Discursive practice - lean thinking, nurses' responsibilities and the cost to care

The Effect of Lean Hospital Practices on Nurses' Direct Care Activities: Time and Motion Study

BACKGROUND

This study investigates the effects of lean management practices on nurses' direct patient care activities and the interruptions they encounter in healthcare settings. The literature indicates that lean management enhances efficiency and improves patient care. Increased nursing time per patient correlates with better outcomes; however, rising patient loads and frequent interruptions hinder nurses' ability to deliver effective care, jeopardising patient safety. Addressing these inefficiencies is essential, given nurses' critical role in ensuring quality care.

METHOD

Using a single-centre, observational, pre-post time and motion design alongside participatory action research from August 2019 to July 2022, the study included three phases: a survey assessing nurses' views on problem-solving and lean management; observations identifying nurses' activities and interruptions; and focus group discussions. The results presented here are from the observation phase, with 34 nurses from surgical, internal medicine, and mixed services participating. Quantitative variables were expressed as means, standard deviations, and significance was assessed at a 95% confidence interval (p < 0.05).

RESULTS

Observations in 2019 (324 h) and 2022 (314 h) revealed that nurses dedicated a significant portion of their time to direct patient care, which increased post-lean implementation (surgical: 50.67%, internal: 50.09%, mixed: 44.38%). Waste rates decreased by 35.81%, and documentation time decreased by 23.55%. Overall interruptions also decreased significantly (p < 0.05).

CONCLUSION

Lean management effectively reduces waste and improves direct patient care time, enhancing patient safety and care quality. Continuous improvement initiatives in nursing practices are essential for success.

Indicadores de cuidado de enfermería hospitalario orientados por modelo de práctica profesional

Objetivo Diseñar y validar indicadores de cuidado de enfermería a partir de la orientación de un modelo de práctica profesional en un hospital universitario de Colombia, 2018 – 2021. Material y Método: Esta es una “Investigación metodológica en enfermería” desarrollada por fases: 1) revisión de los procesos de calidad institucional. 2) revisión de literatura sobre indicadores hospitalarios de enfermería. 3) propuesta de indicadores con orientación del modelo institucional de práctica profesional de enfermería 4) validación de los indicadores mediante criterio de expertos y 5) evaluación de la efectividad preliminar en campo durante 8 meses. Resultados: Los 21 indicadores de cuidado de enfermería propuestos presentaron alta comprensibilidad y validez facial, una razón de validez de contenido (RVC) entre .74 y .96, y un índice de validez de contenido (IVC) de 0.83. Conclusión: Los indicadores de cuidado de enfermería diseñados bajo la orientación de un modelo de práctica profesional y validados mediante el criterio de expertos, mostraron una efectividad preliminar positiva para medir y mejorar los procesos y resultado del cuidado de enfermería de acuerdo con las personas implicadas en la recepción y suministro de dicho cuidado.  Estos indicadores pueden ser empleados en hospitales con plataformas estratégicas similares.

Empowering or addicting? An analysis of the effects of team members–supervisor relationships on job satisfaction in healthcare

Patient-centredness relies on integrated care, which requires teamwork to be effectively implemented. Positive relationships between team members and supervisors are crucial to enhance health professionals’ satisfaction with their job and, consequently, to increase their commitment to organizational excellence. However, the positive effects of team members–supervisor exchange may dilute when the team is endowed with autonomy at work. The article proposes a moderation analysis aimed at collecting evidence of the implications of team members–supervisor relationships on job satisfaction (JS) with team autonomy (TA) as a moderating variable. Results of the study suggest that positive exchanges between team members and supervisors enhance health professionals’ satisfaction with their job. However, TA acts as a negative and statistically significant moderator. Good exchanges between team members and their supervisor seem to lose their positive effects on JS when health professionals are provided with a greater self-determination to accomplish their organizational activities. Tailored management interventions should be designed to sustain teamwork when increased autonomy at work is assigned to health professionals.

