Abstract
Background
The overcrowded environments of emergency departments (EDs) lead to increased clinical workloads for nurses and infl uences the quality of patient care. This study aimed to evaluate whether the quality of patient care meets the expectations of emergency nurses in Taiwan by measuring the amount of time nurses spend on patient care activities.
Methods
The direct observation study was conducted in one suburban academic hospital with approximately 80,000 annual ED visits. This study observed emergency nurses and the time they spent on their nursing activities. The directly measured times and nurse expected patient care nursing times were compared.
Results
For all 88 types of nursing activities recorded, each measured nursing time was less than the expected nursing time. On average, the measured nursing time was 82% less than the expected nursing time (2.0 ± 0.3 minutes vs. 11.6 ± 1.5 minutes, p < 0.01). Among the 88 types of nursing activities recorded, the average measured time spent on 76 types (86%) was less than 3 minutes. The nursing activity on which the longest time was spent was cerebrospinal fl uid study nursing (7 minutes). The most frequent nursing activity was documentation.
Conclusion
The nursing time spent on patient-care activities in EDs was much less than the nurses expected. The results may provide a basis for nursing quality measurements and manpower calculations for EDs.
Keywords: emergency nursing, nursing activity, nursing care quality, patient care nursing time
Introduction
Emergency department (ED) overcrowding is a global phenomenon and has become a severe public health issue.[1,2] The situation for EDs in Taiwan is no exception, with crowded ED environments having been found to increase the length of stay and boarding for patients.[3,4] Overtime, frequent callbacks on days off, and heavy workloads have been found to occur commonly among emergency nurses in Taiwan.[5] The overcrowded environments of EDs lead to increased clinical workloads for nurses and further compromise the quality of nursing care.[6,7] The quality of a given nursing activity is difficult to define and measure. Many quantitative instruments for determining nursing care quality are available.[8]
However, because these quantitative instruments were developed in different settings based on the differing perceptions of nurses and patients, there is no consensus about how to measure nursing care quality. In the field of emergency nursing, some quantitative instruments based on the perspectives of patients have been used to identify the quality of emergency nursing activity.[9,10] On the other hand, emergency nurses in England developed 10 ED nursing quality indicators based on the perspectives of emergency nurses themselves.[11] These quantitative instruments or indicators could be used to measure ED nursing quality, but which method is better is still unknown. Qualitative methods provide another way to explore nursing care quality. One qualitative study from the perspective of nurses found that insufficient time was the main reason for nurses’ inability to consistently provide quality nursing care to all patients.[12] Thus, nursing care quality could be better if emergency nurses were able to spend sufficient time on nursing activities. Previous research has shown how emergency nurses distribute their time over various nursing activities performed in the ED.[13-15] In those studies, emergency nurses were found to spend 70–90% of their nursing time on patient care nursing activities. If emergency patients can receive more nursing time from emergency nurses, the satisfaction of patients and nurses, as well as disease outcomes and the quality of care, may be improved. Little literature exists, however, on how much time emergency nurses spend on individual nursing activities and how the amount of time spent relates to nursing care quality in the ED. Therefore, the aims of this study were as follows: to quantify the amount of time emergency nurses spend on individual nursing activities in the ED and to evaluate if the quality of the patient care provided meets the expectations of emergency nurses by comparing the nursing time actually spent on patient care activities in the ED with the amounts of time nurses expected to spend on said activities.
Methods
This was a prospective direct observational study conducted in one suburban academic hospital in Taiwan with 1,000 beds and approximately 65,000 annual ED visits.
Participants
The study participants were all registered nurses in the ED of the study hospital. In Taiwan, the clinical nursing ladder was based on the period of clinical experience and competence, with less than 12 months as level 0 nurses (N0s), greater than 12 months as level 1 nurses (N1s), 2 years or more as level 2 nurses (N2s), 3 years or more as level 3 nurses (N3s), 4 years or more as level 4 nurses (N4s).[16] The strategies used to encourage nurses to participate included the full administrative support from the head of nurses and the director of ED, and the research briefing meeting to answer the doubts about the study.
