Measuring Clinical Nursing Workload in an Acute Care Hospital in Singapore

Read and summarize the given below journal.

Mei Ling Lim1 and Shin Yuh Ang

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 addi-tional of 9000 staff is needed to support the patients; how-ever, this is an increasing problem due to the declining number of nurses staying in the workforce.2,3 There is also an increas-ing 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 nurs-ing 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 ineffi-ciency in nursing practice will then allow for focused improve-ments 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, docu-mentation and patient care.

Understanding how nurses spend their time is important in order to improve efficiency or to eliminate non-value add-ing 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 1Neuroscience Research Australia, University of New South Wales, Sydney, Australia

Nursing Division, Singapore General Hospital, Singapore Corresponding author:

Shin Yuh Ang, Nursing Division, Singapore General Hospital, Bowyer Block B Level 2, 31 Third Hospital Avenue, 168753, Singapore. Email: [email protected]

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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 com-mencement of ward observations.

Methodology

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, observ-ers 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, meas-ure 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 thera-peutic 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 sepa-rately for the medical and surgical ward. For example, ‘admin-istering 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 nurs-ing activity was reported in percentages.

The majority of the medical RNs’ (in-charge role; n = 4) time was spent on documentation (18%) and medication adminis-tration (18%); only 12% of their time was allocated to patient care activities.

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 hospi-tals 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 sup-portive 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.

Results

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 requi-sites 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 documenta-tion, 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 system-atic review showed that nurses spend between 13% and 31% of their time on documentation.15 Efforts to eliminate dupli-cated 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.