25The Permanente Journal/ Summer 2008/ Volume 12 No. 3
ORIGINAL ARTICLE
A 36-Hospital Time and Motion Study: How
Do Medical-Surgical Nurses Spend Their Time?
Ann Hendrich, RN, MSN, FAAN
Marilyn Chow, DNSc, RN, FAAN
Boguslaw A Skierczynski, PhD
Zhenqiang Lu, PhD
Ann Hendrich, RN, MSN, FAAN, (top, left) is Vice President of Clinical Excellence
Operations, Ascension Health, St Louis, MO and Robert Wood Johnson Executive
Nurse Fellow. E-mail: ahendrich@ascensionhealth.org.
Marilyn Chow, DNSc, RN, FAAN, (top, right) is Vice President of Patient Care Services,
Program Office, Kaiser Permanente, Oakland, CA and Program Director of the Robert
Wood Johnson Executive Nurse Fellows Program. E-mail: marilyn.p.chow@kp.org.
Boguslaw A Skierczynski, PhD, (bottom, left) is a biostatistician for Ascension Health,
St Louis, MO. E-mail: bskierczynski@ascensionhealth.org.
Zhenqiang Lu, PhD, (bottom, right) is a Visiting Assistant Professor of Statistics in the
Department of Statistics, Purdue University, West Lafayette, IN. E-mail: lu25@stat.purdue.edu.
Abstract
Context: Nurses are the primary hospital caregivers. Increas-
ing the efficiency and effectiveness of nursing care is essential to
hospital function and the delivery of safe patient care.
Objective: We undertook a time and motion study to document
how nurses spend their time. The goal was to identify drivers of
inefficiency in nursing work processes and nursing unit design.
Design: Nurses from 36 medical-surgical units were invited to
participate in research protocols designed to assess how nurses
spend their time, nurse location and movement, and nurse physi-
ologic response.
Main Outcome Measures: Nurses’ time was divided into
categories of activities (nursing practice, unit-related functions,
nonclinical activities, and waste) and locations (patient room,
nurse station, on-unit, off-unit). Total distance traveled and en-
ergy expenditure were assessed. Distance traveled was evaluated
across types of unit design.
Results: A total of 767 nurses participated. More than three-
quarters of all reported time was devoted to nursing practice.
Three subcategories accounted for most of nursing practice time:
documentation (35.3%; 147.5 minutes), medication administra-
tion (17.2%; 72 minutes), and care coordination (20.6%; 86
minutes). Patient care activities accounted for 19.3% (81 minutes)
of nursing practice time, and only 7.2% (31 minutes) of nursing
practice time was considered to be used for patient assessment
and reading of vital signs.
Conclusion: The time and motion study identified three main
targets for improving the efficiency of nursing care: documenta-
tion, medication administration, and care coordination. Changes
in technology, work processes, and unit organization and design
may allow for substantial improvements in the use of nurses’ time
and the safe delivery of care.
Introduction
The US hospital system is in a state of
transition. Hospitals face daunting chal-
lenges, such as evolving technologies
and reimbursement policies, demographic
trends, competing fiscal demands, and a
worsening workforce shortage. This point
in time also affords a unique opportunity,
as the US is in the midst of one of the
largest hospital-building and -renovation
booms in history.
1
A reconsideration of
hospital design and work processes holds
the potential to affect the efficiency and
effectiveness of care delivery for the fore-
seeable future. Bold changes in the hospital
work environment are imperative to ensure
the sustainability and affordability of the
hospital as part of the American health care
delivery system.
Nurses are the linchpin of hospital care
delivery. These frontline caregivers represent
a critical and costly resource; maximizing
the efficiency and effectiveness of nurses is
essential to the integrity of hospital function
and the promotion of safe patient care. A
growing evidence base links more nursing
time per patient-day with better patient out-
comes.
2–5
However, increased nurse work-
load and the growing nursing workforce
shortage
6
reduce the amount of nursing time
available for patient care activities.
How medical-surgical nurses spend their
time is a key driver of bold changes in the
hospital work environment.
7–9
Current re-
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26 The Permanente Journal/ Summer 2008/ Volume 12 No. 3
ORIGINAL ARTICLE
A 36-Hospital Time and Motion Study: How Do Medical-Surgical Nurses Spend Their Time?
search suggests that two interrelated
elements—nurse work process and
the physical hospital environment—
contribute to the efficiency and
safety of patient care.
10–12
An under-
standing of how nurses spend their
time will target opportunities for
nursing care effectiveness through
improvements in management,
workforce, work processes, and
organizational culture.
