Health Care TodayHealth Care TodayThe Perfect StormThe Perfect Storm

Marjorie S. Wiggins, RN, MBAMarjorie S. Wiggins, RN, MBAVice President of Nursing/Chief Nursing OfficerVice President of Nursing/Chief Nursing Officer

Maine Medical CenterMaine Medical CenterClinical Nurse Leader Implementation ConferenceClinical Nurse Leader Implementation Conference

June 16, 2004June 16, 2004 Washington, DCWashington, DC

The Perfect StormThe Perfect Storm

Crew of the Andria Gail

1. Hard working crew trying to deliver a product to market

2. Ill-equipped vehicle – aged, malfunctioning

3. Heading toward an “UNKNOWN DISASTER” of storm conditions that would challenge their ability to sustain the elements and subsequently threatened their viability

Nursing

1. Hard working profession trying to deliver a service

2. Aged delivery model functioning in a problematic infrastructure

3. Heading toward a “KNOWN DISASTER” – shortages, decreased reimbursement, increased demand, growing dissatisfaction of care provider – all factors known to threaten our ability to deliver safe care

Current State of NursingCurrent State of Nursing

Nurses are working in health care organizations that are 20 times more

complex than the typical general business or manufacturing organization

Enmet Murphy, et alEnmet Murphy, et alNursing Management 1997Nursing Management 1997

““Nurses are highly Nurses are highly dissatisfied with hospital dissatisfied with hospital

practice.”practice.”• Job Dissatisfaction 41%• High Job Burnout 43%• Intend to leave within year 23%• Under 30 leaving in a year 33%

L. AikenL. AikenUniversity of PennsylvaniaUniversity of Pennsylvania

““Nurses describe the current Nurses describe the current work environment as highly work environment as highly stressful and professionally stressful and professionally

unfulfilling.”unfulfilling.”

Josiah Macy Foundation, 2000Josiah Macy Foundation, 2000

Let’s take a closer look and Let’s take a closer look and see exactly what is it that see exactly what is it that

nurses are complaining about.nurses are complaining about.

A study examining the present A study examining the present workload of the nurse and the workload of the nurse and the

environment of practice environment of practice conducted by Anita Tucker, conducted by Anita Tucker,

DBA, while a doctoral DBA, while a doctoral candidate at Harvard Business candidate at Harvard Business

School.School.

The Day in the Life of a The Day in the Life of a NurseNurse

Details of the StudyDetails of the StudyNursing studied in:Nursing studied in:

• Eight hospitals (Massachusetts, Rhode Island, Minnesota; (Massachusetts, Rhode Island, Minnesota; Ontario, Ontario, Canada; 47 to 433 beds; known for excellence as Canada; 47 to 433 beds; known for excellence as

identified in magnet identified in magnet literature)literature)• Multiple Nursing Units• ICU/Medical-Surgical/Oncology/Maternity• All shifts and days• 30 observations total time 197 hours• Duration: 1 hour 15 minutes to 13 hours 34 minutes• 10 nurses observed for entire shift

A. Tucker, 2001A. Tucker, 2001

MethodologyMethodology

• “Shadowing” nurse throughout shift• Data collection detailing:

the activity location & patient Situational constraints** Nurses response to situational constraints Communication with other departments

St. Mary's Nursing Study Data - Day 1 6/27/00"Peggy"

