Advice For Workflow Routine

[studog12, BSN]

Hey, everyone. I’ll try to keep this as brief as I can so as not to exhaust readers.

So, I am a PCU nurse with about 5 years of experience, and at this point I feel pretty confident in my clinical skills and the knowledge I’ve acquired (though I know there is always tons more to learn). The issue I am having is my workflow, in that I worry I am too slow or over analyzing things. My routine goes something like this on a “regular” night: Get report, look at the MAR and orders to see if something was missed throughout the day that needs to be immediately followed up on. Or if there is, say, a q 6 or 8 hour antibiotic due soon that needs to be brought in with my first assessment. I then complete all of my assessments and return to the computer to write down which patients have AM labs, review the patient’s lab results (sometimes from admission to current date if it’s not too much, in order to look at trends and get a better overall clinical picture), check micro for cultures as applicable, and then vitals to note which meds to hold or question, as applicable. I also fill in anything I didn’t receive in report, like history, consults, bed status, etc. I then begin my med pass as normal. The thing is, I always seem to be behind other nurses. But, I don’t know if that is because I over analyze things or if they don’t look at orders and labs and other important details. I can’t tell you how many times I have caught orders that were missed that would have been caught had the patient been reviewed thoroughly and systematically. That’s not to toot my own horn, and I don’t ask annoying and petty questions during report—it’s just pointing out that even though I am slower in my routine, I think it’s because I am being conscientious and trying to do a good job. But I wonder if others are doing what I’m doing and doing it faster, or if they’re not checking all they should.

In light of the aforementioned, do you all get the perception I am taking too long? For the most part, I am able to give meds and see patients on time, prioritize seeing sicker patients first, at least lay eyes on them during report, and keep up with things (at least on night shift…ha.). But, when I was training in the past, I got the impression from my preceptors sometimes that I was taking too long (granted, I was newer then). More recently, when I was “up training” for ICU to help out during the height of COVID last year, I still got that sense sometimes from the ICU nurses I trained with. I am acutely aware the floor or unit moves very quickly at times, and that you never know when sh** is going to hit the fan. But I also hate not knowing what’s going on with my patients and feel an urgency to fill in missing details from a bad bedside handover, say, or when getting an admission right before shift change. I am also aware you have to use your clinical judgment and prioritize patient care and safety, so that may mean dealing with a sick patient all or most of a shift with an incomplete report or clinical picture due to lack of time to review properly.

All that to say, do you all have any suggestions about what I can do to improve my current routine? Do you have a similar routine? How do you all balance the need to have solid information and prioritizing patient care and safety? 

I really appreciate your time. A part of me has the ICU bug and would like to give it a shot, but even though I have five years of experience and feel confident in my clinical knowledge and ability, I don’t feel particularly confident in my routine and don’t want to run into problems with it if I were to transfer to ICU. As you all know, even though details matter and ICU nurses tend to be on top of things, stuff can happen very fast and you don’t want to get too far behind and overwhelmed. 

Thanks again and hope you all are well where you are.

Sincerely, 

Ethan

[Caroline Keith]

Your intuition to be thorough is amazing, and KEEP IT UP. There are way too many times coming on shift that we get busy or distracted, and there's a ton of pressure to just go-go-go. Being that thorough is SAFE. I found myself in the same situation in PCU, sometimes, because I hated feeling like everything is just task-task-task and you don't get the chance to sit down and get the whole picture. That's fine with med/surg tbh and lower acuity PCU, but mid to high-acuity PCU is tough. That's why I DID transfer to ICU. I'm literally paid to take my time and research EVERYTHING, because it all matters. When I first started ICU I freaked out about giving things late or falling behind, but SAFETY comes first. Every thought I have in my shift is safety--first thing I do when I go into a room is ask, Do I have my ABCs (airway, breathing, circulation)? Do I have oxygen, an ambubag, suction, and a WORKING IV access? Are my gtts all running/properly programmed/compatible? Do I have an emergency chest tube kit/clamps in my room w/ a CT? Yeah, sorry my Senna is late, but I made sure the patient isn't gonna die. 

I also struggled a little initially in ICU because I was slower. Just give yourself grace, it's a tough specialty. Communicate clearly your learning style, your potential weaknesses, and especially your strengths, because they will help you overcome those weaknesses. You'll slowly find your groove and a system that works for you. Good luck!

