On one medical/surgical unit at the North Shore-Long Island Jewish Health System (North Shore-LIJ) in New York, Registered Nurse Julie Denninger is about to document a patient care activity. Not too long ago, before she began this task, Denninger would have first removed her Personal Digital Assistant (PDA) from its hip holster, hit a button that began counting time, quickly scrolled through a menu of documentation activities, and chosen the category that best described the task she was about to document.

Denninger was one of 827 nurses from 36 clinically diverse health care systems participating in the largest environmental multi-site, time and motion study reported in the literature.

Time and Motion Study

With support from the Robert Wood Johnson Foundation (RWJF), study authors Ann Hendrich, R.N., M.S., F.A.A.N., vice president of Clinical Excellence Operations for Ascension Health in St. Louis, Mo. and Marilyn Chow, R.N., D.N.Sc., F.A.A.N., Vice President, Patient Care Services for Kaiser Permanente, Oakland, Calif., used technology to capture a total of 21,955 hours of data documenting how and where nurses like Denninger spend their time during a 10-hour work shift. They call it the "Time and Motion" study.

Denninger's involvement contributed to the "time spent documenting" track of the research. The two other study tracks included collecting data on the range, frequency and time spent in direct and indirect patient care activities, and examining the physiologic and stress loads experienced by nurses on and off shifts. The ongoing analysis of data obtained will have implications for health care decision makers at all levels as they embark on quality improvement initiatives, hospital physical design projects, investments in patient care technologies, and the creation of new local and federal safety and quality policies.

This research comes at a time when health care leaders are facing significant challenges. Health care costs are rising well above inflation each year and pressure is mounting to link health care reimbursement to quality indictors. Outdated physical design and space constraints in many hospitals create stressful environments that are not conducive to healing. Leaders at all levels are searching for solutions to retain nurses at the bedside to allay the looming nursing shortage. As health care leaders themselves, Hendrich and Chow are well-acquainted with these challenges. As a result, they hope the Time and Motion study results will guide the development of practical recommendations and provide health care leaders with evidence-based solutions that will make the hospital work environment more efficient, safe, and conducive to healing.

Nurse Workforce Environment Innovation Summit

In January 2007 in partnership with RWJF, Ascension Health, Kaiser Permanente and the American Academy of Nursing convened a multidisciplinary group of more than 200 frontline nurses, physicians, pharmacists, architects and health care leaders. This meeting, the Nurse Workforce Environment Innovation Summit, was a dynamic three-day event. Summit participants were charged with developing and testing innovative solutions to address the design, workflow and technology inefficiencies existing in most hospitals that were identified in the Time and Motion study.

At the summit, Julie Denninger and two of her North Shore-LIJ colleagues, Nurse Manager Jenny Paul, M.S.N., and Nurse Educator Myrta Rabinowitz, Ph.D., R.N., participated in brainstorming sessions designed to generate ideas that could help address the challenges uncovered by the study data. They immediately took these ideas to Kaiser's Sidney R. Garfield Health Care Innovation Center where they tested them in a simulated nurse work environment. Denninger describes entering this mock hospital with a group of nurses, architects and engineers from across the country and working together to create more efficient spaces. "It was so much fun," she reports. "The nurses would say 'the patient is here so this equipment should go there,' and the engineer would chime in and say 'all we have to do is design the room so that equipment plugs in over here.'"

After two days of engaging in these interactive exercises, the participants joined together to create a set of frontline staff-generated recommendations that hospital, health care and policy leaders could use to increase nurse retention rates, create more healing and less stressful hospital environments, and improve the quality of health care delivery for every patient.

Rabinowitz describes coming away from the summit feeling invigorated. "There are small changes we can make that don't cost a lot but have a big impact. For example, by designing a medication and supply pod for different places throughout the unit we can improve communication and decrease the distance nurses spend going back and forth."

Study investigator Hendrich describes efficient yet significant small change such as this as "change-making in action." She and Chow understand that there is an urgent need for evidence-based solutions. "Everyone in a hospital knows that nurses are pivotal to improving the quality of health care, and the Foundation understands this too. Of all health care providers, nurses spend the most time with patients monitoring progress, coordinating care, and preventing problems before they occur. Until now, there were limited data linking the kind of bedside care that nurses provide to quality. Now, not only is there data, but since the summit, there are multidisciplinary solutions to help strengthen the delivery of patient care."

Participating in Time and Motion has rejuvenated the nursing staff at North Shore-LIJ. Nurse Manager Jenny Paul explains, "We were brought back to looking at every decision from the patient's perspective. The summit encouraged us to think outside the box and question the boundaries of what is possible."