The purpose of the study is to quantify nurses’ time allocation on a variety of nursing activities recorded into three activity dimensions: communication, task and location.
In 2010, The Institute of Medicine (IOM) published a landmark report, The Future of Nursing: Leading Change, Advancing Health (Institute of Medicine, 2011). This document provided a set of critical recommendations outlining how nursing could significantly contribute to improving healthcare and patient outcomes. One of the recommendations, “nurses should practice to the full extent of their education”, reflects the need for nurses to work at the “top of license”. However, research suggests that nurses spend a considerable amount of non-value added time on activities that could potentially be delegated to other team members with greater cost effectiveness (Kudo, Yoshimura, Shahzad, Shibuya, & Aizawa, 2012). Top of license nursing practice addresses how nurses spend their time across the care continuum and examines “non-valued-added” work, which could be executed safely by other healthcare personnel (Antinaho, Kivinen, Turunen, & Partanen, 2015). This is a strategy for providing higher quality and more efficient care. Reaching top of license requires re-definition and re-design of healthcare teams based on consideration of three basic questions: What activities should be redistributed to nursing support staff? What activities should be redistributed to nursing team members? What activities should be done with reduced frequency? The project aims to provide some pilot data to assist in developing innovative and new nursing care delivery models of the future.
Methods:
We conducted a time and motion study to observe and record nursing activities during their working day shifts between 7am to 7pm. The study was conducted on a medical-surgical (med-surg) unit at a mid-west academic medical center. We observed nurses in the general patient care and adjacent areas such as the nursing station, hallway, medication room, patient rooms, and supply areas. A typical 12-hour nursing day shift was split into three time blocks: 7am-11am, 11am-3pm, and 3pm-7pm. The 4-hour observation time block minimized the chance of un-balanced data if a 12-hour day shift happened to have a heavy or light workload, and also prevented observer fatigue. We trained three nursing students to be the observers. They observed and documented nursing activities using TimeCaT, an electronic time capture tool developed to support data collection for time motion studies (Lopetegui, Yen, Lai, Embi, & Payne, 2012). They were required to attend training sessions and trial observations for at least 12 hours, and have inter-observer reliability assessment before beginning data collection. We performed descriptive analysis to summarize nurses’ time allocation on communication, hands-on tasks, and locations.
Results:
We completed a total of 79 observations (316 hours) with 15 registered nurses. Among the 79 observations, 23 were 7am-11am, 30 were 11am-3pm, and 26 were 3pm-7pm. We summarized nurses’ time allocation on communication, hands-on tasks, and locations. On average, in a 4-hour observation, nurses spent the most time communicating with patients (29.99 mins) and other nurses (26.68 mins). As for hands-on tasks, they spent the most time charting in EHR (31.63 mins) and reviewing information in EHR (21.51 mins), following by medication administration (15.70 mins) and getting medications (8.15 mins). They also spent about 13.52 mins on delegable, non-nursing, transportation, and supply-related activities. Nurses expressed they were distracted and burdened by performing delegable and non-nursing activities due to insufficient staffing or inattention by other departments (dietary, housekeeping, transportation) or other nursing staff (patient care assistant and unit clerk), and wished to have more time being with their pateints (Buck et al., 2018). Our time motion study confirmed these findings nurses’ spent 26% of time in patient rooms and only 12.5% of time interacting with their four to five assigned patients. As the healthcare environment becomes complex, it is critical to re-examine the current nursing practice in order to develop new strategies to improve nurses’ time allocation for high quality patient care (Lavander, Merilainen, & Turkki, 2016).
Conclusion:
The study results provide additional evidence to the growing body of literature on nurses’ time allocation. This work can assist nursing leaders to develop strategies for transforming nursing practice through re-examination of nursing work and activities, and to maximize the potential of the nursing workforce by supporting nurses to truly practice at the top of their license.