Two weeks earlier Kate had attended the negotiation/mediation skills for managers class the hospital offered. She asked to meet with Linda and Joanne together to see if she could help them work out a new agreement. Kate opened the meeting by asking what concerns each had about the partnership. Joanne said she was stressed, but satisfied: Linda said she felt like Joanne didn't trust her. Linda didn't understand why Joanne would not let her give medications independently when the hospital's job description for LPNs allowed it. Joanne replied she had never felt more responsible than in a partnership arrangement. She considered giving medications a perfect time for teaching and assessment, and more importantly, for noticing subtle changes which may be the first warning of a more serious complication.

In helping them sort out their interests, Kate helped them see that both wanted the very best for their group of patients, and each wanted to perform to the best of their abilities. In addition she discovered that Joanne was concerned about not being surprised by a sudden change of patient condition, and Linda thought the other nurses must have thought her inept because she wasn't giving medications like the unit's two other LPNs were. Joanne assured Linda that she was very happy with her work, and felt very comfortable with her skills, "but maybe I don't know how to manage everything just right, because this is the first partnership I've been in, and I want it to be perfect for the unit."

Kate asked them for some ideas about how they could manage the partnership so that Joanne felt comfortable and prepared to respond to a change in patient condition if necessary, and Linda felt like she was trusted and viewed as competent. Joanne reluctantly agreed that Linda could give all the scheduled medications independently, and the PRNs only after consulting with her. They both thought that the need for a PRN medication might signal an important change in condition. In addition they agreed that Joanne would check in with Linda weekly for the next two weeks about her sense of being "stifled", and that both would follow up with Kate in two weeks, sooner if needed, about the overall expectations for their partnership.

Michael Johnson, RN, being upset with his new nurse manager, Marlys Stone, approached her the next day to discuss the protocol and its impact on the nursing staff. He wondered why she felt she could implement the new protocol without consulting the staff first. Didn't she value their points of view? He told her the staff was against following the protocol, and didn't see why it was necessary. Marlys indicated that the overall running of the unit was up to her, and she had been hired to turn things around so that both the physicians and Administration were pleased with the results. Michael was more frustrated when he left the meeting with Marlys, as was she. Marlys talked with the Director of Nursing about the situation, who recommended that she consult Carolyn Bowers, the Performance Improvement Coordinator, to see if she would be willing to conduct a meeting with nursing staff representatives, Dr. Jones and Marlys. Marlys agreed with the suggestion, because she really wanted to correct this problem.

Three staff nurses were present at the meeting, one of them Michael, with Dr. Jones and Marlys. Carolyn opened the meeting with her understanding of the purpose. "You have come here to try to resolve the situation about Dr. Jones' protocol. I think I understand the issues, but it would be better if you each presented your view of the situation. I'll record them as you bring them up. Let's start with the staff, then Dr. Jones, then Ms. Stone."

As spokesperson for the staff, Michael summarized their concerns. First was the issue of not being able to handle the monitoring requirements with the patient care demands on them at this time. The staff had calculated that the nurse monitoring this patient would be tied up an additional two hours post-operatively, and this could seriously impact his or her other patients. They didn't see how it was possible for a nurse, no matter how skilled, to assume additional responsibilities without corresponding changes in staffing. Furthermore, they didn't believe staffing changes were possible given all the messages from administration about "working leaner". Secondly, they had questions about the studies that indicated this was necessary. Third, and probably most important, they were feeling left out and disregarded because they had not been consulted. As a manager new to the unit and the hospital, Michael stated that they felt Ms. Stone should have relied on the staff more and that were surprised when she didn't consult them at all.

It was Dr. Jones turn to speak, and he indicated that he felt somewhat to blame in this mess, that he didn't want to cause havoc with the staff, but he wanted them to know how much he appreciated the care they provided for all his patients before, and now he wanted the very best for his patients by being sent to 4-C. He had a copy of two current studies on small groups of patients about the post-op monitoring and both used the protocol that he was proposing. If he couldn't get the staff to agree to do the monitoring, he would have to take his patients elsewhere.

Marlys had two primary concerns; to keep everyone happy, and to do it safely. She just didn't know how she could keep them all happy.

Caroyln asked what each one wanted to achieve. Through more discussion, it became obvious that they all wanted the best for their patients, and they wanted to provide safe care to these new post-op patients as well as to the other patients that would be receiving care on the unit. She then asked them to assume for the moment that the protocol would be implemented as printed in the articles. What were the issues that still needed to be addressed to do this safely and effectively? Together they came up with a list of five items:

(1) Decide whether the staff needed more education about the protocol

(2) Make more monitoring devices available

(3) Evaluate CNA assistance available to the monitoring nurse

(4) Contact the authors of the two studies to determine how they had handled the situation

(5) Project how many patients Dr. Jones expected to admit for this purpose and determine whether additional revenue would be generated to offset the possible cost of adding support staff

Each of the participants volunteered to gather more information to address the issues, and they scheduled another meeting in one week to make a decision about implementation of the protocol. Gradually the tension in the room shifted from one of opposing viewpoints to a cooperative approach where everyone's opinion was respected and invited. Each person left the meeting believing they were working on the issue together.