General Surgery Case Study
Background: Barbara Norris grew up in a small town in western Massachusetts. She developed a fond respect and admiration for the nursing profession due to her mother and grandmother both being nurses. She knew that nursing was the career she wanted to peruse. She obtained her nursing degree from Eastern Massachusetts University, and began to work at EMU in the emergency room. She was an ER nurse for four years then transferred to the trauma unit for a year until she became pregnant with her first child. Barbara then worked part-time for the next several years and had her second child. Barbara returned to full time work in the trauma unit while her children were in elementary school. While her kids were in high school, Barbara began her coursework for a Master’s degree of Nursing and Health Care Administration, with the encouragement of Betty Nolan, Barbara’s friend and mentor.
Not long after Barbara’s graduation from the program, Betty (nurse manager of EMU’s general Surgery unit) announced her retirement. Barbara applied to the open position, with the knowledge of the GSU’s high turnover rates and low retention rates. Barbara was also warned by Betty Nolan to not take the job; Betty stated that “GSU was a lost cause. Spare yourself the grief and aggravation.” Barbara believed that she was up for the challenge of the GSU and wanted to try to turn the unit around. When Barbara accepted the job she was congratulated by the nursing director John Frappewell, who said “you’re doing the right thing, Barb. I’m counting on you to turn this unit around and do it fast.” Until this point she was confident in her decision but now started to think that she may have taken on more than she could handle. Barb had yet to consider the factors working against her that she couldn’t really control, for example: the downward turn the economy had just taken which led to difficult decisions made by the hospital. The hospital’s revenue sharply decreased while the costs increased.
This led to hiring freezes, stopped over-time allowances and decreased shift differentials. GSU Nurse Manager: As nurse manager, Barbara was responsible for managing the staff, scheduling and budgeting for the unit (33 person staff consisting of 25 RN’s and 8 patient care assistants). In the first month as nurse manager of the GSU, Barbara lost 2 RN’s plus the 3 that left just prior to her joining the unit. She was unable to replace some of these positions because of the hospitals hiring freeze. This led the unit to be short staffed. Because of being short staffed, the unit’s morale was low and the stress levels were high. The GSU had the lowest employee satisfaction rates and highest employee turnover rates of all of the departments at EMU, as well as declining patient satisfaction scores.
The GSU also had a culture of favoritism, confrontation and blaming. Unlike the trauma unit where Barb use to work (where the nurses were a close knit group, both at work and outside of work, who worked well together as a team), in the GSU there were tense relationships between not only the nursing staff, but with many of the attending physicians. Barbara soon learned firsthand of the conflict in the department through one on one meetings with the staff. A major problem was that the senior nurses, instead of taking on a mentor role for the new staff members, were highly critical and would complain about the new staff members. On top of that, most of the unit’s RN’s (both new and old) were becoming frustrated with the inadequate training and skill sets of the patient care assistants. On top of all of the conflict she was encountering now, Barb learned of another problem; the records of the staff’s annual performance and reviews were not complete or accurate.
Barbara knew from her own personal experience that open communication and transparent review systems contribute to growth and development. She believed that reviews and informal check-ins were critical management tools. In the hope of inspiring a turn-around of the unit, Barbara decided to run an off-site for her staff. She wanted to start discussion between staff members. To do so she asked all present staff to (anonymously) write down 2-3 things about the unit that frustrate or bother them the most. She collected all papers and read them aloud. The responses were all negative and identified a lack of collaboration and teamwork, interpersonal and intergroup conflict, doctors who treated them as order takers instead of care givers, administrators who cared more about money than patient care, favoritism, dissatisfaction with staffing levels and performance review procedures, etc. After reading these issues aloud Barb facilitated discussion with the staff by asking if anyone wanted to comment or follow up. A few staff members voiced their opinions. One gave her recollection of times where the insensitivity and meanness of the senior nurses left her feeling hurt. Another nurse stood up and said how she wants feedback and actual performance reviews. She mentioned how everyone received the same pay increases, and how it was not fair. As well as stating how they do not receive much, if any acknowledgement for their efforts.
Articulation of the issues that need to be addressed
There are many issues present in this case that need to be addressed, both in the department (GSU) and in the organization (EMU). When the off-site meeting was over Barbara made a list of the items that most frustrated or de-motivated the GSU staff. It was as follows: 1. Our culture does not value collaboration and teamwork
2. In GSU you cannot count on others to help you
3. Our work isn’t acknowledged and our contribution often does not feel valued 4. Our work is becoming more administrative than patient centered 5. We do not have enough opportunity to learn and grow
6. Our performance review system is a mystery and does not seem to actually reward good performers 7. Many assignments are given based on relationships and favoritism 8. We have little input on matters that affect us greatly
9. We feel no one truly defends our interests or advocated on our behalf All of these issues above need to be addressed, as well as the overtime and hiring freeze in effect, “floaters” being used are having negative effects on staff dynamics and quality of patient care, shifts are long and stressful, staff all want one-on-one meetings with manager and are reluctant to discuss issues and feelings during the off-site although they all feel the same (lack of collaboration, teamwork, interpersonal and intergroup conflict, favoritism, dissatisfaction with staffing, etc.), senior nurses are highly critical of younger nurses, complete and accurate records were not kept by Barbara’s predecessor and there are incomplete performance reviews.
