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Civility and Nursing Retention in a Neurosurgical Intensive Care Unit

This article will discuss one way that nursing retention rates were reduced over fifty percent using civility training in conjunction with staff involvement. Increasing the civil interactions between staff members in a neurosurgical intensive care unit can directly affect nurse retention rates. Nursing work environments are important. Retention of experienced nursing staff must be made a priority, especially in high acuity areas like intensive care units (ICUs). By increasing civil interaction between nursing staff, retention can be lowered and working environment for nurses improved.


Introduction
The purpose of this project was to introduce civil interactions as a way to increase employee satisfaction, and thereby increase staff nurse retention. Increasing civility within the culture of nursing environments will directly counteract horizontal violence and simultaneously meet the communication needs of the patients. Within this project, the nurses in a very busy Intensive Care Unit (ICU) were targeted for an improvement project. This project aimed to increase the awareness of civil interactions within the environment, and increase the number of confident interactions between registered nursing staff.

Background
The ICU environments present the most difficult challenges for nurses in regards to healthy communications. Within the ICU environment, nurses witness death, resuscitation and have feelings associated with traumatic patient events [1]. The unpredictability of patient situations within the ICU makes professional interactions challenging and often less than optimal [1,2]. There is evidence that indicates the existence of horizontal violence, and the nurses being most concerned about their colleagues' hostility towards each other, especially within these high acuity environments [2]. This hostility is in direct conflict with what the patients need and expect from the professionals within these high acuity areas.
The essence of civility in the workplace is respectful relationships between people, and the creation of healthy interactions [3]. Workplace civility directly affects ethical behavior, and care delivery [4]. Incivility can be directly tied to nursing attrition [5]. In order to more successfully serve the present population, increasing civil interactions between nurses and keeping qualified, experienced professional staff has become a necessity.
The ICU chosen for this improvement project had a nursing turnover rate over twenty percent for the two years prior to the project. It was identified as an area of high acuity, and high stress. The staff turnover rate in 2009 was 23.08%; in 2010 it was 26.74%. The environment included twenty six beds. The patient population included neurosurgical patients with varying diagnosis, trauma patients requiring neurosurgical interventions, stroke patients, and the occasional overflow from throughout the hospital. The project was designed as a simple quality improvement / quality analysis. It was measured using data on nursing retention rates that are collected routinely every year.

Objectives
Four objectives were chosen with the cooperation after a meeting between the staff nurse involved and the nurse manager. These objectives were chosen to support the ICU, improve the environment, and support the hospital overarching mission. These four objectives would drive the project and be used to ensure the developed materials could be used again if successful. These four objectives were (1) to promote the use of evidenced based practice in the ICU related to civility and the ICU environment, (2) improve compliance with civility training guidelines as identified through seminars and literature search (3) establish unit education that can be shared and (4) inspire nurses within the ICU to be aware of how communications affect care delivery and staff relationships. These objectives would not be used to measure the success of the project, only guide the civility training in a way that established clear avenues for improvement ( Figure 1).

Nurse manager
Managerial involvement included the development of several nurses through utilizing the classes offered in Training and Development, and mentorship throughout the project.
The "Seven Habits of Highly Effective People" by Stephen Covey was attended by three charge nurses and one staff nurse. All nurses were reimbursed for their time to encourage enrollment and attendance.
One Staff Nurse and One Lead Charge Nurse were paired together to do a literature search examining civility and develop key ideas, establishing civility definitions and guidelines for project.

Staff nurse driven
One Staff Nurse and One Lead Charge Nurse were paired together to do a literature search examining civility and develop key ideas, establishing civility definitions and guidelines for project. For this project civility was defined as "the act of showing regard for others" (Farlex, Inc., 2011, expression 2). Civil behaviors are characterized by listening, respectful interactions between people and authentic actions [6]. These civil behaviors are the same ones that create healthy relationships. These intertwined ideals increase the viability of communication and trusting relationships.
Workplace violence is on a national agenda and nurses simply cannot continue to engage in these negative behaviors [5]. Improving quality relationships and finding interventions that have an impact is of paramount importance [7]. The objectives embedded within this improvement project influenced the interventions chosen. The interventions were performed by the staff within the ICU.

Literature search
A literature search was performed using civility, ICU, and intensive care units within the pubmed search engine. The subsequent articles were reviewed and are included throughout this paper, and were utilized as a base for the activities identified. Civil behaviors are characterized by listening, respectful interactions between people and authentic actions [6]. The key components of civility identified were: benevolent intent, integrity, demonstrates capabilities and mutual respect.

