The thought of telling someone that he or she is not doing a great job provokes anxiety for many of us. Most of the time, it’s easier to avoid it and hope that it will either go away or take care of itself. However, safety and quality is of utmost importance in everything we do in health care. Part of the process of ensuring safety and quality is to monitor clinical performance and to provide timely and honest feedback.

Problematic behavior

Poor clinical performance might be difficult to assess but in general any action or inaction by a nurse that puts a patient’s welfare at risk must be addressed. When I became a nurse manager, I had to learn how to address incompetent practice, unprofessional behaviors, and bad attitudes. I also had to establish accountability with the staff.

My actions resulted in 10 grievances that followed the steps in the collective bargaining process; two of those went through arbitration. In addition, there was an unfair labor practice charge stemming from a staff performance evaluation and a sexual harassment complaint filed against a physician in one of my units by a patient and a staff member. This all happened within a span of 18 months. I prevailed in all of those grievances and the two that went into arbitration. The unfair labor practice complaint was withdrawn, and the physician lost his privilege to practice in our institution. When I left the institution to pursue a teaching position, the manager of the collective bargaining unit said he was sad to see me go. The physician’s lawyer who was trying to sue the institution said to me, “I wish I had met you under different circumstances.” I knew I had left that institution in better shape than when I got there after 7 1/2 years in my position.

Step-by-step

Here is a step-by-step process that I followed to address performance issues.

1. Have a job description that clearly outlines performance expectations and the methods and criteria used for performance evaluation. Policies and procedures need to be in place to address poor or unsatisfactory performance.
2. Give regular and consistent feedback to every staff member and not just to those who are having negative performance issues.
3. Implement evaluation methods, policies, and procedures consistently.
4. Document performance issues objectively and address them early. Assist the staff member who is having performance issues in formulating an action plan for improvement. The action plan has to be agreed upon and signed by both parties. This is the first step in the progressive disciplinary process referred to as counseling.
5. Give a verbal warning if the staff continues to perform poorly after the initial counseling, which is the next step of the disciplinary process. The verbal warning involves a meeting with the employee to review poor performance issues. Documentation to support the allegation of poor performance should be available at this meeting. The employee has the right to have a witness present. The supervisor who is addressing the issues can also choose to have another member of the administrative team present. The verbal warning is documented and the consequences for continued poor performance are outlined to the employee at this time.
6. Give a written warning if the poor performance continues. The process is similar to when the verbal warning was given.
7. Terminate the employee if the employee’s poor performance continues.

Terminating an employee

Terminating an employee can become contentious and stressful. When proper communication is followed with each step of the disciplinary process, the final step of termination should not come as a surprise to the employee. However, it might be a surprise to other staff members. If anyone asks why someone has left the organization, I respond with, “I am sorry but I do not have the liberty of sharing that information out of respect for the staff involved.” This response usually takes care of the issue.

Be sure you have appropriate documentation to support your decision, and that you have the support of administration. Be sure to work closely with your immediate supervisor and with your human resources department to ensure that you are following approved policies and procedures. Occasionally, the human resources department will discuss the matter with legal counsel to make sure that the proper legal steps are followed and that the employee’s rights are not violated.

Keep in mind that terminating an employee is accomplished easier during the probationary period.

The burden of providing evidence that the firing was justified lies on the nurse manager. The employee who is fired can seek legal action against the nurse manager and the institution. If adequate documentation had been done all along and the proper procedures followed, defending your action in court should not be that difficult.

Firing an employee is difficult but in spite of how difficult it is, nurse managers should remember that it is the right thing to do. We have to believe that it is the ethical, moral, professional, and legal responsibility of a nurse no matter how stressful and adversarial the situation becomes. It is also important to remember to provide support for those nurse managers who have to go through this process because no matter how justified it is; it’s still emotionally draining and stressful.

A responsibility

An American Nurses Association’s position statement on role competence states, “Assurance of competence is the shared responsibility of the profession, individual nurses, professional organizations, credentialing and certification entities, regulatory agencies, employers, and other key stakeholders.” Each nurse—including managers— has the responsibility to ensure nurses are competent to practice nursing.

Miriam O. Young is an assistant professor in nursing at Montana Tech of the University of Montana in Butte.

Selected references

American Nurses Association. ANA position statement: Professional role competence. 2008.

Armstrong GE, Spencer TS, Lenburg CB. Using quality and safety education for nurses to enhance competency outcome performance assessment: a synergistic approach that promotes patient safety and quality outcomes. J Nurs Educ. 2009;48(12):686-93.

Bradshaw C, O’Connor M, Egan G, et al. Nursing students’ views of clinical competence assessment. Br J Nurs. 2012;21(15):923-7.

Brooke P. Hiring and firing: know the consequences. Nurs Manage. 2008;39(9):50-2.

Chappell K, Koithan M. Validating clinical competence. J Contin Educ Nurs. 2012;43(7):293-4.

Wilkinson C. Competency assessment tools for registered nurses: an integrative review. J Contin Educ Nurs. 2013;44(1):31-7.