. Unfortunately, hospital administration may not be
aware of the significance of incivility in the workplace, as it is often underreported (Nikstaitis &
Simko, 2014). Awareness surrounding incivility is the first step in perpetuating change.

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Lewin Change Theory, Plan for Change, and Implementation

There are a multitude of theories that can be used to direct change in healthcare. Kurt
Lewins Theory of Planned Change is a framework consisting of three stages: unfreezing,
moving, and refreezing (Shirey, 2013).
Unfreezing Stage
The unfreezing stage involves preparing for change. Nurse managers need to recognize
that incivility is a significant problem, and that there is a need to change these behaviors. In
2008, The Joint Commission stated, organizations that fail to address unprofessional behavior
through formal systems are indirectly promoting it (p.1). It is essential that hospitals recognize
and address lateral violence; recognizing these behaviors calls attention to them and helps nurses
identify them as negative. Teaching nurses about what constitutes lateral violence will also
eliminate discrepancies related to thoughts and opinions about lateral violence (Dimarino, 2011).
This will decrease confusion and allow employees to see the need for interventions.
Nurse managers should encourage employees to form a powerful group that can initiate
change (Shirey, 2013). This can be done through motivating staff members to speak up about
their experiences with incivility, and empowering them to take a stand. By actively participating
in this process, nurse managers can understand the behavioral problems occurring on the unit and
be part of the solution. According to Coursey, Rodriguez, Dieckmann, and Austin (2013),
managers must be active participants in the change process in order for lateral violence policies
to be effective. Additionally, clinical settings have a complex interdisciplinary social network.
Working together strengthens communication and relationship skills (Coursey et al., 2013).
Once employees form a cohesive group, members need to approach hospital administrators with

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information about the prevalence of incivility on their unit in a way that insists the need for
immediate change.
Moving Stage
The next stage of Lewins theory looks at change as a process (Shirey, 2013). In the
moving stage, a plan of action is created and detailed. The core group initiating the change must
engage others to participate in this movement. The steps towards change involve managerial and
staff nurse education, workshops to improve effective communication, policy development and
enforcement, and a code of conduct contract.
Managerial education.
Many nurse managers feel they do not have the appropriate support from administration.
Additionally, nurse managers lack the necessary skills that apply to incivility and dealing with
disruptive behaviors. Coursey et al., (2013) found that in a survey with over 600 responses from
nurses in the southeast United States, most comments suggested that ineffective managers make
lateral violence worse. Therefore, nurse managers must first advocate for themselves, and ask
administration for proper training to become successful leaders of change. Education empowers
individuals to know how to prevent incivility, what to do if caught in an encounter, and how to
handle the situation properly.
Staff nurse education.
Mandatory education workshops will be held at the hospital throughout the year for all
staff nurses. This workshop will bring light to the seriousness of the issue at hand, and discuss
the negative consequences that are affecting both staff and patients. The presentation will
discuss items such as: a description of disruptive behaviors, policies and procedures in place
regarding these behaviors, and how to handle these behaviors when witnessed. This workshop

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should involve the audience with role play of potential situations, and discussions on how it
should be handled. The attendees should leave the seminar with confidence in being able to
recognize disruptive behaviors and how to report it, knowing that the management team stands
completely behind them. This will help increase awareness of the incivility that is occurring in
the workplace and the importance of creating and implementing policies and procedures in
regards to how to deal with this type of behavior. According to Rosenstein (2002), education
was the second most recommended solution for disruptive behavior. Also, Longo (2010),
reported that nurses need to be aware of their own actions, and need to develop the skills
necessary to confront and report disruptive behaviors. Had Nurses A and B been educated on the
effects of their uncivil behavior towards each other, this possibly could have prevented the death
of this innocent life.
Lux, Hutheson and Peden (2012) composed a study involving nine nurses from three
separate hospitals in Ohio. They were asked to answer the following seven questions: describe a
time when you successfully managed a disruptive colleague, describe your response to the
situation, what education or life experiences guided your response to the situation, what was the
outcome of the situation, has the ability to successfully manage disruptive behavior improved
over your nursing career, how can nursing education prepare new graduate nurses to manage
disruptive behavior, and any other comments or concerns. The participants indicated they
decided to confront the disruptive behavior of their colleagues in order to ensure the safety of
their patients, prevent the incident from happening again, and to keep a healthy work
environment. The nurses decided the following ways contributed to successfully managing
disruptive behavior: the timing of the confrontation should be at the time it occurs if patient
safety is compromised, or soon thereafter if it can wait. The confrontation should be done in

