Digital Repository Masters Projects Spring 2024 Promoting Psychological Safety in the Workplace Alexis Williams Weber State University Follow this and additional works at: https://dc.weber.edu/collection/ATDSON Williams, A. 2024. Promoting Psychological Safety in the Workplace Weber State University Masters Projects. https://dc.weber.edu/collection/ATDSON This Project is brought to you for free and open access by the Weber State University Archives Digital Repository. For more information, please contact scua@weber.edu. WSU REPOSITORY MSN/DNP Promoting Psychological Safety in the Workplace Project Title by Alexis Williams Student’s Name A project submitted in partial fulfillment of the requirements for the degree of MASTERS OF NURSING Annie Taylor Dee School of Nursing Dumke College of Health Professions WEBER STATE UNIVERSITY 4/26/24 Ogden, UT Date Alexis Williams BSN, RN, MSN Student 4/26/24 Student Name, Credentials (electronic signature) Date Chelsea Pike, DNP, RN, CNE 4/26/24 MSN Project Faculty Date (electronic signature) 4/26/24 (electronic signature) DNP, N, CNE MSN Program Director Note: The program director must submit this form and paper. Date 1 Promoting Psychological Safety in the Workplace Alexis Williams, BSN, RN, MSN Student Annie Taylor Dee School of Nursing Weber State University MSN Project 2 Abstract Purposes/Aims: This project aimed to educate staff members in the pediatric intensive care unit (PICU) in a preeminent children’s specialty hospital about promoting psychological safety through an evidence-based research training program. Staff members and leadership will learn how to promote a safe work environment, address negative behaviors, and promote optimal patient care. Rationale/Background: Incivility has been increasingly reported in nursing and healthcare. Nurses have reported experiencing fatigue, adverse mental and physical effects, and decreased productivity and job satisfaction (Arnetz et al., 2019). When staff members do not feel safe in their workplace, there is a greater chance for medication administration errors, direct patient care errors, and impaired nurse psychological well-being. Methods: A training program will be developed to educate PICU staff members about promoting workplace psychological safety by improving their ability to recognize and respond to bullying. The Iowa Model Revised framework will help identify areas of incivility that can be enhanced within the PICU and guide the development of the training program for staff members. Results: The anticipated results of the project are improved confidence in recognizing and responding to bullying and other negative behaviors within the workplace. Staff members will self-report their experiences pre- and post-training, indicating the effectiveness of the training. Conclusions: Through developing and presenting training on promoting psychological safety in the workplace, staff members and leadership can adequately and confidently recognize and respond to incivility or bullying in the workplace. Keywords: psychological safety, incivility, training programs, workplace violence, bullying, quality improvement. 3 Promoting Psychological Safety in the Workplace The nursing profession is known to be a caring and selfless occupation. While being a nurse and participating in life-changing moments for individuals and families is a beautiful experience, it can also be challenging. Workplace psychological safety is crucial to maintaining patient safety in the hospital setting. Psychological safety can be defined as individuals experiencing feelings of personal engagement who express their ideas and concerns without fear of negative consequences to their self-image, status, or career (Henricksen et al., 2017). By creating a safe and positive work environment, team members can discuss questions and concerns with doctors and other nurses while maintaining a psychologically safe environment free from belittling actions or comments, fear of retaliation, or insensitive comments. Incivility in the workplace leads to safety concerns, jeopardizing the safety of nurses and patients. Workplace bullying remains a common problem in healthcare environments and affects everyone involved, including the offender, victims, bystanders, patients, and families. Bullying can occur through mistreatment, threats, intimidation, humiliation, abuse of power, rudeness, and disrespect (Aljuaid & Alharbi, 2023; Shorey & Wong, 2021; Ovayolu et al., 2014). The results of this behavior include negative impacts on nurses’ emotional and physical health, productivity, and job satisfaction, ultimately leading to nurse burnout (Arnetz et al., 2019). Therefore, action must be taken to improve the nursing workplace culture, as safety is one of the quintessential aspects of the occupation. Once considered a selfless occupation, nursing has gained a negative reputation for hazing and incivility among members of the profession (Andrews, 2019). Being a nurse is difficult; the hours are long, and the work is physically exhausting. While some patients are lovely, others are challenging. Individuals become nurses to help patients at their lowest point to 4 gain strength and improve health. Adding workplace bullying to the lengthy list of occupational challenges that nurses face contributes to unsafe working environments and promotes a toxic culture. Unless the culture improves, nurses will continue to leave their jobs, and toxic workplace behaviors will continue (Hawkins et al., 2023). Patient outcomes may be jeopardized as a result. Research has shown that training and empowering staff to speak up in difficult situations and respond appropriately to negative behaviors can break the cycle of incivility and initiate positive change in the workplace (Hawkins et al., 2023; Krivanek et al., 2020). Therefore, nurses must be willing to participate and interact in ways that address this issue. Leadership can incorporate transformational learning by communicating a clear purpose, assessing staff readiness to learn and facilitate positive change, utilizing interactive learning tools, and considering the staff's previous knowledge and experiences (Vessey & Williams, 2021). While these tasks can be complex, promoting