AORN J O U R N A L MAY 1987, VOL. 45, NO 5

Managing Problem Performance A SUPERVISOR’S RESPONSIBILITY

Robert Goodall

ackie has been working under Anne’s supervision for the last six months. Jackie J had three years of nursing experience in other

areas of the hospital when she came to the operating room. Before hiring Jackie, Anne, the OR supervisor, made sure she had passed the OR orientation course, and she read her previous performance appraisals, which were good.

During Jackie’s three-month probationary period in the OR, Anne pointed out a few areas that needed some improvement, but on the whole, Anne felt she was doing well for an inexperienced OR nurse. Because Jackie had completed the course. and there was not time to orient her further, Anne decided that Jackie could learn what she needed to on the job. With some reservations,

Robert Goodail, MA, Ij. the education coordinator for general programs, Shaughnessy Hospital, Vancouver, British Columbia. He has a bachelor of science degree and master of arts degree in political science from the University of Britkh Columbia, Vancouver.

Anne accepted Jackie as a full-time member of the OR team.

Lately, however, Jackie’s performance has been deteriorating. She has been absent from work more than average, and some of the physicians seem cool toward her. Two staff members have told Anne that Jackie has been somewhat careless about aseptic technique in stressful situations. There have also been vague complaints about Jackie’s “abrasive” personality; it seems she is not always as polite with colleagues and patients as she should be.

Anne has been busy and has been unable to observe Jackie’s performance in the OR. It is clear that some action must be taken, so Anne calls Jackie into her office to talk.

When Anne asks her about some of the reports, Jackie becomes angry and demands to know who “snitched” on her. She denies that her performance has been anything less than perfect. Anne, taken aback by Jackie’s emotional outburst, begins to react defensively. The discussion ends abruptly when Jackie storms out of the office, promising to talk to the director of nursing.

Sound familiar? The above example is a composite illustrating one of the most difficult tasks supervisors face in the day-to-day management of their subordinates: confronting an employee about unsatisfactory performance.

In my discussions with OR head nurses and other hospital supervisors, several specific problems related to discussions about poor performance were identified, including:

dealing with unpleasant or unusual personality types,

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As a manager, you must understand your personal rights and those related to

your role as a supervisor.

confronting poor performance when the employee has personal problems (eg, is a single parent, family illnesses) or is close to retirement, facing overt aggression, denial, or tears, and relying on second-hand information because the supervisor has been unable to directly observe performance.

To deal effectively with these issues, the supervisor must first become fully aware of and comfortable with his or her own values, standards, and role. The supervisor must also develop investigative, administrative, communication, and legal skills.

Values, Rights, and Roles

ursing supervisors are usually promoted into their positions because they have N demonstrated clinical expertise; however,

the requirements for clinical competence and supervisory competence are somewhat different. Therefore, it is important for supervisors to think carefully about the supervisory role, determine acceptable standards of employee performance, and clarify their own rights, responsibilities, and feelings. A supervisor’s personal values and characteristics underly these factors. For example, how do you feel about an employee’s dedication to the job? Should everyone place a high priority on job responsibilities, even if it means sacrificing other values such as a family life? Do you interpret absenteeism as a lack of dedication?

What about expressions of anger? Do you feel comfortable when people let off steam quickly and then become reasonable, or do you believe that tempers should be kept in check at all times? In dealing with Jackie, Anne’s reaction to her anger may have led to her abrupt departure.

As a manager, you must understand your personal rights and those related to your role as a supervisor. Personal rights are those things that “all people are entitled to be, have, or do by virtue

of their existence as human beings.”’ Role rights “are those a person holds by virtue of a formal or informal contract to take on certain respon- sibilities or use certain skills.”2 We would probably agree that human beings have a personaf right to fair, predictable, and impartial treatment in society. We might also agree that supervisors have a role right to insist that those under their supervision perform their jobs in accordance with certain minimum standards, and that employees have a role right to receive clear direction regarding those standards.

