Running head: INCIVILITY IN NURSING

Making Changes to Stop Incivility in Nursing

XXXXXXXX (with permission)
Kaylee Blankenship, LeAnna Ceglia, Maggie Fabry, and Noel Silveira
California State University, Stanislaus
May 12th, 2014

INCIVILITY IN NURSING

Making Changes to Stop Incivility in Nursing

Mason Michael discovered from a high school lab assignment that his AB Blood Type
was incompatible with his Type A parents. Genetic testing expeditiously confirmed that he was
not the biological son of Megan and Matthew Michael. How did this nightmare happen? How
had his family lived with a stranger for 15 years? A revelation would soon prove that Mason
Michael was switched at birth in the midst of a sentinel event at St. Petersburg Medical Center in
Merced, CA. It would further prove that the undermining of the culture of safety and
involvement in workplace lateral violence by nursing staff leads to errors and mix-ups. These
glitches result in sentinel events and need to be addressed and corrected by hospitals under the
guidance of The Joint Commission.
Sentinel Event
A sentinel event is any type of unforeseen event resulting in the demise of, or large-scale
perpetual loss-of-function for a patient that is unrelated to their anticipated course of illness
(Joint Commissions, 1998). A specific type of sentinel event, the one that will be considered
in this case, is the discharge of an infant to the wrong family. Although this experience did not
result in the death of the child or a loss of function, a serious error like this has numerous
ramifications, and The Joint Commission considers it a reviewable adverse outcome (Joint
Commissions, 1998). As this paper will later explain, the presence of intimidating and
disruptive behaviors in the workplace have played a large role in this sentinel event, and also
contributes to many adverse outcomes in the hospital setting.
The term sentinel event is used because these events serve as warnings and alerts that are
issued by The Joint Commission (Joint Commissions, 1998). The Joint Commission
encourages, but does not require, organizations to report sentinel events due to the many benefits

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of doing so. These benefits include: support and expertise from The Joint Commission, the
opportunity to collaborate with a patient safety expert, the promotion of a culture of safety within
the organization, and a more positive outlook from the community (The Joint Commission,
2014). All reported events are investigated by The Joint Commission with the aim of improving
patient care, treatment, and services. The goal is to prevent future occurrences and to focus
attention on understanding the causes of the event. The Joint Commission also focuses on
changing systems and processes to reduce the likelihood of future occurrences (Joint
Commissions, 1998).
Sentinel events have a large range of causes. In the case of 15-year-old Mason Michael,
incivility played a major role (McNamara, 2012). Incivility, in nursing, consists of a lack of
regard for others, violation of workplace norms, disrespectful interpersonal communication, and
disruptive behaviors that hinder positive patient outcomes. When nurses fail to foster a culture of
safety, disastrous consequences can result (McNamara, 2012). This is exactly what happened
when Nurse Janet sent baby Mason Michael home with two, complete strangers.
Incivility and the Culture of Safety
Matthew and Megan Michael flew off the elevator like a bolt of lightning and scrambled
through the doors of the birthing center at St. Petersburg Medical Center. They had been waiting,
for what seemed like an eternity, for this day to come. Upon arrival, a friendly nurse with a
bright smile greeted the couple. Her name was Nurse Janet, and she would help them through the
most magical moment of their lives-the delivery of their first child.
Nurse Janet completed Megans intake interview, did her preliminary assessment, helped
her into a gown, and got her comfortably placed on the monitors. Megan was dilated to four
centimeters and labor was progressing as smoothly as one could hope. Three hours later, an

