Nurses have faced criticisms that they do not spend enough time giving direct patient care, however observations of their practice challenge this view
In this article…
- The benefits of observation
- The amount of time staff spend with patients
- How this time is broken down
Stella Wright is research officer at the National Institute for Social Care and Health Research Clinical Research Centre, North Wales Research Network, Conwy; Wilfred McSherry is professor in dignity of care for older people at Staffordshire University/The Shrewsbury and Telford Hospital Trust, and part-time professor at Haraldsplass Deaconess University College, Bergen, Norway.
Wright S, McSherry W (2013) How much time do nurses spend on patient care? Nursing Times; 109: online issue.
This article presents the findings from observations of nursing care that were conducted in an acute NHS trust, as part of a much larger mixed-methods study that explored the impact of the Productive Ward programme on the delivery of nursing care. It was found that nurses did not always take opportunities to interact with patients in a meaningful way, for example by involving them in ward round discussions; however, qualified nurses were involved directly in the delivery of fundamental nursing care, supported by healthcare assistants.
- This article has been double-blind peer reviewed
- Figures and tables can be seen in the attached print-friendly PDF file of the complete article in the ‘Files’ section of this page
5 key points
- The Productive Ward programme aims to release time so ward staff can work more efficiently
- Nurses have faced criticisms that they do not spend enough time on direct patient care
- Inadequate staffing levels impact on nurses’ ability to provide good-quality care
- The amount of time staff spend with patients varies, and is not necessarily indicative of the quality of the interaction
- Nurses do not always take opportunities to include patients in their care, for example by including them in ward round discussions
One of the major aims of the Productive Ward programme is to release time, by streamlining processes and enabling nursing and ward staff to work more efficiently (NHS Institute for Innovation and Improvement, 2007). The literature on PWP suggests its success in meeting this aim is sporadic, with reported increases in direct care time ranging from 8% (Shepherd, 2009) to 43% (NHS Scotland, 2008). Blakemore (2009) reported an increase of 45-87%.
We collected data by observing every-day practice and used this to explain and support findings from the other quantitative and qualitative phases. We aimed to explore variables such as:
- How tasks are distributed;
- Time spent on each duty;
- The types of activities nurses undertook.
Healthcare regulators frequently use observation as a means of assessing the quality of services. The Care Quality Commission (2011) inspections for dignity and nutrition assessment involved clinical observations as described below:
“This was our first themed programme of inspections using our new ‘outcome-based’ model of regulation. This means we spent the majority of our time observing how care was delivered on wards, talking to patients and their families, and interviewing staff.”
Observations can provide an overview of daily activity in a specific area. This method of information gathering is useful for finding out more about areas, such as communication between staff and with patients, and how the environment is used to promote and preserve patient dignity. It also acts as an opportunity for patients and the public to be involved in service improvement, and increases public confidence.
Observations of care were a central feature of the Royal College of Nursing’s leadership programme in England (RCN, 2005), with participants reporting how valuable and important this aspect of the programme had been.
Observations can be used to refute some of the recent criticisms about the nursing profession made in a number of reports that implied there is a lack of compassion, dignity and respect (The Patients Association, 2011; Healthcare Commission, 2009). These reports suggest qualified nurses are too busy or not visible on wards, and that much of their time is taken up doing bureaucratic roles such as completing risk assessments and nursing documentation.
Inadequate staffing levels will undoubtedly affect nurses’ ability to provide high-quality care. The RCN (2010) has previously published guidance on staffing levels and recently provided more detailed information regarding the care of specific patient groups, for example older people (RCN, 2012).
During our information gathering, we did not measure standards of care or make judgements on the overall quality of the interactions we observed. Observation alone does not give sufficient data to assess quality, and other elements are needed to build a full picture, such as inspection of documentation and discussion with patients and staff.
We spent one hour observing on five case-study wards. The purpose was to record ward activities, contact time, and the length of interactions between patients and staff. A second observation was then undertaken on four of the wards.
Observations were recorded using an observation schedule developed from the Activity Follow, a tool/resource from the NHS Institute for Innovation and Improvement (2007) for use on the Productive Ward programme. The tool is used to document the activity of a single staff member every minute and is designed specifically to record staff activity and interactions from the patient perspective.
Only patients who were well enough to read the information sheet and sign the consent form were invited to take part; this meant that those individuals who had the greatest care needs were not included in the observation.
In total 22 patients and 18 members of staff were observed. Observations were conducted in five male and four female areas. It was necessary to minimise intrusion and disruption to daily ward activities so the observer was positioned where those patients who consented could be observed, but it was not possible to observe care taking place behind curtains.
The study was undertaken between 09:00 and 17:00 as this is typically the time when most activity takes place. Due to limitations - such as the availability of a staff member to identify a suitable bay, protected mealtimes, visiting hours, staff handovers and ward rounds - the findings are not representative of overall ward activity. Some patients who had consented to take part in the observation were discharged, transferred or left the ward during the one-hour observations, for example to attend physiotherapy.
