university of michigan hospital nursing department charge...

University of Michigan Hospital Nursing Department

Charge Nurse Workload Study:

Of the University of Michigan HospitalNursing Units (5A, 5D, 6A, 8C, and Trauma Burn)

April 23, 1998

Program and Operations Analysis:Christen Scozzafave

Kim PargoffMatthew Withey

Table of Contents

Topic: Page:

Executive Summary 1

Introduction and Background 2

Approach and Methodology 3

Current Situation 5

Findings and Conclusions5A 56A 78C 10Trauma Burn 145D 17

Recommendations 19

Action Plan 21

Appendix A: 5A Nursing Unit Charts and Data

Appendix B: 6A Nursing Unit Charts and Data

Appendix C: 8C Nursing Unit Charts and Data

Appendix D: Trauma Burn Nursing Unit Charts and Data

Appendix E: 5D Nursing Unit Charts and Data

Appendix F: Additional Project Materials

Executive Summary

The University of Michigan Hospital (UMH) Nurse Managers and the Program ofOperations and Analysis Department formulated this study to determine the averageproportion of time that charge nurses spend performing patient care activities versuscharge nurse duties in various nursing units throughout the University of MichiganHospital. This report will present information, data, findings and conclusions on how theworkload of the University Hospital Charge Nurses is distributed. We are trying todetermine if the patient care workload that charge nurses are being assigned is too largeto be performed in conjunction with their charge nurse duties.

The University of Michigan Hospital charge nurses performed a two-week randombeeper study in the following units, 5A, 6A, 8C, 5D, and Trauma Bum. Theinvestigation of the six units has resulted in the following findings and conclusions aboutthe distribution of work among the charge nurses in these units. In 5A-Orthopaedics theoverall mean percentage of time spent on charge nurse activities was 28% and patientcare activity consumed 60% of overall time. In 6A-Physical Medicine andRehabilitation, charge nurse activities consumed 28% of overall time and patient careactivity was 61% of overall time. In 8C-Nueropsychiatry, on average, charge nurseactivities took 10% of overall time, and patient care took 76% of overall time. Theintensive care units had a larger percentage of time devoted to charge nurse activities andless time to patient care than the general care units. In the Trauma Burn intensive careunit the overall mean percentage of time spent on charge nurse activities was 53%, whilethe mean percentage of time spent of patient care activity was 37%. 5D-SurgicalIntensive Care Unit showed similar results with charge nurse activities consuming 55%of overall time and patient care activities taking 37% of overall time.

We did further analysis on the breakup of patient care using medicus information and thestated acuity of the charge nurses patient assignments. By investigating the acuity of thecharge nurses’ patient assignments in all units we found that the majority of the time theexpected amount of patient care hours exceeded the available amount of patient carehours. If medicus acuity information is a proper tool for measuring patient care workloadin this study, it reveled that the charge nurses don’t have enough time to performadequate patient care and also perform their charge nurse duties.

The following are general recommendations for all units that could help improve thecharge nurse role. Each unit should have a clearly written definition of expectations andresponsibilities of the charge nurse role. This recommendation could help solve anyconfusion about which charge nurse activities are most time consuming to complete, tomake the position more organized and standardized. Looking at upstream solutions suchas new methods to reduce time spent on staffing, admissions and transfers. These threeactivities consume a lot of the charge nurses’ time and these responsibilities couldpossibly be redistributed or be better predicted before each shift.In most units staffing consumes the most time of all charge nurse activities.We also recommend a future study to investigate the staffing system in all of the units topossibly find new processes to handle staffing and to reduce the large amount of time

UMH/Prog. And Ops. Analysis I C.Scozzafave, M.Withey,K.Pargoff

charge nurses spend on staffing issues. Another way to reduce the time that chargenurses spend on staffing could be to institute a program to decrease absenteeism.Institution of a paid time off policy is being planned for implementation soon, which willtry to reduce sick calls for the nurses. Continuing investigation of the results of the paidtime off program and researching ways for continuous improvement would be a goodidea. Other ongoing efforts throughout the hospital to minimize transferring should beinvestigated to see the resulting progress of this effort and for instituting methods ofcontinuous improvement. In some units the redistributing of the charge nurse’s patientload would bring large improvements. Recommendations such as giving the chargenurses a patient assignment of lower acuity patients and not the same patient load as anormal nurse will lead to more available patient care time and increased quality.

Introduction and BackgroundThis report will present information, data, findings and conclusions on how the workloadof University Hospital Charge Nurses is distributed. The distribution of the workload willbe investigated from numerous different perspectives. Also, recommendations and anaction plan will be presented to give the managers of the charge nurses direction andideas for improving the distribution of work among their nurses. These recommendationswill be focused on changing the distribution of workload so that the job satisfaction of thenurses and the quality of patient care in their respective units increase.

Purpose of Project:To discover the average proportion of time that charge nurses spend performing patientcare activities versus charge nurse duties in various nursing units through out theUniversity of Michigan Hospital. To determine if the patient care workload that chargenurses are being assigned is too large to be performed in conjunction with their chargenurse duties/activities. To test the hypothesis that in some units charge nurse duties createtoo much of a time commitment for these nurses to provide quality patient care to theirassigned patient workload.

Background and environment affecting project:This project was formulated through the joint efforts of the University of MichiganHospital (UMH) Nurse Managers and the Program and Operations Analysis Department.Due to limited resources this project was only previously conducted effectively in onepatient care area. The Nurse Managers, in five different patient care areas, have requesteda second attempt at this study because they want to be better informed about how theworkload of charge nurses is distributed. In addition, the managers may feel the chargenurses are either carrying too much of a patient load or are over-burdened by chargenurse duties.

Goals:To give the nurse managers an accurate picture of how much time their charge nursesspend performing charge nurse activities and patient care duties. To investigate if there isenough time in a shift to perform all of these activities with quality performance, whereneither the patient care nor charge nurse activities are neglected. To recommend change

UMH/Prog. And Ops. Analysis 2 C.Scozzafave, M.Withey,K.Pargoff

that will adjust the charge nurse’s workload so that she/he will be able to perform qualitypatient care and complete all charge nurse duties.

Assumptions/Limitations:Our group is assuming that the workload for a nurse is evenly distributed over the entireday. Also, it is assumed that all the nurses in all the areas have the same standarddefinition of charge nurse activities. A limitations of this project is that, even though thedata collection is random and therefore unbiased, the data collected has the possibility ofstill being inaccurate; therefore, the data is assumed to be the best possible approximationof a charge nurse’s workload.

Approach and Methodology

Involved parties:• Our team — Christen Scozzafave, Kim Pargoff, Matt Withey• The Nurse Managers of UMH 5A, SD, 6A, 8C, and Trauma Burn• The Charge Nurses of UMH 5A, 5D, 6A, SC, and Trauma Burn• Liz Othman - Department of Program and Operations Analysis

Project Steps:Below is a listing of the steps used for completion of this project.• Preliminary meeting with nurse managers of each unit to give overview of study and

arrange dates for study.• Distribution of random beepers, survey directions and cards prior to the start date of

collection in each unit.• Contacted Nurse Managers to confirm the start date of the survey and answer any

question that may have arisen.• Observed and spoke to the charge nurses during the collection period while the

survey is being conducted.• Gave interim report to Nurse Managers during study in their unit.• Gave interim report presentation on March 9.• Collected random beepers, survey directions and cards from each unit after the data

collection period.• Contacted the Nurse Managers to get any missing data or re-collect data due to a

collection error.• Conducted a literature search to find information about other similar surveys that

have been performed.• Performed statistical analysis of the data collected.• Marie initial recommendations.• Upon completion of analysis, a meeting was arranged with Nurse Managers to

discuss our findings and possible recommendations.• Performed additional work or analysis as a result of our meeting with the managers.• Organized and prepared our final presentation.• Gave final presentation to our class on April 20 and to Francene Lundy, Liz Othman,

and Nurse Managers on April 23.


Methodology:Three methodologies were used to collect data in this study. The first and coremethodology used was a self-administered work sampling study using random beepers.This methodology provided objective data required for the study. The secondmethodology used was a survey that was distributed to charge nurses in each unit. Thisinformation provided subjective data necessary for this study. Finally, the lastmethodology used was observation. These methodologies are detailed in the followingparagraphs.

