Practicum Project Plan

Because of the complexity and dynamic nature of the health care system, effective commu- nication remains pivotal to the health care process. This article compares nursing time and user friendliness of two nurse call systems in a large metropolitan hospital. Results identify ways to save RN time and acknowledge the importance of unit secretaries in the daily oper- ation of a nurse call system operation on an adult medical-surgical unit. Key words: com- munication, hospital work environment, nurse call system, nursing performance Nurse Call and the Work Environment: Lessons Learned 7 Journ Nurs Care Qual2001;15(3):7Ð 15 © 2001 Aspen Publishers, Inc. Elaine Tilka Miller, DNS, RN Professor of Nursing University of Cincinnati College of Nursing Cincinnati, Ohio Carol Deets, EdD, RN Associate Dean for Nursing Research University of Cincinnati College of Nursing Cincinnati, Ohio Robert V. Miller, PhD President and CEO Cooper Research, Inc.

Cincinnati, Ohio T ODAYÕS HOSPITAL-BASED NURSES are being challenged on many powerful fronts. Patients are admitted more acutely ill and discharged much more quickly than they were in the past. Concurrently, health care reform and the need to control costs has led to a sometimes drastic reduction in the licensed nursing work force and re- sources available to them. 1Ð3 As a result of these changes, effective communication, a cornerstone in the quality, continuity, and speed of patient care delivery, has become even more crucial than before.

4Ð6 In most in- stances, an efÞcient nurse call system can Òlend order to chaosÓ and signiÞcantly con- tribute to the delivery of high-quality patient care, achievement of patient outcomes, and increased patient satisfaction. 7,8 Just as technology is transforming our lives at home and work, so too is it having a notable impact on nursesÕ ability to commu- nicate with one another and perform their professional responsibilities. 2,9,10 Because of unprecedented technological advances, new and better ways of delivering routine and emergency health care services are also being created, thereby changing the Òwork of patient care itself.Ó 11,12 Because of the paucity of information regarding the advancements Article 2 2/19/01 7:01 PM Page 7 in nurse call systems, research pertaining to this essential component of the health care delivery process must be intensified. Un- fortunately, many decisions about the effi- cacy of nurse call systems are made well after installation.

The purpose of this study was to evaluate two nurse call systems in a large Eastern metropolitan hospital. This research project addressed the following questions: (1) Is nurs- ing time saved using the SystemB nurse call compared to the amount of time needed with the current SystemA nurse call? (2) Does the SystemB nurse call provide a more user- friendly and patient-oriented system than the SystemA nurse call?

DEFINITION OF TERMS Minutes on: Time from when the patient call was placed to when the call light was turned off.

Minutes until prepared: Amount of time until the nurse was prepared to meet the pa- tient need, not that patient need was actu- ally met.

Nursing time: The amount of time the nurse is engaged in performing his or her nursing duties.

SETTING Because of a need to replace its existing nurse call system, the institution conduct-ing this study was willing to explore an alternative system. The unit selected was a 28-bed VIP adult medical/surgical unit that had a diverse group of health-related problems.

THE NURSE CALL SYSTEMS SystemA The hospital had a SystemA that consisted of a master station, outside room dome lights, and call devices from the patient bed, bathroom, and shower. Steady versus ßash- ing room dome lights indicated whether the patient call was a normal or priority call. Pa- tient calls went to the nursing station where the unit secretary answered. If the nurse was needed, he or she was paged via a pocket pager. Nurses routinely initiated calls from patient room call devices to check with the nursing station to respond to pages, ask for help or equipment, and clarify orders.

SystemB The SystemB consisted of a master sta- tion, room station, locator badges, corridor lights, and bathroom and bed call interface units. Through locator badges, a nurseÕs lo- cation was constantly tracked. The master station enabled unit secretaries or nurses to monitor rooms, communicate with patients and staff throughout the unit, locate staff, and store important patient and staff infor- mation in a computer database. The room stations permitted nurses to call the master station, locate other nurses, receive staff and patient calls, and declare emergency situa- tions (e.g., codes, staff emergency). Corridor lights mounted above or near patient rooms alerted staff to emergencies, normal or pri- ority calls, and the presence of a nurse in a patientÕs room. 8J OURNAL OF NURSING CARE QUALITY /A PRIL 2001 Because of unprecedented technological advances, new and better ways of delivering routine and emergency health care services are also being created, thereby changing the Òwork of patient care itself.Ó Article 2 2/19/01 7:01 PM Page 8 Procedure Pretest data were collected approximately one week before SystemB installation. Post- test data collection was conducted one month after SystemB installation. Pretest and post- test data collection consisted of a dual ap- proach using a focus group discussion as well as observational data regarding actual nurse and unit secretary use of the respec- tive nurse call systems.

