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Nurses and Patient Loads: The Solution Lies in Process Change, Not Maximums

Posted on November 1, 2018 I Written By

Andy Oram is an editor at O'Reilly Media, a highly respected book publisher and technology information provider. An employee of the company since 1992, Andy currently specializes in open source, software engineering, and health IT, but his editorial output has ranged from a legal guide covering intellectual property to a graphic novel about teenage hackers. His articles have appeared often on EMR & EHR and other blogs in the health IT space. Andy also writes often for O'Reilly's Radar site ( and other publications on policy issues related to the Internet and on trends affecting technical innovation and its effects on society. Print publications where his work has appeared include The Economist, Communications of the ACM, Copyright World, the Journal of Information Technology & Politics, Vanguardia Dossier, and Internet Law and Business. Conferences where he has presented talks include O'Reilly's Open Source Convention, FISL (Brazil), FOSDEM, and DebConf.

Shortages of clinical staff plague communities around the world. Even my state of Massachusetts, a medical Mecca, has a shocking dearth of professionals in mental health. Health care reformers understand that shortages much be addressed through a careful and deep investigation into the hospital and clinic processes and practices. Streamlining processes through data analytics and the deft application of new technologies for monitoring and recording information will probably help.

Nurses probably experience the crunch of patient loads more than other staff. Unfortunately, some of them try to force a quick fix on their institutions through mandatory maximums. They ignore process, ignore holistic systems thinking, and ignore the potential of technology. Massachusetts is facing just such an ill-planned effort right now in a ballot question that would fix arbitrary patient loads. The public is being asked to regulate an area that can’t possibly understand. (The inscrutable text of this ballot question, number 1 on the ballot, is available about one-quarter of the way down this web page.) But Massachusetts was not the first to face this choice, and will probably not be the last.

In 2003, California passed limits on patient loads that are somewhat of a model for the Massachusetts law, and whose effects are hotly debated. Texas apparently considered a similar law, but I assume it went nowhere because I could find no other reference to it. Massachusetts has a law applying narrowly to emergency rooms, and every state has regulations for nursing homes.

Nurses don’t have it easy; that’s clear. But the solutions must be systemic. Opponents of Massachusetts ballot question 1 point to all kinds of negative effects that the proponents refuse to consider, such as the loss of non-nursing staff who are crucial to helping the nurses get their jobs done. The basic problem is that hospitals and other facilities are not making use of the computing advances, and related process improvements, available in this year 2018.

Health care giant Kaiser Permanente found that clinicians were spending 15 to 40 percent of their doing “hunting and gathering” for supplies before the company optimized its supply chains. The Boston Globe cites numerous management techniques that free up clinicians’ time, some right in Boston. A 2011 NIH report found that nurses spend only 37% of their time taking direct care of patients. Of course, other activities such as administration and documentation are important, but they are begging for process improvement. Partners Health Care has embarked on a large-scale effort to automate repetitive, “soul-crushing” work, and have found that staff are much happier and are spending more time using the skills they were trained to use in handling people issues. Currently, the effort affects HR, finance, and operations. I’m sure nursing would turn up opportunities for improvement when it comes their turn.

We shouldn’t have to spend 35% of nurses’ time on documentation, using systems that are notoriously inefficient and poorly automated. A recent survey showed that most doctors believe that automating common tasks such as documentation could improve clinicians’ efficiency. Nurses use the same systems, so their workloads could probably be reduced through similar improvements in technology.

Some nurses tell me, “Much of our job involves a human touch; it can’t be automated.” The NIH study shows that plenty of tasks that are amenable to computerization, and doing so will give nurses more time to apply their human touch–or as health care workers like to say, “work at the top of their license.”

The proponents of the Massachusetts ballot question count on a knee-jerk distrust of corporations (or at least of large health-care institutions). They have succeeded in winning over many people who call themselves political “progressives,” but a large segment of the Massachusetts public–according to polls, a slightly larger segment–intrinsically sense the ballot question’s flaws, so the polls are running against its passing.

We cannot improve health care and reduce costs if institutions take the status quo for granted. Voting “yes” on question 1 in Massachusetts would accept and perpetuate the assumptions behind our nursing practices. It’s hard to accept that profound systemic problems will take time and data to ameliorate, but the sooner we face that realization, the better we can deal with our clinical staffing problems.

Mandatory Nurse Ratios – Good for Massachusetts?

Posted on October 18, 2018 I Written By

Colin Hung is the co-founder of the #hcldr (healthcare leadership) tweetchat one of the most popular and active healthcare social media communities on Twitter. Colin speaks, tweets and blogs regularly about healthcare, technology, marketing and leadership. He is currently an independent marketing consultant working with leading healthIT companies. Colin is a member of #TheWalkingGallery. His Twitter handle is: @Colin_Hung.

