How far do nurses walk?

How far do nurses walk?

John M. Welton

The estimated distances 146 registered nurses walked within a 12-hour shift in four similar adult medical-surgical units at a university hospital are reported. Findings demonstrate that walking is a significant component of inpatient nursing care.

No published studies quantify either the distance walked or the effects of walking on nurses in the hospital setting. The topic is relevant due to the graying of the nursing workforce as well as the looming shortage of nurses (Buerhaus, Staiger, & Auerbach, 2003; Buerhaus, Staiger, & Auerbach, 2000). Continuous walking and other occupational stressors in older nurses can lead potentially to fatigue, joint pain, and other injuries (Sabine, 1999; Yip, 2001). These responses suggest that walking may be a potential hazard for nurses working in acute care hospitals, yet no previously reported studies identify the distances that nurses travel in a typical shift.

The link between nursing assignment and distance to or between patients also is worthy of scrutiny. Architectural design of the nursing unit was explored by Thompson (2003), but no recent study on the relationship among unit layout, nursing workload, and patient care quality has been published. It may be timely to revisit the design of nursing care units in light of the activity concerns mentioned above, and particularly how to minimize the distance between nurses and patients in an era where patient acuity is rising sharply (Graf, Millar, Feilteau, Coakley, & Erickson, 2003).

The current study is the preliminary result of a pretest-posttest design to evaluate the effectiveness of a wireless phone system and is a replication of a previous study (Spurck, Mohr, Seroka, & Stoner, 1995). Authors hypothesized that the new wireless phones would decrease overall workload of nurses. A main consideration is the amount of time nurses spend going from patient rooms to the central nurses station to receive and initiate phone calls to physicians, or to other areas of the hospital to coordinate care. The results from this study will provide a meaningful estimate of distance walked during a typical shift.

Methods

Design, setting, and sample. The study was conducted prospectively from September 29, 2003, to October 30, 2003 (4 weeks), on four medical-surgical nursing units at a large university hospital in the Southeast. The units, which were similar geographically and architecturally, treated adult patients with a range of medical and surgical diagnoses. All registered nurses working on the study units were invited to participate through email and a letter. An initial meeting was held on each unit for day and night shifts to explain the overall study goals and provide information about the pedometers and documentation. Questions were answered and the investigators reinforced that participation was voluntary. The study was reviewed and approved by the local institutional review board.

Procedure. At the beginning of the shift, the nurse would receive the pedometer from an off-going nurse, reset the device, place the device on his/her right hip, walk 10 steps, then read the number of steps. If the reading was between 9 and 11, the nurse was instructed to proceed with the shift and mark the total steps, hours worked, and room assignment at the end of the shift. If the pedometer was not accurate after repositioning, the nurse was instructed to select another pedometer and repeat the calibration procedure.

The Yamax Digi-Walker (Tokyo) pedometer was selected for the study. These pedometers have been used effectively to measure distance walked in a variety of situations (Hagihara, Tarumi, & Nobutomo, 2001; Manson et al., 1999; Nasr, McCarthy, Walker, & Horrocks, 2002; Silva, Shepherd, Jackson, Dorey, & Schmalzried, 2002; Tudor-Locke, Williams, Reis, & Pluto, 2002). Choice of the instrument was based on demonstrated measurement accuracy and cost (Bassett, Jr. et al., 1996; Crouter, Schneider, Karabulut, & Bassett, Jr., 2003; Schneider, Crouter, Lukajic, & Bassett, Jr., 2003). The device did not use any batteries. Its color was bright yellow for visibility.

Data analysis. Data were entered into a Microsoft Access database from handwritten log sheets by the principal investigator, then analyzed using the Statistical Package for Social Science statistical software version 12.0 (SPSS, Inc., Chicago). No patient or nurse identifying information was included in the analysis data set.

Findings

Tables 1 and 2 describe the overall findings of the 647 observations. Steps per hour worked, miles walked, and miles walked per hour worked were all derived from total steps taken during the shift. Several nurses were sampled for step length (mean distance in feet for each step taken); 2.6 feet was used as a population mean for all participating nurses for the derived value. Although some charge nurses used the pedometers during the study, only those nurses who were assigned patients during the shift were included in the final analysis.

The overall mean distance walked per shift was 4.1 miles (SD 1.4), 8,747 steps (SD 2953), and 0.36 miles per hour worked (SD 0.12). A slight but statistically significant difference existed in total miles walked between day and night shift (4.20 vs. 3.95 respectively, ANOVA F=4.60, p=0.032). No significant difference existed between weekday and weekend shifts.

