Behavior in the Workplace

Behavior in the Workplace
Let’s turn our attention to the opportunity that leaders have in creating a culture of retention in their department or departments. I am going to share with you the results of a study I undertook to understand more fully, exactly what nurse managers/leaders do to create a positive workplace, a place where people want to come to work. I was tired of reading all of the huge national reports on what we should be doing, and decided to go straight to the source. So I found nurse leaders who were successfully creating a culture of engagement in their areas of responsibility, and basically asked them, “How did you do it?” Their stories and words of wisdom give us direction and ideas of where to focus our efforts. Evidence-Based Leadership Practices for Creating a Positive Workplace Jo Manion PhD RN CNAA FAAN 1/8/07 NCSBN

“Never before have organizations paid more attention to talent … Keeping it. Stealing it. Developing it. Engaging it. Talent is no longer just a numbers game; it’s about survival.” Kaye & Jordan-Evans, 2002 --Bowles, 1991 First, we know that retention is a key strategy for tackling the current workforce shortage issues with which we are dealing. In June 2001, about 82% of hospital CEOs reported that workforce shortages top the list of their concerns as they face this decade. In a VHA report in 2002, they found that the state of an organization’s workforce is the primary driver of its performance. 24% of sentinel events were directly attributed to nsg shortage issues (short staffing, fatigue, miscommunication) In New Zealand, staff turnover was the main variable associated with increased LOS for patients So workforce adequacy is essential to achieve the desirable outcomes we are all seeking.

The Plan What is Being Done The Study Design What Managers Actually Do
Cost of Turnover What is Being Done The Study Design What Managers Actually Do Ramifications for Individuals & Organizations

Cost of Turnover $$$$

Economic Benefits of Retention
Replacement costs as % of total payroll base compensation 22 % Average replacement cost per skilled employee $28,877.08 Reduce overall turnover from 31 – 25%, the replacement costs savings $814,045 per year Reduce overall turnover from 31 – 20%, the replacement costs savings $1,424,578 per year In a recent study done by VHA, they did analysis within specific organizations, taking their actual turnover rates and then determined the $$$ cost of turnover. Turnover costs represented 22% of the base payroll compensation. The average cost to replace a skilled employee …. If turnover could be reduced from 31% to 25% … it represented a savings of …. If it could be reduced further, the savings were quite significant. One thing that really surprised me in their study … we think of the enormous cost of recruiting a pharmacist, or a nurse … yet the total costs for many organizations is higher for recruiting and replacing workers such as food service, environmental services and so one … because the numbers of these individuals is so much higher … and the turnover rates are often staggering. Gelinas & Bohlen, VHA Tomorrow’s Work Force, 2002

Cost of Turnover Damages the Brand Loss of Experience, Knowledge
$$$$ Damages the Brand Loss of Experience, Knowledge & Connections Felt Rejection

“Resignation is not just a behavioral act; it is also a state of being
Manion, Health Forum Journal, Sept., 2000

Recruitment is a key strategy for the current workforce shortages, but isn’t enough. It does no good to recruit and select the right people if you can’t keep ‘em. Manion, Health Forum Journal, Sept., 2000

What kept you?

What Kept You? Autonomy, creativity, sense of control
Flexibility: work hours, dress, etc. Security Location Diverse, changing work Fun Responsibility Being part of a team Work/life balance Loyalty & commitment Comfort on the job Exciting work, challenge Career growth, learning & development Great people Fair pay & benefits Good boss Pride in organization, mission, product Great work environment, culture Recognition, valued, respect Meaningful work, making a contribution

89% of all managers STILL believe it is about $$$$$
Why do people work? 89% of all managers STILL believe it is about $$$$$ Kaye & Jordan-Evans, 2002

Positive Relationships
Intrinsic Motivation Meaningful Work Progress When you review the sociological and psychological research into intrinsic motivation, in other words, those things that make us do what we do These are the factors you will find. This then leads to the support and identification of what the leader’s role is in each in terms of building on these motivational factors. Positive Relationships Competence Choices 31

Inspire for Meaningful Work Cheerlead for Progress
Strategies Inspire for Meaningful Work Cheerlead for Progress Believe it or not, these strategies are based on well-founded sociological and psychological research into intrinsic motivation and organizational commitment as well as just good anecdotal experience from the field. These are the strategies I believe are most hopeful. Then I’d like to spend a few minutes talking about each one of these in terms of your role specifically. Build Healthy Relationships Coach for Competence Create Choices 31

How can we Create a culture of retention?

What does a culture of retention mean to you?
What characteristics do you think of when you think of a culture of retention?

The Key Question What do leaders do to create a culture of retention in their area of responsibility?

