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LEARNING CURVE

18 l Nursing2017 l Volume 47, Number 1 www.Nursing2017.com

THE WORK OF NURSES in the acute care setting requires disci- plined time-management skills. Most newly licensed RNs (NLRNs) land their first nursing position in the acute care setting where they quickly progress from an assignment of one to two patients to working indepen- dently and coordinating the care of a group of patients.1,2 Nurse precep- tors, nurse educators, and nurse leaders play an important role in helping them learn to manage time, prioritize responsibilities, and del- egate appropriately.

Cognitive stacking is a workflow management process that helps nurses set priorities and manage their time.3 Nurses at all levels of experience can use the cognitive stacking strategies described in this article to efficiently manage time at the bedside.

Managing unplanned change Cognitive stacking is an invisible and dynamic process in which nurses organize and reorganize their activities according to changes and priorities throughout the shift.4,5 A nurse should have a plan in mind even before arriving on the unit. But because nursing is nonlinear, a nurse rarely goes from point A to B to C.6 Rather, the nurse quickly moves from room to room and constantly encounters unplanned change throughout the shift. As a nurse listens to patient handoff, assesses each patient, addresses a change in a patient’s clinical status, and receives new patient prescrip- tions, the cognitive process of stack- ing occurs.4,5 Cognitive stacking allows the nurse to prioritize tasks

needing immediate attention and to form a mental queue of remaining tasks.4,5

Routinization Developing a routine is a good beginning to developing effective time-management skills. Routiniza- tion is the development of previously successful habits that have become a repeated and integrated approach to routine situations.7 For example, routines for a nurse include noting the room numbers and names of assigned patients; receiving patient handoff; reviewing electronic health records (EHRs); performing patient assessments; administering sched- uled medications; documenting; and providing patient handoff to the incoming nurse. When routinizing tasks, consider both the sequencing of expected activities and the dura- tion of each.

A nurse developing routines and cognitive stacking abilities shouldn’t overlook the value of a tangible list. Make a list detailing the expected tasks for the shift.8 In some organi- zations, this document may be a computer-generated snapshot sheet of each patient that the nurse simply personalizes with handwritten entries of uncompleted tasks. What- ever the format, continue to revise it with each patient’s report and with new prescriptions that occur throughout the shift. NLRNs should ask other nurses to share how they develop their task lists and ask their preceptors for help. It’s a good idea for preceptors and other nurse edu- cators to develop a task list as a model for the new graduates they may be training. At the end of each

shift, they can reflect on what worked and what revisions were needed, then integrate these changes into the workflow.

How long should nurses spend completing each task during typical shifts? Nurses working on general and intermediate care inpatient units commit about 20 minutes to reviewing their patients’ EHRs before seeing their patients.9 Addi- tionally, patient handoffs for both incoming and outgoing shifts take about 35 minutes.9 While these time frames may vary by unit or organization, they provide a bench- mark for the nurse to consider when planning the day’s activities. While waiting for patient handoff, use the extra time to review EHRs. Make sure to note new prescrip- tions entered before or during shift change as well as recent vital signs and new lab or imaging results that may warrant attention and intervention.

Either during patient handoff or soon after, make introductory rounds. Just meeting patients gives the nurse a baseline picture of their needs and reassures them that their nurse is there for them throughout the shift.

Take time to talk to each patient and to develop mutual goals and a plan of care for the shift. Make a list of supplies that need to be ordered and stocked in the room; for exam- ple, dressing change supplies, suc- tion kits, and soon-to-be-needed I.V. solutions.

Performing patient assessments is an essential component of every nurse’s routine. To properly sequence the order of patient assessments,

Cognitive stacking: Strategies for the busy RN By Cindy Kohtz, EdD, MSN, RN, CNE; Connie Gowda, MSN, RN; and Pamela Guede, MSN, RN

www.Nursing2017.com January l Nursing2017 l 19

consider each patient’s clinical status. Did any of the patients have any problems during the prior shift, such as hypotension, shortness of breath, or chest pain? Also consider those patients who’ll soon leave the nursing unit for surgery, diagnostic studies, or discharge.

After determining a sequence of patient assessments, contemplate the amount of time needed for each assessment. The average time to complete one patient assessment on either a general or intermediate nurs- ing unit—minus documentation—is about 13 minutes.9

Documenting findings from a patient assessment can be time- consuming. On average, nurses don’t have all their patient assessments documented until 143 minutes into night shifts and 164 minutes into day shifts.9

Nurses should develop the habit of documenting in the patient’s room rather than at the nurses’ desk or in the hallway. This lets them quickly address anything that may have been overlooked in the initial assessment, provides more time with the patient, and avoids inter- ruptions from call lights or other distractions. Point-of-care docu- mentation is also thought to increase accuracy because it decreases reliance on memory.10

Medication-related activities are important and time-consuming components of nurses’ work. For one medication pass to one patient, nurses devote an average of 15 minutes. So, to administer medica- tions to 4 to 6 patients, plan an average of 60 to 90 minutes.11 Keep in mind that any delay in locating, preparing, administering, or docu- menting medications will increase the time needed. Other factors, such as number of assigned patients and number and route of medica-

tions, will also affect the time needed. Consider medication- related activities a fixed time com- mitment because each organization has a specified window of time in which scheduled medications must be administered. One useful strat- egy is to make the most out of each visit to the patient and to bring scheduled medications during ini- tial assessments when possible.

