Restoring Order

[SpookyRN764]

Hi there!

I'm about to start a new, ill-defined, position in a SNF. The home is in transition and exhibiting all the signs of such! Management is in upheaval. Key positions are vacant. Senior staff are resistant to change. It's frankly, a hot mess.

I was originally hired to be the Clinical Nurse Liaison, however after realizing the experience I had (22 years of LTC/Sub-acute/MDS/PPS/Supervisor) the COO decided I might be able to help establish processes and systems that are apparently not currently in place. It's all sorts of anarchy and chaos.

I will be the "RN Unit Manager" of the 44 bed Sub-Acute unit for now, since they don't really know what to call me. I don't own a set a scrubs so it should be interesting when I show up in my corporate gear to be on the unit. I should probably get at least a lab coat I suppose. Sorry, I digress.

Essentially, I've got to go in and assess the current status of the unit. Audit charts for accuracy and complete documentation. Review the processes they have in place. Review nursing staff performance and flow (they don't have an SDC). Review acute transfer logs. Review Infection Tracking procedures. Basically, the whole "flow" of the unit. After assessing the damage, I will be recommending a plan of action and assisting with the implementation of that plan.

I'm OCD and all about walking into a mess, sorting it out and organizing the heck out of it (I have five children), but I also have ADD and have no idea where to START with doing all of this! I'm going to guess that almost every process is either going to have to be reworked because it's ineffective or established because there never has been a process.

So, where do I start?!

[Psychcns]

How many staff will you be supervising? How about setting up individual meetings to get to know them. Also attend all their meetings:report. Etc. I hope you are getting paid enough.

[SpookyRN764]

For the entirety of the shifts, 5 RNs/LPNs and approximately 10 CNAs (rough estimate) and I do plan to meet with each person individually and/or in groups. I will also be attending their reports/meetings and work on improving the flow of information between management, staff nurses and CNAs.

I'm very much a "transformational" type leader. I want to educate and enroll everyone in the changes that may need to be made and why. I want their valuable feedback about what is currently working for them and what they feel ISN'T working. Then I can go from there. I'm not about reinventing the wheel. If it isn't broken, we don't fix it. I'm about eliminating unnecessary and cumbersome redundancy and inefficient processes in order to allow nurses to focus more effectively on patient care and thus improve patient and staff satisfaction.

I'll be getting my Clinical Nurse Liaison salary, plus mileage (since I will have to be on campus daily and it's 140 miles round trip each day ) plus a yet unknown "stipend" for my help in this particular area. I don't know if I'll be getting paid enough quite yet but we will soon see. I start on the 5th.

[xoemmylouox, ASN, RN]

All I can say is good luck. No one likes change and if management won't enforce your changes it'll be a waste.

(Dealing with a mess at my current employer and I'm kinda bitter at the moment).

Maybe you'll be able to make a huge difference.

[SpookyRN764]

Thank you for your thoughts. The good news is that I have the full backing of the COO. They are currently a 1-star home. The only way is up and they all know it. Anything is better than what they have in place right now. I'll keep you posted on how it goes. And I hope that things start to look up for you as well.

[Psychcns]

Sometimes having national standards (ie jcaho) , or even state rules can be a place to start to get people on the same page about what needs to change.

[Neats, BSN]

I have experience going into "troubled facilities"

First observation (I use the surveyor forms) for 72 hours on all shifts I always fill like I live there my days are long 12-16 hours. Have a week end observance at meal times this will provide an eye full. This will provide you with question and answers.

Sit down on an individual basis with each nurse with expectations of what you need from them as far as data gathering assistance. You cannot do this alone if you want buy in. I provide them surveyor forms as well and give them only a shift to complete the detail I have assigned to them. Who ever I assigned tasking I will almost always help... I take 20 mins to assist the nurse with whatever she/he needs this way I am part of the solution. If they decline I stand my ground and say I need to assist with something because I am needing you to take some time for me. Usually it is to not pass medication but to call or check other things. I have even check wounds.

When I get the information I then have a meeting with the nursing staff. In this meeting I pull out paper and pencils for all and ask them to write down the name of the person sitting two seats to their left, we ensure all names will be written down. I then ask them to write something nice about their co-worker. Reason for two seat separation is because friends/close people sit next to each other. I had a staff member state she could not do this because she had nothing nice to say. I pulled her aside in private and informed her she needed to dig deep I asked her what her favorite color is, she said blue, the person had blue eyes and if that is all she could write down is my favorite color is blue and your eyes are my favorite color it was a step in something positive.

I mandate that each staff person must provide some report to the person taking their place in person face to face. This report should be no longer than 5 minutes. The staff is to keep a record of their reports and pass it to the next person and so forth. The reports over a 24 hour of time goes to the DON with time started and finished (should be 5 mins or less). If they do not have reports to the DON it was never completed and they will get written up. Management does this as well with each other management staff there is weekly staff updates written and posted in staff areas with general questions/answers/suggestions/concerns (general) and facility information.

Start with something real simple like hand washing, have all staff review the policy, initial the policy when reviewed and place in employee file. Have a scavenger hunt to find where the sinks are, where soap is located where the policy can be found... and use the surveyor forms (I teach and give them to mostly NA-C to conduct a survey) They have two hours to complete the survey while I take their place as a NA-C- (again I am perceived as part of the solution and I can do that for 2 hours) I usually have 4 surveys of hand washing. I think the NA-C's judge the hardest on staff then the nurses.

I can go on and you can PM me if you would like additional information but I think you get where I am coming from.

If you are not successful with most changes the place will become even more bitter, resistant to changes even more and become more like silos in their area.

[Anna Flaxis, BSN, RN]

I've never been in your position, but I have other leadership experience.

First, listen. Just listen. Meet with each individual, like you plan, and just hear them out. Don't offer solutions or opinions. Ask them "What would you like to see happen?". Take notes.

Look beyond specific issues to see what the over-arching theme is.

Develop a plan to address the over-arching theme.

Identify your informal leaders and try to get their buy-in to your plan by making it seem like their idea.

Just my uneducated humble opinion. Good luck!

[klone, MSN, RN]

I agree with Anna. It is really hard (possibly disastrous) to go in and start making a bunch of changes as soon as you get there. It will breed suspicion and hostility from staff. They need to get to know you first. You need to establish trust before you can make a bunch of changes. With that in mind, I agree with Anna's suggestions to meet with people, talk to them, ask for their opinions.

[Cheyenne RN,BSHS]

OP wrote "So where do I start?"

I would start with slow deep breaths. LOL.