The top concerns of nurse leaders are related to nurse recruitment, nurse retention, and nurse engagement. A HealthLeaders Intelligence Report details the challenges.
The top three challenges facing nurse leaders are not unexpected:
Nurse retention (61%)
Nurse recruitment (59%)
Nurse engagement (35%) (Nurse leadership development came in a close fourth at 33%.)
And during my conversations with nurse leaders from around the country, I have noticed more and more acknowledgement that both nurse engagement and nurse leadership development influence nurse retention.
In fact, there are a number of concurrent sessions and poster presentations on nurse engagement on the docket at the AONE 2017 annual conference which starts Wednesday in Baltimore.
What did surprise me about the report's findings was that only 10% of the respondents said generational differences were a challenge.
I've heard many nurse leaders say that millennials have very different work habits and preferences than the generations of nurses before them. A significant portion of our discussion at the CNO Exchange focused on how millennial nurses seem to prefer to move from job to job every few years and, if new opportunities are not available, they will leave an organization to find them elsewhere.
In fact, the decade-long RN Work Project study has found that roughly half of all newly licensed RNs leave their job within two years.
Success and Stumbling Blocks
Almost three-quarters of the Intelligence Report's respondents (71%) said their organizations' RN turnover rate over the past 12 months was less than 20%. The others 25% said their turnover rate was 20%.
Nurse leaders are using many tactics to help boost retention rates, but the top four strategies that were showing success are:
Flexible scheduling (53%)
Communication improvements (51%)
Orientation programs for new nurses (48%)
Salary increases for all nurses (48%)
Also in the mix of successful nurse retention tactics were work environment improvements (42%), tuition reimbursement for advanced education and certification programs (42%), and shared governance (41%).
Only 14% of the respondents reported that retention bonuses for new nurses were a successful strategy.
While recruitment and retention of nurses may be the biggest challenges nurse leaders face, they reported the biggest stumbling block in creating an effective nursing program at their organizations was difficulty changing the organizational culture (32%).
An abundance of other priorities (17%), an abundance of higher priorities (14%), and lack of funding (12%) were other hurdles they faced in developing their nursing programs.
When asked if cost containment efforts had affected the quality of their organizations' nursing care, 42% of the respondents said that there had been no change in the quality of nursing care, while 31% said these efforts caused a minor decline (26%) or a major decline (5%) in care quality.
Oncology patients with advanced disease benefit from palliative care consultations triggered by standardized criteria, research shows.
Palliative care in very sick patients can reduce their distress and that of caregivers and decrease unwanted healthcare use. Yet some patients are not offered palliative care.
Standardizing the criteria that trigger palliative care consultations for patients with advanced cancers may help. Standardization has been shown to improve quality of care and reduce 30-day readmissions, according to a study published in The Journal of Oncology Practice.
Patients on an inpatient solid tumor service received an "automatic" palliative care consultation when they met at least one of the following four criteria, or "triggers:"
Had an advanced solid tumor
Prior hospitalization within 30 days
Hospitalization greater than seven days
Active symptoms
Patients who met the criteria and triggered an automatic consultation received palliative care consultations 80% of the time vs. 39% among control subjects. Hospice referrals were greater among the intervention group (26%) compared to the control group (14%).
"Patients with advanced cancer admitted to an acute care hospital often have short life expectancies and high morbidity," said the study's lead author Kerin Adelson, MD, assistant professor of medical oncology at Yale Cancer Center and Chief Quality Officer and Deputy Chief Medical Officer for Smilow Cancer Hospital in media release.
"For these patients, the integration of palliative care has improved symptom burden, reduced patient and caregiver distress, increased referral to hospice, and improved outcomes."
The study shows that rates of 30-day readmissions dropped to 18% among those who received the automatic palliative care consultation compared to 35% in the control group. While length of stay was unaffected, patients in the intervention group received less chemotherapy after discharge (18%) than the control subjects (44%).
Guidelines from the American Society of Clinical Oncologists call for palliative care to be integrated into standard oncology care for all patients diagnosed with cancer.
"Economically, we face a national crisis as costs escalate exponentially and patients continue to receive non-beneficial and burdensome health interventions at the end of life," write Adelson and her co-authors in the published study.
"This pattern of care harms the quality of life in a population with little time left to live; we face an urgent need to revise our policies and practices in caring for patients with advanced cancer."
Critical care nurses who participate in unsuccessful resuscitation attempts report moderate levels of postcode stress and PTSD symptoms, research shows.
