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International Journal of Nursing Practice 2014; 20: 662–673

RESEARCH PAPER

A systematic review of time studies to assess the impact of patient transfers on nurse workload Nicole Blay BHA RN PhD student, Centre for Health Services Management, Faculty of Health, University of Technology, Sydney, Sydney, New South Wales, Australia

Christine M Duffield PhD RN Professor & Director, Centre for Health Services Management, Faculty of Health, University of Technology, Sydney, Sydney, New South Wales, Australia

Robyn Gallagher PhD RN Associate Professor, Chronic & Complex Care, Faculty of Health, University of Technology, Sydney, Sydney, New South Wales, Australia

Michael Roche PhD RN Senior lecturer, Centre for Health Services Management, Faculty of Health, University of Technology, Sydney, Sydney, New South Wales, Australia

Accepted for publication August 2013 Blay N, Duffield CM, Gallagher R, Roche M. International Journal of Nursing Practice 2014; 20: 662–673 A systematic review of time studies to assess the impact of patient transfers on nurse workload Patients in hospital are increasingly being moved between clinical units and between bedspaces; however, the impact of patient transfers and bedspace moves on nurses’ workload is not known. Time studies are an established observational research method that can be used to determine the duration of time taken to perform an activity or process. This review systematically searched four databases for literature published between 2000 and 2013 for observational time study techniques and patient transfers as a nurse activity. Eleven publications from three countries were included in the review. All studies used timing techniques to explore nurse work associated with the transfer process. The review highlights the duration of time spent by nurses on certain aspects of the transfer process. However, as few studies published results from timings, the impact on nurse time is likely to be higher than indicated. Further research is recommended. Key words: nurse workload, patient transfer, time and motion studies, transportation.

INTRODUCTION The demand for health care is increasing in Australia and internationally, forcing hospitals to examine ways to maximise patient throughput. Increased throughput from Correspondence: Nicole Blay, Centre for Health Services Management, Faculty of Health, University of Technology, Sydney, PO Box 123, Broadway, NSW 2007, Australia. Email: [email protected] .edu.au © 2014 Wiley Publishing Asia Pty Ltd

patient turnover results in corresponding increases in staff workload that can negatively affect patient outcomes.1–4 However, the impact of patient turnover on nurse workload is likely to be underestimated, as patient transfers are often not included in workload studies. To some extent, this is because traditional measures of workload such as the midnight census are unable to capture all patients that pass through the patient care unit5–8 or to capture movements from one bedspace to another. doi:10.1111/ijn.12290

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Patient transfers and bedspace moves Patients are frequently transferred between clinical units and bedspaces, often in response to a change in clinical status, although increasingly patients are being transferred without clinical justification as a response to demand for beds.9–12 Furthermore, the transfer of patients can result in a cascade of bedspace moves within the same clinical unit in order that the new/transferring patient can be accommodated. Patients experience a minimum of two transfers during their hospital stay and, in Australia, are nursed in at least two units during their hospital episode.3,13,14 In a sample of long-stay patients, Johnson et al.14 found that at the time of interview, patients had experienced an average of 2.26 wards (range 1–8). Duffield et al.13 reported that 1.25 patients occupied each medical–surgical bed per day. In their longitudinal study of nurse work in 27 Australian hospitals, the number of clinical units per patient increased by 7% over five years.3,13 Considering the frequency of such moves, the amount of time spent by nurses relocating patients could be substantial. Techniques used to examine nursing workload and patient care processes are primarily direct observational methods. In light of the emerging data on patient turnover and specifically patient transfers, nurse researchers are increasingly employing observational timing techniques to study health-care processes. The two main techniques used to investigate workload associated with activities like patient transfers are time studies (TS) and time-andmotion (TM); studies using these techniques are among the subjects of this review.

