Time management issues

kdc290 · Nov 4, 2010

I feel the same way in my LTC and I don't know what to do about it. I have 30 fairly sick people at night. Some with iVs Gtubes and the like. I am discouraged from assessing these people b/c I need to get out on time. They want me out by 730, but can't assess them until last med pass @ 630 then need to give report until 730 then still need to document on 7 people. They get on us for getting out @ 830am. If we don't get done we get in trouble too. What to do? I just graduated in may. I'm rethinking things too.

SlightlyMental_RN · Nov 4, 2010

Do you organize yourself before heading out onto the floor? Do you use a time grid? Do you chart as you go or save it all for the end? All of these things helped me tremendously in getting out on time. I also use Meditech and work AM's. How I work it is: Get report, figure out which patient(s) to see first. Go and pull up the eMar and get the meds to be given over the next 8 hours, mark those down on my time grid. On the same grid, mark when to do specific tasks for patients (dressing changes, IVs, etc.). Round and get all my initial assessments--this also allows me to adjust anything on my grid (for example, if someone is having an issue that I need to address.) After that 1st round, when I've gone a done my head to toe assessment and given out any meds--I chart. Then, I just keep charting as I go, marking down on my grid any PRN meds given for that patient/or abnormal assessments. It makes giving report so much easier to have everything in one spot.

Good luck!

sameasalways, ASN, RN · Nov 4, 2010

Hi, I have a sheet that I have all the basic pt info on and I have to document prn meds given and as soon as i give it I write the time given that way I can redocument that the pain was taken care of within the 60 minutes of giving it.. from 7-3 I usually never hav ea problem keeping up. I get report, look at the computer grid, see what meds are due on who and when, and take care of anyone with insulin or pain first..then with each pt I give the 8 am pass which is small and document on them at the same time. By 10 am all my dressing changes and all 8 am meds and assessments have been done. by 1030 to 11 pm all 10 am meds are done and I am just documetning all the PRN MEDS i have given and checking charts off from the new orders written on all the patients or calling the dr if I have to. Also we have an am meeting at 10 we have to go to and give report to all the other staff. Then I usually am gettin ga post-op at this time as well and trying to track down equipment for the new pt and set the room up. Its uusally lunch time and I am either getting a post op, or one is on the way, or I have just gotten one. These are also considered "new admits" so there is a huge huge questionnaire that has to be done as well as a falls video, and admission assessment and education on using everything, plus all the new orders to check off and trying to get their pain under control from surgery and documenting all their vital signs every 15 minutes. There is another med pass at noon and there are clocks to document on at : 8 am, 10 am, 12, 2 pm, 4 pm, 6 pm. Each of those clocks has a lot of redundencies and I copy/paste/push recall for everything except a new admission or in the 8 am clocks which are huge and the 1600 clocks which are huge..and I push recall but change everything to what is REALLY going on with the patient. Sometiems the scanners go down, and other things that can set me behind are the pharmacy not sending meds up in time or me having to call them or call the doctor or an issue/complication with a patient. Sometimes the patient needs PRN meds every 2 hours and that is a lot of PRN documentation. When I get back from lunch its time to do the 2 pm clocks, 2 pm med pass and the I/O's for the am shift. I do all that and also by 3 pm you pick up two new patients. So the pt load goes up to 6 and it is all new documentation. If you don't have six, you can get another post op patient/new admit..I think it is worse to get that..I would rather have six patients than have all the extra stuff that goes with the new admit/post-op. On the other hand, you MIGHT not get that new admit/post-op so youa re taking a chance on fewer patients vs getting a post op.

Also if you have any discharges or new admits you have to do all that paperwork too. That will really set me behind. So for example on the one day I had 3 discharges and a postop all before noon. I was put on call at 3 so I didn't have to pick up new patients from 3-7 like normal but because there were so incredibly many discharges, everyone was running around like a chicken with their head cut off and I was asked by a few people to help with little things here and there even though it was after 3 pm. I removed PICC line for someone, finsihed a discharge for someone, made sure the dishcarge paperwork was done for the other patient, and had to get ahold of casemanagement to get a prescription for a walker for the patient that was getting discharged. That way the nurse coming on woudln't have to do anything with the discharges except one and all she had to do was take the papers in and have them sign rather than having to fill all the med times and follow up appointments out and take the pICC line out.

