Time motion analysis of nursing work in ICU, telemetry and medical-surgical units

A pre-post interventional study to reduce time spent on clinical documentation by nurses and midwives

AIM

To evaluate the impact of a co-designed intervention to reduce time spent on clinical documentation and increase time for direct patient care.

DESIGN

A pre- and post-test interventional study with multi-method evaluation, reported according to the Transparent Reporting of Evaluations with Nonrandomised Evaluations Designs guidelines.

METHODS

An intervention to decrease the burden of documentation was co-designed and implemented. Pre- and post-intervention data were collected via time and motion studies and the Burden of Documentation for Nurses and Midwives (BurDoNsaM) survey. Documentation audits were conducted to assess intervention fidelity.

RESULTS

Twenty-six shifts were observed (13 pre-intervention, 13 post-intervention). Although the coronavirus pandemic contributed to decreases in staffing levels by 38% (from 118 to 73 staff), the number of task episodes completed increased post-intervention, across all shift patterns. Documentation took less time to complete post-intervention when assessing time per episode. A mean increase of 201 episodes was observed on morning shifts, 78 on evening shifts and 309 on night shifts. There were small increases for time spent on direct patient care compared to pre-intervention but there was less time per episode. Results from the BurDoNsaM survey indicated that participants felt documentation took less time post-intervention. Documentation audits found completion improved as staff gained familiarity, but deteriorated when staffing levels were reduced.

CONCLUSION

The intervention was able to reduce time spent completing documentation, increasing the time available for direct patient care.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

Completing clinical documentation is part of the daily work of nurses and midwives. Clinical documentation needs to accurately capture key information in a concise and streamlined manner to avoid unnecessary burdens and release time for direct patient care.

IMPACT

This study tested a co-designed intervention to address the burden of clinical documentation for nurses and midwives, The intervention reduced time spent on clinical documentation and increased time for direct patient care, This study could be replicated to reduce the burden of clinical documentation in other settings and benefit clinicians and patients by releasing more time for direct patient care.

REPORTING METHOD

The study is reported using the Transparent Reporting of Evaluations with Nonrandomised Evaluations Designs (TREND) guidelines.

PATIENT OR PUBLIC CONTRIBUTION

The research project and intervention evaluated in this study were co-designed through a clinician-researcher collaboration. A research team that consisted of clinically based nurses and midwives and nurse scientists was formed to address the burden of clinical documentation. As the end-users of clinical documentation, the clinically based nurse and midwife co-investigators were involved in the design, conduct, interpretation of the data, and preparation of the manuscript.

The ChatGPT effect and transforming nursing education with generative AI: Discussion paper

AIM

The aim of this study is to present the possibilities of nurse education in the use of the Chat Generative Pre-training Transformer (ChatGPT) tool to support the documentation process.

BACKGROUND

The success of the nursing process is based on the accuracy of nursing diagnoses, which also determine nursing interventions and nursing outcomes. Educating nurses in the use of artificial intelligence in the nursing process can significantly reduce the time nurses spend on documentation.

DESIGN

Discussion paper.

METHODS

We used a case study from Train4Health in the field of preventive care to demonstrate the potential of using Generative Pre-training Transformer (ChatGPT) to educate nurses in documenting the nursing process using generative artificial intelligence. Based on the case study, we entered a description of the patient's condition into Generative Pre-training Transformer (ChatGPT) and asked questions about nursing diagnoses, nursing interventions and nursing outcomes. We further synthesized these results.

RESULTS

In the process of educating nurses about the nursing process and nursing diagnosis, Generative Pre-training Transformer (ChatGPT) can present potential patient problems to nurses and guide them through the process from taking a medical history, setting nursing diagnoses and planning goals and interventions. Generative Pre-training Transformer (ChatGPT) returned appropriate nursing diagnoses, but these were not in line with the North American Nursing Diagnosis Association - International (NANDA-I) classification as requested. Of all the nursing diagnoses provided, only one was consistent with the most recent version of the North American Nursing Diagnosis Association - International (NANDA-I). Generative Pre-training Transformer (ChatGPT) is still not specific enough for nursing diagnoses, resulting in incorrect answers in several cases.

CONCLUSIONS

Using Generative Pre-training Transformer (ChatGPT) to educate nurses and support the documentation process is time-efficient, but it still requires a certain level of human critical-thinking and fact-checking.