Differences in miles walked by number of patients assigned were examined using Analysis of Variance (ANOVA). There was a statistically significant difference in miles walked among 3, 4, 5, and 6 patients assigned. Walking during weekday and weekend shifts was compared using ANOVA (see Table 2), but no statistically significant difference was determined (F=1.933, p=0.165). Day and night shifts were compared using ANOVA (see Table 3). Nurses on day shift walked somewhat further than night shift (F=4.601, p<0.05). This may be attributable to higher unit activity during the day, such as patient transport for tests, participation in physician rounds, and involvement in additional diagnostic tests. Differences in miles walked also were examined across patient assignment. The hypothesis was that nurses with a higher number of assigned patients would walk further. ANOVA with Scheffe post hoc test did not reveal a significant difference among assignment levels of 3, 4, 5, and 6 patients (F=1.985, p=0.116). Figure 1 depicts the miles walked per 12-hour shift based on the number of assigned patients.

[FIGURE 1 OMITTED]

Discussion

This study found that nurses typically walk 4-5 miles during a 12-hour shift and 1/3-1/2 miles per hour worked. Significant differences existed between day and night shifts in distance walked and number of assigned patients. Without previous studies, it is difficult to compare this finding to experiences of other nurses. The extra distance walked when accepting a sixth patient assignment compared to assignments of 3, 4, or 5 is notable but did not reach statistical significance. If additional observations were taken, they may have had enough power to detect a difference with the higher patient assignment.

The higher amount of walking during the day shift compared to nights was expected, though the difference was small. This may indicate that even though nurses walk less during the night shift, patient care is comparable in this busy tertiary setting. The slight difference between weekday and weekend walking distance was not statistically significant.

Benefits and Disadvantages of Walking

The Nurses’ Health Study, a longitudinal evaluation of 72,488 female nurses ages 40 to 65 who resided in 11 states, reported significant findings of reduced Type II diabetes, stroke, and hip fractures in nurses who maintained a vigorous activity and walking regime (Feskanich, Willett, & Colditz, 2002; Hu et al., 1999; Hu et al., 2000). One interpretation of the findings from the Nurses’ Health Study is that older nurses who maintain an active walking regime maintain overall health and may be better able to remain active in their professional roles. On the other hand, excessive walking also can accelerate fatigue, exacerbate underlying orthopedic injuries or illnesses, increase pain and lower limb edema, and decrease function. The unanswered question is whether these health effects adversely affect the quality of nursing care. The current study was not able to identify the overall impression of walking by this nursing staff. A follow up study would be useful to identify how nurses perceive walking to discern whether this is a facilitator or hindrance to patient care, especially comparing younger and older nurses.

Another consideration is the distance walked by nurses in hospitals compared to perceived job satisfaction and turnover. Do units with poor architectural design that place patients far from the center of nursing activity have lower overall staff morale and decreased quality of care? Would a nurse be less inclined to answer a call bell for a patient at the end of a long hallway at the end of a busy shift? This dilemma could create situations where important patient symptoms or status changes are missed due to distance or nurse fatigue.

Limitations

The main limitations of this study are related to use of the pedometer to measure steps and distance walked. A small number of nurses had difficulty wearing the devices, and a few of them were dropped and damaged. The pedometers sometimes were worn home, making an accurate measurement impossible for that shift and resulting in lost opportunity to conduct additional measurements while the device was unavailable. Four Digi-Walkers were lost during the study. These are reasonable instrumentation issues. Also, the use of mean feet per step computed from only a small number of participants may have led to inaccurate estimation of actual distance walked.

Conclusion

In this study, nurses walked typically 4-5 miles in a 12-hour shift. A higher assignment from 4 or 5 to 6 patients increased that distance. Nurses working day shifts walked slightly more than those on night shifts. The findings raise the question of whether this distance walked is a positive or negative effect on nurses working in similar settings. Further research is needed to investigate the association among distance walked, fatigue, workload, and patient quality of care.

References

Bassett, D.R., Jr., Ainsworth, B.E., Leggett, S.R., Mathien, C.A., Main, J.A., Hunter, D.C., et al. (1996). Accuracy of five electronic pedometers for measuring distance walked. Medicine and Science in Sports and Exercise, 28, 1071-1077.

Buerhaus, P.I., Staiger, D.O., & Auerbach, D.I. (2000). Policy responses to an aging registered nurse workforce. Nursing Economic$, 18, 278-284.

Buerhaus, P.I., Staiger, D.O., & Auerbach, D. I. (2003). Is the current shortage of hospital nurses ending? Health Affairs (Millwood), 22, 191-198.

Crouter, S.E., Schneider, P.L., Karabulut, M., & Bassett, D.R., Jr. (2003). Validity of 10 electronic pedometers for measuring steps, distance, and energy cost. Medicine and Science in Sports and Exercise, 35, 1455-1460.

Feskanich, D., Willett, W., & Colditz, G. (2002). Walking and leisure-time activity and risk of hip fracture in postmenopausal women. Journal of the American Medical Association, 288, 2300-2306.

