Appreciate nurses? Remove obstacles that prevent quality care

Addressing these four operational inefficiencies have a huge impact on health systems that struggle with RN turnover and aim to provide high quality care for all. In our conversations with nurses across the country, we found these issues repeatedly mentioned.  Here’s their collective advice:

1. Eliminate redundant paperwork

If you have an EMR (Electronic Medical Record) system, there’s no need for nurses to fill out paperwork with information already in the chart.  Yet nurses must write — with pen and paper — that same information again and again per ‘requirements’ of various departments in their own hospital.  When requesting a lab / a test /a discharge, innovative health systems leverage the EMR. They automate the forms to pull data from the chart. A nurse just needs to sign off.

EMRs enable automated extraction of information that can then populate standardized forms, reports, and tickets. Leveraging this functionality eliminates hours of administrative paperwork that burdens all care providers in the health system.

“The documentation just keeps increasing, year over year. It’s at the point now where we see it cutting into our ability to deliver patient care,” says a NICU nurse with 30 years of experience. “If you can’t do what you need to do for patients because you are spending time documenting again and again, that’s a huge barrier to people feeling job satisfaction.” 

An ER nurse in the Northeast illustrates the point, “For example, at the hospital I was at before, transporters always need a ‘ticket to ride’ – a paper we print out after answering three questions. But those answers are all in the chart. At the hospital I’m at now, the transporter could just check a screen on their ipad and see that information in the chart, no problem. But at my prior place, the transporter had to find the nurse who then needed to go to a computer, enter this information on a form, print it, and hand the form to the transporter. It’s nuts! All this time I was needed by a patient somewhere else. Why can’t the transporter just have access to the chart here when I know it’s technically possible…?”

2. Standardize texting communication with providers 

Senior leadership at healthcare organizations may not realize how difficult it is to get a provider on the phone. Nurses who work at hospitals that do not have a standardized texting/smartphone communication protocol (e.g. Smart Web and Voalte) know exactly how difficult it is. But this problem is fixable and goes to the heart of quality patient care.

Here’s the scenario: a nurse realizes a patient has an issue that the provider should know about — a wound has opened up, a pain med is not working, a blood pressure is wildly elevated. Without a streamlined texting communication protocol, the nurse has to leave the patient and walk down the hall to ‘reception’ to get the doctor’s name and office number.  

The nurse calls, listens to an automated phone tree, and maybe reaches a person. The nurse then leaves a lengthy message. However, the doctor doesn’t read this message and simply calls the number, without knowing who or why the page was placed. The nurse continues attending to patients and may eventually hear a loudspeaker announcement that a doctor (of name XYZ) is returning a call. Hopefully, the nurse is able to run back to answer that call. More often than not, by the time the nurse arrives, the provider has hung up.

“Doctors do not have time to wait around!” explains a frustrated nurse who experienced these communication issues every day. 

The process begins again, and hopefully the nurse and provider connect over the phone at some point…

When health systems have a standardized protocol that same scenario proceeds this way:  A nurse realizes an issue with a patient, sends the provider a message describing the problem in a pithy text (120-500 character limits) which includes the nurse’s call back information. The doctor receives the message in the context of a direct link into the patient’s chart and knows exactly what to do. Perhaps the physician (in one touch!) orders a new medication or  lab test. Or the doctor may call the nurse for additional information. Or, if sufficiently urgent, the doctor can immediately head over to assess the patient.

3. Staff up with aides and phlebotomists so nurses can do what they were trained to do (ie. provide high quality nursing care)

Ensure your staff are working at the top of their license. We hear this all the time, but what does it really mean? It means appropriate staffing of aides and phlebotomists.

From an investment point of view, this is not the place to cut costs, because it leads to increased costs almost immediately down the road. If an aide or phlebotomist — who earns less than a nurse — can do a task, why do hospitals have nurses do it? By ensuring adequate staffing of these and other less expensive ancillary team members, hospitals free up nurses to perform nursing tasks. Such an investment in appropriate staffing leads to better patient outcomes, higher nurse job satisfaction, reduced staff burnout, and money saved. 

Make every attempt to adequately staff the aides (or patient care technicians, “PCTs”) across the hospital.

Typically, PCTs are responsible for tasks such as: 

• obtaining vital signs and blood glucose meter readings, 

• getting patients up to the bathroom, bedside commode, bedpan, or chair, 

• ensuring patients are able to eat their meals, 

• rotating the position of immobile patients to prevent skin breakdown, 

• filling patient water mugs, 

• cleaning up incontinent patients, 

• covering for the 1:1 sitter so that this PCT can take a lunch

The consequences of inadequate PCT staffing?

