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Management of Patients in the Intensive Care Unit: Comparison Via Work Sampling Analysis of an Acute Care Nurse Practitioner and Physicians in Training

	Abstract

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• Background Little is known about aspects of practice that differ between acute care nurse practitioners and physicians that might affect patients’ outcomes.

• Objective To determine if time spent in work activities differs between an acute care nurse practitioner and physicians in training (pulmonary/critical care fellows) managing patients’ care in a step-down medical intensive care unit.

• Methods Work sampling techniques were used to collect data when the nurse practitioner had 6 months’ or less experience in the role (T1), after the nurse practitioner had 12 months’ experience in the role (T2), and when physicians in training provided care on a rotational schedule (nurse practitioner not present, T3). These data were used to estimate the time spent in direct management of patients, coordination of care, and nonunit activities.

• Results Results for T1 and T2 were similar. When T2 and T3 were compared, the nurse practitioner and the physicians in training spent approximately half their time in activities directly related to management of patients (40% vs 44%, not significantly different). The nurse practitioner spent more time in activities related to coordination of care (45% vs 18%; P < .001) and less time in nonunit activities (15% vs 37%; P < .001).

• Conclusion The nurse practitioner and the physicians in training spent a similar proportion of time performing required tasks. Because of training requirements, physicians spent more time than the nurse practitioner in nonunit activities. Conversely, the nurse practitioner spent more time interacting with patients and patients’ families and collaborating with health team members.

Does the time spent in work activities by ACNPs and physicians in training in the ICU differ?

 

Although these studies suggest that the ACNP role is associated with good outcomes, they provide limited information about aspects of ACNP practice that might explain why patients’ outcomes differ.¹¹ For example, it is not clear whether these differences are due to more timely monitoring and adjustment of interventions, greater continuity of care, differences in patients’ acuity or patient caseload, or other factors.^10–12

The introduction of an ACNP into the step-down medical intensive care unit (SD-MICU) at the University of Pittsburgh Medical Center, a tertiary care center, provided the opportunity to prospectively obtain data about the time management of an ACNP and physicians in training in an ICU. Thereby, we hoped to provide further insight into an aspect of practice that might explain differences in patients’ outcomes. The purpose of this pilot study was to use work sampling to estimate the proportion of time spent in various work activities by an ACNP and by physicians in training when managing the care of patients admitted to an SD-MICU. The following research questions were addressed:

• Are there changes in the proportion of time spent in routine management of patients, coordination of care, and nonunit activities by an ACNP managing the care of patients in an SD-MICU when comparisons are made between the initial and subsequent year of employment?
  
• Are there differences in the proportion of time spent in these activities by an ACNP and physicians in training when managing the care of patients in an SD-MICU?
  

	Materials and Methods

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Design
A causal comparative longitudinal design with 19 months of data collection (January 2000–July 2001) was used. Data were collected during 3 periods: (1) when the ACNP had 6 months’ or less experience in the role (T₁), (2) after the ACNP had 12 months’ experience in the role (T₂), and (3) when physicians in training (n = 6) provided care on a rotational basis (ACNP not present, T3; Table 1). The data were collected by 2 graduate nursing students and 2 members of the research team (F.J.T., C.S.) trained in work sampling procedures.^13–15

The nurse-to-patient ratio varied from 1:2 (7 AM to 3 PM) to 1:3 (3 PM to 7 AM). A respiratory therapist was assigned to the unit on all shifts. Six attending physicians provided care on a rotating (1 month) basis. Each attending physician was responsible for medical management of patients admitted to the SD-MICU and an adjacent 14-bed high-acuity MICU. In addition, the service was responsible for management of 14 ventilator-dependent patients in a long-term acute care hospital located 3.2 km (2 miles, a 15-minute drive) from the subacute-MICU.

Sample
The sample was made up of 1 certified ACNP with a master’s degree employed by the university-affiliated practice plan of the service administratively responsible for the unit, and 6 physicians in training who rotated through the SD-MICU once (2 critical care fellows) or multiple times (4 pulmonary fellows) during their fellowship. Both providers (ACNP and physicians in training) were responsible for managing the care of all patients admitted to the unit 5 days a week (Monday-Friday) in collaboration with the attending physician. This role included assessment, diagnosis, and writing all orders for care, including orders for weaning and extubation. Both providers worked an 8- to 10-hour day during daylight hours. During the providers’ off hours, SD-MICU coverage was provided by residents, and weekend coverage was provided by an attending physician. The physicians in training were also on call 1 night per week and 1 weekend night per month in addition to being responsible for a 2-hour outpatient clinic on a weekly basis. The institutional review board granted approval for the study to be conducted without written informed consent. The ACNP and the physicians in training provided verbal consent to participate in the study.

