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SWOT: What’s it all about and how to use it?

David Stonehouse is a Lecturer in Children and Young People’s Nursing with the

School of Health and Society at the University of Salford, Manchester.

Abstract.

This article examines the Strengths, Weaknesses, Opportunities and Threats

analysis tool commonly known as SWOT and how support workers can utilise this in

decision making, problem-solving and in identifying where changes in clinical

practice are needed. The importance of this will be highlighted in the relevant

sections of The Code of Conduct for Healthcare Support Workers and Adult Social

Care Workers in England (Skills for Care and Skills for Health, 2013) and for nursing

associates in the recently amended NMC (2018) code. The article will start with an

overview of the SWOT analysis tool before examining the four separate parts. The

importance of the analysis stage will be highlighted.

Key Words: Analysis, Opportunities, Strengths, Support Workers, SWOT, Threats,

Weaknesses.

Introduction

Support workers are key to the delivery of high quality care to patients. They are

closest to patient care and therefore know the needs of their patient’s best and how

their organisations operate from the ground up. They are best placed to identify

where change is needed and where decisions need to be made. One way in which to

ensure that the right decisions and changes are being implemented is in utilising a

decision making tool such as SWOT. There are other tools available, for example

PESTLE (Taylor et al, 2015), or SPECTACLES (Pettinger, 2012), however SWOT

analysis has been chosen as being simpler, having only four components, and as

Marquis and Huston (2017) state, it is recognised as being both effective and

commonly used in healthcare organisations. The SWOT analysis tool can be used

for a whole range of applications. For managers “to scan their external environment

to identify opportunities and threats so that their internal strengths and weaknesses

are aligned accordingly” (Sola et al, 2018:136), to assisting support workers in

writing their Professional Development Plans by identifying “areas in which

development is required or desired” (Jackson & Thurgate, 2011:293) and by a

learner within the workplace to identify opportunities within their environment

(Wareing, 2016).

Code Words.

The Code of Conduct for Healthcare Support Workers and Adult Social Care

Workers in England (Skills for Care and Skills for Health, 2013), section 2.1 states

that you must “always act in the best interests of people who use health and care

services.” To act in your patients best interests means always delivering care which

is of the highest possible standard. To do this your care and practice must be

evidence based and be open to regular scrutiny. Evidence based practice is defined

as practice which is “based on the best available evidence, patient preferences and

clinical judgement” (Schmidt & Brown, 2015:4). Section 6 is focused upon striving to

“improve the quality of healthcare, care and support through continuing professional

development. This is achieved through, section 6.2, participating in “continuing

professional development to achieve competencies required for your role.” Section

6.4 urges you to “improve the quality and safety of the care you provide” and 6.6, to

“contribute to the learning and development of others as appropriate.” For nursing

associates, the NMC (2018) code also states in Section 25.1 that you must “identify

priorities, manage time, staff and resources effectively and deal with risk to make

sure that the quality of care or service you deliver is maintained and improved.

Through analysing proposed changes to working practices using tools such as the

SWOT analysis tool, support workers and nursing associates will be assisted to

make good, well founded decisions in how care and services can be improved.

Knowing the strengths of that decision and the opportunities it will present. They will

also be empowered to voice their concerns when a change is not in their patient’s

best interests, recognising the weaknesses, and by recognising the external threats

they will be better placed to overcome them.

Undertaking a SWOT Analysis

Before you start you need to identify what it is you are going to analyse. Sale (2005)

states that first of all you need to assess the current situation. What are the drivers

and levers for change? Has something occurred to prompt you or your department to

consider change or to make a decision? This may be a whole range of things, such

as incidents, complaints, new research, or a development in best practice.

The whole department, including support workers and nursing associates, should

meet to perform a SWOT analysis. This is done by examining the four categories,

strengths, weaknesses, opportunities and threats. The order and positioning of the

four categories in the grid is deliberate (See fig. one). The top two categories of

strengths and weaknesses are directed internally at the individual, team, department

or organisation. Wherever, or whoever, the change or decision is aimed at. The

bottom two categories of opportunities and threats are aimed at the external

environment (Phillips, 2009). Together with this, the left hand two categories of

strengths and opportunities are positives whereas the right hand two of weaknesses

and threats are negatives. As Thompson (2012:216) states this is useful as it “helps

us to provide a balanced overview of the situation we are analysing,” and not just to

focus on the negatives.

Fig One. SWOT Analysis Tool.

