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

Documentation burden continues to be an issue.

June 18, 2024

“If it is not documented, then it is not done.” This expression is one that is commonly known amongst nurses working in direct care roles. Beyond this expression, is a need to recognize the value that documentation provides in care delivery.

As a nurse and/or healthcare professional, the responsibility one has is to provide the highest quality care. To do so requires accurate and accessible data and information about the patient.

Data and information about the patient needs to be entered into the record. That data and information must also be retrievable for effective use.

Two weeks ago, AMIA (American Medical Informatics Association) released results from a survey, TrendBurden, taken during the month of April 2024 with over 1200 respondents. In addition to nurses, physicians, social workers, educators, and other healthcare professionals participated in the survey. Details of the survey questions can be found at the above link. The responses were reported on a 3 point likert scale (Agree/Strongly Agree, Neither Agree nor Disagree, Disagree/Strongly Disagree).

Documentation burden may be seen initially as a health information technology issue. However, there are larger implications for the workforce. The questions asked in the survey include:

  1. The amount of time and effort I spend documenting patient care is appropriate. The majority disagreed that the necessary time to document patient care was appropriate.
  2. I finish work later than desired or need to do work at home because of excessive documentation tasks. The majority agreed that they work later or do work at home because of documentation needs.
  3. Recently, there has been a noticeable decrease in the time or effort or both needed for me to complete my documentation tasks. The majority disagreed that there has been a noticeable decrease to complete documentation.
  4. The effort or time required for me to complete documentation tasks impedes patient care. The majority agreed that documentation time or effort impedes patient care.
  5. I find it easy to document patient care using the electronic health record. The majority of physicians disagreed that documentation is easy while nurses’ responses were split between agree (38%) and disagree (38.5%).

Surveys are self-reported data from the users. Having their voices heard in this manner opens the door for exploration into finding ways to address these documentation burdens that continue to persist.

It takes years to become a healthcare professional and even more years to become an experienced to expert care provider. Those years cannot easily be replaced. However, technology can be created to support the workflows and the people who use them and disseminate those at scale.

I would encourage you to explore the responses for yourself here. The responses are broken into three categories of responses: All, Physicians, and Nurses. What I appreciate about this particular survey is the side by side comparison of responses between nurses and physicians (and then an aggregate).

~ Dr. Kelley

Tiffany Kelley PhD MBA RN NI-BC FNAP