Lean nursing: a foreign concept in EC and ICU?

“Here is Edward Bear, coming downstairs now, bump, bump, bump, on the back of his head, behind Christopher Robin. It is, as far as he knows, the only way of coming downstairs, but sometimes he feels that there really is another way, if only he could stop bumping for a moment and think of it. And then he feels that perhaps there isn’t.”                                                                                                                            – A.A. Milne, Winnie-the-Pooh

Recently I started doing some in-hospital shifts again. Since my first shift, I’ve been pondering whether I should say something or if I should just suffer in silence. This blog is about my experience in one private hospital group. I’m well aware that, by posting this blog, I’m exposing myself to not working in said hospital group again. So, why risk future shifts and cash flow by posting this blog? Because I feel that I have to be true to me and what I stand for. And I don’t think that these experiences are specific to the hospital group or applicable to only nurses.
It’s my experience that most nurses working in hospitals feel like Edward Bear: they have a feeling that maybe their working conditions could be different, that there should be another way than the daily struggle that has been normalized. Maybe because I have worked outside of the industry, and as manager within the industry, I know that the daily conditions of clinical nurses can and should be different.
In his book Lean Hospitals, Mark Graban says that healthcare providers often think that our job or the value that we bring to the hospital is our ability to deal with problems and just work around the issues and get on with things, to improvise and cope. We think that it makes us heroes to go home broken after a tough shift. We do things that should not be done; we work hard at the workarounds that adds no value to the facility, to us or most importantly to the patient. I think that it’s especially true about nursing. Here is why:
1) Inefficient systems and waste within nursing
After being involved in LEAN projects, I look at most nursing processes and see them as beyond absurd. The amount of waste, workarounds and the inefficiencies are downright ridiculous. There is much more to LEAN than it being a process improvement philosophy, but I’m going to describe it as that for now. I do think that the LEAN approach at times tends to oversimplify complex issues, but it’s generally a good approach for linear problems. LEAN thinking categorizes wastes (inefficiencies) in the system that any organization should attempt to reduce such as:
The waste of unnecessary motion: Walking up and down to fetch medication, equipment, linen, water, bedpans, etc. are not always necessary. I’ve been tracking my kilometers walked per shift. My average over 2 months is 5.2km per 12 hour shift. To walk 5.2 km on a flat surface takes about an hour, implying that I spend one hour a day walking, not nursing. Most of my shifts have been in ICU, where the patients are within close proximity to each other and the ‘specialized nurse’ is supposed to be mostly at the patient bedside. Thus, one would expect that ICU nurses walk less than nurses in other units. So how much time do nurses in, say, surgical units spend walking versus nursing?
The waste of waiting: I also work in the emergency center (EC). A well-described concern in ECs across the world is access block. Yet, from a nursing perspective, there seem to be more constraints keeping the patient in EC, than processes that enables the flow of patients through the EC. The EC is at its busiest after hours and on weekends. Yet, this is typically when other services in private healthcare slow down and operates on skeleton staff– including radiology and pharmacy. Inevitably, the EC nurse becomes a gatekeeper for these systems, e.g. the EC nurse needs to call the radiographer prior to a patient going to X-rays. This increases the workload on the nurse and waiting time in the EC, and not to mention that after hours the patients are only allowed to X-rays one at a time.
The waste of overproduction: Again in EC, we overdo the administration. Why, for a follow up patient that only needs to see the doctor for a quick checkup requiring no nursing input, does the nurse need to complete a 4 page document? And, for admission, does the nurse need to copy 8 pages of nursing notes and the doctor’s notes? I know it’s for auditing purposes, but what is the value? With only one printer shared amongst EC and reception staff another delay is created for no obvious reason.
To transfer a patient from ICU to the ward requires similar overproduction of nursing notes. There is the implementation record, the transfer record and the ICU chart. Then, there is the ward documentation that some wards insist that the ICU nurse should complete. Again, overkill. Ordering simple blood tests is another complicated process. The doctor writes up the request (this can be on one of two places, so the nurse better check both!). Then, the nurse ticks it off on the blood request form, writes the bloods, patient name and bed number into a diary for pathology and has to write it into her notes. Re-writing the blood request that might be written in two places into three places increases the chances of error or omission of a test (and it happens regularly, especially when the unit is busy).
The waste of overprocessing: Overprocessing means doing things not wanted by the client. In the EC, the patient is required to sign out at two places before they can be discharged (creating a delay): once to say that they did not handover any valuables or received them back and then to agree to discharge. Asking why we need to do this, the answers varied between ‘it’s the hospital’s rule’ ‘its proof of our input, should the patient complain’ and ‘it’s for auditing purposes’. Considering the risk/benefit profile, is it really true that the risk of a patient complaint is worth the time lost and the compromise on patient flow?
And why do the nurses need to rewrite everything that the doctor wrote down? Would a simple nursing checklist on the doctor’s notes, especially in EC, not improve patient flow?
2) Conflict between job description and client expectation
Patients in private healthcare often state that they are paying a premium for the care that they receive and, as such, they have a right to demand a certain level of care. More often than not, the nurse is responsible for meeting these patient demands. Often, these requests are in conflict with the described nursing functions. In a way, this has created a reverse incentive, where, if the nurse meets the patient’s demands, then on paper it will appear as if the nurse didn’t do their job. But, meeting the job description and doing the job on paper means not meeting the patient’s expectations. Is the exhausting paper trail that nurses must leave (which, it seems, is mostly for auditing purposes) really patient centric and valuable?