On November 6th, Massachusetts will vote on mandatory nursing levels. Proponents cite burnout, injuries and patient safety as reasons to vote YES. Opponents claim ERs wait times will rise, small hospitals will close and patient bills will increase.

There is no better way to get a sense of what is on the minds of healthcare leaders than talking with fellow conference attendees. At the recent SHSMD18 event, I had the opportunity to attend a social gathering hosted by the New England Society for Healthcare Communications (NESHCo). There was one topic that dominated the discussion – the upcoming vote on November 6th on mandatory nursing levels in Massachusetts.

Mandatory nurse ration has been a hotly debated issue in the state. Voters will now decide if the state will forge ahead with plans to “limit how many patients could be assigned to each registered nurse in Massachusetts hospitals and certain other health care facilities.”

The proposed MA law sets specific limits on the patient-nurse ratio. For example:

  • 3 patients per nurse in units with step-down/intermediate care patients
  • 1 patient under anesthesia per nurse in units with post-anesthesia care or operation room patients
  • 5 patients per nurse in units with psychiatric or rehabilitation patients

The vote has pitted the Massachusetts Nurses Association (the nurses union, MNA), which strongly supports mandatory nurse ratios, against the Massachusetts Health and Hospital Association (MHHA).

The MNA cites numerous studies, like this one from 2016, that shows for every patient added to a nurse’s workload, the likelihood of a patient surviving cardiac arrest decreases by 5% per patient. And  this one from 2017, that concluded “Exposing critically ill patients to high workload/staffing ratios is associated with a substantial reduction in the odds of survival.”

The MNA has mounted a sizeable campaign to convince MA voters to vote YES. Their website, is full of interesting articles, stories from frontline nurses and quotes from physicians that support the measure.

The MHHA, on the other hand, is encouraging a NO vote. They acknowledge that nursing levels need to be monitored but imposing strict limits based solely on the unit or patient type will cost nearly $900 million every year. According to the MHHA, patients would end up footing the bill through higher healthcare costs.

The MHAA also claims that specifying the maximum number of patients for each nurse, effectively puts a cap on the number of patients a hospital can accept in their ERs – resulting in longer wait times.

For an excellent overview of the law and the arguments both for and against Question 1, check out this excellent article by Boston’s local NPR station – WGBH. The article also has information about the impact mandatory nurse ratios has had in California which enacted a similar law back in 1999.

What I found fascinating about the discussions with NESHCo members was how hospitals in neighboring states were also voicing their concerns on Question 1. If MA was to mandate nursing ratios, that state’s hospitals would suddenly need to hire thousands of nurses in order to comply with the new law. Where would these nurses likely come from? You guessed it, neighboring states like New Hampshire, Maine, Vermont and Connecticut. It’s easy to see why hospitals in those states would be worried.

I honestly don’t know which way I would vote.

On one hand the current working condition for nurses is unsustainable. Nurses are often asked to work longer shifts because hospitals can’t fill open nursing positions fast enough and most are expected to work without breaks. Could you imagine working 12hrs or more without being able to eat or go to the restroom? 70% of nurses are already feeling burnt out in their current positions. Clearly the status quo isn’t working.

On the other hand, there is currently no provision in the law to adjust the nursing ratios as technology advances. New York Presbyterian Hospital, for example, has built a remote patient monitoring center that tracks patient vitals in real-time. Using a combination of AI, specialized technicians and remote nurses, this “command center” can alert the local nursing staff when a patient may be experiencing an issue. Armed with this technology, not only are patients safer but on-site nurses can spend more time with each patient in their unit. The MA law would have the unintended consequence of squashing investment in this type of technology since staffing levels could not be significantly adjusted.

For more on this topic, take a look at the transcript for this week’s HCLDR chat. Government regulation is also the topic for this weeks’ #HITsm chat hosted by John Lynn. Join the discussion Friday 10/19 at noon ET.

Nurses need help. Mandatory nursing ratios is one possible solution. However, I’m not sure legislation is the best way to improve the nursing situation.

National Nurses Day Tribute

Posted on May 6, 2013 I Written By

John Lynn is the Founder of the blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of and John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

Today is National Nurses Day and this week is a celebration of all the amazing nurses in healthcare. I think nurses are the unsung heroes of healthcare. They do an extraordinary job and get very little recognition.

When I think about EMR in general it impacts nurses as much or more than anyone in the clinic. Yet in most cases, nurses have very little involvement in the EMR purchase process. Sure, most places do some sort of meeting with the nurses and they take a little feedback from them, but from my experience they have little involvement in which EMR is chosen.

This means that most nurses just have to deal with whatever EMR their clinic or hospital chooses. Most of them do it with the grace of a nurse.

