QUALITY: Nurses In Time and Motion

Nurses on medical-surgical units in hospitals spend less than a third of their time providing direct patient care. But before you get all indignant and leap to the conclusion that they are spending 70 percent of their time chatting on cellphones, doing their nails, or watching American Idol, think again. Nurses work hard. Very hard. But, through no fault of their own, they are not always working at maximum efficiency actually taking care of patients.

"A picture emerges of the professional nurse who is constantly moving from patient room to patient room, nurse station to supply closet and back to patient room, spending a minority of time on patient care activities," according to the interesting time and motion study called "How Do Medical-Surgical Nurses Spend Their Time?" published recently in the Permanente Journal, brought to our attention by the Robert Wood Johnson Foundation.

Nurses walk one to five miles a day, on 10-hour or longer shifts—a bit less walking on night shifts. Staffing shortages, poorly designed workspaces, tons of paperwork, inefficient medication storage and administration systems, and health information technology shortfalls limit the time they spend with patients. About half their time is spent on "indirect" care, including charting, paperwork (often duplicative), coordinating care from the nurses stations, and walking around—and around and around—gathering supplies. All this despite mounting evidence that direct patient care leads to better outcomes, the authors report.

The study, at 36 different hospitals in 17 different health care systems, looked at three basic approaches to hospital floor plans to see the physical design had much to do with patient care time; whether this could be an architectural issue rather than a systems issue. The answer was mostly no. In fact, there was more variation from one nurse to another in the same unit than there was between different floor plans. Which doesn't mean that given we are in the midst of a hospital building and renovation boom, architects and planners can't learn something. But the study more broadly suggested that documentation, medication administration, and care coordination could all be made much more efficient through changes in technology and work processes, as well as rethinking how med-surg units are organized.