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What happens during nurses' medication work in acute care: an observational study from one hospital in Iceland.

ABSTRACT

The importance of nurses being able to carry out medication work uninterrupted is increasingly identified and emphasized. However, the actual conditions during medication work of nurses are less known. This paper sheds light on what happens during medication work of nurses in acute care. An observational study was carried out in four inpatient university hospital units. Structured quantifiable measures were collected on handheld computers as well as qualitative field notes recorded on digital recorders. Data were gathered during 8 whole shifts. Participants used 17% of their working time for medication related work. On average their work during that time was disrupted 11.4 times per shift. The most frequent influencing factor the nurses encountered was non-self initiated communication by a coworker during medication preparation. Nurses spend a substantial part of their working time on medication preparation and administration; work which requires their full attention. However, their attention is frequently shifted between work activities and factors influencing their work, increasing the risk of medication errors. Findings indicate an urgent need to minimize the risks and the financial costs due to disruptions caused by untimely communication, lack of information and material resources in place during medication related work of nurses in acute care.

KEY WORDS: hospitals, medication, nurses, work

Introduction

Nursing work is complex and non-linear, posing substantial potential risks to safety (Potter et al., 2005; Westbrook & Woods, 2009). Viewing and approaching nursing work as a predictable process comparable to product line work is highly misleading (Cornell et al., 2010). However, previous studies on nursing work assumed this to be the case. This is well reflected in the methodologies used for measuring nurses' work, where work sampling was the most commonly used method (Hendrickson, Doddato, & Kovner, 1990). In recent years, scholars have identified that for understanding the complex work of nursing other methods need to be used as well. Studies using constant observations such as time-and-motion studies with human factors engineering (HFE) (Potter, et al., 2005) and ethnography studies (Ebright, Patterson, Chalko, & Render, 2003) have captured a somewhat fuller picture of nurses' work. For the past decade, study objectives have shifted from measuring solely efficiency to identifying effectiveness with the focus on the safety of patients and health care workers.

Aim

In order to identify potential improvements in nursing work, a study was conducted in a university hospital in Iceland. The aim of the study was to investigate the characteristics of nurses' work and factors influencing their work in acute care. This paper sheds light on what happens during medication work of nurses in acute care.

Method

This was a descriptive mixed methods observational study carried out at the university hospital in Reykjavik, Iceland. Data were collected in two medical and two surgical inpatient acute care units.

Sample and setting

Participants were eight registered nurses (RNs) observed during the same number of eight-hour shifts (totalling about 64 hours). An observer shadowed each participant for an entire shift. Participants had at least three years' experience in their work on the unit or a comparable unit, were employed at least half-time and spoke Icelandic. The study was approved by the Institutional Review Board at the hospital (10/2008) and the Data Protection Authorities in Iceland (S3838/2008). Prior to data collection, all participants gave their written informed consent.

There were 15-21 patient beds per unit and during the observations each participant was in charge of 5-7 patients per shift; with 5 patients being most common. Nursing directors at the hospital had identified these units as quality units that were well staffed and stable and without any major recent or planned changes.

Data collection and analysis

Data were collected in May-June 2008 during morning shifts (08:0016:00 hrs) and evening shifts (15:30-23:30 hrs) on weekdays and weekends. Six trained observers, all graduate nurses with extensive clinical experience, collected the data. A handheld computer (Personalized Digital Assistant (PDA) was used for collecting electronic standardized measures on nursing work (e-SMNW). Using the e-SMNW, data were collected on: 1) the work of nurses, 2) influencing factors, and 3) movements between locations within the unit. The PDA automatically collected data on time as it has a built-in clock. The development of the e-SMNW is described in Bragadottir et al. (2013). Besides collecting data onto the PDA, observers collected qualitative data. They recorded explanations of the nurses' work in their own words on a digital recorder whenever they considered it necessary to add to the quantitative measures in the e-SMNW. Following each shift, observers interviewed participants and asked how the shift had been, whether anything had been left undone or unfinished in the nursing of their patients and whether anything had interrupted them during the shift. In spite of this being a non-participatory observational study, participants were fully aware of all data collection and measures. No attempt was made to prevent participants from hearing recorded explanations and if the observer was not sure of what was being done or why, he/she would ask the participant.