Nurses' Experiences of Care at Crisis Resolution Home Treatment Teams: A case study research

WHAT IS KNOWN ON THE SUBJECT?: There are many international studies on CRHTTs; however, there has been little research on nurses' experiences of working with CRHTTs. Earlier studies focused on the nurses' gatekeeping role but did not explore nurses' perception of care as a construct. WHAT DOES THE PAPER ADD TO EXISTING KNOWLEDGE?: This study provides information based on mental health nurses' experiences. It explains the home environment, the therapeutic relationship and the process of mental health nursing care during a crisis. Also, the study explains nurses' satisfaction with care provided at patients' home. Unlike other studies, this study focused on nurses' experiences while providing care, rather than on nurses' general responsibilities and the services they provide. This study is the first of its kind in Spain with such a focus. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Acknowledging nurses' experiences and their perspectives about the care they provide could help shift mental health nursing paradigms from those based on biomedical models to newer perspectives found in recovery models. Furthermore, this knowledge could improve the quality of care in mental health settings due to its potential to guide nursing practices. Raising mental health care providers' awareness of mental health nurses' personal and professional care constructs would help implement support systems to meet the professional's needs. Meeting the needs of nurses related to the care they provide is likely to impact patient care positively.

ABSTRACT

INTRODUCTION: Crisis resolution home treatment teams (CRHTTs) provide short-term, intensive home treatment to people experiencing mental health crises. There is limited research on nurses' experiences with CRHTTs. While earlier studies mainly focussed on mental health nurses' gatekeeping responsibilities, more investigation is needed in this field.

AIM

To explore nurses' perceptions and constructions about care in CRHTT services.

METHOD

A qualitative case study was employed. Ten semi-structured interviews were performed to nursing staff working in CRHTT services.

RESULTS

Three main categories emerged from the data analysis: nurses' perspectives of the care provided, nursing setting of care at home and nursing care plan at home.

DISCUSSIONS

Findings revealed that nurses experienced greater satisfaction providing care in the home settings, and therefore, it positively impacted the quality of care and reduced patient's stigma. This study also relates the value of developing care plans centred on patients' environments increasing Mental Health Nursing (MHN) work satisfaction.

IMPLICATIONS FOR PRACTICE

Knowledge of the intrinsic experiences of care provided by nurses in CRHTTs may help facilitate the development of the nursing role in CRHTT by improving understanding of care in mental health settings.

The relationship between healthcare service provision models and patient experience

Purpose

User experience is key for measuring and improving the quality of services, especially in high personal and relation-intensive sectors, such as healthcare. However, evidence on whether and how the organizational model of healthcare service delivery can affect the patient experience is at an early stage. This study investigates the relationship between healthcare service provision models and patient experience by focusing on the nursing care delivery.

Design/methodology/approach

65 nurses' coordinators were involved to map the nursing models adopted in the healthcare organizations of in an Italian region, Tuscany. This dataset was merged with patient experience measures reported by 9,393 individuals discharged by the same organizations and collected through a Patient-Reported Experience Measures Observatory. The authors run a series of logistic regression models to test the relationships among variables.

Findings

Patients appreciate those characteristics of care delivery related to a specific professional nurse. Having someone who is in charge of the patient, both the reference nurse and the supervisor, makes a real difference. Purely organizational features, for instance those referring to the team working, do not significantly predict an excellent experience with healthcare services.

Research limitations/implications

Different features referring to different nursing models make the difference in producing an excellent user experience with the service.

Practical implications

These findings can support managers and practitioners in taking decisions on the service delivery models to adopt. Instead of applying monolithic pure models, mixing features of different models into a hybrid one seems more effective in meeting users' expectations.

Originality/value

This is one of the first studies on the relationship between provision models of high-contact and relational-intensive services (the healthcare services) and users' experience. This research contributes to the literature on healthcare service management suggesting to acknowledge the importance of hybridization of features from different, purely theoretical service delivery models, in order to fit with providers' practice and users' expectations.

Highlights

This is one of the first studies on the relationship between provision models of nursing care and patient experience.

Healthcare services' users appreciate service delivery characteristics identified with “be cared by,” or in other words with having a reference nurse.

Nursing models' features that relate to the organizations and that providers tend to judge as professionalizing and evolutive, such as team working, appear not key in relation to patient experience.

Pure models of service delivery are theoretically useful, but hybrid models can better meet users' expectations.

Optimizing nurses' enacted scope of practice to its full potential as an integrated strategy for the continuous improvement of clinical performance: A multicentre descriptive analysis

AIM

This study aims at better understanding the relationships between nurses' enacted scope of practice, work environment and work satisfaction, missed care, and organizational indicators of performance.

BACKGROUND

The enacted scope of practice model describes the determinants and consequences of the actual enactment of the nursing scope of practice.

METHOD

A correlational design was used to investigate nurses' enacted scope of practice in five Canadian healthcare centres.

RESULTS

Suboptimal enacted scope of practice were found in the current sample. Significant positive correlations were found between the total enacted scope of practice score, use of qualification, control over tasks, decisional latitude and psychological demand as well as role ambiguity. Moreover, a higher enacted scope of practice was correlated with lower organizational indicators of short-term absenteeism.

