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Cultivating a high-performing team

Zwillinger, Elizabeth BA, AS, RN, CMSRN; Huster, Tammy MAS, BSN, RN, CMSRN, NE-BC

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Nursing Management (Springhouse): December 2017 - Volume 48 - Issue 12 - p 26-34
doi: 10.1097/01.NUMA.0000526911.54593.96
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Virtua Health System is a community-focused, comprehensive nonprofit in southern New Jersey that delivers services through three health and wellness centers, three fitness centers, three acute care hospitals, primary and specialty physician practices, urgent care centers, 17 ambulatory surgery centers, home healthcare services, two long-term-care and rehabilitation centers, 12 paramedic units, and a wide range of outpatient services.

Virtua Health's Joint Replacement Institute (JRI) opened for surgeries in 2012. This 56,000-square ft, 30-bed inpatient unit houses six ORs, six recovery bays, and eight surgical prep rooms, employing 36 surgical services employees, 27 inpatient employees, and a team of 5 board-certified and fellowship-trained surgeons. The team consists of RNs, patient care technicians, an anesthesia aide, surgical technicians, four medical secretaries, and a product coordinator. There's a physical therapy team of three therapists designated for the JRI daily, as well as a home care coordinator and a case manager. The JRI is a very fast-paced unit, averaging about 12 to 15 surgical procedures per day (over 2,100 surgeries annually), with a patient length of stay of 1.15 days for hips and 1.17 days for knees.

As a brand new unit, the entire JRI team was recruited and trained in a very short time frame of 3 months. This initial phase of prioritizing time and energy focused on hiring led to exceptional quality metrics and high patient satisfaction and employee engagement scores in the 5 years since the JRI opened.

Hiring the best

In 2012, the clinical director was of the belief that it's easy to teach the right person the clinical skills needed to perform a job, but it isn't possible to teach the basics of a moral compass. These qualities include compassion, kindness, empathy, engagement, and a belief that our patients are always paramount. The expectation for new hires at the JRI was that they had to be open to the unknown and possess a pioneering spirit. Hiring the best didn't mean making hasty or wrong decisions; instead, it meant utilizing the tools provided via the recruitment team and performing behavioral interviews.

The health system recruiting team sent viable candidates to be interviewed for potential JRI positions. All candidates had to assent to own and contribute to the Virtua star behaviors, including customer loyalty, quality and safety, resource stewardship, caring culture, and, most important, best people. They also had to agree to exemplify our credo, which states, “Our community is our family. We provide genuine, caring service every time. We believe every interaction is an opportunity to build relationships and loyalty through listening, anticipating needs, collaboration, and engagement.” Adhering to these behaviors is necessary to promote a positive culture on the unit.

Behavioral interviews were used to determine past behavior to predict future behavior.1 This style of interviewing is a method designed to explore real-life situations while evaluating a candidate's decision-making ability, level of accountability, expertise, thought processes, and critical-thinking skills.1 Behavioral-based questions should have responses that demonstrate the candidate's ability to be an advocate for coworkers and patients while at the same time displaying care, respect, and integrity.1 Having the perfect outcome to a behavioral question isn't necessary, only that the candidate is able to articulate meaningful experiences even if those experiences were unsuccessful.

Interviewers must be familiar with the key competencies and characteristics of the position so that they can develop the right behavioral questions.1 Probing by the interviewer may be necessary to get the candidate to provide specific examples. It's important to use the same questions for all of the candidates to be certain that candidates are fairly compared. Instead of asking a candidate, “Where do you see yourself in 5 years?” or “Tell me about your strengths and weaknesses,” consider the following:

  • Tell me about a time when you stood up for your beliefs at work and how you handled the situation?
  • What was the hardest problem you've had to solve and what did you learn from it?
  • Discuss a time when you inspired someone to work hard or do a good job? How did you do this?
  • Reflect on a time when you had to react to a situation rather than plan for it. How did you do this?
  • Describe a stressful situation that you faced at work. How did you handle the situation and what did you learn?

