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Marilyn P. Chow, R.N., DNSc, is the vice president of patient care services, Program Office, at Kaiser Permanente, Oakland, Calif. She also is the program director for the RWJ Executive Nurse Fellows Program; chairs The Joint Commission Nursing Advisory Council; and is a nonsalaried, associate clinical professor at the University of California, San Francisco, Department of Community Health Systems. |
Spurred technology upheavals, nursing shortages and other challenges embroiling the U.S. health care system, a group of researchers from hospitals across the country undertook a year-long time-and-motion study to analyze how nurses spend their time.
After receiving input from 767 nurse participants, the research organizers concluded that three main areas have the biggest impact on the way nurses care for patients: documentation, medication administration and care coordination (for the complete study visit http://xnet.kp.org/permanentejournal/sum08/time-study.pdf).
In the following interview, Marilyn Chow, R.N., vice president of patient care services for Kaiser Permanente, Oakland, Calif., and one of the study’s authors, discusses what surprises came out of the research, how nurses adapt to the unique demands of their hospital environments, and how a neon-colored sash worn at the right time can improve the health and safety of patients.
Q What was the original impetus for the time and motion study? What did you hope to accomplish with it?
A There were a variety of different reasons for doing the project. One was we knew there is a lot of hospital building going on, so there are billions of dollars being spent around the country for new facilities. We had thought that considering the boom, we could [use the study to] come up with a preferred physical unit design. We also knew that there is a growing shortage of nurses. And so the idea of really learning how they spend their time would be important for us to know how to make sure the work environment is supportive of nurses who stay in the inpatient, acute-care setting. Another driver for the study was the issue of patient safety and quality. That was absolutely important. The other issue was we know that technology can support nurses and affect how they spend their time taking care of patients. Nurses are the primary caregivers in hospitals, so it is important to figure out how we could help them be more efficient and effective in the delivery of care.
Q Who provided the funding for the study?
A We have a couple of primary sources. One is the Robert Wood Johnson Foundation and the other is the Gordon and Betty Moore Foundation.
Q What were some of the things you learned from the study? Did any of the results surprise you?
A The main results we found in terms of how nurses spent their time fell into three primary categories: documentation, medication administration and care coordination among patients, physicians, families and so forth. What we were surprised about is that, while all of those are part of nursing practice, the time spent actually doing nursing and patient assessments and reading vital signs represented only about 7 percent of their time, which is a small amount.
There were other things they did that involved patient-care activities, so that bumped [the total time] to about 19 percent. But it [made us wonder] what we could do in terms of making sure that the time they are spending really is for observing patients, spending time with them, teaching them and doing key procedures.
What surprised us was how incredibly flexible and adaptable nurses are—they adapt to whatever work environment they are in and whatever physical work space and design is available. So there wasn’t any one physical space design that said, “This is the one to use.” We know that designing a unit can help nurses be more effective or efficient, but we didn’t find that one particular type of design was better than another. The second surprise is that we learned that nurses each have their own way of organizing their work. And so there was more variation in how they organized their work on a unit than between units.
Q So there wasn’t necessarily commonality among nurses who were performing similar kinds of care?
A There wasn’t, and that was surprising to learn. When I think back to nursing school, no one particularly teaches you how you should organize [yourself for] delivering care. You might learn how to do a catheterization, but you don’t learn how to organize your time. So nurses develop their own routines, not a standard routine taught in nursing school.
Q You mentioned that there isn’t any one kind of physical design that’s shown to be effective for everyone. Is that where the idea of protective zones for the medication-administration process at Kaiser Permanente come from?
A At Kaiser Permanente, because we knew medication administration took a lot of time, we thought that it would be important to examine the entire process to see what we could do to standardize it and make it consistent. Medication administration is very much a safety and quality issue. So we focused on how safe that process was and how standardized it was. In doing that work, we found that it [was important to have] a safe zone. Whenever a nurse is in that zone in front of a medication-administration machine, that means that you do not disturb the nurse. There’s another piece that we do concerning interruptions: Nurses wear either a sash or a vest that is neon colored. When the nurse wears the sash, that’s a signal to anyone on the unit that the nurse is not to be disturbed because [he or she is] delivering medication.
Q What kind of feedback have you gotten from nurses who have taken advantage of the protective zones, the sashes and other tools?
A They really appreciate the [larger] process—it’s officially called KP MedRite. The other piece that is important about our process is that we engage the front-line staff to help us develop that process.
So it wasn’t something that we designed just by looking at what the study findings said, per se. We actually worked with the staff, we observed them doing medication-administration tasks. We engaged them, and [discussed] what some of the solutions would be.
For example, we went to our Garfield Center for Innovation, a simulation center, to do work like this. We brought teams of nurses and pharmacists and physicians to work through [issues such as interruptions]. One of the nurses put a sign on her back that said, “Leave me alone.”
I think that’s where people got the idea that there are times when nurses need to have a quiet time and be left alone so they can really concentrate on their medications.
Q What has been the reaction among other hospital personnel outside of the nursing staff to measures like these?
A They actually have been quite supportive. There were some initial concerns by physicians who said, “If I can’t interrupt a nurse, how do I get the information I need about my patient?”
What we’ve done is educate everyone that [medication administration] is a time for nurses to concentrate, and so what some of the staff have done is to make sure the physician knows that there is another nurse he or she can go to for the information they need. So it’s just a matter of educating the team.
Q What advice do you have in terms of first steps or best practices for hospitals that look at the study’s results and want to apply the solutions to their own situations?
A My advice is to really take a look at the study and know that [what it shows] is probably not very different from [what’s happening in] their own units. And then to engage their front-line staff for solutions. Say, “OK, if documentation and the time we are spending [on it] is taking a lot of time, what can we do to make that more efficient?”
On the issue of medication administration, are there things about the process that we could improve on? On the issue of care coordination, are there technologies that we might use that could help save us time and be more effective? There are technologies out there for communication devices, for example.
One of the other big things that Ann Hendrich, my research partner, and I have really pressed is the issue of technology purchases. Different organizations are spending a lot of money on technologies.
[They need to] ask the question, “Do the technologies connect with each other?” If you have an electronic record, does the biomedical device upload [data] into the electronic health record, for example?
As you make big, expensive decisions, think long term. Also, think about the people who use the technologies so that nurses don’t have to be the human interfaces to technology that doesn’t work.
One last item is that at Kaiser, we launched what we call our Destination Bedside project in our West Los Angeles facility. They have tried to look at technology solutions there. They’ve worked with our unit-based teams to get the staff involved in looking for solutions.
And that’s what I’d recommend other institutions do. Work out a game plan where they involve their staff in finding solutions to make their work environment much more supportive of them being able to care for patients.
This article first appeared in the September 2008 issue of Materials Management in Health Care.
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