Rights and responsibilities are almost always flexible. The best supervisors take the time to think about those rights and responsibilities and clarify them through discussions and negotiations with superiors, peers, and subordinates? When the rules are clear, infractions are less frequent and easier to deal with when they do occur. In addition, deliberate reflection and clarification through discussion is a way of testing yourself and your ideas, which can help to improve self-confidence and self-control. If Anne had thought more clearly about her own feelings and had them under control, and if she had considered her role and personal rights as well as Jackie’s, she might have been able to prevent Jackie’s angry reaction or reacted less defensively herself.

Investigative Skills

nne faced a common problem; she was too busy to observe Jackie’s unsatisfactory A job performance. When she attempted to

talk to Jackie about the problem, Jackie responded in an angry and defensive manner. Two important considerations exist in this type of situation: first, how do we get the information we need, and second, how do we communicate that information to the employee?

A supervisor must act like a detective in order to gather information about an employee’s poor

MAY 1987, VOL. 45, NO 5 AORN JOURNAL

After completing your initial investigation, communicate your findings to the problem employee

in a tactful, yet effective, manner.

performance. One important detective skill is careful observation with sensitivity to subtle clues. Who goes on break with whom? What kind of teasing goes on among various groups of people? Is one employee becoming isolated from the others? Careful attention to the personal interac- tions in your department can help a supervisor stop problems at an early stage or provide avenues for further investigation.

When you suspect that there is a problem, ask questions of those who may have been witnesses. Follow up general questions with more probing questions. To the extent possible, determine times, dates, and specifics of poor performance.

Your witnesses may be less than helpful at first for two reasons. First, they do not know how to observe and report on other people’s behavior. As the supervisor, you can view a performance problem as an opportunity to educate some staff members in the skills of careful observation and communication. With a little coaching, these staff members can become much more objective about their own work and that of others. You can help them to see where their prejudices might be influencing their opinions about their colleague’s performance. Encourage them to describe poor performance in objective terms-terms that will allow the “culprit” to see what she must do differently to succeed. When they state vague complaints about the performance of another staff member, insist that they give you concrete examples and illustrations.

Second, witnesses will be reluctant to provide critical information about a colleague. You might point out to them the importance of safety and quality patient care. Emphasize that all staff members must do what they can to ensure that standards are maintained. It may sometimes be necessary to identify where those standards are not being met, even if it means providing critical information about a colleague. The role of colleague must take a back seat to the role of

patient care provider when safe patient care is threatened.

Written information about problem employees should also be investigated. Check the employee’s personnel file to see if there are any disciplinary notes or performance appraisals. But do not rely solely on what appears in writing; people are often reluctant to place critical written comments in an employee’s file. Follow up written information with a telephone call to the supervisor responsible for the written report. If Anne had called about Jackie’s “good performance appraisals, she might have discovered that the written information did not give a complete picture of Jackie’s competence. Attempt to find out a little more about the employee’s educational background and personal life. You may find information that will help explain the employee’s poor performance and give you some ideas about how it can be improved.

The most important message here is that you should never confront an employee about poor performance that you have not personally observed unless you have thoroughly investigated the facts.

Communication Skills

fter completing your initial investigation, communicate your findings to the A problem employee in a tactful, yet

effective, manner. Most supervisors find these meetings difficult, even if they have had experience with them. Information on stress management provides the reasons.

Stress is an unusual, unexpected, or especially heavy demand on the mind and body. Reactions to stress have been called the “flight or fight” syndrome. Stress is physically characterized by elevated heartbeat, increased breathing, sweaty palms, muscular tension, and churning stomach. Psychologically, stress is characterized either by a desire to strike out and overcome the source.

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Fig I . When meeting with an employee about poor performance, the supervisor should ensure that a private area is used. (Photographs taken at Lutheran Medical Center Outpatient Surgey, Wheatdge, Colo)

or to avoid it. Reactions are instinctive and often beyond our immediate control. During times of severe stress, we are less able to think clearly and objectively about ourselves and the situation.

