The Nurse’s Medication Day

Field observations

Observations were conducted by the first author (Jennings) in increments of about 3 hours each, covering the full 24-hour day and all days of the week. Notes were taken openly and transcribed immediately after leaving the field (Emerson, Fretz, & Shaw, 1995). Grand tour observations were used at the start of the study, followed by more focused observations (Spradley, 1980). The centrality of medication administration to the nurses’ day became especially apparent while shadowing 13 nurses—11 RNs and 2 LPNs; 7 on the day shift and 6 on the night shift—for at least 3 hours on each of two sequential days. These nurses often commented that medication administration was “time consuming” and “neverend[ing].”

Formal interviews

For the analysis featured here, we also extracted information from the 24 interviews in which aspects of medication administration were addressed. These face-to-face interviews were conducted by the first author away from the units; they were audiotaped and then transcribed verbatim. Although the interview questions were initially designed to explore turbulence, during the first several interviews participants spontaneously introduced information about medication administration, such as when they talked about “good” and “bad” shifts being determined by the number, timing, and nature of the medications they had to give, and about aspects of medication administration as entailing turbulence. Because medication administration was mentioned so often in the early interviews, a probe about it was added to subsequent interviews.

Document reviews

Documents relevant to this analysis included monthly medication records for each unit, as well as written hospital policies. The monthly medication records, provided by an informatics analyst, were requested by the first author soon after medication administration was identified as a theme in the observational data. These records were in the form of spreadsheets containing deidentified information from the electronic medication record generated by the barcoded medication administration (BCMA) system. The informatics analyst calculated the average doses of medications given to patients each month on each unit, as well as the percentage of medications that were routine and the percentage that were unscheduled, along with providing information about the ages of patients on the study units. Medication error rates were not provided to us on advice of the hospital attorney; we were, however, shown graphs illustrating that errors related to medication administration steadily declined from the time the BCMA system was introduced in 2006. (No errors of commission or omission were observed during the course of the study, although—as we describe in more detail in the results section—near misses were observed when the BCMA system alerted nurses to potential mistakes and when nurses intercepted mistakes in pharmacy profiling.) Nurse managers provided information about the ages and experience of their respective nursing staff members. Written documents pertinent to medication administration from external organizations such as The Joint Commission (TJC; 2010, 2011), in addition to laws such as the Controlled Substances Act (Department of Justice, 2007), provided a context within which to interpret these medication data.

Number of doses of medications

The number of medications taken by most patients on the units observed, with many requiring multiple doses per day, expanded the duration and otherwise affected the tempo of medication work. On the medical unit, scheduled doses per patient per day averaged 25, and on the surgical unit 22. PRN (pro re nata, as needed) medications accounted for 7% of the doses per patient per day on the medical unit, or an average of 2 doses per patient per day in addition to the scheduled doses, and 14% of the doses per patient per day on the surgical unit, or an average of 4 additional doses. These data indicate that the IOM’s “conservative” (Aspden et al., 2007, p. 111) assumption of 10 doses per patient per day seriously underestimated the actual doses given. Moreover, in the IOM report, no distinction was made between scheduled and unscheduled medication doses (Aspden et al.).

Scheduled medications

Administration times for scheduled medication spanned the full 24-hour day. For example, medications ordered every 4 hours were given at 2:00 a.m., 6:00 a.m., 10:00 a.m., 2:00 p.m., 6:00 p.m., and 10:00 p.m. Twice-a-day medications were scheduled for 10:00 a.m. and 10:00 p.m., although diuretics were scheduled for 10:00 a.m. and 6:00 p.m. to minimize patients having to urinate at night. Bedtime medications were given at 10:00 p.m. Most daily medications were timed for 10:00 a.m., although drugs that needed to be taken on an empty stomach were scheduled for 6:00 a.m., and anticoagulants that were adjusted based on laboratory results were scheduled for 6:00 p.m. Because 25% of all doses were scheduled for 10:00 a.m. on the study units, it was known as the “main med pass.” Seventeen percent of doses were scheduled for 10:00 p.m., with the remaining 58% of the medications given throughout the remainder of the 24-hour day. Although other investigators have reported that the majority of doses are administered between 8:00 a.m. and 10:00 a.m. (Carayon et al., 2007; Elganzouri et al., 2009), the distribution of doses throughout the remainder of the day has rarely been addressed.

