Article

Making Good Use of Your Limited Time

Supporting Novice Nurses

Sheri Matter, PhD, RN, MSN, MBA, MS, NEA-BC*, Kelly A. Wolgast, DNP, RN

KEYWORDS

� Novice nurse � Efficiency � Tools � Precepting � Time management � Benner � Stacking � Technology

KEY POINTS

� Developing a tool kit to provide safe and efficient care is pivotal for the novice nurse’s suc- cessful transition to a competent nurse.

� Embracing personal support elevates the novice nurse’s level of efficiency and provides opportunity to build a tool kit for the future. Personal support may include relationships with peers, such as mentors, and teamwork as well as length and type of orientation.

� System supports include efficiency mechanisms, such as electronic medical records, smart pumps, and a systems approach of providing care.

INTRODUCTION

Novice nurses join the professional work force from a variety of schools, programs, and experiences. Based on Patricia Benner’s1 novice to expert framework, the phases of nursing competence are developed through experience. The levels of competency include novice, advanced beginner, competent, proficient, and expert.1 Achieving the highest level of competency in practice, an expert nurse is one who has a full under- standing of the entire situation surrounding patient care.1 As new nurse’s successful progression from novice to advanced beginner to becoming clinically competent is achieved with proper planning and development of personal and systems support. Nursing efficiency is vitally connected to the solvency, or financial health, of any

health care organization. Economic factors play an influencing role in today’s hospital staffing. Health care has reached a new era of cost containment that is combined with the expectation of quality outcomes. As the strain of economic pressure increases in health care organizations, the accountability for meeting the measures of triple aim

College of Nursing, The Pennsylvania State University, Nursing Sciences Building, University Park, PA 16802, USA * Corresponding author. E-mail address: sxm1898@psu.edu

Nurs Clin N Am 55 (2020) 39–49 https://doi.org/10.1016/j.cnur.2019.10.004 nursing.theclinics.com 0029-6465/20/ª 2019 Elsevier Inc. All rights reserved.

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increases.2 This accountability creates a greater sense of urgency for efficient high- quality patient care. Triple aim is the accountability program that can affect a health care organization’s level of reimbursement by Medicare and insurers.2 According to the Institute for Healthcare Improvement, organizations that achieve triple aim have a healthier population when patients have less complex care, high-quality care, and satisfied patient experience at a lower per-patient cost.3 Ensuring that quality mea- sures are met in a cost-effective manner is included in the role of every bedside nurse and nursing leader. Delivering high-quality care to meet patient expectations in a cost-effective manner

is a skill that nurses need to learn early in their career. Nurses often are the largest line item in the salary budgets of health care systems, and hospitals function on the policy of producing the highest quality care at optimal cost.4 Novice nurses who combine learning efficiency with high-quality compassionate care create success for their ca- reers and play a vital role in the success of their organization. During the orientation period, it is important for novice nurses to gather tools to

apply throughout their career. A tool kit can help establish a foundation built during the novice stage and further develop through advanced beginner to competence. The tools that support nurses are as diverse as their portals of entry into the nursing field and range from support systems to technology. Each day in a nurse’s life is varied by patient care requirements; therefore, the tools need to be as diverse as the situa- tions encountered when entering practice. Huntington and colleagues5 in a quantita- tive study assessing nurses’ work-life balance noted that little has changed to support nurses’ time management both personally and organizationally while health care has become more complex. In 2003, Waterworth6 adeptly addressed the issue of time management and efficiency strategies. Little information was noted at that time and little research or evidence has been added to the literature since Waterworth’s work addressing time management skills.6

The role of the nursing leader is instrumental when guiding the transition of novice nurses to advanced beginner nurses. Strategies and lessons learned in this article are shared through the experiences of 2 seasoned nursing executives with more than 60 years of combined leadership experience. Leaders play a pivotal role in sup- porting the personal and systems support for novice nurses’ success. Nursing leaders set the tone for preceptors and mentors as well as ensure that the systems are sup- porting the team as intended.

