Reflections: "Reimagining the nursing workload: Finding time to close the workforce gap"
Redesigning care models through intentional delegation andpotential tech
enablement can free up nurses’ time.
I learned of this study through twitter (see below) and ongoing awareness of the work, contribution and debate regards management consultants over the years. The research study was conducted in USA and I have no work experience there. As stated many times on W2tQ: my context is UK-based and public sector - NHS. I have been seconded in the past to a project which engaged management consultancy companies, the work involving IT and communications. The latter was focussed upon (much needed) IT engagement and being 'on message'.
If employed long enough in the UK public health sector, you will come across consultancy employees eventually (whoever is in government too). Through news, media, consultants (friendly, with wide experience, eager to engage and deliver) will be introduced to the team, on placement for several weeks to collect data through a series of meetings, and conduct a presentation about impending change. The management consultancy sector often have a bad press, with ongoing critique and debate regards their role, across the Atlantic and globally. More on that to follow.
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| McKinsey: LinkedIn |
A brief introduction to the study follows:
"We conducted a survey of 310 registered nurses across the United States from February 8 to March 22, 2023. Our goal was to understand nurses’ perception of time spent throughout the course of a shift and to identify existing and desired resources to help nurses provide high-quality care. Our sample focused on nurses in roles that predominantly provide direct patient care in the intensive-care unit, step-down, general medical surgical, or emergency department settings. Insights were weighted by length of shift (the minimum shift time included was six hours)." p.2.
To begin, I like 'reimaging' in the title. Healthcare should always be about imagination, envisioning, and action - on an individual and collective basis. Organisational reimaging is also what management consultancy is predicated upon. 'Care model' here, appears to refer to the care environment (and experience?) as found. Gap, also in the title is another positive. Gaps must be seen, to see how we might close, bridge and span them.
Over several decades a preoccupation with 'process' has been apparent: the nursing process and processes as events and sequential series in project management. But what is this? No 'process' but one instance of processes. While this was encouraging, as presented, emphasis is placed on activities and tech - both of which can engender reductive and task-based perspectives. Allied with tech, improved delegation is the stated aim of the study. 'What do you expect?' - might be the rejoinder. As per the twitter replies the study conforms to type, brief and 'message':
"Achieving this may require health systems to invest heavily in technology, change management, and workflow redesign.
Realizing these changes will require bold departures from healthcare organizations’ current state of processes. It will be critical for hospitals to bring both discipline and creativity to redesigning care delivery in order to effectively scale change and see meaningful time savings. Close collaboration beyond nursing is also paramount to ensure alignment across the care team and hospital functions including administration, IT, informatics, facilities, and operations." p.8.
Technology is often described as the catalyst, but the impact (and risks - safety?) are often missed - a case of 'wag the dog'?
There is a global shortfall in the nursing workforce. National governments take a local perspective tempered (we hope) with international agreements on overseas recruitment. From the shortage in the USA listed (below), to the potential time saving equivalence is a significant outcome:
"When we translate the net amount of time freed up to the projected amount of nursing time needed, we estimate the potential to close the workforce gap by up to 300,000 nurses." p.2.
I am a technology enthusiast outside of work, but a technology realist at work (I do enthuse with students and enjoy hearing their views and experiences - personally, at university, on placement). I've used two electronic health record systems in mental health over the past four years. It is usable, but - as ever - could be improved. Thoughts re. tech are currently clouded by the UK use of telecoms and IT as the access point for primary care. Unfortunately this acts as a 'gate'. More tech is not necessarily better. Can it be argued that the pace of technical change (hardware and software - cloud, devices, decision support ...) is so fast that it is constantly contested? New systems need to be re-evaluated for patient benefits, improvements in care, safety, fit for purpose and other desiderata. Many consultants and advisors point to the existence of disciplinary and (hence) knowledge silos. What is key, is how IT can disrupt existing practice through these silos, especially in the form of AI.
To return to the study(!), it is primarily in-patient hence hospital based. Perhaps hospitals are the biggest silos of all? These management studies flow, forming a series, a work-stream that includes:
How ‘Care at Home’ ecosystems can reshape patient care
Virtual hospitals could offer respite to overwhelmed health systems
Nursing in 2023: How hospitals are confronting shortages
These are cross-referenced online, but what price integrated care - and person-centred care at home?
