Nurse managers also described a failure of patients to adhere to established unit safety practices as a risky behavior. Such failures to adhere to policy and practices that were described by participants include ambulating without needed assistance, eating during the Hemodialysis treatment, failure of patients to clean their access sites prior to Hemodialysis initiation, and covering their faces and access devices with blankets during the Hemodialysis treatment, thus impairing patient monitoring by staff. One Hemodialysis unit nurse manager clearly summarized: “Some patients are a little head strong, maybe should be using an assistive device or maybe even should be in a wheelchair as far as ambulating, but they don’t want to let go of that independence.”