Incivility in Nursing

Data Collection

PICOT/Pico question and Literature Search Process

P- Incivility amongst lead roles nurses unto new nurses on a unit

I – Use of progressive write-ups as the framework to deal with cases of incivility

C- zero-tolerance policy against incivility and workplace bullying

O- Reduced incidences of incivility and workplace bullying amongst new nurse thereby enhancing their longevity within their current role with growth and development

T- Within an annual timeline, through random staff survey’s, policy changes, and addressing the behaviors will create a friendly and resourceful environment for all new nurses

Research Question

When dealing with incivility among lead role nurses to the new nurses in a unit, does the use of progressive write-ups a better framework than a zero-tolerance policy help in reducing the incidences of incivility and workplace bullying among new nurses? Does it enhance their longevity within their current role with growth and development within a time of one-year?

Data collection was through a survey. The data collection instrument will be availed to the new nurses throughout the facility. The survey will seek to maintain the anonymity of the participants by ensuring that no specific identification information is required. The researcher will attend various units’ staff meetings with the sole purpose of elaborating the purpose of the study to the nurses. The purpose is to encourage nurses to participate. The participants will receive an invitation letter with further instructions on how to access the survey and an explanation of how the use of the results. The electronic survey application will use Survey Monkey, and accessed through a link sent to the participants. Survey Monkey is an ideal online tool for carrying out this survey as it ensures that the anonymity of the participants. The action of completing the survey will be deduced as implied consent to the participation in the study.

The data collection instrument that will be adapted for the study will be the Nursing Incivility Scale as developed by Guidroz et al (2010). The Nursing Incivility Scale (NIS) is structured into a five-point Likert Scale, ranging from 1 (strongly disagree) to 5(strongly agree). This survey will use the Survey Monkey online application tool. The Nursing incivility Scale will use eight subscales covering hostile environment, inappropriate jokes, inconsiderate behavior, gossip, free riding, abusive supervision lack of respect, and displaced frustration. The survey design will measures the specific sources of incivility. A total of 43 questions are used in this survey. Among these questions, nine of the questions deal with the interaction with other individuals at work. Ten of the questions seek to establish the interaction with other nurses. Seven questions focused on the interactions with the direct supervisors. Seven other questions entail the interaction with the physicians. Ten questions focus towards establishing the interactions with the patients, family, and visitors. The scores from these questions aggregate at a subscale level. The subscale scores will then be added, and a mean acquired to allow the discussion of more specific interventions. Another importance of the source level aggregate will be in assisting in pointing out to the source-specific incivility. The time required to complete the survey will be 5-10 minutes. The participants will receive instructions on the scenarios to think about when providing the scale for the incivility.

One of the methods of ensuring data quality was by seeking to establish the reliability of the Nursing Incivility Scale. Based on the alpha statistics for the eight subscales, the scores for the test ranged between .81 and .90. The determination of item-total correlation for the different item component indicated was at .76, which is an indicator of good internal consistency. The scale is useful due to its capability of providing a baseline assessment of incivility and identification of various sources of incivility. This will be effective in establishing the targeted intervention either using zero-tolerance policy or the progressive write-up interventions. Another method that will ensure the adherence to data quality will be on setting standards and outlining a pre-defined process. The standards will focus on the different quality indicators. Among the quality indicators that the standards will address, include timeliness, relevance, interpretability, accuracy, coherence, and accessibility (Chen, et al. 2014). The process applied to the data collection process will seek to reduce the probability of occurrence of an error such as the omission of answers to the questions. All questions will be marked as required and thereby the system will alert the participants of any incomplete section of the survey during the time of submission. 

