Module 6-Capstone Essay Final

Running Head: WORKPLACE VIOLENCE AND INCIVILITY 1
Workplace Violence and Incivility
Nicole Fournier, Jillian McGee, Taylor Massey
Northeastern University

WORKPLACE VIOLENCE AND INCIVILITY 2
Workplace Violence & Incivility
Ensuring a healthy workplace environment is a fundamental factor in delivering quality
nursing care. It is one that is characterized by a high level of trust, respect, authenticity, and
dignity of which flows throughout all members of the healthcare team, healthcare consumers,
and families. A nursing environment should be perceived as healing and empowering, thus
creating a workplace culture that breeds safe, effective patient care. Unfortunately, this desired
environment may be compromised by violence, bullying, and incivility. It has been stated by the
American Nurses Association (ANA) that some form of violence, bullying, or incivility occurs in
nearly every nursing speciality, practice, and academic setting. This problem affects all
educational and organizational levels of the nursing profession (ANA, 2015).
Bullying, as defined by the ANA, is “repeated, unwanted harmful actions intended to
humiliate, offend and cause distress” (ANA, 2016). Examples include hostile remarks, verbal
threats, and even physical assault. In a 2015 report from the ANA, 43% of nurses and nursing
students had confirmed that they had experienced verbal or physical threat by a patient or
patient’s family, and a drastic 24% had been assaulted within the workplace (Potera, 2016). To
combat this phenomenon, it is required that nurses play a vital role in creating an ethical
environment, bringing forth courtesy, respect, and kindness to all persons within the health care
environment. In addition to the ANA’s ‘Zero Tolerance’ policy for Workplace Violence and
Bullying, multiple methods, models, and best practice strategies have been trialed and
implemented to sustain a healthy workplace. Continuing physical or verbal abuse must no longer
be accepted within the environment of a working nurse (ANA, 2016). As so, this capstone will
address the issue of workplace violence and incivility by various aspects of the nursing
profession, specifically: leadership, management and followership, effective communication and

information technology, nursing resource management, evidence-based practice, quality and
safety, nursing finance, and inter and intra professional collaboration.
Workplace Violence and Incivility: The Effects
Due to the very nature of the profession, nurses are at a predisposition when it comes to
the risk of violence within the workplace. It is typically unknown of who will walk through the
doors and what health conditions or mental statuses one may have. The root of workplace violence
may stem from an individual’s substance abuse, one’s deteriorating status, other organic
complexities, an underlining history of violence, or even from distressed relatives or friends of a
patient (OSHA, 2015). This violence that is spoken of takes on many different forms and origins
(Figure 1), it may not only involve
the patient-nurse dyad in a hospital,
but can involve a nurse-nurse,
physician-nurse, and any other
internal staff at an organization,
clinical setting, or location.
Workplace violence and
incivility is complex, as implied
previously. It is seen on a
continuum, encompassing a wide
array of negative actions, or even negligence (Box 1). According to Yoder-Wise (2011), “the
definition of violence includes overt or covert behaviors ranging from offensive or threatening
language to homicide” (Yoder Wise, 2011, p. 498). Violence can be noted as the general term that
80%
12%
3%
3% 1% 1%
Healthcare Worker Injuries in Days
Away fromWork, by Source
Patient
Other Client or Customer
Co-worker
Student
Assailment, Suspect, Inmate
Figure 1; Retrieved from Bureau of Labor Statistics, 2012 data as cited in OSHA,
(2015)