Measurements
To determine the nursing time for each individual nursing activity, five senior emergency nurses with ED working experience of at least 10 years served as a team which identified all the patient care nursing activities performed for patients in the ED and developed a nursing time evaluation sheet accordingly. If there was disagreement among the team members, they discussed the issues in question until a consensus was achieved. Initially, 118 different types of nursing activities were identified based on the nurses’ clinical experience and the previous literature.[13,14,17] These 118 nursing activities included direct and indirect patient care nursing activities. Direct patient care nursing activities were defined as all nursing activities performed at the bedside requiring the presence of a licensed registered nurses; for example, physical assessment, venous blood sample, wound care, etc. Indirect patient care nursing activities were defined as all nursing activities performed away from the bedside requiring the expertise of a licensed registered nurses; for example, documentation, patient transfer, incident reporting, etc. Unit-related activities or personal activities were excluded. Then, an item-level content validity index (I-CVI) for the scale was determined by experienced experts.[18] The nursing time evaluation sheet with 118 nursing activities was reviewed by six external experts, including two heads of emergency nurses from other hospitals, two nursing supervisors from the department of nursing in the hospital, one nursing professor from a nursing school, and the director of the ED. The 118 nursing activities in the nursing time evaluation sheet were modified to 114 nursing activities based on the opinions of these experts. The four nursing activities that were deleted were removed due to being repetitive or ambiguously named. The CVI of the nursing time evaluation sheet was from 0.85 to 1.00. The Emergency Nursing Association has defined “best practice” staffing as that which provides timely and effective patient care with professional nursing satisfaction in a safe environment. [19] The 42 participating emergency nurses were requested to fill out a nursing time evaluation sheet to determine the expected “best practice” nursing time for each nursing activity. The expected “best practice” nursing time for each nursing activity (expected nursing time) is defined as the nursing time emergency nurses expect to spend on their patients for each nursing activity, in order to provide timely and effective patient care with professional nursing satisfaction in a safe environment. The average nursing time thus indicated for each activity was regarded as the expected “best practice” nursing time for the given activity.
Data Collection
This study used direct observation to measure the actual patient care nursing time for each activity (measured nursing time) with a convenience sampling of day, night, and midnight 8-hour nurse shifts for 6 months from April to September 2013. The measured nursing time for each nursing activity is defined as the nursing time emergency nurses actually spend on their patients for each nursing activity. The four observers were senior nursing students in the last year of a 2-year Bachelor of Science program. To ensure similarity in their observations, the four observers attended a 20-hour training program together before collecting the data. The training included definitions and codes for specific nursing activities, guidance regarding the observation process, and guidance on how to record measurements using paper or a computer. To test the interrater reliability, the observers simultaneously rated 40 selected nursing activities performed by emergency nurses. The interrater reliability was 90%. When engaging in observation, the observers stood as far away from the nurses as possible to decrease contact with the emergency nurses. Two observers worked as a team at the same time. One observed the nurse in charge and the other was responsible for other allocated nurses if there were two or more nursing activities being performed on one patient simultaneously. All the nursing activities engaged in for non-trauma, trauma, and pediatrics patients from triage to disposition in the ED within 6 hours were observed, with data recorded accordingly. All nursing activities of at least 1,000 patients would be included in this study. The proportion of patient amount was based on the patient amounts classified by shifts and triage levels in the hospital in 2012.
Ethical Considerations
Institutional review board approval was received from the boards of the study hospital. Before the observations were made, the purposes of the study were explained to the emergency nurses, and spoken and written consents were obtained from each emergency nurse who participated.
Data Analysis
The actual measured patient care nursing time (measured nursing time) was compared to emergency nurse expected nursing time) to the emergen (expected nursing time) for each nursing activity. We used the Mann-Whitney U test (IBM SPSS 22, IBM Corp., Armonk, NY, USA) to compare the means of the expected nursing times and the measured nursing times.
Results
All 42 (100%) emergency nurses agreed to be observed while performing their patient care nursing activities. The clinical ladder and working experience levels of the emergency nurses are listed in Table 1. The most common nurse level among the ED nurses was N2, and the average working experience was 5.4 years. The total 16,210 nursing activities performed for 1,025 ED patients were observed. N2s performed a majority of the nursing activities. Emergency nurses with clinical working experience of 5–10 years were responsible for half of the nursing activities. Table 2 shows the frequency of the nursing activities in terms of the clinical ladder and the clinical working experience of the participating emergency nurses.
Table 1. Clinical nursing ladder and working experience of emergency nurses.
