Rev. Latino-Am.

Enfermagem Original Article

2014 Jan.-Feb.;22(1):150-7
DOI: 10.1590/0104-1169.3032.2381
www.eerp.usp.br/rlae

Direct and indirect nursing care time in an intensive care unit1

Luciana Emi Kakushi2

Yolanda Dora Martinez Évora3

Objective: to identify the direct and indirect nursing care time in an intensive care unit. Method:
a descriptive/exploratory study conducted at a private hospital. The Nursing Activities Score
classification system was used to estimate the direct care time, and electronic health records
were used to estimate the indirect care time. The data were collected from March to June 2011.
Results: the findings indicate that the average nursing care time was 29.5 hours, consisting of
27.4 hours of direct care and 2.1 hours of indirect care per patient/day. The nursing care time
was higher on weekends and holidays, with predominant use of electronic medical records at
night. Conclusion: ascertaining nursing care times will contribute to a quantitative evaluation of
human resources, assisting in the determination of workloads and workforce size.

Descriptors: Time and Motion Studies; Nursing Care; Intensive Care Units; Medical Records
Systems, Computerized; Workload.

1
Paper extracted from master’s thesis “Measurement and analysis of time direct and indirect nursing care in Internsive Care Unit”, presented to
Escola de Enfermagem de Ribeirão Preto, Universidade de São Paulo, WHO Collaborating Centre for Nursing Research Development, Ribeirão
Preto, SP, Brazil.
2
Doctoral Student, Escola de Enfermagem de Ribeirão Preto, Universidade de São Paulo, WHO Collaborating Centre for Nursing Research
Development, Ribeirão Preto, SP, Brazil.
3
PhD, Full Professor, Escola de Enfermagem de Ribeirão Preto, Universidade de São Paulo, WHO Collaborating Centre for Nursing Research
Development, Ribeirão Preto, SP, Brazil.

Corresponding Author: Copyright © 2014 Revista Latino-Americana de Enfermagem

This is an Open Access article distributed under the terms of the Creative
Luciana Emi Kakushi
Commons Attribution Non-Commercial License (CC BY-NC).
Rua São Salvador, 902 This license lets others distribute, remix, tweak, and build upon your work
Bairro: Sumarezinho non-commercially, and although their new works must also acknowledge
CEP: 14055-260, Ribeirão Preto, SP, Brasil you and be non-commercial, they don’t have to license their derivative
E-mail: lucianakakushi@usp.br works on the same terms.
 Kakushi LE, Évora YDM. 151

Introduction reducing the overall time spent on documenting patient

care activities(7-8).
Measuring the average nursing care time is an The advantages and benefits of an electronic system
objective measure for assessing the quantity and have been surveyed by several authors(6-8). However,
quality of the nursing staff in hospitals because it some studies report that there is insufficient evidence
allows hospitals to evaluate the condition of the existing regarding the time spent on nursing documentation in
human resources(1). Thus, in intensive care units (ICU), electronic systems and its impact on patient care(9-10).
predictions for personnel requirements should be The importance of measuring the time spent on nursing
estimated using instruments that consider the various documentation and other processes involving electronic
nursing activities involved, which helps to quantify the health systems has prompted the following research
actual workload and determine the number of workers question: how much time is spent by the nursing staff
needed to form a team(2). on direct and indirect patient care in the ICU, when
In the current context, the instruments for assessing using an electronic health system?
a patient’s clinical condition and required care needs Thus, the aim of this study was to identify the direct
have become indispensable in efforts to improve the and indirect nursing care time in an intensive care unit.
cost-effectiveness of health care(3). Thus, care indicators
are increasingly needed in nursing to ensure the quality Methods
of care, helping to quantify the number of staff required
to provide care that is safe for both the patients and the This project was a descriptive/exploratory study

health professionals. developed in collaboration with the ICU of a private

Thus, the Nursing Activities Score (NAS) is an hospital located in Ribeirão Preto, state of São Paulo-SP.

instrument that has been designed to measure the The ICU involved in this study serves both children

actual nursing workload in ICUs, quantifying the nursing and adults and has 20 beds, four of which are reserved

care and the degree of complexity involved. The total for patients who require some form of isolation.

