This is an article written by Javier Thomé an intelligent writer whom volunteered with the MNM,I posted this on the MNM site while I was a board member with his permission.Since leaving I thought I would share it with this board.I am unable to show the tables included in the article but I believe I have a link that will take you to it. Just so I do not get sued(LOL) I will give credit to both Javier Thomé for writing the article and The Million Nurse March as the source.(www.millionnursemarch.org)
It is rather lengthy but discusses some interesting facts about time management, scientifically how we can not complete it all in one shift.
Nancy Nurse Speed Demon
© 2000 Javier Thomé, All Rights Reserved
email author: email@example.com
Nursing is a function of time. Whenever the time needed to complete any number of nursing tasks exceeds the number of nurse hours a nursing staff shortage exist. Plotting the Nurse Patient Ratio (NPR) generates a graph that allows the deployment of the equation Time = Distance ¡À Rate. Substituting the distance the nurse walks in a shift and dividing by the walking speed tells us how much time the nurse spends walking during a shift. This is true for any distance and any rate. The difference between the time spent walking and the shift hours is the time left for nursing care. Only 40% of the shift hours are available for nursing. This is the reason why nurses are unable to meet the Standard of Care (SOC), malpractice. This is the reason nurses find themselves in ethical dilemma and patients are defrauded of the health care they pay for.
Statement of the Practice Problem
A frequent complaint by nurses is short staffing (SS). SS is equivalent to high nurse patient ratios and understaffing (Nurse¡-s Legal Handbook, 1996). This chronic complaint is the subject of many articles and media coverage. This chronic complaint is validated by the many want ads in the classified section of any newspaper on any given Sunday. When nurses complain about SS they are immediately placed under the management microscope and counseled for poor time management skills and incompetence. It is the word of nursing management vs. the staff nurse and nursing management always wins.
The dynamics of SS are subordinate to corporate concerns. On 01.04.01 ABC News released to the nation a report on the use of tracking devices. These devices were intended for parolees and now serve to track nurses. Every second of every working day is now recorded and further supports this paper. It is hard evidence that is discoverable. This is done in the interest of improving efficiency.
How do we define SS? Is it a question of numbers or a question of skill? To this end Nancy Nurse Speed Demon is going to provide some of the answers.
The problem of SS can be analyzed in several ways. One way to determine SS is to calculate how much time the nurse uses in getting from point A to point B, walking. Once this is determined the difference between the shift hours and the walking time is the time left for nursing care. Finally, SS can be analyzed against the Nurse Clock (Figure 1); 10 pts get 6 mins/pt/hr of nursing care, 20 pts 3 mins/pt/hr and 30 pts 1.5 mins/pt/hr. Unfortunately the nurse clock is not a 60-minute clock because 100% of nursing time is not used for patient care. It is a 24-minute clock after you subtract the walking time. Reevaluating the previous calculations; 10 pts get 2.4mins/pt/hr of nursing care, 20 pts 1.2 mins/pt/hr and 30 pts 0.6 mins/pt/hr (36 ss) (Table One). Any skepticism can be laid to rest by reading the HCFA study mentioned in the Oct 2000 issue of RN. These facts are crucial in light of the fact that 5 minutes without oxygen lead to brain death.
Current practice allows Nursing Supervisors to send home nursing staff by rounding off staffing numbers to meet predetermined profit based staffing ratios. Predetermined profit based staffing ratios are not negotiable. Staffing is not a priority; it is subordinate to corporate concerns. Efficiency is the word, this means more pts/hour, less nurses, and 13-hours shifts. Ironically pts/hr is the same as nurses/hour.
When a nurse complains about SS her subjective complaint is rebutted with another subjective complaint. Nursing management has a conflict of interest; they are given bonuses to make budget, their assessment is biased.
Summary of Research
Nursing is a function of time. It follows that nurses do not use 100% of their time for nursing care. Therefore what percent of their time is used for nursing care and how do we determine what percent of the time is available for nursing care? Table One makes the first corollary obvious; as the number of patients increase the nursing time per patient decreases. Plotting time against an increasing number of patients shows that nursing time depreciates exponentially (this graph is not shown).