Task Start Stop Time Direct Indirect Unit Rel PersnlWait for report 7:00 7:13 0:13 0:13Report on 207 7:13 7:17 0:04 0:04Document Assignment Acuity 7:17 7:19 0:02 0:02Wait for report 7:19 7:24 0:05 0:05Report on 211 7:24 7:29 0:05 0:05Report on 213 7:29 7:32 0:03 0:03Report on 214 7:32 7:35 0:03 0:03Documents for 211 OR(x-ray, EKG, nurse note, VS) 7:35 7:39 0:04 0:04Look for DIG tests on computer (not there) 7:39 7:40 0:01 0:01Call lab to ask for tests 211 7:40 7:41 0:01 0:01Look in chart for one-op med orders 7:41 7:42 0:01 0:01Document 211 7:42 7:43 0:01 0:01Call OR nruse to give report 7:43 7:47 0:04 0:04Document - gather med sheets for OR 7:47 7:50 0:03 0:03Transport 211 to OR 7:50 7:52 0:02 0:02Talk to OR nurse about status 211 7:52 7:53 0:01 0:01Walk back to St. Marys 7:53 7:54 0:01 0:01Document the "cheat sheet" 7:54 7:57 0:03 0:03Report to Nurses' Aid on patients 7:57 8:02 0:05 0:05Planning care on "cheat sheet" 8:02 8:07 0:05 0:05Talk to Doctor abou 213 8:07 8:08 0:01 0:01Look for labs on computer 211, 213 8:08 8:11 0:03 0:03Computer cardex on 207 8:11 8:12 0:01 0:01Talk to secretary about DIG test results 8:12 8:13 0:01 0:01Get verbal order from Dr. for 214 8:13 8:15 0:02 0:02In room 214 - talk to Dr. about brace 8:15 8:16 0:01 0:01In room 214 - assess patient 8:16 8:17 0:01 0:01Get verbal order from Dr for 214 8:17 8:18 0:01 0:01Move patients foodtray and adjust 8:18 8:20 0:02 0:02Talk to Dr. about transfer date of 213 8:20 8:21 0:01 0:01Gather VS info from temperature sheet 8:21 8:25 0:04 0:04Get verbal order for xray 207 8:25 8:26 0:01 0:01Assess patient 207 8:26 8:30 8:04 0:04Enter COMPUTER STAT x-ray 8:30 8:31 0:01 0:01Call x-ray to tell them STAT x-ray 8:31 8:32 0:01 0:01Gather VS info from temperature sheet 8:32 8:33 0:01 0:01Communicate status to PT on 214 8:33 8:34 0:01 0:01Have secretary call Dr for211 lab results 8:34 8:35 0:01 0:01Communicate status to PT on 214 8:35 8:36 0:01 0:01Make sign for 214 ("don't tighten strap") 8:36 8:37 0:01 0:01Get phone call - order to discharge 207 8:37 8:38 0:01 0:01Enter COMPUTER orders for 214 social svs 8:38 8:40 0:02 0:02Enter order for silvadene in MAR 8:40 8:43 0:03 0:03Fax order to pharmacy 8:43 8:44 0:01 0:01

St. Mary's Nursing Study Data - Day 1 6/27/00"Peggy"

Task Start Stop Time Direct Indirect Unit Rel PersnlWait for report 7:00 7:13 0:13 0:13Report on 207 7:13 7:17 0:04 0:04Document Assignment Acuity 7:17 7:19 0:02 0:02Wait for report 7:19 7:24 0:05 0:05Report on 211 7:24 7:29 0:05 0:05Report on 213 7:29 7:32 0:03 0:03Report on 214 7:32 7:35 0:03 0:03Documents for 211 OR(x-ray, EKG, nurse note, VS) 7:35 7:39 0:04 0:04Look for DIG tests on computer (not there) 7:39 7:40 0:01 0:01Call lab to ask for tests 211 7:40 7:41 0:01 0:01Look in chart for one-op med orders 7:41 7:42 0:01 0:01

Timed Activity by Minute

Summary StatisticsSummary Statistics

For an average 8-hour shift• 6 patients (on average)• Completed 160 tasks• Average task time 00:02:48• Average 4.7 interruptions• Average 6.5 problems per shift• 35% of time spent in direct care - 25 min/patient

A. Tucker, 2001A. Tucker, 2001

Nursing tasks are at Nursing tasks are at staccato pace…staccato pace…

• For an average 8-hour shift• Completed 160 tasks• Average task time 00:02:48

Situational Constraints**Situational Constraints**

“Features of the work environment that act as obstacles to performance by

preventing employees from fully translating their abilities and motivation into

performance.”