Toward ensuring care quality and safety across settings: examining time pressure in a nursing home with observational time motion study metrics based on the Omaha system

BACKGROUND

Meaningful data to determine safe and efficient nursing workload are needed. Reasoning a nurse can accomplish a finite number of interventions and location changes per hour, examination of time pressure using time motion study (TMS) methods will provide a comparable indication of safe and efficient workload for an individual nurse.

METHODS

An observer shadowed 11 nurses at a 250-bed nursing home in the Southeastern United States and recorded 160 h of observations using TimeCaT, web-based TMS data recording software. Predefined Omaha System nursing interventions (N = 57) and locations (N = 8) were embedded within TimeCaT. The time-stamped data were downloaded from TimeCaT and analyzed using descriptive and inferential statistics. Five time pressure metrics were derived from previous TMS findings in acute care settings.

RESULTS

Overall, nurses spent 66 s for each intervention, performed 65 interventions per hour, stayed 130 s at each location, changed locations 28 times per hour, and multitasked for 29% of working time. Computed hourly time pressure metrics enabled visualization of variability in time pressure metrics over time, with differences in multitasking by licensure, unit/role, and observation session time.

CONCLUSIONS

Nursing home nurses consistently experienced a high degree of time pressure, especially multitasking for one-third of their working time. To inform staffing decision making and improve the quality of care, resident outcomes, and nurse satisfaction, it is critical to identify ways to mitigate time pressure. Additional research is needed to refine and extend the use of the time pressure metrics.

Examining Care Planning Efficiency and Clinical Decision Support Adoption in a System Tailoring to Nurses' Graph Literacy: National, Web-Based Randomized Controlled Trial

BACKGROUND

The proliferation of health care data in electronic health records (EHRs) is fueling the need for clinical decision support (CDS) that ensures accuracy and reduces cognitive processing and documentation burden. The CDS format can play a key role in achieving the desired outcomes. Building on our laboratory-based pilot study with 60 registered nurses (RNs) from 1 Midwest US metropolitan area indicating the importance of graph literacy (GL), we conducted a fully powered, innovative, national, and web-based randomized controlled trial with 203 RNs.

OBJECTIVE

This study aimed to compare care planning time (CPT) and the adoption of evidence-based CDS recommendations by RNs randomly assigned to 1 of 4 CDS format groups: text only (TO), text+table (TT), text+graph (TG), and tailored (based on the RN's GL score). We hypothesized that the tailored CDS group will have faster CPT (primary) and higher adoption rates (secondary) than the 3 nontailored CDS groups.

METHODS

Eligible RNs employed in an adult hospital unit within the past 2 years were recruited randomly from 10 State Board of Nursing lists representing the 5 regions of the United States (Northeast, Southeast, Midwest, Southwest, and West) to participate in a randomized controlled trial. RNs were randomly assigned to 1 of 4 CDS format groups-TO, TT, TG, and tailored (based on the RN's GL score)-and interacted with the intervention on their PCs. Regression analysis was performed to estimate the effect of tailoring and the association between CPT and RN characteristics.

RESULTS

The differences between the tailored (n=46) and nontailored (TO, n=55; TT, n=54; and TG, n=48) CDS groups were not significant for either the CPT or the CDS adoption rate. RNs with low GL had longer CPT interacting with the TG CDS format than the TO CDS format (P=.01). The CPT in the TG CDS format was associated with age (P=.02), GL (P=.02), and comfort with EHRs (P=.047). Comfort with EHRs was also associated with CPT in the TT CDS format (P<.001).

CONCLUSIONS

Although tailoring based on GL did not improve CPT or adoption, the study reinforced previous pilot findings that low GL is associated with longer CPT when graphs were included in care planning CDS. Higher GL, younger age, and comfort with EHRs were associated with shorter CPT. These findings are robust based on our new innovative testing strategy in which a diverse national sample of RN participants (randomly derived from 10 State Board of Nursing lists) interacted on the web with the intervention on their PCs. Future studies applying our innovative methodology are recommended to cost-effectively enhance the understanding of how the RN's GL, combined with additional factors, can inform the development of efficient CDS for care planning and other EHR components before use in practice.

