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Keeping Patients Safe: Transforming the Work Environment of Nurses
intercepted prior to administration, again largely by nurses. Overall, nurses were responsible for intercepting 86 percent of all medication errors made by those in all disciplines (Leape et al., 1995).
Coordination and Integration of Care and Services from Multiple Providers
In addition to providing surveillance of patients, therapeutic nursing interventions, and treatments to carry out medical orders, licensed nurses serve as the integrator or coordinator of patient care. These integrating activities include implementing physician treatment orders and explaining them to the patient; planning for patients’ discharge from hospitals or other health care facilities to enable continued care in the home, school, or nursing home; providing health care treatment in the home or other setting of care; and educating the patient and family about the patient’s disease, course of therapy, medications, self-care activities, and other areas of concern to the patient. In addition, while such practices are not desirable, nurses are also pressed into performing a variety of non-nursing patient care activities because of their ever-present availability in inpatient facilities. For example, when delivery of medications, medical equipment or supplies, blood products, or laboratory specimens is required for the patient, and transport staff are not available for the purpose, this activity often is carried out by the nurse. This practice, relying on the “inevitable availability” of nurses, occurs frequently (Prescott et al., 1991; Upenieks, 1998). Large proportions of nurses report spending time delivering and retrieving food trays; performing housekeeping duties; transporting patients; and ordering, coordinating, or performing ancillary services (Aiken et al., 2001a).
The amount of time nurses spend integrating or coordinating care is suggested by the amount of time they spend on “indirect” as opposed to “direct” patient care. Direct patient care encompasses activities carried out in the presence of the patient and family, such as performing a physical examination and other assessments of the patient, administering medications, and performing treatments and procedures. Indirect care involves those activities that are performed away from but on behalf of the patient, such as documenting care, communicating with other health care providers, seeking consultations, and preparing medications (Division of Nursing, 1978). Although numerous work sampling studies of nursing care have been conducted—with varying degrees of divergence from these definitions—and the location of some indirect care activities may be shifting to the bedside (as is the case with automated patient records), the vast majority of studies agree that nurses spend a greater percentage of their time in indirect versus direct care (Hendrickson et al., 1990; Linden and English, 1994; Upenieks, 1998). As a result of all these indirect activities, nurses have substantial