Struggling with time management - what am I missing?

[NewGradNurse3, BSN, RN]

I'm a new grad in my first RN job, I had a two month orientation and now I've been on my own for two months. I still always stay at least 30-45 mins late almost every day to finish charting, and once in a while I don't even have time to stop and eat lunch. And I feel guilty that I still don't have time to do everything that I truly want to be doing, like turning my patients q2 (I usually only have time to turn them twice during the whole shift) or doing proper assessments on my patients. I'm just wondering what I'm doing wrong or how to improve, and also how much of this is just a bigger systemic issue.

The hospital I work at is slated to close this Spring, so there was a mass exodus of staff (I think we probably lost about 50% of our staff). I work night shift in a medical medsurg/tele/stepdown unit with ventilators (we combined with the tele unit because there weren't enough staff for the unit to function). Most of our CNAs are nursing students in their first CNA job with no prior experience besides clinicals, but before that we'd often only have 1 CNA on night shift so we'd be primary for half of our patients. A lot of the nurses on night shift are brand new grads like me, and almost all of the experienced nurses are orienting more new grads.

On a regular night I usually have 5 patients, and one of them is a comatose, obtunded, trach to vent & g tube, complete care patient with stage 4 pressure ulcers on their sacrum - the kind of patient who is back and forth between the nursing home, stepdown and ICU. If I don't have a trach to vent, I have 6 patients. And if I have 4 patients, I usually get an admission.

I do all of the time management tricks I've learned - I make lists, prioritize, plan out my day, group care together. I do everything ahead of time that I possibly can. I don't take breaks or really stop to chitchat with anyone. When I do eat a lunch, I take about 20 minutes. But I still have virtually no down time during my shift and on a good day, just barely have time to get everything done. On a bad day, I don't eat lunch and stay an hour late to chart. 

I don't think I'm exceptionally slow. Some of these trach to vent patients are really heavy, with 3-4 different kinds of IV antibiotics, septic, tachy, comatose, on tube feeds, with lots of wounds. It just feels really hard to give the kind of care that these pateints need, and the care that all of my other patients need, while juggling time and tasks. I feel like, if I had the time and I really did everything I should, I could spend half of my shift just with my trach to vent patient. Right now I just prioritize but I don't always clean them up as quickly as I would like, and I don't turn them nearly as much as I should.

I feel like I only manage to get out on time when absolutely nothing goes wrong on my shift - when all I need to do is the routine stuff - and even then it feels like I have just enough time to get it all done. But any small little wrench like patients who use the call light a lot, or a dementia patient on bed alarm who keeps trying to get up, or someone having some change in status that requires interventions -- then it feels like I get so behind. God forbid I have a code or something, I don't know how I'd ever catch up.

I can't even imagine what working day shift is like. I oriented on days for the first month and it was much busier.

Am I missing something? How do I get faster/more efficient, and why does it feel so hard to get everything done that I'm supposed to?

[LibraNurse27, BSN, RN]

It sounds like you're doing everything right but that the job is hard. Also time management is always a challenge as a new nurse. I'm wondering if you're looking for another job since the hospital is closing, and if so what kind. Do you enjoy the type of job you currently have but just want to work on time management and hopefully find a hospital with better staffing? To me taking care of the comatose/trach to vent/G tube/pressure ulcer pts with no quality of life was really depressing. It was also frustrating how these pts took up so much time, taking time away from pts with more potential to get better. That's not to say I didn't try to provide them the best care possible. Still wanted them to be clean/comfortable, put on music family said they liked, etc.

I usually assessed my alert/oriented pts first to see if they had any pressing needs and do initial room check/assessment. Last would be the comatose pts assessment/first turn and check they're clean. Other than that I'm not sure what else you could improve, sounds like you're doing great. One thing I learned is when a pt calls for something non urgent, like ice chips, snack, etc, I see what else needs to be done at that time since they're awake and to minimize trips to their room. If they request a sandwich at 1945 and have meds at 2000, I will gather meds, then go in at 2000 and give the sandwich meds, whatever else I can get done at that time. Sounds like you're very conscientious and I hope things improve!

[JBMmom, MSN, NP]

I think you need to cut yourself some slack, that sounds like a monumental workload, especially for a new grad. Staying 30-45 minutes sounds great. When I first started in long-term care I think I averaged getting out at 1am when my shift ended at 11:30pm. I never had time to chart a thing until the night nurse came on and I could actually sit down. For anyone that has become a nurse in this nightmare of a year, there have been challenges beyond what's been seen before. Staffing levels seem to be worse in many places, people are being asked to take on higher acuity patients and larger workloads, with no change in their support or training. Sounds like you're doing as well as could be expected, I think everything else will come with time. I think many of the Q2 turns are being neglected everywhere across the country, (although sometimes I suspect that the Q2 is more than necessary for the majority of non-malnourished patients), you're not alone. I don't really have much advice, just want to wish you well because I know you're doing your best and you're probably a pretty great nurse.  

[Emergent, RN]

Learn to quickly knock off the silly, desk jockey driven nonsensical charting ASAP in your shift. Just click the necessary boxes and move on. You do not have to dwell on that stuff at all. Then you don't have it looming over your shift for 12 hours.

One thing that really helps is in many EMR programs is that you can copy the assessment from the previous person. Of course, don't keep it exactly the same because some things might have changed. Go through it and change only the things that are different in your assessment. It's a lot faster that way. That isn't to say that you make stuff up, at all! Truth telling is mandatory. 

 

[Nunya, BSN]

To me it sounds like you're doing ICU patients with a med-surg ratio.  I don't know why you're shutting down but at this point that seems like a good thing.

[LovingLife123]

Are you doing pandemic charting at all?  Vents are not step down patients.  They are ICU patients.  
 

If I had that pt load I’d probably be there longer than 30 minutes after my shift.  I’ve been doing this for a long time too.

[JBMmom, MSN, NP]

15 hours ago, Emergent said:

One thing that really helps is in many EMR programs is that you can copy the assessment from the previous person. Of course, don't keep it exactly the same because some things might have changed. Go through it and change only the things that are different in your assessment. It's a lot faster that way. That isn't to say that you make stuff up, at all! Truth telling is mandatory. 

Our EMR has that functionality disabled. You can copy your own assessment, from within the past 8 hours, but you cannot copy an assessment from another nurse. In many ways that makes sense since we all know some people would just blindly copy and paste and never do their assessment. Then again, plenty of people chart things they never actually assess, You're absolutely right that it's nonsensical, though, it's too bad so much of the time in nursing has to be focused on the wrong things. 

[TheMoonisMyLantern, ADN, LPN, RN]

You'll get there, it sounds like you work on a hell floor but I'm sure you're learning a lot. I hope you are looking toward the future though and have a plan in place for when your hospital closes.

I promise it does get better with time and experience!

[JKL33]

Regardless of the fact that you are a new grad who can be expected to become somewhat more efficient just with experience (knowing what is important vs. what isn't, experience with various situations that makes them easier to prioritize, etc., etc)....the foundation of the problem here is a mismatch between expectations and allocated resources to accomplish the expectations.

Anyone can be hobbled to the point that they can only do so much. New grad or experienced nurse, it doesn't matter.

[NewGradNurse3, BSN, RN]

thank you so much, everyone. this thread was sooo validating! We just hired a bunch of agency/travel nurses and now the patient ratio is more reasonable (like around 4 patients) and it's been way more manageable.