DISCUSSION

This article presents elements of both personal and systems support for creating an efficient competent nurse from a novice nurse. The initial focus is on onboarding and self-help. Personal or individual support includes areas, such as precepting, nurse residency programs, mentorship, and self-management. The latter part of the article addresses systems support elements, such as technology and organizational struc- ture, including the role of information technology through decision support and proto- cols. The Kellogg logic model serves as a visual representation of the development pathway of the novice nurse to supporting the mission and the outcomes of the organization.7

ORIENTATION—ONBOARDING Precepting

A novice nurse’s orientation with a preceptor is part of the foundation for efficiency and competency for a new career and within the current system of employment. A

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40-year-old concept, precepting has become the cornerstone of the onboarding pro- cess for most novice nurses.4 Adequately trained preceptors are critical for novice nurses’ transition from student to advanced beginner nurse. Novice nurses are noted as graduating from the entry-level education but lacking prioritization and time man- agement skills.1 Precepting affords new nurses time to learn routines, develop critical thinking, and develop time management skills by learning from the efficiency of their preceptors.8 A supportive environment is critical when developing the efficiency of the novice nurse. As leaders choose and assign preceptors, it is important that the preceptors are contemporary, embrace personal and systems supports for gaining ef- ficiency, and know how to pass along those strategies and skills to novice nurses.

Nurse Residency or Extended Orientation Programs

Nurse residency programs or extended transition programs have been shown to improve nurses’ transiting into advanced beginner nurses. Programs can range from 6 months to 6 years and are noted to improve planning, prioritizing, communica- tion, and leadership, creating an efficient advanced beginner nurse.9 Through the early development of efficiency skills, time management is an unintended benefit of a formalized and lengthened onboarding program. Nurse residency programs have var- ied formats and there is little to no evidence as to which type of program is best. What is known is that a longer orientation program creates greater success for novice nurses.9 Baumann and colleagues,9 in a cross-sectional study comparing nurses who participated in an extended transition program to nurses who did not participate, found that an extended orientation benefited novice nurses in practice and reduced turnover.9 With that success comes efficiency and improves key dimensions of care.

Mentorship

There are health care organizations that have formal mentoring programs whereas others have no mentoring programs. Mentors have been shown to improve becoming part of the culture on nursing units.10 Mentors who are self-selected fit the needs of the new nurse. Mentors can support a novice nurse’s emotional needs as well as provide tips on how to best provide care. The use of a mentor often is part of a nurse’s tran- sition after the initial orientation program. When asked, many nurses articulate that formal or informal mentors helped transition them to be successful efficient nurses.10

Mentors are known to develop a nurse’s ability to think critically and support effi- ciency.10 This leads to the nurse becoming part of the high functioning team, and nurses who work with others find efficiency making overwhelming situations manageable.10

Stacking

Kohtz11 addressed the concept of stacking as the “dynamic and complex cognitive process which involves decision making, organizing, and reorganizing based on the patient’s needs.” Improving these skills decreases stress, especially in new nurses, and contributes to a healthy work environment on the nursing unit.11 Multiple studies found that during transition, time management was among the most distressing con- cerns.11 Preceptors and nursing leaders play a role in helping novice nurses learn the skill of coordination of care supporting quality of care and efficiency.11 The manager plays a large role by influencing factors, such as unit schedules, interruptions, and developing delegation.11 Preceptors play an important role in teaching delegation and point-of-care (POC) documentation.11 Shaw and colleagues,8 in a mixed methods study, found supporting evidence that enhanced learning opportunities in prioritization

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and timemanagement serve newly graduated nurses and their future patients well and support the need for leaders and preceptors to develop stacking skills.

Self-Management

Among nurses working in hospitals in the United States, 11% are prone to long hours.9

According to Stone and Treloar,12 long hours contribute to stress, high blood pres- sure, unhealthy diets, depression, work injuries, diabetes, and cardiovascular disease. Kirkwood13 found that decreased sleep and long, frequent shifts without rest lead to harmful health effects. Long and frequent shifts should be avoided to preserve all nurses’ health and protect patient outcomes. Significant breaks, including meal breaks, are instrumental during a nurse’s shift to boost health and promote mindful- ness.14 Mindfulness is the quality of attention and can be achieved when the mind is not allowed to wander.14 This can be achieved only when employees take breaks from the work and allow themselves time to refocus.14 Caring for self goes a long way when caring for others. Tired, stressed nurses are not as efficient in providing quality patient care.

