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How Nurses Spend Their Time:
Effects on Quality & Safety in
Hospitals
Association for the Advancement of
Medical Instrumentation
June 2, 2008
Marilyn Chow, RN, DNSc, FAAN
Vice President, National Patient Care Services
Kaiser Permanente
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Big Picture…A View From the Bridge
1.
Facility Design and Construction
2.
Workforce and Practice Models
3.
Patient Safety

4.
“Failure to Rescue”
Pay for Performance

Value-Based Purchasing

27 Never Events
5.
Physician Alignment
6.
Patient Experience/Competition
7.
Operating Margins
8.
Vendor code and standardization
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Problem—Nursing Shortage
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Increased demand
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Decreased supply
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Shortage estimates range from 400,000
to 1 Million RN’s in the United States by
2020
% of RN’s in hospitals has dropped from
65 to 56.2
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Adding to Nursing Supply
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Efforts at recruitment have resulted in
turning away more than 145,000 qualified
applicants last year (NLN 2007)
Shortages in faculty, classrooms, and
clinical placements are slowing preparation
of new nurses
Inadequate number of nurses prepared to
become faculty
Supply cannot keep up with demand
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Retention of Current Workforce
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Nurses demand improvements in the
hospital work environment
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Safety
Efficient systems
Automation
Improved communication
Technological products and processes have
not incorporated nurses’ viewpoints
Multiple studies nationally and
internationally speak to the need to
improve the practice environment as a key
strategy to retaining nurses and improving
patient care outcomes.
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Three Studies Addressing the Work
Environment
Technology Drill Downs (TD2)
Transforming
Care at the
Bedside (TCAB)
Time & Motion
Data synthesis across three studies will build
evidence-based case for new technologies to
improve med-surg units
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A Catalyst for Change
Without bolder changes in the hospital
work environment, the nursing
shortage, coupled with the retiring
nursing workforce and faculty
shortages, will threaten the staffing
sustainability of the American hospital
as part of the care delivery system
within the next 5-10 years.
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Time & Motion Study: How Do MedicalSurgical Nurses Spend Their Time
The purpose of this study is to identify specific
environmental variables of the acute care nursing
workplace that can be altered to positively impact
nursing direct care activity and ultimately, patient
safety. This study is designed to provide detailed
information about:
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The amount of time nurses spend in identified
activity categories
Their movement throughout the nursing unit over
the course of a typical nursing shift
The physical impact of nursing workload and stress
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Study Partners
Principal Investigators
Grant Funding
Statistics, Data Management and Economics
Track A & B
Technology Oversight
Track C
Study Coordination
Track D
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Participating Health Systems
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Participating Hospitals
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The participating health systems operate a
total of 274 hospitals with more than
63,000 beds
The participating hospitals are
geographically dispersed across fifteen
states
Average length of stay for the study units
ranges from 2.62 – 8.67 days, an average
of 4.37 days
Unit size ranges from between 11-20 beds
to 81-90 beds with a median size of 31-40
beds
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Study Protocols
Protocol A
Baseline for EHR
Implementation
Protocol B
How Do Nurses
Spend Their Time
!
Protocol C
Data was collected for
seven consecutive
days, 24 hours a day
on the randomly
selected medicalsurgical units.
Nurse Location &
Movement
Protocol D
Nurse Physiologic
Response
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Data Collection Overview
Protocol C:
Nurses carry locating
RFID tags
Protocol A:
Documentation
time
Protocol D:
BodyMedia
armband
Protocol B:
Nurse work
sampling
Data
download
to laptop
Wireless
Receivers
Secure data
transfer to
24x7 Purdue
Server
Data: Checked
for quality and
loaded into
Oracle DB
R objects
generation
R statistical
software
Graphs
& reports
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Participation Results
On average, 76% of all eligible
licensed nurses consented to
participate during the seven day
study period at 36 hospital sites
97%
97% of those who consented
completed the study while 3%
voluntarily dropped out during the
study period
No participants were removed from the study due
to non-compliance!
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Data Collection Results
763 licensed nurses (RNs, LPNs/LVNs)
completed the study
Track A
Track B
Track C
Track D
385
Participants
382
Participants
750
Participants
288
Participants
In total, study data has been collected on
2,201 work shifts resulting in 21,882 hours
of data
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Key Research Findings
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How do nurses spend their time?

