Ch 20: Selecting, Developing, and Evaluating Staff
Book Reference:
Yoder-Wise, P. S., & Sportsman, S. (2023). Leading and managing in nursing (8th ed.). Elsevier.
Introduction
Nurse leaders are key individuals whose leadership can directly influence quality, safety, service, and satisfaction for patients and frontline nurses. Nurse leaders and managers are really the chief retention officers of a patient care area and have a huge impact on the environment for patient care. Nurse leaders and frontline nurses help shape the environment and learning milieu for new employees.
Nurses must clearly understand what is expected of their performance, including the ramifications of not meeting those expectations. This understanding can be achieved only when all members of the organization have clearly defined roles and overall objectives.
The ongoing development, mentoring, and coaching of staff is vital for a healthy and engaging work environment. Once nurse managers hire new frontline nurses, the ongoing support mentioned previously is essential. Think of a tree and how it needs ongoing care and feeding; you can’t just dig a hole and put the tree in the ground. Similarly, you can’t just hire and walk away from a new nurse who requires ongoing development, performance feedback, and coaching to reach optimal growth.
Roles in an organization
All individuals within an organization play a role. Every role requires an individual to assume the personal as well as the formal expectations of a specified position. Employees must have clear role expectations and perceive that their contributions are valued. Employees who understand their roles and are empowered to succeed in those roles have been noted to demonstrate increased personal health, job satisfaction, and individual performance. They are then more likely to be committed to the organization and to provide a higher level of patient care. These principles are applicable to leaders, managers, and followers.
Nursing program graduates enter the profession with various levels of educational and life experiences. The unit nurse leader plays an integral role in assisting these individuals in the development and acquisition of the complex role as professional nurse. Role development evolves over time and may occur numerous times in a nurse’s career. As an example, a registered nurse (RN) who is an expert medical-surgical nurse takes a new position in the operating room as a circulating RN; this is a new role for the nurse. Whenever such a change occurs, the nurse is likely to feel less confident and competent than before because, instead of typical functioning, the nurse is also focused on learning a new role. The Theory Box provides an overview on the complexity of taking on a new role.
Position descriptions provide written guidelines detailing the roles and responsibilities of a specific position within the organization. The position description reflects functions and requirements of specific roles in an institution. Box 20.1 demonstrates examples of expectations for a nurse in an ambulatory care environment.
Box 20.1
Excerpts from an Ambulatory Care Nurse Job Description
• Assesses comprehensive data, including physical, psychosocial, emotional, and spiritual needs of the patient.
• Involves patient, family, and healthcare team members in formulating a culturally appropriate plan of care.
• Implements plan of care in partnership with patient, family, and healthcare team.
Theory box
Theory/Contributor Key Ideas Application to Practice
Dynamics in Organizations
Kahn, Wolfe, Quinn, Snoek, & Rosenthal (1964) developed this theory. Roles within organizations affect an individual’s interactions with others.
Acquisition of these roles is time dependent and varies based on individual experiences and value systems. For effective communication to take place, role expectations for performance must be understood by all individuals involved. The role of the professional nurse is complex. Role acquisition, role clarity, and role performance are enhanced by the use of clear position descriptions and evaluation standards.
Adapted from Kahn, R. L., Wolfe, D. M., Quinn, R. P., Snoek, J. D., & Rosenthal, R. A. (1964). Occupational stress: Studies in role conflict and ambiguity. New York: Wiley.
Exercise 20.1
Obtain a position description for a registered nurse from an ambulatory care setting and a hospital. Compare them and analyze the general categories. Are specific behaviors outlined? What competencies are different? What competencies are similar?
The position description should reflect current practice guidelines and competency-based requirements. As nursing care models shift to the ambulatory setting, home, and community, nurses must have a clear understanding of the performance that is expected. The nurse is responsible for clearly understanding the roles of the patient care assistant to whom care is delegated. Clear and concise position descriptions for all employees provide the basis for roles in an organization.
Selection of staff
The selection of staff is one of the most important functions that nurse managers complete in their daily routines. Nurse managers want the most qualified individual for the position who also fits the culture of the patient care environment and organization. If an applicant values that the needs of the patient come first, and this value is also articulated via the organization, the individual has similar values. Nurse managers must decide whether frontline nurses will be included in the process and provide appropriate preparation for the interview team (Meyer, 2020). Frontline nurse involvement provides diversity in points of view, which can be valuable to a broad view of healthcare.
