Work Patterns and Time Allocation in Multidisciplinary Home Hospice: A Time-Motion Study

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Standard administrative metrics fail to capture the nuanced workload of this distributed ecosystem. This study aimed to characterize the workday structure and identify operational constraints within a multidisciplinary palliative care team in Singapore. Methods : A time-motion study was conducted in late 2025, through continuous observation to quantify individual durations of discrete tasks. Over 28 staff days, a research assistant shadowed three physicians, seven nurses, and four medical social workers for two days each. Activities were coded across six domains, ranging from direct care to travel, with periodic multitasking captured through concurrent coding. To reconcile multitasking with scheduled clock time, task durations were normalized within 15-minute blocks. Results : The dataset included 2336 distinct activity entries. Observation revealed a sustained intensity marked by concurrent workloads rather than discrete episodes. Across the service, indirect care occupied 39.8% of normalized time. Direct care accounted for 26.8% of the shift. Specifically, clinical documentation alone consumed 24.6% of the workday. Movement between locations required 15.6% of total time. Regarding specific roles, medical social workers experienced peak workload density in the morning. Conversely, nurse workloads peaked in the mid-afternoon. Discussion : Geographic distribution and practice norms heavily influence home care workflows. Standardized morning meetings foster team alignment. At the same time, this synchronization compresses the available window for field visits. Joint clinical visits ensure safety but reduce scheduling flexibility. To mitigate capacity constraints, clinicians frequently use travel time as an interstitial workspace. This practice reclaims productive minutes but eliminates cognitive recovery periods. Future service redesigns could explore decoupled visits for stable patients or protected documentation time to improve workforce sustainability. Palliative & Hospice Care Patient Care Team Professional Practice Workload Time and Motion Studies Efficiency Organisational Figures Figure 1 Figure 2 Introduction Home-based hospice & palliative care is logistically complex and clinically sensitive. Unlike institutional settings with centralized patients and controlled workflows, home hospice relies on a distributed workforce delivering end-of-life care across variable home environments, while managing travel, family dynamics, and multidisciplinary coordination. A multidisciplinary team of physicians, nurses, and medical social workers (MSWs) coordinate as a “hospice without walls”, often contributing complementary expertise asynchronously across locations. Ritchie and Leff (1) describe home-based care not just as a series of visits, but as an "ecosystem" of diverse care models evolving to meet patient needs across time and space. Within this ecosystem, the labor of care is distributed not just by clinical expertise, but by temporal availability. Within this ecosystem, the service is shaped by a distinct relationship to time in two facets. On one hand, care occurs within a limited and uncertain trajectory toward death; teams must prioritize symptom control, patient dignity, and family support while responding to emergent crises and disease progression. At the same time, work is governed by operational “clocks,” including medication administration schedules, travel between homes, clinical documentation requirements, and unpredictable urgent needs. These competing demands create a “temporal architecture” that influences how care is delivered and how capacity is utilised. (2) The evaluation of workforce efficiency in hospice care has historically been plagued by a lack of granular data. Standard administrative metrics, such as "visits per day" caseload per FTE, fail to capture the nuanced texture of a typical workday in palliative care (3, 4). A clinician who spends 90 minutes facilitating a difficult goals-of-care conversation may generate fewer visits than one who performs ten rapid procedural checks, yet the former may provide significantly higher value in terms of hospital avoidance and goal concordance. Time-motion studies offer a rigorous alternative by directly observing and timing discrete tasks (5). This method generates a high-resolution map of the workday and quantifies “invisible work,” including care coordination, travel, and peer consultation, which are essential to home-based palliative care yet not reflected in routine reporting. However, other than Bhavsar et al. (3), who reported on workforce delivery in community-based palliative care, there has been little published literature utilizing this methodology in the home hospice setting. A time-motion study in a home-based hospice in Singapore was conducted to examine diverse workflows within multidisciplinary teams, to characterize the structure of the workday and identify operational constraints that affect provider capacity. The study aimed to address four key areas: workday patterns, task frequency and duration, role-based task allocation, and the relationship between timing and workload. Suggested Time And Motion Procedures (STAMP) guidelines were referenced in the drafting of this report (6). Methods Setting and Participants This study was conducted between September and October 2025 within a community-based home hospice in Singapore, in operations for more than 35 years. Palliative care was delivered in private homes and residential facilities. Clinicians served across the city state of Singapore, with travel primarily by ride-hailing or taxi. Participants comprised the core multidisciplinary team involved in routine home hospice delivery: physicians (n = 3), registered nurses (n = 7), and medical social workers (n = 4). Staff experience levels were mixed and included both long-tenured staff (more than five years) and newer staff (approximately two to three years). Recruitment was based on voluntary participation. Data Collection Each participant was observed for two full workdays from 08:30 to 17:30, yielding 28 staff-days of observation (6 physician days, 14 nurse days, 8 medical social worker days; 252 scheduled hours). All observations were conducted by a single research assistant with 1.5 years of experience in the palliative care setting but minimal direct experience in home visits. There were no prior working relationships with any of the participants. Observation days were determined primarily by staff rosters and observer availability. These days did not include extraneous events or projects outside participants’ core job description. Some observation days were consecutive, while others were separated due to staff or observer leave plans. Activities were coded using a taxonomy grouped into six major domains, with subcodes specifying common tasks, shown in Table 1. The taxonomy drew on prior time-motion and workflow literature in community-based and palliative care services (3), and previous work of this study team. Prior to study launch, pilot observations were done to test the codes and to allow the observer to acclimate to clinical work patterns. Pilot logs were reviewed jointly by the observer and the study investigator to calibrate task coding and refine operational definitions. During the study, the observer recorded each continuous activity episode with a single start time and end time, a location, and a short narrative description. To capture multitasking, the observer could assign multiple concurrent activity codes to the same episode record. Non-work periods were recorded as “NIL” (for example, lunch) and were excluded from coded-work summaries. Work performed after 17:30 was self-reported by participants on the next day. In these instances, the observer recorded task types and their duration and verified work activity where possible using timestamps available within electronic medical records. Table 1. Taxonomy of activities in home-based hospice care. Domain Description Codes Direct Care (DC) Face-to-face patient interaction Patient assessment (DC1), Medication administration (DC2), Symptom management (DC3), Patient or caregiver education (DC4), End-of-life Planning/Discussion (DC5), Psychosocial support (DC6), Other Direct Care (DC7) Indirect Care (IND) Clinical work without patient present Preparing medication / supplies (IND1), Clinical documentation (IND2), Care planning (IND3), Coordinating with colleagues (IND4), Reviewing patient files (IND5) Care Coordination (CC) Communication to facilitate care Family/caregiver phone updates (CC1), Scheduling, referral handling (CC2), Liaison with external agencies (CC3) Administration (AD) Non-clinical organizational tasks Team meetings / case conferences (AD1), Internal admin documentation (AD2), Training, internal emails (AD3) Travel (TR) Movement between locations: transport to and from patient, or satellite centre - Waiting (WW) Involuntary idle time, waiting for elevators and waiting for caregivers to open doors - Analysis Data were transcribed into a spreadsheet and cleaned prior to analysis. Cleaning steps included removal of duplicate entries, verification of time ordering, and review of ambiguous codes against narrative notes. Multi-code episodes were converted from wide to long format. Each code assignment became a discrete row in the dataset, inheriting the duration and timestamps of the parent episode. This transformation allowed independent analysis of concurrent activity layers. We analysed work patterns using 15-minute time blocks. An activity was counted as active if any portion of the episode overlapped with a block. For each block, we then counted the number of active code assignments by domain. This yields a measure of activity prevalence or concurrent workload coverage per 15-minute interval. It weights longer activities more heavily and provides a clock-time view of what work is ongoing across the day. For role-stratified summaries, block counts were normalised by dividing by the number of observed staff-days in that role to obtain active code assignments per staff-day per block. To reconcile multitasking with clock time, we calculated "normalized minutes." Within each 15-minute block, if the sum of concurrent task durations exceeded the block length, the specific code durations were scaled proportionally to fit the 15-minute window. This preserved the composition of work