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angelic baby boy with big blue eyes made his way into the arms of the delivering physician, Dr.
Rocha. He was perfectly healthy and ready to be placed into the welcoming arms of his mother.
The two bonded for several hours before Mason was taken to the nursery for a procedural checkup by the unit pediatricians. Little did Matthew and Megan know, baby Mason would never
return.
The nursery was not unusually busy that day. Unfortunately, however, two nurses
scheduled to work the mid-shift called in sick just hours before they were scheduled to work.
This left just two nurses to care for the 12 newborns on the unit, and also required Nurse Giselle
and Nurse Janet to work four additional hours. Nurse Giselle and Nurse Janet had their hands
full with assessing, monitoring, and feeding the howling babies. Towards the end of their 16-hour
shift, Nurse Giselle asked Nurse Janet to assist her briefly with feeding so they could get the
newborns back to their mothers promptly. Nurse Janet verbally agreed, but her nonverbal
communication was conveying an entirely different message.
Nurse Janet had an unresolved issue with Nurse Giselle that stemmed from previous
incidences of lateral violence (Lewis & Malecha, 2011). Nurse Giselle had been pushing Nurse
Janet around, belittling her, and occasionally even raising her voice towards her. This had been
going on since Nurse Janet got hired as a new graduate one year prior. Some coworkers
suspected that Nurse Giselles troubles were based on the fact that Nurse Janet had a Bachelors
degree, while she, on the other hand, had only an Associates degree. Whatever the reason, this
unacceptable behavior exhibited by Nurse Giselle set the stage for a sentinel event to take place
(Lewis & Malecha, 2011).
As Nurse Janet sat quietly feeding Mason Michael and Benjamin Alley, Nurse Giselle
approached her. Nurse Giselle began performing repeat assessments on Mason and Benjamin,

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knowing well that Nurse Janet had already completed this task. These repeat assessments left
Nurse Janet feeling incompetent and belittled. When she was through, Nurse Giselle demanded
that Nurse Janet remove the newborns armbands and replace them, declaring that they were too
tight and would interfere with circulation. Nurse Janet did not feel comfortable with this switch
because she knew it was against hospital policy, and that duplicate armbands werent readily
available and needed to be printed. Unfortunately, Nurse Janet clipped the old bands because she
felt bullied and compelled to do so.
The unit clerk printed and delivered the new armbands to Nurse Janet, who was still
anxious and unsettled from the encounter she had with Nurse Giselle in the preceding moments.
Nurse Janet placed the armbands snuggly around the infants tiny ankles and wheeled them back
to their mothers. Mason Michael was now in the arms of Courtney and Dominic Alley, while
baby Benjamin Alley rested in the hands of Matthew and Megan Michael.
Root Cause Analysis
Definition
When an organization reports a sentinel event to The Joint Commission, they are also
responsible for disclosing the findings of their root cause analysis (Lambton & Mahlmeister,
2010). A root cause analysis is a retrospective analytical method used to meticulously look for
factors that may have contributed to the adverse outcome of the event. A key component to
conducting the root cause analysis is to focus on the failure of complex systems, instead of
focusing on the failure of an individual within the system. The main goal of this process is to
identify and uncover hidden factors that need correction (Lambton & Mahlmeister, 2010).
The framework for conducting a root cause analysis is typically outlined in a protocol within the
hospital (Agency for Healthcare, n.d.). There is a universal sequence of steps for conducting

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this analysis that may vary slightly from one system to the next, but typically includes data
collection, event reconstruction, participant interviews, and record reviews. All of these steps are
used to piece together the sentinel event and locate the broken link. Once the errors have been
identified, the institution can begin the process of implementing change in order to prevent
similar sentinel events occurring in the future (Agency for Healthcare, n.d.).
Environment
Upon scrupulous examination of this sentinel event, it was established that multiple
components played a part in the switching of the two newborns. One contributing factor was
environment. The fact that the department was short staffed on this particular day set the stage
for mistakes to occur, by establishing an unsafe nurse-to-patient ratio. There is a wealth of
evidence available that conveys inverse correlations between nurse-to-patient ratios and higher
incidences in negative patient outcomes (Halm, et al., 2005). One study demonstrated that when
nurses spend increased hours with their patients, mortality and complication rates decrease.
These complications include pneumonia, gastrointestinal bleeding, urinary tract infections,
shock and cardiac arrest. Another study that was conducted revealed that patients are at an
increased risk for adverse outcomes, including respiratory failure and reintubation, when the
nurse-to-patient ratio is 1:3 or higher. Not only does an increase in patient-to-nurse ratios put
added stress on nurses, it also can lead to emotional exhaustion. According to Halm et al., few
large studies that exist support the premise that higher nurse-to-patient ratios reduce the
incidence of emotional exhaustion and dissatisfaction for RNs (2005). Though the repercussions
of the medical error in this particular case were not physiologic in nature, a lasting social and
emotional impact on the families occurred.

