Honoring the
Nurse-Patient Connection
How to Create Working Environments
for Healthier (and Happier) Patients

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The Nurse-Patient2 THE NURSE-PATIENT CONNECTIONTABLE OF CONTENTS
Executive Summary
The Nurse-Patient Connection
Allocating TimeEHR Difficulties
Physical Strain
Unsuitable Workstations
Increased Nurse Satisfaction and Direct Patient Care
Medication Carts
Conclusion

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THE NURSE-PATIENT CONNECTION 3

EXECUTIVE SUMMARY
A holistic hospital view reveals the importance of relationships:
the relationship between compassionate leadership and a healthy
environment, between a healthy environment and a satisfied staff,
and finally, between a satisfied staff and exemplary patient care. The
cumulative takeaway? When you improve the environment, you improve
the outcomes.
Research supports the notion that happier nurses equal happier andhealthier patients. When nurses are more satisfied with their work
environment, patient satisfaction scores and clinical outcomes improve,
including reductions in hospital-acquired conditions and readmission
rates.
Several road blocks stand in the way of the best work environment
for nurses. Many nurses are unable to effectively allocate their time,sometimes negatively impacting patient care. Nurses also struggle withnavigating electronic health records (EHR), which can cut into direct
patient time. Nursing is also a physically demanding job that can put
significant strain on the human body and lead to long-lasting medical
conditions for caregivers.
Fortunately, there are ways to improve the working environment for
nurses. By addressing substandard physical spaces, improving work
flow, and enhancing workplace ergonomics, organizations can help
nurses reduce documentation time, decrease time spent walking theunit, and minimize the physical stress of the job—improving working
conditions and, in turn, the patient experience.

WHEN NURSES ARE MORE SATISFIED
WITH THEIR WORKING ENVIRONMENT,PATIENT SATISFACTION SCORESIMPROVE, AS DO CLINICAL OUTCOMES,INCLUDING REDUCTIONS IN HOSPITALACQUIRED CONDITIONS AND
READMISSION RATES.

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Better Work Environments Increase
Patient Recommendations andImprove HCAHPS Scores
Source: Kutney-Lee et al. 2009

HCAHPS Scores
Patients Likely to Recommend Hospital After Stay

64.0%
55.4%

Poor
Environments

BetterEnvironments

Paent Recommendaons
60.9%

Patient Ratings of 9 or 10 (High)

59.6%

The Nurse-Patient
Connection
The connection between nurses and patients is an important one that canhave a major impact on a patient’s experience and their clinical outcomes.
Studies have shown when nurses have more time to personally interact
with patients, hospital stay times are shorter, injury rates fall, and thenumber of hospital-acquired infections drop. So do incidents of “failure
to rescue”—a term used to refer to deaths that occur after a treatablecomplication [1,2].
Time spent with patients is just one factor in the quality-of-care matrix.
Another is nurse morale. Research shows that when nurses feel satisfied
with their work environment, they provide better service, which results inbetter outcomes and positive patient feedback.
One way to measure patient satisfaction is how likely they are to
recommend the hospital to friends and family. Hospitals with better work
environments are more likely to receive a recommendation than thosewith poor environments. Additionally, the quality of the work environment
is linked to Hospital Consumer Assessment of Healthcare Providers andSystems (HCAHPS) scores: the better the environment, the higher thescores [3,4].
Four obstacles stand in the way of the best environment for nurse andpatient connections: how nurses are able to allocate their time, the easewith which they can interface with EHRs, the daily toll on their bodies, andthe physical layout of their workspace.
ALLOCATING TIME

Poor
Environments

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BetterEnvironments

Throughout the workday, nurses are pulled in multiple directions, andhow they allocate their time has profound effects on both work satisfaction
and patient care. Of course, nurses prefer to spend as much time as
possible working with patients, but administrative and other duties fight for
their attention.

