Examining the Needs-Based Time Use of Chinese Nursing Assistants: A Time–Motion Study

ABSTRACT Background In light of the worldwide shortage of nurses and to maximize the effectiveness of the nursing care available, it is important to investigate the components of the care regularly provided by nursing assistants (NAs) to older adults. Well-organized allocation of NA care activities is directly linked to the quality of care provided to nursing home (NH) residents and their quality of life. However, relevant knowledge about the actual time allocation of NAs in this context is lacking, as previous related studies have focused only on the duration necessary for NAs to complete nursing activities. Purpose This study was designed to investigate the time allocation of NAs in completing job tasks necessary to meet the needs of residents in nursing care units at an NH in China. Methods A time–motion method and nonparticipatory observations were used to collect data. Two postgraduate students observed 15 NAs' time expenditure and nursing content simultaneously during day shifts for 3 weeks as the NAs provided care to residents in four different nursing care levels. Data on nursing time and activity frequency were collected using a worklist based on the Zuluaga–Raysmith model. Results The 119.6 hours of observation included 8,907 discrete observed activities. In terms of the care provided to meet the needs of residents, the most time-consuming activities were physical health care (26.8%) and communication care (18.3%), followed by mental, emotional, social, and spiritual health care (14.1%) and protection and security care (12.6%). The higher the level of care, the higher the proportion of somatic nursing time and nursing activity frequency. However, the time and frequency of psychological and spiritual care showed an opposite trend. Conclusions Because of their lack of formal nursing training and skills, NAs pay more attention to meeting the physiological needs of residents while ignoring their mental needs. Moreover, their effectiveness in providing spiritual care tends to be quite low. Furthermore, the NA nursing activity classification system based on the Zuluaga–Raysmith model developed in this study is applicable for designing nursing work tasks, organizing NH units, and improving the quality of life of residents, as this model accurately reflects the essence of NA work.


Introduction
As a country with a large population, China's aging rate ranks first in the world because of the continuous decline in the fertility rate and growing numbers of older adults (R. Chen et al., 2019). It is estimated that, by 2050, China's population aged years 65 and above will reach 400 million, accounting for one third of the total population (Ge et al., 2020). Pension problems caused by the surge in the aging population presents a compelling need to establish aged care facilities. A study has shown that among the older adults living in nursing homes (NHs), 90% have one or more chronic diseases and more than 60% are semidisabled or disabled (Z. Wang et al., 2020). Subsequently, nursing staff in NHs attend to people with an increasing number of severe limitations and complex long-term care needs.
Nursing assistants (NAs) are the main care providers in NHs. Adequate allocation of NAs is closely related to older adults' satisfaction with care services and their standard of living (Shin et al., 2018). Although China requires 13 million NAs to provide adequate care to current residents, the actual number of practitioners is less than 300,000 (Zhao, 2018). In general, these NAs are not well educated, lack professional nursing knowledge, and have a high rate of turnover. Shortages of both nursing labor and nursing skills have created a considerable challenge for the delivery of highquality, safe, and efficient aged care services (Drennan & Ross, 2019). Meanwhile, because of low social-economic status, it is difficult to attract potential applicants to work as NAs (Chao & Lu, 2020). Reallocation and process management based on investigations of NAs' actual workloads may be useful in developing solutions to tackle the related challenges.
Three main approaches are currently used to determine NA workloads, including professional judgment (Telford, 1979), benchmarking approaches (Audit Commission, 2001), and the time-motion technique (Hurst, 2003). The former two rely heavily on the experience and judgment of experts to determine the number of NAs to employ and to arrange daily staffing plans (Hurst, 2003). Thus, these two approaches are relatively subjective and unreliable. In contrast, the timemotion technique, which calculates the time required by NAs to complete each task, is more objective and may better reflect the actual needs of older adults (Griffiths et al., 2020).
The time-motion technique allows researchers and nursing managers to obtain a deeper understanding of NA nursing time distributions and workloads. Researchers in Australia using this technique found that oral communication was the most time-consuming activity and that NAs frequently switched within or among oral communication, direct care, and indirect care activities (Qian et al., 2012). Meanwhile, Dutch researchers found unit type to be more significantly associated with time spent on interventions in domains than NA type (Tuinman et al., 2016). Canadian researchers found that older adults who needed only supervision and verbal motivation required as much time as those who were physically dependent on NAs for eating (Simmons & Schnelle, 2006).
Although time-motion studies have been conducted in many countries, NA workloads have consistently been measured as the time needed to complete nursing tasks (Munyisia et al., 2011;L. Wang et al., 2016;Xing, 2015), and studies have concentrated on nursing time required in specific areas (e.g., administration; E. Y. H. Chen et al., 2021) rather than the actual time required to meet the various needs of older adults. Although studies have suggested that focusing on investigations into meeting the varying needs of older adults may contribute to improved quality of life and have a positive impact on reducing existing problems (Fahy & Livingston, 2001;Liu & Yao, 2014;Wise, 2020), as far as the authors are aware, no study on the time expended by NAs on meeting the needs of NH residents has been published in the literature. Thus, it remains unclear how much time NAs spend on meeting these needs, which may vary and influence the type of nursing activities and amount of time spent on each (Tuinman et al., 2016). Exploring the workloads of NAs based on residents' needs is vital to enriching and advancing the field of international nursing management and leadership, enhancing the optimal use of resources, and providing insight into the contributions of NAs to improving the quality of care (Matsumoto et al., 2020).
Therefore, the aim of this study was to empirically investigate the time spent by NAs on various activities to meet the needs of older adult residents of an NH in China using the time-motion observation method.

