Let me tell you what I really think about you'- evaluating nursing managers using anonymous staff feedback

'Let me tell you what I really think about you' – evaluating nursingmanagers using anonymous staff feedback

ILYA KAGAN MA , RN1, RONIT KIGLI-SHEMESH MA , RN

2 and NILLI TABAK P hD , RN , L L B3

1Head, Continuing Nursing Education Unit, Tel-Aviv University, Tel Aviv and Nursing Management Department,Assaf-HaRofeh Medical Center, Tzrifin, Israel, 2Director of Nursing, Ness-Ziona Mental Health Center and NursingDepartment, Tel-Aviv University, Tel Aviv and 3Head, Nursing Department and Head, Ethics and Law Unit, Schoolof Health Professions, Tel-Aviv University, Tel Aviv, Israel

Introduction

Nursing in Israel has undergone many organizational

and managerial changes in recent years and its workings

have come under intense scrutiny. Eliminating tenure in

managerial positions has been proposed and increased

efficiency and higher productivity has been demanded

from nursing directors (Riba et al. 2004). The period-

ical rotation of managerial posts and making senior

managers’ retention of their job conditional on a com-

prehensive achievements’ evaluation are other sugges-

tions.

Employee evaluation is considered a key manage-

ment tool today (Martzki & Gureli 1990, Weizner

1998, McCarthy 2000, Harmati 2003, Kaspi &

Ben-Dor 2003, Garman et al. 2004). In Israel, nurses’

performance evaluation generally takes the form of

senior personnel evaluating junior employees – a ward

nurse evaluated by her head nurse, or outpatient clinic

head nurses evaluated by the district head nurse – and

is performed periodically, at annual or semiannual

intervals, or when the nurse enrols for special or ad-

vanced training and the training facility requires

evaluation for admittance. Despite the relatively well-

developed procedures for the evaluation of junior

employees, having line staff evaluate their managers

and senior nurses has not achieved established status.

We did not find any Israeli reports of subordinates

evaluating senior nursing managers. We know that

there have been local efforts to conduct dialogues in

Correspondence

Ilya Kagan

31/1 Tavor St

PO Box 2217

Gan-Yavne 70800

Israel

E-mail: [email protected] or

[email protected]

KAGAN I., K IGL I - SHEMESH R. & TABAK N. (2006) Journal of Nursing Management 14, 356–

365

'Let me tell you what I really think about you' – evaluating nursing managersusing anonymous staff feedback

The evaluation of employees by their superiors is standard managerial practice butthe value of the evaluation of superiors by their employees is much less recognized.

This study describes a project where for 3 years (2000–02), in an Israeli mental

health center, the Director of Nursing, clinical supervisors, ward head nurses andtheir deputies were evaluated by nurses and nursing aides. Feedback was gathered

through anonymous questionnaires under conditions of confidentiality. Based on

the findings, steps were taken to improve managers’ performance. Evaluators werealso requested to evaluate the project’s contribution to themselves and the hospital

in a second, open questionnaire. All parties, evaluators and evaluated, expressed

satisfaction and recommended that the project continue on a regular basis. Nursesfelt empowered and respected and that manager–subordinate relations were

improved. Other results and recommendations are discussed.

Keywords: anonymity, employee evaluation, nursing managers

Accepted for publication: 21 April 2005

Journal of Nursing Management, 2006, 14, 356–365

356 ª 2006 Blackwell Publishing Ltd

which junior employees were encouraged to express

their opinions openly.

The aim of this project is to describe a 3-year project

where anonymous feedback supplied by subordinates

was tried (at the Abarbanel Mental Health Center, in

Bat Yam, Israel) as a method of evaluating the per-

formance of middle and senior nursing managers. And

we also examine what the Abarbanel Center’s nursing

staff, both evaluators and evaluated, had to say about

the benefits and disadvantages, the implications and

contributions of this type of evaluation as a manage-

ment tool.

Background

Employee evaluation today is considered an integral

part of business life. At least once a year both employers

and employees formally undergo an evaluation of

workplace performance. The declared purpose is to

identify the activities and components required for the

successful performance of specific organizational tasks.

