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Primary Nursing Improves Outcomes

By Janet Weaver, MSN, RN, NE-BC, Consultant at Creative Health Care Management

Janet Weaver, Consultant, Creative Health Care ManagementThere have been times in my career when a change has been introduced, and I cannot for the life of me figure out why the decision was made to alter how we were currently doing things—why we’re changing structures or processes that seemed to be effective and working fine. Sometimes my immediate manager would have an explanation, a hope that this change would effect, and other times … well, there was no good explanation of the why. Still, there was always an assurance that we would have improved outcomes if we would embrace the proposed change and put forth our best efforts into making it work.

When I work with clinical nurses and those supporting the RN to assist them in determining how to implement Primary Nursing, I’m often asked, “Why?” Why should we change our care delivery system to Primary Nursing? What will be different? What about it will be better than how we currently provide care to the patients?

Every essence of my being tells me having a Primary Nurse partnering with patients, their loved ones, and colleagues WILL positively influence all types of outcomes. Sounds pretty strong, I know, but I’ve experienced it first hand from both sides of the bed, and I know the difference of when there is a Primary Nurse and when there is not one. 

What I will do is share with you outcomes of Primary Nursing, from my personal perspective and from evidence, both qualitative and quantitative, of how Primary Nursing improves patient/family and staff outcomes.

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There are many types of outcomes; a few general categories include:

  • Patient satisfaction
  • Patient safety
  • Staff satisfaction and professional fulfillment

HealthStream online Nurse Training

Patient Satisfaction

In one organization patient satisfaction increased from the 89th to the 94th percentile for nurse attention to personal preferences; patient satisfaction for having their emotional needs met increased from 86.3th to the 96.2th percentile; patient perception for nursing response for their concerns improved from 86th to the 96.2th percentile and patient satisfaction for being kept informed went from the 89th to the 93rd percentile in a two year period after implementing Primary Nursing.

Patients have a better perception of the healthcare experience when a registered nurse takes the time to get to know them, to find out what is most important to them, and to plan and communicate that plan to others.

Patient Safety

The Joint Commission and the IHI have increased awareness about the importance of teamwork and colleague communication as it relates to patient safety and improved patient outcomes. One organization reported improved patient and family perceptions of how staff worked together from the 91st percentile prior to the organization implementing Primary Nursing, and three years later survey results showed they were at the 96.3rd percentile for the same question. Staff also stated an improved perception of communication with one another as well as a general impression of improved colleagueship.

An acute psychiatric facility stated that since implementing Relationship-Based Care and Primary Nursing they now rarely make calls to law enforcement or security. They stated that the primary care giver takes responsibility to connect with the patient and other care team members in such a way that violent outbreaks have all but ceased.

Staff Satisfaction and Professional Fulfillment

Nurses repeatedly report that when they state out loud that they are responsible for coordinating care and communicating the patient preferences that they discover by creating a therapeutic relationship with the patient, they experience a sense of great professional satisfaction.

One nurse shared her excitement about several experiences she had with patients following five minute “sit downs” as part of her Primary Nurse role. She shared:

"It feels like a partnership, jointly working on optimizing hospital stay and recovery. Even sitting at the bedside and really looking the patient in the face establishes a feeling of true connection. A surprising variety of responses is generated by questions such as 'What is most important to you that we need to accomplish this shift? I am here until 11:30 p.m.' or  'What is a central concern about your hospitalization that we can address?' or 'What key questions are on your mind that you want answered?' I am using these questions interchangeably with my patients."

A couple of the patient responses she reported in her email include:

  • “Where is my Prilosec? I take it every day but haven’t had it yet here.” [Investigated; pharmacy oversight that got corrected… patient happy and understands]
  • “This bed is killing my back [ant/post spinal fusion]; it’s like it has a hole in it, and I’m afraid it’s going to hurt my incision.” [changed beds; still no-go; got a hard plastic transfer slider for under the mattress, which made for  one happy patient and wife, who asked where to report “going the extra mile.”]

And my personal experiences:

  • As a family member I felt seen and safe and that the nurse really cared for my family member and for me. I felt confident that everything we needed would be tended to and we would all experience the care we desired.
  • As the nurse providing care, I knew in no uncertain terms that I was meeting every expectation of my patient and his family. I felt a sense of accomplishment that comes from seeing and knowing those needing care and meeting not just their physical but also their emotional needs.

I challenge and encourage you to experience the professional satisfaction and the improved patient satisfaction and outcomes possible when you say to your patient, “Hello, my name is _____ and I’m your Primary Nurse.”

Explore Clinical Orientation and Training Solutions for Nurses


As a clinical nurse, Janet connected with her patients and felt great compassion for them. As her career evolved and she moved into leadership roles, something she’s done for nearly 30 years, Janet brought that same sensitivity to her teams. As a consultant for CHCM, Janet’s areas of focus include Primary Nursing, orchestrating the implementation of Relationship-Based Care (RBC) and facilitating Re-Igniting the Spirit of Caring (RSC).


Relationship-Based Precepting: Defined & Why It Matters in Healthcare


Traci Hanlon, Consultant, Creative Health Care ManagementBy Traci Hanlon MN, RN, Consultant at Creative Health Care Management

I recently conducted a preceptor focus group of 35 preceptors at a hospital in the Southern region of the United States. Preceptors in this focus group, who came from multiple specialty areas, reported not feeling adequately prepared to teach or facilitate critical thinking or clinical judgment.

