Abstract

Kanban is a care management tool that values multi-professional work and intensive use of data and has been growingly used in Brazil to address overcrowding in hospital emergency services (HES). The researchers monitored the Kanban for ten months in multiple wards of a municipal HES, and their observations were recorded in field diaries and discussed in biweekly research team meetings. The empirical material was organized from two questions: Are there changes in “traditional attributions” of Kanban-operating nursing? Are Medicine-Nursing interprofessional relationships transformed? A strong nurse adherence to this tool was observed, coupled with greater specialization and fragmentation of their work: nurses working as diarists assume more traditional administrative functions, while those on-call develop more direct assistance to patients. Nurses consider that clinical decisions are still in the doctors' hands, although Kanban provides them with a stronger influence on such decisions. Nurses' role in the management of significant mass of clinical and operational data, central to Kanban's operationalization, strengthens their professional authority.

Key words
Nursing; Emergency medical services; Patient-centered care; Kanban; Medicine-Nursing relationships

Introduction

Events of excessive demand, such as overcrowding and complaints about the quality of health care, manifest in various healthcare services. This is particularly visible in hospital emergency services (HES), either due to the waiting time to receive care or the unavailability of hospital beds for hospitalizations, resulting in a large number of patients lying on stretchers in the hallways for a long time. One of the consequences is the increased rate of illness among work staff due to stressful work environments and processes¹1 Deslandes SF. Frágeis deuses: profissionais de emergência entre os danos da violência e a recriação da vida. Rio de Janeiro: Editora Fiocruz; 2002.

2 Magid DJ, Asplin BR, Wears RL. The quality gap: Searching for the consequences of emergency department crowding. Ann Emerg Med 2004; 44:586-588.

3 Weiss SJ, Derlet R, Arndahl J, Ernst AA, Richards J, Fernández-Frackelton M, Schwab R, Stair TO, Vicellio P, Levy D, Brautigan M, Johnson A, Nick TG. Estimating the degree of emergency department overcrowding in Academic Medical Center: results of the National ED Overcrowding Study (NEDOCS). Acad Emerg Med 2004; 11:38-50.

4 Giglio-Jacquemot A. Urgências e emergências em saúde: perspectivas de profissionais e usuários. Rio de Janeiro: Editora Fiocruz; 2005.^-55 Bittencourt RJ. A superlotação dos serviços de emergência hospitalar como evidência de baixa efetividade organizacional [tese]. Rio de Janeiro: Escola Nacional de Saúde Pública; 2010..

In this context, interventions aimed at improve the ability to identify risks, provide health care, and generate solutions in the HES are of great importance⁴4 Giglio-Jacquemot A. Urgências e emergências em saúde: perspectivas de profissionais e usuários. Rio de Janeiro: Editora Fiocruz; 2005.^,66 Hartz ZMA, Contandriopoulos AP. Integralidade da atenção e integração de serviços de saúde: desafios para avaliar a implantação de um "sistema sem muros". Cad Saude Publica 2004; 20:332-336.

7 Allder S, Silvester K, Walley P. Managing capacity and demand across the patient journey. Clinical Medicine 2009; 10(1):13-15.^-88 Beltrammi DGM. Efetividade das intervenções para redução da superlotação nos serviços de emergência hospitalar [dissertação]. São Paulo: Instituto Sírio-Libanês de Ensino e Pesquisa; 2015.. Hospitals have been experimenting new ways of managing care to rationalize the use of resources, and improve qualification of care towards multidisciplinary and interdisciplinary work, protocolization and intensive use of indicators to monitor and evaluate its success⁹9 Carapinheiro G. Saberes e Poderes no Hospital. Uma sociologia dos serviços hospitalares. Porto: Edições Afrontamento; 1993.

10 Campos GWS, Amaral MA. A clínica ampliada e compartilhada, a gestão democrática e redes de atenção como referenciais teo´rico-operacionais para a reforma do hospital. Cien Saude Colet 2007; 12(4):849-860.^-1111 Chioro dos Reis AA. Entre a intenção e o ato: uma analise da politica de contratualização dos hospitais de ensino (2004-2010) [tese]. São Paulo: Universidade Federal de São Paulo; 2011..

