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Ann Hendrich, RN, MSN, FAAN, Marilyn P Chow, DNSc, RN, FAAN, Boguslaw A

Skierczynski, PhD, and Zheniang !u, PhD


Au"hor in#or$a"ion % Co&yrigh" and !icense in#or$a"ion %
'his ar"icle has (een ci"ed (y o"her ar"icles in PMC)
Abstract
*o "o+
Introduction
The US hospital system is in a state of transition. Hospitals face daunting challenges, such as evolving
technologies and reimbursement policies, demographic trends, competing fiscal demands, and a
worsening workforce shortage. This point in time also affords a unique opportunity, as the US is in the
midst of one of the largest hospital-building and -renovation booms in history. ! reconsideration of
hospital design and work processes holds the potential to affect the efficiency and effectiveness of care
delivery for the foreseeable future. "old changes in the hospital work environment are imperative to
ensure the sustainability and affordability of the hospital as part of the !merican health care delivery
system.
#urses are the linchpin of hospital care delivery. These frontline caregivers represent a critical and
costly resource$ ma%imi&ing the efficiency and effectiveness of nurses is essential to the integrity of
hospital function and the promotion of safe patient care. ! growing evidence base links more nursing
time per patient-day with better patient outcomes.'() However, increased nurse workload and the
growing nursing workforce shortage* reduce the amount of nursing time available for patient care
activities.
How medical-surgical nurses spend their time is a key driver of bold changes in the hospital work
environment.+(, -urrent research suggests that two interrelated elements.nurse work process and
the physical hospital environment.contribute to the efficiency and safety of patient care./(' !n
understanding of how nurses spend their time will target opportunities for nursing care effectiveness
through improvements in management, workforce, work processes, and organi&ational culture.0
1e undertook a time and motion study to provide an evidence-based understanding of how medical-
surgical nurses spend their time and of the influence of unit architectural layout on nurses2 use of time
and distance traveled. 3ocumenting the drivers of inefficiency in nursing practice will allow for
targeted changes to the work environment to positively influence patient safety and quality of care.
The primary ob4ectives of the study were to identify how nurses spend their time during their shift and
to pinpoint environmental variables in the acute-care nursing workplace that can be altered to
positively affect the efficiency of nursing care and, ultimately, patient safety.
Specifically, the study aimed to determine5
the amount of time nurses spend on specific activities5 nursing practice, unit-related
functions, nonclinical activities, and waste
the distance traveled by the aver-age nurse during a typical shift, and whether this movement
is efficient
the physiologic impact of the work environment on nurses.
This study was also designed to provide baseline data regarding documentation activities prior to the
installation of electronic health record 67H89 technology in specific units. These findings are not
included in this article because of complications in the analysis of the data collected.
*o "o+
Methods
The time and motion study was conducted at 0* hospital medical-surgical units within + health care
systems and ) states. Together, these geographically diverse health care systems operate a total of '+:
hospitals with more than *0,/// beds. 7ach participating study health system and hospital2s
institutional review board approved the study protocol.
Study Units and Participants
;rom a list of all eligible medical-surgical units at each of the participating hospitals, one unit per
hospital was randomly selected for inclusion in the study. !n eligible medical-surgical unit was defined
as a unit in which patients who require less care than that which is available in intensive care units,
step-down units, or specialty care units, and receive ':-hour inpatient general medical services,
postsurgery services, or both general medical and postsurgery services. These units may include mi%ed
patient populations with diverse diagnoses and of diverse age groups who require care appropriate to a
medical-surgical unit.
#urses at each participating unit meeting the eligibility criteria were invited to 4oin the study$
participation was voluntary. To be eligible, nurses were required to be licensed 68#, <=#, or <>#9 and
to provide direct nursing care for patients on the study unit. ?n-house pool nurses were eligible if they
worked on the study unit for more than eight weeks. ?neligible nurses included5 float and agency
nurses$ nurse preceptors and preceptees$ and nursing supervisors, charge nurses, or other nurse
specialists, unless they provided direct nursing care with the same acuity and patient load as other
participants.
