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ValueAddedCare:AParadigmShiftinPatientCareDelivery
ValdaV.Upenieks,PhD,RNJalehAkhavan,MHA,RNJennyKotlerman,MS
NursEcon.200826(5):294300.

Introduction
Extrinsicandintrinsicforcesbroughttobearonhospitalshaveplacedtheminaconstantstateoftransition.Onemajordriving
forceinhealthcareisspiralingcostsasadirectresultofscientificadvances,technology,increaseddiversity,informedconsumer
partneringforsafecareanddecisionmaking,andintensiveillnesseswithanincreaseintheagingpopulation.Anadditionalforce
isthehigherdemandbybothprovidersandconsumersforissuesofqualitycareandsatisfaction.Sincenursesarethemost
importantfactorintheoveralloperationofeachhospital,theirpracticeremainsinaconstantstateofchange.Howhavechanges
inthehealthcareindustryaffectedtheuniqueroleofthenurse?Towhatdegreedoesthenurse'srolecontributetocarethatis
bothcompassionateandcosteffective?
Identifyingmethodsofprovidingcarethatcombinehumanisticandscientificperspectiveinasinglemodelisofutmost
importance(Creasia&Parker,2001).Thus,thisgivesmeaningtotheoldadage:"Ifwecannotchangethedirectionofthewind,
wemustlearnhowtosail."
Inanefforttoaddressquality,efficiency,andsafetyoutcomes,manyhealthcareorganizationshaveexpendedmuchenergyin
developingstructuralworkroleredesigns(Capuano,Bokovoy,Halkins,&Hitchings,2004Upenieks,1997Urden&Roode,
1997).Ahistoricalreviewestablishedthatinthe1980sregisterednurses(RNs)werereplacedwithunlicensedassistivepersonnel
(UAP)tomeettheincreaseddemandsfornursingservicesinrelationtoincreasedcost.Theseeffortswerereversedashospitals
werefacedwithanolderandsickerpopulation,andagainwiththeemergenceofpatientsafetyissuesinthe1990s.Theratioof
nurse/patientshasbeenthroughmanyfluctuationswithinthelast2decades(Abrams&Genovese,1999Sovie&Jaward,2001).
Certainlyeffortstowardsdeterminingthedirectnursingcareneededonaspecificnursingunithavereducedlaborcosts,yet
researchfindingssuggestthatthischangemayhavenegativelyaffectedthequalitycharacteristicofpatientcenterednessand
positivepatientoutcomes(Cho,Ketefian,Barkauskas,&Smith,2003).Thelackofasystematicapproachtohealthcaredelivery
issuesmayhavecreatedaballooneffectofperceivedimprovement,whereasimprovementinagivenareahasnegatively
affectedanotherphaseofcare(Katz&Kahn,1966).
Onadifferentwave,anumberofresearchstudieshavecontinuouslysupportedthenotionthatagreaterproportionofRNsinthe
workforceproducebetterandsaferpatientoutcomes(Needleman,Buerhaus,Mettke,Stewart,&Zelevinsky,2002).Forinstance,
atMagnet hospitals,thehigherratiosandproportionsofRNstoothernursingpersonnelhavebeenassociatedwithlower
hospitalmortalityrates(Aiken,Smith,&Lake,1994).Yetnumerousfactorsinfluencetheamountoftimenursescanspendat
thebedsideorindirectcareactivities(Capuanoetal.,2004).Thescienceofdeployingappropriatestaffingonaunitdependson
theassessmentandimplementationofsystematicchangesthataffectcurrentworkpracticesinthecurrenteconomicera.
Nursing'sabilitytoreframepracticeintoaneconomicvalueequationtocapturecost,quality,andserviceremainsanextremely
challengingopportunity.ThisthinkingprocessmustgobeyonddirectcareactivitiesprovidedbytheRNanddevelopanewwayof
assessingworkredesign:aparadigmshiftinthinking.

