JNPD
Preceptorship Column Editor: Mary Beth Modic, DNP, RN, CNS, CDE
Analyzing Performance DiscrepanciesVPart 2
I
n the previous column, the MagerYPipe Analysis Model was presented as an approach to distinguish learning needs from performance problems. Fifteen performance discrepancies were listed. You, the reader, were asked to review each discrepancy and assign a possible explanation for the behavior using the five categories described by Mager and Pipe (1997) in their model. The five categories include ‘‘KSD’’ for knowledge or skill deficiency, ‘‘O’’ for obstacles, ‘‘PP’’ for performance punishing, ‘‘NPR’’ for non-performance rewarding, and ‘‘PM’’ for performance matters.
KNOWLEDGE/SKILL DEFICIENCY Of the 15 behaviors presented, three can be attributed to a knowledge or skill deficiency. The behaviors are treating a low blood sugar with 8 ounces of juice and four added packets of sugar, teaching a patient with heart failure that weighing herself once a week is acceptable, and applying a VAC dressing incorrectly. These are considered knowledge/skill deficiencies for several reasons: These interventions require practice, feedback, and continued refinement. These interventions require a degree of sophistication in knowledge, and progress toward mastery is easily discernible. To address a knowledge or skill deficiency, Mager and Pipe (1997) purported the importance of education, practice, and feedback. Providing structured education and practice is an effective approach in addressing a learning gap. Providing helpful feedback can be challenging, however. Stone and Heen (2014), in their book ‘‘Thanks for the Feedback: The Art and Science of Receiving Feedback Well,’’ describe three types of feedback: appreciation, coaching, and evaluation. Appreciation is given to acknowledge, motivate, and express gratitude for effort and contribution. Coaching feedback is offered to increase knowledge, expand perspective, and refine a skill. Evaluation feedback is provided to rate a skill or an action against established competencies, convey value, and establish expectations. Mary Beth Modic, DNP, RN, CNS, CDE, is Clinical Nurse Specialist, Cleveland Clinic, Ohio. E-mail: [email protected]. The author has disclosed that she has no significant relationships with, or financial interest in, any commercial companies pertaining to this article. DOI: 10.1097/NND.0000000000000181
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OBSTACLES Four behaviors from the list can be ascribed to obstacles. These behaviors include failing to document a patient’s pressure ulcer, administering patients’ medication ‘‘late,’’ not recognizing a patient’s change in blood pressure, and promising to help the nursing assistant and not following through with offer of help. These behaviors are all omissionsVfailure to note, failure to document, failure to follow through. Obstacles can originate from time pressures, conflicting time demands, peer pressure to perfect performance, or different messages from different preceptors on what and how to prioritize. Mager and Pipe (1997) recommend the following strategies to minimize obstacles: n Help the orientee discover opportunities to better manage time by conducting a time study. Observe and record what the orientee is doing at 15- to 20-minute intervals. n Explore what aspects of care are most time-consuming for the orientee. n Minimize interruptions so that the orientee can concentrate on the specific tasks that are time sensitive. Rearrange priorities or shift some responsibilities n temporarily. n Promise and provide more coaching and support. n Rectify the problem that is causing delaysVproperly working equipment and available medications. Arrange a temporary process for staying in touch more n frequently throughout the day. PERFORMANCE PUNISHING Admitting a patient to the ICU and becoming completely flustered could be considered performance punishing. Soliciting more information as to the underlying, cause of the nurse’s distress is warranted in this situation. Occasionally, orientees are progressed through orientation more quickly because they exude confidence or are technically proficient. They may be assigned more complex patients than they feel prepared to manage. Orientation is a critical time in a nurse’s career, so opportunities for self-reflection and contemplation should not be minimized in lieu of acquiring technical prowess. Performance punishing is subtle. Most often, it is unintentional. Suggested techniques
www.jnpdonline.com
May/June 2015
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
by Mager and Piper (1997) to address performance punishing include the following: n Discuss and identify the specific concerns the orientee has about her assignment. n Explore the orientee’s satisfaction with the pace of orientation. n Acknowledge contributions. n Affirm mastery of skills and display of clinical judgment. n Readjust/reevaluate the patient care assignment. n Arrange for to the orientee to have a preceptor available if her confidence wanes.
