Barbara Norris: Leading Change in the General Surgery Unit It was… Barbara Norris: Leading Change in the GeneralSurgery Unit?t was 10 PM and Barbara Norris, nurse manager for the large General Surgery Unit (GSU) atEastern Massachusetts University Hospital (EMU) sat down at her desk to catch her breath. She hadbeen on the unit since 6:30 AM but planned to stay for another two hours to help with the transitionfrom the second to third shift and the orientation of two registered nurses (RN) from the float pool. Ithad been one month since she had assumed the nurse manager role for the troubled unit. During thistime she felt, as she did this evening, tired and overwhelmed.As nurse manager she was responsible for managing the staff, scheduling and budget for the unit.Her 33-person staff included 25 RNs and eight patient care assistants (PCAs). In her first month asnurse manager she had already lost two RNs and in the six months prior to her joining the unit threeRNs had left. But because of the recently instituted hiring freeze at EMU, Barbara was not able toreplace some of these positions.The unit was short-staffed; stress levels were high and employee morale low. In fact, GSU had thelowest employee satisfaction scores and highest employee turnover rate among all of thedepartments at EMU. And although its patient satisfaction scores were average, they had beendeclining steadily over the past few years. Furthermore, GSU was infamous for its culture ofconfrontation, blaming and favoritism. Relationships were tense not only between the nursing staffbut also with many of the unit’s attending physicians.To make matters worse, over-time could no longer be offered due to additional cost cuttingmeasures. Hence, if one of her nurses was sick or needed to take personal or vacation time, Barbaracould not offer over-time to her own staff to cover such absences but instead had to rely on RNs fromthe general float pool. But because “floaters” were not familiar with the unit, its specific proceduresand care protocols, they more often than not had additional negative effects on staff dynamics andthe quality of patient care.?urse NorrisBarbara grew up in a small town in western Massachusetts. Both her mother and grandmotherwere nurses, and she developed a deep respect and admiration for the profession at an early age. Bythe time she entered high school she knew that she, too, like her mother and grandmother wanted tobe a nurse.After graduating with honors from the nursing program at Eastern Massachusetts University,Barbara began work at EMU. She worked in the emergency room for four years and moved to thetrauma unit about one year before becoming pregnant with her first child. For the next several yearsshe worked part time, one or two shifts per week, had a second child and concentrated on raising heryoung family.Barbara returned full-time to the trauma unit and the profession she loved when her childrenwere in grade school. When her two daughters entered high school Barbara, too, was ready for a newchallenge and began coursework for a Masters Program in Nursing and Health Care Administration.Her nurse manager, Betty Nolan, who was a mentor and friend, also encouraged her to pursue theMasters in Nursing Administration. Shortly after Barbara completed her program, the nurse managerof EMU’s general surgical unit announced her retirement.Although GSU’s high turnover and low retention rates were common knowledge throughout theEMU community, Barbara applied for the position in part because she welcomed the opportunity tostay at EMU but also because she welcomed the challenge to try to turn the unit around. After a seriesof interviews with EMU’s nursing director and administrative leadership, Barbara was offered thejob. She consulted with her trusted friend and mentor, Betty Nolan regarding the position in GSU,and Betty did not hold back or mince words: Do not take the job, she cautioned. GSU is a lost cause.Spare yourself the grief and aggravation.Barbara highly valued Betty’s advice but was also looking for a new challenge in her career andsaw the GSU job as an opportunity that was too good to pass.When Barbara accepted the job, nursing director John Frappewell congratulated her and said,you’re doing the right thing, Barb. I’m counting on you to turn this unit around and do it fast. Barbarathanked him for the vote of confidence but secretly worried that she had taken on more than shecould handle.Also weighing on her mind was the hard, downward turn the economy had taken right aroundthe time she accepted the job. All leading indicators suggested recovery was several months if notyears away. EMU’s revenue decreased sharply while costs continued to increase and the hospitalleadership had to make difficult decisions to guide the hospital through the economic crisis and tohelp it stay afloat. They enacted a hiring freeze, stopped all over-time allowance and decreased shiftdifferentials. The administration framed all of these measures within the context of the crisis and forthe greater and longer term good. But an overworked and stressed staff could not always muster thegood will and foresight needed to take the long view, and tensions were growing in the halls of EMU.?eneral Surgery Unit (GSU)The staff in her old organization, the trauma unit, was a close-knit group who worked welltogether as a team. Many of the nurses were friends, ate lunch or dinner together and some alsosocialized outside of work. There was a helping culture within the unit; a tone set and finelycalibrated by Betty who was respected and well-liked. Betty had earned a reputation as a responsivemanager who acknowledged her staff and sought their input on important decisions relevant to theunit.Soon after Barbara began as nurse manager in GSU, she received requests from 29 of the unit’sstaff members for one-on-one meetings and she soon experienced first hand the culture of conflictand blaming she had heard about. For instance, rather than helping and mentoring the newer nursingstaff, the more senior nurses were often highly critical and complained about them behind theirbacks. And many of the unit’s RNs including both new and more tenured nurses were frustratedwith the PCAs and complained that they had inadequate training and skill sets.And Barbara also discovered that her predecessor had not kept made and accurate records ofthe staffs’ annual performance reviews. Barbara viewed regular informal check-ins and the moreformal annual review as critical management tools. And she knew through her own personalexperience how open communication and a transparent review system had contributed to her growthand development.Barbara decided to run an off-site for her GSU staff. At the very least she hoped to provide aforum to begin discussion between members of the unit but her larger hope was that the off-sitewould inspire the beginning of a turn around for the unit.?he Off-SiteBarbara stood in front of her staff that were not on duty and thus able to attend the offsite. Sheasked each of them to take a pen and sheet of