Various technological arrangements for the coordination of care have been used in Brazil and have been induced by the Ministry of Health to face such challenges, in particular from the National Hospital Care Policy¹²12 Brasil. Ministério da Saúde (MS). Portaria no 3.390, de 30 de dezembro de 2013. Institui a Política Nacional de Atenção Hospitalar (PNHOSP) no âmbito do Sistema Único de Saúde (SUS), estabelecendo-se as diretrizes para a organização do componente hospitalar da Rede de atenção à Saúde (RAS). Diario Oficial da Uniao; 2013..

Care technology arrangements are a set of technologies, best practices, and management instances, preferably applied in combination, that are intervention modalities aimed at the application of scientific knowledge for practical purposes in the management and production of health care¹⁰10 Campos GWS, Amaral MA. A clínica ampliada e compartilhada, a gestão democrática e redes de atenção como referenciais teo´rico-operacionais para a reforma do hospital. Cien Saude Colet 2007; 12(4):849-860.^,1313 Fleury ACC. Organização do trabalho industrial: um confronto entre teoria e realidade [tese]. São Paulo: Escola Politécnica da Universidade de São Paulo; 1978.

14 Dussauge P, Hart S, Ramanantsoa B. Strategic Technology Management. Chichester: John Wiley & Sons; 1992.

15 Cecílio LCO, Coutinho AAP, Hamze FL, Silva AF, Batista LA, Carvalho APH. Programa SOS emergências: uma alternativa de gestão e gerência para as grandes emergências do Sistema Único de Saúde. Divulg Saude Debate Rio de Janeiro 2014; 52:202-216.

16 Scarazzatti GL. Tendências da avaliação em saúde. Debates GV Saúde 2006; 2:22-23.

17 Bandurchin A, McNally MJ, Ferguson-Paré M. Bringing back the house call: how an emergency mobile nursing service is reducing avoidable emergency department visits for residents in long-term care homes. Nurs Leadersh 2011; 24(1):59-71.^-1818 Wang M, Wild S, Hilfiker G, Chmiel C, Sidler P, Eichler K, Rosemann T, Senn O. Hospital-integrated general practice: a promising way to manage walk-in patients in emergency departments. J Eval Clin Pract 2014; 20(1):20-26..

Among the various devices used for interventions to improve the production processes of care and management of HES, we can highlight the “Kanban”, implemented in different services under different formats¹⁹19 Bittencourt RJ, Hortale VA. Intervenções para solucionar a superlotação nos serviços de emergência hospitalar: uma revisão sistemática. Cad Saude Publica 2009; 25(7):1349-1454.

20 Crane J, Noon C. The Definitive Guide to Emergency Department Operational Improvement. Boca Raton: CRC Press; 2011.

21 Liu SW, Singer SJ, Sun BC, Camargo CA. Care for Patients Boarding in the Emergency Department: Structure-Process-Outcome. Acad Emerg Med 2011; 18(4):430-435.^-2222 Sousa P, Mendes W, organizadores. Segurança do paciente: conhecendo os riscos nas organizações de saúde. Rio de Janeiro: Editora Fiocruz; 2014..

Kanban is a bed management device that combines clinical priority management practices and visual tools that enable the qualification of care coordination by prioritizing and enhancing clinical decision-making and maximizing bed use, with a strong emphasis on multi-professional teams. The institutionalization of horizontal care has enhanced its action, that is, the daily presence of medical professionals and nurses for better coordination of clinical decisions and continuity of care. Kanban makes intensive use of real-time information produced and used by teams, as well as hospital clinical protocols¹⁵15 Cecílio LCO, Coutinho AAP, Hamze FL, Silva AF, Batista LA, Carvalho APH. Programa SOS emergências: uma alternativa de gestão e gerência para as grandes emergências do Sistema Único de Saúde. Divulg Saude Debate Rio de Janeiro 2014; 52:202-216.^,2020 Crane J, Noon C. The Definitive Guide to Emergency Department Operational Improvement. Boca Raton: CRC Press; 2011.^,2222 Sousa P, Mendes W, organizadores. Segurança do paciente: conhecendo os riscos nas organizações de saúde. Rio de Janeiro: Editora Fiocruz; 2014.^,2323 Bradley VM. Placing Emergency Department crowding on the decision agenda. J Emerg Nurs 2005; 31:247-258..

