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.

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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.

Nursing in Africa

In large parts of Africa, decades of war, conflict and instability have left its people with limited access to basic healthcare services. This is aggravated by the fact that the continent carries 25% of the global disease burden and the lowest number of global healthcare worker per capita.
The challenges that impact healthcare service delivery in Africa include (but are obviously not limited to) lacking infrastructure, poor management, lacking equipment, variable care standards and supply chain issues. In 2001, in an attempt to address some of these challenges, the countries belonging to the African Union (AU) committed to allocate 15% of their fiscal budget to healthcare (Abuja declaration 2001). Sadly only six countries succeeded in doing that. It is estimated that even if all of the AU countries allocated 15%, the size of their budgets are simply not enough to address and overcome some of the challenges that face healthcare systems in Africa.
The budget size and lack of allocation or investment in healthcare leads to another problem: dependency on donor funding. Unfortunately donor funding comes with vested interests and may inadvertently contribute to the vertical development of disease specific fields at the expense of horizontal or strengthening of the whole health system. A good example of this is HIV research that across the continent is disproportionately represented and funded.
Because the burden of disease and the demand for healthcare services that’s continuously rising, larger budgets and more healthcare workers are required. Alarmingly statistics demonstrates that in some African countries there has been a decline in the number of healthcare workers over the past twenty years. In addition, there is a known distribution of healthcare workers towards urban areas, leaving rural areas without adequate healthcare delivery structures and staffing.
In most of Africa, the first healthcare worker to provide care to a patient is a nurse (WHO2008). With nurses being the mostly widely spread and available health professionals on the continent, their role cannot be overestimated. Creating more enabling environments for nurses to be educated and work in better conditions should be prioritized. A few issues that seem to be universal to the ability of nurses to perform in Africa are highlighted below. These issues draw on my experience and my conversations with local nurses in the settings in which I’ve worked.
Quality and appropriateness of nurse training
Formal nursing education was brought to Africa by imperialism. This implies that the people who brought formal nursing education to Africa introduced it in a similar way to how it was done in the countries that they came from. Most of these models were (and still are) based on training nurses in-hospital and where one of the primary roles of the nurse is as team member with a medical doctor and others. This is very different from community based care that’s prevalent and required in rural Africa. In most of Africa, the nurse is often a solo practitioner that’s far from hospitals and other team members. The training of the nurses should prepare them for such roles and situations.
Clinical and educational gaps can be identified by furthering research, especially nursing science research in Africa. This then allows the design of curriculum’s that are contextually relevant to the needs of the continent. This is, however, complicated by other issues, namely:

Limited research on indigenous diseases in Africa
Most of the infectious diseases that are endemic to Africa such as schistosomiasis or trypanosomiasis are not well-researched. With limited evidence based guidance, there can be no best nursing practice for these endemic diseases.
The fields that are researched are according to donor specialization and interest. Sun and Larson (2015) did a review of all nursing research from Africa that was published over a decade and found that the most studied areas were associated with funding resources. They also found that prevalent conditions in Africa e.g. malnutrition, diarrhoea disease and other common causes of death were not studied and/or published. This demonstrated a clear gap between the healthcare needs and the fields researched.
Nursing research needs to focus and address the glaring healthcare issues in Africa. Often care in villages is rendered by persons with no training in healthcare, and addressing issues like the need for reliable community based care when developing curriculums or conducting research could impact the health systems tremendously.

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Training facilities
Training facilities across Africa lack enough classrooms, electricity, running tap water and technological advances. Internet has been reported as a scarce resource across various training settings in Africa. The access to electronic resources is limiting for both students and educators. Open-access resources have helped to make science more accessible globally, but there is still a high cost to obtaining research and information making it incredibly tough to stay abreast of new guidelines, especially for nurses in Africa.
Clinical guidance in hospitals is lacking and there are limited simulation models at training facilities. At some of the facilities where I’ve conducted training there have been no CPR manikin’s or other additional models for training. In most places we had to innovate and make our own manikins and other adjuncts.
For healthcare workers in rural areas, obtaining further education or refresher training means uprooting and even leaving a healthcare facility unattended for the duration of their training. This should be considered when we think about educating and upskilling nurses.
Knock-on impact of the doctor shortage in Africa
The lack of doctors, especially in rural areas has resulted in task shifting. Task shifting occurs when tasks that would normally be seen as the doctors’ domain, are shifted to nurses. It increases the nurses’ workload and the nurses are expected to perform tasks that they have not received training for.
The distribution of health facilities and different tiers of care means that the large drainage areas in the rural districts are often manned by nurses without any further medical support close by. This means that the nurses working in rural areas are isolated when dealing with cases that are not within their scope of practice, limited clinical guidelines and difficulty in obtaining help. Telemedicine and technology may offer some solutions provided that it can be reliable in areas with limited electricity, currently no internet etc.

