Ask any nurse and you'll hear the same refrain: We don't have enough time to spend with our patients.
Marilyn Chow, DNSc, RN, FAAN, vice president of patient care services for Kaiser Permanente, had heard the complaints for years and wanted to find a solution. But first, she had to find out where nurses were really spending their time. The best way to study them was literally to follow nurses around.
To that end, Chow teamed with colleague Ann Hendrich, MSN, RN, FAAN, vice president of clinical excellence operations at Ascension Health in St. Louis to devise a study to look at how med/surg nurses spent their time and energy. Funded by grants from the Robert Wood Johnson Foundation and the Gordon & Betty Moore Foundation, the Time & Motion study was designed to identify system and process problems causing nursing inefficiency.
The study ran from June 2005 to June 2006, with data gathered from 36 hospitals in 17 healthcare systems across 15 states. At each hospital, one med/surg unit was selected at random and all licensed nurses (RNs and LVNs) on the unit were asked to participate; 763 completed the study. Float and agency nurses; nurse preceptors and preceptees; and nursing supervisors, charge nurses or other nurse specialists were ineligible unless they provided direct nursing care with the same acuity and patient load as other nurses. Data was collected over nearly 2,200 shifts for a total of nearly 22,000 hours.
Shift time was divided into activity categories (nursing practice, unit-related functions, nonclinical activities and waste) and locations (patient room, nurses station, on-unit, off-unit). Study participants used personal digital assistants to document random samplings of their work day. For 7 days, participants were asked to stop what they were doing when the PDA vibrated and note their location and activity.
At the same time, the distance nurses traveled throughout their shift and the amount of energy expended were monitored through radio-frequency identification tags, which tracked nurses continuously when they were on the unit. During 10-hour shifts, nurses walked anywhere between 2.4 and 3.4 miles.
The study showed less than one-third of nursing time was spent at the bedside, but more than 75 percent of all reported time was spent in some nursing activity. The largest single chunk of time, nearly 2 1Ú2 hours, was spent on documentation, followed by care coordination and patient care activities at nearly 1 1Ú2 hours each, and medication administration at just over an hour. Only half an hour, or 7 percent of nursing practice, was spent on patient assessment and reading vital signs.Ê Nurses also spent time on "hunting and gathering" activities, such as finding charts, supplies or equipment and tracking down physicians and other key members.
Chow called the results a confirmation of what nurses had been saying for years.
"This study reflects the reality nurses face every day," she said. "Nurses are happy to hear the results verify what they've told us. More time with patients means greater quality of care."
However, the numbers by themselves are only interesting data. Chow noted the next step is the important one.
"There have been other studies that identified some of these same problems, but they just sat on a shelf," she explained. "We hope this study will trigger conversation and solutions."
Preliminary steps have already taken place. One is A Proclamation for Change, a group of recommendations based on the study data to increase the time nurses spend in direct patient care as well as quality and outcomes. The recommendations include patient-centered design; system-wide, integrated technology; seamless workplace environments and vendor partnerships. The proclamation has been signed by a number of healthcare systems and nursing organizations, including Kaiser Permanente, the American Academy of Nursing and the American Nurses Association.
While Chow is proud to be a part of such a large group effort, changes in her own backyard are closer to her heart.
"It took a lot of courage for us to shine a light on what was happening in our own organization," Chow told ADVANCE. "But the only way to make a change was to see where the gaps were in what we were already doing.
"Nurses are incredibly adaptive and flexible," she continued. "They can develop work-arounds for nearly any obstacle so they can focus on delivering the best care to their patients. The results of this study will help them do that."
Chow took the study data and called a meeting of the minds at Kaiser headquarters in Oakland. Unlike most top-level gatherings, however, this brain-trust was made up of front-line nurses, unit supervisors and managers from across the state. All came with the same charge: to create efficient, patient-centered programs flexible enough to allow nurses to spend more time at the bedside while they worked to decrease medication errors. There were no dumb ideas, and innovation and creativity were encouraged.
The result is Destination Bedside, an umbrella project with integrated solutions including KP MedRite and Nurse Knowledge Exchange, being piloted at Kaiser's West Los Angeles (KPWLA) hospital. The aim of the project is to give nurses more time at the bedside by bringing documentation, medication administration, communication, supply management and admission/discharge/transfer there.
If Melody Navarro, MSN, RN, is to be believed, the study has created a sea change for both nurses and patients. Navarro is charge nurse of an adult med/surg/oncology unit at KPWLA and has been part of the solution since the first "deep dive" innovation meeting.
"We used ideas from other industries, such as the airlines," she said. "We were encouraged to think out of the box, with limitless technology. The front-line nurses told us what would help them and we found ways to make things happen."