Purpose
Thepurposeofthispilotstudywastwofold:(a)togainanunderstandingofhowmuchtimeRNsspentinvalueaddedcare,and
(b)whetheranincreasedcombinedlevelofRNsandUAPsincreasedtheamountoftimespentinvalueaddedcarecomparedto
timespentinnecessarytasksandwaste.Thispilotstudystemmedfromalargerprospectiveworkflowstudythatevaluated
Californiastaffingratiolegislation,AB394,inordertoassessthevariabilityofworkloadofRNsfunctioningintwotelemetryand
onemedicalsurgicalunit.

BackgroundandSignificance
Frontlinenursesweresurveyedtoassesswhatspecificworkenvironmentchangeswouldimprovetheefficiencyoftheirunitas
wellastheirlevelofsatisfaction.Overwhelmingly,nursesdesiredtospendlesstimeinnonessentialactivitiessuchaspaperwork
andlocatingphysiciansandsupplies(Capuanoetal.,2004Upenieks&Abelew,2006).ArecentqualitativestudyofMagnet
hospitalsaskedstaffnursestodescribethe"characteristicsofaperfectenvironmentwherenursesareabletoprovidequality
patientcare."Optimalsettingsweredescribedasincorporating"accesstosupplies,equipment,andteammembers""lesstime
spentdoingpaperwork"and"moretimewithpatientsatthebedside."Severalnursesidentifiedtheidealpracticeenvironmentas
onethatfocusedonpatients:"Goodpatientcarecomesfromsatisfiednurses,andsatisfiednurseshavetherighttools,support,
andtimetofeelgoodaboutthecaretheyhaveprovided"(Upenieks&Abelew,2006,p.243).
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Themajorityofsuchstudiesindicatethatmedicalsurgicalnursesspendlessthanhalfoftheirshiftindirectpatientcare
activities.Asreportedintheliterature,thepercentageoftimespentindirectcareactivitiesrangedfrom30%to55%,withthe
average37%ofRNtimespentatthebedside(Heinz,2004Upenieks,1997Urden&Roode,1997).However,inexamining
processesandsystemsofcurrentpractice,notallnursingcarehoursarespentatthebedsidenoraretheyprovidedbyRNs.In
today'sacutecareenvironment,nursinghasbecomeacollaborativeandmultifacetedprocessthatrequiresthenursetoengage
inotherpatientandteamactivitiesnotreflectedasdirectorindirectcare(forexample,patient/familyeducation,physician
rounding,shiftreport,transportingpatients,andcommunicatingwithancillaryteammembers)(Capuanoetal.,2004).
TheTimeStudyRNNationalBenchmarkingDatabasehasintroducedanewconceptinevaluatingnursingworkloadactivities
(RapidModelingCorporation,2006).TheapproachhasbeensupportedbytheRobertWoodJohnsonFoundation(RWJF)
TransformingCareattheBedside(TCAB)initiative,whichconcentratesontransformingbedsidecareinwaysthatenhancethe
nursingprocessandimprovenursingandpatientoutcomes(Hassmiller,Rutherford,Lee,&Greiner,2004).Inthisnationalstudy,
newworkloaddefinitionsbeyonddirect/indirectcarewereaddedtothestudydesignconsistingofvalueadded,necessary,and
nonvalueaddedcare(RapidModelingCorporation,2006).Valueaddedactivitiesweredefinedaspatientcenteredactionsthat
directlybenefitthepatientnecessarytaskswerethosethatareessentialindeliveringpatientcareanddonotdirectlybenefitthe
patientandnonvalueaddedactivitiesweredefinedasactionsperformedbytheRNthatdonotbenefitthepatientandarenot
necessarytodeliveringpatientcare.ThetermUAPinthisstudyreferstonurse'saidesonly(see).
Table1.RapidModelingCorporationProcessMeasureDefinitions

