How Nurses Spend Time?
Name: Maxim Spivakovsky
Ran Zhou
Nikhil Bagewadi
Bursa Ergun
Grace Shin
Samrudhi Patil
Prof. Do, Prof. Zimring, Prof. Cowan, Prof. Ackerman
September 7, 2010
HS 8300
Given the importance of nurses in patient care and the increasing shortage of skilled
nursing case these frontline caregivers represent a critical and costly resource. Therefore,
maximizing the efficiency and effectiveness of nurses is essential to the integrity of hospital
function and the promotion of safe patient care. A great amount of evidence based on many
papers link the availability of more nursing time per patient-day with better patient outcomes. [2],
[3], [4], [5]. However, increased nurse workload and the growing nursing workforce shortage [6]
reduce the amount of nursing time available for patient care activities. In the face of all this
evidence it becomes obvious that ‘How nurses spend their time’ has a great influence on the
efficiency and the key driver of bold changes in the hospital work environment. [7], [8], [9].
In the pursuit of streamlining this costly and essential resource Hendrich et al., 2008
sought further pointers and tried to achieve a better understanding of how nurses spend their
time. According to the study data by Kaiser and Ascension Health, nurses spent about 45% of
their time at the nurse station or off the unit entirely, while patient care activities comprised only
19.3% of nursing practice time. Additional finding is that nurse travels one and five miles per 10
hour day shift. Figure 1 presents the distribution of time during 10 hours nurse shift
Figure 1: Average distribution of a nurse’s time during 10 hours shift
Individual nurses across all study units traveled between 1 and 5 miles per 10-hour
daytime shift. During daytime shifts, average distance traveled ranged between 2.4 and 3.4
miles per 10 hours (median, 3.0 miles). Nurses traveled less distance during nighttime shifts
when most activities and patient tasks change (patients are less mobile, pain often increases).
On night shifts, average distance traveled ranged between 1.3 and 3.3 miles per 10 hours. The
median distance was 2.2 miles, a reduction of 0.8 miles per 10 hours from daytime shifts. Figure
2 presents the distribution of time among different units during a shift
Figure 2: Time distribution among units
The results (Figure 1, Figure 2) demonstrate that nurses devote large proportions of their
time to documentation, medication administration, and care coordination and somewhat less
time to patient care activities. These findings illustrate the complex and demanding hospital
work environment and suggest opportunities to improve the efficiency of nursing work. Changes
to the process and technology of documentation, communication, and medication handling, as
well as the physical design of units, could benefit nursing efficiency and the safe delivery of care.
Bibliography:
1. Hendrich. A, Chow. M, Skierczynski. B, Lu. Z., 2008, “A 36 Hospital Time and Motion Study:
How Do Medical-Surgical Nurses Spend Their Time?”, The Permanente Journal, v18, #3.
2. Ulrich R, Quan X, Zimring C, Joseph A, Choudhary R. “The role of the physical environment
in the hospital of the 21st century: a once-in-a-lifetime opportunity.”
Concord, CA: The Center for Health Design; 2004.
Available from: www.healthdesign.org/research/reports/pdfs/role_physical_env.pdf
3. Aiken LH, Clarke SP, Sloane DM, Sochalski J, Silber JH. “Hospital nurse staffing and patient
mortality, nurse burnout, and job dissatisfaction.” JAMA 2002 Oct 23;288(16):1987–93.
4. Kovner C, Jones C, Zhan C, Gergen PJ, Basu J.” Nurse staffing and post-surgical adverse
events: an analysis of administrative data from a sample of US hospitals, 1990–1996.” Health
Serv Res 2002 Jun;37(3):611–29.
5. Needleman J, Buerhaus P, Mattke S, Stewart M, Zelevinsky K. “Nurse staffing levels and the
quality of care in hospitals.” N Engl J Med 2002 May 30;346(22):1715–22.
6. Anderson S. “Deadly consequences: the hidden impact of America’s nursing shortage”
Arlington, VA: National Foundation for American Policy; 2007 Sep
Available from: www.nfap.com/pdf/0709deadlyconsequences.pdf
7. O’Neil E. “Healthcare workforce in the US economy.” San Francisco: Health Workforce
Solutions LLC; 2007.
8. Lundgren S, Segesten K. “Nurses’ use of time in a medical-surgical ward with all-RN
staffing.” Nurs Management 2001 Jan;9(1):13–20.
9. Hendrickson G, Doddato TM, Kovner CT. “How do nurses use their time?” Nurs Adm
1990 ;20(3):31–7.
10. Quist BD. “Work sampling nursing units.” Nurse Manage 1992 Sep;23(9):50–1.
Transforming Care at Bedside
Team Members
Maxim Spivakovsky
Ran Zhou
Nikhil Bagewadi
Samrudhi Patil
Grace Shin
Busra Ergun
Prof. Do, Prof. Zimring, Prof. Cowan, Prof. Ackerman
September 7, 2010
HS 8300
The Institute for Healthcare Improvement (IHI), in partnership with The Robert Wood Johnson
Foundation (RWJF) have launched an initiative called Transforming Care at the Bedside
(TCAB) and have created a framework for change on medical/surgical units built around
improvements in four main categories:
• Safety and Reliability
• Care Team Vitality
• Patient-Centeredness
• Increased Value
The aims for TCAB are to enhance the quality of patient care and service, create more effective
care teams, improve patient and staff satisfaction, and improve staff retention.[7]
TCAB’s target: [8] [11]
Adverse events are reduced to 1 (or less) per 1,000 patient days