Regulatory issues
In many African countries, graduates are not subject to registration with a statutory body. There may be professional associations, but there is no compulsory registration process and professional licensing. In countries with no regulatory body, there is no representation to lobby for nursing rights or amendments to Acts of Parliament, salaries for nurses or to promote career progression.
Often healthcare worker salaries (including doctors) are not paid on time, if at all. This leads to some healthcare workers having secondary streams of income or funding their own incomes out of privately charging patients’ higher fees.
Gender inequality
In most African societies, gender equality has not yet been achieved. Women receive less education than men, they have less rights and their voice are not heard in the same way. Nursing remains a predominantly female profession and this limits the ability of nurses to assert themselves and it impacts on the ability of the profession to influence national policy.
There is a trend where even though the nurse workforce is mainly female at service delivery level, at top management and policy level it’s represented by men. In the DRC it was established that only 1% of the nurses are male, yet more than 90% of the top levels and education facilities positions are filled by men.
The social determinants allowing people to access healthcare includes basic primary education and gender equity amongst other factors. Sadly neither one of these has been achieved for nurses in Africa and it hampers the progress of nursing education and research across the continent.
Career progression
This tie in with the above, and the fact that because of the role of women in society, nurses being mostly female and the difficulties faced by nurses to render care, career progression may be stunted. Because healthcare workers in rural areas need to travel to further education and because nurses are predominantly women, it is hard for them to leave home and obligations at home to further their career.
Lack of mentorship and language barriers
There is a lack of mentorship to help nurses further themselves as researchers and educators. Organizations such as the AFEM Nurses Group developed a mentorship program with international mentorship support to African nurses. Another program is the Nursing Education Partnership Initiative (NEPI) that was formed in 2011 by PEPFAR to improve nursing and midwifery education in Africa. We need more programs like this.
Mentorship, inclusion into global healthcare networks, research and education are complicated by language barriers. Often nurses working in rural areas do not read or speak English; the language which much of the training material and research is presented in.
Conflict
It has been postulated that there’s a statistically significant relationship between accessibility to care and civil conflict (Rhode 2015). Unrest and conflict creates havoc on the ability to deliver healthcare, train providers, obtain supplies and in violent prone areas access may be restricted as patients are afraid of travelling. During periods of increased violence, the healthcare facilities are looted and healthcare workers intimidated. In violent prone areas, malnutrition is aggravated, harvests are regularly pillaged and access to fields is restricted due to security conditions.
Conclusion
There are various challenges to improving the fragile healthcare systems in Africa. Nurses form the backbone of healthcare service delivery in Africa. The difficulties faced by nurses across the continent are only one challenge; improving dilapidated health facilities and improving on the poor distribution of essential medicines and supplies are other challenges.
In order to improve healthcare systems, nurses needs to be more involved in policy-making, developing healthcare plans and research.

Please note: Africa is not a country and in some of the African countries, the health system is well-established and working. In other’s it’s not going that well. I’m aware that this blog makes blanket statements, however it refers to my experiences and conversations in the country’s that I have travelled to.

References
Munjana OK, Kibuka S, Dovlo D. (2005) The nursing workforce in Sub-Saharan Africa. Issue paper no 7. International Council of Nurses.
Sun C. Larson E. (2015) Clinical nursing and midwifery research in African countries: a scoping review. International Journal of Nursing Studies. 2015 May;52(5):1011-6. doi:10.1016/j.ijnurstu.2015.01.012.
http://www.our-africa.org/women
http://www.who.int/healthsystems/publications/abuja_declaration/en/
Rohde JT. (2015). The relationship between Access to Healthcare and Civil conflict. College of William and Mary. Honors Theses. Paper 99
Abuja Declaration 2001
Klopper HK, Uys LR. 2012. State of Nursing and Nursing Education in Africa: a country by country review. Sigma Theta Tau international
The nursing Education Partnership Initiative in the Democratic Republic of Congo. (2012). Assessment of nursing and midwifery education and training capacity at seven training institutes in the DRC. Synthesis report. Prepared by CapacityPlus, Intrahealth International

The end of the short course route to become a SA paramedic

For years there have been rumors about the end of short course training for paramedics in South Africa.  It became real on 27 January 2017 when the Department of Health published a regulation pertaining to the qualifications for registration of the short courses. 