Thisstudyincludedapproximately40hospitals(varioussizesandaffiliations)acrossthecountrytocollectworkflowdatautilizing
PalmPilot technology.Thedatawerecollectedonmedicalsurgicalandtelemetryunits.Theresultsofthisnationalbenchmark
studyrevealedawiderangeofvariabilityinnursingworkload.Forthemajorityofhospitals,valueaddedcarewasconsistentat
approximately60%,whiledirectcare,whichincludedactivitiesatthebedside(medications,vitalsigns,woundmanagement,
ADLs,etc.)rangedfromaminimumof25%toamaximumof57.5%andindirectcareactivities(chartreview,report,
communicationwithcareteam)rangedfrom7.2%to37%.NodatawerecollectedonUAPstodeterminehowmany"piecesof
thepie"wereallocatedtotheiractivities(RapidModelingCorporation,2006)(see).Theresultsindicatedthattherearemajor
opportunitiestostreamlinekeyworkprocessesandincreasethetimefrontlinenursesspendinvalueaddedcare,thereby
improvingworkforceandpatientoutcomes.
Table2.TimeStudyRNNationalBenchmarkingData

ConceptualFramework
Supportforthetheoreticalsignificanceinconductingthispilotstudystemmedfromthesystemtheoryframework.Asystems
theoristusesquantitativescientificmethodstounderstandcomplexrelationshipsamongorganizationalandenvironmental
variablestotherebyoptimizedecisions(Katz&Kahn,1966).Systemstheoriesareoftencalledmanagementsciencesor
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administrativesciences.Operationsresearchoroperationsanalysisreferstotheuseofmathematicalandscientifictechniquesto
developaquantitativebasisfororganizationaldecisionmaking.LudwigvonBertalanffyfirstarticulatedtheprinciplesofgeneral
systemstheoryin1950,andKatzandKahnwerethefirsttoapplysystemstheorytoorganizationsinthelate1960sexemplified
bytheirinfluentialworkTheSocialPsychologyofOrganizations(1966).KatzandKahnprovidedtheintellectualbasisformerging
classical,humanrelations/behavioral,modernstructural,andsystemsperspectivesoforganizations.Theirworkisoneofthemost
powerfulconceptualtoolsavailableforunderstandingthedynamicsoforganizationsandorganizationalchangeand,asaresult,
forthelastseveraldecadessystemsperspectivehasbecomethemainstreamoforganizationtheory(Katz&Kahn,1966).
Systemstheoryviewsanorganizationasacomplexsetofdynamicallyintertwinedandinterconnectedelements,includingin
puts,processes,outputs,andfeedbackloops,andtheenvironmentinwhichitoperatesandcontinuouslyinteracts.Asystem
takesinputsfromtheenvironmentintheformofenergy,information,money,people,rawmaterials,andsoon.Theorganization
doessomethingtotheinputsviathroughput,conversion,ortransformationprocessesthatchangetheinputs,andtheyexport
productstotheenvironmentintheformofoutputs(Katz&Kahn,1966).Achangeinanyelementofthesystemcauseschanges
inotherelements.Also,theimportationofenergyoperatestomaintainsomestateofequilibrium.Thereisacontinuousinflow
ofenergyfromtheenvironmentandacontinuousexportoftheproductsofthesystem,butthecharacterofthesystem,theratio
oftheenergyexchanges,andtherelationsbetweenpartsremainthesame(Katz&Kahn,1966).Inasystematicapproachto
evaluatingorganizationalchangeasaresponsetotheopposingforces,thesearchfororderamongcomplexvariableshasledto
anextensiverelianceonquantitativeanalyticalmethodsandmodels.Thesystemapproachiscauseandeffectoriented(Katz&
Kahn,1966).
Hypothetically,persystemstheory,achangeintheinputonanursingunit(numberofRNs)willtransformtheenergyavailableon
theunittocreateaprocesschange(timespentinvalueaddedcarevs.nonvalueaddedcare),whichwillultimatelyaffectthe
output/outcomeofpatientcare.However,acriticalpointtoconsiderwhenapplyingsystemstheorytoanorganizationalsettingis
thatinputsalonemaynotcreatethedesiredoutcome.Inputsmustbetransformedtoarriveatthedesiredoutput.Inother
words,changingthenumberofstaffavailableonthenursingunitmaynotbeenoughtoexplainthecauseandeffectrelationship
whichisappliedtosystemstheory.Atransformationintheformofaninterventionneedstotakeplaceinordertoachievethe
desiredoutcomeofstaffnursesspendingmoretimeinvalueaddedcare,andlessinwaste,inordertoarriveatbetterpatient
outcomes(seeFigure1).