Resuscitation attempts in critical care units are not unusual and, unfortunately, not always successful. Often, RNs are involved in these life-saving efforts.
"I was curious to know if there was any published literature on the emotional or psychological consequences on nurses specifically related to resuscitation attempts," says Dawn E. McMeekin, RN, DNP, CNE, advanced clinical education specialist at Baycare Health System in Dunedin, FL.
Published literature on the topic was limited, but McMeekin's recent study, published in the American Journal of Critical Care is shedding some light on the topic.
Its aim was "to explore if participation in an unsuccessful cardiopulmonary resuscitation attempt created a heightened level of stress, referred to as postcode stress, and if coping behaviors individuals utilized influenced the development of a more chronic psychological distress as evidenced by PTSD symptom severity or stress as a result of a traumatic event," McMeekin says.
Additionally, study participants were asked if institutional support in the form of debriefing was available. The relationship between debriefing and the levels of psychological distress was also assessed.
The results of the study were somewhat surprising.
Debriefing's Effectiveness Varies
The study found that when asked to recall an unsuccessful resuscitation, critical care nurses showed moderate levels of postcode stress and PTSD symptoms.
It also found, however, that postcode stress and PTSD symptom severity were weakly associated. In other words, just because a nurse experiences postcode stress, that doesn't mean that he or she will necessarily develop PTSD symptoms.
"I was somewhat surprised that the association between postcode stress and PTSD symptom severity was not stronger," McMeekin says. "Perhaps this demonstrates how critical the coping behaviors are in diminishing the development of chronical psychological distress."
While there were no significant associations between coping behaviors and postcode stress, four coping behaviors (denial, self-distraction, self-blame, and behavioral disengagement) were significant predictors of PTSD symptom severity.
Nurses who had institutional debriefing support reported significantly lower postcode stress scores than those who did not have debriefing support yet this did not hold true for PTSD symptom severity.
"I was somewhat surprised PTSD symptom severity was higher in those nurses with institutional debriefing," McMeekin says.
Study of Interventions Needed
These results point to the need for further study of the effectiveness of various interventions to support nurses after failed resuscitation, McMeekin says.
"The aim of the study wasn't to look at interventions. This was an initial study to see what the psychological distress levels and factors were. Hopefully this is going to open the door for some interventional research into what institutions and nurse leaders can do," she says.
In the meantime, understanding that nurses face very real after-effects after a failed resuscitation is a step in the right direction.
"My advice for nurse leaders would be to acknowledge the potential for psychological distress" under these circumstances, and to understand that "this may compound the burden of emotions and psychological stressors that nurses encounter in daily practice," she says.
"[Nurses] have to be enabled not to hesitate to seek assistance from trained professionals. Nurses need to open a dialogue on this topic with peers and nurse managers on available support for traumatic event exposure," she says.
"As nurses we're not invincible, we're human, and it's OK when we need help."
Surgeons who received monthly cost feedback in the form of scorecards combined with a financial incentive lowered their surgical supply costs by 6.5%.
How much is that retractor in the window? Many surgeons don't know. But those who do have demonstrated lower surgical supply costs without negative effects on outcomes, according to findings in a study published in JAMA Surgery.
The OR Surgical Cost Reduction project, a single-health system, multi-hospital, multi-departmental prospective controlled study, found that surgeons provided with cost feedback scorecards lowered their surgical supply costs by 6.5%.
Those who did not receive the scorecards showed an 7.4% increase in surgical supply costs.
From January 1 to December 31, 2015, each surgeon in the intervention group received standardized monthly scorecards showing the median surgical supply direct cost for each procedure type they performed in the prior month compared with his or her baseline costs which were calculated from data from July 1, 2012, to November 30, 2014.
The scorecard also compared the individual surgeon's costs with the baseline costs of all the institution's surgeons performing the same procedure.
Incented to Reduce Costs
The surgeons in the control group did not receive the monthly scorecard. All surgical departments were eligible for a financial incentive if they met a 5% cost reduction goal.
In the intervention group, the median surgical supply direct costs per case decreased 6.5% from $1,398 in 2014 to $1307 in 2015 which added up to a savings of $836,147 during the year-long study.
In the control group, the median surgical supply direct cost increased 7.4% from $712 in 2014 to $765 in 2015.
After researchers controlled for surgeon, department, patient demographics, and clinical indicators, the intervention group showed a 9.95% decrease in surgical supply costs over the year.
