Patient-focused care improved staff’s work environment

Annika Carlson, Majbritt Telander Dahlström and Birgitta Finsberg enter the foyer of the Stockholm City Conference Centre. It is a cool November day and they have left their work at surgical ward number 6 at the Karlstad Central Hospital to come and talk about their work method ‘Patient-focused care’. It has resulted in happier patients and employees who are so content that the ward’s sick leave levels have fallen below two percent a year. 

It is two weeks since they won a major work environment award at the conference ‘Gilla Jobbet’ (Enjoy Work). It was presented to them by the organisation Suntarbetsliv (healthy work environment), which brings together trade unions and employers to find ways of improving work environments using preventative measures. 

The annual award goes to a workplace which has demonstrated “impressive efforts to improve the work environment”. The motivation for this year’s prize was: “Building on strong, common values using a clear combination of practical solutions and individual needs, surgical ward number 6 at Karlstad Central Hospital in partnership with the Värmland county council presented impressive results and created the basis for a long-term sustainable workplace.”

“We are very pleased with this award. It is a confirmation that we are a good workplace, that we have a good team and good leadership,” says Birgitta Finsberg, a nurse who has worked at the surgical ward number 6 since the late 1990s.

Frustrating longing for patients

It all began with a visit to the dentist in 1999. Nurse Marianne Inde, who was section manager for ward number 6 at the time, sat in the waiting room leafing through a research report talking about the patient-centered care at a Detroit hospital. She became curious. She knew many nurses often talked about wanting to work closer with patients. Marianne Inde went to Detroit to look at their way of doing things and then started work to make ward number 6 more patient-oriented. At that time, their work was dominated by administrative tasks. The ward’s main office could receive up to 100 calls a day and the environment was stressful and confused. 

There were strict divisions between the roles of nurses and assistant nurses, and who did what was very important. As a result, many nurses felt they never reached their patients. Today, 15 years later, work looks completely different.

“People training to become nurses want to work with patients. That is the driving force and if you don’t end up doing it you feel bad. We make sure you are near to where the patient is at all times,” says section manager Annika Carlson, who also has a master degree in care. 

The first thing they did was to shrink the administration, starting with turning the ward’s main office into a reception area. Assistant nurse Majbritt Telander Dahlström was tasked with manning it, and she can tell you about people’s reluctance to restructuring, and what kind of upset a new division of roles between nurses and assistant nurses can provoke.

“I remember when we started with the reception. I felt under fire from my group, as if I had grabbed a new post. It wasn’t as common back then to do something different as an assistant nurse. But I had to do double shifts with the nurses for two weeks and learnt about their job. This new way of working has allowed me to develop a lot,” says Majbritt Telander Dahlström who is an assistant nurse at surgical ward number 6, where she has been working since 1997.

New roles for workers

Today the reception is the heart of the administration and staffed 24 hours. All calls go there and are passed on when needed to the responsible nurse. This is also where the triage system is managed — who is most in need of seeing someone, who should be discharged and which treatments should patients have during the day? At the same time nurses and assistant nurses are being organised in joint ward teams and each team has been given a small, open workstation in the vicinity of the patients’ rooms. This was not all easy — several nurses were worried about loosing prestige if they were made to do more of the assistant nurses’ jobs.  

“You used to talk about working “in” our “out”, which means with admin or with patients. This no longer exists. You are a nurse every day, or an assistant nurse. You work with what you are, no matter the task and it is all about taking what you do seriously,” says Birgitta Finsberg.

“Today patients are more ill and need nurses close at hand. We have taken admin away from nurses and they are closer to the patients. Before it was considered proper to work with papers and less proper to be “out”, but since the time of Florence [Nightingale] being a nurse has been about being near to the patients,” says Annika Carlson.