Study Protocols
The study consisted of four protocols5 !, ", -, and 3 6Table 9. #urses who consented to participate
were randomi&ed to either protocol ! or protocol ". !ll nurses were asked to participate in protocol -,
and any nurse who volunteered to do so took part in protocol 3. ;or each protocol, study staff collected
data for seven consecutive days, ': hours a day, e%cept for protocol 3, for which data were collected for
'0 hours a day.
Table
3escription of study protocols
Protocol A: Baseline Data for EHR Implementation
#urses participating in protocol ! were supplied with personal digital assistants 6=3!s9 to record all
documentation-related activities during their shifts. 1ith these =3!s, unit nurses documentation
categories from the following options5
!dmission paperwork
!ssessment
Transcribe orders
1riting care plan
@edications paperwork
Teaching
3ischarge paperwork
Ather.
;or each documentation activity, nurses selected BstartC on their =3!, then the documentation
category. 1hen they completed the activity, nurses pressed Bstop.C =rotocol ! sought to measure the
amount of time spent on nursing work processes before the installation of 7H8s. =re- versus
postinstallation results will be reported elsewhere.
Protocol B: Ho !urses Spend "heir "ime
#urses in research protocol " carried =3!s that vibrated at random times during their work shift to
remind them to stop what they were doing and record the activity in which they were engaged. 7ach
=3! was programmed to vibrate ') times per 0-hour shift 6in case of overtime9, with a minimum
interval of ten minutes between alarms. ?f the nurse did not respond immediately, the =3! continued
to vibrate every ) seconds until the nurse responded. 1hen the =3! vibrated, the nurse was asked to
select from categoric data sets describing where they were 6patient room, nurse station, on unit, or off
unit9 and what they were doing 6Table '9. ;or this report, the term patient room refers to any patient
room that the nurse visited, not a single patient room.
Table '
-ategories and subcategories of nursing time for protocol "
The nurses2 activities were clustered into categories and subcategories of how much time nurses spend
on activities considered to be nursing practice, nonclinical, unit-related, or waste. These categories and
subcategories 6Table '9 were selected to cluster sufficient increments of time to make strong
comparisons and to identify important targets for change. The goals were to reveal drivers of
inefficiency in how nurses spend their time and to identify opportunities to improve efficiency through
changes to unit design andDor organi&ation.
The subcategory of patient care activities does not represent a comprehensive accounting of all
activities related to patient care. Ather care-related subcategories, such as medication administration,
care coordination, and documentation were separated from patient care activities to help identify what
activities consume nurses2 time. These categories, therefore, are intended to be utilitarian rather than
absolute.
To assess the physical impact of workload and stress on the nurses, volunteers E had their physiologic
response monitored by speciali&ed armbands E
Protocol #: !urse $ocation and Mo%ement
To monitor nurse location and movement, nurses in research protocol - wore radiofrequency
identification 68;?39 tags 68adianse, ?nc, !ndover, @!9 that continually monitored where they were,
how far they traveled, and the duration of activity in any one spot. Signals from each 8;?3 tag were
transmitted to an indoor positioning system installed on each unit for the study week. The 8;?3 tags
measured the distance traveled in relation to the physical layout of the nursing unit. !s nurses spent
only '/ to 0/ seconds in any one spot, each nurse was fitted with four tags to ensure that grouping
signals would not be missed.
Protocol D: !urse Physiolo&ic Responses
To assess the physical impact of workload and stress on the nurses, volunteers from any study group
had their physiologic response monitored by speciali&ed armbands 6Sense1ear =ro !rmband,
"ody@edia, ?nc, =ittsburgh, =!9 to measure the physiologic metrics both on and off shift for '0 hours
a day for a seven-day period 6nurses removed armbands for one hour per day9. The armbands
simultaneously measured skin temperature, near body temperature, galvanic skin response, heat flu%,
and motion via a two-a%is accelerometer. ;rom these data, estimates were made for total energy
e%penditure 6calories burned9, distance traveled, speed, active energy e%penditure, sleep, and
categories of physical activity.