During the pretest and posttest, focus group discussions, approximately 90 min- utes in length, were conducted with groups of 15 to 20 nurses, nursing aides, and unit secretaries on the unit. The focus group questions concentrated on: (1) the manner in which the system was used for conven- tional patient calls, staff emergencies, and code blues; (2) how well the system facili- tates communication between nurses and patients; (3) staffÕs likes and dislikes of the system; and (4) features that should be in- corporated into a nurse call system. During the postinstallation focus groups, an addi- tional questionnaire was administered de- signed to compare attributes of the SystemA with SystemB.

Pretest data collection pertaining to the SystemA nurse call occurred for 28 hours (9 AM to 9 PM , 11 AM to 7 PM , 7 AM to 3 PM ) over three consecutive weekdays. Five trained ob- servers were used (one at the master station console, one hall observer on the private wing, and two others on the semiprivate wing). The last trained observer assisted in the coverage of heaviest demand areas and was available to provide the others with breaks and permit rotation of observer posi- tions. All data were recorded on specially de- signed collection worksheets, one for the master station and another for hall observa- tion. The time the call came on, time off, whether the call was turned off at the master station, reason for the call, and other associ-ated observations or problems such as Òcould not hearÓ were recorded by the master station observer. Hall observers stood in the hallways and noted the time the dome light went on and then off, whether assistance was needed, the amount of time until the caregiver was prepared to give care, and other relevant comments such as noise level, hearing difÞculties, and general unit activity.

The pretest and posttest data collection processes were the same, except posttest data were collected for 36 hours (9 AM to 9 PM , 11 AM to 7 PM , 7 AM to 3 PM , 11 AM to 7 PM ) over four consecutive days. Because of an intermittent electrical short in one of the patient rooms that led to the loss of SystemB data for the Þrst three days, posttest data were collected for the additional 11 AM to 7 PM time period. Throughout the entire data collection process, standard human rights guidelines were followed.

RESULTS During the preinstallation data collection period, 24 beds were occupied with three to four RNs and one LPN typically scheduled on the 7 AM to 3 PM shift and four RNs and one LPN scheduled on the 3 PM to 11 PM shift.

Acuity level during data collection usually involved 14Ð18 patients requiring moderate assistance; the remaining patients required usually a combination of minimal and max- imum assistance. Patient characteristics and needs experienced during the pretest phase were similar to the posttest data col- lection period.

As mentioned, the posttest data collected during the Þrst three days were lost because of an electrical short in one of the rooms; this short affected the entire system and caused all data in the log Þle to be lost. The system would reset itself and begin collect- ing data again only to lose the data the next time the light was used. Every effort wasNurse Call and the Work Environment9 Article 2 2/19/01 7:01 PM Page 9 10 J OURNAL OF NURSING CARE QUALITY /A PRIL 2001 made to resolve the problem, which was eventually found to be a screw that was in contact with a wire, thereby requiring the in- stallation of a new unit in the room. Unfor- tunately, Þnding the Òscrew in the haystackÓ took almost three full days.

The Þrst research question addressed whether time was saved using the SystemB compared to the SystemA nurse call. Data were obtained through a combination of hall and master station observations. Descriptive Þndings involving pretest and posttest data will Þrst be presented.

Pretest and posttest reasons for all col- lected data on calls and time the lights went on are listed in Table 1. Some patient callsdid not contain complete data (time on, time off, reason for call); these data are not re- ported. Only complete data (pretest n =142 and posttest n =65) are reported. Data per- taining to the time until the nurses were pre- pared to meet the call request using each nurse call system are presented in Table 2.

With both the SystemA and SystemB, nurses sometimes called the desk for assistance, clariÞed physician orders, and located the narcotic keys. During the pretest, staff re- ported problems with hearing 14.7 percent of the pretest calls, while no hearing difÞcul- ties were observed during the posttest.