It usually consists of two elements: a comprehensive

questionnaire and feedback supplied to the question-

naire items in discussion with a superior (Stockman

1996, Kaspi & Ben-Dor 2003). Two other principal

reasons are given for performing employee evaluation:

it increases motivation and thereby performance, and is

an important managerial tool for manpower decision-

making (salaries, promotions, dismissals, etc.). Some

experts contend, however, that employee evaluation is

gradually losing its impact (Longeneker 1999).

In Israel, the overall impression gained from the lit-

erature and from our experience is that employee eva-

luation is almost always conducted on the ‘top–down’

principal, reflecting the existing organizational hier-

archy. Junior employees are evaluated by their imme-

diate superiors; middle management is assessed by

senior management, and so on. In the nursing commu-

nity, worker assessment tends to lack focus and to lose

momentum almost entirely when it comes to senior

managers, such as directors of nursing and nursing

supervisors.

Evaluation from different angles

An alternative approach to evaluating performance,

especially where senior staff is involved, is to apply the

principal of ‘bottom–up’ evaluation. In other words,

employees appraise their managers. Both the ‘top–

down’ and ‘bottom–up’ approaches have merits and

each requires and serves a different management

approach. McCauley and Moxley (1996) claim that

performance evaluation by different status groups of

employees throws light on different features of per-

formance. Each group has its own viewpoint. The dis-

parity of reactions derives from a number of factors:

first, levels of interaction and contact will allow some

groups to appraise leadership aptitude more reliably

than others. Subordinates, for example, have a clearer

view of their manager’s efforts to develop and streng-

then his staff than his colleagues or superiors will have.

Secondly, the manager’s behaviour will differ towards

different groups. Her relationship to her subordinate

staff will not be the same as with his colleagues or

superiors. Evaluators’ expectations will also differ; the

managers’ staff will look for different qualities from

those expected by his superiors. Furnham (2002) has

examined the qualities looked for in a good employee

under three situations; evaluation by superiors, by peers

and by subordinates. A group of 149 subjects, of whom

half were top managers, a third middle management

and the rest juniors, were asked to define the ideal

manager, colleague and subordinate. Scores differed

significantly according to the expectations of the

responder.

Appreciating the disparities in perception of different

evaluator groups can thus both contribute to greater

self-awareness on the part of the evaluated and also be

used to design a more efficient evaluation process. The

evaluation of a nursing manager by junior nurses will

emphasize different characteristics and emphasize dif-

ferent features from an evaluation by her superiors, and

also promote trust and respect between them (Farrell

et al. 2002).

Bottom–up evaluation

Most of the research publications concerning manage-

ment evaluation come from industry or business. Most

are concerned with the variables that affect meeting

production quotas (Stathakopoulos 1998, Lockyer

2003) and derive from the assumption that evaluation

performance will improve the productivity of both

managers and staff. One exception is Porter (1997) who

evaluated management and leadership skills as viewed

by employees in an electronics factory. A group of 297

workers filled out a comprehensive evaluation ques-

tionnaire relating to output quotas, leadership qualities

and managerial performance. Based on the findings, a

programme was set up for improving the managers’

management and leadership skills.

A popular tool for evaluating performance is ‘360-

degree-feedback’ – a comprehensive approach by which

a manager obtains multisource feedback from his

Staff feedback

ª 2006 Blackwell Publishing Ltd, Journal of Nursing Management, 14, 356–365 357

superiors, his colleagues, his subordinates, his instruc-

tors and even his clients. The evaluators are given

structured tools and requested to score the subject on

his performance. This can provide rigorous information

of high quality that can then be used for enrichment and

self-improvement (Luthans & Farner 2002, Lockyer

2003, Garman et al. 2004). It can also enable the

manager to evaluate his professional image, as it is

perceived by all around him in his working context and

so become more self-aware and successful. It is most

important to emphasize, however, that the reliability

and credibility of the feedback are governed by the

degree of anonymity of the responses. To protect indi-

vidual evaluators it is customary to present all ratings as

a summary score for each evaluator group (McCauley

& Moxley 1996, Olson 1996). There is a number of

reports on development of nursing managers’ evalua-

tion tools. Garman et al. (2004) developed and valid-

ated a 360-degree-feedback instrument for health care

administrators. In a further study, a data collection

instrument to assess the professional competence of

chief nursing executive by nursing personnel in organ-

ized delivery systems was developed and validated

(Farrell et al. 2002, Farrell 2004). Yet another Manager

Evaluation Tool was implemented by a director of

medical–surgical and transitional care (Olson 1996).