*o "o+
Site Implementation
"efore study startup, the optimal placement of ?=S receivers were mapped on computeri&ed
architectural drawings 6-!3s9 of the study unit. Two days before the data-collection period, the
temporary wireless access points were installed and tested to ensure proper functioning. !t each study
unit, the necessary hardware was installed, and staff and management members were oriented
regarding the purpose of the study and the use of devices before data collection. The hospital study
coordinator managed the data-collection process with the unit manager and nurse e%ecutive.
The study was conducted at each site during a period of seven consecutive days. 3ata for all units were
collected between Fune '//) and Fune '//*.
Unit'Assessment Data'#ollection "ool
! standardi&ed unit-assessment data-collection tool was completed by each study unit2s nursing
manager to collect more than '// hospital unit demographic, technologic, and architectural variables.
These variables were used to interpret unit and nurse variation, as well as cluster relationships that
correlated or e%plained the difference in efficiency and nursing time spent with patients.
Data Mana&ement and Statistical Analysis
The statistical and technical methods used in this study will be reported in detail in a separate
publication. ?n brief, each hospital unit transmitted raw data to computer scientists at =urdue
University who then stored the data in an Aracle database. 3ata was transferred from the Aracle
database to an 8 system for graphics database. ! new framework was used for data display in which a
Bvisuali&ation databaseC e%hibited all cleaned data as well as summary statistics. This deep
visuali&ation allowed for the development of valid statistical models and the performance of
appropriate data analyses.
#ross'(alidation Beteen Protocols
3ata collected from the different protocols allowed for cross-validation of certain findings. 3istance
traveled on the unit, for e%ample, was evaluated in both protocol - 6through 8;?3 tracking9 and
protocol 3 6through armband accelerometer9. #urse location could be validated between protocol "
6=3! selection of location9 and protocol - 68;?3-determined location9. "efore the study was begun,
location data for protocol - was validated by tracking Bwalks in the units.C 8;?3-tracked location was
compared with audio recordings from unit walk-through.
*o "o+
Results
Profile of Participatin& Hospitals and !urses
Af the participating medical-surgical units, 00 were in urban facilities 60 rural9 and + were part of
teachingDacademic institutions. The average length of stay for the study units ranged from '.*' to G.*+
days 6average, :.0+ days9. Unit si&es ranged from to '/ beds to G to ,/ beds 6median, 0(:/ beds9.
! total of :'/ nurses were identified at the 0* study units. Af this total, 00, were deemed ineligible by
study criteria$ G'* of the eligible nurses consented to participate, and +*0 completed the study 6Table
09. #o participants were removed from the study because of noncompliance. The ma4ority of
participants were 8#s 6+G09, and the remainder were <=#D<># 6:09. #urses2 educational background
was as follows5 )+H, !3 or nursing diploma$ :H, "S#$ 'H, @S#.
Table 0
#urses eligible, consenting, and completing study
The study population of +*+ nurses were randomi&ed, 0G) to protocol ! and 0G' to protocol " 6Table
9. !ll nurses were included in protocol -, with the e%ception of nurses at one study unit, leaving a total
of +)/ participants. ;or protocol 3, 'GG nurses volunteered. ?n all, data were collected for ''/
nursing shifts 6'/*) 8#s$ 0* <>#sD<=#s9 and ',GG' total hours 6'/,)+0 8#s$ 0/, <>#sD<=#s9.
!verage shift length was ,.,: hours.
#urses randomi&ed to protocol " responded on average + times per shift. ;igure illustrates the
average time spent by nurses in each location category 6patient room, on the unit, off the unit, nurse
station9$ an additional :) minutes per average /-hour shift 6+.)H of a ten-hour shift9 were not
accounted for by participants 6no response, no location chosen, undefined, or pushed wrong response9.
=ercentages reported below and in

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