The time, places, and activities of nurses in a psychiatric inpatient context - A time and motion study with a time-geographic perspective

Nurses in psychiatric inpatient care spend less time than desired with patients and investigation of the nature of nursing in this setting is needed. This study explores how nursing activities in psychiatric inpatient wards is distributed over time, and with a time-geographic perspective show how this relates to places. Observations were used to register place, activity, and time. A constructed time-geographic chart mapped the nurses' path which showed that nurses spent little time in places where patients are. There might be constraints that affect nursing. Nurses need to evaluate where time is spent and interventions that facilitate relationships are needed.

Time Spent by Intensive Care Unit Nurses on the Electronic Health Record

BACKGROUND

The amount of time spent on the electronic health record is often cited as a contributing factor to burnout and work-related stress in nurses. Increased electronic health record use also reduces the time nurses have for direct contact with patients and families. There has been minimal investigation into the amount of time intensive care unit nurses spend on the electronic health record.

OBJECTIVE

To quantify the amount of time spent by intensive care unit nurses on the electronic health record.

METHODS

In this observational study, active electronic health record use time was analyzed for 317 intensive care unit nurses in a single institution from January 2019 through July 2020. Monthly data on electronic health record use by nurses in the medical, neurosurgical, and surgical-trauma intensive care units were evaluated.

RESULTS

Full-time intensive care unit nurses spent 28.9 hours per month on the electronic health record, about 17.5% of their clinical shift, for a total of 346.3 hours per year. Part-time nurses and those working as needed spent 20.5 hours per month (17.6%) and 7.4 hours per month (14.2%) on the electronic health record, respectively. Neurosurgical and medical intensive care unit nurses spent 25.0 hours and 19.9 hours per month, respectively. Nurses averaged 23 clicks per minute during use. Most time was spent on the task of documentation at 12.3 hours per month, which was followed by medical record review at 2.6 hours per month.

CONCLUSION

Intensive care unit nurses spend at least 17% of their shift on the electronic health record, primarily on documentation. Future interventions are necessary to reduce time spent on the electronic health record and to improve nurse and patient satisfaction.

Research Types and New Trends on the Omaha System Published From 2012 to 2019: A Scoping Review

The Omaha System is a popular and standard term used in community health. This scoping review aimed to update the research types and identify new usage trends for the Omaha System through articles published between 2012 and 2019. The bibliography databases PubMed, CINAHL, Scopus, PsycInfo, Ovid, and ICHUSHI and the Omaha System's Web site were used to search for publications. Research articles published between 2012 and 2019 that included "Omaha System" in the title or abstract and were written in English or Japanese were included in this review. After excluding duplicate articles, 305 articles were screened and 82 were included in our analysis. There was a median of 10.3 articles per year. The percentages for each type of use of the Omaha System to "analyze client problem," "analyze clinical process," "analyze client outcomes," and "advanced classification research" were 18.3%, 12.2%, 23.2%, and 4.9%, respectively. The reclassification of the type "others" (41.5%) included "use the Omaha System data for assessment for other than clients," "use the Omaha System data as structured data," "encode by the Omaha System code," "adopt the OS framework," "clinical information system," and "literature review." This newly reclassified category will help capture future research trends using the Omaha System.

A time motion study of manual versus artificial intelligence methods for wound assessment

Objectives

This time-motion study explored the amount of time clinicians spent on wound assessments in a real-world environment using wound assessment digital application utilizing Artificial Intelligence (AI) vs. manual methods. The study also aimed at comparing the proportion of captured quality wound images on the first attempt by the assessment method.

Methods

Clinicians practicing at Valley Wound Center who agreed to join the study were asked to record the time needed to complete wound assessment activities for patients with active wounds referred for a routine evaluation on the follow-up days at the clinic. Assessment activities included: labelling wounds, capturing images, measuring wounds, calculating surface areas, and transferring data into the patient’s record.

Results

A total of 91 patients with 115 wounds were assessed. The average time to capture and access wound image with the AI digital tool was significantly faster than a standard digital camera with an average of 62 seconds (P<0.001). The digital application was significantly faster by 77% at accurately measuring and calculating the wound surface area with an average of 45.05 seconds (P<0.001). Overall, the average time to complete a wound assessment using Swift was significantly faster by 79%. Using the AI application, the staff completed all steps in about half of the time (54%) normally spent on manual wound evaluation activities. Moreover, acquiring acceptable wound image was significantly more likely to be achieved the first time using the digital tool than the manual methods (92.2% vs. 75.7%, P<0.004).

