How to be faster/more efficient?

  1. 0
    I have been working sub acute rehab for a year now. I carry 12-15 patients, generally 14 on any given day. I have an 8 hour shift and work 6-2:30 but NEVER leave on time. Today I was called to come in and fill in holes on the pain documentation. We have to sign out the narc on the narc sheet, sign it out on the back of the MAR sheet, initial it on the front of the MAR sheet, complete the pain flow sheet and document it's effectiveness on said flow sheet and in our nursing notes. Needless to say the process is cumbersome. There's always SOMEWHERE that I miss, but I just flat out do not have time to double check every single pain med given to make sure I filled in every spot. I'm working hard to get there but right now there's undoubtably something I've missed somewhere. I can say for certain the med is always signed out on the narc sheet and documented in my nursing notes as given and the effectiveness.

    If I'm lucky I can get report and hit the floor at 6:30am. I do my treatments then and then start on my 8am meds. But I never, ever, ever finish passing my morning meds before 10:30am. I then try and chart on a few patients and inhale some food before starting to get blood sugars and passing my noon meds. The noon meds predictably run into the 2pm meds, along with trying to cram in the random treatments I didn't get at 6:30am for one reason or another. Throw in a change of condition and it's all out the window. I generally give report at 2pm and then chart for an hour after my shift is over. I am not that far off the other nurses on my unit, but some of them do seem to do a better job with time management.

    I'll be honest, I have tried prepouring. But I don't find it to be a huge time saver. I keep my OTCs in alphabetical order so I never have to search for something. All my breathing tx are clearly labeled to save time from pulling 4 different advairs out to find Mr Smiths. But just about every patient is on 9+ meds and many need a BP monitored before giving meds. Part of my problem may be customer service related. If I know that someone likes to sleep in or take their meds after breakfast, I always respect that desire. Time wise it would probably be easier to just go room to room and person to person and give them all their meds right away.

    I need some suggestions from experienced nurses on how to streamline things and make it all faster.

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  2. 16 Comments...

  3. 14
    It sounds like you are already doing a lot of what you can. I've been doing first shift (7-3:30 in my case) for a few years now and I still can't get out on time most days.

    I have decided this job is a set up. It is not physically possible to do fifteen BPS, all the meds, all the treatments, all the documentation (and the documentation of one thing in five places...), all the accuchecks and insulins, the wound vacs and IVs, the resp. treatments...at any given time I usually have wound vacs and at least one trache, at least a couple G-tubes. There's also doing at least a bare-bones focused assesment...in addition to shoveling in pills I kind of like to do that AP for BP meds as ordered, listen to the lungs, check the dressings/casts/splints, check for CMS if needed, properly assess the IV sites q 2 hrs, check bowel sounds, check for edema, check for skin breakdown.

    Plus the family members, admissions and discharges and room changes (non-stop in my facility).

    So this is supposed to be possible to complete, perfectly, in 8 hrs, and of course there should be no problem taking a half hour lunch and we should be able to punch out on time easy peasy. If we can't we have poor time management.

    I have seen that for most something has gotta give. Shortcuts upon shortcuts that get more and more questionable and dangerous become standard operating procedure while everyone pretends that everyone is doing things the right way. Management has to know that it isn't physically possible most days to do 12 hrs or more worth of work in 8 hrs but we all just pretend it is and if we can't we blame it on the nurses' poor time management.
    MedChica, bethann27, lesliel, and 11 others like this.
  4. 0
    I don't have experience, but I have worked in a nursing home and I can tell you that many nurses are facing similar situations when they have a large patient load. In the nursing home where I worked, one nurse did treatments and certain meds (nebulizers, insulin and pain medication) for up to 30 patients. They also had to do assessments and handle emergencies as they came up. There was a lot of overtime. They did have CRMAs (med-certified CNAs) that passed standard medications. This is in Maine, and I'm not sure what your state allows for medication administration.

    Are other nurses on your unit having the same problem? Maybe you could talk with some of them about how to make the units run more efficiently. Perhaps the nurses as a whole need to talk with management about some extra staffing during the busiest times. It sounds like you have worked out a great system for organizing your care and the problem is that there are simply too many patients.

    It sounds like many of your patient have medications at different times. Is it possible to reschedule any of those medication times so you need to make fewer trips? For example, all once daily doses of medication can be given at 9am, unless contraindicated. Nebulizer treatments can be scheduled for when you usually give medications, so you don't have to make multiple trips. Also, plan ahead and try to gather all the supplies you might need before you enter a room. Anticipate problems- have an extra IV set, dressings, etc. handy so you don't need to run and get them. Delegate when you can and ask for help if you need it.

    It really sounds like your unit could benefit from some extra staff.
  5. 13
    Wow. Good luck to you! I am a floor nurse so I don't have that much work, thank goodness.

    However, I think you may have answered your own question. Apologize but tell your patients that to keep everyone safe you and happy you have to stick to stick to the schedule. It will also make it easier for your co-workers if everyone keeps the patients on the same schedule.

