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Managers Forum
Managers Forum Section Editor: Polly Gerber Zimmermann, RN, MS, MBA, CEN
GENERATION X STAFF ■ I am having difficulty understanding my “Generation X” employees. What insight can you offer? Answer No. 1 People born since 1965 (eg, “twentysomethings”) are frequently called “Generation Xers,” a term that refers to the fact that they are the 10th generation to come of age in this century. These are some of the distinguishing characteristics of Generation Xers and how to handle them: Marilyn Moats Kennedy 1. Generation Xers are far less optimistic about their future than are baby boomers. They expect future problems; they worry about whether they have the right skills and other attributes to achieve their personal version of success. Respond by teaching them organizational savvy and helpful skills. 2. Generation Xers count every dollar because they never feel financially secure. They are skeptical customers who want a good value for their dollar. Show them the worth of purchases, such as a required educational class. 3. Generation Xers abhor vagueness. Expect questions; be prepared to give detailed explanations. 4. Generation Xers are not joiners and are extremely protective of their time. Being authentic and working hard, not social skills, were emphasized as they were growing up. Plan educational activities that are informative; specifically outline any The opinions expressed are those of the respondents and should not be construed as the official position of the institution, ENA, or the Journal. J Emerg Nurs 2000;26:493-501. Copyright © 2000 by the Emergency Nurses Association. 0099-1767/2000 $12.00 +0 18/9/108352 doi:10.1067/men.2000.108352
time commitment required. You must take the initiative for promoting interactions. 5. Generation Xers tell it like it is. They communicate directly, almost abruptly. They view a euphemistic style as manipulative. Don’t say, “Would you mind doing this?” when you really mean, “You must do this.” Make your point succinctly for effective communication and give particular emphasis on the “why.” Make use of their preferred communication means—the Internet (chat rooms, Web sites) and E-mail. This group is different but valuable. If they believe something will make a difference, they will be loyal.1—Marilyn Moats Kennedy, Managing Partner, Career Strategies (a management and career consulting company), Wilmette, Ill; E-mail: MMKCareer @aol.com Reference 1. Kennedy MM. Recruiting and retaining cross-generational membership. Forum 1999;83:10, 11, 24.
Answer No. 2 Managers need to realize that Generation X employees must be managed differently. Although many management tips are applicable for all employees, some are particularly essential for Generation X employee retention. Studies have shown that some of the things managers do that particularly Claire Raines, MA drive the Generation X employee crazy are as follows: 1. Giving insincere, gratuitous “thank you’s” 2. Throwing people into jobs they are not trained for or qualified to perform 3. Allowing the workplace to be disorganized, cluttered, or dirty 4. Overlooking unacceptable behavior from other staff members
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5. Ignoring employees’ opinions and ideas I have identifed 7 “X” requisites, that is, the most frequent requests Generation Xers make of their managers. Practicing these requisites is pivotal to your success. They include the following: 1. Appreciate us. Generation Xers want you to show them that you care by providing them with personal attention. They want to feel that they are making a difference. 2. Be flexible. Generation Xers like scheduling options that accommodate their personal lives. 3. Create a team. More than 50% of Generation X employees were latchkey children. They want you to give them the family they never had. Creating a team includes holding regular staff meetings. 4. Develop us. Generation Xers want you to help them increase their skills because they see themselves as a commodity. Developing them includes perceiving a potential for internal promotion. They like to spend time with a manager. 5. Involve us. Generation Xers want their opinions to be asked for and heard, even if you disagree with them. They do not believe they need to “pay their dues” before they have a right to speak. 6. Lighten up. Generation Xers want managers who are relaxed and fun. 7. Walk your talk. Generation Xers want to see you practice what you preach and deal with problems.
With today’s shrinking pool of workers and the high cost of hiring and training, retaining workers is essential. Adjusting to the different attitude of your Generation X employees may be difficult, but it is worth the effort. The attributes for which Generation Xers are known will be an asset to your team. These attributes include handling changes well, being comfortable with technology, being independent, being financially savvy, not being intimidated by authority, and being creative. With today’s shrinking pool of workers and the high cost of hiring and training, retaining workers is essential. 1—Claire Raines, MA, author and expert on the generations, Denver, Colo; E-mail: [email protected]
Answer No. 3 I have found that it is necessary for the recruiting job interview to include the expected orientation obligations, such as required training classes, competency testing, attaining certification, and/or shift rotations. In the past, newly hired nurses used to just cope with the inherent demands. Generation X nurses will leave when they feel there are unexpected obligations. Generation X nurses want the job to continually provide learning and creative challenges. Employability is more important to them than a specific job position. Providing educational opportunities is essential to retention. However, I have learned to modify my educational style to be effective. Generation Xers like entertaining presentations with games (eg, Jeopardy), cooperative team participation, visual aids, and scenarios with discussion. They respond well to self-learning opportunities, such as a computer course, as long as objectives and deadlines are clearly set. Generation Xers need to perceive that the presented information or required assignment is clinically relevant. Baby boomers (born between 1946 and 1964), ask, “Is this information true?” Generation Xers instead question, “What use is this information to me?” For instance, the Generation X ED orientees I had resisted spending time in the ICU until I explained the benefit of having hands-on experience with central lines. Some helpful tips I use in managing Generation X nurses include the following: • Offering fast, frequent feedback. Especially in the beginning, we met together every 1 or 2 weeks. They want to know specifically what they have done well and desire guidance about potential growth areas. • Providing individualized attention. Many Generation Xers grew up with 2 busy, working parents and appreciate any personal actions, such as a handwritten note. • Allowing limited time for on-the-job socialization. Rather than wasting time, on-the-job socialization will contribute to productivity. Generation Xers want to feel part of a team. Two books I have found helpful are Beyond Generation X: A Practical Guide for Managers1 and Generation X Goes to College.2—Patty Sturt, RN, MSN, CEN, Staff Development Specialist, Emergency Department, University of Kentucky Hospital, Lexington, Ky
Reference
References
1. Raines C. Beyond generation X: a practical guide for managers. Menlo Park (CA): Crisp Publications; 1997.
1. Raines C. Beyond generation X: A practical guide for managers. Menlo Park, CA: Crisp Publications; 1997.
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2. Sacks P. Generation X goes to college. Chicago (IL): Open Court Publishing; 1996.
that only properly certified individuals perform suturing. As a result of our program, no JCAHO accreditation problems about this limited scope of expanded practice have occurred.
Some nurses have been trained to perform digital blocks because this service would be needed in a deployment situation.