Some organizations use contracted services to shorten the interview time and provide a more relevant applicant pool; others manage the process as a totally internal process. Either way, candidates for a position are eventually interviewed at the unit level by the nurse manager or that person’s designee. Sometimes, a team of unit employees is involved, depending on the organization and availability.
A nurse manager and an applicant both must prepare for an interview to truly determine whether the individual is a good fit for the organization. The manager’s focus before and during the interview is to create questions that are well thought out. Identification of the attributes wanted in a frontline nurse can help guide the selection of interview questions. Interview questions should be directed to evaluate values and critical thinking skills. The phrase “the best predictor of future behavior is past behavior” is the premise on which behavioral interviewing is based. Behavioral interviewing requires applicants to provide an example of a situation that they experienced that highlights how they have dealt with a particular issue. An example of a behavioral interview question could be: Tell me about a time when you were working in a group and there were problems with other individuals who were not doing their fair share. What did you do to maintain a team environment? If the manager opted to include fronline nurses, they too can contribute questions and set expectations for what responses should address. Another strong question to ask can relate to the organization’s mission: Our mission is……; how does that relate to your personal values?
Interviews should be held in a private location where interruptions can be avoided. Providing applicants with information about the position through an e-mail and attaching a copy of the position description for the applicant to review before the interview can help shape the nature of the interview. Even during times of dire shortages, focusing on fit between the person and the organization is critical to prevent additional turnover.
Applicants appreciate the opportunity to tour the patient care area either before or after the actual interview. At the conclusion of the interview, the nurse manager should indicate when applicants will hear about their interview result, who will contact them, and how they will be notified. The shorter the response time, the more satisfying this is for the applicant. Applicants should be thanked for their time and interest in pursuing a position. Because people typically are on their best behavior during an interview, any concerns demonstrated during the entire interview process should be taken seriously. Those who are involved in interviews have the accountability for sharing such concerns and for answering questions applicants have in the most honest way possible.
Applicants also have responsibilities in the interview process. Applicants should arrive on time and alone and be appropriately dressed in business attire. They should be prepared to answer questions honestly and thoughtfully. The use of behavioral-based interviewing requires applicants to describe previous situations and how they were handled. They may also be asked to describe why they are interested in working in a specific work area. At the end of the interview, applicants should thank the nurse manager for the manager’s time and provide any specific follow-up information the manager has requested. A formal note of appreciation for the interview may be sent by the applicant afterward. The wise manager always does the same. With the predicted shortage of registered nurses, small gestures such as this help influence competitive offers.
Exercise 20.2
You are applying for a position as a primary care registered nurse in a community-based outpatient clinic in a rural community and are invited to an interview. Outline how you will prepare for this interview and what questions you will ask.
Developing staff
Once the interview and offer are completed and an applicant has accepted the position, strategies are implemented to help the individual acclimate to the organization and new role. Organizations use a variety of approaches, including orientation to the organization, the department, and role or new graduate residency programs that may provide ongoing support and education for up to a year. Residency programs in hospitals have increased in numbers over recent years and other organizations, such as those that are community based, have taken on the task of creating such programs, as the Research Perspective illustrates. General orientation to the organization is usually a structured program for every new employee. It typically includes the mission, vision, values, benefits, safety programs, and other specific topics for the day-to-day operation of the organization. The orientation period must be used efficiently to benefit both the employee and the organization. Whether during orientation or later, new nurses would be wise to identify role models and mentors to support their professional growth. This proactive approach helps link the individual with the person most likely to be influential on the person’s career.
Research perspective
Resource: Owings, C. R., & Gaskins, S. W. (2020). Evaluation of a community-based nurse residency. Journal for Nurses in Professional Development, 36(4), 185–190.
This article focuses on the evaluation of the impact of a nurse residency program in a community-based hospital. The study was done using a secondary data analysis and a sample size of 121 participants in a Vizient nurse residency program. All participants were new graduates with less than one year of nursing experience. Study participants completed the Casey-Fink survey online through the Vizient database. Findings indicated that participants in the nurse residency program in a community hospital felt supported, experienced lower personal stress levels, and had increased comfort in communication skills and leadership capacity. Participants in the nurse residency program turnover rate was half the turnover rate of nurses not in the residency program.
Implications for Practice
Nurse residency programs have the ability to positively impact the transition for a new graduate nurse in a community hospital setting. The ability to recruit and retain nurses in rural and community settings is an ongoing challenge. A nurse residency program can provide a mechanism to increase staff engagement and successful onboarding.
