Reflections: "Reimagining the nursing workload: Finding time to close the workforce gap"

Redesigning care models through intentional delegation and

potential 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.

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:

Robb, I. H. (1903). The Quality of Thoroughness in Nurses’ Work. The American Journal of Nursing, 4(3), 168–177. https://doi.org/10.2307/3401722

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

|

INTERPERSONAL    :     SCIENCES               

HUMANISTIC --------------------------------------  MECHANISTIC      

SOCIOLOGY  :   POLITICAL 

|

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:

https://www.nber.org/system/files/working_papers/w9633/w9633.pdf

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:

Moisoglou, I., Galanis, P., Meimeti, E., Dreliozi, A., Kolovos, P. and Prezerakos, P. (2019), "Nursing staff and patients’ length of stay", International Journal of Health Care Quality Assurance, Vol. 32 No. 6, pp. 1004-1012. https://doi.org/10.1108/IJHCQA-09-2018-0215 (I have accessed the abstract only).

Kim, J., Lee, J.Y., Lee, E. Risk factors for newly acquired pressure ulcer and the impact of nurse staffing on pressure ulcer incidence. J. Nurs Manag. 2022 Jul;30(5):O1-O9. doi: 10.1111/jonm.12928. Epub 2020 Feb 25. PMID: 31811735; PMCID: PMC9545092.

[ 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
Big 4 really need to dump the Christmas tree models. https://t.co/2zrylhTZOo @McKinsey

— Prof Alison Leary 💙#ProtectNurse (@alisonleary1) June 1, 2023

*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

 

Care by the Quarter*

individual

|

INTERPERSONAL : SCIENCES

humanistic ----------------------------------------------- mechanistic

SOCIOLOGY : POLITICAL

|

group - population

	"A review of almost 1,000 audits by a professional accounting body has found that about a quarter were substandard."

 

*5ths really - the spiritual and never an after-thought...

When we talk of achieving 'balance', 'leverage', being 'on message' and other c-speak, this is clearly never straightforward.

Source:

Louisa Clarence-Smith, Inspectors find a quarter of audits are substandard, The Times, September 29, 2020, p.42.

See also:

Bloomfield, B. P., & Danieli, A. (1995). THE ROLE OF MANAGEMENT CONSULTANTS IN THE DEVELOPMENT OF INFORMATION TECHNOLOGY: THE INDISSOLUBLE NATURE OF SOCIO-POLITICAL AND TECHNICAL SKILLS*. Journal of Management Studies, 32(1), 23–46. https://doi.org/10.1111/j.1467-6486.1995.tb00644.x 

Leys, C. (1999). Intellectual Mercenaries and the Public Interest: Management consultancies and the NHS. Policy & Politics, 27(4), 447–465. https://doi.org/10.1332/030557399782218353

Oliver, D. (2014). Stop wasting taxpayers’ money on management consultancy for the NHS. BMJ: British Medical Journal, 349. Retrieved October 9, 2020, from https://www.jstor.org/stable/26519046

Kirkpatrick, I., Sturdy, A J, Alvarado, N, Blanco-Oliver, A and Veronesi, G. ‘The impact of management consultants on public service efficiency’ Policy & Politics: doi.org/10.1332/030557318X15167881150799. 

http://www.bristol.ac.uk/media-library/sites/policybristol/PolicyBristol_Briefing_54_2018_management_consultancy_inefficiency_in_the_NHS.pdf

Begley, P., & Sheard, S. (2019). McKinsey and the ‘Tripartite Monster’: The Role of Management Consultants in the 1974 NHS Reorganisation. Medical History, 63(4), 390-410. doi:10.1017/mdh.2019.41

https://twitter.com/barry_halverson/status/1314255088874127360?s=20

 

Dear McKinsey and Company, Re. "The era of exponential improvement in healthcare?"

Re. Your article:

The era of exponential improvement in healthcare?

(By Shubham Singhal and Stephanie Carlto)

Technology-driven innovation holds the potential to improve our understanding of patients, enable the delivery of more convenient, individualized care—and create $345 billion to $420 billion in value by 2025.