13
We undertook a time and motion
study to provide an evidence-based
understanding of how medical-
surgical nurses spend their time and
of the influence of unit architectural
layout on nurses’ use of time and
distance traveled. Documenting
the drivers of inefficiency in nurs-
ing practice will allow for targeted
changes to the work environment
to positively influence patient safety
and quality of care.
The primary objectives of the
study were to identify how nurses
spend their time during their shift
and to pinpoint environmental
variables in the acute-care nurs-
ing workplace that can be altered
to positively affect the efficiency
of nursing care and, ultimately,
patient safety.
Specifically, the study aimed to
determine:
• the amount of time nurses spend
on specific activities: nursing
practice, unit-related functions,
nonclinical activities, and waste
• the distance traveled by the aver-
age nurse during a typical shift,
and whether this movement is
efficient
• the physiologic impact of the
work environment on nurses.
This study was also designed to
provide baseline data regarding
documentation activities prior to
the installation of electronic health
record (EHR) technology in spe-
cific units. These findings are not
included in this article because of
complications in the analysis of the
data collected.
Methods
The time and motion study was
conducted at 36 hospital medical-
surgical units within 17 health care
systems and 15 states. Together,
these geographically diverse health
care systems operate a total of 274
hospitals with more than 63,000
beds. Each participating study
health system and hospital’s insti-
tutional review board approved the
study protocol.
Study Units and Participants
From a list of all eligible medical-
surgical units at each of the par-
ticipating hospitals, one unit per
hospital was randomly selected for
inclusion in the study. An eligible
medical-surgical unit was defined as
a unit in which patients who require
less care than that which is available
in intensive care units, step-down
units, or specialty care units, and
receive 24-hour inpatient general
medical services, postsurgery ser-
vices, or both general medical and
postsurgery services. These units
may include mixed patient popula-
tions with diverse diagnoses and
of diverse age groups who require
care appropriate to a medical-
surgical unit.
Nurses at each participating unit
meeting the eligibility criteria were
invited to join the study; participa-
Table 1. Description of study protocols
Study protocol
A B C D
Purpose Baseline data for EHR
implementation
How nurses spend their
time
Nurse location and
movement
Nurse physiologic
response
Data collected All documentation
activities during shift
Random sampling of
work activities
Distance traveled and
location in nursing unit
Physiologic parameters,
steps taken
Study period All on-shift hours for
seven days
All on-shift hours for
seven days
All on-shift hours for
seven days
23 hours/day for seven
days
Device PDA PDA RFID
a
Armband
b
Method For each
documentation activity
• Select category
• Note activity
duration
When PDA vibrates,
select
• Location
• Activity
• Cognitive category
Nurse location tracked
continuously via RFID
tags when on unit
Automatic recording of
parameters throughout
23-hour period
Participation Nurses randomized to protocol A or B All nurses
c
Voluntary
Participating nurses 385 382 750 288
Nurse shifts studied 1113 1083 1906 N/A
a
Radianse, Inc, Andover, MA.
b
SenseWear Pro Armband (BodyMedia, Inc, Pittsburgh, PA).
c
One study unit did not participate in protocol C.
EHR = electronic health record; PDA = personal digital assistant; RFID = radio frequency identification.
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27The Permanente Journal/ Summer 2008/ Volume 12 No. 3
ORIGINAL ARTICLE
A 36-Hospital Time and Motion Study: How Do Medical-Surgical Nurses Spend Their Time?
tion was voluntary. To be eligible,
nurses were required to be licensed
(RN, LPN, or LVN) and to provide
direct nursing care for patients on
the study unit. In-house pool nurses
were eligible if they worked on
the study unit for more than eight
weeks. Ineligible nurses included:
float and agency nurses; nurse pre-
ceptors and preceptees; and nurs-
ing supervisors, charge nurses, or
other nurse specialists, unless they
provided direct nursing care with
the same acuity and patient load as
other participants.
Study Protocols
The study consisted of four pro-
tocols: A, B, C, and D (Table 1).
Nurses who consented to participate
were randomized to either protocol
A or protocol B. All nurses were
asked to participate in protocol C,
and any nurse who volunteered to
do so took part in protocol D. For
each protocol, study staff collected
data for seven consecutive days, 24
hours a day, except for protocol D,
for which data were collected for
23 hours a day.
Protocol A: Baseline Data for
EHR Implementation
Nurses participating in protocol
A were supplied with personal
digital assistants (PDAs) to record
all documentation-related activities
during their shifts. With these PDAs,
unit nurses documentation catego-
ries from the following options:
• Admission paperwork
• Assessment
• Transcribe orders
• Writing care plan
• Medications paperwork
• Teaching
• Discharge paperwork
• Other.
