Nursing Capability in Lean-Oriented Hospital Improvement: Narrative Review

Lean-oriented redesign is widely used to improve hospital flow and productivity, but the capabilities nurses need to implement and sustain change remain poorly defined. This critical narrative review integrates empirical evidence concerning nursing capability, organizational conditions, implementation, sustainment, and performance. Nursing-specific instruments assess perceived Lean implementation or service leanness, but none validates nursing improvement capability as an adaptive individual and collective capacity. The most credible candidate manifestations are practical knowledge and judgement, collective problem-solving, learning, professional agency, and enacted improvement leadership. Staffing, protected time, decision authority, data access, and infrastructure shape whether these capabilities can be expressed but are not equivalent measures of capability. Operational process improvements are reported most often, yet causal attribution is weak. Evidence for reallocated bedside time, net economic value, workforce benefit, patient safety, environmental benefit, and long-term sustainment remains limited or inconsistent. Evaluations should measure capability, context, implementation, sustainment, benefits, and harms separately and prospectively.