Prioritization hierarchies Many nursing schools may have instructed students on the “ABCs of prioritization”: airway, breathing, and circulation. However, the complexity and varied dimensions of profes- sional practice expand for NLRNs coordinating the care of a group of patients.5 Nurse leaders can use the following two hierarchies of prioriti- zation to teach new nurses how to manage multiple, concurrent activities.

The CURE hierarchy uses the acro- nym CURE to prioritize competing patient needs as follows.12

• Critical patient needs. These are situations where immediate interven- tion is necessary to prevent patient deterioration. Examples include respiratory distress, chest pain, or an acute change in level of consciousness. • Urgent needs, or situations with a high potential for harm or patient discomfort if not addressed. Examples include answering a fall alarm, administering PRN analgesics, or clarifying a health- care provider’s prescription prior to implementation. • Routine patient needs. These include, but aren’t limited to, per- forming physical assessments and administering medications. • Extras. These are activities per- formed by the nurse that, while not essential, promote patient comfort. Examples include providing the

patient with a warm blanket or per- forming hair care.12

A second hierarchy of prioritiza- tion titled the normative hierarchy of nursing tasks closely mirrors the initial sequencing of activities outlined in the CURE hierarchy: clinical emergencies, highly uncer- tain situations, and pain and core responsibilities (completing patient assessments, administering medica- tions, performing dressing changes and treatments, and admitting and discharging patients).12,13 In addi- tion, this method follows core responsibilities with other nursing tasks: relationship management activities such as explaining the unit routine to patients and fami- lies; documenting, helping cowork- ers, and providing patient and family teaching; system improve- ments such as organizing and restocking supplies; and personal time for meals, breaks, and social interactions.13

Delegation While developing a routine and prioritizing nursing activities are fundamental to effective time man- agement, interruptions do occur. Nurses average slightly less than six interruptions per hour. Additionally, 54% of these interruptions occur while the nurse is involved in medi- cation administration, increasing the risk of medication errors.14 Appro- priate delegation of tasks can mini- mize the impact of interruptions.

Nurses often provide direct patient care in dyads consisting of an RN and an unlicensed assistive personnel (UAP). While working with the UAP to achieve positive patient outcomes, the nurse can delegate select duties to the UAP. However, the nurse delegating the activity retains accountability for the outcome.15 The National

20 l Nursing2017 l Volume 47, Number 1 www.Nursing2017.com

LEARNING CURVE

Council of State Boards of Nursing proposes “Five Rights” for success- ful delegation: right task, right circumstance, right person, right direction/communication, and right supervision.15 In applying these five rights, follow the rules and regula- tions of the state’s nurse practice act and the facility’s policies and proce- dures regarding delegation and role expectations.16

Delegation works best when the nurse and UAP have a positive working relationship that includes ongoing and timely communica- tion and a shared desire to collabo- rate.17 Evidence supports the value of providing the UAP with a report and a plan for each patient early in the shift to establish a shared agree- ment on goals and timelines of care.17

Delegating nurses shouldn’t forget that they’re part of the team too. When time permits, helping with tasks or performing a task without delegating it promotes teamwork between nurses and UAPs.17

Utilize your lifelines The demands placed on nurses, especially NLRNs, can be over- whelming and result in errors and omissions that potentially jeopardize patient care. Rather than waiting until a mistake occurs, encourage NLRNs to seek help early if too many tasks or concurrent priorities become a problem. Preceptors should remember that they’re lifelines for inexperienced nurses, and their will- ingness to provide time-management guidance is essential to their unit’s success.

Time management is a dynamic process requiring flexibility and patience. Cognitive stacking skills developed with practice and experi- ence serve nurses well throughout their careers.5 ■

REFERENCES

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15. American Nurses Association and National Council of State Boards of Nursing. Joint statement on delegation. 2006. https://www.ncsbn.org/ Delegation_joint_statement_NCSBN-ANA.pdf.

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In Bloomington, Ill., Cindy Kohtz is an associate professor at Illinois Wesleyan University. In Peoria, Ill., Connie Gowda is an assistant professor at Methodist College of Nursing, and Pamela Guede is a clinical nurse at Saint Francis Medical Center.

The authors have disclosed no fi nancial relationships related to this article.

DOI-10.1097/01.NURSE.0000510758.31326.92