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Another contributing factor to the creation of this unsafe environment was the fact that
both nurses were working overtime. Many healthcare organizations try to alleviate nursing staff
shortages by increasing work hours for nurses (Keller, 2009). While this seems like a quick and
easy solution, it, unfortunately, can create many negative consequences for both the patient and
the nurse. For the nurse, increased works hours lead to an increase in fatigue and a decrease in
alertness and productivity, which all negatively impact the employee's well-being. Shifts lasting
longer than eight hours cause nurses to make more medication errors, and increases the risk of
additional errors and near errors due to decreased vigilance (Keller, 2009). It isnt difficult to
understand why medical errors increase when nurses are both physically and mentally
overworked. Both Nurse Giselle and Nurse Janet worked four hours over their regularly
scheduled shift, making exhaustion a factor in the switching of the newborns.
People
The intention of investigating the people involved in the sentinel event is not to single
anyone out, but is meant to determine if there was a human error or a system error that occurred.
An examination of the actions of these two individuals involved in the sentinel event reveals that
Nurse Giselle and Nurse Janet both exhibited behaviors that undermine a culture of safety. Nurse
Giselle is guilty of this by requiring Nurse Janet to renew bands without the new bands readily
available, disregarding the fact that it is against policy. This was Nurse Giselles way of
belittling Nurse Janet and making her feel that her assessment failed to recognize a risk for poor
circulation due to the tight bands. Disruptive behaviors, like the ones demonstrated here,
negatively affect patient outcomes and nursing practice (McNamara, 2012). These behaviors can
lead to compromised quality of care, a decrease in patient safety, an increase in medical errors,
and increased mortality (McNamara, 2012). Evidence-based research shows that hostility in the

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acute care setting threatens patient safety by negatively influencing nursing actions (Wilson &
Phelps, 2013). It impairs nurses judgment, hinders the effectiveness of interventions, and alters
their behavior. One study noted that nurses who experience hostility on the clock are more likely
to carry out an order that they do not believe is in the best interest of the patient (Wilson &
Phelps, 2013). This is explicitly what Nurse Janet did.
Nurse Janet was also a contributor because she failed to respond to Nurse Giselles
intimidating behavior in a constructive manner. By changing the bands, she knowingly broke
hospital policy and jeopardized the safety of the newborns. Her judgment was clouded by fear,
anxiety, and intimidation. She failed to confront and report this year long conflict, thus allowing
the behavior to continue until it resulted in a medical error. Bullying in nursing is persistently
underreported (Franklin & Chadwick, 2013). The majority of events go unreported due to the
worry of retaliation. If the reporting nurse thinks that the offender will be protected from
reprimand, they are more likely to keep the harassment to themselves, as done in this case
(Franklin & Chadwick, 2013). Nurse managers and hospital administrators must be made aware
of conflict in order to intercede and find solutions (McElhaney, 1996).
Management
After an examination of the management was conducted, findings revealed that a handsoff administration approach was regularly used in this department. In this department, the
nursing staff was granted excessive autonomy and few interventions from management took
place. This administrative approach contributed to this sentinel event because the two nurses
were left unsupported and were given no help with conflict resolution. When backseat leaders
put too much trust in their employees without interactive feedback, employees are more likely to
fail to meet the set target actions (Schlachter & Hildebrandt, 2012). Specific to bullying, when

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nothing is done to intervene, the bully will simply continue bullying because they feel that they
have been given permission to do so (Longo, 2013). According to Longo, when no retribution is
seen, there is no need to change (2013). Nurse Giselle was allowed to continue to display these
disruptive behaviors because management failed to fully and effectively participate in the
ongoings of the department.
Management also failed, as a whole, to develop a workplace in which nurses felt that they
could report disruptive behaviors without retribution. As previously mentioned, when staff fears
retaliation or a lack of action by management, rates of reporting decrease.
Policy & Procedure
The investigation of the policies and procedures related to the sentinel event led to the
identification of key system failures. Although Nurse Janet knowingly broke procedure, a
fundamental education and availability of policies and procedures was also lacking in the
institution. Policies and procedures are an integral part of the proper functioning of a hospital
(Randolph, 2006). Policies and procedures help by establishing standardized practices, reducing
the amount of disparities in practice, and increasing adherence and compliance to rules and
regulations within the institution (Irving, 2014). Due to the fact that policies and procedures
serve such an important function within hospitals, quick and easy access to them is crucial to
success. Unfortunately, the policy and procedure handbook in this particular hospital was
printed rather than electronically accessible. According to White, printed manuals can be
confusing and can become outdated quickly (2010). Electronically accessible manuals, however,
allows all employees to have easier access to standardized information (White, 2010).
Staff should take time to periodically review these documents and ask supervisors for
clarification in order to avoid patient harm (Randolph, 2006). All new policies need to be written

