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A new Sentinel Event Alert from The Joint Commission, “Optimizing smart infusion pump safety with DERS,” describes how built-in dose error reduction software (DERS) can improve patient safety.

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Hensler Surgical Technologies has announced its newly obtained CE mark for the Hensler Bone Press (HBP).

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Healthmark Industries has introduced an Anti-Fatigue Mat to its Personal Protection Equipment (PPE) product line.

Managing Your Time: Work Smarter, Not Harder

To quote efficiency guru Brian Tracy, “Time management is not a peripheral activity or skill. It’s the core skill upon which everything else in life depends.”1 Yet, how often have you felt the satisfaction of saying to yourself, “I managed my time well and got a lot done today”? For many nurses, it’s just the opposite: We’re constantly stressed about managing our time better and feel too overwhelmed to figure out what to do about it. Nursing is a complex, dynamic, time-consuming job. If you don’t learn to prioritize and manage your time, you’re at risk of missing critical aspects of patient care. You’ll also find yourself going home constantly displeased with your ability to meet your patients’ needs. Time management (managing one’s own time and the time of others) is a core skill of 21st century nurses.2 It’s the key to improving outcomes and keeping patients safe. This module guides you to determine ways you can be more productive, more efficient and less stressed: in other words, work smarter, not harder.

Defining Time Management

So exactly what is time management? Time management is the ability to analyze how you spend your working hours, set priorities and organize your work to maximize your efficiency.2 There are four “Ps” to consider when analyzing time management:2

• Productivity and efficiency: How much do you get done and how long does it take you? Do you end up staying later than your colleagues most days?

• Performance: How well do you do what really matters? Are you great at talking with patients but always seem behind on physical care? Are you great at technical skills, but not so great at emotional support?

• Perception: How satisfied are you, your coworkers and your patients with what you accomplish?

• Patient outcomes: Are your patients safe and free from avoidable complications? Do they know what they need to know to be independent?

Time Management Barriers

A good place to start when working to improve time-management skills is to gain insight into common time-management barriers. What things are getting in your way? Think about the following common barriers in relation to your efforts to manage time:

Procrastination. Poor organization and planning. Putting tasks off because you don’t like to do them, because they tend to be time-consuming or because you have more enjoyable things to do. Procrastination can also be a personality trait. Do you like to do things at the last minute, or do you like to work ahead?

Having to do everything yourself. Some people have trouble delegating tasks because they need to be in control or because they simply don’t like to ask others to do something for them.

Having to have everything perfect. Are you a perfectionist? Can you let things go when they’re done satisfactorily or do you want them to be perfect? Recognizing when “good is good enough” has saved me an immense amount of time. When you weigh what you have to do against how much time you have to do it all, you have to be realistic. You can’t spend too much time on any one task because you run out of time for other tasks. One nurse I know gains peace over her “perfectionism” by living by the motto “Do your best and leave the rest.” If you’re a perfectionist, this motto can help reduce your stress.

Underestimating how much time you need to get things done. This is a common issue that’s usually solved by experience. This is one of the reasons care continuity is important, especially with complex patients. If you’re a manager, work to keep the same caregivers matched with certain patients to overcome this issue. It’s also good to give estimated time frames for finishing certain tasks in procedure manuals and care plans.

Interruptions and losing focus. I like to call this the “Oh! There’s a squirrel!” issue, referring to the human tendency to be easily distracted (we could be having an important conversation and suddenly be distracted by a squirrel outside the window). A common example of this in health care is getting on the computer to check something and remembering something else we need to check. We change computer screens and may even move on to a different patient’s data. Once in the new screen, we forget to come back to the priority we began with. Because nurses have to deal with multiple requests from patients, families, coworkers, physicians and so on, losing focus is common. How often do you hear yourself saying, “What was I doing before I was interrupted?” Nurses should avoid interrupting their coworkers, especially during crucial times, such as when they are charting or giving medications. When you’re interrupted during an important task, learn to say, “I’ll be with you in a moment” or “I can’t stop what I’m doing right now.” If you must stop what you’re doing, write down exactly what you were working on and make coming back to it your next top priority. Interruptions and losing focus are one of the most common barriers to time management in health care. For this reason, it may be wise to have a unit meeting that addresses these issues.

Poor organization and planning. If you arrive at work just in time to throw your bag in your locker and head for report, your day is likely to be full of delays and backpedalling. Arriving 10 to 20 minutes earlier and checking on your assignment can make a big difference in improving time management and reducing your stress. Get there a bit early and you’ll have time to assess, organize and plan.

Not recognizing time wasters. Leaders must encourage their staff to point out time wasters. For example, if you’re sitting around waiting for medications, linens or transport people, you’re losing valuable time. The same goes for poorly organized units. If you’re wasting steps because of poor unit design or having to document the same things in more than one place, you’re also wasting time.

