A nurse manager comes into your office and says, "Mary Lou just doesn't seem to get it. She makes mistakes and when I talk to her about it she gets really defensive. You need to provide some education for her." Is Mary Lou's performance issue really about lack of skills or knowledge? Or could it be something else entirely?
Staff development specialists (SDS) are often asked to provide education when nurse managers identify individuals or groups of employees who are not meeting performance expectations. Although lack of skill or knowledge can be the cause of under-performance, there are other causes that should be considered.
Because SDS' are neither staff nor management, they can engender trust among the staff and are in a unique position to investigate the root cause of performance gaps. This article provides SDS' with tools to:
- Diagnose common causes of performance gaps
- Formulate a plan to address specific performance problems
- Identify metrics to evaluate the effectiveness of interventions
Don't all nurses want to do a great job? Of course! So, if they are not doing a great job they must need more education, right? Not necessarily, although education is often the "go to" tool in management's tool box. And when performance does not improve, SDS' are just asked to provide more education. This cycle can continue indefinitely if we don't step back and really look at the cause of the performance gap.
The Human Performance Technology model
Human Performance Technology (HPT) is "a systematic approach to improving productivity and competence, through a process of analysis, intervention selection and design, development, implementation, and evaluation designed to influence human behavior and accomplishment" (International Society for Performance Improvement, 2000). The goal is to identify and develop a set of interventions that solve or mitigate barriers to performance. HPT grew out of the instructional design field and is a valuable tool for SDS' in analyzing performance gaps and developing appropriate interventions.
Performance gaps
A performance gap is the difference between what someone is actually doing (or not doing) and what they should be doing. The first step in correcting a performance gap is to understand what the difference is between the behavior being exhibited and what the expectations are. The importance of the gap should be considered next. What will happen if corrective action is not taken? If you do decide to intervene, can a worthwhile result be expected? If inaction will result in patient harm, then of course performance must improve. However, in some cases, the payoff for intervening is negligible and therefore not worth the effort.
Cause analysis
Once it is determined a significant performance gap exists, SDS' can assist nurse managers in determining the cause of that gap to develop the most appropriate intervention. The first step in analyzing the cause of performance gaps is gathering information through interviews of key stakeholders (see the list of questions at the end of this article). There are three primary causes of performance gaps:
- Lack of knowledge or skills
- Lack of motivation, and
- Organizational or system barriers
If nurses have never performed the skill or task expected of them, then formal training is an appropriate intervention. When a knowledge deficit exists, instructor-led classroom training, computer?based programs, or a blended learning approach can be used. If manual skills are required, then use of skills labs or simulators may be effective.
If nurses have been provided the knowledge and performed the skill before, but the opportunity to perform is presented infrequently, a different type of education is required. This may take the form of "just in time" tools such as posters or guidelines outlining the critical steps in performing the skill. Brief in-services, videos, or DVDs available on the unit may also be effective in providing on the spot refreshers. Electronic media, such as PDAs and online resources, are also becoming popular means of ensuring up to date information is available at the bedside.
If nurses possess adequate knowledge and skill, then motivation to perform must be considered. Do nurses perceive some kind of punishment for a job well done? For example, highly skilled and organized nurses may always be asked to take extra admissions or the most acutely ill patients on the unit, leaving the impression that they are working harder than others. The solution in this case is to distribute assignments equally among all staff. A lack of positive feedback for their extra efforts can also lead to a lack of motivation to continue doing a good job.
Acknowledgement of their performance with a simple thank you may be all that is required.
In some cases, non-performance is inadvertently rewarded. For example, nurses who lack organizational skills may not be asked to take extra admissions or be expected to provide assistance to team members. Nurses may get personal satisfaction from their poor performance, perceiving that they don't have to work as hard as others. When it is perceived that non-performance results in a positive or desired outcome, this perception must be removed. Consistent standards of performance must be expected of all staff. When non-performing nurses adhere to expectations, then their behavior must be reinforced with positive consequences.
When we permit poor performance, we promote its continuance. Therefore, positive consequences should increase when nurses meet performance expectations. Conversely, appropriate consequences for non-performance must be consistently enforced.