psychological safety can improve staff morale and patient safety. Teaching team members to uphold psychological safety promotes understanding and protection from the negative consequences of bullying and creates opportunities for an optimal learning environment (Henricksen et al., 2017). Statement of Problem Workplace psychological safety among pediatric ICU nurses is essential for nurses’ wellbeing and that of their patients. However, evidence shows that nurses are being bullied. Workplace bullying, or incivility, is a global issue that harms nurses and negatively affects patient outcomes (Shorey & Wong, 2021). These issues contribute to nurses’ emotional and physical distress and create unsafe working conditions and environments (Armstrong, 2017). Distress in nurses is demonstrated as irritability, anxiety, depression, diminished self-esteem, 5 loss of confidence, and substance use (Vessey & Williams, 2021). Workplace bullying in nursing is recognized as an occupational health hazard and is described as endemic to the nursing profession in the United States and internationally (Arnetz et al., 2019). This problem exists worldwide and must be addressed for the safety of nurses and their patients. This MSN project aims to implement a training program to prepare nurses to recognize and respond to negative workplace behaviors, whether those behaviors are experienced or witnessed. The revised version of the Iowa Model, The Model for Evidence-Based Practice Change, will be applied to address this clinical problem and drive change. The model helps identify workplace problems and provides a framework for improvement through evidence-based practice. The Iowa Model Revised framework best supports this project's goals by detecting and improving an issue. Utilizing this model will help create a safe work environment by improving existing interventions, implementing new interventions, and constantly evaluating their effectiveness (Hanrahan et al., 2019). Significance of the Project This project is essential to promote the psychological safety of all new and established nurses in the pediatric ICU and quickly recognize and address incivility. Researching the existing literature regarding interventions and programs to address this issue can guide the development of an evidence-based program for PICU nurses. Establishing an environment that promotes teamwork, respectful communication, and constructive feedback can reduce incivility and improve nurse retention, as nurses can more fully enjoy their workplace (Krivanek et al., 2020). A gap exists when reporting these negative behaviors; workplace incivility often goes unrecognized because it has become the norm within nursing, and individuals may fear 6 retaliation if they report their concerns (Hawkins et al., 2023). This viewpoint is the driving force that fosters a harmful and toxic culture. Implementing an evidence-based training program can address incivility in the workplace and steer nursing staff toward a more positive and inviting culture. The training will include educating staff on promoting psychological safety, recognizing, responding to, and managing incivility, presenting a self-reporting tool, and promoting teamwork to build trust (Krivanek et al., 2020). As these interventions are implemented and evaluated for efficacy within a unit, nurses can feel safer and empowered to speak up when experiencing or witnessing nurse incivility. Various resources will be reviewed throughout this paper as they directly address the prominent issue of nursing incivility, frameworks to apply for creating change, and thoughts, ideas, and actions that have been shown to encourage psychological safety in the workplace. Review of the Literature This literature review aims to uncover current evidence of nursing workplace incivility and the necessary interventions to promote psychologically safe work environments (Aljuaid & Alharbi, 2023). Such incivility negatively impacts the health of staff and the quality of care delivered to patients (Ovayolu et al., 2014). Possible interventions for promoting psychologically safe environments include training programs and team-building exercises to build trust among nursing staff (Armstrong, 2017). The Iowa Model Revised: Evidence-Based Practice to Promote Excellence in Healthcare was selected as the framework to address this prevalent healthcare issue (Melnyk & Fineout-Overholt, 2019). Framework This MSN project aims to address the issue of incivility in the workplace by recognizing and responding appropriately to negative behaviors. The proposed change to improve the 7 psychological safety of nurses, specifically in critical care units such as the Pediatric Intensive Care Unit (PICU), through an evidence-based training program can positively impact staff morale and create a safer unit for nursing staff, patients, and families. This MSN project will utilize the Iowa Model Revised: Evidence-Based Practice to Promote Excellence in Healthcare (See Appendix A), the revised version of the Model for Evidence-Based Practice Change by Rosswurm and Larrabee (1999). This model provides a step-by-step process with feedback loops that drive evidence-based change and focus on quality improvement (Melnyk & Fineout-Overholt, 2019; Tucker et al., 2021). The Iowa Model Revised promotes evidence-based change as it is team-based, accomplishes change through phases, and aligns with the organization’s priorities (Tucker et al., 2021). The Iowa Model Revised focuses on identifying problems or issues within an organization or unit to help clinicians develop a clinical question to promote a possible change (Hanrahan et al., 2019; Melnyk & Fineout-Overholt, 2019). Problems or issues are often attributed to a knowledge or literature gap where further research findings can be translated into clinical practice to bridge the gaps (Speroni et al., 2020). Utilizing this model can enhance the implementation process by creating awareness and interest, building knowledge and commitment, and promoting action within a unit (Speroni et al., 2020). Once an issue is identified, the model can be applied to address and initiate change within practice and improve standards of care. The Iowa Model Revised includes a