Stress, hunger and fatigue. Working long hours in a stressful environment without breaks or sustenance reduces brain power, concentration and physical abilities. This is a common issue for nurses. I once spoke on a panel that included the U.S. assistant surgeon general and two professionals from Vanderbilt University. We had a 30-minute question-and-answer period. At least 20 minutes were devoted to answering questions from the audience like “You say that breaks are important, but what do we do when we aren’t allowed to take breaks?” We, as nurses, must acknowledge the importance of taking care of the caregivers. We can’t work efficiently when we haven’t paid attention to basic survival needs (food, water, rest). This really hits home in Jim Loehr’s and Tony Schwartz’s popular 2004 book, “The Power of Full Engagement: Managing Energy, Not Time, Is the Key to High Performance and Personal Renewal.”3 As the authors say, “The number of hours in a day is fixed, but the quantity and quality of energy available to us is not. It is our most precious resource.” A key change I made in my workshops after reading this book was to make sure we had plenty of breaks with healthy food and drinks. You would be surprised how often clients responded, “We’re not doing a morning break” or “We don’t have a budget for refreshments” when I asked what was planned for breaks. After I pointed out the findings in Loehr’s and Schwartz’s work, we found a way to include breaks and food, even if it meant asking the nurses to bring their favorite dish from home. (Nurses are great this way …. I have had some GREAT food!)

Setting Priorities

Setting priorities — a skill that comes with knowledge and on-the-job experience — is vital to time management. If you don’t discriminate between what must be done and what’s nice to do, you may endanger your patients because all tasks will be considered equally important. Lots of minor things may get done, while major issues go unaddressed.

The 80/20 Rule was developed by Italian economist Vilfredo Pareto in 1906 and is a great guide for setting priorities.4 Known as Pareto’s Principle, there are many applications of this rule. For example, you wear 20% of the clothes in your closet 80% of the time (think about this the next time you shop or arrange your closet). In nursing, you can apply the 80/20 rule in two ways:

• On any given day, you have a 100% of things you need to do for your patients. To prioritize, you need to identify the 20% that MUST get done — here’s where you need to spend most of your time.

• Twenty percent of your patients will generate 80% of the work that needs to be done.

Setting goals and making a to-do list are key steps in setting priorities. It’s hard for your brain to handle the details and relationships of all your tasks without visual cues that help you see the big picture. Once the to-do list is complete, you can analyze the tasks and decide where they fit into the big picture using the following scale.2

• First-order priority: Must do: important and urgent (e.g., addressing safety risks; assessing unstable patients.)

• Second-order priority: Must do — important but not urgent (e.g., routine vital signs)

• Third-order priority: Nice to do — not as important and not urgent (e.g., chatting with a patient about his vacation).

After organizing your list according to the preceding priorities, ask, “Are there things on this list that I could or should be delegating to someone else? If so, who is the best person to do the task? Keep the tasks that you, and only you, can do; delegate the tasks that someone else can do (see next section on delegating safely and effectively).

Stephen Covey, author of the classic self-help book “7 Habits of Highly Effective People,” gives an excellent model to set priorities.5 His model, referred to as Covey’s Quadrants, involves drawing a grid with four quadrants. Quadrant 1 is for urgent important activities (e.g., safety risks). Quadrant 2 is for things that are important, but don’t have to be done immediately (e.g., patient discharge teaching). Quadrant 3 is for time-pressured issues. They aren’t really important, but someone wants it now (e.g., a family member who wants the number of a good place to order pizza). Quadrant 4 is for things that really don’t need doing because they don’t have much value (e.g., responding to every text message someone sends). If you search “Covey’s Quadrants Images” online, you’ll find examples of how these quadrants are used.

Delegating Safely and Effectively

Virtually every time-management article and seminar addresses the importance of delegation. Delegating tasks that don’t require your detailed attention gives you more time to focus on important priorities that you and only you are qualified to do. Yet delegation is a highly complex skill. As Alice Weydt, RN, MS, points out, “It requires sophisticated clinical judgment and final accountability for patient care. Effective delegation is based on your state nurse practice act and an understanding of the concepts of responsibility, authority and accountability.”6 Knowing what your nurse practice act allows you to delegate — or prohibits you from delegating — is of utmost importance in keeping your patients safe and protecting you from negligence lawsuits. If you’re unsure about what you may or may not delegate, check your policies and procedures, and double check with your manager or unit educator. You can find your state practice act at https://www.ncsbn.org/.

One of the most helpful documents addressing how to delegate is the American Nurses Association and the National Council of State Boards of Nursing’s Joint Statement on Delegation (https://www.ncsbn.org/Delegation_joint_statement_NCSBN-ANA.pdf).