Once management has decided that a candidate is a good fit, he or she is asked to participate in a peer interview. Staff participation in hiring peers increases employee engagement scores and retention.2 Peer interviewing can help provide insight into whether the candidate will be a good fit.3

Staff members at Virtua don't go through a formal educational process on behavioral interviewing, but behavioral-based questions are provided to them by the management team. There are two to three peers involved in the interview who ask a total of five questions via a roundtable process. The questions are different from those the manager asked and each peer has a copy of the same five questions, which is also used as an evaluation form for rating the responses from 0 to 5. If peers agree that the candidate is a fit, then he or she is hired.

Staff members' feedback is important not only because they're the ones who'll be working with the new candidate, but also because having a voice in the hiring process makes it more likely that they'll support and mentor the new team member. Examples of peer questions include:

  • Tell us about a time when you weren't able to satisfy a customer/patient. What did you do?
  • Tell us about a difficult coworker and how you've learned to work with him or her?
  • Our relationships with others at work aren't always perfect. Tell us about the most difficult relationship you've had with a peer, coworker, or patient.
  • Tell us about a change that occurred at your workplace that you had to embrace.
  • What role do you play in sustaining morale at your workplace?

The importance of change

After the team was formed, management determined that it was necessary to inspire, motivate, and engage the staff to become a high-performing team. The focus was to develop shared decision-making skills, cooperation, and accountability. Today's healthcare environment requires strong interdisciplinary collaboration to successfully improve processes and sustain change.4

Interdisciplinary collaboration necessitates that team members have a common understanding of the change process.4 Lewin's change model is often utilized in nursing to help improve processes.4 Lewin's model has three phases: unfreezing, moving or transitioning, and refreezing.4 Unfreezing is getting the team ready for change, moving or transitioning requires the perception of change to be a process rather than an event, and refreezing is ensuring that the change becomes part of the culture.4 The JRI management team often utilizes Lewin's principles to foster change management.

Collaboration and empowerment

Shared governance is used at Virtua to allow for shared decision-making participation and the collaboration between management and direct care clinicians. Each department within Virtua has the opportunity to develop its own shared governance team. All staff members are welcome and encouraged to attend their units' meetings and share their ideas for process improvement.

Shared governance imparts nurses with a sense of professional autonomy. It gives those providing clinical care the opportunity to participate in decision making and the development of process change that directly affects their practice.5 Shared governance contributes to healthy work settings, improved job satisfaction, higher employee engagement levels, and increased quality outcomes for organizations, promoting accountability for improving care quality and safety on the unit.6 Commitment to process change is more successful when staff members have input.

Despite the autonomy instilled into the shared governance model, managers have oversight for resources, finances, and regulatory considerations. Managers are expected to help set the goals and agenda for shared governance meetings, as well as mentor and develop shared governance leaders.

The JRI shared governance team meets monthly and the chairperson also represents the unit at the hospital-level shared governance professional practice council meetings. Key JRI shared governance team members were asked to attend a 4-hour fundamental course on Plan, Do, Study, Act (PDSA) offered by Virtua's education department. This course provides team members with the skills to be able to work together to address potential improvement opportunities. It includes instruction on how to select a project for change via process improvement, skills to implement the change, observing and gathering the results of the change, and analyzing the outcomes to see if further change is needed.

An example of a JRI shared governance team PDSA project is the implementation of a change to increase the number of post-op discharge phone calls being made. The JRI had historically called all post-op patients with a two-page checklist of questions to ask. As the unit became busier, the calls weren't being made with the same regularity because the process took up a lot of time.

In November 2016, the shared governance team reviewed the evidence-based literature related to post-op phone calls. Although the evidence demonstrated that there was no statistical difference in satisfaction between patients who received a post-op phone call and those who didn't, calls are perceived by patients to be helpful, and the JRI team thought that this perception was important enough to trial the project.7

Nurses initiated the post-op phone call the day after discharge. A new, simplified approach was developed to shorten call time:

  • “Good morning/afternoon, my name is ____________ and I'm providing you with a courtesy phone call to see if you have the surgeon's phone number in case you have any needs.”
  • “Do you have any questions about your discharge instructions?”

