Time Management Tips Please

[FutRNRock]

How do you organize your shift? I am on my 4th week orientation and struggling how to manage my time with 4 patients. What’s your schedule looks like? Do you come to floor 30 mins ahead to read notes (unpaid)?

Thank you

[SarHat17, ASN, RN]

Try searching for other posts on this topic; there are a lot of good tips! Here’s my post from there to give you some ideas:

 

Deep breath! You will get through it! This is a VERY stressful and crazy time, and you are NEW and finding your rhythm. Don't be too hard on yourself, although I know that may sound hollow right now. I'm not sure exactly the specifics of your situation, but maybe this will help you and others.

Here's what I do. (I work on an Intermediate/Telemetry unit/CVRU with 3-4 patients per shift.)

I get to my unit on time and am ready for report when the shift starts. Our hospital has nursing handoff sheets for each patient printed out for the shift, so I have my papers and am ready. I have a "grid" I write on the papers to keep report of body systems/assessment to stay organized during report/my shift. I eat breakfast before coming into work; I don't have time available to stop for breakfast during my shift in the morning.

We aren't doing bedside report at the moment (that is coming) and I pop in to say hello to all the patients/make sure they are OK if the off-going RN and I haven't already done that during report. If there aren't immediate needs, I grab a computer and review orders/hx/most recent notes and write down my med lists. I then detour to the telemetry monitor and run a strip on everyone. (I've waited before to do that later in the shift, and had Drs ask about the rhythm and I don't have a specific answer ?‍♀️.)

Then I grab meds on the first patient and start with assessment/med pass on them, then work my way down the list.

 -- Very sick/critical patients get seen first. Hard-Stop. Particularly if I feel like my report kind of indicates the patient is sicker than the previous RN thought, or important things were not addressed, etc. (This doesn't happen often, but it does happen.) I've had a gut feeling a few times like that, and sometimes my gut is right. (Pulses not checked on foot during previous shift post-femoral procedure; any drains set for suction/chest tubes; my first impression of patient in report and then on assessment is "stroke," but night RN didn't see it that way.)

-- ISO patients don't necessarily get bumped to the end of my list, but I make a point to be proactive about bringing in meds/supplies, and I do explain to them that I am doing assessment and med pass, and address any needs while I'm there, but then can come back after seeing the other patients.

-- With chatty patients, I consider whether I have a lot of meds/lengthy assessment to do. That affects when I see them.

-- I know I need my cath/other procedure patients ready and all pre-procedure prep completed fairly early in the shift.

-- If you put wound care/dressing changes off until later in the shift (unless they are going to procedure/Dr coming to assess and the dressing will be coming off, etc) the task will inexplicably take twice as long, and something always comes up to delay it. (LOL, I have learned that the hard way.)

-- I used to (and am actively trying to do so again) chart at least my head-to-toe in the room during med pass. If I get as much charting as reasonably possible done right there and then, well, it's like the dressing changes- it seems to take longer doing it on the back end.

-- I make a point to round throughout the day on my patients, address needs, etc; if there's time for me to stop and scroll social media (as I have seen some coworkers), then there are likely tasks that need to be done. (I don't run around like a crazy-person, but I will clean extra IV pumps/poles and restock, that type of thing.)

You WILL find a rhythm. Ask others/watch others on your unit and see what they are doing. I have very rarely had a patient argue/complain when I explain that I need to see/pass meds/give pain medication down the hall and then will be back; in fact, I think it almost helps them (in certain situations of course) remember that others are here as patients also, and doesn't it feel better when your nurse can bring pain medication in a timely manner if that makes sense. ?‍♀️ Hang in there! We need you and appreciate all the hard work you've done to get to where you are!!

[Been there,done that, ASN, RN]

This question needs to go to your preceptor. As you are only 4 weeks in,  you need direct supervision. I would never come in early to review notes. The assignment could change and it would be a waste of time. 

Any thing off the clock is a HIPAA violation waiting to happen.

Give yourself some time to learn.

 Best wishes

[NightNerd, MSN, RN]

What specific tasks do you find yourself struggling to complete? Med passes? Documenting? Dressing changes? Something else?

I do not come in early to look up my patients. I clock in on time and am ready for report at 7 AM. I worked on one unit where it was the culture to show up early and research your patients off the clock, and I am soooo thankful that is not the norm where I work now. 12 hours is long enough!

My ideal routine (as a med-surg/tele nurse with 4-5 patients and sometimes running charge too): I get report, either bedside or at the door so we can at least confirm bed alarms are on, patient's not in distress, etc. We look at heparin drips or anything else high risk together during that time too. Then I give my AM insulin, document my first rounds and rhythm strips, and look up labs, vitals, and skim the most recent MD and case management notes. Just enough to get a basic idea of the patient's hospital course, the most immediate goals, and what the plan is for working towards discharge. (I do a deep-dive into the chart later in the shift if I have time to see if there's anything else that's important to know or pass on.)

I start my med pass as early as possible, 8:30 AM, do my detailed head to toe assessment, and document my assessments as I go. I typically finish no later than 10:30. If someone is particularly sick, in pain, etc., I'll go to them first; otherwise, I start with my easier patients and snowball down to the more time-consuming ones. Documenting during med pass has actually really cleared up my afternoons, so I recommend that whenever possible. I also see what supplies are at the bedside for incontinence care, dressings, etc., so I can put what's needed in the room afterward and NOT bring something that's already there.

I group my meds together in two hour groups: 8 and 10, 12 and 2, 4 and 6. Mealtime insulin can throw it off a bit, but usually that helps me save a little time. Our documentation system will let me scan meds up to 1.5 hours early, so if someone has meds at 12 and 2, I can technically give them as early as 12:30. I try to get it as close to when it's due as possible, but if everyone's MAR is packed with meds all day, sometimes that's the best I can do.

I typically have better luck doing dressing changes in the afternoon (unless the dressing is already soiled, in which case I do it as soon as possible), helping patients get washed up for the day, anything else that isn't time sensitive. Having all my major documentation done also frees me up to help my coworkers, stock cabinets, make the next assignment if I'm charge, and respond to unexpected events or emergencies. That way I just have to document my rounds, afternoon rhythm strips, and any changes in my assessment for the rest of the day.

If it's a truly perfect day with no complications, I can even squeeze in some annual competencies between lunch and dinner. ? That's not a typical occurrence, but using that extra time when I get it means I don't have to scramble the month they're due.

Sometimes the day is just crazy from start to finish, and it sucks, but it doesn't necessarily mean you're doing anything wrong. You will absolutely find a routine that works for you as you go on. See how others organize their days, try different things, and see what sticks. You will be great!

[1gr8trnstudent, ADN, BSN, RN]

When I was on the floor, I would come in 30 mins early, research all my patients, write down why they are there, their orders that are occurring on my shift so labs, ekg, and procedures anticipated, their mobility status, I was on cardiac so their heart rhythm, fluid restrictions, diet, and then I looked up the med times and who to see first based on report and their acuity status.