Peters, L.H., O’Connor, E. J. and Eulberg, J.R. (1985). Situational constraints: Peters, L.H., O’Connor, E. J. and Eulberg, J.R. (1985). Situational constraints: Sources, consequences, and future considerations. In K. Rowland & G. Ferris Sources, consequences, and future considerations. In K. Rowland & G. Ferris (Eds.), Research in personnel and human resources management (Vol. 3, pp. 79-(Eds.), Research in personnel and human resources management (Vol. 3, pp. 79-113), Greenwich, CT: JA1 Press.113), Greenwich, CT: JA1 Press.

Situational ConstraintsSituational Constraints

• 166 problems• “Costs” of these problems:

Time spent on problems (35 min/shift – 8%) Delay to patient care Interruption to nurse

Inevitable Availability Inevitable Availability or is itor is it

“Fatal Availability”“Fatal Availability”

What does that look like?What does that look like?

Short Segment of One Short Segment of One Shift…Shift…

9:00 9:00 Nurse reviews order to obtain sputum specimen – Nurse reviews order to obtain sputum specimen – obtains requisition and labelobtains requisition and label

9:02 9:02 To supply room for specimen container – none To supply room for specimen container – none availableavailable9:039:03 Borrows container from another unitBorrows container from another unit9:059:05 Obtains specimen and labelsObtains specimen and labels9:069:06 Bring out to desk to send specimenBring out to desk to send specimen9:089:08 Message that physician will be coming by to insert Message that physician will be coming by to insert PICC PICC lineline9:109:10 Pages physician to know what equipment he will needPages physician to know what equipment he will need9:119:11 Another patient calls fro pain med; goes after Another patient calls fro pain med; goes after medication; medication; patient order expiredpatient order expired9:139:13 Misses 1Misses 1stst physician’s call; pages again; leaves detail of physician’s call; pages again; leaves detail of

question with secretary; pages 2question with secretary; pages 2ndnd MD for renewal of MD for renewal of pain pain medicationmedication9:159:15 MD calls back; renews medicationMD calls back; renews medication9:189:18 Try to fit in bath patient # 1 before doctor arrivesTry to fit in bath patient # 1 before doctor arrives9:209:20 Inadequate supply of linen; borrows linen from another Inadequate supply of linen; borrows linen from another room 9:25room 9:25 called out of room to answer phone call from a called out of room to answer phone call from a family member family member to check statusto check status(Lab calls at 2:10 to say they lost sputum specimen)(Lab calls at 2:10 to say they lost sputum specimen)

All the while the nurse is caring for acutely ill patients, she/he is expected to meet patient’s dependency needs,

provide physical and emotional comfort, deliver medication and

treatment, and effectively perform monitoring and surveillance to keep

patients safe.

To appeal to the nurseto stay in hospitals,

we have created the flexible schedule, as well as reduced the

work weekto 3 12-hour days.

Schedule of StaffingSchedule of Staffing

Schedule of StaffingSchedule of StaffingS M T W T F S S M T W T F S

Janie Smith

7a-7p

- - 7p-7a

- 7a-7p

- - - 7a-7p

7a-7p

- - 7p-7a

Donna Clews

- - - 7p-7a

7p-7a

- - - - 7p-7a

7p-7a

- - -

Mary Kay

7a-3p

- - 7a-3p

7a-3p

- - - 3-11:30

3-11:30

- - - 7a-7p

Jean North

- 7a-7p

7p-7a

- - - 7a-7p

7a-7p

- - 7a-7p

- 7p-7a

-

12-hour shifts rarely are scheduledmore than 2 days in a row

Combination of part-time staff and

12-hour shifts have diminished the continuity of care and

compromised monitoring on-going progress of the patient

The New Nurse ManagerThe New Nurse Manager

Nurse Manager roles over the years have seen dramatic changes – covering multi-units, becoming department heads, representing

staff at budget and administrative meetings.

Results – less time on the unit – decreased involvement in clinical

care.

Simplified…Simplified…1. Nurses are task driven

2. Working at a staccato pace

3. System failures are consuming valuable time

4. Shift work is replacing continuity of care givers

5. Managers are moving away from clinical involvement

Who is managing the patient care to identified

outcomes?

Who knows the patient story from beginning to

end?

We know the current We know the current conditions conditions

We have a clear We have a clear understanding of the understanding of the

forecast forecast

We can avoid the storm We can avoid the storm aheadahead