Conclusions

Using the digital assessment tool saved significant time for clinicians in assessing wounds. It also successfully captured quality wound images at the first attempt.

Artificial intelligence and clinical deterioration

PURPOSE OF REVIEW

To provide an overview of the systems being used to identify and predict clinical deterioration in hospitalised patients, with focus on the current and future role of artificial intelligence (AI).

RECENT FINDINGS

There are five leading AI driven systems in this field: the Advanced Alert Monitor (AAM), the electronic Cardiac Arrest Risk Triage (eCART) score, Hospital wide Alert Via Electronic Noticeboard, the Mayo Clinic Early Warning Score, and the Rothman Index (RI). Each uses Electronic Patient Record (EPR) data and machine learning to predict adverse events. Less mature but relevant evolutions are occurring in the fields of Natural Language Processing, Time and Motion Studies, AI Sepsis and COVID-19 algorithms.

SUMMARY

Research-based AI-driven systems to predict clinical deterioration are increasingly being developed, but few are being implemented into clinical workflows. Escobar et al. (AAM) provide the current gold standard for robust model development and implementation methodology. Multiple technologies show promise, however, the pathway to meaningfully affect patient outcomes remains challenging.

Nursing documentation and its relationship with perceived nursing workload: a mixed-methods study among community nurses

Background

The time that nurses spent on documentation can be substantial and burdensome. To date it was unknown if documentation activities are related to the workload that nurses perceive. A distinction between clinical documentation and organizational documentation seems relevant. This study aims to gain insight into community nurses’ views on a potential relationship between their clinical and organizational documentation activities and their perceived nursing workload.

Methods

A convergent mixed-methods design was used. A quantitative survey was completed by 195 Dutch community nurses and a further 28 community nurses participated in qualitative focus groups. For the survey an online questionnaire was used. Descriptive statistics, Wilcoxon signed-ranked tests, Spearman’s rank correlations and Wilcoxon rank-sum tests were used to analyse the survey data. Next, four qualitative focus groups were conducted in an iterative process of data collection - data analysis - more data collection, until data saturation was reached. In the qualitative analysis, the six steps of thematic analysis were followed.

Results

The majority of the community nurses perceived a high workload due to documentation activities. Although survey data showed that nurses estimated that they spent twice as much time on clinical documentation as on organizational documentation, the workload they perceived from these two types of documentation was comparable. Focus-group participants found organizational documentation particularly redundant. Furthermore, the survey indicated that a perceived high workload was not related to actual time spent on clinical documentation, while actual time spent on organizational documentation was related to the perceived workload. In addition, the survey showed no associations between community nurses’ perceived workload and the user-friendliness of electronic health records. Yet focus-group participants did point towards the impact of limited user-friendliness on their perceived workload. Lastly, there was no association between the perceived workload and whether the nursing process was central in the electronic health records.

Conclusions

Community nurses often perceive a high workload due to clinical and organizational documentation activities. Decreasing the time nurses have to spend specifically on organizational documentation and improving the user-friendliness and intercommunicability of electronic health records appear to be important ways of reducing the workload that community nurses perceive.

Clinician and Health Care Leaders' Experiences with-and Perceptions of-COVID-19 Documentation Reduction Policies and Practices

BACKGROUND

Substantial strategies to reduce clinical documentation were implemented by health care systems throughout the coronavirus disease-2019 (COVID-19) pandemic at national and local levels. This natural experiment provides an opportunity to study the impact of documentation reduction strategies on documentation burden among clinicians and other health professionals in the United States.

OBJECTIVES

The aim of this study was to assess clinicians' and other health care leaders' experiences with and perceptions of COVID-19 documentation reduction strategies and identify which implemented strategies should be prioritized and remain permanent post-pandemic.

METHODS

We conducted a national survey of clinicians and health care leaders to understand COVID-19 documentation reduction strategies implemented during the pandemic using snowball sampling through professional networks, listservs, and social media. We developed and validated a 19-item survey leveraging existing post-COVID-19 policy and practice recommendations proposed by Sinsky and Linzer. Participants rated reduction strategies for impact on documentation burden on a scale of 0 to 100. Free-text responses were thematically analyzed.