There is room to develop and research the subject of

manager evaluation in the health care system in Israel.

Our own managerial experience has been that in many

organizations the activity has not been implemented

systematically: evaluation by employees is made spor-

adically if at all. Some organizations attempt to obtain

feedback from employees through individual or group

dialogue. Such an initiative, although important, is

problematic as it is influenced by many factors. These

are principally the nervous tension associated with the

confrontation, the difficulty in openly expressing an

opinion from an inferior rank, and the evaluator’s

dependence on the rulings of the person who is

requesting the feedback. Even without the manager

intending it, the situation can sometimes become

threatening for the employee. Furthermore, one of the

most common mistakes made in appraising worker

performance and productivity by individual interview,

is interviewer bias, for the outcome largely depends on

the expectations and patterns of thought of the ques-

tioner himself (Furnham 2002).

McCauley and Moxley (1996), in discussing 360-

degree evaluation, define a number of guidelines that

should be adhered to when gathering feedback on

managers. The feedback itself should be genuinely

reflective of the scope and content of the evaluated

manager’s activities. The evaluation tool must be reli-

able and valid and designed to allow unproblematic

interpretation of the data. Significantly, the authors add

that feedback gathering in itself does not make a man-

ager more effective. This aim is achieved only after a

stepwise process of self-criticism and improvement that

the manager initiates after receiving the feedback and

with the strong support of the system employing him.

The very act of handing over the feedback to the eval-

uated manager and his superiors triggers sensitivities

that must be taken into account. The transfer often

leaves the evaluated very tense. Usually, they wish to

know who gave them such an assessment, and the weak

points needing correction will often be met with

defensive and emotional responses. To forestall this

tension and minimize the objections the following

points should be observed: (1) include the evaluated in

the decision to employ this evaluation procedure;

(2) define clearly the objectives of the evaluation;

(3) guarantee the confidentiality of the information

received; (4) allow the manager time to digest the

feedback received; (5) bring in an experienced instructor

to work one-on-one with the evaluated to clarify the

meaning of the feedback and reinforce the outstanding

weaknesses revealed. Another important consideration

is the timing of the evaluation relative to the subject’s

career. Suitable times are after the probationary period,

before a promotion, or when performance is in decline

due to burnout or stagnation (McCauley & Moxley

1996).

Anonymous evaluation

There is always the possibility of a manager retaliating

on his evaluators for their criticism. This problem can

usually be avoided by maintaining data confidentiality

and evaluator anonymity. However, it is difficult to

guarantee this with a small staff in a small organiza-

tion. Collins (2002) described a project conducted at

the Department of Environmental Health in Texas,

USA, in the framework of which managers were

evaluated by subordinates but not anonymously. The

results showed that the feedback was diplomatic rather

than critical and did not cross the barrier between

what might have been said and what the manager

would like to hear. Anonymous feedback is usually

proposed as overcoming the shortcomings of the face-

to-face method (Olson 1996, Farrell 2004). The col-

lection and interpretation bias could be related to the

anonymity of evaluation, i.e. evaluated workers can

overstate their negative feelings as to the manager

(Barnes 1997).

I. Kagan et al.

358 ª 2006 Blackwell Publishing Ltd, Journal of Nursing Management, 14, 356–365

Several Israeli organizations that are strictly hierar-

chical nonetheless insist on subordinates supplying

anonymous feedback on their superiors. In the Israeli

Defense Forces anonymous feedback plays a role in

some situations as a significant, even obligatory, step for

an officer to retain his position or continue training.