Self-administered work sampling study utilizing random beepers was the coremethodology used in collecting the data. Charge nurses and any other nurse that wasdelegated charge nurse duties carried one random beeper with them for the duration oftheir charge nurse roles. These beepers were carried by the on duty charge nurses for twoconsecutive weeks in their respective units. Due to time constraints, some of the unitscollected data during the same time frame. The random beepers were programmed to“beep” at an average sampling rate of 3.2 times per hour. Since these beeps are randomlydistributed over time it has been proven that any bias that may exist will be greatlyreduced. Nurses carried with them a pocket sized survey card that categorized theactivities that they may have been performing at any given time. When the randombeepers “beeped” the nurses marked on their cards the category that corresponded to theactivity they were performing. In addition, the cards contained an area to list the names ofthe patients that the nurses were assigned at the beginning and ending of their shifts. Alisting of the acuity for all their beginning of shift patients and end of shift patients wasrequired. This information gave a clearer picture of all the activities the charge nurseswere performing and the time commitment to patient care that could be expected. Basicinformation such as name, date, the start and end time of their shift was also requested oneach card. The cards were given out and collected by the nurse managers.

Distribution and completion of a subjective survey to selected charge nurses in each unitwas the second methodology used. It was very important to gain understanding of howthe charge nurses feel they are performing their job. The survey asked the charge nurseto estimate how much time they spend doing charge nurse duties in a shift, what chargenurse duties consume most of that time, how charge nurse duties affect patient care, andgive an opinion on a reasonable patient load per shift, etc. A copy of this survey can befound in Appendix F. This information compared with the beeper study data helpedformulate recommendations in a given unit.

The third methodology used was observation by members of the group conducting thestudy. This information gave the group a first hand view of how the charge nurses spendtheir time in a given unit. When a charge nurse was performing a specific role it wasnoted and the time for completion of the duty was also noted. This information was alsocompared with information from the other methodologies to make recommendations.

UMHIProg. And Ops. Analysis 4 C.Scozzafave, M.Withey,K.Pargoff

Current Situation

The purpose of this project is to investigate how work is distributed between charge nurseduties and patient care duties among charge nurses. The reason for this investigation isthe hypothesis among charge nurses and/or their nurse managers that charge nurses havea difficult time either completing charge nurse duties or providing quality care to theirassigned patients. The nurse managers believe that many of their charge nurses feeloverstressed or overburdened with work in comparison with the other nurses in the unit.In addition, the nurse managers desired to get a better measurement of the workload oftheir charge nurses to make decisions regarding whether not changes in unit management,staffing, or organization need to be made. This project will try to either validate or rejectthe hypotheses that nurse managers about the current situation regarding the workload ofcharge nurses in their units.

Findings and Conclusions

5A

Data from 5A was similar in both the beeper study and the subjective survey. From thesurvey, charge nurses felt that they spent nearly 25%-30% of their time performingcharge nurse duties. All significant data for the charge nurse workload is displayed intables 1-3. The beeper study revealed that charge nurses spent 27% of their timeperforming charge duties in both shifts. The standard deviation was very small indicatingthat time spent on charge duties is consistent on a daily basis. Of the 26 cards from 5Aused in the study, 22 of them showed charge activities ranged between 10% and 40% ofthe shift (See figure on page 5 of Appendix A). This further confirms that charge activityis very consistent in 5A. Patient care activities were also very consistent for both shiftsand averaged about 59%. Personal and professional time however varied some on bothshifts. This is not significant however due to the randomness of the beeper study.

Overall Nursing Activity for 5AMean Percentage of Time Standard Deviation

Charge Activity 27.5% +1-11.3%Patient Care Activity 58.8% +1-15.3%Professional/Personal Activity 13.7% +/-10.6%Table 1: Distribution of Nursing Activities

Day Shift Nursing Activity for 5AMean Percentage of Time Standard Deviation

Charge Activity 27.5% +/-13.2%Patient Care Activity 61.2% +/-17.4%Professional/Personal Activity 11.3% +/-11.1%Table 2: Distribution oTNursing Activities


Night Shift Nursing Activity for 5AMean Percentage of Time Standard Deviation

Charge Activity 27.5% +/-8.7%Patient Care Activity 55.6% +1-11.9%ProfessionallPersonal Activity 16.9% +1-9.5%Table 3: Distribution of Nursing Activities

Tables 4 and 5 indicate how the charge duties were distributed in 5A on both shifts.Staffing activities were the most time consuming charge duty observed from the beeperstudy. The subjective survey showed that all nurses sometimes found staffing to beoverwhelming and felt this was the most time consuming activity, this agrees with thebeeper study. Also, only staffing activities showed consistency in 5A as indicated by thesmall standard deviations. Staffing activities were much higher during the night shift.Patient transfer activities were the least time consuming charge duty. Patient transferactivities vary tremendously in both shifts as indicated by standard deviations larger thanthe means. Finally, other charge duties defined as covering other patients, helping othernurses, etc., in SA consumed a large portion of charge time in both shifts.

Day Shift Charge Nurse Activities for SAMean Percentage of Charge Standard Deviation

Nurse Activity TimeStaffing Activities 49.8% +/-27.6%Patient Transfer Activities 16.2% +/-18.4%Other Activities 44.0% +/-29.8%Table 4: Distribution of Charge Nurse Activities

Night Shift Charge Nurse Activities for 5AMean Percentage of Charge Standard Deviation

Nurse_Activity TimeStaffing Activities 62.9% +1-24.9%Patient Transfer Activities 5.4% +1-9.5%Other Activities 3 1.7% +1-26.9%Table 5: Distribution of Charge Nurse Activities

The subjective survey indicated that charge nurses felt that their patient load should bereduced. Patient load should range from 3 to 4 patients if the acuity index of the patientsis less than or equal to 3. If acuity of the patients is greater than 3 than patient loadshould be reduced even further.

A t-test analysis was performed on the two shifts; this analysis is used to decide if thedifference in the observed mean values is statistically significant or if the difference inthe observed means can be considered insignificant. The mean value of the observedpercentage of time performing charge nurse activities was tested. The results show therewas no statistically significant difference in the average amount of time spent performingcharge nurse activities on the day shift and the night. That means the average amount ofcharge nurse activities on the two shifts can be considered equal.


The acuity index given to each patient approximates the level of care required by thepatient. This index was created for financial reasons in the hospital but it also predictsthe number of hours of nursing care a patient requires. For each acuity index a range ofhours of patient care needed is given. Acuity was used to evaluate the care provided bythe charge nurses to their patients. Using the acuities indicated on each study card, thenumber of expected patient care hours from the charge nurse on the shift was calculatedusing the low end of the range of hours. This number was compared with the number ofhours available for patient care on the shift for the charge nurse. In almost every case,the number of expected patient care hours was far greater than the available patient carehours. This can mean one of two things. First, it may indicate that patients do notreceive sufficient care from charge nurses since their available hours to the patients arelower than what is required by the patients. Second, acuity may not be an accurate wayto evaluate the nursing care to a patient. Table 6 shows this information for both the dayand night shifts. Additional data, information, and charts for 5A can be found inAppendix A.

Expected Patient Care Hours vs. Observed Available Patient Care Hours for 5APercentage of Average patient care Average patient carepatients that would hours available for hours required byreceive expected charge nurse. patient.nursing care.

Day Shift 33% 6.0 8.4Night Shift 0% 6.2 1 1.5Table 6: Patient Care Hours Analysis

6A

This section details fmdings from the beeper study and the subjective survey conductedin 6A-Physical Medicine and Rehabilitation. Data from the subjective survey showedthat most charge nurses estimated that 25%-30% of their time was spent performingcharge duties on a shift. This is in agreement with data from the beeper study. Thisstudy showed that charge duties consumed an average of 28% of the nurse’s time but thestandard deviation was over half the average indicating that charge duties vary from dayto day. Further study into this matter showed that charge duties were less on weekendsand more on weekdays. Of the 66 cards collected from 6A, 55 of them showed thatcharge activity on a shift was between 10% and 59%, well within one standard deviationof the mean, indicating consistency across all shifts and most days (See figure on page 5of Appendix B). Patient care activity among charge nurses was very consistent overallconsuming around 61% of shift time with a very small standard deviation. Charge nurseworkload activity data is detailed in Table 7.

The subjective survey showed that all charge nurses felt that patient care was affected bycharge duties. The general feeling was that it is too difficult to perform charge duties andmaintain a patient load similar to that of other staff nurses. The charge nursesrecommendation for patient load was 3-4 patients.

