Yonago Acta medica 1999;42:171–174

Implementation of Work Sampling in an Acute Rehabilitation Unit:
Assessing Nursing Efficiency
Ikuko Miyabayashi
Department of Nursing, Tottori University, College of Medical Care Technology, Yonago
683-0826, JapanTo establish appropriate staffing guidelines, roles, reduced labor costs and reduced
cost per unit of service, i) identification of work with appropriate staff members, and ii)
development and utilization of a patient acuity system were studied in an acute rehabilitation unit of a hospital in central Illinois. Acuity of patients (n = 127) was categoried
by using assisting levels of minimal, moderate and maximal based on the Functional
Independence Measure (FIM) score. The FIM score was reevaluated each week. In
the 1st month, volume and time studies were done on all rehabilitation patients. In the2nd month, roles of the registered nurse (RN) and the unlicensed assistive personnel(UPA) were clarified; and in the 3rd month, patients’ acuity levels were reestablishedand staffing management was adjusted. This system also clearly identified patients’
acuity and the role of RNs and UPAs. Hours per unit of RN service was cut from 8.85
to 7.49 per 8 h shift. Cost per unit of service was decreased from $163.6 to $105.2. A
total annual savings of $268,410 indicated a big financial impact on the unit with almost
the same level of patient satisfaction as before. The results of the study suggest that thework sampling method for a management and organizational development program
can be used to objectively assess work load of RNs as a first step.
Key words: registered nurse; unlicensed assistive personnel; work sampling

Due to downsizing in the acute care sector ofhealth care, hospital nurses now face fewer alternative positions in areas where they currently
work. Acute care hospitals increasingly employ patient care delivery models such as unlicensed assistive personnel (UAP). In institutions introducing such models, the responsibilities of nurses are changing from providing total
patient care to delegating certain patient caretasks which have nurse-defined outcomes(Spitzer-Lehmann and Yahn, 1992). The nurses
develop nursing care plans and then select activities that they delegate to the UAP. This practice presumably lowers costs of patient care per
day and increases nursing productivity.
The issue of “cost” becomes a concern whennurses are used for nonnursing tasks. Severalstudies have shown that professional nurses

spend a significant amount of their time inindirect care (Mayer, 1992; Quist, 1992;
McMurray, 1992). A team approach with effective use of the UAP can increase nurses’ productivity and decrease downtime (Spitzer-Lehmannand Yahn, 1992).
The purpose of this study was to establish
appropriate staffing guidelines, roles, reduced
labor costs, and reduced cost per unit of serviceby the delegation of work to appropriate staff
members and development and utilization of apatient acuity system.
Goals were defined as follows: i) Provide
maximum utilization of registered nurse timethrough efficient utilization of the UAP; ii) Decrease patient-care hours from the current levelof 8.85 h to the target level of 7.5 h; iii) Improve the flow of care delivery.

Abbreviations: FIM, Functional Independence Measure; LPN, Licenced Practical Nurse; RN, registerednurse; UAP, unlicensed assistive personnel171

I. Miyabayashi

Table 1. Items included in FIM

Subjects and Methods
This study was conducted from September
1996 to January 1997 in an acute rehabilitation
unit of a hospital in the town of Urbana, IL where
the population was approximately 100,000. Acuity of patients (n =127) was categorized into 3
assisting levels (minimal, moderate and maximal) based on the Functional Independence
Measure (FIM) score. The FIM score (Table 1)
is a set of 18 items (currently, 55 items) whichuses a 7 point scale. The 7 point scale for items
measures the assistance (help) level required forcompleting a task by a patient. The scores of 7and 6 are categorized as minimal assistance, 5through 2 as moderate assistance, and a score of
1 as maximal assistance or dependency. In addition to these categories, safety, teaching/emotional support, medication, treatment assessments and discharge care planning or coordination were added to define acuity of nursing
care. The FIM score of patients was reevaluated each week at a team conference.
During this study period, the rehabilitation
unit had a staff allocation or full time employeeof 8 registered nurses (RNs), 1.5 UAPs, and 1
secretary to cover 24 h or 3 consecutive shifts.
Each staff member was assigned an 8 h shift perday. The average daily number of patients was
6 to 15 (maximal capacity), that is, a 40 to 100%
occupancy rate. Recording data included day,evening and night shifts during each phase. All
staff members were informed of the study andits purpose, and training sessions and periods
were provided by a Nurse Educator and Nurse
Managers. Staff member tasks were categorized as follows: i) a report, ii) shift preparation, iii) direct nursing care, iv) nonlicensed
nursing tasks, v) patient admission, vi) direct
patient discharge, vii) documentation, viii)
communication with patients, staff, patients’family members, physicians, and other department personnel, ix) operation of equipment, x)patient rounds, xi) consultation with a case coordinator, physicians and supervisors, xii) critical thinking, xiii) supervision/delegation, xiv)
clerical work and xv) meetings.
The data was collected in three phases: i)the 1st phase—volume loads and actual work

1. Bladder management
2. Bowel management
3. Eating
4. Grooming
5. Bathing
6. Dressing upper body
7. Dressing lower body
8. Toileting
9. Locomotion: walk/wheelchair
10. Stair climbing
11. Transfers: bed, chair, wheelchair
12. Transfers: toilet
13. Transfers: tub or shower
14. Comprehension
15. Expression
16. Problem solving
17. Memory
18. Social interaction
FIM, Functional Assessment Scale Manual. Version
4. Rehabilitation Institute of Chicago.