The Participants Current managers with direct reports
Recommended by others as an individual who has successfully created a culture of retention Combination of low turnover rates, waiting list of interested staff, positive patient or service outcomes, healthy employee relationships, high employee and physician satisfaction levels To study this question, I asked colleagues for recommendations …. Who in your organization has successfully created a workplace environment where people want to work. They don’t necessarily have to have low turnover rates in their department … Because in some communities and some departments, turnover could be expected. For example, in a community with many military families or on a general med-surg unit when a certain number of years of experience is required of new grads before they can be considered for a specialty unit. Other factors I asked them to consider were …. Departments with high patient, staff and physician satisfaction rates, good patient outcomes, and positive working relationships among the staff. In most of the organizations I contacted, there were only one or two managers who were recommended.

The Study Design Telephone & face-to-face interviews with 32 managers
Face-to-face interviews with 3 of the people to whom they report 3 focus groups of their employees Nurse managers, directors of pharmacy, imaging, PT, RT & Business Office I conducted 26 manager interviews … a combination of face-to-face and telephone interviews. They lasted about an hour. Then to see if those who these people reported to, as well as their staff saw the same kinds of things … I also did interviews of 3 of their “report-tos” and 3 focus groups of their staff. There was a high level of congruence between these. I also used audiences to elicit ideas about a culture of retention …

Analyzing the Data Used a categorical-content analysis approach
Let the themes emerge from the participant’s stories & examples Code the interviews to determine most common strategies or interventions For the analysis … I used a categorical-content analysis approach which simply means that it was content analysis entailing the identification of categories and themes as they became apparent through data review. So the categories and themes are derived inductively from the participant’s words and stories, rather than being fit into any preconceived category on my part. These themes emerged … Then I went back and reread each interview again and coded the words and phrases to determine which were the most frequently or consistently identified.

Defining a Culture of Retention
It’s creating an environment where people want to stay. It means that people enjoy their work so much and the people they work with that they want to stick around and get involved. Everybody is trying to make it a great place to work. It’s an environment that meets people’s needs. So, let’s look at the first question I asked … what does a culture of retention mean to you? These were samples of the comments I heard.

Defining a Culture of Retention
It’s a culture where employees know they are valued. When they come to work, they enjoy being here, they feel good about being here. They feel safe. They can trust each other that the job will be done and done well. They wake up in the morning and want to come to work. They are interested and want to be here.

It’s more than a culture of retention, it’s a culture of engagement & contribution. Because that will lead to a culture of retention. It’s not enough that you stayed for 30 years. It’s what are you giving? How are you contributing? Here is where it was becoming clear to me that we were really talking about more than a culture of retention … but we were looking for areas where there was a culture of engagement and contribution.

create a culture of retention?
What do you do to create a culture of retention?

Creating a Culture of Retention
Forge Strong Connections Partner with the Staff Put the Staff First Creating a Culture of Retention Coach for & Expect Competence Focus on Results

Put Staff First “My staff comes first, not the patient comes first. Because if I make my staff feel valued and respected and good about what they do, then they’re going to give the best care in the world.” “I know that if I’m looking out for them, they will look out for the department. They know when they need me I will be there for them.” “If the staff is going to put service first, I have to put them first. They have to feel that you have their interests at heart. That they are important and not being used & abused.” These leaders were very clear about their priorities. They made comments like ..”my staff comes first, not the patient comes first.” If I make my staff feel valued and respected and good about what they do, then they’re going to give the best care in the world and they are going to be fabulous customer service people. These are some of the words they used. I put my staff first so they will put the patient first. I know that if I’m looking out for you, you’re going to be looking out for the floor. I know they will be there to help me out, because I going to be there for them.” It was very clear that if they took care of the staff, they believed the staff will take care of the patients.

Put Staff First Caring for them as people
In some ways I was a little surprised at the depth of feeling these managers expressed for the staff. They weren’t at all shy about saying right out … I really love these people. They clearly care a great deal for the people they work with.

Caring for Them “It’s caring about people and not just their work.”
“I don’t allow staff to be dumped on. By anyone!” “They know I love them. I have fallen in love with my staff.” These are some of their words. These people were expressing deep and authentic sentiment. It didn’t mean that they liked everything the staff did … but the deep caring was there in spite of some of the behavior and things that happen.

“We are re-focusing on the deep longings we have for community, meaning, dignity, purpose, and love in our organizational lives. We are beginning to look at the strong emotions of being human, rather than segmenting ourselves by believing that love doesn’t belong at work, or that feelings are irrelevant in the organization.” Margaret Wheatley, 1999 --Bowles, 1991 First, we know that retention is a key strategy for tackling the current workforce shortage issues with which we are dealing. In June 2001, about 82% of hospital CEOs reported that workforce shortages top the list of their concerns as they face this decade. In a VHA report in 2002, they found that the state of an organization’s workforce is the primary driver of its performance. 24% of sentinel events were directly attributed to nsg shortage issues (short staffing, fatigue, miscommunication) In New Zealand, staff turnover was the main variable associated with increased LOS for patients So workforce adequacy is essential to achieve the desirable outcomes we are all seeking.

