E-mail marketing

Capturing nurses’ work

Introduction

In chapter five I described the physical environment of the medical and surgical wards and captured a typical working day for nurses in that setting. In chapter six I explored nurses’ concerns about being constantly interrupted and their need to increasingly mind other people’s business to the point where it affected the provision of nursing care. Nurses believed that the changes effecting contemporary nursing practice were still the aftermath of the health sector restructurings of the 1990s which were driven by a desire to establish a cost- effective competitive health care system. Guided by a doctrine of market demand and generic management, the quality of health services was assumed to remain unaffected (Arthur Andersen & Co, 1987; Ashton, 2002; Easton, 1999; Gibbs et al., 1988; Stent, 1998). By changing health care policies and funding, and introducing a competitive model of health care, the emphasis of the reforms was in particular on developing managerial structures that would control cost, to monitor input and output, and to allow productivity to be measured. While the main focus was on the macro structures of health care, far less attention was paid to the effects on service delivery at the individual (micro) level (Ashton, 2002; Devlin et al., 2001).

In this chapter I will explore in greater depth a number of developments which I have come to understand as residual impacts from the generic management decisions commenced in the 1990s. After discussing the effects of shorter hospital stays and increased patient turn-over (‘churn’) on nurses’ workload, I will explore TrendCare, a patient classification system that is utilised to manage nurse staffing levels, as well as the effects of standardised care plans on nursing practice. I contend that despite the change of focus in 2000, which sought to reverse some aspects of the previous reforms, the influence of generic management has not only persisted, but has shaped hospital services, the way nurses perceive nursing, and the way nurses engage in nursing practice.

Shorter hospital stays and increased patient acuity

The trend to decrease the length of hospital stay was a worldwide phenomenon and can be traced back to the 1980s (Ashton, 2002; Reinhart, 1996). In New Zealand this led to the health sector reforms of the 1990s with its emphasis on cost control and the implementation of generic management principles as described in chapter two. Statistical data gathering became an important tool to objectify the complexities of health care in an attempt to justify the change (Easton, 2002; Fagin, 2001; Rankin & Campbell, 2006). Hospital managers and administrators started to focus on admissions, discharges, and transfers to monitor bed utilisation, average length of stay and re-admission data. Results were not only used for comparisons in performance between hospitals, regions and even countries, but were in particular used to highlight where further savings could be made. In the United States the average length of hospital stay decreased by 40% between 1980 and 1995 (Reinhart, 1996). In New Zealand too the average length of time spent in hospital has declined significantly. According to the 2005 annual report (Ministry of Health, 2005) the average length of stay declined by 50% between 1988 and 2003. The drive to improve productivity is ongoing with the Ministry of Health setting targets for DHBs to achieve and publishing the outcomes in annual and public reports. Subsequent reports show that the average length of stay has continued to shorten which was attributed to less invasive surgical treatments, effective drug treatments, improved community (follow-up) care, and more effective hospital administration including bed management (Ministry of Health, 2010), and it is this latter aspect in particular that has a significant impact on ward nursing practice.

Bed management

Bed management refers to the management of admissions, discharges and transfers. Effective bed management is crucial for avoiding underutilisation and in ensuring that resources are used efficiently (Ministry of Health, 2010). Although limited prediction can be made about acute and unplanned admissions, for patients already in hospital, bed utilisation can be managed through the use of clinical pathways which serve as maps or care tracks that identify patient outcomes and expected treatment times (Forkner, 1996). Clinical pathways also referred to as critical pathways, care pathways, care map, and integrated pathways, direct and record key interventions, allowing for early detection of variance while at the same time setting milestones and goals to ensure timely discharge of the patient. The

ability of clinical pathways to contain health care cost by reducing length of stay and making better use of available resources has been a strong incentive for its utilisation as a managerial tool (Aspling & Lagoe, 1996; Gordon, 2005; Rankin & Campbell, 2006).

Clinical pathways are an objectified tool based on a virtual patient with a medical diagnosis or undergoing a specific treatment. It charts the trajectory from admission through till discharge (Gordon, 2005; Hunter & Segrott, 2008). The pathway is virtual and hence does not take into account the effects of any existing co-morbidities or personal circumstances that a real patient may have, but it sets clear indicators for treatment schedules and expects nurses and other health professionals to work accordingly to ensure timely discharge (Rankin & Campbell, 2006). Clinical pathways thus signal a change in orientation from hospitals being analogous to ‘railway’ stations, or places of rest, to hospitals being ‘trains’ where patients hop on for a scheduled length of time to receive a predetermined length of treatment before being required to hop off again.