Patient Outcomes
Patient outcomes—30-day readmission, 30-day mortality, and discharge status—were equivalent or improved after the intervention, and surgeons who received scorecards reported higher levels of cost awareness on compared to the control group.
Attending surgeons in orthopedic surgery, head and neck surgery, and neuro surgery made up the group receiving the scorecards. Those in the control group were cardiothoracic, general, vascular, pediatric, obstetrics/gynecology, ophthalmology, and urology surgeons.
Many chronically ill patients who would benefit from a medium-coverage health insurance plan and preventative care are instead choosing comprehensive insurance plans, researchers say.
Many patients with chronic illness are choosing a pound of cure over an ounce of prevention and driving up medical costs in the process, according to findings in a study examining health insurance choices as they correlate to costs.
"Our results indicate that there exists a sizable segment of consumers who purchase more comprehensive plans than needed because of high uncertainty vis-à-vis their health status, and that once in the plan, they opt for curative care even when their illness could be managed through preventive care," the study says.
Chronic medical conditions such as heart disease, cancer, hypertension, respiratory diseases, diabetes, Alzheimer's disease, and kidney disease account for 75% of healthcare expenditures in the United States.
Individuals with chronic diseases can consume three types of healthcare services:
Secondary preventive care, which includes diagnostic tests
Primary preventive care, which includes drugs that help prevent progression of a disease
Curative care, which includes surgeries and expensive drugs that boost a patient's health
After analyzing three years of data from a health insurer that offered basic, medium, and comprehensive coverage Preferred Provider Organization plans to customers through their employers, researchers found that of the 3,000 people whose data was analyzed, about 14% would have been good matches for a medium coverage plan and preventive care, but they elected the more costly comprehensive plans and curative care instead.
A 'Moral Hazard'
Going from basic, to medium, to comprehensive, the annual premium increased. But the deductible, co-insurance rate, and out-of-pocket maximum decreased.
Johns Hopkins University researcher Jian Ni, PhD, an associate professor in the Johns Hopkins Carey Business School is one of the study's authors.
In a news release, he called this escalation a "moral hazard." The individual doesn't mind choosing a more costly, but unnecessary plan, because he or she knows the insurer will pay for the bulk of it.
"Certainly some people with more serious conditions will benefit from a comprehensive plan and curative care, but the 14% in our study pose the kind of moral hazard that contributes to health care expenses in the U.S. that are higher than they probably should be, roughly a fifth of gross domestic product," Ni, said in the statement.
The study authors suggest that if physicians and insurers provide consumers with clearer instruction and guidance individuals would be more likely to select a health care plan that better fit their health status which would help contain costs to consumers and insurers.
When healthcare teams are exposed to rudeness, clinical outcomes and teamwork suffer. Vanderbilt University Medical Center has developed a process for resolving disruptive behavior among clinicians.
Rudeness has become the attitude du jour.
From the highest branches of our government to our friends' Facebook comments, "I respectfully disagree," has been replaced with, "You're an idiot." Or worse.
Some say it's refreshing to see people casting off superficial niceties and, "telling it like it is." Those who express dismay over the loss of social decorum get labeled "snowflakes," meaning they are thin-skinned, easily offended, and can't handle the truth.
But rudeness causes problems that go beyond hurt feelings, suggests a recent study published in the journal Pediatrics.
Researchers found that when NICU teams were exposed to rude comments from a patient's mother during a simulation training exercise, diagnostic and intervention parameters were negatively affected as were team processes such as workload sharing, helping, and communication.
A previous study published in Pediatrics in 2015, found that when NICU teams were exposed to rudeness by an expert observing them during a training simulation, they had lower diagnostic and procedural performance scores than the control groups that were not exposed to rudeness.
Researchers say that rudeness alone explained nearly 12% of the variance in diagnostic and procedural performance.
For good reason, The Joint Commission calls rudeness and its cousins, incivility, lateral violence, and bullying behaviors that undermine patient safety. TJC has called for hospitals and healthcare systems to prevent them from occurring.
Vanderbilt University Medical Center is tackling these issues through the Vanderbilt Center for Patient and Professional Advocacy.
Disturbances in the Force
Part of the center's work is to help address issues of professionalism for physicians and advanced practices nurses, says William O. Cooper, MD, MPH, director of the Vanderbilt Center for Patient and Professional Advocacy.
"We do this work for Vanderbilt nurses and physicians, but we also have several sites around the country where we support their work in terms of processing their data and providing analysis and training of their leaders on how to address professionals who are associated with more than their fair share of, as we occasionally call them 'disturbances in the force'," he says.