THE NURSE-PATIENT CONNECTION 5

Extended shifts
It’s not uncommon for nurses to work extended shifts of 12 hours
and more. Many nurses prefer working longer shifts when it means
consecutive days off to spend with family along with more continuous
patient care, but there are drawbacks. For instance, the likelihoodof making errors accelerates with the length of the original shift due
to fatigue.
•	
Nurses who worked more than 12 hours committed
more errors.
•	
Nurses who worked overtime or more than 40 hours a week
committed more errors [5].

Nurse Location and Activity
by Time Spent
Source: Hendrich et al. 2008

Location
Off the Unit 2%

On theUnit
18%
Nurse Station
43%
Patient Room
37%

Documentation
According to several studies, nurses spend up to one-third of their timeon documentation, rivaling or surpassing the amount of time spent
on direct patient care [5,6].
Nurses have expressed dissatisfaction with the time spent on “excessive
paperwork” and “wasted time” tracking down documents or equipment.
One study found 6.6% of a nurse’s time was categorized as waste [7].
According to U.S. News & World Report, an average nursing salary is$66,640 per year. That means an organization spends nearly $4,000 per
year, per nurse, for time that doesn’t benefit the hospital or its patients.
Walking TimeFor all of these activities, nurses need to move between patient
rooms, supply cabinets and the nursing station. Research suggests
more than 25% of a nurse’s time is spent walking the hospital floor [7].
How nurses move is just as important as where they are going. Whennurses have to make extra stops, retrace their steps, or deviate fromtheir path, hundreds of feet can be added to their walking burden [8],which can already be up to five miles per day [7].

Activity
Assessment/
Vitals7%
Patient Care
Activities
Patient
19%CareActivities
19%

Medication
Administration
17%

Care
Coordination
21%
Documentation
35%* Percentages may not add up to 100% due to rounding

Medication Administration
Medication administration is also subject to inefficiencies. One study
discovered that for drug administration, nurses spent nearly two-thirdsof their time on drug delivery and the other third on drug preparation.
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EHR DIFFICULTIES
EHRs improve healthcare by offering greater connectivity, transparency,
decentralization, mobility and access to vast amounts of data, but they
can be difficult to implement and navigate. Currently, many hospitals arestill adapting and searching for ways to refine their EHR practices. The
process may take years and impact the amount of time caregivers candevote to patients.
Added Documentation Time
When EHRs were first proposed, the healthcare community assumed
that they would represent a “huge step forward in patient care,” and thatthey were going to be “more accurate, safer, timelier, and faster” [9]. EHR
proponents argued that documenting via a computer would free
up nurses to spend more time with patients. However, nurses havereported that often the opposite is true, and documentation is “taking
longer than ever” [9].

Grappling with the EHR
Source: Philipsen et al. 2014 & Stowkowski et al. 2013

73%

Nurses self-reporting half ofeach shift spent with the EHR

15–26%

Increase in documentation timeafter EHR system implementation

72%

Nurses staying after their shift
to finish charting

One informal survey discovered that a majority of nurses were now
staying past their scheduled shifts to complete daily documentation [9].
This has increased labor costs for hospitals forced to pay overtime.
In other instances, nurses have “clocked-out” and are documenting on
their own time, negatively affecting work-life balance and contributing
to fatigue.
EHRs Contribute to Stress
Nurse fatigue is an epidemic in hospitals, leading to high rates of attrition.
The Robert Wood Johnson Foundation’s RN Work Project showed that
33.5% of newly licensed registered nurses leave their first job within two
years [10]. In one study, 67% percent of nurses expressed that they were
under a great deal of stress because of their job [11].
In the same study, nurses complained that EHRs have increased theirwork volume, are inefficient, and at times, make their role seem moreclerical than clinical. They believe the systems focus on payers rather
than patients.
Some nurses felt they were losing the ability to provide high-quality
care to patients, leading them to reduce their clinical time, move to otherclinical practice types, or leave medicine altogether.