Another example is the evaluation of university lectur-

ers by their students, who fill out a comprehensive

anonymous questionnaire. In some academic institu-

tions this evaluation plays an important role in pro-

motions and sometimes can determine continuation of

employment. Zevulun (1993) describes the application

of a similar approach, under which 24 000 managers

over a period of 3 years were evaluated by subordinates

and also conducted simultaneously a process of self-

evaluation. There is a number of studies and reports

that recommends nurses supplying feedback on their

managers, maintaining anonymity to encourage a

higher level of compliance and quality of response

(Olson 1996, Willard 2000, Farrell et al. 2002, Farrell

2004). The possibility of applying the approach to

senior staff in the Israeli health services has been raised

from time to time in congresses but has yet to be

implemented.

This study

The project at the Abarbanel Mental Health Center,

which we report on, was based on the concepts, pre-

sented above – that anonymous feedback on superiors

generates trustworthy and impartial evaluation at the

same time as it ensures maximum security for the

subordinate evaluators. The essence of the project was

that to the existing traditional annual top–down

evaluation of ward nurses by their head nurses it

added an anonymous evaluation in the opposite

direction. The idea behind the project arose when a

sharp change in hospital management and managerial

approach raised the need for reliable feedback on

existing senior and middle managerial staff. We also

added another feature, unique as far as we know – an

evaluation of the project itself: Should it continue?

What were its negative and positive aspects? How to

improve it?

The tools

To evaluate the management skills of senior nurses

(ward head nurses and their deputies) and nursing

managers (clinical supervisors) the Anonymous Feed-

back Instrument for Evaluating Managers (see Appen-

dix 1) was used. The tool, constructed by the project

planners on the basis of the published literature, focused

only on management skills and ignored clinical skills,

patient care, attitudes to patients, etc., for two reasons:

(1) to narrow the focus to what most interested the

evaluators and (2) to keep the content of the tool uni-

form for all evaluated: clinical supervisors do not care

directly for patients. The tool did not include demo-

graphic data on the responder in order to guarantee

anonymity. It consisted of 16 statements (reduced at the

data analysis stage to 14) regarding human relations,

communications, support for teamwork, problem sol-

ving, credibility and openness, competence and staff

development. An outside senior nursing manager and

two managers of psychiatric departments in our hospi-

tal tested the questionnaire’s face validity. Reliability

and internal consistency rated 0.73–0.91 on the Cron-

bach’s-a test. At the time of the project we did not find a

reliable and valid feedback survey for health care sys-

tems. Later, the appropriate tools were published

(Farrell et al. 2002, Garman et al. 2004).

The Project Evaluation Questionnaire (see Appen-

dix 2) was used to elicit the responders’ evaluation of

the evaluation project itself. It consisted of seven ques-

tions, three closed and four open-ended. We inserted

both open and closed questions in order to obtain as

wide and varied an outlook as possible and to allow free

expression. The closed questions were framed to furnish

direct answers on the evaluators’ overall satisfaction

with the project. The four open questions were designed

to allow a more detailed and wide-ranging appraisal on

the importance of the project, whether it should con-

tinue, its contribution, its strong and weak points, etc.

The replies to the open questions were grouped into

categories by area of content.

Project design and development

Initial response of senior and junior staff to the project

Abarbanel nurses were accustomed to be evaluated by

their immediate superiors once a year. Following a

change in the hospital’s management, in 2000 the

Director of Nursing and one of her five clinical nurse

supervisors proposed the idea of paralleling that top–

down evaluation with an evaluation in the other

direction. Only one other supervisor was supportive.

The objectors expressed themselves either through act-

ive refusal – they would not allow the project in the

wards they supervised – or by indirect, passive resist-

ance and simply ignoring the proposal. From its outset

the project aroused feelings of anxiety and worry,

which persisted even after the questionnaire had been

completed.

Staff feedback

ª 2006 Blackwell Publishing Ltd, Journal of Nursing Management, 14, 356–365 359

As for the junior staff, the evaluators, remarks and

questions were posed about the guarantee of complete

anonymity. Some were even inclined not to write their

answers, fearing their superiors might identify their

handwriting. From the emotional perspective, the nurses

had mixed feelings. At one extreme, they enthusiastic-

ally welcomed the chance to spell out what they had not

been able to say to their superiors, even anonymously,

for many years. At the other extreme, they feared

exposure for their lack of trust. Written evidence for this

emerges from the analysis of the open-ended questions in

the second tool (see Table 1). Ten nurses reported a

feeling of discomfort, embarrassment and anxiety when

writing their evaluation. As time progressed into the

second and third year of the project, the objections

raised became gradually fewer. Evaluation of senior staff

by their juniors came to be seen as inseparable from the

overall process of workforce evaluation. Junior nurses

asked when the evaluation of the seniors was to take

place and even requested that it take place prior to that

of the evaluation in the other direction.