multi-step process with feedback loops to assess the validity of progress related to the question, purpose, or proposed change (Buckwalter et al., 2017; Hanrahan et al., 2019; Melnyk & Fineout-Overholt, 2019; Speroni et al., 2020; Tucker et al., 2021). The process includes the following steps: (1) identify a trigger, (2) state the question 8 or purpose, (3) identify the priority of the trigger, (4) form a team, (5) assemble, appraise, and synthesize the evidence, (6) determine sufficiency of the evidence, (7) design and pilot the practice change, (8) evaluate whether the change is appropriate to adopt into practice, (9) identify and sustain the practice change, and (10) disseminate the results (Buckwalter et al., 2017; Melnyk & Fineout-Overholt, 2019). Throughout this process, users must evaluate their topic, questions, and interventions to determine whether change can occur at that time and continue in the change process or if adjustments are needed to create a better practice change. The Iowa Model Revised will provide the best framework for this MSN project because it requires constant reevaluation of the effectiveness of proposed interventions for positive change. Improving psychological safety within a critical care unit will provide safer work environments for staff and improved patient health outcomes. The framework can also help discover the root of incivility in a designated area and implement an evidence-based program to help staff recognize, respond, and intervene appropriately when negative behavior occurs. Strengths and Limitations The Iowa Model Revised has strengths and limitations when applying it to any project. The strengths of this model include several feedback loops that allow for constant reevaluation at any step of the change process (Melnyk & Fineout-Overholt, 2019). Reevaluation helps identify what is working and what is not, allowing for reconfiguring the plan and implementation strategy. The model creates opportunities to continuously analyze the change implementation and modify the structure, process, and, ultimately, outcomes of the project (Melnyk & FineoutOverholt, 2019). This process creates an environment conducive to the adaptation to the delivery of change as the unit or organization responds. The Iowa Model Revised has been cited over 400 times, requested to be used within institutions/organizations over 1,500 times, and has 9 persevered through times as a “pragmatic, application-oriented and theory-based EBP process model” (Melnyk & Fineout-Overholt, 2019, p. 444). This model has been applied numerous times to improve patient outcomes while assessing current practices within a setting to discern where change needs to occur (Melnyk & Fineout-Overholt, 2019). The model provides a precisely planned approach that will benefit nurses within an organization. While this model has many positive attributes, limitations exist and should be considered. Staff must be engaged and educated regarding evidence-based practice to mitigate opposition and the potential for implementation failure (Speroni et al., 2020). It is critical to the success of a project under this framework to be appropriately outlined and followed, linking the priorities to be accomplished and introducing the phased implementation process (Hanrahan et al., 2019). Failure to do this can result in improper implementation and may jeopardize the integrity and functionality of the framework. The strengths and limitations of change models are essential when choosing a framework to apply to this MSN project, as it is crucial to choose one that properly aligns with the project’s goals. The Iowa Model Revised provides the best framework and guidelines to implement the change process identified throughout this paper and project. Analysis of Literature This review will examine three themes related to psychological safety and incivility in the workplace. These themes include confidence in recognizing incivility in the workplace, enhancing trust among staff members to facilitate positive patient outcomes, and increasing job satisfaction and staff retention through the support of nurse leaders. These themes are crucial for the mental well-being of nurses and the patients they care for. These themes are evident throughout the researched literature aiming to address the following question: How does the implementation of evidence-based training for ICU nurses improve their self-reported awareness 10 and ability to appropriately recognize and respond to disruptive behaviors associated with incivility and bullying as compared to the current standard (no training) over a six and 12-month time frame? Search Strategies A literature search was conducted to identify current evidence using Weber State University’s Stewart Library’s OneSearch, Ovid, EBSCOhost, and Google Scholar. Only articles from 2017 to 2023 were included to ensure recent evidence and information were being used, except for two articles, one from 2014, which provided relevant information to support workplace bullying prevention, and a second from 1999, which provided insight into the original Iowa Model. The search terms included nursing incivility, incivility, workplace violence, bullying, psychological safety, training programs, nursing education, support, patient safety, favorable outcomes, quality improvement, turnover, and retention. Synthesis of the Literature After researching many articles on psychological safety in the workplace, incivility in the workplace, ways to help address this behavior, and ways to help improve nurse retention, three themes became evident. These themes include confidence in recognizing incivility in the workplace, strengthening trust among staff members to deliver positive patient outcomes, and increasing job satisfaction and retention through the support of nurse leaders. The remainder of this synthesis section will review and organize the researched literature to provide insight into ways to combat incivility and promote psychological safety in the workplace. Confidence in Recognizing Incivility in the Workplace Several studies found that instilling confidence in recognizing incivility helped address the issue of bullying within the workplace (Armstrong, 2017; Arnetz et