Time studies TS, also referred to as timing studies technique, was developed over a century ago in the manufacturing era, by Frederick Taylor.15–17 Taylor divided workplace activities into component tasks called elements and then continuously observed and timed each element (and worker) individually to standardise performance and increase efficiency in the workplace.18,19 Meanwhile, Frank and Lillian Gilbreth used sophisticated (for that era) lighting and time-exposed photography to demonstrate the pattern of movements (motions) made by bricklayers and assembly workers, among others. The Gilbreths argued that many motions made by workers were inefficient and that straightening and standardising motions would make said motions more efficient.16,18 In reality, smoothing out and reducing the number of workers’ motions made little

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impact on the time taken to perform a task. After Taylor’s death in 1914, the Gilbreths capitalised on his success by combining the principles of TS with their own motion studies to form the TM technique.18,20

Time and motion TM is classified as a type of TS technique.17 Its major principle is the continuous and independent observation of workers, an activity or a process.20–27 Continuous observation requires that an independent observer follow one individual at a time to record and time all activities performed in sequential order. Each activity, task or process is observed and timed from commencement until completion, or until the activity is halted by an interruption.17,21,24,25,28 As TM can provide information on the frequency with which each activity is performed, the number of interruptions and the duration of time spent continuously performing an activity,27,28 it is considered to be the ‘gold standard’ of observational research methods.20,21,23,28

Work sampling TM and TS techniques are often considered alongside work sampling (WS) techniques, where activities performed by subjects at random or predetermined intervals are recorded. Activity frequencies are proportioned to calculate the percentage of time spent on each activity and describe the pattern of work.21,29–31 WS studies have frequently included the transfer or transportation of patients as a nurse activity.32–36 However, WS studies have been excluded from this review because the technique does not involve the continuous observation and timing of activities. Therefore, the duration of time taken to perform an activity is not measured. For this reason, this paper will focus on TS and TM studies.

Review objective In light of the gap in nursing knowledge on the time spent transferring patients between units and bedspaces, the review aims to appraise current literature to help determine the influence of patient transfers on nursing workload.

METHODS The method and reporting methods used for this review are based on the PRISMA (Preferred Reporting Items for © 2014 Wiley Publishing Asia Pty Ltd

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Table 1 Inclusion and exclusion criteria Inclusion criteria

Exclusion criteria

Articles excluded (n)

Publication criteria

Published in print in the English language between Not published in print in the English language between 2000 and 2013 2000 and 2013

Types of study

Time or time-and-motion studies

Studies that did not include the timing of nurse activities (e.g. work sampling, surveys, qualitative studies) Study design Direct observation by independent observers Self-reported and self-timed studies Mixed methods if direct observation and timing of Audiovisual techniques activities were included within the study design Systematic reviews or meta-analyses Patient Intrahospital transfers between two clinical units Interhospital transfers transfers Intrahospital transfers that did not include the nursing role Studies that did not include an activity associated with patient transfers Quality control measures that focussed on specific aspects of the transfer process (e.g. transfer delays) Patient transfers from chair to bed and other lifting techniques Nurse escort Time spent by nurses escorting patients between Nurse time spent in transit (travelling between two clinical units patients/rooms/tasks).

Systematic Reviews and Meta-analyses)37 and MOOSE (Meta-analysis of Observational Studies in Epidemiology) guidelines.38

Sources A search of the electronic databases MEDLINE, CINAHL, Health Source: Nursing/Academic Edition and PubMed was performed between November 2012 and March 2013 by the corresponding author. The key Medical Subject Headings (MeSH) and Boolean phrases used were ‘time and motion’ OR ‘time study’ OR ‘timing study’ in combination with ‘patient transfer’ OR ‘transportation’ OR ‘intra-hospital’ AND ‘nurse work’ OR ‘nurse ‘workload’ OR ‘nurse escort’. Articles were also located from manual scans of reference lists and Rich Site Summary (RSS) feeds. RSS feeds automatically notify subscribers of changing web content such as journal content lists. © 2014 Wiley Publishing Asia Pty Ltd