The supervisor and the employee are likely to feel stress before and during the meeting. Stress may cause the supervisor to communicate in a more domineering, authoritarian manner than usual in an attempt to control and conquer. This may cause the employee to either argue angrily and irrationally, or to retreat. The supervisor is responsible for reducing the stress and increasing meaningful, positive communication.

The experienced supervisors 1 spoke with have found many ways of reducing or managing the stress associated with a meeting about poor performance. They recommend conducting the meeting in private, dealing with situations quickly once the necessary information is obtained, and allowing time for the employee to vent fears, anger,

and frustration (Fig 1). Supervisors also need to keep these difficult

situations in perspective. Several of them told me that they try to keep their work separate from their personal lives. If too much depends on your successful handling of a difficult meeting with an employee, the pressure may cause you to fail. Distancing yourself from work and those you supervise by taking regular vacations, cultivating other interests, and ensuring that you are physically and emotionally fit can help you respond constructively in stressful situations.

Key Behaviors to Promote Communication

ased on the suggestions of supervisors and the literature on conflict, communication, B and meetings about poor performance, 1

have devised a list of key behaviors that should

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Do not allow the employee to distract you from the issue by making angry

inquiries about who ‘snitched.’

help supervisors communicate more effectively under difficult circumstances.

Present the situation as a problem to be resolved collaboratively. Introducing the issue at hand as a problem requiring mutual attention is more likely to result in cooperation than placing blame squarely on the shoulders of the employee. You may discover as a result of your conversation that you share some of the responsibility for poor performance. Perhaps you have not allowed sufficient time for orientation, or maybe you have been too busy to give the employee feedback about his or her performance until now. If you blame the employee and discover later that you are at least partly responsible, you will only make yourself look foolish and weaken your position. Begin cautiously, take an investigative stance, and avoid accusations.

Take personal responsibility for the infor- mation you are presenting. When you must talk to an employee about performance that you have not witnessed yourself, you must be responsible for what you are presenting. Do not allow the employee to distract you from the issue by making angry inquiries about who has “snitched.” You may prevent that reaction by saying, “1 got the feeling things were not going quite as well as they should, so I started asking some questions. 1 talked to several people in the department. Now I need to talk to you about what I found out. If you don’t agree with me, or if you think the information is incorrect, we can talk about it and see if we can figure out what is really going on.” When the employee knows that you have taken the time to check your information and are not acting on gossip or hearsay, he or she will be less likely to make an issue of your sources.

State the facts as you know them and then wait for a response. Encourage dialogue by asking questions and listening carefully to the answers. It is more difficult to listen carefully

and to hear exactly what the other person means in stressful situations. One of the first rules of effective listening is to stop talking. It is common in this type of meeting for the supervisor to fill in silences with further, more elaborate questions or explanations. A good suggestion is to use the six-second rule; after you ask a question, wait at least six seconds before saying anything else. The next time you are in a position to have to wait for an answer, try counting off six seconds to get an idea of how long it is.

Pauses, silence, and encouragement are particularly important when an employee reacts to the stress by retreating into his or her shell. With more talkative employees, it is helpful to paraphrase their responses to make sure there is mutual understanding.

If, as you listen to the employee, you discover a good reason for current unsatisfactory perfor- mance and expect performance to improve once the underlying cause disappears, you may choose to modify your standards for a specific amount of time. If you make this decision, other employees should be informed (although personal details need not be included) so that they understand the apparent inconsistency.

Focus on the present and future rather than on the past. When an employee is under stress, he or she will often try to avoid discussing immediate problems by bringing up past grievan- ces. If the interview between Anne and Jackie had progressed further, you can probably envision Jackie introducing the topic of her probationary interview and questioning Anne’s sincerity. Anne would be drawn into an unproductive debate about the accuracy of that interview, wasting valuable time and distracting her from the matter at hand. Under these circumstances, the supervisor must keep bringing the discussion back to the current issue and focus on how the situation needs to change in the future.

