What if…?

July 08, 2026

“Lunch?” I heard my co-worker say to me one Friday around noon. A few of my coworkers were headed to get lunch at a nearby sandwich shop, and I was being invited to join. I was sitting at my desk, deep in focus on one of many design document spreadsheets.

“What?” I said as I turned my head toward him with a bit of confusion. I was relatively new to the role and working in IT. I had come from working on the inpatient floor as a nurse. I did not understand the question. I said, “We can do that? We can leave and get lunch?”

Here I am over 20 years later, and for some reason I find myself reliving that moment in my mind. My question and response may seem bazaar to someone who has not worked in clinical care. Some may even think ‘why would you not be able to leave and go get lunch?’ However, I know that any nurse (and/or other healthcare professional), understands this all too well.

To have the opportunity to eat lunch is not a given across the profession. In fact, taking 30 uninterrupted minutes to sit and renourish one’s body over the course of a 12.5-hour workday, can feel like a luxury to a nurse. Nurses learn this incredibly early in their careers. Yet, this is a cultural experience of our profession that does not need to occur.  

We, nurses and healthcare professionals, create the systems (e.g., processes) that are necessary to deliver care for patients. Those systems should be designed to support delivering quality care for patients AND the responsible nurses and healthcare professionals. To effectively deliver care for patients, we need our nurses and healthcare professionals at their own optimal operating capacity and capability. Being able to eat lunch over the course of 12.5 hours is part of that optimal operating capacity and capability.

Unfortunately, there is often an underlying or unspoken belief that the need for a break to eat, or even use the bathroom, is a sign of weakness. You are not strong enough if you cannot power through the day without eating or taking a bathroom break. Yet, we will teach our patients how they need to do the exact opposite to care for themselves. Now, looking back 20 years later, I can see how that is a belief and/or cultural expectation that needs to shift.

Time to Shift that Mindset.

Nurses are humans too. I mention the topic of lunch because it reflects a persistent blind spot (at best) within the profession. Over the last few years, I have seen an increase in attention and promotion of encouraging self-care and burnout reduction strategies. However, we continue to see that one of the more basic needs that could be met (lunch) is often left up to an individual to manage (e.g., find a way to make it happen), rather than an organizational system or process set up to support any and all nurses on a given day.  

The need for organizational systems to support nurses extends beyond far beyond lunch. There are many other areas where nurses work around challenges. Finding equipment, finding answers, finding resources, and finding linen are just four areas where nurses are continuously searching for something to work through the next step in the process of care. Yet often each one of these ‘finding’ steps takes up valuable time. So, the nurse is challenged to take that time or create a workaround, to cut that lost time down.

What if nurses did not have to look in every room and closet for a piece of equipment?

What if the linen cart was always stocked enough?

What if the meds were always in the med room when you were due to give them?

What if the ID band always scanned and lessened the risk for an override or late administration? (Better yet, what if it was not an ID band, but rather a biometric)?

What if you did not need to rush through discharge patient education?

These are just a few examples that I believe many, if not most, nurses who work in direct care can relate to, in terms of areas where you either lose time or do not have enough of it in a day.

I believe these “what if” statements are possible. However, these require more than the bedside nurse. These need system support to create processes that ensure they work well for all involved. (This also includes lunch).

In the age of the growing uncertainty of AI’s place in our lives, there are some areas where technology can assist in these ‘What If’ statements. None of those ‘What If’ statements posed would eliminate the need for a nurse. Instead, such tools would be what we hope technology can be: a tool that meets a specific unmet need.

I’d challenge you to consider your own What If. What would it take to make that thought a reality in the day to day?

Views from the Patient Side

November 24, 2024    |   , , ,

“I am going to have you sign the consent form.”

I heard this while checking into my Primary Care Provider (PCP) appointment a few weeks ago. When I go into a healthcare appointment, I am always looking around for opportunities to improve on the patient experience. However, I never expect what I do encounter.

This visit had been rescheduled and I was happy I got into my PCP within a couple of weeks of making the phone call! The receptionist checked me in for my appointment. She then told me I needed to sign the consent form.

I looked down and there was no paper nor any form of a device for me to see the consent form. I thought she would have given me something to read in either a paper or electronic form.

I asked, “Where am I signing this?”