Strengths

This is the first of the two positive areas and is looking internally. Strengths could be

the things that make you or your team stand out from other areas. What do you do

well and excel at? Are your skills, knowledge and experience you have a strength?

The training you have received to support you in fulfilling your role and in meeting

the organisations objectives. These strengths could be identified from good

evaluations received or patient feedback.

Weaknesses

The first negative area and again internally looking is weaknesses. Are there areas

of your organisation, team or even on the individual level which you can recognise as

being weak? Are there things missing? This could even be around reputation or

image, or deficiencies in accommodation or outdated technology (Mullins, 2013). It

could also be on a more practical level of staff shortages, positions not filled, work

load, morale of the team, or actual working conditions.

Opportunities

This is the second positive area but now is outward facing. What opportunities are

there outside of your team or organisation? Is there a need being generated by

patient expectations, or new guidelines which you could adopt? Is there something

new that you could start doing? Could new funding be accessed that has previously

been unavailable (Phillips, 2009)? This is your chance to identify a new direction, or

new service you could be delivering to meet a previously unmet need. Maybe a new

technique has been identified to provide care in an improved way? Opportunities

could also be experiences gained outside of the current team, which as yet have

been unused (Jackson & Thurgate, 2011). Have team member’s talents been

unrecognised and unused until now?

Threats

The last area is negative and outward facing. This is more serious. It is about

identifying things which could actually threaten your practice, service or organisation.

Are there things out there, external, which could impact negatively on how you

provide your service or care? Threats to the organisation or team could be a loss or

decrease in budget, or a change in political or societal drivers which may threaten

commissioning of the service in the future (Phillips, 2009). Is another organisation

providing care in a more productive way?

Analysis

This is the most important part of the process. For the analysis to be worthwhile, time

needs to be given to complete the four sections above as fully as possible. As

Pettinger (2012:24) states nothing should be off limits, only “once everything is in

front of people, evaluations and judgements can then be made.” Once recorded you

need to be able to tell what the strengths, weaknesses, opportunities and threats are

telling you. If done too quickly or as a tick box exercise, there is a risk that SWOT

may have been performed, but without the analysis (Thompson, 2012), making the

exercise worthless. Thompson (2012) goes on to say that once words have been

inputted into the four areas, you are then able to see if there are any patterns or

themes emerging. Issues previously unrecognised can be acknowledged and

discussed, making the decision making process easier and highlighting the drivers

for change.

Conclusion.

So to conclude, this article has highlighted the usefulness of the SWOT analysis tool,

in supporting an individual, team or department to identify opportunities for change.

Support workers and nursing associates will often know more about how a team and

department is performing, being the key staff members delivering the most hands on

care. They are therefore well placed to contribute the most to a SWOT analysis of

the clinical area, suggesting how strengths can be maximised, weaknesses

improved upon, opportunities grasped and threats neutralised. All this will help to

deliver quality care and services to the patients and families that we serve and

support.

Key Points:

1. Support workers are key to identifying the strengths, weaknesses,

opportunities and threats within their own working environments.

2. Time needs to be devoted to completing the four areas so that it does not

become a tick box exercise.

3. Thinking about an area using SWOT allows you to have a balanced view of

both the positives and negatives, looking both inward and outward.

4. The most important stage is the analysis of the four categories, without which

the tool is useless.

5. Once your analysis of the SWOT has taken place, you can then make better

decisions and changes to benefit both staff and patient care.

Reflective Questions For Your Continuing Professional Development

• In a small group of your peers, conduct a SWOT analysis of your team or

department.

• Identify possible changes you can make to build upon your strengths, or to

remove or diminish any weaknesses.

• As an individual perform a SWOT analysis examining your own personal

learning and development.

References:

Jackson C, Thurgate C. Personal Development Plans and Workplace Learning.

British Journal of Healthcare Assistants. 2011: 5(6):292-296. doi:

https://doi.org/10.12968/bjha.2011.5.6.292

Pettinger R. Management: A Concise Introduction. London: Palgrave Macmillan;

2012

Phillips K. Leading in Complex Environments (57-72). In: McKimm J, Phillips K, eds.