Of the 35 preceptors polled:

  • 40% stated they had never taken a preceptor course, but had learned how to precept by watching other staff and or being mentored by a preceptor on the job. 
  • Almost 70% stated they did not feel their work was recognized adequately or that their organization rewarded them for the work they did on a consistent basis.

Participants indicated that this perceived lack of preparation and reward contributed to their feelings of burnout and lack of desire to continue engaging in the preceptor role.

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What is Needed for a Successful Preceptor Program?

Careful preceptor selection, preparation, reward and recognition, and a solid infrastructure that supports these elements are necessary components for the development and implementation of a comprehensive, structured preceptor program. Another often overlooked component necessary for a successful preceptor program and transition to practice is the use of a framework or model to guide the day-to-day practice of precepting. Below is an example of a precepting model: 

The Relationship-Based Precepting Model (RBP) integrates four core elements that must be addressed in the day-to-day application of precepting. These elements are: supervision, socialization, professional practice, and resiliency.


Supervision is defined as the observation of preceptee interactions with patients, families, and clinical support staff; this includes direct observation of hands-on skills, as well as indirect observation (listening) to interpersonal interactions.


Socialization is defined as inviting individuals to participate in the formal and informal processes and/or routines that create social networks, friendships, and attachments. Without this sense of belonging, individuals often have difficulty assimilating into new routines and environments without a significant amount of stress. High levels of stress can affect an individual’s ability to process new information, and learning can be delayed or even stunted. Precepting methods or strategies must include a thoughtful and formal process of integrating and socializing new staff into their teams.

Professional Practice

Professional practice is the commitment to owning your practice as a preceptor. Preceptors have an obligation to be competent in

  • assessing critical thinking,
  • teaching using effective adult learning strategies,
  • providing feedback using competent communication skills, and
  • modeling healthy interactions between co-workers.

Formal Leadership Role

In the Relationship-Based Precepting Model, preceptors are included as part of the unit leadership team. Preceptors receive the same leadership development as charge nurses and others who are considered part of the unit-based leadership team. Preceptors are socialized into this role by the unit manager in a way that staff recognize them as part of the leadership team and expect them to function in that role outside of the orientation process.


Resiliency is defined as the ability to navigate stress by engaging healthy attitudes, thoughts, communication strategies, and behaviors that build a healthy and emotionally safe working environment. When an individual’s capacity to handle stress is fully developed, he or she is able to more fully engage in a therapeutic relationship that inspires trust and healing.

The Relationship-Based Precepting Model

Relationship-Based Precepting ModelThe Relationship-Based Precepting Model embraces all practices that build capacity and it inspires an authentic connection with others. However, it is the addition of the therapeutic practices contained in the work of Mary Koloroutis and Michael Trout’s Therapeutic Relationship Workshop and their book, See Me as a Person, that really ensure that resiliency is addressed. In the Relationship-Based Precepting Model, the therapeutic practices outlined in these two works are considered an interpersonal competency for both preceptors and preceptees.

Expected outcomes from implementing the Relationship-Based Precepting Model in conjunction with a comprehensive preceptor program are:

  1. Improved preceptor satisfaction
  2. Improved preceptee satisfaction
  3. Improved readiness to practice of orientee/preceptee
  4. Decreased orientation time
  5. Improved staff engagement
  6. Improved staff satisfaction

With today’s challenging healthcare landscape it is imperative that we continue to develop and retain a talented workforce. Relationship-Based Precepting provides a comprehensive model for preceptors to follow during the transition to practice phase. Providing a theory-based model founded on best practices ensures that preceptors have the tools necessary to provide a quality orientation and that staff ultimately experience a smooth, nurturing onboarding experience that facilitates improved staff retention and satisfaction.

Learn more about HealthStream's specialized learning courseware for nurses.


Traci Hanlon MN, RN is a consultant with Creative Healthcare Management and specializes in preceptor, nursing orientation, and transition to practice program development.  

References & Permissions 

Koloroutis, M., and Trout, M. (2012). See me as a person: Creating therapeutic relationship  with patients and their families. Minneapolis: Creative Health Care Management. 

The Relationship-Based Precepting Model is used by permission of Creative Health Care Management, Copyright 2013, all right reserved.

Healthcare Professional, Are YOU a Member of The A-Team?


By Mary Koloroutis, MS, RN, Consultant at Creative Health Care Management

Mary Koloroutis, Consultant, Creative Health Care ManagementEffective teamwork is more than just a “nice to have.” It is essential for safety, retention, continuity of care, positive patient/family experiences, and overall effectiveness.  The Institute of Safe Medical Practices (ISMP) recently published new findings in a study called “Unresolved Disrespectful Behavior in Healthcare.” The ISMP expected to see improvements since its last survey, 10 years prior, but the results show that disrespectful behavior continues to undermine healthcare teams. 

“The results of our 2003 and 2013 surveys expose healthcare’s continued tolerance and indifference to disrespectful behavior. These behaviors are clearly learned, tolerated, and reinforced in the healthcare culture, and little improvement has been made during the last decade.” (ISMP, 2013) 

Do you suppose that people who are behaving disrespectfully in teams are in touch with the meaning and purpose of their work? Do you suppose they are fully engaged? 

It's Very Important For Teams to Work Successfully Together

Health care professionals are consistent in their thoughts about working as part of a team. Here is what they tell us: 

“I would rather work short-staffed with a team of people who are all on board than to work with a full staff of people who aren’t in synch with the reason we’re here.” (Koloroutis & Trout, 2012) 

We have found that when people hear that they will be working with those whom they consider members of their “A” team they feel energized enough to take on more, knowing that the time and workload will flow smoothly. 

