We're going to give you a little bit of time for some case-based interactive discussions. We put together many of these cases based on your input, and just remember that we really want to hear from you regarding questions and or comments on experiences your team has had. We want your case experiences. Use the hand for verbal communication, if you'd like to talk to us, or use the Q&A box to help us collate your input. So while we're doing that, while you're putting in your comments or thinking about some of the things based on our discussions that we've had for the last several talks, let's look at case one. Case one is a senior-level nurse has become passive-aggressive regarding her assignments within the unit. It's reached a point where many of the physicians actually start requesting other nurses to work with them rather than her. Some have complained that when she's in the room, they notice that when they're pushing her to get more efficient, she moves a little slower, and the day winds up being two hours longer than other nurses. And when the nurse is confronted by the nurse manager about expected times, she mentions that if she gets this job assignment changed again or she gets fired, she's going to start thinking about hiring a lawyer. Debbie, I know you've given us a talk about some of the strategies to handle a nurse such as this. John and Misa may have also experienced situations like this. Obviously, you always have to find out from the perspective of the nurse why she's having this type of behavior. I think a lot of it is investigating or just making her recognize this is what's going on, this is what's happening, and then finding out, does she realize that this behavior is causing problems, and is there something behind why this behavior is showing up? I'll open it up to Debbie first. Yeah, I would agree with you. It seems like there's something going on behind the scenes. As a director and working with my managers, I think the best thing, as you mentioned, is to talk with her and ask her, how does she feel things are going? Is this in every physician's room? There's some physicians that won't work with certain nurses. What's the cause of that? What's the reason behind, number one, why she feels that we aren't being on a time schedule? Then the physician, obviously, you want to know what is it that they're seeing in the room? Is it that she's playing on her phone? Is she just not being observant of what's happening in the room? I think that we need to, at this point, sit down with her and see where she feels things are going and how things are going. She may come out and just tell you, I'm not happy here any longer, or I feel like you're putting too many cases on for the day. It's gotten too busy, and it feels like a cow go through it and herd everybody through. I think we need to address what's making that nurse have a change of heart in her work ethic. I completely agree with what Debbie said. I would hearken back to my talk, and I would say, be curious and not judgmental, and sit the nurse down. Maybe it's her arthritic knees, and she can't push the stretchers as quickly as the 20-year-old nurse who just graduated from nursing school. Ask those questions, really hear the nurse, hear her issues, let her verbalize what exactly is going on. Point number two is just consider, across the board, metrics for your unit. In our unit, we have a sign that says, 14-minute turnover from one case to the next. The nurses know it's in every room, posted in every room. The nurses know this is what we're aiming for. Make sure your expectations are spelled out, and the nurses will come to you and tell you, hey, your expectations are ridiculous. There's no way we can make that work. I think if you've got equal expectations for every nurse in every room, your odds of getting everybody to step up to the challenge are much better. I also completely agree with both of you. Actually, while I was listening to Dr. Eisenberg read this question, I was thinking about the be curious and use compassion remark that Dr. Kabilian made during her talk. This is exactly where that would apply. This may even be a situation where, hey, careers evolve, and what used to be great and fun and satisfying for this healthcare professional may not be any longer. It's not about making this person fit into the environment. If there's another environment that might be more satisfying for her career-wise at this point, then the best thing for all involved might be for us to help her find what that is. She may be eternally grateful for that and may even help us to recruit her replacement. That's not a joke. She may know another nurse, and that nurse may be at a point where he's saying, hey, I've been in the clinic environment for a long time, and I've been wanting to try procedures, so I'd love a shot at that. Well, then maybe they trade places. It's not about making what's now a square peg fit into a round hole. It's about how to be helpful, and I think that's what Debbie's nailing down here. Thank you for all that input. I really think that trying to come up with a solution involves everyone on the team, sometimes good for the physicians who are in the room to say, hey, I noticed this is an issue for me, and is there something I can do to help you? Being that curious person instead of just complaining to the nurse manager might help mitigate some of this as well. I know that we have some additional input from our audience, maybe some other questions. Eden, can you help us with that? Yeah, and picking up on the same note that we're on, Angela writes, and if it is physical, what do you do? We still need to continue to move the room. Younger nurses can't expect to take longer rooms all the time because they physically can. It turns into other nurses saying management is not being fair. What are your thoughts on that? I can tell you what I would do in this situation. In talking to the nurse, and like I said, as you mentioned earlier, maybe her knee's hurt. Maybe she's had a knee replacement. I've had nurses who have had these issues, having been in the same practice for so long, and sometimes they get an actual reduced work note from their physician, that they can no longer stand for more than three hours at a time or whatever that may be. If they do have that, if you have the opportunity to offer them a position, as Dr. Martin mentioned, somewhere else in that practice or in that company, I think that's the time then you start working towards that. You know, people transition and progress, and there's always a succession. It's a natural order that we tend to slow down and not able to be able, speaking personally, to do as much as we could before. I think that opportunity, and this comes with cross-training, right? This comes back with adding those skills in as you're having someone in your company. Maybe they go to a triage line for nursing, and they're making pre-op calls. I think the company, if it's a valuable employee, can look at other options to place that person. People will come and go. Some nurses don't like to do anything but work in the procedure room. I think that's where you work with what staff that you have and the personalities of everyone there. If this is indeed someone that is valued, I think that you'll find a space and support