Time Management Tools Chapter 18 of Nursing Leadership and Management by Patricia Kelly Introduction Time Management Time management is “a set of related common-sense skills that helps you use your time in the most effective and productive way possible” (Kelly, p. 427). Importance Time management is important for nurses on the job and nurses in their daily lives. Time management facilitates the prioritization of care, deciding on appropriate outcomes and the performance of the most important interventions first. Overview The Pareto Principle ABC Maslow’ Hierarchy End of Shift Reports/ Shift Plan Triangle Hierarchy Prioritization and Delegation Exercise The Pareto Principle “is a strategy for balancing life and work through prioritization of effort” (Kelly, 427). "Lose an hour in the morning and you will be all day hunting for it" Richard Watley (1864) The Pareto Principle “States that 20% of focused efforts results in 80% of outcome results, or conversely that 80% of unfocused efforts result in 20% of outcome results” p. 427. Example: Reading textbooks while logged into Facebook vs. reading textbooks and focusing on what you are reading. Planning your time leads to more productivity. When you are frenzied and unorganized, you will be less productive. Example: gathering items for a task like a wound change. If you are going back and forth from the supply room, you waste time. If you gather your supplies before you start, you will save time. If you can achieve more with focused effort why don’t more people do so? • They might not know how. • They might enjoy the attention. • They believe they are so busy they do not have time to plan. • They love the state of crisis. Incorporating the Pareto Principle into Practice Establish objectives Prioritize Eliminate tasks-delegate Plan your time! Work smarter, rather than making work harder! McLauchlan, C. (1997). Time Management. Journal of Emergency Medicine, 14(5), 345-346 Conclusion The Pareto Principle can be applied to many situations at work and in daily life. There are times when an unexpected event occurs and the Pareto Principle might not be as effective as other tools. ABC’s of Prioritizationa guide to determining lifethreatening conditions A- Airway B- Breathing C- Circulation First priority: Life-threatening or potentially life-threatening conditions Vital signs or level of consciousness have potential for respiratory or circulatory collapse Risk to themselves or others Can occur at any time during a shift Not always able to anticipate Need to monitor at risk patients to prevent adverse reactions Secondary priority: limb-threatening and sight-threatening ABC’s to determine lifethreatening Airway Is it patent and open? Any obstructions or foreign body? Need for artificial for artificial airway To maximize opening of airway Jaw-thrust Chin-lift maneuver (suspected head or neck trauma) ABC’s continued Breathing Adequate respirations? Rate, rhythm, depth, chest rise, and work of breathing Advantageous or absent breath sounds Pulse oximetry Use of accessory muscles, retractions or seesaw pattern Provide ventilation Inadequate respirations ABC’s lastly Circulation Pulse Slow, irregular, weak or rapid Bounding and full Blood pressure Skin color and temperature High vs. low Warms and dry vs. cool and clammy Possibility of hemorrhage internal or external General Appearance, & LOC Level of Consciousness Is the pt alert and oriented? Confused? Unresponsive? Glasgow Coma Score can be used to determine the LOC General appearance- How does the patient look and act? Table 18-2 Top Priority with Potential Threats to Their ABC’s Respiratory Cardiovascular Airway compromise Choking Asthma Chest trauma Cardiac arrest Shock Hemorrhage Neurological Major head trauma Unconscious/ Unresponsive Seizures Other Major trauma Major amputation Major burn especially involving airway Abdominal trauma Vaginal bleeding Anaphylaxis Diabetic with altered LOC Septic Shock Child or Elder Abuse Activity Scenario 1 You are a nurse who has stopped at the scene of a motor vehicle crash. You are first on the scene. As the ambulances begin to arrive you direct which patients need to be transported in which order. Scenario 2 You are on duty at a small community hospital early one morning when receive reports of a construction accident a mile away. You call the physician on call and then prepare to receive the patients. Three ambulances arrive simultaneously with 5 patients. Gurney, D. (2004). Exercise in Critical thinking at triage: prioritizing patients with similar acuities. Journal of Emergency Nursing, 30(5), 514-515. DOI: 10.1016/j.jen.2004.07.005 Maslow’s Hierarchy Page 20-21 SelfActualization Morality, creativity Esteem Needs Self esteem, confidence, achievement Social Needs/Love and Belonging Interaction with others, friendships Safety Needs Safety of the body, family, health Safe working conditions, job security, benefits Physiological Needs Breathing, food, water, excretion Breaks, adequate salary, working conditions Spend your time according to your needs, or your patients needs. End of Shift Reports Advantages and Disadvantages Face-to-Face Report Advantages Nurses get