77.7% of the time devoted to nursing practice
Unit-Related
Functions, 2.8%
Waste, 6.6%
Non-Clinical,
12.6%
Nursing
Practice, 77.7%
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Where do nurses spend their time?

38.6% of time spent at the nurse station
On the Unit,
23.7%
Patient Room,
30.8%
Off the Unit,
6.9%
Nurse Station,
38.6%
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Three Major Areas Accounted for
Most of the Time
1.
Documentation (electronic/paper)
2.
Medication Administration
3.
Care Coordination/communication with
the patient care team, physicians and
others
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Time With Patients
The amount of time a nurse spends with patients in
patient rooms on daytime shifts varies from about
20% (120 minutes out of 10 daytime hours) to 38%
(228 minutes out of 10 daytime hours) across the
study units. The median is 171 minutes, or 30.8%.
30.8%
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Time on Documentation
The most time consuming nursing practice activity is
documentation (includes all documentation
categories, chart review, and computer data entry).
The amount of time a nurse spends on documentation
on daytime shifts varies from about 16% (96 minutes
out of 10 daytime hours) to 34% (204 minutes out of
10 daytime hours). The median is 147.5 minutes.
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Time on Medication Administration
A time consuming activity is medication
administration: obtaining, preparing, documenting,
and giving medication. The amount of nursing practice
time spent on medication administration averages 72
minutes, or 17.2%
17%
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Distance Traveled
During daytime shifts, study units averaged
distance traveled rates between about 2.4 to 3.4
miles per 10-hours. The median is 3.0 miles.
Individual nurses across all study units traveled
from 1 mile to 5 miles per 10-hour daytime period.
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Distance Traveled (continued)
On night shifts, study units averaged distance
traveled rates between about 1.3 to 3.3 miles
per 10-hours. The median is about 2.2 miles, a
reduction of 0.8 miles per 10-hours from day time
shifts.
During the day time, while off shift, distance
traveled varied from 1.2 miles to 3.5 miles. The
median is 2.1 miles, a reduction of 0.9 miles
per 10-hours from day time work shifts.
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Other Results
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No consistent, statistically significant
relationship was found between
various unit architecture types and
nursing time spent with patients
Distances traveled and time spent on
activities varied considerably between
shifts. Of interest, variability between
individual nurses on the same unit
was often greater than the variance
across different hospital units.
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7% of a nurse’s time is spent on
patient assessment
17% of a day shift nurse’s time (median) is
spent on medication administration
35% of a nurse’s time is spent on
documentation
Day shift nurses spend about
time in
patients
30.8% of their
patient rooms with all of their
During a typical 10-hour day, a nurse
travels 1-5 miles
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Technology Drill Down (TD2) Study
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Technology Targets Study funded by
Robert Wood Johnson Foundation
(RWJF)
Aims of the study

