Nurses need patient time

Kaiser Permanente conducted a time and motion study of inpatient nurses and found a concerning statistic: during each 8-hour shift, they spend only 90 minutes actually caring for patients. Working closely with Kaiser, we sought to understand why, explore the implications for nurses' work satisfaction, and re-imagine the systems that keep nurses away from their patients.

As we shadowed nurses during their workday, we discovered a tangled web of workflow activities: charting and other computer work, retrieving medications and supplies, and dealing with frequent interruptions. As the disruptions and special requests piled up, they kept an always-changing to-do list in their heads. Many nurses would carry around what they called their “brain”—small sheets of paper with hand-written scribbles as a way to keep track of everything.

To avoid interruptions and questions, they walked circuitous paths around their unit, avoiding places where they might get peppered with more requests. Cutting through the middle of the nurse’s station, for instance, was described as “walking the gauntlet.” As an interactional strategy, they would do their best to look overwhelmed to discourage others from interacting with them. Amidst this chaotic workflow, the time they spent with patients was highly fragmented—short interactions that didn’t foster bonds.

In one-on-one interviews, nurses expressed their concerns and frustrations. They told us the reason they became nurses was because they wanted to provide direct care to people. But the growing complexity of their work was taking them away from the part of the job they loved most.

In workshop settings with KP, we developed several solution strategies, including:

Readiness: Ways to provide just-in-time information, supplies, and services by a system that “knows” when items are needed. This reduces the time and effort of nurses who must hunt, gather, ask, and cajole in order to get what they need in the moment.

Managing distractions: Ways to identify and distinguish between short and long distractions, with systems to offload the latter; scheduling that allows for dedicated chunks of time to do charting; and allow KP’s Spectralink communication devices intelligently filter or redirect incoming calls to nurses.

New teams: Redefined team structures and activities to facilitate patient care including more flexible definitions of unit or shift assignments to provide synchronized, well-orchestrated care.

Enhanced nurse-patient interactions: Improvements to Kaiser’s Nurse Knowledge Exchange (NKE)—the information sharing that happens between nurses during shift change—to involve patients in a group discussion with both the incoming and outgoing nurses.

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