Leadership and Management in Integrated Services. Exeter: Learning Matters; 2009:

Marquis BL, Huston CJ. Leadership Roles and Management Functions in Nursing:

Theory and Application. 9th edn. Philadelphia: Wolters Kluwer; 2017

Mullins LJ. Management and Organisational Behaviour. 10th edn. Harlow: Pearson

Education Ltd; 2013

Nursing and Midwifery Council. The Code: Professional Standards of Practice and

Behaviour for Nurses, Midwives and Nursing associates. 2018.

https://www.nmc.org.uk/globalassets/sitedocuments/nmc-publications/nmc-code.pdf

(accessed 21 November 2018)

Sale D. Understanding Clinical Governance and Quality Assurance: Making it

Happen. London: Palgrave Macmillan; 2005

Schmidt NA, Brown JM. Evidence-Based Practice for Nurses: Appraisal and

Application of Research. 3rd edn. Burlington: Jones & Bartlett Learning; 2015

Skills for Care and Skills for Health. Code of Conduct for Healthcare Support

Workers and Adult Social Care Workers in England. 2013.

http://www.skillsforhealth.org.uk/images/services/code-of-

conduct/Code%20of%20Conduct%20Healthcare%20Support.pdf (accessed 21

November 2018)

Sola D, Borioli GS, Quaglia R. Predicting GPs’ Engagement With Artificial

Intelligence. British Journal of Healthcare Management. 2018: 24(3):134-140. doi:

https://doi.org/10.12968/bjhc.2018.24.3.134

Taylor V, Scott H, Walter M. Organization and Management of Health and

Healthcare (334-376). In: Naidoo J, Wills J, eds. Heath Studies: An Introduction. 3rd

ed. London: Palgrave Macmillan; 2015

Thompson N. The People Solutions Sourcebook. 2nd edn. London: Palgrave

Macmillan; 2012

Wareing M. Being a Worker and a Learner. British Journal of Healthcare Assistants.

2016: 10(11):554-561. doi: https://doi.org/10.12968/bjha.2016.10.11.554

UC Irvine Western Journal of Emergency Medicine: Integrating Emergency Care with Population Health

Title Decreased Nursing Staffing Adversely Affects Emergency Department Throughput Metrics

Permalink https://escholarship.org/uc/item/4811645s

Journal Western Journal of Emergency Medicine: Integrating Emergency Care with Population Health, 19(3)

ISSN 1936-900X

Authors Ramsey, Zachariah Palter, Joseph S. Hardwick, John et al.

Publication Date 2018

DOI 10.5811/westjem.2018.1.36327

Copyright Information Copyright 2018 by the author(s).This work is made available under the terms of a Creative Commons Attribution License, available at https://creativecommons.org/licenses/by/4.0/ Peer reviewed

eScholarship.org Powered by the California Digital Library University of California

Western Journal of Emergency Medicine 496 Volume 19, no. 3: May 2018

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†

‡

Brief research report

Decreased Nursing Staffing Adversely Affects Emergency Department Throughput Metrics

Zachariah Ramsey, MD* Joseph S. Palter, MD*†

John Hardwick, MD* Jordan Moskoff, MD*†

Errick L. Christian, MS* John Bailitz, MD‡

Section Editor: David C. Lee, MD Submission history: Submitted September 5, 2017; Revision received November 30, 2017; Accepted January 16, 2018 Electronically published April 5, 2018 Full text available through open access at http://escholarship.org/uc/uciem_westjem DOI: 10.5811/westjem.2018.1.36327

Introduction: The effect of nurse staffing on emergency department (ED) efficiency remains a significant area of interest to administrators, physicians, and nurses. We believe that decreased nursing staffing adversely affects key ED throughput metrics.

Methods: We conducted a retrospective observational review of our electronic medical record database from 1/1/2015 to 12/31/2015 at a high-volume, urban public hospital. We report nursing hours, door-to-discharge length of stay (LOS) and door-to-admit LOS, and percentage of patients who left without being seen (LWBS). ED nursing hours per day was examined across quartiles with the effect evaluated using analysis of covariance and controlled for total daily ED volume, hospital occupancy and ED admission rate.

Results: From 1/1/15-12/31/15, 105,887 patients presented to the ED with a range of 336 to 580 nursing hours per day with a median of 464.7. Independent of daily ED volume, hospital occupancy and ED admission rate, days in the lowest quartile of nursing hours experienced a 28.2-minute increase per patient in door-to-discharge LOS compared to days in the highest quartile of nursing hours. Door-to-admit LOS showed no significant change across quartiles. There was also an increase of nine patients per day who left without being seen by a provider in the lowest quartile of nursing hours compared to the highest quartile.

Conclusion: Lower nursing hours contribute to a statistically significant increase in door-to- discharge LOS and number of LWBS patients, independent of daily ED volume, hospital occupancy and ED admission rate. Consideration of the impact of nursing staffing is needed to optimize throughput metrics for our urban, safety-net hospital. [West J Emerg Med. 2018;19(3)496-500.]