Bulletin boards
In order to promote the use of evidenced based practice in the ICU related to civility and the ICU environment, and improve compliance with civility training guidelines as identified through seminars and the literature search; several bulletin boards explaining civil interactions were placed strategically throughout the unit. One bulletin board incorporated the ideal of teamwork. A second illustrated the ideas presented within the continuing educational offering. . Each contained elements of civility that could be integrated easily throughout the culture. The bulletin boards also represented an attempt to reach the night shift nurses who were unable to attend the educational offering.

Staff meeting skit
In an effort to inspire nurses within the ICU to be aware of how communications affect care delivery and staff relationships. A skit was developed that illustrated an uncivil encounter. The skit was kept secret until it was presented at staff meetings, only the nurse involved and the nurse manger knew it was on the agenda. Specifically, the nurse in the skit interrupted two staff meetings confronting the nurse manager about another employee. The upcoming civility project was outlined for the nurses present within the staff meeting and the first of two research articles was presented within those same staff meetings. The article addressed the intensive care unit interactions and emergency situations [1]. Employee feedback created multiple conversations on all shifts relating to the skit performed, and the research noted as reported by the charge nurses.

Education
The continuing educational offering (that could easily be shared with other ICUs) was an hour long with a food provided. The food was provided by the administration. It was offered on two different occasions to allow staff participation. This education included four identified components of civility; demonstrated capabilities, mutual respect, benevolent intent and integrity and included listening skills and a definition of intentional and unintentional rudeness [8]. The nurses responded favorably as noted by the evaluations of the offering that requested more information on civil interactions and healthy workplace relationships.
A second article was presented relating to new graduate burnout. It was presented to nurses within the unit individually and copies left within the break room for review. This article was important related to the amount of turnover within the unit as indicated by the last year. The article, New Graduate Burnout: The Impact of Professional Practice Environment, Workplace Civility, And Empowerment, was presented to staff and feedback requested [9]. The feedback identified three new graduate nurses (less than 2 years post graduate) who expressed turnover intentions, and all nurses in attendance expressed the need for increased civility and empowerment within the ICU environment.

Civility Worksheet
In an effort to establish more unit education that could be shared, a civility worksheet was circulated throughout all the staff, including housekeepers and patient care technicians. This worksheet taught listening skills, and encouraged active listening.

Newsletter Article
A meeting was held with the nurse manager to review the project and adjust for any other items that administration felt was appropriate. As an addition to the original design of the project, an article was written for the ICU newsletter. This widely read unit newsletter is distributed quarterly, and was utilized to highlight civility as a much needed skill.
nursing turnover rate as reported for a four year period with the civility educational project starting November, 2010 and concluding with a newsletter article in June, 2011 produced a reduction of almost seventy percent in nursing turnover rates by 2012. Projects like these should be repeated to see if similar results can be obtained (Figure 2).

Discussion
This project successfully introduced civility as a way to increase nurse retention rates within a highly stressful environment. The nurses targeted within this ICU environment reflected a decrease of more than 50% in nursing turnover rates. With greater importance being focused towards safe patient transfers, patient satisfaction and quality outcomes, nurses within ICU environments cannot engage in uncivil behaviors. Effective teamwork including communications with patients, their families, doctors and other nurses is elevated by creating a culture of civility within an ICU. With collaboration, ICU environments can produce lower mortality frequencies [1]. Civility encourages the retention of staff and may decrease the stress within the environment.

Limitations and Future Research
Limitations of this improvement project include implementation of hospital wide interventions, level of education increased for new hires to a baccalaureate degree, and the introduction of a new nurse manager in 2010. Avenues for more research include determining if changes can be maintained for an extended period of time, how and which social dynamics reassert themselves during and after civility training, quantitative studies on civility training in new orientating staff members and their effect on the environment and evaluations of environmental constructs that affect the civility within differing healthcare areas.

Conclusion
The implementation of civility projects throughout high stress areas may make a significant difference in nursing retention. This ICU noted a decrease from 23.08% (2009) to 8.89% (2012) in nursing turnover rates. This project examined civility literature, developed key ideas for the environment, established civility definitions, and created education that was disseminated throughout the ICU. Environments within high stress areas, like ICUs, are especially vulnerable to challenging professional interactions. Improving nurse retention rates through increased awareness of civil interactions may be achieved through further projects like this one.