paper from the basket that was making its way aroundthe room and to write, anonymously, the 2 to 3 things that most frustrated or bothered them aboutthe unit. She then collected all the responses and read them one by one to the group.Response after response identified lack of collaboration and teamwork, interpersonal andintergroup conflict, doctors who treated them like order takers rather than care givers, administratorswho cared more about money than patient care, favoritism, dissatisfaction with staffing levels andperformance review procedures… Barbara was blown away by the amount of negativity; she gotmore than she bargained for with this exercise.After she had finished reading all the responses Barbara asked if anyone would like to commentor follow up. Her request was met with complete silence. She asked again this time becoming visiblyflustered, but still there was no response and just as Barbara was about to ask again Megan Mahoneya recent nursing school graduate who had been on the unit for one year jumped to her feet andexclaimed, you people have no idea how mean you are!During her month on the unit, Barbara observed Megan to be a very bright and affable nurse whocared deeply about her patients. And in turn Megan seemed to receive a lot of positive feedback frompatients and their families.Megan was upset with some of the senior nurses. I want to feel like I belong and am a member of theteam, but I often get indirect negative messages and feedback from you. You make me feel like I am doingeverything wrong but won’t address me directly or in a straightforward manner. Megan then shifteduncomfortably in place and her face flushed as she continued to speak. One night a few weeks ago, Ioverheard two of you talking about me at the desk. She paused and drew a deep breath. You said you weretired of me and all of my questions and called me a pest! Megan’s face fell with this last sentence; her eyesfixed on the floor.Just then Jennifer Goodwin stood up. Jennifer had worked on the unit for ten years. Barbara hadnoted Jennifer’s strong skill set especially with new technologies and her wonderful bedside manner.Also, she was one of the few nurses who seemed to go out of her way to help others on the unit.Jennifer said, I want feedback. It helps me to be a better nurse and to be a better co-worker, but the reviewprocess here is a mystery! As is the annual salary increase. I’ve heard that we all receive the same increaseregardless of our performance. Is this true? If it is, I don’t think this is fair.?ennifer also spoke about how she went above and beyond regarding continuing educationrequirements and made it a point to bring herself up to speed on all new technologies, although thisoften meant spending hours of her own time in classes and seminars. I do that because I want to, shesaid, but I have to admit there’s a part of me that is bothered that I do not receive any type of acknowledgmentwhether it be verbal or compensatory for my efforts.Just as Jennifer sat down Louise Scribner moved to the center of the room. Louise had been withEMU for 30 years and worked in GSU for 23 of those 30 years. Barbara knew Louise delivered verygood care to patients but noted she was resistant to change, quick to complain and could come acrossas abrasive to her co-workers.Louise opened by remarking, sometimes I feel like I spend more time tending to machines than I dotending to patients. She then complained about the support asked for by the younger nurses and PCAs.I don’t have enough time to do her own job, she exclaimed. Everyday I have to make difficult decisions aboutwhat I cannot do for patients. I resent this because we have too few nurses in the ward and because some of thatstaff is inexperienced to boot, I am put in the position of having to pick and choose the care I can give. And afterall isn’t that why we are all here? To take care of our patients?Barbara had planned for this session to last for one hour but they were now passing the 1 ?hourmark. She was trying to find a way to close the session using some kind of positive take-away. AfterLouise finished speaking, Barbara stood up and said okay, we have a good overview of our problems butcan anyone offer any solutions?Once again, there was an uncomfortable silence. In the room Barbara recalled how Betty involvedthe nurses in the trauma unit in decisions regarding staffing to great effect. Barbara said, I do, andsmiled. What if, she started, when I’m going to decide on staffing for anything, I involve you? If you tell me,for example, “We need someone to process paperwork on Saturday afternoons,” I can immediately bring thatback to a staff meeting and say this is what we have for full time equivalent (FTE). We can either hire a nurseor we can take some of that money and hire a secretarial assistant. What do you want to do? It’s your choice.This is how much money we have. We can take a little bit of the nursing FTE and we can hire a secretarialassistant but we’re going to lose a little nursing time but this is what we have to work with. And you can helpme make the decision. I can do the same thing if we have to cut resources.At the end of the day Barbara sat alone in the retreat center; everyone else had departed but shewas using these last few moments to reflect on the day’s events. As she worked through theconversations and revelations, she began to make a list of items that most frustrated or de-motivatedher staff:1. Our culture does not value collaboration and teamwork2. In GSU you cannot count on others to help you3. Our work isn’t acknowledged and our contribution often does not feel valued4. Our job is becoming more administration centered rather than patient centered5. We do not have enough opportunity to learn and grow6. Our performance review system is a mystery and does not seem to actually reward goodperformers7. Many assignments are given based on relationships and favoritism8. We have little input on matters that affect us greatly9. We feel no one truly defends our interests or advocates on our behalfBarbara knew she had to set realistic, attainable goals for each item on the list. Could she talk toher director of nurses and seek a reprieve from the hiring freeze and get more staff for GSU? Wouldregular unit meetings build community and a healthier culture on the unit? She knew she could institute a fair and transparent review process, but she might not have any influence regardingmaking annual salary increases commensurate with a review outcome. Perhaps there were otherforms of acknowledgement she could employ? What should she tell her boss who was awaiting astatus report?Question:1.???ow well has Barbara Norris done in her first month as nurse manager of GSU? Was she has a good choice for the position?2.???hat changes is she trying to make and why?3.???hat are three obstacles to effecting change Norris could anticipate and how should she address them?4.???lease device AN action plan for Norris?usinessManagementHuman Resource ManagementADMN 3206
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