NON-PERFORMANCE REWARDING One behavior falls into this categoryVtelling a fellow orientee that he is bored with the pace of orientation. This nurse may not be advancing because he is not meeting current expectations. His preceptor may not believe that he can manage a more complex assignment, so he is being ‘‘rewarded’’ with less work. He may be receiving more attention for failing to meet expectations. Strategies offered by Mager and Pipe (1997) to address non-performance rewarding include the following: n Elicit the orientee’s perception of his performance. n Explore the disparities in performance. n Collaborate on a revised orientation plan. n Provide more coaching and support. n Identify opportunities to provide feedback. PERFORMANCE MATTERS The remaining behaviors are categorized as performance matters issues: ignoring the nursing assistant’s report of a patient’s pain rating of ‘‘7,’’ being unprepared for a patient care conference, taking an hour for lunch on 3 consecutive days, leaving patients’ medications at the bedside when patients remark they ‘‘will take them later,’’ overlooking patient’s weight loss in ‘‘hand-off communication’’ for 2 consecutive days, and responding to a patient’s wife complaint with ‘‘I hear what you are saying, but in all honesty, your expectations for your husband’s care are just too unrealistic.’’ These behaviors are not knowledge or skill deficits. None of these behaviors meet established work norms of safe practice. These behaviors are often challenging for novice preceptors because they require crucial conversations, and the provision of evaluative feedback. The following tips are helpful in addressing these performance discrepancies with the orientee: n Describe the performance discrepancy. n Convey respect and positive regard. n Ask for a self-assessment. n Explore motivations for current behavior. n Identify alternative ways of behaving. n Clarify expectations and misunderstandings.
n Solicit feedback for ways to be more supportive and helpful. n Listen intently. n Use empathy. n Describe the acceptable work behaviors unequivocally. n Seek future opportunities to offer appreciative feedback (Mager & Pipe, 1979). The MagerYPipe Performance Analysis Model offers a different lens to assess performance discrepancies. Rather than devoting energies to reteaching, time can be directed at accurately identifying the genesis of the problem. As a result, problem resolution strategies can be crafted that are timely, individualized, and collaborative. Listed below are the answers to the performance discrepancies. 1. __PP__ Admitting a patient to the ICU and becoming completely flustered. 2. ___O__ Failing to document a patient’s pressure ulcer. 3. ___O__ Administering patients’ medication ‘‘late.’’ 4. ___O__ Not recognizing a patient’s change in blood pressure. 5. __PM_ Ignoring the nursing assistant’s report of a patient’s pain rating of ‘‘7.’’ 6. __KSD_ Treating a low blood sugar with 8 ounces of juice and four added packets of sugar. 7. __KSD_ Teaching a patient with heart failure that weighing herself once a week is acceptable. 8. __NPR_ Telling a fellow orientee that he is bored with the pace of orientation. 9. __PM__ Being unprepared for a patient care conference 10. __ PM__ Taking an hour for lunch on 3 consecutive days. 11. __O___ Promising to help the nursing assistant and not following through with offer of help. 12. __PM__ Leaving patients’ medications at the bedside when patients remark they ‘‘will take them later.’’ 13. __KSD_ Applying a VAC dressing incorrectly. 14. __PM__ Overlooking patient’s weight loss in ‘‘hand-off communication’’ for 2 consecutive days. 15. __PM__Responding to a patient’s wife complaint with ‘‘I hear what you are saying, but in all honesty, your expectations for your husband’s care are just too unrealistic.’’ KSD = knowledge or skill deficiency O = obstacles PP = performance punishing NPR = non-performance rewarding PM = performance matters References Mager, R., & Pipe, P. (1997). Analyzing performance problems or you really oughta wanna (3rd ed.). Atlanta, GA: CEP Press. Stone, D., & Heen, S. (2014). Thanks for the feedback: The science and art of receiving feedback well. New York, NY: Viking Press.