Analysis

The data collected from the survey analysis will use the Statistical Package for Social Sciences (SPSS). The descriptive statistics will describe the demographics of the participants and the mean score for every subscale from the data collection instrument. Descriptive statistics will also be essential in pointing out the specific sources of incivility. The descriptive that will be used to describe the incidences of the occurrences of incivility include percentage, mean, standards deviation, ad p-values. From these statistics, it will be possible to establish the most prevalent cases of incivility behaviors. The descriptive statistics in this case will be essential in describing the relationships between variables. Through the descriptive statics, more knowledge will be acquired on the phenomena of the incidences of nurses’ incivility (Fraenkel & Wallen, 2009). In the descriptive statistics, the manner to which the observations cluster around a central location is will be the mean that measures the central tendency. The waypoints are spread towards the extremes is provided by the degree of dispersion (Ali & Bhaskar, 2016).

The inferential statistics will help analyze data from the study and establish its suitability in making inferences will regard to a wider population. This will seek to answer a specified hypothesis. Among the inferential statistics used, include the p-value. This will seek to establish the calculated probability or the likelihood of an event-taking place by chance where null hypothesis has been found to be true. The p-value is described in a numerical value between 0 and 1 and offers a basis for accepting or rejecting the null hypothesis. The null hypothesis for this study would be, “There is no significant difference in the adoption of either a zero-tolerance policy framework or progressive write-up framework in an effort to reduce the incidences of incivility and workplace bullying among new nurses in a nursing unit.” The interpretation of this inferential statistic will be at three levels. Where the p-value is found be <0.01, this will imply that the results are highly significant, and we should therefore, reject the null hypothesis. Where the p-value is greater or equal to 0.01 but less than 0.5, the interpretation of the results will be significant and we should, therefore, reject the null hypothesis. In the situation that the value of p is greater or equal to 0.05, the interpretation of the results will not be significant, which implies that we should not reject the null hypothesis (Ali & Bhaskar, 2016).

Evaluation

The implementation of this project is expected to create positive outcomes in terms of the interactions between different groups in a healthcare facility and reducing the incidences of incivility and workplace bullying. Among the key stakeholder targeted by the outcome of this study, including the nursing executives, senior management, new nurses, human resource managers, unit supervisors, and the nurses in general. 

As a nursing executive, the study will help me in understanding the perceptions of the new nurses to the incidences of incivility as well as their ideas on initiatives of empowerment and those for addressing incivility. The results will enable me as a nursing executive to understand better the varied levels of incivility within the nursing units. Through the findings, it is possible to assess the current levels of interactions between individuals and the ability of nurses to function and operate safely in a workplace environment. The findings from the study will be essential in pointing out to the nature and sources of the cases of incivility. This will influence the decision made in response to the study findings. This implies that the study will show the direction of the management’s decisions. Through the study, it will become evident to me as the nursing executive on whether the environment is conducive enough to allow the nurses to comfortably report incidences of incivility without fear of intimidation and victimization. This will be essential in facilitating my attainment of goals with reference to providing clinical and patient care and maintaining staffing standards with the target set by the organization (Lewis & Malecha, 2011). With the knowledge acquired from the study, I will be able to offer advice to the senior management on the most effective method between zero-tolerance policy and progressive write-up policy in dealing with incivility in the nursing units.

The senior management to the healthcare facility is bound to acquire improved outcomes from the implementation of this project. The study findings will provide relevant knowledge that will inform the decision-making process for the senior management related to making of strategic decisions. The senior management will be sensitized on the need to institute a policy to deal with incivility and workplace bullying. The study findings will present already tested and possible results from the adoption of either zero-tolerance policy or progressive write-up policy. The findings from the project will assist the senior management to understand the nature of the interactions among the staff and the workplace environment as in most cases they lack the direct connection between to the operational level environment. The results will then justify to the senior management the need to finance the employee empowerment initiatives.