Instrument
The Clinician Activities Tool was designed to document time spent in various activities during management of patients in a critical care setting. The tool includes 42 activities organized into 3 categories and 9 subcategories (Table 2). The first category, routine management of patients, included activities required to assess, diagnose, plan, evaluate, and document patients’ progress. The second category, coordination of care, included activities to facilitate patients’ care and interactions with patients and patients’ families. The third category, nonunit activities, included activities that did not directly relate to management of patients in the SD-MICU, for example, education, meals, and sleeping after being on call. These categories were intended to separate required work (routine management of patients), facilitative work (coordination of care), and nonunit activities. The 42 activities were ascertained from a study¹³ in which time and motion analysis was used to document activities of general internal medicine residents at 2 urban hospitals.¹³ The activities were reviewed by a critical care physician and 2 advanced practice nurses for content validity, sorted into categories, revised as indicated, and pilot tested. Interrater reliability was greater than 95% when the tool was used by 2 data collectors.

Work sampling procedures for this study were as follows. Each day of the week was divided into four 2-hour time blocks or a total of 20 blocks for the 40-hour week. Work sampling observations were randomly scheduled during these 2-hour time blocks for several weeks until all blocks were completed. The maximum observation time per day was 4 hours. Using a stopwatch, the observer recorded work activities at 10-minute intervals and later at 5-minute intervals. The 10-minute interval yielded 13 data points for each 2-hour block (6 per hour + 1 additional recording at the end of the block) x 20 blocks = 260 data points. The 5-minute interval yielded 25 data points for each 2-hour block (12 per hour + 1 additional recording at the end of the block) x 20 blocks = 500 data points. The total score on the Clinicians Activities Tool was equal to the total number of times the activity was observed. Using these data, we estimated the proportion of time spent in activities involved in routine management of patients, coordination of care, and nonunit activities. Data collectors were instructed to remain at a sufficient distance to avoid interfering, but close enough to ascertain the work performed.

Statistical Analysis
Data were analyzed by using the Fisher test for differences between uncorrelated proportions, with a Bonferroni correction for multiple comparisons.¹⁶ Comparisons were made between activities performed by the ACNP and by physicians in training, by the ACNP during the initial and subsequent year of employment, and for the 2 (5- and 10-minute) recording intervals. Data are reported for 5-minute observations, with the exception of comparison of 5- and 10-minute recording intervals.

	Results

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During the data collection period, we found no sig-nificant differences in the number of patients managed per day by the ACNP (mean, 5.9; SD, 0.3) and the physicians in training (mean, 5.8; SD, 0.6) or the number of patients per day being weaned from mechanical ventilation (mean, 2.2 and SD, 1.4 for the ACNP and mean, 2.3 and SD, 1.3 for the physicians in training). The ages of patients managed by the ACNP (mean, 65 years; SD, 16 years) and by the physicians in training (mean, 62 years; SD, 17 years) did not differ significantly. The patients managed by the 2 groups did not differ in percentage of females either (46% for the ACNP and 47% for the physicians in training). Mean scores on the Acute Physiology and Chronic Health Evaluation III on the first day of admission to the SD-MICU were high for patients managed by the ACNP (mean, 51; SD, 16) and physicians in training (mean, 51; SD, 25) but were similar to scores for the first day of admission to other ICUs in this facility (mean, 49; SD, 6).

ACNP Activities According to Length of Experience
To determine the effect of increased experience in the ACNP role, we compared findings during the initial observation time (6 months’ experience) and subsequent year (12 months’ experience). We found no significant differences (Table 3).

View this table: [in this window] [in a new window]   Table 3 Activities of the acute care nurse practitioner during the initial observation period (6 months experience) and during the subsequent year (12 months experience) managing patients in the step-down medical intensive care unit

View larger version (18K): [in this window] [in a new window]   Figure 1 Five-minute data for number of observations of the acute care nurse practitioner and physicians in training in activities involving coordination of care. The total number of observations for each of the 12 activities shown ranged from 6 to 85. Neither making rounds with the on-call person to report patients’ status before signing out nor obtaining consent from patients and their families was observed during data collection. Significant differences are indicated after Bonferroni correction for multiple comparisons.

View larger version (12K): [in this window] [in a new window]   Figure 2 Five-minute data for number of observations of the acute care nurse practitioner and physicians in training in nonunit activities. The total number of observations for each of the 10 activities shown ranged from 1 to 75. No reading, teaching, or travel to educational activities were observed during data collection. Significant differences are indicated after Bonferroni correction for multiple comparisons.

	Discussion

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Major findings of this study were (1) compared with physicians in training, the ACNP spent an equivalent proportion of time in activities related to routine patient management, more time in coordination of care, and less time in nonunit activities; and (2) the proportion of time in these activities did not change significantly with increased experience or the added responsibility of patients in the long-term acute care hospital.

