FEATURES

ADVANCING KNOWLEDGE THROUGH COLLABORATION

Ann Greiner

Ann Hendrich

Putting nurses in the driver’s seat

by Ann Greiner and Ann Hendrich

The ringer on Mary Johnston’s personal digital assistant (PDA) goes off as she is filling out routine forms. Using the instrument’s keypad, Johnston, a Seton Northwest Hospital staff nurse, records what she is doing by scrolling through a menu of work activities and selecting “Documentation” and then “Discharge paperwork.” This scenario is repeated randomly during seven arbitrarily selected days a month for 21 randomly selected RNs on Johnston’s med/surg unit.

This sampling of work activity provides valuable information—for the hospital’s leadership as well as Johnston and her colleagues—on how nurses on the unit spend their time. The study helps administrators gauge whether the changes they are making to work processes and the physical environment through the Transforming Care at the Bedside (TCAB) project are increasing the time that nurses spend with patients and in value-added activities.

Transforming Care at the Bedside is a collaborative effort of The Institute for Healthcare Improvement (IHI), the Robert Wood Johnson Foundation (RWJF) and 13 hospitals across the country to comprehensively redesign medical/surgical care. More specifically, the project focuses on improving safety and reliability, enhancing staff “vitality” or joy in work, making care more responsive to the needs and preferences of patients and families, and enhancing efficiency. [Editor’s note: Another aspect of the Transforming Care at the Bedside project was discussed by Tami Merryman in an article titled “Coming: To a hospital near you,” published in the Fourth Qtr. 2005 issue of Reflections on Nursing Leadership.]

The PDAs used by TCAB hospitals facilitate data collection and analysis of the effects of efficiency measures. At a macro level, they enable nursing leaders to determine if there is a shift from indirect to direct care on a particular med/surg unit. Numerous studies show that nurses spend less than half of their time delivering direct patient care (Linden & English, 1994; Urden & Roode, 1997). Such a shift may also have benefits beyond efficiency in key areas, including quality of care, safety (Needleman, Buerhaus, Mattke, Stewart, & Zelevinski, 2002; Aiken, Clarke, Sloane, Sochalski, & Silber, 2002), staff satisfaction and patient/family centeredness.

How PDAs facilitate work sampling
PDAs are a novel, 21st-century answer to traditional time and motion studies that involved industrial engineers and stopwatches, with one important difference. They generate efficiency data on a unit’s RN staff as a whole, rather than information on the work activity of any single nurse.

This makes PDAs palatable to staff members, who serve as data collectors, and it focuses management decisions at the unit rather than the individual level. This approach engages caregivers, who intuitively know that many efficiency problems result from broader system and process shortcomings rather than individual ones.

The 58 work categories in the PDA-assisted study fall into four domains, which have been refined over time and are carefully tailored to reflect med/surg needs. To document a particular work activity, a nurse first selects a domain—on or off the unit, at the nursing station or in a patient’s room—and then, depending on the domain he or she has selected, chooses one of the nine to 17 activities available on the menu.

For example, in a patient’s room—one of the domains—an RN may select one of the following activities: administering medications, taking vitals, communicating with the care team, providing wound or skin care, assessing the patient, or a dozen other options. A select number of these categories are then broken down further into subcategories. For instance, documentation in the patient’s room includes writing care plans and seven other activities.

Such detail provides important information to nursing leadership and frontline staff. A nurse executive from one of the TCAB hospitals, Tami Merryman, vice president of patient care services at the University of Pittsburgh Medical Center (UPMC), Shadyside Campus, in Pennsylvania, noted that the hospital has improved efficiency by decentralizing supplies to the bedside and adding a charge nurse. Not long after this change, said Merryman, the PDA data indicated that UPMC had decreased time spent in waiting or in hunting for and gathering supplies and equipment, and increased time spent in direct patient care.

In the last year and a half, time spent in documenting care at the 13 participating hospitals has been reduced, while value-added activities have increased. However, because these institutions are implementing so many changes simultaneously, it is difficult to know which changes are directly responsible for the positive results. With time, these cause-and-effect relationships will become more apparent.

Evidence-based management
PDAs and other technology-assisted methods for collecting and analyzing data can support evidence-based management, an approach that the Institute of Medicine (2004) recommends to nursing leaders in its recent report, Keeping Patients Safe. Other characteristics of evidence-based management include fostering “learning organizations” and engaging staff in the redesign of work processes.

For example, PDAs can facilitate data collection that helps leaders understand the costs and benefits of purchasing a second medication management system for a unit. By comparing the capital outlay required for such a system to the time nurses spend retrieving or waiting for drugs—time that takes them away from their patients—managers are able to make decisions driven by actual data rather than undocumented assumptions.

