Gemba: The Real Place (17 mins)

Did you hear about the redesign of the nurse manager role at Advocate Health? This episode discusses the six insights gleaned from three simple questions that just might save the nurse manager role.
Key Points:
-Ask the frontline
-Mutual goals
-Critical mentorship

References:
-Twenter, P (Oct. 21, 2024). Advocate redesigns the nurse manager role. Becker’s Clinical Leadership. https://www.beckerhospitalreview.com/nursing/advocate-redesigns-the-nurse-manager-role.html.
-American Association of Colleges of Nursing (AACN). (Oct. 2022). Nursing Shortage Fact Sheets. AACN News & Information. https://www.aacnnursing.org/news-information/fact-sheets/nursing-shortage
-Incredible Health. (March 16, 2021). 34% of Nurses Plan to Leave Their Current Role by the End of 2022. Inside Incredible Health. https://www.incrediblehealth.comwp-content/uploads/2022/03/IH-COVID-19-2022-Summary-1.pdf.
-Kennedy, M. (Jan. 29, 2018). Experienced Bedside Nurses: An Endangered Species? Off the Charts: Blog of the American Journal of Nursing. Retrieved Nov. 30, 2022, from https://ajnoffthecharts.com/experienced-bedside-nurses-endangered-species/
-Kennedy, M. Nurses at the Bedside--Who Will Be Left to Care? AJN, 118(2), 7. https://www.doi.org/10.1097/01.NAJ.0000530224.10340.d1/
-Lohrenz, C. (2014). Fearless Leadership, 2nd ed. Greenleaf Book Group Press.
-Phillips, David et al. (2010). Christmas and New Year as risk factors for death. Soc Sci Med, 71(8). 1463-71. https://www.doi.org/10.101/j.socscimed.2010.07.024.
-Tarlengco, J. (Nov. 21, 2022). Gemba Walk: Meaning, Process, and Examples. Safety Culture. https://safetyculture.com/topics/gemba-walkTwenter, P (Oct. 21, 2024). Advocate redesigns the nurse manager role. Becker’s Clinical Leadership. https://www.beckerhospitalreview.com/nursing/advocate-redesigns-the-nurse-manager-role.html.

Transcript

Surveys of the nursing workforce reveal that two-thirds of the workforce plan to quit: one-third plans to retire from the profession, and another third plans to quit by the end of the year. I’ve heard a lot of recommendations for hospitals in particular to offer more benefits like wellness programs and educational opportunities to reduce turnover, but I think those interventions miss the mark. Frankly, the solution does not fit the problem of staff retention: It’s like saying that there’s no way to improve the nursing role, but we’ll help you get out if you put in your time.

I have watched the nursing role absorb a variety of ancillary roles over the years while, including environmental services duties, tech support, machine repair, respiratory therapy, unit secretary, and physical/occupational and speech therapy. It seems like every staff meeting includes some new duty that the nursing staff will need to absorb because their role is the most vague and it seems like a good idea to cut the support staff rather than the clinical staff. But at some point, the clinical staff starts to break because there is no one left to help and the expectations are only increasing. Those expectations need a check and balance. The CNO - the chief nursing officer, and the chief medical officer need to have a voice when it comes to workload decisions. We need to sit down and look at what tasks can be cut and how can the changing workload be balanced across other departments. Even a computer will crash if the load is not balanced. Why do we think human beings will never fail from being overworked? Why would we say that it’s a personal failing if they can’t handle it? At some point, we need to see workload balance as part of patient safety and that adding extra steps to a problem isn’t really solving the problem.