Respond to emotion calmly with empathy,

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An employee’s emotional reaction does not mean that you should ‘go easy’

on the performance problem.

probing, and clarification and allow time for emotions to subside. Direct contradiction is another trap into which many supervisors fall. When Anne was faced with Jackie’s denial of poor performance, she probably responded by reiterating the evidence, insisting that Jackie was wrong. Jackie stomped angrily out of the meeting room. Instead of immediately defending your own position, a natural reaction to stress, a supervisor should hold back a little on contradiction and take a more investigative approach. Asking for the employee’s side of the story, indicating some understanding of his or her position, and working to come to some negotiated agreement about the facts is more likely to result in a productive interview than insisting on having your own way.

With other employees, the emotional outburst may mean sobbing and tears rather than anger. In that case, allow the employee time to calm down and then proceed in an empathetic manner to find out why the employee is so upset and what needs to be done about it. Remember, an employee’s emotional reaction does not mean that you should “go easy” on the performance problem. If there really is a problem, you need to discuss it, while remaining as sympathetic as possible.

Report inferences as inferences and not as facts. It can be tempting to base conclusions about an individual’s personal characteristics on a few examples of aberrant behavior. Anne might have believed, for example, that Jackie was an unreliable, difficult person because she had been absent more than usual and there were complaints about her abrasive personality. But if Anne were to convey these impressions to Jackie as facts, it is safe to predict that Jackie’s reaction would not be favorable. Instead, if she mentions her interpretations at all, she should phrase them in such a way that it is clear that they are interpretations. Anne might have said, “Jackie, the records show that you have been away from work 10 days in the last two months. That is

much more than usual here. It makes me wonder about how reliable you are as an OR nurse. Are you having any special problems that make it difficult for you to be here regularly?”

Engage the employee in a search for solutions. If you have followed the steps above and the discussion seems to be proceeding smoothly, encourage the employee to come up with some potential solutions to the problems you have identified. The employee is much more likely to be committed to a solution that he or she has helped devise. At this point it is often helpful to follow the main rule for brainstorming: separate idea generation from idea judgment. Ask the employee to help you make a list of as many ways as possible to deal with the unsatisfactory situation. After you have both exhausted your imaginations, go back over the list and identify the ideas that are most practical and acceptable.

State clearly your needs, standards, and criteria. Willingness to be flexible, listen, and show empathy does not mean taking a soft approach. Although you should avoid demanding complete compliance with your own rules, it is quite legitimate for you to assertively state your position. Invite the employee to follow your example and then work toward an agreement. If you model reasonable negotiating behavior, you will often encourage the employee to respond in kind.

Be prepared to revert to a more direct, authoritarian style if after repeated eflorts to negotiate, the employee refuses to “own” performance that is clearly unsatisfactory. When after repeated attempts by the supervisor, the employee is not responding, the supervisor may need to become more directive. Anne may have had to say to Jackie, “We have spent the last half hour trying to reach a mutual under- standing about your work performance, and it just doesn’t seem to be working. I have tried to listen carefully to your side of the story, but I

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Whether the discussion ends constructively or not, the supervisor should take responsibility

for summarizing the results.

don’t feel you are doing the same for me. Unless things change in the next few minutes, this is what I will do . . . .”

Summarize the discussion and, if appro- priate, state clearly what disciplinary action is being taken. Whether the discussion ends constructively or not, the supervisor should take responsibility for summarizing the results. The summary should include a clear description of the disciplinary action taken, such as, “I think that just about covers everything, Jackie. Before we finish, I want to make clear that this is a verbal warning; nothing will be officially recorded in writing.” Or, “That’s about it for now, Jackie. Before you go, 1 want to make it quite clear that what we have been discussing is a serious performance problem-so serious that I will be putting a written warning in your file.”

There is no question that it is difficult for new supervisors to learn to communicate effectively under the stressful conditions of a disciplinary meeting. Understanding the principles and skills is rarely sufficient; to be effective, the skills and techniques suggested above must become part of the supervisor’s natural way of dealing with problems. If an employee thinks, for example, that you are using a “listening technique” in your discussion with him or her, they will be suspicious of your motives and sincerity. Supervisors should seek out training programs that emphasize repeated practice and integrate specific techniques with personal values and styles.