[studog12, BSN]

9 minutes ago, Caroline Keith said:

Your intuition to be thorough is amazing, and KEEP IT UP. There are way too many times coming on shift that we get busy or distracted, and there's a ton of pressure to just go-go-go. Being that thorough is SAFE. I found myself in the same situation in PCU, sometimes, because I hated feeling like everything is just task-task-task and you don't get the chance to sit down and get the whole picture. That's fine with med/surg tbh and lower acuity PCU, but mid to high-acuity PCU is tough. That's why I DID transfer to ICU. I'm literally paid to take my time and research EVERYTHING, because it all matters. When I first started ICU I freaked out about giving things late or falling behind, but SAFETY comes first. Every thought I have in my shift is safety--first thing I do when I go into a room is ask, Do I have my ABCs (airway, breathing, circulation)? Do I have oxygen, an ambubag, suction, and a WORKING IV access? Are my gtts all running/properly programmed/compatible? Do I have an emergency chest tube kit/clamps in my room w/ a CT? Yeah, sorry my Senna is late, but I made sure the patient isn't gonna die. 

I also struggled a little initially in ICU because I was slower. Just give yourself grace, it's a tough specialty. Communicate clearly your learning style, your potential weaknesses, and especially your strengths, because they will help you overcome those weaknesses. You'll slowly find your groove and a system that works for you. Good luck!

Hey Caroline, 

Thanks so much for your thoughtful and encouraging response. It means a lot to be recognized for being safe by being thorough, as often times speed and the revolving door business mentality is what seems to dominate hospital life, too often at the expense of safety. Even though I am experienced, sometimes I wish I could just be a fly on the wall to observe and learn how other good nurses do things so I myself can be better. You can always ask (like I do on here), but it can be a little awkward to ask about routines in person, particularly if you’re more experienced (“Why is he asking about such a basic question? Doesn’t he have a good and efficient routine by now?”).

I think you are spot on about communicating strengths and weaknesses, especially with preceptors when moving to a new speciality. I try to be as aware as I can of my own and be open to suggestions from anyone, experienced or new, that can make me better. And I think when you’re in training mode and you have different preceptors with different styles and pet peeves, I’ve gathered that your own habits and preferences can clash (for lack of a better term) with theirs. Consequently, just trying to be open and humble by listening and even adapting temporarily to their suggestions so as to not create tension in the relationship, even if you disagree, is a wise thing to do. And as everybody says, one you’re out on your own, you can establish your own flow and do what you think is right. 

Thanks again for sharing your experience. All the best to you during this very difficult time for nurses…

Sincerely,

Ethan 

 

 

[LovingLife123]

I can give some insight to my routine.  I get report, look at orders, then labs, then Emar. Reviewing the charts takes me about 20 minutes.  I then pull my meds for 0800, and 0900.  I pass meds and do my assessments while doing initial rounds with docs.  Providing everything goes the way it should, I’m sitting down to chart by 0930.  
 

There’s always little hiccups here and there.  And some days are a cluster, but, if I can get myself all charted by 10:30, the rest of my day is good.  I will then get my 1000 meds passed by 11.  I get my 0900 meds passed early but get my 1000 done closer to 11, so I’m still not late, but gives me time to chart.  
 

I've been doing ICU for a long time now, so my routine is pretty down.  I’ve learned for the most part everything hits the fan around 1400.  Things build up in the ED, floors finally start giving us beds for transfers to get those ED patients up, so I really like to get as much as possible done early.  

[studog12, BSN]

Thanks, @LovingLife123. Really appreciate your input, and it’s good to know you take the time to look things up and have a good baseline before you start your day, too. It seems like taking the extra time to look things up, as time and the flow of the day permit, is always the safest thing to do. It helps prevent errors down the road.
 

Thanks again! 

Ethan 

[0.9%NormalSarah, BSN, RN]

I don’t think you’re too slow if you’re getting things done on time. I’ll say that maybe you could spend slightly less time initially reviewing the entire chart so you can get assessments and meds done on the early side, but that’s nitpicky. As for your other coworkers, my money is on the chance they aren’t as thorough as you. You sound like an ICU nurse ?.

[studog12, BSN]

Hey @0.9%NormalSarah,

Good tip. I’m trying to take the approach of getting the important details I don’t get in report right after report and then get going to be as efficient as possible with patient care. Afterward, if I have time, I then can dig more, read notes, etc. 

Thanks for ICU reference. I guess I kind of have the brain of one, just not necessarily the desire for the adrenaline rush. Ha. 
 

Appreciate your comment!