Marie Manthey’s Nursing Salon

A recent dialog among Creative Health Care Management (CHCM) consultants resulted in an internal communication I have decided to share with the blog.  As always, your comments are welcome.  (Also…how do you like the new look?)

This communication about Relationship-Based Care started with a question from Mary Koloroutis via email within our company.   

From Mary to all Consultants: 

An issue that continues to surface in the RBC Leader Practicum and in some interactions I have with nurse managers and unit practice council members is that as much as they would like to implement a primary nursing model of nursing practice, that the acuity, staffing realities (ratios and schedules), and the geography of the unit, create huge barriers to their getting there.   How are client managers addressing this?

Jayne Felgen, president of CHCM, sent this reply: 

From Jayne Felgen to Mary, copied to all consultants: 

It IS the HEART of  RBC…accepting a responsibility relationship for the patient’s care throughout their stay on that unit is the ultimate expression of professional practice.

I’m naming it and claiming it! So, the work of the Unit Practice Council is to review current scheduling and assignment practices (Work Complexity Assessment) looking especially for fragmentation reduction opportunities…to make it more likely that the nurse who agrees to perform the admission activities might also chose to be the primary nurse.

So, like an attending physician retains responsibility despite multiple consultants, or her/his day off, so do nurses create an infrastructure in which they claim responsibility for 1-2 patients among their typical assignment. Once those responsibilities are “owned”, the nurses communicate in more deliberate ways, proactively, more precisely…not unlike a parent leaving explicit instructions for the sister who’s caring for the kids while parents have a get-away. When they return, they resume care. While they’re gone, they’ve anticipated every possible need.

Having said that, 100% compliance with this may be impossible, but, we urge them to shoot for it because it’s the right thing to do. And, using Appreciative Inquiry (AI) principles, learn why it worked when it worked, and then do more of that.

Until we accept this responsibility at this level, we’ll continue to ignore the crazy schedules (1 day on, one off, 8-10-12 hour shifts reporting on/off to each other, robbing Peter-to-pay-Paul floating practices, being married to geography rather than relationship, and other craziness that produces high variability and low professional reward/satisfaction in our systems.

I am abundantly clear that we must step up and claim our practice…not by tasks or shifts, but one relationship at a time…nurses, therapists, social workers, pharmacists, etc. It’s the professional v. technical dialog again.

John Nelson — nurse researcher, president of Healthcare Environments and CHCM adjunct faculty —  frequently shares data with us about the outcomes of our work with our clients. One hospital implementing Relationship-Based Care found that a richer skill mix decreased the dollars per Adjusted Patient Day, decreased ventilator-associated pneumonia and decreased patient falls with injury. John would hasten to add that this is a statistical correlation that does not indicate causality, but only a relationship between variables. I think the more we learn how to interpret and correctly discuss this kind of statistic, the better able we are to explain the importance of adequate staffing.

After the “reengineering” of nursing in the nineties (which had nothing to do with nursing, and everything to do with saving money), we lost sight of simple truths and replaced our authentic experience with “grids” which supposedly save money but which in reality wreak havoc with common sense.

Some truths we need to reclaim are:

• Skill mix should be related to acuity not to a financial goal.
• Changes in patient census should drive changes in total FTEs.
• Continuity of assignment increases productivity (having the same patients two days in a row increase productivity by approximately 25%).
• Use of support staff improves when delegation is based on trust. Working together builds trust, so pairing and partnering leads to the best use of NAs and LPNs.
• Staff should only be ‘pulled’ off their home unit when not to do so will have DIRE consequences. It should never be done just “balance the numbers”.
• Morale of the staff determines quality of care. Morale is a function of how staff members treat each other.

Introducing Relationship-based Care is an excellent way to re-introduce these simple truths and return our profession to “common sense management”.

Jean Harry, in reaction to my post of July 28th,  feels that the term “ratios” is troublesome:

You can make a ratio out of any two things, but it doesn’t give any hint to the complexities or potential affect on the outcomes. There must be a better way to describe how intertwined all of this is. People latch on to ratios because it’s concrete, but it minimizes the important stuff. Staff mix is another area of struggle. Not only in terms of RN/LPN, but mix of RN’s with differing educational preparation. In Vermont, the number of both LPN and ADN programs & graduates outnumber BSN. We are creating new issues on top of those we already have.

I agree that the “ratios” is misleading….and that the variety of entry points into practice is increasingly confusing. We need to analyze work complexity in terms of knowledge and skills needed for safe Nursing Interventions in a particular patient population that are sophisticated enough that also take into account the workplace relationships that impact utilization of support staff. I think that by going back to the basics over and over again (knowledge and skills coupled with effective interpersonal relations)….rather than trying to differentiate by broad credentialing, we will be able to see the forest for the trees.

For example, when an LPN works as a care pair or a care partner with the same RN over a period of time, his/her contribution to the RN’s workload changes substantially. Likewise, coupling a new AD or BSN with an experienced clinician rather than having them work straight nights significantly increases the speed with which they get on board.

