Barbara Norris: Leading Change in the General Surgery

Grew up in a small town in Western Massachusetts in US
Her mother and grandmothers were nurses, and she developed a deep respect and admiration for the profession at an early stage. By the time she entered high school, she wanted to be a nurse Graduating with honors from the “Nursing Program” at Eastern Massachusetts University. Start the work at EMU – Emergency Room (x4 yrs)

Move to EMU – Trauma Unit (x1 yr)
Pregnant with her first child
Change the work in Part-Time basis, 1~2 shifts per week (Several yrs) Pregnant with her second child
Full time housewife and concentrated on her young family, give up her work After her kids were in grade-school (primary school), she resume back to the Full-Time Nurse at EMU – Trauma Unit (x? yrs) When her kids entered high-school, Barbara began the coursework for “Master Program in Nursing and Health Care Administration” (Barbara’s mentor & friend, Betty Nolan, her nurse manager, also encourage her to pursue the masters in Nursing Administration) After Barbara completed the program, Nurse manager from EMU’s GSU announced her retirement. Barbara applied for this vacancy

Reason1: She welcomed the opportunity to stage at EMU
Reason2: She want to take the challenge to turn the unit around After a series of interviews with different parties (inc. EMU’s Nursing Director & Administrative Leadership), Barbara was offered the job and become the Nurse Manager in EMU’s GSU Betty Nolan (Barbara’s mentor, trusted friend & nurse manager) advise her that don’t take the offer, she value Betty’s advise but she Confirmed to Go Ahead because of she would like to take the new challenge in her career, as well as the GSU Job was a good opportunity for her to the next step Nursing Director, John Frappewell congratulated her and hope that she can turn around GSU and do it fast Economy is in the downturn, as the result…

Impact 1: EMU’s revenue decreased sharply while costs continued to increase Impact 2: Hospital leadership team make a difficult decision to guide the hospital through the economic crisis and keep it stay afloat. Impact 3: Freeze hiring, stop Over-time allowance and decreased shift differentials. Barbara takes the new role but nightmare just begin …

Barbara’s Network
Betty Nolan
Barbara’s Ex-Boss (before she takes the new role)
Job Role: Nurse Manager at EMU – Trauma Unit
Mentor & Trusted Friend
Encourage her to pursue the Masters in Nursing and Health Care Administration. Betty advised to Barbara “Do not take the job, GSU is a lost cause. Spare yourself the grief and aggravation”

John Frappewell
Barbara’s New-Boss (After she takes the new role)
Job Role: Nursing Director at EMU
Expect she can turn around the unit (i.e. GSU) and turn it fast

Barbara’s Role & Responsibility
Job Role:
Nurse Manager at GSU’s ESU for 1 month only

Responsibility:
Managing the Staff
Scheduling
Define the budget for the unit

GSU’s Organization (HR)
Nurse Manager
Barbara Norris

Total x33 person staff
x25 Registered Nurses (RN)
x8 Patient Care Assistants (PCAs)

Staff Turnover Rate
x2 RNs left since she take the Nurse manager role in the first month x3 RNs left prior she join the unit in six months before
(Hiring replacement is not allowed because of recently instituted hiring freeze at EMU)

GSU’s employee annual performance review mechanism
Ex-Nurse Manager
Staffs’ annual performance reviews are incomplete, inaccurate & non-transparent

New-Nurse Manager (i.e. Barbara)
Regular informal check-ins and formal annual review is a critical management tools Open communication is necessary
Transparent review system required

GSU’s Problem
Barbara (GSU’s Nurse Manager)
Tired
Overwhelmed

Individuals (GSU’s Teammates)
Overworked
Employee Stress Level were high
Employee morale are Low
Senior nurses were often critical and complained the newer nurses behind their back rather than helping and mentoring them Different unit’s RNs (include both new and more tenured nurses) w ere frustrated with the GSU’s PCAs that they had inadequate training and skill sets Unfair and not transparent levels of performance review procedure Work isn’t acknowledged and contribution does not feel valued, no matter this is verbal or compensatory for her effort Not enough opportunity to learn and grow

No one truly defends their interests or advocates on our behalf Job is becoming more administration centered rather than patient centered.

