Bedside nurses are occupied in non-patient care tasks for a quarter of their shifts, according to a new survey. The report shows nurses lose three hours of patient care every 12-hour shift to non-direct care tasks, such as redundant paperwork and regulatory requirements. I've seen other studies that predict nurses spend as little as 30% of their time with patients.

Time away from the bedside, often spent on frustrating and exhausting tasks, increases stress and burnout. Decreasing distractions that take nurses away from patient care benefits both nurses and patients. Studies show a direct correlation between increasing nursing hours per patient day and a reduction in patient morbidity, such as urinary tract infections and pneumonia.

How can healthcare organizations help their nurses spend more time in patient care? Here are 10 successful strategies:

Hourly rounding: Incessant call lights going off decrease nurses' productivity by taking them away from what they were doing to attend to patients' immediate needs. Studies have shown the benefits of moving to an hourly rounding system, where nurses visit each patient at specified times to check on them, attending to pains, position, and bathroom requests. This reduces call-bells and ensures those calls are more important to patients' wellbeing. Patients know their nurse will be in to see them regularly, so they don't use the call bell as often. This increases nurses' ability to complete their tasks without constant interruption.

Bedside reporting: In traditional shift to shift reporting, nurses spend the end of their shift (and often into overtime) transcribing or taping a report for the oncoming nurse, who then spends the first portion of his or her shift reading the notes or listening to the tape. Bedside shift reporting saves time and allows the incoming nurse to ask questions. It also improves patient safety by involving the patient and ensuring patient and caregivers are on the same page.

Bedside documentation: Charting at the bedside improves patient safety, but it's also been shown to save time, especially with the help of technology such as computer carts that can be wheeled to patients' beds. Electronic health records take time to learn and all too often are unwieldy and duplicative, however, causing nurses to find work-arounds that may save time, but circumvent patient safety. When implementing EHRs, involve bedside caregivers in the process to ensure it's user-friendly and avoids duplicating efforts.

Electronic medication administration records: eMARs can save time for all caregivers, for example, by making it easy to access a list of medications a patient is taking, and simplify medication administration for bedside nurses. As with EHRs, if the program is not developed with input from end users, it may add to inefficiencies and even take far longer.

Bedside medication administration: Similar to eMARs, bedside medication administration removes inefficiencies and improves patient safety, but only if the process works for caregivers.

Patient handoffs: Using standardized tools, such as SBAR, provide communication checklists and ensure appropriate information is conveyed swiftly and smoothly.

Keep supplies in close reach: Nurses spend hours hunting and gathering all the supplies they need during a shift, and often walk miles in the process, retrieving medications and then trekking from linen closet to storage room. Reducing the time nurses spend hunting and gathering for supplies is a vital step in increasing time spent in patient care. Keep patient rooms stocked with the items needed during a shift, such as commonly-used supplies (e.g., pre-filled syringes for flushing IV lines) and extra linens. Locating supply closets and nurses stations in central locations also decreases the miles nurses walk each day.

Outsource discharge follow-up calls: Phone calls to recently-discharged patients increase patient satisfaction and reduce the risk of readmission, but they don't have to be done by nurses on the unit. This is an ideal job for older nurses looking to decrease physically-taxing direct patient care.

Seek physician input: Physician involvement can be critical to the success of any time-saving project. Ask physicians about system improvements they can be involved with.

Ask nurses: The easiest way to know what will save nurses time is to ask them. Stop nurses in the hallway and ask about inefficiencies and they will name umpteen things that drive everyone nuts. Saving five minutes here and there all add up. Removing obstacles that hinder nurses' not only saves time, it also saves frustration.

At nursing management conferences, the most jam-packed sessions are about retention and recognition. Nurse leaders want fresh ideas to keep staff happy, engaged, and not tempted by the attractive signing bonuses offered at the hospital down the street.

Conference sessions usually focus on recognition and reward as the most important areas, and suggest simple gestures such as sending personalized thank-you notes, or small gifts to nurses who've done a good job.

Is this what nurses value most? Perhaps not. A new study suggests we focus too intently on the warm-and-fuzzy of recognition and reward instead of a bigger nurse value: progress.

Harvard Business Review recently published a multi-year study by Teresa M. Amabile and Steven J. Kramer that tracked the daily activities, emotions, and motivations of hundreds of knowledge workers across a variety of professions.