embodies lateral aggression, bullying, and incivility. Overall, these actions carried out within a
patient care setting are hazardous to the safety of the entire organization as it can inflict many
harmful effects upon its victims. This furthermore complicates the delivery of care provided by
nurses and other personnel, as they may begin to experience psychological, or even physical
Box 1: Types of Violence
Intimidation 75.9%
Angry Outbursts 71.9%
Hypersensitivity to criticism 71.5%
Belligerence 66.9%
Threatening/Disruptive Behavior 64.6%
Bullying 59.8%
Harassment 51.6%
Threats of physical violence 38.9%
Obsession with a supervisor 28.5%
Ominous or specific threats 27.9%
Physical violence 25.8%
Intentional property damage 17.0%
Preoccupation with recently publicized violent
events
8.3%
Carrying or storing weapons 7.5%
Preoccupation with violent themes 5.9%
Recent acquisition of or fascination with
weapons
5.6%
Box 1; Retrieved from Hader, R (2008) Workplace Violence Survey 2008.
Nursing Management, 39(7), 13-19. As cited in Yoder-Wise (2011, p. 500)
struggle. These factors may even take nurses out of work, depending on severity. Keller et al.
(2016) places emphasis on workplace violence aftermath by explaining that victims may begin to
feel anxious or depressed, they may lose confidence and self-esteem, as well as feel powerless or
humiliated; all of which may act as barriers to optimal care. Nonetheless, it is very important that
workplace violence and incivility be addressed and acted upon. The problem, however, is that it
is largely underreported, in that there is complacency, with many reporting violence being “part
of the job.” This does not, and should not hold true (Potera, 2016). In order to remedy this
persistent problem, measures must be taken first to explore and understand the factors and

circumstances that precede the occurrence of workplace violence and bullying. This way, more
specific and effective prevention, intervention, and protection programs can be developed to
deflect incivility and bullying.
Leadership, Management, and Followership
Across the clinical spectrum, the nursing profession has certainly made its advancements,
as it has become the backbone of the healthcare system (Yoder-Wise, 2011). Nurses take on
numerous tasks and responsibilities, which has demanded a higher extent of sophisticated
knowledge, attentiveness, organization, and communication, amongst other essential qualities.
With that being said, they take on the “willingness to act.” The “willingness to act,” which
involves engagement of patients, families, other nurses, and other health disciplines and agencies
requires several characteristics that fall under the roles of three individuals: leaders, managers,
and followers. In dealing with the prevalence of workplace violence and incivility, every nursing
role can play a part in finding and implementing solutions to this perilous clinical situation.
A leader is one who commits to excellence with purpose and passion, as they willingly
identify and act upon a multitude of complex problems that may arise within the workplace. In
doing so, the nurse leader must possess a set of qualities and objectives. Leaders typically are
role models that have inborn traits crucial towards inspiring and motivating others to reach a
common goal, such as adaptability and communication skills (Yoder-Wise, 2011). In the context
of workplace violence, a nurse leader would first take steps in recognizing and assessing the
problem. Once this occurs, strategic plans would be adapted and created to mitigate the
prevalence of violence and bullying. For example, the nurse leader may primarily take action by
forming focus groups to gather direct opinions and perceptions of nurses and other allied health

professionals in relation to contributing factors of workplace violence (Blando, Ridenour,
Hartley, & Casteel, 2015). This communication can give rise to awareness on many different
levels, thus allowing the leader to develop a vision in fighting the issue. The nurse leader may
then work to form well-written educational and/or prevention programs to train and guide other
staff members to the desired outcome: a healthy workplace environment.
Nurse managers differ from leaders by the fact that they typically guide through a set of
prescribed practices and procedures embedded within the organization; maintaining structure and
stability to keep it operating effectively. Nurse managers oversee the nursing staff, working to
maintain or enhance enthusiasm by validating others’ strengths, knowledge, skills, and abilities
(Yoder-Wise, 2011). These actions taken by a nurse manager can ultimately strengthen one’s
self-reflection and emotional intelligence, thus maintaining optimal work performance and
possibly achieving synchrony between all staff nurses, despite the presence of workplace
violence. From what a leader creates throughout a task force against workplace violence and
bullying, a nurse manager would be one to support the structure of this initiative; raising the
commitment toward eliminating workplace violence. One of many ways could begin with
assuring adherence of the staff to the plan set in by the nurse leader. In working off the previous
example, a nurse manager may encourage attendance to education and/or prevention programs,
encourage staff to report any incidences of violence, log incidents that include names of
witnesses, and make efforts to instill emotional intelligence (Johnston, Phanhtharath, Jackson,
2010). Additionally, with an organization policy against workplace violence, like ANA’s ‘Zero
Tolerance’ policy, nurse managers would also be ones to assure that all employees know and
understand it.