Project design

2000

As noted, in 2000 only two of the five clinical super-

visors were in sympathy with the project and one

offered to participate in a pilot run. With the approval

of the hospital director and with the agreement of the

head nurses and their deputies of the three wards under

that supervisor’s supervision, the project was launched.

The nursing staff (including auxiliaries) of the three

wards supplied the anonymous feedback relating to the

clinical supervisor and to their own head and deputy

head nurse (i.e. all evaluators evaluated the supervisor

but the staff of each ward evaluated only their own two

head nurses, not the head nurses of other wards).

The Anonymous Evaluation Questionnaire was dis-

tributed and filled out at ward staff meetings, after all

senior nurses (head nurses, deputies and supervisors)

had left the room. The completed forms were put in

envelopes, sealed and gathered up by one of the par-

ticipants. Participants were then asked to fill out the

Project Evaluation Form, which was then collected

separately. All the forms were delivered together to an

outside analyst for analysis of the findings. His analysis

was delivered unopened to the Director of Nursing.

Each of the evaluated heard the findings concerning him

or her individually, the evaluated supervisor from the

Director of Nursing and the head nurses and deputies

from the supervisor. In these one-on-one meetings the

findings were discussed in detail and guidance given by

the superior on what to improve and how. Each person

evaluated was given the feedback scores of each state-

ment in the form plus a summary score (the supervisor

received a summary score from each ward separately

and of all wards together; see Table 5).

In response to the findings, a training initiative

designed to improve and strengthen leadership and

administrative skills was introduced. A series of

Table 1Nine items from the clinical supervisor and head nurse evaluation form, showing the overall scores from one ward and their trend from 2000 to2001

Statement

Score 1–5 Score 1–100

Trend2000 2001 2000 2001

Works to improve the atmosphere among staff 4.41 3.87 88.2 77.4 DecreaseMaintains good personal relations 4.47 4.47 89.4 89.4 No changeIs open to others' opinions 4.18 4.27 83.6 85.4 No changePromotes projects at the health center 4.81 4.67 96.2 93.4 DecreaseTreats all staff equally 4.13 3.36 82.6 67.2 DecreaseIs a superior one can trust 3.87 3.93 77.4 78.6 No changePromotes professional training and advancement of staff 4.25 4.40 85 88 IncreaseWorks to promote the status of nursing staff at the center 4.25 4.0 85 80 DecreaseIs a pillar of support when needed 4.71 4.07 94.2 81.4 Decrease

Table 2Project evaluation, 2000–02

Year

Number ofProject EvaluationForms distributed

Number of evaluationforms returned

Responserate (%)

2000 46 28 612001 17* 13* 762002 22� 22 100Total 85 63 79

*The staffers who had returned a project evaluation in 2000 wereasked not to do so again in 2001, hence the low numbers.�Includes only head nurses and deputy head nurses. By contrast, in2000 and 2001 no head nurse or deputy head nurse filled out aProject Evaluation Form.

I. Kagan et al.

360 ª 2006 Blackwell Publishing Ltd, Journal of Nursing Management, 14, 356–365

interactive workshops led by outside instructors was

arranged for head and deputy head nurses, as well as

two workshops for supervisors.

The project evaluation

Table 2 shows the number of Project Evaluation Forms

distributed and returned for the 3 years of the project.