Team (GSU as a whole)
Lowest employee satisfaction scores
High turnover and low retention rates among all of the other departments at EMU Even though the patient satisfaction scores were average now, but tends to be Declining steadily over the past few years Infamous for the culture of confrontation, conflict, blaming, and favoritism, relationship Dissatisfaction with staffing

Little input on matters that affect us greatly
Lack of collaboration and teamwork
Interpersonal and intergroup conflict
Doctors not respect nurses (e.g. treat them like order takers rather than care givers) Administrators care more about money than patient care

Relationship were tense not only between the nursing staff (i.e. internal) but also with many unit’s attending physicians Economy is in the downturn, as the result…
Impact 1: EMU’s revenue decreased sharply while costs continued to increase Impact 2: Hospital leadership team make a difficult decision to guide the hospital through the economic crisis and keep it stay afloat. Impact 3: Decreased shift differentials.

Impact 4: Cost cut for Over-Time Allowance (Great impact if the nurses who were sick or needed to take personal or vacation time, Barbara could not offer over-time to her staff to cover such absences but instead … Fully rely on RNs from the general float pool (limited resources) RNs from the general float pool were not familiar with the unit, it specific procedures and care protocols. Additional negative effects on staff dynamics and quality of patient care Impact 5: Short-Staffed (Hiring the replacement are not allowed because of the recently instituted hiring freeze at EMU)

Trauma Unit Atmosphere
(Barbara’s ex-working place)
Close-knit group who worked well together as a team
Colleagues are friends (lunch or dinner together, even have socialized outside of work) Helping culture
Every teammates respect and well-liked Betty (i.e. Harmony atmosphere) High reputation from Betty, the Nurse Manager from Trauma Unit in EMU. Betty earned the reputation as a responsive manager who acknowledged her staff and sought their input on important decision relevant to the unit

GSU’s Off-site Meeting
(like townhall meeting)
Objective
Provide a forum to begin the discussion between GSU’s staff and Barbara Inspire the beginning of the “Turnaround” situation

Participants
GSU’s staff who need not on duty and able to attend the Off-site meeting

Procedure (Original: 1hr => Now: 1.5hrs)
Each teammate write down 2~3 things that most frustrated or bother them Brabara review the comment one by one and list down all the issues After consolidate all the input, Barbara asked if anyone would like to share the comment / follow-up (Result: Completely Silence) Asked second time (Result: Again…Completely Silence)

Sharing from the Teammates
(inc. Megan Mahoney → Jennifer Goodwin → Louise Scribner) Barbara tried to close the session and ask if anyone have any effective solution? Silent again and she make some proposal

Feedback (General)
Lack of collaboration and teamwork
Interpersonal and intergroup conflict
Doctors not respect nurses (e.g. treat them like order takers rather than care givers) Administrators care more about money than patient care
Favoritism
Dissatisfaction with staffing
Levels and performance review procedure
Little input on matters that affect us greatly
No one truly defends our interests or advocates on our behalfS

Feedback (Individuals)
Megan Mahoney:
Role & Responsibility: Nursing school graduate
Duration: Work in this unit almost a year
Comments: Upset with some Senior Nurses – Not enough opportunity to learn and grow (Often get the indirect negative messages and feedback behind her, keep her feeling that everything go wrong but won’t address to her directly or in a straightforward way)

Jennifer Goodwin:
Role & Responsibility:
Strong skill set especially with new technologies and
Wonderful bedside manner
Willing to give the help to others who work in this unit
Duration: Work in GSU for 10 yrs
Comments:
Upset with the existing performance review process, as the result no “Feedback” is provided from the manager Unfair reward system and does not seems to reward the good performers (same annual salary increase regardless how’s the performance) Work isn’t acknowledged and contribution does not feel valued, no matter this is verbal or compensatory for her effort

Louise Scribner
Role & Responsibility:
Delivered very good care to patients
But Resistant to Change
Quick to complaint and come across as abrasive to her co-workers Duration: 30yrs@EMU = 23yrs@GSU + 7yrs@Rest
Comments:
Job is becoming more administration centered rather than patient centered Frustrated on not enough time to do her work, such that she need to decide which care she can give Reason 1: Not enough nurses