Nurse leaders and managers work in close collaboration of instilling solutions to any
problem that may arise in the workplace. According to Yoder-Wise (2011), both roles take on
the responsibility of accomplishing the vision through similar tactics. Leaders and managers
examine multiple strategies and solutions while energizing values and stimulating growth and
movement towards the desired vision (Yoder-Wise, 2011).
Followers, on the other hand, complement the efforts put forth by leaders and managers.
Further embellishing the position of followers, Yoder-Wise (2011) states that “followership is
not passive direction taking, but, rather, behaviors that model collaboration, influence, and action
with the leader or manager” (Yoder-Wise, 2011, p. 6). These members of the team have an
influential voice in problem solving and evaluation as they are the ones that primarily would
provide input and feedback from daily experiences. Within a focus group created by the nurse
leader, followers are those that provide input, which influences logical solutions to remedy
violence and bullying in the workplace. This input, for example, may be contributing factors to
violence that followers pick up on the floor. Furthermore, followers also provide significant
feedback, which can inform the nurse leader and/or manager how successful strategies and plans
have been after implementation. They play a fundamental role in the progression towards the
desired outcome, as they are the ones that exercise the behaviors and actions needed to achieve
the vision of a safe, healthy workplace environment.
Nurse leaders, managers, and followers collectively put forth a range of efforts in facing
complex problems within the healthcare system; it is a multidisciplinary approach. They each
offer a set of skills and attributes that enhance one another, working as a team to achieve a
desired goal, to optimize patient care and outcomes, and to achieve workplace unity; in short:
strengthening the organization.

Effective Communication and Information Technology
Recurrent interaction between all staff members that is respectful and clear, promotes a
trustworthy environment, and supports different viewpoints are all factors that constitute
effective communication (Yoder-Wise, 2011). Endlessly, communication is a key component of
many things in life; it is to better understand one another, resolve differences, and nurture
problem solving and the creation of ideas, amongst much more. Likewise, it is believed that
successful communication between patients and co-workers may reduce the potential risk of
violence and conflict. Just as nurses do day-to-day, communicating with patients on a consistent
basis and in a way that is calm and professional may have an impact on how a given situation
may develop.
In achieving effective communication within an organization, a set of guidelines can
certainly be of assistance. If lacking, each individual must work to improve personal
communication skills, verbal and non-verbal. Taylor (2014) explains that not only listening, but
also empathizing with patients is a key skill for nurses to have. Primarily, it is important to
recognize how a patient is feeling in order to sufficiently respond to their emotions and to what
they have to say. This also comes with active listening, giving the patient undivided attention
through body language and gesture, for instance. This communication between nurse and patient
may reduce an up rise of patient frustration, anger, or tension, which is one way to reduce the
prevalence of violence and bullying.
Effective communication will also aid in the reduction of lateral violence, or violence
between co-workers. The willingness to listen, the manner in which disagreements are handled,
and the way in which feedback is given, are all ways that can promote successful communication
between nurse leaders, managers, and followers. Now, the importance of communication lies

within the well-known concept of teamwork. As Yoder-Wise (2011) states, working in teams is
one of the most crucial things to keep in mind in regards to achieving a unified goal; “teams are
groups that have defined objectives, ongoing positive relationships, and a supportive
environment” (Yoder-Wise, 2011, p.347). When teams come together and function successfully,
there is a notable difference within the entire workplace environment. And a workplace
environment that is positive is one that can detract workplace violence, bullying, and incivility. It
starts in the hands of all staff members; they must take an active role by setting examples of
professional behavior and by encouraging open communication without intimidation or fear.
Online tools may also be able to prevent health care violence, specifically. The CDC’s
National Institute of Occupational Safety and Health (NIOSH) is now offering free online
workplace violence prevention training programs to educate healthcare workers on how to
prevent and how to recognize work-place violence (HealthcareTraveler, 2013). Included in the
training course are videos demonstrating workplace violence incidents, text, and module quizzes.
Systems like this can allow all healthcare professionals to understand and identify potential risk
factors for workplace violence.
Nursing Resources Management
A well-functioning health care organization begins with, and is characterized by a skilled
and knowledgeable nurse workforce, in short: one that is high in quality and quantity of staff.
Correspondingly, it is crucial for a health care organization to obtain the “right number of nurses
with the right knowledge, skills and attitudes performing the right tasks in the right place at the
right time to achieve the right predetermined health targets” (ICN, 2009). Accordingly, managers
must seek proper candidates to join their staff pool by accurately assessing an individual’s

