1. Worth, Tammy


Direct patient care accounts for less than 50% of working hours.


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Three studies that looked at how nurses spend their time found patient care taking a backseat to activities such as documentation, administering medication, and coordinating care. In the studies, less than half of the nurses' time was spent on hands-on care-meaning that nurses spent a majority of their day performing tasks that offered the least benefit to their patients.


Anyone have the time? The first study, published in the May issue of the Journal of Nursing Administration, noted that nurses on 14 medical-surgical units in three Midwestern hospitals divided their time between patient care activities (assessment, teaching, treatment, and psychosocial support) and support activities (care coordination and clinical records management). Time spent on activities such as waiting, disruptions, delays, and doing work over, was also recorded.


Findings revealed that nurses spent 56% of their time on support activities and 44% on patient care-with the least amount of time spent on psychosocial support (less than 7%) and teaching (7%). Support activities accounted for more than half of the $2.1 million spent annually on wages per nursing unit, and $757,000 was spent on tasks such as hunting for equipment (especially equipment for obese patients), waiting in line for supplies, obtaining medications, and handoffs. Time delays occurred even when nurses used automated medication dispensers and electronic records.


Stemming inefficiency sufficiently. Identifying sources of inefficiency in nursing work processes was also the goal of a study that appeared in the summer issue of the Permanente Journal. It documented how 763 nurses on 36 medical-surgical units in 15 states spend their time. The study found that only 19% of the nurses' time was spent on patient care activities, while 73% was split between administering medicine, coordinating care, and documentation. The investigators concluded that improvements in technology, work processes, and unit organization and design-not unlike those developed by the TCAB (Transforming Care at the Bedside) initiative-may allow for more efficient use of the nurses' time.


Work-arounds are not the solution. Koppel and colleagues studied the use of work-arounds to compensate for technologic problems with bar-coded medication administration at five hospitals. Their study, which appeared in the July-August issue of the Journal of the American Medical Informatics Association, reported that nurses used work-arounds to the bar-coded system to override alerts for 4.2% of patients and 10.3% of medications.

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Bar-coded medication administration is "supposed to be a panacea-a system that will solve nurses' problems," said lead author Ross Koppel, of the School of Medicine at the University of Pennsylvania in Philadelphia. "But all we saw was nurses using work-arounds. They kept saying, 'Are you kidding? If we didn't use work-arounds, our work would take too much time.'"


The authors found 31 problems that had prompted nurses to develop 15 types of work-arounds. The problems included missing patient IDs, unreadable (smudged or torn) bar codes, and broken scanners. The 15 types of work-arounds fell into three categories: omitting steps from a process (for example, administering medication before scanning a patient's ID to confirm that she or he was the correct patient), performing steps out of sequence (for example, administering medication after documenting it), and performing unauthorized actions (such as disabling audio alarms on the machine that signal alerts).


"If a nurse is supposed to administer 20 mg of a drug, but the pharmacy has sent two 10-mg tablets, the scanner will say there's a problem," said Koppel. "It's looking for a 20-mg tablet. So what's the nurse going to do? She's going to override the scanner and administer the 20 mg as two tablets. But all of that takes time."


To reduce the need for work-arounds-as well as reduce the number of errors they cause-Koppel, who is a proponent of medication technology-recommends that more observational research be performed in hospitals. He believes that it will enable administrators to find systematic causes of problems, such as an insufficient number of refrigerators for storing medications or poor communication between a unit and the pharmacy. He also recommends vetting technology vendors and reprogramming software, if necessary, to align user, work-flow, and patient-safety needs.


Transforming care starts at the bedside, and eliminating wasteful time on the unit is the focus of TCAB, an initiative supported by the Robert Wood Johnson Foundation (RWJF) and the Institute for Healthcare Improvement. TCAB began five years ago with 10 hospitals. The goal is to "engage frontline staff so they can be more efficient, which allows them to spend more valuable time with their patients," according to Carol A. Watson, president of the American Organization of Nurse Executives (AONE). In early 2007 AONE was awarded $1 million to help implement TCAB in an additional 50 hospitals. Since TCAB started, more than 200 hospitals have signed up for it.


In June the RWJF placed a TCAB toolkit on its Web site ( and has launched a TCAB Virtual Resource Center where nurses can get help in implementing TCAB at their own facility.


Watson, who's also senior vice president of clinical services and chief nurse executive at Mercy Medical Center in Cedar Rapids, Iowa, said the program is in its early stages but has already resulted in some useful improvements, such as using different-colored status boards to evaluate nurses' workloads and redesigning spaces to permit supplies to be stored nearer to the patients (for more on TCAB, see AJN's new department on the program, Transforming Care at the Bedside, page 71).



Dementia and death and hospitalization. Among adults ages 66 and older with dementia, those who had recently started taking antipsychotics had higher rates of hospitalization and death within 30 days of the start of antipsychotic therapy than those who took none, reported a study in the May 26 issue of Archives of Internal Medicine. Among older adults living in the community, those taking antipsychotics had more than three times as many adverse events than those taking none. Among nursing home residents, those taking antipsychotics had about twice as many events as those taking none. Patients taking atypical antipsychotics (such as risperidone, olanzapine, and quetiapine) had slightly fewer adverse events than those taking conventional antipsychotics (such as haloperidol, loxapine, and thioridazine). In June the Food and Drug Administration required the labeling of conventional antipsychotics to carry a boxed warning noting the higher mortality rate among older adults with dementia who take conventional antipsychotics (an off-label use). Atypical antipsychotics were issued a similar requirement in 2005.