Taking this concept of technology-assisted data collection a step further, a recently inaugurated study, also funded by the Robert Wood Johnson Foundation, will help define an ideal, evidence-based design for nursing units by combining PDA data collection with radio-frequency tracking of RNs. It will measure the effect of an electronic health record in reducing waste and inefficiencies in common care tasks and processes, and will build upon other TCAB findings in determining this design of the future.

Forty other hospitals are also beginning to use PDA work sampling to inform their decisions about work-process design and the physician environment. These institutions, part of a new IHI initiative launched in late 2005, will adapt many of the promising ideas from Transforming Care at the Bedside.

In summary, use of PDAs for data collection promises to facilitate dialogue, based on actual data, between nursing leaders and staff RNs about what needs to change in our nation’s health care organizations and assist in evaluating various options on the pathway to transformation.

“There is a lot we know intuitively about how we are spending our time—and it seems more and more we are away from our patients,” concludes Johnston, the staff RN at Seton Northwest. “The PDAs quantify what is going on and give us a way to collectively make the case to the executive suite that we need to change the way we work. We all want to get back to the bedside and, not surprisingly, the patients want us back there, too.” RNL

Ann C. Greiner, MCP, Silver Spring, Md., is director of the Institute for Healthcare Improvement. Ann Hendrich, RN, MS, FAAN, is a Robert Wood Johnson Fellow and vice president of clinical excellence operations at Ascension Health in St. Louis, Mo. Ron Moen, co-founder and partner of Associates in Process Improvement in Detroit, Mich., also contributed to the content of this article.

Collecting data with PDAs Mercy Health Center’s Ellen Warino, right, helps Samantha Walker with an electronic armband. Both wore the armbands for an entire week to track nurse stress levels. As part of another study funded in part by a grant from the Robert Wood Johnson Foundation, nurses at Mercy Health Center in Oklahoma City spent one week in mid-January entering data into personal digital assistants (PDAs) to track their activity and wearing electronic armbands to record their stress levels. Mercy joined two dozen hospitals nationwide in the study to help Purdue University researchers and scientists discover how to increase nurses’ time at the bedside and what stresses nurses during their shifts. The research will produce a treasure trove of data. While it’s already known that most nurses walk a total of five miles each day on the job, this study will track not only the distance nurses walk, but where their time is spent. “We will also find out exactly when nurses feel stress,” said Gary Parker, RN, Mercy’s clinical education and research manager. “Is it when they first get up in the morning? Is it on the drive to work? Or does it hit at some other time during the day? Finding out that kind of information is critical to help us know how to help our nurses manage stress.” Samantha Walker enters data into a PDA as Gary Parker, Mercy’s clinical education and research manager, looks on. The primary goal of the national study is to identify specific changes that will improve nursing satisfaction and retention, as well as patient safety, in U.S. hospitals. Numerous studies already show that the more time nurses spend at the bedside, the more satisfied patients are. When nurses get to do what they are trained to do—care for patients—they’re happier and that translates directly into happier patients. “With this study, we want to learn how we can reduce the time spent on tasks that take nurses away from the patient--tasks that often have a negative impact on nurse job satisfaction and, ultimately, the quality and safety of patient care,” said Parker. “This study is going to have a far-reaching impact, including influencing future hospital designs and renovations, with a goal of transforming the work environment of nurses,” he said. Mercy Health Center, the only Magnet hospital in Oklahoma and among only 3 percent of hospitals in the United States to be awarded Magnet status, is a member of Mercy Health System of Oklahoma and the Sisters of Mercy Health System. Magnet-designated facilities report higher patient satisfaction rates, deliver better patient outcomes, provide more nursing care at the bedsides of patients and consistently outperform non-Magnet organizations.

References

Aiken, L.H., Clarke, S.P., Sloane, D.M., Sochalski, J., & Silber, J.H. (2002). Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. JAMA, 288, 1987-1993.

Institute of Medicine. (2004). Keeping patients safe: Transforming the work environment of nurses. Washington, D.C.: National Academies Press.

Linden, L., & English, K. (1994). Adjusting the cost-quality equation: Utilizing work sampling and time study data to redesign clinical practice. Journal of Nursing Care Quality, 8(3), 34-42.

Needleman, J., Buerhaus, P., Mattke, S., Stewart, M., & Zelevinski, K. (2002). Nurse-staffing levels and the quality of care in hospitals. New England Journal of Medicine, 346(22), 1715-1722.

Urden, L., & Roode, J. (1997). Work sampling: A decision-making tool for determining resources and work design. Journal of Nursing Administration, 27(9), 34-41.