Some Team Members are Energizing

Here are the characteristics of the team members who energize their peers:

  • positive
  • helpful (fully responsible and accountable)
  • self-motivated
  • proactive
  • fully engaged
  • highly committed 

If people hear that they’re going to have to work with team members who demonstrate lack of responsibility and a victim mentality, they are suddenly “too tired” to take on more or become hyper-responsible trying to compensate for the lack of teamwork; either way the workload will be heavy and the time will be difficult to manage. 

Some Team Members are Energy Drainers

Here are the characteristics of the team members who drain the energy out of their peers: 

  • engage in frequent complaining,
  • show little, if any, initiative
  • demonstrate an apparent apathy toward good patient care or helping their fellow team members 

Self-Assessment: Am I Part of the “A” Team? 

Now let’s look at what sort of team member you are in a little more nuanced way. I invite you to reflect on your answers to the assessment below and then ask yourself this question: Would I be considered a member of the “A” team? 

Healthcare Employee Assessment and Engagement

Note the pattern of your responses to the self-assessment and reflect on the following questions. You may also wish to use these questions in a team huddle or reflection session. 

  • What helps me sustain a high level of contribution to my work and to my team?
  • What stops me from making a higher level of contribution to my work and to my team?
  • What have been moments or longer periods of times when I have definitely worked as an “A” team member?
  • What was it about those times that tapped into the best in me?
  • What have been times that I have not worked as an “A” team player?
  • What do I need from others, from my supervisor, and from my colleagues to help me be an even more valuable member of my team?
  • What might I do more of (or less of) to make sure that I am taking care of myself so that I can contribute to my fullest capacity? (Koloroutis & Trout, 2012, pp. 255-259) 

The stakes are high. People’s lives are in our hands. Because our work is about people’s lives, we don’t have the option of not working well as fully participating and highly engaged members of health care teams. Your commitment to being positive, helpful, self-motivated, proactive, and fully engaged is a commitment to the very best patient care possible. And that is a noble commitment.  

As a co-creator, author, and editor of the Relationship-Based Care series of books and seminars, Mary helps health care organizations create a framework for delivering world-class care with strong underlying values and principles, and then works with them to implement that framework. Her most recent book, See Me as a Person: Creating Therapeutic Relationships with Patients and their Families, co-authored with Michael Trout, helps clinicians in all disciplines to connect authentically with the patients and families in their care no matter how chaotic their care environments may be. Contact Mary at


Institute for Safe Medical Practices, (October 3, 2013). Unresolved disrespectful behavior in healthcare. Medication Safety Alert! 18 (20) 1-4.

Koloroutis, M., & Trout, M. (2012). See me as a person: Creating therapeutic relationships with patients and their families. Minneapolis, MN: Creative Health Care Management.

Better Preceptors Promote an Engaged and Competent Nursing Workforce


By Traci Hanlon MN, RN, Consultant at Creative Health Care Management

Traci hanlon, Consultant, Creative Health Care ManagementThere has been plenty written on developing an engaged workforce with recommendations that point to hiring the right people in the first place (Bowen, Ledford, Nathan, 2013, and Kristof, 2006). The importance of manager competence in screening, interviewing, and identifying the personal characteristics and competencies of individuals who will best complement their teams cannot be overstated. However, as a consultant with more than 20 years assisting in the development, implementation, and evaluation of many acute and long term care institution’s orientation programs, I have observed a gap in how many of us facilitate the transition of new staff to practice. If we are not thoughtful in how we transition new staff into practice, we reduce the effectiveness of our teams and decrease job satisfaction in our newly hired staff. On a larger scale, we may unintentionally pose a threat to patient safety by hampering the ability of our new staff members to develop solid critical thinking skills, healthy communication practices, and a collegial interdependence within teams. 

In the healthcare industry, preceptors are used to socialize, mentor, evaluate, and assist in the transition of new staff into the workforce. Traditionally, preceptors were used only for new graduate nurses and students, but since a key role of the preceptor is to supervise, evaluate, and validate a new staff member’s competency, then it makes sense to use preceptors with all new staff as a model to introduce the norms and nuances of a particular unit and to assess and validate a preceptee’s competency. The length of preceptorship should be determined by the level of experience new staff members have with the profession in general, their familiarity with the hiring organization, their familiarity with the role they are being hired for, and their experience in the specific nursing specialty. 

Specialty Online Nursing Education from HealthStreamManagers invest a great deal of time and energy in the hiring process with the aim of finding the right combination of skill, attitude, and engagement necessary to add value to their teams. What managers often fail to recognize is that if they do not invest that same time and energy into selecting the right combination of skill, attitude, and engagement in the preceptors who will be transitioning their new hires into the work environment, all of their hard work in finding the right fit for their team may end up going down the drain. Preceptors can make or break the new hire’s experience; in fact, I have seen bad precepting experiences lead to increased stress during the orientation phase, which has the potential to impact the development of good critical thinking skills. Poor critical thinking skills can contribute to poor outcomes, which in the long term can reflect negatively on patient safety. Preceptors set the tone for the level of professional practice expected on a unit and make clear the norms and behaviors that are deemed acceptable in the workplace. In other words, everything your new hire learned in orientation, from behavior standards to infection control policies and best practices, can be undone by a preceptor who does not exemplify best practices in his or her own professional practice or lacks crucial critical thinking or interpersonal competencies.

So what criteria should a manager use to select who will orient and precept new hires?