Pointing out that there’s more nursing to do than there are nurses to do it and that many nurses are stretched to the limit, this document addresses 5 Rights and 4 Steps to safe and effective delegation. Keeping in mind that delegation is defined as “authorizing someone to perform a selected task in a selected situation while retaining accountability for results,”7 here’s a summary of what these rights and steps involve.

Five rights of successful delegation are as follows:

Delegate 1)the right task, 2) in the right situation 3) to the right worker, 4) with the right direction and communication, and 5) the right teaching, supervision and evaluation.

Four steps of successful delegation are as follows:

• Assess and plan: Consider the patient, the task and worker competencies to make a plan for what tasks you will assign to whom.

• Communicate: Give clear, concise, complete directions about what must done, how it must be done, what needs reporting and when to touch base with you (verify that the worker understands directions).

• Ensure supervision and surveillance: Monitor the patient and worker performance as frequently as needed based on the above.

• Evaluate and give feedback: Evaluate the effectiveness of the delegation by assessing patient response yourself. Decide whether you need to make changes in the patient’s plan of care or how the worker is completing the task. Evaluate the worker’s performance and give teaching and feedback as needed (this helps the worker improve skills, ultimately freeing you for other important work).

Research on Factors Key to Successful Delegation11

• Good communication

• Positive relationships and attitudes

• Realistic workloads

• Level of nursing assistant’s competence and knowledge

• Supervision and outcome evaluation

Some researchers suggests that tasks such as ambulation, turning, oral care and feeding might become so routine that nursing assistants may become complacent in performance and RNs become less vigilant in supervising these aspects of care.

While all of the preceding is important, remember the following rule: Always assess your patients yourself to determine the results of tasks you delegate. For example, if you delegated the task of getting someone out of bed twice a day, ask the patient directly how many times he got out of bed, how he felt about the experience and if there are things he would like to do differently. When you assess your patients directly, not only do you know the results, but your workers are likely to do a better job because they know you will be checking. This helps ensure your patients are safe and ultimately saves you time because you quickly know when things aren’t going well. You do less backpedalling because you’re dealing with facts rather than assuming that all is going well. From a time-management perspective, you’ll stay focused on priorities and be able to identify care issues and omissions early.

Nine Common Care Omissions8-10

• Ambulation

• Turning

• Delayed or missed feedings

• Patient teaching

• Discharge planning

• Emotional support

• Hygiene

• I&O documentation

• Surveillance (crucial monitoring)

Best Practices

There are best practices that organizations can implement to save time. For example, Ruth Hansten, RN, PhD, FACHE, principal of Hansten Healthcare, has helped more than 175 hospitals to improve outcomes through focused, effective teamwork. She developed a bundle of 10 best practices to improve outcomes and save time.8,9 There are two practices that are especially important: 1) Better planning and 2) Enhanced team communication that focuses on patient/family expectations/results. Hansten says that when nurses set up a plan with assistive personnel for communication — including initial communication to set expectations, timelines for getting things done, parameters for what should be reported and planning for specific checkpoints throughout the shift — they report saving up to an hour a shift. This “found” time comes from ensuring that there’s no duplication of work or time wasted searching for colleagues or data by giving direction early in the shift, ascertaining what tasks will be done within a reasonable time. Hansten says, “When we are rounding on patient care units near change of shift, we often discover assistive personnel ready to clock out, when the RNs aren’t certain what the I&Os are or if the vital signs were within normal limits.” (Hansten, R. Email communication. September 1, 2013.) She stresses the importance of shift report at the point of care, with a focus on patient/family preferred goals and priorities. This helps patients feel engaged in the process as the whole team navigates toward individualized desired outcomes. Nonessential and redundant care is avoided while all efforts focus on the patient’s goals. The entire team streamlines its work and initiates a process that means less omitted care; fewer healthcare-acquired conditions, such as pressure ulcers or falls; and reduced readmissions from unplanned transitions. Nurses report saving at least a half hour per day thanks to an efficient point-of-care handoff process.

Time Management Tips

The following are time-management tips you should consider using in your daily nursing

practice:

Start well. Arrive early so that you can review your assignment, check whom your staff is and get organized. If it seems that you’re not able to arrive early, consider your prework routine. Are there improvements you could make in time management at home? Would simple strategies like setting your alarm clock 15 minutes ahead or not answering phone calls or getting on the computer before work help?

Identify major goals for the day and make a to-do list. Revisit your list frequently during the day, deciding what’s been done and what still needs to be done. Focus on “must-do” tasks before “nice-to-do” tasks. You may use paper to-do lists or a recommended time-management app to make sure you don’t miss the things that aren’t addressed in electronic medical records. You can learn more about electronic time management apps at NurseMind, www.nursemind.com.