Methods
Data were collected for this study at the Qinggang Senior Care Center (QSCC) from April to October 2020.

Study Setting
In 2020, China's Ministry of Civil Affairs announced the need to grade elderly care institutions. It is expected that the initial national unified rating system of pension institutions will be established by 2022 (Xinhua Net, 2020). In the absence of evaluation criteria and on the basis of previous research (Cai et al., 2017), the most common pension institutions in China may be divided into three types: welfare homes, traditional NHs, and hospital-affiliated NHs. Welfare homes and traditional NHs focus on daily life care, and their physical facilities and NA skills are always poor. Hospital-affiliated NHs typically provide the highest quality of services available in the country and offer strong medical support systems. In these facilities, older adults have access to medical treatment, nursing care, pension, and rehabilitation services. To maximize the value of this study in terms of providing insight and exemplary outcomes to assist other NHs in the same and lower grades to learn and improve their management, a hospital-affiliated NH was chosen as the target institution.
The QSCC has ranked first among NHs in China for 4 consecutive years from 2017 to 2019 (QSCC, the First Affiliated Hospital of Chongqing Medical University, 2020). QSCC, located in Bishan in Chongqing Province, is an NH offering a combination of medical and nursing care services based on its affiliation with Chongqing Medical University. It has a self-care area, a nursing care area, and a mental disorder area as well as 3,000 nursing beds and 1,000 medical beds. QSCC has specialized outpatient services for geriatrics and is equipped with a full set of medical and technical departments. In addition to logistics staff, the center has 221 qualified staff, including 21 managers, three doctors, 33 nurses, 150 NAs, three rehabilitation specialists, three psychological consultants, three nutritionists, and five social workers.
The scores of residents for activities of daily living, Mini-Mental Status Examination, depression, pressure risk, falling risk, and cognitive impairment are used to divide nursing care provided by this center into four grades: self-care, assistance, nursing, and full care. Assistance means that residents are able to use assistive devices independently to complete daily life activities. Nursing care means that residents are able to express their needs correctly but require help from NAs to complete daily life activities. According to the degree of help provided by NAs (from less to more), nursing care is divided into Levels I to IV. Level I means that residents need a small amount of supervision and a few instructions in their daily life. Level II residents are able to complete daily activities alone with or without assistive devices but need supervision and instructions throughout the entire process and assistance in the use of living necessities. Residents who require assistance from NAs to complete daily activities are categorized in Level III. Level IV residents are heavily dependent on NA care services in their daily life. The older adults categorized at the self-care and assistance grades live in the self-care area. Full care means that residents rely entirely on caregivers for living. The service relationship between NAs The Journal of Nursing Research Xinxia WANG et al. and residents at the full-care grade is one-way. The older adults at the nursing or full-care grades who are free of mental disorders live in the nursing care area. At the time of this study, the ratio of NAs to nursing care residents was 1:7-1:6, and the ratio of NAs to full-care or mentally disordered residents was 1:3-1:2.5. These ratios are considered quite reasonable and sufficient (Harrington et al., 2020).
The observation was conducted in the three units of the nursing care area because NAs have the most opportunities to interact with residents, and residents can express their needs correctly in this area. Each unit has 40 residents who each had their own room. All units in the nursing care area had a shared living room where residents could have their meals together. There was no significant difference in the nursing care grades of the residents among the three observed units (w 2 = 1.82, p = .95; Table 1).