Personally, I like the structural clarity that comes from licensure delineations to guide differentiation….. and this leads me to my current absolute conviction that the major difference between RNs (of all types of preparation) and LPNs (and other skilled technicians) lies in the decision-making role. RN’s are licensed to make decisions about the amount degree and kind of care patients will receive. Period. No one else has the license to do so. When we step up to the plate and incorporate that in job descriptions, work expectations, nursing education, etc….I think the role of support staff (and appropriate skill mix for any unit) consequently will be clarified. inally, nursing is a practice profession and RN’s need to be able to combine care-giving with care management in order to acquire the complex knowledge about their patient necessary for good decision making

Finally, I guess the diffusion of educational programs (now with the post-baccs, practice doctorates, etc) increases the challenges we will be facing in the coming years. I hope that by focusing on knowledge and skill requirements for patient care, within the structure of licensure healthy workplace cultures, we will have the guidance necessary to maximally utilize the knowledge, skill and talents of every member of the staff. I am optimistic that if we keep focusing on what is right for patient care, what is fundamentally sensible and legally appropriate; we will be able to minimize the confusion of the future challenges to resource utilization.

I’ve been thinking a lot about this issue of staffing and time use, and I think we need to develop new terms to express a new way of thinking about staffing and time use. 

I’ve been thinking a lot about this issue of staffing and time use, and I think we need to develop new terms to express a new way of thinking about staffing and time use.

I’ve expressed my concerns about the universal “staffing mindset” elsewhere, most notably in a speech “Changing the Staffing Mindset.”

We need to be able to pragmatically talk about various workload issues. A set of differentiated situations with clear criteria or standards will make it easier to do this. Some of the factors that need to be considered are benchmarking statistics, unit culture, interdepartmental cooperation, level of leadership skill at the managerial level, interpersonal relationships among the staff, patient turnover (length of stay). There are probably several others, but those are the one that occur to me immediately.

The differentiation could look something like this:

• The Under-Budgeted Unit. By all objective comparative measures, this unit falls short of like units in terms of budgeted positions. The staff feels constantly overwhelmed, despite having effective leadership and good teamwork. Quite often units in this category have bed sizes over 30 and rapid turnover of patients. Larger units require a higher staff/patient ratio because of increased indirect time spent in communication and coordination activities.
• The Understaffed Unit. This unit’s budget is okay, basically similar to that of other like units in other hospitals. However, many positions remain unfilled. This may be due to an overall shortage of nurses, a high turnover rate (perhaps reflecting nurse dissatisfaction with the heavy workload created by empty positions), ineffective leadership, unhealthy interpersonal relations among the staff, or to a myriad of other problems.
• The Inappropriately Ratioed Unit. On this unit, the FTE budget is fine, unit-based work complexity analysis is needed to determine the correct skill mix based on knowledge and skill requirements of those specific patient populations. Whenever skill mix is driven by dollars rather than acuity, the opportunity for an inappropriate combination of RN/LPN/NA is likely. Skill mix adjustments should be made on basis of findings.
• The Appropriately Funded, Staffed and Ratioed Unit. Basically budget and staffing are good on this unit, but workload variation causes frequent peak workload situations, lasting from hours to weeks. Intermittent (unpredictable) workload peaks that last hours and occur several times a week should be addressed in two ways:
  1. Nurses need to have permission to decide what to do and what not to do when there is more work to do than time available and additional resources are not feasible.
  2. Peaks that are excessive (too frequent or lasting for days or weeks) need to be addressed through staffing. Many hospitals are offering innovative part-time (such as 4 hour) jobs that specifically cover routine peak workloads. Another approach is to use travel nurses especially when the peak is seasonal or temporary based on remodeling or other types of unit transitions.

The primary solutions for the first three descriptors are usually a leadership or managerial responsibility. These issues need to be addressed in a timely way, supporting the staff using whatever means are available, from travelers to float pool to intensive recruitment/retention actions.

In all four categories, nurses need to learn the strategies of real-world prioritization, they need to be able to draw a bottom-line and consciously decide not only what will be done and in what time frame, but also what won’t be done. The subterfuge is that if a nurse prioritizes well enough, everything can get done. This is simply not true. Everyone (administrators, physicians and nurses) needs to acknowledge that truth.

Intermittent peak workload issues should not be addressed with efforts to add resources. Usually by the time this type of adjustment is made, the peak is over and now everyone is frustrated — the unit that had to send help as well as the unit that didn’t get the help when it was needed. Perhaps being careful to define “peak workload” issues as being materially different than other staffing problems will be a first step to changing the way we think about staffing and workload. We need to stop the “all or none” thinking that results in staff nurses universally feeling like there is never the right amount of staff for the normal workload. I am convinced this “never enough” thinking is what leads to the fear and anger the average staff nurse today experiences regarding staffing.

