Case Analysis: Barbara Norris Leading Change in the General Surgery Unit

Team 3: Hannah Caldwell, Neil Ennion, Ashley Rivera Mercado,

Joansson Valme, Maria Matijas

Situation Summary
Barbara Norris is the nurse manager for the General Surgery Unit (GSU) at Eastern
Massachusetts University Hospital (EMU). Norris was offered the opportunity with EMU after
working in their emergency room for four years as a nurse, later moving on to their trauma
unit a year before she had her first child. Norris adopted a part-time schedule for the next few
years until her kids were in grade school where she then decided to not only return full-time
but also joined a Master's program in Nursing and Health Care Administration once they
were in high school.
Norris’ nurse manager, mentor, and friend at the time was Betty Nolan who was a
supporter of her earning her Master’s. After Nolan announced her retirement from being the
nurse manager of the GSU, she warned Norris not to take the opportunity of nurse manager,
citing that the hospital was a lost cause. Norris still took the role when offered, explaining that
she felt a need for a change and saw an opportunity to fix a lot of EMU’s issues.
Norris herself underestimated the scale of problems in her new unit, facing
everything from a generally toxic culture to dispirited employees to an economic downturn
that has left her without money for overtime and bonus. Combine all this with a massive
staffing issue, hiring freeze, and a lack of resources, Norris is looking for answers on how to
turn around her unit to make it not only more functional but a good place to work. The faith of
nursing director John Frappewell, and all her subordinates, rely on it.

Problem Statement #1: General Surgery Unit’s Toxic Culture

The General Surgery Unit (GSU) has been experiencing a toxic work environment for
the past few years. GSU has the "lowest employee satisfaction scores and highest employee
turnover rate among all of the departments at EMU" (HBR, 1). Although "patient satisfaction
scores are average, they have been declining steadily over the past few years" (HBU, 1).
The unit is said to be short-staffed, high stress, and lacks employee morale. Throughout
EMU, GSU is known for confrontation, blaming, and favoritism. With recent budget cuts, staff
dynamics and patient care have declined even more. GSU's toxic culture stems from three
interconnected issues: lack of collaboration, lack of training and support for nurses, and low
motivation. So, a lack of collaboration between nurses leads to inadequate training and
support, leading to the loss of motivation.
The lack of collaboration has been addressed by both new and tenure nurses.
Megan Mahoney said, "I want to feel like I belong and am a member of the team, but I often
get indirect negative messages and feedback from you" (HBU, 3). Senior nurses are highly
critical and complain about new nurses rather than helping and mentoring. Louise Scribner,
who has worked in GSU for 23 years, said she does not have enough time for her own job,
let alone support younger nurses and patient care assistants (PCAs). Additionally, many
RNs, both new and tenured, were frustrated with the PCAs and complained that they had
inadequate training and skill sets. Not only is there low support among the nurses, but the
Off-site identified that doctors treated the nurses like order takers rather than caregivers.
Furthermore, Louise stated during the Offsite that, "sometimes I feel like I spend more time

1
tending to machines than I do tending to patients'' and "we have too few nurses in the ward
and because some of that staff is inexperienced to boot" (HBU, 3). During the Off-site,
Barbara identified administrators who cared more about money than patient care. Nurses in
GSU have no motivation driven by performing better or supporting other nurses in the unit.
The prior unit manager did not keep complete and accurate records of the staff's annual
performance reviews. Also, Jennifer Goodwin, a nurse in GSU for ten years, stated, "I want
feedback. It helps me to be a better nurse and to be a better co-worker, but the review
process here is a mystery! As is the annual salary increase" (HBU, 3). She was also not
acknowledged for continuing her education.
A possible outcome of the culture has been the loss of five RNs in the past seven
months. GSU's bad reputation throughout EMU may also keep away good, experienced
managers. Every issue discussed above may result in new nurses not developing more skills
and learning more. This may create an unproductive unit as tenure nurses retire and nurses
outside the unit are reluctant to work in GSU. Additionally, the lack of a rewards system for
nurses is leading to a collective disconnect which contributes negatively to teamwork and
productivity.