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Inclusion criteria The criteria for article inclusion and exclusion are summarised in Table 1. Articles selected for the review included peer-reviewed research studies and metaanalyses or systematic reviews that addressed intrahospital transfers, were written in English and published between the years 2000 and 2013. Studies were included if direct observation was used to time nurse activities associated with patient transfers or the transportation process. Studies involving timing methods such as TS or TM were included if they addressed nursing work and included the transfer, transportation or movement of patients as an activity. Studies were excluded if the focus was interhospital transfers or the role of the nurse in the transfer process was not examined. Self-recorded and self-timed studies were excluded, as data accuracy could not be ensured.

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Publications extracted from initial electronic database search (n = 1056) Excluded following review of title or abstract (n = 1034) Retained for review (n = 22) Articles sourced from RSS feeds (n = 1)

Articles sourced from reference lists (n = 1) Full text not available (n = 1)

Full-text articles reviewed (n = 23)

Articles excluded (n = 12)

Met study criteria (n = 11)

Articles included in final review (n = 11)

Figure 1. Flow diagram of review process.

Search results As shown in Figure 1, the initial database search resulted in 1056 articles being identified, of which 22 were retained for full text review. Two additional articles were sourced from manual scans of reference lists (n = 1) and from an RSS feed (n = 1). Twenty-three of the 24 articles were reviewed, as the full-text version of a Japanese study published in the English language could not be located.39 Articles were included in the review if they met the criteria of being original research articles, systematic reviews or meta-analyses of primary research that were published in the English language between 2000 and 2013 and

observed nurse practice associated with intrahospital patient transfers. Following full text review, 12 articles were excluded for the reasons shown in Table 1. Eleven published articles fulfilled the criteria and were included in the systematic review.

Data extraction Screening of titles and abstracts following initial searches was undertaken, and full text versions were sought for articles that fulfilled the study objectives. A purposefully designed Excel spreadsheet was used to capture information relevant to the review, including country of origin, © 2014 Wiley Publishing Asia Pty Ltd

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setting, study design, sample, transfer activities and outcomes.

Assessment of risk of bias An assessment of the risk of bias was undertaken for the selection of articles included in the review as well as for bias within studies. Scoring observational studies for the assessment of bias is not recommended,37,38 as tools used for such purposes show variability in validity and reliability.40 Studies were assessed as having either low, medium or high risk of bias41 based on five observer-related criteria. These included observer numbers, observer characteristics, observer training, simultaneous practice observation with a clinician or recognised expert, and testing for interrater reliability. Studies considered to have low risk of bias addressed all five criteria; those having medium risk addressed three to four criteria, and high-risk studies provided details on two or fewer criteria. Reviewer bias was assessed on the basis of study heterogeneity as evidenced by diversity in study sites and the number of subjects (Table 2).

RESULTS Eleven articles based on nine research studies were included in the review. One article was published in two parts,46,47 and two publications referred to the same large multisite study.49,50 For essential detail, it was necessary to include both articles for each study in the review. As shown in Table 2, the studies were conducted at 12 adult and/or paediatric rural, suburban or urban hospitals in the USA (n = 6),42,46–52 Australia (n = 2)43,44 and Canada (n = 1).45 Four studies36,42,47,48 indicated bed numbers for five participating hospitals, which ranged from 209 to 950 beds.42,44,47,51 Settings for such studies included eight adult intensive care units (ICUs),42,43,45,50,52 two paediatric ICUs,42,45 one neonatal ICU42 and a paediatric emergency department.48 At unit level, sites included 16 medical–surgical units,44,47,49,50 one oncology ward44 and three maternity units.44,50

Study designs Five studies used a TM technique43,44,48,51,52; two studies followed observational timing techniques45–47; one used mixed methods that included the observation and timing of activities49,50; and another employed behavioural task analysis with real-time observation.42 This last technique very closely followed the TM technique. © 2014 Wiley Publishing Asia Pty Ltd