The poor nurse manager is especially overwhelmed with daily audits and a constant staffing shortage, and they never seem to get the chance to consider how to help their staff thrive. I reported previously that Sanford health had a solution where they used artificial intelligence to offload some of the staffing burden, and I applaud them for trying to find a solution that could potentially decrease the manager’s workload. And I think we need to look seriously at whether our demands for data are helping or hindering our workforce--there is so much data available, but not everything that can be measured should be measured all the time. I remember spending the time I could have been turning my patients printing out sheets of paper to check off whether I turned my patients. With our healthcare data lakes becoming data oceans, it’s time to be more thoughtful about documentation, audits, and data usage as the amount of data is only increasing, and the workforce cannot carry that load without support. 

In addition, I also saw a lot of nurse managers who just had no training on how to manage employees, and this was a place where the ones who had some training in business or education could excel because they had some coursework on how to be empathic leaders, how to manage their own defensive response when voices started to raise, and how to affirm or counsel their employees in an effective manner that brought positive change. Since the board of nursing asks for coursework to focus on the field a nurse is working in, these topics are not always taught because they cannot always be applied to the license. But I think it can be really beneficial in managing an unstable team to have some training on interviewing, counseling, conflict resolution, and risk management.

Why do people become nurses anyway? In an informal survey of my peers in nursing school and on the job, most of us chose to be nurses because we took care of a family member when they were ill and found it to be incredibly meaningful work, or because a family member was a nurse and we admired their knowledge, integrity, and compassion.

Well, I noticed an article in Becker’s this week featuring some fantastic solutions implemented by Advocate Health. While I cannot believe it has taken this long for someone to implement these kinds of ideas in real life, I feel hopeful seeing it happen today.

The problem they identified is that Nurse Managers had become a dying breed. Lots of people try on the role and quit within weeks. But Advocate Health asked why.

You see, hospital administrators often hire HR Recruitment companies or add some other bureaucratic role to do the dirty work of finding out why no one will work in a certain role. Often, those experts seek feedback from the experts on-site – the directors and VPs – to find out what they’re looking for, and the recruiting teams often do not look below their rank to ask what’s going on. So the lonely manager may have a director or VP that assumes they understand, and it also becomes a chance to take shots at a competing director that they just don’t like, and the manager is left out in the cold again. However, Advocate Health did a gemba walk of sorts. 

Gemba rounds come from a methodology in lean manufacturing for quality improvement. Gemba is Japanese and means “the real place,” and the idea is that the administrators should walk where the work is actually done and ask open questions. The goal is not punitive--in fact correction is forbidden because it shuts down the conversation--but the purpose is just to observe where the real work happens and learn about the process. 

This is a great tool for the hospital environment, and it would be great opportunity to mentor nursing staff if they have questions. I also found that when I started working with a large online team with several managers and a large group of employees, we did something similar: We took turns checking a secure open forum where anyone on the team could ask a question (and there were no dumb questions). Then the on-duty manager would respond in a timely manner, and it was kind of like making a Gemba round because we found out a lot about the real process and experience that employees were going through. It also meant that during the weeks we were not on-duty we could focus on our own projects without interruption, but the week we were monitoring the forum we could become more in-touch with the real work that the team was doing and provide support. 

I think if administrators took turns in a secure online forum to answer questions from new managers, like “do I have all the information I need to post this position?” or “do we even have this type of service in our facility?” it would be a profound relief to new managers who are trying to grow into the role. 

So while the gemba walk is a basic quality improvement activity where you walk around and talk to the people who are affected by your decisions, the Advocate Health version was in the form of a simple qualitative survey, which is incredibly cost effective. They asked:

·       What do you do that you shouldn’t be doing? (I love how transparent that question is)

·       What do you like to do? (this implies that it matters)

·       What’s taking up your time? (the cut-stupid-stuff technique can work wonders)

Then they analyzed the data somehow – and as I noted in my previous podcast, this is a fabulous place to use artificial intelligence solutions to analyze text and pull out themes – and their analysis revealed 6 categories that caused problems for managers. Let’s take a look at those top six needs:

1.     Defining scope and span of control. I’ve talked a lot about the problem of vague roles and this survey hits it on the head. What are the managers responsible for? Are they decision makers in these areas? Who really reports to me? This is a great observation.

