Joumal of Advanced Nursing, 1995,22, 623-627

Neonatal nursing staff time involved withmedication-related activities

Helen E Ridge BPharm MR Pharm SResearch Student on Department of Health Pharmacy Practice Research EnterpriseScheme, King's College London

and Alison E While BSc MSe PhD Cert Ed RGN RHVProfessor of Community Nursing, Department of Nursing Studies, King's CollegeLondon, London, England

Accepted for publication 1 December 1994

RIDGE H E & WHILE A E (1995) Journal of Advanced Nursing 22, 623-627Neonatal nnrsmg staff tune involved with medication-related activitiesA work sampling study involving 1920 observations derived from 48 2-hourobservation periods is described Approximately one-tenth of neonatal nursetime was spent on medication-related activities Just over one-third of this timeinvolved medication preparation It is suggested that the use of a pharmacymedication preparation service may be more cost-effective

INTRODUCTION

The issue of the most efficient use of health eare resoureesIS a point of eurrent debate in the western world as eoun-tnes seek to eontam their expenditure on health eareNursing manpower, owing to its size, eonsumes a largepart of tbe health eare budget and not surprisingly is sub-ject to enquiries into how nurses may work moreefficiently The Carr-Hill ef al (1992) study speeifieallyaddressed the relationship between skill mix m the nurs-ing workforee and effeetiveness of nursing eare However,detailed workload analysis was not meluded m that studyalthough the notion of teehnieal effieiency at least eostunderpinned the researeh question Indeed, Newbold(1995) has argued that teehnieal effieieney is a pnme objee-tive of all health eare units as they seek ways of deliveringthe same health eare output at eheaper eost Bell & Storey(1984) found that giving medieation (exeludmg intra-venous) occupied 7 9% of nurse Ume m a district generalhospital, and while Meyer (1984) describes the GRASPsystem of workload measurement no figures are givenregarding the mean distribution of nursmg time (GRASPIS a registered US trademark, an acronym of GraeeReynolds Applieation and Study of PETO )

Correspondence Professor A While, Department of Nursing Studw

King's College London Cornwall House Annexe Waterloo Road Lo don

SEl 8TX England

Interestingly, Wolf (1988) has asserted that giving medi-eation IS a therapeutic ritual whieh serves a partieularfunetion for nurses with some of the routme praetices per-sisting heeause they are part of a ritual Indeed, it may hethe ease that both medieation error (Lepinski et al 1986,Cohen 1990, Ferns et al 1990) £uid nursmg time (Burke1972, Lepinski et al 1986, Ferns et al 1990, Braek et al1992, Plumndge & Maher 1993) eould be reduced if medi-eations were fully prepared at the hospital pharmaeyThere is, however, a gap m the literature regarding theextent to whieh nursing time is spent on medieation-related activities More recently, Wmson (1991) found that61% (n = 128) of first-level nurses viewed registered nursesas competent to engage m smgle-nurse administration ofmedication, a change in nursing practice which wouldmuch decrease nurse time taken m this activity

Key deficiency in care

Ways m which neonatal nurse time and skills may he meixi-mized are of particular eoncem when considenng that theshortage of trained neonatal nurses has been identified asa key deficiency in eare provision of the newborn (Pittman1991) and eontnbutes to the diffieulty of providingspeeialized eare of very low hirthweight hahies (AuditCommission 1993)

© 1995 Blackwell Science Ltd 623

HE Ridge and A E While

THE STUDY

Roberts et al (1982) suggested that work sampling is themost suitable method for measunng activibes that are non-repebtive, have long working cycles and no daily pattemThere eire two approaches to work sampling, namely bmesampling and activity sampling Further advantages of thistechnique are detailed in Table 1

Time sampling, ublizing a bi-dimensional framework,neimely activity and contact, was considered an appro-pnate measurement tool for the observation of the pro-portion of nursing bme dedicated to medication-relatedacbvities Time sampimg, however, is only a reliable emdvalid method if there is a large enough sample (units ofobservation) emd therefore is resource-intensive m termsof time and therefore cost Like all m vivo observation,there is always the observer and observed problem to bemanaged

Activities

The study was conducted withm a sub-regional neonatalunit with 19 cots, including four intensive care cotsNursing staff activibes were separated into medication-related (as listed m Table 2) and non-medication-relatedacbvibes The pnmary contact was defined as the meunfocus of the activity observed, e g nurse under observabonwas commumcatmg with another nurse

A pilot study had identified the medicabon-relatedworkload according to the number of medicabons pre-scnbed for administration dunng 12 2-hour penods intowhich the 24-hour day had been divided Observationswere conducted proporbonally to workload For example,the number of medicabons scheduled to be administeredbetween 08 00 and 09 59 hours was four times greater thanbetween 02 00 and 03 59 hours, thus, the former 2-hourpenod was observed four times more frequently