Figure1.

DepictionofSystemsTheory

Methods
Aworkflowmethodology,prospectivecomparisondesignwasusedtodeterminetherelativeamountsoftimeallocatedto
workloadactivitiesamongRNsintwodifferenttelemetryunitsandonemedicalsurgicalunit.Thestudyfacilityisanacademic
medicalcenteraffiliatedwiththeschoolsofnursing,medicine,dentistry,andpublichealthinLosAngeles,CA.Thehospitalisa
610bedtertiarycarefacility.
Aconveniencesampleofatelemetryfloordividedintotwo30bedtelemetryunitsanda20bedmedicalsurgicalunitconstituted
thesamplingframeforthestudy.Thepatientcareunitswereselectedbasedontheclinicalcomparabilityofadmission
diagnoses.Forpurposesofconfidentiality,thetelemetryunitswillbereferredtoasUnitAandUnitB,andthemedicalsurgical
unitasUnitC.

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TheprospectiveworkflowstudyconsistedofaconveniencesampleofRNsprovidingpatientcareontheseunits.Duringrandomly
selecteddays,anyofsevenRNspresentonthetelemetryunitsandanyoffourRNsonthemedicalsurgicalunitwereselected
andshadowedbyaresearchassistant(RA)torecordworkflowactivities.InclusioncriteriaforRNsincludedallfulltimeandpart
timeequivalents,perdiemnurses,andnewgraduatenurseswhohadcompletedorientation.Inclusioncriteriaextendedto
agencypersonnelandtravelers,whoplayanintegralroleintheamountofdirectcareprovidedtopatients.Chargenurses,UAPs,
andlicensedpracticalnurseswereexcludedfromthestudysincetheywerenotincludedinthemandatedstaffingratioforthe
units.
Instrumentation.APalmPilotinstrument(PDAdevice)wasusedtocollectthecategoricalvariables.ThisPalmPilottechnology
wasusedbyTCABPhaseIIhospitalstoassessleaneffortstodecreasewasteandimprovecontinuousunitflow.ThePDAwas
alsousedtocapturedatafortheTimeStudyRNNationalBenchmarkingDatabaseconductedbyRapidModelingCorporationto
evaluateRNworkintensity.
ThePDAdevicewasprogrammedtosignaltheRA,viavibratingalarm,toinputcurrentlocationandactivityonanaverageof
every10to15minutes.Atthevibratingsignal,theRAwouldselectacategoryandinputdataintothePDA.Categorieswere
dividedintovalueaddedactivities,necessary,andnonvalueaddedactivities.Thesecategoriesweredividedbylevel:directcare,
indirectcare,documentation,administrative,waste,andother(see).
Table1.RapidModelingCorporationProcessMeasureDefinitions

Datacollection.Priortocollectingthedata,operationaldefinitionswerereviewedbytheRAstoascertainaccurateobservationof
nurseactivities.AtestrunwasconductedtodeterminewhethertheRAswereabletoobservetheappropriatenumberofnurses
inthetimerandomlydeterminedbythePDAdevice.BothofthetrainedRAsfoundthatthetimewassufficienttolocateand
observethecorrectnumberofnurses.Patientconfidentialitywasmaintainedfollowingtheinstitution'sreviewboardprotocols.
TwoRAswereassignedtoeachunitandshadowednursesduringtheirshifts.ThePDAiscapableofrandomlycollecting
categoricalactivitydatafor7to10nursesduringthesameobservationperiod.Thus,duringthestudyperiod,thePDArandomly
signaledtheRAstolocate,observe,andentertheactivityofNurse#1itwouldthenrandomlysignaltheRAtolocate,observe,
andentertheactivityofNurse#2,andsoon.Thisprocesswasrepeatedonanaverageofevery10to15minutesduringthe8
hourobservationperiod.
DaysdevotedtoconductingtheworksamplingstudyonallthreeunitswereselectedrandomlyoverthemonthsofMayandJune
2006.Thedatesprovidedacrosssectionofactivitiesthatoccurredondifferentdaysoftheweekanddifferenthoursoftheday.
Dataanalysis.Descriptivestatisticswereappliedtothedistributionofworkflowsamplingcategories.Regressionanalysiswas
usedtodeterminewhetheranincreaseinthenumberofRNswouldincreasetheamountoftimespentinvalueaddedcareas
wellaswhetheranincreaseoftimespentinvalueaddedcaredecreasedtheamountoftimeRNsspentinnonvalueaddedcare.