from others for that nurse. John? Thanks, Gerard. I just want to make mention that we're all healthcare professionals here, and I think it's important for all of us, regardless of which part of the team we come from, to remember that we work in one of the most stressful industries there is out there. A lot of impairment of various sorts can come about as a result of that, and we never know what's going on at the personal level at home. So back to Dr. Kabilian's point of compassion and curiosity, is it really a work issue, or is it just easier to frame it as a work issue when the real problem is with personal health or personal mental health or with stressors at home or in one's personal life? It may actually not be about the stretcher or about standing at all. It may actually be because there's no one at home taking care of a sick child or something like that. So be compassionate and curious, as Dr. Kabilian mentioned earlier, and seek out, is it something that you can actually help with that has to do with nothing at work, really, but with something outside of work? It's a tough field we're in. Yeah, those are great comments. And one of the other things that I would also suggest thinking about is, is this a time to rethink the process of how room turnovers take place? Do you reconstruct the way that patient turnover occurs? Do you bring in a nurse navigator who they get input from the nurse in the room that there's a patient about to be brought out to the recovery area? They can start making room for that patient to come out and send in perhaps a roving technician or a roving staff member to come in and help with some of the physical components of moving patients out so that the nurse who has that physical disability doesn't have to do that. And maybe you can incorporate that in all of the rooms just to make everything fair so that the nurses who are doing some of the physical stuff don't feel like they're being imposed on in a different way than a nurse who asks for a certain disposition regarding their work environment. So those are things to focus on in addition to the personal issues. Eden, do we have any more questions or comments? We sure do. And just so everybody, we're going to cut our 15-minute break to five. Hopefully that's enough for a quick bio break because we do have some more questions in and we have another case. So we're going to try and get as much as we can in the next eight minutes. So our next comes from Sarah. Say that you have four nurses that tell you another nurse has been rude and verbally inappropriate to them. When do you document or when you document, do you suggest that each witness write down their complaint or that the nurse manager writes down all four nurses' complaints themselves? Does it matter how you document? So should we start with Debbie on that one, Dr. Eisenberg? Sounds good. Okay, thank you. I can tell you at Ohio Gastro, what we do is we have the individuals who have had the actual experience or witnessed behaviors write in their words what they saw, what they heard. And I think that that leaves the bias out of it if there's a nurse manager that documents all of it themselves. I mean, they can certainly say this nurse came to me and explained this to me and then write that report and continue on and follow up appropriately. But I think it's important that you have the individuals document what they've experienced. Okay. And yeah, we do. We have another question. This person writes, this is Dr. Edmundo, it's a one barrier to recruitment of endoscopy nurses in our region is the need to take call on nights and weekends. What strategies have been employed at various centers to reduce or eliminate that barrier? Overtime or bonus pay for call does not seem to help us. So do you all have other strategies you're using? Yeah, that's a great question that comes up quite a bit. And it's an issue in which there are just some nurses that do not want to take call, period. And Nisa, I think you had some insight about some of the ways to overcome this challenge, although may not be overcome completely. Yeah, it's certainly a challenge, Gerard. And I think it's been really augmented by the pandemic. I would say that our institution being flexible with our nurses has helped. And what I mean by that is offering almost a barter system. If you're willing to take call, then we will allow you to be the first nurse that goes home when our rooms are finished, or essentially creating some side deals that obviously go through HR and go through payroll and are approved by leadership, but being creative and finding ways to incentivize our nurses to take call on nights, weekends, and holidays. John, I know you also had some suggestions in our chat. Yeah, thanks, Nisa. We've tried a number of approaches with, I would say, limited success. One of the things that we've done is we know that our volume of night time ERCP, so say between 7 o'clock PM and 7 AM, is a very, very low volume in spite of being a large institution. Most of those patients can at least be floated over to first morning case. So we've eliminated ERCP call coverage during those hours, seven days a week. There is no nighttime nursing resource that's been allocated on any regular basis for nighttime ERCP. As for emergency endoscopy in general, obviously, we need to provide that coverage. And the way that we've construed that coverage is through basically a 24-hour scenario where somebody is always on for that shift. So it's not getting called in. You're actually in there. And if you're not taking care of a patient at 1 AM, you're stocking or doing something else that's useful to the unit, putting together the schedule for the nursing team, et cetera. And that buys the whole team basically the pay rate of being an inpatient nurse rather than an outpatient nurse. So the whole team is benefiting from that. And the team is large enough that you only have to do that overnight shift once every few months. So that's actually helped reduce the revolving door, if you will. But it hasn't stopped the door from revolving. I mean, we're always losing nurses to services departments, units that are eight to five where you can drive up and park in front of the door for free and never work a weekend or a holiday the rest of your life. We can't really compete 100% with that. But it's definitely reduced the RPMs of that revolving door. Yeah, one of the other considerations is there are some nurses who are used to working night shifts from having been in the intensive care units or the floors. And they're kind of used to it. And they would be actually willing to just work night shifts. So that might be one way to think about strategizing is just have one or two nurses that just do nighttime calls. They may never get called in for several days. But they're OK with that because they're still getting paid. But it is an expensive proposition. And in our institution, we've utilized the same strategy that John has had where we have not included nurses in some of these ERCPs or even some of these emergent endoscopies that are being done. We just don't have a nurse come in into our inpatient unit at night. So that's one way to think about it.

passive-aggressive behavior

addressing issues

understanding perspectives

alternative positions

flexible scheduling