The implementation of the project will help the new nurses achieve better outcomes in the nursing units. The new nurses in a unit are in most cases vulnerable to the situation of other individuals venting out their stress and emotions on them. The workplace environment may also affect the new nurses due to a unit culture of “eat their young” mentality, which puts pressure to the new nurses on the need to prove themselves on their new job (Longo, 2013). With the implementation of this project, such challenges will be highlighted, and solutions implemented. This will lead to improved outcomes for the new nurses due to clear guidelines on conflict resolution and adequate management support. The new nurses will thereby get a favorable work environment that will allow them to attain their productivity. With the implementation of the project, there is a possibility that the new nurses are likely to get higher levels of structural and psychological empowerment and reduced levels of workplace incivility. This is likely to create high levels of commitment among the new nurses thereby lead to attaining better outcomes. The new nurses will also benefit from the in-service programs with the proper training on the correct approaches to deal with disruptive behavior.

The human resources managers are responsible for promoting the welfare of the nurses. A key concern that they seek to address is workplace bullying and incidents of incivility. Through this project, the human resources will have better outcomes due to the policy framework that put in place to deal with such incidences. This implies that they will have a definite policy to rely on when making human resources decisions such as termination and suspension of staff due to workplace bullying and incivility. The human resources manager will also be guided by the study’s results in the planning and development of staff training programs meant to raise awareness on the need and mechanism to end workplace bullying and incivility. The human resource director, as well as the unit supervisors, will have a basis of monitoring the corrective action needed to fix such vices.

The nurses in different units within the healthcare facility are likely to benefit also from the implementation of the project. The nurses are bound to benefit from the model of nursing culture adopted for the nursing units. The model will require personal initiative in promoting adoption of virtues of collaboration in a cohesive manner and leading by example (Scale, 2016). The adoption of this policy will be a realization of the rights of nurses as highlighted by the American Nurses Association that indicates that every nurse has the right to work in an environment that is free of bullying, lateral violence, and intimidation. The study findings might point out that the nurses are the major causes of the incivility to the new nurses. This will make the nurses realize the effects of their behaviors, which they might have considered true. Nurses will benefit from training programs meant to help them understand the effective mechanism of dealing with the increased workloads in a manner that does not cause disruption to other. Some common factors that nurses might have overlooked such as self-centeredness, immature, defensive, and poor conflict management skills are great impediments to a favorable workplace environment. The project will provide an opportunity for nurses to understand better issues such as job pressure, empowerment roles, and the need and implementation of changes in shift rotation (Lim & Bernstein, 2014).

The unit directors are another category of stakeholders who will benefit from the implementation of this project. The unit director is responsible for ensuring cohesion among the personnel in the unit as well as the promotion of the provision of a favorable workplace environment. The unit director will also be aware of the corrective action that has been recommended by the senior management in dealing with the inappropriate behaviors. The unit director will be able to implement changes in the unit that will improve the level of interaction between the nurses and ensure that right treatment is accorded to the new nurses in the unit. This will be effective in developing and maintaining a culture within the unit that is free of workplace bullying and incidents of incivility. This will have a positive effect on the overall outcome of the unit. 

Improvements to Nurse’s Practice

1. Policy Change

Following the implementation of this project, there will either be an adoption of a zero-tolerance framework or a progressive write-up framework as policies necessary for dealing with workplace bullying and incidences in the healthcare facility. 

The zero-tolerance policy is a framework that indicates that the organization does not cordon acts of workplace bullying or incivility. An action is taken immediately against a party who may be caught engaging in such activities. The disciplinary actions may range from suspension, termination, reduction of clinical privileges, and report to the professional licensing bodies. The American Nurses Association has also called for Zero tolerance for workplace violence and bullying, in its statement, it indicated that it would no longer tolerate any form of violence against nurses in the workplace. This new position was put forward by its professional issues panel on incivility, bullying, and workplace violence. Commenting on the policy, the ANA president indicated that the position was taken in a bid to ensure the safety of patients, nurses, and other healthcare workers in facilities. It is noted that registered nurse and employer within the healthcare system have an ethical, moral, and legal obligation of ensuring a healthy and safe work environment for the registered nurses and the entire healthcare team, patients, families, and community.