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clearly and concisely, so that errors, mix-ups, and misunderstandings do not occur. Ultimately, it
is the nurses responsibility to know the policies before performing a procedure and it is the
administrations job to make sure nurses are well versed with the material (Randolph, 2006).
Communication
In nursing, communication isnt merely the giving and receiving of information. It is the
foundation of patient safety and is crucial in transitions between caregivers and healthcare
professionals (Laskowski-Jones, 2014). Nurse Giselle disregarded this concept when she
continually demeaned, micromanaged, and made ongoing derogatory remarks towards Nurse
Janet. Her communication style was ineffective and conveyed passive aggressive violence
toward Nurse Janet, thereby setting the stage for a medical error to occur. The Joint Commission
estimates that nearly 80% of medical errors are made solely because of miscommunication
(Seifert, 2012). Although this particular sentinel event was more a result of bad communication
rather than miscommunication, it is still important to address the issue.
According to Ennis, Happell, Broadbent, and Reid-Searl, leaders who approach
communication in an open and frank manner are considered more informative by their peers.
Communication from those in leadership roles is regarded as more than an exchange of
information and includes an interpersonal process that can have a direct impact on clinical care
and a teams performance (2013). Research has shown, that when used in an effective manner,
communication skills can empower and support peers in addition to improving responsiveness
and increasing efficiency (Ennis, Happell, Broadbent, & Reid-Searl, 2013). Although Nurse
Giselle was not a manager or supervising official in this event, every nurse has the opportunity to
be an effective leader. This is especially true in this case given the fact that Nurse Giselle is
senior to Nurse Janet, and has a broader knowledge base and scope of experience. Nurse

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Giselles experience gave her a perfect opportunity to perform teaching and provide guidance to
Nurse Janet regarding her assessment of circulation. Instead, she used ineffective and
intimidating communication which resulted in the accidental switch of the newborns.
While Nurse Giselle lacked education on therapeutic communication and leadership
skills, Nurse Janet lacked education regarding assertiveness. Using assertiveness in the
healthcare setting plays a role in patient advocacy and ensuring that all patients receive
appropriate and safe care (Weiss & Tappen, 2015). Both nurses seemed to lack proper training in
the concept of effective communication, which could be a result of a systematic failure of the
hospital to provide educational opportunities. According to Ak, Cinar, Sutcigil, Congologlu, and
Haciomeroglu, the number of undesirable nursing errors decreases significantly when nurses are
provided with communication training (2010). Therefore, this lack of training can be viewed as a
contributing factor to the sentinel event that needs to be addressed.
Change Driven Action Plan
The product of the root cause analysis is an action plan (Joint Commissions, 1998).
This plan must identify the strategies that the hospital proposes to implement in order to reduce
the risk of subsequent analogous events from occurring. The Joint Commission requires that the
plan addresses responsibility for implementation, oversight, pilot testing as needed, time lines,
and strategies for measuring effectiveness (Joint Commissions, 1998).
Targeted Change
Although the root cause analysis revealed many separate issues that all acted as
contributing factors to the sentinel event, the largest, and most direct factor was that of incivility
between the two nurses. Therefore, the targeted change is to curtail incivility in nursing and
keep it from causing further sentinel events. This includes removing behaviors such as lateral