Observations

Forty-eight observational blocks were undertaken duringNovember and December 1993 Two time blocks wereobserved daily, 6 days per week for 4 consecubve weeksA sbabfied sample of G, F and E grade nurses wasobserved, the total number of observabons per grade wasproporbonal to the number of whole time equivalents

Table 1 Advantages of work sampling techniques

A Allowances of the simultaneous study of several workersB The yielding of complete information about the total

operationG Emplo)rment of a technique most acceptable to professional

workers

Table 2 Medicabon-related acbvibes of nursmg staff

Key responsibihtiesSearching for the drug cupboard keys or another matter relatingto drug keys, for example, transfemng keys to another memberof staff which may require mterrupbon of other nursmg dubes

Dmg selectionSelecting and returning of an appropnate drug and/orreconstitution fluid from the drug cupboard or storage position

PreparationPreparation of a medication for administration to a neonateIncludes reconstitution, drawing up solubon, selection ofappropriate equipment for preparation and administration Anurse must be actually in the process of one or more of thesesteps, as opposed to the checking of another nurse performingthese processes, in order to be recorded in this categoryGommencement and removal of mfusions, including therearrangement and disconnecting of tubing, is also categorizedwithm 'preparation' as is the drafting of mfusion labels

ClanficationGonfirmation by the nurse of any part of the prescription withliterature or another member of staff pnor to preparation and/oradmimstration

CheckingI Observing another nurse in the process of preparation of a

drug pnor to administration of a medication to a specificneonate

II Gheckmg that a medication is to be administered to thecorrect neonate

III Gheckmg the treatment care for due medications, etc

AdministrationAdmimstenng a medication to a neonate

Assisting administrationAssisting another member of staff (medical or nursing) or a parentwho IS actually admmistenng a medication to a neonate

ChartingEntering details of drug administration/checking on the treatmentcard

ClencalAny other clerical activity related to medications, for example,adding attachments to the treatment card, requesbng a doctor torewnte a treatment card, requesting a drug from pharmacy

Relative counsellingTalking to parents or grandparents regarding any aspect of drugtherapy (excluding oxygen and blood)

Medication-related communicationsDiscussing an aspect of medication therapy with another memberof staff, for example, at a nursmg handover This category isdistinct from 'clanfication' smce transfer, not confirmation, ofknowledge is involved

OtherOther medication-related activities not descnbed by the abovedefinitions

624 © 1995 Blackwell Science Ltd, Joumal of Advanced Nursing, 22, 623-627

Neonatal nurses' use of time

Table 3 Number of observabon penods and observabonal rabosfor each grade of nursmg staff

Grade

GFE

No ofohservationpenods

221313

WTE

1277

Rabo

1 831 861 86

WTE, whole tune equivalent

(WTE) of eaeh grade withm the neonatal unit as detailedm Table 3 A nurse was assigned randomly for observationdunng eaeh of the 48 bloeks The nurse in eharge ofthe neonatal unit was exeluded fi'om observations Theassigned nurse was ohserved for the 2-hour period, withaetivity and pnmary eontaet hemg reeorded and eategor-lzed by tbe ohserver at 3-minute intervals

Immediately pnor to the imtial observation of an indi-vidual nurse, the nurse was informed that the observerwould he shadowing her/him for the subsequent 2 hoursto record her/his activity at 3-minute intervals The nursewas told specifically that the ohserver was not identifyingthe incidence of errors and to act completely as normalThe nurse was also asked whether or not she/he had anyobjeetions At the conclusion of the initial 2-hour obser-vational penod, the nurse was asked whether the presenceof the observer had altered the way m which she/he hadworked or had caused her/him to behave differently Anegative response was recorded in all eases

In an attempt to reduee hias owing to the possibility ofnursing staff delaying the preparation of medieations dueto be administered on the hour or the 'savmg-up' of medi-eation-related aetivities, no nurse was informed thatshe/he was to be observed until approximately 10 minutespnor to eommencement of the observation If the observerwas unable to identify the activity of a nurse dunng theohservational penod, the nurse was questioned disereetlyas to her/his aetivity at an appropnate point

Inclusion and exclusion criteria

Medieation-related aetivities lneluded all therapies as pre-senhed on the treatment card, excluding blood Oxygentherapy was excluded smee it was not presenhed on thetreatment card Milk was also excluded unless presenbedadditives such as vitamins, buffered phosphate and Duocalwere mcorporated, either at the time of observation or pre-viously In such mstfinces the milk was then consideredas a medication and thus feeding elassed as adminis-tration Doeumentation of medications in the nursingKardex was exeluded smee the observer eonsidered thatnursing staff would eontmue this praetiee notwithstanding

alterations m pharmacy serviees and to observe suehaetivity was judged to he an mtrusion

Certam activities conducted dunng routine nursmgobservations were not meluded hut classified as a non-medieation-related aetivity, for example, eheekmg thetotal volume infused, reqmrmg depression of a smglebutton on the infusion pump

