Review and analyze the case, Barbara Norris: Leading Change in the General Surgery Unit.? Write a paper that addresses the following: ? What is the presenting problem? ? What

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________________________________________________________________________________________________________________ Professors Boris Groysberg and Nitin Nohria and Research Associate Deborah Bell prepared this case. This case is based on field research and interviews conducted with nurses and nurse managers. Data, information, and names have been disguised to protect their confidentiality. HBS cases are developed solely as the basis for class discussion. Cases are not intended to serve as endorsements, sources of primary data, or illustrations of effective or ineffective management. Copyright © 2009 President and Fellows of Harvard College. To order copies or request permission to reproduce materials, call 1-800-545-7685, write Harvard Business School Publishing, Boston, MA 02163, or go to www.hbsp.harvard.edu/educators. This publication may not be digitized, photocopied, or otherwise reproduced, posted, or transmitted, without the permission of Harvard Business School.

B O R I S G R O Y S B E R G

N I T I N N O H R I A

D E B O R A H B E L L

Barbara Norris: Leading Change in the General Surgery Unit

It was 10 PM and Barbara Norris, nurse manager for the large General Surgery Unit (GSU) at Eastern Massachusetts University Hospital (EMU) sat down at her desk to catch her breath. She had been on the unit since 6:30 AM but planned to stay for another two hours to help with the transition from the second to third shift and the orientation of two registered nurses (RN) from the float pool. It had been one month since she had assumed the nurse manager role for the troubled unit. During this time she felt, as she did this evening, tired and overwhelmed.

As nurse manager she was responsible for managing the staff, scheduling and budget for the unit. Her 33-person staff included 25 RNs and eight patient care assistants (PCAs). In her first month as nurse manager she had already lost two RNs and in the six months prior to her joining the unit three RNs had left. But because of the recently instituted hiring freeze at EMU, Barbara was not able to replace some of these positions.

The unit was short-staffed; stress levels were high and employee morale low. In fact, GSU had the

lowest employee satisfaction scores and highest employee turnover rate among all of the departments at EMU. And although its patient satisfaction scores were average, they had been declining steadily over the past few years. Furthermore, GSU was infamous for its culture of confrontation, blaming and favoritism. Relationships were tense not only between the nursing staff but also with many of the unit’s attending physicians.

To make matters worse, over-time could no longer be offered due to additional cost cutting

measures. Hence, if one of her nurses was sick or needed to take personal or vacation time, Barbara could not offer over-time to her own staff to cover such absences but instead had to rely on RNs from the general float pool. But because “floaters” were not familiar with the unit, its specific procedures and care protocols, they more often than not had additional negative effects on staff dynamics and the quality of patient care. Nurse Norris

Barbara grew up in a small town in western Massachusetts. Both her mother and grandmother were nurses, and she developed a deep respect and admiration for the profession at an early age. By

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the time she entered high school she knew that she, too, like her mother and grandmother wanted to be a nurse.

After graduating with honors from the nursing program at Eastern Massachusetts University, Barbara began work at EMU. She worked in the emergency room for four years and moved to the trauma unit about one year before becoming pregnant with her first child. For the next several years she worked part time, one or two shifts per week, had a second child and concentrated on raising her young family.

Barbara returned full-time to the trauma unit and the profession she loved when her children were in grade school. When her two daughters entered high school Barbara, too, was ready for a new challenge and began coursework for a Masters Program in Nursing and Health Care Administration. Her nurse manager, Betty Nolan, who was a mentor and friend, also encouraged her to pursue the Masters in Nursing Administration. Shortly after Barbara completed her program, the nurse manager of EMU’s general surgical unit announced her retirement.

Although GSU’s high turnover and low retention rates were common knowledge throughout the EMU community, Barbara applied for the position in part because she welcomed the opportunity to stay at EMU but also because she welcomed the challenge to try to turn the unit around. After a series of interviews with EMU’s nursing director and administrative leadership, Barbara was offered the job. She consulted with her trusted friend and mentor, Betty Nolan regarding the position in GSU, and Betty did not hold back or mince words: Do not take the job, she cautioned. GSU is a lost cause. Spare yourself the grief and aggravation.

Barbara highly valued Betty’s advice but was also looking for a new challenge in her career and saw the GSU job as an opportunity that was too good to pass.

When Barbara accepted the job, nursing director John Frappewell congratulated her and said, you’re doing the right thing, Barb. I’m counting on you to turn this unit around and do it fast. Barbara thanked him for the vote of confidence but secretly worried that she had taken on more than she could handle.

Also weighing on her mind was the hard, downward turn the economy had taken right around the time she accepted the job. All leading indicators suggested recovery was several months if not years away. EMU’s revenue decreased sharply while costs continued to increase and the hospital leadership had to make difficult decisions to guide the hospital through the economic crisis and to help it stay afloat. They enacted a hiring freeze, stopped all over-time allowance and decreased shift differentials. The administration framed all of these measures within the context of the crisis and for the greater and longer term good. But an overworked and stressed staff could not always muster the good will and foresight needed to take the long view, and tensions were growing in the halls of EMU.

General Surgery Unit (GSU)

The staff in her old organization, the trauma unit, was a close-knit group who worked well together as a team. Many of the nurses were friends, ate lunch or dinner together and some also socialized outside of work. There was a helping culture within the unit; a tone set and finely calibrated by Betty who was respected and well-liked. Betty had earned a reputation as a responsive manager who acknowledged her staff and sought their input on important decisions relevant to the unit.

Soon after Barbara began as nurse manager in GSU, she received requests from 29 of the unit’s staff members for one-on-one meetings and she soon experienced first hand the culture of conflict and blaming she had heard about. For instance, rather than helping and mentoring the newer nursing

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Barbara Norris: Leading Change in the General Surgery Unit 409-090

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staff, the more senior nurses were often highly critical and complained about them behind their backs. And many of the unit’s RNs including both new and more tenured nurses were frustrated with the PCAs and complained that they had inadequate training and skill sets.

