Question about time management

[dinobiceps, ASN, BSN, RN]

I work on a med surg floor. It is the designated COVID floor and usually only has a handful of COVID patients, probably around 5 max (including rule outs and unconfirmed positives). We also have tons of other precaution patients because we already have the PPE on the unit. A typical patient assignment is 5-7 patients, with 7 becoming more and more common. I find that precaution patients take up a large chunk of time, like I can spend around 15-30 minutes for a regular patient and sometimes an hour for a total care patient just passing nine o clock meds (I'm including gathering meds and equipment outside the room as part of this time). I just feel like I'm never able to get my meds passed in time. I'm often still passing nine o clock meds at eleven. It stresses me out, but at the same time when you have to assess a patient, crush meds and feed them to the patient, empty an ostomy, empty a Foley, do a dressing change and check blood sugar and vitals on an ESBL patient (we usually do not have a tech on the floor)... it just takes a lot time. So am I doing something wrong? And is it just me?

[JKL33]

7 patients with no tech?

Things are going to get done when they get done.

If 1) you feel that you are able to maintain your patients' safety and 2) your superiors are not disciplining or unfairly critiquing your performance, then this situation is tolerable (IMO). Prioritize carefully, including having a good understanding of the differences between patients' needs and employers' preferences (fantasies).

On the other hand, if you have patients that are not that stable and their safety is at risk due to your facility's inability to provide nursing surveillance of patient conditions or if your superiors are constantly critiquing nurses and making people feel poorly for not being able to accomplish impossible goals, then it would be time to think about whether there is a better place to work.

Make sure that you are working quickly when in rooms and in general not dilly-dallying while in there. I will say that an hour sounds like a long time in a room although I am fully aware of how time passes when patients need multiple things. Also think about whether it would be better to not provide total care at med pass time--but then the problem would be more time wasted getting ready for a second trip into the room. I just think that overall an hour is a long time to not be aware of anything else going on with any other patient. 

Good luck working this out. It'll probably be okay if you aren't dealing with one of the two exceptions I first mentioned.

 

[RNNPICU, BSN, RN]

Perhaps startyour 9am med pass around 8:30. You can do some assessments early, also think about the length of time it takes to give meds. For the patients that you can be in and out quickly perhaps could be done last. PO or Gtube meds fairly easy and should not take an hour, meds that require IV 5, 15, or 30 minutes a little easier,

Try to think about who to see first as a triage, what may take a long time. 

[walkingon, CNA, LPN]

JKL33, I feel really dumb asking this, but could you expound on the difference between patient’s (in my case, resident’s) needs and employer’s preferences/fantasies?  Something inside really took notice of that statement and made me realize I have a hard time separating the two.  I’m often the only day shift nurse with a QMA and 3 or 4 CNAs for 36 - 39 residents so any kind of direction on time management is helpful as the comments above.  

[JKL33]

10 minutes ago, walkingon said:

JKL33, I feel really dumb asking this, but could you expound on the difference between patient’s (in my case, resident’s) needs and employer’s preferences/fantasies?  Something inside really took notice of that statement and made me realize I have a hard time separating the two.  I’m often the only day shift nurse with a QMA and 3 or 4 CNAs for 36 - 39 residents so any kind of direction on time management is helpful as the comments above.  

Sure, but understand this is my unauthorized opinion only:

I suppose it goes as a little algorithm in my mind: 1) Is it directly related to my patient's well-being or my ability to preserve/maintain/improve their well-being? If yes, do it; prioritize it. If no, then: Is it related to a major matter of law? If yes, comply. If no, then: Is it a major matter of ethics? If yes, stay within ethical bounds. If no, then: Is it a major dereliction of my duties as an employee? Or is it more like something that my employer pretends I should be able to do while they provide inadequate resources to accomplish it?

This works pretty good for me; I naturally prioritize in this general way. I am there to take care of patients and to prioritize things that can be expected to directly/tangibly affect the health and well-being of this particular patient (or group of patients) for whom I am responsible.

This leaves a whole bunch of things that are not my top priority, including some things that....well, it would be nice if I could prioritize them but others will need to cooperate by providing resources if it's that important.

For example, if I were in LTC I would rather pass meds, perform treatments and assess patients carefully, communicate well about their care plans and keep their families well-informed, than do a crappy job at all of that so that I had time to audit others' work, fill out papers, take out the trash, etc.

Some nurses would hear some of the things I've had to deprioritize at times and take umbrage. I can't do anything about it. I'm neither slow nor incompetent. My POV is simply that if we provide crappy direct patient care then there's no point in the bedside nursing role. Anyone can audit, anyone can ask screening questions, anyone can take out the trash, anyone can file papers, and lots of people can rush around trying to meet metrics while not actually taking care of anyone. And I just have no intention of working that way.

[walkingon, CNA, LPN]

Thank you so much for this!  I actually made a paper with these bullet points and taped it to my clipboard for referral to make this train of thought a habit.  Already knew this as well, but the biggest time-suck I face is having to answer the facility phone throughout my shift.  We don’t have a receptionist nor voice mail and the nurses are expected to answer the phone, take messages and run the portable phone to residents when their families want to talk.  Not sure how to prioritize around that.

[JKL33]

35 minutes ago, walkingon said:

 Not sure how to prioritize around that.