Unscheduled medications

Unscheduled medications altered the temporal rhythm of the medication day. The two main types of unscheduled medications were those ordered STAT (statim, immediately) or PRN. Although routine and expected parts of the medication day, unscheduled medications were paradoxically also interruptions to the routine, because they occurred at unplanned times and thereby created discontinuities in work (Brixey et al., 2007). STAT medications were to be given within 30 minutes of being ordered, requiring nurses to stop other work to give STAT drugs. Patients most often requested PRN medications for pain relief; nurses put these requests first, altering the sequencing and tempo of their work. One nurse stated, “Five minutes [in pain] feels like 20 to the patient,” thereby distinguishing between clock and process time (Davies, 1994); clock time dominates views of time, but is often at odds experientially with process time. When process time dominated, patient needs became the priority.

Institutional demands

Hospital policies were designed to ensure that the institution complied with longstanding regulations and standards, as well as the glut of new rules and guidelines that followed the first IOM report on medication errors (Kohn et al., 2000). Regulations came from many sources, including accrediting agencies such as The Joint Commission (2010, 2011), laws such as the Controlled Substances Act (CSA; DOJ, 2007), and numerous private organizations with no official authority but considerable influence, such as the Institute for Safe Medication Practices (ISMP, 2010). To comply with TJC standards and the legal demands of the CSA, several classes of drugs required actions by two nurses. For example, adjustments to doses of high-risk medications such as anticoagulants and insulin required two nurses to calculate the doses separately, a redundancy to safeguard against errors (ISMP; TJC, 2010). Many calculations were straightforward; others were more complicated, like the 13 steps in the transitional insulin order set. The CSA dictated many parameters for administering drugs with the potential for abuse (e.g., many analgesics; DOJ). Two nurses had to participate in “wasting” controlled substances: one to dispose of the unused portion of the drug, one to witness the action. Likewise, two nurses were involved if a controlled substance was returned to storage, although returning was quicker than wasting.

In 2004, TJC accrediting standards for medication management became more prescriptive and detailed (Rich, 2004). All medication orders, for example, were to be reviewed by a pharmacist to ensure there were no contraindications prior to dispensing the medications. Known as “profiling,” this safety check required pharmacists to construct and maintain the patient’s medication list or profile. Except for emergencies, medications were not to be given until they were profiled. On the units observed, delays in profiling of up to 90 minutes were common. Moreover, nurses often discovered mismatches between orders and profiles, giving rise to comments like, “Pharmacy misprofiles all the time.” Eighteen near misses were observed when nurses found mistakes made by the pharmacy related to the patient’s medication profile. Nurses intercepted these mistakes, calling the pharmacy, and then waiting for the profiles to be corrected. These interceptions illustrate a dynamic in Reason’s (1997, 2000) “Swiss cheese model,” whereby nurses served as a barrier, protecting patients from a potential hazard. Calls to the pharmacy were also common to request “missing meds,” followed by waits until they were delivered. Waiting reflected system failures like those Biron et al. (2009), Hall et al. (2010), and Tucker and Spear (2006) reported. The time it took to call for missing items was wasted time (Southerton, 2003; Waterworth, 2003).

Multiple demands derived also from documentation requirements. The essential components of a BCMA system include individually prepackaged medications, each having a unique barcode that is readable with an optical scanner; an optical device used to scan both the medication package (or intravenous solution) and a barcode on the patient’s identification band; and computer software that links to an electronic medication administration record. Although the BCMA system automatically documented the five “rights” (drug, patient, dose, time, route) along with the date of administration and the name of the nurse giving the medication, this did not fulfill all documentation requirements. To maintain compliance with TJC standards, for instance, nurses had to record a thorough description of patients’ needs for PRN drugs and an assessment of their effectiveness within one hour after administration. Technical devices such as patient-controlled analgesia (PCA; a pump connected to an intravenous [IV] catheter that allowed patients to self-administer a narcotic analgesic) escalated documentation requirements because an assortment of patient parameters had to be recorded at set intervals.

Fire codes and TJC standards mandated that hospital hallways remain clear (National Fire Protection Association, 2007; TJC, 2011), creating demands associated with the BCMA system. The BCMA optical scanner was attached to a computer on wheels (COW), a laptop computer situated on a mobile pedestal. Nurses could not leave or “park” their COWs in the hallway when they were not in use. Each time nurses had to give a medication, they first had to retrieve their COWs from the designated parking areas, which were not always near the medication rooms.