Journal for Nurses in Professional Development
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
www.jnpdonline.com
181
Preceptorship Column Editor: Mary Beth Modic, DNP, RN, CNS, CDE
Analyzing Performance DiscrepanciesVPart 2
I
n the previous column, the MagerYPipe Analysis Model was presented as an approach to distinguish learning needs from performance problems. Fifteen performance discrepancies were listed. You, the reader, were asked to review each discrepancy and assign a possible explanation for the behavior using the five categories described by Mager and Pipe (1997) in their model. The five categories include ‘‘KSD’’ for knowledge or skill deficiency, ‘‘O’’ for obstacles, ‘‘PP’’ for performance punishing, ‘‘NPR’’ for non-performance rewarding, and ‘‘PM’’ for performance matters.
KNOWLEDGE/SKILL DEFICIENCY Of the 15 behaviors presented, three can be attributed to a knowledge or skill deficiency. The behaviors are treating a low blood sugar with 8 ounces of juice and four added packets of sugar, teaching a patient with heart failure that weighing herself once a week is acceptable, and applying a VAC dressing incorrectly. These are considered knowledge/skill deficiencies for several reasons: These interventions require practice, feedback, and continued refinement. These interventions require a degree of sophistication in knowledge, and progress toward mastery is easily discernible. To address a knowledge or skill deficiency, Mager and Pipe (1997) purported the importance of education, practice, and feedback. Providing structured education and practice is an effective approach in addressing a learning gap. Providing helpful feedback can be challenging, however. Stone and Heen (2014), in their book ‘‘Thanks for the Feedback: The Art and Science of Receiving Feedback Well,’’ describe three types of feedback: appreciation, coaching, and evaluation. Appreciation is given to acknowledge, motivate, and express gratitude for effort and contribution. Coaching feedback is offered to increase knowledge, expand perspective, and refine a skill. Evaluation feedback is provided to rate a skill or an action against established competencies, convey value, and establish expectations. Mary Beth Modic, DNP, RN, CNS, CDE, is Clinical Nurse Specialist, Cleveland Clinic, Ohio. E-mail: [email protected]. The author has disclosed that she has no significant relationships with, or financial interest in, any commercial companies pertaining to this article. DOI: 10.1097/NND.0000000000000181
180
OBSTACLES Four behaviors from the list can be ascribed to obstacles. These behaviors include failing to document a patient’s pressure ulcer, administering patients’ medication ‘‘late,’’ not recognizing a patient’s change in blood pressure, and promising to help the nursing assistant and not following through with offer of help. These behaviors are all omissionsVfailure to note, failure to document, failure to follow through. Obstacles can originate from time pressures, conflicting time demands, peer pressure to perfect performance, or different messages from different preceptors on what and how to prioritize. Mager and Pipe (1997) recommend the following strategies to minimize obstacles: n Help the orientee discover opportunities to better manage time by conducting a time study. Observe and record what the orientee is doing at 15- to 20-minute intervals. n Explore what aspects of care are most time-consuming for the orientee. n Minimize interruptions so that the orientee can concentrate on the specific tasks that are time sensitive. Rearrange priorities or shift some responsibilities n temporarily. n Promise and provide more coaching and support. n Rectify the problem that is causing delaysVproperly working equipment and available medications. Arrange a temporary process for staying in touch more n frequently throughout the day. PERFORMANCE PUNISHING Admitting a patient to the ICU and becoming completely flustered could be considered performance punishing. Soliciting more information as to the underlying, cause of the nurse’s distress is warranted in this situation. Occasionally, orientees are progressed through orientation more quickly because they exude confidence or are technically proficient. They may be assigned more complex patients than they feel prepared to manage. Orientation is a critical time in a nurse’s career, so opportunities for self-reflection and contemplation should not be minimized in lieu of acquiring technical prowess. Performance punishing is subtle. Most often, it is unintentional. Suggested techniques
www.jnpdonline.com
May/June 2015
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
by Mager and Piper (1997) to address performance punishing include the following: n Discuss and identify the specific concerns the orientee has about her assignment. n Explore the orientee’s satisfaction with the pace of orientation. n Acknowledge contributions. n Affirm mastery of skills and display of clinical judgment. n Readjust/reevaluate the patient care assignment. n Arrange for to the orientee to have a preceptor available if her confidence wanes.
