Leaning Away from Nurses

The politics of nursing care in Saskatchewan

For months, the Saskatchewan government has come under fire for its decision to subject the province’s health care system to lean management, which has its origins in the Toyota Production System and auto manufacturing in Japan. After spending over $40 million on the lean expertise provided by John Black and Associates, a U.S.-based consultancy that has pioneered the application of lean operations to the healthcare industry, health care professionals and unions have emerged as outspoken critics of the process. Dr. Ann-Marie Urban (RN), an Assistant Professor in the Faculty of Nursing at the University of Regina, provides insights to the consequences of lean on nurses and the politics of care.

Editor’s introduction

Leaning Away from Nurses: The politics of nursing care in Saskatchewan

By Ann-Marie Urban

In Saskatchewan, decades of restructuring and bed closures have had profound effects on the health care system. As a result, the largest group of health care providers working in hospitals, Registered Nurses has had to manage the hospital’s ongoing litany of problems. To add, cost cutting and efficiency agendas have resulted in production line caring and working chronically understaffed. All of which has been proven to contribute to injury and illness in nurses. The dominance of business values and hospital priorities clearly dictates nurses’ work. global-manu-promo

In 2007, shortly after the newly elected Saskatchewan Party came into power, the government commissioned Tony Dagnone to review the Saskatchewan health care system. In 2009, the Patient First Review report was released; detailing inefficiencies and areas for improvement. By 2010, most nursing units adopted Releasing Time to Care™, a program which applies lean methods and touted as a means of providing nurses more time with patients. However, in 2012, most hospitals discontinued Releasing to Time™ so that they could focus on Lean Leader training. Remarkably, after it was reported that more than $40 million had been spent on lean initiatives, little had been proven to influence patient care outcomes. At the same time, Premier Brad Wall professed lean strategies had saved Saskatchewan millions of dollars, yet the government lacks evidence on tangible outcomes (e.g. infection rates, medication errors, falls, health care employee absenteeism time). To add, Saskatchewan Union of Nurses, President Tracy Zambory raised concerns about the incongruence between the nursing process and the linear lean process; noting an increasing number of critical incidents and declining patient safety since the implementation of lean. While lean methods of improving efficiency and cost cutting strategies are important for hospitals and governments, again, they ignore the work of nurses.

An aging population with increasing chronic disease and social issues has resulted in higher acuity and over capacity situations in hospitals. These factors have influenced nurses’ work and the working environment in hospitals. For example, isolated patients require nurses to gown, glove and mask every time they enter a patient’s room; shortened wait times means that patients are being transferred from intensive care units and emergency to units that do not have the staffing levels to continually monitor patients; increasing social issues require supports so that patients can be discharged safely to their homes; bariatric patients require specific equipment so that they can be transferred safely; and an increasing pressure to expedite process has resulted in increased patient errors and nurses’ absenteeism. Nurses strive to put their patients first however because of ongoing hospital problems, they are frequently placed in situations where they lack the time, and the resources to care for patients in the way they would like too.

Although efforts to improve working conditions in hospitals have been attempted, substantial evidence reveals that hospital work environments contribute to injuries and illness in nurses. In 2011, the Canadian Federation of Nurses Union reported that Saskatchewan RNs continue to have one of the highest rates of absenteeism at nearly twice the rate of all of other occupations in Canada. Reasons for this include back problems, chronic pain and depression that interfere with nurses’ ability to do their work or cause them to require time off. Overtime, working short-staffed, heavy physical labour also contributes to nurses’ illness and absenteeism. While lean methods of improving efficiency and cost cutting strategies are important for hospitals, they often ignore the health of nurses. Strategies must look beyond serving only the needs of the hospital and governments; they must also support nurses to provide safe, quality patient care. Nurses’ well-being is important since, if they cannot work or if patient care is affected by their ill health, patients and ultimately all of us will be affected.

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8 thoughts on “Leaning Away from Nurses

  1. At Toyota, who use the lean or high participation process, the in house union works collaboratively with plant management. Collaboration with unions is just not part of the Sask. Party DNA

  2. The workloads are crushing in healthcare and ironically “change” is the only constant in this sector. But what this article and numerous others like it fail to acknowledge is that LEANdosen’t just impact Registered Nurses, but every single person who works in the system. SEIU-West represents Licensed Practical Nurses and Special Care Aides who are front line, hands on healthcare providers and a critical part of the healthcare team that is marginalized and forgotten in this article, and healthcare in general. Not everyone in healthcare is a RN; pull out LPN’s, SCA’s and Techs – and no one could do their jobs. Come on Rank and File – do you homework and write the article about the impact on everyone who works in healthcare – not just one classification

    1. I don’t think the writers of this article meant to neglect other union workers, I feel they mentioned registered nurses simply because the president of the SUN union issued a statement in regards to LEAN and the impact it was having on its members. I could be wrong but I haven’t seen a statement from any other union.

  3. Barbara, just to be clear, the article was drafted by an RN and Nursing faculty member at the U of Regina and is not a position established by the RankandFile.ca editors. We encourage you to write a follow up article for RankandFile.ca highlighting the points you raise here. There is certainly a lack of meaningful analysis regarding the impact lean is having on health care professionals throughout the system, and the media in the province has certainly focused on nurses and doctors above LPNs and SCAs. We look forward to publishing your contribution, should you or others in SEIU West wish to write a more comprehensive take on lean and the effect it is having on SEIU members in Saskatchewan.

  4. Lean, in any industry, has a deeply engrained philosophy that says, basically, “take care of the employees so they can take care of the customers.” In healthcare, we’d say “take care of the nurses and staff so they can take care of the patients.”

    Lean focuses on employee safety as a primary aim… improving ergonomics, making sure the right supplies and equipment are available, etc.

    Reducing waste in processes saves time for nurses… instead of racing around searching for supplies and equipment and meds, you have more time for patient care (a core thought in the TCAB methodology, which is Lean-based).

    Lean engages everybody and brings their ideas to the table.

    If nurses, in any hospital or province, are complaining about things like Lean increasing their workload, increasing their stress, not being listened to… whatever is happening around them isn’t really Lean, even if it’s being called that.

    (disclosure: I’m the author of a book “Lean Hospitals”)

    1. Rondelle – Yeah, if things are “authoritarian,” then that’s not Lean. There indeed might have been a “wrong turn.”

      I’m glad to hear things are going better for you in BC. Lean is supposed to engage everybody in improving care. It’s not about experts telling people what to do.

  5. Mark, based on your knowledge of the field, what’s your take on John Black and Associates? They have experience implementing lean in the U.S. – was their experiment south of the border a success? Did something go wrong in Saskatchewan or is the same debacle witnessed elsewhere?

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