Retention of new nursing personnel begins on the day of their hire because costs for replacement and turnover can be substantial. Costs for turnover for a bedside RN range from $40,038 per year to $51,700 for a medical-surgical hospital RN in 2021 per Nursing Solutions Inc. (2021). These costs can vary tremendously based on amount of specialty training required, such as for critical care, emergency department, and labor and delivery, along with the availability of nurses at any given time. Factors related to turnover cost include human resource expenses, temporary replacement costs, lost productivity, training, relocation expenses, and terminal pay cuts. Although the cost of turnover may be calculated differently, the cost of replacement is high. Nurse managers and educators can play a pivotal role in ongoing development of staff. A watchful eye and recognition of talents displayed by nurses throughout their onboarding and ongoing employment can help retain nurses in an organization. As an example, a nurse educator may see that a direct care nurse is excellent at providing diabetic patient education in a primary care clinic. The nurse educator can recommend the idea of becoming a certified diabetic educator as a development goal.
Orientation is a time for new employees to learn the work environment and the staff. Many institutions use preceptors who are frontline nurses, because of their strength as role models, to help orient new staff. Bodine (2020) notes that the preceptor is an important integrating force for the new employee’s transition and can impact the organization’s retention rate. Despite the importance of preceptors in an effective orientation, preceptor preparation can be an ongoing challenge due to turnover and workload, as the Literature Perspective illustrates for one organization’s approach.
Preceptors work with orientees to complete a needs assessment to direct and guide the orientation of new employees in the clinical setting. An important first step is to determine how new employees like to learn. Various learning style assessment tools are available for preceptors to use. When preceptors understand the learning style of new employees, a better focus for implementation of orientation goals is provided. New employees work with preceptors who understand specifically how to address the individualized learning needs. As an example, orientees may learn best by observing a complex dressing change before actually performing it on a patient. Preceptor preparation is an important component of successful onboarding of new nurses. During times of high turnover and hiring in a work unit, nurses who have not been formally trained as a preceptor may need to step into the role. The Literature Perspective speaks to how one organization helped prepare staff nurses to precept in these types of situations.
Literature perspective
Resource: Bagioni, D., Lucas-Breda K., & Eichar, S. (2020). Enhancing preceptor preparation with the 5-minute preceptor. Nursing, 50(12), 15–17.
This publication focuses on the importance of preceptor education and specifically how to build critical thinking skills in newly hired frontline nurses. While most healthcare organizations have preceptor preparation programs, constant change in personnel occurs and not all preceptors have participated in these programs. A 5-Minute Preceptor (5MP) strategy was utilized. A five-step process was built to reflect a nursing-specific focus to provide education and feedback from preceptors. The 5MP process includes the following: take a stand (e.g., deciding what to do), probe for supporting evidence, teach general rules, reinforce the positive, and correct misinterpretations and errors. Nurse preceptors believed the process was something that could be used easily, deployed quickly, and was usable.
Implications for Practice
Nurse preceptors need tools that are simple and applicable to practice that focus on critical thinking for the frontline nurse. Although providing formal professional development for nurse preceptors is important, tools that can be easily deployed for less experienced and prepared preceptors will always be needed in the constantly changing healthcare environment.
Continued development of the staff is a distinct role for the nurse leader. Every member of the nursing team has ongoing needs for continued growth and development. Nurse leaders get to know their employees and what their interests and career goals are. Formal meetings and everyday interactions with frontline nurses help a nurse leader learn what is important to employees. Specific individual development plans can be determined for each employee. The ongoing competency and staff development is critical for the professional development of the staff member. Ongoing competencies are required for many critical components of the frontline staff nurse position, including Basic Cardiac Life Support, Advanced Cardiac Life Support, ECG interpretation, and more. Specific education related to life safety, such as active shooter drills, fire, tornado, and mass casualty events, are all required on a yearly basis. Additionally, specialty areas have expectations for maintaining competencies that contribute to safe, quality patient care.
Empowerment strategies are useful for individual professional development and overall development of staff. Empowerment is a process that acknowledges the values and judgment of individuals and trusts that their decisions will be the correct ones. For individuals to feel empowered, the environment must be open and people must feel safe to explore and develop their own potential. The organizational environment must encourage individuals to use the freedom of making decisions while retaining the accountability for the consequences of those decisions. Organizations with a strong investment in a professional practice development model are more likely to support the development of expert nurses who will impact expert nursing care and patient outcomes (Creta & Gross, 2020). Positive feedback, achievement recognition, and support for new ideas enhance employees’ feelings of empowerment and their ability to perform effectively. What is important to remember is this: empowerment is an internal sense. Nurse managers can create a climate in which others feel safe to speak up, but that doesn’t mean they will. Sometimes, as Brene Brown says in her classic work, we feel anxious about being vulnerable (Brown, 2015).