Stages of Progressive Discipline

o be effective, supervisors must have a thorough understanding of formal disci- T pline procedures. This knowledge enables

the supervisor to act fairly within the constraints of the law and can boost the supervisor’s self- confidence and improve his or her ability to

communicate clearly. The alternative actions available to the supervisor are often referred to as the stages of progressive discipline.

The stages of progressive discipline include: ( I ) a verbal warning, which may be repeated as often as necessary; (2) a letter of discipline or warning placed in the employee’s file; (3) a 30-, 60-, or 90-day probationary evaluation; (4) suspension, with or without pay; and (5) dismissal. Discipline is often cumulative; that is, if a supervisor has warned an employee verbally several times, he or she may decide to escalate the discipline by putting a written reprimand in the employee’s file.

The concept of the culminating incident is important here. Consider a situation in which Jackie had been late for work several times. Anne talked to her about it each time and Jackie promised each time to improve. Since the last time Anne talked to her, Jackie has been arriving on time. But in reviewing her notes about these verbal warnings before Jackie’s performance appraisal, Anne decides that because Jackie was late so often over the past year, she wants to place a written note in Jackie’s tile. This action would be unfair; Anne can only implement further disciplinary action if there is a culminating incident (ie, if Jackie is late again).

There are occasions when the severity of the offense requires a more drastic response than a verbal or written warning. In these cases the supervisor may decide to suspend or dismiss the employee without prior warning. Examples of such incidents include threats or attacks on patients or staff, fighting while at work, drunkenness or drug abuse on the job, and public abuse of a supervisor. In any of these cases, the supervisor should send the employee home immediately and with instructions to call the supervisor later in the day. The employee should not be told whether the time off will be with or without pay. This procedure allows you to choose from a full range of disciplinary options, including no further k ip l ine .

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Fig 2. Supervisors should arrange for adequate time and assistance to teach employees about new equipment.

Documentation

f you choose a verbal warning as the appropriate disciplinary action, you should I make an informal note for your own records.

This will serve only as a reminder to yourself and cannot later be considered a written warning or a part of the employee’s official personnel file.

Any disciplinary action taken beyond a verbal warning must be fully and officially documented. In preparing your written documentation, you should:

include the material facts, date, time, and wrongdoing committed,

0 avoid restrictive words or phrases that imply conclusions, such as grossly negligent, repeated absence, willful, continuous, persistent, serious, reckless, frequent, habitual, intentional, deliberate, flagrant, malicious, or excessive,

refer to any previous oral warnings and include the dates, refer to previous written reprimands, state that it constitutes disciplinary action for the offense charged (if it is a written reprimand); state that the employee is being suspended from work without pay as disciplinary action for the offense charged (if it is a disciplinary suspension), assert that if the employee fails to correct the problem, he or she will be subject to further disciplinary action, including termination of employment, sign the reprimand/suspension letter, and file a copy in the employee’s personnel file.4

These suggestions should be helpful to supervisors who must deal with performance problems. But when serious disciplinary action is contemplated, it is wise to seek the counsel and

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Fig 3. Including the staff in planning helps to motivate and inspire them to feel a part of a larger context.

support of the labor relations specialist at your facility. Each hospital has slightly different rules regarding the discipline process, and you should not proceed on the basis of the above information only.

Prevention

ost people would agree that it is better in the long run to accentuate the positive M rather than the negative. The question

is, how can this be done effectively? One author writes, “the word discipline comes from the same root as the word disciple and means to teach so as to mold. Unfortunately, many people have forgotten the teaching and molding aspects of discipline-the positive aspects-and tend to think of discipline as punishment or reprimand, which are negative a~pects.”~

The first step is careful recruitment of employees. Choosing the right employees for your area can minimize subsequent performance

problems. Think about your work in the OR. There is a great deal of repetition and routine; coffee and lunch breaks are not always possible; and the nurses often work overtime or are on call. Operating room nurses must be able to work at a fast pace for long periods of time in close cooperation with surgeons and other personnel.