RESULTS

Of the 351 surveys initiated, 193 (55%) were complete. Most participants were informaticians and/or clinicians and worked for a health system or in academia. A majority experienced telehealth expansion (81.9%) during the pandemic, which participants also rated as highly impactful (60.1-61.5) and preferred that it remain (90.5%). Implemented at lower proportions, documenting only pertinent positives to reduce note bloat (66.1 ± 28.3), changing compliance rules and performance metrics to eliminate those without evidence of net benefit (65.7 ± 26.3), and electronic health record (EHR) optimization sprints (64.3 ± 26.9) received the highest impact scores compared with other strategies presented; support for these strategies widely ranged (49.7-63.7%).

CONCLUSION

The results of this survey suggest there are many perceived sources of and solutions for documentation burden. Within strategies, we found considerable support for telehealth, documenting pertinent positives, and changing compliance rules. We also found substantial variation in the experience of documentation burden among participants.

Investigating Adverse Childhood Experiences and Nutrition and Physical Activity Behaviors Using the Omaha System

The aim of the current study was to examine the relationship between adverse childhood experiences (ACEs) and nutrition and physical activity behaviors using the Omaha System. A descriptive cross-sectional design was used with 227 women recruited from three vocational institutes. Measures included Omaha System Knowledge, Behavior, and Status ratings for nutrition and physical activity; sociodemographic information; and the ACE Questionnaire. Results demonstrated that more than one half of participants had a history of at least one ACE (n = 132; 58.1%), and 33 (14.5%) had four or more. ACEs score was significantly associated with nutrition, but not physical activity behavior. Understanding the links between ACEs and health behaviors and including a brief screening for ACEs in primary care practice settings may help nurses holistically customize health promotion interventions and lead to better health outcomes. The Omaha System can efficiently measure health-related behaviors; examine their relationship to risk factors, such as ACEs; and capture individual and population-level changes. [Journal of Psychosocial Nursing and Mental Health Services, xx(xx), xx-xx.].

A longitudinal time and motion study quantifying how implementation of an electronic medical record influences hospital nurses' care delivery

AIM BACKGROUND

Many health care services are implementing or planning to undergo digital transformation to keep pace with increasing Electronic Medical Record (EMR) functionality. The aim of this study was to objectively measure nursing care delivery before and following introduction of an EMR.

DESIGN AND METHODS

An extensive program of work to expand an EMR across our health service using a 'big bang' methodology was undertaken. The program incorporated digital care delivery workflows including physiological observations, clinical notes and closed loop medication management. The validated Work Observation Method by Activity Timing (WOMBAT) method was applied to undertake a direct observational time and motion study of nurses' work in a major Australian hospital immediately prior to and six months following the introduction of a full clinical EMR.

RESULTS

Time and motion results were from observing approximately one week of nursing time pre (paper) to six months post (EMR) implementation. A non-significant 6.4% increase in the proportion of time spent on direct care was observed when using the EMR with a statistically significant increase in mean time per direct care task (2.5 min vs 3.9 min, p = 0.001). The proportion of time spent on medication-related activities did not significantly change although the average time per task rose from 2.0 to 2.9 min (p = 0.008). A significant reduction in proportion of time spent in transit and indirect care tasks when using the electronic workflows was reported. No statistically significant changes to the proportions of time spent on professional communication, direct care or documentation were observed.

CONCLUSIONS

Successful EMR implementation is possible without adversely affecting allocation of nursing time. Our findings from deploying a large scale EMR across all healthcare craft groups and workflows have described for nurses that an EMR enables them to spend longer with patients per direct care episode and use their time on other activities more effectively.

How do nurses spend their time? A time and motion analysis of nursing activities in an internal medicine unit

Aim

To describe the nature and duration of nursing activities and how much time registered nurses allocate to the different dimensions of their scope of practice in a Swiss university hospital internal medicine ward.

Design

A single‐centre observational descriptive study.

Method

Using a time and motion study, two researchers shadowed healthcare workers (N = 21) during 46 complete work shifts in 2018. They recorded each activity observed in real time using a tablet computer with a pre‐registered list of 42 activities classified into 13 dimensions.

Results

A total of 507.5 work hours were observed. Less than one third of registered nurses’ work time was spent with patients. They allocated the most time to the dimensions of ‘communication and care coordination’ and ‘care planning’, whereas ‘optimizing the quality and safety of care’, ‘integrating and supervising staff’ and ‘client education’ were allocated the least time.