“The caring part of empathy, especially for the people with whom you work, is what inspires people to stay with a leader when the going gets rough. The mere fact that someone cares is more often than not rewarded with loyalty.” James Champy, 2003 --Bowles, 1991 James Champy is the author of X-engineering the Corporation, 2002

Put Staff First Caring for them as people Treating others with respect
Respect, or the unconditional regard for others was clearly one of the characteristic ways they treated not just staff, but others in the workplace.

Treating Them with Respect
“They have the right to challenge me on any decision. I’m open to that. If I say something wrong, they will come and tell me.” “I always respect their opinions and I don’t judge them. I listen to what they are telling me.” “I treat them with respect in all situations. I never speak badly of anyone in front of others.” “I am just in awe of what they do, I am just stunned by it. Their hearts are so big! They amaze me every day.” “I trust that they are honorable people, if they tell me they need something, I believe it.” One manager told about interviewing a potential applicant … and she was touring her in the department and was introducing her as she went along. Later the applicant told her … you know the reason I took this job is because you introduced me to the housekeeper and you not only knew her by name, but mentioned several things about her. If you hadn’t introduced me to her, I wouldn’t have come here. One of the ways these people demonstrated respect was by listening to their staff … but not as an empty exercise … sincerely listening and using the opinions and ideas of everyone.

A third way these leaders put staff first was by the liberal use of appreciation and recognition. They used a variety of methods: giving “freebees”; requesting funding from the Foundation to send them to a national meeting when they had successfully submitted poster abstracts; bulletin boards where thank yous and kudos are posted; doing things on Nurse Week and special weeks of celebration during the year; send candygrams to each other; thank you notes, paging them to wish them a happy birthday; One manager said that although they include everyone in their fun, the ES gentleman who works most consistently in their unit isn’t the type to come to after-work parties and such. So one day a year they have a special day to celebrate him!! The “retention kits” being more widely used have been helpful with this … some described a kit that had meal and movie tickets, free giveaways … t-shirts and things like that. One manager described it as a pot of money that came out to about $9/head. She and the educator got together at the beginning of the year and decided what it was they wanted to recognize … what’s the behavior … exceptional team work? Working extra? They decided they wanted to reward the “things that come from the heart”. Each manager had unique ways of recognizing people … Using appreciation & recognition liberally

Appreciation & Recognition
Getting people’s accomplishments in a newsletter Bulletin boards to share the thank yous Recognition “tool kits” … give aways Events during recognition weeks Displaying evidence of accomplishments Clinical advancement programs Taking people’s pictures & posting them Thank you notes & special occasion cards Acknowledgement in front of others These are some examples

Using appreciation & recognition liberally Flexibility was commonly mentioned … around scheduling especially. Kathleen … example of nurse who was continually 10 minutes late for the pm shift …. Going to be disciplined Another aspect of this was recognizing and appreciating the diversity and uniqueness of each staff member. What is special about each one … and valuing that … Kathleen … person who turned in 4 QI reports from one shift … being talked about by other staff … told them … we need someone who pays attention to detail like this The staff member who is so quiet but brings a sense of calmness to the floor when she is on. The next way these managers put the staff first was by listening carefully to what their staff was saying … and although they described very good listening behaviors (eye contact, reflective listening, attention, etc.), what was most striking was that when asked how their people knew they were listening … these managers said … “something changes as a result of the listening” In other words, the people knew they had been heard when there was some follow-up or some resolution to their problem as a result of the conversation. It may not have been the answer they wanted, but it was an answer, nevertheless. Meet their needs

Katzenbach, Why Pride Matters
“Getting involved in the everyday problems of your people may violate the HR rule-book, but it’s also the single best way to build an emotional bond with your employees.” Katzenbach, Why Pride Matters More Than Money, 2003 --Bowles, 1991 Jon Katzenbach, in his latest book, Why Pride Matters more than Money says that building emotional bonds with employees is important. Getting involved in everyday problems … really means focusing on those that intersect in the workplace …. Russian immigrant woman being abused … not just made a referral, but also contact attorneys in the city and found several who specialized in these kinds of cases

Using appreciation & recognition liberally Flexibility was commonly mentioned … around scheduling especially. Kathleen … example of nurse who was continually 10 minutes late for the pm shift …. Going to be disciplined Another aspect of this was recognizing and appreciating the diversity and uniqueness of each staff member. What is special about each one … and valuing that … Kathleen … person who turned in 4 QI reports from one shift … being talked about by other staff … told them … we need someone who pays attention to detail like this The staff member who is so quiet but brings a sense of calmness to the floor when she is on. The next way these managers put the staff first was by listening carefully to what their staff was saying … and although they described very good listening behaviors (eye contact, reflective listening, attention, etc.), what was most striking was that when asked how their people knew they were listening … these managers said … “something changes as a result of the listening” In other words, the people knew they had been heard when there was some follow-up or some resolution to their problem as a result of the conversation. It may not have been the answer they wanted, but it was an answer, nevertheless. Meet their needs Listen & respond

Put Staff First Ask questions & listen to the answers:
Of course there were examples of specific questions that helped get the manager information …. One nurse executive was talking with a focus group of staff nurses .. And they were complaining about the amount of time they spent tracking down the electronic thermometers … when she asked them if their nurse manager knew … they said … well they thought so!!! She told the nurse manager who was appalled … she didn’t know!! What took too long today? What is just plain silly? What is holding you back from doing your best work? What keeps you up at night?