For each documentation activity,
nurses selected “start” on their PDA,
then the documentation category.
When they completed the activity,
nurses pressed “stop.” Protocol A
sought to measure the amount of
time spent on nursing work pro-
cesses before the installation of
EHRs. Pre- versus postinstallation
results will be reported elsewhere.
Protocol B: How Nurses Spend
Their Time
Nurses in research protocol B
carried PDAs that vibrated at ran-
dom times during their work shift
to remind them to stop what they
were doing and record the activity
in which they were engaged. Each
PDA was programmed to vibrate 25
times per 13-hour shift (in case of
overtime), with a minimum interval
of ten minutes between alarms.
If the nurse did not respond im-
mediately, the PDA continued to
vibrate every 15 seconds until the
nurse responded. When the PDA
vibrated, the nurse was asked to
select from categoric data sets de-
scribing where they were (patient
room, nurse station, on unit, or off
unit) and what they were doing
(Table 2). For this report, the term
patient room refers to any patient
room that the nurse visited, not a
single patient room.
The nurses’ activities were clus-
tered into categories and subcat-
egories of how much time nurses
spend on activities considered to be
nursing practice, nonclinical, unit-
related, or waste. These categories
and subcategories (Table 2) were
selected to cluster sufficient incre-
ments of time to make strong com-
parisons and to identify important
targets for change. The goals were
to reveal drivers of inefficiency in
how nurses spend their time and to
identify opportunities to improve
efficiency through changes to unit
design and/or organization.
The subcategory of patient care
activities does not represent a
comprehensive accounting of all
activities related to patient care.
Other care-related subcategories,
such as medication administration,
care coordination, and documenta-
Table 2. Categories and subcategories of nursing time for protocol B
Nursing activity category Nursing activity subcategory
Waste Waiting
Looking/retrieving
Delivering
Unit-related functions
a
Unit-related functions
Nursing practice Patient care activities
b
Care coordination
Medication administration
Documentation
Assessment/reading vital signs
Nonclinical Personal time
Patient/family care
Administration/teaching
a
Unit-related functions included preparing equipment, counting narcotics, transporting patients
between departments, using fax or copy machine, and reviewing or updating a status board.
b
Patient care activities included providing care or treatment to the integumentary system;
providing specific education about the patient’s condition and nursing needs; loss of bowel or
bladder control in which the nurse cleans the patient, linens, or floor; participating in or dealing
with a rapid-response team, code, or near code; participating in general discussion with the
patient; conducting intervention activities such as intravenous site changes and urinary catheter
insertion; preparing the patient for hospital admission or discharge; helping the patient with
activities of daily living; providing specific education about the patient’s condition and nursing
needs; assessing patient while off unit; conducting nursing or medical intervention while off unit.
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28 The Permanente Journal/ Summer 2008/ Volume 12 No. 3
ORIGINAL ARTICLE
A 36-Hospital Time and Motion Study: How Do Medical-Surgical Nurses Spend Their Time?
tion were separated from patient
care activities to help identify what
activities consume nurses’ time.
These categories, therefore, are
intended to be utilitarian rather
than absolute.
Protocol C: Nurse Location
and Movement
To monitor nurse location and
movement, nurses in research pro-
tocol C wore radiofrequency iden-
tification (RFID) tags (Radianse,
Inc, Andover, MA) that continually
monitored where they were, how
far they traveled, and the duration
of activity in any one spot. Signals
from each RFID tag were transmit-
ted to an indoor positioning system
installed on each unit for the study
week. The RFID tags measured
the distance traveled in relation to
the physical layout of the nursing
unit. As nurses spent only 20 to
30 seconds in any one spot, each
nurse was fitted with four tags to
ensure that grouping signals would
not be missed.
Protocol D: Nurse Physiologic
Responses
To assess the physical impact of
workload and stress on the nurses,
volunteers from any study group
had their physiologic response
monitored by specialized arm-
bands (SenseWear Pro Armband,
BodyMedia, Inc, Pittsburgh, PA) to
measure the physiologic metrics
both on and off shift for 23 hours a
day for a seven-day period (nurses
removed armbands for one hour per
day). The armbands simultaneously
measured skin temperature, near
body temperature, galvanic skin
response, heat flux, and motion
via a two-axis accelerometer. From
these data, estimates were made for
total energy expenditure (calories
burned), distance traveled, speed,
active energy expenditure, sleep,
and categories of physical activity.