score obtained using the NAS scoring system represents The theoretical framework of this research was

the percentage of time spent by nurses per shift in direct based on the Nursing Interventions Classification

patient care(3). (NIC), which defines direct and indirect nursing care

It is in these scenarios that identifying the nursing interventions and estimates the time required to perform

workload is key to determining the needed workforce each of these activities.

of health professionals. To identify this variable, the The study population consisted of the ICU

time that nurses use to provide patient care must be nursing staff, including nine clinical nurses, 27 nursing

measured, and the tools used to measure the workload technicians, 24 nursing assistants and one nurse

should also consider indirect care activities(4). coordinator. The sample population consisted of eight

According to the Nursing Interventions Classification nurses, 25 nursing technicians and 21 nursing assistants

(NIC), direct care intervention is a treatment performed scheduled to work the morning, afternoon and night

through interaction with the patient(s), direct social shifts and who agreed to participate in the study by

actions and counseling. Indirect care intervention is a signing an informed consent form.

treatment performed away from the patient, but on his/ The data relating to the direct care time were

her behalf or on behalf of a group of patients, where calculated using the NAS instrument, which quantifies

these actions support the overall effectiveness of direct care by scoring nursing activities. The nurses in

care interventions(5). the studied ICU employed this method daily and

Given that the ICU is one of the health care retrospectively (past 24 hours) for all the patients in the

fields where technology is constantly improving, in ICU, as designed and indicated for use. The NAS score

addition to a large amount of patient information was calculated in the form of points and subsequently

and data, a significant amount of attention has been transformed into time units, for which each point in

directed toward electronic health systems. The use of the NAS score corresponds to 14.4 minutes of direct

information technology systems provides easy access nursing care(11).

to information, data sharing possibilities, simultaneous The data regarding the indirect care time were

access to information by multiple professionals, legibility provided by information technology professionals at the

and integration with other health information systems(6), institution. In this study, these times were defined as the

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152 Rev. Latino-Am. Enfermagem 2014 Jan.-Feb.;22(1):150-7.

time required to record nursing staff actions in patient Data were collected from March 2011 to June 2011,
care and perform other processes involving electronic and the results are presented graphically.
health records (EHRs), such as requesting, suspending This project was approved by the Research Ethics
and returning materials and medications to the pharmacy. Committee of the Ribeirão Preto School of Nursing,
These data were obtained via the electronic medical University of São Paulo [Universidade de São Paulo -
record system, which provided a report consisting of USP] (protocol No. 1244/2010) and was authorized by
the following information: Username, Log on - day, Log the institution under study.
on – Time, Log off - day and Log off – time. This
information was used to calculate the time the user Results
spent using the electronic medical records during his/
From March 2011 to June 2011, 477 patients were
her work shift.
admitted to the ICU, with an average of 119 patients/
In total, 25,239 records were obtained for the
month. During the study period, the occupancy rate
nursing staff’s use of electronic medical records, 355 of
remained at an average of 86.7%, making it possible to
which were excluded because the log-off time was not
evaluate the work dynamics of the unit.
recorded. Therefore, the analysis consisted of 24,884
The mean age of the patients was 64 years, which
records.
can be considered an elderly population. They were
The time provided by the information technology
predominately male, at 56.5% (67).
system was in hours, minutes and seconds (hh:mm:ss).
The average ICU stay was 4.4 days, and the older
Statistical tools were used to transform the times into
patients remained in the unit for longer periods due to
decimal places (in minutes), thus allowing the results to
their slower recoveries.
be compared with the NAS.
The predominant reasons for admission were
In addition to transforming the values into similar
clinical at 63.4% (75) and surgical at 36.5% (43), which
units for comparisons, the statistical treatment also
is consistent with the average advanced age of the
determined the direct care time (NAS) and indirect care
patients and the patients’ health requirements.
time (EHR) in the ICU, the care time per number of
The distribution of the professional staff categories
patients, the care time per work period [daytime (07:00
of the unit were as follows: 14.8% nurses, 46.3%
to 19:00 hours) and nighttime (19:00 to 07:00 hours)]
nursing technicians and 38.9% nursing assistants.
and the care time on weekdays (Monday to Friday) and
Figure 1 below shows the direct nursing care time
on weekends and holidays.
(NAS) over the study period.