These disturbances can include interactions with patients, colleagues, or staff members.
"If you have a nursing professional who has encountered a surgeon who, every time she brings up the surgical time-out, the surgeon says, 'No, we're on the same page let's just proceed,' she may not bring it up the next time," says Cooper.
One of the center's goals is to prevent this type of behavior from becoming a pattern.
"We work really hard to try to prevent physicians, advanced practice nurses, and other professionals from having the really unfortunate consequences of having these patterns develop, including malpractice suits and harassment suits," he says.
No Judgment Here
Everyone has an off day here and there so it's important to look at data to see if particular patterns are emerging.
"We assess and analyze various sources of data, including patient complaints and staff complaints, to [identify] those professionals who are associated with a disproportionate share of those data points," Cooper says.
"Ninety-seven percent of professionals won't have significant amounts of trouble, but those small numbers that do create a whole lot of disturbance."
Over a 25-year period, which ended in 2015, fewer than 2% of all physicians practicing were responsible for half of all malpractice dollars paid out, researchers have found.
At Vanderbilt, physicians and APRNs are made aware of individual complaints just so they are aware one was received.
When they develop a pattern, a trained peer messenger takes them aside and says, 'I'm here as your peer today. I'm part of our professionalism committee. I just wanted to let you know that for some reason, your practice appears to be associated with more patient complaints than your colleagues,'
"What we find is that 80% of the time, they'll self-correct," Cooper says.
For those who don't self-correct, a conversation is then had between the provider and someone at a higher level of authority.
"Even those folks that rise up to the authority-level conversation that haven't [already] self-corrected, about 60% of those end up self-correcting," he says.
Perhaps this success is due to the way the message is delivered.
"By sharing information with them in a non-judgmental way, you can really turn things around for them. The ripple effects for that individual and their coworkers and their patients is really phenomenal," Cooper says.
"There has to be a shared vision and values that aren't just around being the best. It's very important to have aspirational goals, but also that we will treat our colleagues with respect."
Patients visiting the ED for suicidal thoughts were more likely to receive inpatient care than patients visiting the ED for other reasons. Costs ranged from $600 million to $2.2 billion over the seven-year period.
From 2006 to 2013, ED visits by adults with suicidal thoughts more than doubled, according to an AHRQstatistical brief. On average, these visits rose by 12% each year over the seven-year period.
By 2013, 1% of all adult ED visits were related to suicidal ideation up from 0.4% in 2013.
The top five most common behavioral health conditions among ED patients with suicidal thoughts in 2013 were:
Mood disorders
Substance-related disorders
Alcohol-related disorders
Anxiety disorders
Schizophrenia and other psychotic disorders
Mood disorders were related to three-fourths of all ED visits related to suicidal ideation.
Patients visiting the ED for suicidal thoughts were more likely to receive inpatient care than patients visiting the ED for other reasons.
In 2013, more than 71% of ED visits related to suicidal ideation resulted in admission to the same hospital or transfer to another facility compared with 19% percent of all other ED visits. From 2006 to 2013, the percentage of ED patients with suicidal ideation admitted to the same hospital increased from about 34% to 41%.
Cost of inpatient care among these patients has risen over the seven-year period. The statistical brief reports that from 2006 to 2013, aggregate ED plus inpatient costs of ED visits related to suicidal ideation resulting admission to the same hospital rose from $600 million to $2.2 billion.
The average length of stay rose to 5.6 days from 5.1 days, an increase of half a day.
ED visits related to suicidal thoughts were more likely to occur for patients from lower income communities compared to patients from higher income communities.
These patients were more likely to have Medicaid or to be uninsured compared to patients visiting the ED for other reasons, who were insured by Medicare or private insurance.
A workforce data analysis predicts a national nursing surplus of 340,000 registered nurses by 2025. But there is more to this story.
The United States is on the verge of a nursing surplus.
Yes, you read that right.
Data from the December 2014 report on the future of nursing issued by the U.S. Department of Health and Human Services, Health Resources and Services Administration, estimates that in 2025 there will be a surplus of 340,000 full time equivalent registered nurses.
"Assuming that Title VIII keeps funding the education and the colleges have faculty, if we keep getting 150,000 new nurses a year over 10 years, that's 1.5 million. [The Bureau of Labor Statistics] says the vacancies are 1.2 million," says Peter McMenamin, PhD, senior policy advisor and health economist at the American Nurses Association.