Time Management

Time management skills are developed throughout a nurse’s career. The foundation of time management can be developed through preceptors, mentors, teamwork, and time spent delivering nursing care. The unpredictability of nursing activities challenges time management and the creation of efficiency. The tools of quality improvement can support the role of time management. There is a need to establish a routine, set prior- ities, coordinate care (including the team), and avoid interruptions.6,15 Routines can be supported through shared decision making at the unit level in scheduled care routines and multidisciplinary patient rounds. Examples of routines include tasks, such as reviewing laboratory data, medication administration, rounding, and hand-offs of pa- tient care.16 Finding a routine can help establish a pattern to a nurse’s day and create a sense of familiarity. Nurses have identified confidence in time management and prioritization, including

delegation skills that can be developed through exposure.16 Exposure to difficult sit- uations and how to navigate through them in a timely manner can be grounded in the novice nurse’s orientation. The support of preceptors, nurse residency programs, and mentors is valuable when developing time management skills. Bergman and Shu- bert16 found that there is increased confidence with frequent exposure supported by simulation and supportive periods, such as orientation.

SYSTEMS

Just as there are individual supports in developing efficiencies for a nurse, there are systems approaches. These approaches include processes, teamwork, and technol- ogy. Fig. 1 is a schematic of the tools that the novice nurse may build on to become an advanced beginner nurse. A logic model is a visual that presents how resources sup- port the plan and change results to achieve sought-after outcomes. This model in- cludes resources/inputs, activities, outputs, outcomes, and impact. The input is the nurse’s education, which varies from nurse to nurse. The activities include systematic inputs as well as inputs that are personal to the nurse. Outputs include efficient and competent care. The outcomes are measured by patient outcomes as well as nurses who find satisfaction in their work. Outcomes lead to the impact of an organization that supports the mission with the competent efficient nurse.7

Input

• Educa on • Experience

Personal Ac vi es

• Precep ng • Mentoring • Nurse Residency • Stacking • Self Management • Time Management

System Ac vi es

• Electronic Medical Record

• Teamwork • Lean Processes • Technology • Portable

Communica on Tools • Smart Pumps • Decision Support • Nurse Drive Protocols • Worklists

Outputs

• Efficiency • Teamwork • Confident Nurses • Money Saved

Outcomes

• Nurse Sa sfac on • Solvent organiza on • High Quality Pa ent

outcomes

Fig. 1. Logic model. (Data from Using logic models to bring together planning, evaluation, and action: Logic model development guide. W. K. Kellogg Foundation. https://www.wkkf.org/resource-directory/resource/2006/02/wk-kellogg-foundation-logic-model-development-guide Published February 2, 2006. Accessed on April 1, 2019.)

M a k in g G o o d U se

o f Y o u r Lim

ite d T im

e 4 3

Matter & Wolgast44

The outcomes are the focus of the systems support for novice nurses. When a nurse reaches competence and can efficiently and independently navigate the day, the nurse has more satisfaction from work.1 A nurse’s experiences and tools needed from a tool kit for care activities are different daily because each day presents with different patients and diagnoses. Understanding the process within the logic model allows the nurse to envision what is needed to efficiently work through their days dur- ing the beginning of a career. This growth can provide the new nurse satisfaction and confidence to move toward competency.

Teamwork

Teamwork is instrumental to creating efficiency in health care systems. Chan and col- leagues17 found that registered nurses support each other when there are heavy work- loads and they are quick to rescue. Teamwork is a part of the unit culture and not a learned response of the nurse. Included in teamwork is delegation, which is a difficult skill to learn as a novice nurse. It often is difficult to delegate care when a nurse is not yet personally comfortablewith the care thenurse is delivering. Delegation is something that needs to be worked on during the orientation period and beyond. This can be diffi- cult because novice nurses are developing their own competencies.9 The future of nursing report by the Institute ofMedicine states that nursesmustworkat the topof their license.18 This improves the novice nurse’s ability to perform the registered nurse–only tasks in a safe and timely manner.18 Through learned delegation techniques, novice nurses working at the top of their license contribute to the team at the highest level.

Multidisciplinary Rounds

Multidisciplinary rounds are a systems approach to efficiency. Although often seen as an interruption, multidisciplinary rounds can create efficiency if well planned.19

Planned rounds decrease interruptions and allow nurses to prioritize and plan their day.19 An added efficiency is to welcome a patient’s family to be present during rounds to help increase timely communication with the family and advance continuity of care. Physicians report fewer interruptions by nurses, families, and supportive de- partments, such as pharmacy and physical therapy, when engaging in multidisci- plinary rounds.19 By having rounds at scheduled times, all parties involved can better plan the activities for the day. All members of the health care team discuss the plan of care and have a clear consistent plan for the patient. Routine rounding also supports a planned discharge that creates efficiency for nurses and patients and sets expectations to support the patient experience and outcomes.20 Rounds must be well planned, follow a structured process, and stay within a time limit to create a focused meaningful process. Cornell and colleagues,19 through a time motion study, found that nurses and physicians who invest in the process see value and develop an understanding of questions to expect and what is to be addressed at the time of the rounding.