Results
WorkflowsamplingwasperformedbytheRAsonUnitsAandBfor14daysduringthemonthofMay2006,andfor28dayson
UnitC(additionaldaysrequiredforauniformsamplesizeamongthethreeunits)duringthesameperiod.Thedayswere
selectedrandomly,andan8hourblockoftimebetween7a.m.and11p.m.wasarrangedforobservation.Totaldatapointsfor
UnitsA,B,andCequaled1,592,1,536,and1,565respectively,representingalargeuniformsamplesizeforstatistical
comparison.Theadmittingdiagnosesfortheseunitsconsistedprimarilyofchronicobstructivepulmonarydisease/asthma,
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diabetesmellitus,congestiveheartfailure,GIhemorrhage/digestivedisorders,andsicklecelldisease.
Duringthestudyperiod,nursinghoursperpatientduringa24hourperiodforUnitAequaled8.81,8.36forUnitB,and7.11for
UnitC.Staffingmixonallunitsconsistedof67%RNsand33%UAPs.FortheRNs,theaveragenursetopatientratioequaled
3.28onUnitA,3.24onUnitB,and3.76onUnitC.FortheUAPs,averagepatienttocarepartnerratioconsistedof6.5onUnit
A,7.0onUnitB,and5.75onUnitC(see).
Table3.ProportionofNumberofFrontLineStaffandTimeSpentinActivities

Descriptivestatistics.Approximately60%oftheactivitiesperformedbyRNsonUnitAwerecategorizedasvalueaddedcare,
19.7%asnecessarycare,and20.7%ofactivitieswerespentinnonvalueaddedcare.UnitARNsspent25.0%indirectcare
activities,37.0%inindirectcareactivities,16.4%documenting,4.2%inwaste,and16.3%inother(whichincludedpersonal
time).TheresultssuggestedthatRNsonUnitAspentaconsiderableamountoftimeinvalueaddedcareactivitiesatthenurses'
station,suchascollaboratingwithteammembers,reviewingcharts,preparingmedications,teachingactivities,and
communicatingwithfamilymembers.Althoughthesetaskswerenotactualdirectcareactivitiesperformedatthepatient's
bedside,theywereconsideredvalueaddedactivities,sincetheyrepresentedadirectbenefittothepatient.Theresultsalso
indicatedthatRNsonUnitAspentaconsiderableamountoftimeinthewastecategoryhuntingforequipmentand/oranother
teammember,andwaitingondelays.
ThemajorityoftheRNtimespentonUnitBwasrelatedtovalueaddedactivities(58.8%),followedbynecessaryactivities
(24.5%),andnonvalueaddedactivities(16.7%).Approximately32%ofRNtimewasspentindirectcareactivities,26.6%in
indirectcareactivities,24%documenting,5%inwaste,and11.6%intheothercategory,whichincludedpersonaltime.The
resultssuggestedthatUnitBRNsspentmoretimeondirectcareactivitiesatthepatient'sbedsidecomparedwithUnitA,and
lessinindirectactivities.Aconsiderableamountoftimeontheunitwasspenthuntingforequipmentand/oranotherteam
member,waitingindelay,andondocumentation.Thepatientdemographicsmayhaveallowedforthesedifferences,aswellas
thephysicallayoutoftheunit,stafflevelofexperience,andotherworkplacevariables.
OnUnitC,RNsspent54%oftheirtimeinvalueaddedcareactivities,25%inthenecessarycategory,andapproximately21%in
nonvalueaddedactivities.Comparedtothetelemetryunits,lesstimewasspentinvalueaddedactivities.TheseRNsspent30%
oftheirtimeindirectcare,25%inindirectcare,and23%oftheirtimedocumenting.Comparingtheseresultstothetwo
telemetryunits,lesstimewasspentcollaboratingwithteammembers,preparingmedications,teachingactivities,and
communicatingwithfamilymembersmoretimewasspentondocumentation.Theresultsmayindicatethepatientdynamicson
theunit,suchasafasterpatientturnover,moretimespentdocumenting,pagingresidents/hospitaliststogetadmission/discharge
orders,andsoforth.
Regressionanalysis.ThetotalnumberofRNsandUAPswascalculatedbytotalingthenumberoffrontlineteammembersfor
eachdayoftheworkflowsamplingperiod.ThisvariablewasmergedwiththetypeofactivityperformedbytheRNvalueadded,
necessary,andnonvalueaddedactivities.Thetotalnumberofactivitieswascalculatedbytotalingthenumberofvalueadded,
necessary,andnonvalueaddedobservations.Theproportionofeachactivitywascalculatedbydividingthenumberofeachtype
ofactivitybythetotalnumberofactivitiesforeachdayduringthestudy.Theresultsdemonstratedthatthenumberofeachtype
ofactivitychangedwiththeincreasedcombinednumberofRNsandUAPs(see),buttheproportionofeachtypeofactivitydid
notchange(reflectanyincreasednumberofcombinedRNsandUAPs)(see).Inotherwords,byaddingRNsorUAPs,thetime
spentinallactivitiesincreased,asmorefrontlineteammemberswerepresentperformingmoretasks.However,therewasno
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significantdifferenceintheadditionoffrontlinestaffandtheproportionalityofmoretimespentinvalueaddedcareandless
timeinnecessarytasksandwaste.AllpvalueswerecalculatedusingANOVAmodelsandanalyseswereperformedusing
STATA10.
Table3.ProportionofNumberofFrontLineStaffandTimeSpentinActivities