Staffing and Sample
NAs are not legally registered as nurses in China. They generally receive training on practical skills such as basic bedside care, taking vital signs, rehabilitation care, and psychological care. They will also provide care in support of basic activities of daily living such as bathing and food preparation. In the QSCC, NAs are not generally responsible for cleaning, with the exception of residents' bed units, and they are not allowed to perform invasive operations.
Six NAs served on the day shift and two NAs served on the night shift in each of the three units targeted in this study. For the day shift, three NAs worked from 6 a.m. to 4:30 p.m. and another three worked from 11:30 a.m. to 8:30 p.m. NAs on the night shift worked from 8.30 p.m. to 6 a.m.
Under the national vocational skill standard for NAs (2019 edition), the "general education level" of employees was adjusted from "junior high school graduation" to "no education requirements." People with no educational background may be employed as NAs after being under probation for more than 2 years (Song et al., 2014). Because qualification varies widely within NAs, we recruited NAs who met the following inclusion criteria to enhance comparability: (a) ≥ 3 years of work experience in the nursing care units, (b) holding an NA qualification certificate, (c) ability to read and write, and (d) having volunteered to participate in this study. We selected the 8-hour day shift of 8 a.m. to 4 p.m., as a high volume of nursing activities is typical during this period. Fifteen of the 18 NAs in these three targeted units participated in this study. No significant differences in demographic characteristics were found among the participants (Table 2).
Although the number of participants was relatively small, the unit of analysis was individual activity rather than participant. On the basis of the results from the powerful calculation formula for the time-motion study (Sittig, 2005) and data collected from the pilot study, the minimum number of observed activities was 819 for the Zuluaga-Raysmith (Z-R) model. In this study, data were collected on 8,523 observed activities and recorded for the Z-R model, which is significantly more than the minimum sample size.

Ethical Consideration
The ethical review board of Chongqing Medical University and the managers of the senior care center approved this study (approval number: 2020-032). To ensure that NA participation in this study was entirely voluntary, the researchers informed the NAs about the purpose, significance, and methods of the study and told them they could withdraw from the study at any time without any adverse effects. Moreover, they were informed that the collected research data would be stored securely and accessible only to the researchers. Only after explicit written consent was acquired from each participant were observations of that person's activities begun. Residents were also asked to provide written informed consent to permit observers to enter residents' homes.

Measurement Instruments
A three-step process was followed to develop the observation list: (a) field observation to identify nursing activities specific  to the study setting, (b) Delphi panel to develop an observation list based on the Z-R model, and (c) field testing to confirm the validity of the observation list.
In the first step, two observers who were nursing postgraduate students observed four NAs from 8 a.m. to 4 p.m. on 4 separate days. The nursing background and clinical experience of the observers helped them recognize and distinguish various nursing activities. They recorded all of the activities conducted by each NA over the course of the entire shift. During the observation, the observers communicated with the NA if necessary to determine the nature of the nursing activities.
In the next step, using two series of structured questionnaires, a Delphi panel of eight experts, including six nursing management specialists and two senior managers in the care center, reached consensus on 43 nursing activities ( Table 3). The experts synthesized nursing activities identified from the literature and those directly observed in the field. The finalized comprehensive list of activities was included in the observation list and represented 10 domains of the Z-R model. The Z-R model is based on Maslow's theory of basic human needs, which includes 10 basic human needs: physical health; mental, emotional, social, and spiritual health (MESSH); income; accommodation; protection and security; knowledge; mobility; communication; self-development; and need to make contributions. The Z-R model facilitates holistic assessment of entities and recognizes the validity and importance of self-perceiving needs deficits. Thus, this model fits well with person-oriented care. The nature of the 10 domains of the Z-R model was determined from the literature (Zuluaga, 2000). In addition, researchers investigated the contents and connotations of the needs of participants in a previous study who also lived in the same nursing care area of this center (Zhang & Shen, 2019). These preliminary surveys can help experts better match the needs domains of residents to NA nursing activities. In addition to these activities, nonresident-related items such as breaks, transit activities (time between activities, e.g., walking in the corridor), and private activities (e.g., toileting) were added (Tuinman et al., 2016).
In the last step, the observation list was validated in a 2-day observation by two observers who had conducted observations in Step 1. After independently observing the same activities, the two discussed the similarities and differences in their records, which helped them better understand the meaning of each category and improve the internal consistency among raters in formal observation.

