A time–motion observation study to measure and analyse clinical nursing workload in an acute care hospital in Singapore

Abstract

Internationally, there are concerns about rising nursing workforce shortages, which could be attributed to both recruitment and retention issues. As the population rapidly ages in Singapore, there is an increase in demand for more trained nurses to staff new facilities. Given the problem that Singapore is facing, there is a need for other solutions besides increasing recruitment rate. A time-motion study of nurses’ workload can assist us in determining how and what nurses spend their time on during their working shift. Work processes can then be studied to allow for improvements and implementation of strategies to ease nurses’ workload. Results of the current study demonstrated four main processes (preparing and clearing requisites, documentation, care coordination, transportation) that can be improved upon. Some of these processes do not require dedicated nursing skills; and can potentially be performed for other staff members. Results also demonstrated that nurses spent significantly less time on patient care activities as compared to nurses in United States; with as much as 31% of the nurses’ time being spent on documentation. Future studies can target on the effectiveness of strategies to improve the efficiency and quality of nursing care.

Introduction

In less than 10 years, Singapore could become a ‘super-aged’ nation where 20% or more of our population is 65 years of age or older. ¹ Our Ministry of Health expects that an additional of 9000 staff is needed to support the patients; however, this is an increasing problem due to the declining number of nurses staying in the workforce.^2,3 There is also an increasing demand for more trained nurses to staff new facilities due to the influx of hospitals like the recently launched Sengkang General Hospital. ⁴ In view of the nursing shortage and the increasing roles of nurses, strategies to improve performance (effectiveness and efficiency) are essential in addressing nursing workforce shortages.

Strategies targeted at work processes, physical hospital environment or organisation culture can only be done by understanding how nurses currently spend their time. Systematic and rigorous documentation of drivers of inefficiency in nursing practice will then allow for focused improvements to the work environment which in turn will improve patient safety and quality of care. ⁵ Nurses play a huge part in a hospital; many activities require nursing interventions, such as medication administration, hand-over of care, coordinating care, communication, teaching junior nurses, answering and making calls, clear requisites, education, transportation, documentation and patient care.

Understanding how nurses spend their time is important in order to improve efficiency or to eliminate non-value adding tasks. Ideally, more time should be spent on patient care activities given that a higher level of involvement in patient care activities is associated with improved patient safety. ⁶ The aim of the current study was to determine the amount of time nurses spend on specific activities as well as to identify processes that could be streamlined and non-value adding tasks.

Methodology

A time and motion direct observation methodology was adopted and performed in Singapore General Hospital. Ethical approval was obtained from SingHealth Centralised Institutional Review Board (CIRB ref no: 2016/2436). This study was conducted in one medical and one surgical ward in an acute care hospital in Singapore. The sample included 18 nurses: eight Registered Nurses (RNs) performing in-charge role, eight Enrolled Nurses (ENs) and two RNs performing supportive roles were observed during the data collection period in Oct 2016. Informed consent was obtained from all participating nurses by the study team prior to the commencement of ward observations.

The study wards consisted of cohort rooms with up to eight patients in a room. During the data collection period, the average nurse to patient ratio was 1:5. The average shift length was 9 hours, inclusive of the nurses’ rest time. A time–motion app installed in a tablet was used for data collection. The app allowed for the creation of nursing-specific activities as well as time measurement of multiple concurrent motions. With the time–motion app, the continuous observation was done by external observers. ⁷ Observers were RNs who were not working in the same ward as the participants. Each trained observer was assigned to follow and observe one nurse per shift (from start to end of shift). Each observer independently indicated the start time and end time of each activity. Training on the use of the app was provided prior to data collection by the research team. During training, observers had opportunities to clarify specific nursing interventions to ensure that the most appropriate nursing interventions were selected during data collection. Observations were conducted as unobtrusively as possible.

