NUR4083 Module 3 workflow analysis example

The Fifty-Eight-Minute Admission: Mapping a Medical Unit's Nursing Admission Workflow, Clicks Counted and Workarounds Marked

Student Name

American College of Education

NUR4083: Nursing Informatics

Module 3 Assignment

Instructor Name

January 25, 2027

Why Map the Admission

Nurses on a 30-bed medical unit, an invented setting built for this paper, say that admissions take too long and pull them away from their other patients. That complaint is common, and it is easy to dismiss as a feeling. Cornell et al. (2010) observed medical-surgical nurses for more than 98 hours and found that assessment, communicating and charting were their most frequent activities, that 40 percent of activities lasted less than ten seconds and that nurses constantly switched between activities and locations with little continuous flow. A long admission workflow adds to that fragmentation, because the nurse is interrupted repeatedly while completing it.

To move from complaint to evidence, a staff nurse and the unit's clinical informatics liaison observed five consecutive weekday admissions from the emergency department over two weeks. They recorded each screen the admitting nurse opened, counted mouse clicks and keystrokes that selected or confirmed an entry, timed each section and noted every time the nurse left the workflow and returned. They did not observe night admissions, which is a limitation noted later. Counting clicks and minutes is one of several ways documentation burden has been measured; a scoping review of the field found that studies used many different measures, from time spent in the record to after-hours work and fragmentation of workflow, and that standard, validated measures are still lacking (Moy et al., 2021). The measures used here were chosen because nurses and informatics staff could both understand them. The purpose was not to time the nurses; it was to time the workflow, so that the design could be judged separately from the people using it.

The Workflow in Order

The admission workflow has nine sections that the record presents in a fixed order, and the nurse cannot sign the admission until all are complete. Across the five admissions, the median total time was 58 minutes, ranging from 44 to 81, and the median number of clicks was 212. The first section, patient identification and allergies, took a median of 4 minutes and 18 clicks. Allergies had already been entered in the emergency department, but the admission section required the nurse to review and reconfirm each one individually rather than accepting the list as a whole.

The second and longest section was the home medication history, with a median of 16 minutes and 61 clicks. The emergency department had already recorded a preliminary list, but the unit's process required the admitting nurse to rebuild it from the patient's report and bottles, entering dose, route, frequency and last dose for each medication. For a patient taking eleven medications, this section alone took 27 minutes. The third through sixth sections, the head-to-toe assessment, fall risk, pressure injury risk and nutrition screening, took a median of 18 minutes and 74 clicks combined; much of the head-to-toe assessment duplicated the emergency department assessment completed two to four hours earlier.

The remaining sections, psychosocial and advance directive questions, the patient's valuables and belongings inventory and the admission education checklist, took a median of 20 minutes combined, including 9 minutes for the education checklist, which asked the nurse to document teaching on fourteen topics at a time when most patients were tired and many were in pain. The two sections that consumed the most time, medications and education, were also the two in which the nurses most doubted the value of what they were entering.

Workarounds Marked

Four workarounds appeared in the five admissions. In three admissions, the nurse completed the assessment on a paper worksheet at the bedside and transcribed it into the record at the nurses' station, because the workstation on wheels was in use or the patient's room had no space for it. In two, the nurse copied forward the emergency department's skin assessment rather than repeating it, then edited only the fields that had changed. In all five, the nurse left the education checklist until the end of the shift and completed it from memory. And in one, the nurse signed the admission with the home medication list marked as incomplete, with a note that the family would bring the bottles the next morning.

Koppel et al. (2008) studied barcode medication administration systems and found that workarounds usually have identifiable causes in technology, workflow or environment rather than in careless users, and that each workaround carries its own risks. The same logic applies here. The paper worksheet exists because equipment and room layout do not fit the design, and it creates a transcription risk and a delay between assessment and documentation. Copying forward exists because the record asks for a second full assessment within hours of the first, and it risks carrying forward findings that have changed. Completing education from memory exists because the checklist asks for fourteen topics at the wrong moment, and it produces documentation of teaching that may not have happened as recorded.

Software Problems and Process Problems

Separating what the software requires from what the unit has chosen shows that not every problem needs a vendor. The rule that each allergy must be reconfirmed individually is a configuration choice that the informatics team could change to a single review-and-confirm action. The fixed order of nine sections is a software constraint on this record, and the nurses cannot change it. But the requirement for the admitting nurse to rebuild the full medication history is a unit and pharmacy process: the hospital employs pharmacy technicians who take medication histories in the emergency department during weekday hours, and the unit had never arranged for their histories to count as the admission history.

Similarly, the fourteen-topic education checklist at admission is a unit policy written years ago to meet an accreditation expectation, not a requirement of the software. Moving most of those topics to the discharge education record, where they are taught anyway, would leave the admission checklist with the three topics that matter on the first day: call light use, fall prevention and how to report pain.

Recommendations

The unit can make three changes on its own. It can accept the pharmacy technician's medication history as the admission medication history when one exists, with the admitting nurse reviewing it rather than rebuilding it, which on the observed admissions would have saved a median of about 12 minutes. It can shorten the admission education checklist to three topics. And it can place a second workstation on wheels on the unit, which the manager can request from the existing equipment budget, to reduce the need for paper worksheets.

Two changes need the informatics team. The first is to allow the admission head-to-toe assessment to display the emergency department's findings with each system marked as reviewed and unchanged or updated, so that copying forward becomes a visible, deliberate act rather than a hidden one. The second is to replace individual allergy reconfirmation with a single review. The unit will repeat the observation of five admissions three months after the changes, including at least two night admissions to address the limitation of the first study, and compare median time and clicks.

Conclusion

Mapping five admissions turned a common complaint into a specific finding: a median of 58 minutes and 212 clicks, with the longest sections duplicating work already done in the emergency department and the least valued section asking for teaching at the wrong moment. The workarounds nurses used were not signs of carelessness but markers of where the design did not fit the work, and each carried its own risk. Some of the fixes belong to the informatics team, but the largest ones were within the unit's own control. A workflow map is useful precisely because it shows which is which.

References

Cornell, P., Herrin-Griffith, D., Keim, C., Petschonek, S., Sanders, A. M., D'Mello, S., Golden, T. W., & Shepherd, G. (2010). Transforming nursing workflow, part 1: The chaotic nature of nurse activities. Journal of Nursing Administration, 40(9), 366-373. https://doi.org/10.1097/NNA.0b013e3181ee4261

Koppel, R., Wetterneck, T., Telles, J. L., & Karsh, B.-T. (2008). Workarounds to barcode medication administration systems: Their occurrences, causes, and threats to patient safety. Journal of the American Medical Informatics Association, 15(4), 408-423. https://doi.org/10.1197/jamia.M2616

Moy, A. J., Schwartz, J. M., Chen, R., Sadri, S., Lucas, E., Cato, K. D., & Rossetti, S. C. (2021). Measurement of clinical documentation burden among physicians and nurses using electronic health records: A scoping review. Journal of the American Medical Informatics Association, 28(5), 998-1008. https://doi.org/10.1093/jamia/ocaa325