clarification and can ask questions The nurse giving report has an actual audience and tends to be less mechanical Nurses are more likely to give pertinent information than they would give a tape recorder. Disadvantages It is time consuming It is easy to get sidetracked and gossip or discuss non-patientrelated business Both oncoming and departing nurses are in report Patients are not included in the planning Walking Rounds Advantages Provides the prior shift and incoming shift staff the opportunity to observe the patient while receiving report; staff can address any assessment or treatment questions Information is accurate and timely Patient is included in the planning and evaluation of care Accountability of outgoing care provider is promoted Patient views the continuity of care Incoming shift makes initial nursing rounds Departing nurse can show assessment and treatment data directly to oncoming nurse Disadvantages It is time consuming There is lack of privacy in discussing patient information After the shift hand-off report is accomplished, the next step is to formulate the plan for the shift. The nurse needs to look at the big picture in regards to the assigned patients. Decide on optimal and reasonable outcomes Set priorities based on life-threatening conditions, safety considerations, and activities essential to comfort, healing, and teaching Make assignments when possible to optimize time and expertise- delegate tasks Determine timing of the necessary interventions, whether they are flexible or a completion time must be determined Kaplan, B., & Ura, D. (2010). Use of multiple patient simulators to enhance prioritizing and delegating skills for senior nursing students. Journal of Nursing Education, 49:7, pp. 371-377 In this study the authors investigated the use of multiple patient simulators to help develop the prioritizing and delegating skills of nursing students. They sought to address the difficulty new nurses experience when they make the transition to being a practicing nurse, and need high-level leadership skills. It is necessary that they acquire not only knowledge, but the ability to apply conceptual and critical thinking in prioritizing and delegating care in the critical setting. In this study, the participants listened to an audiotaped change-of-shift report on three simulated patients, so they would not be able to ask questions. This was to see if they would attempt to collect more information through the mock patient chart or patient assessment. Of the three patients, one was stable, one had potential for problems, and one had been admitted at night and was considered unstable. The nurse was supposed to prioritize based on patient status, and staff competency. The most urgent needs would be identified and the nurse would have to delegate some of the care. The self-reported confidence in both prioritizing and working in teams was increased, as was the understanding about how to prioritize and delegate care. Following the implementation of this program into the curriculum, students voiced their desire to complete weekly simulation exercises until graduation. They stated that the simulation activity gave them true insight into the shifts in responsibilities experienced when bridging the gap between being a student and a practicing nurse The Prioritization Triangle Do First Things First! Nurses needs to come to terms with limited resources that can happen in the hospital. Example: someone calls in sick and there is no replacement. It would be difficult to reinforce teaching or discus home environment with a patient that is getting D/C the next day but you would perform life-saving interventions because these would be the highest priorities. The safety of patients and staff is most important. Kelly, P. (2012). Nursing Leadership & Management (3rd ed.) Being Able to Set a Priority for Patients and Time Management Requires “Knowing” A research article written by Catherine Litchfield and Keri Chater (2007) followed new graduate nurses in a neonatal unit and found: When these nurses did not know the clinical condition of different neonates, they felt unable to manage their time because they had to spend more time looking for information as well as learning how to care for the neonates. The nurses felt out of their depth, which caused them to feel anxious about not knowing what to do for that neonate and anxious that something would happen. When the new graduate nurses gained knowledge, they were able to manage their time more effectively by prioritizing what was important, knowing what to expect and knowing routines, which enabled them to predict outcomes and made work easier. The Prioritization Triangle Contains four levels Life-Threatening Conditions: Check ABCs (highest priority/ foundation of triangle) Potentially Life-Threatening Conditions (2nd level of triangle) Essential Safety Measures (3rd level of triangle) Comfort, Healing, and Teaching (4th level of triangle) Kelly, P. (2012). Nursing Leadership & Management (3rd ed.) First Priority Nurse should give first priority to levels one and two (Life-Threatening Conditions and Potentially Life-Threatening Conditions). Patients who