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

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.

About the author

Andy Oram

Andy Oram

Andy Oram writes and edits documents about many aspects of computing, ranging in size from blog postings to full-length books. Topics cover a wide range of computer technologies: data science and machine learning, programming languages, Web performance, Internet of Things, databases, free and open source software, and more. My editorial output at O'Reilly Media included the first books ever published commercially in the United States on Linux, the 2001 title Peer-to-Peer (frequently cited in connection with those technologies), and the 2007 title Beautiful Code. He is a regular correspondent on health IT and health policy for He also contributes to other publications about policy issues related to the Internet and about 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.

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