while constraining totals to scheduled clock time. Normalised minutes were then summed across blocks to produce per staff day-time allocation by code and domain and expressed as minutes and percentages of the scheduled 540-minute shift. Minutes not captured by any code within the scheduled window were treated as uncoded time. To ensure the analysis reflected the core operational hours of the multidisciplinary team, outlier activities recorded prior to the official start time of 08:30 (specifically a single staff member starting at 06:45) and after 17:30 were excluded from the temporal pattern analysis. Qualitative descriptions recorded alongside activity codes were synthesized to provide context to the quantitative findings. Ethical Considerations Ethical approval was granted by the National Council of Social Service Ethics Review Committee under expedited review (NERC/009/2025). Written informed consent was obtained from staff participants. Participation was voluntary and revocable without penalty. Data were analysed in aggregate and not used for individual performance evaluation. Data were anonymized using alphanumeric codes (e.g., DOC1Q, NUR3Q). During home visits, patient interactions were observed with consent. If the observer was asked not to remain in the room or home, they will move away to a different location and recorded the activity type after the episode based on staff report. Results Across 28 observed staff days, the dataset contained 2,336 coded activity entries (mean 83.4 per staff day). Nurses contributed 99.6 coded entries per nurse day, compared with 69.4 per MSW day and 64.5 per physician day. When coded entries were aggregated into 15-minute blocks (Table 2 ), Indirect Care accounted for 561 of 1,530 active code assignments (36.7%) and Direct Care accounted for 512 (33.5%). Travel contributed 193 (12.6%) and Administration contributed 150 (9.8%). Care Coordination contributed 90 (5.9%) and Waiting contributed 24 (1.6%). Start-of-day work was dominated by Administration and Indirect Care, with minimal Direct Care. Direct Care and Travel rose from mid-morning and remained prominent through the afternoon, consistent with deployment and patient visits. Concurrent workload coverage peaked in the afternoon, with the highest total active code assignments observed at 15:00 (57 codes). A sustained high band (40–50 codes per block) was also observed from late morning into early afternoon (lunchtime). Table 2 Frequency of coded entries by domain by 15-minute time-blocks Time-block Administrative work (AD) Coordination & Communication (CC) Direct patient care (DC) Indirect clinical work (IND) Travel (TR) Waiting (WW) 08:30 26 1 11 08:45 26 1 14 09:00 24 1 1 23 09:15 20 1 1 29 1 09:30 11 5 1 30 2 09:45 5 7 27 3 2 10:00 3 5 2 17 5 1 10:15 4 1 8 21 6 2 10:30 4 6 11 16 9 10:45 1 3 20 16 7 3 11:00 1 2 15 9 5 2 11:15 1 3 26 13 7 11:30 4 29 7 1 1 11:45 1 22 8 5 12:00 1 14 5 9 12:15 13 13 9 12:30 2 19 8 8 12:45 1 1 23 9 3 13:00 2 15 9 8 13:15 1 17 9 5 1 13:30 1 1 20 5 7 13:45 2 23 11 5 1 14:00 2 15 13 5 14:15 3 14 8 11 2 14:30 2 25 9 10 1 14:45 1 28 10 9 15:00 4 35 14 3 1 15:15 1 3 19 4 9 15:30 2 5 17 14 11 15:45 5 9 18 8 1 16:00 1 4 17 10 5 2 16:15 1 3 16 15 6 1 16:30 1 1 8 18 3 3 16:45 1 8 12 18 3 17:00 2 2 8 25 3 17:15 2 1 5 17 2 17:30 2 1 23 17:45 1 2 19 18:00 2 2 16 Total 150 90 512 561 193 24 Figure 1 shows that role-normalised patterns differed by discipline. Nurses showed their highest concurrent workload coverage in mid-afternoon, peaking at 15:00 with 2.36 active code assignments per nurse-day per block. Physicians peaked earlier, with the highest physician-level coverage at 10:45 (1.83 active code assignments per physician-day per block). Medical social workers peaked in the morning, with the highest MSW coverage at 09:15 (2.50 codes per MSW-day per block). Using clock-based normalised minutes, mean coded work time was 525 minutes per observed staff-day (97.2% of the scheduled 540-minute shift). The breakdown is provided in Table 3 . Indirect Care accounted for the largest share of time (214.7 minutes, 39.8% of the scheduled shift), driven primarily by clinical documentation (IND2), which averaged 132.8 minutes per staff-day (24.6%). Direct Care totalled 144.8 minutes (26.8%), with substantial time in psychosocial support (DC6, 34.1 minutes, 6.3%), patient assessment (DC1, 30.8 minutes, 5.7%), and patient or caregiver education (DC4, 29.5 minutes, 5.5%). Travel accounted for 84.2 minutes (15.6%). Team meetings and case conferences (AD1) remained a major fixed component at 47.5 minutes (8.8%). Care coordination codes together accounted for 19.4 minutes (3.6%), while coded Idle Time (e.g., waiting for patients, waiting for transport) accounted for 8.2 minutes (1.5%). Table 3 Normalised minutes per observed staff-day across the whole MDT, pooled across all observed staff-days, as a proxy for service workload. Code Normalized Duration (mins) As % of 9-hr workday* Team meetings / case conferences (AD1) 47.5 8.8% Internal admin documentation (AD2) 4.8 0.9% Training, internal emails (AD3) 1.2 0.2% Family/caregiver phone updates (CC1) 6.9 1.3% Scheduling, referral handling (CC2) 9.6 1.8% Liaison with external agencies (CC3) 2.9 0.5% Patient assessment (DC1) 30.8 5.7% Medication administration (DC2) 15.8 2.9% Symptom management (DC3) 4.1 0.8% Patient or caregiver education (DC4) 29.5 5.5% End-of-life Planning/Discussion (DC5) 4.8 0.9% Psychosocial support (DC6) 34.1 6.3% Other Direct Care (DC7) 25.7 4.8% Preparing medication / supplies (IND1) 11.9 2.2% Clinical documentation (IND2) 132.8 24.6% Care planning (IND3) 15.7 2.9% Coordinating with colleagues (IND4) 35.2 6.5% Reviewing patient files (IND5) 19.1 3.5% Travel (TR) 84.2 15.6% Idle Time (WW) 8.2 1.5% (Uncoded) 15.2 2.8% Synthesized timeline of a typical workday Figure 2 summarises the typical workday by activity domains. Observation notes and time-block counts indicated a consistent three-phase structure. The workday began with a synchronisation block (08:30–10:00) during which virtually every staff member engaged in team meetings, case discussions, and visit planning, lasting up to 1.5 hours (average 50 minutes). This critical handover allowed the team to review patient statuses, prioritise overnight updates, and plan routes. Following this block, the team separated into role-specific preparation. Nurses transitioned to packing medication kits and coordinating logistics before deployment. Physicians reviewed case notes and coordinated routes with their nurse partners. MSWs shifted into a high-intensity block of Care Coordination, managing subsidy applications, grant paperwork, and external agency liaison to stabilise patients' home environments before entering the field. The field phase (10:30–16:00) was characterised by sustained concurrent activity, with the Doctor-Nurse dyad emerging as the fundamental unit for complex care. Nearly all physician visits were conducted in tandem with nurses: physicians focused on clinical decisions (identifying deterioration, adjusting medications, coordinating emergency transfers) while nurses executed hands-on care and provided observational input that informed physician decision-making. Nurses dedicated approximately 44% of their time to Direct Care, performing wound care, catheter management, and physical assistance alongside substantial patient and caregiver education (e.g., teaching families to administer morphine, manage oxygen equipment, or recognise signs of imminent death). In visits requiring psychosocial intervention, MSWs operated either independently or in Nurse-MSW pairs, stepping in for counselling and therapeutic conversation while nurses managed physical care needs. A synchronised peak occurred around 11:15 (50 distinct activities) as morning visits concluded and generated work—prescriptions, referrals, follow-up calls—required action. Staff breaks between 12:00–14:00 were fragmented; persistent Travel codes during this window suggested clinicians ate while in transit between patients. A secondary peak at 15:30 represented a "decision block" where staff finalised plans and determined which patients required evening follow-up or hospitalisation. Travel was a major feature throughout the workday. This block is often not rest or dead time. Rather, staff would use this time as an "interstitial workspace." Physicians and nurses utilize ride-sharing services to perform work. Descriptions such as "On the way to patient #1 house, reading up on patient’s case notes" or "Replying to emails" are common. 18 activities were recorded between 18:00 and 21:30. These after-hours sessions were lengthy (ranging from 60 to 206 minutes) and totalled approximately 800 workload minutes. Observation notes described clinicians completing progress notes, medication orders, and referral forms after shift end, consistent with a deferral mechanism where daytime field activity crowds out the uninterrupted time needed for comprehensive documentation. Discussion This study addressed four questions regarding workday patterns, task frequencies, role-based differences, and how temporal structures shape capacity. First, the hospice workday follows a three-part structure: a morning synchronisation phase (08:30–10:00) dominated by team meetings and case coordination; a sustained high-intensity field phase (10:30–16:00) characterised by overlapping direct care, travel, and documentation. Rather than discrete care episodes separated by recovery intervals, we observed home-based workday as being a period of sustained, concurrent workload. The morning synchronisation block, while essential for clinical handover and route planning, compresses clinical activity into a denser midday block. Across the service, Indirect Care dominated normalised time (39.8%), with clinical documentation alone accounting for 24.6%. Direct Care represented 26.8% of the day, while Travel consumed 15.6%. Role-stratified analysis revealed distinct work-patterns: Physicians peaked early (10:45), focusing on complex decision-making; MSWs showed the highest activity density in the morning (09:15), reflecting their heavy coordination load before field deployment; while Nurses demonstrated the highest overall activity density, with a concurrent workload peak in mid-afternoon (15:00). To our knowledge, Bhavsar et al. (3) is the only comparable time-motion study in community palliative care. Contrasting our findings with theirs highlights the distinct pressures of a purely home-based model. Our data shows a substantially lower