Listen & Respond “They are the ones with the gems. They will come to you with their problems. You’ll know what needs to be fixed, ‘cause they’ll tell you what’s broken.” “I address issues they have brought up, it surprises them sometimes.” “I may not have the answer right away because I like to go back and process things, but I always get back to people and they really appreciate that.” “Listening is probably one of the most important things I do. I repeat what they said and then I get back to them on it.” “I ask them, if you were in this position, what would you do?” One manager described her own situation where she had reached a point of total burnout .. Total depletion and had to take FML herself, just to regroup. Her organization provided little to no support for her. Her VP, in that final interview said to her … “You know, ____, just because we haven’t done anything doesn’t mean we weren’t listening.” And finally, the last way of putting staff first, is this whole idea of being supportive.

Using appreciation & recognition liberally Recognize & appreciate diversity Meet their needs Listen & respond Support was seen as a way to show caring for the staff. Some of the items mentioned here were things like getting involved in dealing with physician ruckuses Having a non-blaming, non-punitive environment for mistake making Having support people (clinical specialists, unit-based educators, pharmacists, social workers, etc.) available and accessible. Advocating for the staff … standing up for them … Some actually gave examples of where they provided support for the rest of the organization as well. Orienting new staff members for other departments; Other examples you would expect are things like support during very difficult times … loss of a loved one Having educational money available Making sure they know they will be supported. Support

Forge Strong Connections Put the Staff First Creating a Culture of Retention

Forge Strong Connections
Connect with people, as people Get to know them The first major behavioral theme was that these nurse leaders focused on forming strong connections with their staff. Connect with people, as people “I think that each person needs to have some kind of personal connection, individual connection with the manager.” “I take time to connect with my staff and listen to them.” How they did this varied … by having team events, by working together as a team (on ortho, 6 people coming in to help move a patient to a stretcher), by asking about their interests and preferences, by being vulnerable with them. “Sharing some of myself with them. Letting them know I care about the same things they care about. Get to know them They know the people they work with, they call them by name, not just the nursing staff, but the housekeepers, RTs, anyone who comes into the unit. Kathleen … story of CAN … 6 mo training program and left the other hospital … “they still didn’t know my name” Knowing something personal about them is important, who has kids, dogs, what they like to do …

Get to Know Them “It’s understanding what’s important to them outside the institution. That they’re human, that they have important lives and need to feel valued.” “I know all of them. I know their names, their families, their dogs, what they like to do.” “I don’t do it as a strategy. I do it from my heart, but I know it makes a huge impact on them. Because I remember.” Get to know them These are some of the ways these managers describe this … One manager said, “I make a note of things that are special about people so I can remember them. I lost a sister years ago and it was very hard. And now, if someone asks me how it is without Mary, that has meant so much to me. So I know what that feels like. So if it’s an anniversary of one of the nurse’s father’s death or something … I’ll just say ..”How are you today? Are you thinking about your Dad?” and I don’t do it as a strategy .. I do it from my heart, but I know it makes a huge impact on them. Because I remembered and because they’re not alone in their memory. I’m not the person to be real social at the Christmas part or out after work for a drink or whatever … I don’t like to go to the cafeteria and eat with them … I think some people aren’t comfortable with their manager and that break time is theirs. I know something about each one of my people … all 150! I invest time in them, I make rounds, I ask them … what’s going on? What’s important to them. The investment in them makes them feel wanted. It creates a bond and a rapport. They need to know who I am, I have pictures of my wife, my kids, my cat on my desk. I let them know who I am.

Kathleen … VP asked her for a list of who was on during a day of Nurse Week … she send a list of the 14 people and something personal about each one of them. Create a sense of community Some of these managers stories were accounts of an extraordinary sense of community. Staff member got a call … 13 yo suicide attempt … they got her off immediately and arranged for an emergency counseling session that night … covered her schedule for the next 2 weeks so she could focus on her daughter. People know we would do the same for everyone. Giving paid leave time, staff member broke an ankle and was out of work for a month … collected almost $3,000 in cash for her Young staff member … said she was moving in with her boyfriend cuz she couldn’t afford a wedding … the staff got it together … manager, ordained minister married them, it was at the social worker’s house, staff all brought food, a ring had been left that no one claimed … another staff member sang, a physician gave a night in the honeymoon, 2 staff members sewed the wedding dress Note: these people are very inclusive, they include patients, families, physicians, housekeepers, and everyone in their events. Even float nurses …. Several mentioned getting cards from float nurses who worked up there … telling how much they enjoyed it!!! Connect with people, as people Get to know them Create a sense of community Hire the right people

Hire the Right People “I look for people who are passionate around their work.” “I’m very selective. I know that if people want to learn the job, they will. I’m looking at attitudes and behaviors, enthusiasm.” “We look for people that really have the energy and the sort of sense of humor that fits with our group.” “I want someone who has the heart and the caring and this is of interest to them.” “We want someone who is going to contribute, participate on committees, be a part of what’s going on.” In many cases these managers talked about staff being involved in the interviews. Comparing notes and then agreeing on who to make the offer to …. In some instances, the decision for who to hire is left to the staff and the manager said … I have never disagreed with one of their decisions. They don’t hire because the person has the right credentials behind the name … but because they are going to contribute.

