Confronting Performance Problems - Emerging Nurse Leader

By Rose O. Sherman, EdD, RN, FAAN

I was discussing the challenges of being a nurse leader in today’s environment in a conference presentation. A leader in the audience told me that one of her great challenges was confronting performance problems, especially those involving customer service. “I just expect because my staff are all professionals that they will come to work, do their jobs and be courteous to patients and families. But this does not always happen and sometimes I am surprised about the behavior of some staff toward patients and families. Yet, I am so busy that I don’t always deal with performance issues in a timely manner and they go unaddressed.” This leader is not alone in her failure to deal with performance problems in a timely manner. I have learned from my research that nurse managers today supervise an average of 65 FTE. Meeting the needs of this many staff can be quite challenging but add performance issues to the mix and leaders can easily feel overwhelmed.

Why Dealing with Performance Problems Matters

Over time, performance problems rarely will go away on their own especially those that involve behavior. Most nurse leaders don’t have problems addressing performance issues when it involves technical skills, role responsibilities and meeting goals. But as in the case described by the manager above, when the problem involves tone of voice, approach, interpersonal skills or motivation, leaders are often more uncomfortable broaching the topic especially with their experienced staff. There are several good reasons why nurse leaders should make this a priority. The first is that other staff do watch how you manage performance problems. If you are lax in what you expect from staff with respect to customer service then this lack of concern can become part of the unit culture. A second good reason is that with reimbursement now clearly tied to customer service and HCAHPS scores, a lack of courteousness or a negative attitude by a staff member could cost the organization both money and customer loyalty.

A Better Approach

Coaching and staff development is a key part of the nurse leader role. Every staff member has strengths and weaknesses. Poor customer service or a negative attitude can ultimately derail an employee’s career if it is not confronted. These discussions are never easy especially if the staff member is not in touch with how others perceive them. The following are some helpful steps in the process:

1. Prepare for the discussion by gathering information and outlining what you want to say. If it is a serious issue, you may want to have an HR representative present. If your hospital is unionized, the staff member may be entitled to have a union representative present.

2. Select a time for discussion when the incident you will be discussing is still fresh in the mind of the staff member. Arrange the meeting in a private place

3. Clearly explain the performance issue – using very specific examples. Some good tools include:

SBR (Situation, Behavior, and Result): “On your rounds this morning, Mrs Jones asked you a question about her husband. You told her that you were too busy and she needed to ask the doctor. She became very upset and called the patient advocate to complain about your rudeness.”
BFE (Behavior, Feeling, and Effect): “When you become angry at the ED staff for calling to admit a patient at a time not convient for you, you convey an attitude that is not patient-centered. That sets a poor example for the rest of the team.”

4. Ask for reasons and listen.

You may be very angry when you hear about discourteous behavior. It is important to show restraint as you begin your conversation. A good question to ask is “So help me understand how this could happen?” The key here is to really listen for facts and feelings. You staff member may have a legitimate reason for a behavior from their perspective. You may not agree. Avoid allowing sidebar distractions such as “I am not the only one on this unit with this problem.” If this happens, let the staff member know that their behavior is the focus of the discussion. Understanding the real underlying causes will help you to move to the next step.

5. Work jointly on a solution.

Staff need to know that you have confidence in their ability to improve and want to work collaboratively on solving the problem. Elicit their ideas and suggestions about how they could handle situations like these more effectively in the future. Give your ideas and suggestions. Let them know that the behavior is not acceptable and their performance needs to improve.

6. Seek and commitment and arrange for a follow-up discussion.

Depending on the nature of the problem, a performance action plan may or may not be needed but it is important to set goals. Set a time for followup and reiterate the importance of behavioral improvement. Often, more than one follow-up session may be needed. During these sessions, you will want to discuss improvements that you observe or any additional performance issues that need to be addressed.

Performance discussions like all crucial conversations are rarely easy to conduct which is why they are frequently avoided until situations spiral out of control. When possible, don’t allow yourself to get drawn into one of these conversations on the spur of the moment. The key to success in these conversations involves careful planning of how the discussion will be conducted, what you intend to say and what you hope as an outcome. Writing down some key points can be helpful to keep you on track. Some seasoned nurse leaders use their colleagues as sounding boards to practice how they will conduct conversations where they expect considerable push-back from the staff member involved. For beginning nurse leaders, conversations about tough performance issues can be especially difficult and sometimes personally painful. Over time, leaders begin to realize that these conversations are necessary with staff to help them learn and grow.

Read to Lead

McCarthy, D. (April 2nd, 2013 Blog) How to Confront an Employee Performance Problem.

Patterson, K., Grenny, J., McMillan, R. & Switzler, A. (2012). Crucial Conversations: Tools for Talking when the Stakes are High. New York: McGraw-Hill.