She pointed me to the pen pad for signature. I realized I was not going to see the consent form before signing it.

I asked, “Can I read the consent form?”

Now I know in general what I expect to see in the consent form. There is language about HIPAA, Consent to Treat, Payment Responsibility, and more. However, I also know that I should have the ability to read the form before I sign and acknowledge that I read it.

The receptionist got up and got a master copy from a folder and gave it to me to read. I then asked if I could get a copy. She did print out a copy for me to take with me after I read and signed it.

Had I not asked, I may not have read it nor had an opportunity to get a copy to take with me.

Now, I do not think that the practice aims to not provide the consent forms. More than likely, the intended workflow has slowly eroded over time from what is expected to occur.

As a patient, you cannot change the workflow, but you can (and should) ask questions!  

Lost Time is Costly for Nurses and Patients

November 05, 2024

Approximately 10% of the time during a nurse’s shift (e.g., workday) is spent on workarounds [1]. Workarounds arise due to systemic inefficiencies or barriers that complicate the ability to complete an activity needed for care delivery. Between 65 to 80% of nursing shifts are 12 hours in length. With 10% time lost to workarounds on a 12-hour shift, this equates to a total of 72 minutes (or 1.25 hours) per nurse lost to operational inefficiencies.

The median hourly wage for nurses across the United States is $41.38 [2]. Many states have a starting hourly wage higher while others lower than this rate. However, consistently across the U.S., nurses are not recognized as a billable service. Instead, nurses are (unfortunately) recognized as a cost to a healthcare organization [3] despite research evidence demonstrating the positive impact of nursing care on improving patient health outcomes [4].

Hospitals are broken into different care units and areas. I worked on a medical care unit, a medical/surgical unit, and a cardiac step-down unit during my years in direct care practice. I worked at three pediatric academic medical centers across the United States. As a bedside nurse, I was responsible for as few as 3 to as many as 6 patients per shift. The number of patients assigned depended on the severity of the patients’ collective care acuity needs and the staffing norms of the unit.

If we use the assumption that there are 8 nurses working on a patient care unit per shift, and each nurse is losing 72 minutes to inefficiencies, the unit loses 576 minutes or 9.6 hours per day! Now, with two shifts per day, that becomes a collective 19.2 hours lost to workarounds per patient care unit.  A total of 19.2 hours times the average hourly wage of $41.38 per hour equates to a total of $794.50 per day per patient unit. Applying that daily cost to a full year equates to $289,992 of lost time per year for one patient care unit.  Each hospital will have many units. If approximating one hospital to 10 care units, the cost then becomes $2.89 million in time lost over the course of the year. The average salary for a nurse in the US is $89,010. Thus, this equates to the cost of 32 nurses per year.

Now, these are general assumptions made about the number of nurses per unit and number of units per hospital or health system. However, the fundamental opportunity exists. How can nurses obtain 10% of their time back with the help of system (e.g., organizational) level changes while also helping to save costs of nurses that are not there (e.g., 32 nurses per year for example) There are many opportunities to do so. However, such help must be a collective effort between leadership within the healthcare organization and the nurses who are experiencing these challenges in care delivery.

[1] https://pubmed.ncbi.nlm.nih.gov/25102517/

[2] https://www.bls.gov/ooh/healthcare/registered-nurses.htm

[3] https://www.wolterskluwer.com/en/expert-insights/shifting-the-payment-paradigm-for-nurses-and-why-direct-reimbursement-is-critical

[4] https://www.nursing.upenn.edu/live/profiles/93-linda-aiken

Caring for Oneself while Caring for Others

October 17, 2024

I was eager to become a nurse and help other people. My mother has shared with me that even as early as pre-school, I was eager to help others in the classroom. Fast forward a few decades, and the desire to help others continues in a variety of ways. While I am no longer in direct patient care, I have always felt that the roles that I have taken on have been with the purpose of helping other nurses and healthcare professionals.

As a nursing student, you learn how to care for others. You are trained on how to assess another person across all body systems while also applying the science of nursing to the care delivery process. From nursing diagnoses of knowledge deficit that often apply to most if not all patients, to something more specific that applies to the admitting diagnosis for the patient, nurses are continually thinking about how to improve the health of others.