    Also, I've gotten REALLY, REALLY sick of being the ones that always suffer. It is unreasonable that managers and owners consistently expect nurses to live and work like animals. It's not right. I've gotten to the point that I try to file an incident report every shift short staffed to have IN WRITING that I made the managers aware, repeatedly, that we are short staffed. And I've begun to email my manager whenever I have a short staffed day and tell her how short staffed we were and that I didn't get lunch. I have twice been counselled about two policies I screwed up on in the last few weeks. My opinion, I was super short staffed. Had I not been working my tail off with an unsafe assignment, patients could die. So you know what? Staff the floor well. If you choose to staff terribly, I don't want to hear your hand-wringing about policy and protocols and MINOR policy issues. YOU SHOULD BE THANKING ME NOBODY DIED!


    To me, the worst part is that, on my floor, we're not allowed to tell the patients that we're short staffed. So I have to be like, "Sorry I kept you waiting forever. I was eating bon bons and watching TV."

    I'll probably get fired eventually. But I refuse to be treated like a beast of burden. Meanwhile the managers are getting paid vacation and 8% bonuses while the nurses and patients suffer.

    Forgive the rant!
    lesliel, bethann27, esperanzita, and 10 others like this.
  6. 7
    You are really just setting yourself up for an impossible ideal. I remember when I tried and tried to get done as early as some of the nurses that I worked with. They seemed to have everything done on time, have time to chat...etc. While I worked my tail off and never had a moment to take a pee break, much less eat or chat. Come to find out later, "shortcuts" were being used, that I would never consider. You will notice that usually, those folks that seem to be able to sit around a lot, aren't going to share their tips with you because they are not doing what they should be. Too much is expected of nurses. We can safely do only so much, and they always want more. That's why I now work in labor and delivery. Safety is much more valued there
  7. 0
    Ugh. I agree with everyone but this isn't much help. I've worked with the "done early" nurses. I can make a good guess at how they got done so early but frankly I can't do it. I also can't find another job. I've tried. For the most part I love my job. I love seeing such sick people admit and leave a few months later with a drastically improved quality of life. I love my coworkers and patients. But I'm genuinely scared that I am going to lose my job if I can't be faster.
  8. 0
    Good luck to you. I hope you find another job soon.
  9. 0
    Sounds to me like you are killing yourself. Agreed with above. Go out and find another job. Easier said than done, of course, but seriously, you are doing whatever you can and beyond, and when you leave, they will probably just hire two more people to replace you. They will never see how hard you are working, and obviously don't care too much about the care of their staff or patients. Protect yourself like you protect your patients.
  10. 6
    Sit down with the docs or the pharmacy consultants and see which of the multitude of medications can be discontinued...or given at a higher dose with a lower frequency, or given on 3-11, or...get rid of 98% of the blood pressure parameters. It makes no sense to have to check someone's blood pressure if you haven't had to hold the medication for a couple of weeks. I've seen people with parameters for meds that haven't changed in 3 years and haven't EVER been held. We aren't working in an ICU. Probably no one would suffer a bad outcome if their pills were 20 minutes late. In many states (not Massachusetts yet) meds are being written for "give in the morning" or "give before lunch". That way people can sleep late one day or not be bothered if they are in the middle of an activity to take a medication (they most likely don't really even need.)
    I've been in long term care since the days before you had to be certified to be a nurses' aide. I've thought of quitting on many occasions and actually did quit once for a few months. I'm not quite sure why I stay with it except that a good nurse in LTC is a treasure and you really can make a difference every day in someone's life.
    LockportRN, bethann27, esperanzita, and 3 others like this.
  11. 0
    Quote from CapeCodMermaid
    Sit down with the docs or the pharmacy consultants and see which of the multitude of medications can be discontinued...or given at a higher dose with a lower frequency, or given on 3-11, or...get rid of 98% of the blood pressure parameters. It makes no sense to have to check someone's blood pressure if you haven't had to hold the medication for a couple of weeks. I've seen people with parameters for meds that haven't changed in 3 years and haven't EVER been held. We aren't working in an ICU. Probably no one would suffer a bad outcome if their pills were 20 minutes late. In many states (not Massachusetts yet) meds are being written for "give in the morning" or "give before lunch". That way people can sleep late one day or not be bothered if they are in the middle of an activity to take a medication (they most likely don't really even need.)
    I've been in long term care since the days before you had to be certified to be a nurses' aide. I've thought of quitting on many occasions and actually did quit once for a few months. I'm not quite sure why I stay with it except that a good nurse in LTC is a treasure and you really can make a difference every day in someone's life.

    Those are good tips. My facility did come up with a policy regarding BPs and APs. We have to do them q shift for a week, at least daily and before any BP meds for a month, and then weekly thereafter. For the patients that do stay for more than a month that is helpful. I know it sounds beyond silly that knocking one or two BPs off a med pass could make me happy but honestly I'll take the five or ten minutes anywhere I can get it!

    I wish something could be done about the med situation. I think they've moved meds around on the LTC floors, but on subacute every q d med still gets written for 9 am unless it's specifically ordered for HS (like a sleeper, or sometimes simvastatin or an antidepressant). We also get all the inhalers and the lidoderm patches and eyedrops (again, I know I sound really petty but having all this stuff on the med pass in addition to all the pills is what really slows it down to a crawl...and I love having to apply a lidoderm patch or voltaren gel to the lower back of someone who is already fully dressed and up in their wheelchair by the time I get to them...).

    I know the DON at my facility is also trying to promote the docs reducing the number of accuchecks per day and working to control the blood sugar as much as possible basally, reducing the amt. of sliding scale insulin we have to give. ANY reduction in the insane amt. of accuchecks we do is helpful.


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