Numerous hospital-specific policies also affected the temporal structure of the medication day. According to the policy, medications were to be scheduled on even-numbered hours. The pharmacy, however, could schedule them at other times, yielding occasions when patients had medications due hourly. Nurses believed that “pharmacy holds the reins, control[ling] whether your shift is good or bad,” because pharmacists did not always set medication administration times based on the policy. When even a couple of patients required medications every hour, the time demand on the nurse increased exponentially because of the numerous steps involved in medication administration (as detailed later in this article).

The nurses’ medication day was affected by additional hospital policies such as those related to meal times. Medications like short-acting insulin had to be given just before or with meals, which, for these units, were to arrive at 7:30 a.m., 11:30 a.m., and 4:30 p.m. The actual meal delivery times varied, with food arriving from 30 to 60 minutes on either side of the scheduled times. Nurses had to monitor the timing of meal service to coordinate with insulin administration, giving it neither too early nor too late, or even overlooking it. The demand of coordinating insulin administration and meal service escalated for the 7:30 a.m. dose because of the concurrent work of changing shifts, creating the possibility that an insulin dose might “slip through a crack.” Nurses were the hospital team members who most often had to adjust their work to the work of others, reflecting a lack of synchronization among members of the care team (Waterworth, 2003).

Demands of technical devices

The numerous technical devices nurses interacted with throughout the day created their own demands separate from whether the devices functioned or malfunctioned (cf. Treiber & Jones, 2010). Some of these devices were integral to medication administration; alarms on safety devices such as “smart” IV pumps used with almost every patient prompted nurses to find the source of the alarm, then determine and manage its cause, creating interruptions (Biron et al., 2009; Carayon et al., 2007). Other devices, such as the cordless phones nurses were required to carry, facilitated communication but also made nurses constantly accessible (Hall et al., 2010). Many relatively simple devices were essential to administering medications, such as medication cups, syringes, needles, tubing, tape, gloves, and alcohol wipes. Nurses used blood pressure cuffs and stethoscopes to evaluate patient vital signs prior to giving certain medications; they used glucometers to determine whether patients needed insulin, and if so, how much. More complex devices included automated medication dispensing cabinets (AMDCs), BCMA, “smart” IV pumps, and PCAs. These devices have been touted by policy organizations such as the IOM (Aspden et al., 2007; Page, 2004) as solutions for improving safe medication practices. The various complex devices were implemented in the hospital at least 3 years prior to this study, and the nurses were adept in using them.

The almost constant need for technical devices often altered the tempo of medication work by slowing it down. For example, alcohol wipes were sometimes out of stock in the patient rooms. Some technical devices were in short supply at certain times of day, creating periods of waiting. Glucometers were always in high demand at meal times and bedtime. The AMDCs located in the medication rooms were in almost constant use. Both units had two AMDCs, with each AMDC designated for patients in a specific location. Accordingly, three to four nurses, in addition to a respiratory therapist and the pharmacy technicians who restocked them, shared the AMDCs throughout the day. Although nurses viewed the AMDCs as “safe” and a “time saver,” some AMDC features, such as verifying the number of medications remaining, slowed down obtaining medications (cf. Balka, Kahnamoui, & Nutland, 2007). Additional medication delays associated with the AMDCs occurred when a medication was out of stock, a common occurrence for frequently given medications.

The COWs created demands associated with their weight (67 pounds) and maneuverability; both male and female nurses regarded them as heavy, cumbersome, and difficult to push. Nurses talked about hurting their backs and hips from “dragging” the COWs. By the end of a medication day, it was common for nurses to experience sore shoulders from pushing their COW to each patient’s room every time they gave even one dose of medication, and then back to the designated parking area. Devices also created demands when they malfunctioned, “slowing” nurses down and “throw[ing them] off schedule.” For example, although BCMA systems made the “five rights foolproof,” nurses frequently had to scan the barcoded medication packets, as well as patients’ barcoded armbands, multiple times (cf. Carayon et al., 2007; Koppel, Wetterneck, Telles, & Karsh, 2008; Novak & Lorenzi, 2008). Repeated scanning was inefficient, because it increased the duration of medication administration. One nurse was observed scanning the same medication packet eight times before the BCMA system recognized it. Despite these delays, nurses knew the BCMA system would reflect precisely when they gave medications, “sensitiz[ing] nurses to the medication schedule in a new way” (Novak & Lorenzi, p. 518). Seven near misses were observed involving alerts from the BCMA system that precluded nurses from making potential mistakes. These near misses were in addition to those involving nurses’ interceptions of pharmacy misprofiling.