Yet, over the last several years, I have had the opportunity to reflect on caring for oneself while also caring for others. I realized that in many ways, I had to learn how to care for myself. I had spent so many years thinking like a nurse and putting the needs of others ahead of my own. “I would be fine”, I would often think to myself. Whether it was cutting corners on sleep or exercise, or other areas, surely the other person needed that time more than I did.

Today, I see the limitations in that thinking pattern. I am not a machine nor are you. Even if we were, machines need downtime to recharge and full the battery again or be upgraded with the newest updates and fixes to the software platform. Vehicles need gas or an electric charge to run.

Why would we not think that we also need that time to recharge, reboot, upgrade, and more simply put, care for ourselves?

We are soon approaching 2025. The last five years have been both long and fast in terms of seeing time pass us by. In the last 5 years, I learned how to care for myself and I will continue to do so while also caring for others. You can accomplish both.

I have found this has started with one small act of caring for myself on a regular basis that turns into another and another. Over time, you begin to see the results of those self investments.

I encourage everyone to consider ways they can reflect on what it means to care for oneself and know that this can be done while also caring for others. For nurses, this may require a new person to focus on, yourself.

Sincerely,

Tiffany Kelley

Resilience, Linen Carts & Syringe Pumps

August 25, 2024    |   , , , ,

What is the role of resilience in being a nurse? 

I believe I am a resilient person. I also believe that my resilience has been as a result of challenges that I have overcome over the years. Recently resiliency came up in conversation in the context of nursing practice.

The U.S. Department of State describes resilience as, “the ability to successfully adapt to stressors, maintain psychological well-being in the face of adversity. It is the ability to “bounce back” from difficult experiences.”

To be resilient means that you have had to adapt and adjust to adversity. 

While I agree with this as a beneficial and often necessary competency in the context of innovation, intrapreneurship, and entrepreneurship, I am hesitant to see this as an entry level competency for a new nurse entering into clinical practice. 

Let me explain through two commonly experienced unnecessary inefficiencies in nursing practice. 

The first is the linen cart. 

In direct care, one of the first responsibilities that you have is to assess each patient. This is often done at the start of each shift. 

As part of that assessment, I, and many others, would take the opportunity to change the bed linens. This would take me to the linen cart that is on the unit. 

Each unit has at least one linen cart. There, I would locate a top sheet, bottom sheet, pillow case, gown and some towels and washcloths for the patient to have in the room.

However, on many occasions, I would run into an issue where one or more of these items would be out of stock. So, I would need to come up with a solution, a workaround, if you will. 

I could not enter the room without a pillow case or a gown when I have all of the other items. That would make no sense and look very strange to the patient. (How could the hospital not have enough?, one might think). 

Instead, I would run to the adjacent unit and grab the missing linen items from the cart. I must have done this at least once a shift. Not once did I think about the fact that it would leave their cart short. Not once did I think that there was another solution to this challenge. Not once did I think of sharing this with my nurse manager as a challenge that could benefit from a larger solution. 

Instead, I was focused on how much I had to do and how this challenge of missing linen was slowing me down from the more intensive care needs that needed to happen for that patient and all others. I also would get more and more frustrated as this seemingly small challenge would build over time with the other small challenges. 

The Second involves Syringe Pumps

Another small challenge is the ability to easily access a syringe pump for medication administration. 

The patients I cared for often required frequent IV medications for their treatment plans. Some of these meds required a syringe pump technology to infuse the IV medications. 

The syringe pumps are hard to find in a care unit. Some are in use, while others are often scattered around the unit. The challenge is in finding one when you need it because there is rarely (if ever) a surplus. Instead, these items often feel scarce. 

As a result, I, and others, would anticipate the need for these pumps and try to locate them in advance of needing them for our medication administration time. If lucky enough to find one, we would put them in a drawer in an empty room, if one was available, and pull the curtain a bit with hopes that no one would come looking for that pump before you need it. 

What a workaround, huh? 

I never thought anything of this practice other than I needed the syringe pump. I never thought to ask that we could use a better way to find and store syringe pumps. I thought this was what it was and I was having a hard time accepting the culmination of these small challenges that built up over time. 

Did I develop resilience from these experiences? I am not sure. I do remember developing great frustration in being able to be a good nurse. 

I talk about these workarounds as clues of innovative opportunities for system level solutions. 