The thing I hate most is when I have a wound vac change or wet to dry wound packings because you have to try to somehow fit that in between the 8 and 10 am med pass and it can be hard. I actually enjoy doing wound vac changes, but it really sucks all the time out of your day. Oh and when the doctor comes you are supposed to drop everything and go in the room and stand there. I left late the other day because i had to help the doctor with a procedure for an ileiostomy while he put a few sutures in and used the electro cautery machine, and then also the same day aroudn the same time I had just gotten a post op right before he came up and then was time for lunch so i had to do the ileostomy thing with the dr instead...and then my patient was supposed to get blood but needed a blood warmer which i had never used so that sucked even more time out of my day...with all the clocks that you have to add to the system for blood administration and getting the machine, calling distribution, setting it up ect. Plus I had to remove a flexiseal which i had never done and the physical thereapist had accidently broken the two tubes that you use to inflate it with and to irrigate it with. So the charge nurse told me to print out the policy and that it "isn't hard to do". Well I had never done it. No its not hard to do but it was broke and the lady was morbidly obese and I I wasn't sure if I would be able to get it out. I wasn't comfortable with it due to that but I did it anyway and no it wasn't hard to do but I just feel it wasn't right to be in that situation and neither one of them even would look at the flexiseal to see what I was talking about. Or the past times I had a psych patient who would become agitated, kick scream grab pinch pull her NG tube out pull at her foley, try to walk around the hall into everyone's room and I am having to physically restrain her with 4 others for 45 min because her O2 is dropping and her HR is way up. That pretty much sucked the time out of my day. And yah of course getting two extra patients at 3 and getting report at 3 again..trying to get the fingersticks and I/O's and meds done at 1800.. trying to get the huge 1600 clocks done while all this is happening. I get overwhelmed around 5 pm..I am not gonna lie. Oh of course the hospitalists come in and write more new orders around 4 so try to get those checked off and implemented and documented as well. Fax all the new orders to pharmacy. My manager knows its tough..because everyone from 3-7 says the same thing.

If I have a day that is no complications, there isn't a problem..honest. But when all these things happen then I am majorly behind. I left at 830 pm that night with the doctor and blood/blood warmer and flexiseal pt.. My boss said she wants to see me succeed and I know she does. This situation makes me feel incompetent to the point that I am nervous about working anywhere else because what if I am even worse somewhere else? And I know I will move in 4 or 5 months like I said I have had so many nurses say to me "why do you stay on that floor" or one of the doctors wanted me to work in the OR and I was gonna take the job but I knew I was moving soon and I coudln't do that so it is the only reason I didn't but when i shadowed and went through the PACU the PACU nurse (we see them all the time because they bring us our post-ops) was like "OMG!! You are trying to get away from the ______ floor aren't you!!! haha". Yah the floor is hectic even the manager says so.. even the surgeons know it.

Some floors the charge nurse checks off all the orders and calls the doctor if a paitent is having an issue. And those floors don't get post-ops either. We get jealous of that. A lot of the nurses on the floor stay because the manager is truly exceptional and also like everyone there says, if you can make it there you can make it anywhere. Our manager says we won't have to check off our charts if we wanna take six patients all day but I think from 3-7 when we have six patients, maybe the charge nurse SHOULD be checking off orders if she can.

I just hope my next job is better than this...I don't even know what to look for. I am so lucky I have a good manager and if it wasn't for her I know I would have went somewhere else in a heartbeat.

nurse2033, MSN, RN · Nov 4, 2010

You sound like you are pretty seriously organized and conscientious. Like many others on this site you are getting worked, hard. And we all are getting buried by all the responsibilities that keep getting piled on more and more, like that video. Give yourself a break. This is floor nursing. Since you are moving, I would just do your best and get through this period. When you look for a new job screen employers by asking about their patient ratios. A specialty area may give you the ability to focus more on patient care, again it depends on the hospital. I'm guessing that other nurses on your floor either sacrifice customer service or are taking other shortcuts to get through their shift. This is a natural, unfortunate consequence of what I think is poor management. That you are so concerned shows your heart is in the right place. It's not you, it's them, do your best and allow yourself to be not perfect. Best of luck.

sistasoul · Nov 4, 2010

Same as always,

You poor thing you. I can feel the stress in your post. I would just try to stick it out. If this is a floor that is known for being busy you are doing well by only getting out less than an hour late. I have time management problems too because I talk too much to the patients and help them to the bathroom, etc. I am always told to delegate more but I feel like it sends the wrong message to the patient if I have to tell them that I will send the LNA in when I am right there. Sometimes the aides are busy and the poor patient has to use the bathroom.