Little has been addressed about possible impacts and reconfigurations of Kanban on health professional's practices and interprofessional relationships. This paper follows the line of international literature that emphasizes advanced practice nursing, or nurse practitioner, in emergency services²⁴24 Chan SS, Cheung NK, Graham CA, Rainer TH. Strategies and solutions to alleviate access block and overcrowding in emergency departments. Hong Kong Med J 2015; 21(4):345-352.^,2525 Williams K. Advanced practitioners in emergency care: a literature review. Emerg Nurse 2017; 25(4):36-41.. What is known is that advanced practice nursing can improve access, reduce the number of patients, improve the quality of care, reduce the length of stay, and increase patient satisfaction²⁶26 Jennings N, Clifford S, Fox AR, O'Connell, Gardner G. The impact of nurse practitioner services on cost, quality of care, satisfaction and waiting times in the emergency department: a systematic review. Int J Nurs Stud 2015; 52(1):421-435.^,2727 Bristow DP, Herrick CA. Emergency department case management: the dyad team of nurse case manager and social worker improve discharge planning and patient and staff satisfaction while decreasing inappropriate admissions and costs: a literature review. Lippincotts Case Manag 2002; 7(3):121-128..

What remains to be known are the possible transformations that Kanban can produce in the nursing profession: 1) whether there are changes in the “traditional attributions” of nursing in the division of labor; and 2) whether relationships with medicine are transformed in the operationalization of this arrangement.

Material and methods

The paper is part of a broader investigation that aimed to understand how professionals operationalize HES care management arrangements. A qualitative case study research²⁸28 Albarello L, Digneffe F, Hiernaux JP, Maroy C, Ruquoy D, Saint-Georges P. Praticas e metodos de investigacao em ciencias sociais. Lisboa: Gradiva; 2000.^,2929 Poupart J, Deslauries JP, Groulx AL, Mayer R, Pires A. A pesquisa qualitativa: enfoques epistemologicos e metodologicos. Petrópolis: Editora Vozes; 2016. was conducted in this work.

The study was conducted at an Urgent and Emergency Care Hospital (UECH) of a municipal health network. It is a hospital unit certified as a teaching hospital, a reference for urgent and emergency care, meeting both self-referred demand, as referred by SAMU and the municipal UPAs. The technological arrangements proposed by the Ministry of Health's National Hospital Care Policy¹²12 Brasil. Ministério da Saúde (MS). Portaria no 3.390, de 30 de dezembro de 2013. Institui a Política Nacional de Atenção Hospitalar (PNHOSP) no âmbito do Sistema Único de Saúde (SUS), estabelecendo-se as diretrizes para a organização do componente hospitalar da Rede de atenção à Saúde (RAS). Diario Oficial da Uniao; 2013., such as reception with risk classification, bed, and care management (Kanban), are implemented in the hospital.

Kanban was chosen for the reflections intended in this text because of the central role of nurses in the “conduction” of the arrangement. Table 1 describes the main characteristics of the Kanbans made in the UECH.

The ethnographically-oriented methodological strategies adopted translated into a prolonged, continuous presence of field researchers to observe the staff's daily operationalization of the Kanban. This option resulted in a micro-political approach to care management and production³⁰30 Lapassade G. As microssociologias. Brasília: Liber Livro; 2005., assuming that these processes are redefined and redesigned as institutional stakeholders use them.

Field diaries elaborated by the researchers at each field trip at different days and times of the week for almost a year were processed in the research group that met in seminars. In the first analytical systematization, the empirical material was organized into three major blocks: internal team relationships, team relationships with users and hospital management. From this material, scenes were selected as feedback to the teams in two shared seminars of researchers with hospital teams, which gave rise to new questions and the need for further meetings, now with specific professional groups (doctors, nurses, and non-doctors/non-nurses).

Table 2 describes the different data production techniques used. All shared seminars were recorded and later transcribed, with the consent of those involved, who signed the Informed Consent Form.