proportion of Direct Care across all disciplines (26.8% service-wide), likely driven by the 15.6% travel burden inherent to our setting (which Bhavsar et al. did not report as a distinct category). Travel absorbs time that would otherwise be available for patient contact, demonstrating how geography is a defining constraint of home hospice capacity. Vaartio-Rajalin et al. (2) found Finnish home healthcare nurses spent approximately 48 minutes per shift on travel (approximately 18–26% of working time). In our model, Travel operates as both a temporal constraint and an adaptive workspace where clinicians perform documentation and coordination tasks. While this creates an avenue for productivity, it eliminates cognitive recovery. As noted by Chu et al. (7), layering tasks into transit time removes the "white space" necessary for mental resets. This lack of recovery is compounded by workflow fragmentation. Cornell et al. (8) and Zheng et al. (6) have established that high-frequency task switching increases cognitive load. Our finding that clinical documentation (IND2) alone accounts for 24.6% of normalised time across the entire multidisciplinary team. This finding aligns with broader literature on documentation burden in healthcare. Sinsky et al. (9) found that ambulatory physicians face a ratio of approximately 2:1 favouring administrative tasks. Our service-wide ratio (39.8% Indirect Care to 26.8% Direct Care, or approximately 1.5:1) is comparable to those reported by Bhavsar et al. but still indicates substantial administrative demands. Documentation functions as a persistent “background layer,” engaging roughly a quarter of the workforce at any given time-block rather than occurring as a discrete end-of-day task. This finding mirrors observations by Mamykina et al. (10) regarding the distributed nature of clinical documentation. Importantly, our observation of after-hours documentation (18 episodes totalling approximately 800 workload minutes) suggests that our daytime figures may underestimate the true documentation burden, consistent with the phenomenon of “pajama time” described in primary care settings. (11) The interdisciplinary communication burden observed in our study (nearly 10% of workday time) reflects the distributed nature of home hospice care. Unlike institutional settings where team members share a physical space, home hospice requires active coordination to maintain clinical coherence across dispersed locations. Oliver et al. (12) found that hospice team meetings average 4.7 minutes per case discussion, with information flow challenges including data redundancy and references to absent team members. Our morning synchronisation block, averaging 50 minutes, represents a substantial investment in mitigating these coordination challenges. Framing these findings as operational trade-offs illuminates potential intervention points. The morning synchronisation block represents a trade-off between coordination quality and field-time capacity: consolidating information exchange reduces downstream rework but compresses the available window for patient visits. Alternative configurations might include staggered start times, asynchronous pre-shift handovers using electronic systems, or selective attendance policies that excuse some team members from portions of the morning meeting. The qualitative findings describe the clinical dyads (particularly Nurse-Physician and Nurse-MSW teams) as the “fundamental production unit” for complex care. This coupling pattern has operational implications. While pairing clinicians for high-acuity visits may enhance clinical reliability by allowing simultaneous assessment, prescribing, and hands-on intervention, it also creates rigid dependencies. A delay for one clinician propagates immediately to their partner, reducing scheduling flexibility and contributing to the sustained high-utilisation states. For stable patients with predictable care needs, “decoupled” visits (routine assessments by a single clinician) might preserve capacity. This tiered approach would require risk stratification protocols and clear escalation pathways but could reduce workload. That said, team-based support structures common in community care offer protective benefits to staff’s psychosocial safety despite the distributed nature of the work, as observed by Fattori et al. (13). Documentation deferral represents a trade-off between clinical workflow and work-life boundaries. Protected documentation time might reduce after-hours charting, though at the cost of further compressing the field-visit window. Alternatively, scribing support, voice-to-text documentation, or streamlined charting templates could reduce the time required for documentation without altering its temporal placement. These trade-offs are not unique to our setting. Lupu et al. (14) note that community-based palliative care programs must balance clinical intensity against operational sustainability, particularly as services expand to meet growing demand. The sustainability implications are significant. Moy et al. (15), in a scoping review of documentation burden measurement, found that extended work hours and time constraints have been linked to burnout, job attrition, and threats to patient safety. Our findings suggest that home hospice teams may be particularly vulnerable to documentation-related strain given the additional demands of travel and field-based care. The NHPCO Hospice Staffing Framework (16) emphasises the need for staffing models that account for travel time, documentation burden, and interdisciplinary coordination; all factors that our findings quantify. Limitations Findings should be understood considering the study’s limitations. First, this study was conducted in a single home hospice service in Singapore, an urban and dense setting with common use of ride-hailing. Travel time, visit sequencing, and the feasibility of doing “interstitial work” during transit may differ in settings with longer distances, fewer transport options, or different safety norms. Participation was voluntary and observation scheduling was convenience-based, which may introduce selection effects if volunteers differed from non-participants. Observation days were chosen as the next available full duty day and excluded atypical activities outside core roles, which improves comparability but may under-represent surge days, unusual crises, and periodic administrative cycles. Several measurement limitations also apply. Direct observation can change behaviour, and the use of a single observer limits formal inter-observer reliability assessment, despite pilot calibration. Some sensitive encounters were not directly observed and required staff-estimated durations, which could bias estimates if such episodes are systematically longer or more variable. Task coding simplifies complex work and requires assumptions when allocating overlapping time under multi-tasking. Activity density captures fragmentation and task switching but does not measure quality, complexity, or appropriateness of care. Finally, the findings are primarily descriptive and support mechanism hypotheses, but they do not establish causal effects of alternative workflows or technologies. Conclusion This time-motion study provides a high-resolution description of how a multidisciplinary home hospice team distributes time across direct care, indirect clinical work, coordination, travel, and office-based synchronization. The findings show that system design features, including a shared morning alignment block, coupled physician-nurse visits, and a large documentation workload, shape field capacity by compressing patient-facing time and shifting charting into fragmented intervals and occasional after-hours work. Framing these patterns as mechanisms and trade-offs supports future work that links workflow signatures to patient and caregiver outcomes, or evaluation of counterfactual service designs, such as selective solo visits and protected documentation time, to improve temporal flexibility without compromising clinical reliability. Abbreviations MSW: Medical Social Worker Declarations Ethics approval and consent to participate Ethics approval was granted by the National Council of Social Service Ethics Review Committee under expedited review (NERC/009/2025). This study adhered to the Declaration of Helsinki guidelines. Written informed consent was obtained from staff participants through a participation consent form. Participation was voluntary and revocable without penalty. Data were analysed in aggregate and not used for individual performance evaluation. Participants were anonymized using alphanumeric codes (e.g., DOC1Q, NUR3Q). Consent for publication Not applicable. Availability of data and materials The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interests The authors have no competing interests as defined by BMC, or other interests that might be perceived to influence the results and/or discussion reported in this paper. Funding There was no funding involved in this study. Authors contributions ZZY and PHC conceptualized the study. JC collected the data for the study. All authors analysed the data. All authors contributed to the writing and data of the manuscript. Acknowledgements Not applicable. References Ritchie C, Leff B. Home-Based Care Reimagined: A Full-Fledged Health Care Delivery Ecosystem Without Walls. Health Aff (Millwood). 2022;41(5):689-695. doi:10.1377/hlthaff.2021.01011 Vaartio-Rajalin H, Näsman Y, Fagerström L. Nurses’ activities and time management during home healthcare visits. Scand J Caring Sci. 2020;34(4):1045-53. doi:10.1111/scs.12813 Bhavsar NA, Bloom K, Nicolla J, Gable C, Goodman A, Olson A, et al. Delivery of community-based palliative care: Findings from a time and motion study. J Palliat Med. 2017;20(10):1120-6. doi:10.1089/jpm.2016.0433 Burden M, McBeth L, Keniston A. Salient Measures of Hospitalist Workload. JAMA Netw Open. 2023;6(8):e2328165. Published 2023 Aug 1. doi:10.1001/jamanetworkopen.2023.28165 Lopetegui M, Yen PY, Lai A, Jeffries J, Embi P, Payne P. Time motion studies in healthcare: what are we talking about?. J Biomed Inform. 2014;49:292-299. doi:10.1016/j.jbi.2014.02.017 Zheng K, Haftel HM, Hirschl RB, O'Reilly M, Hanauer DA. Quantifying the impact of health IT implementations on clinical workflow: A new methodological perspective. J Am Med Inform Assoc. 