I guess this is how healthcare is on the floors. Barely enough time to assess and give meds and then get out of the room. The art of nursing you learn so much about in NS is not possible because of the bottom line. I am a bedside nurse and I really enjoy that aspect of being a nurse. I love hands on care and makeing my patients feel like they are cared about. Because of all the paperwork, charting, and other crazy tasks we must do there is little time left over for bedside nursing.

You sound like a great nurse. It is not you it is the system. Hang in there. I think your manager just wants to talk to you about ways to make your day go smoother.

SlightlyMental_RN · Nov 4, 2010

I agree--the charge nurse should (if at all possible) be checking off new orders. That way, you only need to see that there is a NEW designation on your list. Honestly, even though you only have 4 months left, if you have a current opportunity to transfer within your hospital, I would take it. That floor sounds like a nightmare...and way too much like the "Floor of Nursing-doom" from my old hospital.

sameasalways, ASN, RN · Nov 4, 2010

You really made me feel better. I think my managers email freaked me out a little. It's scary in today's economy :-(

I really never wanted to have to rush in a pt's room and try to evade their questions or concerns and I don't want to do things unsafely. There are things people do at work to take shortcuts..I am only beginning to see some of them... as in:

*not flushing IV's, but documenting you did, and then they clot up and the next nurse comes on shift and has to re-start it

*removing the catheter after 3 pm so that the night nurse has to ensure the pt voids

*Pushing recall for assessments you never made

*Not checking NG placement

*Not noting how much output the pt REALLY had from their NG or wound vac, ect.

*not listening to bowel sounds

*not checking how long it has been since last BM

*not doing heparin flushes after medication adminsitration through PICC or CVL

I say these things because I have seen it happen. One nurse takes the flushes and does them but she uses the same flush for every patient and keeps it in the drawer so she can keep using it.

I really don't feel safe not doing those things..but I know people do them. I think they just make up some of the admission question answers too (religious preference for example or living will), or they document that they showed the fall video when they really didn't. When a patient says no one has opened their abdominal binder since coming to the floor it angers me...on the other hand, it is evident to me that somehow I must speed up

To be honest...after doing my job, I am so scared to ever have to go to the hospital..(as a patient).

sameasalways, ASN, RN · Nov 4, 2010

Thank you so much for your feedback everyone..because people who are not nurses don't understand. I still consider myself "new" and have lots to learn..as a patient a few times in the past I always respected the nurse because I knew she saw me way more often than the dr and knew what was really going on with me..and thankfully most of my patients are the same way. I feel so much better now.

SlightlyMental_RN · Nov 4, 2010

One nurse takes the flushes and does them but she uses the same flush for every patient and keeps it in the drawer so she can keep using it.

I found this really disturbing! That is one incredibly awful infection control issue. Seriously, it makes my skin crawl.

AprilRNurse · Nov 4, 2010

Wow- I'm sure you want to keep your job but it exhausted me to read your post. The reason you can't get out on time? Because you're having 7 patient's in a shift! I can't imagine that- though I know it happens. We rarely have 7 patient's on night shift.. WITH an LPN helping. (we do team nursing) That's only if someone called in sick or something.

7 patient's, minus what you're SUPPOSED to have to breaks ... only equals about an hour per patient AND charting on them. How is anyone supposed to get that done? Our day shift nurses only get 3-4 patient's alone... or 5-6 with an LPN. (LPN does cares, oral meds, toileting...) RN does assessments, careplans, IV meds...

I don't think it's a time management issue...it's a safety issue.

86toronado, BSN, RN · Nov 4, 2010

It sounds like you are doing everything you should be. If I were you I would tell my NM that you need more support from your team if she wants you getting out on time. You need a charge nurse who is more fair with giving assignments, and if this charge nurse doesn't have her own assignment (which is what it sounds like) then she should be helping the rest of you out by taking off orders, assisting with admissions, etc. Also, I would hand my pager over to the night shift, or back to that secretary at 1915. The night shift is there, and has taken over care of the patients at that point. Don't forget that you are the RN, and don't be afraid to put someone who is supposed to be your subordinate in her place.

As far as looking for a new job... at this point, it wouldn't be fair to a new facility, or even another floor in your facility to train you just for a couple months. I would suggest trying night shift on your floor, since they tend to not have all of the interruptions that dayshift gets. But whatever you end up doing, when you start interviewing for jobs once you move you'll be able to say "I worked on the busiest floor in the hospital, and I held my own." That could be worth the aggravation of staying on for a few more months!