Reason 2: Staff are not experience enough (inc. Junior nurses & PCAs)

Suggestion from Barbara
Involve everyone for staffing decision during the team meeting (e.g. hiring decision for a nurse or secretarial assistant to process the paperwork in the Saturday afternoon, this is what they have for Full Time Equivalent FTE) Open and transparent discussion with the team (e.g. how much budget we have, how to allocate in each areas, even how to cut resources) Interpersonal and intergroup conflict

Ch
Key Topics
Questions
Answers

Learning Cycle
Important v.s. Urgent
How to apply learning cycle to Barbara’s situation?

What the tasks that are important and urgent which you would handle with priority if you were in Barbara’s position? Concrete experience (Experiencing):
Refer to “GSU’s Problem” – After Barbara became the nursing director, she experienced GSU’s problems first hand. Before she joined the job, she got information on the situation via her network (Betty Nolan and John Frappewell)

Reflective observation (Reflecting):
Barbara took the problems on board and arranged off-site to listen to her staff and explore possible solutions

Abstract conceptualization (Abstracting out):
Refer to above table – “Suggestion from Barbara”. Barbara made suggestions to the issues raised by her staff in the offsite and asked her team for buy-in on implementation

Active experimentation (Experimenting):
Not mentioned in the case – this should be the implementation stage after Barbara’s suggestions have been accepted by her team

Tasks which are defined as “important and urgent”: crises, pressing problems, deadline-driven projects Refer to “GSU’s problems” – individual problems should be given priority Easier to start with individuals – to understand their problems (care and empathy) Pressing problems as stress level is high and staff morale is low – more nurses may quit and Barbara cannot afford further loss of staff A formal appraisal system should be introduced to every individual – clear objectives for each individual, understandable and fair compensation system to motivate the team to put in more effort A learning and development plan should be prepared for every individual to increase transparency of their career paths 1

Transition
Organization Analysis Framework
Success follow by Failure
What type of Transition Barbara is facing?
Transition Phase:
Transition from a “Nursing Program graduate” at Eastern Massachusetts
University to “Registered Nurse (RN)” at Emergency Room → Focus on the Technical Tasks like how to take care the patient and work with the team at Emergency Room Transition from “RN” at Emergency Room to “RN” at “Trauma Unit → Keep focus on technical Tasks (i.e. job nature still be the same) but environment, people and technical area have changed. Transition from “Full-Time RN” to “Part Time RN” after she give the birth → Keep focus on technical task but her focus was shifted to the family rather than work Transition from “Part-Time RN” to “Full time housewife” after she give the birth for her second child → Give up her career life and focus to her family Transition from “Full Time housewife” back to Full-Time “RN” at Trauma Unit→ Focus on Technical Tasks at Trauma Unit as what she worked before Transition from “Full-Time Nurse” at Trauma Unit to “Nurse Manager” at GSU after she graduate from the Nursing and Health Care Administration Master course → Focus more on interpersonal tasks rather than technical work

After Barbara on-board, what is the key objective and expectation from her boss, John Frappewell (Nursing Director at EMU)? And what type of transition GSU is facing? GSU Transition John & Barbara understand that there have lots of problems in GSU nowadays (inc. Infamous for the culture of confrontation, conflict, blaming, favoritism, relationship problem, etc), John expected that Barbara can lead the team to make the transition and help to turn around the current situation fast.

Definition of “Turnaround”
The team have lots of issues nowadays and management team try to define some strategy and action plan to fix the issues and resume the operation back to normal

Barbara’s approach
Under the “Turnaround” situation, this is necessary to give the “Hope” to all her staff in order to overcome the feeling of despair. In addition, motivation and reenergize them are some possible ways help to fix the issue. In order to setup a good starting point to turnaround the current situation, Barbara have setup an off-site meeting with her team to execute her plan:
Provide a forum to begin the discussion between members of the unit Inspire the beginning of the “turnaround”