In the context of innovation and intrapreneurial mindsets, you can see how the workarounds can be used to inform the solutions. 

Resilience

However, what if we work to solve these workarounds and relieve some of this pressure nurses face each day? 

Should we be building resilience in nurses because of these inefficiencies that could be solved with some creative thinking, resources, time, and a commitment to better? 

Does resilience truly need to be a skill we develop in the context of the work environment? 

Would it not be better to leverage the challenges nurses face in providing complex care to patients at an individual level as the better source of building resilience? 

I do see the need for developing resilience as an innovator, intrapreneur and/or entrepreneur.

I use these two examples in talks that I give as clues of innovative behaviors and opportunities to solve at a system level. However, to solve for these inefficient workarounds, leadership must be a part of the innovative development process and implementation effort. 

If new nurses walked into these care areas and never knew of the linen cart or syringe pump workarounds, that would be a good thing. That would demonstrate progress in shifting away from a culture of workarounds. In those cases, the resilience is not needed and that energy can be placed to the care intended that required those items and tools, rather than on finding the items to deliver care. 

So, I leave you with a thought provoking question, “what if we were able to reimagine and recreate work environments that focused on the needs of the nurse rather than teaching nurses how to be resilient in the work environment? Would that not be an amazing thing for the nurses, but also the patients?” 

Read more from Dr. Kelley on Know My Voice

Access to information does not always equate to value

June 30, 2026

Have you ever been in a store that just had too much to look at or look through? Perhaps you went to dinner at a restaurant where the menu could be a book with dozens of options. In both examples, there is just too much to process and find what you are looking for at that moment in time.

We are entering an age where you will hear, “it is all available online”. “Just ask <insert the name of the preferred LLM (large language model)>.

However, having something available via a short prompt does not necessarily make it meaningful nor address all information needs. Instead, you must create the meaning behind the data, information, knowledge and wisdom.

Lawrence Weed wrote “Medical Records that Guide and Teach” in 1968, published in the New England Journal of Medicine. Here we are in 2026, nearly 60 years later, and reading that historical referent holds true still today.

What does this mean? We still have more work to do in order to ensure people have the right information needed for their healthcare experiences.

Where is the roadmap?

March 15, 2026

I was asked this question, “Where is the roadmap?” a few years ago from someone who is not a healthcare professional. We were in a conversation about nursing and healthcare in general. I was explaining a bit about the culture in nursing and healthcare from a nursing experience. I have had far more nursing experiences than patient experiences. However, these are very different experiences.

To be a patient requires that someone has found a healthcare provider (e.g., doctor, nurse practitioner, nurse, phlebotomist, etc.) to receive some form of care. Before this happens, one is a person in need of care. However, how do you find it? How do you find the care that you need from the best person and/or organization that can deliver it?

While there are multiple pathways, the short answer today is ‘it depends’.

A logical first step is to search providers in network with one’s health insurance company, (if one has health insurance and/or a directory to search).

From there, one will receive a list of names that may say, “Accepting New Patients” or “Not Accepting New Patients”. One can then filter out the “Not Accepting New Patients” and work from the “Accepting New Patients” list. However, then one is making choices based on information that may or may not be available. This entire process could be enough to delay or stop some from getting to the initial appointment.

Another option is to take to a search engine or what now many are likely using, generative AI models, to provide responses. Yet, one cannot truly know if that healthcare professional is the best person for them without an initial appointment or consultation. The bedside manner, practice and/or organizational standards, wait times, responsiveness, supportive technology, trust, success rates, and more can all impact this experience. Sometimes, whether a person selects a provider or not has nothing to do with the condition or reason for visit that makes or breaks the next step on the healthcare roadmap journey.

If one is lucky, they may know someone who can provide the best name and/or be referred by someone else. However, this is not something available to everyone.

Yes, there are a few emerging companies working to provide these matches. However, this is just the beginning of the healthcare experience. What does one do when they have passed the entry point? What is one to expect? What questions should be asked? What should they know? What could be learned on the side of the patient? What is expected of the patient but not clearly communicated to the patient?

Now, the healthcare experience is not one that can be prescriptive as each person has different clinical and personal needs for care. However, we do not have a consistent onramp for anyone to know how to navigate what could be the most important decision that one could make around who to see (or not see) for a specific healthcare concern.