Quantitative data analysis was done with Microsoft Office Excel, SQL, R and Graphviz software. Observers' field notes and interviews with participants were content-analyzed.

Results

All participants considered the shifts manageable or extremely manageable and not out of the ordinary. They claimed to have not been interrupted or influenced by anything special during their work and that they were able to tend to all of their patients' needs.

On average, participants used 17% of their working time on medication work. For the time used for medication work, 64.48% was used for medication preparation and 35.52% for medication administration.

As seen in Table 1, most time was spent on preparing non-injectibles such as oral medications. More time was spent on medication preparation than medication administration during morning shifts compared to evening shifts.

On average, medication preparation and administration was disrupted 11.4 times per shift; more often during medication preparation. An independent t-test indicated a significant difference between the number of disruptions in medication preparation between morning shifts (M = 9.5, SD = 2.517, N = 4) and evening shifts (M = 3.5, SD = 3.109, N = 4), t(6) = 3, p = .024. No significant difference was identified between frequencies of disruptions during medication administration during morning and evening shifts, or between medical and surgical units, whether for medication preparation or medication administration (p [less than or equal to] .05).

Table 2 lists the factors influencing nurses during medication preparation and administration. The most frequent influencing factor the nurses encountered was non-self initiated communication by a coworker during medication preparation.

Explanations from observers' field notes are in concordance with the quantitative data as the following example indicates:
   She [the RNJ is still preparing the medications and there have just
   been numerous small interruptions ... someone will just come and
   speak to her ... not directly relating to the nursing of her
   patients ... but this [medication preparation] has been interrupted
   with several small interruptions.


Participants often multitasked and moved frequently from one location to another within the unit during medication-related work, adding to their attention shifting. The following explanation from an observer's field notes describes well the frequent attention shifting during a nurse's work:
   [The RN] was administering oral medication and enters a patient
   room ... checks the status of the patient--he needs injections
   tomorrow --and she finds out he is still in much pain ... so she
   goes to get painkillers ... then he [the patient] is lacking water
   ... [the RN] takes it with her ... when she [the RN] prepares the
   meds in the medication room a licensed practical nurse comes so she
   delegates work to her, asks her to take some medication to another
   patient. So she is doing very many things at once.


Discussions

Medication preparation and administration took up 17% of participants' time during manageable shifts; a substantial part of their working hours. Studies from the United States, Australia and the United Kingdom indicated that medication-related work takes 11-27% of nurses' time (Ball, Murrells, Rafferty, Morrow, & Griffiths, 2013; Cornell, et al., 2010; Keohane et ah, 2008; Potter, et ah, 2005; Westbrook & Ampt, 2009). Participants' work during medication preparation and administration was frequently disrupted, especially during preparation time. The most frequently occurring factor influencing the work of participants was non-self initiated communication. These results are comparable to results of other studies (Biron, Lavoie-Tremblay, & Loiselle, 2009; McGillis Hall, et ah, 2010), indicating that the culture of nursing and acute care services is especially tolerant to, and even encourages, communication at all times. Presumably a substantial portion of this communication is necessary at the time, but much could be eliminated or postponed until another time. The factors influencing the work of participants in this study are all identified as possible causes of medication administration errors, jeopardizing patients' and nurses' safety (Keers, Williams, Cooke, & Ashcroft, 2013).

In this study no attempt was made to evaluate whether errors were made and it is assumed that no major or obvious errors occurred as observers did not report any in their field notes. However, medication errors are a hidden problem as nurses themselves often do not realize or notice their own errors and are reluctant to report them even when noticed (Mrayyan, Shishani, & Al-Faouri, 2007).

