by Carolyn Roe, MSM, BSN
Regardless of your personal beliefs about unions, you automatically assume a responsibility for your employer’s fiscal health—in addition to the well being of your patients and staff—when you assume a management position.
Statistics show that unionization can increase hospital costs by 17 to 21 percent (Permanent Solutions Labor Consultants). In some cases, these cost increases may be warranted. However, in other cases, the additional expense can be avoided or minimized when nurse leaders proactively address the issues that draw employees to unions in the first place. Here are two scenarios.
Thirty plus years as a nurse executive and leader has led me to conclude that the frontline manager or director plays the most significant role in establishing and maintaining healthy interpersonal relationships. The following real-life scenario demonstrates how a frontline manager can influence positive relations in a unionized or a nonunion environment.
The Situation
A renowned hospital affiliated with prestigious medical and nursing schools had multiple issues in its cardiovascular service line, which was comprised of seven departments. Two departments, the ICU and cardiovascular (CV) step-down, had 35 percent staff turnover. There were several major contributors to the high turnover:
- An inadequate number of qualified, competent, and trained CV staff to care for a high volume of patients.
- Behavior-related physician issues that affected outcomes and caused nurses to feel devalued by the medical staff
- Patient flow and throughput inadequacies that led to quality issues
Exasperating the already volatile situation, the leaders of these two departments were ineffective. Staff had voiced their frustrations and concerns, but there had been a lack of action by senior leadership to resolve burning issues. Staff had a deep distrust of management. They did not feel listened to by their leadership and felt disrespected by the organization.
There were no unions and no obvious signs of intent to organize the RN or support staff. The possibility of unionization, however, was present. Staff was desperate for resolution to the staffing and patient care issues they faced daily. A smart, professional union organizer could easily have obtained card signing by 50 percent of staff in this facility to be represented by a union. If the proposed federal card check legislation (i.e., the Employee Fair Choice Act that has been reintroduced in Congress) had been the law, this facility would have been unionized without an election.
Interpersonal and working relationships will disintegrate when turnover is high, particularly in a division that provides a significant percentage of a health system’s bottom line. (The service line at this hospital generated about 35 percent of revenue for a three-hospital system.) Disrespect and not listening to staff concerns are primary reasons staff seek representation by organized labor or file grievances and even law suits against an employer.
The Resolution
The right director came on board and resolved the major issues in a few short months. Here are some of the strategies she used to stabilize relationships in this service line with over 200 employees.
Walk in the shoes of staff. The director visited with the majority of employees, on all shifts, including weekends, in each of the service line’s seven departments. She observed the care and interactions of staff, physicians, and patients.
Hold one-on-one conversations. The director talked one on one with 50 percent of the specialty ICU staff to diagnose the causes of high turnover and other issues. She listened, made notes, and communicated that these observations were for diagnosing strengths, weaknesses, and opportunities for improvement—and not to threaten staff.
Build trust and respect. The director promised staff that she would share information with others only when the employee had given his/her permission, and after verifying that the director had accurately heard what the employee had to say.
Take timely action to remove barriers impeding professional practice. For example, the director placed both ineffective managers on action plans, and taught each manager how to assess the effectiveness of his/her leadership. The director also applied discipline fairly and consistently, quickly intervening when staff members did not follow policy or best practice.
Address the major issues. The director involved the medical and nursing staffs in prioritizing the critical issues that were hurting the service line. Within two weeks of assuming her new position, the director had empowered staff to address the most pressing issue: disrespectful relationships and behaviors between medical and nursing staffs in the critical care units.
A nursing and medical staff communication council was formed for the ICU. The council includes medical intensivists, anesthesiologists, surgeons, internists, seasoned staff nurses, and a charge nurse. The service line director serves in an advisory capacity.
Some of the actions taken by the council included developing a code for professional behavior and communication that physicians and nurses agreed to follow. Infractions on either side were brought to the council. Council members also role modeled giving and receiving care recommendations, which seemed to be a stumbling block for many nurses due to the fear of being criticized or made to feel stupid by senior staff and physicians. In addition, a letter of praise and recognition for achieving good outcomes during an extremely busy, high-census period was written and signed by each member of the council. These letters (along with movie tickets) were hand delivered by council members to all staff in the ICU, including physicians.
Within four weeks, great strides were made in changing behaviors on both sides. Within three months, ICU vacancy was reduced from 17 to 3 FTEs.
Forgo the negative and pass praise. The director expected herself and her staff to achieve positive outcomes by focusing on what is right rather than what is wrong. She brought out the best in staff. When a good outcome was achieved, the director redirected praise to staff members critical to the resolution of the concern. She gave public praise and private criticism. She also taught staff how to solve peer conflicts positively, not allowing “he said, she said” communication.
Advocate for quality care. The director made it clear that patient care quality was a priority by addressing patient care issues promptly with the medical staff. Other examples: She personally spoke to top leadership regarding inadequacies in the new service line tower being constructed, and involved medical and nursing staff in redesigning the nursing station and equipment areas to improve work flow and safety.
Be Visible and Accessible
The crisis at this hospital is over for the moment. Great expense, time, and effort would have been expended on unionization, defending lawsuits and resolving grievances, yet the issues with quality, staffing, medical staff relations, and ineffective leadership would still have existed. It took the leadership skills of one frontline director to give employees what they truly wanted.
Regardless of the presence or absence of a labor union, staff will rebel if they are not listened to and will seek whatever means available to solve issues important to them. Hospital leadership must develop a means to be visible and accessible to staff. Most important: Staff’s legitimate concerns regarding patient care and safety must be addressed.
Today’s political and economic climate requires first-line managers and directors to exercise refined communication and relationship building skills to achieve safe and excellent care while surviving the financial hazards being faced. At the same time, senior leadership needs to recognize that they must provide critical support to the removal of barriers that prevent staff from making a difference professionally. Equally important for both senior leadership and front line managers, is demonstrating respect, honesty, and compassion in communications with staff.
Carolyn Roe, MSM, BSN, is currently associated with Permanent Solutions Labor Consultants; her background includes positions as chief nurse executive, vice president, and interim leader within various health systems (info@pslabor.com).
Additional Resources
Click here for Carolyn Roe's advice on labor relations in a unionized environment.