Rather than expecting additional resources to fix a “peak” we should practice Smart Care (as opposed to Total Care). Smart Care is the result of entrepreneurial thinking. Nurses who practice Smart Care stop trying to do everything. Instead they consistently sort, prioritize and choose the most strategic activities to meet the patients’ goals as well as the medical and nursing goals.

I know if I said this in a speech before an audience of nurses, many would get angry, and some would probably walk out. And yet, it is a statement I believe to be true. Not all nurses. Not in all work situations. Not all the time.

But over my many years in the profession, I have seen the restraints that handicap our role expansion and have envisioned the contribution nurses could make to the health care of society if those restraints were removed. The realities I call restraints are both internal and external. Some are imposed by regulations designed to protect the job security of others, as well as the job security of nurses. Some are in place because of historical precedents not yet dissolved….precedents like inadequate education, cost constraints, physician-nurses role delineations disputes, and the sexual discrimination still somewhat prevalent in today’s society. Some of these are so big, and are kept in place by such powerful forces, they seem insurmountable.

Others are restraints of our own making. These include a pervasive reluctance/fear to accept responsibility for ourselves, our practice and our interpersonal relationships. They include a ‘within the profession’ reluctance to assert the right of control over nursing practice by virtue or our license. They include a willingness to work in environments that are dysfunctional….without either fixing the problem or leaving the work setting. They include an incredible tolerance for ‘within the profession’ disputes about solvable problems like entry level educational standards and proper utilization of support staff (including Lens). Enormous amounts of energy is dissipated at the highest levels of professional development on issues that require strategic and tactical decision making among various interest groups within the profession. Decisive action in these areas, (while probably not agreed to universally) would still have the power to restore energy to more productive uses.

What do I envision? For openers…the lack of continuity at the system level patients suffer from could be solved by developing procedures for call-backs to patients homes. Not all patients, not all the time….but always a decision of a responsible nurse whether to do so or not. I can envision a role for RN’s that includes time for ‘looking at the big picture’ and exercising real coordination/cooperation among specialties in highly complex situations. This can be done by providing appropriate technical support staff. I can envision nurses partnering with physicians (or other primary providers) collaborating in decision making, along with empowering patients to participate/own health care decisions. I can envision nurses creating support structures for non-nurse care providers that both educates them in the techniques of patient care and also supports them emotionally

I am a partner in a company that has software for healthy people to track their own health care data…..and set goals under the guidance of an advanced practice nurse. The employees enrolled in our program have significantly fewer major health problems, and cost their employer much less for health care.

We are so bogged down in task performance…so diminished by our sense of self-worth…and so willing to abdicate responsibility for what we are licensed to do…we haven’t taken the time to lift our eyes…envision a new future…and learn how to play together to create a world here nurses are having a major impact on the health of society and are manifesting health lives ourselves!

For years, we’ve expanded or contracted their roles based on the supply of RNs (and the money to pay them). As a group, few have contributed as much, or been valued as little as these folks. In my opinion, there is no doubt that we need skilled technicians to act as assistants to RNs. Why? Logic dictates that with today’s acuity levels we need more skilled technicians than patient care aides. When RN energy is consumed with clinical activities, it is not available for the professional work of nursing. Making decisions about the amount degree and kind of nursing care a patient will receive, in the context of a therapeutic relationship with the patient.

This is what RNs are licensed to do. The license does not say RNs have to give 100% of the care tasks patients receive…but is does say we are the only care providers in the whole system with specific responsibility to make decisions about nursing care. And yet, this is the activity most often given up in order to perform tasks. This is the activity most often given up in order to ‘fix’ a system problem with dietary…or with lab…or with pharmacy…etc. etc.This is the activity most often given up in order to do almost anything else. Albeit some tasks require the high skill level of an RN. Others however are routine or of lower skill level. And yet, often regardless of staffing levels, the exercise of professional authority regarding the amount degree and kind of nursing care a particular patient will receive is on the lowest rung of any RNs work-priority rating.

The pressure to perform tasks and to ‘fix’ system problems is almost overwhelming. The pressure to accept professional responsibility for managing the care of a patient is totally underwhelming. No one asks about nursing decisions. Everyone asks if the tasks were performed and documented.  Job descriptions are even silent about decision-making!

You may ask “What does this have to do with LPNs?” My answer is “If I were a chief nurse today, I would hire well-trained LPNs to work in partnerships with experienced RNs!” When this is the arrangement, LPNs can safely contribute high-quality, highly -skilled bedside care to the maximum of their ability within the framework of effective delegation. RNs as senior partners can contribute to deliver bedside care, and have the time and energy to evaluate individual patients and decide on the amount and kind of nursing care they will receive. We have seen the benefits of well-designed and well-executed partnership systems. We have also seen that often logistical problems exist in terms of union rules, schedule preferences or employment practices. These are problems that need to be solved in order to create staffing paradigms that will benefit patients today and the profession tomorrow. As long as RNs are running around performing countless tasks in high-pressured environments, nursing will not develop as a profession.