After reading this article, you will be able to:
- Assess whether issues are due to performance gaps or knowledge deficits
by Barbara Mayer, RN-BC, MS, PhD(c)
Editor’s note: Mayer is director of professional nursing practice at St. Vincent Medical Center in Los Angeles.
Staff development specialist (SDS) time is a valuable yet scarce commodity, so we must identify appropriate use of this valuable resource. For example, imagine a nurse manager comes into your office and says, “Mary Lou just doesn’t get it. She makes mistakes, doesn’t seem to know much about medication administration, and when I talk to her about it she gets really defensive. You need to provide some education for her.” Is Mary Lou’s performance issue really about lack of skills or knowledge? Or could it be something else entirely?
SDSs are often asked to provide education when nurse managers identify individuals or groups of employees who are not meeting performance expectations. Although lack of skill or knowledge can be the cause of underperformance, there are other causes that should be considered.
Don’t most nurses want to do a great job? Of course! So if they’re not doing a great job, they must need more education, right? Not necessarily. Education is often the go-to tool in management’s toolbox, and when performance does not improve, SDSs are asked to provide more education. This cycle can continue if we don’t step back and really look at the cause of the performance gap.
The Human Performance Technology model
Human Performance Technology (HPT) is “a systematic approach to improving productivity and competence, through a process of analysis, intervention selection and design, development, implementation, and evaluation designed to influence human behavior and accomplishment” (Stolovitch, Keeps, & Finnegan, 2000). The goal is to identify and develop a set of interventions that solve or mitigate barriers to performance. HPT grew out of the instructional design field and is a valuable tool for SDSs in analyzing performance gaps and developing appropriate interventions.
Step 1: Identifying performance gaps
A performance gap is the difference between what someone is doing (or not doing) and what they should be doing. The first step in correcting a performance gap is to understand the difference between the behavior being exhibited and the expectations.
The significance of the gap should be considered. What will happen if corrective action isn’t taken? If you intervene, can you expect a worthwhile result? If inaction will result in patient harm, then of course performance must improve. In some cases, however, the payoff for intervening is negligible and not worth the effort.
Step 2: Cause analysis
Once it is determined that a significant performance gap exists, SDSs can assist managers in determining the cause of that gap and developing appropriate interventions. The first step in analyzing the cause of performance gaps is gathering information through interviews of key stakeholders (see the list of questions in the sidebar on p. 7). There are three primary causes of performance gaps:
Lack of knowledge or skills. If nurses have never performed the skill or task expected of them, then formal training is an appropriate intervention. When a knowledge deficit exists, instructor-led classroom training, computer-based programs, or a blended learning approach can be used. If manual skills are required, use of skills labs or simulators may be effective.
If nurses have received education and performed the skill before, but the opportunity to perform is presented infrequently, a different type of education is required. This may take the form of “just in time” tools such as posters or guidelines outlining the critical steps in performing the skill. Brief in-services, videos, or DVDs available on the unit may also be effective in providing on-the-spot refreshers. Electronic media, such as PDAs and online resources, are also becoming popular means of ensuring that up-to-date information is available at the bedside.
Lack of motivation. If nurses possess adequate knowledge and skills, consider motivation to perform. Do they perceive some kind of punishment for a job well done? For example, highly skilled and organized nurses may always be asked to take extra admissions or the most acutely ill patients, leaving the impression that they are working harder than others. The solution in this case is to distribute assignments equally among all staff. A lack of positive feedback for nurses’ extra efforts can also lead to a lack of motivation to continue doing a good job. Acknowledgment of their performance with a simple “thank you” may be all that is required.
In some cases, nonperformance is inadvertently rewarded. For example, nurses who lack organizational skills may not be asked to take extra admissions or be expected to provide assistance to team members. Nurses may get personal satisfaction from their poor performance, perceiving that they don’t have to work as hard as others. When it is concluded that nonperformance results in a positive or desired outcome, this perception must be removed. Consistent standards of performance must be expected of all staff. When underperforming nurses adhere to expectations, their behavior must be reinforced with positive consequences.
When we permit poor performance, we promote its continuance. Therefore, positive consequences should increase when nurses meet performance expectations. Conversely, appropriate consequences for nonperformance must be consistently enforced.