Connect with people, as people Get to know them Create a sense of community Hire the right people And finally … these people said we have fun together They gave numerous examples of ways to keep the workplace a little more lighthearted and fun. Filling a jar with syringe caps and having a contest to guess how many are there … have a game … how many butterflies were used last month in the department. Prizes like movie tickets or a free dessert in the cafeteria were the give-aways. Birthday parties, celebrations of every kind Some depts actually had a team of staff members to plan the fun. One such group … focused in 3 areas … inside work activities, outside activities and the bulletin boards. The bulletin boards had a theme for each month … Outside activities were things like a golf tournament, going to a theatre, holiday parties. Potlucks, birthday parties, exchanging valentines, Easter egg hunt, when people were done orienting, the manager took everyone to breakfast Spontaneously, baking cookies or making popcorn, including pts, drs. And families Have fun together

Have Fun Together “We try to keep it lighthearted. I have a good sense of humor. They see that and it sets the tone for the department.” “I use humor and fun to emphasize the things I think are important. For example, we always celebrate the end of orientation. I take the orientees out to breakfast … and the preceptors out to dinner.” “We have so much fun at our parties, we started having these little cookouts every month or so. One of staff brings his grill & we’ll do hamburgers & hotdogs around 6 pm so oncoming and off going staff can have some. We invite everyone.” These managers talked about creating a positive work environment by making sure it was fun. As long as the work gets done. It might be making brownies or going down and getting them candy.

Forge Strong Connections Put the Staff First Creating a Culture of Retention Coach for & Expect Competence

Coach for & Expect Competence
A major way these leaders created a culture of retention was by focusing on the growth and development, both personal and professional of the people in the department. They set high standards both for themselves and others and helped people achieve these standards. Sets high standards & expectations

Sets High Standards “My leadership team and I actually look for and create new goals every year so that people are always feeling challenged. So we’re always on the cutting edge. You cannot be satisfied with what you did last year.” “I have very high expectations, I expect them to participate in PI efforts, to attend the committee meetings that they are on, to practice their profession in a quality way.” “I don’t expect anything of them I wouldn’t do myself.” “I have high standards, but I’m a soft touch person. There are a core set of rules, like patient safety. We don’t bend rules there.” These leaders had concrete standards for themselves and their staff … both around patient care as well as interpersonal behaviors and how they treat each other.

These leaders focused on their people’s development. Included things such as sending them to conferences, encouraging and helping them write abstracts to present posters or write articles, or speak at conferences. Paying close attention to new orientees … keeping in touch with them and finding out how things are going. Giving feedback to the preceptors and staff based on what is found. Sometimes it was more basic, starting a unit library, getting some journal subscriptions, implementing a stronger orientation program, encouraging people to be members of their professional associations, offering basic in-service classes. Encourage them to take advantage of tuition reimbursement. Sets high standards & expectations Coaches for development

Coaches for Development
“I am very well known for developing my staff. I have given birth to 10 managers here” “I look for opportunities for them.” “I get them involved in things. I ask them, what do you want to do?” “Each employee has special strengths and it means recognizing those and asking people where they would like to develop. They may like teaching others, or improving their clinical skills, maybe they want to be a manager or a case coordinator. So what kinds of experiences would be beneficial to help them prepare for that role?” These managers looked for opportunities for people to grow and develop.

Another way that these managers coached is through modeling the behavior they wanted. ‘I model the behavior I want to see.” Examples …. SKI … talking about a staff member as if they were gossiping, we don’t the staff do it, we cannot do it either. Being positive Having a non-blaming, non-punitive approach Modeling calm and control You just don’t give up … Sets high standards & expectations Coaches for development Models behavior

Models Behavior “I have faced many situations that would get most people down, but I don’t let it. I’m choosing my attitude every day.” “You have to lead by example. We have to help each other. This job is difficult enough as it is. We just need to be supportive of each other. If you see that someone is sinking and having a really tough day, help them out.” “I try to model the behavior I think employees want … they want honesty, they want fairness, and they want to see that I treat everyone the same.” Modeling behaviors wasn’t always easy.

