1. Nguyen, Christi MHA, MSN, RN, NEA-BC, FACHE

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When a leader acquires a unit that has historically struggled with low employee satisfaction scores, high turnover, and a negative culture, the culture of the unit must change. This takes a transformational leadership approach backed by a change theory or model.

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A 24-bed, medical-surgical unit at a large metropolitan hospital underwent a change in unit culture over a 2-year period. The medical-surgical department was trailing behind the entire hospital's nursing and financial indicators. The Press Ganey employee engagement score was at an all-time low of 67.7%. The majority of the nurses on the unit weren't participating in the career advancement program. An unhealthy culture existed on the unit, including lack of teamwork, gossip, and a sense of favoritism, as the nurses came to accept the negative work environment and became desensitized to bullying.



A new nurse manager started in January 2013. The manager incorporated the transformational leadership style and shared governance practices through the American Nurses Credentialing Center's Magnet Recognition Program,(R) McDowell and Williams' Caring Leadership Model, and Lewin's Theory of Planned Change to transform the unit's culture.1-3 (See Table 1.) Once the management team demonstrated the Caring Leadership Model and transformational leadership style in their daily practice, communication and teamwork became essential in facilitating the change process.

Table 1: Core values... - Click to enlarge in new windowTable 1: Core values of the Caring Leadership Model crosswalk

After assessing the unit and the team, the manager recognized the lack of unit celebrations and a formal recognition program. The manager started a spirit committee led by the staff members to get their peers engaged and build teamwork. A new formal employee recognition program was initiated to create fairness and standardize the selection process for the employee of the month, quarter, and year. The manager used the shared governance model to rebuild the unit-based council, involving staff in the decision-making process.


Meeting with staff members one on one (employee rounding), the manager and supervisors developed a relationship with the employees to discover their strengths, weaknesses, and long-term goals. Using employee rounding data, the manager and supervisors worked with the staff members to provide them with growth opportunities. The hospital instituted a formal nursing development program, and the manager and educator raised awareness about this program and encouraged staff members to participate in their career growth and development.


The manager utilized the Agency for Healthcare Research and Quality TeamSTEPPs principles to drive quality indicators.4 Bedside reporting was implemented in 2012, but staff members weren't 100% compliant due to a lack of accountability. Hourly patient rounding was initiated to address key issues, referred to as the "Five Ps:" (1) pain, (2) potty, (3) position, (4) possessions, and (5) pump. Leadership arranged an hourly rounding clinic for staff to attend and assess proficiency by May 2013. Leadership also initiated daily shift briefings to increase communication between shifts and improve the unit's quality indicators. Key indicators, such as patients at high risk for falls, pressure ulcers, catheter-associated urinary tract infections, central line-associated bloodstream infections, and restraints, were reviewed to ensure that staff members were aware of initiatives that needed to be implemented.


In addition to building a relationship with the team, the manager communicated a shared vision and motivated staff to be innovative and take risks to improve. The manager met with the supervisors weekly to help develop them in their leadership role, as well as ensure that everyone was communicating the same message to the team. During the meeting, the leadership team also developed the game plan for the week or month and worked on being proactive with any potential employee, patient, or physician issues. The manager created a weekly newsletter to keep staff informed of important news from the hospital, issues identified from incidence reports, near misses, staff feedback, and any significant information related to quality indicators. The newsletter also recognized employee achievements.


As the leadership team worked on changing the unit by encouraging active listening, building team collaboration, and increasing fairness, the unit culture evolved into a more positive, motivated, engaged, and cohesive team. Establishing a supportive, encouraging environment that respects the dignity of both patients and nurses increases the level of respect among coworkers. Being used to the status quo, staff members didn't feel comfortable holding each other accountable for performance and behavioral issues. Through time and the development of trust, staff members became more comfortable reporting issues such as bullying. The low-performing employees and bullies who didn't improve their behavior eventually left the organization. As the low performers left, leadership brought in new employees who were a good fit with the team and the unit's culture changed to a more nurturing environment.