UMHIPr0g. And Ops. Analysis 7 C. Scozzafave, M.Withey,K.Pargoff

Overall Nursing Activity for 5AMean Percentage of Time Standard Deviation

Charge Activity 28.1% +1-16.1%Patient Care Activity 61.2% +1-15.8%Professional/Personal Activity 10.7% +1-10.6%Table 7: Distribution of Nursing Activities

Tables 8-10 detail nursing activities according to shift. Upon reviewing the datasignificant differences and similarities between shifts were found. Charge nurse activitieswere much greater during the day shift than on the evening or night shifts. Patient careactivities were more consistent than charge activities for all shifts as indicated by a smallstandard deviation relative to their means. The night shift and evening shift showed thesmallest variation for all charge activities indicating that activity for these shifts is veryconsistent.

Day Shift Nursing Activity for 5AMean Percentage of Time Standard Deviation

Charge Activity 33.4% +1-21.5%Patient Care Activity 56.9% +1-17.9%ProfessionallPersonal Activity 9.7% +1-9.4%Table 8: Distribution of Nursing Activities

Evening Shift Nursing Activity for 5AMean Percentage of Time Standard Deviation

Charge Activity 27.3% +/-11.8%Patient Care Activity 60.3% +1-16.1%Professional/Personal Activity 12.4% +1-14.5%Table 9: Distribution of Nursing Activities

Night Shift Nursing Activity for 5AMean Percentage of Time Standard Deviation

Charge Activity 23.4% +1-10.9%Patient Care Activity 66.2% +1-12.2%Professional/Personal Activity 10.3% +1-8.4%Table 10: Distribution of Nursing Activities

Determining which charge nurse duties were most and least time consuming was veryimportant. The subjective survey showed that most nurses felt that staffing was the mosttime consuming charge duty along with collecting reports. Tables 11-13 detail chargeduties among all shifts. Only staffing activities had any consistency on all shifts. Datafrom the beeper study showed that staffing activities consume over half the charge dutiesof the charge nurse in all shifts. This is in agreement with findings from the survey.Patient transfer and other charge duties show no consistency for all shifts indicated bystandard deviations much larger than the means. This may be due the randomness andinability to predict these events.


Day Shift Charge Nurse Activities for 6AMean Percentage of Charge Standard Deviation

Nurse_Activity_TimeStaffing Activities 52.1% +1-42.2%

Patient Transfer Activities 18.6% +1-28.7%Other Activities 20.6% +/-29.0%Table 1 1: Distribution of Charge Nurse Activities

Evening Shift Charge Nurse Activities for 6AMean Percentage of Charge Standard Deviation

Nurse_Activity TimeStaffing Activities 58.3% +1-38.7%

Patient Transfer Activities 15.8% +/-29.9%Other Activities 26.0% +/-37.3%Table 12: Distribution of Charge Nurse Activities

Night Shift Charge Nurse Activities for 6AMean Percentage of Charge Standard Deviation

Nurse Activity TimeStaffing Activities 68.1% +/-31 .3%Patient Transfer Activities 14.3% +/-20.8%Other Activities 17.7% +/-29.8%Table 13: Distribution of Charge Nurse Activities

A t-test anaiysis was performed on the three shifts; this analysis is used to decide if thedifference in the observed mean values is statistically significant or if the difference inthe observed means can be considered insignificant. The mean value of the observedpercentage of time performing charge nurse activities was tested. The results show therewas no statistically significant difference in the average amount of time spent performingcharge nurse activities on the day shift, evening shift and night shift. That means theaverage amount of charge nurse activities on the three shifts can be considered equal.

The acuity index given to each patient approximates the level of care required by thepatient. This index was created for financial reasons in the hospital but it also predictsthe number of hours of nursing care a patient requires. For each acuity index a range ofhours of patient care needed is given. Acuity was used to evaluate the care provided bythe charge nurses to their patients. Using the acuities indicated on each study card, thenumber of expected patient care hours from the charge nurse on the shift was calculatedusing the low end of the range of hours. This number was compared with the number ofhours available for patient care on the shift for the charge nurse. In almost every case,the number of expected patient care hours was far greater than the available patient carehours. This is especially true of the night shift. In this shift charge nurses carry morepatients. Also this is when the least patient care is needed and these calculations arebased on the assumption that patient care is evenly distributed over the twenty-four hourday. Also, very few charge nurses on their shifts had enough patient care hours available


to provide adequate care (as defined by acuity) to their patients. This indicates one oftwo possible explanations for the results. The first being that charge nurses may carry tooheavy of a patient load and are unable to provide sufficient care for the patients whilealso trying to complete charge nurse duties. The second explanation is acuity may not bean accurate way to statistically evaluated patient care. Table 14 shows this data andadditional data, information, and charts for 6A can be found in Appendix B.

Expected Patient Care Hours vs. Obserwed Available Patient Care Hours for 6APercentage of Average patient care Average patient carepatients that would hours available for hours required byreceive expected charge nurse. patient.nursing care.

Day Shift 13% 4.9 8.1Evening Shift 11% 5.6 7.5Night Shift 0% 5.6 12Table 14: Patient Care Hours Analysis

8C

Data collected from the random beeper study was captured in three general categories,charge nurse activities, patient care activities, and professionallpersonal activities. Theaverage percentage of time that each charge nurse spent performing an activity fromthese categories was calculated. Table 15 shows the breakdown of time spent on theseactivities for the 8C unit overall.

Overall Nursing Activity for 8CMean Percentage of Standard Deviation

TimeCharge Nurse Activities 9.9% +1- 12.9%Patient Care Activities 75.5% +1- 17.1%Professional/Personal Activities 14.6% +1- 14.3%Table 15: Distribution of Nursing Activities

When the standard deviation for charge activities and professional/personal activities iscompared to their respective mean percentages of time, it is shown that these two groupsof activities have a very high amount of variability from charge nurse to charge nurse.This represents a general lack of stability in how a charge nurse’s workload is distributed.Since 8C usually has more than one charge nurse per shift this unstable distribution ofwork may be either from nurse to nurse on the same shift or may be from shift to shift.Through informal interviews with several of the charge nurses, it did not seem to be thecase that charge nurses on the same shift often had large differences in the amount oftime they spent on these activities. The nurses suggested that there was cooperation orshared responsibility among the charge nurses to get all the necessary activities done.Therefore, the large variability in these two groups of activities is most likely seen fromshift to shift. Tables 16-18 breakdown by shift of the three general nursing activities thatwere observed.


Day Shift (7am-3pm) Nursing Activity for 8CMean Percentage of Standard Deviation


Evening Shift (3pm-llpm) Nursing Activity for 8CMean Percentage of Standard Deviation

TimeCharge Nurse Activities 7.6% +1- 17.1%Patient Care Activities 7 1.7% +1- 23.4%Professional/Personal Activities 20.7% +1- 19.7%Table 17: Distribution of Nursing Activities

Night Shift (llpm-7am) Nursing Activity for 8CMean Percentage of Standard Deviation

TimeCharge Nurse Activities 6.9% ÷1- 7.4%Patient Care Activities 83.4% +1- 8.5%Professional/Personal Activities 9.8% +1- 6.5%Table 18: Distribution of Nursing Activities

The amount of time observed performing patient care stayed approximately the same onthe day and evening shift, and it increased slightly on the night shift. The amount of timespent performing professional/personal activities varied on all shifts. The amount of timespent performing charge nurse activities was about the same for the evening and nightshifts, and it increased on the day shift. Relative to the observed means the standarddeviation of charge and professional/personal activities remained significant on all threeshifts which supports the theory that the amount of time spent on these activities often isvery inconsistent. Additionally, a t-test analysis was performed on all the shifts; thisanalysis is used to decide if the difference in the observed mean values is statisticallysignificant or if the difference in the observed means can be considered insignificant. Themean value of the observed percentage of time performing charge nurse activities wastested. The results show that the average amount of time spent performing charge nurseactivities on the day shift and the night are different with statistical significance.

The charge nurse activity portion of the data was analyzed deeper. It was broken downinto three categories, percentage of time spent on staffing activities, percentage of timespent on patient transfer activities, and percentage of time spent on any other chargenurse duties. Table 19 shows the distribution of charge nurse activities as observed in therandom beeper study.

UMHIPr0g. And Ops. Analysis 11 C.Scozzafave, M.Withey,K.Pargoff

Overall Charge Nurse Activities for 8C

Mean Percentage of - Standard DeviationCharge Nurse Activity

TimeStaffing Activities 50.0% +1- 44.8%Patient Transfer Activities 34.7% +1- 44.0%Other Charge Nurse Activities 15.2% +1- 29.4%Table 19: Distribution of Charge Nurse Activities

The majority of the charge nurse activities are related to staffing and patient transfer;however, once again there is a large amount of variability in these means. This continuesto show the inconsistency in the observed workload distribution for nurses. Thisinformation implies that charge nurses do not reliably expect to have a certain percentageof time dedicated to dealing with a specific charge nurse duty. The mean percentage ofcharge nurse activity time does give a decent approximation of how activities aredistributed. The distribution of charge nurse activities on each shift gives an approximatetrend as to how different activities are more expected than others. For example, morepatient transfer activities were observed during the day shift than the evening or nightshifts. Tables 20-22 give the breakdown of charge nurse activities by shift.