N: clinical nursing ladder.
| Clinical ladder | Nurses | Working years | Nurses |
|---|---|---|---|
| N0 | 4 | < 1 | 4 |
| N1 | 5 | ≥ 1 to < 3 | 5 |
| N2 | 27 | ≥ 3 to < 5 | 9 |
| N3 | 2 | ≥ 5 to < 10 | 16 |
| N4 | 4 | ≥ 10 | 8 |
| Total | 42 | Total | 42 |
Table 2. Frequency of nursing activities based on clinical nursing ladder and working experience of emergency nurses.
N: clinical nursing ladder.
| Clinical ladder | Nursing activities | Working years | Nursing activities |
|---|---|---|---|
| N0 | 627 | < 1 | 627 |
| N1 | 1,251 | ≥ 1 to < 3 | 1,251 |
| N2 | 12,540 | ≥ 3 to < 5 | 3,572 |
| N3 | 1,311 | ≥ 5 to < 10 | 8,107 |
| N4 | 481 | ≥ 10 | 2,653 |
| Total | 16,210 | Total | 16,210 |
Of the previously identified 114 different types of nursing activities, 88 types were observed (Supplement Table 1). For all 88 types of observed nursing activities, the average measured nursing time was less than the expected nursing time. The means of the measured nursing times and expected nursing times were not equal (2.0 ± 0.3 minutes vs. 11.6 ± 1.5 minutes, p < 0.001). On average, the measured nursing time 82% less than the expected nursing time. Among the 88 types of observed nursing activities, the mean measured nursing time for 76 types (86%) was less than 3 minutes. Table 3 shows the top 10 ED nursing activities ranked by duration. The longest nursing activity was lumbar puncture (6.9 minutes). For lumbar puncture and central venous catheterization, the measured nursing times were similar to the expected nursing times. In contrast, for the other nursing activities, the measured nursing times were only one-third to one twelfth of the expected nursing times. Table 4 shows the top 10 ED nursing patient care activities ranked by frequency. The most frequent nursing activities were documentation, order transcription, and communication with patients and families. On average, emergency nurses performed an act of documentation at least twice for each patient. Order transcription, communication with patients and families, and triage were performed for almost every patient. For these frequent nursing activities, the measured nursing times were one-fourth to one-sixteenth of the expected nursing times.
Table 3. Top 10 emergency department nursing activities by duration.
ICU: intensive care unit; M ± SD: mean ± standard deviation.
| Nursing activities | Measured nursing time M ± SD (minutes) | Expected nursing time M ± SD (minutes) | p-value |
|---|---|---|---|
| Lumbar puncture | 6.9 ± 5.2 | 7.6 ± 4.5 | 0.613 |
| Central venous catheterization | 6.8 ± 4.3 | 7.7 ± 4.4 | 0.095 |
| Airway insertion and stabilization | 6.7 ± 5.9 | 28.1 ± 21.3 | 0.002 |
| Incident reporting | 6.2 ± 4.2 | 27.3 ± 12.3 | 0.007 |
| Foley insertion-female | 5.7 ± 4.9 | 16.2 ± 8.4 | < 0.001 |
| Wound care | 3.7 ± 3.1 | 17.7 ± 11.7 | < 0.001 |
| Wound irrigation | 3.7 ± 2.0 | 13.3 ± 6.3 | 0.001 |
| Transport to ICU | 3.5 ± 2.8 | 18.5 ± 11.2 | < 0.001 |
| Abuse protection support | 3.5 ± 1.5 | 41.8 ± 31.2 | 0.002 |
| Cardiopulmonary resuscitation | 3.4 ± 1.5 | 40.1 ± 14.3 | < 0.001 |
Table 4. Top 10 emergency department nursing activities by frequency.
