UK: Nurses Struggle to Get Their Work Done; Dissatisfaction Soars, Quality in Jeopardy?


Screen Shot 2013-02-06 at 7.29.26 AMI recently saw this headline in the London Evening Standard: “Nurses struggle to ‘get the job done' due to staff shortages and lack of time on 12 hour shifts.” The article starts with jumping to solutions (needing/wanting more staff), but the problem statement is what we should focus on – and it's an important one:

…almost nine in 10 nurses said that at least one “necessary activity” was not done on their last shift due to lack of time – despite the average shift lasting for 12.8 hours.

This is something I've seen a lot of in American hospitals, as well. Let's presume “necessary activity” means “value” to the patient. Necessary activities that don't get done might commonly include:

  • Not doing hourly rounding (which can lead to falls or patient dissatisfaction)
  • Not repositioning patients every two hours if they are at risk for bed sores
  • Not giving medications at the proper time

Nurses generally know what they should be doing. But, when the system is designed poorly (or was just allowed to evolve instead of being designed) and there's too much waste, job satisfaction (of course) suffers:

Research, conducted by the National Nursing Research Unit, found that two fifths of nurses are dissatisfied with their job, with 44% saying they would leave their job if they could.

From the article again:

In wards where there were fewer patients to care for, nurses felt more satisfied with their jobs.

Nurses who had to care for fewer patients were also more likely to say that patient safety was good or excellent.

Adding more nurses isn't likely to happen in countries that are struggling to pay for healthcare (which seems true in the UK, with the rounds of cost cutting).

If you had the money, adding nurses MIGHT be an acceptable “short-term countermeasure” as my former Toyota friends might call it. It's not the ultimate answer and it's not the solution to the root cause problem, but adding nurses might better serve patients (safety and quality first), but that's probably not the most affordable way to solve this problem. That said, if you ONLY wanted to look at the financials and ROI — if the cost of increased nursing care was less than the money saved by preventing things like falls, pressure ulcers, and infections, then it might make sense to increase staffing. But, with a cost-cutting view of the world, leaders are hesitant to spend money to save money.

I've seen way too many nursing units where staff are stressed and patients aren't getting the best possible care… it's no shortage of caring… it's a matter of too much waste.

We HAVE to fix systems and reduce the waste – that's where Lean comes in. Virginia Mason Medical Center has systematically reduced waste to free up nurse time and more than DOUBLE the amount of time they can spend at the bedside. That's the equivalent of hiring twice as many nurses, but it's far less costly.

The NHS has its Lean-based program of “Releasing Time to Care” – but it's not as universally effective as the VMMC approach? RTTC is supposed to be addressing this and the program has been going on since at least five years (it was being rolled out when I worked in England in 2008).

Back to the problem statement:

42% of nurses are suffering from emotional exhaustion, with male nurses showing more signs of a “burnout” than their female counterparts.

More than a third of nurses said that important care information is often lost during shift changes and more than half think that “things fall between the cracks when transferring patients from one unit to another”.

We need to fix this – not just England, but the U.S. as well – because the patients and the nurses are suffering.

What is your hospital doing to reduce waste and to ensure that things aren't falling through the cracks in patient care? How are your leaders driving improvement? How are they managing the system each day to make sure the right things are being done the right way?

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Mark Graban
Mark Graban is an internationally-recognized consultant, author, and professional speaker, and podcaster with experience in healthcare, manufacturing, and startups. Mark's new book is The Mistakes That Make Us: Cultivating a Culture of Learning and Innovation. He is also the author of Measures of Success: React Less, Lead Better, Improve More, the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, and the anthology Practicing Lean. Mark is also a Senior Advisor to the technology company KaiNexus.


  1. Mark
    Thanks for the post above. I believe your observations from both the article and experience are rampant in hospitals, CAHs and hospice facilities across the US. I too have seen the frustration, turnover and HCAHPS numbers dive as census increases and traditional cost (head)cutting shops prevail. The CNO at a hospital in TX recently described it as being trapped in an unending game of whack-a-mole. Just when she feels in a position to look at process strategically, crisis emerges and all hands are on deck, overtime is authorized, agency resources are deployed…you know the rest. In a plea for help, the hospital has chosen to take a concerted approach to attacking any all activities (value added or not) from a work balance perspective. While nurses are more than qualified to do the many tasks that consume their 12.8+ hr days, there remains a population in the organization (some 20% or more) that DO have availablity and capability. Installing the STD Work and ANDON, while uncomfortable for those being asked to relinquish some duties (and OT), is proving to be very effective in driving improvement in both Patient and RN satisfaction.