There are only two reasons for doing research to qualify and to quantify. The qualifying component is evaluated on the basis of distance, rate, time and the Pythagorean theorem. These concepts are scientifically accepted and serve as the tools to determine reasonable scientific calculations. Precise calculations can then be determined by measuring, quantifying. The estimates used are based on years of nursing experience.
Intuitively to a nurse everyone has a sense of SS, understaffing and high NPR. The volumes of subjective articles on the subject are a testament to this. Equally large volumes of articles are available about the consequences of SS; increased errors, omissions, and substandard care (Nurse¡-s Legal Handbook, 1996). Plotting medication errors against nursing time or NPR reveals the second corollary; as nursing time decreases exponentially the number of adverse patient consequences increase. Graphs and data to support this corollary are omitted because it is not the focus of this document.
Plotting the NPR generates a graph that allows the determination of the distance the nurse walks during an 8-hour shift. Quantitative research can then be initiated and pedometers placed on nurses to verify the actual distance, or the time data from the nurse¡-s tracking devices can be substituted.
Subjects and settings
This research is applicable to any nurse in any health care setting. The concepts can be used to evaluate nurses in home health who use their car (a word of caution to nurses that might have a tendency to inflate their mileage, think again).
This qualitative research is enough to encourage lawsuits against nurses, hospitals and nursing homes. It is enough to amplify the lawsuits to include nursing management. Even an error of 10% means that only 50% of the shift hours are available for nursing care. The nurse must meet the SOC in half the shift hours or the probability of malpractice is certain. Any nurse who knowingly accepts an assignment with high NPR could be a party to the commission of fraud.
Nurse Patient Ratio
Once picture is worth a thousand words, Chart One. The data for the graph is the NPR, one nurse (x = 1), represented in red with the number of patients increasing and represented in blue. The horizontal nurse line is shown and is defined by the equation y = 1. The graph allows us to define SS, x < 1. The ascending patient line is defined by the general equation of a straight line, y = mx + b.
Fractions are not allowed because you cannot cut nurses or patients in half. To staff a fraction of a nurse for a fraction of a patient is malpractice and fraud.
The slope m = ¨ö is constant until the lunch hour when the Relative Assignment (a temporary assignment of patients without report) of Nancy Nurse doubles. The slope rapidly approaches 1 at this point. The slope intercept represented by b is not valid, b ¡Ã1. Labels for the different units are superimposed consistent with the ideal NPR in those units.
The graph reveals the Functional Distance between the nurse and the patients. The actual distance can be determined if the graph is to scale. The functional distance is the distance determined from the graph when the graph is not to scale. The functional distance is directly proportional to the actual distance and this relationship is expressed mathematically, Fd + c = Ad, where c represents a constant. This distance will closely approximate the measured distance.
The distance between any two points (patients) and the distance between the nurse and the patients can also be determined using the Pythagorean theorem. The formula, Time = Distance ¡À Rate is deployed to examine a few problems. The equation is solved for time to allow for quick substitution of values.
To facilitate the calculations a distance of 10 miles is randomly selected for an 8-hour shift. This is consistent with Table One, column four and the Nurse Clock (Figure 1) set at 24 minutes. However a distance of 8 miles or 1 mph is consistent with Table One, column 3, 50% Nursing/50% Walking. This is the same as 30 minutes for nursing care and 30 minutes for walking. This equates to 12 to 15 miles in a 12-hour shift. A walking speed of 2 mph is substituted in the equation. (The Calorie Control Council, www.caloriecontrol.org
says that 2¨ö mph is considered walking slowly, 4 mph is brisk walking and 6 mph is jogging).
Time = Distance ¡À Rate
5 hrs = 10 miles ¡À 2 mph
This means that in an 8-hour shift the nurse spends 5 hours walking. This is a mathematical fact. Only three hours remain, 180 minutes for nursing tasks.