NON-PERFORMANCE REWARDING One behavior falls into this categoryVtelling a fellow orientee that he is bored with the pace of orientation. This nurse may not be advancing because he is not meeting current expectations. His preceptor may not believe that he can manage a more complex assignment, so he is being ‘‘rewarded’’ with less work. He may be receiving more attention for failing to meet expectations. Strategies offered by Mager and Pipe (1997) to address non-performance rewarding include the following: n Elicit the orientee’s perception of his performance. n Explore the disparities in performance. n Collaborate on a revised orientation plan. n Provide more coaching and support. n Identify opportunities to provide feedback. PERFORMANCE MATTERS The remaining behaviors are categorized as performance matters issues: ignoring the nursing assistant’s report of a patient’s pain rating of ‘‘7,’’ being unprepared for a patient care conference, taking an hour for lunch on 3 consecutive days, leaving patients’ medications at the bedside when patients remark they ‘‘will take them later,’’ overlooking patient’s weight loss in ‘‘hand-off communication’’ for 2 consecutive days, and responding to a patient’s wife complaint with ‘‘I hear what you are saying, but in all honesty, your expectations for your husband’s care are just too unrealistic.’’ These behaviors are not knowledge or skill deficits. None of these behaviors meet established work norms of safe practice. These behaviors are often challenging for novice preceptors because they require crucial conversations, and the provision of evaluative feedback. The following tips are helpful in addressing these performance discrepancies with the orientee: n Describe the performance discrepancy. n Convey respect and positive regard. n Ask for a self-assessment. n Explore motivations for current behavior. n Identify alternative ways of behaving. n Clarify expectations and misunderstandings.
n Solicit feedback for ways to be more supportive and helpful. n Listen intently. n Use empathy. n Describe the acceptable work behaviors unequivocally. n Seek future opportunities to offer appreciative feedback (Mager & Pipe, 1979). The MagerYPipe Performance Analysis Model offers a different lens to assess performance discrepancies. Rather than devoting energies to reteaching, time can be directed at accurately identifying the genesis of the problem. As a result, problem resolution strategies can be crafted that are timely, individualized, and collaborative. Listed below are the answers to the performance discrepancies. 1. __PP__ Admitting a patient to the ICU and becoming completely flustered. 2. ___O__ Failing to document a patient’s pressure ulcer. 3. ___O__ Administering patients’ medication ‘‘late.’’ 4. ___O__ Not recognizing a patient’s change in blood pressure. 5. __PM_ Ignoring the nursing assistant’s report of a patient’s pain rating of ‘‘7.’’ 6. __KSD_ Treating a low blood sugar with 8 ounces of juice and four added packets of sugar. 7. __KSD_ Teaching a patient with heart failure that weighing herself once a week is acceptable. 8. __NPR_ Telling a fellow orientee that he is bored with the pace of orientation. 9. __PM__ Being unprepared for a patient care conference 10. __ PM__ Taking an hour for lunch on 3 consecutive days. 11. __O___ Promising to help the nursing assistant and not following through with offer of help. 12. __PM__ Leaving patients’ medications at the bedside when patients remark they ‘‘will take them later.’’ 13. __KSD_ Applying a VAC dressing incorrectly. 14. __PM__ Overlooking patient’s weight loss in ‘‘hand-off communication’’ for 2 consecutive days. 15. __PM__Responding to a patient’s wife complaint with ‘‘I hear what you are saying, but in all honesty, your expectations for your husband’s care are just too unrealistic.’’ KSD = knowledge or skill deficiency O = obstacles PP = performance punishing NPR = non-performance rewarding PM = performance matters References Mager, R., & Pipe, P. (1997). Analyzing performance problems or you really oughta wanna (3rd ed.). Atlanta, GA: CEP Press. Stone, D., & Heen, S. (2014). Thanks for the feedback: The science and art of receiving feedback well. New York, NY: Viking Press.
Journal for Nurses in Professional Development
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
www.jnpdonline.com
181
