1 TL9- The Various Methods by Which Direct Care Nurses Access Nurse Leaders Nurse leaders at Riverside are hired with an expectation to maintain a schedule that facilitates open communication with direct care nurses on all shifts and days of the week. This is accomplished through the established Riverside nursing hierarchy/chain of command that facilitates communication and offers opportunities for face-to-face interaction/clarification any day or time. The culture at Riverside embraces small town closeness and a family atmosphere which helps eliminate barriers to communication with senior leaders that could exist. All nursing leaders performance appraisals assess communication effectiveness on a regular basis and a strong commitment to this standard is an expectation. Being highly visible and accessible fosters our climate of open and effective communication so necessary to building team relationships, managing change, and promoting a culture of employee engagement that encourages nurses to practice at Riverside. Open Door Policy Like Dave, Deena and Allen, all Riverside nursing leaders are expected and do have an open door policy for direct care nurses to access them. This encourages real time discussions and problem resolution. In addition, multiple methods of communication to assure direct care nurses are engaged and informed are utilized and described within this story. From printed methods, to phone access and meetings, leaders are expected to keep direct care nurses informed to drive desired outcomes and employee engagement. 24-7 Access: Electronic Communication and Pager At Riverside Outlook e-mail access is available to all employees and all nursing leaders carry a pager and make home phone numbers available. Direct care nurses have access from any computer at the hospital to email and can also access their Riverside email from on their home computers with an Internet connection. This mechanism is utilized to provide vertical communication and information as well as offer an opportunity to direct care nurses to have questions or concerns answered by their leaders in a timely manner via email or pager. Individualized Face to Face Communication: Leadership Rounding Since 2005, Riverside has expected nursing leaders to round on their patients and their own direct care nurses as communicated during the 2005 LDI (as described in TL 6). Specifically, during leader rounding, leaders explore the following questions/topics with their direct care nurses: 1. Ask a relationship-building question (e.g. about staff s family). This reinforces that we care about direct care nurses as a person first.
2 2. Ask: What s working well today? This is to keep direct care nurses focused on what is positive rather than what is wrong and to reinforce the difference they make. 3. Ask: Is there anyone we can recognize (e.g. department, coworker, physician)? This fosters appreciation across departments and areas. 4. Ask: Do you have the tools/equipment you need to do your job? This way leaders can remove barriers to delivering care or obtain documentation throughout the year of how often this is an issue in order to request budget approval to purchase more resources if needed. 5. Ask: What s not working so well and what do you suggest? This allows for shared decision making in the moment and supports direct care nurses-leader connectedness and collaboration. In addition to 1:1 rounding, meetings are held for direct care nurses to access their leaders. Group Communication: Department Meetings and Huddles Traditional unit meetings are held monthly (e.g. in MHU, GSU and Bolder) in some area s while only quarterly in other areas in addition to huddles (pull-together, standing meetings in the nurse s station) as needed. The meetings are held on evenings as well as weekend hours to address the fact that we are a 24 hour a day 365 day a year operation. Each leader establishes the agenda and provides minutes for those unable to attend. Discussion is pertinent to what is happening on the unit, sharing volume as well as performance improvement data, and policy change. Direct care nurses have input to the agenda as well as the opportunity to share concerns or stories at the meetings. Unit meetings are longer and more formal in nature; huddles are quick standing meetings to provide for a group of direct care nurses and their leader to touch base during a busy shift to allocate resources or discuss hot topics (e.g. Joint Commission is here to topics heard from senior executives at Patient Care Forum or Flex Staffing meetings). State of Riverside Townhall Meetings The State of Riverside townhall meetings which are conducted for the entire health system and last quarter, over 1200 employees attended, feature a formal presentation by our executive team (five of which are nurses), and then the meeting is opened up for questions from direct care nurses and all staff in attendance. For example, last quarter s meeting question focused on patient volumes and our local economy while continuing to build the East Tower and allowed for open, transparent and reassuring communication between leaders and direct care nurses.