2010;17(4):454-61. doi:10.1136/jamia.2010.004440 Chu WM, et al. Home-based palliative care: Benefits, challenges, opportunities and future directions in a super-aged society. J Hosp Palliat Care. 2025;28(3):81-93. Cornell P, Herrin-Griffith D, Keim C, Petschonek S, Sanders AM, D’Mello S, et al. Transforming nursing workflow, part 1: The chaotic nature of nurse activities. J Nurs Adm. 2010;40(9):366-73. doi:10.1097/NNA.0b013e3181ee4261 Sinsky C, Colligan L, Li L, Prgomet M, Reynolds S, Goeders L, et al. Allocation of physician time in ambulatory practice: A time and motion study in 4 specialties. Ann Intern Med. 2016;165(11):753-60. doi:10.7326/M16-0961 Mamykina L, Vawdrey DK, Hripcsak G. How do residents spend their shift time? A time and motion study with a particular focus on the use of computers. Acad Med. 2012;87(6):827-32. doi:10.1097/ACM.0b013e318254591d Arndt BG, Beasley JW, Watkinson MD, Temte JL, Tuan WJ, Sinsky CA, et al. Tethered to the EHR: Primary care physician workload assessment using EHR event log data and time-motion observations. Ann Fam Med. 2017;15(5):419-26. doi:10.1370/afm.2121 Oliver DP, Wittenberg-Lyles E, Demiris G, Tatum P, Regehr K, Burt S. The role of the hospice medical director as observed in interdisciplinary team case reviews. J Palliat Med. 2010 Mar;13(3):279-84. doi: 10.1089/jpm.2009.0247. Fattori A, Pedruzzi M, Cantarella C, Bonzini M. The burden in palliative care assistance: A comparison of psychosocial risks and burnout between inpatient hospice and home care services workers. Palliat Support Care. 2023;21(1):49-56. doi:10.1017/S1478951521001887 Lupu D, Quigley L, Mehfoud N, Salsberg ES. The growing demand for hospice and palliative medicine physicians: Will the supply keep up? J Pain Symptom Manage. 2018;55(4):1216-23. doi:10.1016/j.jpainsymman.2017.12.478 Moy AJ, Schwartz JM, Chen R, Sadri S, Lucas E, Cato KD, et al. Measurement of clinical documentation burden among physicians and nurses using electronic health records: A scoping review. J Am Med Inform Assoc. 2021;28(5):998-1008. doi:10.1093/jamia/ocaa325 National Hospice and Palliative Care Organization. NHPCO Hospice Staffing Framework. Accessed January 7, 2026. https://www.nhpco.org/Center to Advance Palliative Care. Home-based palliative care for sustainability [Internet]. 2019 [cited 2026 Feb 6]. Available from: https://www.capc.org/ Additional Declarations No competing interests reported. Supplementary Files AppendixWorkPatternsandTimeAllocationinMultidisciplinaryHomeHospiceATimeMotionStudy.docx Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 27 Apr, 2026 Reviews received at journal 25 Apr, 2026 Reviewers agreed at journal 25 Apr, 2026 Reviews received at journal 02 Apr, 2026 Reviewers agreed at journal 26 Mar, 2026 Reviewers agreed at journal 24 Mar, 2026 Reviewers agreed at journal 22 Mar, 2026 Reviews received at journal 09 Mar, 2026 Reviewers agreed at journal 27 Feb, 2026 Reviewers invited by journal 24 Feb, 2026 Editor assigned by journal 24 Feb, 2026 Submission checks completed at journal 24 Feb, 2026 First submitted to journal 24 Feb, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8825752","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":598384565,"identity":"aacfc595-48bd-4eab-a132-61380096ad76","order_by":0,"name":"Zhi Zheng Yeo","email":"","orcid":"","institution":"HCA Hospice Limited","correspondingAuthor":false,"prefix":"","firstName":"Zhi","middleName":"Zheng","lastName":"Yeo","suffix":""},{"id":598384566,"identity":"f1c69c4c-b514-42d8-8ccd-f4087d28c586","order_by":1,"name":"Jerome Chua","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABNklEQVRIiWNgGAWjYBACxgYILWfAwMAGYvAQrcWYeC0wkLgBqoUwYG7vffjoRoVd+nb2w88efPhzR4a/vfnh54oKBjnz/gXMH79gcVjPcWPjnDPJuTt70swNZ7Y945E4c8xY8swZBmOZGw/YpGWwaJmRxiad23Ygd8MNBjNp3obDPAYSOQySjW0MiTMkDrAxS2DRMv8ZUMu/A+kGN9i/SfP8AWqRf8P8s/EfWAvzZ2xaZrABtTQcSDC4wWMmzcMGsoWHTbKxAaiFv4FB8gM2v6QxG+ccSzbccCanTBLilzQzy4ZjEsYSEoxt0lhCzLD9GOPjnBo7eYPjx7dJAEPMnr/98OObDTU2chL8hw9//IFFSwMq/wCMAfSERGIDM5aYlUfjH0Bi8x9gYMRiyygYBaNgFIw4AAA2OmcIa3haFQAAAABJRU5ErkJggg==","orcid":"","institution":"HCA Hospice Limited","correspondingAuthor":true,"prefix":"","firstName":"Jerome","middleName":"","lastName":"Chua","suffix":""},{"id":598384567,"identity":"0b7ac50a-32c8-4eeb-bd05-ff394538db70","order_by":2,"name":"Poh Heng Chong","email":"","orcid":"","institution":"HCA Hospice Limited","correspondingAuthor":false,"prefix":"","firstName":"Poh","middleName":"Heng","lastName":"Chong","suffix":""}],"badges":[],"createdAt":"2026-02-09 04:38:36","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8825752/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8825752/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":104166744,"identity":"76571f09-44cc-48b5-bf4a-14e1a2cd992e","added_by":"auto","created_at":"2026-03-08 14:19:26","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":70139,"visible":true,"origin":"","legend":"\u003cp\u003eActivity-density by staff role over the workday\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8825752/v1/30caba4977524ec8d1d339c4.png"},{"id":104403832,"identity":"6bea69d2-b4de-48c8-b33a-e9fd257f8386","added_by":"auto","created_at":"2026-03-11 12:19:10","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":93137,"visible":true,"origin":"","legend":"\u003cp\u003eActivity-densities of domains over the workday\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-8825752/v1/37392db7c26b7fa91bdf3f8b.png"},{"id":104408675,"identity":"a62c353a-0fb4-441f-9dab-bf0d86f04eab","added_by":"auto","created_at":"2026-03-11 12:43:05","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":831124,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8825752/v1/779a12a7-b476-4ea3-81b0-18bf3045d2e3.pdf"},{"id":104166745,"identity":"6ac02890-1ab5-4d65-bc77-6de699a1b67e","added_by":"auto","created_at":"2026-03-08 14:19:26","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":49150,"visible":true,"origin":"","legend":"","description":"","filename":"AppendixWorkPatternsandTimeAllocationinMultidisciplinaryHomeHospiceATimeMotionStudy.docx","url":"https://assets-eu.researchsquare.com/files/rs-8825752/v1/18ffb92286fe8c5d5eb3fc72.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Work Patterns and Time Allocation in Multidisciplinary Home Hospice: A Time-Motion Study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eHome-based hospice \u0026amp; palliative care is logistically complex and clinically sensitive. Unlike institutional settings with centralized patients and controlled workflows, home hospice relies on a distributed workforce delivering end-of-life care across variable home environments, while managing travel, family dynamics, and multidisciplinary coordination. A multidisciplinary team of physicians, nurses, and medical social workers (MSWs) coordinate as a \u0026ldquo;hospice without walls\u0026rdquo;, often contributing complementary expertise asynchronously across locations. Ritchie and Leff (1) describe home-based care not just as a series of visits, but as an \"ecosystem\" of diverse care models evolving to meet patient needs across time and space. Within this ecosystem, the labor of care is distributed not just by clinical expertise, but by temporal availability.\u003c/p\u003e \u003cp\u003eWithin this ecosystem, the service is shaped by a distinct relationship to time in two facets. On one hand, care occurs within a limited and uncertain trajectory toward death; teams must prioritize symptom control, patient dignity, and family support while responding to emergent crises and disease progression. At the same time, work is governed by operational \u0026ldquo;clocks,\u0026rdquo; including medication administration schedules, travel between homes, clinical documentation requirements, and unpredictable urgent needs. These competing demands create a \u0026ldquo;temporal architecture\u0026rdquo; that influences how care is delivered and how capacity is utilised. (2)\u003c/p\u003e \u003cp\u003eThe evaluation of workforce efficiency in hospice care has historically been plagued by a lack of granular data. Standard administrative metrics, such as \"visits per day\" caseload per FTE, fail to capture the nuanced texture of a typical workday in palliative care (3, 4). A clinician who spends 90 minutes facilitating a difficult goals-of-care conversation may generate fewer visits than one who performs ten rapid procedural checks, yet the former may provide significantly higher value in terms of hospital avoidance and goal concordance.\u003c/p\u003e \u003cp\u003eTime-motion studies offer a rigorous alternative by directly observing and timing discrete tasks (5). This method generates a high-resolution map of the workday and quantifies \u0026ldquo;invisible work,\u0026rdquo; including care coordination, travel, and peer consultation, which are essential to home-based palliative care yet not reflected in routine reporting. However, other than Bhavsar et al. (3), who reported on workforce delivery in community-based palliative care, there has been little published literature utilizing this methodology in the home hospice setting.\u003c/p\u003e \u003cp\u003eA time-motion study in a home-based hospice in Singapore was conducted to examine diverse workflows within multidisciplinary teams, to characterize the structure of the workday and identify operational constraints that affect provider capacity. The study aimed to address four key areas: workday patterns, task frequency and duration, role-based task allocation, and the relationship between timing and workload. \u003cem\u003eSuggested Time And Motion Procedures\u003c/em\u003e (STAMP) guidelines were referenced in the drafting of this report (6).\u003c/p\u003e"},{"header":"Methods","content":"\u003ch2\u003eSetting and Participants\u003c/h2\u003e\n\u003cp\u003eThis study was conducted between September and October 2025 within a community-based home hospice in Singapore, in operations for more than 35 years. Palliative care was delivered in private homes and residential facilities. Clinicians served across the city state of Singapore, with travel primarily by ride-hailing or taxi.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eParticipants comprised the core multidisciplinary team involved in routine home hospice delivery: physicians (n = 3), registered nurses (n = 7), and medical social workers (n = 4). Staff experience levels were mixed and included both long-tenured staff (more than five years) and newer staff (approximately two to three years). Recruitment was based on voluntary participation.