Patient-centeredness is one of the six parts of quality care. To be patient-centered is to provide care that addresses the individual needs of the patient to make decisions for optimal care outcomes. Being both a nurse and a patient at times, there is great opportunity to increase the voice and experience of the patient within the care experience.

~ Tiffany Kelley PhD MBA RN NI-BC FNAP FAAN


“We’re going old school… analog.”

March 05, 2026

Every Thursday night at 9pm EST, I tune into the latest episode of The Pitt on HBO . The Pitt is the most realistic medical show (from my perspective) in my 25 years as a nurse and healthcare professional. As you watch, you almost forget that Dr. Robbie is really Noah Wyle, an actor, instead of the Chief ER (Emergency Room) Attending MD of your hospital.

In last week’s episode, The Pitt is under a potential ransomware cyberattack. As a preventative measure, the IT systems are all shut down within seconds of the ER staff hearing about this unplanned downtime.

You see Dr. Robbie announce to the ER staff, “We’re going old school… analog.” Below is a 55 second clip of that part of the episode.

As I watched that episode, it brought back memories of the exact opposite: transitioning from paper to computers.

Now, many of you reading this may have never worked directly from paper based medical records. However, that was the standard of practice for decades up until the 2000’s when there was an effort to digitize patient records across the United States.

Due to the complexity, cost, resources, and several other factors, federal incentives were needed to move the digital health needle forward. This occurred through the HITECH Act (Health Information Technology for Economic and Clinical Health) Act and the EHR (Electronic Health Record) Incentive Program.

Yet, such transitions from paper to digital platforms were less than easy to do. Additionally, many were just as hesitant to digitize as they are in this clip to turn to paper based records. Significant training and preparation (after years of development efforts) was necessary for each healthcare professional that needed to interact with the new form of a patient chart.

Now, we see this sense of fear in the staff of The Pitt on how to effectively care for their patients without any significant warning that the systems would be offline. [This is called an unplanned downtime… the name alone should tell you that no one favors these offline breaks].

Imagine what that would be like to have no data on any of the patients if all of it is digitized… you would feel a myriad of emotions as many depicted in the clip above. However, there are downtime plans that are created for just these types of situations. Additionally, IT teams are behind the scenes working to bring the system up as quickly as possible.

Hours and hours between many meetings and discussions review how to support staff in clinical care situations when an unplanned downtime occurs. As a result, you do not need to have someone on shift like Dr. Joy with a photographic memory to recall all of the details on the digital board. Instead, you need to know the procedures to gain access to the downtime reports.

Whether health records are digital or paper based, this episode depicts how essential access to patient data and information is in order to effectively provide patient care.

~ Dr. Kelley

People are humans, not algorithms.

February 26, 2026

People are complex. Every healthcare professional knows this and is trained on how to assess a person. That assessment is for the purpose of evaluating the patient’s health status. However, that assessment extends into how to approach that person as well. Every person is an individual that has nuances beyond the diagnosis that is given or being ruled out at that time. Every person knows when they are being treated as an individual versus a diagnosis. They may never say it to you, the healthcare professional. However, having experienced being treated as both a patient and a ‘reason for visit’ myself, I can tell you that they (e.g., patients) know. That differentiation between being seen as a person over a diagnosis is what makes the difference for that person’s experience in that setting and perhaps healthcare overall.

Now, here we are in an elevated landscape around how to maximize technical product scalability coupled with a daily reminder that AI is coming at us fast (if not already here). In my 20+ years in this field, I have always advocated to have the tech meet the needs of the person rather than having the tech drive how the person works. This may sound nuanced but when in the throes of care delivery, you know instantly when it interferes with how you want to work. This is still an ongoing challenge as healthcare is complicated. I say that and those that are not in the field may think, “how complicated could it be?” Far more complicated than you would imagine I would say.

Are there opportunities to reduce the complexity? Absolutely and yes please! However, this must be done with an understanding and appreciation for who is at the center of healthcare delivery and that is people, not the technology. People are humans, not algorithms. People can benefit from algorithms that are designed to meet the needs of human. This is a critical distinction that must remain in the forefront of our minds as healthcare becomes more digitally integrated with care.

~ Dr. Kelley