qualifications and attitudes towards patient care. These components must mesh well with other
employees to foster positive relations, positive work culture, and good teamwork (Daley, 2013).
The foundation of a strong nursing workforce is supplemented by multiple tools and resources;
those that drive decision-making processes and aid in the care delivery process. It is critical that
the nurse leadership of an organization take advantage of these resources and work to instill them
within the nursing staff. These efforts will help an organization to reach its operational
objectives, thus improving overall health care delivery.
Taking the reins in effective resource management are, of course, nurse managers. Nurse
managers take on a variety of duties and responsibilities in promoting and restoring the health of
patients each and every day. It is clear that in achieving this success, they must collaborate and
work with the nursing staff (Yoder-Wise, 2011). In terms of workplace violence and incivility, it
is required that they develop a set of guidelines to prevent and reduce workplace violence. Using
OSHA’s guidelines as a foundation, a nurse manager must include policy recommendations,
reporting procedures, and a variety of methods and strategies within their plans, such as risk
assessments (MNA, 2016.). The bulk of these components can be found within evidence-based
research. However, from one facility to another, there may be different precursors and hazards
associated with violence and abuse. As a result, the nurse leadership of an organization must
develop an individualized plan (MNA, 2016). The construction of such plan should also involve
input and feedback from employees. Providing the staff with this responsibility and autonomy
can also contribute to the creation of a positive work culture and environment. Nurse managers
must also be responsive and supportive to their staff, engage in thorough communication, and
influence positive relations. While this feedback can contribute to feeling a sense of involvement
within the processes it also provides managers with useful and accurate information to consider

additional policies and programs (Daley, 2013). For example, a “threat-management team” can
be assembled. This team would be comprised of representatives from legal, security, human
resources, and psychiatry departments as well as local law enforcement, for instance. A threat-
management team would be trained accordingly; to protect the organization by having the
capacity to detect and handle potential threats (Smith, 2015).
Evidence-based Practice, Quality, and Safety
In addressing workplace violence within the health care environment, it is quite necessary
to incorporate resolute, organized strategies and methods. Nonetheless, it is ideal that an
organization seeks these interventions through credible, evidenced-based resources. In doing so,
the focus of research would be on evaluation data of such interventions to determine their
efficiency. However, according to McPhaul, London, and Lipscomb (2013), evidence-based
research for workplace violence is unambiguous, even though it has surely emerged. This may
likely be due to in part by the minimal report of workplace violence. It has been found that many
employees either consider the majority of violence and bullying as “part of the job” or they may
not even consider it to be significant enough to report. This is why a clear, consistent definition
of workplace violence must be developed. If all employees in all industries and companies
shared the same conception of what constitutes workplace violence, it could be more accurately
and consistently reported, thus allowing reliable prevention strategies to be conducted and
assessed for credibility.
Taylor and Rew (2011) actually conducted a study with an aim to identify characteristics
of evidence-based interventions that have been set to avoid workplace violence. For this study,
three databases were used: CINAHL, PsychINFO, and MEDLINE. Throughout each different

database and the articles within them, there was no consistent definition of workplace violence to
be found, which made research difficult. Throughout the literature, varying definitions and
perceptions depicted acts of violence as spitting, pulling hair, biting, and stalking, while others
called abuse, harassment, sexual harassment, and sexual assault as acts of violence (Taylor &
Rew, 2011). The lack of trends found within the research is one of the key barriers to
implementing effective strategies and programs.
Primarily though, the basic structure of all prevention programs is derived from the
Occupational Safety and Health Administration (OSHA). OSHA’s paradigm incorporates the
following elements: management commitment and employee involvement, hazard analysis or
assessment, hazard controls, employee training, and recordkeeping and evaluation (McPhaul,
London, & Lipscomb, 2013). As mentioned, these elements are basic guidelines in constructing a
program, but more specific measures are needed to address specific precursors that contribute to
the occurrence of violence and bullying. This would assist in forming the best strategies to
remedy workplace violence and incivility.
Despite the lack of credible evidence-based interventions, there are multiple methods,
models, and strategies that can be found within the literature, however. The majority of these
interventions do not provide information on how effective they are, which leaves researchers
uncertain as to whether or not they should consider trialing them. As an example, Taylor and
Rew (2011) noted of a useful method in shaping the framework of a violence prevention
initiative. Although simple and quite obvious, it was stated that recording a workplace violence
incident as it occurs, the witnesses involved, its descriptive characteristics, pre- and post-
interventions, and outcomes would be very useful (Taylor & Rew, 2011). These detailed reports
may not only help leadership teams in building strategies and methods around such factors, but