Site Implementation
Before study startup, the op-
timal placement of IPS receivers
were mapped on computerized
architectural drawings (CADs) of
the study unit. Two days before
the data-collection period, the
temporary wireless access points
were installed and tested to ensure
proper functioning. At each study
unit, the necessary hardware was
installed, and staff and manage-
ment members were oriented
regarding the purpose of the study
and the use of devices before data
collection. The hospital study
coordinator managed the data-
collection process with the unit
manager and nurse executive.
The study was conducted at
each site during a period of seven
consecutive days. Data for all units
were collected between June 2005
and June 2006.
Unit-Assessment Data-Col-
lection Tool
A standardized unit-assessment
data-collection tool was com-
pleted by each study unit’s nurs-
ing manager to collect more than
200 hospital unit demographic,
technologic, and architectural vari-
ables. These variables were used to
interpret unit and nurse variation,
as well as cluster relationships that
correlated or explained the differ-
ence in efficiency and nursing time
spent with patients.
Data Management and
Statistical Analysis
The statistical and technical
methods used in this study will be
reported in detail in a separate pub-
lication. In brief, each hospital unit
transmitted raw data to computer
scientists at Purdue University who
then stored the data in an Oracle
database. Data was transferred
from the Oracle database to an R
Table 3. Nurses eligible, consenting, and completing study
Participant status and reason codes Subtotal Total
Total nurses in study units 1420
Ineligible for study 339
Does not meet nurse definition 109
Inactive 23
New nurse in orientation 19
Not scheduled during study 169
Other 19
Total eligible for study 1081
Did not consent 255
Felt that study entailed “Big Brother watching” 3
Disliked consent process 11
Just said no 116
Other 43
Too busy to “mess with” 43
“Too much equipment” used in study 11
Would not participate in any study 28
Consenting for study 826
Did not complete study 63
Did not start study 59
Voluntarily dropped out during study 4
Completed study 763
To assess
the physical
impact of
workload
and stress on
the nurses,
volunteers
… had their
physiologic
response
monitored by
specialized
armbands …
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29The Permanente Journal/ Summer 2008/ Volume 12 No. 3
ORIGINAL ARTICLE
A 36-Hospital Time and Motion Study: How Do Medical-Surgical Nurses Spend Their Time?
system for graphics database. A
new framework was used for data
display in which a “visualization
database” exhibited all cleaned
data as well as summary statistics.
This deep visualization allowed for
the development of valid statistical
models and the performance of ap-
propriate data analyses.
Cross-Validation Between
Protocols
Data collected from the different
protocols allowed for cross-valida-
tion of certain findings. Distance
traveled on the unit, for example,
was evaluated in both protocol
C (through RFID tracking) and
protocol D (through armband ac-
celerometer). Nurse location could
be validated between protocol B
(PDA selection of location) and
protocol C (RFID-determined loca-
tion). Before the study was begun,
location data for protocol C was
validated by tracking “walks in the
units.” RFID-tracked location was
compared with audio recordings
from unit walk-through.
Results
Profile of Participating Hos-
pitals and Nurses
Of the participating medical-
surgical units, 33 were in urban
facilities (3 rural) and 17 were part
of teaching/academic institutions.
The average length of stay for the
study units ranged from 2.62 to
8.67 days (average, 4.37 days).
Unit sizes ranged from 11 to 20
beds to 81 to 90 beds (median,
31–40 beds).
A total of 1420 nurses were iden-
tified at the 36 study units. Of this
total, 339 were deemed ineligible
by study criteria; 826 of the eligible
nurses consented to participate,
and 763 completed the study
(Table 3). No participants were
removed from the study because
of noncompliance. The majority of
participants were RNs (783), and
the remainder were LPN/LVN (43).
Nurses’ educational background
was as follows: 57%, AD or nursing
diploma; 41%, BSN; 2%, MSN.
The study population of 767
nurses were randomized, 385 to
protocol A and 382 to protocol B
(Table 1). All nurses were included
in protocol C, with the exception
of nurses at one study unit, leav-
ing a total of 750 participants. For
protocol D, 288 nurses volun-
teered. In all, data were collected
for 2201 nursing shifts (2065 RNs;
136 LVNs/LPNs) and 21,882 total
hours (20,573 RNs; 1309 LVNs/
LPNs). Average shift length was
9.94 hours.
Nurses randomized to protocol B
responded on average 17 times per
shift. Figure 1 illustrates the aver-
age time spent by nurses in each
location category (patient room,
on the unit, off the unit, nurse sta-
tion); an additional 45 minutes per
average 10-hour shift (7.5% of a
ten-hour shift) were not accounted
for by participants (no response,
no location chosen, undefined,
or pushed wrong response). Per-
centages reported below and in
Figures 1 through 5 do not include
undocumented time.