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eData Collection\u003c/h2\u003e\n\u003cp\u003eEach participant was observed for two full workdays from 08:30 to 17:30, yielding 28 staff-days of observation (6 physician days, 14 nurse days, 8 medical social worker days; 252 scheduled hours). All observations were conducted by a single research assistant with 1.5 years of experience in the palliative care setting but minimal direct experience in home visits. There were no prior working relationships with any of the participants.\u003c/p\u003e\n\u003cp\u003eObservation days were determined primarily by staff rosters and observer availability. These days did not include extraneous events or projects outside participants\u0026rsquo; core job description. Some observation days were consecutive, while others were separated due to staff or observer leave plans.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eActivities were coded using a taxonomy grouped into six major domains, with subcodes specifying common tasks, shown in Table 1. The taxonomy drew on prior time-motion and workflow literature in community-based and palliative care services (3), and previous work of this study team.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePrior to study launch, pilot observations were done to test the codes and to allow the observer to acclimate to clinical work patterns. Pilot logs were reviewed jointly by the observer and the study investigator to calibrate task coding and refine operational definitions.\u003c/p\u003e\n\u003cp\u003eDuring the study, the observer recorded each continuous activity episode with a single start time and end time, a location, and a short narrative description. To capture multitasking, the observer could assign multiple concurrent activity codes to the same episode record. Non-work periods were recorded as \u0026ldquo;NIL\u0026rdquo; (for example, lunch) and were excluded from coded-work summaries. Work performed after 17:30 was self-reported by participants on the next day. In these instances, the observer recorded task types and their duration and verified work activity where possible using timestamps available within electronic medical records.\u003c/p\u003e\n\u003cp\u003eTable 1. Taxonomy of activities in home-based hospice care.\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eDomain\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDescription\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCodes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e\u003cem\u003eDirect Care (DC)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29px;\"\u003e\n \u003cp\u003eFace-to-face patient interaction\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003ePatient assessment (DC1), Medication administration (DC2), Symptom management (DC3), Patient or caregiver education (DC4), End-of-life Planning/Discussion (DC5), Psychosocial support (DC6), Other Direct Care (DC7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e\u003cem\u003eIndirect Care (IND)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29px;\"\u003e\n \u003cp\u003eClinical work without patient present\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003ePreparing medication / supplies (IND1), Clinical documentation (IND2), Care planning (IND3), Coordinating with colleagues (IND4), Reviewing patient files (IND5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e\u003cem\u003eCare Coordination (CC)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29px;\"\u003e\n \u003cp\u003eCommunication to facilitate care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003eFamily/caregiver phone updates (CC1), Scheduling, referral handling (CC2), Liaison with external agencies (CC3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e\u003cem\u003eAdministration (AD)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29px;\"\u003e\n \u003cp\u003eNon-clinical organizational tasks\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003eTeam meetings / case conferences (AD1), Internal admin documentation (AD2), Training, internal emails (AD3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e\u003cem\u003eTravel (TR)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29px;\"\u003e\n \u003cp\u003eMovement between locations: transport to and from patient, or satellite centre\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e\u003cem\u003eWaiting (WW)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29px;\"\u003e\n \u003cp\u003eInvoluntary idle time, waiting for elevators and waiting for caregivers to open doors\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003ch2\u003eAnalysis\u003c/h2\u003e\n\u003cp\u003eData were transcribed into a spreadsheet and cleaned prior to analysis. Cleaning steps included removal of duplicate entries, verification of time ordering, and review of ambiguous codes against narrative notes. Multi-code episodes were converted from wide to long format. Each code assignment became a discrete row in the dataset, inheriting the duration and timestamps of the parent episode. This transformation allowed independent analysis of concurrent activity layers.\u003c/p\u003e\n\u003cp\u003eWe analysed work patterns using 15-minute time blocks. An activity was counted as active if any portion of the episode overlapped with a block. For each block, we then counted the number of active code assignments by domain. This yields a measure of activity prevalence or concurrent workload coverage per 15-minute interval. It weights longer activities more heavily and provides a clock-time view of what work is ongoing across the day. For role-stratified summaries, block counts were normalised by dividing by the number of observed staff-days in that role to obtain active code assignments per staff-day per block.\u003c/p\u003e\n\u003cp\u003eTo reconcile multitasking with clock time, we calculated \u0026quot;normalized minutes.\u0026quot; Within each 15-minute block, if the sum of concurrent task durations exceeded the block length, the specific code durations were scaled proportionally to fit the 15-minute window. This preserved the composition of work while constraining totals to scheduled clock time. Normalised minutes were then summed across blocks to produce per staff day-time allocation by code and domain and expressed as minutes and percentages of the scheduled 540-minute shift. Minutes not captured by any code within the scheduled window were treated as uncoded time.\u003c/p\u003e\n\u003cp\u003eTo ensure the analysis reflected the core operational hours of the multidisciplinary team, outlier activities recorded prior to the official start time of 08:30 (specifically a single staff member starting at 06:45) and after 17:30 were excluded from the temporal pattern analysis. Qualitative descriptions recorded alongside activity codes were synthesized to provide context to the quantitative findings.\u003c/p\u003e\n\u003ch2\u003eEthical Considerations\u003c/h2\u003e\n\u003cp\u003eEthical approval was granted by the National Council of Social Service Ethics Review Committee under expedited review (NERC/009/2025). Written informed consent was obtained from staff participants. Participation was voluntary and revocable without penalty. Data were analysed in aggregate and not used for individual performance evaluation. Data were anonymized using alphanumeric codes (e.g., DOC1Q, NUR3Q). During home visits, patient interactions were observed with consent. If the observer was asked not to remain in the room or home, they will move away to a different location and recorded the activity type after the episode based on staff report.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eAcross 28 observed staff days, the dataset contained 2,336 coded activity entries (mean 83.4 per staff day). Nurses contributed 99.6 coded entries per nurse day, compared with 69.4 per MSW day and 64.5 per physician day.\u003c/p\u003e \u003cp\u003eWhen coded entries were aggregated into 15-minute blocks (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e), Indirect Care accounted for 561 of 1,530 active code assignments (36.7%) and Direct Care accounted for 512 (33.5%). Travel contributed 193 (12.6%) and Administration contributed 150 (9.8%). Care Coordination contributed 90 (5.9%) and Waiting contributed 24 (1.6%). Start-of-day work was dominated by Administration and Indirect Care, with minimal Direct Care. Direct Care and Travel rose from mid-morning and remained prominent through the afternoon, consistent with deployment and patient visits. Concurrent workload coverage peaked in the afternoon, with the highest total active code assignments observed at 15:00 (57 codes). A sustained high band (40\u0026ndash;50 codes per block) was also observed from late morning into early afternoon (lunchtime).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eFrequency of coded entries by domain by 15-minute time-blocks\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTime-block\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAdministrative work (AD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCoordination \u0026amp; Communication (CC)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eDirect patient care (DC)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eIndirect clinical work (IND)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eTravel (TR)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eWaiting (WW)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e08:30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e08:45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e09:00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e09:15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e09:30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e09:45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10:00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10:15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10:30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10:45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e11:00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e11:15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e11:30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e11:45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e12:00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e12:15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e12:30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e12:45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e13:00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e13:15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e13:30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e13:45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e14:00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e14:15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e14:30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e14:45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e15:00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e15:15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e15:30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e15:45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e16:00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e16:15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e16:30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e16:45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e17:00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e17:15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e17:30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e17:45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e18:00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e150\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e512\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e561\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e193\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eFigure \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e shows that role-normalised patterns differed by discipline. Nurses showed their highest concurrent workload coverage in mid-afternoon, peaking at 15:00 with 2.36 active code assignments per nurse-day per block. Physicians peaked earlier, with the highest physician-level coverage at 10:45 (1.83 active code assignments per physician-day per block). Medical social workers peaked in the morning, with the highest MSW coverage at 09:15 (2.50 codes per MSW-day per block).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eUsing clock-based normalised minutes, mean coded work time was 525 minutes per observed staff-day (97.2% of the scheduled 540-minute shift). The breakdown is provided in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. Indirect Care accounted for the largest share of time (214.7 minutes, 39.8% of the scheduled shift), driven primarily by clinical documentation (IND2), which averaged 132.8 minutes per staff-day (24.6%). Direct Care totalled 144.8 minutes (26.8%), with substantial time in psychosocial support (DC6, 34.1 minutes, 6.3%), patient assessment (DC1, 30.8 minutes, 5.7%), and patient or caregiver education (DC4, 29.5 minutes, 5.5%). Travel accounted for 84.2 minutes (15.6%). Team meetings and case conferences (AD1) remained a major fixed component at 47.5 minutes (8.8%). Care coordination codes together accounted for 19.4 minutes (3.6%), while coded Idle Time (e.g., waiting for patients, waiting for transport) accounted for 8.2 minutes (1.5%).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eNormalised minutes per observed staff-day across the whole MDT, pooled across all observed staff-days, as a proxy for service workload.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCode\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNormalized Duration (mins)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAs % of 9-hr workday*\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTeam meetings / case conferences (AD1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e47.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8.8%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInternal admin documentation (AD2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.9%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTraining, internal emails (AD3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.2%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFamily/caregiver phone updates (CC1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.3%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eScheduling, referral handling (CC2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.8%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLiaison with external agencies (CC3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.5%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatient assessment (DC1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e30.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5.7%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedication administration (DC2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e15.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.9%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSymptom management (DC3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.8%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatient or caregiver education (DC4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e29.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5.5%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEnd-of-life Planning/Discussion (DC5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.9%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePsychosocial support (DC6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e34.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6.3%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther Direct Care (DC7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e25.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4.8%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreparing medication / supplies (IND1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e11.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.2%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClinical documentation (IND2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e132.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e24.6%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCare planning (IND3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e15.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.9%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCoordinating with colleagues (IND4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e35.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6.5%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReviewing patient files (IND5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e19.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3.5%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTravel (TR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e84.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15.6%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIdle Time (WW)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.5%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e(Uncoded)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e15.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.8%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eSynthesized timeline of a typical workday\u003c/h2\u003e \u003cp\u003eFigure \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e summarises the typical workday by activity domains. Observation notes and time-block counts indicated a consistent three-phase structure.\u003c/p\u003e \u003cp\u003eThe workday began with a synchronisation block (08:30\u0026ndash;10:00) during which virtually every staff member engaged in team meetings, case discussions, and visit planning, lasting up to 1.5 hours (average 50 minutes). This critical handover allowed the team to review patient statuses, prioritise overnight updates, and plan routes. Following this block, the team separated into role-specific preparation. Nurses transitioned to packing medication kits and coordinating logistics before deployment. Physicians reviewed case notes and coordinated routes with their nurse partners. MSWs shifted into a high-intensity block of Care Coordination, managing subsidy applications, grant paperwork, and external agency liaison to stabilise patients' home environments before entering the field.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe field phase (10:30\u0026ndash;16:00) was characterised by sustained concurrent activity, with the Doctor-Nurse dyad emerging as the fundamental unit for complex care. Nearly all physician visits were conducted in tandem with nurses: physicians focused on clinical decisions (identifying deterioration, adjusting medications, coordinating emergency transfers) while nurses executed hands-on care and provided observational input that informed physician decision-making. Nurses dedicated approximately 44% of their time to Direct Care, performing wound care, catheter management, and physical assistance alongside substantial patient and caregiver education (e.g., teaching families to administer morphine, manage oxygen equipment, or recognise signs of imminent death). In visits requiring psychosocial intervention, MSWs operated either independently or in Nurse-MSW pairs, stepping in for counselling and therapeutic conversation while nurses managed physical care needs.\u003c/p\u003e \u003cp\u003eA synchronised peak occurred around 11:15 (50 distinct activities) as morning visits concluded and generated work\u0026mdash;prescriptions, referrals, follow-up calls\u0026mdash;required action. Staff breaks between 12:00\u0026ndash;14:00 were fragmented; persistent Travel codes during this window suggested clinicians ate while in transit between patients. A secondary peak at 15:30 represented a \"decision block\" where staff finalised plans and determined which patients required evening follow-up or hospitalisation.\u003c/p\u003e \u003cp\u003eTravel was a major feature throughout the workday. This block is often not rest or dead time. Rather, staff would use this time as an \"interstitial workspace.\" Physicians and nurses utilize ride-sharing services to perform work. Descriptions such as \"On the way to patient #1 house, reading up on patient\u0026rsquo;s case notes\" or \"Replying to emails\" are common.\u003c/p\u003e \u003cp\u003e18 activities were recorded between 18:00 and 21:30. These after-hours sessions were lengthy (ranging from 60 to 206 minutes) and totalled approximately 800 workload minutes. Observation notes described clinicians completing progress notes, medication orders, and referral forms after shift end, consistent with a deferral mechanism where daytime field activity crowds out the uninterrupted time needed for comprehensive documentation.