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Create an improved process for
identifying technology solutions to
medical/surgical unit workflow
inefficiencies.
Capture the attention of and prompt
industry to develop technology that
improve workflow processes.
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TD2 Process
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Two day process of brainstorming and
visioning
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20 – 30 multidisciplinary representatives
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Primary Purpose
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Map gaps between current workflow & idealized
workflow
Identify potential technological applications that
could close the gaps
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Preliminary Findings from TD2 Sites
Documentation
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Computerized Order Entry included in
electronic record
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Touch screen/Voice activated
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Global Documentation System
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Multidisciplinary
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Real time
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Universal – physician, hospital, home
care
Flash Drive/Smart Card
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Preliminary Findings from TD2 Sites
Patient Care
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Smart Monitoring Devices –
interfaced with EHR
Portable devices to quickly add
information and updates to patient
charts
ID Bracelet or Tracking Chip System Use with a handheld scanner. Linked
to chart. Interfaces with screen at
bedside.
Smart Bed
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Preliminary Findings from TD2 Sites
Communications
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Computerized, centralized patient
scheduling system for all
departments
Wireless voice communication
device/Hands free communication
device.
RFID for caregivers.
Universal Translator/Automatic
language interpretation device.
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Preliminary Findings from TD2 Sites
Medications
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Robotic delivery
Medication Barcode/Chip System
(same system for labs, blood
products)
Smart IV/Blood Pump
Simplify systems and eliminate
redundancies
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Preliminary Findings from TD2 Sites
Supplies & Equipment
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RFID tag - item scanned when used
Inventory to central computer
Include linens, supplies & equipment
Robot to restock and deliver supplies
& equipment
Ensure availability at the point of
care
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What We Believe
A Working Proclamation:
Recommendation Prototype…
Proclamation For Change
o
Key study findings presented in January 2007 to more
than 200 health care executives and frontline staff
o
Leaders developed a set of national recommendations
for the idealized unit design to maximize efficiency
and reduce work stress, in order to improve the
quality and safety of patient care
o
Resulting “Proclamation for Change” presents four
principles to guide decisions about hospital design and
technology
While they sound simple in theory,
implementing the principles requires that the
silos that America’s hospital staff operate in –
technology, nursing, facilities, etc. – be
removed.
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In order to transform the hospital-patient
care environment and improve the delivery
of safe, high-quality, patient-centered
care, we believe in the need for:
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Patient-centered design. Hospital and technology
design should be organized around patient needs –
helping patients and their families feel engaged in the
caregiving process rather than removed from it – and
be tailored to address unique factors and diverse
patient populations.
System-wide, integrated technology. Architects
and technology vendors should work closely with
nurses, physicians and other caregiving departments
(i.e., pharmacy, lab, housekeeping, admitting) in all
aspects of designing workspace and technologies in
order to ensure a system-wide approach to meeting
patient needs.
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In order to transform the hospital-patient
care environment and improve the delivery
of safe, high-quality, patient-centered
care, we believe in the need for:

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Seamless workplace environments. To
consistently provide the highest quality care to
patients, the physical design of medical-surgical
units should be completely integrated with
caregiver work processes and the technologies
they use, so caregivers always have the right
medication, materials and information, in the right
place, at the right time.
Vendor partnerships. The design and operation
of technology devices should be intuitive, errorfree, and part of interoperable systems – so that
health care providers can access information in
hospital or outpatient settings – and not waste
time serving as human bridges that link multiple
technology devices in different locations.
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We believe…
Our work processes can’t be dictated
by technology and space. It must be
the other way around.
o
Nurses need to be innovators of their own
work systems
o
Vendors and architects must include us in
the co-design of our work systems
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We believe…
Our space and tools must support
collaboration (among providers,
patients, and family)
o
Design environments that allow people to
remain connected throughout their work-time
and across disciplines
o
The renovation and/or new construction
design process must include the input of
those who will use it
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We believe…
We will only buy technology solutions
that work well together (and with us!)
o
Technology providers need to align around a
common platform for interoperability of
different types of equipment
o
The user experience must be intuitive, and
not require the nurse to be the bridge
between different devices and systems
o
A nurse is not an interface
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If these principles are followed, then:
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Documentation will be a byproduct of care
Needed patient supplies and medical equipment will be
available on demand
Medication will be administered as part of a seamless
system that provides accurate and timely information
about the patient
Communication systems will link healthcare providers
as appropriate, fostering efficient, effective
communications across and between disciplines
Patients and families will experience nurses and other
care providers who spend more time in direct patient
care
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How Can You Help Nurses?
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Understand the work environment
Be alert to how you can simplify the
environment
Listen to the concerns of nurses
Be astute observers of how nurses interact
with biomedical and clinical IT devices
Be translators of technology “gobblygook”
Think about how to integrate new clinical
technology seamlessly into the work
environment.
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