Figure 2 illustrates how nurses
spent their time by activity cat-
egory. More than three-quarters
of nurses’ time was devoted to
nursing practice (417 minutes,
77.7% reported time per shift).
Activities considered to be waste
consumed 36.3 minutes, or 6.6%,
of reported time per 10-hour shift.
Nurses’ time was further analyzed
according to activity by location,
and by subcategory. Figure 3 il-
lustrates the amount of time per
activity category in each of the
four locations. Nursing practice
accounted for the majority of time
in all locations except off the unit.
Waste and nonclinical activities ac-
counted for larger proportions of
time spent by nurses on the unit
(excluding patient room and nurse
station) or off the unit, compared to
the patient room and nurse station.
Time devoted to nonclinical activi-
ties was approximately equivalent
for nurse station (20.6 minutes),
on the unit (17.8 minutes), and off
the unit (18.2 minutes); nonclini-
cal activities accounted for only
11.3 minutes of time spent in the
patient room.
Figure 1. Reported nurse time by location.
In protocol B, location was selected by the nurse from four categories:
patient room, nurse station, on the unit, and off the unit. Data were
normalized to a 10-hour shift (600 minutes). Of this total, 45 minutes
(7.5% of total) were not accounted for by participants (data not shown).
Data in chart are percentages of all reported time (555 minutes).
Figure 2. Reported nurse time spent by care category.
In protocol B, activity category was selected by the nurse from the
following: nursing practice, nonclinical, unit-related functions, or
waste. Data were normalized to 10-hour shift (600 minutes). Of
this total, 63.5 minutes (10.6% of total) were not accounted for by
participants (data not shown). Data in chart are percentages of all
reported time (536.4 minutes). Nursing practice accounts for over
three-quarters of all nursing time.
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30 The Permanente Journal/ Summer 2008/ Volume 12 No. 3
ORIGINAL ARTICLE
A 36-Hospital Time and Motion Study: How Do Medical-Surgical Nurses Spend Their Time?
Nursing Practice: Locations
and Subcategories
Nursing practice time was con-
centrated in the patient room (155.7
minutes) and nurse station (180.6
minutes) (Figure 4A). Within nurs-
ing practice, the greatest proportion
of time was devoted to documenta-
tion (147.5 minutes, 35.3%, Figure
4B). Care coordination—communi-
cation with team members or other
departments—accounted for 86
minutes (20.6% of nursing practice).
Patient care activities accounted for
less than one-fifth of total nursing
practice time (81 minutes, 19.3%);
time spent on assessment and ob-
taining vital signs was least among
subcategories of nursing practice
(30.9 minutes, 7.2%).
The subcategories care coordina-
tion and documentation were further
analyzed by dividing each according
to nurses’ location (Figure 5A/B).
Both were performed predominantly
at the nurse station (documentation:
119 minutes, 80.6% documentation
time; care coordination: 59.4 min-
utes, 69.2% care coordination time).
Only a minority of care coordination
(2.4 minutes, 2.8%) and documenta-
tion (4.13 minutes, 2.8%) took place
in the patient room.
Unit Architecture
Three different unit architectural
types were included in the study:
“racetrack,” “corridor,” and “ra-
dial.” Of 36 study units, 19 had a
racetrack design; 12, corridor; and
5, radial. The effects of these three
design types and design subtypes
on nurses’ activities were evaluated.
No consistent, statistically significant
relationship was found between the
various architectural types and nurs-
ing time spent with patients.
Distance Traveled
Individual nurses across all study
units traveled between 1 and 5 miles
per 10-hour daytime shift. During
daytime shifts, average distance
traveled ranged between 2.4 and
3.4 miles per 10 hours (median,
3.0 miles).
Nurses traveled less distance
during nighttime shifts when most
activities and patient tasks change
(patients are less mobile, pain often
increases). On night shifts, average
distance traveled ranged between
1.3 and 3.3 miles per 10 hours. The
median distance was 2.2 miles, a
reduction of 0.8 miles per 10 hours
from daytime shifts.
Nurses spent considerably less
Figure 3. Reported nurse time in each activity category by location.
Activity category data from protocol B were examined by each of the four nurse locations: patient room (3A),
nurse station (3B), on the unit (3C), and off the unit (3D). Unreported time is categorized as “other.” Nursing
practice accounted for most time in the patient room and at the nurse station and a majority of time on the unit.