Patient demands

Patients’ physical and mental capacities, along with their preferences and requests, created another set of demands on the nurses’ medication day. This was especially evident when nurses had 13 pills, an injection, and IV antibiotics to give to one patient at one medication pass, as they often did. Patient demands also increased if a patient was added to the nurse’s assignment, or there was a change in a patient’s condition.

Demands related to the patients’ ages also affected the duration of medication administration (average age of medical patients was 65 [range = 19 to 102]; average age of surgical patients was 62 [range = 16 to 97]) because of issues with patients’ ability to swallow, level of independence, and cooperation with medication administration. Many patients swallowed only a few pills at a time, with the nurse helping them finesse the right combination based on pill size. Some patients needed the nurse to place the pills in their mouths, requiring the nurse to don gloves. For other patients, nurses had to crush their pills and then mix them with applesauce to facilitate swallowing; nurses regarded crushing medications as the most time-consuming aspect of actually giving medications. As Novak and Lorenzi (2008, p. 517) observed, nurses often had to “find creative ways to get patients to take their medications.” Combative or otherwise uncooperative patients placed special demands on nurses to find the right technique to coax them into taking their pills, allowing injections to be given, or cooperating while eye drops were instilled.

Throughout the medication day, nurses assessed patients’ medication needs that ranged from antianxiety drugs and antipyretics (to reduce fever) to antiemetics (to reduce nausea and vomiting) and antacids. Nurses often had to call physicians to request an order for these medications. Nurses also called physicians requesting orders to be renewed, such as expired insulin orders on patients whose glucose values remained above normal. If physicians returned calls promptly, the demand was minimized, obviating the need for nurses to make another request.

Nurses anticipated spending as much as 20 minutes in each room during a medication pass because they knew that patients would take advantage of their presence and make requests. A frequent request involved assisting patients to the bathroom, an event complicated by the technical devices to which most patients were tethered. In this study extremes were observed, such as an occasion when it took 45 minutes to give medications to a single seriously ill patient with numerous needs. The rhythm of the entire medication day could be altered by one patient, whether an additional patient in the nurse’s assignment or a patient whose condition was unstable or declining. Nurses typically cared for five patients on days and six patients on nights. Occasionally, they were assigned one more patient than usual, potentially turning a single medication pass into a 120- to 140-minute event. If nurses spent more than 20 minutes with a patient, or other demands emerged during the medication pass (e.g., frequently checking on a patient recently admitted from the postanesthesia care unit or giving PRN medications), a medication pass could exceed the “on-time” window defined by hospital policy as an hour before to an hour after the scheduled time. If a patient’s condition was unstable, that patient dominated the nurse’s time. In extreme circumstances, such as when the rapid response team was called, medication work for other patients in that nurse’s assignment came to a standstill until the crisis was over.

Other patient demands also altered the temporal rhythm of the medication day. For example, blood administration occurred frequently. This involved checking the blood with another nurse prior to hanging it, remaining with the patient during the first 15 minutes of the infusion, and checking vital signs 30 minutes before the transfusion, every 15 minutes for the first hour of the transfusion, and at the completion of the transfusion.

Demands of the physical environment

Policy groups such as the IOM have questioned whether the physical design of patient care units affects efficiency and patient safety (Page, 2004). Missing from such discussions is how the physical environment creates demands specifically related to medication administration and the dilemmas of using 21st-Century technologies designed to improve quality and patient safety in 20th-Century hospital structures. In this study, many of the patient safety practices had to be retrofitted into the 40-year old hospital. The strong commitment to keep hallways clear and free from safety hazards created a demand to make parking spaces for the COWs. These parking areas needed to have sufficient electrical outlets so the COWs could be plugged in to keep their batteries charged. To minimize bending and squatting, it was highly desirable for the outlets to be situated at waist height, which was achieved in only some of the parking areas.

Nurses commented that two medication rooms were insufficient; they identified medication rooms as places of turbulence because of the high demand to use them. Because the AMDCs filled the medication rooms, the COWs had to remain outside. Constraints were also posed by the small size of the patient rooms (cf. Koppel et al., 2008), aggravated by the clutter in them (cf. Battisto, Pak, Vander Wood, & Pilcher, 2009), often making it a tight squeeze to get the COWs far enough into patient rooms so the scanning device could reach the patient’s armband.

