A core responsibility of the nurse manager is staff development and coaching. Unfortunately, managers anecdotally report spending the majority of their coaching time with low performers when they could be accomplishing more if they nurture and grow the middle and high performers. Evidence-based research by the Studer Group has shown that in most organizations, 34% of staff members are high performers, 58% are middle, and 8% are low. Ideally, nurse managers could shift the majority of time spent on the fewest people (low performers) to make better use of their coaching time.1 Development and accountability conversations can be difficult, emotionally charged, and time-consuming. Nurse managers aren't routinely taught an effective, simple process to guide these important but complicated conversations. This case study asserts that through the use of an efficient communication process during conversations with low performers, nurse managers can become more effective leaders.
Although accountability conversation techniques are uncommon, every RN is well versed in The 5 Rights of Medication Administration.2 This medication safety concept is central in the nursing curriculum from a nursing student's first class to the last, and consists of right patient, right medication, right dose, right route, and right time. This same concept is repeated through nursing orientation and reinforced as nurses mature in their practice. Through consistent repetition over time and broad recognition that all five elements must be present to prevent medication errors, this conceptual structure is core to nursing. By applying The 5 Rights in a new context—staff development conversations—nurse managers can more effectively and efficiently coach low-performing nurses up or out.
What makes a team healthy?
This innovative communication tool can be used to empower nurse managers in their efforts toward healthier, more productive teamwork in hospital inpatient units. (See Figure 1.) The 5 Rights of a Healthy Team enables nurse managers to depersonalize tough conversations, create a nonjudgmental context, and provide structure for resolution-focused feedback. This communication tool has been utilized across 11 inpatient medical & surgical units within a large, Magnet®-recognized, 750-bed hospital. The associate director for nursing practice and nurse managers employed this tool across dozens of staff development conversations and reported increased efficiency of communication, increased empowerment of staff, and increased staff satisfaction as measured by Morehead/Press Ganey staff engagement surveys.
Early positive impact warrants additional use and study. Increasingly, nursing science research indicates that empowerment of clinical nurses and nurse managers positively correlates with patient satisfaction. The gold standard of nursing quality—Magnet recognition—incorporates nurse empowerment as a proven strategy for improving outcomes in nurse staffing and clinical quality.3 According to Laschinger, Wong, and Grau, “Employee empowerment is a fundamental component of healthy work environments that promote nurse health and retention, and nursing leadership is key to creating these environments.”4 The American Association of Critical-Care Nurses identifies authentic leadership as one of the six standards imperative to achieve a healthy work environment.5 Further, Institute of Medicine reports specifically highlight the salient role of transformational leadership and emphasize that strong nursing leadership is necessary to implement effective management practices that create cultures of safety.6,7
Origins of The 5 Rights
The concept of The 5 Rights of a Healthy Team was developed in 2008 by this author while serving as nurse manager of an 11-bed, 45 full-time equivalents bone marrow transplant unit at the University of Rochester Medical Center Strong Memorial Hospital. At that time, the team had three nurses with distinct performance issues. The first nurse, A, was a team leader with decades of experience. There were performance issues, however, and staff members lacked trust in A. The second nurse, B, was new to nursing. Although she was performing clinically according to expectations, her stress level was consistently, visibly high and out of character. C, the third nurse, also had decades of experience but was stuck in a communication rut despite receiving consistent feedback across multiple evaluations regarding the need to improve her communication skills.
Individual coaching conversations between these nurses and the new nurse manager were time-consuming and didn't lead to clear improvements. As a new nurse manager, this author experienced significant stress caused by recognizing the issues, investing in coaching unsuccessfully, and lacking a clear path forward. It was challenging to deliver direct feedback without pushing the nurses toward feelings of personal failure. The three nurses felt judged and frustrated. In an attempt to shift this dynamic, the new manager stepped back from the individual issues and sought a strategy for coaching and empowering nurses. From that shift in perspective and the resulting search for a cohesive strategy, the idea of The 5 Rights of a Healthy Team crystallized.
Tackling trouble zones
The new nurse manager applied The 5 Rights thinking to the situations with A, B, and C. In exploratory conversations with each RN, she verbalized this structure and asked probing questions. In those first three conversations using The 5 Rights of a Healthy Team, epiphanies quickly rose to the surface.
* A had a role issue. She was a strong clinical nurse and dedicated to the unit, but was pressured by personnel responsibilities. Team leadership wasn't the right role for her. Ultimately, she voluntarily surrendered the leadership role and instead continued serving successfully as a clinical nurse on the unit.
* B had a place issue. By talking through The 5 Rights of a Healthy Team, it came to light that she believed if she wasn't successful on the bone marrow transplant unit, she couldn't be successful as a nurse anywhere. That misguided belief was addressed and B was encouraged to explore where she felt called to serve. She felt magnetized toward labor and delivery nursing. She made a smooth transition to the maternity team and continues to serve as an exceptional nurse there.
* C had a tools issue. She had received the same feedback across multiple evaluations—improve your communication skills—but she hadn't been provided with the tools to develop that nebulous, subjectively measured skill. To address this, C was provided work time to participate in communication classes, supplied with books about communication, and scheduled for ongoing coaching to ensure that she could translate her learning into practice.