Time off the unit was fragmented into multiple categories.
Figure 4. Nursing practice by location and by subcategory.
Analysis of nursing practice time by location revealed that the largest proportion of nursing practice was done
at the nurse station (4A). Three subcategories of nursing practice (4B) consumed most nursing practice time not
accounted for by patient care activities: documentation, medication administration, and care coordination.
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31The Permanente Journal/ Summer 2008/ Volume 12 No. 3
ORIGINAL ARTICLE
A 36-Hospital Time and Motion Study: How Do Medical-Surgical Nurses Spend Their Time?
time moving when they were not at
work. While they were off shift dur-
ing the daytime, distance traveled
varied from 1.2 miles to 3.5 miles.
The median was 2.1 miles, or 0.9
miles fewer per 10 hours compared
with daytime work shifts.
Variation Between Shifts
Distance traveled varied widely
by shift. Distance per shift varied by
a factor of four or more, even within
the same unit (data not shown).
Time spent on various activities
(including documentation) also
varied considerably between shifts.
Of interest, the variability between
individual nurses on the same unit
was often greater than the variance
across different hospital units.
Physiologic Impact
The normalized metabolic equiv-
alents (nME), defined as energy
expenditure during activity normal-
ized to energy expenditure during
sleeping time (ie, nME = 1 during
sleep), were calculated for nurses
in protocol D. The median nME
for nurses on daytime shifts was
1.71. Nurses working on night shifts
had a reduced nME, with a median
of 1.52, an 11% reduction. While
they were off shift, nME dropped
to a median of 1.5, a 12% reduction
from the daytime shift.
Discussion
This study is the first hospital en-
vironmental study to quantify how
nurses spend their time, in real-time
and in real work contexts. The find-
ings demonstrate that nurses spent
more than three-quarters of their
time on nursing practice-related
activities—but less than one-fifth of
all nursing practice time on activities
defined as patient care activities.
Three other activities accounted
for the majority of nursing practice
time: documentation, care coordina-
tion, and medication administration.
Only 7.2% (31 minutes) of nursing
practice time was dedicated to
patient assessment and recording
of vital signs.
Of all reported time, 6.6% (36.3
minutes) was categorized as waste.
Activities within this category—
many of which were “hunting and
gathering” behaviors—are clearly
targets for improving efficiency.
The much larger proportions of
time devoted to care coordination,
medication administration, and, in
particular, documentation may also
represent opportunities for process
improvement. Documentation ac-
counted for the largest proportion
of nursing time; in fact, this category
by itself accounts for 27.5% of all re-
ported time, more than unit-related
functions, nonclinical activities, and
waste combined.
Among locations, the nurse sta-
tion featured prominently. Nurses
spent the largest proportion of their
time—38.6% (214.2 minutes)—at
the nurse station, compared with
less than one-third (171 minutes)
in the patient room. It is also the
primary location for activities related
to documentation and care coordi-
nation. Whereas time spent in the
patient room and at the nurse sta-
tion was almost entirely devoted to
nursing practice (Figure 3), nurses’
time at other locations on the unit
and off the unit was fragmented
between nursing practice, nonclini-
cal activities, unit-related functions,
and waste.
A picture emerges of the pro-
fessional nurse who is constantly
moving from patient room to room,
nurse station to supply closet and
back to room, spending a minority of
time on patient care activities and a
greater amount of time on documen-
Figure 5. Care coordination and documentation subcategories by location.
Analysis of nursing practice subcategories by location found that care coordination was performed primarily
at the nurse station (69.2%) and documentation was also performed primarily at the nurse station (80.6%).
A picture
emerges of the
professional
nurse who
is constantly
moving from
patient room
to room, nurse
station to supply
closet and
back to room,
spending a
minority of time
on patient care
activities …
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32 The Permanente Journal/ Summer 2008/ Volume 12 No. 3
ORIGINAL ARTICLE
A 36-Hospital Time and Motion Study: How Do Medical-Surgical Nurses Spend Their Time?
tation, coordination of care, medica-
tion administration, and movement
around the unit. The motion findings
of the study support this picture.
Nurses walked significant distances
while at work and walked farther
while on shift (median, 3.0 miles)
than when not at work (median, 2.1
miles). In previous studies, walking
has been identified as a major time
consumer for nurses, and evidence
suggests that time saved walking
translates into more time spent on
patient-care activities.
1
Previous research has shown that
a primary reason for nurse attrition
is the workloads traditionally inher-
ent in this profession.
14
Our find-
ings regarding the physical activity
required in nursing—long distances
traveled and increased metabolic
expenditure—corroborate the phys-
ical and workload demands nurses
endure on a regular basis.