Conclusions

The constant observation during whole shifts, the use of computer technology and collecting both quantitative and qualitative data all added to the value of the study by providing rich and reliable data on the work and work environment of nurses. Study results provide a clear picture of nurses' work in acute care, shedding light on the many factors influencing medication preparation and administration by nurses. This knowledge has practical implications for clinicians, administrators and educators, and points out the many issues that still need to be studied for safe patient care in hospitals. Clinicians and administrators need to pay closer attention to what really happens during medication-related work of nurses. Interventions should be aimed at the competence of nurses, collaboration, communication and culture in acute care, as well as the physical environment supporting nursing work. Nurses' attention should be focused on patients and their safety. Actions need to be taken to minimize the risks and financial costs of unnecessary shifting of attention during medication-related work in acute care.

Helga Bragadottir, Associate Professor, Chair Nursing Administration, PhD, RN, Helgi Thor Ingason, Associate Professor, PhD, Sigrun Gunnarsdottir, Associate Professor, PhD, RN

Accepted for publication 05.06.2014

Helga Bragadottir, Associate Professor, Chair Nursing Administration, PhD, RN [1,2]

Helgi Thor Ingason, Associate Professor, PhD [3]

Sigrun Gunnarsdottir, Associate Professor, PhD, RN [1]

[1] University of Iceland Faculty of Nursing, School of Health Sciences, Eirberg, Eiriksgata 34, 101 Reykjavik, Iceland. Telephone: +354-5254988; Fax: +354-5254963; helgabra@hi.is; sigrungu@hi.is

[2] Landspitali University Hospital, Hringbraut, IS--101 Reykjavik, Iceland.

[3] Reykjavik University, School of Science and Engineering, Menntavegur 1, IS--101 Reykjavik. Telephone: +354-5996532; helgithor@ru.is

Corresponding author: Helga Bragadottir, University of Iceland Faculty of Nursing, School of Health Sciences, Eirberg, Eiriksgata 34, IS--101 Reykjavik. Telephone: +354-5254988; Fax: +354-5254963; heigabra@hi.is

References

(1.) Ball, J.E., Murrells, T., Rafferty, A.M., Morrow, E., & Griffiths, P. (2013). 'Care left undone' during nursing shifts: associations with workload and perceived quality of care. BMJ Quality and Safety. Advanced online publication, doi: 10.1136/bmjqs-2012-001767.

(2.) Biron, A.D., Lavoie-Tremblay, M., & Loiselle, C.G. (2009). Characteristics of work interruptions during medication administration. Journal of Nursing Scholarship: an official publication of Sigma Theta Tau International Honor Society of Nursing/Sigma Theta Tau, 41(4), 330-336.

(3.) Bragadottir, H., Gunnarsdottir, S., & Ingason, H.T. (2013). The development and piloting of electronic standardized measures on nursing work: combining engineering and nursing knowledge. Journal of Nursing Management, 2/(4), 679-689.

(4.) Cornell, P., Herrin-Griffith, D., Keim, C., Petschonek, S., Sanders, A., D'Melio, S., ... Shepherd, G. (2010). Transforming nursing workflow, part 1. The chaotic nature of nursing activities. The Journal of Nursing Administration, 40(9), 366-373.

(5.) Ebright, P.R., Patterson, E.S., Chalko, B.A., & Render, M.L. (2003). Understanding the complexity of registered nurses work in acute care settings. The Journal of Nursing Administration, 33(12), 630-638.

(6.) Hendrickson, G., Doddato, T.M., & Kovner, C.T. (1990). How do nurses use their time? The Journal of Nursing Administration, 20(3), 31-37.

