Creating a New Tipping Point in Intensive Care

Abstract

Hospital work is unique. It is altruistic in nature, intellectually challenging, and important. The people drawn to it want to make a difference in the lives of patients who are increasingly vulnerable and frail. But there are few nurses or physicians who don’t find themselves quickening their pace when they walk into the hospital to begin a work shift. Increasingly, hospitals have become difficult places to work. As institutions, hospitals are traditional, bureaucratic, and hierarchical. The regulatory burden has grown exponentially, and few hospitals have figured out how to use information technology to reduce that burden. The “reengineering” (a code word for layoffs) of the 1990s, combined with current shortages in the healthcare workforce, has left many nurses and physicians—as well as other members of the team—with impossible workloads and a residual suspicion of hospital administration. Many healthcare professionals working in the hospital feel frustrated by the lack of interdisciplinary teamwork, stymied by the disciplinary silos and rigid roles, and exhausted by the daily workload. Regulation around the work hours of medical residents and clinical nurses, though welcomed by many as safer for patients and more humane for staff, has led to increasing fragmentation. Reduced hospital lengths of stay (with the national average being 4 days 1 ) means that, for nurses working outside the intensive care unit (ICU), 25% of patients are discharged every day and replaced by new patients—a turnover rate that may be only 25%, but one that feels like 50%. For nurses working in the ICU, the turnover may be even greater depending on the nature of the ICU. A culture of low expectations has evolved in many hospitals: everyone on the team comes to expect and accept impossible workloads, poor interdisciplinary collaboration, ineffective communication, and treatment errors.