Timing of activities varied in that only one study reported that observation and timing were performed in a continuous manner.42 Others did not provide enough detail regarding the timing technique43,44,46,47,49–51 or limited observation to the subject’s work unit.45 Timing ceased when subjects left the unit for any reason. For the most part, study objectives were to examine nurse activities and/or workload,42,43,45 to examine the impact of information systems on nurse workload46–48,52 and to determine which nurse activities could be considered to be of value in terms of nurse cost and time.49,50 Two studies focused on activities associated with the patient transfer process,44,51 and two studies recorded the dominant activity observed.48,52 In line with their different designs, methods and reporting styles, studies varied in the likelihood of risk of bias. As shown in Table 2, two studies were considered as low-risk,42,43 two as medium-risk45,51 and the remainder as high-risk.44,46–50,52

Subject of observation The subject of observation, defined in eight studies, ranged from health-care workers42,43,45–48,52 to patient transfers51 and the unoccupied bed.44 When health-care workers, including nurses, were the subjects, participant numbers ranged from 10 to 230.42,43,47,52 Hendrich and Lee51 tracked and timed ‘more than 200’ patient transfers, whereas a more recent study focused on 517 unoccupied beds, of which 277 were associated with temporary transfers,44 such as occur when patients attend other departments for investigations or procedures.

Nursing activities associated with patient transfers Activities associated with the transfer process are shown in Table 3. All studies included an activity performed by nursing staff associated with either organising a transfer, transferring the patient, direct patient care or preparation of the bed/room. Activities included the gathering of medications,44 information and equipment46,47; communication with other health professionals44,51; the transfer or transportation of the patient42–48,51,52; and nursing activities necessary to receive a transferred patient, namely, assessment and orientation of the transferred patient,46,51 nursing handover,49,50 and documentation of the transfer and updating of patient charts.51 One study included the review of bed and staff allocations,45 a nurse activity

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Table 2 Assessment of risk of bias Study

Region & country

Site , total beds and setting

Douglas et al. North-eastern Site: A tertiary-referral teaching states hospital (2013)42 (rural), Beds: 400 USA Setting: Two adult and two paediatric ICUs

Subjects

Observers, observer training and interrater reliability

Risk of bias

230 RNs

Observers: Two observers with human-factors Low engineering backgrounds (one observer was also an RN) Observer training: Extensive training in relation to the data collection tool, familiarisation with the site and practice sessions in an affiliated ICU Interrater reliability: Approximately 14 h of simultaneous observation resulting in 73% agreement within 10 s. Abbey et al. Queensland, Site: Private hospital 10 RNs Observers: Pilot study: an experienced ICU RN as Low (2012)43 Australia Beds: ND researcher and a ward RN as research Setting: Adult ICU assistant; main study: one RN researcher Observer training: Practice observation undertaken in a different ICU Interrater reliability: Three simultaneous periods of observation to test tool and interrater reliability; Bland–Altman test applied to compare recorded time data between observers Webster et al. Queensland, Site: Tertiary-referral hospital 517 unoccupied Observers: Two research nurses High (2011)44 Australia Beds: 950 beds (277 Observer training: ND associated with Interrater reliability: ND Setting: Medical, surgical, oncology and maternity units temporary transfers) Ballermann Alberta, Site: One adult tertiary-referral 106 health-care Observers: No details provided Medium et al. Canada hospital and one paediatric one workers Observer training: Minimum 12 h training in use (2011)45 of PDA and simultaneous scoring with an Beds: ND Setting: Adult and paediatric ICUs experienced observer Interrater reliability: Training continued until minimum 85% accuracy was attained Cornell et al. USA. Site: Two acute-care general 125 RNs Observers: Two (no further details provided) High (2010)46,47 hospitals Observer training: Training in use of PDA Beds: 250 and 209 Interrater reliability: ND Setting: Five medical–surgical wards Yen et al. Urban and Site: ND Nurses and Observers: Multiple (no details provided) High (2009)48 suburban Beds: ND physicians (no Observer training: Yes (no details provided) areas, USA Setting: Paediatric emergency details Interrater reliability: Not tested; this was department provided) recognised as a limitation by the authors Storfjell et al. Urban and Site: Three inpatient hospitals ND Observers: ND High (2008, suburban Beds: ND Observer training: ND 2009)49,50 areas, Setting: Two ICUs, two Interrater reliability: ND midwestern maternity units and 14 USA medical–surgical units Hendrich and USA Site: Tertiary level facility > 200 patient Observers: Three RNs Medium Lee Beds: 750 transfers Observer training: Observers ‘trained as research (2005)51 Setting: Intrahospital assistants’ and in the use of the tool Interrater reliability: ND Wong et al. Long Beach, Site: Veterans Affairs Medical 10 nurses Observers: One ICU clinical nurse specialist High (2003)52 California, Center Observer training: Yes (no details provided) USA Beds: ND Interrater reliability: N/A Setting: ICU ICU, intensive care unit; N/A, not applicable; ND, not defined; PDA, personal digital assistant; RN, registered nurse.