It’s a core nursing function to coordinate all other service providers (e.g. physiotherapy, dietician, food requests, and radiology) and all of these services have preconceived ideas of what the nurse’s function and responsibility is. So, it is not surprising that nurses’ end up feeling pulled in every direction and is consistently told that they are not meeting someone’s expectation of what they were supposed to do that day.
3) Doctors behaving like toddlers
Doctors still throw their toys out of the cot…and nurses are still required to pick it the toys. I count quite a few doctors as close friends, so I felt apprehensive making such a blanket statement. But, hear me out – there is no formal process that prevents doctors (and other service providers) from behaving poorly towards nurses. When I worked on the cruise ships, there was a guest vacation policy. Guests could be asked to disembark or leave a public space if they behaved rudely towards the ship’s staff. Perhaps hospitals need to implement a similar kind of policy for inappropriate behavior towards nurses. Nurses are at the core of service delivery in private healthcare and, as such, the hospital and nursing management should ensure the psychological safety of their nurses.
On a recent shift, a doctor behaved poorly in front of patients, visitors, and other staff by shouting at a nurse. He had the nurse in tears for something that was completely out of her control. When he eventually left, even the patient was in tears. How is this patient-centered? And, why should the nurses still be expected to cover for this type of behavior, smooth things over and apologize on behalf of the doctors to the patients and their families?
Another LEAN principle is respect for people…nurses are also people and should be treated as such.
4) My time is valuable
This has probably been the toughest part of returning to clinical nursing. Covering the unit is the most important aspect of a nurse’s life. Family events or plans after work simply need to be adjusted according to the unit’s needs. Fulltime staff members’ shifts change regularly, sometimes at incredibly short notice. If a shift change happens late, the other shift just needs to stay on, no explanation needed. Even though a part of me gets that, a part of me also rebels against the frequency with which it happens.
As an agency nurse, there is the opportunity cost of being booked for a shift. The agencies have the right to cancel your shift up to 2 hours before your shift was due with no financial compensation. Yet, you probably said no to other work or gave up on other opportunities in order to be available for the agency. Taking into consideration that you are required to be on shift 15 minutes early and sometimes have a 30-60 minute travel time, they basically cancel you as you are already on your way to work. Not really fair….and, beware- should you cancel a shift, you are ‘punished’ by not being booked for a few days.
5) The absence of nursing leadership
There are good nursing managers out there. But, are they showing leadership and advocating for nursing care? As I’ve been told: you can see that the unit is busy because the unit manager is hiding in her office behind a closed door.
Why do they do hide? Are they ignorant of the issues on the floor? I think not. I think it’s more a case of the managers feeling as helpless and disempowered as their staff… and they are caught between the staff and the higher levels of management.
Again referring back to LEAN, ‘Go and See’ is crucial. What the nurses on the floor need is for the nursing managers (hospital managers, head office representation) to be there, to be involved, to produce policies that enable them to do their job, to remove constraints and workarounds, basically to operationally manage the unit. By going and seeing those positioned to improve circumstances can experience the current conditions and frustrations. Currently  they remain removed from the daily grind and they hide behind their audits, checklists and paperwork. Nursing and nursing management has become paper and audit driven rather than patient driven. Why this irrational fear of protection with administration?
6) Level of dissatisfaction
In the short time that I’ve been doing shifts again, I’ve really felt disheartened with the level of frustration expressed by nurses. Not to mention the lateral violence, where nurses take out their frustrations on peers or those lower qualified. I daresay that the lateral violence is a direct result of the daily frustrations with waste and inefficient processes, the behavior of doctors and lack of nursing leadership. There is very little psychological safety within the current nursing environment and, again, as someone told me: the managers don’t have our backs.
The LEAN philosophy describes another waste: the waste of human potential. It’s my belief that the current hospital environment wastes nursing potential and therefor is losing great nurses.

When-a-flower-doesn_t-bloom-you-fix-the-environment-in-which-it-grows-not-the-flower
Summary
A quick unscientific Facebook stalking of my university nursing friends revealed that maybe 3-5 of them are still clinically nursing in hospital. Something must be wrong. Especially seeing that people love telling us that nursing is a calling. If that is true, then we all seem to have lost our calling…
Or, is it that the environment has become so detrimental that nursing is no longer appealing or sustainable as a long-term career option? I wrote this blog because I believe that we can and should change the environment. But, it will take strong nursing leadership. Step one of being the patient’s advocate is by being a nursing advocate, advocating for better nursing conditions so that we can be better patient advocates.

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One thought on “Lean nursing: a foreign concept in EC and ICU?

  1. Thank you Charmaine for that very insightful overview of the nursing profession, from your perspective in SA. I think you and SA is not alone with the paper/audit war, I am sure that other countries have similar frustrations. The down side of all of the above, is that the central purpose of nursing is lost – Patient Care, and the Patient. Sadly I see similarities with the EMS profession. Would you be interested in making contact with me, with respect to writing an article for Ambulance Today, under my Africa Desk editorial page? If so message me and we can chat further.

    Like

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