Two remarkable moments occurred after having these transformational conversations that each promptly yielded significant shifts toward improvement. First, the manager's stress was replaced by hopeful rejuvenation because the structure of The 5 Rights served as a springboard. The conversations were quicker and more effective, which provided relief for the nurse manager. Second, by using a concrete structure that wasn't personal, the nurses were able to view the performance gaps not as personal shortcomings but as disconnects that were repairable. The 5 Rights structure depersonalized the issues and enabled focus on necessary changes. The nurses left the conversations feeling empowered instead of judged. By naming the gap as an area of The 5 Rights of a Healthy Team, they could envision a correction that enabled them to be successful in nursing. Research has shown that structural empowerment of nurses has been inversely related to anticipated turnover; more empowerment leads to lower anticipated turnover scores.8
Value of the tenets
The communication process is effective for a variety of conversations: staff development, individual coaching, accountability, disciplinary action, hiring, or terminating to name a few. The broad applicability stems from overlaying the same five tenets to each situation and from communicating The 5 Rights framework frequently and visibly to the entire staff. To most effectively leverage this tool, nurse managers need to promote this model as part of the vision for the unit's success as a healthy work environment. All team members need to be familiar with the model to create consensus that healthy teamwork is a shared goal. Then, when a difficult conversation regarding low performance is necessary, the conversation begins with agreement and enables efficient identification of which element is broken or lacking. To illustrate, a nurse manager initiates the discussion with this potential script:
“As a team, we agree that creating a healthy work environment is an important goal, correct? And as we've discussed before, The 5 Rights of a Healthy Team helps us accomplish that. Having the right person, in the right place, in the right role, at the right time, supported by the right tools is best for the individual and the group. I need to share with you my conviction that we have disconnects in these roles. You were recently promoted to a higher level of responsibility, but, since then, I've become aware of several examples of poor communication with your teammates. Perhaps the role isn't appropriate...”
The rights defined
Utilizing person as the first of the five tenets is purposefully validating and empowering. The person tenet serves as the “centering stake in the ground.” In other words, a problem of the person is rare. Starting the conversation by acknowledging the value and worth of the person serves to honor the individual and begin with a positive connection. The nurse is more likely to leave the conversation feeling whole, with the supervisor validating his or her ability to be successful as a person and nurse, maintaining self-respect and self-worth. This process reflects self-determination theory, which recognizes the importance of the individual's inner resources for personality development and behavioral self-regulation.9 To encourage people toward their highest potential, leaders can leverage themes of innate competence, autonomy, and relatedness.9
More commonly, performance gaps can be linked to the place, role, time, or tool tenets. By addressing disconnects of place, nurses can change where they work within the organization to become more productive. The organization benefits through nurse retention and the staff member benefits when his or her work is aligned with professional goals and abilities. Through early identification, this can save the organization from costly turnover. Or, if a disconnect of place is identified relative to the organization's core values, resolution through termination may be appropriate.
The same is true of finding the right fit for role and time. Examples of disconnects in role or time might include a nurse seeking promotion prematurely or experiencing burnout that requires a change of role to heal. Time issues can also arise when an employee's personal situation is affected by a death, divorce, or other challenge with significant stress negatively affecting his or her work.
The last tenet—being supported by the right tools—imparts symbiotic responsibility on the leadership team, organization, and team member. Just as the first tenet of person provides connective value, the tools tenet anchors the process with supportive engagement toward improvement. Strong healthcare organizations provide the supportive processes, structures, training, coaching, and education that nurses need to perform optimally. This shared involvement reflects empowerment and synergy. Nurses are less likely to leave if they're members of patient care teams in which nurses engage in synergistic communication.10 (See Table 1.)
Utilizing the structure of The 5 Rights enables leaders to depersonalize tough conversations, establish a context that's concrete yet nonjudgmental, and provide structure for feedback that could be perceived as subjective. Its use keeps conversations focused and illuminates options for resolution.
Empowering managers and staff
The 5 Rights of a Healthy Team tool has been used in dozens of conversations since its inception at the University of Rochester Medical Center Strong Memorial Hospital's adult medical & surgical nursing service. Overall, positive accomplishments partially attributable to nurse leadership were gained for the whole hospital, as well as the adult medical & surgical nursing service, with a 15% increase in staff member satisfaction from 2009 to 2012.
As a single case study, generalizability is limited. Further investigation is required to validate that this communication tool for frontline nurse managers correlates with measurable satisfaction improvements for staff members, nurse managers, and patients. Additionally, verification is required to determine applicability across clinical settings.
The frontline nurse manager role is challenging and not for the faint of heart. Nurses are faced with grueling 24/7/365 schedules, intense change, ever-increasing demands for improvement, and the pressure of demonstrating excellent teamwork and strong communication in life or death situations. In light of these traits, characteristics, and environmental factors, holding nursing team members accountable while simultaneously creating a culture of empowerment is incredibly complex. Utilizing a simple communication tool—The 5 Rights of a Healthy Team—is pivotal in enabling nurse managers to effectively and efficiently hold staff members accountable while supporting staff development and empowerment.