2.     Managing pace of change. While pace is a great point, I think just inviting the managers to the table on implementation planning is going to make tremendous progress for managers.

3.     Minimizing the burden of onboarding. Again – excellent. Why is the manager with a license and advanced degree doing the pre-hire paperwork and copying their BLS cards?

4.     Elevating nurses to practice at the top of their licenses, which meant eliminating tasks like filling out equipment repair requests. For a long time, there has been a trend of eliminating help and shoving the leftover tasks on nurses. If this is implemented effectively, it will improve care as well as retention, because specialists in equipment are better qualified to report problems in equipment, for example. If they really do this, you’ll see decreased cost on equipment because a nurse will more likely order new than deal with something repairable.

5.     Reviewing the audit processes to reduce unnecessary paperwork and verify that it has a positive effect if it continues. Again – thank you.

6.     Strengthening partnership between nurses and the support department.

One of the improvements they made was to create a manager relief program. Boy, I like the sound of that. It was a sort of “float pool” for nurses who are interested in trying out the manager role on a temporary basis. Previously, the remaining managers were expected to manage an extra department if someone was on a Leave of Absence or when a position was unfilled. This way, nurses could experience management to see if it was a good fit, and the managers remaining could coach them rather than take over all the work. Advocate reports that this intervention has been very successful and that they believe it better supports frontline managers, where they have seen a stabilization in staffing and turnover rates.[1]  Honestly, this idea of providing mentors for newbies and ensuring adequate support for leadership with the float pool model sounds tremendously helpful to me.

I love that Advocate has tapped into the issue of vague roles. We often escalate the use of vague language in an effort to cover more work tasks, but the problem with a vague job description is that you never feel like you’re doing a good job when you don’t know what the goal of the job is. Carey Lohrenz, the first female Navy fighter pilot, talked about this in her book Fearless Leadership, stating that without a clear goal the mission is dead in the water. She writes, “when the seas get rough, the vision allows you to navigate the challenges and come out ahead.”

Another issue clouding the role definition is that the recruiters who are in charge of finding the right person for the role are unfamiliar with the work, and managers will not see a candidate unless they check all the boxes in the computer’s algorithm first. So flexible candidates with extensive experience may be passed over because they are unfamiliar with a particular electronic health record, for example. So the search for nurses is highly specific but the role itself is broad, and I think that probably needs to flip, where employers search for a broad pool of possibilities during an worker shortage, and the description of the job is reviewed to become more highly focused with outcome-based goals.

Advocate is also spot-on in identifying collaboration with other departments as a high-need area since so many of our colleagues from other departments have been trimmed to bare-bones staffing and had drastic changes in their procedures. With so much change, it makes sense that some of those tasks will need to be reviewed to determine what’s necessary and who else could help.

I just hope that Advocate will look at bedside floor nursing next. With most nurses are leaving bedside nursing within two years, combined with a looming demographic cliff where the working generation is smaller than the generation needing their care, the healthcare workload will need to adapt and balance in the midst a population surge -- and we have not yet seen the true impact of that demographic cliff in the hospital.

This demographic shift can result in a general lack of experience on the unit as well, as skilled professionals retire and new nurses are leaving after a whopping two years of service. Suddenly, there is a lack of mentors for the inexperienced nurses. If the most experienced nurse on the unit only has two years of experience (a level considered competent but certainly not expert), how much will they be able to help the new nurses? And having a mentor isn’t just a warm and fuzzy emotional perk -- there are a number of studies that show inexperience is associated with medical errors, so giving our new nurses an expert resource is something we all should be concerned about. From a quality perspective, we need to get ahead of this knowledge gap and be proactive about it.

