It’s Not the Doing, It’s the Thinking: Supporting the Knowledge Work of Nurses

Last month, my mother suffered a fall, necessitating two surgeries. Her care was delivered by competent, caring, compassionate practitioners, yet as I watched, it felt like the system was completely conspiring against their success.

  • Care coordination was entirely absent. Every practitioner focused competently on their tasks and accountabilities, but no one looked at the whole picture. By the day of discharge, everyone seemed to have forgotten that this elderly “bedridden” patient had actually fallen on a walk one mile from her home.
  • Handoffs were a disaster. It ultimately required my calling the hospital quality department to get rehab orders four days after discharge! Unsurprisingly, rehab was hindered by her orthostatic hypotension after eight days of being bedridden.
  • Most notably, despite 30 years of using EHRs, everyone relied on their handwritten notes, and communication between clinicians was largely verbal. I watched as person-to-person-to-person communication devolved into the children’s game of telephone, where the message became increasingly garbled.

No wonder nurses are burnt out.

What’s most concerning is that my mom’s situation wasn’t unusual. As I shared my experience with a number of my colleagues, they all described similar experiences. Social media is replete with clinicians themselves lamenting the care their loved ones received. Repeatedly my mother’s caregivers lauded the fact that my sister and I stayed at her bedside and served as her advocates. In other words, we know that we work in a broken system that isn’t achieving our goal of delivering well-coordinated, quality care for our patients.

No wonder nurses are leaving hospital practice.

Many of us are striving to reimagine nursing, launching innovative solutions and new models of care to improve care delivery. Yet, I fear that too many of us are missing an essential point—redesigning around what nurses do, rather than what nurses know. We have lost sight of the fact that nurses are knowledge workers. The real work of a nurse is applying their unique professional knowledge and expertise to their patients and the system. And the only way they can do that is by having the time, information, interactions, and resources to support their knowledge application.

Yet, our systems are not designed for knowledge workers. They are designed for data collection, producing a task list, and checking off completed assignments. They are not designed for the relational connection and application of information about the patient in a way that is useful. I don’t mean just our EHR or information systems—I mean all of the processes of care delivery. The crisis we are in today provides a great opportunity to rethink our systems around knowledge work. The tasks will get done if we give nurses and other care providers the resources they need to easily access necessary information about their patients and coordinate care with each other and with the patient.

Let’s stop wondering and start talking about how we can support nurses in applying their knowledge to deliver excellence in care. Only then can we chart a path forward for nursing and health care.


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