INTRODUCTION Emergency department (ED) efficiency remains a vital

aspect of delivering safe, quality care. ED utilization has risen considerably without a corresponding rise in available emergency services.1,2 To respond to the increased demand, it is imperative to identify factors that contribute to delays in care. Researchers have identified several hospital

John H. Stroger Hospital of Cook County, Department of Emergency Medicine, Chicago, Illinois Rush Medical College, Department of Emergency Medicine, Chicago, Illinois Northwestern Memorial Hospital, Department of Emergency Medicine, Chicago, Illinois

characteristics associated with worse ED throughput or ED time on ambulance diversion including ED crowding,3 percentage of ED patients admitted,4,5,6 number of elective surgical admissions,5 hospital occupancy,5,6,7 training level of the treating physician,3 access to expedited diagnostic testing,8 socioeconomic status of the surrounding neighborhood,9 and decreased nurse staffing.10

Volume 19, no. 3: May 2018 497 Western Journal of Emergency Medicine

Ramsey et al. Decreased Nursing Staffing Adversely Affects ED Throughput Metrics

Prior studies identified that increased nurse-to-patient ratios correlate with improved patient outcomes11,12 and that lower staffing is associated with increased left without being seen (LWBS) rates13 and increased ED care times.10 Our urban, tertiary care, safety-net, teaching hospital suffered a nursing shortage during 2015 due to an administrative initiative to decrease costs by limiting nurse overtime hours. Without a concomitant increase in hiring, this change caused significant gaps in ED nurse staffing. These gaps led to unpredictable closures of sections of the ED and increased average nurse-to- patient ratios. Our goal was to evaluate the impact of decreased nurse staffing on ED throughput metrics. We believe decreased nurse staffing adversely affects these metrics.

METHODS Our hospital is an urban, tertiary care, safety-net hospital

with 254 medical/surgical inpatient beds and 80 ED beds. The ED is staffed by full-time, board-certified attending emergency physicians who supervise emergency medicine residents, residents from other specialties, and physician assistants. Hospital-stipulated maximum nurse-to-patient ratios were not changed or exceeded during the study period. Nurses work a mix of 8- and 12-hour shifts. The ED is also staffed by patient care technicians and patient transporters.

We conducted a retrospective observational review using Cerner First Net electronic medical record (EMR) database. All EMRs of 105,887 ED visits from January 1, 2015, to December 31, 2015, were queried after institutional review board approval. We included in the analysis all patients discharged or admitted to the medical/surgical inpatient beds in the analysis regardless of inpatient or observational status. Patients admitted to the intensive care unit or the ED observation unit were excluded as the admission protocol to these units varies significantly from general admission; therefore, we could not accurately capture the length of stay (LOS) of these patients from EMR review. A total of 6,602 patients were excluded.

The unit of measure was a 24-hour period starting at midnight. Daily number of patients admitted, discharged, and LWBS as well as the total daily volume in the ED was recorded. Daily nursing hours were determined from nursing staff records for each shift and summed for each day. We measured door-to- discharge LOS in minutes as the interval from the time of presentation to the ED to when the provider discharged the patient. We captured the time of initial presentation by the time the patient was registered at the front desk. The time of discharge was captured by a physician order for discharge placed in the EMR. Door-to-admit LOS was measured in minutes as the interval from the time of ED presentation to when the nurse placed an electronic order that the patient was ready to be transported to the ward. We defined hospital occupancy as the sum of the number of patients in a hospital bed at midnight and the number of patients discharged in the

preceding 24 hours divided by the total number of hospital beds. This method was used previously by Forster,7 which helps capture the true use of inpatient beds during a 24-hour period.

We evaluated the effect of ED nursing hours on throughput metrics using analysis of covariance and controlled for total daily ED volume, hospital occupancy and admission rate. Daily nursing hours were compared across quartiles as a fixed factor. We used daily door-to-discharge LOS, door-to- admit LOS, and the number of patients who LWBS as the dependent variables in each model. SPSS Univariate GLM procedure was used for all analyses.

RESULTS The mean number of visits per day was 290 with a range

of 129 – 425. Nursing hours ranged from 336 – 580 nursing hours per day with a median of 464.7. The daily mean LOS for discharged patients was 249.8 minutes, and the range was 155 – 389. The daily mean LOS for admitted patients was 441.5 minutes, and the range was 259 &

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