time were recorded, ii) the 2nd phase—roles of
the RNs and UAP were clarified, and iii) the 3rdphase—patient acuity levels were reestablished, and staffing management was adjusted.
Results
The distribution of tasks of RNs and UAPs aretabulated (Table 2). Based on the volume load
and actual work time, RNs spent more than 30%of their time (at least 2 h and 25 min during an 8h shift) for nonlicensed nursing tasks that are
mainly UAP duties such as oral feedings, bathing, transferring and transporting patients inaddition to clerical duties such as patient admission and discharge. Direct patient care accounted for about 30% of the time or 2 h and 25 minduring an 8 h shift. Documentation accountedfor 13% or 58 min of the time spent, and verbal
reporting patients’ conditions to the following
staffs represented 12% or 54 min.
Nonlicensed tasks represented the majorityof UAP time spent on the unit, accounting for
35% or approximately 3 h during an 8 h shift.
Direct care accounted for 13% of their time.
Thus, a total of 48% of UAP time (3 h and 50min) was spent on patient-care activities. Clerical tasks represented a substantial portion of thetime spent by unit secretaries, when the secre-172

Work sampling in an acute rehabilitation unit

Table 2. Distribution of tasks of RNs andUAPs in an 8 h day shift
Type of tasks

Percentage
in an 8 h shift (%)
RN*UAP

Direct patient care
26†
13
Non-licensed tasks
30‡
35
Documentation
130Report
120
Communication, consultation
450
Secretarial tasks—‡29
Others——RN, registered nurse; UAP, unlicensed assistivepersonnel.
* RNs spent more than 8 h during an 8 h shift.
† Including some nonlicensed tasks.
‡ Including some secretarial tasks.

tary was present. The clerical tasks required
approximately 2 h and 19 min during the dayand 52 min in evenings. The proportions oftime allocated to each activity were similar,
when day, evening and night shifts were compared; however, variations were noted in thedistribution. For RNs, a greater percentage ofdirect patient care was noted in the evening shift(34%) as compared to day (26%) or night shift(30%). Documentation represented a substantial portion of time in the day and evening
shifts. Verbal reporting patients’ conditions tothe following staffs represented a greater
amount of time in the evening than in the day ornight shift. Communication and consultation
occurred most frequently in the day shift.
Furthermore, patient admissions and discharges
occurred more in the day than in the evening
shift, while no patient admission and discharge
occurred in the night shift.
Overall, the data indicated that:* RNs were performing too many nonlicensed
tasks and/or clerical functions.
* UAP and unit secretary work was not distributed evenly for each shift.
* RN tasks were different based on patients’
acuity, spending about 2.5 times more timewith dependent patients than minimal assist
patients.
* RNs required overtime, because they spent
too much time on nonlicensed tasks.

From the data, a shift management index wascreated with an increase in number of UAPs
who could manage clerical work (the hospitalprovided cross training sessions), since a newunit secretary was not hired (one secretary resigned during this study). Effective distributionof nursing staff (using on-call status) was suggested. Nurses were encouraged to delegate
nonlicensed nursing tasks to appropriate personnel (continuing education was planned andprovided by the Continuing Nursing Education
Department). Patients’ acuity levels were reevaluated every week or whenever patients’conditions changed.
Using this program, patients acuity androles of the RNs and UAP were clearly identified. Hours per unit of service by RNs were reduced from 8.85 to 7.49 per 8 h shifts. The cost
per unit of service was decreased from $163.6
to $105.2. The total annual savings were$268,410 with similar patient satisfaction asbefore.

Discussion
Currently, the outpatient sectors (Home Care)of the US health care delivery system as well as
the Japanese health care system are growing
much faster than the acute care sectors. Besides, if health care costs continue to rise as in
the United States, this effect would impel hospital employees to provide complex care to
more acutely ill patients under tighter time constraints, and would often reduce the number ofRNs. This trend will be seen in Japanese healthcare in near future; Japanese nurse leaders will
also be under pressure to decrease patient care
hours yet increase nursing productivity as seenin the United States. This change in the healthcare environment is affecting professional nursing practice and the relationship of the RN tothe UAP, that is, nursing assistants, unit secretaries, Licensed Practical Nurses (LPNs) andothers. However, the RN still retains the responsibility for the total nursing care of patients. In Japan, work assignment of the RN is
not well defined as compared to the UnitedStates, where RNs and LPNs have defined rolesin the health care system. To be accurately

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I. Miyabayashi

assessed for work, Japanese RNs need to continue to define what their job description is.
The present results suggest that the work sampling method for a management and organizational development program can be used toobjectively assess the work load of the RNs as afirst step. Moreover, the work sampling study
could become an affective and accurate tool for
management redesigning, which helps nurse
administrators to obtain a clear vision, to identify problems and to provide steps for unit redesign. Effectiveness of nursing time should
improve the quality of patient care.

Acknowledgments: This study was carried out at theAcute Rehabilitation unit of the Carle Hospital, one
associate hospital of the University of Illinois. The
author thanks all personnel involved in this study.

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(Received December 7, 1998, Accepted May 19, 1999)

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