I had some terrific mentors—Elaine, Phany, and Mary in particular--helped me by reviewing my assessments to make sure I didn’t miss anything before calling the doctor. I had so many questions about how they could just tell if a patient was going to worsen, and they patiently talked me through new skills and situations, like my first chest tube removal or the first time I assisted with a spinal tap. That’s not the sort of thing you want to shrug off and say I’ll wing it. It’s complicated. One time I paged the specialist in the middle of the night without talking to them because they were busy with new admissions and my patient could not wait. She was fine all day and suddenly showed signs of respiratory distress. I gathered vital signs, an oxygen level, applied oxygen and paged the respiratory therapist to help start albuterol while I went to the phone. When the doctor called, I gave the information I had including labs and vital signs, the history of the patient’s change in condition, and then he asked, “Okay, what are her lung sounds?” I had a patient in mild respiratory distress, and I had not listened to her lung sounds! The physician was furious and had to wait on hold while I checked. This is the stuff that only a new nurse would do, but most of the time my mentors prevented me from leaving the specialist on hold at 3:30 in the morning by letting me ask them questions before I called.

But who is there to mentor the current nursing workforce? They have questions that can’t just be answered by an internet search engine. They need an experienced clinician, but most of those have retired or left. And it’s true that a mentor can give affirmation that you’re doing a good job when you really need to hear it. It meant so much to me when one of my mentors said, “you handled that well” and it meant a lot, too, when they reassured me when I felt like I had failed. It was a great way to debrief, and those were days that I renewed my passion for excellence as a nurse.

In closing, blogger Hilary Link writes in “Meeting Gen Z: Avoiding the Demographic Cliff and Preparing for Their Future,” that Gen Z thrives in a collaborative, creative learning environment that makes a difference in the real world. Carey Lohrenz also said about teamwork that “we may not have chosen one another as teammates, but we can all get focused on doing one thing and doing it well.” This is what Advocate is promoting for the director/manager relationship to help both positions become more effective and satisfied by working on the same job with the same goals. And with poor staffing across the board in healthcare, it is the perfect time to pull together a dream team to balance the load. If Advocate is successful in balancing that workload, a lot of nurse managers will start to love their jobs again.

References:

American Association of Colleges of Nursing (AACN). (Oct. 2022). Nursing Shortage Fact Sheets. AACN News & Information. https://www.aacnnursing.org/news-information/fact-sheets/nursing-shortage/

Incredible Health. (March 16, 2021). 34% of Nurses Plan to Leave Their Current Role by the End of 2022. Inside Incredible Health. https://www.incrediblehealth.comwp-content/uploads/2022/03/IH-COVID-19-2022-Summary-1.pdf.

Kennedy, M. (Jan. 29, 2018). Experienced Bedside Nurses: An Endangered Species? Off the Charts: Blog of the American Journal of Nursing. Retrieved Nov. 30, 2022, from https://ajnoffthecharts.com/experienced-bedside-nurses-endangered-species/

Kennedy, M. Nurses at the Bedside--Who Will Be Left to Care? AJN, 118(2), 7. https://www.doi.org/10.1097/01.NAJ.0000530224.10340.d1/

Lohrenz, C. (2014). Fearless Leadership, 2nd ed. Greenleaf Book Group Press.

Phillips, David et al. (2010). Christmas and New Year as risk factors for death. Soc Sci Med, 71(8). 1463-71. https://www.doi.org/10.101/j.socscimed.2010.07.024.

Tarlengco, J. (Nov. 21, 2022). Gemba Walk: Meaning, Process, and Examples. Safety Culture. https://safetyculture.com/topics/gemba-walk/

Twenter, P (Oct. 21, 2024). Advocate redesigns the nurse manager role. Becker’s Clinical Leadership. https://www.beckerhospitalreview.com/nursing/advocate-redesigns-the-nurse-manager-role.html.

[1] Twenter, P (Oct. 21, 2024). Advocate redesigns the nurse manager role. Becker’s Clinical Leadership. https://www.beckerhospitalreview.com/nursing/advocate-redesigns-the-nurse-manager-role.html.