Exercise 20.3
Think about a nurse leader and a nurse manager whom you interact with on a regular basis. What are the similarities and differences in the nurse leader’s and nurse manager’s behaviors that support empowerment?
Performance appraisals
Feedback to employees regarding their performance is one of the strongest rewards an organization can provide. Performance appraisals are individual evaluations of work performance. Ideally, appraisals are conducted on an ongoing basis, not just at the conclusion of a predetermined period. Performance appraisals are generally done annually and also may be required after a scheduled orientation period for new employees. The intent of performance appraisals is to allow the individual to integrate comprehensive feedback to improve performance.
Performance appraisals can be formal or informal. An informal appraisal might be as simple as immediately praising the individual for performance recognized. A compliment from a family member or patient might be conveyed. Some work areas have a specific bulletin board for thank-you notes from patients and their families. Sometimes a simple “Thank you for all your hard work today!” can be extended from the nurse manager to the staff. The more specific the feedback can be, however, the more influential it is on reinforcing specific performances.
The formal performance appraisal involves written documentation according to specific organizational guidelines. The formal performance appraisal usually involves the use of a standard form or method developed by the organization to measure employee performance. Employees must have a clear understanding of their job description. Providing a new employee a position description is helpful because it can provide a basis for how the individual’s performance will be measured. The example in Box 20.2 contains an excerpt from a performance appraisal form in which a nurse manager can evaluate a frontline nurse related to health teaching and promotion.
Box 20.2
Performance Appraisal, Clinical Registered Nurse
Health Teaching and Health Promotion
____a. Uses teaching strategies appropriate to patient’s condition and learning needs.
____b. Uses health promotion to support patients and families in developing skills for self- management.
____c. Maintains a safe, clean, and organized environment for patients, families, and staff.
Performance Levels (Enter code in blank)
AE: Achieves expectations
NFD: Needs further development
UTA/NA: Unable to assess/not applicable
A performance appraisal is an opportunity for the employee and manager to have a dedicated time together to review how the employee is meeting the performance expectations outlined in the position description. It provides an opportunity to give the employee feedback related to not meeting, meeting, or exceeding expectations. Addressing strengths and areas for improvement related to the employee’s performance is important. Although the most improvement can occur with capitalizing on a person’s strengths, all expectations must be met at a satisfactory or better level.
If an employee is not meeting performance expectations, a performance improvement plan is put in place with specific, measurable, achievable goals outlined that is understood and articulated by both the manager and the employee. This allows each individual to understand one’s role expectations and the ramifications when not meeting performance goals.
Specific behaviors by the nurse manager enhance the actual appraisal process. Box 20.3 provides key behaviors for the performance appraisal session.
Box 20.3
Key Behaviors for the Performance Appraisal Session
• Provide a quiet, controlled environment, without interruptions.
• Maintain a relaxed but professional atmosphere.
• Put the employee at ease; the overall objective is for the best job to be done.
• Review specific examples for both positive and negative behavior.
• Allow the employee to express opinions, orally and in writing.
• Provide written future plans for learning needs and goals.
• Set follow-up dates as necessary to monitor improvements, if cited.
• Show the employee confidence in the employee’s performance.
• Be sincere and constructive in both praise and criticism.
Ongoing feedback is essential between the nurse manager and employees. An employee’s regular performance appraisal should never be the first time a concern is identified. Feedback is best given as soon as a positive or negative occurrence with the employee happens. For example, if a frontline nurse demonstrates inappropriate behavior at a patient care area staff meeting, the manager should provide feedback about the behavior as soon as possible after that meeting.
Performance appraisals may include self and peer evaluations as well as managerial components. In sophisticated units, a 360 evaluation may be made. This means that peers, subordinates, and unit nurse leaders all provide input so that an individual nurse has a full performance perspective. An advantage for an individual is seeing where relationships need to be strengthened; an advantage for a manager is being able to speak from a broad perspective about performance.
A critical part of the performance appraisal is the development of goals and career development for the upcoming year. The employee should come to the appraisal prepared to discuss goals to accomplish over the next year. Examples of goals that may be put into an individual nurse’s appraisal are noted in Box 20.4.
Box 20.4
Performance Appraisal Goal and Accomplishment Examples
Examples of Goals
1. Obtain specialty certification as a Critical Care Registered Nurse (CCRN) from the American Association of Critical-Care Nurses by the end of next January.