A brief background to those unfamiliar with the system:  Until now there has been a dual system to become a paramedic.  Taking the short course route meant completing a 4-6 week course in order to qualify as a Basic Ambulance Assistant (BAA). The BAA can do the basics including (but not limited to) the administration of oxygen and splinting of fractures.  For a long time (possibly still?) BAA’s was the backbone of the Emergency Medical Services (EMS).  Especially in the urban areas where there is a high density of hospitals, the BAA is valuable because they can perform basic care, load the patient and rapidly proceed to the closest facility.  This implies fast access to definitive care.  Career-wise to advance the BAA had to complete working full-time for 6 months or 1000 hours as prerequisite to apply for the next course. If successful, the BAA could then do the Ambulance Emergency Assistant (AEA) course.  The AEA can perform skills including nebulization and commencing IV therapy.  Again after 1000 hours or 6 months of full-time working, they can apply to do the 9 month advanced life support paramedic course.  This course has limited space and the entry exams are tough; thus AEA’s often have to work for a number of years and gain experience prior to doing the course.  This pathway to become an Advanced Life Support Paramedic is now being scrapped in favor of a 4 year degree program at selected UT’s.

In many ways this agenda has been driven by a desire to professionalize and create the capacity for research within the field.  Still there is an eerie sense of dèjá vu; the impact on training is similar to what happened to nursing not so long ago.  During the late 90’s in an attempt to restructure nursing, various colleges were shut down, shorter nursing courses were suspended, the university curriculums were adapted and the intake of nursing students at these institutions reduced.  Shortly thereafter community service for new nursing graduates became compulsory and to become a nurse meant 5 years of studying.  Fast forward about 20 years, and South Africa has an estimated shortage of 45 000 nurses, with only 3 500 new nurses are trained per year.  According to Nursing Council statistics 48% of Professional Nurses are above the age of 50 with 25% of nurses under the age of 40; of these only 5% are under the age of 30.  The shortage of nurses is dire and will continue for the foreseeable future, especially when the 48% above 50 start retiring in the next decade. 

The shortage gave rise to contract nursing, also known as ‘moonlighting’ where nurses work overtime shifts or only work as agency nurses.  Moonlighting caused (well-described) drastic consequences on the quality of nursing care in South Africa.  Furthermore it attributes nurse burnout.  Sadly it also costs the hospitals more money to buy-in agency staff, it increases the load on the nurse managers to process hours, plan staffing, negotiate and book agency staff. 

There are a few lessons to learn from the above.  Sadly though, paramedicine seems to be on the same trajectory. Other concerns include

1)      University qualified paramedics = higher salary expectations = higher budgetary demand

Remunerating a workforce that consists of degree paramedics will be at a far higher cost than paying different levels of short-course practitioners.  In a country where the health system is struggling with budgetary constraints exists I’m not sure whether the provincial health services would be able to accommodate increased salary budget demands without compensating other vital aspects such as vehicle maintenance, equipment or stocks.

2)      Related to the above.  The cost to train a degree paramedic

The cost per student is higher at a university than with in-service training. The duration of the courses are longer, meaning that any investment will only yield results in 4-5 years.  How can this be seen as cost-effective in a country with budgetary constraints, a growing burden of disease and ever-increasing demand? 

3)      Brain drain

It is not a new problem that newly qualified paramedic graduate leave the country in hordes.  They earn better salaries in Qatar, the UK and as contractors for the oil and gas industry. Thus the back bone of the provincial services has remained short course paramedics.  In the Western Cape the vacancy rate for paramedics in the public sector is 7.5% (2015/16 DOH report).  This is the highest across all healthcare professionals in the public sector; it is even higher than the nursing vacancy.  Taking away the short courses, spending all the money to train graduates and then have them leave the country doesn’t seem to solve the pressing issue of high vacancy rates.  The vacancy rate might already imply a paramedic shortage. 