The reasons for calls were divided into two categories: those that required an RN to meet Table 1.Summary of minutes call light request placed and light turned off Variable % N Mean SD Range Mistake SystemA 4.9 7 0.32 0.10 0.23 SystemB 6.1 4 0.64 1.01 2.03 Medicine SystemA 7.7 11 0.58 0.54 1.83 SystemB 29.2 19 0.41 0.32 1.18 Bathroom SystemA 38.7 55 0.43 0.37 1.95 SystemB 15.3 5 0.29 0.20 0.48 Staff need help SystemA 6.3 9 0.44 0.32 1.07 SystemB 23.1 15 0.25 1.88 0.58 Foods/ßuids SystemA 1.4 2 0.37 0.19 0.27 SystemB 18.5 12 0.46 0.28 0.90 IV SystemA 9.2 13 0.38 0.24 0.78 SystemB 0 Personal care SystemA 2.8 4 0.39 0.18 0.42 SystemB 0 Discharge SystemA 1.4 2 0.38 0.18 0.25 SystemB 0 Questions about care SystemA 4.9 7 0.44 1.60 0.42 SystemB 0 Do something in room SystemA 3.5 5 0.41 0.16 0.38 SystemB 0 Put back to bed SystemA 3.5 5 0.79 0.78 1.78 SystemB 0 Fix (catheter, dressing) SystemA 13.4 19 0.99 1.72 6.92 SystemB 6.1 4 0.57 0.94 1.90 Note: SD =standard deviation Article 2 2/19/01 7:01 PM Page 10 Nurse Call and the Work Environment11 Table 2.Summary of minutes until prepared to meet expressed need Variable % N Mean SD Range Medicine SystemA 7.7 11 5.68 6.14 17.83 SystemB 15.3 19 1.49 1.28 4.15 Bathroom SystemA 38.7 55 2.19 3.37 22.95 SystemB 7.6 5 0.94 0.76 1.78 Staff needs help SystemA 13.8 9 1.77 1.52 4.63 SystemB 23.0 15 1.11 1.06 3.00 Foods ßuids SystemA 1.4 2 1.10 0.15 0.22 SystemB 18.5 12 1.46 2.15 7.88 IV SystemA 9.2 13 1.26 0.78 2.23 SystemB 0 Personal care SystemA 2.8 4 4.43 5.67 11.52 SystemB 0 Discharge SystemA 1.4 2 .97 0.47 0.07 SystemB 0 Questions about care SystemA 4.9 7 3.44 4.97 11.75 SystemB 0 Fix something in room SystemA 3.5 5 2.35 1.40 3.00 SystemB 0 Put back to bed SystemA 3.5 5 4.93 6.88 16.75 SystemB 0 Fix catheter, dressing SystemA 13.3 19 2.82 3.99 16.67 SystemB 2.8 4 1.09 1.02 2.15 Note: SD =standard deviation the need and those that did not. If the per- son answering the call could ascertain the skills required, the right level of caregiver could be sent to meet the expressed need. In fact, the patient would often say ÒI need a nurseÓ and the RN would be called. When the RN arrived, however, frequently it was found that a non-RN could have been sent instead. As indicated in Table 3, more than 75 percent of the pretest calls and 50 per- cent of the posttest calls did not require RN knowledge and expertise.

On the Þnal 11 AM to 7 PM day of postin- stallation data collection, student nurses were caring for patients. The students did not have badges so the care they provided their patients is not reßected in these data.To make the pretest and posttest data com- parable, one dayÕs pretest data between 11 AM and 7 PM were used to compute the compari- son and are presented in Table 4. The range and standard deviations indicate that there is considerable consistency across the amount of time the call light was on. A one-way analy- sis of variance (ANOVA) was computed to test for pretest to posttest differences in the data.

The Òuntil preparedÓ variable data result in a signiÞcant F-test (1, 96 df ) at the 0.004 level.

In other words, signiÞcantly less time was taken to get prepared at posttest than at pretest.

Because the sample size had been reduced due to the loss of data, a power analysis was computed for the signiÞcant Þnding. The Article 2 2/19/01 7:01 PM Page 11 12 J OURNAL OF NURSING CARE QUALITY /A PRIL 2001 power for this analysis was 0.83. A power level of 0.80 is considered an acceptable power level. 13Because the data for the post- test period was problematic, additional analy- ses were not conducted.