3 Patient Care Council/Unit-Based Council (UBC) Meetings Nursing leaders provide announcements and attend, minimally, UBC report-offs on a monthly basis in order to be visible, provide support, and respond to questions from UBC members. Print Publications Newsletters are another mechanism that fosters communication at Riverside. Of course, there is the organizationwide Riverside Connection that comes out weekly via email to all staff and includes some nursing information. Specific to the hospital is the newsletter, Nursing News at Riverside, a monthly publication that targets all nursing areas of practice. It focuses on current trends/awards/educational opportunities as well as policy changes and news for nurses. The Magnet Minute, an update on the Patient Care Council s activities, is embedded in the publication. A unit specific example, 3Ortho- Neuro Footnotes is published weekly on Fridays and keeps direct care nurses up-todate on changes that impact their practice as well as any direct care nurses changes. The Quarterly newsletter for this 3Ortho-Neuro is called Bonehead News and offers direct care nurses and physicians opportunities to include articles on best practice as well as inspirational messages and messages from the unit manager, Cheryl Tyson. Nursing Supervision Coverage Nursing Supervision provides an RN administrative representative to all nursing units during the hours of 5a-5p M-F and 24 hours on weekends. This person offers support, as well as information regarding policy clarifications, to direct care nurses. On rounds the nurse (also called house) supervisor may identify concerns that need to be immediately addressed by the nurse unit leader for prompt resolution. In their Own Words: Nursing Leader s Quotes on Communication and Access Below are several quotes from Riverside nurse leaders that highlight the various methods of communication used in their areas of responsibility to support access to them and assure their nurses are engaged and informed: Amy Memenga, RN Nurse Manager of 5 th Telemetry: I round on direct care nurses, eat lunch with them occasionally, Lynn Christian a night Team Leader RN writes footnotes biweekly with up-to-date information. I also have an open door policy. The day and night team leaders pick up randomly on the weekends and share information. We have tech huddles at 2 and 10 each shift to give and receive updates on how the day is going. I think you have to have multiple ways of communication, of repeating the same message over and over, so everyone receives the message. Mary Kohl, RN Director for Peri-operative Care:
4 I communicate with direct care nurses through rounding daily, early morning meetings twice a week and monthly unit meetings. I find rounding is the most effective communication tool in addressing open communication with my staff. I can address and sometimes address issues right then and there that help to provide the tools for the staff to do their jobs. Manager OPS/PACU/SPL: Minimally, I round each morning and afternoon to all of my areas. Usually, small issues can be remedied right then. If follow-up is needed, I let them know when to expect answers or further information. Charge nurses are made aware of my daily schedule and how and when I may be contacted. All nurses e-mail me via Outlook and know I will answer them within 24-hours. They are all aware I may be paged, called on my cell phone or at home at any time. They may request to meet with me at any time and I will accommodate them as soon as possible. Tanya Huston, RN ER Manager: Of course, in the ER we use: e-mail, and also our newsletter and written memos that are posted and daily shift meetings. I don t think anything can be more effective than in person communication. My door is open and staff are comfortable to drop in. I come in early sometimes or stay late so that I can connect with off shifts. The team leaders also are a resource to let me know if someone needs attention and may not feel comfortable making the initial approach. Measuring Direct Care Nurses Perceptions of Access: To measure direct care nurses perception of the many elements of their position, including management/leadership communication effectiveness, an Employee Opinion Survey was conducted during the summer months of 2009. This survey was based on questions from the Great Place to Work survey, and was distributed to all employees of Riverside Medical Center (all corporations in the health system). 82% or 1,869 employees participated on the 2009 survey an increase from the 2007 survey which had 79.5% of staff responding from all job titles and departments. We are pleased to share our results are consistent with prior years with a majority of our direct care nurses rating their experience as true or almost always true as shared below on the 3 questions highlighting management access: Management makes its expectations clear o 65% of direct care nurses said this was true or almost always true - an improvement over 2007 s results of 62%. Management keeps me informed about important issues/changes o 62% of direct care nurses said this was true or almost always true )a slight decrease from 2007 s results of 63%. Management is approachable and easy to talk with o 67% of direct care nurses felt this was true or almost always true an improvement compared to 63% in 2007
5 Information from this survey has been distributed to staff that are collaborating with management in developing measurable goals for each area. Although these results are not yet where we want them to be, the 2009 results are particularly positive given that 2009 results nationally according to the Great Places to Work Institute (and other employee survey organizations) fell to their lowest levels in over a decade during 2009 attributed to the recession. In fact, from 2007 to 2009, Great Places to Work shared they saw, on average a 9% to 13% decrease per question item on their survey instrument from 2008 which we did not experience. Our ultimate goal is to improve to 80% of staff rating these questions positively, consistent with the Fortune Top 100 Great Places to Work benchmark for these questions. We also use the NDNQI Practice Environment Scale to measure perceptions of leaders by direct care nurses. From 2007 to 2009, we have seen some positive improvements. As shown in the table below comparing the NDNQI results side by side for each year on the Nurse Manager Ability, Leadership and Support of Nurses, in each year since we have fostered leader rounding, our UBC shared governance structure, Internet email, and unit-specific newsletters prepared by nursing leaders, we have improved our results over prior year. What makes these results significant is that we started the process with an excellent response rate and well below the all hospitals benchmark, and in each year since we implemented the results and have conducted this survey, we have not only improved our own results by 0.12 to 0.16 each year over the prior year, but have also improved at a rate more than quadruple that of the all hospitals database. Granted, we began this process below the All Hospitals database, but ended our most recent 2009 survey with results above the All Hospitals database for the first time. By Survey Year, Comparison of NDNQI PES Results for Rating on: Nurse Manager Ability, Leadership and Support of Nurses All Hospitals Database Overall Rating RMC Overall Rating All Hospitals Mean Change from Year-to- Year 2007 2.89 2.70 Data not available-did not participate in prior surveys RMC Mean Score Change Year-to- Year Not applicable - no survey prior year 2008 2.92 2.82 0.03 0.12 2009 2.95 2.98 0.03 0.16 Summary Multiple Methods Drive Access to Nursing Leaders As described in this story, there are numerous methods from printed and emailed newsletters to rounding, to meetings on the unit or UBCs, to carrying pagers 24-7, to Internet email to an Open Door policy that Riverside nurse leaders use to promote access and maintain visibility, give Riverside nurses a sense of support 24-7, and provide direct care nurses with the sense that nursing leaders heard their ideas and
6 concerns to advocate for their needs and help them feel a valued member of our care team. This journey by our nursing leaders to give direct care nurses access and their full attention during a leader s busy day is a continued focus in order to promote high levels of ownership, engagement and appreciation in how we fulfill our mission. And, to sustain and drive our desired culture of helping direct care nurses feel supported by accessible leaders, we will continue to conduct State of Riverside townhall meetings mini employee opinion surveys, full organizational opinion surveys, and the NDNQI PES survey.