A recently released study on how med/surg nurses spend their time is providing a wake-up call to healthcare providers and administrators by proving what most nurses have been saying for years: Med/surg nurses don’t have enough time at the bedside. They spend much of their nursing time documenting, and they walk for miles on every shift.
Using electronic tracking devices, including personal digital assistants (PDAs) and radio frequency identification tags, study authors Ann Hendrich, RN, MSN, FAAN, vice president of clinical excellence operations at Ascension Health in St. Louis, Mo., and Marilyn Chow, RN, DNSc, FAAN, vice president of patient care services at Kaiser Permanente in Oakland, Calif., followed 767 med/surg nurses in 36 hospitals across the country in 2005 and 2006.
Though they found that nurses spent more than three-quarters of their time on nursing practice, less than 40% of it occurred in patients’ rooms. Nurses in the study spent most of their nursing time on documentation, medication administration, and care coordination, according to the study, which was published in The Permanente Journal, a peer-reviewed medical science and humanities journal published by Kaiser Permanente.
“The study made us more aware of how much time we spend away from the patient, which is a sad thought,” says Julie Denninger, RN, a staff nurse in oncology at Long Island Jewish Medical Center in New York, who participated in the study. “It made us much more aware of the time wasted.”
Less than 20% of nursing time — about an hour and 20 minutes of a 10-hour shift — was spent on patient care activities, and only about 7% of nursing time about a half-hour was used for patient assessment and reading vital signs.
Documentation devoured at 35.3% of nurses’ time, followed by care coordination at 20.6%. Medication administration accounted for 17.2% of nursing time.
“To me it means that we’re not using our RNs as the clinical leaders they should be on the unit,” says Kathleen Reeves, RN, MSN, CNS, CMSRN, president of the Academy of Medical Surgical Nurses (AMSN) and an assistant professor at the University of Texas Health Science Center at San Antonio.
The study’s other key findings include
Activities considered “waste,” such as waiting for lab results or hunting down supplies, consumed 6.6% of reported time on a 10-hour shift. These activities were not considered part of nursing practice time. Other areas not included in nursing practice time included non-clinical activities, such as personal time, teaching or administration, and unit functions, such as preparing equipment or transporting patients.
Nurses spent the largest portion of their shift 38.6% at the nursing station and 30.8% in patient rooms.
Nurses in the study walked between 2.4 and 3.4 miles during a 10-hour daytime shift and eight-tenths of a mile less on average during night shifts.
“The task now is to test solutions to create a more effective work environment that supports clinicians in the direct care of patients,” the study’s authors conclude.
The study’s preliminary findings were released to hospital executives and staff in January 2007 and have been presented nationally.
In response, a number of healthcare facilities and associations, including AMSN and some of the hospitals that participated in the study, have signed a proclamation supporting efforts to increase nursing time at the bedside through more patient-friendly design of nursing units and patient rooms, integrated systemwide technology, workplace systems and processes, and partnerships with vendors.
One of the most important things administrators can take away from the study, its authors say, is that nurses and other frontline clinical staff need to be involved in the design and implementation of new architecture and technology.
“When you think about why people are in the hospital, the main reason is that they need 24-hour care,” says Chow.
Nurses assess and evaluate patients and teach them how to take care of themselves after discharge, she says. “Do you really want them to spend that time looking for supplies?”
Although many med/surg nurses say they wish they had more time to spend with patients, seeing the numbers was an eye-opener for some.
“I thought I was spending time with my patients,” says Melody Navarro, RN, MSN, a med/surg oncology charge nurse at Kaiser Permanente West Los Angeles Medical Center. After attending a presentation of the study’s preliminary findings, she realized much of her time was spent talking to doctors and getting medications.
“I was doing things for them, but often they didn’t perceive me as spending time with them,” she says. “It wasn’t quality time.”
Quality time, say med/surg nurses, is talking, teaching, assessing, comforting, holding things many nurses go into the profession for but so often don’t get to do. Eventually, some become frustrated and leave, says Susan Hassmiller, RN, PhD, FAAN, senior program officer and team leader for the Robert Wood Johnson Foundation, which funded most of the study in conjunction with its Transforming Care at the Bedside (TCAB) program.
TCAB recently launched a website (http://www.rwjf.org/qualityequality/product.jsp?id=30051) that offers resources for nurses and administrators looking to increase nursing time with patients and make nurses’ work more efficient. Some hospitals have already started implementing changes, Hassmiller says, most of them suggested or developed by nurses.
“Part of the (TCAB) program is to get staff nurses to come up with solutions to get them back to the bedside,” Hassmiller says. “Our goal is to have them at the bedside 70% of the time” instead of the 30% to 40% of time they now spend with patients.
Some ideas include creating a “no-interruption” zone for nurses who are administering medications; bedside shift hand-offs that involve patients as well as nurses; and white boards with colored magnets next to nurses’ names showing whether they are available to care for new admissions, are approaching their limit, or cannot safely accept another patient.
Ascension Health has started a pilot program using bedside monitors that transfer information directly into patients’ electronic records. Ascension also is using beds that weigh and turn patients and enter that information into their records.
The technology transfers eliminate the need for nurses to scribble patient vital signs on a piece of paper and then later enter them into a computer at the nurses’ station.
Kaiser nurses have developed and piloted a program in which nurses wear a yellow sash while giving medication to patients. While they wear the sash, no one can interrupt them except for emergencies, says Navarro, who helped develop the program. The program has reduced the time it takes to give medications and will be used in all Kaiser hospitals by next year.
Other hospitals that participated in the study are looking at putting supply cabinets in or just outside patient rooms or using rolling supply carts to deliver supplies to nurses. Some are using computers in patient rooms or portable computers to document at the bedside and are involving nurses in decisions about purchasing new technology.
Chow and Hendrich say they were surprised unit architectural design did not directly affect the amount of time nurses in the study spent with patients. Those who navigated long halls spent about the same amount of time in patient rooms as those who traveled shorter distances.
“This shows the nurses are quite flexible,” Chow says. “They will adapt to whatever physical environment they have.”
Improved design or new technology may help nurses spend more time with patients, but these are not answers unto themselves. Investing in an integrated electronic record-keeping system or building a natural, healing environment won’t do much good if the processes keeping nurses from the bedside aren’t changed, Chow and Hendrich say.
The time-motion study is the largest of its kind, Chow says, and as far as she knows the first to use extensive tracking technology. Nurses in the study wore holsters with PDAs that beeped at intervals, prompting them to enter information about tasks and the amount of time they spent on them. Radio frequency tags tracked their movements around the hospital. Some nurses wore armbands to track physiological responses both on and off their shifts to assess stress.
After a while, pushing the PDA buttons became second nature, says Denninger. The nurses were thrilled to participate in a project that could have major implications for their profession, she says.
“There was a lot of excitement and electricity in the air for that one week (of the study). We still talk about it,” says Denninger.
Simply being part of the study has made Denninger more aware of how she spends her time, she says. She has been making changes in her routine to allow her more time with patients. Recently, she needed to drain a patient’s pleural catheter and draw blood. Before she went into the room, she made piles in her mind of what she would need — tubes, needles — and gathered everything at once.
She spent nearly half an hour in the patient’s room. While Denninger worked, she talked with the female patient about results of her recent tests and her children.
“I felt good because I arranged that time to stay and talk with her” instead of running back and forth, she says. “It was a good moment for both of us.”