al., 2019; El Ghaziri et 11 al., 2021; Hawkins et al., 2023; Palumbo, 2018; Shorey & Wong, 2021). Workplace bullying continues to be underreported, protecting perpetrators while enabling toxic behaviors (Arnetz et al., 2019). Nurses have reported witnessing and experiencing incivility inflicted by their instructors, preceptors, and nurses in the clinical setting (Palumbo, 2018). Enabling negative behavior facilitates the cycle of bullying and damages nurses' physical and emotional well-being, directly affecting the quality of patient care (Hawkins et al., 2023). Hawkins et al. (2023) suggest investigating self-reported exposure to negative work experiences through The Negative Acts Questionnaire to challenge the existing culture. This questionnaire consists of twenty-two items measuring exposure to negative workplace behaviors, with a high score indicating an increased prevalence of negative workplace behaviors. Face-to-Face Training An intervention that can increase confidence in recognizing incivility is the face-to-face training called The Respectful Workplace Workshop, which aims to promote a respectful workplace and instill skills in identifying, managing, and mitigating negative workplace behaviors (Hawkins et al., 2023). While the implementation of this intervention did not have measurable significance, with more research and development, there could be potential for this workshop to indicate significance when implemented within the workplace. Armstrong (2017) implemented educational training that showed improved self-efficacy and confidence in responding to incivility. Following this intervention, it was found with a statistical significance of 0.002 that staff felt they could respond appropriately to incivility and alter their responses as the situation adapted. Educating Students on Recognizing and Addressing Bullying 12 El Ghaziri et al. (2021) conducted research among clinical nurse faculty to identify bullying and negative behaviors within the nursing profession. Like Hawkins et al., El Ghaziri utilized The Negative Act Questionnaire to determine the prevalence of negative behaviors. El Ghaziri et al. (2021) conducted a cross-sectional study (N = 76) to understand better the prevalence of bullying and its impact on nurses. The data indicated significant p-values of 0.002 and 0.001 for nursing staff experiencing high levels of stress in the workplace related to bullying. Through the self-reporting questionnaire, individuals reported that education about recognizing and addressing bullying and incivility should be initiated in nursing schools to promote healthier work environments throughout nurses’ careers (El Ghaziri et al., 2021). By addressing this issue from the beginning, nurses’ confidence in addressing negative behaviors later on will improve. In a qualitative systematic review, Shorey & Wong (2021) indicated that nurses lost confidence in their skills and abilities when bullied and felt unworthy of being nurses. This information and data suggest that building trust through the support of peers and nurse leaders can create a safer environment for nurses and patients. Aiding staff members to recognize their abilities, strengths, and areas needing improvement can empower them to stand up, speak up, and respond appropriately to workplace incivility. Team Trust Can Improve Patient Outcomes Building trust within a team is crucial for the psychological safety of staff and the outcomes of patients (Aljuaid& Alharbi, 2023; Clark, 2020; El Ghaziri et al., 2021; Murray et al., 2022; Shanahan & Cunningham, 2021; Shorey & Wong, 2021). Clark (2020) indicates that learner safety is diminished when individuals are belittled, demeaned, or harshly corrected. Derogatory actions destroy trust and encourage a passive, complacent, idle work environment. Individuals may fear asking questions that promote workplace safety, ultimately putting 13 themselves and patients at risk. Building workplace trust is integral and foundational to developing relationships and achieving the best possible patient health outcomes (Shanahan & Cunningham, 2021). When staff feel psychologically safe, they are more likely to speak up and take action without fear of retaliation, being seen as disruptive, or jeopardizing their reputation (Murray et al., 2022). In a descriptive, correlational study (N = 300), staff members were given a questionnaire regarding their incivility experiences; results indicated that uncivil acts by managers and physicians contributed significantly to patient safety concerns (Aljuaid & Alharbi, 2023). Additionally, El Ghaziri et al. (2021) indicated that 60.6% (N = 76) of participants needed more confidence that their leaders would appropriately respond to reports of bullying. Shorey & Wong (2021) indicated that patient safety is adversely affected when bullied nurses deliver patient care. Being bullied increases nurses’ potential to make mistakes. Nurses can flourish in a united environment that promotes psychological safety (Clark, 2020). Ensuring that staff members are treated well and that all acts of incivility are addressed can promote safety within a unit. By promoting safety, patients can receive better care and experience improved outcomes. Job Satisfaction and Staff Retention Increase with Support Nurses' job satisfaction and retention rates remain low as burnout increases, motivation and work engagement decreases, and incivility occurs (Andrews, 2019; Armstrong, 2017; Clark, 2020; Forde-Johnston & Stoermer, 2022; Krivanek et al., 2020; Ovayolu et al., 2014; Vessey & Williams, 2021). Vessey & Williams (2021) performed a quality improvement project that helped cultivate psychological safety by providing an educational training portfolio with tools and interventions for managers and leaders to develop and sustain a climate of civility. By 14 creating this kind of support, nurses can feel safe in their units, leaders can be held accountable for their actions, and patient safety can be upheld. Ovayolu et al. (2014) found that nurses who experienced bullying displayed increased absenteeism, lost their desire to go to work, and ultimately resigned. Nurses are three times more likely to be victims of violence from patients, families, and