LTC Nanette A. Hill and EMS staff at William Beaumont Army Medical Center, Ft Bliss, El Paso, Tex
SUTURING ■ Do other emergency departments have someone other than physicians perform suturing, and if so, how do they handle the training? Answer No. 1 The Army must maintain its medical personnel’s battlefield skills to fulfill its wartime mission. Even during month-long training exercises in remote areas, wartime conditions are simulated with only a medic and physician assistant for basic medical needs. The dilemma is how to do that within the hospital setting and Joint Commission of Accreditation for Healthcare Organizations (JCAHO) regulations. We have solved that by establishing a suturing certification program for our medics. Some nurses have also been certified but usually do not perform suturing because their time is focused on higherskilled needs, such as medication administration or management of a trauma patient. The program includes independent preparation, didactic lectures, practicum, and then direct evaluation by a physician. Staff members use a suture study guide, attend a physician-taught class, and practice on pigs’ ears or feet. They then must be observed 3 times by a physician who determines whether they are competent to suture without direct supervision. The emergency physicians retain the responsibility to decide when a patient needs sutures and always do any suturing on the face, hands, or joints. The system also has a built-in check through the nursing education department, which maintains an education folder for each staff member and verifies
Medics do not use topical liquid skin adhesive (Dermabond) or apply staples. Registered nurses and medics are trained to remove staples and sutures. Some nurses have been trained to perform digital blocks because this service would be needed in a deployment situation, but they do not currently do this in our hospital emergency department. Saving the physician’s time is a big benefit from this program. Suturing of simple lacerations by medics helps free up our limited professional staff.—LTC Nanette A. Hill, RN, MS, CEN, Chief, Emergency Medical Services, William Beaumont Army Medical Center, Ft Bliss, El Paso, Texas Answer No. 2 Some of our physicians have informally instructed interested registered nurses on suturing basic lacerations when scarring is not a concern. The physician stays in the room to supervise and to assume responsibility for the nurse’s performance. Anecdotally, there have been no follow-up wound complications with any suturing performed by nurses. Suturing performed by nurses has not been an issue with JCAHO visits, but we would develop a more formalized program to allow it to continue if it was a problem. The reality is that nurses frequently administer potent medications and perform procedures with potentially serious complications on the basis of their nursing training and licensure. Suturing is a manual dexterity skill rather than a complex application of advanced knowledge. Our physicians support capable nurses in assuming this task within an appropriate scope.—Anthony Laviano, RN, CEN, ED Nurse Manager, Spring Hill Regional Hospital, Spring Hill, Fla Answer No. 3 In Hong Kong, nurses with at least 2 to 3 years’ emergency nursing experience generally are trained in suturing techniques for superficial wounds, including wounds located on the face, hand, and fingers, as well as on the more traditional areas of scalp,
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Wai Kwong Poon, RN Dip, GN, MBA, PhD(c)
extremities, and so on. They also apply Dermabond and remove superficial foreign bodies. However, they do not perform suturing when there is tendon involvement. The 6-month training course includes 16 contact hours of instruction, suturing of 15 patients with direct supervision, and suturing of 15 patients reviewed by a trainer before the patient’s discharge. We undertook a study, the first of its kind in Hong Kong, to evaluate the results of this standard procedure. Patients returned to the emergency department for suture removal so that the condition of the wound could be assessed. Evaluation criteria included the condition of the wound (including discharge), edge approximation, functional ability, and patient teaching as evidenced by the patient’s compliance. Our study included 118 follow-up patients. We had 100% good wound edge approximation and function and 91% patient compliance. A purulent discharge was present in only 2 wounds. We concluded that trained registered nurses can independently provide capable wound suturing and care in the defined limitations.—Wai Kwong Poon, RN Dip, GN, MBA, PhD(c), Instructor and Staff Nurse, Accident & Emergency Department, Queen Elizabeth Hospital, Kowloon, Hong Kong; E-mail: [email protected]
PRECEPTING ■ How do other emergency departments handle arranging and motivating capable seasoned nurses to act as preceptors for new employees or trainees? Answer No. 1 The availability of excited, excellent preceptors is an issue for us because our large trauma facility attracts many nurse applicants who come to obtain ED experience. I found that some of the most experienced staff members are not willing to spend
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the necessary time in new trainee development. In addition, it is a skill to be able to share one’s expertise at a level in line with the trainee’s current ability. We provide “perks” to our preceptors on completion of the new employee’s orientation. The rewards include grab bags with goodies, donated by volunteer services, such as car wash tickets, dinner at a local restaurant, or movie tickets. We provide educational opportunities for our consistent, energetic preceptors. The department pays for all of their verification courses (Trauma Nursing Core Course [TNCC], Emergency Nursing Pediatric Course [ENPC], etc). In addition, each year the manager sends 3 nurse preceptors, with all their expenses paid, to the ENA Annual Meeting. I invite nurse preceptors to attend local educational offerings with me and/or get them involved in other opportunities, such as a task force. Thus they are rewarded with some “fun” activities, as well as gain skill- and career-building experiences. My concept of rewards for preceptors is based on my previous experience at another hospital. This hospital believed that good preceptors save the hospital money by developing satisfied, competent employees and ensuring that there is completed paperwork for the regulatory visits. The nurse’s precepting hours accumulated if the new orientee’s paperwork/checklist was completed on time and the orientee gave the preceptor a satisfactory evaluation rating. When preceptors obtained 500 hours, they were given a 12-hour vacation day.—Michael Wicklander, RN, Clinical Educator, Emergency Department, Hermann Hospital, Houston, Tex Answer No. 2 Our hospital provides incentives for experienced registered nurses who serve as preceptors or mentors for students. Our preceptor incentive program has 4 levels and a longevity (retention) bonus. With a level I preceptorship, the students are enrolled in a school of nursing with which we have an established teaching/clinical affiliation. This type of preceptorship is a normal expectation of professionalism, and no incentive is awarded. With a level II preceptorship, the nurse works with a student nurse (usually a senior) who has no on-site instructor supervision. A $50 gift certificate is awarded on the student’s successful completion of the rotation. At a level III preceptorship, the nurse assumes full responsibility for the orientation of a registered nurse (RN) who has a minimum of 1 year of recent relevant experience in the delivery of acute care. This role includes identifying the orientee’s learning needs, mutual goal setting, collaboration with colleagues to assist the orientee in meeting goals, ongoing evaluation of goals, and preparing the final evaluation summary and
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postorientation goals. The primary preceptor receives a $100 gift certificate and 12 hours of choice time (eg, paid time off at a time mutually agreed on with the manager). A second RN serves as an off-shift secondary preceptor and is eligible for a $50 gift certificate and 6 hours of choice time. When the orientee has Robin J. Gilbert, less than 1 year of recent RN, BSN, CEN relevant experience, it is considered a level IV preceptorship. Then the primary preceptor receives a $200 gift certificate and 24 hours of choice time, and the secondary preceptor is eligible for a $100 gift certificate and 12 hours of choice time. The longevity bonus is given to the primary preceptor of a level III or IV preceptorship on each of the first 3 annual anniversaries of the precepted employee. To qualify for the $200 gift certificate each year, the precepted employee must have remained on staff, without interruption, in a regular part-time or full-time position. In addition, the preceptor must have met the performance expectations on his or her job evaluation with no active disciplinary counseling on file.