There is a significant body of literature that provides ample recommendations for determining preceptor selection criteria (Eddy, s. 2010, Altmann, T. 2006, Hartline, C. 1993).  Upon review of the most recent research articles articulating preceptor best practices, several preceptor characteristics and competencies stood out to me as providing the best indicators for preceptor success. They are:

  1. Demonstrates self-directed advancement of professional practice
  2. Demonstrates authentic leadership
  3. Demonstrates exceptional performance  in clinical  and interpersonal competencies
  4. Demonstrates the desire to become a preceptor (self-selection)

Demonstrates Self-directed Advancement of Professional Practice

People demonstrating this characteristic have taken ownership for their own professional development. They are the ones who volunteer for quality improvement projects and participate in life-long learning as evidenced by attending conferences, classes, or in-services that expand their clinical and critical thinking and their interpersonal competency.

Demonstrates Authentic Leadership

Individuals who engage in authentic leadership have a track record of treating others with kindness and respect. They do not engage in gossip, and often these individuals hold others accountable for destructive behaviors by having kind, yet firm peer-to-peer conversations related to observed unhealthy work behaviors.

They have a clear vision and purpose for the work they do and can often articulate how their personal values align or complement the organizational mission, vision, and values. These individuals are engaged and committed to their organization. This is demonstrated by their ability to embrace change with a positive attitude and their early adoption of initiatives, processes, and philosophies that may stretch their current way of thinking and or practice.

Demonstrates Exceptional Performance in Clinical and Interpersonal Competencies

These individuals are self-directed learners who will typically be the first to complete any competency or learning requirements. In other words, they will not be the individuals you have to hunt down, remind, and micro-manage to provide evidence of their competency. These are also individuals who continually seek to improve their current skill levels; they are receptive and value constructive feedback.

Demonstrates the Desire to Become a Preceptor (self-selection)

This characteristic speaks to the importance of choosing only individuals who have an authentic desire to precept and (ideally) who proactively seek the opportunity to do so.  Managers who mandate precepting as an expectation for all staff risk entrusting individuals who are not suited to precepting or lack the skill to undertake such an important and critical role with one of the most important jobs in health care.  

Selecting preceptors who demonstrate competency in the four areas described above to facilitate the transition of new staff into your team is a crucial part of the hiring process.  To neglect this step and allow individuals who lack the necessary desire and skills to precept is setting up the entire team to fail, especially the new person. 

An engaged and competent workforce relies on a solid foundation that begins the first day they step onto their unit. The preceptor plays a vital role in this process and can make or break a new person’s experience.  It is for this reason that managers must focus their attention on the entire continuum of hiring, from the first screening phone call, to the interview, all the way through their orientation of which preceptor selection is a most vital aspect.

Learn more about HealthStream Specialty learning courseware for nurses.


Traci Hanlon MN, RN is a consultant with Creative Healthcare Management and specializes in preceptor, nursing orientation, and transition to practice program development.


Bowen, D., Ledford, G., Nathan, B., (2013). Hiring for the organization, not the job.  Academy of Management Perspectives. 27(3).

Kristof, A.  2006. Person-organization fit: An integrative review of its conceptualizations, Measurement, and Implications.  Personal Psychology, 49(1).

Eddy, S. 2010. Lesson learned from formal preceptorship programs.  Creative Nursing, 16(4).

Altmann, T., (2006). Preceptor selection, orientation, and evaluation in baccalaureate nursing education.  Nursing Education. 3(1).

Hartline, C., (1993). Preceptor selection and evaluation: A tool for educators and managers.  Journal of Nurse Staff Development. 9(4).

Why Primary Nursing has Everything to do with Professional Practice


By Janet Weaver, MSN, RN, NE-BC, Consultant at Creative Health Care Management

Janet Weaver, Consultant, Creative Health Care ManagementWhen I first heard Marie Manthey state, “Primary Nursing is the only care delivery system that nails professional practice,” I wanted to know more. At the time I’d just begun what was to become an intense interest, belief, and later a transference of information to care providers about this way of delivering care to those experiencing illness, a procedure/surgery, or wellness care.

When searching for clarity on what defines professional practice, I found a variety of definitions and statements. According to Larson (Magali Sarfatti Larson, The Rise of Professionalism: a Sociological Analysis, Berkeley, California: University of California Press, 1978, p.208) there is agreement on a number of characteristics possessed by a profession, which include having:

  1. A professional association
  2. Institutionalized training
  3. Licensing requirements
  4. Work autonomy
  5. Colleague control (peer evaluation)
  6. A code of ethics

I wondered which of these characteristics, if any, Primary Nursing had that other care delivery systems do not. The answer was clear: work autonomy.

Decision making by a Primary Nurse involves the RN making decisions for a patient based upon the therapeutic relationship that a nurse has established, which, in contrast to all other care delivery systems, is sustained for an entire episode of care, which may be 15 minutes or 15 weeks. This doesn’t mean the Primary Nurse is the only one responsible. Each nurse caring for the patient has responsibility to follow the plan of care established by the Primary Nurse, change it when necessary, and even to make decisions in the best interest of the patient (that may differ from the plan of care), using common sense and critical thinking skills. In all other care delivery systems, functional, total patient care, and team nursing, decisions are often made by a charge nurse or manager, and if the RN providing care makes decisions, there is no structure for decisions to be followed by subsequent RNs caring for the patient.HealthStream Specialty Nursing Courseware

How Primary Nursing is Different

When the Primary Nurse states, “I will be responsible for you during your stay…,” these Primary Nurses report an internal shift in the perception of their role. One nurse stated, “I was overcome by the feeling, ‘I am responsible,’” which quickly translated to, “I MUST do my best.” When a Primary Nurse assumes responsibility, it is far more likely that he or she will develop a therapeutic relationship and adopt practices such as a five-minute, eye-to-eye conversation with each patient each day.  This type of behavior takes the nurse from a task-based focus to a relationship-based focus and provides the infrastructure for professional practice. 