Data Collection
Data collection was conducted from August to September 2020. Structured observations were made using the timemotion technique. The two observers involved in the construction of measurement instruments served as observers in the data collection phase. Before the formal observation, the two observers attended trial observations for 2 days.
They were also required to conduct a six-round interobserver reliability assessment to ensure data consistency before beginning data collection. The formal observation lasted 15 working days (Monday to Friday) over a 3-week period. This schedule was chosen because family members and friends were permitted to visit the residents on weekends and residents could go out of the center with their family. Five NAs evenly distributed among the three units were observed by both observers during each of the 3 weeks. Each NA was observed once based on their shift schedule to capture their activities adequately. A stopwatch was used to record the start and end times of each performed activity that was listed on the observation sheet. The observers also noted in the records the nursing care level of each resident receiving nursing care. Observers stood at a suitable distance from the NAs under observation and were not allowed to interact with them to capture accurate time durations and contents.

Analyses
The registered time of observed activities was entered into IBM SPSS Statistics 22.0 (IBM Inc., Armonk, NY, USA) to analyze activity time and frequency. Interrater reliability was calculated using an intraclass correlation coefficient (ICC) based on a two-way random model with absolute agreement (single measures) with 95% confidence intervals (CIs). Values < .40 are considered poor, those between .40 and .59 are considered fair, those between .60 and .74 are considered good, and those ≥ .75 are considered excellent (Cicchetti, 1994). Pearson's chi-square test was used to compare the percentage of time spent on each domain of activities and the proportion of the activity frequency in each domain at each of the four nursing care levels. After determining the normal distribution and variance homogeneity of the activity frequencies for each nursing care level, one-way analysis of variance was used to examine the differences in activity frequency among the four nursing care levels for each domain. A statistically significant difference was defined as p ≤ .05. Post hoc pairwise comparisons were performed using Bonferroni correction.

Results
The observations resulted in 119.6 hours (7,176 minutes) of time registered for 43 nursing activities categorized in 11 domains. Of this time, 5,928 (82.6%) minutes were assigned among 10 Z-R domains and 1,248 (17.4%) minutes were designated as "other activities." Fifteen NAs were observed for a period of 15 days.   Observation List of Nursing Work Activities

Care Domain Nursing Activities
Physical health care Basic care (e.g., oral care, perineal care, skin care) Activities of daily living (e.g., toileting, dressing, bathing) Changing diapers for a resident Washing clothes for a resident Tube feeding (e.g., diet, drinking) Measuring a resident's vital signs (e.g., temperature, blood pressure, oxygen saturation) Administering oral medications Administering medications through a gastric tube Noninvasive treatment (e.g., inhaling oxygen, physical hypothermia) Assisting a resident to get tests or the clinic of the care center (e.g., transferring a patient from a bed to a wheel chair) Observing a resident's conditions (e.g., sleeping, eating, fluid management)

