Want to Avoid Performance Improvement Plans? Add Real-Time Feedback to Nursing Orientation

• Some new graduate nurses have received performance improvement plans at the 11th hour with little feedback up to that point. 
• To avoid this situation, one nurse argues for the implementation of real-time feedback by nurse educators and nurse managers. 
• This, she says, can help identify issues in a timely manner and benefit both the new nurse and the supervisors. 

When I was a new unit-based nurse educator, there was a new graduate nurse who was completing the second shift of her final week of orientation. During that shift, her nurse manager called me into her office to discuss her progress. At that moment, I was asked to be a part of a performance improvement plan (PIP) for this nurse. I was also told there was a potential for termination.  

The nurse manager showed me a laundry list of concerns detailed in emails from preceptors, charge nurses, and other nurses. Keep in mind that her preceptors were asked to use a form to document her progress for every shift.

I met with the preceptors and nurse together every two weeks to review the written feedback and set goals. The goals were set around the usual time management skills, but nothing like what was in the emails. This was the first time in almost 12 weeks I had heard of the concerns included on this list. The new graduate nurse was also surprised by the performance improvement plan.

If you’re reading this as a nurse educator, it may sound like one of your stories. If you’re a nurse manager, you might have been on the receiving end of the extensive list of concerns emailed at the 11th hour

In the next few paragraphs, I will discuss the importance of real-time feedback for nurse educators and nurse managers to identify issues in a timely manner and respond effectively to concerns. 

Nurse Educator & Nurse Manager Observations During Check-Ins 

Every organization is different. In some, orientation check-ins include the educator, preceptor, and orientee. Others include the nurse manager with the educator, preceptor, and orientee. Whatever way you choose to conduct these meetings, a few observations can be made to ensure feedback is thorough and correct.

Check-ins should be a collaboration. Ensure that both the orientee and the preceptor are verbalizing areas where they are thriving and areas where improvement is needed. That way, you can determine if their perspectives align

Pay attention to nonverbal cues. What’s the preceptor’s body language? Does it line up with the feedback provided? How thorough is the written feedback? Is the preceptor able to give examples of feedback? When asked about areas for improvement, is the preceptor not able to identify those areas?

A new nurse only knows so much, so is it realistic if there’s not at least one area for improvement during orientation? Also ensure that the orientee is participating in the conversation. Acknowledging areas for improvement verbally, along with written feedback, is agreement. This can be used in later meetings to gauge how well the orientee is improving.

If you find there isn’t much engagement during the meetings, consider scheduling a follow-up with the preceptor and orientee by themselves. The reality is that some preceptors are uncomfortable having difficult conversations about areas of improvement for the orientee. On the other hand, some orientees may have issues with their preceptor’s communication or precepting style and are uncomfortable voicing that. Individual meetings create a safe space for everyone to express their concerns.

However, it does not stop there. As adults, we should be able to have conversations with each other. These separate meetings are an opportunity to coach the preceptor or orientee on how to express their concerns to each other. The nurse educator and/or the nurse manager should be present for these conversations and the plan forward should be documented.  

The scenario I provided earlier presented a few pitfalls. Presenting a list of concerns at the end of orientation is just not fair. It doesn’t give the orientee a chance to progress in areas where there’s opportunity for improvement. At that point, it just seems like hearsay. The other issue is that some of the items were safety issues. For the sake of patient safety, these issues needed to be addressed in real time.  

Responding to Complaints

I remember one day, I walked to my director’s office to discuss a conflict I had with another coworker. At this time, I was an educator, and I was in tears (of anger) about the interaction. Before my director responded based on just my emotions, she said something very profound.  

She said, “I can see that you are visibly upset. I have not been given the opportunity to hear both sides of the story. My first question to you is, ‘When did this happen?’ My second question is, ‘Have you had a conversation about this since the initial conversation?’” 

My response was, “It happened about 15 minutes ago, and no, I have not had another conversation.” She then said, “After you cool off. I would like you to have a conversation with her about how the interaction made you feel. If you cannot come to a resolution after that, I can facilitate a conversation between the two of you. Do you need any advice on how to initiate the conversation?”

I was stunned. It was clear who was in the wrong! I did not want to talk to this person who disrespected me. But after I cooled off, I realized that my director’s response was fair. She acknowledged my concern and feelings. She was practicing fairness to my coworker, as she had not heard her perspective. For all she knew, I could have been reacting dramatically without a cause. Slander is not uncommon, so she had to be wise in her response to me.

The other key is that she essentially encouraged me to be an adult and learn to how resolve conflict. She offered coaching and a chance to have her facilitate a conversation if my efforts were unsuccessful.

Before I could initiate a conversation with my coworker, she walked down to my office and started a conversation with me. Through that conversation, we discovered that both of us had some areas where we needed to improve our communication. We gave each other the opportunity to make an informed decision on working together more effectively.

You may be asking, “What does this have to do with clinical nursing practice and orientation?” Well, let’s translate this.

As a nurse educator or nurse manager, you may encounter written or verbal complaints about a nurse’s clinical practice or skills. The first questions may be, “Did you have a conversation with this individual at the time you made this observation?” “Did you redirect them at that time?” “Did you complete an incident report?

One of our responsibilities as nurses (regardless of title) is to hold each other accountable. Patient safety depends on this. Real-time feedback also allows for accurate documentation and gives the orientee a chance to respond to the concern promptly. Imagine being presented with an incident from 10 weeks ago and trying to remember exactly what happened, what you were thinking, or who the patient was. 

Nurse Manager vs. Nurse Educator Role in Performance Improvement Plans

In some institutions, the lines are blurred between a nurse educator and a nurse manager. In my experience, it’s vital to have a good partnership between nurse manager and nurse educator for the best collaborative experience. When there is effective communication between a nurse educator and a nurse manager, clear responsibilities can be established. 

For instance, a nurse manager might want to meet with the unit’s nurse educator to discuss education needs for the staff. In those conversations, they can review the root cause of certain issues and determine if there’s a unit-wide issue or if certain caregivers are showing a need for education.

They can discover what might be causing poor performance. Does the orientee have all the resources needed? Does the orientee perform better under the guidance of certain preceptors? Is there a knowledge gap or blatant noncompliance? If it is discovered that there is a compliance issue, the manager can move forward with appropriate disciplinary action. If it is a true knowledge gap, the nurse educator can be involved. 

The Bottom Line

The culture of a nursing unit is only as good as the mindset of its leaders. As nurse managers and nurse educators, the example we set is vital. If you have not done so already, develop a formative assessment for new nurses, which includes regular check-ins.

Set boundaries so you aren’t pulled into conversations that may be gossip or hearsay. Consider the source of the complaint. Consider the timing of the complaint. Encourage and empower nurses to have direct conversations with each other. Coach them on having those difficult conversations.

Transparently, as leaders, we are sometimes the ones who need coaching. It is more than OK to seek out coaching to become more effective at responding to these types of situations. Orientation is the foundation that influences the trajectory of a nurse’s career. Real-time feedback can make a world of difference. I wish you all the best! 

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