Question: Are nurses being educated and treated as knowledge workers?
Background: As early as the 1950’s, Peter Drucker identified numerous challenges
and opportunities related to the growth in knowledge work and knowledge
workers. In Drucker’s 1973 book Management he stated, “Managing
knowledge work and knowledge workers will require exceptional imagination,
exceptional courage, and leadership of a high order.”
Thomas Davenport, the author of Thinking for a Living, defined knowledge
workers as follows: “Knowledge workers have a high degree of expertise,
education, or experience, and the primary purpose of their jobs involve
the creation, distribution, or application of knowledge.”
Royer-Maddox-Herron Advisors has been interested in knowledge worker research
and issues since we specifically identified this area in a scenario planning
project completed over five years ago. At this time, we saw the majority
of hospital-based workers, but especially nurses, falling under the knowledge
worker profile. At the same time, we saw the expanding role of nurses,
along with the rapidly increasing use of information technology within
the hospital, accelerating the knowledge worker role.
Drucker predicted increasing the productivity of the knowledge worker would
be one of the significant challenges facing organizations in the 21st
century. Healthcare has not been exempt from this challenge. Hospitals
can achieve significant benefits from improving knowledge worker productivity.
The critical question is: How?
Manual worker productivity improvements can be traced back to the work
of Frederick Winslow Taylor in manufacturing during the late 1800’s.
Largely as a result of Taylor’s initial research, manufacturing
productivity experienced a 50 times improvement over the next hundred
years. In conducting our research for knowledge worker productivity improvement
efforts, we discovered relatively little research in the public domain.
In fact, much of what exists on productivity improvement largely traces
back to Taylor’s manual worker productivity efforts. The few examples
and initiatives focused on improving knowledge worker productivity we
discovered were undertaken at consulting or technology companies. It appears
the hospital knowledge worker has somehow flown under the business management radar.
In Peter Drucker’s book, Management Challenges for the 21st Century,
he outlines the following six major factors that determine knowledge worker
Knowledge worker productivity demands that we ask the question: “What is the task?”
It demands that we impose the responsibility for their productivity on
the individual knowledge workers themselves. Knowledge workers
have to manage themselves. They have to have
- Continuing innovation has to be part of the work, the task and the responsibility
of knowledge workers.
- Knowledge work requires continuous learning on the part of the knowledge
worker, but equally continuous teaching on the part of the knowledge worker.
Productivity of the knowledge worker is not –at least not primarily-a
matter of the
quantity of output.
Quality is at least as important.
Finally, knowledge worker productivity requires that the knowledge worker
is both seen and treated as an “asset” rather than a “cost.”
It requires that knowledge workerswant to work for the organization in preference to all other opportunities.
Drucker goes on to point out, “Each of these requirements-except
perhaps the last one-is almost the exact opposite of what is needed to
increase the productivity of the manual worker.” To the extent manual
worker productivity models exist in healthcare today should not be a complete
surprise. In 1912, when Frederick Taylor testified before Congress about
his “scientific management” theories, he referenced the Mayo
Clinic. In addition, from a cost standpoint, employment related costs
have approximated about half of a hospital’s operating costs so
continuous attempts at controlling these costs have been accelerating
ever since Medicare shifted from cost reimbursement to prospective payment
We Googled “How have nurses roles changed?” and came up with
almost 21 million responses. In scanning a few of the responses, we found
a consistent theme: nursing has drastically changed from Florence Nightingale
to today. Not a significant revelation! What we wonder, however, when
we look at Drucker’s knowledge worker productivity factors have
education, leadership and roles for nurses kept pace with the evolving
knowledge worker role.
While not absolute and certainly variable across the many hospitals in
the United States, our experience in the culture and operations of most
hospitals indicates hospitals operate through hierarchies, silos and very
strong cultures. All of which can be obstacles to implementing a high
performing, knowledge worker environment. Originally, the primary knowledge
worker in a hospital setting was the physician. As such, the physician
generally moved to the top of the organizational hierarchies. Today, this
has resulted in the Senior Vice President of Nursing silo now working
with the Chief of Medical Staff silo to resolve clinical matters. So as
we fast forward to the growing issues of the present and future like payment
reform changes now placing quality in the reimbursement equation. While
vast improvements have been made and continue to be made in patient satisfaction
scores, the expectation is by connecting financial incentives the improvement
process will accelerate. Not surprisingly, this emphasis on quality is
consistent with Drucker’s point that “quality” is as
important as “quantity” to the knowledge worker. (Clayton
Christensen in his book, The Innovator’s Prescription, described
how significant reimbursement is in maintaining the status quo. We find
it interesting that in order to drive quality improvement reimbursement
changes were necessary.)
Nursing shortages continue to be an issue forcing hospitals to fill vacancies
with temporary nurses. Whether or not this process will continue with
the change in reimbursement has not been determined. (Will temporary nurses
perform at levels adequate to not adversely impact reimbursement?) Additionally,
the $30 billion government mandated electronic medical record initiative
is just another example of the many additional sources of “information”
nurses are expected to routinely process. In addition to electronic clinical
information, there has been a dramatic increase in productivity systems,
cost accounting systems, logistic systems, voice mail, company Internet,
and other administrative systems.
These ever increasing complexities and the ever-growing demand for nurses
outside the four walls of the traditional acute care hospital are accelerating
the need for a knowledge worker friendly environment. Recent studies show
approximately 60% of nurses work in acute care hospitals. With burgeoning
outpatient surgical centers, standalone emergency care facilities and
concierge medicine, the hospital-based nurse percentage is sure to continue
to drop. Projections from the US Department of Labor for the period 2014
to 2024 suggest that job growth for nurses in the inpatient setting will
be less than half the growth rate in ambulatory settings. In addition,
population health initiatives alone will provide many new opportunities
for nurses, particularly in community settings and in care management roles.
We believe in light of the aforementioned challenges, the acute care hospital’s
work environment is more critical than ever. In some regards, the hospital
has had a captive workforce and only had to compete for nurses with other
hospitals. Like many things in today’s healthcare environment, this
is rapidly changing. With more financial pressure on escalating nurse’s
pay, organizations will be challenged to find new ways to differentiate
themselves in the very competitive nursing marketplace. We strongly believe
the knowledge worker nurse is critical to the ultimate success of any
acute care hospital. Creating a knowledge worker environment, however,
is a two way street that also significantly changes the expectations of
a knowledge worker nurse. Drucker’s prediction regarding the challenge
of improving knowledge worker productivity is proving prophetic. (In the
next paper, the importance of organizational culture will also be discussed.)
We are curious about what gaps might exist between Drucker’s knowledge
worker productivity factors and the real world. We are also curious about
what gaps might exist between today’s expectations of a nurse and
the expectations of a “knowledge worker nurse.” As a result,
this is the first in a series of blogs exploring the current state of
nursing and how far along the knowledge worker curve hospitals and nurses
have progressed. Imagination, courage and leadership are necessary to
manage the knowledge worker. We intend to reach out to our network of
nursing professionals and conduct some surveys to better understand the
state of the profession from education to current leadership. All thoughts
and comments are encouraged.