coworkers in the workplace than any other type of healthcare personnel, indicating a need for support and eradication of bullying from superiors and peers (Ovayolu et al., 2014). In contrast, when nurses were involved in teambuilding and group cohesion activities, job satisfaction improved with a statistical significance (p = 0.037) (Armstrong, 2017). Clark (2020) supported this principle by stating, “The leader’s task is to simultaneously increase intellectual friction and decrease social friction” (p. xii). In the United Kingdom, an initiative called “Listen to Staff” was implemented to provide a platform for nurses to discuss their concerns and frustrations within their workplace openly. It is crucial to show support by listening and acting when concerns are presented (Forde-Johnston & Stoermer, 2022). Supporting staff members encourages feelings of safety and reassurance that their concerns are valid and will be addressed. Addressing workplace incivility promotes intellectual stimulation while decreasing negative behaviors. A survey conducted in Queensland, Australia, determined that more than 50% of Australian nursing students had been bullied, harassed, and left feeling anxious and questioning their career choices (Andrews, 2019). These behaviors result in individuals questioning their decision to become nurses and can result in nurses leaving the profession. Organizational and unit leaders are responsible for supporting, protecting, and being proactive when these behaviors occur (Andrews, 2019). Creating a work environment where nurses feel comfortable to speak up about their concerns, feel supported by their leaders, and are educated 15 about workplace violence can lower the incidence of bullying by promoting a culture of zero tolerance (Andrews, 2019; Ovayolu et al., 2014; Vessey & Williams, 2021). Ultimately, if nurses are not taken care of and given the resources to cope with work difficulties, job satisfaction can decrease, and turnover rates can increase. Group cohesion and job satisfaction are improved when nurses are given opportunities to work together and grow as a team. Summary of Literature Review Findings and Application to the Project The literature reviewed illustrated the need for a change in the nursing field regarding workplace bullying. Psychological safety and support within a work environment are vital to reducing bullying and mitigating the adverse effects on work engagement; nurses must openly discuss complex work problems with one another to support these changes (Arnetz et al., 2019). The literature also informs readers that educating staff on recognizing, responding to, and managing workplace incivility can improve their work environment and promote a safe, respectful, and dependable team (Aljuaid & Alharbi, 2023; Murray et al., 2022; Shorey & Wong, 2021). Staff must feel confident that they can ask questions and make mistakes without fear of retaliation, marginalization, or punishment (Arnetz et al., 2019). Creating a psychologically safe environment includes staff who feel included and safe to learn, contribute, and challenge the existing work culture when a change is required (Clark, 2020). Discussion with staff, continual check-ins, and constructive feedback can be implemented to achieve psychologically safer environments. A high-performing team will be assertive and deliver high-quality care while maintaining staff engagement and improving patient outcomes (Murray et al., 2022). Implementing a training program for nursing units can help educate and empower nurses to recognize, respond, and mitigate incivility when it occurs. Empowering staff members can help them feel confident in 16 themselves and their team, as negative situations can be addressed in the moment rather than after the fact. This type of engagement encourages staff to speak up for themselves and others and promotes psychological safety among their team. These changes can positively impact the delivery of care and improve patient outcomes. Project Plan and Implementation Creating change within a department can be difficult. Intentionally creating a positive plan and implementation process can improve staff acceptance of the project. Building an evidence-based educational program that appropriately addresses ways to recognize and respond in adverse situations will help accomplish and establish confidence in this skill and improve team trust and job satisfaction, ultimately improving patient outcomes. Moving forward, this paper will discuss how the above-stated goals can be accomplished by working closely with an interdisciplinary team to produce a well-rounded training program that will help nurses learn how to feel empowered in their positions and their abilities to recognize and respond to negative behaviors to promote a psychologically safe work environment. Plan and Implementation Process This project will be implemented using a human-centric approach to promote and develop solutions to incivility faced within the PICU. Focusing on educating and empowering PICU staff to engage in causes that advance safe workspaces will help them recognize and respond to negative behaviors, decreasing incidences of incivility. A meeting will be held with all interdisciplinary team members to initiate this training. A discussion will ensue regarding areas and instances of incivility within the PICU. Once these cases have been presented, a training program will be developed with the help of the unit educators and management to address ways to promote psychological safety in the unit and 17 eliminate incivility as it presents. This training will include evidence-based research, actual events, and scenarios to help solidify and rectify appropriate behavior when discourse occurs. A slide show will present findings and proper education on recognizing and responding when incivility occurs. This training program will be given to all new hires in the PICU as they attend their orientation classes, and existing staff will be expected to participate in this training in person or online through Zoom. To further encourage psychological safety, all individuals will be given an infographic with quick reminders on addressing incivility and promoting safety (see Appendix