are at risk for respiratory or circulatory collapse and harming themselves are given high priority and should be monitored all throughout the shift. -ABCs Kelly, P. (2012). Nursing Leadership & Management (3rd ed.). Second Priority Being able to provide safe care to patients and having a safe work environment for staff is extremely important. Life saving monitoring, medications, and equipment to protect patients from fall and infection are essential. Example: asking for help with turning or moving patients, prevention of falls or pressure ulcers. Kelly, P. (2012). Nursing Leadership & Management (3rd ed.) Third Priority This level includes comfort, healing, and teaching and is essential to the recovery of the patients. If these activities are not completed, the patient’s recovery will be delayed. Examples: interventions that relieve pain and nausea, promote healing like nutrition, ambulation, positioning, medication administration, and teaching. Kelly, P. (2012). Nursing Leadership & Management (3rd ed.) Overview General time management strategies include an outcome orientation, analysis of time cost and use, focus on priorities, and visualizing the big picture. Shift planning begins with developing both optimal and reasonable outcomes. Priority setting takes into account what is life threatening or potentially life threatening, what is essential to safety, and what is essential to the plan of care. The shift action plan assigns activities aimed at outcome within a time frame. Overview Continued End-of-shift hand-off reports include face-to-face meetings and walking rounds. The shift action plan is evaluated at the end of shift by asking if optimal or reasonable outcomes have been achieved. Time wasters that might interfere with outcome achievement include procrastination, inability to delegate, inability to say “no,” management by crisis, haste, indecisiveness, interruptions, socialization, complaining, perfectionism, and disorganization. Quality time can be achieved by analyzing time use and energy patterns. Strategies to Enhance Personal Productivity Time management and organization can be applied to daily activities Nurses can create more personal time by hiring someone else to do work and/or getting up one hour earlier every day which totals 365 hours extra each year. Nurses can use downtime, for example, having reading and writing materials available at all times, listening to books on tape in the car when traveling. Kelly, P. (2012). Nursing Leadership & Management (3rd ed.) References Kelly, P. (2012). Nursing Leadership & Management (3rd ed.). Clifton Park, NY: Delmar Cengage Learning Litchfield, C. & Chater, K. (2007). Can I Do Everything? Time Management in Neonatal Unit. Australian Journal of Advance Nursing, 25(2), 36-45. Gurney, D. (2004). Exercise in Critical thinking at triage: prioritizing patients with similar acuities. Journal of Emergency Nursing, 30(5), 514-515. DOI: 10.1016/j.jen.2004.07.005 McLauchlan, C. (1997). Time Management. Journal of Emergency Medicine, 14(5), 345-346 Kaplan, B., & Ura, D. (2010). Use of multiple patient simulators to enhance prioritizing and delegating skills for senior nursing students. Journal of Nursing Education, 49:7, pp. 371-377 A Nursing Team Leader Caring for Multiple Clients You are the team leader providing care for six clients. The team includes yourself (RN), an LVP, and a newly hired nursing assistant. Mr. C, 68 y/o M with unstable angina who needs teaching for a cardiac catheterization scheduled this morning. Ms. J, a 45 y/o F experiencing chest pain scheduled for a graded exercise test later today. Mr. R., a 75 y/o M with a 4day-old left sided stroke Ms. S. an 83 y/o woman with heart disease, a history of MI, and mild dementia. Ms. B, a 93 y/o F, newly admitted from long-term care with decreased UO, ALOC and an elevated temperature of 99.5F Mr. L, a 59 y/o man with mild SOB and chronic emphysema 1. 2. Which clients should you assign to the LVN? Which client should you assess first? 1. 2. 3. 4. Mr. C Ms. J Ms. B Mr. L Mr. C, 68 y/o M with unstable angina who needs teaching for a cardiac catheterization scheduled this morning. Ms. J, a 45 y/o F experiencing chest pain scheduled for a graded exercise test later today. Mr. R., a 75 y/o M with a 4day-old left sided stroke Ms. S. an 83 y/o woman with heart disease, a history of MI, and mild dementia. Ms. B, a 93 y/o F, newly admitted from long-term care with decreased UO, ALOC and an elevated temperature of 99.5F Mr. L, a 59 y/o man with mild SOB and chronic emphysema Which of the following tasks should you delegate to the nursing assistant? 1. Ask Ms. S memory-testing questions. 2. Tell Ms. J about treadmill exercise testing. 3. Check pulse oximetry for Mr. L. 4. Monitor urine output for Ms. B. Close to the end of the shift, the LVN reports that the nursing assistant has not totaled clients’ intake and output for the past 8 hours. What is your best action? 1. Confront the nursing assistant and instruct her to complete this assignment. 2. Delegate this task to the LVN as the nursing assistant may not have been educated in this task. 3. Ask the nursing assistant if she needs assistance in completing the intake and output records. 