In several previous studies in which work sampling was used to determine the time house staff spend in various activities, findings were similar. Guarisco et al¹⁷ asked house staff rotating through an internal medicine service to record the activity the house staff were performing when signaled by a randomly activated beeper. In a 12-week period, 6599 recordings (3533 on-call days, 3066 off-call days) were obtained. When grouped into our broad categories (routine management of patients, coordination of care, and nonunit activity), the proportion of time spent in routine management of patients (45%), coordination of care (22%), and nonunit activities (33%) were similar to our findings for physicians in training, that is, 44%, 18%, and 37%, respectively. Finkler et al¹⁵ calculated the percentage of time house staff spent performing various activities. When grouped into our broad categories, the findings were again similar. Internal medicine house staff and the physicians in our study allocated similar amounts of time to routine management of patients (43% vs 44%), coordination of care (15% vs 18%), and nonunit activity (42% vs 37%).

The results of several previous studies suggest that the acuity of ACNP-managed patients may differ from the acuity of patients managed by house staff. Howie and Erickson¹⁰ described activities of an ACNP team affiliated with a general medical service in a university hospital. The ACNP team admitted and managed patients who had a lower probability of acute cardiac decompensation or need for ICU admission and did not provide care for patients who required transfer to the ICU. Admissions to the ACNP team were capped at 3 to 5 patients per day compared with 10 patients per day for the medical team. Rudy et al⁶ also reported differences in acuity and workload. Compared with the ACNP-PA team, residents cared for patients who were older and sicker and cared for more patients. Conversely, in our study, 1 ACNP or 1 physician in training (pulmonary/critical care fellow) was assigned to the SD-MICU, and both managed a similar caseload with similar acuity, as indicated by scores on the Acute Physiology and Chronic Health Evaluation III on SD-MICU admission.

Both providers spent approximately half their time in activities related to routine management of patients, a finding that suggests equivalent efficiency in performing required tasks. We found no change in this time allotment when comparisons were made between initial and subsequent employment in the ACNP role, suggesting quick acclimatization. As anticipated, physicians spent more time in training-related activities. Conversely, our results indicated that the ACNP spent more time interacting with patients, patients’ families, and nursing staff. None of the observations involved personal conversation (listed separately under nonunit activities). Unlike the physicians in training, who rotated through the unit at 2- to 4-week intervals, the ACNP directed patients’ care in the unit before data collection and was the sole primary care provider for an extended period. Thus, the results indicated that the staff had a greater opportunity to develop a professional relationship with the ACNP and subsequently felt more comfortable asking the ACNP questions. On the basis of a survey of ACNPs, physicians, administrators, and staff nurses, van Soeren and Micevski¹² identified similar success indicators. ACNPs were cited as enabling greater continuity of care, giving increased attention to issues of patients and patients’ families, and promoting a team approach. Previous research suggested that a team-oriented culture characterized by supportive nursing leadership and timely communication is associated with a shorter hospital stay, higher technical quality of care, and greater ability to meet needs of patients’ families.¹⁸ Further research is needed to confirm this possibility.

Consistent presence of an ACNP focused on coordinating care may enhance quality of care and shorten patients’ stay.

 

Significant differences were not seen when comparisons were made between observations during the initial (6 months’ experience) and subsequent year (12 months’ experience) of ACNP employment, despite the additional responsibility of managing patients in the long-term acute care hospital. When absolute differences were compared, 12-month data reflected a 2% reduction in the proportion of time spent in routine management of patients, a 1% reduction in time spent in coordination of care, and a 3% increase in off-unit activities. The increase in off-unit activities most likely was due to duties in the long-term acute care hospital, which occurred outside the SD-MICU, and were therefore documented as off-unit activities. The ability to manage both groups of patients without a significant change in the proportion of time spent in routine management of patients (42% vs 40%) suggests greater efficiency in carrying out the requirements of the role. However, this potential cannot be confirmed by using work sampling data.

This study has several limitations. First, observations were made in only a single ICU, and only 1 ACNP was observed managing patients’ care. Therefore, our findings may not reflect work performed in other settings or be representative of other nurse practitioners. Second, study data were obtained by work sampling. Our methods may have resulted in over-reporting or underreporting of activities. However, our findings were based on direct observation, which yields more reliable results than does recall or self-report.^19,20 Further, findings were consistent when observations were made over time for the ACNP, and little change occurred when 5- and 10-minute recordings were compared. Also, our findings were similar to the results of other studies in regard to time spent in various categories of activities.^15,17

	Conclusion

Top Abstract Materials and Methods Results Discussion Conclusion References

 
The ACNP and the physicians in training had equivalent efficiency in performing required tasks. As anticipated, physicians in training spent more time in nonunit activities. Conversely, the ACNP spent substantially more time interacting with patients and patients’ families and collaborating with other health team members. Further study is indicated to determine if these differences affect patients’ outcomes.

	ACKNOWLEDGMENTS

 
This study was performed at the University of Pittsburgh Medical Center and was supported by grant RO1 NR05204 from the National Institute for Nursing Research, National Institute of Health, US Public Health Service.

To purchase reprints, contact The InnoVision Group, 101 Columbia, Aliso Viejo, CA 92656. Phone, (800) 809–2273 or (949) 362–2050 (ext 532); fax, (949) 362–2049; e-mail, reprints{at}aacn.org.

	REFERENCES

Top Abstract Materials and Methods Results Discussion Conclusion References

 

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