FINDINGS

Activity dimension

Since observations were conducted at 3-minute intervals,40 observations were reeorded dunng eaeh 2-hour obser-vation period Thus, 1920 observations were made duringthe 48 penods, resulting m 850, 520 and 520 ohservationsfor G, F and E grade nurses respectively The percentageof nursing time spent on eaeh activity is summanzed inTables 4 and 5 The data were summed to reveal theproportion of medication-related nursing time spent ondifferent activities (Figure 1) with medication preparationoeeupymg approximately one-third of medieation-relatednursing time

Nurse senionty was assoeiated vyath more medication-related aetivities (x^ 9 2025, 2 df, P=0 01) Several trendswere noted, with mereasing nurse senionty hemg assoei-ated with more preparation of medieations, eheeking ofmedications and more administration of medications

Table 4 Percentage of nursing tune spent on each ohservationalactivity by grade of nurse

Activity

Non-medication-related activityKeysDrug selectionPreparationClanficationCheckingAdministrationAssisbng administrationChartingClericalRelative counsellingMedication-related discussionOther

G

86 50 00 65 50 13 11 80 00 30 70 10 90 5

F

89 20 4

0 22 50 02 9

1 50 00 00 80 21 01 4

E

91 70 21 03 50 01 40 60 00 40 20 60 60 0

Table 5 Percentage of medication-related activity spent onpreparation and checkmg hy grade of nurse

Activity G F

PreparabonChecking

40 322 7

23 226 8

41 316 1

© 1995 Blackwell Science Ltd, Joumal of Advanced Nursing, 22, 623-627 625

HE Ridge and A E While

AB

A C362 D

\ EFG

' H1JK

PreparationCheckingAdministrationMedication-relateddiscussionClericalEducationOtherCounsellingChartingKeysClarification

Figure 1 Percent^eof timespent by nurses on differentmedicabon-related acbvitiesNon-medication relatedacbvity, 88 7%, medicabon-related acbvity, 11 4%Assisbng administration wasnot observed in any grade

A NursesB SelfC NeonateD DoctorE ParentF ChemistG PharmacyH Literature

Figure 2 The proportion ofprimary contacts formedicabon-related activities(in percentages)

Conversely, less seniority was associated with more coun-selling of relatives and less medication-related nursingtime

Primary-contact dimension

Primary contacts related to medication are set out inFigure 2, with nurses frequently working together or ontheir own The data (Table 6) revealed that the nursesfrequently checked medications with other nursmgstaff (63 0% of G grade 'checking' observations, 60 0% ofF grade 'checking' observations and 71 4% of E grade'checking' observations)

Table 6 Percentage of primary contacts regarding medicabon-related acbvities by grade of nurse

Contact

DoctorLiteratureNurseNeonateObserverParentPharmacySelf

G

5 00 8

41 220 2

0 80 80 8

30 3

F

7 10 0

46 423 2

0 01 80 0

214

E

2 30 0

51 214 00 07 00 0

25 6

626 © 1995 Blackwell Science Ltd, Joumal of Advanced Nursing, 22, 623-627

Neonatal mules' use of hme

DISCUSSION

Nursing staff were observed to spend about one-tenth oftheir bme (G grade 13 5%, F grade 11 8%, E grade 8 3%)on medicabon-related activibes, with medication prep-aration occupying a significant proporbon of that bme(G grade 40 3%)

Evidence (Burke 1972, Lepinsla et al 1986, Ferns et al1990, Brack et al 1992, Plumndge & Maher 1993) indicatesthat the use of a pharmacy medication-preparabon serviceIS more cost-effective regarding manpower costs and,further, may also reduce medication error (Lepinski et al1986, Ferns et al 1990, Cohen 1990)

Examples of medicabon errors include the avoidance ofdrug lnteracbon between gentamicin and hepann, genta-nucm and frusemide, and bolus administration of vanco-mycm The pharmacy preparation of medication may alsopermit the safe introducbon of smgle-nurse admmistrabonof medication, thereby releasing skilled nursing bme forotber elements of patient care

Plumndge & Maber (1993) have suggested that cost sav-ings may be made with preparabons for a 24-hour periodHowever, Diehl et al (1992) recommended 8-hour periodsfor preparation so that medicabon wastage is mmimizedalthough greater pharmacy manpower costs will beincurred

CONCLUSION

This study has revealed that a significant amount of skillednursing time is spent on medication-related activitieswhich may be undertaken m part by a pharmacymedication-preparation service The quest for technicalefficiency m health care delivery demands that skillednursing should be opbmally employed and therefore itmay be appropnate to consider the lnfroducbon of phar-macy medication-preparabon services especially wheremedication errors could be avoided m areas of complexhealth care delivery such as neonatal and other mtensivecare setbngs Further, in the neonatal setting such a servicemay m part compensate for the shortage of trained neo-natal nurses by releasing nursing bme for other nursingcare acbvities

Acknowledgement

Helen Ridge was supported by a Department of HealthPharmacy Pracbce Research Enterpnse SchemeStudentship

References

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