Toxic Incivility at the Unit Level

Toxic Incivility at the Unit Level: Jeannie Walker just accepted a job as nurse manager for the ortho-neuro unit of a large community
hospital. She recently graduated with her master’s degree in nursing with an emphasis on nursing
leadership in healthcare settings. Excited about the new role and opportunities to influence positive
changes on a nursing unit, Jeannie was not at all concerned when the human resources officer
mentioned that the last three managers on the ortho-neuro unit left the position after 12 to 18
months. Jeannie had lots of clinical experience, and now armed with all that she had learned in
graduate school, she was confident that she would be able to handle the management of the 32-
bed unit with a staff consisting of 120 full- and part-time employees. The human resources officer
had told her that half of the staff were long-term employees, but the other half were fairly new to
the unit. There seemed to be a lot of turnover among newer employees, but the long-term
employees had worked on the unit an average of 20 years. Jeannie had aspirations of leading her
unit in collaborative governance and hopefully influencing other directors and managers to begin
the Magnet® journey.
During her first few weeks in the role, Jeannie discovered a lot of facts about the staff and the
care delivery model. With a nurse-to-patient ratio of one nurse to four patients and one nursing
assistant for every eight patients, the unit seemed to be reasonably staffed for the expected
workload required for patient care. She also discovered that only 35% of the nurses were prepared
at the baccalaureate level, 55% had attained an associate’s degree, and 10% had a diploma in
nursing. There was a strong ethnic mix as well, with nearly 30% of the nurses educated in foreign
countries such as the Philippines (20%) and India (10%) and others who were second-generation
immigrants from the Philippines (30%), the Middle East (10%), Canada (7%), and Germany (3%)
educated in the United States. The remaining 20% were American born and educated. Jeannie also
discovered that the unit was experiencing a higher than hospital and national average rate for
hospital-acquired infections (HAIs), patient falls, and medication errors. Nurse satisfaction levels
were the lowest of all of the nursing units at the hospital, and if this was not enough, the patient
and physician satisfaction levels were also lower than the hospital average. Jeannie was surprised
by these quality indicators, but she attributed the poor performance to the need for a consistent,
strong, and visionary leader who would inspire the staff to work together and improve these quality
indicators. She felt up to the challenge to transform this staff and voiced this commitment to
excellence to nurses at her first staff meeting. After an energetic and inspiring “state of the union”
address accompanied by her vision for the future, Jeannie was a bit surprised that the staff remained
absolutely stoic and had no response to her plans to create a collaborative governance structure
with unit councils providing staff input into decisions affecting nursing and patient care. Perhaps
it was because she was new?

Toxic Incivility at the Unit Level
Over the course of a few months, Jeannie tried to establish a Unit Practice Council (UPC) and a
Research and Evidence-Based Practice (REBP) Council, but few of the staff volunteered to
participate on either of the councils. Jeannie sought a handful of nurses who she believed would
be strong leaders and talked with them about her vision for empowering the nurses through council
involvement. She was shocked to hear a resounding “no” from the nurses, who shared that they
were afraid to participate. The repetitive answer from many of the nurses was “I only want to do
my job and go home.” As Jeannie inquired more and more, she discovered that the staff were
extremely fractionated into cultural groups who did not like to integrate or communicate any more
than absolutely necessary with other cultural groups. Not only were the nurses in firm social
cliques, but the more senior nurses on both shifts had first preference for scheduling, patient
assignments, and lunch breaks. They refused to take assignments to orient new personnel or to be
preceptors for nursing students. Because they were such a powerful group, they seemed to make
the decisions for all of the staff. If any of the nurses from other cultural groups voiced a complaint,
they were the ones who were canceled first for scheduled or overtime shifts or received the most
difficult patients for an assignment. Toxic Incivility at the Unit Level
Jeannie learned that there was often open conflict among the nurses with name calling,
accusations, threats, and retaliations. Evening shift nurses accused day shift nurses of being “lazy,”
not completing patient care assignments, or leaving the bulk of work to the evening/night shift
nurses. Day shift nurses complained that night nurses were “sleeping on the job” and not properly
assessing patients or documenting appropriately. To make matters worse, several of the physicians
joined in with their own complaints and accusations that “these nurses are the worst of any unit in
the entire hospital,” “they don’t know anything about ortho-neuro patients,” and “they call all
hours of the night for trivial things.” After a few weeks of hearing all the complaints from multiple
sources, seeing the negative unit quality indicators, and refereeing a number of conflicts among
nurses and physicians, Jeannie felt completely overwhelmed. She mentioned to a comanager, “I
feel like the man in the circus who spins plates on a bunch of poles all at once. He has to keep
dancing around just to keep a plate from falling down and breaking.”
Toxic Incivility at the Unit Level. Get help today

Instructions to Students:

1. No later than Friday, carefully review the detailed case-study provided and post
your complete response to the correct learning team forum.
2. Throughout the remainder of the week, work collaboratively with team members
to arrive at the best response to the case-study.
3. Actively participate in the evaluation of each member of the team no later than
Monday.
4. A team leader will be appointed by the course faculty in a course announcement.
Each member of the team will serve as team leader at least once and some
members will serve multiple weeks.
5. When serving as the team leader, ensure the collaborative assignment is
finalized, the collaborative evaluation is completed, and that both are submitted
no later than Tuesday at 11:59 pm ET.
6. The Peer Evaluation form is located in the weekly materials and students
participate in the evaluation of each team members contributions to the casestudy assignment (each student receives one total score that is based on a
collaborative evaluation by the team). Students do NOT participate in evaluation
of their own performance.
7. A group grade is based on the quality of the case-study work submitted for
grading. No member of the team will earn a grade higher than the team grade.
Individual grades may be impacted by the peer-evaluation scores.
8. No later than Tuesday at 11:59 pm ET, the weekly team leader will make a final
post to the discussion forum that begins with, “FINAL VERSION FOR GRADING”
and includes the finalized version of the case-study response in the body of the
post and has the Peer Evaluation Form attached to the post. Failure to fully
complete this step by the deadline results in a 10% reduction in the team grade
for each day the assignment is late up to a maximum of three days, at which time
a grade of zero is recorded for each team member.
9. Contact course faculty with any questions!

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