Before the PDSA project was implemented, only about 25% of patients were receiving post-op phone calls. After implementation, the calls increased to over 60%. The project was successful; change outcomes continue to be monitored and reevaluated, with the goal of reaching 100%.

Both Lewin's change theory and the shared governance model have been part of the JRI culture since opening. Quality results are shared with the team weekly via daily unit huddles. These data are utilized to create problem awareness (unfreezing) so that the team is able to change the thought process from “this is the way we've always done things” to “how can we make this process better?” Staff members are encouraged to change (move or transition) their practice by seeking alternatives, articulating the benefits of those alternatives to the rest of the team and then implementing them. JRI management participates collaboratively with the shared governance team to monitor the change (refreeze) to ensure that it's consistently integrated and utilized.

Clinical quality outcomes

Outcome measures are the most accurate way to determine clinical quality outcomes.8 The Centers for Medicare and Medicaid Services (CMS) Value-Based Purchasing Program is a format used to provide quality information to consumers. The CMS now makes value-based incentive payments that are dependent on the results of certain quality outcomes from the acute care setting. Providers receive payment based on performance, with the goal of improving quality within the healthcare setting.

The JRI has historically had very good quality outcomes. (See Tables 1 through 4.) Quality results are shared with the staff, and shared governance team members are guided by management to look for areas of opportunity to improve processes.

Table 1:
Table 1::
Falls with injury per 1,000 patient days
Table 2:
Table 2::
Percent of surveyed patients with hospital-acquired pressure injuries stage 2 or above
Table 3:
Table 3::
Central line-associated bloodstream infections per 1,000 central line days
Table 4:
Table 4::
Catheter-associated urinary tract infections per 1,000 catheter days

Employee engagement

Nursing is a dynamic and ever-changing environment. Delivering high-quality care in this complex workplace requires that nurses be engaged. Nurse engagement is defined as nurses' commitment to the organization and the nursing profession, as well as their level of satisfaction with their job.9 Nurse engagement correlates closely with patient outcomes and experiences, and is a key operational metric for most hospitals.9,10 Engagement leads to increased productivity, better outcomes, and improved patient satisfaction.11

Anonymous engagement surveys are given to Virtua employees annually. The survey is a useful tool that gives employees a voice so that the management team can collaborate with them in developing action plans to address their needs. The surveys are benchmarked for comparison with other hospital organizations. One hundred percent of JRI employees participated in the 2016 engagement survey. Eighty-five percent were found to be engaged, compared with the 2016 median engagement benchmark score of 36.4% and the 90th percentile engagement benchmark score of 52.7% for all participating hospitals. (See Figure 1.)

Figure 1:
Figure 1::
2016 employee engagement survey

The engagement scores at the JRI have had a direct causal effect on obtaining high patient satisfaction scores. The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey is a national standardized survey of patients' perspectives of the care they received while in the hospital. The HCAHPS survey results are publicly reported on the Hospital Compare website as “top-box,” “bottom-box,” and “middle-box” scores. To date, the JRI HCAHPS scores have remained in the top-box 99th percentile in the composite questions as compared with all other hospitals since opening in 2012. This correlates to having 99% HCAHPS scores for 19 straight quarters, or for the last 5 years. The HCAHPS survey composite questions include information about:

  • communication with nurses
  • communication with physicians
  • responsiveness of hospital staff
  • pain management
  • communication about medications.

It also includes two individual items—cleanliness and quietness of the hospital environment—and two global items—overall rating of the hospital and willingness to recommend the hospital.