MESSH care
Leading a resident to participate in activities of the unit (e.g., finger exercise, singing) Leading a resident to participate in activities of the center (e.g., birthday party, festival party) Assisting a resident in shopping (e.g., buying clothes, daily articles) Assisting a resident to receive express delivery Psychological consultant Helping older adults participate in religious activities (e.g., going to the church, supplies preparation) In the domains of physical health care, accommodation care, and protection and security care, NAs spent a significantly higher proportion of time on Level IV residents than on those at other levels, with no significant difference in the percentage of nursing time found among residents in Levels I, II, and III. In the domains of income care and mobility care, NAs spent a significantly higher proportion of time on residents in Levels III and IV than on the other levels, with no significant differences found between Levels III and IV residents or Levels I and II residents.
In the domains of MESSH care, knowledge care, and communication care, NAs spent a significantly higher proportion of time on Level IV residents than on other resident levels, with no significant difference in the percentage of nursing time found among residents in Levels I, II, and III. In the domain of self-development care, NAs spent a significantly higher proportion of time on Level I residents than other resident levels, with no significant difference found among residents in Levels II, III, and IV. In the domain of making contributions care, using the Fisher's exact test, NAs were shown to spend a significantly lower proportion of time on residents in Level IV than those in Levels I and II, with no significant difference found among Levels I, II, and III or between Levels III and IV.

Activity Frequency
The proportion of nursing activities in each domain of the Z-R model and the frequency by activity category for each level of nursing care is presented in Table 5. Similar to the distribution of nursing time, the most frequently conducted activity was physical health care (27.9%), followed by communication care (18.1%), MESSH care (13.5%), and protection and security care (10.1%).
Resident nursing care level was shown to relate positively to the frequency of nursing activities provided by NAs in the domains of physical health care, income care, accommodation care, protection and security care, and mobility care. Conversely, a higher nursing care level was associated with a lower frequency of nursing activities provided by NAs in the domains of MESSH care, communication care, and knowledge care. No significant difference in the frequency of activities provided by NAs was found among the four groups of residents in the domains of self-development care and contributions care. In addition, no significant differences in activity frequency were found among the four groups of residents in the domains of self-development care and making contributions care.

Discussion
This was the first study to investigate the time allocation of nurses in meeting the care needs of older adults in an NH setting in China. It included an investigation of the actual nursing time spent on activities and the frequencies of activities based on the Z-R model over an 8-hour shift.

Nursing Assistants Need Resident-Oriented Nursing Classification Systems
No nursing classification system for NAs (analogous to the Nursing Intervention Classification system) has been established The Journal of Nursing Research Xinxia WANG et al. in China. Because NAs focus on providing comprehensive life care to older adult patients, the nature, skills, and contents of their work differ significantly from nurses. With the gradual development of institutional pensions and the expansion of NA work content, it is necessary to establish a classification system for nursing interventions performed by NAs (Han & Shi, 2016). The nursing activity classification system for NAs developed in this study includes 43 distinct activities based on the Z-R model. This system not only reflects the work characteristics of NAs, which are person oriented and emphasize meeting the overall needs of older adults, but also facilitates the accurate identification and recording of nursing activities using field observations. It is expected to be useful in designing nursing work tasks, organizing NH units, and comprehensively improving the quality of life of residents.