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violence, scapegoating, relational aggression, oppression, and negativity amongst staff members.
These behaviors should be replaced with kindness, teamwork, direct communication,
constructive behaviors, acceptance, and collaborative problem solving (Donnelly, 2013). The
change, outlined below, will be comprehensive and address all aspects of the system failure.
Stakeholders and Roles
Hospital stakeholders can be partitioned into three groups- internal, interface, and
external (Fottler, Blair, Whitehead, Laus, & Savage, 1989). The internal stakeholders include
management, professional staff, and non-professional staff members. They operate entirely
within the defined boundaries of the institution and are important for the maintenance of the
hospital functioning. According to Lyne Quines research study, based on the extent of workplace
bullying in United Kingdom hospitals, 38 percent of nurses have reported being bullied within
the last year (Stevens, 2015). Of the same population, 42 percent of those nurses have witnessed
the bullying incidents. Another study Quine conducted showed that of 462 British midwives, 46
percent have reported being bullied. These percentages are very high, amounting to almost half
of the hospitals nursing population. Of the 46 percent of midwives who reported being bullied,
55 percent have considered leaving their job within a year (Stevens, 2015). Decreasing incivility
would decrease turnover of these staff members and improve job satisfaction while maintaining
an effective operating framework (Fottler et al., 1989).
Interface stakeholders consist of the physicians, hospital board of trustees, corporate
parent company, stockholders, taxpayers, and other contributors (Fottler et al., 1989). These
individuals function both in and out of the hospital setting. They are important for the
maintenance of financial balance and success of the hospital system as a whole. According to
Hibbard, Stockard, and Tusler, a study was conducted based on making hospital performance

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reports public (2015). What the study found was that hospitals, whose performance reports were
made public, believed that it would affect their public image and reputation. Having a poor
reputation was found to affect not only their client population, but also their investors. If a
hospital has a poor image to the public eye, then investors and taxpayers will want to see their
money go elsewhere. Therefore, these hospitals were found to be more motivated to fix the areas
that needed improvement in order to avoid a poor performance report (Hibbard, Stockard, &
Tusler, 2015). One of the biggest contributors to poor patient care and satisfaction that can lead
to a poor report is lateral violence. This includes between both health care staff members and
their patients. A reduction in occurrences of lateral violence would prevent sentinel events and
reassure these factions that their monetary contributions to the hospital are sound investments
(Fottler et al., 1989)
External stakeholders are made up of patients and third-party payers (Fottler et al., 1989).
They function entirely outside of the organization and provide monumental input. The
relationship between the hospital and these external stakeholders is symbiotic and
interdependent. According to Johnson, a hospitals reputation is the key to its success, and the
patients are the individuals who give a hospital its reputation (2014). Johnsons research was
based off of the study of the National Research Corporation Market Insights Survey (2014). This
survey is considered the largest health care consumer survey in the United States. The survey
found that eight percent of patients rated their hospital experience poor enough to not reuse the
services themselves nor recommend the facility to family or friends. As a consequence of losing
these patients, the hospital will also lose money. However, if the patient has a positive and
highly engaged experience with their hospital, not only will they return for the services, they
may also bring more patients to the facility (Johnson, 2014). The hospital depends on these

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stakeholders for its survival. Incivility that leads to sentinel events would deter these
stakeholders from utilizing hospital services and impact the hospital significantly (Fottler et al.,
1989).
Target Population
The targeted population that is specific for this modification of behavior is nurses and
nurse managers (Lewis & Malecha, 2011). The goal is to set standardized expectations regarding
mutual trust and respect between all members of staff. Implementation is crucial because
relationships between nurses, managers, and peers are critical to healthy work environments.
With that being said, it is important to understand that each of these individuals and positions
have specific roles. The role of the nurse manager is to set the tone of the environment (Lewis &
Malecha, 2011). More specifically, they are responsible for the quality of nursing practice and
the care provided to their nurses and patients. Nurse managers oversee all budget matters and
personnel while maintaining an environment that encourages employee engagement and
professional practice to thrive (Cipriano, 2011). The role of the floor nurse is to work
collaboratively and cooperatively with co-workers and patients, in order to provide the safest and
most efficient patient care possible (Lewis & Malecha, 2011). To get a nurses perspective on
the issue of incivility or standardized expectations, other than through research, an interview was
conducted with a floor nurse at Memorial Medical Center in Modesto, California . The registered
nurse agreed that nurses need to work together and that managers play a huge role in the
dynamic of that relationship (J. Smallwood, personal communication, October 30, 2014). Her
attitude towards incivility was strong. She implied that all nurses have a duty to their patients and
that there is simply no room for dramatics in the workplace. Janet, the interviewed nurse,
regarded passive aggressive and undermining behaviors as a useless waste of time that needs to

