On White 10, a 20-bed general medical unit at Massachusetts General Hospital that's participating in the Transforming Care at the Bedside (TCAB) initiative, we're experimenting with ways to improve the hospital experience for patients, families, and staff. In the November and December 2008 issues I related the experiences we had implementing our first test of change, having nurses present clinical snapshots of their patients in morning rounds. Confident of our progress, we decided to tackle the next initiative—scheduling hour-long, off-unit meal breaks for day-shift nurses. This change, like the first, required a shift in the culture, and it didn't happen overnight. Surprisingly, our biggest barrier wasn't finding coverage for patient care but rather the nurses' own reluctance to take an hour-long break. Overcoming that resistance wasn't easy.
The off-unit meal break idea had emerged at the brainstorming retreat we'd held before launching TCAB (see Transforming Care at the Bedside, October 2008). For more than two years staff members on White 10 have worked 12-hour shifts, an arrangement they say lets them better balance their work and life demands. For patients, the 12-hour shifts minimize handoffs, and they say they appreciate the enhanced continuity of care. However, the shift's length makes it vital that the nurses take breaks in order to reenergize. They seemed to be running throughout the shift, and we thought it was important for them to care for themselves as well as for their patients.
In the past our nurses had considered meal breaks a luxury—something we were always too busy to take. Everyone was supposed to take a half-hour meal break and two 15-minute breaks during the shift, but the reality was that the 15-minute breaks were routinely skipped and meals were hurriedly eaten in the unit's cramped break room in between responses to frequent patient calls, phone calls, and overhead pages. There was no predefined time for meal breaks, and nurses weren't accustomed to passing off their patients to others for coverage. Nurses were rarely able to get to the cafeteria because they didn't have enough time to walk there, get their food, and then return to the unit; 30 minutes just wasn't enough.
Before instituting this change, we stressed that everyone had to participate to give it a fair chance. The new arrangement would, we hoped, help staff members feel refreshed and less fatigued, which would lead to greater job satisfaction and improve patient care. We planned to use focus groups to determine if the change was a success.
In keeping with the TCAB approach to first conduct small tests of change within the unit—"one nurse, one patient, one shift"—before rolling them out to larger groups, we decided to try the one-hour, off-unit meal break with the typical complement of eight nurses on the day shift. There would be two different meal breaks, one immediately following the other, with the resource, or charge, nurse asking the nurses which break they preferred and then assigning half of the nurses to each one. A new assignment list would be posted at the nurses' station each day.
Before taking their breaks, nurses were to check on their patients to make sure they were comfortable and to take care of their immediate needs and then report off to the nurses assigned by the resource nurse to cover their patients. No additional staff would be provided, with the number of nurses on duty during breaks simply decreasing to the night-shift level of four.
BREAKING OLD HABITS
We went "live" after two weeks of planning, and I quickly recognized that it would be a little more difficult than we'd thought. Once again, we were asking for a cultural shift. To support the staff during the first few days, Susan Kilroy, MS, RN, the unit's clinical nurse specialist, and I helped the resource nurse make break assignments, reminded the staff to plan the break into their day, and answered patient call lights during break times. Although all the nurses had been informed about the change at our weekly TCAB meetings and by e-mail, a few looked at me quizzically when I told them they would be taking their meal breaks off the unit. Everyone had agreed that it was a good idea during the planning phase, but when it was time to leave, no one felt they could. As the resource nurse and I tried to help them pass off their patients on the first day, the anxious and frustrated nurses responded with statements like "I couldn't possibly leave the unit today," "I promise to try this on another day," "Do I have to go for the full hour?" and "If I take a lunch, do I have to go off the unit?"
Their resistance surprised me. I reminded the nurses of the pact we had made to give each test of change a fair chance for a week or two. If it wasn't working and could not be adapted, we would abandon the change and move on to our next TCAB test. We knew that not every test would be a success, and that we could learn much from even those that didn't work.
After the first day the anxiety and resistance began to subside, and the nurses ended up selling the idea to one another. All it took was one break away from the unit for a nurse to support the idea. Staff nurse Carol Wicker, BSN, RN, CMSRN, typically the unit's enthusiast, was reluctant at first. She recalled, "I already felt challenged to complete everything on time, and I saw this as a barrier. I couldn't even try it on the first day, but by the second day I did because of the pact we had made as a team. When I returned to the unit after lunch I realized I hadn't yet been away a full hour. The second time I was able to kick back and enjoy my meal. My husband even met me one day and we had a picnic lunch on the campus lawn. After that, you couldn't keep me from doing it."
She also made another important observation: "The last day I worked was Saturday and we—we—went outside. Three other nurses and I made a date to go out and have lunch together. Now, that was fun. It wasn't just about me, it was really about interacting and socializing with my colleagues, and we didn't talk about work. I think that was the whole essence of this change, and I finally got to experience it."
We used the weekly TCAB meetings to conduct our focus group discussions about the change. Reflections like Carol's were common. The nurses talked about feeling as if they were just arriving for the day, refreshed and ready to go, when they stepped off the elevator upon returning from their meal. Another nurse, Emmanuela Paul, BSN, RN, CMSRN, said, "The morale on the unit seems better, and I think it's related to the lunch breaks."
I detected a stronger sense of camaraderie, community, and teamwork. Nurses were depending on one another more, offering and asking for help. Conversations over shared breaks were about getting to know one another on a more personal level.
To try to keep the meal breaks on track, we suggested that the nurses use "positive peer pressure." The second-break nurses would encourage the first-break group to break on time by asking what they could do to help them pass off their patients, and the first-break nurses reciprocated upon returning to the unit. This worked very well.
Of course some days were more challenging than others. When I reminded nurses on very busy days that it was nearing time for their breaks, they often said that they were just too busy to leave the unit. I'd reply, "This is the perfect day to make sure you take a break. We'll watch your patients." After about three weeks the nurses were accustomed to the new routine, and within two months it was part of our culture.
One day our unit-based case manager, Abbey Riley, BSN, RN, commented on the progress our team had made in this test of change. She had often eaten lunch in the break room with the nurses and said, "Before the change the nurses were rarely able to take a full break. They were often interrupted, and it wasn't good. I am glad they are trying to consistently go off the unit." The new routine had no effects that I'm aware of on physicians or other hospital personnel.
Having day-shift nurses take one-hour, off-unit meal breaks has been positive for the unit. We made the change a year ago and now the nurses don't need prompting and never skip a day. (Our night-shift nurses try to take hour-long meal breaks, but they stay on the unit.) They say that of the TCAB changes we've instituted, this is among their favorite. The feedback at the TCAB meetings also validated our predicted outcomes: the nurses reported feeling refreshed and less fatigued, enjoying increased teamwork and familiarity with their colleagues, and having improved time-management skills.
And the nurses may not be the only ones benefiting. We're evaluating our data to determine what effect the change has had on patient care, but we have noticed that the unit is much quieter now during the meal breaks. Because nurses address their patients' immediate needs and concerns during rounds prior to leaving the unit, our perception is that the volume of patient calls decreases during these times. Although we have no formal data, the decreases in the number of call lights to answer, monitor alarms to respond to, and noise in general are notable. Considering all we know about the impact of noise levels on rest and recovery, this outcome deserves our continuing attention and support.
Next month, I'll discuss our test of putting often-used clinical supplies at patients' bedsides.