The second research question centered on the user friendliness and how Òpatient ori- entedÓ the two systems were. During the preinstallation focus groups, a combined group of 20 staff nurses, nursing assistants, and unit secretaries shared their percep- tions. Nurses were generally dissatisÞed withthe SystemA nurse call system and reported difficulties associated with the quality of the transmission, unreliability of the voice pagers, inability to distinguish emergency and nonemergency calls, and inability to easily locate other nurses. Content analysis of the focus group discussion postinstalla- tion of SystemB revealed most of the 15 par- ticipants thought this new system saved time locating another staff member and pro- vided validation that the call was received, a feature not provided by the previous system. Table 3.Comparison of calls requiring RN vs. non-RN skills to meet needs with SystemA and SystemB Variable/System Number Mean Std Range Time onSystemA RN 24 0.48 0.41 1.98 Non-RN 102 0.55 0.83 6.95 SystemB RN 19 0.41 0.32 1.18 Non-RN 21 0.44 0.44 1.90 Time until preparedSystemA RN 24 3.15 4.52 17.87 Non-RN 102 2.59 3.76 22.95 SystemB RN 19 1.45 1.28 4.15 Non-RN 21 1.26 1.69 7.88 Table 4.Comparison of SystemA and SystemB data Variable SystemA SystemB Number of calls 63 65 Mean time on .42 min .42 min Standard deviation .29 min .27 min Range 1.98 min .98 min Mean time until prepared 2.59 min 1.23 min Standard deviation 3.16 min 1.36 min Range 16.95 min 8.10 min Article 2 2/19/01 7:01 PM Page 12 Problems identified were: locator badges being covered by clothing, thereby inhibit- ing transmission of the badge signal; staff turning away from the signal receivers; the lack of signal receivers in all hallways and at the nursing station; and the occasional Òfalse callsÓ resulting from the electrical shorting in one patient room. Focus group data further suggested that room-to-room communication was not widely used by staff because it had not been fully explained in the initial inservice training. However, of those who used room-to-room communi- cation, no problems were reported pertain- ing to patient confidentiality. When using SystemB, staff typically established norma- tive behavior and only referred to room numbers and kept detailed information to a minimum.

Results from the Nurse Call System Fol- low-up Questionnaire revealed at least 80 percent of the participants preferred Sys- temB to SystemA for communication efÞ- ciency with patients and staff and ÒoverallÓ system satisfaction. In general, postinstalla- tion focus group participants rated SystemB much more favorably than the preexisting SystemA. More than 50 percent also indi- cated that SystemB increased their produc- tivity, but they did not report a perceived dif- ference in patient average length of stay.

In summary, the unit staff performed at a high level of nurse call system proÞciency even before the introduction of SystemB.

Even so, SystemB nurse call was able to save the nurses time and enable them to meet the patients needs more swiftly than the prior system.

DISCUSSION AND IMPLICATIONS EfÞcacy of a unitÕs nurse call system has multiple ramiÞcations to the delivery of nurs- ing care and user satisfaction. Clearly, the pretest and posttest data reafÞrm the impor-tant role a unit secretary can play in the day- to-day operation of any nurse call system.

When the unit secretary is functioning at such a high rate of proÞciency as in this study, SystemB saves little additional time until the call is answered. The real time saver, as expected, occurs after the call has been answered. The signiÞcant ANOVA illus- trates the value of the posttest SystemB in reducing the time nurses spend in getting prepared to meet patient needs. This reduc- tion can probably be attributed to nurses knowing ahead of lime the request (e.g., pain medication and preparing to fulÞll it before entering the patientÕs room). Data from Table 4 further reveal 85 minutes of nursing time during an 8-hour pretest period could poten- tially be saved and thereby used for other purposes. This Þnding supports other re- search that found an effective nurse call sys- tem can save nursing time as well as improve patient care. 2,9 Experts agree that profes- sional nursing time is a valuable commodity that must be preserved for activities requir- ing the RNÕs knowledge and skill. Results from a study of more than 170,000 health care workers revealed that the number of activities performed by RNs is signiÞcantly higher than other occupational groups in health care-74 activities. 1Thus, a nurse call system that complements the many facets of a professional nurseÕs role performance is a tremendous time and money saver.

Data were categorized into RN and non-RN activities and suggested that more than 75 percent of the pretest nurse calls and 50 percent of the posttest calls could proba- bly have been answered by a less skilled worker. Once again, the study by Murphy and colleagues support that on average 51 percent of the time RNs perform activities outside the role deÞnition and do not require their level of knowledge and ability. 1Admit- tedly some of the other calls in particular Òstaff needs helpÓ may sometimes require RN Nurse Call and the Work Environment13 Article 2 2/19/01 7:01 PM Page 13 14 J OURNAL OF NURSING CARE QUALITY /A PRIL 2001 expertise, but based on the information ob- tained from this staff, the majority of calls could have received a response from less- skilled personnel.