Organizational or system barriers. The third common cause of performance gaps is system-related issues. First, do nurses know what is expected of them? Ensuring that performance standards exist and that they are clear, complete, and readily available to staff is essential. Of course, nurses must have read the standards and understand them.
Lack of available resources may also result in suboptimal performance. It is difficult for nurses to meet performance standards if the tools they need are not available. Ensuring that staff, in adequate numbers and with the appropriate skill mix, are available to meet the acuity needs of patients is essential. Inadequate supplies may also present an obstacle to good performance. Checking par levels and ordering procedures will ensure availability of adequate supplies to get the job done correctly. Equipment that is in proper working order and conveniently located on the unit will also enhance desired performance.
Step 3: Selecting the appropriate intervention
Before implementing an intervention, consider other factors, such as quality or regulatory standards, time, and finances. SDSs can work with nurse managers to develop criteria based on these factors and select the intervention that best fits those criteria and the goal of improving performance. It will be important to gain commitment from all key stakeholders prior to implementing interventions.
Step 4: Measuring success
Determine how you will measure success prior to implementing any interventions. The change in behavior must be clearly stated and understood by both managers and staff nurses. Deadlines for improvement must be identified and adhered to. Other key metrics may include a reduction in errors or injuries and increased satisfaction scores from patients, staff, and physicians.
If performance does not improve, other factors may be involved. Nurses may be in the wrong role (e.g., they are just not cut out for critical care). Perhaps the nurse is in the wrong area of specialty and transfer to another unit can be considered (e.g., labor and delivery may be a better fit for the nurse’s skills in communication and compassion). It’s also worth asking whether the nurse’s professional goals are congruent with the goals of the organization. Perhaps another organization or setting would better meet his or her professional needs.
There are many reasons that nurses do not perform as expected. The HPT model can be a useful tool for SDSs in leveraging their role in the identification of performance gaps and appropriate interventions. The unique position of SDSs as neither staff nor management engenders trust between them and staff nurses. By strengthening relationships with nurse managers, they can play an integral role in improvement of staff performance.
Fournies, F. (1999). Why Employees Don’t Do What They’re Supposed to Do and What to Do About It. New York: McGraw-Hill.
Human Performance Technology Central. (n.d.) Available from www.humanperformancetechnology.org/hptmodels.html.
Mager, R. & Pipe, P. (1997). Analyzing Performance Problems. Atlanta, GA: Center for Effective Performance.
Stolovitch, H.D., Keeps, E.J., & Finnegan, G. (2000). Handbook of Human Performance Technology: Improving Individual and Organizational Performance Worldwide, Second Edition. Hoboken, NY: Wiley Periodicals, Inc.
Gathering information to determine performance gap or knowledge deficit
The first step in analyzing the cause of performance gaps is gathering information through interviews of key stakeholders.
Questions to ask staff members include:
- Can you explain what is expected of you?
- Have you been given a job description?
- How do you find out what is expected of you?
- How do you know when you are meeting job expectations?
- Do you get feedback? How often? From whom?
- Do you have all the equipment or supplies you need to do your work?
- Have you requested materials or supplies that you have not received?
- What happens if you do an outstanding job on a particular day?
- Does the structure or culture of the organization help or hinder your work?
- How effectively are changes in practice communicated to you? What about tools?
- Are you getting enough help and guidance?
- Do you know how to do _______? Was this covered in your orientation?
Questions to ask managers
- Has the employee received adequate training to perform this task?
- Has the employee ever performed this task satisfactorily?
- How often is the task performed?
- Does the employee experience something undesirable when he or she performs this task?
- Is there something about performing the task that is perceived to be punishment?
- Does the employee get some sort of payoff for not doing what is expected?
- Does the employee get prestige, status, or other self-gratification for poor performance?
- Are written standards available?
- Are written standards complete and clear?
- Have the standards been read?
- Are the working conditions suboptimal?
- Does the organizational culture support the desired behavior?
- Are supplies adequate?
- Do the given tools fit the job?
Source: Adapted from Mager, R., and Pipe, P. (1997). Analyzing Performance Problems. Atlanta: Center for Effective Performance.