And finally, it was almost unanimous … that managing performance was a critical way these managers created a culture of retention. They recognized and rewarded good behavior and dealt with problems immediately. Sets high standards & expectations Coaches for development Models behavior Manages performance

Manages Performance “You have to deal with problems head on and not let them fester.” “I hold people accountable for their behaviors. We follow a process, it’s time-consuming, but you know what? They either comply or they move on.” “Here’s the bar. It’s set right here and if you don’t get up to that bar, then there are consequences. Too many people are afraid to discipline, afraid to counsel, because of workforce shortages. But the reality is, you can’t keep bad apples. You really dilute the quality of service and the morale.” Most of these managers had learned the hard way that you can’t ignore the problems. And their own credibility with their staff was just too important to jeopardize by ignoring the problems. “if things have to be addressed, I address them. It doesn’t do any good by waiting for it to go away, cause it doesn’t.”

Manages Performance “You know, it takes a lot of time and energy, but you have to.” “In my most difficult conflict times over the years in management, I never ran away from it. I knew I was going to be in the hotseat, but I will not let that stop me from doing what I needed to do.” “When employees bring these problems, they want to see that they are taken care of.” “They want to know, to trust that something will happen.” These managers looked for opportunities for people to grow and develop.

Forge Strong Connections Put the Staff First Creating a Culture of Retention Coach for & Expect Competence Focus on Results

Focus on Results Solve problems
A major theme from these successful managers involved the fact that they focused on results, they solved problems, they made improvements for staff based on what they heard from people. This seemed to be a key way that they became credible to the people with whom they worked. They continually ask the staff for input on what needs to be fixed and then they deal with it. Some of the bigger system problems take longer and results may be slow, but they always gave feedback on what was happening with it. And as a result, the staff felt like something was at least moving ahead. All of these people talked about things that had changed or been improved under their watch … Getting desk and file cabinets for the oncology clinic nurses Cluster staffing in OR Implementing a bedside registration process in ED Changing the staffing mix on a surgical unit Combining nursing and medical documentation records Creating a protocol for narcotic-induced constipation Care delivery changes Batching our calls to c/v surgeons at night

Solve Problems “I try and deal with whatever they need in a very timely manner. I try and be very responsive to them. They don’t have to come back to me again and say ‘whatever happened with?’” “People know they’ve been heard when the problem is solved.” “Taking action very quickly is crucial. Delay, delay, delay will kill them and the manager’s reputation & credibility. If they bring something forward or you see something wrong, take care of it now.” “People We’ll trial things … if it doesn’t work, we’ll go back to the drawing board Great example of listening during the implementation of a huge change project. There were little green cards that the staff could fill out during their shift that identified problems and issues with the change. These were collected each day and problems resolved as they came up. “So the staff felt like someone was paying attention to them all the time we were going through that change.” Working on systems that just “kill us” … neurologists using ED beds to work their patients up Throughput in ED Staff not being able to get what they need…. B/P cuffs, new fax machine, etc. Taught them how to read the budget and fill out the requisitions …

Focus on Results Solve problems Empower & involve employees
Probably one of the most important ways that these leaders got results was from empowering the staff. There were just exquisite examples of staff involvement, participation and high level of autonomy and decision-making that came out of these stories. Many efforts were what you would expect … Unit council meetings where staff members were instrumental in making decisions that impacted the department; these often focused on practice issues quality improvement and morale issues. Teaching people new skills and assigning responsibilities so they could handle broader sets of tasks The situations ranged from dealing with interpersonal issues and conflicts, to ordering equipment and supplies when needed without requiring manager approval, float RNs and nursing assistants making decisions about where their help was most needed; decisions about what education is needed in the department and how they would do it. Empower & involve employees

Empower & Involve Staff
“A big role of the leader in this environment of retention is that you start giving up as much power as possible. I measure my success by how little they need me anymore!’” “Micromanaging kills you. You’ve got to let go. You think you’re going to do it all, but you can’t. It will kill you. You’ve got to have everyone helping you.” “I want to create more leaders on my unit, people that can just take the ball and run with it instead of always feeling like they have to come to me. And my goal is to get them so self-sustaining that they don’t need me anymore.” “the less control the manager has and the more that is given to the staff, it’s great. It means that employees are making more of their own decisions.” Involvement in committees, both in the department and house-wide. Collaborative practice committees on a multi-disciplinary basis. Involvement in scheduling, decisions about how to do the mandatory education. ****we don’t usually have trouble finding people to participate. It appeals to people who want to have a broader perspective or have another experience in their careers, in addition to direct care giver. Our councils and committees are very robust. A key thing is for the manager to promote participation, value it, support it and be a mentor. If you approach someone to participate, but don’t follow through in terms of helping them get the time off to go to the meetings … it just generates frustration and is a lose-lose proposition.