Nurse-related records were extracted from the field diaries for the preparation of this work. Also, the transcripts of six shared seminars were used, either the one conducted specifically with nurses, or in the others, when other professionals made references to the work of nurses.

Results

Preservation or changes in the “traditional attributions” of nursing?

Kanban's logic is based on two main axes: a) interprofessional work to qualify the diagnosis and therapeutic project for each patient (clinical management); b) the intensive use of up-to-date, real-time patient information shared by the team, ensuring that all necessary referrals are streamlined for maximum turnover and use of beds (bed management). Nurse performance is fundamental in both lines. Over time, the relationship between clinical and bed management has changed in the dynamics of Kanban's functioning, affecting significantly nursing work, as the following observation illustrates:

Analyzing nursing's internal processes, Kanban accelerated or escalated the specialization and fragmentation of nurses' practice. The nurses are divided into “diarist” and “on-call”. The former, working every weekday at the hospital, are “horizontal”, and in principle, should have close and continuous contact with a particular group of patients under their responsibility. The second group has more one-off or discontinuous contacts with hospitalized people. Diarists are involved with “bed management”, and are those who most realize how much administrative tasks were gradually taking up more of their daily work, to the detriment of clinical contacts with patients.

Therefore, what was gaining greater visibility were the effects of micropolitics on the operationalization of Kanban on the work of nurses, hence the very striking division between the “diarists” and the “on-call workers”. Some nurses acting in the same care unit have very different practices among themselves.

Purely administrative duties, which hold a large part of the day's work, keep them away from the clinical activity, to the point that they consider that the overload of such activities would compromise their performance in other realms of care. Moreover, on the contrary, they assess that the “on-call nurse” would be closer to the clinic and the patient (and the doctor), because they are exempt from the daily administrative activities.

Therefore, it is necessary to recognize the fragmentation and specialization of nursing practice resulting from the implementation of Kanban, to realize the subtler differentiation within the profession.

This restructuring of nursing work in the Kanban dynamics has produced overload and stress in daily work, as pointed out mainly by diarists. They feel more pressure to perform from different service professionals, both the administrative sector and the assistance team:

Thus, instead of the existence of new nursing professional practices, intra-professional roles and responsibilities are redistributed, leading to work dissatisfaction, especially among diarists, and, in their opinion, a deteriorated quality of care. As one nurse stated:

Nursing and Medicine: new interprofessionality or reproduction of power relations?

Nursing is thought to be the apex of a chain of command and control of the nursing staff, with legal-formal, technical-based authority, due to the knowledge it acquires during the undergraduate course, so much so that “it leaves the undergraduate program with a team of technicians to lead” (Nurse, Shared Seminar). The issue of authority arises for the nurse concerning its own professional body. The study was interested to see whether and how the management arrangements studied resulted in new interprofessional relationships, in particular, if there would be new configurations of nursing authority, particularly with doctors.

Historically, the nursing staff has always had a great deal of responsibility for the recording and continued data production⁹9 Carapinheiro G. Saberes e Poderes no Hospital. Uma sociologia dos serviços hospitalares. Porto: Edições Afrontamento; 1993., which is central and becomes operational with higher intensity in the Kanban. If, on the one hand, this intensification results in more work overload and responsibility, on the other, it could be an element of “promotion” of nursing in the hospital context, its increased prestige, and authority vis-à-vis other professionals³¹31 Carvalho T. Nova Gestao Publica e Reformas da Saude: o profissionalismo numa encruzilhada. Lisboa: Edições Sílabo; 2009..

One of the central roles of nurses is to collect and organize information, specifically the organization of spreadsheets, a fundamental tool to facilitate Kanban, as they contain the information about each patient required for discussion and referral of measures, which has already been conceptualized as corresponding to their own “facilitating role”³²32 Clarke J, Newman J. The Managerial State. Londres: Sage; 1997..

Spreadsheets are the backbone of Kanban meeting's dynamics, and, as nurses organize information, they assume a strategic role in bed management, and this is undoubtedly an essential realm of hospital nursing authority reinforced by Kanban's operating logic.