Graf, C. M., Millar, S., Feilteau, C., Coakley, P.J., & Erickson, J.I. (2003). Patients’ needs for nursing care: Beyond staffing ratios. Journal of Nursing Administration, 33, 76-81.

Hagihara, A., Tarumi, K., & Nobutomo, K. (2001). The number of steps taken by flight attendants during international long-haul flights. Aviation, Space, and Environmental Medicine, 72, 937-939.

Hu, F.B., Sigal, R.J., Rich-Edwards, J.W., Colditz, G.A., Solomon, C.G., Willett, W.C., et al. (1999). Walking compared with vigorous physical activity and risk of type 2 diabetes in women: A prospective study. Journal of the American Medical Association, 282, 1433-1439.

Hu, F.B., Stampfer, M.J., Colditz, G.A., Ascherio, A., Rexrode, K.M., Willett, W.C., et al. (2000). Physical activity and risk of stroke in women. Journal of the American Medical Association, 283, 2961-2967.

Manson, J.E., Hu, F.B., Rich-Edwards, J.W., Colditz, G.A., Stampfer, M.J., Willett, W.C., et al. (1999). A prospective study of walking as compared with vigorous exercise in the prevention of coronary heart disease in women. New England Journal of Medicine, 341, 650-658.

Nasr, M.K., McCarthy, R.J., Walker, R.A., & Horrocks, M. (2002). The role of pedometers in the assessment of intermittent claudication. European Journal of Vascular & Endovascular Surgery, 23, 317-320.

Sabine, P.M. (1999). Taking care of your feet. Accident and Emergency Nursing, 7, 197-200.

Schneider, P.L., Crouter, S.E., Lukajic, O., & Bassett, D.R., Jr. (2003). Accuracy and reliability of 10 pedometers for measuring steps over a 400-m walk. Medicine and Science in Sports and Exercise, 35, 1779- 1784.

Silva, M., Shepherd, E.E, Jackson, W.O., Dorey, F.J., & Schmalzried, T.P. (2002). Average patient walking activity approaches 2 million cycles per year: Pedometers under-record walking activity. The Journal of Arthroplasty, 17, 693-697.

Spurck, P.A., Mohr, M.L., Seroka, A.M., & Stoner, M. (1995). The impact of a wireless telecommunication system on time efficiency. Journal of Nursing Administration, 25, 21-26.

Thompson, J.D. (2003). Caring and curing: The evolution of hospital design. In W.D. White (Ed.), Compelled by data: John D. Thompson (pp. 141-56). New Haven, CT: Yale University.

Tudor-Locke, C., Williams, J.E., Reis, J.P., & Pluto, D. (2002). Utility of pedometers for assessing physical activity: Convergent validity. Sports Medicine, 32, 795-808.

Yip, Y. (2001). A study of work stress, patient handling activities and the risk of low back pain among nurses in Hong Kong. Journal of Advanced Nursing, 36, 794-804.

Table 1. Descriptive Findings (N = 647 Observations)

N (%) Mean (SD)

Shift Day 369 (57.1%)

Night 277 (42.9%)

Weekend or weekday Weekday 495 (76.5%)

Weekend 152 (23.5%)

Hours worked category 0-11 hours 86 (13.4%)

11-13 hours 526 (82.1%)

> 13 hours 29 (4.5%)

Patient assignment 1 1 (.2%)

(# pts) 2 7 (1.2%)

3 62 (10.7%)

4 181 (31.3%)

5 289 (50.0%)

6 38 (6.6%)

Charge or staff nurse Staff nurse 577 (89.2%)

Charge nurse 70 (10.8%)

Hours worked 11.65 (1.68)

Steps 8748 (2953)

Steps per hour worked 756.49 (243.14)

Miles walked 4.1 (1.4)

Miles per hour worked 0.36 (.12)

Average room distance 55.3 3 (14.42)

in feet for assignment

Note: Small differences in category totals are due to missing

data and rounding.

Table 2. Comparison of Weekday and Weekend Miles Walked

N Mean (SD)

Weekday 478 4.136 (1.415)

Weekend 147 3.952 (1.343)

Total 625 4.093 (1.399)

Table 3. Comparison of Day vs. Night Shift Miles Walked

Shift N Mean (SD)

Day 358 4.197 (1.396)

Night 266 3.954 (1.396)

Total 624 4.093 (1.400)

John M. Welton, PhD, RN, is an Assistant Professor, Medical University of South Carolina, College of Nursing, Charleston, SC.

Maureen Decker, MSN, RN, is a former Nurse Manager, Medical University Hospital Authority, Charleston, SC.

Julie Adam, MSN, RN, is a former Nurse Manager, Medical University Hospital Authority, Charleston, SC.

Laurie Zone-Smith, MSN, RN, is a Director, Special Projects, Medical University Hospital Authority, Charleston, SC.

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