Orientation, Time Management & Brain Sheets

[FinallyRNStatus, BSN]

Hi fellow nurses:

I'm a new grad about ready to complete a 9 week orientation on a tele unit. I'm really struggling with time management.

First I was orienting 5 weeks on days (-1.5 weeks for hospital orientation/classes). My day preceptor expected me to manage 5 patients from day one with little mentoring/guidance except on things I've never seen before (ie chest tube). To be fair, I did complete 5 weeks worth of preceptor shifts on the same unit as a student nurse, so maybe she had high expectations for me. She was never around to answer questions, I would have to hunt her down. Her approach was more or less "sink or swim". If I was busy and forgot to give a med or implement a new order, she taught me by watching me fail miserably and telling me she hoped I learned my lesson. This added a lot of stress to learning my role as a RN. It is a very fast-paced tele floor. Med-surg RN floats use to 6-7 patient load, say they dread coming to our unit because they get their "booty kicked". I've always known time-management was an issue for me, but I never figured out how to improve in my weak areas. I could barely stay afloat managing 5 patients on day shift orientation, especially when you throw in a discharges and admissions, but I was always overwhelmed and behind. Basically I felt like I was completely on my own for the whole 5 weeks of day shift orientation.

My day preceptor never helped me implement reading recent doctors notes, delegate to the CNA's, check on pending labs or call on labs that should be ordered, or give change of shift report. A couple times I attempted to give shift report on a pt only she had received report on or admitted; I was lost, obviously. Towards the end I finally gave shift report, but I was so busy on days I was clueless on what to focus on. All I knew was what the pt was admitted for, chief complaint and system assessment. Since I NEVER got a chance to read doctor's notes or assess the trending labs/ tests, I was always completely clueless about what the plan was for the patient unless the night nurse mentioned it and there were no updates.

I was suppose to have 2 weeks on nights, but once I switched I became completely overwhelmed with all the new information and they gave me an extra week. I felt like my night preceptor had to catch me up to speed on everything I didn't learn the last 5 weeks on days!!! I was really slow with assessments, and multi-tasking while in the patients room. Thanks from some excellent tips from my night preceptor, now I can assess most patients in under 5min and with the easy patient's complete assessment/medpass in under 15min/per patient. It's the other 1-2 time-consuming patients that hang me up which I try to save for last. (ie 1:1 patient; confused, agitated non-adherent patient; angry demanding IV drug abuser; chatty cathy; non-english speaking; patient with 8 wounds). The hospital I'm in has a large population of repeat admission IV drug abusers that are usually demanding and very difficult.

Currently, I've been slow to figure out the "night nurse routine" (ie chart checks???) and it takes me 1.5-2hr to: read at doctor's notes for the last 2 days, assess/sign tele strips, write nurse notes with average of 6-12 problems for 5 patients. All the night RN's say it is the most time-consuming part of the shift, but I'm sure it takes me at least 30-45min longer to write nurse notes. Other than learning to write faster notes, I don't know what I can do to save time.

Because I was so overwhelmed with information, I've found using a brain sheet very helpful to organize myself and have a list of my main tasks, priorities, new orders, documentation,assessments, VS. My employer is not happy with my time-management because I've been clocking out 30-45min late all through my orientation and is worried I'm not ready despite extra time they have given me. I feel safe and ready, but haven't been able to save myself an extra hour d/t RRT's on 2/3's of every night shift I've had.

However, my current preceptor keeps encouraging me to stop filling out my brain sheet at the beginning of my shift. She says it is a "time waster" However a majority of the information I write on it is comes from shift report, new orders, VS, abnorms from pt. assessment. I maybe spend 5-10 minutes reviewing my orders/careplans and filling in pt times meds are due, diet, name/room# to keep me organized. She writes much of the same information on her 5 printed patient care plans, so I don't understand why it is a "time waster" for me and not for her to write notes to stay organized. Does anyone else feel filling out brain sheets are wasted time? Am I missing something here? I feel it helps me be: more organized+group tasks+decrease amt of time sifting for pt info = time efficient.

Any advice about brain sheets or helping me with time management would be much appreciated.

[jadelpn, LPN, EMT-B]

If time management is your issue, brain sheets are a lifesaver. If you can print out a general plan of care for each patient, do so, and highlight what you need to, red pen orders by folding the paper. This would save time as far as making out a new one each time. For continuity of care I am assuming that you have the same patient for a couple of days? When you review your orders at the beginning of the shift, each time you have the same patient, use a different color pen, use the same brain sheet. (ie: Mondays are green pen day, Tuesday is blue, Wed is black, Thurs....you get what I mean)

You will get faster as time goes on. Chart checking and such becomes easier as you get your flow. And you will. Much like you have fine tuned your assessments. And be sure that you chart as you go. Don't save charting until the end of the shift. You can just do it as you see it, and move on, then back and down the line for your PM meds. Make note of any labs that need to happen early a.m., finger sticks, whatever. If bells ring, delegate the CNA to answer them so you can concentrate on your chart audits.