C). All staff must receive this information to help promote safe workspaces for themselves, their peers, and their patients. Interdisciplinary Team The team members that will contribute to this project include members of management, unit educators, nurse leaders (charge nurse, expanded roles, etc.), staff nurses, and attendings/fellows/residents in the PICU. Teamwork is essential for the PICU's vulnerable population to ensure they receive outstanding care. Providing this care includes team members feeling comfortable asking for help, recommending possible changes to improve the quality of care, and speaking up when an issue is present. The team will also include the patient (if appropriate) and their families when making these decisions. A cohesive team of caregivers ensures patient safety in all clinical decisions while considering the patient's status when making changes. As a caregiver team establishes clinical expectations for a patient, continuity of care can be provided. Expected Roles The management team and unit educators will collaborate to ensure the education plan and training are carried out in new-hire classes. They will also collaborate to help staff feel safe 18 approaching them when situations of incivility arise and help nurses manage and address these problems. Nurse leaders will be proactive and address situations of incivility when they are happening. This action by nurse leaders can help both parties recognize what is happening and promote positive correction to create a psychologically safe environment. Staff nurses will receive this training in new-hire orientation classes. They will be taught how to recognize and respond when incivility occurs. Attending this educational training is critical for staff nurses as they are the frontline workers who experience the most incivility. Empowering staff through education on this topic will help staff hold each other accountable for treating others with respect, dignity, and kindness. Attendings, fellows, and residents will also receive this training to encourage and promote a safe place for nurses to suggest changes and actively participate in their patients’ care plans. Due to their positions of authority and power, this group of individuals can intimidate staff. Creating positive interactions where individuals listen to and validate concerns, questions, and suggestions can promote a psychologically safe work environment. Working as a Team Behaviors like marginalizing, ridiculing, or embarrassing coworkers should not be tolerated in nursing. A positive team environment is essential for the promotion of psychological safety. When team members feel safe, they can act without fear of retaliation or negative consequences. Creating positive relationships with peers and other interdisciplinary team members can encourage learning opportunities rather than barriers and obstacles in learning. Creating psychologically safe environments improves performance and problem-solving abilities 19 and contributes to individuals' taking ownership of their decisions (Clark, 2020). As everyone collaborates to promote psychological safety, nurse retention and patient safety can improve. Description and Development of Project Deliverables Deliverables for this project are essential for understanding and improving negative behaviors. Visual and interactive materials can help maintain staff engagement and interest in the topic. Deliverables help establish clear goals, plans, and strategies that demonstrate the purpose of a project and its desired outcomes. Evaluation can also be achieved through the presentation of deliverables. For this project, three deliverables will be used. Individuals will participate in a pre- and post-survey, have access to an infographic, and attend a presentation on the importance of psychological safety. Surveys. The pre- and post-surveys consist of questions assessing staff knowledge and feelings on psychological safety. The pre-survey discusses staff's feelings and thoughts about how the unit interacts with one another before the training is implemented. The post-survey will be taken six and twelve months after receiving the training and will assess the effectiveness of the training based on staff self-reporting (See Appendix B). Infographic. The infographic provides a quick and easy-to-read guide and reminder on lessons learned through the psychological safety training. This graphic will be posted throughout the unit to ensure staff, patients, and families understand the expectations when interacting with one another (See Appendix C). This graphic will provide information to help individuals recognize, respond, resolve, and create positive change. Psychological safety can be maintained as individuals hold themselves and others accountable. Supporting each other through this positive change and new perspective can foster valued relationships among team members, encourage open dialogue, build trust, and create success in performance (Murray et al., 2022). 20 Presentation. The presentation on psychological safety creates a brief outline of the topic, the importance of recognizing and addressing negative behaviors, and the consequences of negative behaviors (See Appendix D). Understanding the impacts of incivility in the workplace is essential because actions have consequences, whether they be positive or negative. Promoting a psychologically safe work environment requires eliminating the culture of bullying by standing up against bullies and their negative behaviors, educating staff on ways to mitigate this behavior, and empowering staff to promote safety by welcoming questions and appropriately explaining rationales for the way things are done (Shorey & Wong, 2021). Reflection can also be a positive tool to promote introspection and improve staff behaviors. Timeline The proposed timeline for this project's initial preparation and implementation is one and a half years (See Appendix E). Starting in January of the new year, data will be collected through stakeholder meetings and the pre-survey (See Appendix B). After two months of collecting data, the training program will be created. The data and information from the meeting will help create an outline for the training