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Sample: Nurses (n = 47), physicians (n = 18), respiratory therapists (n = 25), unit clerks (n = 16) Setting: 17-bed paediatric ICU and a general ICU with 24 operational beds Sample: Nurses (hospital A, n = 76 ; hospital B, n = 49) Setting: Five medical–surgical units

Observational study to Method: Work Observation Method by Activity Timing (WOMBAT) used validate the Work random observations of activities performed by health-care providers: Observation Method by observers followed staff for 90 min periods, entering observed tasks into a Activity Timing PDA; observation was suspended when subject was off-unit and during (WOMBAT) and assess personal time, and a total of 14 928 tasks were observed over 232 h ICU staff activities and Transfer categories: Direct care (patient escort) and administrative (bed workflow allocation). Transfer activities: Patient escort and bed allocation Observational timing study Method: Observational timing study pre- and post-introduction of EMR system at to record and measure two sites, with part 1 focusing on pre-EMR at hospital B and part 2 on prenursing activities preand post-EMR at both hospitals—the nurse to be observed was randomly and selected by the Nurse in Charge on the day, and independent observers post-implementation of followed the nurse for 1–4 h, entering nurse activity, time and location an electronic directly into a PDA; baseline observations (n = 22) were conducted at one medication record site, whereas post-redesign observations (n = 63) were conducted at both (EMR) system Transfer category: N/A Transfer activities: Admission-transfer (excludes admission of new patient), defined as ‘gather information, orient patient to the unit’, and transporting patients, defined as ‘moving patients’

Time-and-motion study to describe and analyse activities performed by 10 ICU nurses during the day shift Webster et al. Time-and-motion study to quantify nursing (2011)44 activities and time associated with the unoccupied bed

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Cornell et al. (2010)46,47

Ballermann et al. (2011)45

Abbey et al. (2012)43

Sample/setting Sample: Purposeful sampling of 230 experienced, clinical RNs Setting: Four ICUs (cardiac, medical–surgical, paediatric and neonatal) Sample: Convenience sample of 10 ICU nurses observed and timed while caring for patients Setting: 12-bed ICU Sample: Convenience sample of admissions (n = 102), transfers (n = 277) and discharges (n = 138) associated with the unoccupied bed Setting: Four units (medical, surgical, oncology and maternity)

Real-time observation to describe the work of adult and paediatric critical care nurses