Processes—Lean Management Systems

There are quality-improvement processes that focus on efficiencies and decrease waste. One example is the Lean principles based on the Toyota system.21 Virginia Ma- son Medical Center is an example of a health care organization that applies the Toyota principles to transform care delivery.21 Recognizing the changing health care reim- bursement system, the organization embraced the Lean way of thinking to provide efficient high-quality patient care. Based on the concepts that there are 7 types of waste, including time, motion, inventory, processing, defects, transportation, and overproduction, processes throughout the organization have been reworked to avoid

Making Good Use of Your Limited Time 45

waste.21 Lean organizations create efficiencies by implementing supportive systems and avoiding overproduction. This is valuable to the novice nurse because Lean pro- cesses have fewer steps and consistently promote the delivery of high-quality care in the same simplistic way. Virginia Mason experienced fiscally responsible staffing with high-quality outcomes and high patient experience scores after beginning in the pro- cess in 2001 and achieved positive results within 4 years of process deployment.21

Positive results encourage staff involvement in identifying and presenting areas of waste as part of their employment expectations.21

Lean principles are being adopted by a growing number of health care organiza- tions.22 Due to the growing financial pressures of health care systems, health care leaders are compelled to change system processes to remain fiscally sound. Nurses benefit from this system approach that focuses on efficient practice grounded in qual- ity care. These improvements are based on the Toyota production system principles of removing wasted time, movement, and resources.23 Barnas and Adams23 noted, how- ever, that Lean processes are not enough, and the practices of gaining efficiency in all that is done need to be integrated into the culture throughout the organization. Plan-do-study-act is the basis of Lean process changes and stems from W.

Edwards Deming’s ongoing improvement work on total quality management, with the driving focus on the concept that quality can always be better.24 The individual and the system must continually work on improvement.10 By involving bedside or direct care nurses in the total quality management process, they learn cause and ef- fect while improving processes and improving care.10

Technology

Technology can either support or hinder the efficiency of a nurse. Extensive technol- ogy requirements associated with patient care can lead to nurse frustration and inef- ficiency.25 There often are interruptions in a nurse’s workflow and learning as new equipment is introduced. As noted by the National Academy of Medicine, innovations may benefit millions of patients, yet they often challenge nurses with complexity.26 It also is noted that technology can support continual learning and create efficiencies for nurses.26 Technology often is sought after for efficiency and to promote standardiza- tion of care. New technology can be disruptive to nurses who must change their pro- cesses due to the equipment or support systems. When technology is embraced and new processes are learned, the technology often is the more efficient answer to the provision of care. Nurses who are looking for a place of employment now explore the technology being used, the age of the technology, and the upgrade or replacement plans. New nurses also inquire what technology the organization has invested in to support the nursing staff in the organization. Some of the technologies are simple and focus on nursing efficiencies, such as phones or nursing call systems. Other tech- nologies are more complex and when embraced can create efficiencies throughout the workday.27

Portable Communication Tools

There are support pieces of equipment that help nurses bemore efficient. Research on the use of smartphones and effects on efficiency is in the early stages. More cost- effective phones do not have the ability to access the Internet yet save nurses travel time to desk or to hall phones to communicate. Some health care organizations have begun to use iPhones as a nurse’s personal computer. These types of devices can be cost prohibitive for many organizations, limiting the opportunity for assess- ment. The more complex phones are minicomputers that are loaded with medical in- formation. The technology creates an easy way to access evidence at the bedside as

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well as policy and procedural manuals, all while allowing for easier POC documenta- tion. Several devices have the capability of being used for medication administration as well. A pocket device can be an efficient means of documentation, data retrieval, and overall management.27

Call Systems

Technology to aid nurses at the bedside is always evolving. Nurse call systems have become more creative and user-friendly. Technology advancements can now inte- grate the call system with the portable phones.25 This technology decreases steps and helps the nursing team be more efficient. There are systems that can differentiate the types of calls between calls that are for the assistive personnel and those for the nursing staff. Decreasing interruptions is important as novice nurses establish their routine and create efficiencies.