• A delay in — or even disregard for — performing the above-named tasks.

• A delay — or complete neglect of — essential nursing tasks when nurses must abandon their tasks to backfill PCT tasks.

• An increase in falls from ‘high falls risk’ patients who now get up by themselves.

• An increase in patients becoming dehydrated or dizzy because they are not drinking or eating.

• An onset of painful and costly skin breakdown for patients when their position is not rotated every two hours.

Hospital managers need to incentivize and reward unit managers who adequately staff their own unit. They also need to ensure they are maintaining a deep enough float pool (or resource pool) of PCTs to cover the inevitable yet unexpected staffing needs hospital-wide. 

When hospitals regularly pull scheduled PCTs from an adequately staffed unit to cover an understaffed unit, this reinforces dysfunction by rewarding the wrong behavior. Instead, specific financial rewards and penalties for under- and adequate- staffing needs to be implemented with consistency and transparency.

“Why should my unit, that has put forth the effort to remain staffed, ever have to surrender our PCTs to another unit?” asks a nurse manager at a Southwestern health system. A nurse at a different health system in the West noted, “Hospital managers never pulled staff from our unit. They worked with the unit manager of chronically understaffed units to determine how to fix their problem…”

Phlebotomists should be the ones drawing blood for lab tests (aka “lab draw”).

Using phlebotomists increases patient satisfaction and the delivery of care systemwide. 

They have the skills to poke a patient just once, efficiently and effectively. Many patients have veins that are difficult to locate. With a phlebotomist, this may not be a problem, but when a health system relies on the bedside nurse, there’s a domino effect of issues. The nurse may not have enough time or skill to obtain a lab draw. The lab draw is then delayed or never obtained. Multiple bedside nurses are then side-tracked by this patient in attempts to obtain the lab draw. The patient may become highly agitated due to multiple pokes, subsequently refusing all future lab draws. 

Ultimately, NOT utilizing phlebotomists negatively impacts patient care in two main ways:  

• for the specific patient: care is delayed when, as a result of the belated or aborted lab draws, the providers cannot see the lab values they ordered. 

• for general patient care: difficult lab draws divert the nurse from providing nursing care to other patients 

4. Sufficiently staff the Ultrasound-Guided Peripheral IV Placement machine

Up to 80% of patients receive a peripheral intravenous (or “PIV”) catheter during their hospital stay.  Many factors (obesity, dehydration, limb restrictions, drug abuse, hypovolemia, etc) make it difficult, if not impossible, to ‘find a vein’ and place these essential PIVs. Fortunately, there is a way to visualize the structures under the surface and guide the PIV by using an Ultrasound machine.

Many health systems have a Vascular Access Team that ‘own’ several of these machines, but they are a very busy team. They work across the hospital placing central and mid-lines, and are therefore not usually available to place PIVs when a nurse calls. This is further complicated by the fact that in many hospitals this team only works between 9am and 5pm on weekdays.  

Patients need PIVs placed — and replaced — at all hours, and suffer greatly when this need is delayed by hours or days. For example, patients that require intravenous antibiotic treatment every 6 hours, cannot endure a night, never mind an entire weekend, without IV access. Such patients may needlessly endure numerous pokes from multiple bedside nurses attempting to re-secure IV access.

Hospitals can solve this problem with relative ease:  train additional staff to do the ultrasound-guided PIV placement. Emergency Department staff — such as paramedics or patient care techs — and critical care charge nurses are capable of placing USG PIVs. Either by having access to the Vascular Access Team’s machine in after-hours or by owning their own, this additional staff can assist the entire hospital with difficult IV access (DIVA) patients. 

This approach is an across-the-board win. Financially, since health insurance compensates hospitals more for USG PIVs, these machines could be making more money for the hospital. For patients, any reduction in delays to essential treatment — and reduction in needless needle pokes — is much appreciated. 

What does this have to do with nurse satisfaction?  

If the point hasn’t already been made, let’s state it clearly: anything related to quality of care and patient satisfaction impacts nurse satisfaction.  Nurses want to deliver quality care. When they work at a health system that intentionally and effectively removes obstacles, they appreciate that. 

So, we celebrate Nurse Appreciation Day. We applaud Nurse Appreciation Week.  However, if we truly want to show our appreciation for nurses, we should be finding ways to make sure that when they show up for work, they can do the job they chose to be trained to do.