M ± SD: mean ± standard deviation.
| Nursing activities | Frequency | Measured nursing time M ± SD (minutes) | Expected nursing time M ± SD (minutes) | p-value |
|---|---|---|---|---|
| Documentation | 2,321 | 1.0 ± 0.7 | 16.0 ± 15.3 | < 0.001 |
| Order transcription | 1,475 | 0.7 ± 0.6 | 5.4 ± 3.8 | < 0.001 |
| Communication with patients and families | 1,108 | 0.8 ± 0.7 | 11.9 ± 7.5 | < 0.001 |
| Triage | 1,025 | 2.0 ± 1.0 | 9.0 ± 4.0 | < 0.001 |
| Transfer from triage to treatment area | 953 | 0.9 ± 0.9 | 5.0 ± 2.6 | < 0.001 |
| Health education | 807 | 1.0 ± 0.5 | 7.5 ± 4.4 | < 0.001 |
| Physical assessment | 708 | 0.8 ± 0.3 | 6.2 ± 3.7 | < 0.001 |
| Venous blood sample | 671 | 1.7 ± 1.3 | 7.1 ± 5.2 | < 0.001 |
| Discharge planning | 650 | 1.1 ± 0.5 | 7.9 ± 5.8 | < 0.001 |
| Intravenous insertion | 631 | 2.5 ± 0.5 | 10.5 ± 7.0 | < 0.001 |
Discussion
To the best of our knowledge, this was the first time that the nursing time spent on patient care activities was measured in the ED in Taiwan. This study successfully quantified the amount of time sent on 88 nursing activities performed in the ED and found that the quality of patient care did not meet the expectations of the emergency nurses by comparing the measured and expected nursing times for the various patient care activities. According to the study results, the measured nursing time was, on average, 80% less than the emergency nurse expected “best practice” nursing time. Thus, the nursing time spent on the patient care activities was much less than the nurses expected would be spent. The results suggested that the emergency nurses could complete the various patient care nursing activities in time, but could not spend more time on the activities in order to ensure the “best practice.” In other words, the quality of the patient care provided did not meet the expectations of the emergency nurses. The emergency nurses expected to spend more time on the various nursing activities so as to improve the quality of patient care.
In this study, most of the ED nursing activities were of very short duration, with the average time for 86% of the nursing activities being less than 3 minutes. The results that the time of ED nursing activities was short and emergency nurses could not spend more time on the nursing activities in order to reach the “best practice” may imply that the emergency nurses had work overload, which forced them to perform the nursing activities hurriedly, thereby indirectly shortening the nursing time devoted to patient care, which may further hinder the nursing care quality.
Previous research has revealed that overtime, frequent callbacks on days off, and heavy workloads commonly occurred among emergency nurses in Taiwan.[5] The nurse-to-patient ratio has been found to be a useful index by which to measure the workloads of emergency nurses.[14] A statement from medical staffing of National Taiwan University Hospital ED in 2015 revealed that the nurse-to patient was 1:14.[20] The high patient-to-nurse ratio reflected the work overloads of emergency nurses in Taiwan.
Several contributing factors have been found to cause work overload. The first is patient overcrowding in EDs. The overcrowded environments of EDs lead to increased clinical workloads for nurses and further compromise the quality of nursing care.[6,7] The Taiwan government has not really executed the health care referral system, leading to the strange phenomenon that any patient can easily and directly visit any ED of any size hospital, even if the patient only has a common cold. Additionally, the Taiwan national health insurance system provides quite cheap health care, such that patients abuse health resources, especially EDs. The more patient visits an ED has, the greater the workload an emergency nurse working there has. Second, a shortage of nurses has also worsened the ED work overloads.[21] Under the Taiwan national health insurance system, the reimbursement for nursing care is low due to the hospital global budget payment system, which has caused hospitals to be unable to employ additional emergency nurses to cope with the heavy clinical workloads.[22] With understaffing, overtime work has become a common phenomenon in EDs.[5] The more and more fatigued emergency nurses seek to escape, while the nurses who choose to stay will have work overloads. It is a vicious cycle. Finally, stressful and chaotic ED working environments also play important roles in causing work overloads. Emergency nurses have previously reported feeling considerable stress because they often encounter all kinds of verbal and physical violence from patients, the family members of patients, and other healthcare providers.[23,24] In such stressful working environments, they have to perform nursing activities correctly within limited amounts of time. As such, it is hardly surprising that the nursing times for patient care activities found in this study were extremely low, or that the quality of patient care did not meet the expectations of the participating emergency nurses. The huge differences between the measured and expected nursing times may also reflect to a considerable extent the stress felt by the emergency nurses.