Responsibility and Privilege of Primary Nursing

As I think about the internal shift that occurs when an RN embraces the responsibility and privilege of being a Primary Nurse, I find myself thinking back to my days at the bedside. Of course it makes sense that as a Primary Nurse I would be more intentional with everything I do, especially when it comes to establishing relationships with patients and families. Professional practice would naturally move me from task-based care to knowledge-based care; from fixing to healing; from a focus of only physical care to one of holistic care that includes the body, mind, and spirit; from decisions based solely on policies and procedures to using professional standards and current research to make decisions; and from rules, habits, and routines driving my practice to my critical thinking and innovation being the impetus. 

Being Decisive

As the professional Primary Nurse, my thinking may sound something like this: I have 12 hours and four patients, what will I do with my time? If I spend five minute eye-to-eye with each patient, this will guide my choices for what I do and when I do it, as I’ll know what is most important to my patients. When it’s time to pass medications I’ll move from previous task-based thinking that I have to administer all medications within 30 minutes of the designated time to using my education and critical thinking to balance what meds actually need to be delivered in this timing with what will best serve those I’m caring for. Primary Nursing means the staff nurse is empowered as a decision maker for the nursing care the patient receives.  

Nurses must decide what to do and what not to do, and it is okay to leave things undone when they are not the priority. We cannot do everything. When choosing to not do something, rationale must be provided. This is the job of a professional nurse.  

Learn more about HealthStream Specialty learning courseware for nurses.

* * * * *

As a clinical nurse, Janet connected with her patients and felt great compassion for them. As her career evolved and she moved into leadership roles, something she’s done for nearly 30 years, Janet brought that same sensitivity to her teams. As a consultant for CHCM, Janet’s areas of focus include Primary Nursing, orchestrating the implementation of Relationship-Based Care (RBC) and facilitating Re-Igniting the Spirit of Caring (RSC).

Making Healthcare Staff Meetings More Engaging


Mary Strom, Consultant, Creative Health Care ManagementBy Mary Griffin Strom, MSN, RN, Consultant, Creative Health Care Management

Here’s an issue that managers across the health care spectrum deal with all the time:

Today is the monthly leadership meeting for our organization. The agenda was posted yesterday and includes a review of the following items:

  • Core measures report out
  • Financial report covering current month and year-to-date information
  • Update on HIPPA and compliance initiatives
  • Productivity review for month and year-to-date
  • Report from IT on upgrades and CPOE implementation

The meeting is scheduled to be two hours long. As a manager of a patient care department, I hope there are copies of these reports so that I can accurately reflect this information in my staff meetings, which I schedule for the week after the monthly leadership meeting. My staff meetings are only one hour long, so I will really have to truncate the information into smaller parts so that I can cover each topic.

OK, I don’t know about you, but I do not find anything inspiring or engaging in that long list of agenda items or the thought of mashing all of that information down and telling it to my staff.

Staff Meetings Should Be Motivating and Engaging

HealthStream Employee Engagement Surveys for Healthcare

As a leader of the front line staff members who are the closest to our core business, (i.e. delivering care and service to our patients/families in acute care, emergency departments, ambulatory care facilities, and clinics) I wonder about the relevancy of all this information/data. I wonder what type of staff meetings our staff members are hoping for. I must pause and ask myself, “If I were them, what would motivate me to attend a staff meeting and what types of agendas would be engaging?”

Patient care providers at the point of care delivery want to discuss what it takes to come to work every day and give what is needed to make a difference in patients’ lives, not just in their clinical outcomes, but also in their quality of life outcomes. They want to know that what they do every day has made a difference for someone, and it would be really nice to know that someone in a leadership position knows it and cares enough to provide time and space for dialogue about what really matters. That would motivate me to come to staff meeting, and to be engaged and participative versus a passive receiver of data/information, which I will probably forget once I leave the meeting.

Leaders' Responsibilities for Staff Meetings

I would like to come together with my peers, in an uninterrupted time, when I am not trying to be at a meeting and attend to patients, to dialogue about my work environment, teamwork, and patient outcomes that matter to my clinical arena. I would like my leader to demonstrate caring, compassion, appreciation, and gratitude for all the hard work we do, and to listen more than speak. This is caring leadership at its best: for the leader to be the follower, and for the leader to recognize that the staff know best how to create positive work environments, make a difference in patient/family acceptance of the treatment plan, and adhere to best practice. This type of care is provided “in the moment,” not when someone in quality examines the data, creates the graphs, and reports the results.

Caring Leaders Create a Compassionate Environment

If we want our front line leaders to lead like this, then our directors and executives need to model the way. Caring leaders create an environment of caring and compassion, and inspire folks to use their talents and gifts in an organization that is fueled by their energy, enthusiasm, and passion for the work. Caring leaders must be found at the very top of our organizations in order for leaders at all levels to know that this style of leading is what is most effective and engaging to our employees. I believe we can do both, provide data and information that is necessary to the business we need to address, AND inspire and engage all employees to know that our core business is taking care of patients/families who are suffering, hurt, in pain, and come to us for needed care and attention.  We must treat their whole body/mind/spirit in order to provide healing care, and for that work, we need our hearts firmly connected to our heads. 