The International Classification for Nursing Practice (ICNP®) – Nursing Interventions was used to create, measure and document the activities. ⁸ The ICNP® is a unified nursing language system that supports the standardisation of nursing documentation at the point of care. The nursing interventions consist of concepts that represent the therapeutic activities of nurses such as ‘teach about managing pain’ and ‘assess attitude towards treatment regime’. ⁸

Data analysis was done using descriptive statistics. Given differing patients’ needs, the analysis was conducted separately for the medical and surgical ward. For example, ‘administering intravenous medication’, ‘administering subcutaneous medication’ and ‘administering inhalant medication’ were grouped as ‘medication administration’ (see Table 1). The time spent by nurses on each of the broad categories of nursing activity was reported in percentages.

Table 1.

Classification of nursing interventions.

Broad category of nursing activity	Nursing interventions (INCP)
Medication administration	• administering intravenous medication • administering inhalant medication • administering medication • administering subcutaneous medication • blood therapy • checking patient identity • discontinuing intravenous therapy • maintaining intravenous therapy • medication handling
Handover	• shift to shift handovers • transfer handovers
Coordinating care	• discharge planning • arranging transport of device • scheduling follow up appointment • referring to community services • referring to support group therapy
Communication	• communicating with superiors • consulting healthcare provider • consulting pharmacist about generic medications • reporting arterial blood gas results • reporting status to family • reporting status to interprofessional team • reporting status to patient • reporting test results • reporting to interprofessional team
Teaching junior/staff	• teaching of junior nurse or student nurse
Answering/making phone calls	• answering or making phone calls
Prepare/clear requisites	• preparing of requisites for procedures • clearing of requisites for procedures
Educate patient/caregiver	• teaching patient • teaching caregiver
Transportation	• transporting patient
Documentation	• documentation
Patient care	• accompanying patient • assisting health care provider • taking diet orders • transporting patient • bathing the patient • assisting with eating or drinking • assisting with hygiene • assisting with mobility • assisting with mobility in bed • assisting with self-care • assisting with toileting • dressing patient • implementing parenteral feeding • maintenance of patient environment • positioning patient • providing food • transferring patient • measuring blood glucose • measuring body temperature • collecting specimen • assessing wound • evaluating wound healing • irrigating urostomy • removing suture
	• stoma care• wound care• wound dressing change• discontinuing wound drain• admission assessment• applying physical restraint• applying safety device• checking device safety• inserting vascular access device• maintaining isolation techniques• managing device• providing instructional materials• providing supportive device

Result

The majority of the medical RNs’ (in-charge role; n = 4) time was spent on documentation (18%) and medication administration (18%); only 12% of their time was allocated to patient care activities. Figures 1 and 2 illustrate the results from the medical ward. The least amount of time was spent on caregiver and patient education (3%). The RNs also spent 9% of their time on coordinating care; this includes performing administrative work related to discharge planning for the patients, scheduling outpatient follow-up appointments and referrals to the community partners. For nurses performing supportive roles (n = 6), more than half of their time (57%) was spent on patient care activities. Up to 3% of their time was used to transport patients for diagnostic scans and procedures outside the medical ward.

Figure 1.

Activities of Registered Nurses in the medical ward (in-charge role).

Figure 2.

Activities of Registered Nurses and Enrolled Nurses in the Medical Ward (supportive role).

In contrast, RNs (n = 4) from the surgical unit spent 41% of their time on documentation (21%) and patient care (20%). Similarly, nurses performing a supportive role (n = 4) spent most of their shift hours on patient care activities (56%). Besides patient care, transportation of patients for diagnostic scans and procedures outside of the surgical ward also accounted for a substantial amount of their time (10%). Figures 3 and 4 illustrate results from the surgical ward. In one observation, one EN spent a total of 128 min for transporting three patients for different procedures that were outside the ward; the longest trip was 81.9 min as the nurse had to stay with the patient in the procedure room located off-site from the ward.

Figure 3.

Activities of Registered Nurses in the surgical ward (in-charge role).

Figure 4.

Activities of Enrolled and Registered Nurses in the surgical ward (supportive role).