These professionals often assume the place of coordinating Kanban meetings, which could be understood at first glance as a reinforcement of their professional authority.

There is, therefore, what the team values highly and calls “the pre-Kanban”, that is, all the interprofessional micro-political articulation that precedes the Kanban meeting, and in which nursing, particularly diarist nurses, has an active role, evidencing the “facilitating role” as can be seen from the following observation:

Several manifestations indicate dissatisfaction and conflicts in the relationship with doctors. It seems that they often feel they are doing their actions at the service of doctors to make their work easier. The study reveals a facet of the nurse's work (and cause for much dissatisfaction) that is to play the role of “information bridge”, but could be called “working as a message boy” among multi-professional staff and doctors, or among the doctors themselves.

Surprisingly, nurses often put themselves in the position of conflict mediators, especially among medical professionals.

In any case, the nurses reported having “gained some power” from the implementation of Kanban.

At the same time, and almost paradoxically, nurses also relativize this empowerment by stating that the physician still has the power of decision.

However, they consider that, in some contexts and depending on the situation and the doctor, they can share the decision, or at least influence the clinical decision.

Discussion

The adoption of Kanban in the studied hospital illustrates the managerial process to which the health sector has been submitted all over the world. It is known that managerialism principles aim at strengthening economic management, efficiency, and effectiveness of public activity, although their achievements vary among countries and services³²32 Clarke J, Newman J. The Managerial State. Londres: Sage; 1997.. The Kanban, in particular, is a “local” mechanism (as it is located within the hospital) that performs a dual function associated with managerialism principles: undoing (clinical and bed) management processes based on monoprofessionalism and self-regulation, and introducing governance mechanisms specific to organizations, whose effectiveness is expected to be due to adaptability and flexibility compared to management tools external to health organizations (top-down). In other words, Kanban aims to reconfigure interprofessionality, focusing on greater information sharing and decision making, and achieving greater effectiveness by bringing decision-making closer to professionals.

The direct consequence is having to look at the effects of Kanban on health professions. The discussion presented here focuses on nursing, insofar as health work reconfigurations tend to favor analyses of the medical profession³³33 Correia T. The Interplay between managerialism and medical professionalism in hospital organisations from the doctors' perspective: a comparison of two distinctive medical units. Health Sociology Review 2013; 22(3):255-267.

34 Currie G, Croft C. Examining hybrid nurse managers as a case of identity transition in healthcare: developing a balanced research agenda. Work, Employment and Society 2015; 29(5):855-865.

35 Jamra C, Cecílio LCO, Correia T. Os médicos e a racionalização das práticas hospitalares: novos limites para a liberdade profissional? Saude Debate 2016; 40(108):86-94.^-3636 Reis D, Cecílio LCO, Andreazza R, Araújo E, Correia T. Nem herói, nem vilão: elementos da prática médica na atenção básica em saúde. Cien Saude Colet 2018; 23(8):2651-2660..

A relevant discussion aspect concerns the bipartition of traditional nurse activities between direct patient clinical care (on-call nurse) and the bureaucratic-administrative functions (diarist nurse). The latter refer to both the “steps” required to increase bed turnover and the collection and organization of information that will be used at team meetings. The nurse has always accumulated these two attributions, although, in recent decades, some debate regarding the crushing of time devoted to direct care to the bed has emerged because of the more bureaucratic and administrative responsibilities³⁷37 Carvalho T. Managerialism and professional strategies: a case from nurses in Portugal. J Health Organ Manag 2012; 26(4):524-541.. The point is that Kanban allows an intra-professional differentiation, which fits into the literature on hybrid professionals (or hybrids). Hybrids are central to the realization of managerialism, as they lead managerial rationality into cultures and professional identities, rather than being imposed from outside³⁸38 Llewellyn S. 'Two-way windows': clinicians as medical managers. Organ Studies 2001; 22(4):593-623.. There has been no consensus in the debate about the practical ability of hybrids to operate the expected changes in work processes, thus, in the “professional thinking” mode. One reason concerns the hybridized professional group: Hybrid doctors generally reinforce their power because, besides technical-scientific competences, other doctors and professionals also recognize management skills³⁹39 Correia T, Denis JL. Hybrid management, organizational configuration, and medical professionalism: evidence from the establishment of a clinical directorate in Portugal. BMC Health Services Research 2016; 16(Supl. 2):161.. In contrast, hybrid nurses struggle to assert themselves above all in their relationship with other professional groups, as they are not recognized as having competences for this role⁴⁰40 Apesoa-Varano EC. Educated caring: the emergence of professional identity among nurses. Qualitative Sociology 2007; 30(3):249-274.^,4141 Nugus P, Greenfield D, Travaglia J, Westbrook J, Braithwaite J. How and where clinicians exercise power: interprofessional relations in health care. Soc Sci Med 2010; 71(5):898-909., which may configure reactive management roles.