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THE NURSE-PATIENT CONNECTION 7

The Joint Commission and EHR EffectivenessSince the widespread adoption and use of EHRs, the Joint Commission,in its charter to identify adverse events, high risk conditions, and theunderlying causes, found that incorrect or inaccurate informationentered into EHRs contributed to a significant number of adverse
events. In the 2015 Joint Commission Sentinel Event Alert, 120 sentinel
events identified over a three-year period were directly related to EHR
usage. Some examples cited included a chest X-ray being ordered forthe wrong patient, incorrectly labeled injections and inconsistency inpharmacy ordering. The primary causes attributed to the reported eventswere problems with the human-computer interface (33%), including
ergonomics and usability issues [12].
As a result, the Joint Commission recommends that clinicians shouldhave access to workstations every 50 feet, minimizing the potential for
misplacing or misremembering important patient information before
entering it into the system. In the instance of adopting EHRs, thisemphasizes the importance of understanding both the application of the
EHRs in the workflow and the support of caregivers and patients within
this workflow. It also provides healthcare facilities a starting place toreview inherent issues in processes to better understand how they stack
up against these alerts and what actions should be taken as a result.

Causes for Healthcare IT-Related
Adverse Events
LocaonLocaonSource: The Joint Commission (2015)
External Rules,
Regulaons, &Pressures
Hardware &1%
Soware Compung
Infrastructure
6%

SystemMeasurement &Monitoring
1%

People6%
Internal Organzaonal
Policies, Procedures,& Culture
6%

Human-Computer
Interface
33%
Clinical Content
23%
Workflow &Communicaon
24%
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Nursing is a physical job. It involves manual patient handling, spending
long stretches standing, performing repetitive tasks, and often working
in less than ideal physical environments, which can lead to cumulative
trauma disorders (CTDs) such as carpal tunnel syndrome, low backpain, and other musculo-skeletal disorders (MSDs). Finding ways tominimize the physical impact on nurses is vital to improving nurses’ jobsatisfaction and ultimately, the patient experience.
Musculoskeletal Disorders and Cumulative Trauma Disorders
Nurses and nursing assistants have some of the highest rates of MSDs
and CTDs of any workers from across all industries. CTDs, such as carpal
tunnel syndrome, occur in nurses due to highly repetitive work, suchas documentation and involve recurrent and persistent pain that canprogress in severity over time [13].
Low back pain is another contributing factor to nurse discomfort. It is
one of the most common work-related occupational health problems
and is particularly common among nurses because of improper bodymechanics, manual patient handling, repetitiveness and continuous
standing [14].
Alleviating MSDs, CTDs and low back pain involves improving theergonomics of nursing workstations by balancing sit-stand times,
creating physical spaces that promote good posture, and reducing
fatigue-causing conditions.
Let’s not forget about mental strain. Nurses care for their patients’needs both physically and mentally, so it should come as no surprisethat nurses themselves may find themselves needing support to deliver
the best medical care they can. Mental resilience in the face of suffering
patients and their family members can be difficult to maintain, evenamong the most experienced healthcare practitioners, yet nurses
are expected to retain their professionalism while treating distressing
symptoms, pain and suffering.

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THE NURSE-PATIENT CONNECTION 9

Nurses that have access to properly-designed equipment and the rightamount of rest have the ability to manage self-care and more effectively
cope with mental strain on the job.
UNSUITABLE WORKSTATIONS
Mobile and wall-mounted workstations can resolve many issues nurses
face: walk time, unsuitable ergonomics and proximity to patients.
However, some mobile and wall-mounted workstations come with theirown sets of problems.

Alleviating MSDs, CTDs and low
back pain involves improving theergonomics of nursing workstations
by balancing sit-stand times,
creating physical spaces that
promote good posture,and reducing
fatigue-causing conditions.

One study found that hospitals had not purchased enough workstations,
forcing nurses to waste time searching for available units. Additionally,some mobile workstation models were heavy and cumbersome,requiring significant strength to navigate them through hallways. Finally,
nurses have had problems with long EHR reboot times on both stations
and uncharged portable table scanners on mobile workstations [5].
While mobile and wall-mounted workstations can improve nurses’
workflows, choosing the right workstation, based on nurses’ needs andthe physical layout of the unit, is important to avoid potential difficulties
that can come with their use.