Medication demands

Finally, the medications themselves created demands based on attributes such as the nature of the drugs and their routes of administration. Antibiotics exemplified drugs that, by their nature, escalated demands on nurses. They could put nurses behind in giving scheduled medications. Nurses, therefore, set a goal of “staying up with antibiotics” that were typically given multiple times each day; the drug-related demands were repeated with each administration. For example, an antibiotic ordered for serious bacterial infections, Piperacillin (Zosyn), was not premixed by the pharmacy; nurses had to reconstitute the drug every time a dose was needed. This took extra planning, because Zosyn had a reputation for being “a bear to mix. It’s like glue”; it also took about 10 minutes to dissolve.

When multiple antibiotics were scheduled at the same time for a single patient—a frequently observed occurrence—nurses experienced increased demands. They had to go into the patient’s room multiple times to give medications for a single medication pass, bringing their COW with them each time. When three antibiotics were scheduled concurrently, it was sometimes impossible to administer all of them within the on-time window, especially if infusions were slowed to ease the burning some patients experienced. Still, nurses preferred juggling antibiotics scheduled concurrently to having medications scheduled every hour.

Of the various routes of drug administration, three routes accounted for 91% of the doses given on the study units. On average, the most common route was parenteral (via needle; 45%), followed by oral (42%) and enteral (via tube; 4%). The parenteral route consisted of four subtypes: intravenous (IV), intramuscular (IM), subcutaneous (SC), and intradermal (ID). Demands from IV medication administration were reduced when patients had IV fluids running continuously. Frequently, however, patients who did not need medications or fluids infusing constantly had their IV lines capped between uses, a practice known as “plugging” or “hep locking,” because a solution was instilled into the IV lines to prevent clotting. Plugging involved instilling a normal saline solution into the line to keep it patent; hep locking involved instilling a heparin solution. The type of IV determined the type solution used. Once plugged or hep locked, patients had more freedom of movement between doses of medication, but it took more of the nurses’ time to reestablish the IV infusion and, when it was completed, “plug” the line again. Although only 4% of the doses were given by the enteral route, they posed a unique set of demands. For instance, if patients were getting continuous feedings through an enteral tube, the nurse had to stop the feeding 30 to 120 minutes prior to giving medications. In addition, nurses had to take several actions to prepare the medications, give them, and clear the tubing after the medications were administered.

Sequencing medication administration

Nurses moved from room to room in no immediately discernible pattern during medication passes, choosing the sequence based on patient demands rather than the numeric room order. The goal was to administer as many medications “on time” as possible. Patients who needed their medications crushed were placed at the end of a medication pass, improving the chances of giving other patients their medications on time. Conversely, patients with several IV antibiotics scheduled concurrently were put first in the sequence to aid in administering them within the allocated timeframe. To maximize efficiency, nurses reprioritized tasks (Tucker & Spear, 2006), converting waiting into usable time. For example, instead of waiting while the pharmacy created or corrected medication profiles or sent missing medications, nurses diverted their efforts to accomplish other patient care activities to avoid wasting time.

Clustering care with medication administration

Nurses took advantage of their time in patient rooms during medication administration to cluster other care (Strauss, 1988). They changed dressings, completed patient assessments including evaluating pain and taking vital signs, read parameters from monitoring equipment, and interacted with patients and families. Nurses gave as many medications as possible at once; 8:00 o’clock and 10:00 o’clock medications were administered at 9:00 o’clock to manage time. If patients requested pain medication, nurses also gave all scheduled medications within the acceptable timeframe to “make one visit do.”

Multitasking during medication administration

Multitasking, a reflection of timing or when events occur (Flaherty, 2003; Zerubavel, 1976), involved doing several tasks simultaneously (Southerton, 2003) rather than sequentially. For instance, nurses were adept at bending their heads to one shoulder to secure their phones while talking. This allowed them to use their hands to concurrently draw-up, scan, or give medications; push their COWs; or get medications from the AMDCs. They also talked with patients and family members and addressed care questions from other staff members while doing the work of medication administration.

Individualized techniques for managing temporal load

Some strategies to stay up with the demands of medication administration were adopted by nurses because “it works for me.” One such timesaving technique was to keep all medication wrappers for each patient until all aspects of giving medications at a scheduled time were completed. If the computer malfunctioned, nurses could quickly rescan the wrappers rather than spend time digging them out of the trash to “start [scanning] from scratch.” Another technique was to create a list of each room in their assignment, the times medications were due, and the number of medications due at each time. At the end of a shift, “everything should be crossed off.” Southerton (2003) noted that list making helped people stay on schedule despite impending temporal overload.