Day Shift Charge Nurse Activities for SC

Mean Percentage of Standard DeviationCharge Nurse Activity

TimeStaffing Activities 28.5% +1- 38.8%Patient Transfer Activities 47.0% +1- 46.3%Other Charge Nurse Activities 24.5% +1- 34.1%Table 20: Distribution of Charge Nurse Activities

Evening Shift Charge Nurse Activities for 8CMean Percentage of Standard Deviation

Charge Nurse ActivityTime

Staffing Activities 75.7% -i-I- 39.9%Patient Transfer Activities 15.3% +1- 31.5%Other Charge Nurse Activities 9.1% +1- 30.2%Table 21: Distribution of Charge Nurse Activities

Night Shift Charge Nurse Activities for 8CMean Percentage of Standard Deviation


Staffing Activities 67.9% +1- 40.9%Patient Transfer Activities 26.8% +1- 42.1%Other Charge Nurse Activities 5.4% +1- 14.5%Table 22: Distribution of Charge Nurse Activities

UMHJProg. And 0ps. Analysis 12 C. Scozzafave, M.Withey,K.Pargoff

The standard deviation for each type of charge nurse activity is very large. Difficulty incapturing charge nurse activities seemed to be a reason for the large standard deviations.Approximately 64% of the nurses reported several charge nurse activities during a shift;however, there were approximately 36% of data collection cards that reported zerocharge nurse activities observed.

The acuity index given to each patient approximates the level of care required by thepatient. This index was created for financial reasons in the hospital but it also predictsthe number of hours of nursing care a patient requires. For each acuity index a range ofhours of patient care needed is given. To evaluate the care provided by the charge nursesto their patients acuity was used. Using the acuities indicated on each study card, thenumber of patient care hours expected from the charge nurse on the shift was calculatedusing the low end of the range of hours. This number was compared with the number ofhours available for patient care on the shift for the charge nurse. The acuity of patientsranged from type 2 to type 5 in the 8C unit. The beginning of shift acuity of the chargenurse’s patient load was analyzed. The assumption that patient care is evenly distributedover a 24-hour period was made here to help in making the analysis less complicated.Inferences can be made as to how the results could change based on personal knowledgeof what the actual disthbution of patient care is over a 24-hour period. Table 23summarizes the comparison of expected patient care hours per shift and the observednumber of available patient care hours per shift from the random beeper study.

Expected Patient Care Hours vs. Observed Available Patient Care HoursPercentage of Observed Average Calculated Average

Charge Nurses that Number of Number ofcould meet their Available Patient Expected Patient

expected Number of Care Hours Care HoursPatient Care Hours

DayShift 11.8% 6 8.4Evening Shift 12.5% 6 9.6Night Shift 4.8% 7 11.4Table 23: Patient Care Hours Analysis

The above information is approximate, assumes that University of Michigan Hospital’sconversion of patient type to care hours is accurate and that all patient are designated asthe correct type. Given those assumption, the comparison of expected patient care hoursversus observed available patient care hours supports the conclusion supports the claimthat typically the charge nurse’s patient load is too great for them to provide qualityhealth care and perform their charge nurse activities. The majority of charge nurses thatwere interviewed stated the same claim. They felt that an average patient load of threepatients would be ideal for them to provide both quality patient care and be able toreasonably fulfill their charge nurse activities.

Many findings were made in the informal interviews conducted with the charge nurses.Each charge nurse estimated that they spend between 0-2 hours or 2%- 10% of their shift


dealing with charge nurse duties. Staffing, staff conflicts and admissions were given asthe most time consuming charge nurse activities. The charge nurses recommended thatthey should carry a patient load of three, sometimes four if acuity was low. Also, they allfelt that the charge nurse role affects their patient care; however, most seemed to stipulatethat it was noticeably affected most when they were short staffed. It was also stated thatgood organization was important to be able to do both roles. Some nurses felt that thecharge nurse role was complicated by the fact that many of the normal nurses in the unitare either new nurses, traveling nurses or CSR nurses. The charge nurses said that thisforced them to take the hardest patients because the other nurses are not able to handlethem. They stated that turnover has caused this problem to continually persist.From discussions with the charge nurses it seemed that many of them felt overburden oroverstressed when on shift due to the general confusion and instability of their workloads.

AU additional data, information, and charts for 8C can be found in Appendix C.

Trauma Burn

Data collected from the random beeper study was captured in three general categories,charge nurse activities, patient care activities, and professional/personal activities. Theaverage percentage of time that each charge nurse spent performing an activity fromthese categories was calculated. Table 24 shows the breakdown of time spent on theseactivities for the Trauma Burn unit overall.

Overall Nursing Activity for Trauma BurnMean Percentage of Standard Deviation

TimeCharge Nurse Activities 53.2% +1- 16.9%Patient Care Activities 36.2% ÷1- 16.7%Professional/Personal Activities 10.6% -i-I- 6.3%Table 24: Distribution of Nursing Activities

Charge nurses were observed performing patient care for such a small percentage of timein Trauma Burn because they did not normally carry a patient load. Usually the onlypatients that they would take as “their own” would be new admissions into the unit. Inaddition, the majority of the patient care that was observed fell under the category ofrelated to other patients rather than related to patient assignments. This shows that themajority of patient care activities that a charge nurse does are to assist other nurses. Also,due to the nature of the work in the Trauma Burn unit normal nurses sometimes may needto ask for another nurse to cover an assigned patient for a short period of time. Thecovering of patients is normally done by charge nurses and is defined as a charge nurseactivity; furthermore, in Trauma Burn charge nurses have to deal other non-patient careactivities such as road trips. Therefore, the random beeper survey reported a large numberof ‘other’ charge nurse activities, which is the main reason for the amount of charge nurseactivities.

Tables 25 and 26 breakdown by shift of the three general nursing activities that wereobserved.

UMH!Prog. And Ops. Analysis 14 C.Scozzafave, M.Withey,K.Pargoff

Day Shift Nursing Activity for Trauma BurnMean Percentage of Standard Deviation


Night Shift Nursing Activity for Trauma BurnMean Percentage of Standard Deviation

TimeCharge Nurse Activities 54.4% +1- 18.7%Patient Care Activities 35.2% ÷1- 20.4%Professional/Personal Activities 10.4% +1- 6.6%Table 26: Distribution of Nursing Activities

The amount of time observed in all categories stayed approximately the same on the dayand night shift. Relative to the observed averages the standard deviation of charge andprofessional/personal activities varied slightly more on the night shift than the day shift,which shows that the distribution of work may be more inconsistent from day to day.Additionally, a t-test analysis was performed on the two shifts; this analysis is used todecide if the difference in the observed mean values is statistically significant or if thedifference in the observed means can be considered insignificant. The mean value of theobserved percentage of time performing charge nurse activities was tested. The resultsshow there was no statistically significant difference in the average amount of time spentperforming charge nurse activities on the day shift and the night. That means the averageamount of charge nurse activities on the two shifts can be considered equal.

The charge nurse activity portion of the data was analyzed deeper. It was broken downinto three categories, percentage of time spent on staffing activities, percentage of timespent on patient transfer activities, and percentage of time spent on any other chargenurse duties. As mentioned previously, the other activities categoiy was considered to bean important part of the definition of a charge nurse in Trauma Burn because much timeis spent covering other patients, going on road trips, etc. Table 27 shows the distributionof charge nurse activities as observed in the random beeper study.

Overall Charge Nurse Activities for Trauma BurnMean Percentage of Standard Deviation




The approximately half of the charge nurse activities are related to staffing and patienttransfer, and the observed workload varied equally at +1- 13%. Therefore, it can beconcluded that a charge nurse spends approximately 25% of their time dealing withstaffing and patient transfer activities (patient transfers include admissions). Thevariability of how workload is distributed into these three categories is moderate, andideally should be lower, possibly below 10%.

The distribution of charge nurse activities on each shift gives an approximate trend as tohow some activities are expected more than others are. For example, more patienttransfer activities were observed during the day shift than the night shift. Tables 28 and29 give the breakdown of charge nurse activities by shift.