NAS total

50000
45,563.2
45000

40000

35000
Time in minutes

30000

25000

20000

15000
21,288.9
10000

5000

0
1
9
17
25
33
41
49
57
65
73
81
89
97
105
113
121

Days

Figure 1 - Distribution of the direct nursing care time (NAS) for the period between March 2011 and
June 2011, Ribeirão Preto, SP, Brazil, 2012

www.eerp.usp.br/rlae
 Kakushi LE, Évora YDM. 153

The care times varied over the study period (a Figure 2 below shows the indirect nursing care time
minimum of 21,288.9 minutes and a maximum of (EHR) over the study period.
45,563.2 minutes). The average time was 32,391.4 The distribution of the indirect care time was also
minutes (539.8 hours) per day in the unit, and thus, not constant (a minimum of 1,221.4 minutes and a
each patient required an average of 1,649.3 minutes maximum of 4,082.0 minutes). The average was 2,420.1
(27.4 hours) of direct nursing care per day. minutes (40.3 hours) per day in the unit, of which each
The conversion of the NAS score into points, which patient received 126.0 minutes or 2.1 hours of indirect
represents the percentage of nursing time per shift spent nursing care per day.
in direct patient care, yielded an average of 114.3% per Figure 3 shows the distribution of direct and indirect
ICU patient in this study. nursing care time (NAS + EHR) over the study period.

EHR total

4500
4,082.0
4000

3500
Time in minutes

3000

2500

2000

1500

1000
1,221.4
500

0
1
9
17
25
33
41
49
57
65
73
81
89
97
105
113
121
Days

Figure 2 - Distribution of the indirect nursing care time (EHR) for the period between March 2011
and June 2011, Ribeirão Preto, SP, Brazil, 2012

NAS + EHR
47,511.8
50000

45000

40000

35000
Time in minutes

30000

25000

20000
22,025.9
15000

10000

5000

0
1
9
17
25
33
41
49
57
65
73
81
89
97
105
113
121

Days
Figure 3 - Distribution of direct and indirect nursing care time (NAS + EHR) for the period between
March 2011 and June 2011, Ribeirão Preto, SP, Brazil, 2012

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154 Rev. Latino-Am. Enfermagem 2014 Jan.-Feb.;22(1):150-7.

There is variability in the care time (a minimum Thus, the nursing care time in the ICU in this study
of 22,025.9 minutes and a maximum of 47,511.8 was 29.5 hours per patient/day, 27.4 hours (93%)
minutes). The average care time was 34,811.5 minutes of which was for direct care and 2.1 hours (7%) for
(582.7 hours) per day in the unit. Therefore, each indirect care.
patient required an average of 1,774.8 minutes (29.5 Figure 4 below shows the direct and indirect nursing
hours) of nursing care per day. care time analyzed in relation to the days of the week.

Care time
NAS + EHR
35500

35000
Time in minutes

34500

34000

33500

33000
Weekdays Weekend and
Holidays

Figure 4 - Distribution of the direct and indirect nursing care time (NAS + EHR) in relation to the
days of the week, for the period between March 2011 and June 2011, Ribeirão Preto, SP, Brazil, 2012

Figure 4 shows that the direct and indirect nursing Given the distribution of the time spent on EHR
care time is higher on weekends and holidays at during the daytime and nighttime shifts over the study
35,009.5 minutes (583.4 hours), compared to weekdays period, shown in Figure 5 below, the nurses spent an
at 34,728.6 minutes (578.8 hours), i.e., 29.7 hours are average of 878.9 minutes (14.6 hours) during the
required on weekends and holidays and 29.3 hours daytime shift and 1,541.3 minutes (25.6 hours) during
on weekdays, which is an increase of 24.0 minutes of the nighttime shift on EHR.
nursing care per patient/day on weekends and holidays.