Smart Pumps

The use of smart intravenous (IV) pumps creates efficiencies while supporting best ev- idence and safe practice. The novice nurse is supported by many factors by the smart IV pumps, such as medication dosing, educational references, and drug compatibility. Smart pumps are a safety tool because they place parameters on high-risk medica- tions to avoid dosing errors. Evidence-based programs within the pumps save time by having references for dosing, indications, and interactions. The smart pump is an efficient system supporting safe patient care.27

Electronic Medical Record

The electronic medical record (EMR) is one of the most complex tools used in health care and serves as an efficiency tool guiding a nurse’s practice.28 Documenting at the POC is instrumental in efficiency of the EMR and improved outcomes. Creating this practice of POC documentation can quickly become a learned habit when practiced at the time of orientation and when new work flows are being developed. It is pivotal that preceptors engage in this practice as they orient the novice nurse. The EMR also provides other tools for time management beyond the documentation functions. Embracing the EMR and using the following tools within it are instrumental in gaining the available efficiencies.26,27

Decision support Decision support systems are the tools embedded in the EMR. Decision support tools prompt nurses on practice decisions and are based on the best research evidence. Organizations build the support system within the routine documentation and work- flow processes. Novice nurses learn as they are guided in their practice in an efficient manner with the support of decision support systems tools.26 Decision support exam- ples can include hospital initiatives, such as a sepsis care bundle or checklist. When certain triggers or indicators of impeding sepsis are noted, the system can send an alarm to the nurse for further investigation. These processes can be lifesaving as well as time saving. Tools that build nursing knowledge are viewed as an advantage when applied to care at the bedside.26,27

Nurses often are in the space of multitasking, and novice nurses are working on un- derstanding the complexity of patients while being efficient in their practice. Having a system, such as the EMR, with decision support helps guide a nurse’s critical thinking and can be a valuable resource. The system can identify that there could be upcoming patient issues and the EMR can trigger an alert. The alert can guide the nurse to begin nurse-driven protocols and seek out additional assistance.26,27

Making Good Use of Your Limited Time 47

Nurse-driven protocols Nurse-driven protocols allow nurses to practice at the full extent of their scope of prac- tice.27 The nurse can enact approved order sets that are based on decisions regarding certain patient criteria and presentation. Examples of nursing protocols are varied and include indwelling catheter removal, potassium replacement, or a ventilation weaning program. Protocols can be initiated by a nurse based on a patient’s situation and a nurse’s competency. The large numbers of diverse protocols create efficiency by decreasing calls to phy-

sicians for orders as well as the potential to improve a patient’s length of stay. Order sets also create consistency in patient care and allow for nurses to create an efficiency as how they deliver high-quality patient care. Order sets are built within the EMR and the care often is delivered within a nurse’s work list.27

Work lists and to-do lists Work lists and to-do lists live within most EMRs and are created to guide efficient work throughout a nurse’s day. Most work lists can be created by nurses to support their daily routine and can be adjusted to meet the needs of the individual nurse. The work from protocols and decision support often is part of a work list or to-do list.27

Not all reminders are built into decision support because over-notifications can lead to alarm fatigue. Alarm fatigue is when systems over-alert and alarms are ignored.27 It is important to have staff input as to which vital alarms are included and which are not. There also is the ability for individualization of the work lists as nurses strive to provide standardization to their lists. The list can include regulated care and focused organi- zational initiatives. This routine keeps nurses focused on important tasks while not having to write and rewrite paper lists on a daily basis. This focused approach creates efficiency in providing quality patient care during the day and at times of care transi- tions between shifts.18,26,27

FINAL THOUGHTS

Efficiencies for novice nurses are learned and gained through a systems approach as well as individually developed. Combined, there are tools and strategies that novice nurses acquire with the help of preceptors and mentors to become efficient members of a team and to successfully reach and function as an advanced beginner nurse. Through the tools and strategies described previously, nurses learn and grow to perform their skills at a highly efficient level and contribute to the overall organizational mission to support the triple aim. Both the personal tools and systems support struc- tures are interconnected and facilitate safe, quality patient care. The nurse leader plays an important role to understand the support systems and to ensure that ongoing development for new nurses is encouraged and supported. The nurse leader is instru- mental in the novice nurse transition to advanced beginner and to ultimately support- ing the organization’s quality, safety, and fiscal goals.

DISCLOSURE

The authors have nothing to disclose.

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