Improving life for nurses - and patients

Not long ago, it wasn't unusual for nurse Kristin Liehr to roam the hallways of her St. Paul hospital searching for a wheelchair. Or a crib. Or a cart. Or dash out of a patient's room for bandages or syringes. It would happen, she says, more than a dozen times a day.

Nursing experts call it "hunting and gathering." And studies suggest that it can consume more of a nurse's time than actual patient care.

"It's such a frustration," said Liehr, who works with children recovering from surgery at Gillette Children's Specialty Healthcare.

But last year, Liehr's unit -- 4 West -- became part of a national project called Transforming Care at the Bedside. She and her colleagues discovered they could save a lot of time and "a ton of aggravation" with some modest innovations -- such as relocating the supplies they use most.

For four bitter months, nurses and managers at other Twin Cities hospitals have clashed publicly over how many nurses are needed at the bedside, as part of a bitter labor dispute that ended last week. The Minnesota Nurses Association tried and failed to get strict staffing ratios, arguing that hospitals are dangerously understaffed, and some members have called on the Legislature to impose staffing rules.

But behind the scenes, dozens of Minnesota hospitals, such as Gillette, have quietly been looking at ways to ease the burden on nurses by streamlining their workload rather than adding staff.

"One theory is, if the quality of care is better with more nursing care, let's hire more nurses," said Pat Rutherford, who helped launch the project at the Institute for Healthcare Improvement in Cambridge, Mass.

But in practice, she said, nurses at most hospitals struggle with "chaotic, inefficient" systems that keep them away from their patients for much of the day. "It's irresponsible to just add numbers without getting rid of the waste," she said.

'Terrible waste of time'

Studies show that nurses on a typical inpatient floor spend only 20 to 35 percent of their time on direct patient care, Rutherford said. The majority of their time and energy is spent on the phone, tracking down information, checking medications, updating medical records and gathering supplies -- with an endless series of interruptions along the way.

In 2008, a study found that nurses walk up to five miles in a 10-hour shift.

"It's a terrible waste of time and energy, and it really breaks your spirit if you're drawn to do patient care," said Joanne Disch, director of the Densford International Center for Nursing Leadership at the University of Minnesota.

Transforming Care at the Bedside, funded by the Robert Wood Johnson Foundation, aims to change that. It encourages hospitals to examine themselves and find ways to free up more time for patient care.

Gillette started by asking the nurses.

On 4 West, Liehr helped lead a brainstorming session known as snorkeling -- so called, she explained, "because you're doing a deep dive into the problem."

"Our question was, what would you change in your unit or your practice?" she said.

After some hesitation the ideas started flowing -- 256 in all. The biggest gripe: chasing supplies.

"People were doing a lot of running back and forth," said Becky Hamilton, a charge nurse at Gillette. Even for something as simple as saline solution, which they use several times a day, they had to slip down the hall to a central supply cabinet.

Instead, they decided to create a small supply shelf in every patient room and stock it with the 21 items they use most frequently, such as gauze, alcohol wipes and specimen cups. At the nurses' suggestion, the supply cabinets, which open with a punch code, have special hinges "to open easily with one hand," Liehr said.

The nurses voted on the top dozen or so suggestions and began experimenting. A few weeks ago, they converted one patient room into a parking lot for equipment -- wheelchairs, commodes, breathing monitors -- that used to be "scattered all over," said Hamilton.

Not all of the changes were designed to save time. They started posting white-boards in patient rooms to make it easier to share information (who the nurse is, when the last medication was given) and give patients and family a space to write their own questions. "It's nice, very helpful," said Mary Jackson of Duluth, whose son Michael, 16, was recovering from a spinal procedure last week. "It lets families know what's happening."

Letting nurses make the call

As part of the project, the nurses are encouraged to keep trying new things and abandon them quickly if they don't work, said Pat Reese, the nurse manager. "Most people can think of a million things they'd like to change," she said, and so far, "the cost of the changes was minimal."

At St. Cloud Hospital, the transformation has been noticeable on one 29-bed unit, which has been part of the project for three years. Nurses are putting in less overtime, turnover is down, and surveys show satisfaction is up among both patients and staff.

"We have more time [with patients], and there's less rush," said Joy Plamann, a nurse manager. There's even been a decrease in patient falls, she said, suggesting they're getting more attention from staff.

One hospital system in Appleton, Wis., says it was able to cut labor costs, as well as improve the satisfaction rate among nurses, after it joined the Transforming Care pilot project in 2003. At ThedaCare, nurses have been able to save one to three hours a shift by relocating supplies and other changes, managers say. "They have what they need, they don't have to leave the patient constantly and apologize," said Jamie Dunham, a nurse who led the project.

Among other changes, ThedaCare also assigned nurses to teams, on which they could spend more time on patient assessment and education, while others such as nursing assistants handle more basic personal care. As a result, nurses on the medical-surgical units actually handle an average of one more patient per shift than they used to, Dunham said. "They are still tired at the end of a shift, because nursing is demanding work," she said. But "they have [more] satisfaction with the work that they do." In nurse surveys, the satisfaction rate has jumped 68 percent, she said.

Next month, about two dozen more Minnesota hospitals are slated to join the project, according to the Minnesota Hospital Association.

The Minnesota Nurses Association (MNA), which maintains that staffing levels are the key to patient safety, declined to comment on the project.

Many nurses, however, have been skeptical of attempts by hospitals to improve efficiency, saying they're trying to impose an assembly-line mentality on patient care. As one commented on an MNA website: "I love how people who do not and cannot do my job tell me how to do my job more efficiently."

But supporters say this is an attempt to give nurses a say in improving patient care.

"In the end, it's the patient that benefits the most," said Lawrence Massa, executive director of the Minnesota Hospital Association. "We've got the same goals as the MNA. We all want better, safer care." The only difference, he said, "is how we're going to get there."

Maura Lerner • 612-673-7384