they may also be compiled for research purposes to identify trends within the literature that seem
to be lacking. Another method found within the literature is based on emotional intelligence, an
idea thought to play an integral role in combatting lateral violence, remember: the violence
between co-workers. Enhancing emotional intelligence is thought to assist health care providers
with conflict management and stress tolerance, thus reducing maladaptive emotional responses
(Littlejohn, 2012). As introduced, there are surely some evidence-based methods and strategies
to promote quality and safety, however, further research must be done to assess the effectiveness
of such interventions.
Nursing Finance
The American Nurses Association (ANA) works together with the Institute of Medicine
(IOM) to define what a hospital's understanding of nursing finance should be. Within a
healthcare setting, the ANA works to educate nursing staff on how financial aspects apply to
health care. The potential for harm, consumer care needs, task difficulty and desired outcomes
are those that nurses and health care providers must be aware of. All nurses should be mindful of
anything that occurs within the workplace, as there is usually always a financial responsibility
behind it (Muller & Karsten, 2012).
According to Yoder-Wise (2011), the cost of workplace violence is high, as it results
from lost business and productivity, litigation, medical care, psychiatric care, higher insurance
rates, increased security measures, and negative publicity. Accordingly, when examining the
financial effects that workplace violence has on a healthcare facility, both direct and indirect
costs are involved. A direct cost would include a court case becoming an expense for the
organization. The average cost of litigation of workplace violence is about $120 billion dollars
per year. On average, it was found that a hospital or other health care organization would owe

nearly $3.1 million dollars per person, per violence incident. This expense is typically a result of
an employee lacking efforts in being proactive, as well as disengaging from preventative
measures. Hence why reporting the incident is so crucial (Potera, 2016). On the other hand,
indirect costs for an organization include a higher than average turnover, increased requests for a
leave of absence related to medical reasons, and injuries/illness related to stress. If a nurse
decides to resign after experiencing an act of violence or bullying within the workplace,
replacing that nurse can range from $22,000 for a new nurse to $64,000 for a more experienced
nurse (Potera, 2016).
Besides physical workplace violence, there are many indirect causes and costs of
psychological violence as well. These hidden costs, for instance, are found within billing for
counseling, stress illness, and the cost of allowing managers to take part in the investigation of
the workplace violence. One outstanding cost of violence and bullying is a drop in productivity.
Those directly affected typically suffer workplace violence aftermath, which may include a drop
in self-esteem and self-sufficiency. This can furthermore affect the entire unit, as patient
outcomes may become substandard. Additionally, negative publicity as well as embarrassment,
fear, and shame may also be factors playing a role in the loss of productivity (Papa & Venella,
2013).
As so, when dealing with workplace violence, it is imperative for healthcare facilities to
take preventative measures of safety to avoid any implications in the future. Papa and Venella
(2013) stated that if the proper preventative measures were not obtained and an act of violence
had occurred, the reaction afterwards is one hundred times more expensive than if it were
prevented (Papa & Venella, 2013). Currently, the Institute of Finance and Management came up
with an estimate cost that each facility pays towards their employee. This totals $5.50 per

employee, and they are saying that this cost may rise since there has been an influx of violent
incidents in health care environments across the nation (Papa & Venella, 2013).
This being said, all healthcare organizations should have a set protocol placed for
preventative measures as well as what to do if any physical or psychological acts of violence
occur. Whether the acts are between co-workers or patients, they will cause financial
implications that will ultimately have a negative impact on the organization.
Inter and Intra Professional Collaboration
As for all healthcare organizations, the use of inter- and intraprofessional collaboration is
essential for attaining optimum patient care. Collaboration a term that is known as working
together with a common group with a common goal (Dimitriadou et al., 2008). The Metropolitan
Hospital Center in New York City took the initiative of creating a professional collaborative
team that specifically deals with incidents of workplace violence. The specific tasks involved are
discussing and reviewing the characteristics of violent acts, planning and implementing
countermeasures, observing and assessing potential risks, establishing sound procedures, and
providing appropriate training and guidance to staff members. This training is structured around
three main factors: prevention, responding, and reporting. The prevention aspect works towards
preventing a violent act from ever occurring, the responding is to de-escalate any rise of a violent
act, and reporting is to make sure the incident is well-documented and handed to the appropriate
task force (Notaroberta, 2012).
Generally, the main goal of a collaborative team such as this is to create the best solutions
that will work to prevent a violent incident from occurring, while also responding to any acts of
violence that have already occurred.