Time = Distance ¡À Rate
4 hrs = 8 miles ¡À 2 mph
This means that in an 8-hour shift the nurse spends 4 hours walking. This is a mathematical fact. Only 4 hours remain, 240 minutes for nursing tasks.
If it takes at least 20 mins to start an IV (Intravenous Therapy, 1995), 20 mins to do four finger sticks, 20 mins for two breaks, 90 mins to do an admission and 60 mins to do a discharge, this adds up to 210 mins. The nurse has only 30 mins left to do her nursing care. Even if she is twice as fast that still does not leave enough time to complete the nursing tasks on Table Two. The time needed for completion of the nursing tasks is 527 mins, that¡-s 8.78 hrs. Even if Nancy Nurse just spends one hour walking, she does not have enough time to complete the tasks.
Nurses might argue that they walk faster than 2 mph. When 4 mph is substituted into the equation this speed reveals the nurse spent 4 hrs walking and has 4 hrs left for nursing care. A nurse might start out at 4 mph but is unlikely to finish the shift at this speed. Beyond this a speed of 4 mph for half a shift (4 hrs), gives us a distance of 16 miles. Also Nancy Nurse will have to double her speed from 4mph to 8mph when her patient ratio doubles. This is still not enough time to complete the nursing tasks in Table Two.
The subject of time is crucial to the delivery of nursing care but no less important than chronology. Nurses have many non-nursing tasks they must perform. Many of them are single mothers who need to check on their children. They become ill and require doctor¡-s appointments and prescriptions. They have allergies, take antihistamines and suffer the side effects. This however does not excuse them from pulling their 13 hours. The additional hour is needed to engage in a ritual called Retrograde Charting (charting done at the end of the shift).
Nurses have physiologic needs not unlike the patients they care for; they urinate twice in an 8-hour shift and defecate at least once. They take breaks.
The hospital environment has many time consuming tasks for nurses; fire drills, fires, bomb threats, baby kidnappings, code blues, code strong, code pink, computer breakdowns, equipment failures, payroll problems, staffing and communication problems.
They have to perform total assessments, administer medications, maintain the CBI in room 321, receive a patient from surgery and do vital signs every 15 mins x four, followed by every 30 mins x 2, followed by every hr x 4, then every 4 hours. They have to supervise others, make doctors rounds answer their calls and respond to panic values.
They have to communicate with doctors, nurses, security, patients, and laboratory personnel. Table Two is a very short list of the many tasks that nurses have to do on a daily basis.
Acuity means the patient is sicker. In terms of nursing this means he requires more nursing care. Since nursing care is a function of time it can be measured. Hospitals do not staff on the basis of acuity. Translation: they do not staff according to the needs of the patient.
Dehumanizing choices follow; take care of those that have a high probability for survival first, take care of VIP¡-s as designated by management, take care of those patients who, ¡°scream the loudest¡±, and finally take care of those that have little probability for survival.
Dehumanizing choices follow; assign your least experienced nurse to those patients that have little probability of survival.
The qualitative research in its entirety is derived from the graph (Chart One) generated by plotting the NPR, the Nurse Clock (Figure One) and Table One. An observation is made; the application of the concepts of time, distance, and rate are as applicable to nursing as they are to any other situation. The application of the Pythagorean theorem is as applicable to this graph as it is to any other. The laws of math and science are indisputable. The proofs are not included. The values used in the equation Time = Distance ¡À Rate are estimates. The Nurse Clock (Figure One) further supports these findings. At 2.4 mins/pt/hr the nurse has 19.20 mins/pt in an 8-hour shift. This adds up to 192 mins for 10 pts or 3 hrs 12 mins. This is consistent with problem 1 for any nurse walking 10 miles at 2 mph.
The definitions are also observations from Chart One; SS is defined as x < 1. This means if there is a patient but not a nurse, there is a nursing shortage. Most policies state that two nurses must be available on a unit. Logically if there are any number of nurses and the patient needs CPR and none of the nurses know CPR, there is a staffing shortage. Therefore nursing is a function of time and skills. This corollary is not derived from the graph.