Discussion

Our RNs (in-charge role) spent a lower proportion of time (12–20%) on patient care activities as compared to those reported in previous studies conducted in acute care hospitals in the United States, United Kingdom and Australia, where nurses allocated 26.5–37.5% of their time to patient care activities.^5,9,10 In contrast, our nurses performing the supportive role (mainly ENs) used more than half of their time on patient care activities. This difference could be attributed to different models of care, and the availability of ENs in Singapore whose training and scope of work focused on patient care activities.

The care environment could also affect how nurses spend their time. In our participating wards, the nurses’ stations and main requisites holding areas were located outside and away from the patients’ room. The nurses spent 4–10 % of the time in preparing and clearing requisites (which included time used to search for consumables). A study conducted in the United Kingdom hospitals found that more than one third of the nurses surveyed spent at least an hour to search for items during an average shift. ¹¹ With better planning and allocation of items, ¹¹ time spent on searching for consumables and devices could potentially be reduced

Hendrich et al. also found that nurses who were assigned with greater centrality to their patients’ rooms were reported to make more visits into their patients’ rooms (i.e. more time spent with the patient). ¹² Hence, the ward layout could potentially affect how long nurses spent in retrieving requisites for procedures as well as affect how frequently nurses enter patients’ rooms. Healthcare managers should consider looking into the spatial qualities of the nurses’ assignments and unit layout in order to maximise work efficiency. ¹²

Past literature showed that more direct care time of nurses with patients has been associated with better patient’s outcomes.^13,14 Hence, some of the non-direct nursing care activities (e.g. documentation, patient transport) that were observed in this study could be revised so that nurses can reallocate the extra time to be spent on patient care activities. All the nursing activities observed and summarised in this study were essential for patient care. We discovered that there were four areas of activities where the work process could be streamlined. These processes include documentation, care coordination, preparation and clearing of requisites and transportation.

The time spent on documentation and care coordination accounted for a significant amount of the RNs’ shift hours. Our results were in congruence with Hendrich et al.’s studies, ⁵ where documentation (35.3%) and care coordination (20.6%) took up 53.6% of the nursing time. Likewise, a recent systematic review showed that nurses spend between 13% and 31% of their time on documentation. ¹⁵ Efforts to eliminate duplicated documentation should be encouraged so that nurses can allocate more time for patient care activities or patient education. In our study, care coordination encompassed time spent on discharge planning administrative work, scheduling outpatient appointments and referring patients to community services. These processes could also be streamlined with improved appointments system and delegation of these assignments to trained clerical staff.

From the research, it is shown that more than half of nurses’ time was spent on patient care activities. However, some of these patient care activities processes have the potential to be improved. One such example is the transporting and accompanying patients for procedures away from the ward area. This can be done by someone else other than nurses under a certain specified condition. One participant spent 81.9 min accompanying a patient to an off-site procedure room. This meant that other nurses in the ward had to function with one less staff for the whole duration that the nurse was away. Having a well-planned intra-hospital transfer protocol or an intra-hospital transfer team that consists of trained and qualified personnel might be helpful in ensuring efficient use of nursing manpower. ¹⁶ Alternatively, having a trained nurse in the procedure area to care for the patients during the procedure time would then enable the ward nurse to return to their unit and care for the other patients. Thirdly, the availability of services in the inpatient area would eliminate the need to transport patients to another area. To illustrate, this study’s results prompted a review of work processes for patients who require plaster casting. Plastering is now carried out at the bedside and no longer at a dedicated plaster room; this reduces the need for the ward nurses to transport and stay with the patients throughout the plastering process.

Conclusion

This study identified the drivers of inefficiency in our current nursing practice and has allowed for focused improvements to the work environment. Results from this study have also helped us to better estimate demand for care and served as baseline data for the evaluation of the impact of new technology and staff mix on work efficiency. Using this research data, improvements can be made to certain work processes which include documentation, care coordination, prepare and clearing of requisites and transportation. This, in turn, will allow assisting nurses in their workload and allow for better care and environment for the patients.