Keeping up with the nurses

I received quite some response on the blog on nurses who run the hospital. It appears that to several people who are a nurse or represent nurses it felt like some kind of recognition or appreciation for what they do. Nevertheless, the fact that nurses ‘run’ the hospital is not necessarily good news. It means that nurses have a lot of activities that are not ‘nurse related’, such as stock management, administration, walking around to pick up materials from elsewhere, transporting patients, calling doctors or other nurses multiple times a day, transferring patients to others. Given the fact that there is a large shortage of nurses, as has been in the news in the Netherlands for quite some time, it seems quite obvious to do something about this.

For my research I observed two nursing wards and I joined nurse Alice in doing her work. Besides the logistical activities I saw her doing, I was struck by another thing. Process researchers or consultants tend to model healthcare processes as a linear series of activities. Below you see what process a surgery patient goes through on the nursing ward: 10 consecutive steps in time (from left to right). This takes place within one day or during multiple days, depending on the type of surgery.

patient proces

This process is not like this at all for nurse Alice. She is doing every step of the way in an order as presented below, or in another order as this is just an example. First the intake for patient 1 takes place, then the intake for patient 2, 3 and 4 and then she receives a call from the nurse anesthetist saying that patient 2 should have premedication now, then the call for patient 1 comes in, then for patient 2 and 3. And so on. The 10 steps are executed for, in this case, 4 patients, in a sort of random order. The order is not fixed as all steps are triggered by other agents than the nurse: the patient (arrives at some point), the nurse anesthetist (calls at some point), the recovery nurse (calls at some point).

nurse process2

Nurses therefore constantly shift between tasks. In factory terms: they have changeovers. I assume this costs valuable time as well. Even if we were to consider a nurse as a machine (which of course is a bit insulting and untrue, because I don’t think machines are as empathic as nurses to name only one thing), we could state that even machines need changeover time. So why not nurses?

What nurses do to manage their work, is to look for information or any sign to make the sequence of events predictable and keep changover times short. They look at the surgery program every 5 or 10 minutes, they call people all day, they ask their colleague who has just been at the Recovery about how other patients are proceeding in the process. Alice who is a experienced nurse had all sorts of signs she would constantly be looking for to make work more manageable. What a job. A bit confronting as well I must say. As I was walking along with nurse Alice and other nurses, I could not keep up with any of them, whether they had long or short legs. Apparently this is part of their training, as someone confided to me: walk fast all the time, but don’t make it look like running.

Centralization without hierarchy: a ground for organizational firework?


Happy new year! These fireworks are in fact nine social networks for nine tasks that are performed in order to do surgeries for patients. The entire network in my previous blog is built up from 23 social networks, one for each task. Tasks are for example: making the master schedule for the operating theatre (OT), admitting the patient to the ward or performing the surgery. The networks shown here all show centralization. Centralization is the extent to which a set of people are organized around a central person. This is seen in the networks here as one or a few persons in the middle, surrounded by people who interact with the central person(s).

You might expect that these central persons have a hierarchical position towards the others; that they are the boss who ask or instruct people to do things. This is not the case. In most cases in these networks the persons in the middle have no hierarchical position towards others whatsoever. The central people in the networks shown here are the OT day coordinator and the OT capacity planner, logistical staff, secretaries and nurses. In fact the people who do have formal power, in the organizational structure of the hospital, do not have central positions in the operational system of the hospital I studied.

So, not only is the hospital run by people in the operational system itself – mainly by nurses -, it appears that the operational system functions largely on its own, independent or loosely connected to management. This reminds me of one of my first blogs in which I was amazed at the unexpected and undesirable outcomes of strategic transformations of hospitals. I am wondering if it is true that management knows so little about how the operational system works that strategic decisions can lead to unpredictable outcomes. They are not able to observe the operational system and data on the operational system do not always seem to represent reality (see previous blog). This has little to do with competence, but rather with the impossibility to oversee the operational system. And perhaps this applies to all of us, people not working in this operational system. And does it also work the other way around? Do people working in the operational system know what other interests (financial, legal, ethical, technological etc etc.) are at stake besides treating the patient? I think connecting the strategic and operational reality is one of the most important challenges of our time. In 2019 I will make a further attempt to make some kind of contribution to that.