Empowering Nurses to Address Incivility at Work
Staff knowledge increased regarding what to do when incivility occurs on the unit.
A hospital unit project on workplace incivility in nursing enhanced staff knowledge and confidence in identifying, managing and preventing uncivil behaviors, to align with organizational values and foster a healthy work environment (HWE).
“Promoting a Healthy Work Environment: Increasing Staff Confidence to Address Incivility,” in Nursing Management, notes that the project also improved understanding of how incivility can contribute to medical errors, higher costs, staff turnover, decreased patient satisfaction and preventable adverse outcomes.
According to previous research, up to 87% of nurses report being victims of incivility, the article notes, adding that uncivil behaviors can range from overt acts such as workplace violence and bullying to subtle gestures such as eye-rolling, sighing and sarcasm. Developing comprehensive training programs is essential to enhance awareness and provide practical tools for effective intervention.
The evidence-based practice project, conducted from October to December 2022 at a nonprofit children’s hospital, involved 77 staff members from the infectious disease unit, including 46 nurses without previous incivility training. Participants volunteered for a three-hour online module about workplace relationships and a four-hour in-person workshop to practice responding to uncivil behaviors. Postintervention surveys showed significant improvement across all areas.
“As a result of this project, there was an increase in staff knowledge of behaviors associated with incivility, knowledge of what to do when incivility occurs on the unit, and knowledge of the organizational position regarding incivility,” the article notes.
Limitations include the project’s single-site design, anonymous surveys preventing individual tracking, and inconsistent participation across intervention components. Future research should explore broader settings and assess long-term effectiveness to ensure sustained outcomes and wider applicability, the article adds. AACN’s Healthy Work Environments webpage can assist nursing units with evidence-based resources. The page includes tools to conduct free workplace assessments and guidance on implementing the six HWE standards to improve nurse staffing and retention, and overall workplace well-being.
Joint Committee Revises ACS Clinical Practice Guidelines
The guidelines cover a range of topics from initial evaluation to discharge.
Revised clinical practice guidelines from the American College of Cardiology and American Heart Association on managing acute coronary syndrome (ACS) include updated evidence and new recommendations supported by study data.
“2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines,” in Journal of the American College of Cardiology, notes that the joint committee issued nine top messages from the updated guidelines that include an embrace of bleeding reduction strategies for antiplatelet therapy and non-statin lipid-lowering therapies.
“Patients with ACS are at the highest risk for cardiovascular complications both acutely and chronically, which emphasizes the importance of staying up-to-date on the most recent evidence presented in this guideline,” adds lead author Sunil Rao, New York University Langone Health System, in a news release cited by Medpage Today.
Updating several guidelines dating back as far as 2013, the committee offers new recommendations and revised guidance on a range of topics from initial evaluation to discharge. The nine key recommendations and strategies are as follows:
- Dual antiplatelet therapy for patients with ACS
- Aspirin and oral blood-clot inhibitors for 12 months when bleeding risk is low
- High-intensity statins with the optional addition of a non-statin lipid-lowering agent
- Invasive approach to revascularization for patients with elevated risk of ischemic events
- Angioplasty procedures prefer radial over femoral approaches and intracoronary imaging for patients with complex lesions
- Complete revascularization for patients with unstable angina; method based on complexity
- Microaxial flow pumps to reduce mortality risk for patients with cardiogenic shock
- Red blood cell transfusion for anemic patients not actively bleeding to maintain hemoglobin of 10 g/dL
- Focus on secondary prevention post-discharge
Each topic includes a synopsis and supporting evidence, with data and diagrams as applicable. The report includes a review of evidence gaps and unanswered questions, particularly for secondary prevention.
SQuID Protocol Outperformed IV Insulin
Since SQuID began at one center, ICU admissions for patients with LTM DKA decreased by 33%.
For patients with low-to-moderate-severity diabetic ketoacidosis (LTM DKA), the SQuID protocol demonstrates comparable safety, superior clinical effectiveness, reduced ICU admissions and shorter emergency department (ED) stays compared with IV insulin.
“SQuID (Subcutaneous Insulin in Diabetic Ketoacidosis) II: Clinical and Operational Effectiveness,” a single-center study in Academic Emergency Medicine (AEM), reports that SQuID has become the study hospital’s default pathway for treating patients with LTM DKA, leading to a 33% reduction in ICU admissions for these cases.
The one-year study at Barnes-Jewish Hospital, affiliated with Washington University in St. Louis, compared 62 patients with LTM DKA treated with the SQuID protocol to 22 who received traditional IV insulin. Findings reveal that patients with the SQuID protocol required rescue dextrose less frequently (8% vs. 18%). The study reported median times for the following: achieved anion gap closure 1.4 hours faster, spent 10.4 fewer hours on protocol and had a shorter median ED stay (9.8 hours vs. 8.3 hours) compared with patients in the IV group.
Other studies of subcutaneous insulin protocols have expanded beyond efficacy and safety to focus on implementation, impacts and inclusion in guidelines for low-severity DKA. In addition, a virtual program is being explored in which centralized nursing staff familiar with the protocol would guide others through telehealth consultation.
“If safe and successful, this could greatly expand access for treatment of LTM DKA in non-ICU settings,” the study notes.
One key study limitation is its single-center design, which may limit generalizability to other institutions with different practices. Also, the small sample size and real-world nature of the study, including nonrandomized patients and unequal group sizes, could have influenced the results.
A companion article in AEM highlights that 65% of ED nurses and physicians involved in the study preferred the SQuID protocol over traditional IV infusion. They found SQuID acceptable, easy to use, effective, fair to patients and minimally disruptive to other activities.
Evaluation Models Aid Nurse Mentors
The Tanner model involves noticing, interpreting, responding and reflecting; the Lasater rubric helps to track progress and provide feedback.
