How Much Time are Physicians and Nurses Spending Together at the Patient Bedside?

Data in the literature regarding how much interaction physicians and nurses have, especially at the bedside, are sparse and vary widely. In a recent study using medical students as observers by Stickrath et al., 807 MD rounding events led by medicine attendings were observed over 90 days. The frequency of rounding events that included “communication with nurse” was only 12%.¹⁹ Furthermore, only 64.9% of these communications were at the bedside, for an effective prevalence of bedside MD–RN communication of 7.8%. This number is low compared to our observed frequency of 30.0%. On the other extreme, a study from a hospital that intentionally institutes multidisciplinary rounding (explicitly defined as involving a physician and a nurse at a bedside) reported a frequency range of 63% to 81%.⁷ A follow-up study by the same group again demonstrated a high frequency of multidisciplinary rounds (74%) across a variety of ward and specialty types (range 35% to 97%.).¹¹ However, because of the selection bias of this particular setting, the high prevalence does not reflect a generalizable frequency of bedside MD–RN overlap at most hospitals.

The length of time spent by physicians at the patient bedside balances the competing demands of patient care and rapport-building with maintaining efficiency and progressing to other important tasks. In our study, physicians spent an average of 7.31 minutes at the bedside per patient. A previously published multiinstitutional observational study, which included our hospital, reported that the average length of rounds at bedside was 4.8 minutes.¹³ A second study reported that 8.0 minutes were spent at the bedside per patient.⁷ All three studies examined the same setting of internal medicine rounds at academic university-based hospitals, led by an attending physician with junior and senior residents present. However, the methodologies to measure the length of physician rounds were different: Priest et al. involved observers, Gonzalos et al. used E-mail-based surveys, and we utilized RFID-based locators. Additional institutional, individual, and patient-based factors also influence the length of rounds and are challenging to directly measure.

Furthermore, the discovery that the length of rounds and the frequency of MD–RN overlap did not statistically differ between weekdays and weekends (P > .05) was unexpected. Given the general trend of reduced physician staffing on weekends and the practice of cross-covering larger patient censuses, we would have expected shorter rounds and less frequent MD–RN overlap on the weekends.^7,20 The remarkable similarity between weekday and weekend metrics suggests that our workflow and rounding habits are not compromised on the weekends.

In addition, we found that MD rounds with a nurse at bedside took longer than rounds without a nurse, and that patient rooms located farther away from the central nursing station had a lower frequency of MD–RN overlap. However, we want to emphasize that these findings are merely associative, and not causal. For example, sicker patients usually take longer to round on than stable patients, and it is also the sicker patients who are more likely to have their nurses at the bedside, independent of physician rounding activity. Furthermore, even if rounding with nurses takes more time, it may ultimately result in fewer pages and overall time savings for both physicians and nurses.⁶

With regards to the association between room location and frequency of MD–RN overlap, the data can be interpreted in two ways. On the one hand, if the distance between the patient room and the nursing station does, in fact, reduce the frequency of overlap by almost 2% per room (Figure 4b), these data can be informative for future workflow development, quality improvement projects, or even hospital design. On the other hand, many wards might intentionally place more stable, less acute patients farther away from the nursing station because they do not need to be watched as closely. In that case, these data confirm their expectations and no action is needed.

There are several limitations to our study. The principal limitation, as discussed above, is that while our RFID system can generate large quantities of precise data on MD–RN overlap, we do not know the qualitative nature of the overlap. Just because a nurse and a physician are in the same room at the same time does not mean that they are communicating with each other. Second, we defined “rounding” as lasting a minimum of 10 seconds at the bedside. We believe that at least 10 seconds is needed to engage in any meaningful interaction between the physician and the patient, or the physician and the nurse. Reducing the time cutoff below 10 seconds risks capturing more “noise,” (decreasing specificity) whereas increasing the time cutoff above 10 seconds risks losing out on encounters that actually had substantial communication (decreasing sensitivity). Even if the communications can be classified as pure “social check-ins,” we believe these are important data to capture, as social check-ins are an important part of the patient’s care and experience. Third, several studies have commented on the modest accuracy of RFID technology as a locator system.^15,21 To address this, we both validated the accuracy of our RFID tags prior to the study and restricted our measurements to only inside patient rooms, which has less signal noise than hallways.

Future directions include expanding this study to include housestaff and physicians from other specialities, which may reveal different patterns and metrics of patient and nurse interactions.