First, Amabile and Kramer asked more than 600 managers from a range of companies to rank workplace factors in relation to their effect on employee motivation and emotions:

1. Recognition
2. Incentives
3. Interpersonal support
4. Support for making progress
5. Clear goals

The managers overwhelmingly ranked "recognition" as the most important factor for employees. But Amabile and Kramer found that employees were happiest, most engaged, and motivated when they made headway in their jobs, or received support to remove obstacles. When obstacles got in their way, they felt weighed down, unmotivated, and dissatisfied.

The study involved gathering more than 12,000 e-mail diary entries from participants, and showed that making progress in one's work—no matter how small or large the progress—is associated with positive emotions and high motivation. The survey notes that when participants experienced progress in their jobs, 76% of them reported it as their best day.

Amabile and Kramer say their findings are good news for managers, who have the power to help staff excel and progress. To make that happen, managers must clarify goals, ensure staff get the right support, and create an environment where minor glitches are seen as learning opportunities, rather than insurmountable hurdles.

This makes sense. Recognizing an employee's hard work is important and affirming, but it won't overcome a poor work environment where nurses feel they are thwarted at every step.

Having said that, don't abandon recognition. Even though progress may be the leading motivator of performance, managers must always recognize staff for a job well done. If nurses meet or exceed their goals, praise them. It reinforces motivation. Everyone wants to believe they are making progress and getting things done, and that their efforts are appreciated.

Nursing issues have been in the news in the last week and not all of them have been good. First, AMN Healthcare released a survey that found nearly half of the nurses who responded want to make a career change in the next three years, and more than a third said they were dissatisfied with their job.

Then there was a piece in The New York Times' "Well" blog by Theresa Brown, RN, about the disturbing prevalence of bullying in nursing. And finally—some good news—Texas whistleblower Anne Mitchell, RN, (whose case I wrote about last week) was acquitted of all changes.

A thread runs through these stories: the lack of autonomy in nursing.

Brown quotes nurse researchers Cheryl Woelfle and Ruth McCaffrey's article "Nurse on Nurse" to speculate why nurses attack their own. "Nurses often lack autonomy, accountability, and control over their profession," they write. "This can often result in displaced and self-destructive aggression within the oppressed group."

More than 40% of the nurses in the AMN Healthcare survey were not satisfied in their positions, which may be due to a lack of control over the things that matter to them in their jobs. Mitchell lacked autonomy in her hospital to do something about a physician she perceived as unsafe, so she went to the Texas Medical Board as her only option.

Employees are happier where they have a degree of autonomy over their jobs. Successful organizations work to give their nurses as much autonomy as possible.

Eileen Dohman, vice president of nursing at Mary Washington Hospital in Fredericksburg, VA, says nurse leaders' must create an environment where nurses have autonomy—and are held accountable—for their behavior and practice.

"My responsibility is the environment that nurses practice in," says Dohmann. "That's my job: To create, reinforce, and ensure that nurses have the environment they need to safely practice."

Dohmann is accountable for all the patient care that happens in the building but she doesn't provide any of that care. She sees her role as being an advocate for the nurses and to provide an environment where nurses are in control of what happens to them. That doesn't mean nurses always get what they want. Dohmann cites the example of productivity. Mary Washington Hospital has emphasized nurse-to-patient ratios and productivity targets. Dohmann has created an environment where nurses understand their parameters and what they have to work with to provide care.

"My job is to help them understand; it's not necessarily my job to help them like it," says Dohmann. "But my job is to help them understand and then give them the autonomy. I say to my nurses all the time, 'keep it legal and keep it safe. Those are the rules. So figure it out.' Nurses at the bedside in our hospital don't want me making decisions about how they practice nursing at the bedside. I don't do it. They do it. I see my job is letting them know what the confines are that they have to live within, and the rest of my job is making sure that I get any barriers out of the way so they can do what they need to do."

Nurses treating one another poorly is nothing new. Dohmann says nurse leaders play a huge role in creating the environment that does not allow bullying. Leaders have to set expectations and hold people to those expectations.

"When you talk about behaviors and how people feel and accountability and autonomy, you have to give people permission to be accountable and autonomous," Dohmann says. "People don't feel autonomous unless you create an environment and give them permission to feel that way."

Nursing leaders must cultivate an environment where nurses can tell them what is working and what is not.