In order to create sustainable change, a lot of energy has been put into developing the softer parts of the business. Many new routines have been created to improve conversation on the ward. There is now a daily morning meeting led by the section manager where everyone meets to looks at what will happen that day and when. The meeting also decides what time in the afternoon everyone should meet for feedback — a meeting where they dissect the day, what has been good and what was less good. How was the workload for the three teams, for instance? And what can be improved the next day?

Set structures, not set routines

“Every day is structured depending on needs. In order to be flexible we have no set routines but set structures,” says Birgitta Finsberg.

Every third week there is also time set aside for common reflection. Because of all these opportunities for conversation, the gruff never gets a chance to collect, they explain. The team has also worked to create a forgiving environment. In health care there is a great fear of making mistakes, not least among new employees. They get to have supporting conversations every third week for the first three months. This is an emergency ward, the tempo is high and if you are not given support the stress an uncertainty can easily become a work environment problem.

“We have been talking a lot about the fear of making mistakes, and we have worked to get rid of that feeling. If something does go wrong you should know that someone will come to your aid,” says Birgitta Finsberg.

“We have been working with the term ‘good enough’, and how to handle stress. People in the group support each other. We have seen that new arrivals are happy, also with the support they get in reception,” says Annika Carlson.

There is little sick leave, below two percent, and the ward was recently granted a health certificate by the local county council. This means staff have the right to spend one hour a week doing physical exercise during working hours, and they get a gym membership. It can be hard to fit this in when you work on an emergency ward, but those who exercise outside of working hours can document this in order to take time out from their rota later. Work rotation is another health-promoting measure. Both nurses and assistant nurses are allowed to swap and broaden their tasks.

Leadership through surveys

Communication is central to the entire operation. Clear goals are being set and there is frequent feedback on what works, what doesn’t and why. Each year begins with a planning meeting where goals are presented and last year’s goals are assessed. The goals are then broken down into manageable, relevant plans which everyone understands and knows about. Everyone is included and is kept informed about what is going to happen, how it is to be done and everyone gets feedback about how the goals are being achieved. The organisation is in constant development. Using patient and worker surveys, everyone knows where the organisation is heading at all times.

“Feedback is key. If you don’t have that, many plans just fade away. What you want to introduce or improve must have an ending and a beginning which everyone is aware of. We measure much of what we do and I use surveys as part of my leadership — being able to prove that changes lead to results makes it easier to motivate and carry through different improvements,” says Annika Carlson. 

Leadership plays an important role and one of the cornerstones of creating patient-focused care is leaders being present in the workspace. From the very beginning the goals and value basis have been communicated to employees, and everyone has been sticking to what has been decided and feedback has been given. Both Annika Carlson and Majbritt Telander Dahlström describe how they sometimes have felt like nagging witches who squabble in order to stick to what has been decided. You have to have stamina to be able to constantly follow up things, explains Annika Carlson. 

“You need leadership on several levels too. Each person must lead him or herself. In reception, for instance, you need to have a mandate to make decisions about your own work, just like on the ward teams. If you want to influence and drive development, you must lead yourself,” she says.

Annika Carlson has also chosen to put together each day’s teams herself. She knows her colleagues, knows who might be going through a tough time or who is particularly tired, and she plans the groups and tasks with that in mind. At some periods in life you don’t have the energy or chance to make work priority number one, and there needs to be space to accept that.

“We meet people who are in the middle of a life crisis and that is quite demanding for our employees. That’s why we need to be able to find safety in our work and to show understanding of the fact that we are all strong or weak at different times. That’s how you get sustainable employees,” say Annika Carlson.

Work, but also fun

Back to the Stockholm City Conference Centre. Time has flown by and a conference organiser is hurrying them along. They are due on stage to tell their story about how good care and a good work environment go hand in hand.

“It is fun to get this award also because it proves we are not wrong when we think we’re good. It might also increase interest in our way of working in the hospital. It’s not always easy to get the message out at home,” says Birgitta Finsberg.

The 50,000 kronor award money will be spent on something good for the entire team. They know how to have fun both in everyday life and at parties.