Day Shift Charge Nurse Activities for Trauma BurnMean Percentage of Standard Deviation



Night Shift Charge Nurse Activities for Trauma BurnMean Percentage of Standard Deviation


Staffing Activities 35.1% +1- 12.6%Patient Transfer Activities 6.8% ÷1- 7.3%Other Charge Nurse Activities 58.1% +1- 14.4%Table 29: Distribution of Charge Nurse Activities

The acuity index given to each patient approximates the level of care required by thepatient. This index was created for financial reasons in the hospital but it also predictsthe number of hours of nursing care a patient requires. For each acuity index a range ofhours of patient care needed is given. To evaluate the care provided by the charge nursesto their patients acuity was used. Using the acuities indicated on each study card, thenumber of patient care hours expected from the charge nurse on the shift was calculatedusing the low end of the range of hours. This number can be compared with the numberof hours available for patient care on the shift for the charge nurse. The averagepercentage of time performing patient care activities equates to an observed number ofavailable patient care hours per shift, for Trauma Burn the number of available patientcare hours equals just over 4 hours. This means that if the charge nurses in Trauma Burnwere to carry a patient assignment and still perform the same charge duties, they couldonly be assigned either one type 3 patient or two type 2 patients. Inferences can be madeas to how the results could change based on personal knowledge of what the actualdistribution of patient care is over a 24-hour period. The above claim is supported by

UMHIPr0g. And Ops. Analysis 16 C. Scozzafave, M.Withey,K.Pargoff

comments that charge nurses made in informal interviews. They responded that therecommended patient load that they should carry be either zero or one patient to provideboth quality patient care and be able to reasonably fulfill their charge nurse activities.

Several findings were made in the informal interviews conducted with the charge nurses.Each charge nurse estimated that they spend approximately 75% of their shift dealingwith charge nurse duties. This is an overestimate based on our collected data. Therefore,the charge nurses have underestimated the amount of time they have to provide patientcare. Staffing, reporting and helping cover other nurse’s patients were given as the mosttime consuming charge nurse activities. The charge nurses recommended that they shouldcarry a patient load of zero to one.

All additional data, information, and charts for Trauma Burn can be found in AppendixD.

SD

In our investigation of the percentage of time that charge nurses spend on patient care,charge nurses duties and personal and professional activities in the SICU the followingfmdings and conclusions were reached. During a 12 hour shift, on the average the chargenurses spend more than half, approximately 55% or 6.5 hours, of their time on chargenurse activities, either staffing, patient transfers or other. On average, the charge nursesare spending a little less than half of their 12-hour shift on patient care activity,approximately 37% or 4.5 hours. The other 8% or around 1 hour of their time on averageis spent on personal or professional activities. The standard deviations of the abovedivisions are small and show that from day to day these predictions are fairly consistent.Large fluctuations from the above means are unlikely to occur.

Our statistical analysis of the day shift and the night shift independently revealed thatthere is some difference between the percentage of time spent on various activities duringthe day and night shift. The charge nurses on the night shift in comparison with the dayshift spent more time on charge nurse activities and less time on patient care. Whenstudied independently the amount of patient care changed from 40% on day shift to 34%on the night shift. This finding was expected because the patient care workload usuallydecreases during the night shift. Due to this decrease in the patient care load during thenight shift, the nurses have more time to spend on other activities, such as charge nurseactivities that didn’t have priority during the day shift. We found that the priority of thepatient care in the SICU requires patient care to be handled first then charge duties thatare urgent and necessary fill the remaining time. We performed a statistical t- test on thisdifference of the means between the day and night shift and found it to be statisticallyinsignificant. The difference between the means was not large enough to be a concernand will only be covered briefly in the remainder of are report.

When looking at the breakdown of charge nurse activities into the three divisions ofstaffing, patient transfers, and other activities, the most time was spent on the division ofother activities. On average, ‘other’ activities consumed 41% of total charge nurse


activity, staffing 35%, and patient transfers 25%. The standard deviations of eachdivision was small and showed that these above findings are fairly consistent from day today and huge fluctuations of these means don’t normally occur. Analysis of the day andnight shift independently show approximately the same results with insignificantdeviation.

The distribution of overall charge nurse activity was found to have a mean of 55% with adeviation from a normal distribution because of the high number of observations ofcharge nurse activity that were found at the 70%-79% interval. We found that at times inthe SICU the demand of charge nurse activities on the charge nurses can reach a veryhigh level of around 75% of their 12 hour shift. In extreme cases of fluctuation of theamount of charge nurse responsibilities it is much more likely to deviate above the meanof 55% to a high percentage of charge nurse responsibilities, than below the mean to havea lighter percentage of charge nurse responsibilities.

The majority of time that the charge nurses spend on patient care in the SICU is related toother patient assignments and not their own patient assignment. We found that overall58% of patient care time (approximately 4.5 hrs. in a 12 hr shift) was devoted to otherpatients, such as helping with other patients and answering call lights. On the average thecharge nurses only spent 42% of patient care time dealing with their patient assignment.Our study also showed that approximately 75 % of the time a charge nurse had a patientassignment. By analyzing separately only the charge nurses that had a patient assignmentwe still found that they spent 48% of patient care time on other patients and 52% ofpatient care time on their own patient assignment.

Further conclusions were reached about patient care by analyzing the patient assignmentsof the charge nurses using medicus information and the stated acuity of each patient. Theaverage patient in the SICU, approximately 60% of all patients, is acuity 5 and requires 7hours of patient care during a 12-hour shift. Approximately 20% of the patients areacuity 6 patients and require 10 hours of care in a 12-hour period. Twenty percent of thepatients are acuity 4 patients and require S hours of patient care during a 12-hour shift.These calculations were done using the low range medicus numbers, which assume thatthe patient is on the less severe and is less time consuming of a level 5 patient. Evenusing these low range numbers we found that the average charge nurse carrying a level 5patient in the SICU was spending only 4.5 hours on total patient care and their patientassignment requires 10 hours. On the average half of the 4.5 hours on is spent on otherpatients, which is leaving only 2.2 hours for their own patient load. If the medicus acuityinformation is a proper representation of the patient workload then charge nurses areoverloaded and do not have enough time to give quality care to their patients. Theaverage level five patient requires 10 hours of patient care while only 4.5 hours isdevoted to patient care while over half of that time is spent on other patients. Thesefindings are assuming that medicus, acuity information is the appropriate tool to use toanalyze the patient care load in this study. We are also assuming that the patient careload is evenly distributed over a 24 hours period. This assumption is a limitation to ourstudy that we will accept and understand that these are approximate values.


According to the subjective survey completed by charge nurses in 5D, the time they feelthey spend on charge duties is greater than what the beeper study indicated. The averageresponse was a range of 70%-80%. Most charge nurses felt that staffing was one of themost time consuming activities and this is in agreement with the beeper study. Chargenurses also felt that another time consuming activity was helping other nurses andpatients. This would fall into the ‘other’ category for charge activities. Again, accordingto the beeper study, most of the charge activity time was spent doing ‘other’ activities.The recommended patient load from the charge nurses was 1 patient, or 2 patients at amaximum. However, charge nurses stated to avoid a patient load if possible.

All data, information, and charts for 5D can be found in Appendix E.

Recommendations

General

The following recommendations apply to all units participating in the study.

A written definition of expectations and responsibilities of the charge nurse (specificto each unit) should be made available to all charge nurses.• WHY? — To clarify for the charge nurses the charge nurse activities are most

important to complete, to make the position more organized and standardized, andbecause standardization of work tasks has been found to increase productivity.

• Also, a clear definition of ‘other’ charge duties should be made available to chargenurses. This is especially important since it consumes a large portion of the chargenurse’s time in some units.

• Any means to reduce time spent on dealing with staffing and admissions should beconsidered. This will lead to an increase in possible patient care time, which is value-added time to the patient. Future analysis into changing upstream processes, such asre-engineering the way CSR provides replacement staff to the units or possiblychanging the ways to deal with sick calls. Another suggestion is to decrease staffingwork for charge nurses by instituting program to decrease absenteeism.

• Increase communication between Nurse Managers and the Charge Nurses, possiblythrough monthly meetings to discuss issues.

• UMH is currently working on trying to increase the predictability for admissions tounits and decrease the number of unit to unit transfers. Nurse managers areencouraged to support these efforts because they may decrease charge nurse duties.