Until we can capture and inspire peoples’ hearts, we will never engage their heads in the work of our business. Emphasis on outcomes, scorecards, and results, must be preceded by emphasis on caring, compassion, connection—in short, our core business. Then we have established a culture that supports staff members who know best how to reach outcomes. Just ask them, and listen to their response, and follow their lead.

Learn About HealthStream's Employee Insights Survey.


Throughout her career, both as a nurse at the point of care and as an administrator, Mary has seldom used the word “patient” without the word “family” following right behind it.  Currently, Mary is a consultant at Creative Health Care Management, where she partners with health care organizations on team building, patient safety and quality, leadership development at all levels, physician engagement, and patient experience. Mary can be contacted at

Five Essentials of Nursing Orientation


Susan Cline, Consultant, Creative health Care ManagementBy Susan Cline, MSN, MBA, RN, NEA-BC, Consultant and Creative Health Care Management

Nursing orientation plays a pivotal role in the competency and retention of newly hired registered nurses. Effective orientation and precepting programs produce nurses who provide competent, quality patient care and are enculturated as productive members of the healthcare team. With the replacement cost of one registered nurse estimated to be as high as $64,000, retention of staff continues to be an important objective for nurse managers and directors. Additionally, collaborative relationships and teamwork have been identified as key indicators of nurse satisfaction.

Effective nursing orientation programs should include these five essential components:

1.       Preparation 

Successful nursing orientation requires the development of a curriculum and the training and preparation of preceptors. Specialty units should consider implementing a didactic portion of orientation that focuses on common diagnoses and procedures, along with high risk/low incidence competencies. It is important to understand that an expert clinical nurse may not make for an effective preceptor. Preceptors should be selected both for their clinical expertise and for their ability to teach and evaluate new staff members. A preceptor workshop with modules on adult learning and providing feedback can be very helpful in preparing preceptors to orient newly hired registered nurses. 

2.       Incorporation HealthStream Nurse Onboarding Training

New staff members should be welcomed and incorporated into the team as early as possible. Introduce new staff members in morning huddles, staff meetings, and by e-mail communication. Provide a thorough tour of the environment, introducing team members by name and role. Encourage preceptors to take rest periods and lunch breaks with new staff members during the orientation period. Nurse managers should check in with new staff members on a daily basis, even if it is just a quick “Hello” and “Is there anything that you need?” Ensure that new staff nurses have access to all of the electronic systems as early as possible, including computer log-ins, parking garage and door access, and medication dispensing system access. Not having access to the department’s systems is frustrating and alienating, and it creates a barrier to learning. 

3.       Goal-Directed Precepting 

Nurse managers should establish weekly benchmarks to guide precepting activities. Benner’s From Novice to Expert model is an effective approach; new staff nurses start with basic competencies and move toward more complex procedures as the weeks go by. Evaluation forms with the suggested behaviors for each week are an efficient way to track progress and guide patient selection. Preceptors are encouraged to share the new staff member’s learning goals and objectives with the charge nurse and staff nurses on a daily basis so that they can identify patient care and procedural opportunities. Team ownership of onboarding new staff sends a powerful message about collaboration and teamwork. 

4.       Direct and Timely Two-way Feedback

Nurse managers should meet with new staff nurses and their preceptors weekly or bi-weekly. Both the preceptor and the new staff nurse should provide feedback on their progress. Ask new staff nurses to be open and honest about their confidence and comfort level.  It is frustrating for everyone to discover that the new staff nurse is behind in achieving orientation benchmarks. Feedback should be honest but encouraging, with concrete suggestions for improvement. Preceptors are encouraged to provide feedback as close as possible to patient care events or procedures. Timely and effective feedback will enhance the learning experience and increase the new nurse’s confidence. It is important to note that there will be new team nurses that will required an extended orientation but will continue on to success. Plan ahead for this as you evaluate completion of weekly benchmarks.

5.       Ongoing Support 

At the conclusion of the nursing orientation period, the nurse manager should make plans for the future support of the new staff nurse. The assignment of a mentor or “buddy” provides a resource and a sounding board for clinical questions and debriefing. Any routine documentation audits should be explained throughout orientation so that expectations are clear. The annual evaluation process, along with any forms or documents, should be reviewed. Involvement in shared governance councils and unit projects will support retention and longevity of new staff nurses. Participation in unit activities and continuous learning are key to engagement and prevention of burnout.

Incorporation of these elements as part of nursing orientation provides structure for the initial onboarding, precepting, evaluation, and ongoing support of new staff nurses.  These practices are a worthwhile investment in teamwork, nurse satisfaction, and high quality patient care.

Learn About HealthStream's Online Nurse Orientation Training.


Susan’s experiences as a Magnet® Program Director and front line manager have re-ignited her passion for her profession. As a consultant at Creative Health Care Management, her greatest joy is mentoring individuals, teams, and hospitals to develop their gifts in pursuit of a culture of excellence. Susan’s professional interests include mission and vision development, project management, and transformational leadership through effective communication in addition to the development of structures and processes to support a Magnet® journey. Susan can be contacted at