To improve clinical judgment, an essential skill for new graduate nurses, mentors can use established evaluation models to track progress and provide coaching, thereby enhancing patient safety and quality outcomes.
“Coaching and Evaluating New Graduate Nurses,” in American Nurse, suggests that preceptors and mentor nurses should use Tanner’s Clinical Judgment Model and the Lasater Clinical Judgment Rubric to measure the four cognitive processes that form clinical judgment. In addition, mentors can “use their expertise and the Mentor’s Clinical Judgment Coaching Tool to coach and evaluate clinical judgment.”
One study shows that fewer than 10% of new graduate nurses master the clinical judgment skills necessary to provide patient safety, with 40% failing to recognize urgent problems and 50% failing to intervene appropriately. Another cited study finds that 65% do not observe and react to clinical deterioration, and 50% of medication errors can be traced to poor clinical judgment.
The Tanner model emphasizes noticing, interpreting, responding and reflecting, and mentors can use the Lasater rubric to track progress and provide objective feedback. “Although all four processes have a role in patient situations, mentors take advantage of teachable moments to focus on the most appropriate,” in addition to breaking down each cognitive process.
“Since acquiring expert clinical judgment takes years, all healthcare organizations should set continuing professional development on this subject as a goal to increase safety, decrease liability, and improve high-quality outcomes,” the article adds.
AACN resources to develop nurse competencies include Competence Framework and Toolkit for Progressive and Critical Care, which includes documentation; knowledge, skills and abilities lists; and teaching tools; and Fundamental Skills for Preceptors, an online skill-building course for preceptors. The AACN Knowledge Assessment Tool supports nurses who are new on a unit or new to ICU or PCU patient care, by identifying their educational needs.
ICU Patients Pedal to Faster Recovery
The review summarizes evidence on the effectiveness of cycle ergometry in the ICU.
In-bed cycling for critically ill patients may improve physical function at ICU discharge, reduce ICU stays and shorten hospital recovery with little or no effect on other outcomes.
“Leg Cycle Ergometry in Critically Ill Patients – An Updated Systematic Review and Meta-Analysis,” in NEMJ Evidence, involves 33 randomized controlled trials conducted between 1998 and 2024, and 3,274 patients in 13 countries. Patients were randomized to receive cycling interventions or no cycling, with physical function as the primary outcome.
Patients assigned to cycling had slightly shorter ICU (one day) and hospital stays (1.5 days) with rare adverse events and no difference in mortality between the groups. Mobility tests and walking assessments suggest improved physical function before and after hospital discharge. The review acknowledges, however, that most findings were based on low certainty of evidence.
Cycling alone was examined in 12% of trials, cycling with physiotherapy in 33% and cycling with electrical stimulation and physiotherapy in 9%. Cycling was most often part of multicomponent interventions, making up 45% of trials.
“In-bed cycling is one way to reliably introduce early rehabilitation activities with critically ill patients and warrants further study in addition to usual care or as part of a multifaceted rehabilitation strategy for several reasons,” the review adds.
Those reasons include the following:
- Cycling can start early in a patient’s stay, even during sedation or mechanical ventilation.
- Once the patient is set up, cycling requires only one person for monitoring.
- Cycling offers versatility with passive, active-assisted or fully active modes depending on the patient’s contribution.
The study is limited by the scarce trial evidence on ICU cycling, leading to the inclusion of studies regardless of admission diagnosis. Also, lack of a universally agreed-upon outcome measure resulted in 18 trials reporting 13 different functional outcomes at various time points.
AACN offers these resources to implement early mobility interventions:
- Webinar: “Awake and Walking ICU: Mastery of the ABCDEF Bundle”
- Article: “Measuring Performance on the ABCDEF Bundle During Interprofessional Rounds via a Nurse-Based Assessment Tool”
- Resources: Early mobility
Cannabis Associated With Cardiovascular Risk
The acute and chronic adverse effects of cannabis are becoming apparent.
Cannabis is related to significant adverse cardiovascular harm, including increased risk of myocardial infarction even in young, healthy patients. Strong synthetic and novel cannabis can create further risks.
“The Relationship Between Cannabis and Cardiovascular Disease: Clearing the Haze,” in Nature Reviews Cardiology, and a related study in JACC: Advances note that increasing evidence points to myocardial infarction, cerebrovascular accidents, arrhythmia and heart failure being related to regular cannabis use. “Therefore, with the increasing availability and use of cannabis, the acute and chronic effects of this drug are becoming apparent,” adds the review in Nature.
Evidence shows that the risk of atrial fibrillation and atrial flutter can increase in regular users (frequently younger patients). Synthetic products such as K2 or Spice could have even more risk, and combining cannabis with tobacco creates added potential for adverse effects.
“Clinical reports and case studies provide insight into the acute adverse effects and potential complications associated with the recreational use of synthetic cannabinoids, including respiratory depression, cardiovascular events, neuropsychiatric symptoms and death,” notes a related article in Cardiovascular Business.
“Myocardial Infarction and Cardiovascular Risks Associated With Cannabis Use: A Multicenter Retrospective Study,” in JACC: Advances, a review of 4.6 million patients ages 50 and younger with no previous coronary artery disease, found significantly increased risk of cardiovascular events with cannabis use. The review, which included data from 12 studies with over 75 million people, found a 50% higher risk of myocardial infarction among cannabis users, with an average age of 41, when ages were available, a news release adds.
Welcome to the Future of Nursing Education
Meet longtime NTI presenter Michael Ackerman, director of the Center for Healthcare innovation and Leadership at The Ohio State University. In this video interview, he shares his experiences using virtual reality (VR) and the metaverse to educate nurses. “It’s fun, and there are things you can do with VR that you just can’t do in a classroom or simulation lab.”