• Charge nurses often complained about encountering ‘really bad days’, where theamount of charge nurse duties were unusually high for the unit. It is recommendedthat a contingency plan be created and implemented that shifts some nursingresponsibilities of the charge nurse to other staff in the unit. This leveling of taskswill help to reduce the burden experienced by the charge nurse on these days andpossibly increase the sense of job satisfaction for all staff on the unit.

• Any charge activities that can be transferred to the night shift or to any weekendshifts may be considered.


Unit Specific Recommendations

6A

After reviewing the data from the beeper study and the subjective surveys the followingrecommendations are being made for 6A-Physical Medicine and Rehabilitation.

• Try to more evenly distribute charge duties among the charge nurse and team leader.This may lead to more patient care hours available for both nurses and may makecharge duties less burdening.

.

SC

• An unstable workload distribution was observed between charge nurses on the sameshift. If assignments can not be adjusted to account for this, it would be worthwhile toconsider assigning the charge nurse duties to one nurse. This would cause a necessaryreduction in the charge nurse’s patient load. It is recommended that the reduction beto 3 patients, which is consistent with the number of patients most charge nurses feltcomfortable carrying.

• Better communication routes need to be established between charge nurses and nursemanager so that management knows when and why charge nurses are havingdifficulty.

• Put limits on the acuity level that charge nurses can carry that is to assign the lessserious patients to charge nurses. Similarly, it may be beneficial if they instead carryfewer high acuity patients.

Trauma Burn and SD

• When possible it is recommended that the charge nurse will not carry a patientassignment. This recommendation was reached because the charge nurses had fouravailable patient care hours based on the beeper study. Therefore, if the charge nurseswere to carry a patient assignment and still perform the same charge duties, theycould only be assigned either one type 3 patient or two type 2 patients. Furthermore,patients with acuities higher than 3 are most common in these areas, and chargenurses typically spend the majority of their patient care duties with other patients.

• The charge nurse spends almost half of its patient care time on other patients andmany times doesn’t have time for both a patient assignment and charge nurseactivities. During the times when the charge nurses activities are at a low the chargenurses can take care of can help with other patients or prepare for a rush

UMHIPr0g. And Ops. Analysis 20 C.Scozzafave, M.Withey,K.Pargoff

Action Plan

Most of our recommendations can be implemented through resources with in the nursingunits. Recommendations that involve changes in the description, responsibilities,expectations, or structure of the charge nurse role should include a charge nurse in theimplementation process. Inclusion of a charge nurse will help validate whether thechanges are beneficial or wasteful. Recommendations that involve changes in processes,especially those upstream or outside of the nursing unit, probably will require assistancefrom other University Of Michigan Hospital resources to implement. For example, therecommendation that addresses decreasing the time it takes for CSR nurses to be obtainedwhen extra staff is needed would be a project that the Program and Operations AnalysisDepartment could possibly pursue. The nurse managers of each respective unit will havethe responsibility of choosing which recommendations would be to implement in theirunit. In some instances, the charge nurses will be responsible for following through onthe implementation and acceptance of these changes in the unit. Most importantlycommunicate with your charge nurse frequently so that feedback received on changesthat have been made and those that still need to be implemented.


Appendix A:

5A Nursing Unit Charts and Data

• Overall Nursing Activity Distribution• Nursing Activity Distribution by Shift• Charge Duty Distribution by Shift (Pie Charts)• Charge Duty Distribution by Shift with Standard Deviation• Frequency Chart of Charge Nurse Activity• T-test Statistics• Raw Data

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%Charge %ChargeMean 0.275239 0.275509Variance 0.017287 0.007546Observations 15 1 1Pooled Variance 0.013228Hypothesized Mean D 0df 24t Stat -0.005899P(T<=t) one-tail 0.497671t Critical one-tail 1.710882P(T.<=t) two-tail 0.995342t Critical two-tail 2.063898

Since the t Stat is less than the t Critical two-tail, the differences in the MeanPercentaae of Charae Nurse Activity is zero.

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Appendix B:

6A Nursing Unit Charts and Data


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6A t-test


%Charge %ChargeMean 0.313108 0.234805Variance 0.049576 0.011851Observations 23 23Pooled Variance 0.030713Hypothesized Mean Difference 0df 44tStat 1.515163P(T<=t) one-tail 0.068441t Critical one-tail 1.68023P(T<=t) two-tail 0.136883t Critical two-tail 2.015367

Since the t Stat is less than the t Critical two-tail, the differences in the MeanPercentage of Charge Nurse Activity is zero.

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Appendix C:

8C Nursing Unit Charts and Data

• Overall Nursing Activity Distribution• Nursing Activity Distribution by Shift• Charge Duty Distribution by Shift (Pie Charts)• Charge Duty Distribution by Shift with Standard Deviation• Frequency Chart of Charge Nurse Activity• Bar Chart comparison of data cards with zero recorded charge activities versus data

cards with at least one recorded charge activity• T-test Statistics• Raw Data

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%Charge %ChargeMean 0.126384 0.068623Variance 0.010623 0.005517Observations 34 23Hypothesized Mean 0df 55t Stat 2.457775P(T<=t) one-tail 0.00858t Critical one-tail 1.673034P(T<=t) two-tail 0.01 716t Critical two-tail 2.004044

Day Shift v. Evening Shiftt-Test: Two-Sample Assuming Unequal Variances

Reject the hypothesis

The means do not equal each other statistically

%Charge %ChargeMean 0.126384 0.075968Variance 0.010623 0.029265Observations 34 26Hypothesized Mean 0df 39t Stat 1.329479P(T<=t) one-tail 0.095707t Critical one-tail 1.684875P(T<=t) two-tail 0.191415t Critical two-tail 2.022689


Evening Shift v. Night Shiftt-Test: Two-Sample Assuming Unequal Variances

%Charge %ChargeMean 0.068623 0.075968Variance 0.005517 0.029265Observations 23 26Hypothesized Mean 0df 35t Stat -0.198776P(T<=t) one-tail 0.421 794t Critical one-tail 1.689573P(T<=t) two-tail 0.843588t Critical two-tail 2.0301 1

[ice the t Stat is less than the t Critical two-tail, the differences in the MeanIfercentage of Charge Nurse Activity is zero.

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Appendix D:

Trauma Burn Nursing Unit Charts and Data

• Overall Nursing Activity Distribution• Nursing Activity Distribution by Shift• Nursing Activity Distribution by Shift with Standard Deviation• Charge Duty Distribution by Shift (Pie Charts)• Charge Duty Distribution by Shift with Standard Deviation• Frequency Chart of Charge Nurse Activity• T-test Statistics• Raw Data

CC

Ave.PercentageofTimeObservedF\)C)

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Trauma Burn Nursing Activity Distribution

%ProflPers11%

%ChargeI 53%

Trauma Burn Day Shift Nursing Activity Distribution

%ChargeI 50%

%Prof/Pers12%

%Patient’38%

Trauma Bum Night Shift Nursing Activity Distribution

%Prof/Pers10%

10.6%

6.3%

%Prof/Pers

U Mean Values

• Stand 0ev.

C53 2%

Trauma Burn Nursing Activity Distribution

500%

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0.0%

362%

16.9% 16.7%

I%Charge ‘PatienI

50.72%

Trauma Burn Day Shift Nursing Activity Distribution

60.0%

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10.0%

0.0%

37’ 56%

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U Mean Values

• Stand. 0ev.

13.24%11.73%

%Charge %Patient

54 36%

%Frot/Pers

40.0%

30 0%

35 19%

200%

Trauma burn Night Shift Nursing Activity Distribution

1045%

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18.74%

100%

20.42%

0 Mean Values

.• Stand. 0ev.

0 0°.

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nn

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har

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ion

mMean 39.51% 18.02% 42.48%

DStd. Dev. 14.36% 14.93% 14.78%

Trauma Burn Night Shift Charge Duty Distribution

Trauma Burn Charge Duty Distribution

50%

40%Z4

__ _ _

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20%,,J

10%4A I1

% Staff % Pt. Trans

•Mean 37.70% 13.65% 48.64%

Std. Dev. 13.33% 14.47% 18.85%

%Other

Trauma Burn Day Shift Charge Duty Distribution

50%

______________________

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_______

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ctiv

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TB ttest


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(NIG

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Appendix E:

5D Nursing Unit Charts and Data


n

.

0) 0) C’)

0 E I 0 a) .1-’ C a) C) a) 0 >

10%

NIG

HT

SHIF

T

70%

60%

5DN

urs

ing

Act

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ft

50%

40%

30%

20%

(0!

U/0

--

OV

ER

AL

LD

AY

SHIF

T

Charge

•%P

aent

Car

eD

%_P

rof.