Focus on Results Solve problems Empower & involve staff
Just some other points about getting results. This is similar to some other factors I have shared, but I think it bears repeating … to make certain the point is made! Responsiveness to staff was crucial. “I really try to work at addressing, helping them prioritize what the issues are, not just my issues, but theirs, and work in engaging them in solving them. As a result, they feel very heard and supported. I really believe that the people who do the work have to be involved in it, and the decisions that are made around it, because I don’t do that work. I mean, I know about it, but I don’t actually do it.” Providing adequate resources This is included as a major point, because it is one of the areas around which there often needs to be results! “just giving them the necessary things to do their job … b/p cuffs in the room, enough thermometers … isolation gowns. “It’s the little things that tick nurses off … like when you got to get some linen and there’s not enough there. Or you go to find a PCA pump and we don’t have any. So I consider it my job to make sure that the staff are not wanting for anything to do quality care.” Responsiveness to staff Provide adequate resources Create a pleasing physical environment

Partner with the staff Works interdependently
These leaders described their leadership style as one of partnering with the staff. Some people used the word itself, but more of them simply described a style that was based on a partnership relationship. Several talked about working closely with the staff to solve problems that have been identified. Ruth … patient room that was too small … had the VP of nursing and plant ops come up … toured by the staff and explanations shared … converted to a private room A staff member who is very interested in safety issues … does the regular inspections, serves on the housewide committee and keeps the manager apprised of needs. The manager shows a tremendous amount of confidence in them. Works interdependently

Partners with Staff “My job is to facilitate their work. I make a joke about it, but really the truth is that I work for them. They don’t work for me … I work for them.” “All of these things create a sense that I’m working for them, and it creates an environment where there’s mutual respect between us.” “It’s understanding that it’s never about me …it’s about we. I’m not retaining people, we are.” “My job, and I can never forget this, my job is to provide service to those employees. That’s my job, I’m working for them.” These leaders were very clear on what their role was, and how important it was to be working interdependently with the staff. They saw their role as working for them … They described things that could be identified as a particular leadership style … Paying attention to consistency of the message from the leadership team Creating an environment where people feel liberated Risk taking environment Positive attitude, have to stand up for yourself, not let anyone bully you Not afraid of making change, keeping things stirred up a bit Stick to your word and be consistent Insist on fairness and consistency Treating people fairly

Partner with the staff Works interdependently Visibility
Visibility was crucial for these people. And it wasn’t just being seen, or present, it was jumping in and helping out in many cases. Making rounds was probably the most common example. But it also meant being visible for all of the shifts … some talked about actually coming in on the “off-shifts” while others just made it a point to be there at the time of shift change. Many gave examples of previous managers they had known that had never seen the staff and didn’t know the people from the other shifts … they resolved to do better because they felt it communicated a lack of caring. Some of what these people described might be considered just standing around and “smoozing” … but it was a deliberate intervention on their part, very conscious, very important. Works interdependently Visibility

Visibility “I just make a point of getting out at least once a day, making rounds and seeing everyone.” “Where ever I can just jump in and help out … that’s a good opportunity to be with that employee.” “I’m here in the morning to see the night shift, and then in the afternoon to see the evening shift.” “I spend time out at the desk … I take as much of my work out there that I can. Just to be around people.” “I block time out on my calendar to make rounds.” These leaders are out in their units a lot … they see that as of prime importance. The way they pitched in and helped was unique to each one … some liked to take off orders … so people would see her name in the chart. Others could actually work clinically and relieve staff in difficult situations … for breaks, etc. Others didn’t feel comfortable clinically or technically any more … but they could answer the telephone, make calls, help out with nursing assistant work and so on. “You just feel what’s needed for the unit and you do it, I think it sets the tone, an example for the others.” One very astute manager said … presence doesn’t always mean physical presence … “It’s getting back to people, following through, answering their phone mail, leaving them a note in their mailbox, even if I don’t have the answer or don’t know the answer, it’s staying connected in all of these ways.”

Partner with the staff Works interdependently Visibility Accessibility
Accessibility is very similar to visibility … but both were mentioned frequently. They talked about frequent staff meetings, having an open-door policy, being available to people. Having somebody available to them at all times. They talked about having their office in the inpatient unit … and responding to s at any time … Works interdependently Visibility Accessibility

Accessibility “I’m out there with them. I tell them, I’m available … this is what I’m here for. If you need me or need to talk about something, I’m here.” “Things like where your office is is important. What you wear to work. If you come in dressed to work or you are in business attire. Wearing the proper clothing that sends the message, ‘if you need my help, I’m ready.’” “I post my schedule on the my door so people will know where I am at all times. If they want to talk to me and don’t know where I am or when I am coming it, it creates a lot of frustration. This way they know.” One talked about keeping her office in the unit even though she was getting some pressure to move it more centrally, in the new administrative building. And she said … it might be wise politically to move it, but I’m going to stay down here with the patients and the staff. Another said that after she moved her office right into the bowels of the unit … staff will just pop in to share a “quick something” or ask a quick little something … much more now that she is located in the dept.