Conclusion

This study provided a reliable description of nurses’ time use at work. It highlighted suboptimal use of the full scope of nursing practice.

Impact

Both work organization and culture should be reconsidered to promote better use of nursing skills. Practice optimization should focus on the following three main areas: (1) greater involvement of registered nurses in building relationships and directly caring for patients and their families; (2) better use of registered nurses’ skills in the activities required of their proper roles, including nursing clinical assessments and patient education and (3) more systematically updating registered nurses’ knowledge.

General nurses' and nursing technicians' complexity of activities: Cross-sectional study

AIMS

This study aimed at describing the job content of general nurses and comparing it to the work of nursing technicians, arranging it for orientation and level of work with things, data or people.

BACKGROUND

There is limited evidence on the content of the general nurses' and nursing technicians' job in post-transitional countries.

METHOD

A quantitative analysis was conducted. The study was performed in a Slovenian medical hospital and in primary health centre. The variables were collected observing nursing activities at 10-min intervals.

RESULTS

Forty-three hospital and seven primary health centres' nursing staff participated in this study. A total of 14,584 nursing activities were recorded. The focus of general nurses was on working with data, and the focus of nursing technicians was on working with people (t = 18.328; df = 34,041; p < .001).

CONCLUSIONS

General nurses' and health care technicians' duties differ in content. General nurses work mostly with data, but health care technicians with people. The job content of both profiles differs related to the setting.

IMPLICATIONS FOR NURSING MANAGEMENT

It is recommended to return the focus of registered nurses from data to people. There is a need to do job analysis to enhance current practices in nursing management and professional development initiatives.

A Randomized Prospective Time and Motion Comparison of Techniques to Process Autologous Fat Grafts

BACKGROUND

Time and motion studies provide a reliable methodology to quantify efficiency and establish recommendations for best practices in autologous fat grafting. The purpose of this study was to compare the rate of graft processing of three frequently used systems for graft preparation.

METHODS

The authors conducted a prospective randomized comparison of three methods to prepare adipose tissue for autologous fat grafting: an active filtration system (Revolve; LifeCell Corporation, Branchburg, N.J.), a passive filtration system (PureGraft 250; Cytori Therapeutics, San Diego, Calif.), and centrifugation. An independent observer collected data according to the study's behavioral checklist. The primary outcome measure was rate of adipose tissue processed.

RESULTS

Forty-six patients (mean age, 54 years; mean body mass index, 28.6 kg/m2) were included in the study (15 per arm; one patient was included with intention to treat after a failed screening). The rate of adipose tissue preparation was greater for the active filtration system compared with the others (active filtration: 9.98 ml/min versus passive filtration: 5.66 ml/min versus centrifugation: 2.47 ml/min). Similarly, there was a significant difference in total grafting time (active: 82.7 ± 8.51 minutes versus passive: 152 ± 13.1 minutes, p = 0.0005; versus centrifugation: 209.9 ± 28.5 minutes, p = 0.0005); however, there was no difference in total operative time (p = 0.82, 0.60).

CONCLUSIONS

As the number of fat grafting procedures increases, there is interest in developing techniques to harvest, process, and inject fat to improve clinical outcomes and operative efficiency. The results of this study indicate that an active fat processing system is more time efficient at graft preparation than a passive system or centrifugation.

Scope of nursing practice on a surgery ward: A time-motion study

AIM

To log the activities of registered nurses and nursing assistants on a visceral surgery ward.

BACKGROUND

By prioritizing their activities, nurses fail to exercise their full scope of practice even though this is essential for health care systems to function effectively and efficiently.

METHOD

A descriptive observational time-motion study was conducted over a period of 48 days. The activities of nurses (n = 24) and nursing assistants (n = 9) were logged over the course of their entire work shifts, both in the day and at night.

RESULTS

In all, 499 hr of observation were logged. Tasks that fell under the dimensions of care activities and of communication and care coordination, which cover documentation, non-care activities and delegated medical tasks, were the ones that took up most of the nurse work time. Patient assessment, relational care, therapeutic teaching/coaching, and knowledge updating and utilization were categories that nurses were under-engaged in.

CONCLUSION

The study shows that the scope of nursing practice was not optimal.

IMPLICATION FOR NURSING MANAGEMENT

The results can serve to improve the work environment of carers, optimize the use of human resources and increase the visibility and efficiency of nursing work.