Table3.ProportionofNumberofFrontLineStaffandTimeSpentinActivities

StudyLimitations
Beforediscussingthestudyresults,certainlimitationsmustbeconsidered.First,researchobservationswereutilizedversusself
sampling.Sincenurseactivityinvolvesmultitasking,itisnotalwayspossibleforanobservertoaccuratelyclassifytheworkbeing
performed.Althoughthismaybeconsideredastudylimitation,selfsamplingcanalsoutilizeselfselection,meaningthatthe
observerwilldenotewhatworkistrulybeingperformed(e.g.,personaltime).Also,theRNmaynotbeabletoinputthedata
whenthePDAdevicesignalsforexample,heorshemaybeinisolationandnotabletoaccessthedevice,whereastheobserver
willalwaysbeabletocapturethisinformation,resultinginfewermissingdatapoints.Thesecondlimitationofthestudywasthat
nurse'saidesandLVNswerenotobservedsincetheywerenotincludedinthestaffingratioformula,whichmadeforan
incompletepictureoftheoverallnursingactivitiesontheunit.Neitherdidthestudyconsiderthepresenceofotherancillarystaff,
suchasliftteam,volunteers,casemanagers,respiratorytherapists,etc.

Discussion/NursingEconomicImplications
Theparadigmshiftinthinking,introducedbytheRapidModelingCorporationinthe2006TimeStudyRNNationalBench
markingDatabase,andsupportedbyRWJF'smostcurrentresearchinitiative,TransformingCareattheBedside,PhasesIIand
III,entailsassessingnursingstaffingandworkflowfromthestandpointoftimespentbyfrontlinenursesinvalueaddedcare
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activities(RapidModelingCorporation,2006).Thegoalofthisrevolutionaryapproachistoallowhospitalstoincreasetheamount
oftimenursesspendinvalueaddedactivities,andtoreducetimespentinnonvalueaddedactivitiesthiswillimproveworkflow
efficiency,affordcareprocessesthatarefreeofwaste,andpromotecontinuousflowofpatientcareactivitiesthroughthe
appropriateuseoflicensednursesandUAPs(Rutherford,Lee,&Greiner,2004).Thisnewwayofthinkingentailsviewingnursing
productivityintermsofvalueaddedcare,avisionthatgoesbeyonddirectcareactivitiesandincludesteamcollaboration,
physicianrounding,increasedRNtoaidecommunication,andpatientcenteredness,allofwhicharecrucialtothenurse'srole
andthepatient'swellbeing.
Thestudyalsodemonstratedthatnumbersalonecannotexplaintheentirescopeofcare,norcanaddingRNstotheequation
increasetheamountoftimespentinvalueaddedcare.Inanytrueapplicationofsystemstheorythereneedstobea
transformationinthethroughputofcare.Aninterventionmustbeappliedtoeffectanincreaseinvalueaddedcareanda
decreaseinwaste.SeveralTCABPhaseIIhospitalshavetakenthisconceptandappliedinterventionstotheirmedicalsurgical
units(Viney,Batcheller,Houston,&Belick,2006).Theseinterventionshaveconsistedofchangingthephysicallayoutoftheunit
(e.g.,relocatingthemedicationmanagementunittoamorecentrallocation),andredesigningthepatientcareroomstoallow