/Per

sona

lj

5D Overall Nursing Activity Distribution

5D Day Shift Nursing Activity Distribution

% Prol/Pers.9%

5D Night Shift Nursing Activity Distribution

% Prot/Pers.7%

5D Overall Charge Duty Distribution

%Other40%

5D Day Shift Charge Duty Distribution

%Ottier41%

%Pt.Trans23%

50 Night Shift Charge Duty Distribution

%Other41%

50 Charge Duty Distribution

5O%

30%V1

__ _

:,I-i

O%4

•Mean 35.50% 23.41% 41.09%

DStd. Dev 20.51% 14.77% 22.97%

5D Night Shift Charge Duty Distribution

50%

40%

30%

20%

0% 4 A

I

r

%Staff %Pt.Trans

mMean 34.59% 24.55% 40.86%

OStd. Dev 17.84% 18.13% 23.68%

%Other

5D Day Shift Charge Duty Distribution

50%

40%

30% -

20% -

10% -

0% -

%Staff I %Pt.Trans %Other

I

I

U%Statf %Pt.Trans

Mean 31.95% 26.82% 41.23%

DStd. Dev 14.34% 23.14% 26.70%,

%Other

7 6 5

0 C .24

a, U, 0 3*:

2 1 0

89-8

0%

Dis

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Nur

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(5D

)

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%

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0%39

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29-2

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9-0%

Per

cen

tag

eof

CN

Act

ivit

y

5D ttest


0.551724 0.761905Mean 0.505822 0.574294Variance 0.033339 0.034256Observations 14 10Pooled Variance 0.033714Hypothesized Mean [ 0df 22t Stat -0.900665P(T<=t) one-tail 0.18876t Critical one-tail 1.7171 44P(T<=t) two-tail 0.377521t Critical two-tail 2.073875

Since the t Stat is less than thet Critical two-tail, the differences in the MeanPercentage of Charge Nurse Activity is zero.

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Appendix F:

Additional Project Materials

• Work Sampling Study Directions for Charge Nurses• Data Collection Card• Subjective Survey Form• Article about “The Affects of Randomness”• Article about “Work Sampling as a Management Tool”

University of Michigan Medical Center

Charge Nurse Workload Study

January 1998

What is this about?This study is intended to collect data regarding the Charge Nurse role... specifically, what proportion oftime is spent on “charge nurse duties”, patient assignment and other activities. During the study periodnurses assigned as “charge nurses” are asked to participate.

How long will this go on?Data will be collected over the 24 hours for two weeks if participation is high. If there is incomplete datathe study will have to go on longer. You are asked to complete both sides of the orange-colored datacollection form and the use a random beeper.

What if I “delegate” some charge nurse activities or ask someone to help me?If you delegate any part of your charge nurse function to someone other than another charge nurse it will benecessary for that person to take another beeper and complete a data collection form during the fulltime of the delegation of duties. If this is not done the data will not accurately reflect the charge nurserole. Your Nurse manager will have extra beepers available for this purpose.

Who do I call if I have questions?You can ask your Nurse Manager or you can call Liz Othman at 62469, or you can e-mail one of thefollowing people who are conducting the study from the office of Programs and Operations Analysis.

Kim Pargoff [email protected] Scozzafave [email protected] Whithey [email protected]

If you are not sure how to categorize some activity and assistance is not available, just use your bestjudgment and confer later.

What is a Random Beeper?

The “random beeper” is a specially manufactured beeper designed for “self-collection” of workload data.Statistically, random sampling is considered a very powerful tool and if the sample is large enough, theresults can be used for decision making.

Your beeper has been set to “go off’ at random intervals, 3 times an hour on the average. Thus, forexample, the beeper might not go off at all in one hour and might “go off’ 5 times in another hour. It mayeven “go off’ twice in a one-minute interval!! It is very important that you check off the activity whichbest represents what you are doing at that moment, even if you think the results are skewed and notrepresentative of your work distribution. Please remember that personal rime is okay.

Please remember to turn your beeper “on” and “off’. You can use either the audible or silent mode. Ifyour beeper does not “beep” in a 2-hour period you may need to replace the batteries.

Charge Nurse Activities: Check off activities in this section if they are related to the duties you would

usually do because you are the charge nurse.

Stalling Activities:Check this box if you are doing staffing related activities such as: taking calls from employees,

calling NRP for staff, calling staff at home, arranging for current staff to work extra, making

assignments.

Pt. Transfer Admission Activities:Check this box for transfer/admission duties related to your charge nurse role. These activities

might include taking report, assigning beds, making transfer arrangements, interacting with other

departments.

Other Charge Nurse Activities:Use this box for charge nurse activities that do not fit in the above 2 categories. This box should

also be used when you are “covering” patients because it is a charge nurse duty.

Patient Care Activities: Check off activities in this section for activities related to your patient

assignment or your activities as a nurse doing patient care.

Related to Patient Assignment:Use this box for any direct or indirect care related to your patient assignment such as taking a report,

talking to your patient’s family members, charting, conferring with other personnel regarding your patient.

Related to Other Patients:This box should be checked for activities that are related to the care of other patients that you would

normally do as a member of the care team (being a charge nurse would have no bearing on your

participation in these activities). Such activities might include answering a light, answering the phone,

helping to move a patient.

Other Activities:

Professional Activities:This area is used to indicate activities such as professional development, inservices, unit meetings that are

not related directly to your patient care assignment or chargenurse functions.

Personal Activities: Everyone has down time and this area is used to indicate those times when you might

just be doing nothing, having a personal conversation or on “break”.

Random Beeper Survey: Activities

Charge Nurse Activities

Stattint Activities:‘t. tiC •tiJ. .liIittC 1r tjtI. ,iInmcnis

Pt. Transfer. Admission Activities:tctnt. rrort. a ninC ‘cd. ithr rrangerncnt”

Related to Other Patients:helpint ‘. oh .inuIfler p,iticni. .iti crtn ‘ail Ite!tt.

if OT spei i caiR dci tncu a narge nurc nIc

•

. Other Activities

Professional Activities:(education. meetings, interactions not directly related to

pt. assignment or charge nurse dutiest

Personal Activities:(breaks, bathroom, doing nothine. personal interactions

Random Beeper Survey: Activities

aüenteAçtiyite

Related to Patient Assignment:(direct and indirect care, charting. report. familt

Staffing Activities:taking calls. calling for staff. .tssignments

-..

,

Pt. Transfer, Admission Activities:(taking report. assigning bed. other arrangements)

Other Charge Nurse Activities:(co’erlng other pts. because it is a charge nurse duty

or any other charge nurse “jobs”. meetings or Interactions)

Did you delegate any charge nurse activities’?Yes No

To Whom?

_______________________

Related to Other Patients:I helping with another patient. ans\% ering call lights.

if NOT specificalk defined as charge nurse role)

.

.

•

:. Other Activities.,,,

Personal Activities:(breaks. bathroom, doing nothiniz. personal interactlon%

Professional Activities:(education. meetings, interactions not directly related to

pt. assignment or charge nurse duties

Patient Care Activities

Related o Patient Assignient:dircct a1J InoIrct carc. ‘t.runc. -crort .mii

Other Charge Nurse Activities:)ctcring other pis. because it is a charge nurse duty

or .in other charge nurse ‘iobs”. meetings or interactionsi

Did you delegate any charge nurse activities’?Yes No

To Whom?

