Editor's note: This is the first article in a two-part series on managing employee performance during the night shift. The first article describes the escalation of bad behavior among night-shift employees. The second article will describe four approaches to improving employee behavior and ensuring service excellence after hours.

Hospitals never sleep. Patients require expert vigilance and safe, respectful service 24 hours a day, seven days a week. If hospitals are to produce excellent outcomes, patient-care employees need to be competent, fully engaged and compliant—night and day.

However, it's difficult to hold the night-shift employees accountable. Rounding house supervisors (clinical managers) often are too busy or too scarce to monitor compliance to performance standards or to provide positive feedback. And while night shift employees are required to attend special training, follow-up coaching is not planned or executed often.

For the most part, night-staff members work unobserved, unsupervised and unrecognized. If "good to great" or service excellence is the goal, the time is ripe for health care leaders to tune up their approaches to managing excellence around the clock.

The Challenge Is Escalating

Night-shift horror stories abound. Employees leave their work stations to visit friends on other units, leave campus to pick up fast food, sleep for hours at a time, shop on the Internet, sabotage new employees' attempts to provide care, send text messages to other workers, or refuse to lend a hand or answer a call light simply because "it's not my job." Furthermore, loud noise (staff talking or partying), especially at night, is an all-too-common patient complaint.

This is not a new problem. Night shifts long have been known to take liberties, to bond closely, to have their own brand of humor and to mask cooperation, all while following a clandestine set of group norms.

However, recent feedback from managers and employees in multiple settings indicates that problematic behaviors are escalating on the night shift. This may be due in part to increased ambiguity; for example, try writing an organizational cell phone policy that will be viewed as fair and embraced by a majority of employees.

Because employees' perspectives vary significantly, there is fuzziness over right and wrong, good and bad practices. Increasingly, employees feel at liberty to interpret what is acceptable practice without factoring in others' views or organizational directives.

In addition, managers often are compelled to assign new employees and recent graduates to the night shift simply because that is where there are open positions. During these off hours the enthusiasm of novices is quickly squelched. They must find a way to fit in or suffer ostracism from the old guard. New employees and inexperienced workers need the support of managers in the face of such pressure; otherwise, their performance will begin to match the operative norms defined by workers with more tenure.

Excellent patient care and service require focus, attentiveness, empathy and strategic intervention. Vigilance is essential, because patients can feel devastated when they press a call button and receive a delayed response or no response at all, or they're kept awake by loud conversations or noises. In these circumstances, the risk for the patient and the liability for the organization are immense.

Raising the bar is not simply about eliminating negative behavior. The challenge is to raise the bar and hold people accountable to specific behaviors that are consistent with service excellence. Without a coaching presence, there is no compelling reason to fall into step with expectations.

It's also important to recognize that night-shift employees sacrifice a lot by living an upside-down life, and we are indebted to them for their willingness to work while we sleep. And many employees who work the night shift are excellent, devoted caregivers. They continue to perform at exceptional levels despite their co-workers' urging them to lighten up or wise up to the way things are done on the night shift.

Past Practices No Longer Cut It

Using house supervisors (or clinical managers) who make regular rounds and keep matters under control is a good way to extend leadership around the clock. The problem is that in large facilities, the odds that these rounds occur are slim. Finding beds, opening night pharmacy cabinets or responding to emergencies all too often consume the time of these hard-working managers. Checking up on staff is difficult to do on a regular or consistent basis, and performance feedback is limited.

There is also a void between what the night managers are monitoring and what the day managers need to have addressed. And often there is no common quality continuum applied to behavior upon which all managers evaluate performance. Lack of formal communication processes, distrust among managers, and an occasional lack of management competency impede continuity.

Some health care organizations have named coordinators to ensure oversight during off hours. But these people are hourly employees who usually handle a full patient assignment and who are quickly underused and under attack by bullying forces. Coordinators are pressured to ease up and to join forces in support of the "way we do things."

Four Solutions

There are four approaches that health care systems can take to ensure 24/7 oversight and to enable service excellence around the clock.

  • Increase management presence at night and hold staff to the same standards as employees on other shifts.
  • Rotate nonconforming staff or break up coalitions of bullies.
  • Find ways to celebrate and recognize the "night forces of good."
  • Engage the team in self monitoring.

Next week: Each of these approaches will be described in detail. If adopted, they can help night-shift employees provide excellent service to their patients.

R. Ann Fitzgerald, R.N., M.H.S.A., R.C.C., Ph.D., is the president of Caregiver's Coach, a consulting firm in Sagamore Hills, Ohio. She is also a senior associate of Wendy Leebov and Associates in Philadelphia.

The opinions expressed by authors do not necessarily reflect the policy of Health Forum Inc. or the American Hospital Association.