Douglas et al. (2013)42

Study method/transfer category/transfer activities Method: Behavioural task analysis used to observe ICU nurses at work; observers continuously followed and recorded the tasks performed by one preselected, experienced clinical nurse directly into a portable tablet computer. Software enabled the start and completion times and multiple tasks to be recorded Transfer category: Direct patient care Transfer activity: Transporting patients Method: Direct observation using a manual timing device (stopwatch) (no further details provided); activity times recorded on a tool designed by the researchers Transfer category: Direct care Transfer activity: Transporting patients Method: Observation of nursing activities associated with unoccupied bed using a manual timing device (stopwatch)—nursing activities (identified by informal discussions with nursing staff) and associated times were recorded on a precoded activity sheet; details of how timings were performed (e.g. at what point timing of an unoccupied bed was commenced/completed) were not provided Transfer category: Unoccupied bed associated with temporary transfer for provision of another health service Transfer activities: Preparation of the bed and equipment, collecting medications, documentation, patient escort and communication with health professionals and carers

Study design/purpose

Study

Table 3 Summary of timing study designs, methods and transfer outcomes

Admission-transfer: hospital A, mean 4.56 min (n = 12); hospital B: mean 3.12 min (n = 7) Time spent transporting (moving) patients: hospital A: mean 18.42 min (n = 28); hospital B: mean 4.45 min (n = 9)

45% (n = 412) of observed nursing activities were associated with temporary transfers and unoccupied beds Nurses undertook an average of 1.49 (SD 1.2, range 1–7) activities per temporary transfer, taking on average 8.65 min (SD 11.75) Average time managing the bed: 8.31 min, including 3.30 min spent requesting and organising equipment (n = 23, SD 5.53) Average time for nurse escort: 13.81 min (n = 94, SD 9.71) ND

Transporting patients consumed 19 min, representing 0.4% of nurse time (n = 1)

ND

Transfer and nurse workload outcomes

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Time-and-motion study to determine the impact of a computerised order-entry system on physician and nurse time Mixed methods, including timed observations to understand nursing costs associated with value-added (VA) and non-value-added (NVA) time Method: Observational study before and after implementation of an IT system; study technique was labelled time-and-motion but more closely fit work sampling, with observers shadowing subjects for 3 h and manually recording the major activities performed by subjects in 30 s increments Transfer category: Direct patient care Transfer activity: Transporting patients Method: Activity-based costing approach using focus groups, interviews, observation and surveys: focus groups and interviews were held with representative sample of nurses from each participating unit to determine nurse activities, time spent on activities and drivers of value-added and non-value-added time—when necessary, timed observations and surveys were used to support staff responses; details of the observation and timing process were not provided Transfer category: Coordinate care Transfer activities: Admission, transfer, discharge, and shift and transfer handoffs

Transfer duration: ND ICU nurses spent 2.2% of their time conversing on the telephone, reduced to 1.9% after installation of the ICU information system Mean time spent on administrative duties: 4.9 min pre-implementation and 7.4 min post implementation

Sample: 10 full-time ICU nurses Setting: 10-bed ICU

Sample: Pilot study: 21 transfers; main study: ‘more than 200’ transfers Setting: ND

Admission, transfers and discharges and associated handovers (shift and transfer) found to be high-cost processes associated with non-value-added time Drivers of non-value-added time: searching for receiving nurse, medications or equipment; waiting for patient data/orders; repeat calls for transport, housekeeping or bed management; and non-patient related discussion during handovers In response to patient turnover, including transfers, repeated telephone calls for additional staffing were made Average time taken to transfer a patient was 60 min (patient preparation 22 min, transportation 7 min and post-transport 31 min) Nurses (RNs, LPNs and NAs) spent on average 30 min transferring patients

Sample: ND Setting: 14 medical–surgical nursing units, two ICUs and two maternity units in three sites

Sample: Convenience sample ND of nurses and physicians (no further details provided) Setting: Paediatric emergency department

ICU, intensive care unit; LPN, licensed practical nurse; N/A, not applicable; NA, nurse assistant; ND, not defined; PDA, personal digital assistant; RN, registered nurse.