The third common cause of performance gaps are system-related issues. First, do nurses know what is expected of them? Ensuring that performance standards exist, are clear and complete, and that they are readily available to staff is essential. Of course, nurses must have read the standards and understand them.
Lack of available resources may also result in suboptimal performance. It is difficult for nurses to meet performance standards if the tools they need are not available. Ensuring that staff, in adequate numbers, with the appropriate skill mix are available to meet the acuity needs of patients is essential. Inadequate supplies may also present an obstacle to good performance. Checking par levels and ordering procedures will ensure availability of adequate supplies to get the job done correctly. Equipment that is in proper working order and conveniently located on the unit will also enhance desired performance.
Selecting the appropriate intervention
Before implementing an intervention, it is important to consider other factors such as quality or regulatory standards, time, and finances. SDS' can work with nurse managers to develop criteria based on these factors and select the intervention that best fit those criteria and the goal of improving performance. It will be important to gain commitment from all key stakeholders—nurse managers, staff, and other ancillary departments involved—prior to implementing interventions.
Measuring success
Measures of success must be determined prior to implementing any performance improvement interventions. The change in behavior must be clearly stated and understood by both managers and staff nurses. Deadlines for improvement must be identified and adhered to. Other key metrics may include a reduction in errors or injuries and increased satisfaction scores from patients, staff, and physicians.
If performance does not improve, other factors may be involved. For example, nurses may be in the wrong role, e.g., they are just not cut out for critical care. Perhaps the nurse is in the wrong area of specialty and transfer to another unit can be considered. E.g., labor and delivery may be a better fit for the nurse's skills in communication and compassion. It's also worth asking whether the nurse's professional goals are congruent with the goals of the organization, Perhaps another organization or setting would better meet his or her professional needs.
Summary
There are many reasons that nurses do not perform as expected. The Human Performance Technology model can be a useful tool for SDS' in leveraging their role in the identification of performance gaps and appropriate interventions. The unique position of SDS' as neither staff nor management engenders trust between them and staff nurses. By strengthening relationships with nurse managers, they can play an integral role in improvement of staff performance.
Questions to ask a staff member:
- Can you explain what is expected of you?
- Have you been given a job description?
- How do you find out what is expected of you?
- How do you know when you are meeting job expectations?
- Do you get feedback? How often? From whom?
- Do you have all the equipment or supplies you need to do your work?
- Have you requested material and supplies that you have not received?
- What happens if you do an outstanding job on a particular day?
- Does the structure or culture of the organization help or hinder your work?
- How effectively are the goals and strategies of the organization communicated to you?
- What about changes in practice? Tools?
- Are you getting enough help and guidance?
- Do you know how to do _________? Was this covered in your orientation?
- Has the employee received adequate training to perform this task?
Questions to ask a manager:
- Has the employee ever performed this task satisfactorily?
- How often is the task performed?
- Does the employee experience something undesirable when he or she performs this task?
- Is there something about performing the task that is perceived to be punishment?
- Does the employee get some sort of pay-off for not doing what is expected?
- Does the employee get prestige, status, or other self-gratification for poor performance?
- Are written standards available?
- Are written standards complete?
- Are written standards clear?
- Have the standards been read?
- Are the working conditions suboptimal?
- Does the organizational culture support the desired behavior?
- Are supplies adequate?
- Do the given tools fit the job?
References
Human Performance Technology Central. (n.d.) Available from www.humanperformancetechnology.org/hptmodels.html.
Wilmoth, F., Prigmore, P., & Bray, M. (2002). "HPT models: An overview of the major models in the field." Available from www.humanperformancetechnology.org/Models%20hpt1.pdf.
Stolovitch, H. D., Keeps, E. J., & Finnegan, G. (2000). Handbook of Human Performance Technology: Improving Individual and Oganizational Performance Worldwide (second edition). Hoboken, NY: Wiley Periodicals, Inc.
Fournies, F. (1999). Why Employees Don't Do What They Supposed to Do and What to Do About It. New York: McGraw-Hill.
Barbara Mayer, RN-BC, MS, PhD(c), is director of professional nursing practice at St. Vincent Medical Center in Los Angeles.