AAN: Technology may to be blame for nursing shortage

Study leaders seek more efficient use of nurses' time

Nobody questions the seriousness of the nursing shortage, but so far no one has come up with a satisfactory solution. The American Academy of Nursing believes it is on the right track with a project called "Technology Targets," funded by the Robert Wood Johnson Foundation.

"In 2002, the American Academy of Nursing [AAN], in response to the sustained shortage of nurses, began to look at what initiatives it could bring to the table to help improve the work environment — which is often cited as one of the main factors in nurses spending decreased time in the hospital," recalls Linda Burnes Bolton, DrPH, RN, FAAN, vice president of nursing at Cedars-Sinai Medical Center in Los Angeles and principal investigator for Technology Targets.

"At the same time, providing care has become so much more complex and that care was adversely impacted by the amount of waste in a nurse's time — they could not provide as much care as they had in the past because they were too busy with other things like trying to find supplies and equipment or waiting for information and documentation," says Burnes Bolton.

Looking for feedback

In 2002 the organization began to look at demand and how other industries had been able to address work and work flow, to see if technology might apply to helping nurses. It held a three-day invitational conference including futurists and invited staff nurses from around the country.

"Since health care is a 'team sport,' we included architects, engineers, human factor experts, experts in technology, doctors, CEOs, pharmacists, and respiratory therapists," says Burnes Bolton. "We asked them to think about the future work environment — what it would look like — and what we needed to get in order to be able to create it." In other words, she explains, they were looking for an environment in which nurses would stay in spite of the shortage.

"The consensus we arrived at was that we needed to delve deeper into understanding the work environment and what was needed by nurses and the other team members — including manufacturers," says Burnes Bolton. (All major manufacturers also had been invited, and all had attended.) "The nurses said the technology that was being produced took more of their time, not less, and they had developed work-arounds because of it," Burnes Bolton reports.

On to TD2

The next step was to get a grant from the foundation for pilot testing that ultimately led to the development of a process the group called "Technology Drill Down," or TD2. "The drill down was a way to get to see what in the work environment needed to change and what type of technology products were needed," Burnes Bolton explains.

The first step was to conduct non-participant observation, having others watch what people do. "We had doctors, engineers, and hospital executives watch nurses work, and then we talked to the nurses," she says. This process was piloted in three hospitals, and led to the creation of TD2, says Burnes Bolton.

TD2, according to the AAN, "precisely defines and measures the technological gaps between practice and need and, in generic terms, describes technological products that could close the gaps."

"We went out to 25 different hospitals and systems involving over 10,000 individuals from a variety of settings — rural, urban, academic," says Burnes Bolton. "We conducted drill downs and identified over 1,000 different things that needed to be produced."

At Cedars-Sinai, for example, a random sample of 20 staff nurses was selected, and then volunteers were requested to fill the other team slots. "In the three months before we did the actual drill down, we conducted observation of work and work patterns, which were then analyzed by the [nursing] academy staff," recalls Burnes Bolton. "Then we held an invitational session where we posed the following question: What would make a perfect workday for you?"

From prior literature, she adds, it was known that anywhere from 20% to 40% of a nurse's time was spent moving back and forth looking for supplies, waiting for someone to assist them, or waiting on the phone. "We also knew from 20% to 33% of their time was spent in documenting, which means less time in direct patient care," says Burnes Bolton.

The remainder of day one was spent asking for suggestions about redesigning the work flow. On day two, the participants were asked to envision ideal products in the morning session. "Then in the afternoon we showed them the technology products on the market — even if they did not have them in their hospital," says Burnes Bolton. The participants were then asked to prioritize the 1,000 solutions they had proposed.

The feedback indicated the most complex parts of nursing work involved medication systems and communication (no matter with whom). "The third issue was that the existing technology products don't talk to each other," says Burnes Bolton. "So, for example, if you need data from an infusion pump, you read it, and instead of that data going directly to the electronic medical record, you have to put the results on paper and then enter them into the system. That's a lot of the documentation time we're talking about."

Another example would be a patient who needs to be ambulated and requires two helpers. "It may take three phone calls to get someone to assist you, although there are technology products out there that allow you to schedule therapy events," says Burnes Bolton.

More direct care

The take-home message of the project, says Burnes Bolton, "is that workers are not spending as much time as they should in direct patient care — and we know from the literature that the more time nurses can spend in direct care, the fewer incidents they will have. What's more, other studies have found that the more time is spent in direct patient care, the more satisfied nurses are and the more likely it is that they will stay. "

What AAN wants, she continues, "is for hospital CEOs and chief information officers and vendors to step up to the plate and demand that they address this lack of interoperability that can affect our ability to provide safe patient care. That's the policy piece we want — to have one set of standards."

As for hospitals themselves, Burnes Bolton adds, "I hope, in terms of their product selection, they will not purchase something if it does not meet the right standards." The bottom line here, she emphasizes, is that "money talks."

"We believe strongly that if we can get a critical mass of institutions to say to vendors that if their product won't talk to another product they are not going to buy it, we will get results," Burnes Bolton asserts.

Vendors, she emphasizes, "need to listen to the voices of the people who need to use their products." And for hospital executives, "we will be saying that we will give our process away to every hospital in the U.S. Here's how to conduct a technology drill down. You should do this first so you don't buy something your staff won't use."

[For more information, contact:

Linda Burnes Bolton, DrPH, RN, FAAN, Vice President of Nursing, Cedars-Sinai Medical Center, Los Angeles, CA. Phone: (310) 423-5191.

For a free copy of TD2, go to: www.aannet.org/committees/td_orderform.asp.]