Recommendation #1:
Culture is built on the strategic behaviors enacted by the organization. In this case,
the nursing department needs to establish the strategies by which it needs to live by. We
recommend that the nursing unit have 4 key strategies that include: Education and workforce
development, Excellent customer experiences, communication and feedback, and employee
wellness. Culture is said to be affected by the strategies and is not a quick fix, adjusting
company culture can take a long time. A company with a very positive culture has employees
who are very motivated. The biggest issue in this unit is the toxic culture, but in order to
improve this, we will need to first look into the different methods we are going to need in
order to achieve the 4 key strategies of the nursing unit.
Education and workforce development will begin by having our employees participate
in quarterly skill classes to improve their techniques while on the job. Some of these classes
will be communication, teamwork, critical thinking, and empathy skills courses. These are
some of the most important skills that a nurse needs to perform effectively. We will schedule
these skill classes once a quarter, so that it can be consecutive and bring on reminders of
what is needed to maintain a positive work culture.
Excellent customer experiences will be measured through patient surveys at the end
of every stay. Barbara will look over these surveys monthly and an average score at the end
of every year. In order to achieve these positive experiences all the strategies will tie together
with motivation. In the article, Employee motivation: “A powerful new tool” the authors talk
about the four drives that underlie motivation. These four drives include the drive to acquire,
bond, comprehend, and defend. We want to create a system where we can reward the
nurses who are performing great while maintaining a good customer experience. We will
have Barbara talk with her boss to recommend using some of the money from the lost RN’s
to incentivize our current team with bonuses based on reviews. The RN’s with low
satisfaction scores will go on probation after a 6 month low score average. Barbara will have
to build relationships with her staff by getting to know each one and understand each person.
The nursing department will have clear roles and organization will play a big part. Nurses
who want overtime can request an extra admin shift to help alleviate some of the stresses

2
such as scheduling, filing, etc. Barbara will create trust within the department by being fair
and transparent with everything going on. Being short staffed is a big problem, but if
employee morale is high, employees are more likely to be able to hold on in the short term
until the situation improves.
Communication is the key. Barbara will have to have open lines of communication
not only with herself and the staff but within the entire unit. There will be daily team meetings
for nurses to begin every shift that will let them know what is going on that day to have
nurses work together to assist each other. Barbara will have to get comfortable with stepping
in and giving ongoing feedback wherever and whenever necessary. An official feedback
review will be done once a year and can include a 360 to see what changes in employee
engagement has been made.
Some employee wellness programs can be introduced to make the nurses and the
entire department feel valued and that the company cares about them and what they bring
everyday to work.

Problem Statement #2: Barbara’s Management Experience

Barbara is inexperienced as a manager. Although Barbara has years of experience
as a nurse in her recent history before taking the next step to manager, she has never been
a manager or has had proper practical training as a manager. It is mentioned though, that
Barbara, prior to her applying for the manager role, had just completed her master’s degree
in nursing administration which was her active start to want to begin that management path.
Equipped with her new degree, she was welcoming of a challenge, which is indicative of
someone who is minimal in experience that is needed.
In addition to this, the company is facing its hard times in the GSU, with high
turnover, low employee satisfaction, a hiring freeze, being understaffed, and no overtime pay.
Also, the economy is facing a downward turn, from which the hospital is currently subjected
to. EMU’s revenue has been decreasing sharply while costs increased, leading to tough
decisions that leadership will and must make in order to maintain the hospital from going
under. Along with minimal support from upper management, these factors that are present in
this company need to be handled by a manager who is properly equipped/trained and
experienced. An experienced manager in a difficult company time will be able to make better
and more sound decisions in pressurized situations to bring in productive and positive things,
rather than a new upcoming manager who has just recently completed a related degree. An
example of Barbara’s inexperience that we saw was when she held the off-site meeting for
herself and her employees, where employees essentially consolidated their complaints about
the company and coworkers. We saw this as moreover counterproductive than helpful, and
as another indication that Barbara’s lack of experience is apparent and a problematic factor.
The meeting ran over way longer than the anticipated time set, and ended up turning to a
destructive session rather than a constructive session.
Within Barbara’s first month as the manager, she has had two RNs leave, which is
notable.