What challenge Barbara is facing during the transition?
Sink or swim mindset – Zero support (human resources and budget), mentoring and guidance from her direct report (John Frappewell , Nursing Direction at EMU), just let her manage the work by herself even not give her a clear direction, goal setting and expectation Leadership development – Zero training or support is provided to Barbara Today’s capabilities are often not what you need tomorrow – Barbara’s situation even worst because of her job was shifting from the technical tasks to the interpersonal tasks, which is totally irrelevant from her previous working experience. Flat, fast organization have reduced mentoring – Flat structure like GSU’s subordinates all reported to her but she’s report to the Nursing Director at the same time. “Hazing mentality”

Group: Problem Solving Skill & Decision Making
N/A
Group decision-making process is not applicable in this case because: The team is not required to make decision on turning the situation around – only Barbara is Trust, rapport and bonding have to be built before any effective decision could be made (have to resolve team conflicts first)

But Barbara could improve future group decision-making process after solving all the pressing problems by the followings: Establish a results driven structure
Clear roles and responsibilities in the decision making process Be transparent in communications
Establish norms to facilitate sharing of all information
Build a collaborative climate
Encourage the sharing of unique information
Reinforce members for sharing conflicting or negative information Create an open culture to build trust
Give the team member certain degree of autonomy to make decision

Individual: Problem Solving Skill & Decision Making

Don’t think the theories in the notes are applicable to this case though Barbara is trying to solve the problems… She doesn’t have any choice but to fix the problem so basically I don’t think she has decision to make… re the problem solving, I think we already cover under various sections, like motivation / transition…

Motivation
What is Barbara’s motivation taken the new role even she realize that the team has lots of problems? Intrinsic Motivation:
1) Born to be a nurse (Her mother and grandmothers were nurses, she developed a deep respect and admiration for the profession at an early stage) 2) She understand that lots of the issues in EMU’s GSU, but she would like to take the challenges and apply for the Nurse manager post because of the following reason: Reason1: She welcomed the opportunity to stay at EMU

Reason2: She want to take the challenge to turn the unit around

Extrinsic Motivation:
1) Betty Nolan (Barbara’s mentor, trusted friend & nurse manager) advise her that don’t take the offer; Barbara value Betty’s advise but she confirmed to take the offer because of she love to take the new challenge in her career, as well as the GSU Job was a good opportunity let her to moving forward 2) Even though she understands the new job is tough, due to the economy is in the downturn and it’s better to accept the offer and secure her job.

Nurses are all de-motivated, what kind of the strategies can help to motivate them?

Problems:
Our work isn’t acknowledged and our contribution often does not feel valued
Our performance review system is a mystery, unfair and does not seem to actually reward good performers. In addition, there have no “Feedback”, “Recognition” & “Acknowledgement” from the management level no matter this is verbal or compensatory on their effort Different unit’s RNs (include both new and more tenured nurses) were frustrated with the GSU’s PCAs that they had inadequate training and skill sets

Solutions:
Extrinsic Motivation:
Use expectancy to set a clear expectations and goals setting for the team and each individual, as well as provide enough support like training and advice to the PCAs Pay scheme rules to make the compensation package transparent, fair and understandable Build-up the equity / justice culture in the team

Ensure equity in pay review and appraisal to minimize favoritism Increase procedural fairness to reduce inequality and improve transparency Intrinsic Motivation:
Motivate the staff who love their work and take care of the patient. Motivation can be in the form of Goal Setting (e.g. Define the annual objective more focus on take care the patient rather than pay attention to the administration work) and Job Design (e.g. assign the job role base from their interested and professional areas)

What is the problem from the existing performance review system? How can we solve it? Problem
Upset with the existing review process, as the result no “Feedback” is provided Unfair about the reward system (same annual salary increase regardless how’s the performance) No acknowledgement no matter this is verbal or compensatory for her effort

Solution
Using expectancy to motivate the staff:
Make performance standards clear & achievable
Be clear about what behaviors you desire
Confirm staff belief that they can achieve standards
Provide support as needed (training, advice, etc)
Find out what staff value & use multiple rewards
Reward behaviors and performance – be consistent
Make sure rewards are noticed & linkages are clear
Rewards should be related to the performance, and fair enough for everyone

Rewards can help to motivate her:
Pay (base, benefits, performance related)
Gifts
Recognition
Development opportunities (human capital)
Interesting and challenging work
Status
Flexibility (days off, control of schedules, etc)

Others:
Regular informal check-ins and formal annual review with all the staff Open discussion and communication all the time
Review system should be transparent

Fair and transparent review process is necessary, but Barbara may not have influence to make sure the salary fully aligned with the individual performance, Any acknowledgement she can make?