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private, unless it is urgent due to a patient safety issue; the confronter should remain calm, listen
and acknowledge the perpetrators side of the story, clearly identify the disruptive behavior, and
discuss ways to approach the incident in a non-disruptive manner. The participants identified
that they learned from experience, and how co-workers react to certain situations by working
alongside them (Lux, Hutheson & Peden, 2012).
Explaining and illustrating examples on how to successfully manage disruptive behaviors
would be beneficial to nurses on the unit. Implementing the idea from this study and providing
an annual mandatory class discussing disruptive behavior, communication, and conflict
management would help them understand ways to successfully handle disruptive behaviors.
Providing and explaining examples after the class on how disruptive behaviors were
successfully managed based on personal stories could help nurses relate and understand on a
deeper level.
Nikstaitis and Simko (2014) utilized the Nurse Incivility Scale to screen for incivility.
The survey is used to measure the amount of incivility nurses experience within their workplace.
It is comprised of 41 questions with a 5 point Likert scale, with responses ranging from never to
very often (Nikstaitis & Simko, 2014). This tool can be utilized one week before and 4 weeks
after the conflict management, assertive and effective communication, and disruptive behavior
class. A baseline measurement of staff incivility would be obtained before the class. Afterward,
it would measure adherence and success of the class in decreasing disruptive behavior among
staff members.

Effective communication workshop.

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Ineffective communication is a significant factor as to why the incident above occurred.

Improving communication between nurses can help decrease workplace incivility because
messages will be better conveyed, and will leave less room for confusion or frustration.
Ceravolo, Schwartz, Foltz-Ramos, and Castner (2012) suggests holding 60-90 minute
workshops to improve communication between nurses, specifically assertive communication,
healthy ways to resolve conflicts, and reducing the silent nurse culture. The researchers
surveyed nurses on seven criteria pre and post workshop, they were asked to vote whether they
agreed or strongly agreed with the following statements: I feel respected by peers, I feel
supported by peers, I have good working relationships, peers respect my opinions, work is a safe
environment to express my opinions, I resolve conflict through direct conversation, and I have
not gossiped in the last month. The researchers found the following results post workshop:
respect by peers went from 78% to 88%, peer support went from 75% to 87%, good working
relationships went from 64% to 75%, respected opinions went from 64% to 72%, feeling safe to
express opinions went from 52% to 63%, resolving conflict through direct conversation went
from 48% to 54%, and not gossiping in the last month went from 38% to 45% (Ceravolo et al.,
2012). Sending nurses to short workshops could be an easy and effective way to decrease the
rates of lateral violence. Providing a workshop of this nature to the nurses of this unit could be
beneficial to improve relationships, increase respect for one another, and most importantly, allow
them to communicate with each other more effectively.
Policy development and enforcement.
Developing a clinical nurse specialist (CNS) position for the unit would be valuable in
terms of updating and creating policies. A study by Linck & Phillips (2005) resulted in a CNS
being highly beneficial to the healthcare team. Other roles of the CNS include provision of

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bedside consultation regarding crisis, intervention and conflict resolution, staff education, and
support for staff morale (p. 47). Upon utilizing the CNS role as the part of the team, all
outcomes including: employee engagement, nurse retention, and policy and code compliance
were all improved. Additionally, the results showed nurses awareness of management support
in both disruptive and abusive situations as being statistically significant (Linck & Phillips,
2005). Clinical nurse specialists are highly trained in their area of expertise, and would be an
appropriate person to update and develop policies. Having a designated person responsible for
this task will assure that policies are up to date and better enforced.
Lack of policy enforcement can be a source of frustration for the nurse experiencing
incivility. Through research conducted by Coursey, Rodriguez, Dieckmann, and Austin, they
found that policies are better enforced when the following four elements are present:
Changing behaviors in ways that encourage a culture that supports lateral violence
policies, involving nursing administration with nursing personnel frequently and
consistently, including in matters relating to lateral violence, intentionally changing
policy and the environment, and implementing multiple interventions simultaneously that
may not be effective when used alone (2013, p.105)
Management is in a position of authority, and those in authoritative positions are in
positions of power. Employees are not going to follow zero-tolerance policies if management is
turning a blind eye about lateral violence, or worse, participating in it. If managers had zerotolerance policies in place, the incivility between the nurses that contributed to the patients death
could have been prevented.