4)      Loss of tacit knowledge and experienced practitioners 

Over the past decade the career progression for paramedics that came through the ranks by doing the short-courses has become more and more limited. Often despite their years of experience, they cannot apply for management positions; they earn less that their newly qualified inexperienced colleagues.  Because they know the system they often end up carrying newer qualified degree paramedics.  Over the years with the constant threat of the end of short-course training, and the rise of more and more degree paramedics, these practitioners have become disgruntled and unhappy.  Now that their qualification is officially extinct, why should they stick around in the industry? And can South Africa really afford to lose their knowledge and experience?

5)      Increased barriers to access emergency care 

I’ve been part of the Hout Bay Volunteer Ambulance Service (HBVEMS) since 2004, a community-driven ambulance service that predominantly functions with short course practitioners.  With no more short courses, the growth and sustainability of services such as HBVEMS are stunted.  The volunteer pool will shrink until there is no service left.  This is true for volunteer services across the country and it creates a gap in service delivery and access to essential emergency care.

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6)      Impact on fire services 

In Hout Bay and other areas, the fire services fill an important gap as first responders.  Often patients are taken to fire stations where care is rendered whilst waiting for an ambulance.  This is done by fire fighters that have completed the short courses.  As rendering emergency care is not their primary duty is seems nonsensical for them to do a 4 year degree.  Again the impact of fire fighters no longer being qualified to render basic care will be felt by the community.

7)      Paramedicine = exclusivity

A degree program has higher entry requirements than skills based programs, helping the professionalization of the field.  I fail to see how the professionalization and more elite paramedical qualification contributes to better serving the need of our country’s growing population.  Would the same money to train degree paramedics, not be more useful if used to purchase more ambulances?   Is scrapping short-courses really in-line with the needs of the population of South Africa?  Not to mention that there’s been studies questioning whether having higher qualified paramedics on scene actually equals better care, as they are more likely to spend longer time on scene performing advanced interventions that is not always required.  In the end one of a paramedic’s core functions is to stabilize and transport to definitive care. 

The key arguments for discontinuing short courses are that short courses do not comply with the National Qualification Framework Act.  And in order to professionalize paramedicine a degree program is required.  It has also been stated that the Health Professionals Council of South Africa has to protect the public by ensuring the registration of appropriately qualified emergency care providers who has the skills to practice their profession safely. 

“We learn to do something by doing it. There is no other way.” – John Holt

I completely agree that there should be a degree program that helps advance the field, promote research and education.  However in the end, a good paramedic is someone that can apply their skills.  Paramedicine is a skills-based function and whether having a degree equals being more skilled to perform practical interventions are questionable.  I disagree that the ‘professionalization’ of paramedicine at the expense of short-course programs is the best way forward.  Especially in a country that has a growing population, quadruple burden of disease and inequality in accessing care.  In fact to solve some of the problems that we face in emergency care, maybe we should rather follow one of the ideals of the Gates foundation:  “The ideal is creating a skills-based credential that is well trusted and well understood enough that employers view it as a true alternative to a degree” (Bill Gates 2013)

Making sense…learning about sense-making

Remember the movie ‘Back to the future’ where Marty (Michael J. Fox) travels through time, whilst figuring out what is happening and how to influence the future whilst simultaneously dealing with the current situation?

It reminds me of sense-making. Sense-making is about how we give meaning to a situation. Sense-making is based in our decisions and beliefs and it is influenced by aspects such as power relations, hierarchy, autonomy, linguistics, temporalization (focus on now, the past or the future), justification, culture and traditional society, equality, bargaining power, locus of control, openness to change. Sense-making is done individually or collectively in organizations and communities.  Capturing these underlying nuances in our perceptions allows deeper insights into why an organization or community are angry, failing, succeeding, innovating, etc.

Brenda Dervin, Gary Klein, Karl Weick and David Snowden are a few of the contributors to sense-making. They all describe their own theory about sense-making either as individual or collective activity.  Snowden combined several sense-making theories into one tool.  For my studies I am using his tool to capture community perspectives regarding cost as a barrier to access emergency care. 

Today I’m sharing my understanding of Brenda Dervin’s metaphor for sense-making.  Dervin sees sense-making as the individual activity of information seeking, processing, recreating and application. Information is described as a tool designed by humans whilst making sense of reality.  Methods of communication and the application of information (knowledge) are key aspects of sense-making.

