Health Care Today

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Health Care Today The Perfect Storm
Marjorie S. Wiggins, RN, MBA Vice President of
Nursing/Chief Nursing Officer Maine Medical
Center Clinical Nurse Leader Implementation
Conference June 16, 2004 Washington, DC
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The Perfect Storm

• Crew of the Andria Gail
• Hard working crew trying to deliver a product to
  market
• Ill-equipped vehicle aged, malfunctioning
• Heading toward an UNKNOWN DISASTER of storm
  conditions that would challenge their ability to
  sustain the elements and subsequently threatened
  their viability

• Nursing
• Hard working profession trying to deliver a
  service
• Aged delivery model functioning in a problematic
  infrastructure
• 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

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Current 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 al
• Nursing Management 1997

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Nurses are highly dissatisfied with hospital
practice.

• Job Dissatisfaction 41
• High Job Burnout 43
• Intend to leave within year 23
• Under 30 leaving in a year 33
• L. Aiken
• University of Pennsylvania

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Nurses describe the current work environment as
highly stressful and professionally
unfulfilling. Josiah Macy Foundation, 2000
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Lets take a closer look and see exactly what is
it that nurses are complaining about.
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A study examining the present workload of the
nurse and the environment of practice conducted
by Anita Tucker, DBA, while a doctoral candidate
at Harvard Business School.
The Day in the Life of a Nurse
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Details of the StudyNursing studied in

• Eight hospitals (Massachusetts, Rhode Island,
  Minnesota Ontario, Canada 47 to 433 beds
  known for excellence as identified in magnet
  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, 2001

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Methodology

• Shadowing nurse throughout shift
• Data collection detailing
• the activity location patient
• Situational constraints
• Nurses response to situational constraints
• Communication with other departments

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Timed Activity by Minute
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Summary Statistics

• For an average 8-hour shift
• 6 patients (on average)
• Completed 160 tasks
• Average task time 000248
• Average 4.7 interruptions
• Average 6.5 problems per shift
• 35 of time spent in direct care - 25
  min/patient

A. Tucker, 2001
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• Nursing tasks are at staccato pace
• For an average 8-hour shift
• Completed 160 tasks
• Average task time 000248

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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., OConnor, E. J. and Eulberg, J.R.
(1985). Situational constraints Sources,
consequences, and future considerations. In K.
Rowland G. Ferris (Eds.), Research in personnel
and human resources management (Vol. 3, pp.
79-113), Greenwich, CT JA1 Press.
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Situational Constraints

• 166 problems
• Costs of these problems
• Time spent on problems (35 min/shift 8)
• Delay to patient care
• Interruption to nurse

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Inevitable Availability or is itFatal
Availability
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What does that look like? Short Segment of One
Shift
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900 Nurse reviews order to obtain sputum
specimen obtains requisition and label902
To supply room for specimen container none
available903 Borrows container from another
unit905 Obtains specimen and labels906 Bring
out to desk to send specimen908 Message that
physician will be coming by to insert PICC
line910 Pages physician to know what equipment
he will need911 Another patient calls fro pain
med goes after medication patient order
expired913 Misses 1st physicians call pages
again leaves detail of question with secretary
pages 2nd MD for renewal of pain
medication915 MD calls back renews
medication918 Try to fit in bath patient 1
before doctor arrives920 Inadequate supply of
linen borrows linen from another room
925 called out of room to answer phone call from
a family member to check status(Lab calls at
210 to say they lost sputum specimen)
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All the while the nurse is caring for acutely ill
patients, she/he is expected to meet patients
dependency needs, provide physical and emotional
comfort, deliver medication and treatment, and
effectively perform monitoring and surveillance
to keep patients safe.
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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 Staffing
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Schedule of Staffing
12-hour shifts rarely are scheduled more than 2
days in a row
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Combination of part-time staff and 12-hour
shifts have diminished the continuity of care and
compromised monitoring on-going progress of the
patient
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The New Nurse Manager
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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.
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Simplified

• Nurses are task driven
• Working at a staccato pace
• System failures are consuming valuable
  time
• Shift work is replacing continuity of care
  givers
• Managers are moving away from clinical
  involvement

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Who knows the patient story from beginning to end?
Who is managing the patient care to identified
outcomes?
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We know the current conditions We have a clear
understanding of the forecast We can avoid the
storm ahead