Discovering what nurses do and what it costs

Unit-Related Factors That Affect Nursing Time with Patients: Spatial Analysis of the Time and Motion Study

Objective:

The primary goal of this study was to test the hypothesis that nurses adopt distinct movement strategies based on features of unit topology and nurse assignments. The secondary goal was to identify aspects of unit layout or organization that influence the amount of time nurses spend in the patient room.

Background:

Previous research has demonstrated a link between nursing hours and patient outcomes. Unit layout may affect direct patient care time by determining aspects of nurse behavior, such as the amount of time nurses spend walking. The recent nurses' Time and Motion study employed multiple technologies to track the movements and activities of 767 medical-surgical nurses. With regard to unit layout, initial analysis of the data set did not detect differences between types of units and time spent in the patient room. The analysis reported here applies novel techniques to this data set to examine the relationship between unit layout and nurse behavior.

Methods:

Techniques of spatial analysis, borrowed from the architectural theory of spatial syntax, were applied to the Time and Motion data set. Motion data from radio-frequency identification tracking of nurses was combined with architectural drawings of the study units and clinical information such as nurse-patient assignment. Spatial analytic techniques were used to determine the average integration or centrality of nurse assignments for each shift.

Results:

Nurse assignments with greater average centrality to all assigned rooms were associated with a higher number of entries to patient rooms, as well as to the nurse station. Number of entries to patient rooms was negatively correlated with average time per visit, but positively correlated with total time spent in patient rooms. The data describe two overall strategies of nurse mobility patterns: fewer, longer visits versus more frequent, shorter visits.

Conclusions:

Results suggest that the spatial qualities of nurse assignments and unit layout affect nurse strategies for moving through units and affect how frequently nurses enter patient rooms and the nurse station.

The impact of integrated care on direct nursing home care

BACKGROUND/AIM

The introduction of integrated nursing home care is an important policy goal in many countries and is expected to affect the type, frequency and duration of activities delivered to nursing home residents. The exact impact however is unknown. The aim of this paper is to reduce this information gap in order to provide decision supporting information to policy makers and managers. DESIGN/METHODS/ETHICAL ISSUES: At three measurement points between 1999 and 2003, caregivers belonging to 18 functions registered activities delivered to somatic and psycho-geriatric nursing home residents in The Netherlands. Residents either received traditional care, integrated care or care that contained elements of traditional and integrated care (hybrid care). Thirty-six thousand and seventy-one registration lists were used for data analysis. Data analysis included determining, comparing and linking the (total) average frequency and duration of each activity per care type, measurement point and type of resident.

RESULTS

The (total) average frequency and total duration of most activities were higher for integrated care than for traditional and hybrid care. The average duration per activity was generally higher for traditional care. The (total) average frequency of most direct care activities at most measurement points and the total average duration per resident per day were higher for somatic care than for psycho-geriatric care.

CONCLUSIONS

The introduction of integrated nursing home care affects the total average duration and frequency of direct care activities. However, there is no noticeable impact on individual activities or on differences in activities received by somatic and psycho-geriatric residents and the degree to which the occurrence of an activity is related to the duration of that activity. This is because a large proportion of care delivery represents patterned behaviour (routines). Because existing routines are difficult to get rid of, we should not have too high expectations about the effect of integrated care on service delivery.

Work sampling: valuable methodology to define nursing practice patterns

The volatile clinical and managerial environment of today's health care system demands that the nursing sector regularly evaluates how staff deliver care. Management's central purpose is to support clinical core activities, striving for a reasonable balance between cost effectiveness and quality care. Various methodologies, such as work sampling and time-and-motion studies, have been used to explore work-related activities. As a cost-effective and useful methodology, work sampling warrants more in-depth exploration of the various techniques involved to ensure nurse managers, clinicians and researchers appreciate the complexities of the approach and its potential to contribute to an understanding of nursing work. The present paper describes work sampling as a method, reviews its use through the literature and outlines some of its advantages and disadvantages in comparison to the time-and-motion methodology, a method similar in many ways. It is intended to enhance readers' appreciation of work sampling's potential value to nurses and other health professionals, and to enhance the understanding of the difference between work sampling and time-and-motion studies.

Nursing documentation time during implementation of an electronic medical record

OBJECTIVE

To determine, within the context of all nursing duties, the amount of time nurses spend on documentation during the implementation of an electronic medical record (EMR) on an intrapartum unit.

BACKGROUND

Increased documentation needs during EMR implementation may necessitate increased staffing requirements in an already labor-intensive and demanding environment.

METHODS

A work-sampling study was conducted over a 14-day study period, and 18 of 84 (21%) potential 4-hour observation periods were selected. During each period, a single observer made 120 observations and, on locating a specific nurse, immediately recorded that nurse's activity on a standardized and validated instrument. Categories of nursing activities included documentation, bedside care, bedside supportive care, nonbedside care, and nonpatient care.

RESULTS

A total of 2160 observations were made. The total percentage of nursing time spent for documentation was 15.8%, 10.6% on paper and 5.2% on the computer. The percentage of time spent on documentation was independently associated with day versus night shifts (19.2% vs 12.4%, respectively).

CONCLUSIONS

Despite charting concurrently on both paper and computer, the amount of time spent on documentation was not excessive, and was consistent with previous studies in which neither electronic nor "double charting" occurred.

Work sampling. A decision-making tool for determining resources and work redesign

Efficiency and productivity are important factors in managing programs and human resources and in determining resource allocation. Absence of practice productivity and efficiency data leads to inappropriate decisions and actions resulting in detrimental outcomes. It is critical that nurse executives and managers have effective measures by which to analyze productivity and to evaluate empirically the effects of management actions and decisions for any proposed or implemented change. The authors describe a work sampling methodology that can be used to establish a data base for evaluating programmatic, staff mix, role redesign, or care delivery model changes.