Health care provider time in public primary care facilities in Lima, Peru: a cross-sectional time motion study

BACKGROUND

In Peru, a majority of individuals bypass primary care facilities even for routine services. Efforts to strengthen primary care must be informed by understanding of current practice. We conducted a time motion assessment in primary care facilities in Lima with the goals of assessing the feasibility of this method in an urban health care setting in Latin America and of providing policy makers with empirical evidence on the use of health care provider time in primary care.

METHODS

This cross-sectional continuous observation time motion study took place from July - September 2019. We used two-stage sampling to draw a sample of shifts for doctors, nurses, and midwives in primary health facilities and applied the Work Observation Method by Activity Timing tool to capture type and duration of provider activities over a 6-h shift. We summarized time spent on patient care, paper and electronic record-keeping, and non-work (personal and inactive) activities across provider cadres. Observations are weighted by inverse probability of selection.

RESULTS

Two hundred seventy-five providers were sampled from 60 facilities; 20% could not be observed due to provider absence (2% schedule error, 8% schedule change, 10% failure to appear). One hundred seventy-four of the 220 identified providers consented (79.1%) and were observed for a total of 898 h of provider time comprising 30,312 unique tasks. Outpatient shifts included substantial time on patient interaction (110, 82, and 130 min for doctors, nurses, and midwives respectively) and on paper records (132, 97, and 141 min) on average. Across all shifts, 1 in 6 h was spent inactive or on personal activities. Two thirds of midwives used computers compared to half of nurses and one third of doctors.

CONCLUSIONS

The time motion study is a feasible method to capture primary care operations in Latin American countries and inform health system strengthening. In the case of Lima, absenteeism undermines health worker availability in primary care facilities, and inactive time further erodes health workforce availability. Productive time is divided between patient-facing activities and a substantial burden of paper-based record keeping for clinical and administrative purposes. Electronic health records remain incompletely integrated within routine care, particularly beyond midwifery.

Understanding Nursing Workflow for Inpatient Education Delivery: Time and Motion Study

Background

Diabetes self-management education and support improves diabetes-related outcomes, but many persons living with diabetes do not receive this. Adults with diabetes have high hospitalization rates, so hospital stays may present an opportunity for diabetes education. Nurses, supported by patient care technicians, are typically responsible for delivering patient education but often do not have time. Using technology to support education delivery in the hospital is one potentially important solution.

Objective

The aim of this study was to evaluate nurse and patient care technician workflow to identify opportunities for providing education. The results informed implementation of a diabetes education program on a tablet computer in the hospital setting within existing nursing workflow with existing staff.

Methods

We conducted a time and motion study of nurses and patient care technicians on three medical-surgical units of a large urban tertiary care hospital. Five trained observers conducted observations in 2-hour blocks. During each observation, a single observer observed a single nurse or patient care technician and recorded the tasks, locations, and their durations using a Web-based time and motion data collection tool. Percentage of time spent on a task and in a location and mean duration of task and location sessions were calculated. In addition, the number of tasks and locations per hour, number of patient rooms visited per hour, and mean time between visits to a given patient room were determined.

Results

Nurses spent approximately one-third of their time in direct patient care and much of their time (60%) on the unit but not in a patient room. Compared with nurses, patient care technicians spent a significantly greater percentage of time in direct patient care (42%; P=.001). Nurses averaged 16.2 tasks per hour, while patient care technicians averaged 18.2. The mean length of a direct patient care session was 3:42 minutes for nurses and 3:02 minutes for patient care technicians. For nurses, 56% of task durations were 2 minutes or less, and 38% were one minute or less. For patient care technicians, 62% were 2 minutes or less, and 44% were 1 minute or less. Nurses visited 5.3 and patient care technicians 9.4 patient rooms per hour. The mean time between visits to a given room was 37:15 minutes for nurses and 33:28 minutes for patient care technicians.

Conclusions

The workflow of nurses and patient care technicians, constantly in and out of patient rooms, suggests an opportunity for delivering a tablet to the patient bedside. The average time between visits to a given room is consistent with bringing the tablet to a patient in one visit and retrieving it at the next. However, the relatively short duration of direct patient care sessions could potentially limit the ability of nurses and patient care technicians to spend much time with each patient on instruction in the technology platform or the content.