2001

The second run of the project followed the same

structure as the first, except that a second supervisor –

the only other that supported the project – agreed to be

evaluated. However, she stipulated that at this stage,

only one of the three wards she was responsible for

would evaluate her. The three wards polled in 2000

were repolled, so that in all four wards were polled. The

head nurses and deputies evaluated the previous year

could see if their scores had risen or fallen in the interim

(see Table 1). Again, in response to the scores the

Director of Nursing provided instruction and guidance

through ongoing personal supervision, which focused

on discussion of different conflict situations, interper-

sonal aspects of manager–employee relationship, and

enhancement of administration and leadership skills, to

the two clinical supervisors evaluated. In addition, all

senior nurse managers participated in a longitudinal

workshop, which was initiated by the Director of

Nursing and was supplied by external expertise in hu-

man resources management.

2002

The third stage of the project was planned to follow the

same structure as the first two with one important

addition. After the project’s second run, the ward head

nurses asked to give feedback on all senior nurse man-

agers that is the Director of Nursing and all her five

supervisors. The Director of Nursing agreed and in her

wake also the three stand-out supervisors. For two

reasons the body of evaluators was restricted to head

and deputy head nurses: (1) it was not felt practicable to

poll all the hospital’s nurses (the five supervisors were

responsible for all wards in the hospital) and (2) the

Director of Nursing and her team of supervisors worked

far more with head and deputy head nurses than with

rank and file nursing staff. This element of the evalua-

tion was carried out but before the head nurses them-

selves could be evaluated for a third year the hospital’s

new management ran into trouble with the staff over

other issues, the Director of Nursing quit the hospital,

and the evaluation project, planned to be a long-term

constituent of the hospital management regime, came to

a premature end.

Discussion

Perhaps the two outstanding findings of the evaluation

project are (1) the high response rates over the 3 years it

lasted – about 90% for the Personal Evaluation Ques-

tionnaire (Table 3) and almost 80% for the Project

Evaluation Questionnaire (Table 2) and (2) that 87% of

the responses to the second questionnaire supported and

justified the idea of juniors evaluating their seniors

(Table 4). About 61% of the responses to the second

questionnaire stated positively that junior–senior eval-

uation should continue at least once a year and all the

Table 3Evaluated and evaluators, 2000–02

Year Evaluated EvaluatorsResponse rate

(%)Number of

wards

2000 1 Nursing supervisor ? Nurses* 93 33 Ward head nurses ? Nursing aides*2 Deputy ward head nurses 43 Total responders6 Total managers evaluated 46 Total staff receiving

questionnaires2001 2 Nursing supervisors ? Nurses* 81 4�

4 Ward head nurses ? Nursing aides*3 Deputy ward head nurses 51 Total responders�

9 Total managers evaluated 63 Total staff receivingquestionnaires�

2002 1 Director of Nursing 21 Ward head nurses 100 All5 Nursing supervisors� 1 Deputy ward head nurse6 Total managersevaluated

22 Total staff receivingquestionnaires

*The distribution of responders between nurses and nursing aides is not known. There were on averagefour aides in each ward.�Includes the same wards and staffers as in 2000.�One supervisor was also training coordinator.

Staff feedback

ª 2006 Blackwell Publishing Ltd, Journal of Nursing Management, 14, 356–365 361

remaining responses, bar one, assumed that it would

continue (Table 5, question 7). Equally significant is it

that this highly positive reaction was the same for both

the senior nurses, who for the first time had had the

uncomfortable experience of being evaluated by their

subordinates, and for their subordinates, who now

found themselves both evaluators and evaluated.

Nurses saw the evaluation process primarily as a way

to correct and improve weak points in the performance

of senior nurses and managers and to upgrade the

management regime throughout the organization (Ta-

ble 5, question 4). Another perspective that emerged

was the project’s empowerment of junior staff. It gave

them a chance to observe the complexity of the work-

ings of senior management. One nurse wrote: ‘I felt

some of the power that the managers have but also the

problems involved in employee evaluation and taking

responsibility’. No responders felt that the evaluation

demeaned the seniors. On the contrary, they saw it as

improving communications and confidence between the

rank and file and the senior staff. The project, they

thought, enhanced the managers’ image in the subor-

dinates’ eyes. Relatively, very few negative points were

cited. Perhaps the most important of these was that

small minorities felt that they did not know the work of

the seniors being evaluated well enough to evaluate its

(Table 5, question 5) and were put under stress by the

evaluation (Table 5, question 6). These results are

consistent with previous findings of feeling of uncer-

tainty and unfair during evaluation of chief nursing

executive (Farrell et al. 2002, Farrell 2004). However,

most of the responses to question 6 were very positive.