program. This program will be designed in two months. After the outline for the training is completed, it will be presented to members who have helped create it to provide a trial process for implementation; this process should take a maximum of two months. Changes will be made as needed, and by July, the training program will be implemented with the next hire group of new nurses in the PICU, staff nurses, doctors, and other ancillary staff members within the PICU. Once all staff has been through the training, they will be reevaluated after six months through a post-survey that will be emailed to them (See Appendix B). Staff members will have the opportunity to provide feedback on the training, their experiences before and after the training, and suggest changes that can be made, as well as 21 positive outcomes that resulted from the training. The planning team will then have two months to hold a meeting to review the results of the post-surveys. This team will evaluate the effectiveness of the training through staff members’ feedback, providing valuable information on how the training can be improved for the next hire group. The long-term sustainability plan for this project is to develop a curriculum or training program/presentation for new hires, staff members, ancillary staff members, doctors, and management regarding ways to recognize and respond to incivility in the workplace and promote psychological safety. This sustainability plan will be done through pre- and post-surveys, infographics hung in the unit, and a thorough training presentation program. This project aims to foster an environment for staff members to feel empowered and safe when speaking up regarding negative behaviors or concerns. Project Evaluation Staff members will be asked to participate in formative pre- and post-surveys about their knowledge and experience regarding the presence or lack of psychological safety within the PICU and outcomes after the training. There will also be a required summative reflection for staff to complete in Workday Learning, a tool used within the PICU to gather and store pertinent information regarding a nurse and their progression in learning tasks. Nurses will include a summary of their opinions and experiences surrounding the training and if they have seen a difference in the culture of the PICU since its implementation. These tasks will populate in Workday Learning as management creates and assigns them. Evaluation Staff members will be asked to complete a post-training Google Forms survey six and twelve months after the training. This survey will include short answer questions regarding the 22 individual's thoughts and feelings on the training and how it has helped them in their practice. Individuals will be asked how they perceived the training, whether or not they feel more confident in recognizing and responding to negative behaviors, and if they have seen an increase in psychological safety after implementing this training, etc. Feedback is essential to make changes and improve the training program to help individuals feel heard and achieve their potential in curating a reliable and integral work environment. Evaluating a new implementation process will provide reliability and help staff members understand their roles; feedback is vital in creating positive change. Ethical Considerations Ethical considerations are important to acknowledge when developing project plans. This project includes informed consent, voluntary participation, confidentiality of responses, and encouraging honest answers and feedback to advance this important cause. Participation in this project plan will result in minimal harm or risk. This project aims to include all staff members in the PICU who are involved in direct patient care and does not discriminate on any basis. Everyone’s participation and feedback are encouraged and welcomed. Staff members should be reassured that the information they provide is focused on promoting their health and well-being so that they may provide the best and most informed care to their patients. Individuals with objections to participating in this training can voice their concerns to unit management. A plan will be made with the individual, educators, and management to address their concerns while encouraging them to participate, as the content will benefit them in their practice. All existing employees and new staff members should participate in this training as a part of the new hire process to ensure everyone has the same knowledge and education on this topic. The educators and management will closely monitor staff participation. Promoting and maintaining 23 psychologically safe work environments for nurses can promote exemplary care of patients, improving their outcomes. Discussion The dissemination of information about this project will be discussed in this section, along with the significance of this project in advancing nursing practice. The project's implications, recommendations for furthering the project's aims, and the conclusion of this project will also be discussed. Implications of this project will include strengths and limitations of the project and how this information will increase knowledge within the nursing profession. Evidence-based Solutions for Dissemination This project will be presented in poster format to peers and faculty at Weber State University in April 2024. The information can also be shared during a Research and Engagement Symposium at WSU or the Western Institute of Nursing Conference in Salt Lake City. These are great opportunities to share the research on this topic. It is crucial to share information on this topic when teaching, coaching, and informing management of issues within a unit, program, or job to help create a safe environment for nurses to provide optimal patient care. Significance to Advance Nursing Practice Incorporating psychological safety training for staff members within the PICU can help improve the unit's culture. Nursing is a caring and nurturing profession, but as nurses provide this care for their patients, they often can be “dreadful to one another” (Andrews, 2019, p. 1). Support and care for patients should translate to support and care for coworkers. Organizations must help create a proactive, caring, supportive culture when bullying and negative behaviors arise. Promoting a culture of zero tolerance towards bullying and encouraging staff to speak up when they feel uncomfortable in a situation will mitigate bullying and fear (Andrews, 2019). 