Method: Random observations of patient transfers identified the process and aided Hendrich and Observational time and development of the data collection tool (pilot); for the study proper, over Lee (2005)51 motion study to examine efficiency, cost 200 random patient transfers observed and ‘tracked’ from time of transfer and time of intra-unit order to patient assessment in new location, with focus on activities transfers performed by many disciplines; details of timing methods were not provided Transfer category: Events before, during and after patient transport Transfer activities: 21 activities associated with the transfer process were identified; 10 activities could be considered to be nursing responsibilities Observational time and Method: Independent observation and real-time motion analysis in 4 h periods: a Wong et al. motion study to assess nurse observer entered the predominant task performed by each ICU nurse (2003)52 nurse time, pre- and into a laptop computer in real time, with tasks being automatically date- and post implementation of time-stamped; nurses were studied for a mean 211.7 min pre-implementation an ICU information of the IT system and 230.6 min post-implementation. system Transfer categories: Direct care and administrative Transfer activities: Transporting patients, either without equipment or with more than one piece of equipment and continuous monitoring; time spent ‘conversing (telephone or face-to-face) on arranging, negotiating, coordinating appointment schedules/transferring of patients’

Storfjell et al. (2008, 2009)49,50

Yen et al. (2009)48

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likely to be associated with patient turnover, including transfers.

Nurse workload and patient transfers Studies in this review either focused on patient transfers or included an aspect of patient transfers as a component of nurses’ work. Studies aimed to assess nurse activities and workflow,42–45 to assess the impact of information systems on nurse time46–48,52 and to understand costs associated with the transfer process and nurse time49,50,51 (refer to Table 3). Four of the nine studies reported results of timings related to patient transfers51 or transfer-associated activities.43,44,47 The number of observed transfers ranged from 1 to 277.43,44,47,51 Observations captured one critical care transfer during a 2-week period,43 19 transfers (defined as ‘admission-transfer’) and 37 patient transports (defined as ‘moving patients’) in 4 weeks across two sites,47 over 200 patient transfers in 5 months51 and 277 unoccupied beds associated with temporary transfers in 9 weeks.44 Five studies did not indicate how many transfers (if any) were observed.42,45,48,50,52 In 2005, patient transfers were found to take 60 min of health-care workers’ time.51 The clinical nurse spent on average 20 min preparing and transferring (relocating) patients, and the clinical coordinator spent approximately 40 s on pre- and post-transfer nursing activities.51 Intensive-care nurses spent 2% of their time or 5–7 min coordinating transfers and/or arranging appointments,52 and medical–surgical nurses spent 15% of their time coordinating care.49 Many activities associated with transfer preparation were considered to be of high cost and a waste of nurses’ time.49,50 Nurses spent much time (not defined) searching for equipment, supplies and other health-care workers, calling for transport, beds and other services and waiting for patient results.49–51 Of the eight studies that included the actual transfer or relocation of the patient as an activity, four indicated the duration of time taken.43,44,47,51 The shortest time for transfer was for medical–surgical patients (n = 4)47 at 4.4 min,46 and the longest time, at 19 min, was for a critical-care patient (n = 1).43 Larger studies reported similar times. The average time taken to transfer 200 patients was 7 min,51 increasing to 13.8 min if a nurse escorted the patient (n = 94).44 Furthermore, during temporary transfers when the bed was unoccupied, 8.3 min was spent by clinical nurses and 4.4 min by the nurse manager or clinical coordinator on activities in preparation for the patient’s return.44 © 2014 Wiley Publishing Asia Pty Ltd