"It should be enough warm bodies to fill all the vacancies," he adds.
McMenamin edited and curated ANA's Nurses By The Numbers report, a curated source of federal data on RNs. But that number doesn't tell the whole story about the future of the nursing workforce.
Experience Needed
While there may be a national nursing surplus, certain geographic areas may experience nursing shortages, according to the HRSA data. Estimates project surpluses in Midwestern states such as Illinois and Minnesota while Western states such as California and Colorado will see shortages.
This infographic created by Nursing@Georgetown's Online FNP Program is a good visual on which states are projected to have shortages and which states will have surpluses.
While supply outpaces demand in many areas, it doesn't account for the loss of knowledge that will occur when nearly one million nurses who entered the profession in the mid-1970s and early-1980s retire, McMenamin says.
"There's going to be a tremendous human capital loss. That's where the shortage is. It's not a shortage of nurses. It's a shortage of experienced nurses," he says.
McMenamin encourages hospitals to take proactive steps to facilitate the transfer of knowledge from those experienced nurses before they retire.
"Hospitals ought to recognize that their most senior nurses are a valuable resource and that they might be able to extend their careers by offering some of them the opportunity to become mentors to new nurses," he says.
"If the hospitals hired a few more new nurses, we're not talking hundreds, we're talking a half a dozen or a dozen that they otherwise might not have, and then treat them well, bring them along, grow their own experienced workforce, then they wouldn't be confronted with the choice of either being shorthanded or trying to bid up wages from their neighbors across town."
Plan for the Future
It will take planning to address the loss of experienced nurses, but it can be done, McMenamin says.
"If you're in a kayak at the top of a whitewater rafting course, it is possible to get to the bottom and not capsize or hit the shore," he says. "But you can't do it blindfolded and you can't put on auto pilot. You have to keep your eyes open and adjust as things are going on."
There will be time to facilitate that knowledge transfer over the next few years. All retirements won't occur on December 31, 2024. They will happen gradually and can be dealt with through creative thinking.
"You can plan for weathering the retirements. It may give you sleepless nights every once in a while, but it should be manageable," he says.
"You have to think it through and have a long-range strategy, not jump at some whim and [think] 'I've got to hire people with 30 years of experience tomorrow. Where am I going to find them?'"
Moral distress among chief nursing officers is seldom acknowledged. Two researchers, both RNs, hope their work will help address the elephant in the room.
The concept of moral distress in nursing—the disequilibrium resulting from the recognition of and inability to react ethically to a situation—has been around since the 1980s, and it's been acknowledged that some bedside nurses experience it during challenging situations such as when there is a conflict surrounding end-of-life care.
But what about chief nursing officers? They aren't providing direct care at the bedside, but do they still experience moral distress?
The answer, according to a qualitative study published in the Journal of Nursing Administration in February, is yes. It's just taboo to talk about it.
"There's shame and isolation when you do have the experience, so it can make it very difficult for people to feel like they can openly discuss it," says Rose O. Sherman, EdD, RN, NEA-BC, FAAN, professor and director of the Nursing Leadership Institute at Florida Atlantic University.
Sherman is one of the study's authors. "I think that the other piece of it is, CNOs might not always label it as moral distress. But these are uncomfortable situations where they're making decisions against their values systems."
The Causes of Moral Distress
Through oral interviews, Sherman and her co-author, Angela S. Prestia, PhD, RN, NE-BC, discussed chief nursing officers' experiences of moral distress, including its short and long-term effects. Prestia is corporate chief nurse at The GEO Group.
The study's 20 participants described their experiences of moral distress, and several said they experienced it on more than one occasion. It was often related to issues around staff salaries and compensation, financial constraints, hiring limits, increased nurse-to-patient ratios to drive productivity, counterproductive relationships, and authoritative improprieties.
"For example, a physician went to someone over a CNO's head and said, 'I think you should pay a scrub tech more. She is very valuable to me," Prestia says. "And of course he was a high-admitter, high-profile physician."
The CEO approved the special compensation, creating a salary inequity among the other scrub techs.
In another scenario, six participants reported their CEOs had improper sexual relationships with staff members. Prestia points out that the CNOs did not object to these relationships because of religious or moral beliefs, but because they were harming productivity at the organization.
"In their [the CNOs'] mind' of right and wrong, these people had access to things that they should not have had access to and [those relationships] create barriers to getting the work of the organization accomplished."