Refinement, reliability and validity of the Time Capture Tool (TimeCaT) using the Omaha System to support data capture for time motion studies

AIM

To refine and assess the inter-rater reliability and content validity of the embedded interface of nursing/midwifery activities in the Time Capture Tool (TimeCaT) using an interface terminology, the Omaha System.

METHODS

This methodological study was conducted in two Family Health Centers (FHCs) in Turkey with a total of 13 nurses and midwives. In phase one, five nurses/midwives in a FHC were observed for a total of 80 hr, and 84 nursing/midwifery activities were generated and validated with 15 content experts. In phase two, the nursing/midwifery activities were mapped to the Omaha System and inter-rater reliability of the mapping was assessed. The mapping was validated with seven content experts. The nursing/midwifery activities were embedded in the interface of the TimeCaT. In phase three, the embedded interface of the TimeCaT was evaluated while observing eight nurses and midwives in the other FHC.

RESULTS

The scale-level content validity index was 0.98 for the generated activities in phase one and 0.96 for the mapped activities in phase two. Kappa statistics for inter-rater reliability was 0.88 for Omaha System problems, 0.83 for categories and 0.83 for targets. The nursing/midwifery activities were adequately mapped to the Omaha System. The embedded interface of the TimeCaT has acceptable inter-rater reliability and content validity values for using in the Turkish FHC context.

CONCLUSION

The study results confirm that the TimeCaT using the Omaha System is a valid and reliable tool to measure nursing/midwifery workflow in FHC settings.

Method Development for Describing Content of Multitasked Interventions Using the Omaha System

Background

Understanding multitasking within nursing and midwifery is needed for efficient, effective, and cost-effective health services. Methods are needed to measure and analyze multitasking in alignment with the nursing process. The Omaha System operationalizes the nursing process and may be a valuable resource for multitasking analysis.

Purpose

The purpose of this study was to develop and test a method for describing intervention content of nurse/midwife multitasked interventions using the Omaha System and Time Capture Tool (TimeCaT) in a family health center in Turkey.

Methods

Eight nurses/midwives were observed with TimeCaT in a family health center in 2016. Preidentified 84 nurse/midwife interventions employed in the center were mapped on Omaha System terms and entered in TimeCaT software for data collection. Co-occurring interventions were analyzed using descriptive and inferential statistics and visualization techniques.

Results

Of 1066.8 total minutes observed, 34.0% included more than one intervention that occurred at the same time. Caretaking/parenting and postpartum problems, teaching, guidance, and counseling category, and caretaking/parenting skills target were more often multitasked than others.

Implications for Practice

It was feasible to use the Omaha System and TimeCaT to categorize, describe, and measure multitasking nursing/midwifery interventions. This method may be applied to other time–motion data when more than one co-occurring intervention is recorded.

A Prospective Pilot Study Comparing Rate of Processing Techniques in Autologous Fat Grafting

BACKGROUND

Autologous fat grafting (AFG) is increasing in popularity to address a variety of defects. There is interest in developing techniques to harvest, process, and inject fat to improve clinical outcomes as well as operative efficiency.

OBJECTIVES

The purpose of this pilot study is to compare the rate of graft processing of two commercially available systems for graft preparation.

METHODS

Twenty consecutive cases using an active filtration system (system-AF) were observed followed by 20 consecutive cases using a passive filtration system (system-PF) to compare efficiency rate. Fat processing rate was quantified in milliliters/minute.

RESULTS

Forty patients underwent AFG with no differences in patient characteristics between the groups. There was 1 incidence of palpable fat necrosis per group (5%). For all patients, this was the first fat grafting procedure; 20% of patients (n = 4 per group) had additional fat grafting. Overall, the rate of adipose tissue preparation was significantly higher with system-AF compared to system-PF (19.8 mL/min vs 5.3 mL/min, P ≤ 0.001). The resulting percent of graftable fat was comparable (AF: 41% vs PF: 42%; P = 0.83).

CONCLUSIONS

Time and motion studies such as this provide a means to systematically document each of the steps involved in fat grafting in a reliable fashion. The authors demonstrate a significantly higher rate of lipoaspirate processing using an active filtration system compared to a passive system. Further large-scale studies of the efficacy and cost analysis of AFG are a necessary component of determining best practices in the field.

LEVEL OF EVIDENCE: 2