This study reminds the government officials and hospital managers or stakeholders that it is the time to take actions to increase the nursing time allowed for nursing activities and thereby improve the quality of nursing care. Taiwan government could improve ED overcrowding in order to decrease unnecessary ED visits, while also increasing the reimbursements for nursing care in order to improve nurse-to-patient ratios. Hospitals could in turn invest in improvements to the ED environment and in the nursing staff. A safer ED environment without violence may make emergency nurses less stressed and less likely to be interrupted in their duties. Emergency nurses could then expend more effort and time on patient care. On the other hand, hospitals could exempt emergency nurses from un-professional, extending works or hire certified nurse aides with skill mixed model[25] to share the clinical workloads of emergency registered nurses so that emergency nurses can spend more time on individual nursing activities.
For the top 10 ED nursing activities in terms of the length of time spent, all the mean nursing times were actually very short. The longest mean time for a nursing activity was the 6.9 minutes for lumbar punctures, while the mean time for cardiopulmonary resuscitation was 3.4 minutes. The short nursing times were probably caused by assistance from emergency physicians or nurse practitioners. Take the lumbar puncture and central venous catheterization activities, for example, emergency physicians usually helped the emergency nurses to prepare for these procedures, because the doctors knew the nurses were very busy. During resuscitation activities, nurse practitioners always worked together with the emergency nurses as a team to perform cardiopulmonary resuscitation. Nurse practitioners may help emergency nurses to prepare and perform cardiopulmonary resuscitation, and thus shorten the nursing time performed by emergency nurses for cardiopulmonary resuscitation. Therefore, mutual support from other healthcare providers may worsen nursing care. Fragmented nursing care is dangerous, and may be harmful to the safety of patients and healthcare providers. Adequate valuing of nursing care, proper reimbursement and staffing are essential in developed countries.
In terms of the top 10 ED nursing activities by frequency, the emergency nurses performed triage, communication with patients and families, order transcription, and documentation for every patient just as they should regularly do. The most frequent nursing activity was documentation. On average, emergency nurses performed an act of documentation at least twice for each patient. Therefore, emergency nurses spent 2 or 3 minutes on documentation for each patient within the patient’s first 6 hours in the ED. However, the expected nursing time for documentation was 16 minutes. This may reflect the possibility that the emergency nurses desired to spend more time on documentation in order to make the documentation detailed and clear. Although handwritten medical records have been replaced by electronic medical records for a number of years, it is clear that what the emergency nurses needed was “more time” to record what they did for the patients, no matter which type of record they used. Easy access to nursing information system may save more time for emergency nurses on documentation. Mobile computerized nursing carts with user friendly interfaces may allow emergency nurses to perform instant data inputs and real-time data reviews.
This study revealed the fact that although the emergency nurses in Taiwan worked very hard in order to achieve the expected best practices, there is still a huge gap between the reality and the ideal. Besides nursing care quality, the huge differences between the measured and expected nursing times may reflect that the nursing staffing of EDs does not meet the expectations of emergency nurses. The calculation of nursing staffing of ED in Taiwan is based on the hospital accreditation, which states that “for medical centers, there should be one nurse for every 10 daily patient visits in the treatment area of ED (12 daily patient visits for regional hospitals) and one nurse for every one ED observation beds.”[26] The nursing staffing calculation of current regulation in Taiwan underestimated the nursing staffing in the ED.[27] This study may help the Taiwan government officials and hospital managers or stakeholders to develop new nursing staffing calculations, similar to emergency nursing workforce tool in United States and Australia.19,[28]
This study may provide a simple method for nursing leaders and hospital administrators to evaluate the nursing care quality in an ED and further to develop strategies to ensure adequate workloads. More resources should be used in addressing patient overcrowding and nurse shortages in order to create a healthy work environment for emergency nurses and to improve the quality of emergency nursing care in the future.
Limitations
This study has three limitations. First, this study was conducted in one suburban academic hospital. Thus, its findings may not apply to other hospitals of different sizes, locations, or hospital systems. Consider, for example, that the nursing activities and nursing times for an urban community ED with a predominantly pediatric patient population may differ from those of our hospital. Second, using convenient sampling inevitably brings the problem of selection bias. Some of the nursing activities may have been sampled with low frequency, which may have influenced the accuracy of the measured nursing times. Finally, only 88 of 114 nursing activities were observed in the study, and the lack of observation for the other 26 nursing activities may have influenced the study results. The reason for this lack of observation may simply be that these unrecorded nursing activities are rarely performed, leading to these nursing activities not being sampled in the study.