The longevity bonus is given to the primary preceptor of a level III or IV preceptorship on each of the first 3 annual anniversaries of the precepted employee. Nurses have been very receptive to this new policy. Staff members provided input about the time, energy, and commitment required for new staff orientation because they have recognized that the quality of the new nurse often reflects the orientation he or she received. Because the ED staff members have extremely high standards, they realize they need to take the time to help new hires gain the necessary knowledge, skill, and expertise. The ED staff has always been receptive to serving as preceptors; it is now nice to have that attitude and effort recognized and rewarded.—Robin J. Gilbert, RN, BSN, CEN, ED Nurse Manager, Central Maine Medical Center, Lewiston, Me; E-mail: [email protected]
Answer No. 3 When I was a nurse manager, I had an established routine for new employees. I spent the first days with them because I wanted to make sure the individual understood the department’s and my expectations and philosophy. Although the new orientee worked with one experienced staff nurse, I assigned the person to specific staff members, according to their departmental responsibilities, for blocks of time. This allowed the new employee to learn from the departmental expert of each “piece of the pie” (quality improvement, scheduling, discharge instructions, etc) without burdening one individual with all the work. In addition, this system allowed all staff members and the new employee to develop a working relationship. Our hospital also has a contract for a preceptor program for EMS and paramedic students.—Jan Johnson, RN, BSHA, CEN, SANE, Clinical Forensic Services Coordinator and Cardiac Rehabilitation Nurse (former ED Manager), Central Peninsula General Hospital, Soldotna, Alaska; E-mail: [email protected] Answer No. 4 We understand that excellent clinical skills do not necessarily make nurses good preceptors. Preceptors in our hospital are trained through a 7-hour formal class developed by the staff development department. In addition, all ED preceptors meet with the ED clinical educator to verify that they understand the role and expectations. The ED clinical educator is in the process of formalizing our department-specific requirements, in addition to the hospital’s developed guidelines. Serving in this role is included in our clinical ladder. Nurses also serve as preceptors for paramedics, EMTs, medical students, and nurse practitioner students. Any precepted student must have a written agreement with the medical center that includes objectives and evidence of malpractice insurance. Our department clinical educator and paramedic liaison nurse work closely with the involved schools to ensure that we are meeting the needs of the program and that their students comply with our medical center policies.—Chris Clare, RN, MN, CEN, CNA, Director, Med/Surg and Critical Care, Kaiser Permanente-Harbor City, Harbor City, Calif (formerly Nurse Manager, Express Care/Industrial Medicine, Employee Health, Loma Linda University Medical Center, Loma Linda, Calif); E-mail: Christine.X.Clare@ kp.org Answer No. 5 Local paramedic training programs prefer to use our hospital because of the teaching opportunities from our trauma population. However, we do
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not believe we have adequate available nursing time to serve satisfactorily as preceptors for them in addition to our own new employees. Therefore, they must make arrangements on their own to bring a preceptor with them. This individual is often a teacher or an offduty emergency nurse.—Amy Smith-Peard, RN, MSN, ENP, Nurse Practitioner, Sentara Norfolk General Hospital, Norfolk, Va; E-mail: [email protected]
CART SYSTEMS ■ We are considering the use of specialized supply carts in our new emergency department. Have they worked for other departments? Answer No. 1 All rooms in our new emergency department are monitored and set up alike. We then tailor them to the patient’s need through various carts containing the equipment and supplies for basic procedures. For example, we have a separate cart for suturing, otorhinolaryngology, casting, gynecologic, orthopedic, pediatric, isolation, and genitourinary/ gastrointestinal cases. The carts are stored under the nursing station desk, which is at standing height, on the outside facing the rooms. The cart system has helped reduce patient waiting time for a specific specialized room, because a patient with a nosebleed or laceration can be cared for in any room by bringing the appropriate cart to the bedside. It has reduced the amount of stock we maintain or that expires before use. The physicians have everything they need and do not have to ask a staff member to retrieve anything from a central location.
We have a separate cart for suturing, otorhinolaryngology, casting, gynecologic, orthopedic, pediatric, isolation, and genitourinary/ gastrointestinal cases. The carts are stored under the nursing station desk, which is at standing height, on the outside facing the rooms.
was kept in the express care area. We were not willing to give up a monitored bed for an eye chair used only for patients with eye, ear, nose, or throat symptoms.—Laura Roepe, RN, MA, CEN, Administrative Manager, Emergency Nursing Services, Norwalk Hospital, Norwalk, Conn; E-mail: laura.roepe@ norwalkhealth.org Answer No. 2 We made all our ED rooms multipurpose. Generic stretchers can all hold stirrups for a pelvic examination. Each room has a generic supply cart with restricted supplies, such as sharps, locked in the top drawer. Our nurses’ station is a reverse counter with the back cut out to allow space to store the specialty carts in an easily accessible area that is still out of the way.
(l. to r.): Doreen Anderson, RN, Kathleen Raife, RN, MS, Ingrid Bachtel, RN, MA (seated), Nichola Treece, RN, MSN, and Debra Howard, RN.
We also made eye problems the exception. We located the “eye room” conveniently between the main emergency department and fast track area, so that staff and patients do not have to walk through the other area to reach it. The use of specialty carts has been a key factor in our improved patient flow because we have eliminated patients waiting for a special room.—Nichola Treece, RN, MSN, Assistant Director; Debra Howard, RN, Assistant Director; Doreen Anderson, RN, Assistant Director; Ingrid Bachtel, RN, MA, Director; Kathleen Raife, RN, MS, Emergency CNS; Emergency Department, Desert Samaritan Medical Center, Mesa, Ariz
HANDLING DISCHARGE ■ How are other emergency departments making their discharge process more effective?
The only type of injury for which we do not have much flexibility are eye problems. Our “eye chair”
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Answer No. 1 At our hospital the nurse provides the information to the discharged patient at the bedside and
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then escorts the patient to the business office area for billing and information verification. This current procedure can be problematic if the patient has extensive discharge instructions. We do not have the luxury for an in-depth conversation because the nurse is also juggling other patients’ needs. We anticipate that our expansion, which will triple the size of the department, will help with the current necessity to always quickly vacate a bed. Another problem is that the patient impatiently asks, “What am I waiting for?” if the instructions are not immediately ready after the physician leaves the bedside. I suggested 2 changes to help address the situation, one of which is incorporating a discharge instruction sheet into the chart so the nurse can easily complete an ongoing record of any teaching given throughout the ED stay. Use of such a sheet should help document the information provided during the initial assessment or caregiving. The other suggested change is having a designated nurse discharge patients. The patient is escorted to the business office, with follow-up appointments scheduled, and then speaks with the discharge nurse. That nurse has adequate time to properly review and reinforce all information in a private setting without interruptions. The chart is always available so the nurse knows he or she has included everything. In my experience, patients have been more satisfied with this process because the movement to different areas created a sense of progress.