All healthcare organizations should have a variety of interprofessional members working
together as a team to combat workplace violence. For example, the inclusion of managers within
the team can help overcome some of the main barriers standing in the way of a successful
initiative. These barriers include communication breakdown and indistinguishable role
responsibilities (Notaroberta, 2012). Department managers are those that can break down these
barriers as they can relate to the issues of safety and security matters, patient care implications,
community concerns, and union concerns.
Within the majority of healthcare organizations, lateral violence has been highly
prevalent, as many nurses have reported issues with verbal abuse from physicians. This verbal
abuse likely stems from the conflict experienced in choosing what is best for patients. This can
create a constant tension between two healthcare providers. Interprofessional strategies can lead
to a better well-being of all staff members, as well as all patients (Dimitriadou et al., 2008).
The Massachusetts Nurses Association (MNA) also coordinated an interprofessional
collaboration which included administrators, managers, and frontline workers to address
workplace violence. This interprofessional collaboration met quarterly in order for members to
discuss incident reports and/or to develop new solutions or interventions that are appropriate and
up-to-date with the safety manual. Managers and frontline workers would discuss any concerns
that they may have related to workplace violence, develop new solutions to prevent an incident,
and acknowledge any mistakes made by either parties (Preventing Workplace Violence, 2015).
Interprofessional collaboration leads to a more well-rounded and balanced solution by breaking
down the causes, preventative measures, and outcomes of any workplace violence incidents.
(Notaroberta, 2012).

Conclusion
The Institute of Medicine, also known as IOM, came up with five core competencies that
help guide all healthcare professionals in providing optimum quality care to their patients. The
core competencies include (1) membership of an interprofessional team, (2) delivery of optimum
patient-centered care, (3) practicing and incorporating evidence-based medicine, (4) focusing
care on quality improvement, and (5) using information technology (Edlin, 2013). Previously
discussed topics incorporate these core competencies that the IOM has created for optimum
patient care. However, the achievement of such successes are burdened by workplace violence
and incivility. Any occurrence of a violent incident typically throws a negative impact to all
healthcare providers within an organization, as well as the organization itself. It can cause
psychological complications and physical complications to its victims, and it can decrease an
organization’s productivity. These repercussions leave it extremely crucial for workplace
violence to be addressed and acted upon using the best strategies through a multidisciplinary
approach. This framework incorporates the IOM’s competency of utilizing the interprofessional
teams.
Evidence based practice provides leadership management with the most up-to-date
methods and strategies, although lacking credibility in regards to efficiency. Multiple approaches
were found to fight workplace violence incivility, such as recording and documenting, emotional
intelligence, and threat management teams. On another spectrum, there were also inconsistent
definitions of workplace violence found within the literature, acting as a major barrier in
reporting and finding trends in useful tactics. Nonetheless, there is surely an amount of support
for this ongoing phenomenon, as future research is to be conducted. As for technology, online

sources can be used to educate and train and technological devices can be used to monitor and
regulate patient safety standards.
The basis of nursing is to provide patients with the best possible care that they can during
and throughout their entire hospital stay. Nurses are those who work to promote an environment
full of compassion and comfort that will promote healing. Due to the high levels of workplace
violence and bullying, it can compromise the care provided to patients, so it is imperative to
avoid any instances of violent acts. To provide quality care improvement to all patients, any
incidents of violent acts should be reported and solved, never hidden (ANA, 2016). Overall,
workplace violence is an ongoing issue that is often kept quiet, but should be discussed more to
better the experience of employees as well as providing optimum patient care.

Appendix
Page #
Figure 1: Healthcare Worker Injuries in Days Away from Work, by Source
Retrieved from Bureau of Labor Statistics, 2012 data as cited in OSHA, (2015) 3
Box 1: Types of Violence
Retrieved from Hader, R (2008) Workplace Violence Survey 2008. Nursing
Management, 39(7), 13-19. As cited in Yoder-Wise (2011, p. 500) 4

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