Such a policy puts the registered nurses to task in promoting a safe workplace environment. The nurses are required to commit towards achieving healthy interpersonal relations as well as being cautious of their personal interactions, which entails their actions and inactions. The nurses are required to embrace the culture of diversity and inclusiveness as well as conflict negotiation and resolution training. The nurses need to report any incident of incivility or bullying as per the institution. It is not part of the nurses’ duty to withstand such incidents. It is essential that a record of what happened, parties included, dates, and witnesses if any be maintained.

A zero-tolerance policy on workplace bullying and incivility also puts the employers to task. The management of the healthcare facility needs to develop a comprehensive violence-prevention program that matches the federal health and safety guidelines. The nurses should be part of the team giving the contribution to the development of such a policy. The employer should provide a mechanism for nurses to get support whenever such incidents occur. The zero-tolerance policy against incivility and bullying should treat all cases in the same manner irrespective of the parties engaged (Brown, 2015).

An alternative policy is the progressive write-up policy. The policy on progressive disciplinary action does not entail a zero tolerance but rather offers a change in the conduct of those who acted in such a manner. This policy would, however, clearly declare that acts of workplace bullying and incivility are unacceptable within the institution. The policy will also seek to offer hostile workplace protection to everyone irrespective of his or her position. The progressive disciplinary policy will offer inescapable definition where prohibitions are necessary for severe incidents. This will also seek to clarify the threshold for taking an action. This differs from the zero-tolerance policy where the action is taken immediately after an incident is reported and verified. The progressive disciplinary action policy will ensure that it provides a non-punitive separation for safety. The intention of this is to ensure appropriate accommodation of incidences of bullying within the health and safety domain and accorded the appropriate attention. This policy makes it mandatory for the documentation of the adverse impact. This will be carried out with an aim of discouraging frivolous complaints and abuse of policy on the malicious ground. It will also ensure that it considers the perpetrator pattern and trends in practice over time to ascertain the most appropriate action.

The progressive write-up policy would call for credible third-party investigation and adjudication process. This is essential as it improves on the employee trust as well as eliminating the influence of personal relationships, which may contribute to prejudiced reports. Under this policy, there will be retaliation prohibition where the offenses of retaliation are accounted for separately to stop the cycle of violence (Namie, 2003).

ii. Providing Training Programs in Incivility

The theory by Benner (2001) notes that, nurses can transform information into knowledge through experiential learning. Benner provided a philosophy of how basic knowledge progresses from superficial levels to a deep understanding level. The learning process takes place through five stages. The lowest level is the novice level where there are beginner learners. At this level, the nurses only have basic facts about the issues of incivility and workplace bullying. The next stage is the advanced beginner stage where the nurses should portray an understanding in incivility matters beyond the basic level. The next stage of learning is the competent stage where the knowledge of the nurses on the issues of incivility can be said to be objective, abstract, and analytical, but lack flexibility in dealing with incidences. The fourth stage of learning as per Benner’s framework is the proficient stage. At this stage, the nurses are capable of understanding the whole situation from a holistic view as opposed to the consideration of just the isolated parts. At expert stage, a nurse is expected to have acquired sufficient knowledge through experience and can be expected to handle an incident of incivility or workplace bullying in a diligent manner.

Under the learning process described above, the nurses can harness their knowledge on incivility within their respective units and whole facility at large. Implementing this practice would require the project head to guide the nursing in highlighting examples of previous experiences. The project head would also facilitate the learning process of the nurses through different expertise levels. This practice encourages the use of experiential learning in progressing from learned information such as interpersonal communication skills to deeper understanding of knowledge regarding incivility. Nurses are able to learn through simulated practice thereby making them better placed to avoid the occurrence of incidences of incivility (Abdollahzadeh et al, 2017).