The interpersonal and intergroup conflict/issues among nurses and staff need to be addressed; Low morale and high turnover rates need to improve; The whole rewards and feedback system needs to be fixed; Open communication needs to occur; value needs to be given; and the amount of administrative duties each member need to do needs to be lowered. Analysis of the Problem/issues
Throughout our readings we have uncovered many effective avenues an organization can go down to figure out how satisfied their employees are, how committed they are, and how their well-being is affected. There are many issues present in the GSU that need to be addressed by the EMU organization. The Enthusiastic Employee (Sirota, 2013) focused on asking the employees what they want and giving it to them. Barbara took the first step when she decided to run an off-site to really have discussion open up about what is bothering the employees (causing their low satisfaction). Her exercise helped not only the employees, who learned that the issues that were bothering them are department wide, but it also helped Barbara to understand what her staff needs and what her department needs to change in order to have a positive effect. Open communication was also mentioned in the Enthusiastic Employee. This is important because it allows for transparency between managers and staff. It helps because if there is open communication/ transparency from the higher-ups and everyone knows what is going on, there won’t be misunderstanding from staff because this takes the guess work out.
We have mentioned in class that, as humans, we fill in the blanks. We only need partial information and we fill in what’s missing, and we usually think the worst. Open communication is vital to organizational understanding. When we think the worse, it can lead to worried employees. When you are worried, I feel, that it will reflect in you work and can lead to poor performance, lower satisfaction, and higher anxiety. I believe that it would affect my well-being. My worries would not allow me to enter a state of flow, yet alone, produce my best work. Harter, Schmidt, &Keyes (2002), Sirota & Klein (2013), and Judge (2012) show the importance of an enjoyable interaction with the environment.
They emphasize how important the social environment is to an employee. Sirota & Klein (2013) call this factor camaraderie and states that without camaraderie individuals won’t feel equity, and in turn won’t be satisfied completely with their job. Judge (2012) states perceived social support predicts satisfaction levels above and beyond the characteristics of the work itself, and that social environment includes co-worker support, social networks, and effective leadership. In the GSU the negative social relationships and lack of support from co-workers is a big factor in the units low satisfaction rates, and in the declining patient satisfaction scores. The social environment in the GSU needs to be improved! Through our readings we have also learned that pay dissatisfaction plays a big role in overall satisfaction. And it is an issue in the GSU, their merit based pay system needs to actually reflect performance rather than just giving the same raise to everyone regardless of actual performance. Suggested alternatives and solutions:
Barbara needs to fight for a reprieve from the hiring freeze. This would help the unit because it would no longer be understaffed and she would be able to hire back some of the talent she lost immediately prior to and during her first month as nurse manager. Barbara needs to show the director how having the proper talent and positions filled by the proper people will improve not only moral and satisfaction, but patient satisfaction as well. If she can show the return on investment and how the company will actually benefit from spending some money on hiring, she has the chance of improving her unit. Another solution is that Barbara can create model mentor program for new employees. Have a senior employee take a new employee under their wing. The new employee will have someone they can go to and feel comfortable discussing questions or issues with. This can help with the conflict that occurs from highly critical senior nurses and the frustration felt by the new employees. This mentor program can help build a bond or relationship between the staff and help improve morale. Barbara can also have new and senior staff participate in and lead trainings (on such topics such as OSHA and HIPPA laws) to the rest of the staff. This would help with the staff being able to learn new information and be recognized for doing so. Another way to continue bonding the unit is to do a fundraiser together, as a unit, such as raise money for a cause/ campaign that they all agree on.
The unit needs open communication. Barbara should institute an “Open Door Policy” so all employees are informed and aware of decisions, issues, etc. She can create a suggestion box for all to access so everyone can have a say; they know that their voice is hears even if they want to keep it anonymous. The suggestion box would be available for any and all suggestions for the unit or the organization. Another solution of great importance deals with the issues of “floaters”. It was mentioned that they are coming from all different departments and may not know exactly what is going on. Therefore, floaters should be assigned to complete administrative work and a unit member familiar with the surgery should deal with patient care. This would lead to fewer issues with patient care; it is better to have them mess up on paper work than to mess up during a procedure! Since the off-site meeting went well in terms of finding out problems, Barbara should organize monthly meetings or future Off-Site meetings. These should be regular and through these meetings, staff will have the opportunity to voice issues and Barbara will get to see if the changes she makes are actually have an improvement.
But it would be unfair to say that Barbara needs to make all the changes. In order to change the culture of the unit (which is in dire need of a change) all managers need to get on board to instill new beliefs and values, and to change morale. Barbara can’t do this alone! She needs the help of not only her unit managers but of HR as well. In order to tie pay to performance (which is a big issue in the unit) Barbara needs to get approval and support from EMU’s HR staff to support the performance appraisal system. The performance appraisal and reward system needs to be up to date and evaluations need to be enforced! These are critical management tools that cannot be overlooked. Her staff not just wants, but needs a new system. They require verbal praise and recognition. To help temporarily while the system gets in gear, Barbara can, herself, increase verbal praise, and start a program like having an “Employee of the Month” board and for being employee of the month you get a little reward such as a better parking spot, being the person in charge of the nurses for a shift, free dinner, etc.
When Barbara accepted the position of head nurse she accepted the challenge of the general surgery unit. She has many issues that she needs to address/ fix to be able to turn the unit around, but she has taken the first step and now that she has all the current issues in front of her she will be able to make the proper steps in moving the unit forward.
Harter, J.K., Schmidt, F.L., & Keyes, C.L.M. (2002). Well-being in the workplace and its relationship to business outcomes: A review of the gallup studies. In C.L. Keyes & Haidt, J. (Eds). Flourishing: Positive Psychology and the Life Well-Lived. APA Publishing Judge, T.A. & Kammeyer-Mueller, J.D. (2012). Job attitudes. Annual Review of Psychology, 63, 341-367.
Sirota, D., & Klein, D.A. (2013). The Enthusiastic Employee: How Companies Profit by giving workers what they want, 2nd ed.