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Post-transfer activities were reported to take 30 min overall and averaged 10 min of nurse time.51 Reviewing care and assessing the transferred patient averaged 22 min of nurse time, plus 7 min for observations.51 Bedside charting post transfer was reported to take 13 min,51 but as the study was multidisciplinary, timings might have included other health-care professionals. Timings of transfer communications were reported in two studies.44,51 Nurse transfer communications occurred with other nurses, the bed manager and/or shift coordinator,44 other health professionals and departments,44 the patient51 and family members.44,51 The nurse spent on average 3.68 min conversing with family members44,51 and 5.0 min orientating the patient to the new surroundings.51 The longest conversations, at 5.3 min, occurred between the nurse and bed manager or shift coordinator.44 Data on the time taken to hand over transferred patients’ care are conflicting. Telephone handover was reported as 0 min in one study, and face-to-face handovers were not listed as an activity.51 Another study reported that searching for nurses to receive transfer handover, followed by non-patient-related discussion,49,50 contributed to making patient transfers one of the most high-cost, timeconsuming nursing activities.49

DISCUSSION This systematic review of the nursing literature has revealed that patient transfers are a time-consuming activity, although precisely how much time was spent by nurses on patient transfers remains unclear. Researchers recognised that transferring patients impacts on nursing workload, as evidenced by their including transfer-related activities in workload studies; however, few studies reported results from timing. Furthermore, diversity in the subjects of observation and timing methods made comparisons between studies difficult. In line with methodological variability, few studies disclosed how observers were trained or if interrater reliability was assessed. This is a major limitation, as training and simultaneous practice with a recognised expert increases reliability and validity of timings and observations. Even though most studies included the actual transfer (relocation), few studies provided timing results. One study included patient escort as an activity but limited observation to the nurse’s unit,45 meaning that nurses escorting a patient were not timed. Notwithstanding the geographical layout of individual hospitals, the time taken to physically relocate a patient was similar between

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studies, with the majority of patient movements completed with 15 min. Transfers requiring a nurse escort took the longest. This is not surprising, because patients being escorted are likely to require constant supervision and are sometimes transferred with medical equipment. Wong et al.52 recognised that preparing the patient for transfer will take longer if equipment is involved. In their study, transfers with and without equipment were differentiated. Coordination of transfers and other services took from 2% to 15% of nurses’ time, depending on clinical specialty. The number of transfers within and between medical–surgical units could be expected to be quite considerable, explaining why medical–surgical nurses spent much more time on arranging transfers. By comparison, the number of transfers from critical care units could be expected to be fewer, meaning that less time would be spent by nurses on transfer-related tasks. It is interesting, however, that clinical nurses52 and nurse managers44 working in diverse specialties spent similar periods of time (approximately 5 min) on the coordination of transfers. This is possibly because patient transfers are a multidisciplinary process and some tasks are undertaken by clerical staff and bed managers. Furthermore, Hendrich and Lee51 recognised that not all nursing activities were undertaken during every transfer. The authors did not describe the destination of observed transfers, and therefore some of the transfers might have been within the same clinical unit (i.e. bedspace moves). This would help explain why the average time spent by the nurse on posttransfer activities was seemingly short and why nursing handover was excluded from timings. Based on data presented in this review, nurses spend at least 30 min on the transfer process, including the time taken to coordinate the transfer, prepare and escort the patient and assess and settle the patient following transfer. Considering that some studies identified transfers as highcost activities and that transfers are increasing in frequency, the actual time spent by nurses is likely to be much longer. In addition to transfers between units, patients are also being moved from one bedspace to another. As the impact of patient transfers and bedspace moves on nurse time has yet to be realised, further research is recommended.

CONCLUSION This review examines the published literature for timing studies that have addressed nurse workload and

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specifically patient transfers. Evidence is emerging that intrahospital patient transfers are increasing in frequency, but the impact on nurse workload is not usually captured by conventional workload tools. Nurse researchers have begun to recognise that patient transfers are a feature of nurse work. Accordingly, the transfer process and bedspace moves should be considered when undertaking workload studies. TS and the TM technique are well established methods frequently used to measure nurse workload. In the process of examining nurse workload and patient transfers, this review identified methodological inconsistencies between studies, making comparisons difficult. Despite these inconsistencies, emerging data suggest that nurses spend at least 30 min of time per transfer. Considering the rising rate of transfers in the hospital system, the impact on nurse time and workload is not insignificant.

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