CONCLUSION

Results suggest an insufficient deployment of nurses' enacted scope of practice, likely caused by some job characteristics, leading to lower work satisfaction and negative patients and organizational outcomes.

IMPLICATIONS FOR NURSING MANAGEMENT

Optimizing nurses' enacted scope of practice would be a significant integrated strategy for improving organizational performance, patient care and nurses' satisfaction and well-being. Nurses and frontline managers must be involved in the decision-making process necessary to improve nurses' enacted scope of practice.

Lean management in health care: a review of reviews of socio-technical components for effective impact

PURPOSE

The aims of the implementation of lean management in health care are to improve quality of care, to eliminate waste and to increase efficiency. The purpose of this study is to contribute to the advancement of knowledge by investigating which main socio-technical factors are considered to be effective for the implementation and management of lean initiatives.

DESIGN/METHODOLOGY/APPROACH

A systematic review of literature reviews on lean management in health care was conducted. The components of the socio-technical system are identified by moving from the socio-technical drivers that support organization-wide quality improvement practices and the lean implementation process in health care. The impacts of lean management are classified using the internal processes, patient, learning and financial dimensions.

FINDINGS

The 28 reviews retrieved confirm the current and increasing interest in lean management. While more than 60% of them call for a system-wide approach, system-wide implementations have rarely been observed, and, instead, adoption in isolated units or departments, or the use of single techniques and tools, prevails. The most commonly investigated socio-technical components are organizational structure, techniques and tools and organizational culture and strategic management. Significant impacts are reported for all the four dimensions. Nonetheless, the review reveals that there is still a lack of evidence on the sustainability of lean results and a need for a standardized impact measurement system.

ORIGINALITY/VALUE

This work stands out as the first review of reviews of how the socio-technical components of the lean management approach obtain positive impacts within the patient, internal processes, learning and financial dimensions.

Are data on missed nursing care useful for nursing leaders? The RN4CAST@IT cross-sectional study

AIM

To describe nurses' reported missed nursing care activities among hospitalized adult patients medical and surgical wards and explore gaps in service provision.

BACKGROUND

In 2015, Italy replicated the RN4CAST study, which heralded the exposition of missed care as an international phenomenon. In Italy, nurse-patient workload is high, with high levels of burnout and dissatisfaction reported, all factors associated with missed care.

METHODS

A cross-sectional study (n = 3,590) was conducted using the 13-item online Task Left Undone Tool aimed at collecting data on missed nursing care.

RESULTS

The frequency of omission of activities ranged between 7% and 50%. There were significant differences between morning, afternoon and night shifts and the various clinical settings. Oral care was the most frequently missed care activity.

CONCLUSIONS

This study takes step forward in identifying and reducing missed care on medical and surgical wards, both in Italy and also internationally, which needs to take into account the specific organisational characteristics of each setting.

IMPLICATIONS FOR NURSING MANAGEMENT

Although more essential activities are missed less frequently, much is known about the relational deficits such as information giving, education, communication and discharge advice, which managers ought to spearhead through local initiatives to improve these practices.

Factors influencing missed nursing care in public hospitals in Australia: An exploratory mixed methods study

BACKGROUND

Missed nursing care (MNC) is a significant health care issue that impacts on the quality of health care and patient safety. It refers to delayed or omitted aspects of nursing care (totally or partially). MNC is an under-researched area in the Australian health care context.

OBJECTIVE

This research sought to further explore the MNC phenomenon in the context of an acute care hospital and to identify its common elements and the factors influencing its occurrence.

DESIGN

A convergent parallel mixed methods design was employed involving secondary analysis of routinely collected hospital data and a survey of 44 nursing staff using the MISSCARE survey instrument. The two sources of data were converged to address the objective.

FINDINGS

The study found that the most common elements of missed nursing care include failure of patient ambulation, emotional support for patients and/or family, and the provision of full documentation. These elements are consistent with previous international studies conducted in acute care hospital settings. This study identified that local context impacting on MNC was also important and included interruptions to workflow, "perceived" lack of management support, poor handover, and communication breakdown between the nursing team and medical staff.

CONCLUSION

Consideration of the local health care context is foundational in understanding the MNC phenomenon. The findings of this research may help nursing managers mitigate the possible effects of MNC and therefore improve patient safety in their acute care environment. Additional multisite studies are required to further explore factors associated with MNC in both general and local contexts.