The patient impatiently asks, “What am I waiting for?” if the instructions are not immediately ready after the physician leaves the bedside. The hospital that followed this procedure had 200 to 300 patients per shift, so the discharge nurse’s time was fully accounted for. In our smaller-volume emergency department, I am recommending that the discharge nurse be located near the triage area. When the nurse is available, he or she can support the triage area, such as by assessing ambulance patients, collecting laboratory specimens, or even directly discharging patients with minor problems after the physician has seen them in triage.—Michael Wicklander,
RN, Clinical Educator, Emergency Department, Hermann Hospital, Houston, Texas Answer No. 2 The physician places the chart of the patient ready for discharge in one established place that is easily visualized throughout the department. The nurse then pulls up computerized discharge instructions by diagnosis from our MICROMEDEX System,* a subscribed service that includes frequent updates. The nurse customizes and prints the information on a 2-part form that the patient and nurse sign. One copy is given to the patient and the other one stays with the chart. Occasionally when it is very busy, the unit secretary prints the instructions for the nurse. We usually provide discharge instructions at the bedside. However, our computer system is in a separate little corner that can be used for private instruction if the patient came out into the hallway or the bed is needed immediately.—Kay Gay, RN, Clinical Coordinator, Emergency Services, Peachtree Regional Hospital, Newnan, Ga (Thanks also to Eileen Boehm, RN, MSN, CEN) Answer No 3 We have a decision observation unit that is adjacent to the emergency department and uses the emergency physicians and nurses for staffing. This unit is intended for patients with simple but time-consuming needs. Examples include patients with delayed films for a renal calculus or patients needing hydration, respiratory treatments, or observation after a single-system trauma. This unit is also helpful for obtaining consultations, monitoring diet tolerance, or providing additional patient teaching. The hospital discharge planner becomes involved, as needed, with these patients’ discharge needs. The emergency nurses also make a follow-up call after discharge to check on their progress, reinforce any educational issues, and answer questions. In addition, we have nurses employed by the hospital who do home visits and manage cases. They usually do this for a particular physician’s patients, but we can request the service for a specific patient, and we have done so with some elderly patients. These visiting nurses reinforce any teaching or verify if appropriate home services are available. The hospital also has a number of community health education classes for chronic conditions, such as cardiac rehabilitation and asthma. We provide information about these classes and encourage patients to use them as a supplement.—Deborah Blazys, RN, BSN, Staff Nurse, St Mary’s Hospital, Waterbury, Conn *MICROMEDEX is a registered trademark of MICROMEDEX, Inc, 6200 S Syracuse Way, Suite 300, Englewood, CO 80111; (800) 5259083; www.micromedex.com
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CUSTOMER SATISFACTION ■ What are others doing to improve customer satisfaction? Answer No. 1 Our hospital has a family-centered care emphasis throughout the facility. At the emergency department, we implemented it by forming a committee with parents, some whose children need frequent ED visits and some who had only been to our department once. We simply asked them, “What is Kirsten Johnson wrong with our emergency Moore, RN, MSN department?” In addition, the committee has been a source of feedback about other changes. Some of the things they suggested we cannot provide, such as child-sized toilets in the bathrooms. However, other successfully implemented ideas include the following: 1. Decorating each treatment room in a theme from a children’s author, such as rainbow fish, with appropriate artwork and books. The enriched atmosphere fosters education and child-parent interaction. 2. Providing portable telephones in the treatment areas. We previously had a family telephone in the hallway, but it was not very private when difficult matters were discussed. Now each room has a telephone line and modem line (for laptops); we will provide a plug-in telephone to use for the duration of their stay.
We have sleeping chairs for family members, a playroom, and a liberal visiting policy. 3. Allowing food in the ED treatment area. Food was formerly prohibited because of concerns about cleanliness. We worked with environmental service to have more extensive cleaning between patients. The department sometimes smells like McDonalds (which has a franchise inside our hospital), but it has improved the patient satisfaction immensely without any sanitation problems.
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3. Having a child-life specialist who works with the ill child to help with distraction/coping during procedures. The specialist is also valuable with the siblings. Often the entire family comes in with a sick child or after a car accident and the related ED visit management includes all the children, not just the affected child. There is a dedicated social worker who makes rounds and assists as needed. 5. Developing bereavement resources. Staff members created a packet with appropriate literature, such as how to talk to a sibling or arrange a funeral; providing a time to obtain a locket of the child’s hair; and appropriate paper to take the child’s handprint. We now have a readily available aide for dealing with deaths in the department. We have taken the position that “it takes as long as it takes” for the family to become ready for their deceased child to be removed from the department. This attitude was recently tested with a Muslim family, which, because of religious beliefs, would not allow their child to be taken for the medical examiner’s requested autopsy. Twelve hours passed until this matter was satisfactorily resolved through interactions with additional family members, clergy, and the medical examiner. As a result, we have identified Muslim resources within our hospital for future needs. In addition, we have sleeping chairs for family members, a playroom, and a liberal visiting policy. All of these measures have increased inclusion of our patients’ families and their satisfaction.—Kirsten Johnson-Moore, RN, MSN, Director, Emergency Nursing Service, The Children’s Hospital of Philadelphia, Philadelphia, Pa Answer No. 2 I believe administration must support the emergency department’s natural gatekeeper role for the hospital. I find the complaints are not about the ED staff’s clinical care but are from patients with minor physical needs who were dissatisfied with their experience before receiving care. I am budgeting for a concierge: an individual to initially greet patients and families. In addition, this person will continue to work with the families during the patient’s treatment, because a large part of patient satisfaction is family satisfaction. We provide handouts, but I find that the spoken word goes a lot further. I would also like to add valet parking for ED patients. A local hospital experienced a dramatic increase in its patient volume after adding this service. Gaining approval for such positions is difficult. However, it is a low-dollar position compared with a nurse’s wages. I am requesting a 3-month trial of the concept, using money from the marketing budget.
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I believe that the position will reap more positive results than the one or two major print ads that could be purchased with those same dollars.—Stephanie Jones, RN, Clinical Nurse Manager, Emergency Department, Western Medical Center, Santa Ana, Calif
RESPONDING TO A REPORTER’S QUESTIONS ■ How do I make sure working with a reporter will result in a positive report? Answer No. 1 Mother Teresa used to say, “Facing the press is more difficult than bathing a leper.” Use the 5 techniques of analogy, metaphor, homonym, perspective, and refocusing. These techniques will allow the reporter to more fully understand your story while making your information notable and quotable. For instance, Peter F. Jeff a surgeon provided perspective while describing the precision of a bypass heart surgery by saying that he practiced “by circumcising gnats.” Be aware of the ways a reporter may try to get you to say something you shouldn’t. Watch for the following phrases:
• “What if…” (Hypothetical) State that you do not respond to hypothetical questions. • “Why is morale down…” (Suggestive) Do not repeat the negative. • “Just between us, what…” (Personal) Keep your private response the same as your public one. • “Hmmmmmm” (Silent treatment) Do not play the waiting game. Simply repeat what you just said or fill the silence with a previously prepared message you want to get across. Phrase your key message in 10 words or less that you keep repeating no matter what question you are asked. (“The real issue is…” or “I am not sure about that, but I can tell you that…”). Repeat your message again at the end of the time. It may sound repetitious to you, but the redundancy will influence the reporter’s perspective.—Peter F. Jeff, former newspaper reporter and corporate public relations professional, President, LeaderShip Company, Grand Rapids, Mich; (616) 445-4747
Management questions from nurses are welcome, as are names and addresses of nurses in management who are interested in answering questions. Submit to Polly Gerber Zimmermann, RN, MS, MBA, CEN, 4200 N Francisco, Chicago, IL 60618; phone (773) 539-1048; E-mail: pzimmermann@ ccc.edu.
Submit Your Article to Journal of Emergency Nursing! Have you thought about writing an article for the Journal of Emergency Nursing? Please refer to pp 11A-13A for information for authors and contact information for specific section editors.