Make charting a high priority. Complete patient records as soon as you can. This is especially important in acute care settings. Charting often triggers you to recognize something important that needs to be done. With some electronic health systems, when you enter in certain data, the system will cue you to consider patient status changes or other things that need to be done. Charting creates records that promote safe patient care. These records may serve in your defense if you’re accused of negligence. If you chart in a rush at the end of the shift, your records are likely to reflect that. You may be an excellent nurse, but if your charting doesn’t show that, you and your patients may be in jeopardy.

Build relationships with staff at all levels. The saying “credentials on a wall do not make you a decent human being” applies. Teamwork is all about relationships and empowering your coworkers.

Involve patients and families. Ask them, “What’s the most important thing you want to get done today?” Let patients know what they are allowed to do for themselves (many will be unsure). Teach them what they need to know to be independent.

Set limits. It’s easy to keep adding to your to-do list. If your list keeps growing, you may not have time to focus on your own priorities and patients. Don’t be afraid to say, “I can’t right now. Can you get someone else?”

Create routines, such as doing huddles at specific times during the day. Huddles should be less than 10 minutes and can be held at the beginning of the shift or whenever significant changes in work flow arise.10 Getting the team in a huddle to discuss what’s happening and make adjustments improves work flow and aids both patients and staff.

Organize the environment. Designate places for specific things (e.g., frequently needed equipment) and tasks (e.g., charting, education).

When under pressure, ask, “What’s the most important thing I have to do RIGHT NOW?” Stay focused on this task.

Cluster activities before entering a room. Think ahead and anticipate needs (e.g., a need for pain medication).

If you feel overwhelmed or “out of your league,” consider whether you should ask for help. For example, you may need to call the pharmacy to answer your questions or notify the rapid response team if you’re concerned about a patient. Delays in getting help contribute to poor patient outcomes.

Reserve time in your daily schedule for unexpected events. Work ahead because a new admission or patient crises may put you behind.

Keep in mind that multitasking is risky, especially if you have a lot of interruptions. You may end up doing a little bit of a lot of things, but not complete any one major task.

If you’re struggling with time management, ask your preceptor, manager or trusted coworker to give you his or her time management strategies. There are many different work styles and we can all learn from one another.

There will always be more than enough requests, demands and distractions to deal with. Time management will continue to be a core skill and challenge of 21st century nurses. As circumstances change, you’ll need to develop new approaches. Developing these skills helps you do more of what you must do faster. It doesn’t mean cutting corners or reducing quality. It means using your resources to get the best results for your patients and health care team. The good news: Gaining control over how you use your time boosts your performance, gives you a sense of satisfaction, reduces your stress and keeps patients safe.

Rosalinda Alfaro-LeFevre, RN, MSN, ANEF, is the president of Teaching Smart/Learning Easy (www.AlfaroTeachSmart.com) in Stuart, Florida. She’s known nationally and internationally for her writings and programs on teaching critical thinking and improving personal and professional performance.

References

1. Tracy B. Time management: why your life depends on it. Brian Tracy International Web site. http://www.briantracy.com/blog/time-management/why-your-life-depends-on-time-management-personal-goals-increase-productivity/. Published January, 23, 2013. Accessed March 27, 2014.

2. Alfaro-LeFevre R. Critical Thinking, Clinical Reasoning and Clinical Judgment: A Practical Approach. 5th ed. Philadelphia, PA: Elsevier-Saunders. 2013.

3. Loehr J, Schwartz T. The Power of Full Engagement: Managing Energy, Not Time Is the Key to High Performance and Personal Renewal. New York, NY: Simon and Schuster. 2004

4. Reh F. Pareto’s Principle: The 80-20 Rule About.Com Management Web site. http://management.about.com/cs/generalmanagement/a/Pareto081202.htm. Accessed March 27, 2014.

5. Covey S. The 7 Habits of Highly Effective People. New York, NY: Simon & Schuster. 1989.

6. Weydt A. Developing delegation skills. Nursing World Web site. http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol152010/No2May2010/Delegation-Skills.htm. Published 2010. Accessed March 27, 2014.

7. American Nurses Association and the National Council of State Boards of Nursing. Joint statement on delegation. NCSBN Web site. https://www.ncsbn.org/Delegation_joint_statement_NCSBN-ANA.pdf. Published 2005. Accessed March 27, 2014.

8. Hansten R. A bundle of best bedside practices: field evidence. Health Care Manage. 2009;28(2):111-116.

9. Hansten R. 10 Best practices for nursing at the bedside. (Recording of 2/28/13 Webinar). http://rrohc.com/nursesweek2011.html. Accessed March 27, 2014.

10. Steward E, Johnson B. Huddles: increased efficiency in mere minutes a day. TransforMed web site. www.transformed.com/workingPapers/Huddles.pdf. Published 2007. Accessed March 27, 2014.

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