The nurses would be expected to take part in the training programs targeting issues such as effective communication, diversity and integration, and conflict negotiation and resolution. Through such training, the nurse can come with a common code word of signaling others in case they find themselves in a situation of incivility. The training program should enlighten the nurses on incivility and bullying and even cover the use of evidence-based strategies for prevention of such acts. The learning programs will assist the nurse to learn more about the organization’s policies and procedures. With this form of training, it is expected that the nurses will be equipped, analyze the occurrences in the workplace environment, and thereby anticipate any potential violence. The training programs will also sensitize the nurses on the available conflict management and resolution practices and ways to engage in respectful communication.

Dissemination of Results

The results of this project can be shared with the stakeholder using different means and platforms. The project may be availed to the website of the healthcare facility where any relevant stakeholders may access them. The results for the project will be availed to the senior management through their regular meeting where a copy of the printed copy could be availed to each of the management’s team. The nurses within the facility will receive the results through their official emails. To ensure that the results of this evidence-based practice are shared with members of the future practice in the nursing management, the paper can be published to the national journals such as PubMed as an open access journal thereby making available to others even in future.

Conclusion

This evidence-based project was focused on the following research question, “When dealing with incivility among lead role nurses to the new nurses in a unit, does the use of progressive write-ups a better framework than a zero-tolerance policy help in reducing the incidences of incivility and workplace bullying among new nurses? The research approach used to identify the problem was a descriptive design that locates the core features of the problem in nursing with incivility. The issue of incivility is critical to a nurse executive as it is one of the major issues in nursing plaguing all units in every setting throughout the world. The sampling method used in this study will be convenience sampling. The convenience sampling method is a non-probability sampling method that uses the judgment of the research to select the sample to be included in the research. Data collection for the study was through an online survey. The data collection instrument that will be adapted for the study will be the Nursing Incivility Scale. The methods used for ensuring data quality was by seeking to establish the reliability of the Nursing Incivility Scale and ensuring the adherence to data quality will be on setting standards and outlining a pre-defined process. The descriptive statistics will describe the demographics of the participants and the mean score for every subscale from the data collection instrument. The inferential statistics will help to analyze data from the study and establish its suitability in making inferences with regard to a wider population. Among the key stakeholders influenced by the outcome of this study, including the nursing executive, senior management, new nurses, human resource managers, unit supervisors, and the nurses in general.

Following the implementation of this project, there will either adoption of a zero-tolerance framework or a progressive write-up framework as policies necessary for dealing with workplace bullying and incidences in the healthcare facility. The zero-tolerance policy is a framework that indicates that the organization does not cordon acts of workplace bullying or incivility with action taken immediately against a party caught engaging in such acts. The policy on progressive disciplinary action does not entail a zero tolerance but rather offers a change in the conduct of those who acted in such a manner. Another change in nursing practice will be through providing Training Programs on Incivility and workplace bullying and ways to deal with such situations.

References

Abdollahzadeh, F., Asghari, E., Ebrahimi, H., Rahmani, A., &Vahidi, M. (2017). How to Prevent Workplace Incivility?: Nurses’ Perspective. Iranian Journal of Nursing and Midwifery Research, 22(2), 157–163.

Ali, Z., & Bhaskar, S. B. (2016). Basic statistical tools in research and data analysis. Indian Journal of Anaesthesia, 60(9), 662–669.

Benner, P. (2001) From novice to expert: Excellence and power in clinical nursing practice (commemorative ed.). Prentice Hall: Upper Saddle River, N.J.

Chen, H., Hailey, D., Wang, N., & Yu, P. (2014). A Review of Data Quality Assessment Methods for Public Health Information Systems. International Journal of Environmental Research and Public Health, 11(5), 5170–5207.

Lewis, P. S., & Malecha, A. (2011). The impact of workplace incivility on the work environment, manager skill, and productivity. Journal of Nursing Administration, 41(1), 41-47.

Namie, G. (2003). Workplace bullying: Escalated incivility. Ivey Business Journal, 68(2), 1-6.

Scale, N. I. (2016). Decreasing workplace incivility. Nursing Management, 47(1), 1