Now, the empirical findings of this study seem to prove doctors' resistance, if not indifference, to the increased bureaucratic skills that diarist nurses (hybrids in this case) acquire in Kanban.

The findings also allow us to observe another relevant aspect of the discussion of hybridization. Diarist nurses did not change their hierarchical position in the hospital (vertical mobility) compared to other nurses and other professional groups. This reinforces resistance, if not the indifference of them all, to the attempts to assert management control that diarist nurses are claiming in the Kanbans. In a nutshell, evidence suggests that nursing hybridization without formal alteration of the emergency service organization chart has limited effects. On the other hand, it is not clear what effects are possible if the formal alteration of the organization chart reinforces the role of hybrid professionals.

Other evidence reveals that the fact that nurses have official, not just unofficial, and negotiated control, is not necessarily a central element in their interprofessional assertiveness³⁷37 Carvalho T. Managerialism and professional strategies: a case from nurses in Portugal. J Health Organ Manag 2012; 26(4):524-541.. The most striking example of this finding is the workload and discontent of diarists for taking on the so-called “administrative” activities, living an even more radical departure from direct patient care, an activity more associated with on-call personnel, due to their proximity to doctors and their relief of such more routine activities.

Nursing's responsibility for the real-time collection, recording and systematization of information, an essential element to Kanban's functioning, gives it an active role and visibility in the device's conduct, although this leadership is not seen, by the category, as necessarily an increased power vis-à-vis the doctors, who would still mostly hold the clinical decision and case conduct.

In preparing for the Kanban – “the pre-Kanban” – when all the necessary articulations are made for the meeting to be swift, the nurse remains irreplaceable, among other things because it is the professional with more permanence in the hospital, which circulates the most, and holds the most information, and that is where its professional power lies, sometimes invisible but fundamental and irreplaceable. That, we might say, was already a feature of the profession that remained unchanged with the Kanban.

What could be said is that Kanban takes on two meanings for nursing, as it provides nurses with a more significant role in the work processes, specifically in bed management, but, at the same time, distances them from the ideals on which the nursing practice has become professional, and considers it to be its distinctive mark compared to medicine. Participation in Kanban shows nursing professionalism at a crossroads: between the bureaucratic control of organizations and the empowerment of the application of its knowledge before medicine.

Conclusions

Kanban has caused essential changes in nurses' professional practice, although there is still ambiguity about how much new interprofessionality has been produced when considering the relationship with doctors. The relatively recent adoption of the device may not yet allow for a more far-reaching assessment of possible ongoing transformations. Ambiguous perceptions are found the nurses as to how much Kanban has, in fact, provided a new interprofessionality, in which they would have a more horizontal relationship with doctors, influencing more the conduct of cases, or would be living only an exacerbation of “doctors' secretaries” function, mainly carrying out support activities for those professionals and other professionals on the team. The fact that nurses are the “keepers” of information and play a crucial role in enabling the real-time use of a large mass of clinical and operational data – the backbone of Kanban's logic – undoubtedly gives these professionals more visibility, and the recognition of its indispensability when it comes to improving hospital care. We might say, metaphorically, that the Kanban has been producing small quakes in the territory of interprofessionality, but not a seismic shake capable of producing a radical reshuffle of the long-held power relationships still dominant in the hospital.

Acknowledgments

We are grateful to the staff of the study hospital. The research was financed by Fapesp.

References

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