Recommendation #2:
It is important for Barbara to understand that her mindset must change now that she
is in a management position. In the article How Managers Become Leaders by Michael D.

3
Watkins, there are seven seismic shifts that new leaders must navigate to have a successful
transition into a leadership position. These shifts are as follows:

Specialist to Generalist, Analyst to Integrator, Tactician to Strategist,

Bricklayer to Architect, Problem Solver to Agenda Setter, Warrior to
Diplomat, Supporting Cast Member to Lead Role. (Watkins, 2012)

While some of these shifts will apply to Barbara more than others, it is advised that
Barbara be aware of these shifts and understand their importance during her integration into
the management role. The only action she can take here is more of an exercise in
self-awareness and self-regulation. As Watkins states, “The skills that got you where you are
may not be the requisite skills to get you to where you need to go.”
A major disadvantage Barbara faces is the reality that she has inherited an existing team and
was not able to select her employees herself. In this situation, Barbara would be best
advised to follow the steps provided in Michael D. Watkins article, Leading the Team You
Inherit. In this article, Watkins describes three steps that all new managers should follow
when they take over an existing team. These steps are Assess the Team, Reshape the
Team, and Accelerate the Team’s Development.
To assess the team, Barbara should devise a criterion to evaluate each member of
the GSU nursing staff. Her assessments can be done through a series of one-on-one
sessions (also part of Recommendation #1), unit meetings, and on-the-job observations.
This will allow Barbara to know that she has the right people in the right positions. Barbara
should also be sure to explicitly state her criteria to employees, as Watkins' article states that
this will allow her assessments to be “faster and more accurate.”
Barbara will then need to utilize her assessments to reshape the current dynamic of
the GSU. Restructuring the team to one that can work together cohesively is not an easy
task, but it is necessary for Barbara to efficiently manage their performances. A plan to
reshape could include dividing the unit into pods of 5-6 nurses, with high-potential nurses
taking the role as team leaders. By doing this, Barbara can pair up individuals that she
believes will work best together and create a sense of unity within the teams. Additionally,
Barbara can customize shifts to utilize the strengths of nurses that are better with patients
and to those that are better with administrative duties.
After assessing and reshaping, Barbara needs to energize her team by setting some
difficult but attainable short-term goals. This could include aiming to reduce average patient
wait times, increasing patient satisfaction scores by a predetermined margin (i.e., 10%), or
decreasing department unit expenses without cutting back on care. By completing these
goals within 1-3 months, Barbara will give the unit a much-needed jolt of confidence and
proof that the new team dynamic is truly working.
Finally, it is crucial for Barbara to actively seek the involvement and attention of her
Nursing Director within the department. For the GSU to complete the turn-around in the
expected time frame, the Director must be aware of any progress that the unit is making
along with any shortcoming that may still be lingering. Some examples of this could include
Barbara sharing any unit milestones, suggesting training or coaching that will improve
performance, or recommending staffing changes that will allow the unit to run more smoothly.
This is how Barbara can effectively “manage up” and ensure that she is receiving the support
she needs to be successful.

4
 Works Cited

Watkins, Michael, and Alex “Sandy” Pentland. “Leading the Team You Inherit.” Harvard Business
Review, 16 Dec. 2020, https://hbr.org/2016/06/leading-the-team-you-inherit.

Watkins, Michael. “How Managers Become Leaders.” Harvard Business Review, 30 Jan. 2019,
https://hbr.org/2012/06/how-managers-become-leaders.

Groysberg, Nohria, and Bell. “ Barbara Norris Leading Change in the General Surgery Unit.” Harvard
Business Review, 13 Mar. 2009,
https://hbr.org/barbara-norris-leading-change-in-the-general-surgery-unit