During my observations in the field, several charge nurses referred to the tensions that exist between the needs of the patients for individualised nursing care and the institutional expectations to increase patient turn-over and efficiency. That patient turn-over is an important responsibility was evident as charge nurses attended special meetings, the so called ‘bed meetings’ to discuss admission and discharge

figures, look at and compare statistics, and obtain an overview of how the hospital and/or the wards were performing. Absorbed by admissions and discharges and the management of the ‘here and now’, charge nurses are in a difficult position. On the one hand, as the most senior nurse leader in the ward, charge nurses ought to support, guide and motivate staff, give clinical advice, and create the conditions where nurses are able to work as individuals and within a team to deliver professional nursing care. On the other hand, as ward managers, charge nurses are accountable towards hospital managers and administrators for efficiency gains, for achieving admission and discharge targets, for managing allocated ward staff, and for remaining within budget. One of the charge nurses described her role as

‘challenging’ due to balancing her role as clinician and manager. This excerpt was selected because it best demonstrated the pressures placed on charge nurses to keep patient turning over:

I feel as a Charge Nurse a bit like the meat in the sandwich. You have got this constant pressure. The biggest pressure in the day is to get patients discharged and to get new patients in. That is a constant, from the minute you get to work. The first thing I do in the day: “Who are the discharges? Who are we going to get out? Who are we getting in?” Then you move on

and you look at roster: “How many nurses have I got? Who is off sick”?

And then you just move on through the day. (Linda, stakeholder)

Patient ‘churn’

Contemporary hospitals focus on efficiency of services and bed management. Patient ‘churn’ refers to the constant movement of patients, both through admissions and discharges as well as between wards and treatment areas (Duffield et al., 2007). Two decades ago most patients would not be discharged home until they had recuperated from their illness or treatment. Nurses were caring for patients along a wider scale on the ill-health – wellness continuum, from newly admitted acutely ill patients to patients who required only minimal input while awaiting discharge. Because of the spread of patients along this continuum, nurses’ workloads were not as heavy and appeared to be better manageable. However, the drive for efficiency and increased productivity, which was at the centre of the 1990s health sector reform, has resulted in significant changes in the way hospitals are run and the way nurses are required to manage their work (Aiken, Clarke, & Sloane, 2000; Dingwall & Allen, 2001; Parker, 2004; Rankin & Campbell, 2006; Weinberg, 2003).

Nurses frequently mentioned the impact of patient churn on work flow. Nurses were much busier as they had to arrange for patient transfers to and from other wards, taking patients to or collecting patients from treatment departments, as well as all the ‘waiting around’ that accompanied such activities. The effects of patient churn on nursing workloads, including admissions and discharges, is considerable and should not be underestimated (McWilliam & Wong, 1994; Unruh & Fottler, 2006). Present day hospitalised patients are sicker while the shortened length of their stay has increased the nurses’ workload (Norrish & Rundall, 2001; Unruh, 2003). The increased complexity of care and the increased use of technical equipment has resulted in today’s medical/surgical patients being the equivalent of the ICU patients in the 1970s (Benner et al., 2010). Gordon referred to this increased intensity of nursing as ‘heightened patient acuity’ as more needed to be accomplished over a shorter period of time (2005, p. 258).

Patient churn also increases the workload in less obvious ways. For example, the patient allocation board might indicate at seven o’clock in the morning that nurse X has been allocated five patients for the day. By ten o’clock two patients are discharged while two new patients are admitted early in the afternoon. The board still indicates that nurse X has five patients yet the true accumulative workload is seven patients which is not reflected in the workload. Unruh and Fottler’s (2006) research demonstrated that workload calculations based on nurse - patient ratios are inaccurate by underestimating the true workload of nursing staff.

In this study senior nurses Jolanda, Madeleine and Kim, with long professional careers in hospital nursing, expressed concerns that nurses spent less time at the bedside even though patients were sicker than in the past. They noted that patient care had become much more focussed on performing tasks such as administering medication, measuring vital signs, or providing physical care while virtually no time was spent attending to patients’ psychological, social, or cultural needs. Nurses in this study reported feeling under constant pressure to free up beds for new admissions. Their concerns were also confirmed in a passing comment by one of the nurses with whom I went to morning coffee; "It becomes a rare phenomenon to see a nurse sit at the bedside. To be honest, I cannot remember when I last saw that".

Olga, a registered nurse of 15 years has worked in a variety of wards as staff nurse and charge nurse. Being a clinical nurse specialist for a number of years, she too has noted the effects of high patient turn-over. Olga maintained that contemporary nursing is characterised by high intensity and a less personal approach to patient care.

