Nationally, new hires make up 30% of all health care turnover. One reason new hires leave is if they don’t have strong relationships with their peers. But leaders often struggle to detect the uncivil behavior among frontline staff that can drive new hires away (not to mention make the work environment worse for more tenured staff).

Saint Luke’s Health System, a 10-hospital system in Kansas and Missouri, uses results from a brief survey of float pool staff to generate a unit-level civility index. This index helps leaders and staff pinpoint hotspots of incivility—which empowers them to address the issues.

We recently spoke with Jamie Luark, System Director of Educational Services at Saint Luke’s Health System, to learn more about the index and how it supports Saint Luke’s efforts to improve nurse retention.

Read on for:

• Survey Goals and Process
• Using the Index
• Results

Survey goals and process

Q: What do you hope to achieve through surveying float pool staff about the work environment?

A: We believe that if we can get a nurse through the door, we can make them a Saint Luke’s nurse for life. That strategy permeates our entire organization: we’ve designed our website around that goal, we talk about being a Saint Luke’s nurse, and we tell stories about being a Saint Luke’s nurse. It is for this reason that we created the Unit Civility Index, as a way to improve work environments and, ultimately, promote retention.Many times the manager, as well as the core unit staff, will be working in the same environment for so long that they don’t realize that the environment is no longer the way we want it to be. The index operates on the belief that if we can make a better environment, then people are going to want to stay. Float pool staff are the perfect people to provide an outside perspective on the environment (since they tend to have experience working in many types of environments, with some better than others).

We use the “Heavenly Seven” questions for the survey, developed and copyrighted by Dr. Cole Edmonson, DNP, RN, FACHE, NEA-BC, FAAN and Joyce Lee, MSN, RN at Texas Health Presbyterian Hospital Dallas. The questions are included in the “Stop Bullying Toolkit,” available free of charge online at stopbullyingtoolkit.org. The toolkit was developed by an Action Learning Group of the 2012 Robert Wood Johnson Foundation Executive Nurse Fellows program.We ask float pool nurses to rate their agreement with the following statements, based on their last shift:

1. I felt welcome on the unit
2. Someone offered help when I needed it
3. If floated again, I would enjoy returning to this unit
4. I had the resources I needed to complete my assignment
5. I witnessed someone expressing appreciation to another for good work
6. Staff showed concern for my well-being
7. I received appreciation for my work

Q: When do you conduct this survey, and who completes it?

A: We email the survey out every other week on alternating days. One week, we send it out on Mondays, and the next week, we send it out on Thursdays. We do this to make sure we’re capturing responses at different times of the week (so people can’t dismiss the results as being dependent on the day of the week). We use Survey Monkey.

Float pool nurses and unit-based staff with regular float requirements complete the survey.

Q: Who is in charge of receiving and interpreting the survey data?

A: We have a nursing quality data analyst, and she plays a very important role. We have so much data to intake and analyze, and it’s key to have someone who understands data management and analysis. She puts all the data in a simple tool that allows us to benchmark against ourselves (given that there’s no national benchmark). It really doesn’t do you much good if you know your civility score is a “three” but you don’t know what a three means.

Then we look across six quarters to see if we have trends in the scores across each unit. Six quarters was an arbitrary choice, but we felt it gave us enough time to best assess the data’s messages.

Q: You introduced a Bully-Free Workplace Contract alongside the Unit Civility Index. What are the advantages to pairing these two rollouts?

A: We rolled out the Unit Civility Index in 2015, and I think the key to its success is that we rolled it out alongside our Bully-Free Workplace Contract, a very direct policy about bullying and what kinds of behaviors are bullying.

This policy gives staff a clear outline of what behavior is not acceptable in our organization. This initiative was a partnership with our HR team. They were on board with rolling out some very descriptive language with that policy, which ultimately made it easier for us to implement the Unit Civility Index.

Using the index

Q: What do you do with results from the survey?

A: We compile the survey results into an index and track that on a quarterly basis. Each quarter we send this information out to managers and directors, and we give managers the freedom to share results however they choose.

Some managers decide to address the results during staff meetings, while others choose to post them on their unit’s huddle board. The directive is to get the information to frontline staff because we want to be transparent--the data is about their working environment, not the managers’.

When using our results tool, managers can choose to benchmark themselves against specific unit types across our facilities. A common story we tell ourselves is “the community hospital has it better” because they’re in a better part of the city than the academic medical center downtown, but the truth is, we find that there’s a lot of similarity across them. The ability to slice and dice the data any way you want has really helped to get rid of stories justifying low performance.

We teach that if your scores are low, it’s not that your unit is “bad.” The goal is to find ways to change how your unit is perceived. This is a key message we want managers to hear.

Q: How have units used feedback to change the working environment?

A: One example that comes to mind: we had a unit consistently scoring low, and the manager and her unit couldn’t figure out why. The manager asked a couple of strong float pool nurses to come tell the unit why they were scoring so low, and the unit found the biggest problem was indifference. Nobody seemed to care when staff joined the unit. They would simply say, “Your patients are there, go take care of them.” People rarely said hello or thank you.

The staff appreciated that the feedback was so actionable, and they made it a campaign. They worked with their charge nurses to identify when float pool nurses were on the unit. Core staff then intentionally made a point to say hello to the float pool nurses on their unit. Then at the end of the day, the charge nurses did rounds to whoever was floating to say thank you for coming to the unit and acknowledging their contribution. The next quarter, this unit’s scores went up exponentially. It’s a simple thing, but if we didn’t have this index, I don’t know that the unit would have changed.

Q: Since managers share these results with frontline nurses, how do you help frontline nurses interpret the results?

A:That took a bit of conversation, because we don’t want our unit-based staff to blame float pool nurses. We had to have a lot of conversation promoting the notion that feedback is a gift, a gift that allows you to improve things that you are unaware of.

Second, it’s important to ensure fair assessments. When managing the float pool, you have to have a commitment to truth. For example, the story might be: “I had a harder assignment than anyone else,” when the truth is that it was just a hard day for the entire unit. We work really hard to drill down to what the truth is, and then make decisions based on the truth and not the story.

Results

Q: What results have you seen since first implementing the Unit Civility Index?

A: This is not our only initiative focused on retention and so our results are not completely based on the index, but we did see an increase in our RN retention. In 2015 we went from 87% to 92% and as of 2017 we are at 93% (93.6% for our recent graduates after their first year). We are really proud of these numbers because in our labor market, when we lose a nurse we cannot guarantee their replacement.

We have also found that if a unit has a single quarter that is low on our Unit Civility Index, it does not correlate to our employee engagement survey results. However, if we have a unit that is consistently scoring lower, it does correlate with our engagement scores.

Q: What steps have you taken to ensure that this practice remains sustainable?

A: One of our tactics is having intentional conversations. The first of these conversations, which I touched on above, was with our core staff: They need to understand that this feedback is a gift, and to utilize this gift requires some work. Units first need to figure out why their scores might be a little bit lower, and then they must be proactive about improving the unit’s environment. We empowered our frontline staff, as well as our managers, to change their world. They can’t change the whole organization, they can’t change the whole system – that’s just too big. But they can change their unit and their world.