Lasting Effects
The study uncovered six significant themes related to CNO moral distress:
Lacking psychological safety
Feeling a sense of powerlessness
Seeking to maintain moral compass
Drawing strength from networking
Moral residue
Living with the consequences
CNOs reported they often felt very isolated during the experience of moral distress.
"If they pushed back on a decision because they felt it was in conflict with their values they were isolated within the organization and they no longer felt safe. They weren't invited to meetings. They weren't included in decision making," Sherman says.
Even though they took steps to do what they felt was right—documenting meeting minutes, reviewing policies and procedures, and referring to The Joint Commission standards—to maintain their moral compass, those efforts were often unsuccessful.
"What happened was when they were in this situation… they were beat down at every turn," Prestia says. "Then the 'flight' started to set in. 'Maybe I need to leave? Maybe I should resign? Maybe I need to start planning my exit strategy?' Or before they could do that, they were terminated."
Moral Residue
Even once they were out of the situation, many CNOs reported the experience left them with a 'moral residue.'
"It is a lingering effect of the moral distress. I liken it to a fine talc that lingers on your skin and it manifests itself either physically or emotionally," Prestia says. "We actually had several participants say, 'When I get a call about staffing now in my new job, all of a sudden I get this feeling of impending doom.'''
Both Sherman and Prestia hope this research will open up a larger conversation about CNOs and moral distress. They will present their findings at the AONE 2017 conference in March.
"What we found in the work that we did was, clearly, collegial support from a strong network is very important in building one's resiliency and being able to deal with these situations," Sherman says.
"I think that having others who've been through it is very important, which is why forums that allow people to talk about this candidly, when a CNO finds him or herself in this situation, become critical."
Thanks to field research on workflow, ProMedica Toledo Hospital cut nurses' walking distance in half. Now they can spend more time with patients.
You don't know what you don't know until you know it.
That's the lesson leaders at ProMedica Toledo Hospital in Ohio learned during the design of its 615,000 square-foot patient tower set to 2019.
As part of the design process, the organization took part in research to identify and refine ways to improve nursing care and efficiencies, including distance traveled during a shift.
Architects from HKS, Inc., the firm designing the building, approached Alison Avendt, OT, MBA, vice president of operations, at ProMedica Toledo Hospital about doing the research.
"We have a building that we opened in 2008, so they wanted to look at how we were using the spaces [there], and get feedback from nursing on how it was working," Avendt says.
"That was really attractive to me because I heard we had issues with the building that we were in and there were many things that we wish we could have done better. I thought if we could do a good design diagnostic and learn something from that, it would really help guide our design work."
An Applesauce Moment
During two days of onsite observation, researchers shadowed ICU nurses and intermediate-level medical-surgical nurses. The researchers assessed the existing floor plan, used a parametric modeling tool, and created heat maps to provide a graphic representation of what a nurse's 12-hour shift looked like in terms of workflow and walking distances.
"One of the big [revelations] was around our whole process of medication passing," says Deana Sievert, RN, MSN, metro regional chief nursing officer and vice president for patient care services at ProMedica.
Observation revealed that a nurse reviewed the patient's medication administration record in the patient's room, walked to the supply room to get the medication from the Pyxis machine, and then often had to stop by the patient refrigerator to get something—like applesauce—to aid in the medication pass before walking back to the patient's room to administer the medication.
"It was something that was just so ingrained in our staff nurses' normal daily activities," Sievert says. "When they did the heat mapping it was like…'Wow. [There's a] big pinch point that we as staff nurses didn't really even realize was there.' "
Avendt says the researcher called this realization "the applesauce moment."
"Nurses are masterful at just making things work. There are a lot of things that the nurses knew were not value-added or were problematic, but they would just make it work," she says.
"It was really good to flesh out what those things were by observing because if you just ask[ed] them, the nurse would often not be able to verbalize what the problem was. But by seeing it, it came to light."
The architects used this information to design a unit that would cut down on walking time. Instead of a long corridor with a common area at one end, the unit was broken up into pods and supplies were located in multiple areas so nurses could get them from the location to which they were closest.
"We were able to take them from a three-mile journey on their shift to 1.5 miles. We cut in half the steps that they were taking," Avendt says.
After the tower opens, more research will be done to see how the design is affecting workflow.
"We've since learned that [field research] is not common for people to do. We paid a little bit of money to do that, but in the scheme of things it was well worth the investment," Avendt says.
"Everybody wants to give the nurse as much time as possible to be with the patient [and] try to take away the things that are not value-added in the nurse's day."