The metaphor 

timespace

It starts in a time-space milieu, implying constant energy and movement. This environment is never static and time-space energy propels us forward or pulls us back, always fluctuating and never stable.

Moving through time-space we have Mr. Squiggly.  Humans are depicted as squiggly because we are caught between certainty and uncertainty.  Thus there is a constant flux within the person (internal) and between the person and the environment (external).  Mr. Squiggly carries an umbrella, symbolizing mind-set, perceived constraints and enablers. (I feel that it should be a backpack – demonstrating our baggage).

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Whilst moving through time-space, a gap or barrier is encountered. For the purposes of my work, the gap is a life-threatening injury or illness requiring urgent care. The gap can however be any barrier or difficulty in daily life (in an organization it could be new policies, a new boss etc.). The gap forces Mr. Squiggly to stop until a way has been found to ‘bridge’ the gap and reach an outcome.

The outcome depends on how the gap is bridged.  Some potential outcomes are not obvious in the beginning and it may only become apparent retrospectively, influencing future decisions and beliefs.

Moving from situation to outcome requires a bridge. The building blocks used to build the bridge consists of different types of blocks.  One being the individual mind-set, during a life-threatening emergency it would include individual beliefs about health, healthcare, medication, culture. Building blocks also include inputs from others, the stories within the community about a time that something similar happened to someone else, financial hardships suffered, patient outcome etc.  Mr. Squiggly consciously and unconsciously use all the information in the form of building blocks to create the bridge.

Once the bridge is built, Mr. Squiggly can leap across the bridge to the outcome; this is aptly called gap-bridging.  The building blocks of information is now applied, thus knowledge are created. Dervin use the term ‘verbing’ as an important gap-bridging and sense-making tool.  Everyday examples of verbing include the use of words for example emailing, googling or ubering. Verbing thus occurs when a noun is turned into a verb, creating action or experience.  It certainly fits a methodology where knowledge is seen as a context-specific sense-making activity in a specific point in time and space.

 teh gap.png

I’m using sense-making to capture the various roles within a community perceive gaps, bridge gaps and view the outcomes during a life-threatening injury or illness. Perceptions will be captured using a type of narrative enquiry, where the participant is asked to tell a descriptive story.  After telling the story, the storyteller explains the meaning of their own story by indexing it onto a predesigned framework.  This is very different from ‘traditional’ research where the investigator assigns meaning to the stories. Neutral questioning is used to guide the indexing.  Questions are framed in such a way to capture the nuanced aspects of hierarchy, autonomy, equality etc.  After capturing, the data are combined and the software allows for it to be visually displayed, enabling easy identification of patterns and trends.  More details on the software are a story for another day.

This technique has been applied to monitor, evaluate, communicate, and create feedback loops in projects, organizations, communities and even broader society.

I am using sense-making because I’m passionate about the voice of the ‘voiceless’ in organizations and communities.  I feel that tacit knowledge is often overlooked.  Sense-making provides a tool to capture many voices, combine the different perspectives and seek common ground, emerging trends or underlying moods. This is powerful, whether in an organization, community or development project. It prevents the implementation of one perspective, ‘outside’ views or only top-down approaches. Inclusive sustainable implementation requires more than one story, one perspective and more than one type of knowledge.

 As Chimamanda Ngozi Adichie says in her powerful TED talk about the danger of a single story:

The single story creates stereotypes, and the problem with stereotypes is not that they are untrue, but that they are incomplete. They make one story become the only story.”

References

I adapted the pictures from: Facing a gappy situation. Sense-making methodology: communicating communicatively with campaign audience.  Dervin, B. 2003.  In Dervin B, Foreman-Wernet L (Eds). Sense-making methodology reader: selected writings of Brenda Dervin, Cresskill, NJ: Hampton Press 2003.

http://www.ted.com/talks/chimamanda_adichie_the_danger_of_a_single_story?language=en

Access to care: time to reconsider the concept?

Imagine the uncertainty and level of decision-making required to visit a healthcare facility for a cholesterol test, blood pressure check or the renewal of a script versus requiring care and transport at the scene of an accident where there’s multiple injured patients, some requiring urgent care.

