Work Smarter, Care More

Maureen Larkin, for HealthLeaders Media, March 27, 2008

When most of us think of nurses, we picture a caregiver at the bedside, taking the blood pressure of a patient or giving them the medication they need to get well. We don't picture them in the back corner of an office, surrounded by mounds of patient charts. But a new study--commissioned by the Robert Wood Johnson Foundation--shows that nurses are spending more time on paperwork and less time caring for patients.

"Nurses spent 60% of their time on the computer, or on the paper trail," says Susan Coombes, MA, CHC, manager of regulatory compliance for Oregon Health & Science University. The result is less time at the bedside, putting patients at risk and our efforts to improve quality in jeopardy.

Nurses are essential to our quality improvement efforts. They're on the front line--spending more time with patients than any other member of the medical staff. They dispense medication, take vitals, and provide that hand to hold when a patient needs a little TLC. They develop relationships with their patients and can often spot a change in condition just by looking in a patient's eyes or hearing strain in his or her voice. But standards set by regulatory agencies are taking nurses away from the bedside, where they are less likely to notice these things.

Everyday tasks that once took minutes are now taking nurses double and triple the time, says Deborah Eldredge, PhD, RN, director of evidence-based practice and assistant professor at the OHSU School of Nursing. Not only does a nurse have to take a patient's vitals, but now has to document that the vitals were taken, and verify that the vital check was documented.

"If we're having to do that every two hours on every four patients, when are we supposed to do the other things that nurses do--teaching, counseling, and making people feel better?" Eldredge asks.

This isn't to say that nurses aren't strong believers in providing quality care--they are. The desire to provide patients with the care and comfort they need is what brought them to this profession in the first place. But they are humans, and we can only ask so much of them.

"New demands in the arena of patient safety are already running nurses out of time in patient care," says Coombes. "These aren't the wrong things, but there are too many things."

The RWJF study was released last week by the Center for Studying Health System Change. Many of its findings were things that we already know. But perhaps it included ideas we haven't considered: As our nursing population shrinks and demands grow, we need to think twice about the load we're putting on our nurses and how much care we're allowing them to give.

This doesn't mean that we need to eliminate documentation efforts, or that our efforts are doomed to fail, Eldredge says. Documentation requirements are here to stay--and there are probably more on the way. To get the most out of our workforce without compromising care, we have to get smarter about our processes.

Instead of going from room to room checking patients who are at risk for pressure ulcers, then starting all over again to check those patients who are at risk for falls, Eldredge says there's opportunity to more efficiently address related risk and care needs. "It's all about work redesign," Eldredge says. "Think about what is going to make the biggest difference. You want a nurse's day to be as organized as possible."

Part of that organization is training, Coombes says. Nurse managers often get so bogged down in the "must dos" of their daily shift that they don't have the time to spend training nurses on how to do more with less.

"Middle management in healthcare takes a beating because they have to make everything happen...they get pulled away too much," Coombes says. "It's been our goal to get the managers back to the bedside and put their hands around practice."

Getting your nurse managers back into patient care can go a long way to solving a unit's care issues, Eldredge says.

"If we could free up nurse managers to be at the bedside to address patient needs and mentor new nurses, we'd be much better able to identify system problems."

Maureen Larkin is quality editor with HealthLeaders magazine. She can be reached at
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