Is it significant that the response rate for the Personal

Evaluation Questionnaire dropped from 93% in the

first year to 81% in the second? This perhaps needs

investigation.

Both during private conversations and in their written

feedback, the nurses mentioned the importance of the

evaluation’s anonymity. Given the fears of reprisals

voiced before and during the evaluation, anonymity was

clearly vital and clearly justified itself in the response to

question 2 of the Project Evaluation Questionnaire,

where only one of 58 replies said that the responder did

not feel free to say what she had wanted to in the

evaluation form (Table 4).

Only two junior staff expressed interest in taking an

active role in improving their superiors’ performance

(Table 5, question 7) but 10 emphasized how important

it was that somebody draws conclusions and somebody

makes the due corrections. Some nurses wanted to

examine the association between the results of manag-

ers’ evaluation and their subsequent performance. In

view of this attitude, it was clearly very important that

the evaluation findings were not simply left to collect

dust in a drawer but acted upon by setting up work-

shops for both head nurses and supervisors. Another

important decision of the Director of Nursing was, in

the third year, to put herself up for evaluation by her

staff. Clearly, it was this that persuaded the three stand-

out supervisors to do likewise (however, the premature

cut-off of the project saved them from actually being

evaluated).

Summing up, a great deal of satisfaction was

expressed with the project. Participants noted that in

giving anonymous feedback to senior management the

project became both important and innovative and

come close to the standards of transparency required of

modern management. Overall, critical and negative

responses were remarkably few.

Conclusions and recommendations

This study confirms the contention that an organization

that evaluates itself creates trust that all employees

appreciate and places feedback in a context of fruitful

manager–subordinate interaction (Martzki & Gureli

Table 4Project Evaluation Questionnaire: responses to the closed questions

Number Question Category of reply Frequency number (n ¼ 63) Frequency percentage

1. Is evaluating seniorstaff and managers justified?

Yes 55 87.3No 2 3.2No response 6 9.5

2. Did you feel free to say what youwanted on the manager evaluation form?

Yes 50 79.4No 1 1.6Moderately, relatively free 7 11.1No response 5 8.00

3. Are you satisfied with theevaluation project?

Satisfied 51 81.00Dissatisfied 2 3.2No response 10 15.9

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362 ª 2006 Blackwell Publishing Ltd, Journal of Nursing Management, 14, 356–365

1990, Weizner 1998, Edwards 2001, Collins 2002,

Garman et al. 2004). Subordinate staff needs a feed-

back opportunity because they know that they have the

ability to think, to disagree and to substantiate their

opinions, even ones that the boss does not agree with

(McCarthy 2000). Obtaining feedback from subordin-

ates is a first step to showing willingness to introduce

changes into the managerial culture and organizational

values (Edwards 2001).

The anonymous evaluation of managers is an effect-

ive tool by which real feedback is gathered on ‘things,

which are not talked about’. It is the nearest thing to

objectivity that can be obtained today in the area of

senior health care staff performance. For low-rank

employees it is an almost unique opportunity to convey

a message to their manager without fear of exposure or

reprisals on their chances of promotion or of keeping

their jobs. Moreover, supplying anonymous feedback

increases trust in the organization and its managers.

Periodic anonymous feedback can also be useful in

assessing how new senior staff are adapting to their new

positions.

In view of this study’s findings it is worth considering

using anonymous feedback by employees for the routine

evaluation of nursing managers’ performance. It is also

desirable to extend it to other staff sectors, such as

doctors, administrators and maintenance staff. But

before it can become fully established all tools need to

Table 5Project Evaluation Questionnaire: responses to the open questions

Number Question ItemsFrequencynumber

Totalresponses %

4. What are the project'spositive points?

Will enable senior staff to improve their performance 38 113 33.6Guarantees anonymity and immunity to responders 10 8.9Allows genuine and objective evaluation 18 15.9Makes staffers' opinions important and empowers them 11 9.7Indicates a positive change in management regime 11 9.7Informs managers how subordinates see them 13 11.5Improves relations and ties betweenseniors and subordinates