Documentation
Documentation is an essential
part of nursing practice and accounts
for a major portion of the nurses’
time. The documentation process
in many hospitals is also rife with
inefficiencies. For example, nurses
and other care providers often
must transfer information between
data collection systems, consuming
nursing time and contributing to
transcription errors. Documentation
is often duplicated between depart-
ments and disciplines because of
the lack of a single patient problem
list for all providers. The result is
fragmentation of care, duplication
of data sets, and the inability to
quantify the outcome of the care
provided. Evolving regulatory and
public policy requirements for
documentation (such as “present on
admission”) may exacerbate these
problems.
15
The efficiency of documentation
is a multifactorial problem, and solu-
tions remain varied and controver-
sial. Health care systems will need
robust processes driven by caregiv-
ers to improve efficiency and reduce
time dedicated to documentation.
There is hope that EHRs will improve
efficiency, but whether they can has
not yet been documented.
Medication Administration
Like documentation, medica-
tion administration is an essential
component of nursing practice.
Because nurses devote consider-
able time to this category of care,
opportunities may exist to improve
efficiency. Approximately two-
thirds of all time spent on medica-
tion administration in this study
was related to drug delivery to the
patient (46.7 minutes). The other
third (24.9 minutes) was spent
preparing drugs for administra-
tion. Process improvements could
reduce the time required for this
step. Furthermore, medication
administration has been identified
by other researchers as a leading
source of operational failures.
10
Hospital medication processes
may be affected by the fragmen-
tation of the informatics infra-
structure. In an ideal patient care
nursing unit, medications would be
administered as part of a seamless
closed-loop system that provides
accurate and timely information
about the patient, including patient
identification, order verification, al-
lergies, laboratory values, potential
reactions, and preferences. Opera-
tional failures within this process
demand the nurse’s attention and
time and may be a source of ad-
ditional distance traveled.
Proposed improvements to this
process include advanced automat-
ed dispensing systems, the use of
small medication cabinets within the
patient room, and the use of case
carts to provide most medications
predicted on that basis of patient
condition. Creating closed-loop
medication administration systems
will require an interdisciplinary ef-
fort, including supply chain, infor-
matics, work process, and vendor
platform integration.
Care Coordination
Care coordination (communica-
tion regarding the patient) accounts
for approximately one-fifth of nurs-
ing practice time. The benefits of
timely and efficient communication
between team members have been
documented by other investiga-
tors.
16–19
However, inefficiencies in
communication may consume nurs-
es’ time and put patients at risk. Fail-
ure to rescue—death following the
occurrence of an adverse event—is
a nurse-sensitive outcome that has
been correlated with nurse–patient
ratios, communication, and patient
surveillance, among other factors.
2

Indeed, many failure-to-rescue situ-
ations can be traced back to commu-
nication delays or omissions.
The efficient flow of patient in-
formation and status updates could
reduce wasted time and the poten-
tial for errors. Proposed technology
solutions include wireless networks,
handheld and ear devices for the
delivery of patient information, and
intelligent systems that automati-
cally track the physical location of
a medical provider.
Most care coordination time is
spent at the nurse station. Indeed,
the nurse station itself may repre-
sent an opportunity for design and
process improvement. The location
of terminals and/or wireless devices
for data entry, for example, could
reduce the need for and time spent
at the nurse station. Such changes
could reduce walking time between
patient rooms and the nurse station,
and increase the amount of time
available in the patient room.
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33The Permanente Journal/ Summer 2008/ Volume 12 No. 3
ORIGINAL ARTICLE
A 36-Hospital Time and Motion Study: How Do Medical-Surgical Nurses Spend Their Time?
Nursing Unit Design
One of our study objectives was
to describe the variation in distance
traveled, time spent by category,
and workload between units with
different physical layouts. No sta-
tistically significant correlation was
found between type of unit design
and time spent with patients. In
fact, there was more variation in
miles traveled and patient time
between nurses on the same unit
than between units. One likely
explanation for these findings is
that nurses’ ability to organize their
work and staffing assignments has
greater impact on these measures
than does physical space by itself.
For example, a nurse with geo-
graphically contiguous patient as-
signments traveled less than a nurse
with an assignment based on the
level of acuity of illness in which
patients were placed in noncontigu-
ous rooms. This finding suggests
that process and policy, as well as
relatively minor physical changes
within a unit (such as distribution
points of supplies or medications),
can have a major impact on nurse
workload.