Prof Alison Leary's tweet highlights research that has demonstrated the improved patient outcomes when care is delivered by Registered Nurses. The importance of training, registration and need to study the 'work' of nurses and their workload is not new:
Plus,"One of the new applications for decision analysis derives from the realization that if physicians are to become effective advocates for quality health care delivery under the incentives engendered by the newer cost-containment strategies, a common language is required to permit communication between physicians, regulators, policy makers and patients relative to what comprises effective care and why physicians do what they do." Preface, v. (my emphasis)
Knoebel, S.B. (1986). Perspectives on Clinical Decision-Making. New York: Futura Publishing Co., Inc., Mt. Kisco.
Whether 'physician', 'doctor' is cited as the user - an electronic health record should cohere across disciplines including nurses - the multi-disciplinary team; even as disciplinary system use may have its own signature (subsets). We are still seeking a language. For me this remains SOCIO-technical.
Innovations are mentioned in the study, but the specifics are not stated in explicit nursing terms, but related to the role of technology, electronic health records (yes, a care record is critical), building on existing tools and reducing implementation risk. Sadly, the informational environment (body politic?) appears to place constraints on the nursing 'care models' referred to here.
On delegation, the following makes a lot of sense: "While nurses report wanting to spend more time
overall on direct patient care, there are specific
tasks that could be delegated both vertically
and horizontally to ensure that the work nurses
perform is at the top of their license and promotes
professional satisfaction." p.5. (my emphasis)
INDIVIDUAL
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INTERPERSONAL : SCIENCES
HUMANISTIC -------------------------------------- MECHANISTIC
SOCIOLOGY : POLITICAL
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GROUP
| Nurses thinking of leaving - reasons include: "not feeling valued by their organization and not
having a manageable workload." with additional settings inc. home care
and long-term care facilities. This is a common expressed wish by nurses: "spend more time with their patients" but how often is it qualified psycho-socially? | 310 subjects - nurses ".. estimates still suggest a potential shortage of 200,000 to 450,000 nurses in the United States, with acute-care settings likely to be most affected." Settings include: intensive-care
unit, step-down, general medical surgical, or
emergency department. |
Direct patient care - relationship building, empathy and rapport? |
effectiveness, efficiency and equity* The politics of health systems and health service delivery globally. |
In the 1990s organisational hierarchies were flattened, middle management roles were reduced. Technology played its part, but there are many other factors:
At a time when applied AI is increasing, nursing is open to innovation, but synergy and assurance of high quality, safe, person-centred care is essential.
Socially we also need to preserve forms of work that have a role in well-being and community health - care of older people. Hierarchies and the services they 'deliver' will be flattened further and rationalised - if as nurses we are sufficiently passive. Consider the thoughts of Prof. Acemoglu, Economist, MIT:
"He [Acemoglu] imagines a day when teachers could use AI to create individual lesson plans for every student, or nurses might be able to take on much greater roles in, for example, diagnosing disease. 'Why is it that nurses cannot prescribe medications? Why must everything go through this very hierarchical approach where you have to call a doctor [to do that]?' As it is today, the people who spend the most time with patients - nurses, not doctors - are those who are paid and valued the least." p.3.
Foroohar, R. 'When mistakes involve powerful technologies, you're going to have trouble', Lunch with the FT: Daron Acemoglu, FT Weekend, Life&Arts, 20-21 May, 2023, p.3.
There is most likely a 'corporate' signature common to these reports as there will be to the posts here (2006 ... ). For nursing's sake - vested in the sustainable development goals, the determinants of health, and climate change - we need to preserve 'models of / for care' defined, applied and refined by nurses, the profession and professionalism, registration and holistic bandwidth.
See also:
[ Thanks to Phil Wilson: https://twitter.com/ph_wilson1/status/1667869284305977346?s=20 ].
By one of the big four. It does try to look at workload redistribution but seems to conveniently ignore the evidence regarding the improved outcomes of RN delivered care & bad tech. #Nursing
— Prof Alison Leary 💙#ProtectNurse (@alisonleary1) June 1, 2023
Big 4 really need to dump the Christmas tree models. https://t.co/2zrylhTZOo @McKinsey
*Apply the 3Es across the domains of Hodges' model.
Reimagining the nursing workload: Finding time to close the workforce gap
https://www.mckinsey.com/industries/healthcare/our-insights/reimagining-the-nursing-workload-finding-time-to-close-the-workforce-gap
orcid.org/0000-0002-0192-8965