4. Notify the nurse manager to include this on the nursing assistant’s evaluation. Shortness of breath, Edema, and Decreased Urine Output Ms. J. is a 63 y/o F who is admitted directly to the medical unit after visiting her physician for SOB and increased swelling in her ankles and calves. Her admitting DX is rule out chronic renal failure (CRF). Ms. J states that her symptoms have become worse over the past two to three months and that she uses the bathroom less often and urinates in smaller amounts. Her past medical history includes HTN (30 years), CAD (18 years) and type 2 diabetes. Ms. J. is a 63 y/o F who is admitted directly to the medical unit after visiting her physician for SOB and increased swelling in her ankles and calves. Her admitting DX is rule out chronic renal failure (CRF). Ms. J states that her symptoms have become worse over the past two to three months and that she uses the bathroom less often and urinates in smaller amounts. Her past medical history includes HTN (30 years), CAD (18 years) and type 2 diabetes. Admission vital signs: Temp: 97.8 F BP: 162/96 HR: 88 RR: 28 Pulse ox: 91% on room air Admission lab tests to be collected on the unit include serum electrolytes, renal function tests, CBC and urinalysis. A 24 hour collection for creatinine clearance has also been ordered. You are the team leader, supervising an LVN. Which nursing care action for Ms. J should you delegate to the LVN? 1. Insert and intermittent catheter to assess for residual urine. 2. Plan fluid restriction amounts to be given with meals. 3. Check breath sounds for presence of increased crackles. 4. Discuss renal replacement therapies with the patient. As team leader, you observe the nursing assistant (NA) perform all of these actions for Ms. J. For which action must you intervene? 1. NA assists Ms. J to replace oxygen nasal cannula. 2. NA checks Ms. J.’s vital signs after the patient drinks fluids. 3. NA ambulates with Ms. J to the bathroom and back. 4. NA washes Ms. J’s back, legs, and feet with warm water. You are supervising a new orienting nurse providing care for Ms. J, who has had surgery to create a left forearm dialysis access. Which of the following actions performed by the nurse requires that you intervene? 1. The nurse monitors the patient’s operative site dressing for evidence of bleeding. 2. The nurse obtains BP reading by placing the cuff on the right arm. 3. The nurse draws post-operative lab studies from temporary dialysis access. 4. The nurse administers oxycodone by mouth for moderate post-operative pain. Assessment of Ms. J after dialysis reveals all of these findings. Which assessment finding necessitates immediate action? 1. Ms. J’s weight is decreased by 4.5 pounds 2. Ms. J’s systolic blood pressure is decreased by 14 mm Hg. 3. Ms. J’s level of consciousness is decreased. 4. Ms. J.’s temporary catheter dressing has a small blood spot. Six months later, Ms. J is readmitted to the unit. She has just returned from hemodialysis. Which nursing care action should you delegate to the nursing assistant? 1. Obtain vital signs and post-dialysis weight. 2. Assess hemodialysis access site for bruit and thrill. 3. Check and assess site dressing for bleeding. 4. Instruct patient to request assistance getting out of bed. Cardiovascular Problems You are the charge nurse for the coronary step down unit. Which patient is best to assign to an RN who has floated for the day from the general medical-surgical unit? 1. Patient requiring discharge teaching about coronary artery stenting prior to going home with spouse today. 2. Patient receiving IV furosemide (Lasix) to treat acute left ventricular failure. 3. Patient just transferred from the radiology department after a coronary angioplasty. 4. Patient just admitted with unstable angina and who has orders for a heparin infusion and aspirin. You are working in the ED caring for a patient who was just admitted with left anterior chest pain, possible unstable angina or myocardial infarction. Which nursing activity will you accomplish first? 1. Auscultate heart sounds. 2. Administer SL nitro. 3. Insert an IV catheter. 4. Obtain a brief patient health history. A patient with atrial fibrillation is ambulating in the hallway on the coronary step-down unit and suddenly tells you, “I feel really dizzy.” Which action should you take first? 1. Help the patient to sit down. 2. Check the patient’s apical pulse. 3. Take the patient’s BP. 4. Have the patient breath deeply. A diagnosis of ventricular fibrillation is identified for an unresponsive 50-year-old patient who has just arrived in the ED. Which action will you take first? 1. Defibrillate at 200 Joules 2. Start CPR 3. Administer Epi 1 Mg IV 4. Intubate and manually ventilate. You are ambulating a cardiac surgery patient who has telemetry cardiac monitoring when another staff member tells you that the patient has developed a supraventricular tachycardia with a rate of 146 beats per minute. In which order will you take these actions? 1. Call the patients physician. 2. Have the patient sit down. 3. Check the patients blood pressure. 4. Administer oxygen by nasal canula.