My favorite nurse story comes from my experience with this wonderful nurse I worked with named Shelley. She is a vivacious and passionate nurse that loved her job. She wasn’t afraid to tell you what she really thought and had a heart as big as I’ve ever seen. Plus, she gave the best bear hugs!

When it came to the idea of going to EMR, Shelley was one of the biggest critics. She was not looking forward to the change and was vocal about it. Despite her and others fear of EMR, we pressed forward. One of the very first days after we implemented the EMR I came into the nurses station where I saw one of the nurses struggling with some EMR function. Next thing I know, EMR averse Shelley is reaching over the nurse’s shoulder and teaching her how to fix her EMR problem. It became a kind of running joke in the clinic that Shelley could go from EMR critic to EMR trainer.

I think this highlights the beauty of so many nurses. First, the ability to adapt to challenging situations. Second, the concern and care for fellow nurses and patients. Shelley was such a great representative of nursing to me.

On this National Nurses Day, I want to honor my friend Shelley and all the other caring, professional, wonderful nurses out there. This video from RWJF highlights the greatness of nurses.

Food Brings Clinical and IT Together and Other Clinical-IT Perceptions

Posted on August 8, 2012 I Written By

John Lynn is the Founder of the blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of and John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

I’ve gotten quite the response from my post about Hospital IT and Nursing Perceptions on EMR and HIPAA. Since many of you don’t read all the comments (particularly those that are sent to my by email or left on other social media), I thought I’d share a couple of them that I found worth sharing.

First up is what I think is an eternal principle: FOOD!

As an Rn who spent most of 30yrs in IT thus works well:

Advice for Nursing: Sent Pizza
Advice for IT: Bring Doughnuts

Then take the time to listen. Ya gott’a have Big Ears!!!!!!!!!

Since I’m an IT Guy by background, I can assure you that I’ve done amazing work on the back of doughnuts. Although, I think Pizza would have worked for me as well, but it’s hard to beat a great doughnut. I do like the final comment though about listening. I always love “breaking bread” with someone because then you have something special that remains with you after the fact. Plus, I have a great memory and so once I’ve shared a meal with someone I will never forget them (their name maybe, but never them).

This next opinion is a bit stronger (and possibly more cynical), but I hope will start some really good discussion.

I’ll tell you I’m a former clinical lab person who moved to IT, so I have a warped sense of nursing and their perception of their purpose in life from way back.

IT’S PERCEPTION OF IT: We’d be more than happy to double our personnel in order to halve our response time if administration would fork over the budget for it. We have done everything we can think of to speed response time—help desk carries the phone with them at all times so they can answer it regardless where in the hospital they are, we have the capacity via VNC to spy on a session so the person doesn’t have to wait for us to walk over to the nursing unit to see what is going on, and more. If the people other than help desk are not on the phone, they get the call when it is forwarded.

IT’S PERCEPTION OF NURSING: Nurses are control freaks with OCD issues. We have a computer every four feet along every wall in every nursing station, in every patient room, and on wheels so they can be taken anywhere they want. They decide which one they are going to use for the day and, if it dies, they cannot be pried away to a different device. THEIRS is broken. And they have no idea that electronics are part of patient care now, not just an add-on to their work. Too many cannot comprehend that because they don’t feel like scanning a patient armband before giving them meds, it is okay to get the computer off their back by scanning anything with the patient number on it instead—a marvelous way to circumvent patient safety aspects of computerization.

If nursing (and physicians, too, for that matter) spent as much energy deciding they were going to learn how to most efficiently use their electronics as they do complaining about them, there wouldn’t be extra time taken away from patient care. It would become a break-even proposition.

One thing is absolutely certain: it’s not an easy task to bridge the IT and clinical divide. I bet a great book could be written on the subject.

Perceptions of Hospital IT and Nursing

Posted on August 3, 2012 I Written By

John Lynn is the Founder of the blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of and John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

In response to my post about the Old Boys Club of Healthcare IT, David Allinder, RN offered these interesting perceptions of IT and nursing. These are generalizations, but worth considering:

PERCEPTIONS OF IT: The IT department is sealed behind coded doors locked away from patient care. The only way to contact them is by calling the help desk (which usually doesnt). Time is taken away from patient care to sit on hold for what seems like forever. And then after you define your issue they say let me contact the IT person they will call you back.

PERCEPTIONS OF NURSING: Nurses are control freaks with OCD issues. No one had better mess with my unit, pateints, processes, workflow. Nursing is sitting in a hallway with opened desks with call lights and phones constantly ringing they are there to respond instantly to demands and requests. Nursing are at the bedside taking care of patients. Electronic devices take too much time away from the patient care. I cant do my job because the stinking computer is broken AGAIN.

Don LeBreux summarized my feelings on the above comments, “Your “perceptions” are basically dead on. Funny and sad.”

What strategies have you seen that work to bridge the divide and overcome these perceptions?