The definition of Relative Assignment is also revealed in the graph. When one nurse goes to lunch Nancy is informed and she assumes care of those patients temporarily until that nurse returns. This is not done for short intervals, breaks. The Absolute Assignment mention now for the first time is given to Nancy in writing at the beginning of the shift. She has report, specific knowledge of the patients on the list. A nurse has only general information about the patients, the Relative Assignment. Report on these patients was eliminated.
1. Based on the graphs, equations, tables and figures presented; any nurse, health care consumer, and attorney, can now determine with reasonable accuracy short staffing. Beyond this they can show that the nurse is unable to meet the SOC (what a reasonable prudent nurse would do in the same or similar situation) when they only have 36 ss/pt/hr. HCFA nursing home studies suggest 12 minutes a day from RNs, according to the article in RN October 2000. 36 seconds x 24 hours = 14 minutes. HCFA is recommending less nursing time. This can and will be used to make a case of malpractice and fraud against the nurse. 2.4 mins/pt/hr will not serve to insulate the nurse from liability.
2. More lawsuits will be filed against nurses, doctors, and hospitals. Law enforcement will use the equation to prosecute fraud.
3. Malpractice insurance
will become more expensive.
4. Our legislators should be made aware of this information to guide legislation that will benefit health care consumers. Consumers should be aware that only 40% of nursing hours are available for direct patient care.
5. The Boards of Nurse Examiners will be able to use the information to guide peer review and to determine blame or exculpate nurses for incidents directly related to short staffing.
6. Nurses will have to make use of peer review to exculpate themselves from potential incidents caused by understaffing.
7. Nurses in Texas will have to implement the Safe Harbor Act during short staffing situations or risk the employer saying they were not informed.
8. Nurses have to conduct time studies to eliminate redundancies.
9. Technologies that are faster must be identified and implemented.
10. Acuity based NPR will have to be mandated and nursing management held accountable for deviations.
11. Organize Labor (www.millionnursemarch.org) will use the concepts advanced by Nancy Nurse Speed Demon and use this to bargain for their membership.
12. Legally the SOC is the omission or commission of an act by a prudent nurse at one moment in time. This may resonate well in the halls of justice and be the journalistic hype for the Chicago Tribune, but it is a shrill cry in the medical surgical floor where all of these acts define the practice of nursing. Care is the operative word, care means nursing, and continuity of care becomes jargon.
The research needed to support the qualitative analysis this document advances is the quantitative research. We need to measure the distance the nurse travels in the health care setting. We also need to measure the floor layouts. This information will allow us to possibly decrease the distance the nurse travels by allowing us to look at present day designs. We as a profession may advocate going back to the old wards in some settings.
Technology comes bearing time saving gifts and we need to make the most of these devices to the benefit of all. Close circuit television needs to be exploited for patient teaching. Patient teaching can be done creatively by nurses writing and directing ¡°soaps¡± with a health goal. Advertising can pay for many of these things. This is cost containment.
The concepts advanced are a barometer to help us decided on staffing issues. Ethical dilemmas, all problems, have solutions. To continue predetermined profit based staffing ratios that render us mercenaries in today¡-s health care environment is unconscionable and we will pay the price. To allow a nursing unit to be short a nurse when the CEO is making $1.5 million dollars is criminal. Fraud and malpractice suits will be brought against nurses to the detriment of our profession.
Graph One has broad general application for nursing care. The formulas deployed are sound scientific principles and permit the mathematetical analysis of NPR in every setting. The graphs and tables are objective data and reflect patient care in general. Nurses need to become familiar with these tools now before they are surprised in deposition.
The NPR is the subject of debate and this debate is about to move into the courts. The Nurse Clock is ticking; it is a simple tool that juries can understand.