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GENERATION X STAFF ■ I am having difficulty understanding my “Generation X” employees. What insight can you offer? Answer No. 1 People born since 1965 (eg, “twentysomethings”) are frequently called “Generation Xers,” a term that refers to the fact that they are the 10th generation to come of age in this century. These are some of the distinguishing characteristics of Generation Xers and how to handle them: Marilyn Moats Kennedy 1. Generation Xers are far less optimistic about their future than are baby boomers. They expect future problems; they worry about whether they have the right skills and other attributes to achieve their personal version of success. Respond by teaching them organizational savvy and helpful skills. 2. Generation Xers count every dollar because they never feel financially secure. They are skeptical customers who want a good value for their dollar. Show them the worth of purchases, such as a required educational class. 3. Generation Xers abhor vagueness. Expect questions; be prepared to give detailed explanations. 4. Generation Xers are not joiners and are extremely protective of their time. Being authentic and working hard, not social skills, were emphasized as they were growing up. Plan educational activities that are informative; specifically outline any The opinions expressed are those of the respondents and should not be construed as the official position of the institution, ENA, or the Journal. J Emerg Nurs 2000;26:493-501. Copyright © 2000 by the Emergency Nurses Association. 0099-1767/2000 $12.00 +0 18/9/108352 doi:10.1067/men.2000.108352
time commitment required. You must take the initiative for promoting interactions. 5. Generation Xers tell it like it is. They communicate directly, almost abruptly. They view a euphemistic style as manipulative. Don’t say, “Would you mind doing this?” when you really mean, “You must do this.” Make your point succinctly for effective communication and give particular emphasis on the “why.” Make use of their preferred communication means—the Internet (chat rooms, Web sites) and E-mail. This group is different but valuable. If they believe something will make a difference, they will be loyal.1—Marilyn Moats Kennedy, Managing Partner, Career Strategies (a management and career consulting company), Wilmette, Ill; E-mail: MMKCareer @aol.com Reference 1. Kennedy MM. Recruiting and retaining cross-generational membership. Forum 1999;83:10, 11, 24.
Answer No. 2 Managers need to realize that Generation X employees must be managed differently. Although many management tips are applicable for all employees, some are particularly essential for Generation X employee retention. Studies have shown that some of the things managers do that particularly Claire Raines, MA drive the Generation X employee crazy are as follows: 1. Giving insincere, gratuitous “thank you’s” 2. Throwing people into jobs they are not trained for or qualified to perform 3. Allowing the workplace to be disorganized, cluttered, or dirty 4. Overlooking unacceptable behavior from other staff members
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5. Ignoring employees’ opinions and ideas I have identifed 7 “X” requisites, that is, the most frequent requests Generation Xers make of their managers. Practicing these requisites is pivotal to your success. They include the following: 1. Appreciate us. Generation Xers want you to show them that you care by providing them with personal attention. They want to feel that they are making a difference. 2. Be flexible. Generation Xers like scheduling options that accommodate their personal lives. 3. Create a team. More than 50% of Generation X employees were latchkey children. They want you to give them the family they never had. Creating a team includes holding regular staff meetings. 4. Develop us. Generation Xers want you to help them increase their skills because they see themselves as a commodity. Developing them includes perceiving a potential for internal promotion. They like to spend time with a manager. 5. Involve us. Generation Xers want their opinions to be asked for and heard, even if you disagree with them. They do not believe they need to “pay their dues” before they have a right to speak. 6. Lighten up. Generation Xers want managers who are relaxed and fun. 7. Walk your talk. Generation Xers want to see you practice what you preach and deal with problems.
With today’s shrinking pool of workers and the high cost of hiring and training, retaining workers is essential. Adjusting to the different attitude of your Generation X employees may be difficult, but it is worth the effort. The attributes for which Generation Xers are known will be an asset to your team. These attributes include handling changes well, being comfortable with technology, being independent, being financially savvy, not being intimidated by authority, and being creative. With today’s shrinking pool of workers and the high cost of hiring and training, retaining workers is essential. 1—Claire Raines, MA, author and expert on the generations, Denver, Colo; E-mail: [email protected]
Answer No. 3 I have found that it is necessary for the recruiting job interview to include the expected orientation obligations, such as required training classes, competency testing, attaining certification, and/or shift rotations. In the past, newly hired nurses used to just cope with the inherent demands. Generation X nurses will leave when they feel there are unexpected obligations. Generation X nurses want the job to continually provide learning and creative challenges. Employability is more important to them than a specific job position. Providing educational opportunities is essential to retention. However, I have learned to modify my educational style to be effective. Generation Xers like entertaining presentations with games (eg, Jeopardy), cooperative team participation, visual aids, and scenarios with discussion. They respond well to self-learning opportunities, such as a computer course, as long as objectives and deadlines are clearly set. Generation Xers need to perceive that the presented information or required assignment is clinically relevant. Baby boomers (born between 1946 and 1964), ask, “Is this information true?” Generation Xers instead question, “What use is this information to me?” For instance, the Generation X ED orientees I had resisted spending time in the ICU until I explained the benefit of having hands-on experience with central lines. Some helpful tips I use in managing Generation X nurses include the following: • Offering fast, frequent feedback. Especially in the beginning, we met together every 1 or 2 weeks. They want to know specifically what they have done well and desire guidance about potential growth areas. • Providing individualized attention. Many Generation Xers grew up with 2 busy, working parents and appreciate any personal actions, such as a handwritten note. • Allowing limited time for on-the-job socialization. Rather than wasting time, on-the-job socialization will contribute to productivity. Generation Xers want to feel part of a team. Two books I have found helpful are Beyond Generation X: A Practical Guide for Managers1 and Generation X Goes to College.2—Patty Sturt, RN, MSN, CEN, Staff Development Specialist, Emergency Department, University of Kentucky Hospital, Lexington, Ky
Reference
References
1. Raines C. Beyond generation X: a practical guide for managers. Menlo Park (CA): Crisp Publications; 1997.
1. Raines C. Beyond generation X: A practical guide for managers. Menlo Park, CA: Crisp Publications; 1997.
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2. Sacks P. Generation X goes to college. Chicago (IL): Open Court Publishing; 1996.
that only properly certified individuals perform suturing. As a result of our program, no JCAHO accreditation problems about this limited scope of expanded practice have occurred.
Some nurses have been trained to perform digital blocks because this service would be needed in a deployment situation.