During the study we noted the following:
- Patients were observed helping frail patients and assisting each other with eating and drinking. When this was discussed during one-to-one interviews, they reported helping each other socially, rather than through obligation or because staff were not available;
- Staff commented at times that the observation was taking place during a quiet time of day. This could be due to the timing of the study for example, avoiding protected mealtimes;
- One doctor was observed interrupting a patient’s lunch in order to take blood;
- One patient reported that she had been a patient in Area 5 on eight occasions in a year and had “nothing but praise for staff”;
- In Area 5, two staff nurses and a student nurse spent over 13 minutes on handover within the bay, but did not interact with any patients specifically; as such, the handover was not formally recorded as it could not be attributed to individual patients;
- Staff performing bedside handover spent considerably longer with some patients than others.
Across nine hours of observations, staff interacted with participating patients for a total of two hours and 25 minutes. There was a great deal of variation in the length of interaction between the areas we observed (Table 1). The total length of interaction per area ranged from 12 minutes to one hour and five minutes.
Across all staff grades, the three activities that took up the most staff time were:
- Nursing procedures such as giving injections, changing dressings and inserting catheters (27 minutes);
- Hygiene (22 minutes);
- Toileting (19 minutes).
The shortest total time periods were spent on:
- Mobilising (25 seconds);
- Meal rounds (10 seconds);
- A staff member going to a patient then leaving because the patient was still with the doctor (five seconds) (Table 2).
There were no recorded instances of:
- Relative liaison (probably due to most observations taking place outside of visiting hours);
- Responding to call bells or ward rounds.
In terms of demarcation of duties, nurses spent the greatest total amount of time on:
- Nursing procedures (26 minutes);
- Medicine rounds (12 minutes);
- Hygiene (eight minutes).
Healthcare assistants spent most of their time on:
- Hygiene (14 minutes);
- Toileting (12 minutes); and
- Patient communication (seven minutes).
During the observations, nurses were observed undertaking patient care for over one hour 20 minutes - 23 minutes longer than the total for healthcare assistants.
Patients generally received most care from qualified nurses, which shows that nurses of all grades are involved in delivering nursing care. Table 2 illustrates that the activities undertaken by staff nurses were centred on core nursing processes, while healthcare assistants tended to undertake more personal care and patient communication. However, the length of time staff spend with patients does not necessarily indicate the quality of the interaction - such as when staff were in the bay but not communicating with patients.
Unfortunately, much of the nursing activity could not be recorded, during a period of observation as the observation schedule could only be used to record nursing care provided to patients who had given consent.
The varying length of interaction may be due to factors such as patient dependency or when the observation took place, for example a nurse may have performed a procedure during the observation. It should also be noted that it is also possible that behaviour was affected by the presence of the observer (Sarangi, 2010).
Hourly comfort rounds were introduced in the trust in 2011 to provide a regular staff presence and ensure patients received support when they needed it. Although comfort rounds were ranked twelfth in Table 2, it is possible that the small amount of time spent on this activity addresses patient needs promptly and may contribute to improvements, for example a reduction in falls.
The number of hours spent undertaking observations is small when compared with a recent investigation by Tadd et al (2011) who spent a total of 617 hours observing 16 wards in four acute trusts. Our study was not an observational study however and, although the aim was to observe nursing activity and the amount of time spent on direct patient care, this element was only a small component of a much larger mixed-methods study.
Our findings provide some valuable insight into the roles, activities, types and length of interactions taking place between nurses and patients. We found that nurses at all levels do not always take opportunities to interact with patients in a meaningful way, for example involving them in ward-round discussions. However, the observations show that qualified nurses are involved directly in the delivery of fundamental nursing care, supported by healthcare assistants.
Blakemore S (2009) How Productive Wards can improve patient care. Nursing Management; 16: 5, 15-18.
Care Quality Commission (2011) Dignity and Nutrition Inspection Programme: National Overview.
Healthcare Commission (2009) Investigation into Mid Staffordshire NHS Foundation Trust. London: Commission for Healthcare Audit and Inspection.
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NHS Scotland (2008) Releasing Time to Care Evaluation, July-December 2008.
Royal College of Nursing (2012) Safe Staffing for Older People’s Wards: RCN Summary Guidance and Recommendations. London: RCN.
Royal College of Nursing (2010) Guidance on Safe Nurse Staffing Levels in the UK. London: RCN.
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Tadd W et al (2011) Dignity in Practice: An Exploration of the Care of Older Adults in Acute NHS Trusts. NIHR Service Delivery and Organisation Programme, 2011.
The Patients Association (2011) We’ve Been Listening, Have You Been Learning? London: The Patients Association.