Clean linen, the night shift
A nurse is working the night shift on an oncology floor, and she has run out of clean linen. Her patients' beds need changing, and the cupboard on her unit is empty. So she walks to another unit, one that has linen in stock, and takes what she needs from its supply. She takes more than one set. She brings back several, for the other nurses on her floor. It takes her a few minutes. The beds are changed. Nobody is told.
This nurse is not a composite. She was observed on an American hospital floor by the researchers Anita Tucker and Amy Edmondson, who described her in a paper published in 2003. When they asked her about it, she said this:
"Working around problems is just part of my job. By being able to get IV bags or whatever else I need, it enables me to do my job and to have a positive impact on a person's life—like being able to get them clean linen. And I am the kind of person who does not just get one set of linen, I will bring back several for the other nurses."
Every manager would want her on the team. She is resourceful, generous and calm. And her resourcefulness is, in the researchers' account, exactly why the hospital will run out of linen again next week. The problem was solved for her patients. It was never reported to anyone who could stop it happening, and the several sets she carried back left a gap in the other unit's cupboard that someone there would solve the same way.
Ammanuel Santa Anna's canon, writing about who in an organisation can see what, puts the nurse's position in two sentences that hold the whole difficulty: "Senior leaders typically have broad but shallow visibility — they see strategic patterns and cross-functional dynamics but may miss the lived reality of frontline work. Frontline workers have deep but narrow visibility — they know their process intimately but may not see how it connects to the larger system." The nurse knows the linen runs out. The hospital, which pays her, does not.
A nurse in her position carries the difference in her body, though few would put it that way. The walk to another unit is a few minutes, taken from patients on a shift that had no minutes to spare, and the paper records the feeling that comes with getting back: seven of the nine nurses interviewed said they felt gratified when they found a way round an obstacle. The gratification is real, and it sits on top of a tiredness it does not lift. Each time a nurse solves the problem this way, she also confirms, to herself and to anyone watching, that this is a problem a good nurse solves alone.
This issue makes one claim. The largest unclaimed asset in most organisations is the knowledge of the people closest to the work: what fails, how often, and how they get round it. The organisation has already paid for it, in wages and in years of experience, and it spends that knowledge every day on fixing the same problems again, rather than collecting it once and removing them. The gain is in the difference, and the people who hold the knowledge should share in what it is worth.
The rest of this article, its sources and its practice are kept in Where the Flow Stops, Chapter 4, in the colour art edition.