Partner with the staff Works interdependently Visibility Accessibility
And with all of this visibility, accessibility and knowing the staff … these leaders were clear about the boundaries. “They know I am the leader. I don’t really socialize with them, I go to the parties and everything, but I maintain a distance that I know the leader needs.” “They clearly want to know that there’s a leader there … and they clearly want me to be that leader and not their friend. They don’t need me as their friend, they need me as their leader.” An issue for these leaders was balancing accessibility with staying focused or protecting themselves so that they’re putting their time where they can make the most difference. SKI --- CEO confronted her … everyone is coming up to you and asking you questions that other people could handle. She was insulted at first and then thought about it … she put a note in the communication book. “it’s not that I don’t want to hear about your problems, but please go to the charge nurse first, if she/he can’t handle it, then fine, come to me. (you don’t ask the general if you want a weekend pass … you go to your commanding officer). She told them that this prevented her from focusing all of her efforts on the bigger problems they needed her to focus on. No one was insulted or miffed … Open and honest communication was an important part of their relationship with their staff. Works interdependently Visibility Accessibility Establishes clear boundaries Communication is open & honest

Open Communication “I am very honest with them and tell them: ‘I will tell you the way it is, whether you like it or not …I’m going to tell you. It’s going to come from me. The good and the bad, you will hear it from me. If you hear it elsewhere, it’s gossip.’” “I don’t hide anything from my employees that they need to know.” “I am very up front with them. The previous leader lost their trust because of misinformation given. I expect the same from them that they expect from me.” “I try and approach things from a ‘no surprise’ perspective.” Here are some examples of what they are talking about …

“The people in the good-to-great companies did things that seemed so incredibly obvious, straightforward, simple… the comparison companies may have been very smart people, brilliant, but they saw things as complex, and they had elaborate plans and complicated strategies.” Jim Collins,in HealthForum Journal,2002 --Bowles, 1991 In Jim Collins book, From Good to Great, he does a wonderful job of enumerating the discoveries he made in his research on how companies went from merely good to great. It is a very solid piece of research … and his findings are very practical. I was struck by his observation of what differentiated the org he and his research team studied … Hedgehog and the Fox an old Greek adage. The fox knows many things, the hedgehog but one simple strategy. He rolls himself into a ball of sharp spikes, but he uses that strategy very effectively. He said he suddenly saw how completely this described his successful orgs. They know one big thing. Their world is not terribly complicated. The comparison people were smart, but they couldn’t grab onto anything simple that would actually work.

Action Plan What should I start doing? What should I stop doing?
And with all of this visibility, accessibility and knowing the staff … these leaders were clear about the boundaries. “They know I am the leader. I don’t really socialize with them, I go to the parties and everything, but I maintain a distance that I know the leader needs.” “They clearly want to know that there’s a leader there … and they clearly want me to be that leader and not their friend. They don’t need me as their friend, they need me as their leader.” An issue for these leaders was balancing accessibility with staying focused or protecting themselves so that they’re putting their time where they can make the most difference. SKI --- CEO confronted her … everyone is coming up to you and asking you questions that other people could handle. She was insulted at first and then thought about it … she put a note in the communication book. “it’s not that I don’t want to hear about your problems, but please go to the charge nurse first, if she/he can’t handle it, then fine, come to me. (you don’t ask the general if you want a weekend pass … you go to your commanding officer). She told them that this prevented her from focusing all of her efforts on the bigger problems they needed her to focus on. No one was insulted or miffed … Open and honest communication was an important part of their relationship with their staff. What should I start doing? What should I stop doing? What should I keep doing? What are 3 action steps to which I will commit?

Ramifications/Individual
Do an honest self-appraisal--- “How do I measure up against these five principles?” Look for opportunities to apply these 5 principles Seek out other supportive managers Incorporate self-care into daily routine Find your voice, speak up & speak out Use evidence-based leadership practices If the manager is the chief retention officer, then we have to look seriously at what support is needed for this individual to adequately fulfill this role. It can’t just be lip service. What are the resources we need to supply in order for this person to be fully effective? We cannot just keep adding responsibilities without taking an honest, hard look at what these people need in order to be successful. Use AI …. Find the pockets in your organization where things are going well … and then we have to recognize and reward those who are effective Peers often were the source of conflict … some of these people were actually seen as very negative by others in the organization

Ramifications/Organization
Know what makes the difference, expect evidence-based leadership practice Provide necessary resources, not just lip service Leaders need authority to solve problems and change what needs to be changed Provide support for dealing with polarities & managing boundaries Recognize & reward those who are effective rather than letting them be penalized in the system Strengthen the working effectiveness between HR and operational managers If the manager is the chief retention officer, then we have to look seriously at what support is needed for this individual to adequately fulfill this role. It can’t just be lip service. What are the resources we need to supply in order for this person to be fully effective? We cannot just keep adding responsibilities without taking an honest, hard look at what these people need in order to be successful. Use AI …. Find the pockets in your organization where things are going well … and then we have to recognize and reward those who are effective Peers often were the source of conflict … some of these people were actually seen as very negative by others in the organization

Creating a culture of engagement is hard work, but, it isn’t rocket science and it doesn’t cost a lot of money. Developing such a culture requires being authentic, caring about people and making yours a good place to come to work.

it is far too late and things are far too bad for pessimism
. . . it is far too late and things are far too bad for pessimism In such times as these, it is no failure to fall short of realizing all that we might dream; the failure is to fall short of dreaming all that we might realize. Dee Hock, 1999

Behavior in the Workplace

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