Why Is Nursing Time Management Hard?

You know what it feels like: the shift ends and everything's done... no staying late (on the clock? off the clock?) to finish charting, no "missed care," all patients making good progress. Effective time management is a great feeling: you're at your best, and your patients have received truly good care. But how do you get there? Time management is one of the hardest parts of the job of the nurse. There is always more to do, and never enough time. Setting priorities, not losing sight of the big picture, multi-tasking (especially while juggling interruptions), and delegating are essential skills, subtle and complex, acquired only with years of experience. Here are some of the issues I've confronted in my own practice.

Prioritization Effective prioritization is hard. Obviously, do the most important thing first. But how do you know what that is? You start your shift by rounding your patients, perhaps with the outgoing nurse. You do 5-minute head-to-toe assessments -- another art every nurse masters -- to build your mental task list and to set your goal(s) for each of your patients. Of course, life-threatening issues -- patient codes (require emergency resuscitation), falls, etc. -- come first, but then what? Consider what resources (support staff) you have and what can be delegated. Stay on top of the changes that happen constantly: acuity levels change, new patients are admitted, new orders arrive, families make requests, etc. Whereas other medical staff -- physical therapists, pharmacists, dietitians, and so on -- are specialists, you the RN are the generalist, the patient advocate, the one with the big picture. A common result of nursing overload is "missed care". In Missed Nursing Care: A Qualitative Study, Beatrice Kalisch describes how this happens. She observed that certain tasks are often omitted: ambulation, turning, hygiene, education, and so on. When nurses are swamped, these lower-priority tasks can get dropped. Indeed, prioritizing is one of the hard parts of nursing time management.

Repetition Much of nursing work is neither explicitly ordered (ordering is done by physicians not by nurses) nor charted, but it is repeated work that is expected to be done nonetheless. For example, as a nurse you might be tasked (by your charge nurse, the nurse who is in charge of your unit during your shift) with patient surveillance when your patient is at risk for falls. You put them in a room near the nurses' station where you can watch them as you do your other work. It's a repetitive, background activity -- one of many -- and neither ordered nor charted yet it must be done well; falls are bad bad bad. Another repetitive task is ambulation. You must ambulate your post-op patient every couple of hours to support recovery. Other such tasks are toileting, bed bathing and other hygiene activities. To prevent bedsores, you must reposition them regularly if they are bedfast. This, too, is neither ordered nor charted. You do these tasks as a backdrop to the ordered ones such as administering medications and therapies such as incentive spirometry (keeping your patient's lungs working) or catheter insertion. Some tasks have narrow time deadlines; others can be more flexible. Juggling these timings while making sure it all gets done is part of your time management challenge.

Cognitive Burden There is a lot to remember. Demands from families, for example, can be challenging. They often require remembering and communicating requests to other staff, especially at shift change. You might need to alert the incoming nurse that, after a patient is discharged (on that nurse's shift) a family member will be a caregiver and requires education on procedures. Coordinating with co-workers, too, can be a challenge. Examples are arranging for patient transport to a procedure such as imaging, or contacting pharmacy to make an adjustment to a medication order (which must also be cleared by the MD). Sometimes people don't call you back so you must remember to follow up. Here's another. We are exhorted to answer call lights promptly. This is tied closely to customer satisfaction to which hospitals are sensitive because it impacts reimbursements, so our managers pay attention to this aspect of our performance. Some patients abuse this service while others do not use it even when they should. Thus, handling it effectively involves judgment and patience. Even so, that call button takes some of your time management choices out of your own hands; it obliges you to drop what you're doing and hasten to that bedside.

Interruptions Perhaps the most stressful part of time management is interruptions. Any activity that takes more than a minute or two is likely to be interrupted. This forces you to do something else for a while and then remember to return and resume. And the interruption is likely to be interrupted. All this piles on to your cognitive burden; it's easy to fumble or forget to complete interrupted tasks. In a famous study, Kaiser found that medication errors are often due to interruptions and thus requires nurses to wear a don’t-bug-me-right-now yellow sash while passing meds. Nursing has a less-visible side: the wide variety of activities that are essential yet generate no revenue for the institution. For example, toileting a very ill patient could take you a half hour. This is neither tracked nor billed; it's rolled into the "rack rate". Hospital management rarely knows in detail what consumes nurses' expensive time. They may not need this level of detail but effective nursing management does.1

Optimizations Experienced nurses do continuous optimization. For example, when you make a trip to the supplies closet for an IV tube, you anticipate all your needs – dressing changes, bedpans and so on -- not just the one that triggered the trip. (We call this "Remember the applesauce" because another of your patients has difficulty swallowing and will need pills mashed.) Load up your pockets with supplies for several patients, not just the one you're working with at this moment. This is hard to do! My novice nurse brain just isn't that good at predicting, so I lose time and shoe leather repeatedly running down the hall for supplies.2 Another optimization done by experienced nurses is grouping tasks by location. Do as much as you can in a particular room so you'll have less need to return repeatedly to it.3

The Big Picture But these are details; it is also essential to keep unfailingly in mind the big picture. This helps you to anticipate bottlenecks, crunch times when many tasks are due within a short period of time. Get a head start on them so you're not swamped when they all hit at once. Similarly, anticipate periods when the load is relatively light. That's when to take your break.4 There is more to say about the big picture, perhaps its central concept: for each of your patients, identify your goal(s) for them for the shift. Review this in your head as you enter their room and stay focused on it. For example, they may have pain that needs to be controlled, or they may need to be gotten ready for discharge.5

Delegation When you're hammered -- a patient coded, or several complex orders arrived all at once -- and you need to delegate, the temptation is instead to say, "It's too much to explain, I'll just work faster." But when you have the mental plan of your work well organized, you can delegate effectively. You know exactly what your tasks are and so you can list them succinctly for a co-worker. Experienced nurses do this instinctually, having learned over many years to anticipate and avoid trouble spots. A form of delegation that every nurse does at the end of every shift is the hand-off (“giving report”) to the incoming nurse. This is surprisingly difficult. It requires a thorough grasp of the status and main issues for each patient and the ability to communicate them effectively. One technique that, under the guidance of an inspired Director of Nursing, Pam Conlon at Mills-Peninsula Hospital in Burlingame, California, I helped develop that is in wide use today was the SBAR -- Situation, Background, Assessment, Recommendation. That is, what's going on with your patient and what to do about it. SBAR is usually suggested but not required; some nurses find it useful and others do it their own way. The point is, complex information must be distilled and delivered succinctly. Efficient hand-offs are an art every nurse must master. In developing the NurseMind app, I constructed a taxonomy of nursing activities. This enables it to construct to-do lists. There are three categories: tasks that are done per-shift (for example, giving report), tasks that are done per-patient (for example, head-to-toe assessments, or giving meds), and those that are ad hoc (which I term Remind Mes, for example family education, or follow-up with a clinician). You develop your own mental models; this is one that's been useful for me.

Conclusion Maintaining that big picture, prioritizing, handling interruptions, and delegating are essential, mastered only with years of experience. These are the elements of effective time management. Can you handle it all? Of course! You're a nurse! Time management is what we do. But nobody says it's easy.

Footnotes My NurseMind app collects nursing activity information and makes it available in real time. NurseMind anticipates supplies needs; tasks that require supplies have badges that you see at a glance and remind you to fetch them. NurseMind supports this optimization, too, knowing where patients are and what they need. NurseMind visually displays tasks on a timeline so that you can anticipate task clusters at a glance. NurseMind tracks the goal(s) for each patient and reminds you of it/them with a tap.

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