(7.) Keers, R.N., Williams, D., Cooke, J., & Ashcroft, D.M. (2013). Causes of medicaiton administration errors in hospitals: a systematic review of quantitative and qualitative evidence. Drug safety. Retrieved from http://link.springer.com/article/10.1007%2Fs40264-013-0090-2/fulltext.html

(8.) Keohane, C.A., Bane, A.D., Featherstone, E., Hayes, X, Woolf, S., Hurley, A., ... Poon, E.G. (2008). Quantifying nursing workflow in medication administration. The Journal of Nursing Administration, 35(1), 19-26.

(9.) McGillis Hall, L., Pedersen, C., Hubley, R, Ptack, E., Hemingway, A., Watson, C., & Keatings, M. (2010). Interruptions and pediatric patient safety. Journal of Pedriatric Nursing, 25(3), 167-175.

(10.) Mrayyan, M.T., Shishani, K., & Al-Faouri, I. (2007). Rate, causes and reporting of medication errors in Jordan: nurses' perspectives. Journal of Nursing Management, 15(6), 659-670.

(11.) Potter, R, Wolf, L., Boxerman, S., Grayson, D., Sledge, X, Dunagan, C., & Evanoff, B. (2005). Understanding the cognitive work of nursing in the acute care environment. The Journal of Nursing Administration, 35(7-8), 327-335.

(12.) Westbrook, J.I., & Ampt, A. (2009). Design, application and testing of the Work Observation Method by Activity Timing (WOMBAT) to measure clinicians' patterns of work and communication. International Journal of Medical Informatics, 78 Suppl 1 (Journal Article), S25-33.
Table 1. Time spent on medication preparation and administration

                                 Morning shift
                                  08:00-16:00
                                  N=4 shifts

                         Medication         Medication
                         preparation      administration
Type of medication            %                  %

Non-injectibles              9.9                3.6
(oral, suppository,
inhalants, topical)
Injections                   2.3                1.2
IV fluids                    0.2                0.2
Blood                        0.0                0.0
Total time                  12.4                5.0

                                 Evening shift
                                  15:30-23:30
                                  N=4 shifts

                         Medication         Medication
                         preparation      administration
Type of medication            %                  %

Non-injectibles              5.1                2.3
(oral, suppository,
inhalants, topical)
Injections                   3.3                2.3
IV fluids                    0.4                2.0
Blood                        0.2                0.5
Total time                   9.0                7.1

Table 2. Influencing factors during medication preparation and
medication administration

Influencing factor                      Morning shift   Evening shift
                                         08:00-16:00     15:30-23:30
                                         N=4 shifts      N=4 shifts

Medication preparation                        n               n

Non-self initiated communication             14              16
  with coworker
Assists a coworker                            9               9
Medication out of stock                       5               7
Assesses patient condition                    1               3
Nursing supplies out of stock                 0               2
Non-self initiated communication              2               2
  with relatives
Needs intervention of another nurse           2               2
  to complete a task
Lacks written information about               1               2
  a patient
MDs written order missing                     0               2

Medication administration                     n               n

Assesses patient condition                    7               4
Brings water to patient                       5               0
Non-self initiated communication              2               1
  with coworker
Patient hygiene, such as assists              0               3
  patient with bath, bed bathing,
  dressing and grooming, mouth/
  dental care, caring for patient's
  assistive devices such as dentures,
  hearing aids, prosthetics
Medication out of stock                       0               2
Nursing supplies out of stock                 0               2
Turns / helps patient move in bed or          1               1
  chair, between beds, from bed to
  chair
Empties bed-pan/bottle/urine bag/             1               1
  drainage bag
Educates patient                              2               0
Equipment/supporting gear missing,            1               1
  insufficient, or not working
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Article Details
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Author:Bragadottir, Helga; Ingason, Helgi Thor; Gunnarsdottir, Sigrun
Publication:Nordic Journal of Nursing Research
Article Type:Report
Geographic Code:4EXIC
Date:Dec 22, 2014
Words:2529
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