LTC Nanette A. Hill and EMS staff at William Beaumont Army Medical Center, Ft Bliss, El Paso, Tex
SUTURING ■ Do other emergency departments have someone other than physicians perform suturing, and if so, how do they handle the training? Answer No. 1 The Army must maintain its medical personnel’s battlefield skills to fulfill its wartime mission. Even during month-long training exercises in remote areas, wartime conditions are simulated with only a medic and physician assistant for basic medical needs. The dilemma is how to do that within the hospital setting and Joint Commission of Accreditation for Healthcare Organizations (JCAHO) regulations. We have solved that by establishing a suturing certification program for our medics. Some nurses have also been certified but usually do not perform suturing because their time is focused on higherskilled needs, such as medication administration or management of a trauma patient. The program includes independent preparation, didactic lectures, practicum, and then direct evaluation by a physician. Staff members use a suture study guide, attend a physician-taught class, and practice on pigs’ ears or feet. They then must be observed 3 times by a physician who determines whether they are competent to suture without direct supervision. The emergency physicians retain the responsibility to decide when a patient needs sutures and always do any suturing on the face, hands, or joints. The system also has a built-in check through the nursing education department, which maintains an education folder for each staff member and verifies
Medics do not use topical liquid skin adhesive (Dermabond) or apply staples. Registered nurses and medics are trained to remove staples and sutures. Some nurses have been trained to perform digital blocks because this service would be needed in a deployment situation, but they do not currently do this in our hospital emergency department. Saving the physician’s time is a big benefit from this program. Suturing of simple lacerations by medics helps free up our limited professional staff.—LTC Nanette A. Hill, RN, MS, CEN, Chief, Emergency Medical Services, William Beaumont Army Medical Center, Ft Bliss, El Paso, Texas Answer No. 2 Some of our physicians have informally instructed interested registered nurses on suturing basic lacerations when scarring is not a concern. The physician stays in the room to supervise and to assume responsibility for the nurse’s performance. Anecdotally, there have been no follow-up wound complications with any suturing performed by nurses. Suturing performed by nurses has not been an issue with JCAHO visits, but we would develop a more formalized program to allow it to continue if it was a problem. The reality is that nurses frequently administer potent medications and perform procedures with potentially serious complications on the basis of their nursing training and licensure. Suturing is a manual dexterity skill rather than a complex application of advanced knowledge. Our physicians support capable nurses in assuming this task within an appropriate scope.—Anthony Laviano, RN, CEN, ED Nurse Manager, Spring Hill Regional Hospital, Spring Hill, Fla Answer No. 3 In Hong Kong, nurses with at least 2 to 3 years’ emergency nursing experience generally are trained in suturing techniques for superficial wounds, including wounds located on the face, hand, and fingers, as well as on the more traditional areas of scalp,
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Wai Kwong Poon, RN Dip, GN, MBA, PhD(c)
extremities, and so on. They also apply Dermabond and remove superficial foreign bodies. However, they do not perform suturing when there is tendon involvement. The 6-month training course includes 16 contact hours of instruction, suturing of 15 patients with direct supervision, and suturing of 15 patients reviewed by a trainer before the patient’s discharge. We undertook a study, the first of its kind in Hong Kong, to evaluate the results of this standard procedure. Patients returned to the emergency department for suture removal so that the condition of the wound could be assessed. Evaluation criteria included the condition of the wound (including discharge), edge approximation, functional ability, and patient teaching as evidenced by the patient’s compliance. Our study included 118 follow-up patients. We had 100% good wound edge approximation and function and 91% patient compliance. A purulent discharge was present in only 2 wounds. We concluded that trained registered nurses can independently provide capable wound suturing and care in the defined limitations.—Wai Kwong Poon, RN Dip, GN, MBA, PhD(c), Instructor and Staff Nurse, Accident & Emergency Department, Queen Elizabeth Hospital, Kowloon, Hong Kong; E-mail: [email protected]
PRECEPTING ■ How do other emergency departments handle arranging and motivating capable seasoned nurses to act as preceptors for new employees or trainees? Answer No. 1 The availability of excited, excellent preceptors is an issue for us because our large trauma facility attracts many nurse applicants who come to obtain ED experience. I found that some of the most experienced staff members are not willing to spend
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the necessary time in new trainee development. In addition, it is a skill to be able to share one’s expertise at a level in line with the trainee’s current ability. We provide “perks” to our preceptors on completion of the new employee’s orientation. The rewards include grab bags with goodies, donated by volunteer services, such as car wash tickets, dinner at a local restaurant, or movie tickets. We provide educational opportunities for our consistent, energetic preceptors. The department pays for all of their verification courses (Trauma Nursing Core Course [TNCC], Emergency Nursing Pediatric Course [ENPC], etc). In addition, each year the manager sends 3 nurse preceptors, with all their expenses paid, to the ENA Annual Meeting. I invite nurse preceptors to attend local educational offerings with me and/or get them involved in other opportunities, such as a task force. Thus they are rewarded with some “fun” activities, as well as gain skill- and career-building experiences. My concept of rewards for preceptors is based on my previous experience at another hospital. This hospital believed that good preceptors save the hospital money by developing satisfied, competent employees and ensuring that there is completed paperwork for the regulatory visits. The nurse’s precepting hours accumulated if the new orientee’s paperwork/checklist was completed on time and the orientee gave the preceptor a satisfactory evaluation rating. When preceptors obtained 500 hours, they were given a 12-hour vacation day.—Michael Wicklander, RN, Clinical Educator, Emergency Department, Hermann Hospital, Houston, Tex Answer No. 2 Our hospital provides incentives for experienced registered nurses who serve as preceptors or mentors for students. Our preceptor incentive program has 4 levels and a longevity (retention) bonus. With a level I preceptorship, the students are enrolled in a school of nursing with which we have an established teaching/clinical affiliation. This type of preceptorship is a normal expectation of professionalism, and no incentive is awarded. With a level II preceptorship, the nurse works with a student nurse (usually a senior) who has no on-site instructor supervision. A $50 gift certificate is awarded on the student’s successful completion of the rotation. At a level III preceptorship, the nurse assumes full responsibility for the orientation of a registered nurse (RN) who has a minimum of 1 year of recent relevant experience in the delivery of acute care. This role includes identifying the orientee’s learning needs, mutual goal setting, collaboration with colleagues to assist the orientee in meeting goals, ongoing evaluation of goals, and preparing the final evaluation summary and
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postorientation goals. The primary preceptor receives a $100 gift certificate and 12 hours of choice time (eg, paid time off at a time mutually agreed on with the manager). A second RN serves as an off-shift secondary preceptor and is eligible for a $50 gift certificate and 6 hours of choice time. When the orientee has Robin J. Gilbert, less than 1 year of recent RN, BSN, CEN relevant experience, it is considered a level IV preceptorship. Then the primary preceptor receives a $200 gift certificate and 24 hours of choice time, and the secondary preceptor is eligible for a $100 gift certificate and 12 hours of choice time. The longevity bonus is given to the primary preceptor of a level III or IV preceptorship on each of the first 3 annual anniversaries of the precepted employee. To qualify for the $200 gift certificate each year, the precepted employee must have remained on staff, without interruption, in a regular part-time or full-time position. In addition, the preceptor must have met the performance expectations on his or her job evaluation with no active disciplinary counseling on file.