Besides salary adjustment, there have number of rewards above to motivate the staff like the followings Pay (base, benefits, performance related)
Gifts
Recognition
Development opportunities (human capital)
Interesting and challenging work
Status
Flexibility (days off, control of schedules, etc)

Power
Network
Social Influence
What is Barabara’s network as mentioned from the case?
Network
Social Arena (Former Employer & Friends)
Betty Nolan: Barbara’s mentor & friend, her nurse manager, also encourage her to pursue the masters in Nursing Administration. Social Arena (Current Employer)
John Frappewell: Barbara’s boss in the new role – Nursing Director, expect she can turn around the unit (i.e. GSU) and turn it fast Social Arena (Subordinates)
x25 Registered Nurses (RN) and x8 Patient Case Assistants (PCAs) Social Arena (Family)
Her husband & two Childs

Teamwork
Conflict Management
Unique Information
Psychological Safety
Leadership
What’s the Conflict at GSU?
Q1) Different unit’s RNs (include both new and more tenured nurses) were frustrated with the GSU’s PCAs that they had inadequate training and skill sets A1) Enough resources and support should be provided to PCAs in order to stimulate the Team effectiveness by improving the employee’s ability, motivation and coordination

I think the problems are more personal rather than conflictual as the team lacks communication and interaction. The only conflicts I can think of are the conflicts between the team of nurses and the management because of under-resourced, lack of transparency, favouritism, lack of communication, expectations do not match with each other.

Would the regular unit meeting can build-up the community and better teamwork
culture?

Yes, Open communication in the regular unit meeting can help to build-up the challenge assumption and encourage debate in order to minimize the Affective team conflict

Organizational Change
What is the problem from GSU during the change?
Problem
Top Urgent Change but Barbara’s Power is low → Hard to make any change, what she can do is required gradual build to institutionalization but this is take time to do so. Unclear Vision for the Change: Barbara’s new boss, John Frappewell expected that she can turn around the unit (i.e. GSU) and make it fast after she on-board. But he never mentioned the detail of the change, why we need the change, how can we make it, what do the unit want to be? What’s the expectation and objective for the change? What is the Goal Setting? Zero support from Barabara’s new boss, John Frappewell (include human resource and budget, especially EMU is hiring freeze now)

Credibility – As compare to rest of the Nurse managers from some other units, Barbara is nobody and with zero reputation within the team. This is quite hard for her to initiate the change at this moment Communication – Mis-communication within the team

Training – Not enough staff and all staff are not experience enough (include Junior nurses & PCAs), even it will impact the senior staff as they need to give the guidance as well as reserve the time to handle the administration paperwork Technical – Current reward system is unfair and no

Feedback” is provided from the manager. This unfair reward system seems does not reward to the good performers. In addition, Work isn’t acknowledged and contribution does not feel valued, no matter this is verbal or compensatory for her effort Resister – Lots of the staff are not willing to change and bad mouth to the others, it will greatly impact the execution of the change
Cultural – Teammates from GSU always believed that the existing problems cannot be fixed anyway, they feel despair about the current situation and just let it go.

Solution:
Instead of asking Barbara help to turnaround the situation, the vision and goal setting should be clear enough and well defined from John (such that Barbara understand what’s the expectation and define the corresponding action to achieve the goal) In addition, six type of the change levers she can consider

Enabling (i.e. Raise awareness for targets)
Credibility – Get the external party (like her boss John) to make the influence and motivate the team; In addition, it can help to increase her credibility because of everyone realize that even the senior management support her action plan Communication – Setup a town hall meeting (like the off-site meeting) for sharing the issues, define the possible solution and communicate algother. Training – Provide enough training to the staff (especially to the Junior RN, RN from the float pool and PCA). It can help to motivate the non-experience staff as well as release the workload from the senior staff (e.g. Guidance and on-job training) Substantive (i.e. Facilitate adoption by targets)

