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Nurse managers continue to struggle with one of the most elusive areas of their responsibilities, staff evaluations. But some nurse educators say they are coming closer to a solution that may also bode well for lowering high turnover and improving job satisfaction in the ICU.
"There isn’t a nurse manager in the country who likes to do performance evaluations. It’s very hard for people to give accurate assessments, especially in a busy environment like the ICU," says Colleen M. O’Brien, RN, a nurse educator with the cardiac care center at Bellin Hospital in Green Bay, WI.
Traditionally, hospitals have not done a good job of defining sound objective measures of individual job performance. And the problem has been particularly acute in the ICU, where nurses are expected to work as a closely knit team despite high staff turnover, which has repeatedly undermined efforts to maintain performance goals.
The problem isn’t due to a lack of objective measures. "If [a behavior exists], it can be measured," says O’Brien, who works in a large, 14-bed cardiac critical care unit staffed by 45 nurses and 20 technicians. The challenge is to develop a dependable tool that can accurately measure your staff’s performance.
ICUs are uniquely different from other patient-care departments due to the highly charged emotional air and life-or-death patient acuity levels that consistently affect both patients and the clinical staff. Nurse burnout is a constant problem.
So it isn’t surprising that administrators are under intense pressure to evaluate their nurses objectively while not alienating and, possibly, accelerating an individual’s decline, says Neva Rogers, MSN, MBA, a performance appraisal expert with Development Dimensions Inter-national (DDI), a global human resources consulting firm based in Bridgeville, PA.
Earlier this year, clinicians at Bellin Hospital instituted a formal evaluation program targeted at new nursing hires to help them adapt to the demands of their departments. The program affects all departments throughout the facility. (Editor’s note: Critical Care Management will revisit Bellin in six months to assess the results of its assessment program.)
The tool, which the hospital is using with new hires, can easily be adapted for annual performance reviews because most of the elements apply or can be modified for use with veteran staff, O’Brien says. And if properly executed, the approach can serve as an opportunity for improving on-the-job performance and morale. Here’s how it works:
• Tool offers specific details for assessment.
The tool employs a customized evaluation instrument called "The Maximizing Performance Tool" adapted to Bellin’s needs from concepts produced by DDI.
The approach emphasizes evaluating personnel in several key performance areas, which are broken down to specific skills or duties such as hemodynamic monitoring or timeliness of making rounds rather than in broad strokes.
But unlike many appraisals, the evaluation is conducted periodically rather than at the end of a review period. Instead of a cumulative evaluation, employees get micro-assessments each week, month, or quarter. Management determines the time interval for each assessment. The smaller the interval, the more data there are available for the review.
• Data on specific performance categories are formally recorded and kept.
The information is recorded at regular intervals on a progress form and kept by a charge nurse, or someone working close to the subject. At Bellin, the individual responsible is called a preceptor. The form allows the preceptor to document daily or weekly anecdotal observations. (See a sample copy of this form, inserted in this issue.) The unit also uses a set of clinical pathways that chart the progress of each nurse over a 12-week period that isn’t integral in appraising veteran nurses.
• The performance ratings are nonthreatening and nonjudgmental.
A key component of the system uses a nonthreatening, nonjudgmental, and nonquantitative set of values represented in letter-grade ratings to measure performance. In contrast to using numerical values such a 1 for excellent and 2 for good, the letter-grade approach encourages improvement while it assesses competency levels without risk of bias, O’Brien says. Therefore, the letter grades go as follows: E — Exceeds (instead of excellent), M — Meets, P — Progressing, and NI — Needs Improvement.
• Letter-grade method focuses on intangibles.
Another key to the appraisal tool emphasizes performance areas that usually defy measurable evaluation. These are employee characteristics that O’Brien calls "soft skills," which are extremely important in critical care but are frequently overlooked or downplayed by appraisers because they are so difficult to assess.
Soft skills are more or less important in other inpatient departments, but they are essential to a smooth-running ICU, Rogers observes. They include people skills such as the level of commitment to a job, critical thinking skills, customer service orientation, integrity, and trust.
On the progress form, the preceptor places a letter grade in each box for each soft skill being evaluated during the appraisal period. For example, if the nurse meets the ICU’s standards for decisiveness or teamwork, the preceptor is likely to place a letter M in the corresponding boxes on the progress form. Implied in the grade in each case is whether in the preceptor’s view the subject met the standard more than 50% of the time, says Rogers.
• Technical skills are identified as specific objective.
Technical competency is usually easier to recognize than soft skills, says O’Brien. A nurse either meets ACLS (advanced life cardiac support) standards or does not. A checklist that covers most of the ICU’s technical requirements forms part of the evaluation process. But the challenge lies in accurately assessing how well those technical skills are displayed on the job.
Again, to a great extent the evaluation is subjective. But nevertheless, preceptors can play a big role in observing a nurse and offering constructive criticism in discreet terms. "You did this task very well," a preceptor would say during a feedback discussion, says Roger, "but how would you do it better?"
Davis advises managers to think in terms of "critical success factors." These are specific areas in which the nurse must perform well in order to succeed as a team member. These include: clinical competence, customer service, cost consciousness, teamwork, and professionalism, using the letter-grade and anecdotal assessment tool.
Equally important for managers is to "quantify the variables." This means placing the assessed behavior in a particular time frame. Doing so enables you to compare time periods and observe improvements. It also permits managers to assess the validity of their own expectations.
"If most of your nurses come in too low in your expectations range, maybe you need to lower the bar slightly," Rogers concludes. n
• Colleen M. O’Brien, RN, Nurse Educator, Cardiac Care Center, Bellin Hospital, 744 S. Webster Ave., Green Bay, WI 54305-3400. Telephone: (920) 433-3500. Fax: (920) 433-3452. E-mail: firstname.lastname@example.org.
• Neva Rogers, MSN, MBA, National Accounts Manager for Health Care, Development Dimensions International, 1225 Washington Pike, Bridgeville, PA 15017-2838. E-mail: www.ddiworld.com.