Hospitals have leaned on wage increases and contract workers as short-term solutions to the nation's nursing shortage, but these actions fail to address many of the issues that are spurring nurses to leave the bedside for roles with better hours and less stress.
When it comes to bringing frustrated, disillusioned nurses back to the bedside, the solution is nothing less than a complete overhaul to the nurse's workday, according to Richard Shannon, MD, chief quality officer at Durham, N.C.-based Duke Health.
He said hospital leaders should start with a review of their clinical care delivery system and placing an emphasis on allowing nurses to do what they do best: care for patients one on one.
Leah Binder, president and CEO of The Leapfrog Group, pointed to Dr. Shannon's leadership, noting Duke Health has been "successful in rethinking the nurse's workday to ensure registered nurses are practicing at the top of their capacity."
With an eye on quality as well as process, Dr. Shannon shared his philosophy on how to improve conditions for hospital nurses, along with initiatives he said will have a direct impact on patient safety, experience and, ultimately, outcomes.
Editor's note: Responses were edited for length and clarity.
Question: There are so many priorities in healthcare right now. If you had the power to tackle one of them overnight and make real improvements, which would you choose and why?
Dr. Richard Shannon: We must work on redesigning clinical care delivery with the people who do the work. We are still delivering care the way we did 20 years ago. The main difference now is that we continue to add tasks to the front-line teams without taking any away. There's more and more documentation, more and more checks and balances, more and more pieces of work around maintaining safety. People are overwhelmed.
It's time we reimagine the care delivery system. Let's really look at our systems of care — what are the roles of the doctor, the nurse, the physical therapist, the pharmacist? Each of the people on every team need to understand their roles and their overall contribution to restoring a patient to good health.
Q: Where do you even begin to make the systemic changes you are suggesting?
RS: First, you must understand the work of the front-line team. At Duke Raleigh (N.C.) Hospital,we have watched and documented what happens during 12-hour shifts in 12 inpatient units. We found nurses doing valuable work only about a third of the time. The rest of the time they are doing work that has little value or is a complete waste of time.
For example, we found 30 to 35 percent of a nurse's time is spent documenting electronic management records. How valuable is that documentation? How does it advance a patient's care? Another one-third of a nurse's time is spent running around finding supplies, transporting patients and finding missing medications, among other time-wasting tasks.
We have to look at what's being done and eliminate the waste so nurses can spend more time interacting with patients and families. Delivering meds and wheeling people from test to test are required tasks, but do nurses need to do them? No. Nurses need to spend time face-to-face educating, consoling and teaching patients about their illness, their medications and discussing their recovery time.
We have to create purpose again in nursing work. If front-line leaders don't redesign the way nurses work, we will not get nurses to return to the bedside.
Q: Digging deeper, what's really at the core of the problem?
RS: Redundancies. You can make tasks priorities or you can add tasks to what nurses are already doing and make their lives more miserable. There is no time to do duplicative work. If you are not taking away value-less work or waste, you are not helping. In fact, you are disrespecting the professional and you are not acknowledging the time it takes to do everything you expect them to do.
For example, at Duke, there are 75 questions a nurse is supposed to ask when a patient is admitted to the hospital. How much of that information has already been captured in the emergency room? Why is the work being repeated? Why are we asking nurses to document what their colleagues have already done?
What's worse is that you often see a nurse frantically scribbling the answers to these questions and then having to spend time documenting them in the EHR. I highly doubt anyone's birthday, address, marital status or employment will change in a day. But, asking them how much their chest hurts — that's the kind of thing we need nurses to focus on.
Q: What is the biggest mistake that's been made in healthcare in recent years that set us on a path to where we are today?
RS: We have become infatuated with measurements. Everyone is so focused on measuring things but they are not focused on improvement. We have conflated measurement with quality. Just because you can measure it doesn't mean you should. And good measurements don't necessarily mean quality.
We spend a lot of time auditing and looking for documentation. Do we observe people doing the work? Rarely. The truth is that inspection after the fact is too late. Quality comes not from inspecting, but from improving the work process. All of the measurements are after the fact. We have to spend time intervening before something becomes a problem. Focus on the work process; that's where quality gets built in.
Instead of measuring everything, use a defect or event to drive improvement. Every fall, every pressure injury, every blood stream infection is an opportunity to make improvements in your process. Fix the standard if it's not delivering high-quality outcomes.
We need to stop wasting peoples' time with audits. Look at the work processes, not the documents.
Q: At the end of the day, with everything coming at them so fast, how can clinical leaders filter what's important through all the noise?
RS: Leaders must spend their time focusing on the development of their people, supporting their people and meeting their needs. The only way to do that is for leaders to get out of their office and go to where the work is done. You have to understand and see the barriers to the work nurses are being asked to do. That's the only way to understand how badly the front-line people are overburdened. Zoom meetings and planning sessions are no substitute for a leader going to see the work in action.
I challenge leaders to look at their calendars. Ask yourself, "How much of my time is spent with the people who actually do the work as opposed to time talking to my peers who all think the same way?"
The greatest waste is the failure to use the skills of our workforce.