25% reduction in deaths on the TCAB unit

95% compliance with all key clinical process measures (all-or-nothing measure) for the
three top clinical conditions on the TCAB unit

95% of clinicians, students, and staff say, “I work within a supportive environment that
nurtures my professional formation and development” [10]

95% of clinicians, students, and staff say, “I am part of an effective work team that
continuously strives for excellence even when the conditions are less than optimal” [10]

95% of patients are willing to recommend and are satisfied with physical comfort,
emotional support, and respect for their values and preferences

Clinicians spend 70% of their time in direct patient care

Clinicians spend 90% of their time in value-added activities
IHI and RWJF encourage hospitals to get started by trying the some ideas.
Forming Rapid Response Teams, who are particularly experienced at assessing patients’
symptoms and anticipating the trajectory of their medical conditions. Instead of waiting for a
patient to suffer a cardiopulmonary arrest, nurses and other bedside providers can summon the
RRT at the first sign of potential decline, to prevent an arrest. [4] In the Australian study, use of
the RRT at Melbourne’s Austin and Repatriation Medical Centre resulted in a 65 percent
reduction in cardiac arrests, a 57 percent decrease in deaths from cardiac arrests, and an 88
percent decrease in inpatient days following cardiac arrests.[1]
Traffic Light System: Give nurses on the responsibility to determine their capacity to care for
additional patients through use of a centrally located mechanism. Track data and look for trends,
such as the percentage of time nurses’ status is red, yellow, or green; flow of patients into and
out of the unit; and satisfaction with the system among nurses within and outside the unit, as
well as among physicians and other providers. [8]
Implement Multidisciplinary Rounds and Establish Daily Goals: Care teams (physician,
nurse manager, staff nurses, pharmacists, social workers, nutritionists, case managers, pastoral
services, and discharge planners) visit patients together at the bedside within the scope of
decreasing length of stay and improving compliance with core measures, as well as improving
staff and patient satisfaction. [4] Use rounds to set and discuss daily goals with patients. Also,
increasing leadership skill of nurses is significant to organize themselves and the flow of the
work.[9]
Schedule Discharges: Start patient discharge at least one day in advance, plan for and
schedule the tasks that typically precede discharge. Give the patient a discharge appointment a
day in advance so that he or she can arrange for transportation at that time. Consider posting
the patient’s discharge appointment date and time on their door and redesign the patient
education process to improve patient and family caregiver understanding of self-care. Provide
customized, real-time critical information to the next care provider(s) that accompanies the
patient to the next institution. [6]
Acuity-Adaptable Beds: Research shows that, to receive the care that matches their level of
acuity, patients often move three to six times during a typical hospital stay. Each transfer is an
opportunity for missed or delayed treatment, miscommunication that can lead to errors or
omissions of care, patient falls, or other problems that are not only bad for patients, but that
consume additional staff time and resources. [3]
Decrease Falls: Use visual indicators to quickly communicate with the care team about patients
at risk of fall or injury. Educate the patient and family members about risk of injury from a fall on
admission and throughout the hospital stay, and about what they can do to help prevent a fall.
[2]
References
1. Duncan KD, Kelly M, Sherman S, Levine C. Rapid Response Teams: Success and
lessons learned. NRC Picker Focus. August 2009:1-6.
2. Boushon B, Nielsen G, Quigley P, Rutherford P, Taylor J, Shannon D. Transforming
Care at the Bedside How-to Guide: Reducing Patient Injuries from Falls. Cambridge,
MA: Institute for Healthcare Improvement; 2008
3. Hendrich AL, Fay J, Sorrells AK. Effects of acuity-adaptable rooms on flow of patients
and delivery of care. American Journal of Critical Care. 2004 Jan;13(1):35-45.
4. Lee B, Shannon D, Rutherford P, Peck C. Transforming Care at the Bedside How-to
Guide: Optimizing Communication and Teamwork. Cambridge, MA: Institute for
Healthcare Improvement; 2008.
5. Lee B, Peck C, Rutherford P, Shannon D. Transforming Care at the Bedside How-to
Guide: Developing Front-Line Nursing Managers to Lead Innovation and Improvement.
Cambridge, MA: Institute for Healthcare Improvement; 2008
6. Nielsen GA, Bartely A, Coleman E, Resar R, Rutherford P, Souw D, Taylor
J. Transforming Care at the Bedside How-to Guide: Creating an Ideal Transition Home
for Patients with Heart Failure. Cambridge, MA: Institute for Healthcare Improvement;
2008.
7. Rutherford P, Lee B, Greiner A. Transforming Care at the Bedside. IHI Innovation Series
white paper. Boston: Institute for Healthcare Improvement; 2004.
8. Rutherford P, Bartley A, Miller D, et al. Transforming Care at the Bedside How-to Guide:
Increasing Nurses’ Time in Direct Patient Care. Cambridge, MA: Institute for Healthcare
Improvement; 2008.
9. Rutherford P, Phillips J, Coughlan P, Lee B, Moen R, Peck C, Taylor J. Transforming
Care at the Bedside How-to Guide: Engaging Front-Line Staff in Innovation and Quality
Improvement. Cambridge, MA: Institute for Healthcare Improvement; 2008.
10. Schall MW, Chappell C, Nielsen GA, et al. Transforming Care at the Bedside How-to
Guide: Spreading Innovations to Improve Care on Medical and Surgical Units.
Cambridge, MA: Institute for Healthcare Improvement; 2008.
11. TCAB improvements double nurse time at the bedside: An interview with IHI's Pat
Rutherford. HFMA The Business of Caring newsletter; Jul/Aug 2008:13.