Healthcare advances have delivered great benefits to society, bringing material improvements in average life spans and quality of life.¹ Yet these improvements have come at a cost—an ever-expanding portion of the US GDP is being consumed by healthcare expenses.² Could technology, enabling delivery of healthcare advances while improving affordability, be part of the solution? We have reviewed the evidence, done the math, and identified technology-enabled use cases that could create between $350 billion and $410 billion in annual value by 2025 (out of the $5.34 trillion in healthcare spending projected for that year³ ).

Read more ...

<>

But how would we recognise the era of exponential improvement in healthcare?

SELF - individual

|

INTERPERSONAL : SCIENCES

humanistic ----------------------------------------------- mechanistic

SOCIOLOGY : POLITICAL

|

group - POPULATION

The exponential benefits realised 'elsewhere' in global, local and glocal health and healthcare systems finally sees the achievement of parity of esteem with mental health not only fully funded, but designated as the key that must be turned 4 happiness. Despite the diametrical opposition of this domain to the political domain, there is a breakthrough in policy makers and the body politic prioritising "The Long Now"

"Predictions of an exponential increase in people living with dementia in the coming 30 years require evidence-based strategies for advancing dementia care and maximizing independent living. However, the evidence required to inform priorities for enabling improvements in dementia care is rarely presented in a way that stimulates and sustains political interests."  Martin, O’Connor, & Jackson (2018).

Community-based healthcare becomes  the norm and the educational, preventive and sustainable ethos for health and healthcare systems is adopted globally. Look at the readiness and response-to potential epidemic crises, plus  interventions in population health.  Exponential benefits are accrued. Evidence - look at the number of  (new) hospital beds. The community IS the market.

Exponential growth in global healthcare funding, health information for all, access to universal health care.  Social Determinants of Health not just a vision: but enacted and ongoing #SDoH-X. Evidence - climate change slowing, air quality improving - the 21st Century truly begins ...

Martin, A., O’Connor, S., & Jackson, C. (2018). A scoping review of gaps and priorities in dementia care in Europe. Dementia. https://doi.org/10.1177/1471301218816250

My source:
email - McKinsey Insights

Notes (II) for a 2010 introduction to the Health Career Model

... Where to start?

By its very nature as already suggested Hodges' model is difficult to explain. There are so many elements that demand our attention and so many avenues to run. Despite revealing one heading to be followed, Murphy (2002) describes how a theory of concepts is still elusive. From this we might focus purely on nursing and take a professional stance. We should be able after all to assume solid grounds for the system that supports nursing: namely nurse education. There is no need to do this as existing theories of concepts can provide a vehicle for explanation and research of Hodges' model.

Frequently acknowledged as a science AND an art, the individual-group axis in Hodges' model and the accent on communication makes individual and group psychology as much a pivotal source of knowledge as human anatomy and physiology. There are differences in the methods of verification, but the dependency is there and evident in the core nursing curriculum. Even though psychology remains a young science, resort to psychology is advantageous in other respects as the development of cognitive science and computer science can also inform our thought and research on Hodges' model. Fundamental to this is the basic form of the model construct the 2 x 2 matrix.

There are a great multitude of models that take this 2 x 2 matrix form. Apart from mathematics examples one the most commonly cited and influential is the so-called Johari window model of Harry Ingham and Joseph Luft which dates from 1955. Luft and Ingham were psychologists who created their model at the University of California, Los Angeles, while researching group dynamics. The Johari model has found a home in soft systems problems and can now be found in many other variations and one-off examples. There are whole books devoted to the subject of '2 x 2', an acknowledgment indeed of their utility and ubiquity (Lowy and Hood, 2004). From the OHP transparencies of old to the latest data projection forms, the 2 x 2 matrix is the tool of choice in the management consultant's armamentarium. This special cognitive device can also serve the local and global health and social care community.

Ref:
http://www.amazon.com/Power-Matrix-Thinking-Decisions-Management/dp/0787972924

The Power of the 2 x 2 Matrix - at Wiley

Additional links:

http://hodges-model.blogspot.com/2008/02/big-book-of-concepts.html
[ Murphy, G. L. (2002). The big book of concepts. Cambridge, MA: MIT Press. ]

http://hodges-model.blogspot.com/2010/02/notes-for-2010-introduction-to-health.html

Nursing management consultants & being optically challenged

Being somewhat optically challenged at present (need new glasses!) I have nonetheless managed to sort some old papers. I came across a more recent news item from the Nursing Times 8 September, p.3 by Sally Gainsbury. What use is late news?