Nurse Managers: The Formula for Building Strong Teams


By Traci Hanlon MN, RN, Consultant at Creative Health Care Management

Traci Hanlon, Consultant, Creative health Care ManagementI believe Nurse Managers have the toughest job on the planet. They are accountable for operations, budget, staff satisfaction, patient satisfaction, staffing, quality outcomes—heck, all outcomes! The buck stops with them. It is not acceptable to give in to excuses such as “I didn’t have time,” or” I forgot.” The reality is that their leadership can make the difference between a team that thrives and a team that dies. Teams that are disengaged and dissatisfied with their work are literally dangerous to patients. We know this from the research that reports that mistakes in interpersonal communication account for approximately 60 percent of all medication errors, and that every year 2 million (1 out of 20) patients contract a hospital acquired infection; 90,000 of these patients die. In the case of each of these infections, there was likely someone at some point who witnessed a team member not following protocol or not washing his or her hands. The Silence Kills study, conducted by VitalSmarts and AACN, point out that most nurses (64 percent) when confronted with a colleague who takes a short cut or does not follow protocol, do not speak up. Those are some tough statistics to be responsible for; and yet, nurse managers ARE responsible. For this reason (and others), it’s essential for nurse managers to cultivate high-trust cultures on their units. (Maxfield, D., Grenny, J., McMillan, R., Patterson, K., Switzler, A. (date). Silence kills: The seven crucial conversations for healthcare. Provo, UT: VitalSmarts.)

How does a nurse manager build a team where trust is so strong that teammates feel empowered to hold one another accountable for speaking up? Where skilled communication is a top competency alongside technical skill? Where teamwork is so engrained in the fabric of who individuals are that any patient’s call light is everyone’s call light?

The secret formula is an acronym I call KAER.

HealthStream Nurse Manager TrainingK stands for Kindness.

It is imperative that nurse managers embrace an authentic leadership style where transparency and kindness are guiding principles. Mangers who don’t walk their talk and treat employees as a means to an end will generate a culture of mistrust. Mistrust will lead to policies only being followed when the manager is on the floor. The true test of an authentic leader is what her staff are doing and saying when she is not there.

AE stands for Articulated Expectations.

Too often we think we have communicated clearly about what we expect from others, but what I find is that this is often where managers (myself included) miss the boat. We may tell our team members what we want or expect, but when one person does not meet the standard we set, and we do not follow through with consequences, we inadvertently set a new standard. The new standard is: “Yeah, she says we have to do x, y, and z, but nothing happens when we don’t, so it’s not really that important.” Michael Cohen says it beautifully when he says: “What we accept is what we teach.” When it comes to communication, I expect 100 percent of all communication with all people to be kind and respectful 100 percent of the time. The trick here is that my team and I had to define, in specific terms, what was considered kind and respectful and what was considered disrespectful communication. I let my team lead this. Top of the list? Eye rolling was considered to be disrespectful as was excessive complaining about a patient assignment. With this clear definition in place, when someone slipped, I helped to remind them what we agreed to as a team: that we would all communicate with kindness and respect and what that meant. I used a little tool called Commitment to My Co-workers, which outlined the basics of how we would all communicate, and then the team added things they felt were important. When I saw a pattern of someone not meeting that agreement, I followed up with consequences 100 percent of the time. The outcome? Our team held kind and respectful communication as a high priority and the expectations around that behavior were articulated and people were held accountable for sticking to them.

R stands for Respect.

Some people tell me this word speaks for itself, but I find that people hold onto the belief that you can’t respect someone if you don’t like them. I believe this is not true, and a belief I had to hold up and ask my team to examine very carefully. Respect is not about liking someone; it’s about recognizing their humanness.  At the very least, we can learn to separate a person’s behaviors from who they are as a person, and respect them as a human being with the same rights and needs we have.  Although I can’t mandate respect, I can mandate kind and respectful communication; asking my team to examine their beliefs around this value was the first step in helping them build a mindset that would ultimately set them up to address issues with people in a kind and respectful manner.  It’s true that there are some people who have the personality only a mother can love, but within all of us lies the capacity to have compassion for another human being and in the face of their unacceptable behavior, find the courage to ask ourselves, “What is going on with this person?” What piece of information do I not have that would lead me to understand why this person acts the way she does? It’s when we hold a compassionate space for each other that we get to know them and perhaps understand their pain in a way that allows us to see them not as a villain, but as another human being who needs our support and friendship. When we come from kindness, we are able to hold each other accountable for unacceptable behavior in a way that is less likely to be seen as an attack and more likely to be seen as a mutual agreement to help each other succeed. Let’s face it; we all have bad days where we slip up. I’m grateful for a team of people who care for me enough to gently and respectfully remind me when I do slip and help me bring my best self forward.


Traci Hanlon MN, RN is a consultant with Creative Healthcare Management and specializes in preceptor, nursing orientation, and transition to practice program development.

Creating Positive Change in Healthcare Through Appreciative Questions


Susan Wessle, Consultant, Creative Health Care ManagementBy Susan Wessel, RN, MS, MBA, NEA-BC, Consultant, Creative Health Care Management

Appreciative questions are a simple and effective way to inspire people and reinforce desired behavior. They can put a positive spin on huddles, staff meetings or during casual rounds with staff. They can be used during interviews or performance dialogues to draw out stories that will give you insight about the person. An example of an appreciative question is asking someone to tell you about his/her most fulfilling patient interaction in the last few days instead of asking about what challenges or obstacles they’ve faced. 

Amplify Positive Behaviors

The underlying principle behind the practice of asking appreciative questions is that you get more of what you choose to focus on. If you focus on problems and what is wrong, those things seem to fill everyone’s attention (and drag everyone down). If you discover and lift up what is going right, this creates positive energy and it also encourages those good practices to be done more intentionally. Appreciative questions are created to discover examples of things going well. The mere asking of them amplifies the positive behaviors you seek. 

