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.

Advertisements

On ‘death and dying’ and organisational change

‘Buy-in’ is a term commonly used when talking about change in the workplace. We want everyone to buy in to the change.  Often, supervisors and managers appear completely perplexed when people do not simply buy in or change their ways when told to.  Numerous books have spoken about ‘managing change’ and ‘obtaining (the elusive) buy-in’.

The lean methodology addresses some crucial aspects of ‘obtaining buy-in’,  including involving the people performing the task in the change process, empowering people to experiment with new ways, and coaching employees in problem-solving techniques.

There is a significant human factor that, if ignored, hampers sustainability of change: emotions.  In the work environment, where change is underway, these are labelled different names such as resistance, anger, or passive aggressiveness.  In this blog we will call this emotion grief.

We become emotionally attached to our routines, and our way of doing things.  And even though we might logically know that it’s not the best way to perform a task, we experience a feeling of safety and a sense of belonging within our routines.

In organisations with strict hierarchies and bureaucracies with red tape such as hospitals, those that have been around for a long time find and establish the loop holes which enable workers to get the job done based on longstanding networks and local knowledge.  Long-serving staff may view a suggested change to the way they do a well-established process as a threat. Exposing the loop holes can lead to feelings of vulnerability, frustration and anxiety about getting into trouble with management; especially within the ‘blame culture’ typically found in these bureaucracies.

Elizabeth Kubler-Ross, a psychiatrist who studied near-death situations and the emotions involved,   identified five stages of grief as a pattern of adjustment: denial, anger, bargaining, depression, and acceptance.  Each person will pass through these stages at their own rate and in their own way.  The task of a grief counsellor is to provide support during these phases.

A criticism of the model is that Kubler-Ross did not adequately take into consideration the role that the personal environment plays.  Certain environments make grieving easier.  And not everyone experiences grief in the same way, as some people are more resilient and adapt with little grieving.   Charles Corr, a social psychologist and a critic of Kubler-Ross’s work stated that grief and resilience are influenced by patient empowerment.  The more empowered the patient, the faster and better they adapt to the end of life situation. He highlighted two important aspects from Kubler-Ross’ work that I think are also true for organisational change: 1. that each person will react in their own way to the challenges that confront them, and 2. that one cannot become an effective supporter or carer unless one has learnt to actively listen to the person grieving.

How do we create an environment where employees feel empowered during the ‘death of the old ways’?  This question is particularly difficult to answer in the beginning of a lean journey, where management (and the organisation) are using traditional methods, the ‘blame culture’ is still firmly established and people have no success stories to demonstrate that the changes are in fact improvements.

I’d like to suggest though that we can better support employees during organisational transitions by preparing people for change, supporting their emotions during change and making it ok to grieve.

Grief is personal and subjective.  We can’t measure grief by comparing it to other people’s grief or phase of adjustment. We need to create an environment in which it’s safe to express emotions without judgement, where concerns are not simply dismissed, challenges ignored and what-if scenarios discarded. Emotions and feelings should not be denied when implementing change, otherwise staff will feel oppressed and devalued.

As such, I am making a case that the direct line manager is not the most appropriate person to provide emotional support during large-scale change initiatives.  The line manager is emotionally invested in the change and going through their own grief and adjustment, especially if they are confronted with challenging their beliefs on how to manage and problem-solve within their unit. They are grieving themselves.

So who should provide support then?  Could Human Resources become more involved? Is this perhaps a role for HR departments, with an understanding in lean thinking?  I’m not sure.  What I am sure of, though, is that whoever provides emotional support needs to be like a grief counsellor:  slightly removed from the actual incidence, with little emotional investment in the operational processes and ways.

Kubler-Ross: Phases of grief in organisations

Denial:  This is often expressed through statements such as, ‘We don’t have any problems in our department.’  or, ‘If only Department XYZ worked harder, faster or better, then our results would improve.’

Anger: In organisations this is expressed as passive-aggressive behaviour rather than actual aggressive outbursts.  If the not-so-obvious symptoms of this phase are not managed, the change will not be sustainable.  It’s important to support people through all the phases; however the anger phase is probably the hardest to diagnose as its symptoms may be subtle. Behaviour or symptoms of the phase include obstruction, lateral violence and bullying of others.  Other symptoms may include threatening to resign or requesting a move to another department.

Bargaining: If anger is the hardest phase to diagnose and support, then bargaining is the tipping point for change. The following remarks may be heard in this phase: ‘This is additional work, so I will make the change if you increase my salary’, ‘This is not in my job description so we need more time/resources/payment and then we will be able to follow through with this’ or ‘If this way doesn’t work, then I will leave and go work somewhere else’.  These employee responses should be carefully managed if the organisation would like to move past a point of consistent bargaining or negotiation towards sustainable change and behavioural acceptance.

Depression:  People might appear to be sulking, sullen and unhappy at work.  An important ‘sub-stage’ of depression is testing: testing the new ways and acknowledging that the new ways are not  all bad, but the employee is still not ready to openly accept it.  This is when people come to the realisation that perhaps it is not as bad as they thought.

Acceptance:  This is the‘buy-in’ you were hoping for from the start, or acceptance of the change.

Summary

Lean organisations should strive towards resilience, a state that is at the other end of the spectrum to grief, because people feel safe, supported and are able to adapt within their environment.  This desired state of resilience takes time to attain.