Technical – Align the reward system with the change initiative and individual performance. Fairness is important in the reward system and this is the way to motivate the staff contributed with better performance Political – Private talk / confront all the resister within the team (included problem makers, staff who are not willing to make the change, or staff with bad mouth all the time), it will greatly impact the team morale and atmosphere Cultural – Tell a success story to the team (e.g. Role model and good example at Trauma Unit, her ex-working place)

x8 Core Tasks from Manager
Barbara joined the team as a new leader. What challenges are she facing and
how can she overcome? Problems:
– Short-staffed
– High stress level
– Low employee morale: lowest employee satisfaction scores and highest employee turnover rate – Patient satisfaction scores are declining steadily
– There is a culture of confrontation, blaming & favoritism
– Tense relationship between nursing staff & physicians

Solutions: (from Lesson 1 notes)
– Eight core tasks
1. Diagnosing your situation – same as above problems
2. Assessing your vulnerabilities – may face resistance when introducing changes to the team; new to the team so do not have a deep bonding with the team members; under the pressure of the Director to fix the situation quickly 3. Accelerating your learning – talking to team members, boss, peers… 4. Working with your new boss – communication

5. Building you team – communication
6. Creating partnerships – building networks – get boss, subordinates, peers and possibly external parties (e.g. consultant) to support the change initiative 7. Achieving alignment – get buy-in from key stakeholders on the change objectives and implementations 8. Prioritizing to succeed – decide what are the most pressing problems to address first; build up personal credibility for the changes; build rapport with team

Others
Could Barbara talk with her boss (Director of Nurses, John Frappewell) to “Reprieve from hiring freeze and get more staff for GSU” (Q from Case)?

Not possible in the short term as the economy is in the downturn, it is highly unlikely that the hospital would reverse its policy. The economic situation is not something that Barbara could turnaround.

What should she tell her boss who was await for the status report (Q from
Case)?

Just tell her the truth and let her boss realize that have lots of issues right now. Overworked
Employee Stress Level were high
Employee morale are Low
Senior nurses were often critical and complained the newer nurses behind their back rather than helping and mentoring them Different unit’s RNs (include both new and more tenured終身nurses) were frustrated with the GSU’s PCAs that they had inadequate training and skill sets Unfair and not transparent levels of performance review procedure Work isn’t acknowledged and contribution does not feel valued, no matter this is verbal or compensatory for her effort Not enough opportunity to learn and grow

No one truly defends their interests or advocates on our behalf Job is becoming more administration centered rather than patient centered. Infamous for the culture of confrontation, conflict, blaming, and favoritism, relationship

What actions can Barbara take under current transition (from Jen)?

Refer to Sections “8 x8 Core Tasks from Manager” and “4 Motivation”.

As a leader, how can Barbara influence the team (from Jen)?

Rational persuasion: Use of facts, logic reasoning in a non-emotional manner Pressure: Threats, guilt, chastising another’s judgment on non-rational grounds Inspirational appeals: Arousing enthusiasm for values, ideals, aspirations Consultation: Seeks participation of others planning; willing to modify decision based on others’ input Ingratiating: Praise, flattery, friendliness

Personal appeals: Reminders of friendship, loyalty to group to motivate agreement Coalition building: Create sub-group to cause others to feel pressure to conform Exchange: Reciprocation of benefits in order to
accomplish task Legitimating tactics: Reference to higher authority, tradition, rules, or policies

What potential challenges Barbara might have in her plan (from Jen)?

She might face resistance from the team because:
The team culture does not value collaboration and teamwork
The team is under staffed and hence do not have additional resources to support the change initiatives The team feel that their assignments are given based on relationships and favoritisms so they might not put in 100% effort on the change initiatives The team feels that no one truly defends their interests or advocates on their behalf. This lack of trust might hinder the implementation of Barbara’s plan Her team is not motivated

They do not receive recognition and appreciation for the work they did They do not have a clear career path and no support on training and development The compensation system is not transparent and does not have a concrete process to follow Favouritism is common in the team