And Barbara also discovered that her predecessor had not kept complete and accurate records of the staffs’ annual performance reviews. Barbara viewed regular informal check-ins and the more formal annual review as critical management tools. And she knew through her own personal experience how open communication and a transparent review system had contributed to her growth and development.

Barbara decided to run an off-site for her GSU staff. At the very least she hoped to provide a forum to begin discussion between members of the unit but her larger hope was that the off-site would inspire the beginning of a turn around for the unit.

The Off-Site

Barbara stood in front of her staff that were not on duty and thus able to attend the offsite. She asked each of them to take a pen and sheet of paper from the basket that was making its way around the room and to write, anonymously, the 2 to 3 things that most frustrated or bothered them about the unit. She then collected all the responses and read them one by one to the group.

Response after response identified lack of collaboration and teamwork, interpersonal and intergroup conflict, doctors who treated them like order takers rather than care givers, administrators who cared more about money than patient care, favoritism, dissatisfaction with staffing levels and performance review procedures… Barbara was blown away by the amount of negativity; she got more than she bargained for with this exercise.

After she had finished reading all the responses Barbara asked if anyone would like to comment or follow up. Her request was met with complete silence. She asked again this time becoming visibly flustered, but still there was no response and just as Barbara was about to ask again Megan Mahoney a recent nursing school graduate who had been on the unit for one year jumped to her feet and exclaimed, you people have no idea how mean you are!

During her month on the unit, Barbara observed Megan to be a very bright and affable nurse who cared deeply about her patients. And in turn Megan seemed to receive a lot of positive feedback from patients and their families.

Megan was upset with some of the senior nurses. I want to feel like I belong and am a member of the team, but I often get indirect negative messages and feedback from you. You make me feel like I am doing everything wrong but won’t address me directly or in a straightforward manner. Megan then shifted uncomfortably in place and her face flushed as she continued to speak. One night a few weeks ago, I overheard two of you talking about me at the desk. She paused and drew a deep breath. You said you were tired of me and all of my questions and called me a pest! Megan’s face fell with this last sentence; her eyes fixed on the floor.

Just then Jennifer Goodwin stood up. Jennifer had worked on the unit for ten years. Barbara had noted Jennifer’s strong skill set especially with new technologies and her wonderful bedside manner. Also, she was one of the few nurses who seemed to go out of her way to help others on the unit.

Jennifer said, I want feedback. It helps me to be a better nurse and to be a better co-worker, but the review process here is a mystery! As is the annual salary increase. I’ve heard that we all receive the same increase regardless of our performance. Is this true? If it is, I don’t think this is fair.

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409-090 Barbara Norris: Leading Change in the General Surgery Unit

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Jennifer also spoke about how she went above and beyond regarding continuing education requirements and made it a point to bring herself up to speed on all new technologies, although this often meant spending hours of her own time in classes and seminars. I do this because I want to, she said, but I have to admit there’s a part of me that is bothered that I do not receive any type of acknowledgment whether it be verbal or compensatory for my efforts.

Just as Jennifer sat down Louise Scribner moved to the center of the room. Louise had been with EMU for 30 years and worked in GSU for 23 of those 30 years. Barbara knew Louise delivered very good care to patients but noted she was resistant to change, quick to complain and could come across as abrasive to her co-workers.

Louise opened by remarking, sometimes I feel like I spend more time tending to machines than I do tending to patients. She then complained about the support asked for by the younger nurses and PCAs. I don’t have enough time to do my own job, she exclaimed. Everyday I have to make difficult decisions about what I cannot do for patients. I resent this because we have too few nurses in the ward and because some of that staff is inexperienced to boot, I am put in the position of having to pick and choose the care I can give. And after all isn’t that why we are all here? To take care of our patients?

Barbara had planned for this session to last for one hour but they were now passing the 1 ½ hour mark. She was trying to find a way to close the session using some kind of positive take-away. After Louise finished speaking, Barbara stood up and said okay, we have a good overview of our problems but can anyone offer any solutions?

Once again, there was an uncomfortable silence. In the room Barbara recalled how Betty involved the nurses in the trauma unit in decisions regarding staffing to great effect. Barbara said, I do, and smiled. What if, she started, when I’m going to decide on staffing for anything, I involve you? If you tell me, for example, “We need someone to process paperwork on Saturday afternoons,” I can immediately bring that back to a staff meeting and say this is what we have for full time equivalent (FTE). We can either hire a nurse or we can take some of that money and hire a secretarial assistant. What do you want to do? It’s your choice. This is how much money we have. We can take a little bit of the nursing FTE and we can hire a secretarial assistant but we’re going to lose a little nursing time but this is what we have to work with. And you can help me make the decision. I can do the same thing if we have to cut resources.

At the end of the day Barbara sat alone in the retreat center; everyone else had departed but she was using these last few moments to reflect on the day’s events. As she worked through the conversations and revelations, she began to make a list of items that most frustrated or de-motivated her staff:

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 job is becoming more administration centered rather 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 advocates on our behalf

Barbara knew she had to set realistic, attainable goals for each item on the list. Could she talk to

her director of nurses and seek a reprieve from the hiring freeze and get more staff for GSU? Would regular unit meetings build community and a healthier culture on the unit? She knew she could

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Barbara Norris: Leading Change in the General Surgery Unit 409-090

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institute a fair and transparent review process, but she might not have any influence regarding making annual salary increases commensurate with a review outcome. Perhaps there were other forms of acknowledgement she could employ? What should she tell her boss who was awaiting a status report?

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