Nurses’ adaptability may allow
them to compensate for limitations
imposed by the physical design of
the unit. This adaptation may mask
potential effects of unit layout on
distance traveled and time spent
per activity. Additional statistical
analyses of time and motion data
are currently underway to detect in-
teractions between unit architecture
and nurse time and movement.
It may be that for unit layout to
make a difference in nursing time
spent on patient care activities,
other contextual factors must also
change. Such factors include the
interoperability of technology, staff
work assignments, and work pro-
cesses. Previous research provides
compelling evidence that poorly
organized practice environments
can negate the benefits of excel-
lent staffing and positive patient
outcomes.
20,21
A holistic approach
is needed whereby people, process,
and technology come together
harmoniously in a physical space
to produce the maximum medical-
surgical unit efficiency.
Study Limitations
The challenge study nurses faced
in continuing their jobs without in-
terference from the time and motion
study (both with respect to patient
needs and ensuring study validity)
might have led to problems in the
data collected. For example, some
nurses in protocol A forgot to turn
off their PDAs after completing their
respective activity, leading to outlier
times in the database. In protocol
B, nurses occasionally selected no
category or pressed incorrect but-
tons. These are limitations of the
self-report methodology.
The study design required identi-
fication of all activities of a nursing
shift and grouping these activities
into cogent, useful, and appropriate
categories. The rationale for these
activities and groupings could be
sensibly debated. The category of
patient care activities, for example,
does not include activities, such
as medication administration, that
have obvious and direct impact on
patient safety and outcomes. The
categories were selected with the
intention of grouping activities that
comprise sufficient nursing time to
provide useful data while avoiding
more vague terms such as direct
and indirect care.
Conclusions
Nurses are the primary hospital
caregivers, and the efficient use of
their time and energy is critical to
the future of American hospitals.
Our study evaluated the time that
nurses spent and the distance that
they traveled across 36 geographi-
cally diverse medical-surgical units.
The results demonstrate that nurses
devote large proportions of their
time to documentation, medi-
cation administration, and
care coordination and some-
what less time to patient care
activities. Nurses also travel
significantly larger distances
and exert more energy dur-
ing daytime shifts than when
away from work.
These findings illustrate
the complex and demanding
hospital work environment
and suggest opportunities
to improve the efficiency of
nursing work. Changes to
the process and technology
of documentation, communication,
and medication handling, as well as
the physical design of units, could
benefit nursing efficiency and the
safe delivery of care.
Truly transforming the hospi-
tal–patient care environment to
improve the delivery of safe, high-
quality, patient-centered care would
be a paradigm shift. The task now
is to test solutions to create a more
effective work environment that
seamlessly supports clinicians in the
direct care of patients. v
Disclosure Statement
The author(s) have no conflicts of
interest to disclose.
Acknowledgments
This study was funded by grants from
the Robert Wood Johnson Founda-
tion and the Gordon and Betty Moore
Foundation.
We thank the following health systems:
Ascension Health, Aurora Health Care,
Carolinas HealthCare System, Christiana
Care Health System, Duke Univer-
sity Health System, Henry Ford Health
System, Intermountain Healthcare, Inova
Health System, Kaiser Permanente, Legacy
Health System, Moses Cone Health
System, New York–Presbyterian (the Uni-
A holistic
approach
is needed
whereby
people, process,
and technology
come together
harmoniously in
a physical space
to produce
the maximum
medical-surgical
unit efficiency.
Sum08.indd 33 5/15/08 11:38:32 AM

34 The Permanente Journal/ Summer 2008/ Volume 12 No. 3
ORIGINAL ARTICLE
A 36-Hospital Time and Motion Study: How Do Medical-Surgical Nurses Spend Their Time?
versity Hospital of Columbia and Cornell),
North Shore-Long Island Jewish Health
System, Saint Barnabas Health Care
System, Sisters of Mercy Health System,
Trinity Health, and Vanderbilt University.
We are indebted to Wendy S Goshert,
National Study Coordinator, Health
Evolutions, Inc; the Purdue University–
based time and motion study research
team led by William S Cleveland, PhD,
Department of Statistics, and Christopher
W Clifton, PhD, Department of Computer
Science; James Serack, PhD, Chief Tech-
nology Officer, CSC; and the Ascension
Health and Kaiser Permanente project
managers with special recognition to
Sylvia Speck and Curtis Dikes.
Joshua Kilbridge of Kilbridge Associates
provided writing assistance.
Katharine O’Moore-Klopf of KOK Edit
provided editorial assistance.
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What You Can Do
Do not let what you cannot do interfere with what you can do.
— John Wood, b 1910, UCLA Basketball Coach
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