There was another recent post where an inpatient charge nurse was talking about having to answer multiple phone calls (that was the gist of it if I recall). I think the general consensus there was that the phone would have to ring.

That's what I meant above when I said that sometimes, some of the things that would ideally never be de-prioritized will have to be if there simply aren't enough resources. I would not continually interrupt ongoing patient care or important duties like med passes to answer the phone. If it's that important someone else is going to have to cooperate. At the very least there is no excuse for the nurse to not be able to have the phone on their person (and even that isn't great compared to having someone responsible for clerical duties).

 

[SpaceCowgirl, BSN]

I *always* let the phone ring and ring and ring when we don't have a secretary ... When enough people complain that the phone isn't getting answered, then they'll get us a secretary! If my manager ever complains to me that we should be more diligent about the phone, I will gladly whip out an itemized list of my responsibilities and ask her which of those she would like me to forfeit in favor of phone duty.

[Hannahbanana, BSN, MSN]

On 11/2/2020 at 8:50 PM, walkingon said:

 Already knew this as well, but the biggest time-suck I face is having to answer the facility phone throughout my shift.  We don’t have a receptionist nor voice mail and the nurses are expected to answer the phone, take messages and run the portable phone to residents when their families want to talk.  Not sure how to prioritize around that.

Don’t answer the phone as a priority over the excellent list JKL gave you. I like the, “And then what?” approach to decision making in a case like that. For example:

We don’t have desk help and are supposed to answer the phones. I don’t have time to be answering the phone. I don’t want to leave my patients to do that, it messes up my whole plan of the day for care.

And then what?

It will ring and ring.

And then what?

The callers will be mad.

And then what?

They’ll complain to management OR The families will complain to us or management.

And then what?

Management /families will come down on us.

And then what?

We’ll tell them if it’s a choice between patient care / meeting patient needs and a secretarial chore, nurses must prioritize patient needs. What would they prefer us to do?

And then what?

They will stop, think, and eventually come to the idea that a damn unit secretary is the solution. 

This approach takes a little time. But if you are patient enough to see the conversation through, the natural connection of fault and the solution reveals itself, all the more powerfully because it doesn’t have to come from looking like you’re whining and dodging something that’s “your responsibility.” 
 

Good luck!

[walkingon, CNA, LPN]

Thank you for that useful comment!  No sarcasm intended at all.  We did, very recently, get a new phone system with a phone tree and voice mail that automatically routes the calls to the appropriate staff (mostly), and that’s solved about 75% of the problem.  I’m now using the “and then what” approach to answer the calls that still come through, because I do truly need to take some of them, but still waiting for management to complain about it so I can ask about how I’m to prioritize.  

[rac1, ASN, BSN, RN]

On 10/15/2020 at 11:50 AM, RNNPICU said:

Perhaps startyour 9am med pass around 8:30. You can do some assessments early, also think about the length of time it takes to give meds. For the patients that you can be in and out quickly perhaps could be done last. PO or Gtube meds fairly easy and should not take an hour, meds that require IV 5, 15, or 30 minutes a little easier,

Try to think about who to see first as a triage, what may take a long time. 

EDIT: HA - just saw the date this was asked - a day late a dollar short - sharing my response anyway - but now you know I was really late with med passes. ? 

 

I'd be starting my 9am meds at 8am with that many patients. And I would be in the room already, finished with my assessment, meds scanned and passed BY 8am. Every place I've worked allows for meds to be passed an hour early. And on busy units with 5 patients I've been passing meds at 11 still.

 

Make sure you're doing bedside report so you can assess the situation you're walking into - we are doing 12 things at once as nurses right? Bedside report really is advantageous to you for your first assessment of the patient and the situation you're walking into. You can look at the room and see what you need to bring - does the patient have water for meds, blankets, is the continuous fluids almost empty? Ask them specifically what they need you to bring to the room when you come back - this stops them from calling you too - then write it on your report sheet and bring everything to their room at once so you aren't running for things to get them settled. This is a first look at who your needy patients are - the ones who talk a lot, or are very sick. You can tell your talky patients you'll be back soon with all their requests (they always request!), but go to their room last so you can spend the extra minute letting them talk - it'll save you time during the shift because they'll feel heard and will hopefully be less needy. I hardly ever answer my phone when I'm in a patient room - unless I'm charting and not engaging with the patient at the time. What did we do before phones? If it's an emergency you'll know. Always start earlier than you think you should. I would save total cares, wound cares and complicated patient research (chart review stuff I mean) for AFTER first med pass is complete. Just go in assess and get first med pass done. Then go back and do your major stuff.

When you have 7 patients are you getting low acuity patients with minor/no meds, ready to d/c in the mix (I hope so?!) - go see them first and assess and be done, and on to the next - or at bedside report tell them since they have no meds you're going to see some other patients first, ask if they need anything before that so you can take care of them, and then see them last.

If you don't have low acuity patients in your mix of 7 patients - maybe it's a charge nurse assigning issue? Or you just have really sick patients on your unit?

Again - when I was on a very busy unit with 5-6 patients It was 11 and after plenty of times when I was doing first med pass. Ask for help when you need it. If you don't have it maybe you need to find a better team (it makes all the difference) to work for. Sitting down to chart really well at 3-4 was normal for us.