    • Hi Michael – thanks for reading and commenting.

      Yes, you’re right that some nurses (and techs) do have some extra availability from time to time. It seems that no matter what method is used to assign workloads, patients get discharged, their conditions change, etc. and workload is never evenly balanced.

      The best systems I’ve seen have created visuals or other mechanisms for nurses to signal if they are red/yellow/green in their workload at the moment. They’ve worked to create an environment where it is OK to honestly report your given status and nurses or techs actually help each other out based on the signals or they even reassign patients in the middle of the shift — as a team-based decision.

  2. Good post, Mark. Interestingly, one enlightened hospital CEO continues to retain me in every hospital he moves to focus on “stop doing” activities so nurses can spend more time at the bedside doing the work they went into nursing to do, and produce higher quality. It works like a charm. When you dig into everything a nurse dose throughout a shift, we often eliminate 20-30% of the time they’ve been spending that’s 100% non-value adding. Even 5S’ing a unit can free time. Borrowing from Matt May (The Laws of Subtraction), subtracting is key. Not adding.

    • Yes. I ran into another situation where “productivity” was a dirty word to some physicians. But, they cringe because they associate the word with “work harder” (often with completely unrealistic expectations).

      The beauty of Lean, of course, is that productivity means eliminating waste and making work easier and less frustrating thanks to better systems and processes. Then, productivity isn’t a dirty word and seeing more patients is OK, if not enjoyable, rather than being a burden.

  3. Saw this yesterday:

    Hospital scandal rocks Britain’s National Health Service

    British Prime Minister David Cameron this week issued a formal apology for the National Health Service (NHS) after a report revealed “truly dreadful” patient care at an English hospital.

    The report-which examined conditions at Stafford Hospital in Staffordshire from 2005 to 2009-was prompted by the Healthcare Commission, which oversees NHS care and became concerned with unusually high mortality rates at the hospital in 2007.

    It cited myriad examples of atrocious patient care, including patients who were:
    – Left unbathed and lying in their own filth;
    – Denied medication;
    – Left without food or water;
    – Developed infections due to unsanitary conditions; and
    – Sent home to die after receiving an incorrect diagnosis.

    “This is the story of the appalling and unnecessary suffering of hundreds of people,” said Robert Francis, the lawyer tasked to lead the government inquiry. He added that it would be impossible to determine how many patients died because of the substandard care at the hospital.

  4. I have been a user of the services of the NHS for the past 16 years that I have been living in the UK. I can compare the NHS to the healthcare systems of USA and France – the two other countries I have lived in.

    I am also trying to change the mindset and culture of my own business to “lean thinking”. As the owner of my business, a restaurant and hotel with 20 employees, I am finding it difficult to make the change. However, the early results are amazing.

    The NHS employs nearly 1.5 million people. This is about the same amount of people on active duty in the American military. Many in the NHS are dedicated and are the best in the world. You can understand why most British people treasure the NHS enough to feature it in the opening ceremonies of the Olympics.

    As a large and political organisation, there are many entrenched interests which are not congruent with the best interests of the patient. Several UK governments, including the current one, have tried to make changes to the way the NHS operates. After 60 years of operating as it has, most staff realise that they can just wait for the current changes to ebb and brace themselves for the next wave.

    I my business, just getting the staff to see things from the customer’s perspective is often more difficult than I expected. I am sure you can imagine in a huge organisation like the NHS, viewing things from the patient’s perspective is even harder.

    I believe that healthcare in all countries is a limited resource. In the USA, it is rationed based on who can pay for it or it is rationed by insurance companies bureaucracy. In France and UK, it is rationed by government or organisational bureaucracy. On neither side of the Atlantic, has anyone truly confronted this situation. I have personally experienced waiting to be treated.

    If the NHS were to truly commit to lean, it would be a gigantic undertaking. I believe that if the NHS could undertake this, it would become the model for the world. I fear, however, this is a step too far with the current leadership, culture and structure.

    There is mura in any large entity. As poor as the hospitals were in Staffordshire, I was eternally grateful that when my eight week old had his surgery in Great Ormond Street hospital. It was an excellent experience.


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