Results from the pretest and posttest focus groups also reafÞrmed nurse call sys- tem features that nurses and unit secre- taries identiÞed as complementary to their performance. Locating staff, direct room- to-room communication, corridor light de- lineation of emergency and nonemergency calls, and clear sound quality were de- scribed as critical attributes enhancing job performance. Although conÞdentiality of pa- tient information was a concern pertaining to room-to-room communication, nurses in- dicated that they informally had established some norms of what could and could not be said. In spite of the comfort expressed, fur- ther exploration of this issue may be war- ranted as institutions purchase nurse call systems that provide this feature. The one product beneÞt that nurses noted as making the greatest difference in their role perform- ance was the locating function available in the posttest SystemB nurse call. Being able to locate another staff person from the pa- tientÕs room and then directly calling him or her was instrumental, according to the nurses, in reducing the amount of time Òwasted.Ó This Þnding is supported by Lin- den and English, who, in a work sampling of 6,709 random observations, found that al- most 10 percent of nursing time is spent Òlooking for someone.Ó 14 Some nursing ad-ministrators estimate that this amount of time is far higher.

Although the nurses reported using the room monitor to Þnd nurses and talk with them, the researchers did not observe any interroom communications during the Þrst two days of postdata collection. At the end of the second day, one of the nurses was re- minded of this feature and it was demon- strated to her. On the third day, she reported using it and Þnding it very helpful. Because of her concern and enthusiasm, she gener- ated much interest among the other nurses and thereby facilitated nursing interroom communication interchanges. Admittedly, these comments during the focus group probably reßect the data collection teamÕs intervention.

This study has limitations in that it was conducted on an adult medical surgical unit willing to evaluate its existing nurse call sys- tem as well as a new one. Also, data were lost during the posttest because of the intermit- tent electrical problem. The power analysis, however, indicated the sample size was ac- ceptable. In spite of these limitations, this investigation provides beginning insights into how nurse call systems affect nursing time and the features nurses perceive as valuable to the performance of their nursing activities. Although technology will continue to modify how nurses perform their duties, research must continue to examine how these technological advancements affect the delivery of health care. REFERENCES 1. E. Murphy, S. Ruth, J. Pepicello, M. Murphy, ÒManaging an Increasingly Complex System,Ó Nursing Management28 (1997): 33Ð36.

2. P. Spruck, M. Mohr, A. Seroka, M. Stoner, ÒThe Impact of Wireless TelecommunicationSystem on Time EfÞciency,Ó Journal of Nurs- ing Administration25 (1995): 21Ð26.

3. S. Gordon, E.D. Baer, ÒFewer Nurses to An- swer the Buzzer,Ó The New York Times, De- cember 6, 1994; Section A, page 23, column 2. Article 2 2/19/01 7:01 PM Page 14 Nurse Call and the Work Environment15 4. E. Felt, ÒUpgrading Systems: A New Pager,Ó Nursing Management25 (1995): 39.

5. C. Boston, ÒData Systems, Data Sets, and Work Transformation,Ó Journal of Nursing Ad- ministration24 (1994):11Ð12.

6. L.L. Parisi, ÒImproving the Process of Commu- nication at the Bedside,Ó Journal of Nursing Care Quality9 (1994): 10Ð15.

7. D. Arthur, ÒNurse Call Choice on Area, Lay- out, and StafÞng,Ó Health Facilities Manage- ment6, (1993): 42Ð44.

8. E.A. McConnell, ÒIf the Communication Sys- tem Fits. . .Ó Nursing Management29 (1998):

57.

9. E.T. Miller, C. Deets, R.V. Miller, ÒNursing Call Systems: Impact on Nursing Performance,Ó Journal of Nursing Care Quality11 (1997):

36Ð43.

10. D. Snyder, ÒA Cooperative Effort to Probe In- formation TechnologyÕs Pivotal Role in HealthCare Reform,Ó Health Information Manage- ment8 (1995): 39Ð40.

11. M.C. Tonges, ÒReengineering the Work Re- design-technology Link,Ó Journal of Nursing Administration23 (1993): 15Ð122.

12. T.A. Burke et al., ÒA Comparison of Time-and- Motion and Self-reporting Methods of Work Measurement,Ó Journal of Nursing Adminis- tration30 (2000): 118Ð125.

13. J. Stevens, Applied Multivariate Statistics for the Social Sciences, 2d ed. (Hillsdale, NJ:

Lawrence Erlbaum Associates, 1992).

14. L. Linden, K. English, ÒAdjusting the Cost- Quality Equation: Utilizing Work Sampling and Time Study Data to Redesign Clinical Practice,Ó Journal of Nursing Care Quality8 (1994): 34Ð42. Article 2 2/19/01 7:01 PM Page 15