EHR daytime EHR nighttime

3500

3000

2500
Time in minutes

2000

1500

1000

500

0
1
8
15
22
29
36
43
50
57
64
71
78
85
92
99
106
113
120

Days

Figure 5 - Distribution of time spent on electronic patient records (EHR) during the daytime and
nighttime shifts for the period between March 2011 and June 2011, Ribeirão Preto, SP, Brazil, 2012

www.eerp.usp.br/rlae
 Kakushi LE, Évora YDM. 155

The average time spent on EHR during the daytime carry out the procedure, increasing the total NAS score
shift was 46.0 minutes per patient/day, and during the by 17.0 points.
nighttime it was 79.9 minutes (1.3 hours) per patient/ The NAS score was not affected by the fact
day, i.e., an increase of 33.9 minutes per patient/day that the unit receives both children and adults, as
during the nighttime shift. the determination of the points for the classification
The distribution of 2.5% during the daytime shift instrument is based on the nursing activities performed
and 4.3% during the nighttime shift for the use of on the patient.
electronic medical records combine for a total percentage The time spent on electronic records was 2.1
of indirect care nursing time of 7%. hours for nursing documentation, i.e., a decrease of
24.0 minutes per patient/day spent on documentation
Discussion using an electronic record system compared to the
time estimated by the NIC classification system(17)
The daily direct and indirect nursing care time
(2.5 hours). The time spent on electronic records in the
in the ICU in this study was 29.5 hours. Based on
ICU in this study not only accounts for the documentation
the levels established by Resolution No. 293/2004(12)
of nursing activities, but encompasses all processes
of the Federal Nursing Board (Conselho Federal de
that involve the use of the electronic systems, such as
Enfermagem – COFEN), the hours of care measured here
the activities of requesting, suspending and returning
were higher than the number of hours recommended
materials and medications, i.e., nursing actions aimed
by the resolution, established at 17.9 nursing hours per
at indirect patient care.
client for intensive care.
It is important to note that the electronic systems
According to the percent distribution of the number
in the unit in this study do not have a time out function,
of nurses in the ICU in this study, the number of nurses
i.e., a safety feature that logs out a user after a few
here was lower than the numbers indicated by the
minutes of no activity on the system. Thus, the user can
COFEN Resolution No. 293/2004(12). The resolution has
remain logged in without necessarily using the electronic
established a proportion of 52-56% for nurses and the
health records.
remaining percentage for nursing technicians in intensive
The percentage of time used for indirect nursing
care units. The National Health Surveillance Agency
care (7%) is consistent with the results of other studies
(Agência Nacional de Vigilância Sanitária –ANVISA) also
that also used the NIC classification system in measuring
recommends that the nursing care of patients in the
the average documentation time and that showed that
ICU(13) be performed by nurses and nursing technicians.
the time spent on documentation by nursing staff to be
It is important to note that in this unit, the nursing
9.6%(18), 9.3%(19) and 6.74%(20). However, these studies
technicians and nursing assistants performed the same
do not identify the electronic systems used.
nursing activities.
The time spent on documentation using electronic
The NAS scores for the unit studied (114.3%)
health records during the daytime (2.5%) and nighttime
can be compared to other studies that have reported
(4.3%) shifts differ from each other and also from other
averages of 80.1%(14), 96.2%(15), 96.7%(16) for an ICU
studies that reported percentages of 19.2% for the
specializing in cardiac surgery. It is worth noting that the
daytime shift and 12.4% for the nighttime shift(21) and of
ICU studied here also cares for patients in the immediate
11.3% in the morning and 6.7% in the evening(19). This
postoperative period following cardiac surgery (16% of
difference in the documentation times between shifts
admissions), which could explain this increase in the NAS
can be explained by the increased number of patients
score. Another factor that could account for this increase
in these units during the daytime shift, which differs
may be related to the item administrative and managerial
from admittance into the ICU. The prevalence of the
tasks, through the application of various protocols for
use of EHR at night can be explained by the increased
all patients admitted to the unit, including protocols for
availability of computers during this period, as these
preventing ventilator-associated pneumonia, preventing
devices are shared with various health professionals
pressure ulcers and preventing falls, which together add
who attend to patients during the day.
23.2 points to the score of nursing activities. It may
The nursing care time was higher on weekends and
also be related to the item mobilization and positioning,
holidays, which is consistent with the results reported
regarding the daily transfer of patients to another bed
by other researchers who have shown that this variation
within the ICU, which requires three or more nurses to
in workload was also observed on different days of the

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156 Rev. Latino-Am. Enfermagem 2014 Jan.-Feb.;22(1):150-7.

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