In the fast-paced, complex healthcare environment, nurses do whatever it takes to manage patient care – despite the risks.
Hospitals are stressful places to work, especially for nurses who are on the frontline of patient care.
High patient acuity, a myriad of documentation and operational tasks and technologies that truly do not support the workflow of nursing, are just a few of the burdens on today’s nurses. The time and information needed to make complex decisions required for safe care is often inadequate.
Existing technologies, such as complex electronic health record (EHR) systems and outdated hospital communications devices, frequently hinder rather than streamline workflows.
In order to achieve their goal of providing optimal patient care, nurses may rely on manual processes and workarounds that are prone to error and may even violate hospital policies, standards of practice or privacy laws.
Understanding the difficulty of delivering nursing care is essential for making changes that effectively promote healthy work environments that lead to improving patient safety.
Increasing Complexity of Nursing
The workload of providing patient care has dramatically increased in the last few years for a variety of reasons, not the least of which has to do with healthcare reform and declining reimbursements. In 2013, the Bureau of Labor Statistics reported healthcare job creation had slowed down to its worst pace in a decade as hospitals sought to cut costs through wage reductions, layoffs and buyouts.
With cuts to staffing, nurses not only have heavier workloads, but are also responsible for more patients than before. The Agency for Healthcare Research and Quality reports that the number of nurses is expected to grow by only 6% by 2020, while demand for nursing care is expected to grow by 40%.
While there are no national requirements for specific staffing levels, many hospitals measure nursing hours per patient per day as a way to monitor quality of care. Overwhelmed with tracking human resources, equipment and medications, as well as documentation requirements, many nurses spend less than two hours of a 12-hour shift in direct patient care.
Taken together with shorter lengths of stay and increasing acuity levels, today, hospital nurses take care of more patients who are sicker, so not only are the workloads heavier but also more complex.
In addition, researchers have reported additional factors that challenge nurses while delivering care, including frequent cognitive shifts and interruptions. Studies have indicated that the average time nurses spend on one task is only 3.1 minutes, yet during that time nurses are interrupted mid-task eight times per shift.
Toll of Stress on Safety & Quality
With unpredictable changes in their daily work routine, expectations from patients and their families, on top of the stress of emergent care needs and end of life issues, nurses can experience work-related psychological disorders such as post-traumatic stress, burnout syndrome – characterized by emotional exhaustion, depersonalization and lack of personal accomplishment – depression and anxiety.
A recent survey indicated that fatigue leaves many nurses concerned about their ability to perform safely, with two-thirds of nurses reporting they had nearly made a mistake at work because of fatigue and more than a quarter saying they had made a fatigue-related error.
The challenging workload not only impacts job satisfaction but also adversely impacts patient safety and satisfaction. Medication errors, such as omission, wrong dosage and infusion rates, are among the most common mistakes that lead to longer hospital stays and drive up treatment costs.
The Institute of Medicine (IOM) reports that these errors injure 1.5 million Americans every year at a cost of $3.5 billion in lost productivity, wages and additional medical expenses. In addition to medication errors, research has also shown that lower staffing levels are linked to an increase in patient falls, infections and even death.
Managing Cognitive Workloads
Sound clinical decision-making requires the ability to focus and prioritize care under all situations. This mental listing process, called stacking, is a continuous workflow management strategy that enables nurses to create a hierarchy of tasks based on criticality.
This hierarchy then informs the order of care. Its effectiveness depends on nurse’s powers of observation, deep understanding of the patient care process, and therefore improves over time as a nurse grows in experience. In the absence of technology-enabled workflows, nurses turn to taking notes on scraps of paper – their “paper brain”- to help them remember the myriad of details to attend to and document before the end of their shift.
With heavy workloads, nurses often don’t have enough time to collaborate and communicate with other care team members as well as patients and families. It can also leads to deliberate violations of rules, policies or procedures – otherwise known as workarounds – that frequently happen when nurses are under time pressure or high workload because of emergency situations.
For example, one study found that more than two-thirds of nurses use their personal mobile phones to support clinical communications and workflow, despite hospital policy restrictions, raising concerns about HIPAA compliance and data breaches.
Rather than rely on manual processes that are prone to error, the solution to managing cognitive workload and creating a healthier work environment is to implement technologies that can streamline, automate and reduce the complexity of nursing workflows.
Case for Mobility
Consider how technology supports the workflow of healthcare management staff. Everyone from executives to line managers carry a smartphone with them at all times. In addition to communicating via phone or texting, alerts such as calendar reminders help keep them on schedule for the next meeting and let them know who is available to meet.
The devices have auditory, visual and kinetic notifications as well, with ways to delay reminders for another five minutes if necessary. If you were to ask anyone if they would be willing to do their jobs without their smartphone, the answer would most likely be “no.”
Nurses and other hospital-based clinicians however, are told to check their smartphones at the door and revert to 1980s technology. Reminders and notifications from the EMR are great.just as long as you are in front of a computer. For example, how do nurses or respiratory therapists get notified of a new medication order?
The next time they log-in to a computer which could be 5-30 minutes from the time of order placement. With computers on carts and desktop solutions, nurses may log in and out of these system up to 100 times per shift depending on workflow design. Documentation at the point of care is still a goal we are working towards.
Technology solutions should support nursing cognitive workload, rather than hinder it. As hospitals and health systems increasingly adopt EHRs, there is a growing need to balance between delivering quality patient care and documenting that care on stationary systems that were never optimized for point-of-care nursing use. Leveraging mobile solutions that match workflows and capture patient data at the point of care is the best option for obtaining precise, comprehensive, consistently collected data.
Nurses need choices in the methods of communication that include secure, encrypted texting and email. There also needs to be clinical context around communication in order to properly identify the patient. Use of pictures should also be part of the available communication methods even if they cannot be uploaded to the EHR.
Mobile technologies that use a combination of wireless communication devices, remote sensors and computational algorithms to identify the user, location, availability and preferred method of contact can provide contextual information to clinicians, enabling them to monitor, collect and process data such as vital signs in real time. Such applications can also be integrated with a knowledge system or rules engine that can identify the most appropriate recipient of a message and escalate alerts. Rather than limiting nurses to secure text messaging, mobility also delivers synchronous messaging through voice and video conferencing capabilities.
Lastly, having a single device strategy is critical when it comes to designing workflow that supports clinical workload. Many clinicians are justifiably tired of dealing with multiple devices to accomplish patient care and communication activities.
More Time for Patients
As the complexity of nursing increases, clinicians need more sophisticated tools to help them do their jobs.
Mobile technologies and applications that can capture and transmit data, as well as facilitate communication, are increasingly needed to streamline workflows, increase productivity and improve patient safety.
Mobile technologies not only help nurses with patient identification, medication management and documentation requirements, it also helps ease the physical and emotional stress of nursing by managing cognitive workloads, giving them greater control of their schedules and workflows, and allowing them to spend more time in direct care of patients.