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be addressed and resolved immediately. The nurse should be terminated if patient safety is
risked. Smallwoods overall message involved the absolute need for the implementation of a
change in current practice in order to put an end to incivility (J. Smallwood, personal
communication, October 30, 2014).
Plan for Change Using Lewins Theory
Unfreezing
The first step in Lewins change theory is unfreezing (Goldberg & Sifonis, 1994). This
stage requires a nurse or nurse manager to first recognize the need for change (Shirey, 2013). An
analysis of the environment must then be carried out in order to recognize the differences
between the current state, an environment that is negatively affected by incivility, and the desired
state, an environment free of incivility. This is followed by increasing the driving forces that will
direct behavior away from disruptive behavior (Shirey, 2013). For instance, staff will be
reminded during report that they are to write down each instance of lateral violence they witness
that day. This information will be used for review at a weekly staff meeting, thus bringing
awareness to how often this violence occurs, as well as the affects it has on the staff as a whole.
The ultimate goal is to have fewer instances of lateral violence, which will lead to fewer adverse
patient outcomes and sentinel events. As occurrences of lateral violence decrease, so too will the
frequency and length of these meetings.
To better prepare staff to deal with disruptive behavior, administration will work with the
education department. They will collaboratively implement programs that teach skills and
confidence building exercises for the management of unacceptable behaviors (Goldberg &
Sifonis, 1994). One such improvement is to educate staff on the cognitive-behavioral approach
(Flateau-Lux & Gravel, 2014). This consists of rehearsing prototypical responses to the most

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often occurring types of bullying so that nurses will be more confident in addressing the issue
when it occurs. This assertive technique was tested in a study using 26 new registered nurses in
Boston, Massachusetts and was proven effective. Using this approach provides the staff with
effective conflict management skills and effective strategies to reduce or eliminate lateral
violence by confronting their offenders (Flateau-Lux & Gravel, 2014). Administration will use
evidence-based techniques, as mentioned above, to initiate change and provide resources for staff
to review prior to making that change. The goal is for staff to understand that administrators are
objective in the process (Goldberg & Sifonis, 1994).
Decreasing resistance to change is another aspect of unfreezing (Goldberg & Sifonis,
1994). Change occurs rapidly in healthcare due to restructuring the workplace, advancements in
technology, and the need for efficiency and growth (Curtis & White, 2002). Healthcare workers
are affected by these constant changes and it can cause feelings of stress, uncertainty, ambiguity,
and the loss of control which results in resistance to change. Nurse managers attempting to
Implement new programs or strategies to decrease lateral violence, need to recognize that these
feelings of resistance are likely to occur. Decreasing resistance can be accomplished using
several strategies. Introducing the change slowly allows nurses to adjust and to accept the change
without becoming overwhelmed. Allowing nurses to actively participate in the planning and
implementation of change reduces uncertainty and increases acceptance of change. Providing
education regarding the benefits of the change should be discussed frequently through discussion
and presentations so that nurses are aware of the purpose or goal of the change. Also, developing
a sense of trust and support between management and employees allows for an easier transition
through change because staff will feel more comfortable with asking questions, requesting
guidance, and giving feedback. This sense of trust will help to ensure that events of lateral

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violence do not go unreported due to a fear of retaliation. While resistance will occur with any
change, its important that its not viewed as a threat, but as an opportunity to improve the work
environment. Its up to management to implement and enforce these changes in a supportive
manner (Curtis & White, 2002).
Changing and Moving
The second step in Lewins theory is change (Goldberg & Sifronis, 1994). This stage
involves implementing the changes that were designed by nurse managers to improve the work
environment (Shirey, 2013). The proposed action plan of weekly meetings and discussions will
officially begin with the guidance of management. Nurse managers will be expected to be a
source of support for new nurses (Khadjehturian, 2012). They will be taught to talk, listen,
clarify, and mediate. Team meetings will be held at the beginning of each shift and will address
nurses concerns and patients needs. This is intended to encourage teamwork, raise morale, and
promote effective communication (Khadjehturian, 2012). It can be rewarding to make changes
and work towards a solution that, when implemented, creates an environment that benefits
everyone (Weiss & Tappen, 2015).
Its important to address disruptive behavior in the weekly meetings but, its also
important to address it directly following its occurrence. In the event of lateral violence, physical
proximity promotes a supportive environment and nurses will be advised not to walk away when
they see bullying (Khadjehturian, 2012). They should stand behind the victim and show strength
and support, especially with novice nurses because they are less likely to stand up to experienced
nurses. There becomes a shift of power when a nurse exhibiting bullying behavior is confronted
by several nurses rather than just one (Longo, 2010). Sometimes this alone resolves the issue of
disruptive behavior (Longo, 2010). Nurse managers should also always be made aware of these