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study addressed four questions regarding workday patterns, task frequencies, role-based differences, and how temporal structures shape capacity.\u003c/p\u003e \u003cp\u003eFirst, the hospice workday follows a three-part structure: a morning synchronisation phase (08:30–10:00) dominated by team meetings and case coordination; a sustained high-intensity field phase (10:30–16:00) characterised by overlapping direct care, travel, and documentation. Rather than discrete care episodes separated by recovery intervals, we observed home-based workday as being a period of sustained, concurrent workload. The morning synchronisation block, while essential for clinical handover and route planning, compresses clinical activity into a denser midday block.\u003c/p\u003e \u003cp\u003e Across the service, Indirect Care dominated normalised time (39.8%), with clinical documentation alone accounting for 24.6%. Direct Care represented 26.8% of the day, while Travel consumed 15.6%. Role-stratified analysis revealed distinct work-patterns: Physicians peaked early (10:45), focusing on complex decision-making; MSWs showed the highest activity density in the morning (09:15), reflecting their heavy coordination load before field deployment; while Nurses demonstrated the highest overall activity density, with a concurrent workload peak in mid-afternoon (15:00).\u003c/p\u003e \u003cp\u003eTo our knowledge, Bhavsar et al. (3) is the only comparable time-motion study in community palliative care. Contrasting our findings with theirs highlights the distinct pressures of a purely home-based model. Our data shows a substantially lower proportion of Direct Care across all disciplines (26.8% service-wide), likely driven by the 15.6% travel burden inherent to our setting (which Bhavsar et al. did not report as a distinct category).\u003c/p\u003e \u003cp\u003eTravel absorbs time that would otherwise be available for patient contact, demonstrating how geography is a defining constraint of home hospice capacity. Vaartio-Rajalin et al. (2) found Finnish home healthcare nurses spent approximately 48 minutes per shift on travel (approximately 18–26% of working time). In our model, Travel operates as both a temporal constraint and an adaptive workspace where clinicians perform documentation and coordination tasks. While this creates an avenue for productivity, it eliminates cognitive recovery. As noted by Chu et al. (7), layering tasks into transit time removes the \"white space\" necessary for mental resets. This lack of recovery is compounded by workflow fragmentation. Cornell et al. (8) and Zheng et al. (6) have established that high-frequency task switching increases cognitive load.\u003c/p\u003e \u003cp\u003eOur finding that clinical documentation (IND2) alone accounts for 24.6% of normalised time across the entire multidisciplinary team. This finding aligns with broader literature on documentation burden in healthcare. Sinsky et al. (9) found that ambulatory physicians face a ratio of approximately 2:1 favouring administrative tasks. Our service-wide ratio (39.8% Indirect Care to 26.8% Direct Care, or approximately 1.5:1) is comparable to those reported by Bhavsar et al. but still indicates substantial administrative demands.\u003c/p\u003e \u003cp\u003eDocumentation functions as a persistent “background layer,” engaging roughly a quarter of the workforce at any given time-block rather than occurring as a discrete end-of-day task. This finding mirrors observations by Mamykina et al. (10) regarding the distributed nature of clinical documentation. Importantly, our observation of after-hours documentation (18 episodes totalling approximately 800 workload minutes) suggests that our daytime figures may underestimate the true documentation burden, consistent with the phenomenon of “pajama time” described in primary care settings. (11)\u003c/p\u003e \u003cp\u003eThe interdisciplinary communication burden observed in our study (nearly 10% of workday time) reflects the distributed nature of home hospice care. Unlike institutional settings where team members share a physical space, home hospice requires active coordination to maintain clinical coherence across dispersed locations. Oliver et al. (12) found that hospice team meetings average 4.7 minutes per case discussion, with information flow challenges including data redundancy and references to absent team members. Our morning synchronisation block, averaging 50 minutes, represents a substantial investment in mitigating these coordination challenges.\u003c/p\u003e \u003cp\u003eFraming these findings as operational trade-offs illuminates potential intervention points. The morning synchronisation block represents a trade-off between coordination quality and field-time capacity: consolidating information exchange reduces downstream rework but compresses the available window for patient visits. Alternative configurations might include staggered start times, asynchronous pre-shift handovers using electronic systems, or selective attendance policies that excuse some team members from portions of the morning meeting.\u003c/p\u003e \u003cp\u003eThe qualitative findings describe the clinical dyads (particularly Nurse-Physician and Nurse-MSW teams) as the “fundamental production unit” for complex care. This coupling pattern has operational implications. While pairing clinicians for high-acuity visits may enhance clinical reliability by allowing simultaneous assessment, prescribing, and hands-on intervention, it also creates rigid dependencies. A delay for one clinician propagates immediately to their partner, reducing scheduling flexibility and contributing to the sustained high-utilisation states. For stable patients with predictable care needs, “decoupled” visits (routine assessments by a single clinician) might preserve capacity. This tiered approach would require risk stratification protocols and clear escalation pathways but could reduce workload. That said, team-based support structures common in community care offer protective benefits to staff’s psychosocial safety despite the distributed nature of the work, as observed by Fattori et al. (13).\u003c/p\u003e \u003cp\u003eDocumentation deferral represents a trade-off between clinical workflow and work-life boundaries. Protected documentation time might reduce after-hours charting, though at the cost of further compressing the field-visit window. Alternatively, scribing support, voice-to-text documentation, or streamlined charting templates could reduce the time required for documentation without altering its temporal placement.\u003c/p\u003e \u003cp\u003eThese trade-offs are not unique to our setting. Lupu et al. (14) note that community-based palliative care programs must balance clinical intensity against operational sustainability, particularly as services expand to meet growing demand. The sustainability implications are significant. Moy et al. (15), in a scoping review of documentation burden measurement, found that extended work hours and time constraints have been linked to burnout, job attrition, and threats to patient safety. Our findings suggest that home hospice teams may be particularly vulnerable to documentation-related strain given the additional demands of travel and field-based care. The NHPCO Hospice Staffing Framework (16) emphasises the need for staffing models that account for travel time, documentation burden, and interdisciplinary coordination; all factors that our findings quantify.\u003c/p\u003e\n\u003ch3\u003eLimitations\u003c/h3\u003e\n\u003cp\u003eFindings should be understood considering the study’s limitations. First, this study was conducted in a single home hospice service in Singapore, an urban and dense setting with common use of ride-hailing. Travel time, visit sequencing, and the feasibility of doing “interstitial work” during transit may differ in settings with longer distances, fewer transport options, or different safety norms. Participation was voluntary and observation scheduling was convenience-based, which may introduce selection effects if volunteers differed from non-participants. Observation days were chosen as the next available full duty day and excluded atypical activities outside core roles, which improves comparability but may under-represent surge days, unusual crises, and periodic administrative cycles.\u003c/p\u003e \u003cp\u003eSeveral measurement limitations also apply. Direct observation can change behaviour, and the use of a single observer limits formal inter-observer reliability assessment, despite pilot calibration. Some sensitive encounters were not directly observed and required staff-estimated durations, which could bias estimates if such episodes are systematically longer or more variable. Task coding simplifies complex work and requires assumptions when allocating overlapping time under multi-tasking. Activity density captures fragmentation and task switching but does not measure quality, complexity, or appropriateness of care. Finally, the findings are primarily descriptive and support mechanism hypotheses, but they do not establish causal effects of alternative workflows or technologies.\u003c/p\u003e "},{"header":"Conclusion","content":"\u003cp\u003eThis time-motion study provides a high-resolution description of how a multidisciplinary home hospice team distributes time across direct care, indirect clinical work, coordination, travel, and office-based synchronization. The findings show that system design features, including a shared morning alignment block, coupled physician-nurse visits, and a large documentation workload, shape field capacity by compressing patient-facing time and shifting charting into fragmented intervals and occasional after-hours work. Framing these patterns as mechanisms and trade-offs supports future work that links workflow signatures to patient and caregiver outcomes, or evaluation of counterfactual service designs, such as selective solo visits and protected documentation time, to improve temporal flexibility without compromising clinical reliability.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eMSW: Medical Social Worker\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cem\u003eEthics approval and consent to participate\u003c/em\u003e\u003cbr\u003eEthics approval was granted by the \u003cem\u003eNational Council of Social Service Ethics Review Committee\u003c/em\u003e under expedited review (NERC/009/2025). This study adhered to the Declaration of Helsinki guidelines. Written informed consent was obtained from staff participants through a participation consent form. Participation was voluntary and revocable without penalty. Data were analysed in aggregate and not used for individual performance evaluation. Participants were anonymized using alphanumeric codes (e.g., DOC1Q, NUR3Q).