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INCREASED NURSE SATISFACTION
AND DIRECT PATIENT CARE
Numerous studies show that nurse satisfaction and more direct patientcare deeply affects patient satisfaction and clinical outcomes. Whenhospitals take steps to improve the working environment, nurses areable to dedicate more time to patients and do what they do best—
provide clinical care.

Satisfied Nurses Lead toBetter Clinical Outcomes
Source: National Database of Nursing
Quality Indicators 2013

5–20%

Quality of care increased

87%

Infection rate decreased

17%

Injury falls decreased

59%

Hospital-acquired pressure
ulcers decreased

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The National Database of Nursing Quality Indicators, which charts
performance and outcomes at the unit level, discovered a clear
correlation between satisfaction levels of nurses and clinical outcomesfor patients. On units with high nursing satisfaction levels, patient care
excelled according to several metrics: quality of care, infection rates andon-unit patient injuries [2].
Ergonomics
The Occupational Safety and Health Administration defines ergonomics
as “the science of designing the job to fit the worker, rather thanphysically forcing the worker’s body to fit the job” [15]. Ergonomics
implemented correctly can relieve nurses of many physical strains,
reducing CTDs and MSDs.
There is arguably no environment where ergonomics is more important
than in a healthcare facility, where poorly designed equipment has
the potential to harm those who heal. There are tremendous physicaldemands placed on caregivers, and the negative impact that fatigued
and uncomfortable caregivers may have on patients is tangible.
Ergonomics can have a very real impact on patient treatment, staff
satisfaction and a healthcare organization’s bottom line.
Ergonomic improvements can include customizing workstation deskheights for each worker, setting proper monitor viewing heights anddistances from the viewer, and upgrading older workstations that were
not designed to accommodate computer use [13].

THE NURSE-PATIENT CONNECTION 11

Workstation Improvements
Restructuring the physical environment to better fit nurses has asignificant indirect influence on job performance. When nurses are
more comfortable in their physical space, they can do their job more
efficiently, communicate with other nurses and physicians more easily,and complete tasks with fewer interruptions [16].
Nurse workstations may “represent an opportunity for design process
and improvement” [7]. The placement of free-standing or wall-mounted
terminals throughout the unit can decrease nurses’ walking time, which
increases the amount of time nurses are able to spend with patients.
Likewise, mobile workstations can save time by allowing nurses to workwhere they are instead of spending time moving between stations.
Wall-mounted workstations are generally compact and best placed
either in the patient room or in the unit hallway as touchdown points foraccessing or entering information for brief periods. With a single sign-on
system, clinicians can easily move from one wall-mount unit to the next
without reentering login credentials.
Mobile workstations require more floor space, since they are typicallyloaded with supplies and a computer terminal. They act as a mobile
office that is immediately accessible and allows caregivers to stay logged
into their system all day.

WHEN NURSES ARE MORE
COMFORTABLE IN THEIR PHYSICALSPACE, THEY CAN DO THEIR JOB MORE
EFFICIENTLY, COMMUNICATE WITH
OTHER NURSES AND PHYSICIANS
MORE EASILY, AND COMPLETE TASKSWITH FEWER INTERRUPTIONS.

Managing workstation power systems is one way to alleviate caregiver
stress. When caregivers approach a workstation with low or no battery
power, searching for alternative equipment disrupts patient care, adds
unnecessary steps, and may erode trust.
Before purchasing wall-mounted or mobile workstations, organizations
should fully understand the ergonomic needs of its staff—as determinedby a worker assessment—and the ergonomic profile of the proposed
workstations.
When assessing the current physical environment and planning for
improvements, organizations should consider sit-stand heights, easeof adjustment, storage, security, weight and mobility. Consulting withan ergonomics expert can help educate decision-makers about which
system is the best fit for their organization. With the right workstations,caregivers can work comfortably and efficiently to better serve
their patients.