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incidents (Khadjehturian, 2012). Stopping disruptive behavior in the instance that it happens
helps to reduce negative outcomes (Trossman, 2014). A qualitative study was done by
interviewing nine nurses, who had experience with disruptive behavior, about how to
successfully manage it. It was a consensus that situations were handled more effectively when
handled calmly, in a private setting, and when each nurses point of view was taken into
consideration (Lux, Hutcheson, & Peden, 2012). These are all things that can be implemented
and discussed in the weekly meetings.
A zero-tolerance policy for any bullying or aggression should be created and
implemented (Khadjehturian, 2012). This should be a collaborative effort in which
administrators, nurse managers, staff nurses, physicians, and other members of the healthcare
team work together to take responsibility for the environment in which they work (Rocker,
2008). The policy should outline the goals for an anti-bullying environment which includes the
following: treating nurses and patients with dignity, respect, and fairness, preventing demeaning
behaviors such as discrimination or exclusion, communicating openly and constructively, being
creative with handling conflict, making full use of nurses talents, and developing positive
behaviors (Rocker, 2008). The policy should also outline a code of conduct that describes
behaviors that are considered to be disruptive (Longo, 2010). The actions that need to be taken
following a breach should be clearly outlined. Staff members that choose to break policy should
be mentored and guided on ways to improve their behavior and interactions with other staff
members and patients. If behavior does not change after mentoring, mandatory classes will be
available for the patient to attend to address their behavior. Its important that these steps in
correcting behavior are well documented. The last step in addressing breaches is disciplinary
action that can result in suspension or termination if behavior does not change and adhere to

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policy. The Policy should be easy to understand and easily accessible to review (Longo, 2010).
The importance of the enforcement of this policy will be re-emphasized regularly at weekly
meetings and on the floor to promote the change of culture. Nurses and nurse managers will hold
briefings with self-appointed representatives to make displays, posters, and put together short
presentations at staff meetings with regards to the importance of civility (Farrelly, 2013). The
education provided will also include topics such as communication skills, willingness to
communicate, the code of conduct, how to report a breach, and skills to help confront disruptive
behavior (Longo, 2010). The idea of shared governance will be used to help maintain
equilibrium in the workplace (Farrelly, 2013). Nurses will head committees and be invited to get
involved and take control of their floors. They will be motivated and empowered to be examples
and lead their peers to a more safe and productive culture of civility (Farrelly, 2013).
Refreezing & Unanticipated Consequences
The third and final step in Lewins theory is refreezing (Goldberg & Sifronis, 1994). At
this point, the change will be established as a new habit and become the new standard operating
style (Shirey, 2013). Compliance audits will be conducted monthly, for one year, by a selfappointed team of staff nurses and nurse managers (Healy et al., 2008). At this time, the
refreezing aspect of the change theory will be realized. Steps can be taken, as needed, to continue
to move the culture of nursing away from incivility. Some of the implementation techniques may
be effective and others may not. Adjustments can be made during audits to guide the direction of
the plan and form new goals. Unanticipated outcomes can be expressed and addressed at
monthly audits as well. They may include failure of nurses to cooperate, a lack of follow-through
from nurse managers, decreased morale, exhaustion over civility issues, and reversion back to
prior behavior. Outcomes will be taken into consideration and reiterated to the audit committee,

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who will work collaboratively with all staff to continue to make improvements. Patient safety is
worth the ongoing effort and continuation of the change of culture (Healy et al., 2008).
Through a thorough investigation by St. Petersburg Medical Center and The Joint
Commission, Mason Michael discovered that he was switched at birth in the midst of a sentinel
event. It was revealed that the undermining of the culture of safety and involvement in
workplace lateral violence by nursing staff led to his mix-up. Through the use of Lewins Theory,
this horrific mistake can lead to positive change. Lewins theory is crucial for the development,
implementation, and sustainability of civility in nursing. This tool acts as a blueprint that needs
to be adopted by all nurses in order to improve faculty communication and interaction. These
improvements will, in turn, enhance patient care, and help to prevent unwanted sentinel events
from occurring in the future.

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21
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