2. Participate in shared governance committee as unit representative next year.
Accomplishments (12 Months Later Summary)
1. Successful completion of CCRN examination (see documentation submitted).
2. Participated in every unit council meeting (see attendance records for the unit council meeting) and chaired the documentation task force of the shared governance committee (see email asking me to chair this committee).
Coaching
The overall evaluative process can be enhanced if the manager uses the technique of coaching. Coaching is the process that involves the development of individuals within an organization. This coaching process is a personal approach in which the manager and the employee interact on a frequent and regular basis with the ultimate outcome that the employee performs at an optimal level. Coaching can be by an individual or may involve a team approach (Fig. 20.1). When implemented in a planned and organized manner, coaching can promote team building and optimal performance of employees. Coaching is a learned behavior for the nurse manager, which takes time and effort to be developed. Hancock and Meadows (2020) note that coaching provides the employee with ideas, support, and inspiration. The rewards for both the employee and the nurse leader are significant. Coaching involves asking questions, supporting forward movement and general guidance, rather than telling someone what to do. Coaching generally takes more time and has longer lasting effects.
FIG. 20.1 Coaching can promote team building and optimal performance of the employees. (Copyright © Photodisc/iStock/Thinkstock.)
Conclusion
Selecting new members of a team is critical to success for both the frontline nurse and the nurse manager. Nurse managers and their teams know their individual patient care areas best and are critical to the interview and orientation process. Selecting the right individual for the right reasons is key to successfully achieving positive outcomes for the individual, patient, and organization. Making certain that new employees are oriented in a comprehensive manner and providing ongoing feedback—including a regular, formal evaluation—helps people grow in their own right and contribute more effectively to the mission of the organization.
The solution
Jolene Piper
My experiences as leader of a unit council on an inpatient medical surgical unit early in my career sparked my interest in change management, leadership, and engagement. A primary care unit council existed but it needed to be reenergized. I wanted a primary care unit council to be something staff wanted to be a part of. As the nurse manager, I wanted a group I could lean into to help me implement change. The unit council could help me identify gaps and support change management from a peer-to-peer model rather than a top-down implementation approach.
I was enthusiastic about developing this unit council and getting new members rotated in immediately. Developing nurses as a group is an important part of the development process.
First, the team decided to change the structure of the council to have co-leaders. Having an LPN and RN co-leading the group together was essential to support change. Traditionally, this council leadership role was only for RNs on the committee.
Reenergizing the committee didn’t happen overnight. When issues or concerns were brought up, such as requesting a change in a workflow or process, the unit council was my first consideration for seeking feedback or input on the matter. It became a standing agenda item every month at staff meetings to highlight what things are being covered by the unit council. We shared the council meeting minutes with all staff, and a member of the council usually had a moment to talk or answer questions from the broader group. These actions allowed the staff to see that they had a voice and an impact on decisions.
During a difficult Minnesota winter, several clinic days were impacted due to weather, and we were faced with suddenly opening Saturday clinics for patient access. Very few individuals were volunteering to work on these Saturdays. Patient needs had to be be met; thus, a system to choose people to staff Saturday clinics had to be developed. Immediately, I engaged the unit council to discuss, brainstorm, analyze, and implement the plan for staffing. These were the subtle but important ways staff could be involved. Yes, staffing Saturday clinics was a temporary and unpopular project. However, staff representatives, through the primary care unit council, could choose how the staffing process was created, tracked, and implemented. The unit council and staff were able to establish parameters around how the process would be done. The patient needs were able to be met and clinic access was achieved. Working in shared leadership improves satisfaction, drives excellence, and cultivates leaders, who perhaps didn’t know they had it in them or even wanted to be a part of it.
Would this be a suitable approach for you? Why?
Reflection
Have you gained a new perspective on the role of the nurse leader or manager while reading this chapter? Explain how you gained appreciation for how the nurse leader affects the environment in a patient care area. How would you help someone develop in that person’s role if you were in charge of a unit?
Best practices
Nurse leaders are pivotal in implementing positive work environments. Nurse leaders who provide a high frontline nurse engagement, robust orientation and professional development programs, and coaching are important to nurse recruitment and retention. Engaged frontline nurses lead to better patient outcomes and satisfaction.
Tips for selecting, developing, and evaluating staff
• Value the role of the nurse leader in recruitment and retention of frontline nurses.
• Articulate the importance of the preceptor in influencing new orientees in their intention to stay at an organization.
• Identify how the new frontline nurse joining an organization can set goals for professional development in the first year.
• Expect that nurse leader ongoing feedback and coaching contributes to the success of an individual nurse and the organization.