Code of conduct contract.

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Dimarino (2011) suggests having staff members sign a code of conduct when becoming a
member of a unit. She employed this strategy as the manager of an ambulatory surgical center,
and reports that she has had no staff turnover due to lateral violence in 2010. Additionally, she
reports that there were no reported incidences of lateral violence for the same year (Dimarino,
2011). The code of conduct contains the following statements: treat colleagues with the utmost
respect, courtesy, and civility, always act in a professional manner toward fellow employees,
patients, and family members, work as a member of the team to achieve the common goals of the
surgery center, negative behaviors will not be tolerated in the workplace and will be subject to
disciplinary action, and employees are expected to recognize and report misconduct to
administration and may do so without fear of reprisal (Dimarino, 2011, p. 586). By creating
clear expectations that employees are well-informed of, this holds them accountable for their
actions. In regards to the above incident, including a code of conduct would provide a means of
accountability to hold nurse A and nurse B to.
Refreezing Stage
The last stage of Lewins theory is the refreezing stage, which involves incorporating the
planned changes into the culture of the unit to be utilized at all times. Nurse managers and
leaders must ensure that there is continuous training, support, and feedback in order to make this
change successful. These changes will lead to a safer, more comfortable work environment
leading to safer patient care, with a decreased amount of sentinel events. Some adjustments may
need to be made depending on the needs of the department. There will undoubtedly be
challenges because of all the changes that are being implemented, but the unit will have to work
as a team to make the change successful.
Budget

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A prospective budget was formulated to determine the costs of the actions outlined in the
change plan. An approximate cost of $138, 309 will be needed in order to initiate and invoke
these changes to combat incivility. Sadly, no amount of money can bring back the infant whose
life was taken as a result of disruptive behaviors. However, future deaths can be prevented if
appropriate changes are implemented and enforced. With this budget, staff members can be
properly trained and educated on the tragic effects that incivility causes.
Conclusion
Unfortunately, incivility is common in the workplace and has devastating effects on
patient care and patient outcomes. In the case of the infant in the Bay Area NICU, death was the
consequence. Because of their devastating consequences, sentinel events can and should be
prevented. The root cause analysis effectively outlined underlying factors that contributed to this
unfortunate event; it is an important tool to prevent future sentinel events. Kurt Lewins change
theory assisted with analyzing the best way to apply changes. Workshops aimed at improving
communication and education for nurse management can improve communication skills and
better prepare nurses to deal with incivility. Additionally, having policies updated by a clinical
nurse specialist, and having nurse managers increase enforcement of these policies provides the
means to correctly deal with incidents of this nature. In addition, proper training for nurse
managers will allow them to recognize these behaviors and take appropriate disciplinary action.
Lastly, having employees of the unit sign a code of conduct contract will inform employees of
their expected behavior and consequences if they do not behave accordingly. The loss of an
innocent patients life cannot be replaced, but healthcare professionals can learn from the
mistakes of others and strive to not let it happen again.

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Appendix A

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Appendix B. Preventing Incivility in the Workplace Budget

Year: 2015
Organization: Bay Area Hospital
Submitted by:
Budget Planning: Total Budget: $138,309
Line

Items

Description/Justification

Qty.

Study on
incivility on
the unit

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)

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24

Nurse
manager
training

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)

Materials
for nurse
manager
training

Videos, paper materials, powerpoint presentation

Focus
groups

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)

12

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)

Materials
for
workshops

Snacks, water, videos, paper materials, powerpoints

Tools for
measuring
outcomes

Paper materials for surveys, individuals to analyze results, computer program