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MEDICATION CARTS
Using medication carts helps contribute to nurse satisfaction and overallpatient care. One study surveyed 195 nurses about their experiences withmedication carts and found a consensus for “the adoption of medication
cart technology and its benefits” [17].
Mobile workstations with integrated medication delivery can offer a total
point-of-care solution, further reducing time spent on documentationand distribution. Having workstations and medication carts in the same
unit can mitigate the potential for erroneous medication delivery as
nurses have more immediate means of reviewing health records before
administration. With one workstation, caregivers have the technology
and tools they need for seamless workflows that support a stronger
nurse-patient connection.
CONCLUSION

Medication Carts Make Work
Easier and Reduce Medication
Incidents/Accidents
Source: Rochais et al. 201280%

Nurses who agreed
medication carts madework easier64%

Nurses agreed
medication carts reducerisk of medication
incidents/accidents

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Improving the working environment for nurses has an indisputableeffect on the health and happiness of patients. Access to equipment that
addresses concerns such as ergonomics, distance between patient rooms
and the nursing station, point-of-care access to patient health records,
and effective medication administration can help any organization
improve the working environment and, in turn, the patient experience.
Understanding the integral relationships across the whole hospital,
between leaders, staff, patients and the work environment encourages
organizations to invest in equipment and work environment improvementsthat makes a difference for both caregivers and patients. These
improvements not only enhance the surroundings—they improveoutcomes.
Driven by advances in technology, the future of healthcare will foster
greater connectivity, transparency, decentralization, mobility and accessto vast amounts of data, which will help shape the next generation ofcare. To usher in this new era, organizations need to place caregiverwell-being and workflows at the forefront. As everyday heroes, they walkwith patients through pivotal, life-changing moments. To ensure they
thrive—and provide exceptional patient care—they need comfortableworkstations that allow them to complete documentation efficiently
and the best work environments to do their changing work. A greatercollaboration between leadership, caregivers and patients will ensure wehonor all roles for the value they bring to the care environment.
For more information about ergonomic healthcare solutions,visit healthcare.ergotron.com.

THE NURSE-PATIENT CONNECTION 13

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DiChiara, J. (2015). How the Nursing Work Environment Affects Patient Outcomes.
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Shifting Shifts, Originally Published in Nursing Leadership, 17(3): 1–4 July 2004.

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Philipsen, N., Carruthers, W., Chi, G., Ensey, D., Shmorhun, A., & Valdez, R. (2014). A Mixed-Methods
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Westbrook, J. I., Duffield, C., Li, L., & Creswick, N. J. (2011). How Much Time Do Nurses Have for 		
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8

Hendrich, A. (2008). A 36-Hospital Time and Motion Study: How Do Medical-Surgical Nurses Spend
Their Time? The Permanente Journal, 25-34.

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Yi, L., & Seo, H. (2012). The Effect of Hospital Unit Layout on Nurse Walking Behavior.
HERD: Health Environments Research & Design Journal, 6(1), 66-82.

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Medscape. Retrieved from Medscape.com.
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12 Linzer, M., Poplau, S., Babbott, S., Collins, T., Guzman-Corrales, L., Menk, J., & Ovington, K. (2016).		
Worklife and Wellness in Academic General Internal Medicine: Results from a National Survey. 		
Journal of General Internal Medicine.
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CIN: Computers, Informatics, Nursing, 21(3), 150–157.
15. Habibi E., Pourabdian S., Atabaki A.K., & Hosseini, M. (2012). Evaluation of Work-Related 			Psychosocial and Ergonomics Factors in Relation to Low Back Discomfort in Emergency Unit 		
Nurses. International Journal of Preventive Medicine, 3(8), 564–568.
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26(2), 131–137.

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USING HUMAN-CENTERED DESIGN PRINCIPLESAND THE TECHNOLOGY OF MOVEMENT,WE BUILD ENVIRONMENTS
THAT HELP PEOPLE THRIVE.

MOVING YOU FORWARD@Ergotron@ErgotronInc@Ergotron@ErgotronGuy@Ergotron

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The Nurse-Patient
Connection

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Better Working Environments Lead to Healthierand Happier Patients© Ergotron, Inc. 08.30.2019
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