The longevity bonus is given to the primary preceptor of a level III or IV preceptorship on each of the first 3 annual anniversaries of the precepted employee. Nurses have been very receptive to this new policy. Staff members provided input about the time, energy, and commitment required for new staff orientation because they have recognized that the quality of the new nurse often reflects the orientation he or she received. Because the ED staff members have extremely high standards, they realize they need to take the time to help new hires gain the necessary knowledge, skill, and expertise. The ED staff has always been receptive to serving as preceptors; it is now nice to have that attitude and effort recognized and rewarded.—Robin J. Gilbert, RN, BSN, CEN, ED Nurse Manager, Central Maine Medical Center, Lewiston, Me; E-mail: [email protected]
Answer No. 3 When I was a nurse manager, I had an established routine for new employees. I spent the first days with them because I wanted to make sure the individual understood the department’s and my expectations and philosophy. Although the new orientee worked with one experienced staff nurse, I assigned the person to specific staff members, according to their departmental responsibilities, for blocks of time. This allowed the new employee to learn from the departmental expert of each “piece of the pie” (quality improvement, scheduling, discharge instructions, etc) without burdening one individual with all the work. In addition, this system allowed all staff members and the new employee to develop a working relationship. Our hospital also has a contract for a preceptor program for EMS and paramedic students.—Jan Johnson, RN, BSHA, CEN, SANE, Clinical Forensic Services Coordinator and Cardiac Rehabilitation Nurse (former ED Manager), Central Peninsula General Hospital, Soldotna, Alaska; E-mail: [email protected] Answer No. 4 We understand that excellent clinical skills do not necessarily make nurses good preceptors. Preceptors in our hospital are trained through a 7-hour formal class developed by the staff development department. In addition, all ED preceptors meet with the ED clinical educator to verify that they understand the role and expectations. The ED clinical educator is in the process of formalizing our department-specific requirements, in addition to the hospital’s developed guidelines. Serving in this role is included in our clinical ladder. Nurses also serve as preceptors for paramedics, EMTs, medical students, and nurse practitioner students. Any precepted student must have a written agreement with the medical center that includes objectives and evidence of malpractice insurance. Our department clinical educator and paramedic liaison nurse work closely with the involved schools to ensure that we are meeting the needs of the program and that their students comply with our medical center policies.—Chris Clare, RN, MN, CEN, CNA, Director, Med/Surg and Critical Care, Kaiser Permanente-Harbor City, Harbor City, Calif (formerly Nurse Manager, Express Care/Industrial Medicine, Employee Health, Loma Linda University Medical Center, Loma Linda, Calif); E-mail: Christine.X.Clare@ kp.org Answer No. 5 Local paramedic training programs prefer to use our hospital because of the teaching opportunities from our trauma population. However, we do
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not believe we have adequate available nursing time to serve satisfactorily as preceptors for them in addition to our own new employees. Therefore, they must make arrangements on their own to bring a preceptor with them. This individual is often a teacher or an offduty emergency nurse.—Amy Smith-Peard, RN, MSN, ENP, Nurse Practitioner, Sentara Norfolk General Hospital, Norfolk, Va; E-mail: [email protected]
CART SYSTEMS ■ We are considering the use of specialized supply carts in our new emergency department. Have they worked for other departments? Answer No. 1 All rooms in our new emergency department are monitored and set up alike. We then tailor them to the patient’s need through various carts containing the equipment and supplies for basic procedures. For example, we have a separate cart for suturing, otorhinolaryngology, casting, gynecologic, orthopedic, pediatric, isolation, and genitourinary/ gastrointestinal cases. The carts are stored under the nursing station desk, which is at standing height, on the outside facing the rooms. The cart system has helped reduce patient waiting time for a specific specialized room, because a patient with a nosebleed or laceration can be cared for in any room by bringing the appropriate cart to the bedside. It has reduced the amount of stock we maintain or that expires before use. The physicians have everything they need and do not have to ask a staff member to retrieve anything from a central location.
We have a separate cart for suturing, otorhinolaryngology, casting, gynecologic, orthopedic, pediatric, isolation, and genitourinary/ gastrointestinal cases. The carts are stored under the nursing station desk, which is at standing height, on the outside facing the rooms.
was kept in the express care area. We were not willing to give up a monitored bed for an eye chair used only for patients with eye, ear, nose, or throat symptoms.—Laura Roepe, RN, MA, CEN, Administrative Manager, Emergency Nursing Services, Norwalk Hospital, Norwalk, Conn; E-mail: laura.roepe@ norwalkhealth.org Answer No. 2 We made all our ED rooms multipurpose. Generic stretchers can all hold stirrups for a pelvic examination. Each room has a generic supply cart with restricted supplies, such as sharps, locked in the top drawer. Our nurses’ station is a reverse counter with the back cut out to allow space to store the specialty carts in an easily accessible area that is still out of the way.
(l. to r.): Doreen Anderson, RN, Kathleen Raife, RN, MS, Ingrid Bachtel, RN, MA (seated), Nichola Treece, RN, MSN, and Debra Howard, RN.
We also made eye problems the exception. We located the “eye room” conveniently between the main emergency department and fast track area, so that staff and patients do not have to walk through the other area to reach it. The use of specialty carts has been a key factor in our improved patient flow because we have eliminated patients waiting for a special room.—Nichola Treece, RN, MSN, Assistant Director; Debra Howard, RN, Assistant Director; Doreen Anderson, RN, Assistant Director; Ingrid Bachtel, RN, MA, Director; Kathleen Raife, RN, MS, Emergency CNS; Emergency Department, Desert Samaritan Medical Center, Mesa, Ariz
HANDLING DISCHARGE ■ How are other emergency departments making their discharge process more effective?
The only type of injury for which we do not have much flexibility are eye problems. Our “eye chair”
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Answer No. 1 At our hospital the nurse provides the information to the discharged patient at the bedside and
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then escorts the patient to the business office area for billing and information verification. This current procedure can be problematic if the patient has extensive discharge instructions. We do not have the luxury for an in-depth conversation because the nurse is also juggling other patients’ needs. We anticipate that our expansion, which will triple the size of the department, will help with the current necessity to always quickly vacate a bed. Another problem is that the patient impatiently asks, “What am I waiting for?” if the instructions are not immediately ready after the physician leaves the bedside. I suggested 2 changes to help address the situation, one of which is incorporating a discharge instruction sheet into the chart so the nurse can easily complete an ongoing record of any teaching given throughout the ED stay. Use of such a sheet should help document the information provided during the initial assessment or caregiving. The other suggested change is having a designated nurse discharge patients. The patient is escorted to the business office, with follow-up appointments scheduled, and then speaks with the discharge nurse. That nurse has adequate time to properly review and reinforce all information in a private setting without interruptions. The chart is always available so the nurse knows he or she has included everything. In my experience, patients have been more satisfied with this process because the movement to different areas created a sense of progress.