24 Creating this training course to educate staff on recognizing and responding to bullying can help address the prevalence of bullying within a nursing culture and mitigate the impact of uncivil acts among nursing peers (Aljuaid & Alharbi, 2023). The significance of this topic and the adverse effects bullying behaviors have on nurses and staff members require immediate attention and action. The development of this training course will shed light on the significance of this issue and educate staff members on proper ways to mitigate and eradicate negative behaviors. Implications One identified strength of this project is that it is one of a limited number of reliable resources that assess staff bullying within the PICU. Implementation of this project provides a safe and confidential outlet for staff members to speak freely about their experiences with bullying. Another strength of this project is its organized method of collecting data for interpretation. This will allow further dissemination of information on promoting psychologically safe work environments. This project focuses on the PICU in a single hospital and does not account for other units or hospitals. This project's design is specific to how the PICU at this particular hospital is organized and managed and does not account for other units or floors outside of this specialty. Slight changes can be made to adapt this training should other hospitals or units find this implementation project productive and informative. Implementing this project will further nursing knowledge by providing staff with safe opportunities to ask questions and provide constructive feedback. If nurses have questions regarding the care provided by their peers, they should start a conversation with those peers rather than making assumptions. When assumptions are made regarding patients’ medical conditions, medication regimens, lab findings, or provided interventions, an increased risk for unsafe patient care is created. 25 The demands of the nursing profession are extensive. If nurses and other staff members feel safe in their work environments, they can trust that their actions, thoughts, and suggestions will be mutually respected and discussed as needed. Promoting psychological safety supports nursing staff by encouraging positive and productive conversations and actions to promote desirable work environments and a healthy, healing space. Patients can reap the benefits of a nursing staff that feels safe and respected. When staff members feel that their mental health and well-being are prioritized in the workplace, they can become better advocates for themselves, their peers, and their patients. Recommendations To improve this project, it would be beneficial to inquire about other topics related to psychological safety that PICU staff members would like to learn more about. Utilizing feedback from the individuals directly affected by the training is essential to supplement and improve the content. Following the initial introduction of this training program, further development of the training content will incorporate staff feedback on the efficacy, evaluation of post-surveys, and evaluation of the effectiveness of the unit’s psychological safety practices. These points can be evaluated by assessing individuals' interactions and focusing on interactions that promote a safe environment. When staff members encourage safety in the work environment, they should be recognized and applauded for their actions to reinforce the behavior. Further research should be conducted on the best practices to promote psychological safety to improve upon and add to the training outlined in this project. The modalities of information dissemination may be adjusted depending on staff response and participation. Conclusions 26 Psychological safety in the workplace is essential to achieving and maintaining optimal health and well-being of employees and optimizing care delivered to patients. Bullying or incivility that exists in the workplace must be promptly addressed. To address and decrease bullying and promote psychological safety in the workplace, staff members will be taught how to confidently recognize and respond to incivility in the workplace and build trust within a team. As staff members work on these skills, they should also find support from management; everyone must work together to create a safe and healthy work environment. Educating staff on these topics and promoting the skills needed to create an emotionally safe workplace can improve job satisfaction and staff retention. When staff members are cared for and educated on negative behavior presentation and how to manage negative situations, they are better prepared to appropriately address hostile encounters or situations. Organizations may see better patient outcomes as the team members providing patient care are cared for themselves. Promoting psychological safety in the workplace can benefit all individuals involved at every level of care. Ensuring that the staff who work endlessly to support their patients are supported and cared for mentally, emotionally, and physically at work can create a safe workspace that is free from fear and promotes optimal patient care. 27 References Aljuaid, N. 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Implementation science: Application of Evidence‐Based practice models to improve healthcare quality. Worldviews on Evidence-Based Nursing, 18(2), 76-84. https://doi.org/10.1111/wvn.12495 30 Vessey, J. A., & Williams, L. (2021). Addressing bullying and lateral violence in the workplace: A quality improvement initiative. Journal of Nursing Care Quality, 36(1), 20–24. https://doi.org/10.1097/NCQ.0000000000000480 31 Appendix A Iowa Model Revised (Melnyk & Fineout-Overholt, 2019, p. 438) 32 Appendix B Pre-and Post-Surveys 33 34 Appendix C Infographic for Psychological Safety 35 Appendix D Presentation on Psychological Safety 36 37 38 39 Appendix E Timeline