It is physically impossible for Nancy Nurse to meet the SOC because it is mathematically impossible. Not every nursing task is considered for evaluation and the estimates used to draw this conclusion are not all random. These tasks are identified in Table Two. According to the literature it takes 20 mins to start an easy IV and up to 45 mins for a difficult insertion (Intravenous Therapy, 1995). No 46-year-old nurse, with two jobs, working 13-hour shifts it going to realistically go from 2 mph to 4 mph when her assignment doubles.
The Health Care Industry may petition and lobby the federal government from liability and large awards but health care personnel will find it difficult to defend criminal prosecution.
1. Maria Bonilla, RN, BSN, my friend and coworker who has supported my observations from the beginning and encouraged me to proceed.
2. Jaime Barceleau, MS, LSW, for helping me through the thinking process.
3. Carmen Stanfield, for her editing.
Terry, Judy, Baranowski, Leslie, Lonsway, Rose Anne & Hedrick, Carolyn (Eds.). (1995).
Intravenous Therapy Clinical Principles and Practice. Intravenous Nurses Society. W.B. Saunders Co. p.27.
2.Simmons, George F., 1987. Precalculus Mathematics in a Nutshell, Janson Publication,
2. Nurse¡-s Legal Handbook, 3rd Ed., (1996). Springhouse Corp.
4. RN, October 2000, Vol 63, No.10, p.14.
6. Souza, Joanne E., RN, BSN, MBA, Basic Law, Course #556, National Center of Continuing Education, Inc. p 25, 2000.
1. The ascending line represents the increasing number of pts. The 10 pt model is consistent with a medical floor. The spike in the line is representative of what happens during the lunch hour, the nurse¡-s Relative Assignment doubles. The spike falls on the 8 pt assignment. When the assignment doubles the speed of the nurse has to double if the nurse is going to see the pts. 2. The horizontal line represents the nurse. The distance between pts and nurse, points on the line, can be determined using the Pythagorean theorem. 3. A larger graph could include more pts, 30 pts in the first shift would be consistent with a nursing home model and the spike for the lunch break would be absent. These pts are on ¡°autopilot¡±. More nurses and more pts can be added to the graph at one¡-s discretion. 4. Superimposing time on the graph will reveal that as the number of pts increase, nursing care time decreases, superimposing medication errors and adverse incidents will show them increasing concurrently.
Nursing and Walking Time
100% Nsg mins/pt/hr
75% Nsg 25% Walk min/pt/hr
50% Nsg 50% Walk mins/pt/hr
40% Nsg 60% Walk mins/pt/hr
We can make several observations from the table.
100% Nursing Time is not possible with one nurse.
Four pts at 100% nursing time = 3 pts at 75% nursing time/25% walking = 2 pts at 50% nursing time/50% walking time. If we graph the information in the table we can then extrapolate the nursing time/walking time for any mix.
The 30 pts are consistent with nursing home staffing, the 0.6 mins is 36 secs. At 100% nursing time they only have 2 mins/pt/hr.
The 10 pts are consistent with hospital assignments in the medical floor.
Itemized Nursing Tasks
I & O¡-s
Total Time 527 minutes
*These items are not estimated they are calculated or derived from other sources.
1. The list of nursing task is very short; many of the tasks that are performed daily have been left out. Some tasks like narcotic counts are now computerized but are done every time the nurse goes into the system. All task on the nursing floor are ultimately nursing task.
2. The total time in mins for these tasks is approximately an 8-hour shift. Even if the estimates were off %50, it would still require almost 4 hours.
1. The Nurse Clock is the simplest way to look at nursing time. It is one hour for 10 patients; this is the same as 6 mins/pt/hr. The hand is set at 24 mins, 2.4 mins/pt/hr, consistent with Table One, column 4.
2. The concepts of distance, rate, time and Pythagorean theorem can be analyzed on the Nurse Clock, by superimposing the Unit Circle.
Nancy Nurse Speed Demon
© 2000 Javier Thomé, All Rights Reserved
email author: firstname.lastname@example.org
[ May 07, 2001: Message edited by: Chellyse66 ]