"I want people to tell me what's not going well. I can't advocate for you if you don't tell me what's going on," says Dohmann. "We have to be willing to listen and we have to be willing to hear. More importantly, we have to be willing to do something about what we hear."

We should listen to nurses, said the Robert Wood Johnson Foundation recently, which teamed with Gallup to survey opinion leaders from a variety of industries on nursing's influence. While noting that nursing is one of the most trusted professions, this trust does not translate into action, the survey found. Nurses have less influence on healthcare reform than government, pharmaceutical, and insurance executives.

My colleague, Janice Simmons, covered the survey in detail here. The stark portrayal of nursing's voice in big picture, national issues got me thinking about day-to-day issues, and whether nurses have a place at the decision-making table in most healthcare organizations.

Union leaders argue that all too often they do not, and that unions should be the ones to provide the voice. Some organizations ensure nursing's voice is heard and that nurses are involved in all decisions through shared governance.

Shared governance models—such as those developed by Tim Porter-O'Grady—turn traditional hierarchical structures into flat, decentralized systems where decision-making lies with stakeholders (i.e., nurses at the bedside), rather than with senior leadership.

One organization that practices this model is the Lehigh Valley Health Network, based in Allentown, PA, which has had robust shared governance since the 1980s that gives nurses a voice in determining nursing practices, standards, and quality of care.

"To us it means that all staff have the responsibility and are held accountable for decisions that impact their role," says Kim Hitchings, RN, manager of the Center for Professional Excellence at Lehigh Valley Hospital, and a national speaker on best practices for adopting shared governance. "It's not just staff nurses; it's also nurses who are in management positions, or unlicensed assistive personnel. In this organization, we believe everyone is responsible for decisions that impact their role and responsibilities."

At LVHN, this means that nurses at the bedside are empowered to make decisions about the practice of professional nursing. And Hitchings says it results in a nice place to work, evidenced by the fact the hospital has been on Fortune's 100 Best Companies list for three consecutive years. When ranking the health system, Fortune noted the robust culture of involving staff in decision making as a prime reason for making it on the list.

LVHN's structure has been in place long enough to self-measure success. Six components are involved:

1. Practice: Nurses make decisions about their practice, rather than having decisions announced from above. For example, a night-shift staff nurse attended the Academy of Medical-Surgical Nurses annual conference, where she heard about a bedside shift report process that she thought would benefit her unit. So she researched the process and brought the idea to her unit's practice council, where it was collectively decided to implement bedside shift reporting. It is now being implemented house-wide.

2. Quality: Individual units have quality improvement councils and metric boards showing quality indicators are displayed in public areas so that all staff, visitors, and patients see data relating to pressure ulcers, patient falls, etc.

"Staff know their unit's scores and analyze the data," says Hitchings. "For example, if a patient fall occurs, staff on that unit will sit down and do a root cause analysis and then create an action plan on how to prevent similar falls in the future."

3. Evidence-based practice and research: "It is the responsibility of the organization to not only have the structures in place, but if you want a robust shared governance model, you have to provide resources for nurses to then do it," says Hitchings. Nurses at LVHN base their practice on evidence, have councils to consider evidence when weighing practice changes, and regularly initiate research projects to determine for themselves the answer to clinical questions.

4. Professional excellence: The organization budgets operational dollars and utilizes donated funds for staff to attend professional development meetings outside the organization. The goal is to have at least one staff member attend every major national nursing conference.

5. Reward and recognition: The organization assigns dollars to each department, based on FTEs, for reward and recognition activities; that department then decides how to spend the money and recognize and reward its staff members.

"What you perceive as reward and recognition may not be perceived by someone else as reward and recognition," notes Hitchings. "Our staff on each unit decide what's important to them."

6. Operations: To many nurses, control over their schedule is a priority. "They work out and determine how they do their schedules," says Hitchings. "One unit will have one way to decide who works Christmas and another unit will do it differently. But it's not decided by a director or some central process or even electronically. Nurses determine the guidelines and create the schedule themselves."

Similarly, staff are involved in the hiring process for managements positions and peer interviews when staff nurses are hired.

Hitchings says shared governance is an important part of life for her organization and she can't imagine nursing not being involved in decision making. "Our senior leadership and middle management recognize the value from staff being involved in decisions," says Hitchings. "And we all recognize the impact it has on staff, and ultimately patient, satisfaction."