I raise this now because public sector health finance provides the impetus, so this subject is perpetual motion. It is also reported ongoing by HSJ. I refer to this not to take sides, but to acknowledge that politically there is a need to make decisions and find the required £20bn efficiency savings. The news line reads:

DH told 1,500 district nurses could go with no damage to patient care

The item focuses on a report for the DoH produced by McKinsey management consultants. The government has distanced itself from the reports recommendations, but the need for action remains. The Nursing Times news item includes two clocks (with the total nursing time available depicted as 1 hour) that break down the time spent on patients on general medical wards and community wards. While this is just one aspect of a report of more than 100 pages, the findings are of great interest. ...

GENERAL WARD: 15 mins Physical care; 10 mins Psychosocial care; 35 mins non-patient care.
COMMUNITY NURSES: 17 mins Antenatal activities; 13 mins Postnatal; 27 mins npc; 3 mins other and classes.
I have not worked on a general or mental health ward for a long time, but I was surprised to see the time spent on patient being less on the wards than the community - 25 minutes v. 30 minutes. There are challenges in comparing different clinical areas, but I would have thought travel, administration - including paper and e-record data entry would impinge much more on community. On mental health wards there has been an effort to free nurses to nurse - with protected time? So pause for thought there - but only for a moment....

Thinking about community - providers will no doubt vary in the way (district) nursing teams are organized, the location of their bases and how that impacts average journey times. Districts also vary in the way the population is distributed, especially those neighbourhoods were social and economic deprivation is higher and need may be increased.

This is why access to GIS (geographical information systems) by team managers and members is crucial and should not just be some esoteric academic and intelligence artifact. While we should not under estimate the potential use of GIS to inform inpatient care, it is community services that are best placed to benefit from improved intelligence, planning and decisions.

There is a long thread here and the politicians of all parties know it leads into the forest ....

For example, much can be read in a single word "... McKinsey found that only 15 minutes was on the "physical care" of patients while the remaining 10 minutes went on "psychosocial" care, such as talking to patients." I hope that 'only' does not suggest that talking to patients is 2nd best, even though basic nursing care is the factor in the news regarding public perception of the quality of nursing care. This is a constant problem as we move to outcomes. Are we going to have patients saying - "The physical care was excellent, but I felt like I was in a religious retreat. Nobody hardly spoke, explained anything." Patient education, self care, staying well, the effective use of medication and treatment ... is predicated on psychosocial engagement.

What is also very troubling is that cost savings might mean detrimental changes in the skill-mix; the ratio of qualified to health care assistant staff. Some of the best 'natural' nurses I have worked with and work with today are dedicated HCAs. They have a major role and contribution to make, but if safety gains are to be maintained and improved upon then 'safe' skill-mix is critical.

Given the present demographic, 'nurses' are not new to cuts. In the public sector cuts are part of that perpetual motion I mentioned at the start. What frustrates is working on the holistic care mosaic to produce something that is safe, effective, quality care; then as we come to finally add the threads - clinical supervision, PDP, health IT, outcome measures, public engagement we have to unravel and start again.

Image source used with permission and thanks: D L Ennis. Visual Thoughts http://dlennis.wordpress.com/

20/20 vision minus 1, 2, or 4 blind spots....

Basic science classes very quickly introduce students to 'the eye' and vision.

This includes the simple experiment that can be done which reveals the blind spot.

Here's an example from (what was) Service Works Consulting:

Consulting companies pride themselves on knowledge, foresight and expertise. This is fine if there is only one blind spot to deal with, but of course we each have two. From the perspective of project management there are many more blind spots.

Hodges' model suggests there are potentially four;
five even if we include the spiritual domain.

A benefit of using Hodges' model* is that just as in normal vision our two eyes overlap and compensate for the blind spots; so attention paid to just one additional care domain may diminish the impact of care domain blindness.


3 out of 4 domains - is better (more holistic) than - 2 out of 4.

The problem in health and social care, is that any one of four blind spots (ironically the site of the optic nerve bundle) can become a fuse for trouble or disaster.

If you have the gift of vision - best to use it.^#
*cognitively or deliberately on paper or computer

Image source with many thanks: John Eric Hughes

Additional links:
Visual acuity: http://en.wikipedia.org/wiki/Visual_acuity

^#Wish I had and could do that!