supplies,medications,andlinentobecomereadilyavailable.Theresultsindicatedasubstantialdecreaseintheamountoftime
nursesspendhuntingandgatheringequipment,reducingwasteby8%to10%andincreasingtheamountoftimespentata
patient'sbedside.Theseinterventionshavealsoservedtoreducetheturnoverrateofnursesfrom16%to10%.Nursesclaimthey
enjoytheirworkbetterthanbeforethesechangeswereimplementedminimizingwasteimprovesthecontinuousflowofpatient
careactivities,andthusmorale(Rutherfordetal.,2004).
Nursingisasynergisticanddynamicprofession,onethatintegratesartandscienceinauniqueway.Justasuniquearethe
consumersofhealthcare(patients).Regardlessofthetypeofcaredelivered,adheringtoasetofnumbersalonewouldmissthe
overallpictureofthisdistinctaspectthatdifferentiatesnursingfromotherhealthprofessions.Toprovideastrongerbasisfor
practice,onethatcanbeintegralinimprovingefficiency,quality,andreducingcost,thequantificationoffrontlinestaffshouldbe
replacedbyamoresystematicapproachtothedeliveryofpatientcare.Throughtheunderstandingandacknowledgmentof
valueaddedcare,nursingfunctionscanbemeasuredintermsofquality.Thus,asystematicinterventioncanenhancevalue
addedcareandreducewasteinthehealthcaresystem.

Sidebar:ExecutiveSummary
Spiralingcostsinhealthcarehaveplacedhospitalsinaconstantstateoftransition.Asaresult,nursingpracticeisnow
influencedbynumerousfactorsandhasremainedinacontinuousstateofflux.Multiplechangeswithinthelast2decadesin
nurse/patientratioandblendoffrontlinenursesareexamplesofthistransition.Toreframethenursingpracticeintoaneconomic
equationthatcapturesthecost,quality,andservice,aparadigmshiftinthinkingisneededinordertoassessworkredesign.
Nursingproductivitymustbeevaluatedintermsofvalueaddedcare,avisionthatgoesbeyonddirectcareactivitiesandincludes
teamcollaboration,physicianrounding,increasedRNtoaidecommunication,andpatientcenterednessallofwhicharecrucialto
thenursesroleandthepatientswellbeing.
Thescienceofappropriatingstaffingdependsonassessmentandimplementationofsystematicchangesbestillustratedthrough
asystemstheory'framework.Athroughputtransformationisrequiredtocreateprocesschangeswithinputelements(numberof
frontlinenurses)inordertoincreasetimespentinvalueaddedcareandtodecreasewasteactivitieswithanimprovementin
efficiency,quality,andservice.
Thepurposeofthispilotstudywastwofold:(a)togainanunderstandingofhowmuchtimeRNsspentinvalueaddedcare,and
(b)whetherincreasingthecombinedlevelofRNsandunlicensedassistivepersonnelincreasedtheamountoftimespentin
valueaddedcarecomparedtotimespentinnecessarytasksandwaste.
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TheauthorsandallNursingEconomicsEditorialBoardmembersreportednoactualorpotentialconflictofinterestinrelationto
thiscontinuingnursingeducationarticle.

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