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eConsent for publication\u003c/em\u003e\u003cbr\u003e\u0026nbsp;Not applicable. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAvailability of data and materials\u003c/em\u003e\u003cbr\u003e\u0026nbsp;The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eCompeting interests\u003c/em\u003e\u003cbr\u003e\u0026nbsp;The authors have no competing interests as defined by BMC, or other interests that might be perceived to influence the results and/or discussion reported in this paper.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFunding\u003c/em\u003e\u003cbr\u003e\u0026nbsp;There was no funding involved in this study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAuthors contributions\u003c/em\u003e\u003cbr\u003e\u0026nbsp;ZZY and PHC conceptualized the study. JC collected the data for the study. All authors analysed the data. All authors contributed to the writing and data of the manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAcknowledgements\u0026nbsp;\u003cbr\u003e\u0026nbsp;Not applicable.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eRitchie C, Leff B. Home-Based Care Reimagined: A Full-Fledged Health Care Delivery Ecosystem Without Walls. Health Aff (Millwood). 2022;41(5):689-695. doi:10.1377/hlthaff.2021.01011\u003c/li\u003e\n \u003cli\u003eVaartio-Rajalin H, N\u0026auml;sman Y, Fagerstr\u0026ouml;m L. Nurses\u0026rsquo; activities and time management during home healthcare visits. Scand J Caring Sci. 2020;34(4):1045-53. doi:10.1111/scs.12813\u003c/li\u003e\n \u003cli\u003eBhavsar NA, Bloom K, Nicolla J, Gable C, Goodman A, Olson A, et al. Delivery of community-based palliative care: Findings from a time and motion study. J Palliat Med. 2017;20(10):1120-6. doi:10.1089/jpm.2016.0433\u003c/li\u003e\n \u003cli\u003eBurden M, McBeth L, Keniston A. Salient Measures of Hospitalist Workload. JAMA Netw Open. 2023;6(8):e2328165. Published 2023 Aug 1. doi:10.1001/jamanetworkopen.2023.28165\u003c/li\u003e\n \u003cli\u003eLopetegui M, Yen PY, Lai A, Jeffries J, Embi P, Payne P. Time motion studies in healthcare: what are we talking about?. J Biomed Inform. 2014;49:292-299. doi:10.1016/j.jbi.2014.02.017\u003c/li\u003e\n \u003cli\u003eZheng K, Haftel HM, Hirschl RB, O\u0026apos;Reilly M, Hanauer DA. Quantifying the impact of health IT implementations on clinical workflow: A new methodological perspective. J Am Med Inform Assoc. 2010;17(4):454-61. doi:10.1136/jamia.2010.004440\u003c/li\u003e\n \u003cli\u003eChu WM, et al. Home-based palliative care: Benefits, challenges, opportunities and future directions in a super-aged society. J Hosp Palliat Care. 2025;28(3):81-93.\u003c/li\u003e\n \u003cli\u003eCornell P, Herrin-Griffith D, Keim C, Petschonek S, Sanders AM, D\u0026rsquo;Mello S, et al. Transforming nursing workflow, part 1: The chaotic nature of nurse activities. J Nurs Adm. 2010;40(9):366-73. doi:10.1097/NNA.0b013e3181ee4261\u003c/li\u003e\n \u003cli\u003eSinsky C, Colligan L, Li L, Prgomet M, Reynolds S, Goeders L, et al. Allocation of physician time in ambulatory practice: A time and motion study in 4 specialties. Ann Intern Med. 2016;165(11):753-60. doi:10.7326/M16-0961\u003c/li\u003e\n \u003cli\u003eMamykina L, Vawdrey DK, Hripcsak G. How do residents spend their shift time? A time and motion study with a particular focus on the use of computers. Acad Med. 2012;87(6):827-32. doi:10.1097/ACM.0b013e318254591d\u003c/li\u003e\n \u003cli\u003eArndt BG, Beasley JW, Watkinson MD, Temte JL, Tuan WJ, Sinsky CA, et al. Tethered to the EHR: Primary care physician workload assessment using EHR event log data and time-motion observations. Ann Fam Med. 2017;15(5):419-26. doi:10.1370/afm.2121\u003c/li\u003e\n \u003cli\u003eOliver DP, Wittenberg-Lyles E, Demiris G, Tatum P, Regehr K, Burt S. The role of the hospice medical director as observed in interdisciplinary team case reviews. J Palliat Med. 2010 Mar;13(3):279-84. doi: 10.1089/jpm.2009.0247.\u003c/li\u003e\n \u003cli\u003eFattori A, Pedruzzi M, Cantarella C, Bonzini M. The burden in palliative care assistance: A comparison of psychosocial risks and burnout between inpatient hospice and home care services workers. Palliat Support Care. 2023;21(1):49-56. doi:10.1017/S1478951521001887\u003c/li\u003e\n \u003cli\u003eLupu D, Quigley L, Mehfoud N, Salsberg ES. The growing demand for hospice and palliative medicine physicians: Will the supply keep up? J Pain Symptom Manage. 2018;55(4):1216-23. doi:10.1016/j.jpainsymman.2017.12.478\u003c/li\u003e\n \u003cli\u003eMoy AJ, Schwartz JM, Chen R, Sadri S, Lucas E, Cato KD, et al. Measurement of clinical documentation burden among physicians and nurses using electronic health records: A scoping review. J Am Med Inform Assoc. 2021;28(5):998-1008. doi:10.1093/jamia/ocaa325\u003c/li\u003e\n \u003cli\u003eNational Hospice and Palliative Care Organization. NHPCO Hospice Staffing Framework. Accessed January 7, 2026. https://www.nhpco.org/Center to Advance Palliative Care. Home-based palliative care for sustainability [Internet]. 2019 [cited 2026 Feb 6]. Available from: https://www.capc.org/\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-palliative-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pcar","sideBox":"Learn more about [BMC Palliative Care](http://bmcpalliatcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pcar/default.aspx","title":"BMC Palliative Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Palliative \u0026 Hospice Care, Patient Care Team, Professional Practice, Workload, Time and Motion Studies, Efficiency, Organisational","lastPublishedDoi":"10.21203/rs.3.rs-8825752/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8825752/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eIntroduction\u003c/strong\u003e: \u0026nbsp;The delivery of home hospice care involves complex logistical and clinical demands. Standard administrative metrics fail to capture the nuanced workload of this distributed ecosystem. This study aimed to characterize the workday structure and identify operational constraints within a multidisciplinary palliative care team in Singapore.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e: \u0026nbsp;A time-motion study was conducted in late 2025, through continuous observation to quantify individual durations of discrete tasks. Over 28 staff days, a research assistant shadowed three physicians, seven nurses, and four medical social workers for two days each. Activities were coded across six domains, ranging from direct care to travel, with periodic multitasking captured through concurrent coding. To reconcile multitasking with scheduled clock time, task durations were normalized within 15-minute blocks.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e: \u0026nbsp;The dataset included 2336 distinct activity entries. Observation revealed a sustained intensity marked by concurrent workloads rather than discrete episodes. Across the service, indirect care occupied 39.8% of normalized time. Direct care accounted for 26.8% of the shift. Specifically, clinical documentation alone consumed 24.6% of the workday. Movement between locations required 15.6% of total time. Regarding specific roles, medical social workers experienced peak workload density in the morning. Conversely, nurse workloads peaked in the mid-afternoon.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDiscussion\u003c/strong\u003e: \u0026nbsp;Geographic distribution and practice norms heavily influence home care workflows. Standardized morning meetings foster team alignment. At the same time, this synchronization compresses the available window for field visits. Joint clinical visits ensure safety but reduce scheduling flexibility. To mitigate capacity constraints, clinicians frequently use travel time as an interstitial workspace. This practice reclaims productive minutes but eliminates cognitive recovery periods. Future service redesigns could explore decoupled visits for stable patients or protected documentation time to improve workforce sustainability.\u003c/p\u003e","manuscriptTitle":"Work Patterns and Time Allocation in Multidisciplinary Home Hospice: A Time-Motion Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-08 14:19:21","doi":"10.21203/rs.3.rs-8825752/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-04-27T06:37:57+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-25T15:14:41+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"276369451423419161432153615649389996485","date":"2026-04-25T14:46:48+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-02T09:36:28+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"165535401610218294720017375008177785365","date":"2026-03-26T12:56:32+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"339102983476967759129580868599327784280","date":"2026-03-24T14:55:41+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"16807174813861587630745534123327105184","date":"2026-03-22T19:47:36+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-09T22:21:37+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"299167577900449509532403025069128797110","date":"2026-02-28T00:33:06+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-02-25T01:15:11+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-02-24T17:50:10+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-02-24T09:01:52+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Palliative Care","date":"2026-02-24T08:55:23+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-palliative-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pcar","sideBox":"Learn more about [BMC Palliative Care](http://bmcpalliatcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pcar/default.aspx","title":"BMC Palliative Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"95e06d06-e71e-44ba-9ec1-250533d37b95","owner":[],"postedDate":"March 8th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-15T08:09:14+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-08 14:19:21","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8825752","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8825752","identity":"rs-8825752","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}