The phases of grieving must be diagnosed, addressed and managed.  If this is not done appropriately it will have long-term adverse effects, including bullying or consistent bargaining to perform tasks.

Until organisations reach the point of resilience, they need to plan emotional support into the improvement process.  This emotional support should not be seen as an extension of the direct line manager’s task.  Rather it should be outside of the functional unit. This is of the utmost importance in organisations starting a large-scale lean transformation.

grief

The stages

Mentalities….Business firefighting versus real-life firefighters

In business language the firefighting mentality is not meant as a compliment.  Instead it refers to poor strategic planning and a disjointed organisation that is spending it’s time fighting unnecessary issues that could’ve been prevented with better management practises.

I’ve always felt uncomfortable about this accepted “business definition”.  My feeling is that whoever coined the term had no idea about the intricacies and complexity of real-life firefighting. At first I thought that maybe I just don’t get what is meant in a business sense, so I kept quiet about the fact that I completely disagree with the analogy.

However after this week’s devastating fires that swept through the Southern Peninsula and yet again observing the firefighters at work I need to say this:  Perhaps organisations need to develop a firefighter mentality.   11046952_398822600291088_530584084941375836_n

According the business definition a firefighting mentality is one where the organisation’s members are frantically rushing, making impulsive decisions; applying “Band-Aids” to problems without in-depth investigation, suppressed problems with short-term solutions.  According to the business analogy if you are proactive you won’t have many fires to fight.  I disagree.  In both nature and business, fire is a natural occurrence, it happens despite measures to prevent it.  There are always uncontrollable forces that organisations cannot influence.  So rather expect the fire, be prepared, train and vigilantly monitor for fires.

The business definition ignores how firefighters actually do their job.  Organisations can learn some principles on teamwork and decision-making from firefighters.

The REAL firefighter mentality

  1. Preparedness.  When not actively firefighting, fire fighters are preparing for the next fire.  If you visit a fire station you will find that the gear is ready and checked first thing on the shift, the vehicles are ready, fire suits ready, the control room is manned.  There is regular practise for emergencies and when the call comes in, everyone are trained and knows their role.  There is no need to add to the complexity of a fire situation by figuring out task allocations or panic about readiness and what next.  Firefighters know what is controllable and what is not controllable.  Controllable is preparedness, uncontrollable is wind direction.  By preparing for what can be controlled, decision-making during the fire is simpler and only targeted to strategies to deal with this fire now.  The groundwork to enable this focus has been done way before the fire.
  2. Consistent communication.  Close up to where the fire is being fought you can hear the fire fighters calling for more water, move closer, watch out, etc.  They are constantly speaking and updating each other, nobody is left out of the communication loop.
  3. Implicit trust.  During a major event the in-charge or commander are removed from the incident.  Decisions with a major impact such as evacuation of homes or mobilisation and withdrawal of resources are made relying on the feedback and opinion from the persons on the forefront.  Think about this….there is no time to check the integrity of a report, to micro-manage or to-do-it yourself.  There is limited time to question; Fire chiefs trust their team with life threatening decisions in a way that few managers trusts their team with minor decisions.
  4. Team approach.  Ever opened a fire hose?  The water comes out at a high pressure and it’s advised to have a buddy standing behind you for support.  Firefighters know that you can’t fight a fire on your own.  A team is dispatched to a fire and not a lone firefighter or fire chief.  Firefighters move together, they work together and they look out for each other, no one is wandering off doing their own thing.

    10900080_416000981908430_7134571997949818654_o

    Photo credit: Sullivan photography. Picture posted on Facebook.

  5. Strategic planning. Firefighters do not simply rush into a fire.  They arrive prepared, they make a decision and then they execute it rapidly.   What from the outside may appear as impulsive is actually an ability to stay calm under an immense pressure combined with experience and hours of simulation practise.

    11042974_10153157297066133_99558182578589751_n

                             Working together

  6. Practise. Firefighters practised and simulate various scenarios so many times that when they arrive on scene they are not even aware of making decisions.  If you are interested in reading more about how firefighters make decisions, Gary Klein has done fascinating research on how firefighters build a repertoire of patterns to help them frame a situation and make split second decisions.   It’s a combination of tacit knowledge, intuition and experience.

    Practise makes perfect

                   Practise makes perfect

  7. Courage and ability to remain calm under pressure.   Approaching a fire is scary and firefighters put themselves and their team members at risk with each decision they make.  It takes courage as well as physical and emotional strength.
  8. Humour during stressful situations.  Firefighters and other emergency workers relief tension by laughing, joking and teasing each other during stressful times.   I can think of plenty management moments where a smile, a joke or even just some friendliness could relief the tension.

To all the firefighters I salute you.  Well done.

To see what these brave men and women at work during the Southern Peninsula fires: http://ewn.co.za/media/2015/03/04/inside-the-flames

To read some more about decision-making process of firefighters, ICU nurses and fire fighters:

Brockman, J. (2013) Thinking: The New Science of Decision-Making, Problem-Solving and Prediction.  HarperCollins, New York.

Klein, G., Ross, K.G., Moon, B.M., Klein, D.E., Hoffman, R.R., Hollnagel, E. (2003) Macrocognition.  IEEE Intelligent Systems. May/June 2003 pp.81 – 84

Klein, G., Hoffman, R.R. (1992) Seeing the invisible: Perceptual-cognitive aspects of expertise.  Cognitive Science Foundation Instruction.  pp 203 – 226

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.