The pressure to make decisions, the emotional intensity involved (fear, anxiety, anger, remorse) and the perceptions about the possible barriers to obtain emergency care seem more complex than those required when visiting a primary healthcare clinic. Injury, accidents, sudden illness and complications from non-communicable disease all fall under the umbrella of emergency care.  Because emergency care is a frequent entry point into the healthcare system, one would assume that the barriers to access emergency care have been well-described and explored.

I reviewed more than 50 of the most cited papers that describe access to care and only three mention emergency care. Another interesting observation is that most authors do not clarify what they mean when using the term ‘access to care’. Most articles do however refer to either the behaviour model of access to care or the 5A model.

Models in brief:

The behavioural model of access to care (Aday and Andersen, 1974) highlights the relationship between utilisation and access.  It suggests utilisation as a proxy to measure access.  The flaw of using utilisation as a proxy is that patients that died prior to reaching care are not captured in the measurement.  In emergency care those that could not access care and the reasons why they couldn’t or chose not to access care are incredibly important.

In the 5A model (Pechansky and Thomas, 1981) access to care is described as a best-fit between the characteristics of the health service, the provider and the patient.  (5A’s=Availability, accessibility, affordability, acceptability, accommodation).

In recent years, the approaches became more ‘holistic’ considering variables including culture, society and gender. Access to care has clearly become more than arriving at a healthcare facility.  But again, the ability to seek care during an emergency, at the site of injury/ out-of-hospital or during transit is not mentioned.

Most countries in Africa do not yet have emergency care systems or the infrastructure to support the development of emergency care. Functional and accessible emergency care systems would enable these countries to address the burden of disease, reduce the impact of road traffic accidents and under-5 mortality to name just a few.

In these countries, when a household member requires emergency care the household needs to make harsh decisions and weigh the risk of financial ruin against a family member’s life.  This can cause irrational decision-making or a delay to make the decision. How can this not be a consideration when describing access to care?

Why including emergency care in access to care discussions matter?

The terms emergency care and out-of-hospital care are relatively new and not included in discussions on access to care, especially not those building on the older, generic descriptions.  It makes it hard for policymakers and funders to actually understand what emergency care is, how it enables access to the rest of the healthcare system and why it matters.

If key stakeholders do not understand the terminology used, they are unlikely to prioritize it, promote it or fund it. Measurement and evaluation are important to stakeholders.  Emergency care does not lend itself to quick, affordable projects with measurable outcomes.  For instance to a politician or funder arriving in a village and vaccinating 500 children is measurable and can be promoted.  To develop emergency care takes time and is harder to define and measure and thus less likely to be funded. If we can clarify the concepts around access to emergency care better, we might be able to create measurable outcomes and thus obtain funding and prioritization.

Not including emergency care as a core aspect when defining access to care in general complicates the development and advocacy of emergency care.  Maybe it’s time to design a model similar to the 3D model used for maternal mortality to define the determinants of access to emergency care.

I would love to hear your thoughts:  how would you describe access to care and if you agree that emergency care deserve more mention (or am I just biased?).

Please note that due to space I’m not including all the article. I can send a spreadsheet if anyone would like to see it.  Some of the authors include Donabedian, Aday and Andersen, Frenk, Pechansky and Thomas, McCintyre et al., Ensor and Cooper, Dutton, Gulliford, Goddard and Smith, Hadid and Mohindra, Mooney, Culyer, van Doorslaer and Wagstaff, Peters, O’Donnel and others.

A match made in healthcare improvement heaven

I’ve been collaborating with the Lean Institute Africa for the past six months and the collaboration has now been formalised.  As such, Lean Institute Africa will be posting some of my blogs on the news section of their webpage.

A bit of background about Lean Institute Africa (LIA): they were formed in 2008 as a non-profit organisation in South Africa.  LIA uses applied research approaches to implement the lean management philosophy.  Prof Norman Faull, LIA chairman describes lean as a management process for creating thinking people and eliminating waste.

One of the aspects of the lean philosophy that speaks to me is the concept of gemba (going to the problem or place of work and seeing).  From a lean perspective, problems are not addressed from a boardroom, intellectual discussion or based on opinion.  Rather, in-depth knowledge about a problem is gained in an empirical way, at the actual place of work, involving the actual people performing the task.   The actual ’workers’ are coached to think about the problem and solve it in a scientific way of experimentation until the most appropriate solution is found.