______________________

. “—C.•:’

A FEW WORDSEIGHT HOURS AT 2.5 SIGNALS PER HOUR

R probability probability probabilityof exactly or R or of more than

4J3OUPJ R signals fewer R signals

0 .00000 .0000 .9999+1 .00000 .0000 .9999+RANDOMNESS 2 .00000 .0000 .9999+3 .00000 .0000 .9999+

The concept of a random sample is simple: every member of .00001 .0000 .9999+

me population is equally likely to be chosen. In the domain of time 5 .00005 .0001 .9999

rnpling it is convenient to think of a population of seconds, each of 6 .00018 .0003 .9997

-iich is equally Likely to be chosen. Statistics books sometimes 7 .00052 .0008 .9992

ss this in terms of the INTERVALS between samples and some- 8 .00131 .0021 .9979

nes in terms of the NUMBER of samples in a given period. We .0050 .9950

.11 consider the latter here although the other approach is equally 10 .00582 .0108 .9892

did.11 .01058 .0214 .9786

Unfortunately, a random series may not seem random to the 12 .01763 .0390 .9610

sual observer. Apparently it is part of the human mental process 13 .027 12 .066 1 .9339

extract meaningful patterns from data and this is done even 14 .03874 .1049 .8951

nen inappropriate. The gambler who speaks of the dice being “hot” 15 .05 165 .1565 .8435

simply seeing a pattern that isn’t there, if we assume the dice to 16 .06456 .2211 .7789

? honest. Similarly, the user of a Random Reminder will see “clus- 17 .07595 .2970 .7030

rs” of signals that don’t fit an intuitive notion of randomness. 18 .08439 .3814 .6186

athematical analysis of thousands of data points has shown, how. 19 .08883 .4703 .5297

er. that signals from Divilbiss Random Reminders have the cias- 20 .08884 .5591 .4409

c Poisson distribution.21 .08461 .6437 .3563

22 .07691 .7206 .2794

S THE RAM WORKING 23 .06688 .7875 .2125

ROPERL Y?24 .05573 .8432 .1568

25 .04459 .8878 .1122

Since signals from a Random Reminder are completely unpre. 26 .034 29 .922 I .0779

icti,ble, checking the operation is rather different from checking 27 .02540 .9475 .0525

e ‘ation of a calculator or stopwatch. Proper operation means 28 .018 15 .9656 .0344

ri tiat the number of signals in a given period conforms to the 29 .0 1252 .9782 .02 18

Dpropr ate statistical law. Because computation of the Poisson 30 .00834 .9865 .0135

‘ibution is tedious, a few representative cases have been tabulated 31 .00538 .9912 .0088

32 .00336 .9952 .0048

33 .00204 .9973 .0027

34 .00112 .9985 .0015

35 .00068 .9992 .0008

From the table above it can be seen that for an expected value

of 20, actual values of fewer than 8 or more than 35 are quite un

likely. Or. viewed in a slightly different way, there is a 90% probabil

ity that the actual value will lie between 13 and 27. The table above

applies to all situations where the expected value is 20 eigeeI and

not just to the case of eight hours at 2.5 signals/hr.

For a typical study of 200 hours at an average rate of 2.5 sig

naLs per hour, the expected value is 500 but there is only about one

chance in 56 that the actual value will be exactly 500. A simplified

table may help to make this clear.

ONE HOUR AT AN AVERAGE RATEOF 2.5 SIGNALS PER HOUR

R probability probabilityof EXACTLY of R or

probabilityof more thanRsignalsR signals fewer

0 .082 .0821 .9179

1 .205 .2873 .71272 .257 .5438 .4562

3 .213 .7576 .2424

4 .134 .8912 .1088

5 .067 .9580 .0420

6 .028 .9858 .0142

7 .010 .9958 .0042

8 .003 .9989 .0011

9 .001 .9997 .0003

Thus, there is a probability of .082 that there will be zero sig

als during one hour of operation, .205 that there will be exactly one

ignal and so on. If there were ten signals during the hour this

‘ould suggest that something might be wrong since the probability

there being more than nine signals is only .0003 or about one

nance in 3000. On the other hand, failure to beep during a one hour

eriod is not a particularly unlikely event (for the specified rate of

5 ‘md should not be taken as evidence of malfunction. A rea

D test for a Random Reminder is to determine the number of

gns (‘beeps’) that occur during an interval such that the “ex

ected” number of signals is 20. This might be an hour with the rate

et at 20/hour or it might be four hours with the rate set at 5Ihr, etc.

The next table is similar to the preceding one except that the

expected” number of signals is 20. Eight hours at a rate of 2.5 sigaim per hour is common when the Random Reminder is used for

‘lf’obseryation at work.

EXPECTED VALUE = 500

range probability

495-505 .19490-510 .36480-520 .64470-530 .83450-550 .98

In short, there is only a .19 chance of the actual number of

signals being within 1% of the expected value but a very high likeli

hood of being within 10% of the expected value. A 10% variation in

the number of samples will seldom have any effect on the validity of

a study.

© 1982 Divilbiss Electronics

:-

and tahulaung the sampled data from all the operators on thatshift. This was not much of a burden since the sampling ratechosen (0.4 sampleshour) generated only about 20 to 25samples per shift. By combining the sampled data from all theoperators. we accomplished two important objectives. One, wegot an appropnate total sample size while keeping the recordingrequirement extremely low for individual operators. Two, the

process guaranteed anonymity.Anonymity might not bepossible in every situation, hutwhere possible, it is desirable.

Figure 1 summarizes thedata collected over a three-month period and was createdusing nothing more than apencil and a pocket calculator.For operations significantlylarger than our pilot plantoperation. it would bereasonable to use a spreadsheet. It is also true that insome companies, computer-generated reports commandmore respect, the regrettabletriumph of form over content.

The next step is not atraditional one, but it is the keyto this being a win-win tool.Operators and management,working together, wentthrough the table analyzingand discussing every activity.

Was this activity taking toomuch time? Should this activiEybe receiving more emphasis?As an example, activity 5(facility cleaning) shows 61 samples for November and December. As a result of that data, we received additional janitorialsupport in December, which explains why the figure dropped sosharply in January.

Activity 14 (operating systems) represents a fairly highpriority activity that we assumed would take perhaps 3 to 5percent of the operators’ time. When the study made it clearthat the time devoted to this was almost negligible, we had tomove in a new direction. Upper-level management was persuaded that four operators should be released from theirnormal work assignments for four weeks in order to dedicatefull time to this activity. For persuading upper level management, nothing is more effective than having numeric data inhand.

Operators are an expensive resource, and there is alwaysconcern that they are being used effectively. The study served toreassure upper-level management that two potentially troublesome activities are not a problem at all. First, the amount of timetaken by personal (activity 9) is very low considering that thisincludes both lunch and scheduled breaks. The data is reported

( anonymously so we have every reason to believe that the figure isaccurate. Second, waiting (activiw 15) takes so little time that itwill not even be a listed activity in future studies. Operators donot spend much time waiting because there is always a backlogof work to be done, there is no shortage of equipment, they arewell trained, and they have the right attitude.

I want to emphasize that the operators did not merely

a snapshot in time. The realbenefit comes from doingstudies on a continuing basis,

constantly asking the question “Could we be running theoperation better?” We plan to repeat this study at regularintervals, making only some revisions in the activity categories.Some of these revisions will be the result of new governmentalregulations. Others will reflect our attempt to fine tune theoperation. As an example of the latter, we will probably splitoperation (actiitv 1) into two or more sub-activities. Because

operation takes by far the largest amount of time, it representsthe greatest potential payoff through the use of labor savingdevices.

The cost of a studs’ is negligible, it helps us to run theoperation at maximum efficiency, and the employees benefit aswell. It is not every day that you find that kind of managementtool.

Rick Rutter is manager of process operations for G. D. Seorfe in Skokie,Ill. He has a Ph.D. in Chemistry from the University of Illinois atChampaign-Urbana.

- . .- - .., —,-— ;,f:!— __i —-

n

Work Sampling Data Proc Ops. Dept.

agree to take part in the studs’. The’ supported it enthusiasti

cally. Their enthusiasm was certainly warranted when you

consider the following benefits:• They are involved in the management process and canapply their expertise to create a more efficient productiosvs tern:• By documenting what they do, they have increased their

visibility and respect within

the company:

___________________________________________________________

• They now have a tool forjustifring additional equip-Activity Nov. Dec. Jan. Total Percent ment (pumps. cleaning tools,automated controls. etc.) and294 372 349 1015 40.3 support services (ventilation.88 67 39 194 7.7 janitorial. etc.); and24 17 30 71 2.8• Decisions arrived at by23 17 48 88 35 consensus create a feeling of31 30 5 66 2.6 teamwork and a higher level10 6 10 26 1.0 ofjoh satisfaction.14 20 25 59 2.4 From the perspective53 25 26 104 41 of management, the benefit113 107 122 342 13.6 of a time study is a smoother40 16 36 92 3.7

- running, more efficient9 7 12 27 1.1 operation. Less obvious, but6 26 39 71 2.8 equally important, we believe18 31 34 83 3.3 that this kind of study creates10 3 9 22 0.9 a higher level of safety. Safety4 4 5 13 0.5 may seem an odd dividend67 44 65 176 7.0 from a time study, but we17 19 32 68 2.7 believe it comes from thefeeling of teamwork and theTotal Samples 821 811 886 2518 100.0 close attention to detail.

Any single time study’

OperationEquip. CleaningRun PreparationDocumentationFacility CleaningWaste HandlingSupport ActivitiesTrainingPersonalRaw MaterialsOp. SuppliesCant. Impr.Eng. SupportOp. SystemsWaiting limeOperator Comm.Other

FIGURE 1

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