Every day felt like a Monday morning. A rainy one. That's the only way to describe the dark mood that hung in the ORs and hallways of Good Samaritan Hospital in Cincinnati, Ohio. Surgical managers didn't communicate with hospital administration, veteran nurses played power trips, new hires came and went faster than fast-tracked patients and we were better at turning over staff than rooms. Our department had a 50-percent vacancy rate and the hospital continued to downsize nurses in an effort to crawl out of the $48 million hole it was in.

Today, Good Samaritan's OR nursing staff is 100 percent filled, we have a waiting list for new hires and only six people - three RNs and three surgical techs - have left over the last five years. We turned things around by adjusting the staff's attitude and by creating a positive work environment. Here's how we did it and how you can, too.

Assessing the damage
The hospital's administration hired an outside consultant who talked with our facility's staff, surgeons, managers and department directors for feedback on how we could fix the problems that plagued our hospital. The consultant changed the OR director, looked to make our surgical schedule more efficient and worked with the purchasing department to cut the costs of expensive implants. As a result, we found room in the hospital's budget for allocation into staff payroll, brought on an interim OR director, lifted the hiring freeze and changed our orientation program.

Revamping the orientation program essentially involved cleaning house. The negative energy of the staff had made its way back to the educators and ultimately affected the attitude that our facility projected to new hires. The vicious circle of negativity needed to stop, and changing the first impression of our hospital was the essential first step. A new nurse educator joined the team and increased the number of preceptors from three to 12.

After turning over the orientation team, our interim OR director received feedback from the surgical staff and came to the conclusion that the department's managers weren't visible or available enough. As a result, we brought the staffs of the main ORs and the outpatient surgery department together for weekly half-hour meetings every Friday. I earned my stripes - or lashes (I'm not quite sure which) - at those meetings.

At first, I didn't know how to handle the venom spewed at me during the gatherings. It took me a good six months before I learned how to read the staff's personalities, to know when to cut off the venting and move on to the next topic. I realized that all the staff really wanted was attention. The simple fact that meetings were scheduled was appreciated, even if the interaction was at first more negative than positive. The bottom line: The meetings told our hospital's management team that the front-line staff carried just as much anger about the lack of staff support as we did, and things needed to change.

Back to the future
Our first step to recovery involved dusting off a concept we first experienced in the mid-1980s, called the Service Excellence program - a training session for all hospital directors and managers. Its premise: How do you treat people? How do you want to be treated? Managers then took the concept back to their departments.

The idea behind the program was to get everyone on the same page with respect to turning the attitude of our hospital around, but in essence the higher-ups told the nurse managers that staff retention was now part of our job descriptions. Our raises and bonuses became dependent on our abilities to keep fulltime staff from leaving. We were just as upset as the staff about the environment we worked in, and now we were told it was our job to convince them to stay.

To get staff buy-in, I put together a Service Excellence Committee, comprised of employees with strong personalities. The committee consisted of eight members I carefully selected to represent a cross section of the surgical team - nurses with 20-plus years experience, nurses with less than two years of service at the hospital, a surgical tech and specialty team leaders. I met with them once a month for an hour-and-a-half about ways to bring the Service Excellence concept back to the frontlines. Winning the committee over was key; they were influential members of the surgical team and once they were convinced, they'd become champions of the cause throughout the department.

The committee and I asked staff to recognize each other through service-grams. If a nurse stayed late to help during a procedure or pulled a case for a co-worker, that employee wrote their thanks in a service gram. During staff meetings we recognized both the sender and the recipient, and read the gram aloud.

At first, both parties involved received a nominal gift certificate, but some nurses abused that practice by writing bogus messages. So after four months we awarded gift certificates only to the employee performing the good deed. But even without our intervention, the staff's own internal peer pressure increased the perceived value of the service-grams and the unit began to take them very seriously. The grams eventually became a badge of honor and truly boosted our staff's morale and feeling of team unity.

A fish tale
In the midst of implementing the Service Excellence program, we heard about something called the Fish Philosophy. It's a school of thought based on the beliefs of workers at the Pike Place Fish Market in Seattle. Success at work, they say, is all about attitude. Be present in the moment when dealing with people and have fun. Easier said than done, right? We thought so too, but decided to give the Fish Philosophy a shot.

We showed a 15-minute video about the philosophy at one of our weekly staff meetings. It was rough; the response was sarcastic, at best. But as I roamed the halls after the meeting, many employees told me how much they had enjoyed the video and many were interested in trying to implement its teachings.

To officially launch the Fish Philosophy in our surgical department, I placed an aquarium in the staff lounge and dubbed it "The OR Good Deed Tank." Employees earned their fish - of the plastic variety - to be placed in the tank when a manager caught them doing something good. Managers stopped them in the hall, recognized the act, wrote the employee's name on the fish they chose and handed it over.

The idea was to include all employees and to develop a sense of togetherness, so the criteria for receiving a fish weren't difficult. Things like helping to push a bed down the hall, running for an item needed in the OR and helping to hold a patient's arm or leg for a prep earned a fish. The concept might seem hokey, but you'd be surprised how important it became for nurses to be recognized. They were proud to receive a fish, and actually cared where they placed it in the tank. Some nurses even added designs to their fish, or used tape to stick them to the aquarium's glass.

The aquarium was three feet tall, two feet wide and filled with colored gravel, plastic trees and of course, the proverbial castle. I didn't fill the tank with water - the plastic fish would float and limit the space available and I was also wary of the water becoming murky during the program.

I spent $50 for the gravel and accessories. The tank itself was donated. I also purchased little plastic fish through an Oriental trading company. It was important to get enough fish to cover each OR employee; I also bought enough so each surgeon and anesthesiologists would have a fish if they wanted to participate. In the end, I purchased 175 fish for $15.

Looking back, it's clear that instant action was instrumental to the success of the program. Once we announced the idea, surgical managers immediately roamed the floor with fish and permanent markers. We also needed to include everyone. I came in early and stayed late so all shifts had a chance to be recognized. To ensure that each employee received a fish, I kept a checklist on my desk and paid particular attention to the staff I needed to catch.

As the concept took hold, even the surgeons wanted to get involved. Our nurses agreed to include them, but playfully raised the stakes for a doc to earn a fish. Believe it or not, we had surgeons mopping OR floors during room turnovers.

The Fish Philosophy lasted for a month and generated a lot of togetherness. Staff meetings were filled with banter about who did, and who didn't, have a fish in the tank. One employee even set up a fisherman puppet on the side of the tank to extract the fish of employees who slipped up. Others suggested a skillet for the fish of those who misbehaved.

The staff was having fun again. This was in 2002; our vacancy rate dropped 25 percent and we no longer relied upon traveling nurses. Things were turning around, and all because we gave our staff a little extra attention.

All the way back
When we conducted employee surveys in 2002, only half of the 40 items questioned were things the staff thought the hospital's administration did well. The same survey given in 2004 increased that number to 38. We challenged our staff, they responded and their feedback shows a marked improvement in their job satisfaction, and ultimately, in our retention levels.