510 minutes: A MNA RN Explains a typical shift

To Whom It May Concern:

I’m an acute care registered nurse at a St. Paul hospital and am
concerned (as are the majority of nurses) about the way nurses are being
portrayed in their quest for safe staffing. However, I also realize the
majority of the population doesn’t know exactly what a nurse does when
he/she is outside the patient room. The public hears us talk about needing
more time at the bedside, but doesn’t understand why they see nurses at
the desk so often. With this understanding, I set out to give a detailed
account of what nurses’ duties are outside the patient room.

Every shift a nurse has legal obligations and guidelines that need to be
followed. If these duties are not done accordingly, the hospital doesn’t
get paid for services rendered, the nurse’s license can be in jeopardy,
and the hospital can be fined. Not to mention, the patient may not get good
continuity of care due to lack of communication between shifts. So what are
these duties? How much time do these duties consume? These are good
questions and deserve good answers.

I have broken down an 8 hour nursing shift into minutes and timed how long
it takes (on average) to do each of the duties that occur outside the
patient room. Each shift a nurse has 8.5 hours, or 510 minutes, at work,
including a 30-minute unpaid break. In this time the nurse has to receive
and write shift report, conduct a chart and medication administration
record (MAR) review, create a comprehensive interdisciplinary care plan,
give a verbal report to the charge nurse, and chart their findings and
assessments. The assessments include a head-to-toe assessment, vital signs,
falls assessment, skin assessment, wound assessment, pain assessment,
psychosocial assessment, and follow-up assessments for pain, surgical
wounds, invasive tubes, cardiac monitoring, blood sugars, unstable vital
signs, and any intake/output the patient has had. All of these tasks need
to be performed for each patient on every shift.

Each duty takes time away from the patient’s room, but is necessary for
the patient’s care. Charting takes, on average, 20 minutes per patient
(this includes both initial and follow-up assessments). Receiving shift
report at the beginning of the nurse’s shift is 30 minutes and it takes
the nurse 10 minutes per patient to write report for the next nurse. An
interdisciplinary care plan requires another 5 minutes per patient. The
chart and MAR review takes 10 minutes per patient and giving verbal report
to the charge nurse requires approximately 2 minutes per patient.

When these times are calculated and subtracted from the 510 minutes a
nurse is allotted for his/her shift, the time left over is what can be
spent in the patient room. The amount of time changes depending on how many
patients the nurse has in his/her care. The amount of patients a nurse has
for an assignment varies from shift to shift and from unit to unit, but on
an average acute care unit the nurses have from 4 to 7 patients each. This
means that for 7 patients (or a 7:1 ratio) a nurse has 2.2 minutes per hour
in each patient room. The time in the patient room increases as the number
of patients decreases. For instance, a 6:1 ratio means 3.5 minutes per
patient per hour, a 5:1 ratio increases to 5.4 minutes per patient per hour
and a 4:1 ratio equals 8.2 minutes per patient per hour.

The times stated above are decreased even further by numerous issues that
can arise. Some of these issues are obvious; for instance, another patient
starts bleeding, stops breathing, or incurs some other life threatening
complication. But what about the patient who’s medication was ordered
incorrectly, wasn’t sent up by pharmacy, or isn’t controlling their
pain? What about the admissions ER and OR need to send, even though each
nurse already has a full assignment? And how about the patient being
discharged who needs education about a new medication, a new diagnosis, new
equipment needed at home, or a new appliance that has been surgically
implanted? These are just a few out of hundreds of issues the nurse may
encounter that require juggling around of patients and/or a call to a
physician, a pharmacy, a family member, or even the previous nurse. Because
of this, the time spent in the patient room is prioritized into what needs
to be done, rather than what should be done.

Prioritizing patient care is unfair to the patient. What this means is the
nurse spends time assessing the patient, giving medications, and monitoring
the different equipment being used on the patient. At times, the nurse may
get a chance to reposition the patient, help the patient to the bathroom,
or address a comfort issue the patient is having. However, many times the
patients go without because the time isn’t there. Prioritizing the
patients also involves making sure extra time is found for patients that
are more critical or debilitated. Unfortunately, the patients that are able
to go to the bathroom independently and are more medically stable get even
less time with their nurse because another patient needs the attention.

Every patient within the nurse’s assignment pays the same amount of money
for their nursing care and the hospital bills for eights hours of nursing
care per shift; therefore, shouldn’t every patient be entitled to the
same quality of care?

The only way to increase time at the bedside is to ensure patient to nurse
ratios, which take acuity of patients into consideration, are in place.
Nurses supplement the time they have currently by skipping breaks, and
using afore mentioned prioritizations. This causes burnout for the nurses
and improper care for the patients. Any person with common sense can see
that lower patient ratios provides more time with the patient to prevent
falls and skin ulcers, promote health education and increase good patient
care.

Thank you,
Kelly Hedblad, RN