The simple practice of appreciative questions is based on the philosophy of appreciative inquiry, developed by David Cooperrider and his colleagues (Cooperrider, D; Whitney, D; and Stavros, J. (2003). Appreciative Inquiry Handbook. San Francisco, CA: Berrett-Keohler). Appreciative inquiry is a multi-step method for leading change, with appreciative questions being only one part, a part that can be used easily in our daily lives. As leaders, part of our role is to find what’s right, acknowledge it with gratitude, and build on it. 

Appreciative Inquiries Focus on the Positive

An appreciative question is worded in such a way that it asks for examples of something positive. It conveys to others what is important to us, and the answers we receive provide a great opportunity to recognize and affirm the successes of others. We can create these questions specifically around things that we want to see happen more often. For example, if you want staff members to collaborate more effectively with physicians, you can create an appreciative question around that. Or you may want staff members to welcome and mentor new employees or to find out from patients and families what is most important to them. For any behavior that you want to affirm and encourage, you simply need to ask regularly for examples of staff having success with that desired behavior.  HealthStream Online Nursing Training

Examples of Appreciative Questions

Over the last six years I have collected examples of appreciative questions written by participants in our course on leading Relationship-Based Care. These are some of my favorites: 

  • Share a story of when your caring relationship with a patient made a difference for them.
  • Describe a time when your collaboration with a physician resulted in a positive outcome.
  • (Interview) Tell me about a time you made a difference for a patient or family that they especially appreciated.
  • Describe a situation when your clinical knowledge and critical thinking had a positive impact on a patient outcome.
  • In what ways have you been able to make a float person feel really welcome to your unit?
  • Who would you like to appreciate on your team today, and why?
  • Share an example of how bedside shift report improved your communication with patients.
  • What have you done this week that really helped a co-worker?
  • Share about a time when you incorporated a patient into the planning of his or her care.
  • Describe an example of how you exhibited patient advocacy.
  • What have you discovered about your patient’s main priority for this shift?
  • Describe a time when caring for a patient taught you something or positively changed how you provide care to other patients.
  • What went well with your patient care today?  

As you regularly use one or two of these, staff get used to them and have more answers readily available.  You may want to begin every huddle or every staff meeting with an appreciative question, so that everyone can hear several positive examples (teamwork, patient care that goes above and beyond, or whatever your question is about). 

Spreading Positive Energy

I often find myself making rounds on units in hospitals that are new to me. I always begin with an appreciative question to the manager, and it sets the stage for a relaxed and positive experience. For those situations, I like to ask, “What are you most proud of having accomplished on this unit?” It’s a great way to spread positive energy. 

As a consultant at Creative Health Care Management, Susan partners with hospitals to improve patient care through the design and implementation of Relationship-Based Care. She develops leadership teams to build trust, collaboration, and personal accountability. She also specializes in creating an engaged workforce and building professional practice environments consistent with Magnet® Recognition criteria. Contact Susan at


[1] Cooperrider, D, Whitney, D and Stavros, J. (2003). Appreciative inquiry handbook. San Francisco, CA: Berrett-Keohler.

Writing a Healthcare Competency: How Detailed Should You Get?


By Donna Wright, MS, RN, Consultant at Creative Health Care Management

Donna Wright, Consultant, Creative Health Care ManagementI get many questions from people about how detailed to get when writing a healthcare competency statement. Should you write a competency statement and then add a sub-set of details that reflect all the skill aspects of that competency or details that describe the steps of a given procedure? The answer to this is, “Not necessarily.”

When measuring a healthcare competency, it is important to be specific about the objective measurement that will be used to assess the competency. However, the articulation of the objective measure that will be assessed in the competency does not necessarily have to appear in the competency documentation. Here are some examples of how to indicate the details without adding them to the competency statement:

Competency statement:

Assess the individual’s ability to start an IV, using procedure number 33.14.2 of the policy manual. 

  • You see the detail of the procedure is indicated in a reference to the policy manual without writing all of the details into the statement itself.
  • This approach also decreases the challenge of having to update both procedure and competency lists when practice changes. 

Competency statement:HealthStream Competency Center

Demonstrate the ability to safely mix the XYZ medication for IV administration, using the preparation poster in the medication room. 

  • Again, you have specified the details of the competency through the reference tool you want people to use when doing this action.
  • This approach is also better because you are teaching people to use the reference tool you want them to use every day. If you put the details in the competency documentation, you bypass the reference tool, and therefore do not teach and reinforce the reference tool. 

Competency statement:

Demonstrate the ability to manage a difficult customer service encounter where a family member or visitor is aggressively demanding or their behavior is escalating.

Use either the “difficult customer service encounter exemplar form” or the case study packet on “difficult customer service encounters.” 

  • This competency has two possible verification methods. Each of the verification methods is a specific tool that has the expectations, details, and policy indicated in it. You do not just write “case study” in the verification method list, but instead you indicate the specific case study on “difficult customer service encounters.” 

In summary, a healthcare competency statement does not have to indicate specifically all of the details themselves as long as it indicates where the details to complete the competency can be found. If the competency statement refers to details that can be found elsewhere, you can avoid the mess of plugging up your documentation on the competency record with all the steps or details of a particular competency. And, as in two of the examples above, pointing out the details in another location actually helps to make people aware of reference tools and information systems in your organization and reinforce their use. 

A staff development specialist known for her irreverent wit, Donna brings a global perspective to her work. In this country and in the over two dozen others, Donna’s best known for the work she does based on two of her books, The Ultimate Guide to Competency Assessment and Relationship-Based Care (co-authored with several CHCM colleagues). The Ultimate Guide has become the industry standard for HR departments in establishing and assessing competency, and Donna specializes in setting up systems for organizations to ensure accountability and measure competency.

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