Nursing Assistants Invest More Time and Energy in Physiological Rather Than Psychological Care
Differences were found to exist in the time distribution of NAs caring for older adult patients at different levels of nursing care, which echoes the findings of Yen et al. (2018). Compared with residents in Levels I and II, NAs allocated higher proportions of nursing time on caring for residents in Levels III and IV in terms of physical care, income care, accommodation care, protection and security care, and mobility care. Meanwhile, the frequency of nursing activities was also found to be higher at greater levels of nursing care. This may be because higher nursing care levels are negatively associated with the ability of residents to live independently, making them more reliant on NAs to provide life services to ensure survival and safety. Other researchers have similarly found evidence that nursing staff spent more time on providing basic life services to residents with higher dependency levels than on providing mental and psychological care (Paquay et al., 2007). Previous studies (Donoghue et al., 2005;Munyisia et al., 2011) indicate that communication tasks may be the most time-consuming nursing activities, possibly because of the different classifications of nursing activities. In those studies, communication tasks refer to communication activities initiated by NAs and include communication with residents, other nursing staff, and doctors. However, communication in this study refers to meeting the communication needs of older adults such as helping residents communicate with their peers and family. However, NAs spent relatively less time on and engaged less frequently in MESSH care, knowledge care, and communication care domain activities with Level IV residents than with residents at lower care levels. This may be attributable to the shortage of nursing human resources and the lack of professional attainment of NAs (Ludlow et al., 2021). NAs often ignore or have no time to meet residents' spiritual or emotional needs or to help them pursue knowledge or realize their self-worth (Campagna et al., 2021;Rodriguez-Pereira et al., 2020). Meanwhile, because somatic problems such as falls, pressure sores, and choking are related to the wage performance of NAs, they are more inclined to focus on physical and safety care for residents in Level IV (who have significantly higher rates of limb weakness and physical dysfunction) to the detriment of psychological and spiritual care activities, which are typically not considered in performance scores. However, demand for spiritual support and psychological comfort increases with the decline in independent living ability, as elderly individuals who are highly dependent on NAs are more likely to be depressed, anxious, and lonely (Trybusińska & Saracen, 2019). It has been proven that care dependency and depression are closely related to residents' quality of life (Chang et al., 2020). From a holistic perspective, communication care and MESSH care require significant time, collectively accounting for more than a third of the nursing time in this study and ranking as the second (18.3%) and third (14.1%) largest demands on NA work time, respectively. In a previous survey on the long-term care needs of older adults in this care center, we found the residents to be very satisfied with the physical and basic life care received but dissatisfied with the spiritual and psychological care received (Zhang & Shen, 2019). The low efficiency of NAs in providing corresponding care services for nursing care Level IV residents is quite low and may be attributable to the lack of knowledge and skills necessary to meet these care needs (Campagna et al., 2021). Separation from family and familiar environments puts NH residents at a higher risk of mental disorders such as loneliness, depression, and anxiousness. Therefore, it is very important to provide spiritual support education and training to NAs, as they are primary care providers who are responsible for the mental health of NH residents (Ludlow et al., 2020).
It is interesting to note that, although no significant differences were found in the frequency of activities in the selfdevelopment and contributions care domains among the four groups, the proportions of nursing time spent on these two domains decreased with increasing nursing care level. This may be because the participants in the four nursing care levels perceived the level of care provided in these two domains to be consistent despite the reductions in activity duration provided to those at Levels III and IV because of poorer health status.

Limitations
The findings of several previous studies indicate NA qualifications such as educational level, skill level, professional training level, and hours of on-the-job education impact the time allocation of nursing activities and quality of care provided (Karacsony et al., 2019;Yen et al., 2018). In this study, we aimed to provide a broad overview of how NAs allocated their time in meeting residents' needs in NH settings. Thus, details of activities, including the skills required to perform each task, were not considered. Because no significant differences in demographic characteristics were found among the 15 NAs, we assumed that qualifications would not significantly influence the results. However, future studies may be designed to compare differences in nursing time allocations among NAs with varying qualifications to improve the generalizability of the results.
The degree of interrater agreement was not consistent in all observation domains. However, the focus of this study was on the allocation of nursing time to meet the complex needs of residents. As the consistency among raters was excellent in the 10 domains of the Z-R model, interrater agreement variability did not affect the results.
Best efforts were made to minimize the Hawthorne effect (Goodwin et al., 2017). These included maintaining adequate distance from the participants and not talking to NAs during the formal observation period. Moreover, during the 8-day preobservation period, NAs were fully informed regarding the purpose and significance of this study and were assured that the study had no relationship to the NH or its affiliated hospitals. In formal observation, they quickly became comfortable with the presence of the observer. Moreover, it would have been difficult for them to alter certain work behaviors because of their intensive workloads.

Conclusions
This study investigated the frequencies of and time expenditures on nursing activities in nursing care units of a hospitalaffiliated NH in China. Physical health care, communication care, MESSH care, and protection and security care were found to consume most of the NAs' work time. More nursing time and frequencies were associated with physical and safety care, whereas less was associated with spiritual and psychological care, indicating that NAs pay more attention to meeting the physiological needs of residents than meeting their spiritual or psychological needs. Finally, higher nursing care levels were associated with higher proportions of somatic care.