As people walk onto the unit, evidence of friendliness, approachability, and teamwork is present. In 2013, the unit won an esteemed hospital award known as the "traveling trophy" for its highly successful, seamless move into a newly renovated 23-bed unit. This unit and its adjoining unit moved all 46 of its patients within 2.5 hours. Teamwork and communication between the unit and multiple departments (facility operations, pharmacy, information technology, housekeeping, and senior leadership) were evident in making this transition a success with minimal operational disturbances.


The nursing unit became more engaged over the course of the 2-year implementation period and was selected for several nursing initiatives and pilot programs. The following accomplishments were achieved with this unit serving as the pilot unit: the "out of bed" evidence-based practice study, a designation education program with a prestigious nursing school, the Nurses Improving the Care for Healthsystem Elders program, and a "tap and go" single sign-on system.


Employee engagement

Staff members became more engaged on the unit. The spirit committee held monthly potlucks to celebrate birthdays and recognize employees for their achievements. In 2014, the manager created employee boards on the unit with the nurses' professional pictures, degrees, certifications, and any career advancement program achievements. The employee of the month, quarter, and year were also displayed on the unit. Staff members gained pride as patients, visitors, physicians, and other caregivers looked at the boards. As staff members became more engaged and teamwork became the fabric of the unit's culture, they were more involved with hospital committees and community service.


In 2013, 5 months after the new manager initiated the transformation plan, the Press Ganey employee engagement score increased to 74.7%. In 2014, it went up to 92%. (See Figure 1.)


Financial outcomes

In 2012, the unit didn't meet its financial goals. Overtime was at an all-time high of 40%. Through communicating with staff at monthly meetings, encouraging teamwork, and staffing by acuity, overtime decreased to less than 2% by December 2013 and was maintained in 2014. In order to staff by acuity, charge nurses were taught how to use the computer-generated patient list to distribute the patient assignments among the nurses and patient-care technicians. Acuity points were generated from the preceding 24 hours of nursing documentation based on the patient's assessment, procedures performed, and time spent providing care. Utilizing this system balanced the patient load, which became evident as the nursing team left the unit together versus one or two nurses still charting and trying to finish their shift. Teamwork throughout the shift also helped the nurses and patient-care technicians finish at relatively the same time.


The team performed a Lean Six Sigma project on linen waste reduction in 2014, with an annualized savings of $6,937. This project won the 2014 operational excellence team's financial sustainability award. The unit also completed a very successful waste reduction project focused on wound care dressings, with an annualized savings of $28,467 in 2014. The team achieved the waste reduction by taking only what was needed to the patient's bedside. If a physician requested that supplies be at the patient's bedside, only enough supplies for 2 days were stored. Physical therapy also partnered with the nursing unit by not giving away free supplies when the patient was discharged. If the patient needed supplies, case management became involved and arranged for supplies to be delivered through a durable medical equipment company.


Time for change

In this difficult time in healthcare, organizations must develop strong, caring leaders who are on a course not only to survive, but thrive. To transform a challenging nursing unit's culture, you must build a relationship with the team, get the team engaged, and hold staff accountable. Using the transformational leadership style will help you inspire a vision, disseminate information effectively, and enhance employee engagement. When your staff members are engaged, your unit, or even your entire organization, will be transformed.




1. American Nurses Credentialing Center. Announcing a new model for ANCC's Magnet Recognition Program. [Context Link]


2. McDowell JB, Kautz DD, Williams RL. Teaching the core values of caring leadership.


3. Shirey MR. Strategic leadership for organizational change. Lewin's Theory of Planned Change as a strategic resource. J NursAdm. 2013;43(2):69-72. [Context Link]


4. Agency for Healthcare Research and Quality. TeamSTEPPS: national implementation. [Context Link]