The American Nurses Association Code of Ethics for Nurses defines accountability as being “answerable to oneself and others for one's own actions.”12 At the JRI, it's been instilled that we're all accountable to our patients, ourselves, our team, our profession, and the unit and its outcomes. Organizations that prioritize teamwork, transparency, and accountability promote a culture of safety.13 In addition, a safe culture includes shared decision making related to common goals and the engagement and empowerment of all employees.13

When staff members are held accountable, they feel safe to speak up and address issues and conflicts that may arise on the unit without fear of punitive action. There must be a balance between blame and not tolerating flagrant actions or errors.13 A culture of safety should put emphasis on accountability, honesty, and integrity so that when an adverse event occurs, the focus is on what went wrong and not a blame game of who did something wrong.13

Occurrence reporting is an example of how JRI staff members understand process improvement without fear of punitive outcomes. An occurrence should be reported about any event that may or did cause harm to a patient. It's a tool used as a problem identifier to assist in process improvement to help increase levels of safety and quality within the hospital setting. (See Figure 2.)

Figure 2:
Figure 2::
Hospital survey on patient safety culture


Through effective and clear communication, the team shares responsibility for achieving and sustaining high-quality outcomes. Communication and transparency help support engagement on the unit and inspire creative thinking to drive passion for patient care. Communication at the JRI is intended to support and reinforce unit expectations for each member of the team.

Daily 15-minute huddles at a staff-chosen designated time are used as one format to promote effective communication. Such things as new practices, processes or changes in patient care delivery, areas of opportunity for quality improvement, information about the biweekly budget, staffing ratios, hiring, The Joint Commission visit expectations, and systemwide initiatives are representative of the variety of things that can be discussed during the daily huddles.

A weekly huddle e-mail is sent to each team member summarizing information discussed during the daily huddles throughout the week. Informal leaders on the unit are given the opportunity to have monthly one-to-one meetings with management during which their personal and professional growth opportunities and contributions to the team are discussed.

Rewards and recognition

Research has shown that employees who are engaged significantly outperform employees who aren't engaged.14 In a 2013 survey of more than 1,200 workers, it was found that employees were motivated and fulfilled by nonmonetary recognition; being recognized as an individual was the most motivating and meaningful.15 An employee's engagement is positively correlated with his or her perception of receiving appropriate recognition that isn't monetarily based.14 Rewards, recognition, and celebrations are crucial to supporting a positive work environment at the JRI. Meaningful recognition not only provides motivation for the recognized team member, but also serves as an inspirational catalyst for the rest of the team.

The JRI regularly celebrates milestones by hanging banners recognizing individual and group achievements, such as a certification or a degree earned, as well as baby and wedding showers, house purchases, and birthdays. The JRI has held potluck luncheons, pizza parties, hot dog parties, and ice-cream parties, as well as chili, chicken, cupcake, and cookie bake-offs. A voluntary program in which staff members can contribute $2.00 each month to maintain membership, the Sunshine Club is a forum to help defer some of the costs of these celebrations.

The JRI has participated in outside activities, such as yoga classes, spinning classes, picnics, painting parties, and 5K runs to help bond the team on a more personal level than what they experience at work. The surgeons have also had social gatherings for the team at their private homes. Any action that goes above or beyond the normal expectation is recognized through different measures, such as meal passes, small gifts, and hand-written thank-you cards. A simple thank you has a profound effect and helps JRI team members feel appreciated for all of their contributions.

How do you spell success?

Successful teams don't happen by accident. Hiring the best means using behavioral-based interviewing. Staff members should understand change theory and how it leads to collaboration and empowerment. An engaged, effective work environment exists when staff members believe that their ideas matter. The team is empowered to identify new processes to improve workflow and address perceived process flaws. This kind of collaboration is motivating to employees and improves overall morale on the unit, allowing staff members to become change agents while at the same time improving their communication and collaboration skills.16 By participating in shared decision making, employees feel that they can voice their ideas and their contributions are valued. Accountability is achieved partly through the utilization of the shared governance team, but also by the idea of working in a safety culture. Effective communication is important to keep staff informed about the hospital and the unit. And, finally, celebration and recognition—no matter how big or small—is imperative to promoting engaged employees who'll go above and beyond to continuously see difficult tasks through to completion.


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