11 9.7

There are no positive points 1 0.9Did not respond 18

5. What are the project'snegative points?

There are no negative points 17 50 34.0Causes staff feelings of uneasiness,embarrassment, stress

9 18.0

There is no guarantee that lessons will be learntand conclusions drawn

3 6.0

Subjective; not objective 3 6.0The questionnaire is not comprehensive 3 6.0The questionnaire is not anonymous enough 2 4.0Evaluators are not familiar enough with the workof some of the seniors evaluated

12 24.0

Lets disgruntled employees `get even' 1 2.0Did not respond 19

6. What were your feelings as youfilled out the form?

Good, at ease, satisfaction, free 27 50 54.0Feelings of partnership, belonging, equality,that I meant something

10 20.0

Uncertain, embarrassed, uneasy 10 20.0Confidence, in control, power 3 6.0Did not respond 16 32.0

7. Recommendations forproject's continuation

It should continue at annual/biannual rate 38 62 61.3Would like to be partner in work to improve performance 2 3.2Improve and expand the evaluation form 3 4.8Draw conclusions and take correctivemeasures accordingly

10 16.1

The project should not continue 1 1.6Present the findings for open group discussion 2 3.2Replicate for all staffers and sectors 5 8.1Consider doing an open evaluation 1 1.6Did not respond 12

*These four open questions evoked a wide variety of responses, which were categorized by content. Some respondents preferred to give severalanswers to a question; at times these related to different areas of content. In some cases the responses were partial and only parts of the openquestions were addressed. As a result the number of responses does not necessarily match the number of responders.

Staff feedback

ª 2006 Blackwell Publishing Ltd, Journal of Nursing Management, 14, 356–365 363

be systematically validated and the entire process

empirically examined. It is possible that the 360-degree-

feedback survey developed by Garman et al. (2004) can

be useful in Israeli health care services.

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364 ª 2006 Blackwell Publishing Ltd, Journal of Nursing Management, 14, 356–365

Appendix 1 Anonymous Evaluation Questionnaire for hospital managers and senior nurses

Please use this form to give your feedback on the performance of _______. Before you are 16 statements characterizing the work ofthese senior staff; please circle the number that reflects your level of agreement with the statement, on the following scale.

Definitely correct Largely correct Moderately correct Not very correct Not at all correct

5 4 3 2 1

Number Statement Feedback scale

1 Works to improve the atmosphere among staff 1 2 3 4 52 Promotes professional training and advancement of staff 1 2 3 4 53 When I have a problem in the ward I feel comfortable asking her for help 1 2 3 4 54 Every time I turn to her for help I get a positive response 1 2 3 4 55 Maintains good personal relations 1 2 3 4 56 Is open to others' opinions 1 2 3 4 57 Works to promote projects at the health center 1 2 3 4 58 Treats all staff equally 1 2 3 4 59 Sets staff a personal example 1 2 3 4 510 Is a superior one can trust 1 2 3 4 511 Works to promote the status of nursing staff at the center 1 2 3 4 512 Cultivates a new generation of psychiatric nursing staff 1 2 3 4 513 Demonstrates real professionalism 1 2 3 4 514 Backs up the ward head nurse's decisions 1 2 3 4 515 Is a pillar of support when needed 1 2 3 4 516 She performs satisfactorily in her present position 1 2 3 4 5

Note: During the process of data analysis the 16 statements were reduced to 14.

Appendix 2 Questionnaire on the evaluation project itself

Thank you for your feedback on senior nursing staff. We now request that in this form you express your opinion about the evaluation project itself.Your opinion will help decide whether it continues and in what format.

1. Is evaluating senior staff and managers justified?(1) Yes (2) No, Specify

2. Did you feel free to say what you wanted on the manager evaluation form?(1) Yes (2) No, Specify

3. Are you satisfied with the evaluation project?(1) Yes (2) No, Specify

4. What are the project's positive points?5. What are the project's negative points?6. What were your feelings as you filled out the form?7. What are your recommendations for the project's continuation?

Staff feedback

ª 2006 Blackwell Publishing Ltd, Journal of Nursing Management, 14, 356–365 365