It is fine for a more experienced nurse to have opinions on how to manage a patient load. But with a high patient ratio, you need to have some sort of brain to keep it all clear. That your preceptor does not is her issue/practice.

Another thought is to make a template on your computer and type in general patient information, and the like. Add "odd" medication times, labs whatever. You could fit all of your patients on one sheet, fold over to make notes, and just add to it daily.

You will get your groove, best wishes!

[mmc51264, BSN, MSN, RN]

I use a brain sheet for shift report and important needs for my shift. I am not sure what EMR you use, but ours has a work list tab that will tell me what is due each hour. I can do it by individual pt or for all my patients by time due. I usually don't print that one out because we have computers in each room, but it really helps me.

[Rebel Nurse]

I'm newly orienting to a cardiac/oncology floor, and I completely understand how overwhelmed you feel! We can get up to 6 patients, and people say it's one of the toughest/most fast paced floors in the hospital. I can't imagine having 7 patients on day shift!!

That said, I made a brain sheet that I make copies of for every shift, and it's the only way I keep track of anything! My coworkers actually think it's a really good idea, and many say they used similar tools when they were first starting out. It's really too bad that your preceptor can't see the value of organizing your shift in advance, especially when you say she takes notes, too. Have you tried coming in early to fill out your brain sheet and research your patients? Our shifts start at 7, but even some of the most experienced nurses show up by 6:30 to organize their day, so that's what I do, too (and it still never feels like enough time, but it does help!).

Good luck, fellow newbie.

[thenightnurse456]

I am a night nurse. When I used to work on the floor I would:

1. Receive report and proceed to do walking rounds to introduce myself to my patients. This gave me a quick opportunity to do a quick room assessment . Ie: patient A's fluids are nearly empty, when I come back to do my head to toe, I'll bring a fresh bag. Patient B requested pain meds, I'll bring them back when I do my head to toe. The walking rounds help you prioritise your care.

2. Head to toe assessment. This is something you will get faster with as time goes on. During my head to toe I would inform them of the plan for the night. This is most important to night shift as you can tell them approximately the amount of times you need to wake them during the night. Chart as I go.

3. Medicate. Wound care. Rinse and repeat. Chart as I go.

4. Settle my patients. We never had techs so I would always make sure I offered hygiene care and a cup of tea. Fluff and buff. Really noticed a difference in amount of call lights when everyone was tucked in nicely.

5. Complete my brain for the rest of the night. When meds/IV are due. Pressure care. Etc etc.

6. Night shift chart check. Check charts, red line. It takes time! You'll get faster.

7. Hourly round. It's tedious but can work well.

8. Put out fires.

My biggest tip on nights is to cluster your care when safe and legal. It saves so much time and your patients won't have to be woken every 5 minutes.

[FinallyRNStatus, BSN]

Thank you for all your feedback and valuable input. I appreciate having some nurses understand why I want to use a brain sheet and not look at me like I have two heads!

I actually was let go because I could not improve my time management in time before my 8 week orientation shift ended. On one of my last shifts I had 2 patients with an RRT!!! I was like S*** ... I give up. I was trying so hard but every shift I had an RRT and just could not finish my Pie notes/documentation fast enough to make up for that lost time.

I think if I had the the night preceptor the whole orientation I would have been ready to start on my own. Her teaching style was more hands on with a lot of feedback and worked better to help me learn and improve in my weaker areas.

[Rebel Nurse]

That's too bad I hope you find a new job that you enjoy more.

[FinallyRNStatus, BSN]

Thank you Rebel Nurse! I chalk it up as experience to get me to where I need to be, hopefully at a place I like more! I would love to be in the ICU actually. We'll see what doors open and what is meant to be will work out.

Jade RN - thank you for suggestions about different day, different pen color. I like that. Some patients I did see on several days. Generally I was too busy to document everything as I went, but I did as much as I could document in the room. Written pie notes were really the largest time killer.

mmc51264 - I too like using the worklist manager. Ours only shows medications or IV flushes which helps keep me on track with those; can they be set up to show other tasks too?

thenightnurse456 - so many helpful tips thank you! I like doing a quick walking round to to check in on the patients and do a quick eye-ball assessment and see if they need fluids/pain/PRN meds as well. I noticed this helped me make less trips and could be done in under 10mins too. I was beginning to cluster my care better towards the end. I'll have to try the other tips on such as tucking in patients at my next job! Wow no techs!!! My it must have been busy, how many patients did you have?