If you want to build a ship, don’t drum up the men to gather wood, divide the work and give orders.  Instead teach them to yearn for the vast and endless sea.  Antoine de Saint-Exupery

If you search for patterns in my blogs you would’ve gathered that I strongly believe in continuous learning and I am constantly exposing myself to new experiences. Another thread that you might have identified is that I use narratives or stories to shape perceptions and I believe that stories are an underutilised resource for influencing culture when implementing, improving and innovating the workspace.  I’ve addressed this as a conference speaker on a few occasions. My passion for storytelling is well-suited to the standardised storytelling approach (A3 problem-solving), as used by lean methodology.

The Lean Institute Africa has increasingly been involved with public health sector improvement and as you may have gathered from my other blogs, this is something I am very passionate about.

You can read more about the important work that LIA does at http://www.lean.org.za/ and follow them on LinkedIn, Facebook and Twitter.cropped logo

“Now this is not the end, it is not even the beginning of the end.  But it’s perhaps the end of the beginning.”  Winston Churchill

More good news is that whilst writing this blog I was asked to participate in writing a few blogs for the Emergency Nurses Society of South Africa (ENSSA), so I’ll still be writing about emergency medicine, access to care and more clinical nursing topics.

Harmony – should lean organisations strive for this?

Paging through textbooks on how to manage people I noticed how much time is dedicated to the importance of establishing harmony within the workspace.  The picture is painted of the utopian workspace where everyone is in agreement on everything all of the time and they are working together without a hitch. According to this literature, creating this harmonious workspace is the ultimate goal and measurement of the good manager.

I disagree.  Harmony is an undesirable goal in a functional workspace.  The objective is not to create a workspace where everyone is agreeing.  The objective is to build a workspace where the capability is developed to recognise hitches, speak about it and experiment with countermeasures.  It’s the manager’s role to facilitate time, resources and a safe space to allow for countermeasures.  The manager also needs to be aware that managers are often poorly positioned to provide countermeasures to on-the-floor issues.

harmonious workers

Any manager that views harmony as the goal of teamwork is setting themselves up for failure.  Diversity in personality, culture and generational gaps in the modern workspace make it an impossible goal.  Managers should aim to celebrate the diversity of opinions and to create space for constructive conflict.  Conflict should be seen as a sign of diverse perspectives and people that are thinking about what they do and how they do it.

If everyone is thinking alike, then no one is thinking.  Benjamin Franklin

A team that is focused only on harmony will not perform well; people might not speak up due to the fear of creating conflict.  This leads to stagnation and the stifling of good ideas.  What a good team needs is a bit of substantive conflict that is solely focused on tasks, policies, and work problems (rather than individuals).

This type of conflict stirs creativity, new thinking, experimentation and leads to improved ways. It is conflict that challenges the way things are done, never settling for less than what is best at the time.

A note of caution: extremes are never good and as much as too much harmony may lead to stagnation, conflict that is not managed well or allowed to become affective and uncontrolled is dysfunctional.  So a balance must be found.

Ways to balance conflict:

  • Psychological safety.  The manager needs to create an environment where people feel safe enough to speak up, and where they are willing to experiment without the need to defend themselves.
  • Address issues appropriately.  Use facts such as measurements to tackle a problem as opposed to tackling a person.
  • Establish ground rules.  Establish parameters within conflict behaviour within teams, where people can treat each other with respect throughout the conflict.
  •  Accountability.  Allow for people at the lowest possible level in the organisation to be accountable and take responsibility for resolving issues at their level, prior to escalation.
  • Coaching on communication and listening skills.  In most organisations little time is spent on personal development, and people using constructive communication is vital in managing conflict effectively.
  • Formal problem-solving techniques.  Train everyone in the organisation on how to use methodologies such as the A3 process to address problems, whichever technique is used it should be focused on the problem or causes of conflict as opposed to people.
  • Explore alternative hypotheses.  Assign a responsible person for this role, and support them in testing these alternatives whilst using a standardised problem solving technique.
  • Manager as mentor. The manager needs to set the example by welcoming conflict and demonstrating that challenges can be dealt with constructively.

If we want team members that question, always strive to work better and improve, and who always find new ways to add value, we need to ask ourselves:  as manager, is our ultimate goal that of harmony or is it one of creative tension?

A great team is not the absence of conflict.  It’s the presence of a reconciling spirit.  When a team shares a strong sense of community, team members can resolve conflict in such a way that strengthens relationships, rather than weakens them.