The patient impatiently asks, “What am I waiting for?” if the instructions are not immediately ready after the physician leaves the bedside. The hospital that followed this procedure had 200 to 300 patients per shift, so the discharge nurse’s time was fully accounted for. In our smaller-volume emergency department, I am recommending that the discharge nurse be located near the triage area. When the nurse is available, he or she can support the triage area, such as by assessing ambulance patients, collecting laboratory specimens, or even directly discharging patients with minor problems after the physician has seen them in triage.—Michael Wicklander,
RN, Clinical Educator, Emergency Department, Hermann Hospital, Houston, Texas Answer No. 2 The physician places the chart of the patient ready for discharge in one established place that is easily visualized throughout the department. The nurse then pulls up computerized discharge instructions by diagnosis from our MICROMEDEX System,* a subscribed service that includes frequent updates. The nurse customizes and prints the information on a 2-part form that the patient and nurse sign. One copy is given to the patient and the other one stays with the chart. Occasionally when it is very busy, the unit secretary prints the instructions for the nurse. We usually provide discharge instructions at the bedside. However, our computer system is in a separate little corner that can be used for private instruction if the patient came out into the hallway or the bed is needed immediately.—Kay Gay, RN, Clinical Coordinator, Emergency Services, Peachtree Regional Hospital, Newnan, Ga (Thanks also to Eileen Boehm, RN, MSN, CEN) Answer No 3 We have a decision observation unit that is adjacent to the emergency department and uses the emergency physicians and nurses for staffing. This unit is intended for patients with simple but time-consuming needs. Examples include patients with delayed films for a renal calculus or patients needing hydration, respiratory treatments, or observation after a single-system trauma. This unit is also helpful for obtaining consultations, monitoring diet tolerance, or providing additional patient teaching. The hospital discharge planner becomes involved, as needed, with these patients’ discharge needs. The emergency nurses also make a follow-up call after discharge to check on their progress, reinforce any educational issues, and answer questions. In addition, we have nurses employed by the hospital who do home visits and manage cases. They usually do this for a particular physician’s patients, but we can request the service for a specific patient, and we have done so with some elderly patients. These visiting nurses reinforce any teaching or verify if appropriate home services are available. The hospital also has a number of community health education classes for chronic conditions, such as cardiac rehabilitation and asthma. We provide information about these classes and encourage patients to use them as a supplement.—Deborah Blazys, RN, BSN, Staff Nurse, St Mary’s Hospital, Waterbury, Conn *MICROMEDEX is a registered trademark of MICROMEDEX, Inc, 6200 S Syracuse Way, Suite 300, Englewood, CO 80111; (800) 5259083; www.micromedex.com
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CUSTOMER SATISFACTION ■ What are others doing to improve customer satisfaction? Answer No. 1 Our hospital has a family-centered care emphasis throughout the facility. At the emergency department, we implemented it by forming a committee with parents, some whose children need frequent ED visits and some who had only been to our department once. We simply asked them, “What is Kirsten Johnson wrong with our emergency Moore, RN, MSN department?” In addition, the committee has been a source of feedback about other changes. Some of the things they suggested we cannot provide, such as child-sized toilets in the bathrooms. However, other successfully implemented ideas include the following: 1. Decorating each treatment room in a theme from a children’s author, such as rainbow fish, with appropriate artwork and books. The enriched atmosphere fosters education and child-parent interaction. 2. Providing portable telephones in the treatment areas. We previously had a family telephone in the hallway, but it was not very private when difficult matters were discussed. Now each room has a telephone line and modem line (for laptops); we will provide a plug-in telephone to use for the duration of their stay.
We have sleeping chairs for family members, a playroom, and a liberal visiting policy. 3. Allowing food in the ED treatment area. Food was formerly prohibited because of concerns about cleanliness. We worked with environmental service to have more extensive cleaning between patients. The department sometimes smells like McDonalds (which has a franchise inside our hospital), but it has improved the patient satisfaction immensely without any sanitation problems.
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3. Having a child-life specialist who works with the ill child to help with distraction/coping during procedures. The specialist is also valuable with the siblings. Often the entire family comes in with a sick child or after a car accident and the related ED visit management includes all the children, not just the affected child. There is a dedicated social worker who makes rounds and assists as needed. 5. Developing bereavement resources. Staff members created a packet with appropriate literature, such as how to talk to a sibling or arrange a funeral; providing a time to obtain a locket of the child’s hair; and appropriate paper to take the child’s handprint. We now have a readily available aide for dealing with deaths in the department. We have taken the position that “it takes as long as it takes” for the family to become ready for their deceased child to be removed from the department. This attitude was recently tested with a Muslim family, which, because of religious beliefs, would not allow their child to be taken for the medical examiner’s requested autopsy. Twelve hours passed until this matter was satisfactorily resolved through interactions with additional family members, clergy, and the medical examiner. As a result, we have identified Muslim resources within our hospital for future needs. In addition, we have sleeping chairs for family members, a playroom, and a liberal visiting policy. All of these measures have increased inclusion of our patients’ families and their satisfaction.—Kirsten Johnson-Moore, RN, MSN, Director, Emergency Nursing Service, The Children’s Hospital of Philadelphia, Philadelphia, Pa Answer No. 2 I believe administration must support the emergency department’s natural gatekeeper role for the hospital. I find the complaints are not about the ED staff’s clinical care but are from patients with minor physical needs who were dissatisfied with their experience before receiving care. I am budgeting for a concierge: an individual to initially greet patients and families. In addition, this person will continue to work with the families during the patient’s treatment, because a large part of patient satisfaction is family satisfaction. We provide handouts, but I find that the spoken word goes a lot further. I would also like to add valet parking for ED patients. A local hospital experienced a dramatic increase in its patient volume after adding this service. Gaining approval for such positions is difficult. However, it is a low-dollar position compared with a nurse’s wages. I am requesting a 3-month trial of the concept, using money from the marketing budget.
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I believe that the position will reap more positive results than the one or two major print ads that could be purchased with those same dollars.—Stephanie Jones, RN, Clinical Nurse Manager, Emergency Department, Western Medical Center, Santa Ana, Calif
RESPONDING TO A REPORTER’S QUESTIONS ■ How do I make sure working with a reporter will result in a positive report? Answer No. 1 Mother Teresa used to say, “Facing the press is more difficult than bathing a leper.” Use the 5 techniques of analogy, metaphor, homonym, perspective, and refocusing. These techniques will allow the reporter to more fully understand your story while making your information notable and quotable. For instance, Peter F. Jeff a surgeon provided perspective while describing the precision of a bypass heart surgery by saying that he practiced “by circumcising gnats.” Be aware of the ways a reporter may try to get you to say something you shouldn’t. Watch for the following phrases:
• “What if…” (Hypothetical) State that you do not respond to hypothetical questions. • “Why is morale down…” (Suggestive) Do not repeat the negative. • “Just between us, what…” (Personal) Keep your private response the same as your public one. • “Hmmmmmm” (Silent treatment) Do not play the waiting game. Simply repeat what you just said or fill the silence with a previously prepared message you want to get across. Phrase your key message in 10 words or less that you keep repeating no matter what question you are asked. (“The real issue is…” or “I am not sure about that, but I can tell you that…”). Repeat your message again at the end of the time. It may sound repetitious to you, but the redundancy will influence the reporter’s perspective.—Peter F. Jeff, former newspaper reporter and corporate public relations professional, President, LeaderShip Company, Grand Rapids, Mich; (616) 445-4747
Management questions from nurses are welcome, as are names and addresses of nurses in management who are interested in answering questions. Submit to Polly Gerber Zimmermann, RN, MS, MBA, CEN, 4200 N Francisco, Chicago, IL 60618; phone (773) 539-1048; E-mail: pzimmermann@ ccc.edu.
Submit Your Article to Journal of Emergency Nursing! Have you thought about writing an article for the Journal of Emergency Nursing? Please refer to pp 11A-13A for information for authors and contact information for specific section editors.
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