Conclusion
This was the first study in which the nursing times spent on patient care activities were measured in an ED in Taiwan. Compared to the emergency nurse expected “best practice” nursing times, the actual nursing times spent on patient care activities were extremely low. These results suggested that the quality of patient care did not meet the expectations of the emergency nurses. The emergency nurses expected to spend more time on the various nursing activities in order to improve the quality of patient care. However, the work overloads caused by patient overcrowding, nurse shortages, and stressful working environments may have been the reasons the nurses’ expectations were not generally met. This study may provide the basis for nursing quality measurements and manpower calculations for EDs in the future.
Supplement Material
Supplement Table 1. Types of nursing activities.
| Nursing activity | |
| Observed nursing activities | Triage |
| Vital signs measurement | |
| Glasgow coma scale | |
| Body weight measurement | |
| Physical assessment | |
| Health education | |
| Airway suctioning | |
| Intravenous insertion | |
| Dressing | |
| Change bed sheets | |
| Change diaper | |
| Self-care assistance: bathing/hygiene | |
| Medication administration: oral | |
| Medication administration: intravenous | |
| Medication administration: intramuscular | |
| Medication administration: eye | |
| Medication administration: enteral | |
| Medication administration: subcutaneous | |
| Medication administration: rectal | |
| Medication administration: skin | |
| Wound care | |
| Ice pillow use | |
| Ice packing | |
| Nasogasrtic tube care | |
| Tracheostomy care | |
| Foley care | |
| Surgical preparation | |
| Equipment use and management | |
| Transport to observation room | |
| Transport to ward | |
| Transport to intensive care unit | |
| Discharge planning—may be discharged | |
| Discharge planning—against advise discharge | |
| Postmortem care | |
| Transport to consultation unit | |
| Referral to other hospital | |
| Transport from triage into emergency room | |
| Venous blood sample for blood exams | |
| Venous blood sample for biochemistry exams | |
| Venous blood sample for bacteria culture | |
| Urinalysis | |
| Arterial blood gas | |
| Finger sugar | |
| Pregnancy test | |
| Plain radiography including transport | |
| Computerized tomography including transport | |
| Magnetic resonance imaging including transport | |
| Endoscopy including transport | |
| Electrocardiography | |
| Resuscitation | |
| Endotracheal tube insertion and stabilization | |
| Splinting | |
| Suturing | |
| Wound bleeding compression | |
| Foley insertion—male | |
| Foley insertion—female | |
| Urinary catheterization | |
| Blood transfusion | |
| Fluid resuscitation | |
| Intravenous therapy | |
| Oxygen therapy | |
| Central venous catheterization | |
| Check central venous catheterization level | |
| Lumbar puncture | |
| Ascites tapping | |
| Vital signs monitoring | |
| Physical restraint | |
| Bowel irrigation | |
| On neck collar | |
| Domestic partner abuse protection support | |
| Oral or nasal airway | |
| Documentation | |
| Communication with patients and family | |
| Photography | |
| Chest physiotherapy | |
| Hand over | |
| Enteral tube feeding | |
| Contact family | |
| Incident reporting | |
| Laboratory data interpretation | |
| Medication reconciliation | |
| Order transcription | |
| Self-care assistance: toileting | |
| Supply management | |
| Wound irrigation | |
| Patient rounds | |
| Communication between departments | |
| Filling in the consent form | |
| Unobserved nursing activities | Positioning |
| Monitor input and output | |
| Eye irrigation | |
| Medication administration: ear | |
| Pressure ulcer care | |
| Heating light | |
| Chest tube care | |
| Endotracheal tube care | |
| central venous catheterization/intravenous line Care | |
| Percutaneous nephrostomy/cystofix care | |
| Gastrostomy/colonstomy care | |
| Discharge planning—critical discharge | |
| Angiography including transport | |
| Defibrillation | |
| Chest tube insertion | |
| Hemodialysis therapy | |
| Menthal packing | |
| Child abuse protection support | |
| Code management | |
| Conflict mediation | |
| Rape-trauma treatment | |
| Birthing | |
| Emergency cart checking | |
| Team resource management | |
| Suicide prevention | |
| Infection isolation protection measures |
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