What kinds of people do well under these conditions? Do your interview questions help you find the right staff? Although it is not always possible to find nurses who are perfect for the OR, it is wise to spend considerable time and effort trying to locate such staff. One RN surgical director told me that although she was under- staffed, she waited for five months before she found two new employees who met her standards.

Another important step toward prevention of discipline is proper orientation. Orientation for new employees should begin as soon as they join your unit. A good orientation program will have two outcomes: first, it will familiarize the new employee with his or her colleagues and general

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work environment; second, it will inform the new employee about the rules, procedures, standards, and expectations of the unit. If a new employee feels he or she is joining a well-organized, friendly team of workers, destructive behavior is less likely to result.

In-service education should continue for experienced employees as well. When new procedures or pieces of equipment are introduced, supervisors should arrange adequate time and assistance for those who need to learn about them (Fig 2). It is also helpful when employees can be involved early in decisions about innovations so that they can assist in the planning, help decide what in-service programs are needed, and generally contribute to a team effort.

Continued education does not guarantee that an employee’s performance will improve. Employees like Jackie, however, are more likely to perform well if they receive proper orientation and continuing support.

A third important step toward prevention of the need for discipline is the establishment and communication of clear goals and standards for the unit. Employees must know about and understand these goals and standards. Collabo- ration between a supervisor and employees to set or revise goals and standards will enhance the likelihood of employee cooperation (Fig 3). A sign in one director’s ofice reads, “When people plan the fight, they seldom fight the plan.” Even if an employee cannot contribute to goal or standard setting such as with new employees, a clear explanation of expectations will help the employee to perform well.

But effective goal-setting goes beyond specifics. David Berlew writes about the need for “cha- rismatic leadership” in organizations? Not only do charismatic leaders provide specific goals, but they also act as the promoters of the corporate vision; that is, the broader, more general purposes of a unit or hospital. By promoting this vision, these leaders inspire employees and help them feel a part of a larger context. The results are higher levels of motivation, greater effort, and improved teamwork. In the OR, the vision may be one of a group of people dedicated to the highest levels of patient care who are proud of their ability to

work efficiently as a team and respond quickly and correctly to emergencies. By discovering and becoming a champion of such values, you can encourage top performance from your people.

The fourth way to prevent discipline problems is to praise and encourage an employee when he or she performs well, thus helping to ensure that this performance will continue. The supervisor should compliment employees not only when they do outstanding work, but also when they show significant improvement.

Summary

ollowing the suggestions in this paper will not guarantee that you will never have F discipline problems or that you will deal

with them effectively every time they arise. But the OR supervisor who provides good orientation, sets clear goals and standards, and who consistently motivates employees through foresight, praise, and encouragement should have fewer discipline problems. And if the supervisor develops the self- knowledge, communication skills, and adminis- trative capabilities described in this paper, he or she should be able to cope with unavoidable problems more effectively. 0

Notes

(San Diego: University Associates, 1979) 57. 1. C Kelley, Assertion Training: A Facilitator’s Guide

2. Ibid, 6 1. 3. I M Rubin, R E Fry, M S Plovnick, “Clarifying

and negotiating role responsibilities,” in Managing Human Resources in Health Care Organizations: A n Applied Approach (Reston, Va: Reston Publishing Co,

4. E Grossman, “Handling discipline progressively,” Dimensions in Health Service 54 (September 1977) 50.

5. P Suessmuth, “A training session on discipline,” in Ideas for Training Managers and Supervisors (La Jolla, Calif University Associates, 1978) 284.

6. D E Berlew, “Leadership and organizational excitement,” in Managing Human Resources in Health Care Organizations: An Applied Approach (Reston, Va: Reston Publishing Co, 1978) 220-232.

1978) 87-92.

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