I think the throughput of patients is so much more rapid. We are constantly up to full capacity so there is not that downtime, if you see what I mean. Patients are acutely ill uhm.., and gone are the days when they could stay in for another week to rest before they went home. So there doesn’t seem to be that let up of capacity and patient condition. Uhm.. so I think that has an impact on the way we work. Everything is always in a rush these days cause there is not the time and I guess the personal touch is not there as much as it used to be uhm.... (Olga, stakeholder)

Routinisation of care

Olga’s notion that the personal touch has been lost was confirmed by my own observations in the field which showed nurses being in perpetual hurry, running from one activity to the next with very little time left to care in a more holistic way for patients. The combination of high patient turn-over and the influence of clinical pathways contributed to the routinisation of nursing care. I became aware of this at the early stages of my research when I intended to explore the role of health assessment in clinical decision-making. Participants maintained that the workload was too hectic and that there were not enough hours in the day to be able to assess patients. Quite a few nurses labelled the observations of vital signs as the main assessment activity and argued that there was little need for additional assessments as that would cross into medicine. There was a belief that patients were over-assessed as many members of the multi-disciplinary health team would routinely ask similar questions to complete the required standardised documentation; ‘patients must get sick of all the questions repeated time and again’.

While observing clinical practice I noticed that the nursing assessment document was seldom completed fully. It was not uncommon for parts of the assessment form to be completed by the nurse in the office without the patient being consulted. On such occasions the nurse gained the data from other notes without confirming the accuracy of it with the patient. Generally the nursing assessment documentation was filed in the patient’s notes, and hardly ever re-looked at. I mentioned my findings to Kim and asked her for a response.

That comment made me smile, that it is just filed and we don’t go back to it. I have heard that comment from a lot of people. So I am sort of quite bemused that they say they file it. I guess, they have no ownership of it or find it of no value. I find it bizarre that nurses sit in an office and do it, because traditionally that is the one bit of paper you take to the patient and do it with the patient. With the majority of nurses there is no connection from a nursing assessment to a nursing care plan, to the progress notes. I think in some nurses’ minds there is a sort of linear perception, that you start at this point and your end point is that. (Kim)

As it was difficult to find out more about nursing assessment activities while observing nursing practice, I focused my questions around ‘decision-making’ on the assumption that this would lead me back to assessment but it did not. Nurses felt that care delivery was very much standardised and that it required mainly ‘routine

decisions’ based on protocols. Indeed, it can be argued that when nursing decisions are based on set routines and protocols rather than individual patient needs, patient assessment loses its value.

Quite a lot of them are routine decisions. Here in this hospital, as you know yourself, there are many protocols and usually if you’re having some trouble making a decision, there’ll be a protocol to tell you what you should be doing anyway. I think on a day to day, we make fairly basic and routine decisions that we are well-trained to do. (Kitty)

In the hospital environment they are very much routine decisions. Cause usually it is pretty much, you know routine. Whether they are gonna have a shower (laughs), do they need blood sugar levels, it is stuff, it is the same stuff different day. (Sonja)

The above comments highlight the effects of high patient turn-over and clinical pathways which led to a type of care best described as ‘conveyer belt’ health care nursing where set routines mark expected patient progress. Although nurses did not mention so much the concept of clinical pathways, their replies very much indicated that patient care followed a strict trajectory with most if not all nursing interventions being routine practice. The voice of medicine was strongly represented as any discussions concerning the patient’s care were framed in medical jargon and centred on medical diagnoses.

Reviewing my data, I gained the impression that nursing interventions considered most important concerned the administration of medications and monitoring infusions while the bulk of the remaining tasks mainly related to physical care which needed to be done as a matter of course. While nurses sometimes referred to the concept of holistic nursing, they often did so in terms of emphasising the discrepancy between the ‘ideal situation’, what they would like to do and what was actually done. The patient as a person was rarely mentioned apart from the aim to achieve discharge by a certain day. Nurses followed protocols and talked about what happens to patients on ‘Day One’, ‘Day Two’ and so on. As Sonja noted nursing is routine, decision-making is routine. Nurses do ‘the same stuff’ as

yesterday, today, every day, ‘the same stuff’ just a different day or different patient.

By following the routine nursing practices, Sonja and her colleague nurses contribute to the structures of the ward even though they may not have had any part in establishing these routines in the first place. Giddens (1987) concept of the duality of structure is applicable here; as routinisation becomes more and more

normalised it becomes less likely that any individual nurse will find the discursive space in which to imagine practice differently.

While in the vast majority of cases clinical pathways worked well in terms of achieving early discharge, observations in the field also provided several situations where adhering to clinical pathways resulted in inappropriate discharge. One such situation concerned an elderly woman who lived by herself and was admitted following a fall in which she sustained a fractured left wrist and right elbow. With both arms in plaster casts she was substantially incapacitated yet she was prepared for discharge that day. The patient was anxious and expressed concern about her ability to manage. During the two days that she had been in hospital she required assistance at meal times and with hygiene care and she wondered how she was going to cope on her own. The nurse felt anxious too that the patient was perhaps not ready for discharge but did not share her concerns with the patient. She continued the planned discharged, reassuring the patient that she would be alright. However, later that morning she did go into the office and shared her concerns about the patient’s ability to manage at home on her own, with three